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Interim Report: Removal and retention of human material
Annex B: Law and Guidelines
Introduction
The meaning of 'post-mortem'
The 'removal' and 'retention' of tissue - an
overview
'Organ' and 'tissue'
Short-term and long-term retention of tissue
Removal and short-term retention
Longer-term retention
- Black's Medical Dictionary [1]
defines a post-mortem examination [2]
as 'an examination of a body to determine the causes of death ...' There
is no statutory definition of what constitutes a post-mortem examination.
[3]
The 'removal' and 'retention' of tissue - an overview
- Several statutes regulate different aspects of the removal and retention
of tissue. The key Acts are the Human Tissue Act 1961 [the '1961 Act'],
the Anatomy Act 1984 [the '1984 Act'], the Coroners Act 1988
[4] as amended [the '1988 Act']
and The Human Organ Transplants Act 1989 [the '1989 Act']. The relevant
aspects of these statutes are considered below.
'Organ' and 'tissue'
- The 1961 Act, the 1984 Act and the Regulations made under the 1984 Act, all refer to 'bodies' or 'parts of bodies' but do not define either organs or tissue. The 1989 Act defines organ [5] as 'any part of a human body consisting of a structured arrangement of tissues which, if wholly removed, cannot be replicated by the body'. The 1988 Act does not refer to parts of a body, but Rule 9 of the 1984 Coroners Rules ('the 1984 Rules') which provides for the retention of parts of the body at a Coroner's post-mortem examination refers to the 'preservation of material' which may bear upon the cause of death.
- Black's Medical Dictionary defines tissue as 'The simple elements from which the various parts and organs are found to be built ... It is customary to divide the tissues into five groups: epithelial tissues, connective tissues, muscular tissues, nervous tissues and wandering corpuscles of the blood and lymph' and defines organ as: 'A collection of different tissues that form a distinct structure in the body with a particular function or functions...[for example] the kidneys, brain and heart.'
- The report of the Nuffield Council on Bioethics, 'Human Tissue Ethical and Legal Issues' [the 'Nuffield Council report'] [6] took the term tissue to comprise: 'Organs, parts of organs, cells and tissue, sub-cellular structures and cell products, blood, gametes [sperms and ova], embryos and fetal tissue.'
- In this Report, we use a more general term, 'human material', which
is intended to avoid confusion between tissue in the sense of samples,
blocks and specimens, on the one hand, and organs, or parts of organs
or material such as amputated limbs. In this Annex, however, because
the various Acts refer to tissue or organs, we use the word tissue,
in its wide sense (i.e. including organs), so as to examine the law.
Short-term and long-term retention of tissue
- It is important, at the outset, to distinguish tissue which, once
removed, is subsequently reunited with the body for burial or cremation
from that which, once removed, is:
- retained for a short period after burial or cremation of the body and disposed of separately;
- retained long term.
- The Inquiry heard evidence on standard practice in relation to post-mortem
examinations and why, in certain circumstances, it was not thought possible
to carry out the necessary investigations into the cause of death and
return tissue to the body in time for burial or cremation.
[7]
Removal and short-term retention
- Professor Green [8] advised that the view of the Royal College of Pathologists was that no post-mortem examination was complete without microscopic examination of a representative small piece of tissue from every major organ. [9] There were many circumstances when it was difficult, impossible or unsatisfactory to examine an organ immediately it had been removed from the body. In relation to the examination of the heart of a neonate 'It is often necessary... to inject the blood vessels of the heart ... to cut serial sections, as many as 300, through the so-called "conducting bundle" and this can only be done on fixed tissues. To fix a heart in formalin takes 10 days.' [10]
- In relation to the practice of examining tissue in addition to the heart, Professor Green continued, 'a goodly percentage of congenital heart disease is in fact not confined to the heart. There are associated abnormalities of the vessels which run between the heart and the lungs and also the aorta, the main blood vessel ... it was desperately important to take the thoracic organs en bloc, fix them, recolour them and then look at them with the aid of magnifying spectacles, television camera, dissected against a clean and bloodless background, and ... it takes 10 days to do it properly and you would delay the funeral for 10 days if you returned the organs to the body.' [11]
- Professor Berry [12]
advised: 'Examination of hearts after surgery for congenital heart disease
often involves some of the most difficult dissection pathologists encounter.
It was often our practice to perfuse the heart with preservative under
pressure for several hours to restore its contours in life, and to carry
out much of this dissection after the post-mortem examination of the
body itself. Lung tissue was sometimes retained, either to maintain
the relationship between the heart and lungs where there were congenital
abnormalities of the connections of important vessels, or because they
might show microscopic evidence of pulmonary hypertension (raised blood
pressure in the lungs) contributing to death. Other tissues were sampled
for microscopy to document any other disease process according to good
practice.' [13]
Longer-term retention
- As to longer-term retention, the Inquiry heard evidence from Professor Robert Anderson [14] regarding the benefits of retention of hearts for study and teaching purposes. He considered that one of the many reasons for improvements in mortality in centres of excellence for cardiac surgery was the knowledge that had accrued from the study of retained hearts. [15] He gave evidence as to the scale of the retention of congenitally malformed hearts in this country. [16] He estimated that the largest collection was at Alder Hey Children's Hospital with approximately 2,500 hearts; he had built up a collection at the Royal Brompton Hospital of some 2,000; and there were collections at Great Ormond Street of 2,000, at Birmingham Children's Hospital of about 1,500 and other, smaller collections, in Leeds, Bristol, Southampton, Newcastle and Manchester.
- Professor Anderson explained that in the case of a congenitally malformed heart it was necessary to retain the whole organ in order to study and demonstrate it.' [17] 'In the case of a heart, no two organs are ever identical, and for proper study, it is essential to retain the entire organ.' [18]
The meaning of 'post-mortem'
Footnotes
1 39th Edition [Return to text]
2 Or 'autopsy' [Return to text]
3 Although Rule 10(1) and Schedule 2, Coroners Rules 1984 prescribe a form for the pathologist to report the results of a post-mortem to the coroner, see WIT 43 60-61 [Return to text]
4 This Act consolidated the Coroners Act 1887 and the Coroners (Amendment) Act 1926 [Return to text]
5 Section 7(2) [Return to text]
6 April 1995 [Return to text]
7 See Report [Return to text]
8 Michael Alan Green, Emeritus Professor of Forensic Pathology, University of Sheffield, Consultant Pathologist to the Home Office, WIT 54, T 42 [Return to text]
9 See also RCPath 1/74 [Return to text]
10 WIT 54 T42 [Return to text]
11 T42 p. 47-55 [Return to text]
12 (Peter) Jem Berry, Professor of Paediatric Pathology at the University of Bristol, and Consultant Paediatric Pathologist at the Bristol Royal Hospital for Sick Children, WIT 204/5 para 12 [Return to text]
13 WIT 204/8 and 9, para 26 [Return to text]
14 Robert H Anderson, Joseph Levy Foundation Professor of Paediatric Cardiac Morphology, University College London, President elect of the British Paediatric Cardiac Association, T45 [Return to text]
15 His letter to the Inquiry of 25 January 2000, WIT 546/1-2 [Return to text]
16 T45 p. 104-106 [Return to text]
17 T45 p. 108. [Return to text]
18 WIT 546/2. [Return to text]