Should virtual anatomy replace time spent with body donors? Ethical considerations from a student's perspective

Donor ‘A’ had a large hepatic mass and appeared thin, pallid, and worn down—except for her fingernails, which were painted a flawless bubblegum pink. There were no chips or smudges, and her nails had not grown out even a millimeter. Did she paint them in anticipation of her death, one final act of self-care? Did someone else paint them for her? Who held her hand in her final days? Questions like these cross my mind frequently in the anatomy laboratory, though medical students may find themselves asking them less often than in prior generations. Many medical schools have moved away from long hours of dissection, dedicating more curricular time to other disciplines and augmenting hands-on experiences with digital anatomical resources.1 These modalities include digital anatomical libraries, interactive virtual reality (VR), and generative artificial intelligence (AI), the latter of which could eventually create highly sophisticated simulations incorporating realistic tissue physics, accurate force feedback, natural variations, and complex pathologies.2 Although these technological advances offer promising educational opportunities, I argue that they cannot—and should not—replace the experience of learning from human body donors. The integration of digital resources raises critical ethical questions while potentially undermining essential aspects of medical education that can only be achieved through direct engagement with donated human bodies. Interactive three-dimensional study tools have enhanced my understanding of structures that are otherwise difficult to visualize in donors or in two-dimensional drawings. I can twist, turn, zoom, and scroll through structures with ease from anywhere with an internet connection (without the hassle of gloves, scrubs, or eye protection). Digital resources also offer significant practical advantages, particularly in democratizing anatomy education by making high-quality, donor-derived images and simulations available in rural or low-resource settings.2-4 The use of these technologies in contemporary anatomy curricula is an active area of study and warrants further attention.5-9 Though accessible and visually appealing, these digital resources hardly resemble the anatomy I encounter in the operating room, where patients' arteries and veins are neither neatly color-coded nor symmetrical. Even the most sophisticated AI simulation cannot capture the full complexity of human anatomical variation, pathology, and the unpredictable nature of real surgical encounters. In addition to concerns about accessibility and accuracy, the integration of digital anatomy resources also raises several important ethical concerns, beginning with questions about consent, autonomy, representation, and provenance of data derived from human bodies. If the donor with the large hepatic mass donates her whole body to a medical school, does she also consent to having her liver made into a VR module, even if the final product is fully anonymous? Does she consent to having that resource sold and distributed to other institutions at a profit? The International Federation of Associations of Anatomists (IFAA) recently released updated guidelines regarding the ethical use of anatomical images, calling for more specific consent practices if images are to be used in any potentially identifiable way or for commercial use,10 meaning consent practices will need to evolve as digital resources become more established and widely used. The use of digital anatomical resources usually relies on preexisting datasets, which may not represent the diversity of human anatomy adequately. Donors are disproportionately White,11 and it is therefore reasonable to worry that digital resources derived from donated bodies would underrepresent marginalized populations. This underrepresentation can impact students' learning and clinical practice, leading to potential biases in understanding anatomical differences across various populations.7 It is worth noting that hands-on experience with the human body is not immune to these challenges; the anatomy laboratory can raise feelings of anxiety, distress, and cultural or religious conflicts, especially for students from diverse backgrounds.12 These potential harms underscore the importance of implementing inclusive practices and providing appropriate support systems when maintaining body donor programs. The ethical discourse surrounding digital anatomical education must address not only emerging technological concerns but also, critically, the profound implications of the learners' diminished exposure to the anatomy laboratory. Medical students often consider their donor their “first patient,” and important lessons in empathy, respect, and humanism necessarily follow.13, 14 For many learners, like me, working with donors is their first up-close encounter with death and dying, grounding them in the complex emotional and moral demands of being a physician. When I first entered the anatomy laboratory, I was shocked by its cold, pungent stillness and in awe of the donors' gift to our education. Abstract knowledge of anatomy and physiology turned into a sacred responsibility—to our donors now, and soon to patients of our own. In addition to gaining familiarity with real surgical instruments, the anatomy laboratory provides irreplaceable tactile knowledge that cannot be replicated digitally. Students learn to distinguish between different tissue textures, understand spatial relationships through physical manipulation, recognize patterns and variations, and develop the manual dexterity essential for clinical procedures. I remember well my first time dissecting the saphenous vein; I tore it in two places before I recognized just how fragile it is in comparison to the nearby femoral artery. Later during my clinical rotations, having felt the walls of arteries and veins with my own hands, I understood when a surgeon described to me why he so feared injuring a large, difficult-to-repair vein (and why the thicker walls of arteries offer better structural support for sutures). Some medical schools have intentionally incorporated procedural skills into their anatomy curriculum, improving student performance and increasing student confidence on the wards.14, 15 Medicine, at its core, represents an intimate human-to-human connection that transcends technological advancement. Although digital anatomical resources offer valuable learning tools, they cannot fully replicate the educational experience of studying the human body in its authentic form. The relationship between digital resources and traditional anatomical study parallels that between standardized clinical examinations (OSCEs) and actual patient care: both serve as valuable pedagogical tools but cannot capture the full complexity of human experience. A standardized patient portraying acute cholecystitis, for example, can demonstrate textbook symptoms, but cannot embody the genuine distress, ambiguity, and unpredictability that characterize real clinical presentations. An AI simulation does not actually feel right upper quadrant pain. Our donors' bodies tell unscripted stories of lived experience—of pain endured, adaptations made, and lives fully lived. The adoption of digital-only anatomy education raises important questions about educational equity. At institutions with limited funding or access to human body donations, digital tools can bridge the gap, providing students with valuable learning experiences without the substantial ethical challenges and operational demands—including facility maintenance, specialized staff, and preservation infrastructure—traditionally associated with the maintenance of a body donation program. This may be particularly important on a global scale. Reliance on digital resources, however, should be approached with caution. If low-resource or rural medical schools adopt digital-only study of anatomy, their students lose in-person exposure to donors, potentially disadvantaging them in their understanding of human anatomy, clinical skills development, and lessons in empathy and professionalism. High-resource medical schools are more likely to integrate useful digital technologies alongside existing anatomical gift programs, embracing the efficiency and engaging nature of new resources while also giving students the opportunity to learn directly from donors. The adoption of digital resources could therefore exacerbate existing inequities in anatomy education. It is also worth noting that even high-resource institutions are not immune from the ethical challenges inherent to working with human remains, as evidenced by recent mishandling of donated bodies at Harvard Medical School.15 Rather than viewing digital and traditional anatomy education as competing approaches, medical schools should pursue thoughtful integration that maximizes the benefits of both modalities while addressing their respective limitations. An important first step is for medical schools to protect and maintain time in the anatomy laboratory for preclinical students, and they should avoid the temptation to shutter their anatomical gift programs in favor of promising new technologies. Instead, they should invest in the programs to ensure that donors are obtained and treated appropriately. The study of anatomy should continue across the medical training continuum, including surgical skills workshops with the donors, elective courses involving dissection and mock surgeries for third- and fourth-year students,16 and opportunities for affiliated residents to teach medical students in the anatomy laboratory. Interinstitutional collaborations should bring students from rural, low-resource, or international medical schools into the laboratory space, especially if those students otherwise learn anatomy exclusively through digital means. By maximizing the educational potential of each anatomical gift, institutions honor donors' intentions while addressing broader challenges in anatomical education access. This approach requires careful consideration of consent processes, equitable resource distribution, and ongoing evaluation of educational outcomes. I paint my nails while I talk on the phone with my parents, or before my basketball teammate's wedding, or because I just like the way it feels to wear Pink Flamenco polish. Our donor's painted fingernails—and her scars, wrinkles, and tattoos—offer glimpses into the stories of her life and assert her dignity. They inspire me to take great care with every incision and retraction, while knowing that mistakes made in earnest remain an inevitable and necessary part of my learning. Dissection has given me confidence that one day I will be able to perform procedures well enough to help someone whose story is still unfolding. No medical student should go without the opportunity to experience that most profound gift. Ellery Koelker-Wolfe: Writing – original draft; writing – review and editing; conceptualization; investigation.