By Cara Swain

‘Live tissue training’ (or LTT) is a term used to describe the use of living anaesthetised animals for medical education purposes. Within surgical specialties, live animals are used for skill acquisition and practice in a variety of surgical techniques, including laparoscopic, endoscopic, robotic, microsurgery as well as traditional ‘open’ surgery. Examples range from using rats to practice micro-anastomoses – the joining of small blood vessels using delicate instruments and a microscope – to the use of pigs for practicing techniques to manage of major bleeding inside the abdomen. The animals are anaesthesised at the outset, and then may be deliberately wounded to reflect diverse types of injuries. Once the training is completed, the intention is to euthanise the animals without them regaining consciousness.

An example of LTT has been seen depicted in popular culture, featuring in Grey’s Anatomy episode ‘Life during Wartime’ (series 5, episode 6). In this episode, US Army trauma surgeon Dr Owen Hunt uses LTT to teach the surgical residents “how to work quickly and efficiently to keep someone alive”. Military use of LTT has drawn significant attention from animal activist groups, including People for the Ethical Treatment of Animals who have campaigned to stop NATO militaries from engaging in it. Several people, including the creator of the hit TV series Homeland, have spoken out against the practice in the media.

However, LTT is not a new practice, and nor is the controversy surrounding it. In 1903, it was alleged that William Bayliss of University College London performed an operation on a live, anaesthetised terrier in front of an audience of medical students. His actions were reported to the National Anti-Vivisection Society and he was accused publicly of breaking the law, although his accuser was subsequently found guilty of defamation. In 1906, animal rights campaigners raised funds to erect a bronze statue of the dog in Battersea, London. Following this, a series of riots occurred, organised by medical and veterinary students who felt strongly that their education had been compromised. Not least due to the requirement for a constant police presence at the statue’s location, the ‘Brown Dog’ memorial was removed in 1910. Although civilian use of LTT has decreased due to availability and advancement of simulator technology, animal activist groups continue to campaign against hospitals and facilities where LTT is thought to take place.

Our article reviews the published scientific literature to explore the values at stake regarding LTT in the context of surgical trauma. Our aim was to present the pro and contra arguments and consider whether LTT can be ethically justifiable, to any degree.

The main argument against LTT is a normative one – that animals have rights. Tom Regan presents a deontological view, that animals have the same rights as us and therefore should never be killed, irrespective of the benefit to humans. Peter Singer’s utilitarian position is that animal use for the benefit of humans is wrong due to unavoidable suffering.

Other empirical work completed on this topic has demonstrated that medical personnel believe they have a duty to their patients and must obtain the best training possible. Many surgeons hold a consequentialist mindset, such as “the ends justify the means”. Utilitarian thinkers would consider that using animals for LTT is justified if there is no suitably better alternative and the overall effect of the training is greater (in terms of wellbeing) compared to not conducting LTT. The pro-arguments presented in the literature, are likely underpinned by this view. The belief that LTT is unique, engages the emotions and is the most realistic training available are strongly held views presented in the literature.

We can all recognise the requirement for medical professionals to be sufficiently trained in order to save human lives and reduce suffering. Simulation training was introduced to mitigate the risk to human patients, and LTT is a type of simulation training. Undoubtedly, your opinion on the ethics of LTT will be underpinned by your own moral position regarding animals. This article, amongst other work, seeks to encourage thought and discussion around this topic. Further research is required to qualify the educational use of LTT and further inform simulator development, in the hope that live animal use can be replaced, reduced or refined, in accordance with the principles of humane animal use (3Rs).

Paper title: Considering the ethics of live tissue training in trauma surgery

Author(s): Cara Swain, Rory Rickard, Klas Karlgren & Gert Helgesson

Affiliations: Karolinska Institutet, Stockholm, Sweden (CS, KK, GH); Academic Department of Military Surgery & Trauma, Royal Centre of Defence Medicine, Birmingham, UK (CS, RR)

Competing interests: None

Social media accounts of post author(s): Cara Swain (X), @TriScalpel