key: cord-0907938-5hh1l1dt
authors: Lemos, George Azevedo; Araújo, Diego Neves; de Lima, Fernando José Camello; Bispo, Rodrigo Freitas Monte
title: Human anatomy education and management of anatomic specimens during and after COVID-19 pandemic: Ethical, legal and biosafety aspects
date: 2020-10-03
journal: Ann Anat
DOI: 10.1016/j.aanat.2020.151608
sha: 3f4eeaac288b6bada1f0dfefe1978b598588236b
doc_id: 907938
cord_uid: 5hh1l1dt

COVID-19 is an infection caused by the SARS-CoV-2 virus, initially identified in the city of Wuhan, China, in December 2019. Since then, the virus has spread to the continents, causing a major pandemic. The impacts of this pandemic on the education of human anatomy interfere in at least two aspects: (1) receiving and managing anatomical specimens in anatomy laboratories and (2) adaptations for classes on remote virtual teaching. Therefore, this study reviewed and discussed the legal and bioethical aspects, considering the scenario of a South American Country, aiming to stimulate the debate on these two relevant themes in the international community. Because of the COVID-19 pandemic and the impossibility of mass testing, anatomists and other workers in the field must deal with the risk of receiving bodies infected with SARS-CoV-2. In this situation, additional care measures in biosafety practices are essential to protect the staff. Such measures are: the bodies must be preserved by the perfusion of formaldehyde or other fixative solutions; embalming must be performed in ventilated rooms with a good air exhaust system; to avoid excessive manipulation of bodies and procedures such as pulmonary insufflation or craniotomy; and proper use of personal protective equipment, including lab coat, gloves and masks. As for exposure of body images in online classes, this review showed that there are no legal impediments to this end. However, anatomists must adopt measures aimed at protecting the memory of the deceased, such as using secure digital platforms with restricted access; family authorization/consent and student awareness.

Human Anatomy laboratories of Higher Education Institutions (HEIs) are important education and research environments in the areas of health and biology. They possess and use a series of didactic-pedagogical resources such as synthetic models, computers and software with digital atlases, and cadaverous pieces, allowing the study of systemic and/or topographic anatomy Finally, legislation on the right to personality and its implications related to the exposure of images and videos of the dead human body during remote virtual classes, a common alternative in this COVID-19 pandemic, is discussed. It is expected that this discussion in the light of a South American country legislation will stimulate the debate on these two relevant themes by the entire international community, respecting local legal and socio-cultural aspects.

In Brazil, most anatomic specimens used in teaching and research in human anatomy are unclaimed bodies. In this regard, Law 8.051, from November 30, 1992 (regulates the use of unclaimed anatomic specimens for purposes of scientific studies or research and provides other measures), in its second article, decides that the unclaimed corpse, within thirty days, may be sent to medical schools for teaching and scientific research. In case of unidentified corpses, the competent authority shall publish in the main newspapers of the city, (as a public utility service, for at least ten alternate days) the news of the death (article 3) and at any time, family members or legal representatives will have access to the cadaveric remains and corpse data, including identification photos, fingerprint record and necropsy results, if performed (article 5) (Brasil, 1992) . In addition, J o u r n a l P r e -p r o o f each Brazilian state has its own laws that aim to guarantee the moral, ethical and legal principles regarding the admission and management of dead human bodies in anatomy laboratories.

On the other hand, a voluntary donation in life is also possible in Brazil and guaranteed by law 10.406, article 14, of January 10 th , 2002, of the Civil Code. Furthermore, the disposition act can be freely revoked at any time, including by responsible family members after death of their own family member (Brasil, 2002) . In general, the anatomic specimen will only be available for use in HEIs after the death document is filled with the availability of the corpse for teaching and research, both for unclaimed bodies and for those donated in life or by family members (Melo and Pinheiro, 2010) . Regarding destination of the cadaverous remains, the medical schools must communicate to the registry office when they are no longer interested in keeping the body, for the purpose of registration in the respective death document, and to the family, in the case of donated anatomic specimens (Pernambuco, 2008 ; Rio Grande do Norte, 2012). Family members will have a 15-day deadline to express their intention to proceed with the burial (Pernambuco, 2008; Melo and Pinheiro, 2010) , and in case of no response in a timely manner, the medical schools will be able to carry out the burial or cremation according to current health legislation (Pernambuco, 2008 ; Rio Grande do Norte, 2012).

For long-term custody purposes in medical schools, the anatomic specimens can be chemically embalmed or cooled to -20 •C, the latter being a better procedure for training surgical techniques, due to the similarity of the tissues in terms of texture and color with the living Considering that the used chemical agents are also effective in inactivating SARS-CoV-2, the embalming procedures of anatomic specimens can be maintained in HEIs during and after the COVID-19 pandemic, however, the anatomic specimen manipulation, since its arrival until the act of infusing chemical substances requires additional care and reinforcement of biosafety procedures in anatomy laboratories (IFAA, 2020a). Therefore, it is essential that all people who work handling the corpses comply with the rules and routines, because only in this way can barriers be created to minimize or cancel the risks.

It is noteworthy that the exposure to physical, chemical and biological agents for students occurs for a short period, therefore, it does not necessarily imply a risk to the health of users, since contact is for a short time and on alternate days according to the schedule of practical classes. The In this paper we do not aim to discuss the best teaching methods in anatomy, but to discuss the ethical and legal aspects related to the exposure of images and videos of human anatomic specimens during online classes.

The Brazilian Civil Code, in its Art. 6, defines that the existence of the natural person ends with death (Brasil, 2002) . Therefore, it is presumed that, after death, the rights of the human person would be finalized. However, it is widely known that the corpse has legal protection, proven by the existence of several laws, and some of them will be discussed below.

Law 5.250, of February 9, 1967, which regulates the freedom of expression of thought and information, defines in Art. 24 that they are punishable, in the terms of articles 20-22, slander, defamation and injury against the memory of the dead (Brasil, 1967) . Following this understanding, the Civil Code, in Art. 12, states that the spouse or any relative in a straight line, up to the fourth degree of a dead person, is entitled to request or demand that the threat or injury to the right to personal identity to be ceased and claim losses and damages (Brasil, 2002) . In other words, relatives can legally demand compliance with the law in cases of violation of the right to personal identity of the dead, including intimacy, honor and image (Brasil, 1988) . It is important to highlight that the right to personal identity refers to the guarantee of human dignity, internationally recognized by the Universal Declaration of Human Rights (UN General Assembly, 1948). To vilify is the action of outraging, disrespecting or violating the lifeless human being and his/her memory. The consummation of this crime is therefore intimately linked to the right to personal identity, regarding the right to image and privacy. Not related to the dead person, but to his/her family and friends (Duarte, 2016) . Duarte (2016) argues that the crime of vilifying an anatomic specimen leaves doubts about its consummation, especially related to the conduct performed by the subject and its purpose. These guidelines and policies reinforce the ethical conduct of respect for the anatomic specimen; however, they do not specifically address the cases of images and videos of unclaimed ones. For these cases, there is no possibility of authorization from family members, who in most cases are not identified. In addition, as previously discussed, the right to personal identity continues after death, as it can be claimed by family and friends. In this case, the following question arises: if there are no known relatives or friends, would the unclaimed corpse be without rights? Could consent be waived? These questions demand great ethical discussion by anatomists from all over the world, and a deep reflection needs to be carried out.

It is known that the study of human anatomy provides knowledge about the structure of the human body, but it also allows the development of skills such as feelings of gratitude, respect for death and ethical awareness for students. These are fundamental ideas in their future professions. We reiterate that, in cases of need for practical online classes, with the exhibition of images or videos of anatomic specimens, some measures must be adopted, aiming at the preservation of human dignity, as follows: a) Use of secure digital platforms with restricted access only to students and professors of the course; b) Authorization/consent from the anatomy sector/department, and from family members in cases of donated bodies; c) Awareness of students about the legislation related to the protection of the corpse and; d) Adoption of an ethical stance of respect for the corpse, regardless of its origin and condition.

In this study, we describe the legal processes for obtaining corpses for education and The need for new strategies for the proper and safe management of anatomic specimens that tested positive or suspect for COVID-19 is evident in the absence of specific studies on the effectiveness of biosafety standards in this condition (Yaacoub et al., 2020) . Therefore, these rules must be rethought and expanded, aiming at the safety of all users, especially the technical professionals and professors responsible for embalming new corpses.

Besides, we instigate the debate on the legal and ethical aspects of the exhibition of images of human anatomic specimens and their parts, guided by the Brazilian legislation. We encourage an in-depth discussion on the topic and the adoption of some practices to guarantee ethical principles of respect for the corpse, when its exposure is inevitable.

The adoption of routines, sequences, protocols and standards must be pursued by everyone;

and their proper implementation will depend on the individual and collective effort of students, professors, technicians and the cleaning staff.

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The authors declare no conflicts of interest, and that the manuscript has not been published, accepted for publication or under editorial review for publication elsewhere.All authors have read and accepted responsibility for the manuscript's contents.J o u r n a l P r e -p r o o f