A parting gift

BY CLIVE COPEMAN

WHEN THE terminally ill Ian mumbles his way through his last interview it's hard not to feel sympathetic.

After a long bout of kidney disease, Ian received a transplant in his 20s. Then came a heart attack and bypass surgery. Now in his 50s, he's undergoing treatment for cancer of the tonsils and this time the writing's on the wall. The expression in Ian's bullseye-blue eyes tell you he's endured much at the hands of doctors, but there's more to come. A lot more. Ian has decided to donate his body to science.

More precisely, Ian has bequeathed his body to Otago University's School of Medical Sciences, a parting gift to the system that has done so much for him over the years: "Go for it, folks... hope you can learn something from this old body of mine."

An unreformed smoker, Ian admits to no fear or regrets about the way he has lived, but he does confess to a curiosity about the fate of his body after death. The look in those eyes makes it feel like a last wish for some kind of afterlife: "... to follow it through after my demise... to answer some of those questions I've asked myself over the years..."

What exactly happens when someone donates their body to science? It's not just a question facing Ian and other donors. For years, it's what many New Zealand donor families were left wondering and it's the subject of Dr Paul Trotman's latest television documentary.

"I just had this idea that it would be great to make a film where we were able to follow a group of people donating their bodies," says Trotman, a South Island GP and Sunday Star-Times columnist, who answers reader questions in the Escape section. "To interview them when they're alive, and follow them through the whole process."

Trotman's documentary, Donated to Science, is a journey of caskets and body bags, through the halls of Otago medical school and into its dissecting room. It's as revealing a film as you can make without descending to grave-robbing voyeurism. Trotman reveals not just the fate of the dead, but the growing relationship between the donors and the anatomy students who gradually dismantle them.

It's a profound experience in the making of Otago's young doctors, and a difficult one for many, as Trotman confesses. "I was one of the medical students that didn't like doing dissection at all ... I just scraped through by the skin of my teeth."

BASED IN Port Chalmers, Trotman commutes to work at Gore Hospital when not making documentaries or writing for journals under the title of Doctor Know. After two medical series and a film on the Elephant Man's DNA for Discovery Channel, this is the second documentary produced by his PRN films (PRN is medical Latin for "Take as required"). On top of the usual obstacle course facing Kiwi documentary makers – cajoling broadcasters, distributors and funders – he also had to convince medical authorities, donors and students that this was a project worth backing.

The idea of filming human dissections faced a mountain-range of sensitivity issues. "I thought, I haven't got a chance in hell of getting to make that film." But Trotman's first approach to the Otago School of Medicine was perfectly timed. Dean of the Otago School of Medical Sciences, Professor Helen Nicholson, arrived in Dunedin in 2000 after studying and working in the UK. There it was normal for medical schools to invite donor families or medical students to some kind of memorial or thanksgiving service. When she arrived to lead the Department of Anatomy and Structural Biology, there was no such acknowledgement of the donors' act of generosity.

In 2004 she oversaw the department's first thanksgiving service for donor families, medical students and staff to attend. When Trotman's approach came in 2005, she had been hearing from funeral directors in the medical school's catchment area that some donor families still had unresolved questions after loved ones died.

"I was aware that there was a need for people to understand what happened," says Nicholson. "Ignorance breeds myth."

In the film, one relative admits to a fear of entering the anatomy department building lest she see her aunt's remains: "I expected her to be stuffed in a bottle, sort of peering out."

Nicholson hopes the film will provide much needed information about what really happens to donor bodies.

DONATING YOUR body to Otago's medical school isn't as simple as leaving your intentions in a will. So that the body can be retrieved and embalmed without delay, donors must be within certain catchment areas of the South Island: Balclutha to Oamaru, Timaru to Cheviot and Blenheim to Takaka. The anatomy department receives inquiries from about 200 potential donors a year, 75% of whom actually go through with the paperwork. The bequest must be registered with the medical school well before death, and, even when these requirements have been fulfilled, donors may still not make it to the dissecting table: A body weight over 90kg, organs taken for transplantation or just a spell of OE in the 1980s can rule you out. Even if you do satisfy all the acceptance conditions, the bequest programme may be out of storage space for the year and accept no more bodies. Family also have the right to veto your donation.

The full university and medical school permission process took Trotman about a year to navigate. Once he had the go-ahead and funding, it was a matter of contacting members of the donor list to see who would be willing to be in the film.

George and Ian (last names withheld to give their families a small degree of anonymity) were among those who agreed and both already had terminal cancer. Trotman interviewed them in 2006, and, after their deaths, began filming their final journeys in 2007.

For the film's opening, Scarfies director of photography Stephen Downes follows the transportation of George's body, its embalming and preparation, ending on a tender tracking shot of the body lying – as if in state – on a gurney. It could be the hills in a Grahame Sydney landscape. It's the last time we'll see George whole. His next appearance will be in the dissecting room.

If you think that might be hard to watch, spare a thought for George's nearest and dearest. George's decision to donate his body came as no great surprise to his family, but son Tim was unhappy about the idea of him appearing – and piece by piece, disappearing – in Trotman's documentary. When the cinema-length version of the film screened for family members earlier this year, Tim admits, "I went along to watch it basically looking for a fight... it was just a dreadful thought."

While the film delivered on some of Tim's expectations, it also served up some surprises. "Oddly enough, one of the bits that got me the most was at the very beginning ... that was Dad's head having its hair shaved off."

By the end of the film, Tim's attitude had changed. "We were completely turned around from being pretty bloody anti, to being so very, very proud that dad had a part in it."

Much as Donated To Science is about the dismantling of donors, it's also about the making of doctors. Rather than being a grisly guide to dissection, Trotman's film charts the strange, subtle relationship that grows between the donor bodies and the students that practise on them. Most are in their second year of university, just 19 years old. At the start of the film they almost glow with a sense of mission: professional, humane or heroic. That youth and all the possibilities it holds is about to confront the certainty and finality of death.

Well before they see a cadaver, Nicholson lectures the class on all the ethics and sensitivity issues surrounding the use of dead human tissue, but nothing can adequately prepare them for the experience. For most, the contents of the dissecting room's grey vinyl body bags is a complete mystery. Says Nicholson: "Once they go through those doors and spend time with the dead, they'll never be quite the same again, and that's the point."

On their first day in the dissecting room, staff lead students up to a gurney in small groups, like grown-ups leading careful toddlers to the ocean shore. Gloved hands unzip the lifeless bag and gently reveal what lies in that deep stillness. Some may already have seen dead family members – either freshly deceased, or after embalming. The Med School preservation process uses the same chemicals, just more thoroughly – cadavers have to keep for two years or more. Gone are the made-for-viewing flesh tones and heavenly repose seen in open caskets. Think Peter Jackson's orcs, and you're closer to the truth. Downes' camera spares viewers that slice of reality. But it's one Nicholson's students must face, sometimes weekly, for two years.

Student Kathryn Foster recalls her first sight of Ian's body. "As soon as I saw him I just burst into tears... it didn't really register on any intellectual level, it was devastating to see him lying there. I lost it in about 10 seconds."

The film follows Foster and classmates for the next 18 months as they learn to find a balance between professional detachment and human sensitivity. Some seem to find it quickly, and it's not all about coming to terms with death. There's also the thrill of doing real medicine for the first time. The body before them is their first patient. The discovery of Ian's transplanted kidney gives them a mystery to solve, leading them to their first diagnosis.

Why put students through all this, when other Australasian medical schools have adopted other teaching tools? Nicholson points to several reasons: Video and interactive computer demonstrations are all very well, but don't impart vital manual skills. Examining prosected body parts can teach structure, but not how to view the human body as a person.

It's what the donor bodies teach students about live medicine that is so valuable. Students are forced to think about issues of life and death before they see a living patient – or a dying one. As Foster puts it: "It forced you to come up with some coping strategies before it really mattered."

One thing you won't see in Trotman's film is the 10% of donated bodies that are used for research instead of teaching. You might think that after almost 300 years' study, there's not much left to know about human anatomy, but Nicholson says there are still gaps in our understanding. As surgery becomes more technical, more detailed knowledge is necessary and even common ailments are being rethought in light of new work done on donor tissue.

One Otago study is finding that a source of common hip pain in middle-aged women may not be due to inflammation of the hip's natural cushioning as previously thought, but changes in the major muscles nearby. As we learn more about the site and cause of this common form of pain, better treatments will become possible.

Towards the end of the film, Trotman's students watch the interviews he conducted with the donors. Their common reaction is an overwhelming sense of gratitude for the priceless learning material and the emotional journey it has taken them on. For some, there's even something like survivor's guilt. One fights back tears as she confesses to being judgmental about Ian's continued smoking after he received his kidney transplant. Foster weeps for her part in what she calls Ian's destruction: "... and the worst part is that it's what he wanted... he just wanted us to learn."

It's good to see that this is the kind of stuff our young doctors are made of. It's what changed Tim's mind about Donated To Science. "It was just so well done and so worthwhile and so dignified... Just the sheer goodness of the students overall, just the sheer humility... these were nice, good people, and that was the making of it."

Practising medicine in Gore, Trotman examines patients and tries to envisage what's going on inside. Most often, it's the limbs, organs and structures he dissected in Dunedin that come to mind. It's something you'll hear other Otago graduates echo. George's strong heart and the architecture of Ian's neck will serve and persist long after their life, death and deconstruction. For them and their fellow donors, Donated To Science shows there really can be some kind of afterlife.

Donated To Science screens on TV3 on Wednesday, November 18, at 9.30pm.

- © Fairfax NZ News