Viewability Part 2: Dignity as a determinant of treatment and local practice?

Imogen Jones and Gemma Norburn

In the first of what now looks to be a series of posts on the topic of ‘viewability’, I explored the way in which viewability had been constructed as a dignity issue involving the right to family life. This highlighted the scope for interpretation and local differences in practice and standards. At the end of that post I posed four questions:

  • The HTA require ‘sufficient’ freezer (as opposed to refrigerator) storage to facilitate storage, but what if this isn’t available. Contingency additional storage solutions typically offer refrigeration only.
  • How does this map onto periods of excess death, or indeed disaster? And what of the role of others involved in death care i.e. if the funeral directors also don’t have capacity and so refuse to collect the dead?
  • Who makes the decision about whether a body is viewable and what are the consequences of this?
  • How does appearance map onto dignity, and does context affect this?

On reflection, they are some big questions and we can only begin to scratch the surface here. Part 2 is going to focus on the last two bullet points, and at some point in the future there will be a part 3 on what I am currently terming ‘The economies of viewability’.

This blog has been produced in collaboration with a wonderful APT named Gemma Norburn, who’s thoughtful engagement with me and my work demonstrates how much those in this profession have to bring to the issues. You can find her personal blog here:

What is dignity anyway?

Just reading this title will, no doubt, make the bioethicists snort. Without getting distracted by the extensive academic debates, we’re going to posit that dignity is a device which is useful to explain and ground an emotion (a bit like love maybe). Devices like this can be useful to ground legal rights in (such as human rights) but it is not possible to reduce them to some scientific objective standard. Because of this subjectivity and in the context of the treatment of the deceased body, what dignity mean differs widely in each establishment. Some establishments may therefore align dignified treatment with basics (not naked and clean) whereas others may require more in depth ways of demonstrating this (for example, focus on peaceful appearances via procedures such as asking nurses to close a patient’s mouth shortly after death).

When, as was often the case in Imogen’s interviews with APTs, the issue of dignity arose, probing APTs about what this meant resulted in tying dignified treatment to how the APTs would want their own body, or that of someone they love, to be treated. This links to a subjective view of what is important, and treatment is linked to what makes the individual feel comfortable. Against this background, we can also understand that context matters – what is dignified in during an autopsy will be different to what is dignified out of that context. The same people may be dealing with and acting upon the body, but they do so against varying needs. So, dignity is individual, it is emotionally and culturally subjective, and it is context specific.

Restricting viewings

As we move out of pandemic measures, we can also usefully reflect on the impact of restrictions on viewings. One thing that many APTs feel is a duty to care for the deceased person, and the bereaved, via the dignified treatment of the body. Yet, during COVID19, the ability for viewings to be facilitated within mortuaries was  disrupted by both the practicalities posed by the number of deaths and the legal restrictions on interactions within closed spaces. Under these conditions, the ability for APTs/medics to view each deceased person as an individual was arguably impeded because the time was not available for there to be care beyond ensuring a refrigerated space for each deceased. Moreover sometimes the deceased would be in the mortuary for no longer than a day before being transferred to another location where there was better capacity to store the body. They never, in short, got to ‘know’ the deceased. For many APTs, Gemma included, depersonalisation felt undignified, particularly when some families would later question why their loved one was sent and others would be very accepting that it was just a need of the time. Thus, dignity can be about emotion and connection – we want to be viewed as individuals with independent worth, and if our ability to acknowledge that is removed, then this can feel undignified to those tasked with dealing with the dead.

Who decides?

As was noted in the Brennan decision, different mortuary managers (and indeed APTs, funeral directors, and the bereaved) will have varying opinions on when a body is viewable. This not only extends to the physical body, but also to what a viewing is. Again, we therefore see massive variance in local practice, with all the associated implications for those operalisationalising and experiencing it. In Gemma’s experience, even within a single mortuary, the decision can, and has, been taking by a range of people. These include Family Liaison Officers and Coroner’s Officers. In some establishments, viewings may be organised by a Bereavement Team or MEO Team. These teams may, in turn, be located and work closely with the mortuary, or may be separated.

A further layer to this is what viewing actually is. There seems to be an assumption in Brennan that a body is only viewable if the whole thing can be seen, but this is often not the case. For example, bodies may arrive at the mortuary in a fragmented condition or already in a state of decomposition. That does not mean that viewing can’t take place, but instead that what we understand viewing to be might be modified. To quote one of Imogen’s interviewees:

One thing that I like to do when I am setting up viewings as well is I like to look at their hands, and if the deceased has nice hands, there is not a lot of bruising or anything, I like to put them out, outside of the shroud, because normally we have picture like a duvet and someone’s arms by the side and the duvet goes across the body, covering the arms.  But, if their hands are nice, I like to bring them out, because I have noticed a lot of times families will go straight for hands, and like to put their hands on the hands.’

Furthermore, if there is to be an autopsy, to preserve evidence, prior to this the bereaved will not be allowed physical access to the deceased person. I was reminded of this in the tweet by Antonia Rolls whose son recently took his life. She reflected that ‘Today I sat with Costya in the morgue. He is behind a screen until his postmortem. I can come back after that without a screen. He’s so peaceful & beautiful.’ (see: AntoniaRollsTweet). It is clear from the accompanying image that Costya is visible but, other than his head, is covered by a sheet. There is a glass screen allowing Antonia to see into the viewing room.

The point here is that there are many reasons why bodies may not be viewable in their entirety (and, indeed, for them to be presented in that way could be considered undignified) but that does not mean that meaningful viewing cannot be facilitated. The key then may be managing expectations, explaining what will be experienced to those viewing the body. It is not our primary function here but of course this requires not only understanding of the condition of the body but also involves a vast amount of emotional labour. That’s another massive topic that cannot be dealt with here but it is important to note the impact this may have on decisions re whether to facilitate viewings.

It is clear that viewings are complicated and that can be very daunting for trainee and established APTs. The bereaved can be angry, violent even, and that is directed at the person carrying out the viewing. That places enormous pressure to ‘get it right’ when it’s impossible to know what that is for each person. We return then to the idea that a dignified viewing is as much about individuals and feelings as it is a particular state or presentation of the body.

Who’s dignity anyway?

Whenever we talk about the treatment and interests of the deceased, we are forced to think about whether it is really the deceased person who we are concerned with. Again, there is considerable academic debate on the rights and/or interests of the dead (see, for example, Jones, Justice article) and we don’t have time or space to engage with that here. It is however important to briefly note that viewability is often in practice about the experience of those doing the viewing. They may wish to see the body presented in what they perceive to be a dignified fashion, just as those who care for the body may want to treat it in a dignified way. But the actual beneficiaries of these enactments of dignity are the bereaved or the professionals. In summary, the viewing facility, the set up and the presentation of the deceased, allows for a dignified viewing which is much more in the interest of the bereaved than it is for the deceased. Not dissimilar to how they say funerals are for the living.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s