LAUSR

We read with great interest the letter by Prof. Winkelmann on behalf of the Federative International Committee for Ethics and Medical Humanities (FICEM) of the International Federation of Associations of Anatomists (IFAA). Prof. Winkelmann raises important issues about anatomical research ethics and we sincerely appreciate his feedback. We feel it is important to address the issues raised and provide some explanations and suggestions as we seek an international consensus on reporting of anatomical studies. First, we would like to clarify that the Anatomical Quality Assurance (AQUA) Checklist (Tomaszewski et al., 2017) comprises only reporting guidelines, not replacements for journalspecific or any applicable ethics guidelines. The AQUA Steering Committee strongly supports the IFAA’s “Recommendations of good practice for the donation and study of human bodies and tissues for anatomical examination” (International Federation of Associations of Anatomists, 2012). However, in contrast to the Helsinki Declaration, which places ultimate responsibility on the individual researcher, the IFAA’s recommendations place primary responsibility on the institution (i.e., university, medical school or anatomy department). As individual researchers often have little influence over their institutions’ policies or their countries’ laws, we feel that specific endorsement of these recommendations on the Checklist could discourage some researchers from using it. This would be counterproductive to the primary objective of the AQUA Checklist, which is to enhance the overall quality and clarity of reporting of all anatomical research, including with respect to ethics. The greatest challenge in developing the AQUA Checklist was to generate a checklist that could be employed universally for all types of anatomical research. In the letter, it is suggested that several items proposed in Winkelmann et al. (2016) should be incorporated into the Checklist. However, many of these items are, in essence, already included: “What are the biological characteristics of the specimens (sex, age at death, preservation method)? (item 8); “Was there written consent of donors during their lifetime?” (item 16); “Which institution provided the specimens?” (item 6); “What was the legal/ethical basis for the availability of specimens (e.g., local laws or guidelines, approval by review boards)?” (item 16). Of course, the wording of such items is not specific to cadaveric studies or any specific form of research, but is written to encapsulate all anatomical methodologies. Moreover, although we include an Acknowledgments item (item 27), we provide only descriptions (as we do for all items), considering it inappropriate in the Checklist itself to provide specific suggestions about whom authors should acknowledge. We believe this is beyond the scope of reporting guidelines. Irrespective of the above, the AQUA Steering Committee is dedicated to improving ethical standards in anatomical research and hopes to collaborate with Prof. Winkelmann and all members of the FICEM of the IFAA to update and improve the items related to ethics. We feel this is of the highest importance and hope to update all ethics-related items to reflect both Prof. Winkelmann’s proposals and the IFAAs recommendations, while promoting the Checklist’s usage in all forms of anatomical research, as well as the role of the researcher. We emphasize that the AQUA Steering Committee does not make unilateral changes to the AQUA Checklist. Like all reporting guidelines, the AQUA Checklist is an evolving document and we welcome participation and encourage all input from the global anatomical community. We hope, as the Checklist comes to be employed in a wide spectrum of anatomical research, to receive plentiful and constructive feedback. After one full year of use, we plan to update it through a large, global Delphi panel. Nonetheless, we fully believe the current version of the Checklist is a major step toward improving the quality of reporting in anatomical studies. In the meantime, we will prepare and publish an explanation and elaboration of the AQUA Checklist expeditiously, with respect to its use in reporting on the ethics of anatomical research. In this manuscript, we will provide detailed explanations with examples and suggestions about all items related to ethical reporting for the most common types of anatomical research methods. This will allow us to address in detail the issues specifically raised by Prof. Winkelmann in respect of body donation and cadaveric research and explain how this should be reported in both the manuscript and the checklists. We sincerely hope to collaborate with Prof. Winkelmann and other members of FICEM of the IFAA on this explanatory document. Finally, we want to address the comment regarding the lack of an ethics domain in the Anatomical Quality Assessment (AQUA) Tool (Henry et al., 2017). During development of the tool, we defined anatomical study “quality” to include “internal validity, strong enough methodological description to allow reproducibility, clarity and consistency in reporting of both study data and anatomical descriptions” (Henry et al., 2017). From this, we built a risk of bias tool to evaluate these characteristics. Although we strongly agree with Prof. Winkelmann that the ethical component is an important