Our view is that Anatomical Sciences Education (ASE) programs in medical schools should foreground the social construction of cadavers (SCC) as a routine and helpful part of working with body donors. As an anatomy teacher and a historian of medicine, our interest in SCC emerged from our historical research on anatomy in medical education.1, 2 Social construction occurs when a society or group assigns social meaning to an object or person (or any number of things), such as acknowledging bodies used for dissection as “donors” or “teachers” or “patients.” Social constructions emerge because they provide an advantage to some or all members of a group. Today, SCC performs useful pedagogical functions in ASE, such as helping learners to cultivate empathy and respect for patients' dignity and autonomy. Indeed, it plays an important role in medical education and therefore warrants critical reflection—with help from the humanities and social sciences. Critical discussions of SCC could benefit anatomy learners by encouraging them to shift between viewing cadavers as scientific objects and as fellow humans—an experience that often initially provokes apprehension—and to do so with increasing confidence and sensitivity as appropriate. A recent study, discussed below, suggests that this ethical reconciliation process is important for both anatomical learning and the future care of patients.3 To encourage anatomy educators to develop critical engagement with SCC, a framework is provided for one critical discussion based on historical and contemporary studies of human dissection in medical education. It is structured around two case studies that represent contrasting extremes of SCC—one dehumanizing and the other humanizing. Basic instructional content and discussion points for facilitators are suggested along with corresponding learning resources for each case to share with students. Ever since cadaveric dissection moved to the center of biomedical education around 200 years ago, anatomy teachers and students have socially constructed the bodies they dissect in various ways and for various purposes. Social constructionism is a theoretical framework used for analyzing everyday phenomena that are assigned social meaning. It asserts that much of the knowledge and norms that group members take for granted as “natural” or “universal” are often creations (or “constructs”) specific to that group's accepted cultural values and shared ways of thinking. A benign example is that in some cultures a goldfish is perceived as lucky, whereas other groups consider a cow or ladybug lucky. There are countless, more consequential examples, however. The social meanings assigned to thinness, small feet, or a pale complexion are markers of feminine beauty that dominate women in various cultures.4 The social hierarchies based on the significance that some societies assign to ethnicity, occupation, language or physical characteristics are used to justify unfair policies, harassment, discrimination and violence.5 Far from being innate or predetermined, social constructs are influenced and maintained through collective understandings and everyday social interactions.6 Social scientists and humanities scholars have produced an enormous body of literature on the constructed nature of not only gender, race, caste, nationality, and religion, but also professions, diseases, and bodies. Their analyses have revealed both the harmful consequences that result from some social constructions and the productive insights that emerge from critically examining those constructs. Lessons drawn from such studies can inform and benefit ASE. It is helpful to consider what philosophers say about social construction. Its core principle, according to Kenneth Gergen, is that “what we take to be the truth about the world importantly depends on the social relationships of which we are a part.”7 Reality is not neutral; rather, it is always “constructed” from agreed upon values, knowledge, and language. Social constructionism is often compared to realism, the theory that the external world (and its objects) is straightforwardly there for us to observe and understand (and dissect), and that language depicts that world accurately and objectively to everyone. Gergen emphasizes, however, that “whenever people describe reality—that death is real, or the body, the sun, and the chair on which they are sitting—they are speaking from a particular standpoint or tradition of understanding. To be sure, there is something, but when you try to describe what that something is, you will inevitably rely on some tradition of sense making.”7 Social constructions, according to Vivien Burr, gain significance from their utility to the group and its traditional ways of thinking.8 In this case, the group is medical educators and students in the last 200 years and how they have made sense of human dissection. A social construction perspective facilitates critical analyses around the following four useful tenets: (1) the categories and concepts that humans create and use are historically and culturally specific; (2) knowledge is sustained by social processes; (3) knowledge and social action are inseparable; (4) skepticism toward taken-for-granted ways of understanding the world forms an important part of critical thinking.9 Historians, sociologists, and anthropologists have used social research methods to examine SCC in specific educational settings. In his analysis of the intertwined social constructions of death, the body, and anatomy in nineteenth-century America, historian Michael Sappol emphasizes: “We all have bodies, are bodies, but our vocabulary and grammar of embodiment vary according to location in history and society.”10 Anthropologist Rachel Prentice studies how physicians today come to embody not only the techniques of biomedicine in the anatomy lab (e.g. cutting, suturing) but also uniquely biomedical perceptions, judgments, and ethics. These internal processes, she argues, are constituted by the particular techno-social milieu of medical education and practice, making them accessible to social analysis. “Good doctors are made,” Prentice concludes, “not born.”11 SCC in medical education can serve epistemological, pedagogical, professional and/or ethical objectives.10, 12-20 Most historical studies reveal coercive, discriminatory, racist, and sexist practices that were socially embedded in the selection, acquisition, and usage of human remains for purposes of medical education.21-26* The SCC is widely used today to ensure that future physicians have a strong orientation toward compassionate care and respect for patient autonomy.28 This Viewpoint was inspired by research on the utility of shifting between viewing bodies as objects and as persons in medical education. In the 1950s, sociologist Renée Fox identified this tendency as a coping strategy to deal with the emotional conflict experienced by medical students, including during anatomy education, faced with understanding bodies as human beings versus scientific objects. Fox famously proposed the concept of “detached concern” to account for how physicians are socialized by the entire arc of their medical education to maintain a dynamic balance between the two.29 Extrapolating from Fox's work, many researchers have since shown that the ambiguous tension between objectification and personification produces ethical and conceptual challenges that can interfere with anatomy instruction.30, 31 In her 2013 ethno study, Prentice observes students using this strategy to manage the emotional challenges of “the emergence of personhood” during cadaveric dissection. She describes it as “tactical objectification” and emphasizes the utility of being able to objectify the body or call forth the person, as needed, for physicians.32 In a recent study, Jennifer Burr and Nigel Russell-Sewell examine “how the dead human body is socially produced” through teaching practices in a UK university anatomy lab. Based on interviews with teachers and students, they examined participants' experiences, reflections, and emotional responses during practical cadaveric dissection. Predictably, they found that participants socially constructed cadavers as objects and persons and that they continuously shifted between these perceptions while dissecting and describing their experiences.3 Yet Burr and Russell-Sewell suggested another utility for SCC: that “anatomists learn to normalise the transgressive activity of human dissection” not through detached concern or tactical objectification, but “via processes of reconciliation.” They argue that it is the ethical framework of voluntary body donation, specific to anatomy programs, that facilitates this reconciliation. Constructed as “donors,” bodies for dissection can be viewed ethically and interchangeably as scientific objects (which can legitimately be treated as specimens) and as fellow humans with agency and personhood (whose wishes to be dissected should rightly be honored). Through the relationship between anatomist and donor, which is configured within a network of scientific knowledge, the “transgressive elements” of human dissection are resolved.3 The SCC, therefore, appears inevitable. Furthermore, there is good evidence that medical students quickly learn to toggle conceptually between bodies as objects and persons (whether instinctively and/or by modeling teachers), and that their earliest encounters with this process happen around SCC during anatomy instruction. There is not much evidence, however, to indicate that educators or learners are aware that SCC occurs or how it can influence learning and clinical practice. Frank discussions about SCC could help make its use in ASE visible and thereby amenable to critical reflection. A single 60-min session, when learners are introduced to working with body donors, suffices. Below we describe a discussion framework based on historical and contemporary examples organized into two cases of opposite extremes. The objectifying and personifying tendencies around SCC are evident in historical research: in the nineteenth century, cadavers were objectified as grotesquely inhuman, and in the late twentieth century, they were reconceptualized as donors, patients, and teachers.1 Discussion facilitators are encouraged to invite students to compare these two very different examples of SCC—dehumanizing (objectification) and humanizing (personification). Extreme cases were deliberately chosen to make the tacit practice of SCC more apparent and the difficult concept of social constructionism more accessible. Facilitators can share each recommended learning resource with students at the start of the discussion and use the discussion points for each case below to structure discussions and instigate critical reflection on the uses of SCC in ASE. More details and insights can be found in additional references cited throughout. Many historians have examined how nineteenth-century medical schools and students used and misused human remains in pursuit of scientific knowledge and professional status.10, 12-14, 16 For this case, facilitators and students should rely on Dissection: Photographs of a Rite of Passage in American Medicine by John Harley Warner and James Edmonson.33 In their graphic visual history of human dissection in North American medical schools (so graphic that some facilitators may decide to provide learners with a “trigger warning”), Warner and Edmonson explain why medical students routinely staged class portraits with cadavers. A common practice until the 1920s, students not only photographed cadavers on the dissection table—they propped up and posed the bodies. Over one hundred photographs give the impression that many students relished posing with decomposing bodies (there were no effective preservation methods in this period). Medical students at women's and Black medical colleges also photographed themselves with their cadavers (these groups were barred from “mainstream” medical schools, so they opened their own). Some scenes are serious, staged to show off students' new medical knowledge and skills by displaying anatomy books, saws, and scalpels alongside the cadaver they are dissecting. Others depict cadavers sitting or standing, smoking cigarettes and playing cards with the medical students, or dressed in costumes. These physicians-in-training physically manipulated and visually ridiculed the cadavers, treating them as trophies and stage props, not merely as scientific objects. Photographing this dehumanization was a powerful way to demonstrate their control over and comfort with the decomposing bodies.34 This photographic record shows how medical educators and students in the nineteenth century constructed cadavers as inhuman. What is perceived today as disrespectful and callous, however, had multiple social utilities. Foremost, these dehumanizing constructs upheld the racism of white superiority that dominated North American societies. In the dissection photographs, most dissectors are men of European ancestry, and a large proportion of the dissected individuals are of African ancestry. Warner and Edmonson emphasize that “the power relations and violence ring clear” in how the medical students represent themselves, and the authors draw our attention to similarities with photographs of lynchings in the same period.35 Within the context of medicine, notions of dehumanized cadavers served several purposes. By the middle of the nineteenth century, anatomical pathology was the core of medical training. Human dissection was the gateway to specialized scientific knowledge considered the exclusive domain of physicians. Medical schools needed a constant supply of cadavers. It was a time before voluntary donation programs, when an intact body still played a vital role in many families' death rituals and people feared what medical students reportedly did to dead bodies. Medical schools regularly purchased bodies from those who supplied them by stealing human remains from cemeteries (which threatened all social groups) or by murdering individuals (overwhelmingly from poor, criminalized and racialized communities). One utility of dehumanizing cadavers, therefore, as Sappol shows, was institutional: it enabled anatomists to rationalize an otherwise disturbing economy of dead human bodies considered necessary for medical education.21 The SCC as “unhuman” also served a professional purpose commemorated in the morbid class portraits. Once a medical student overcame the unnerving experience of human dissection, they were considered to be of sufficiently strong “character” to become a moral and scientific physician. This demonstration of control over fear and disgust when faced with decaying bodies confirmed a student's readiness to enter the profession of medicine. In an era without infection control or many effective cures, managing bodily decay (abscesses, necrosis) and death was the mainstay of medical practice.16, 36 In order to provide effective and compassionate care, according to nineteenth-century perceptions, medical training encouraged doctors to respond impassively—the equanimity famously espoused by the influential academic physician William Osler.37 In this way, the dehumanizing constructions that medical students tacitly learned during anatomy training fulfilled a clinical utility. Warner and resource a with all the facilitators to and critical discussions of with these photographs, the authors as to critical of what students to describe as an activity that and very of the could also helpful to facilitators and The case the emergence of humanizing SCC in medical education, and using two examples from medical education programs around the world human remains used for dissection as This new emerged to serve new pedagogical The concept of donation had from in and which bodily by increasing of and As a to cadaver result of for human remains and other social many medical schools voluntary body donation The by Warner and Edmonson describes how this shift from bodies to donation to the experience of human dissection and the relationship between and The of is accepted in ASE today because it the dissected and It can help cultivate critical therefore, to encourage students to consider why more humanizing constructs also into the of the twentieth century, medical educators introduced the SCC as “teachers” and to for what they viewed as the harmful of a dehumanizing in medical education that with equanimity and with Fox's detached By the and that physicians to their were which was perceived as and medical educators the of emotional and viewed the of empathy as a humanizing SCC emerged to serve these new pedagogical in use the most are and In of dissection experiences, some physicians how they perceived their cadavers as a or Discussion facilitators can students with the following two examples from that the of cadavers, from objectified bodies to served as part of the difficult processes in the as and scientists had bodies used for anatomy education were who in people in and or These individuals were often and chosen for dissection. In the as was some physicians were to These doctors the to bodies from the to They also that could decide to to dissection. shows, “the history of anatomy education and the ways in which bodies have used in society the of relationships and the of The SCC as “teachers” played a role in these processes of which hierarchies and for A example facilitates discussion of another practice of SCC that could be viewed as could students they with this In the the organized the to encourage people in to their bodily remains to anatomy education In the ASE at the of Medicine new anatomy lab and rituals to the SCC as in to Facilitators can share with students the by and which a and of these dissection class by body with and of most North American programs, the to relationships between body and students. For the is the dissection serve as a constant of the human the of students and also with during dissection and at a the of the students about their of dissection, which are to their “teachers” along with and of upon their students that they had a relationship in with both the and the Medical students are for using their skills to the remains to a for the death and they in those as the the remains are to in the on the medical to several these anatomical and practices are for students to with in and develop and The students at this medical are encouraged to relationships with and their which is why this of SCC is as donation programs, North American medical schools are also with on dissection experiences, including to body donors. In one small study, all student participants toward their donors. One identified the as his the student his relationship with all future the as a and “not and a the pedagogical of acknowledging a body as or by including these as core teaching in The social utility of humanizing dissected bodies in these ways to a practice of treating and their bodies with empathy and Some medical educators however, that there is a in encouraging medical students to cadavers as the of objects and persons in the anatomy lab could them to as they more compassionate clinical In students could on it be to take humanizing constructs with these examples, facilitators are to students (1) to on the functions of social constructs and (2) to compare various forms of SCC and how they can serve and/or educational there are as many as there are human dissection programs This is because social constructs are always specific to their particular and because they can along multiple of racist, and/or In some particular are In the nineteenth-century North American the racism with new educational and professional in to the SCC as inhuman. In the example from the of a teacher was in the case of of meaning is a to shared understandings in the relationship is a of and emotional as as knowledge and In each case, the social utility of SCC was useful to medical training we may or some of those social functions of on SCC as a pedagogical anatomy teachers and learners are encouraged to in critical reflection about the nature of its social utility to both anatomy and medicine. The SCC is in culturally medical schools playing a role in how those programs ethical and professional values to physicians in training. were because they represent extremes of SCC that invite students to and critically on the In critical can about teaching and to Critical learners deal with and their and with ethical and professional critical around SCC suggests two it medical students that bodies as and bodies as fellow humans are both social constructs that to physicians to scientific and compassionate they develop this in the anatomy we are that physicians will it with them into the and they because social constructs influence how individuals themselves and and how societies justify and we all benefit from physicians who are able to and their social functions and and and This research was by and the of in Medical Education in the of Medicine at the of The authors no of is an anatomy and She with an from the Anatomical Sciences Education of Medicine of is an historian of and the in of Medicine at of by
Ehsan et al. (Sun,) studied this question.