| This
is
the
second
of
three
chapters
that
address
the
fourth
of
my
Terms
of
Reference.
The
lack
of
objection
of
relatives
to
organ
and
tissue
retention
is
a
central
issue
for
the
future
and
for
research
that
involves
organs
and
tissues
from
post
mortems.
|
|
|
|
| While
public
attitudes
may
have
changed
and
many
people
have
no
concerns
about
post
mortems
or
the
retention
of
organs,
there
are
faith
communities
whose
fundamental
objections
to
both
have
not
altered.
The
chapter
considers
how
best
these
objections
can
be
recognised
and
what
measures
are
available
to
meet,
in
part,
the
religious
requirements
of
these
faiths.
|
|
|
|
| Historical
Christian
objections
|
|
|
|
| In
the
18th
and
early
19th
centuries,
such
was
the
demand
by
anatomists
for
cadavers
to
dissect
that
grave
robbing
became
common.
At
that
time
Christian
theology
laid
emphasis
on
the
importance
of
the
resurrection
of
the
body.
Relatives
who
could
afford
to,
fortified
graves
to
prevent
robbers
jeopardising
the
bodily
resurrection
of
the
deceased.
|
|
|
|
| The
legislation
of
the
late
18th
century
permitted
the
dissection
of
the
bodies
of
criminals
executed
for
murder
but
not
of
those
executed
for
other
crimes.
Murderers
were
considered
beyond
redemption.
|
|
|
|
| Attitudes
to
post
mortem
examination
in
the
last
40
years
|
|
|
|
| Attitudes
of
the
Christian
denominations
to
dissection
have
changed
since
those
times,
but
even
in
the
1960s
and
1970s
very
few
members
of
the
public
knew
what
a
post
mortem
examination
involved,
indeed
few
wanted
to
know.
Relatives
did
not
ask
what
was
involved.
|
|
|
|
| Thirty
years
ago
the
public
were
much
more
inclined
to
accept
what
doctors
advised
without
question
or
challenge.
When
a
hospital
post
mortem
was
suggested
the
relatives
were
expected
to
agree.
The
doctor's
opinion
that
a
post
mortem
was
needed
was
trusted.
Indeed,
there
was
surprise
and
often
an
argument
when
the
relatives
refused
to
give
consent.
|
|
|
|
| As
earlier
chapters
have
shown,
organ
retention
was
virtually
unknown
except
to
pathologists,
morticians
and
the
health
professionals.
These
matters
were
not
appropriate
for
discussion
with
relatives.
If
questions
were
asked
bland
replies
were
often
given
'to
avoid
distress'.
The
deficiencies
of
consent
forms
have
been
discussed
already.
|
|
|
|
| These
attitudes
underlay
the
omission
of
references
to
organ
retention
in
post
mortem
reports
to
Coroners.
|
|
|
|
|
|
| When
a
Coroner
ordered
a
post
mortem
the
only
route
open
to
relatives
to
prevent
the
examination
was
an
application
to
the
High
Court
for
an
injunction.
Such
applications
were
exceptionally
rare.
The
High
Court
remains
the
route
available
for
relatives
to
make
their
case
that
a
post
mortem
should
not
take
place.
|
|
|
|
| Changing
attitudes |
|
|
|
| In
the
1980s
and
90s
attitudes
began
to
change.
Patients
and
relatives
were
less
deferential
to
doctors
and
more
willing
to
question
the
doctors'
views.
When
a
person
died,
many
relatives
wanted
to
know
why
a
hospital
post
mortem
was
necessary.
If
they
did
not
consider
the
reasons
were
sound,
a
growing
number
of
requests
were
refused.
These
refusals
have
been
reflected
in
the
steady
decline
in
the
number
of
hospital
post
mortems
that
began
long
before
the
recent
publicity
given
to
the
scale
of
organ
retention.
|
|
|
|
| As
public
awareness
grew,
the
fall
in
the
number
of
hospital
post
mortems
increased,
but
it
was
the
report
from
the
inquiry
into
the
Royal
Liverpool
Children's
Hospital,
published
in
January
2001,
which
placed
post
mortems
and
organ
retention
under
intense
media
scrutiny.
|
|
|
|
| Nevertheless,
in
today's
secular
society
many
people
have
no
objections
to
post
mortem
and
to
organ
retention;
indeed
they
consider
that
post
mortem
research
should
be
encouraged
to
improve
patient
care
and
treatment
in
future.
|
|
|
|
| Objections
to
post
mortems |
|
|
|
| Many
of
those
who
reject
post
mortems
and
organ
retention
do
so
for
religious
reasons.
Unlike
others
in
the
community,
the
faith
groups
have
always
known
what
was
involved.
Their
objections
are
longstanding
and
deeply
held,
unlike
the
changing
attitudes
of
secular
society.
The
faith
groups
have
vigorously
expressed
to
Coroners
their
objections
to
post
mortems.
|
|
|
|
| Organ
and
tissue
retention
in
Coroners'
cases
|
|
|
|
| As
public
attitudes
have
changed
so
has
the
practice
of
organ
and
tissue
retention
in
Coroners'
post
mortems.
While
some
relatives
still
prefer
not
to
be
told
the
details,
the
majority
now
want
to
know
whether
organs
and
tissues
have
been
retained
and
why,
and
what
will
happen
to
these
organs
and
tissues
when
the
Coroner
no
longer
needs
them.
|
|
|
|
| Many
Coroners
have
responded
to
concerns
by
introducing
forms
that
are
completed
by
the
pathologist
at
the
end
of
every
post
mortem.
The
forms
record
what
tissues
have
been
retained
and,
equally
important,
the
relatives'
instructions
regarding
their
eventual
disposal.
Annex
113
is
an
example
of
the
form
now
in
use
in
one
coronial
district.
There
are
similar
forms
used
in
many
other
districts.
|
|
|
|
Positions
of
faith
communities
|
|
|
|
| The
Hindu,
Jewish
and
Muslim
faith
communities
are
prominent
among
those
who
reject
post
mortems
and
organ
retention.
These
practices
are
incompatible
with
their
religious
laws
and
beliefs.
The
requirements
of
the
faith
communities
were
explored
through
meetings
with
senior
representatives
of
the
Hindu,
Jewish,
and
Muslim
faiths.
|
|
|
|
| The
Registrars
of
the
London
Beth
Din
and
the
Manchester
Beth
Din,
the
Sadhus
of
the
Shri
Swaminarayan
Mandir
(Hindu
Temple)
in
Neasden,
and
the
Muslim
Burial
Council
of
Leicestershire
each
provided
comprehensive
descriptions
of
the
reasons
why
their
respective
faiths
reject
post
mortems
and
organ
retention.
The
faith
communities
believe,
on
the
basis
of
their
religious
laws
and
centuries
old
principles,
that:
|
|
|
|
there
should
be
no
assault
of
any
kind
on
the
body
of
any
deceased
person.
|
|
|
|
| To
the
faith
communities,
interference
with
the
body
between
death
and
burial
or
cremation
breaks
religious
law.
It
is
the
duty
of
the
relatives
to
prevent
a
post
mortem
if
this
can
lawfully
be
done.
For
some
faiths,
any
interference
with
the
body
after
death
will
prejudice
the
future
of
the
deceased
in
their
next
life.
|
|
|
|
| These
faith
communities
are
not
alone
in
their
rejection
of
post
mortems.
Objections
are
still
held
by
some
Christian
denominations.
|
|
|
|
| There
are
others
whose
objections
have
no
religious
basis
but
who
believe
the
human
body
after
death
has
a
special
status.
A
post
mortem
is
an
affront
to
that
special
status
and
does
not
respect
the
dignity
of
the
deceased.
|
|
|
|
| Whilst
a
description
of
the
faith
communities'
reasons
for
their
objections
to
post
mortems
and
organ
retention
go
beyond
the
scope
of
this
report,
the
objections
of
the
communities
are
very
sincere
and
deeply
held.
In
a
multicultural
society
these
objections
must
be
recognised
and
respected
wherever
possible.
|
|
|
|
| All
the
faith
communities
accept
that
in
this
country
legal
requirements
will
dictate
that
a
Coroner's
post
mortem
examination
is
a
legal
necessity
in
cases
such
as
murder,
suicide
or
other
suspicious
circumstances.
The
faith
communities
are
greatly
concerned
that
post
mortems
are
too
readily
undertaken
when
there
are
no
such
compelling
reasons,
for
example
when
the
deceased
was
already
ill
with
a
known
terminal
disease.
|
|
|
|
| There
are
similar
concerns
when
organs
are
retained
on
the
instructions
of
the
Coroner
and
these
are
not
returned
to
the
bodies
from
which
they
have
been
taken.
Such
retention
prevents
disposal
of
the
whole
body
in
accordance
with
the
religious
observance
of
the
deceased.
|
|
|
|
| It
is
the
more
important
in
a
multicultural
society
that
the
sincerely
held
beliefs
of
minorities,
including
the
faith
communities,
are
acknowledged
and
respected.
|
|
|
|
| The
use
of
Magnetic
Resonance
Imaging
as
a
non-invasive
method
of
determining
the
cause
of
death
has
been
welcomed
by
leaders
of
some
faith
communities
as
a
way
of
ensuring
that
both
the
sensitivities
of
religion
and
the
demands
of
the
law
can
be
harmonised
where
this
technique
avoids
a
post
mortem
in
some
cases,
but
by
no
means
all.
|
|
|
|
| What
can
be
done
to
recognise
these
objections?
|
|
|
|
| 1. Discussion
with
the
relatives
about
the
reasons
for
a
post
mortem |
|
|
|
| The
principle
must
be
frankness
about
the
reasons
for
the
examination.
|
|
|
|
| One
consistent
complaint
during
this
investigation
has
been
the
lack
of
information
provided
to
the
relatives
about
the
post
mortem.
Some
relatives
were
not
informed
there
would
be
a
post
mortem,
others
were
told
that
a
post
mortem
was
'routine',
or
words
to
that
effect.
None
was
told
that
the
Coroners
Rules
allow
them
to
request
a
representative
to
attend
the
post
mortem.
|
|
|
|
| The
relatives
and
the
faith
communities
want
to
know
why
a
post
mortem
is
necessary,
not
that
it
is
'routine'.
Time
spent
explaining
the
reasons
may
not
lessen
their
objections
but
will
help
to
avoid
misunderstandings.
|
|
|
|
| It
will
not
be
possible
to
contact
relatives
before
the
post
mortem
in
every
case,
but
when
this
is
not
practicable,
the
relatives
should
be
informed
as
soon
as
possible.
(An
exception
may
be
deaths
under
investigation
by
the
police
where
a
relative
is
in
custody.)
|
|
|
|
| The
simple
expedient
of
explaining
to
relatives
why
the
post
mortem
is
necessary,
and
when
and
where
it
will
take
place
will
avoid
the
commonly
voiced
complaint
that
'we
were
not
told
what
was
happening
and
why.'
|
|
|
|
| 2. Why
organs
or
tissues
are
retained |
|
|
|
| There
must
be
openness
about
the
retention
of
organs
and
tissues
and
why
this
is
necessary.
|
|
|
|
| The
cases
in
this
report
show
how
damaging
the
discovery
of
a
retained
organ
can
be,
particularly
when
this
comes
to
light
after
the
funeral
or
cremation.
The
consequence
has
been
that
some
relatives
and
faith
communities
no
longer
trust
the
information
they
have
been
given.
|
|
|
|
| There
is
no
easy
way
to
re-establish
trust,
but
there
are
measures
that
can
be
taken
to
increase
the
confidence
of
relatives
and
to
demonstrate
to
those
with
religious
objections
that
their
concerns
have
been
recognised.
|
|
|
|
| 3. Measures
to
assist
those
who
have
objections
to
post
mortems
and
organ
retention |
|
|
|
| The
presence
of
a
medically
qualified
representative
at
the
post
mortem,
as
provided
for
by
Rule
7(2)a
of
the
Coroners
Rules,
could
provide
reassurance
that
no
organs
or
tissues
have
been
covertly
retained.
This
could
prevent
a
recurrence
of
the
disbelief
that
has
been
voiced
by
relatives
whose
trust
has
been
undermined.
|
|
|
|
| Where
for
valid
diagnostic
reasons
an
organ
has
to
be
retained,
the
relatives
should
be
given
time
to
decide
what
should
happen
to
the
retained
organ
when
this
is
no
longer
needed
for
the
Coroner's
purposes.
|
|
|
|
| The
retention
of
'slides
and
blocks'
may
be
more
acceptable
than
whole
organ
retention,
though
not
the
complete
solution.
|
|
|
|
| Practical
measures |
|
|
|
| Coroners
have
introduced
a
number
of
procedures
to
demonstrate
to
the
faith
communities
that
their
religious
concerns
and
observances
have
not
been
forgotten.
Extra
organisation
and
effort
is
required
to
modify
procedures
to
meet
the
needs
of
the
faith
groups.
|
|
|
|
| Reducing
delays |
|
|
|
| For
those
relatives
whose
religious
beliefs
require
burial
or
cremation
on
the
day
of
death,
rapid
completion
of
the
post
mortem
and
of
any
investigation
should
take
place
as
soon
as
possible.
|
|
|
|
| During
my
investigation,
districts
have
been
visited
where
strenuous
efforts
are
made
by
all
involved
to
expedite
the
post
mortem
examination
and
release
the
body
for
burial
or
cremation.
The
speed
with
which
post
mortems
have
been
undertaken
in
some
districts
has
indicated
to
the
faith
communities
that
their
concerns
have
been
recognised
by
the
release
of
the
body
at
the
earliest
opportunity.
|
|
|
|
| There
will
be
a
minority
of
cases
where
early
release
of
the
body
is
not
possible.
The
faith
communities
have
recognised
that,
in
such
cases,
the
law
and
the
principles
of
justice
must
prevail
over
their
religious
requirements.
|
|
|
|
| Observance
of
rituals |
|
|
|
| For
some
faith
communities,
the
body
of
the
deceased
should
not
be
left
unattended
and/or
special
prayers
should
be
said
over
the
body
during
the
period
between
death
and
burial
or
cremation.
|
|
|
|
| Where
these
rituals
do
not
interfere
with
the
investigation
of
the
cause
of
death,
the
opportunity
to
follow
religious
observances
will
reduce
distress.
|
|
|
|
| In
some
districts,
when
bodies
have
been
removed
to
public
mortuaries,
rooms
are
provided
where
relatives
and
religious
representatives
may
sit
with
the
body
and
follow
the
observances
of
their
faith.
|
|
| Some
rituals
such
as
the
washing
of
the
body
cannot,
however,
be
carried
out
until
after
the
post
mortem
examination,
as
any
interference
with
the
body
could
remove
vital
evidence
before
it
has
been
examined
by
the
pathologist.
|
|
|
|
| While
the
washing
of
the
body
may,
for
these
reasons,
have
to
be
delayed
until
after
the
post
mortem,
there
are
mortuaries
where
rooms
are
provided
for
these
rituals.
|
|
|
|
Limiting
the
extent
of
the
examination
in
a
Coroner's
post
mortem
|
|
|
|
| The
scope
of
a
coroner's
post
mortem
was
discussed
in
Chapter
43.
The
case
for
limiting
the
extent
of
the
examination
is
particularly
relevant
in
post
mortems
when
the
Coroner
knows
that
there
are
religious
objections
to
the
examination.
Once
the
cause
of
death
has
been
identified,
to
continue
with
a
full
post
mortem
is
an
unacceptable
denial
of
the
wishes
and
rights
of
the
relatives
and
an
unjustified
assault
on
the
body
of
the
deceased.
|
|
|
|
| The
fact
that
the
examination
was
authorised
by
the
Coroner
does
not
justify
extending
the
procedure,
for
example,
to
open
the
skull,
if
the
cause
of
death
has
been
found
in
the
chest
or
abdomen.
|
|
|
|
| The
need
for
'consent'
is
the
cornerstone
of
modern
medical
practice,
and
should
also
be
required
for
carrying
out
a
more
extensive
post
mortem
than
is
required
to
determine
the
cause
of
death
for
the
Coroner's
purposes.
|
|
|
|
| Faith
communities
that
require
disposal
through
cremation |
|
|
|
| The
Hindu
faith
requires
cremation
of
the
body
but
the
preferred
method
of
cremation
in
the
open
is
not
available
in
this
country.
However,
many
crematoria
make
special
arrangements
for
the
relatives
to
participate
in
the
disposal
in
a
manner
that
is
as
close
to
the
traditional
practice
as
English
law
permits.
|
|
|
|
| While
discussion
of
methods
of
body
disposal
are
beyond
my
terms
of
reference,
the
requirements
of
the
Hindu
faith
illustrate
that
in
a
multicultural
society
the
procedures
of
post
mortems
and
retention
of
organs
should
be
modified
as
far
as
possible,
to
take
account
of
the
religious
beliefs
of
the
faith
communities.
|
|
|
|
| Disposal
of
retained
organs |
|
|
|
| There
is
one
particular
problem
which
results
from
past
covert
organ
retention.
Among
the
retained
organs
held
in
NHS
hospitals,
Universities
and
other
locations
are
some
removed
from
those
whose
religion
demands
that
any
retained
organ
should
be
reunited
with
the
body
or,
if
this
is
not
possible,
interred
in
a
burial
ground
of
the
deceased's
faith.
|
|
|
|
| A
number
of
retained
brains
were
identified
during
the
course
of
this
investigation
that
come
into
this
category.
There
will
be
other
retained
organs
taken
from
deceased
persons
of
the
faith
communities
in
places
I
have
not
visited.
|
|
|
|
| Where
a
retained
organ
can
be
identified
as
belonging
to
a
member
of
a
faith
community,
the
guiding
principle
should
be
that
the
opportunity
is
given
for
the
relatives
and/or
the
religious
authorities
of
the
relevant
faith
community
to
be
consulted
about
what
should
happen
to
the
retained
organ.
|
|
|
|
| For
some
faith
communities
organs
retained
in
these
circumstances
present
a
doctrinal
dilemma.
The
principle
is
that
the
relatives
and/or
the
religious
authorities
must
have
the
opportunity
to
decide
how
to
dispose
of
the
retained
organ
in
keeping
with
the
religious
beliefs
of
the
deceased.
|
|
|
|
| Summary |
|
|
|
| There
are
long
standing
and
deeply
held
objections
to
both
post
mortems
and
organ
retention.
These
are
founded
in
religious
belief
in
the
sanctity
of
the
human
body.
|
|
|
|
| Public
attitudes
to
post
mortems
and
to
organ
retention
began
to
change
in
the
last
two
decades,
but
did
not
become
the
focus
of
public
attention
until
the
scale
and
circumstances
of
organ
retention
at
the
Royal
Liverpool
Children's
Hospital
became
known.
|
|
|
|
| The
lack
of
openness
about
organ
and
tissue
retention
has
caused
distrust
even
among
relatives
who
have
no
objections
in
principle
to
retention,
when
this
took
place
without
their
knowledge.
|
|
|
|
| Certain
faith
communities,
Hindu,
Jewish
and
Muslim,
have
always
rejected
post
mortems
for
religious
reasons.
There
are
also
some
Christian
communities
and
individuals
who
believe
post
mortems
violate
the
body.
|
|
|
|
| In
a
multicultural
society
it
is
important
to
acknowledge
the
strongly
held
objections
of
the
faith
communities,
and
make
adjustments
to
procedures
to
accommodate
religious
observances
where
these
do
not
interfere
with
the
proper
investigation
of
the
death.
|
|
|
|
| In
all
Coroners'
cases,
the
relatives
should
be
given
an
explanation
of
why
a
post
mortem
is
necessary
and,
if
organ
retention
is
required,
why
this
too
is
necessary
in
determining
the
cause
of
death.
|
|
|
|
| There
are
practical
ways
in
which
a
Coroner's
post
mortem
can
be
adjusted.
For
example,
the
post
mortem
can
be
expedited
so
that
burial
or
cremation
takes
place
as
soon
as
possible
when
religious
belief
requires
this.
|
|
|
|
| Organs
should
be
retained
only
on
the
specific
instructions
of
the
Coroner
where,
for
evidential
reasons,
there
is
no
alternative,
but
with
the
knowledge
of
the
relatives.
|
|
|
|
| The
relatives
should
be
consulted
regarding
their
wishes
for
eventual
disposal
of
any
organ
retained.
|
|
|
|
| Once
the
Coroner's
need
to
retain
an
organ
has
ended,
the
relatives'
instructions
for
disposal
should
be
carried
out.
|
|
