"I see autopsy as the most exhaustive, and final, medical exam that a doctor can provide for a patient.  I don’t see autopsy as something horrendous and macabre. Yes, it’s not pleasant, I can tell you. I don’t like it. It’s just that I know how to do it fast,  effectively, cleanly, and to get the most out of it."

Miguel Reyes-Múgica (Mexico and USA)

  More quotes on Autopsy

A common misperception about pathologists is that they spend all their time doing autopsies. This misperception was encouraged by the media’s handling of the Alder Hey controversy, when pathologists were dubbed “doctors of death”.   But as Derrick Pounder points out, “Most pathologists are not performing autopsies, they're in hospital practice and doing laboratory work to support the investigation of illness in the living.” 

And, he says, there are other less obvious ways in which postmortem work contributes to saving lives.  “We forget where [the momentum for public health safety measures such as seat belts] started sometimes -- it started in the autopsy room.”  Pounder’s account emphasises the community benefits of autopsy work, which in his case and that of Sue Black, includes investigating human rights violations. 

Irene Scheimberg and Paola Domizio, among others, point out that the results of postmortems are extremely important for families in coming to terms with a death.  Sometimes the information yielded has implications for other members, as in the case of certain hereditary diseases.  And with paediatric and perinatal autopsies, says Scheimberg, “There are very, very few cases in which we cannot say something useful for the next pregnancy.

Many interviewees underline the continuing importance of autopsy in medical research. “The way in which autopsies have really contributed to medical advance is the recognition of new diseases.” (Nick Wright) This aspect is exemplified in the accounts of Ironside and Pounder about the discovery of new variant CJD, and Sebastian Lucas’ account of the investigation of HIV/AIDS in Africa and the UK in the early years of the epidemic.  The central role of autopsies in building up archives of tissue, organs, and information over time is vital for this kind of work. 

Good, observational, descriptive pathology [is] the absolute bedrock“Good, observational, descriptive pathology [is] the absolute bedrock” of medical knowledge,  says Waney Squier. The loss of this kind of historical picture is one of the key concerns expressed about the decline in autopsy rates worldwide.

A range of reasons is put forward for this decline, notably financial considerations, public distaste and reluctance either to ask for or grant consent, and a belief that new technology has made autopsy investigations redundant. 

The attitude seems to be, says Squier, that “the autopsy is a bit of an old-fashioned, rather gruesome way of looking at pathology... I think they're completely wrong... I mean I hate doing autopsies... but the information we get is absolutely invaluable... MRI gives us so much information, but it's actually seeing the structure with the naked eye and then looking at it under the microscope that really teaches us so much.” 

Miguel Reyes-Múgica argues similarly:  “You should never lose track of the fact that those are virtual images, and pathology has real images.  This is where things stop.  There is no more accurate and real examination than a pathological exam.”

González-Crussí has an interesting perspective on why autopsies might be undervalued.  “In some institutions, the autopsies are delegated to the least able.  Why? There is a [hierarchy] of pathologists.  Number one is the researcher, then of course the prominent service people, and the autopsies are way down.  So they are done in a neglectful way, by people who are not very experienced, and of course the report at the end is not very informative.”

Autopsies also play a vital role in teaching, and in quality control and audit.  Dhiren Govender in South Africa says: 

Autopsies are a form of quality assurance, clinical audit, for a hospital“I believe strongly that autopsies are a form of quality assurance, clinical audit, for a hospital... We used to have what we called the clinical-pathological meetings where we'd pick up some of the errors [in cause of death]... But we don't have those any more.” 

The phenomenon is not uncommon.  Domizio says, “Clinicians on the wards think they know the cause of death, but actually in [at least] 10% of cases they're wrong, big time!” 

Another real concern is the impact on epidemiology.  In South Africa for example, as Govender points out, AIDS is believed to be a leading cause of maternal mortality, but the low rate of autopsy means that there are many unanswered questions: “Are they getting opportunistic infections?  Are they developing malignancies?  Who knows?  We never know.”

Bill Bass, a natural storyteller, and one of the two forensic anthropologists in the archive, draws at length from his casebook.

I don't see them as dead bodies.  I see them as forensic cases."I don't see them as dead bodies.  I see them as forensic cases."

Many interviewees talk about how they feel about actually performing autopsies and the achievement of professional distance while retaining respect.  Maesha Deherogada relates the story of her anatomy tutor reading a poem written by a relative of one of the cadavers. “The theme was just about respecting that person as someone who really wanted to teach us...that we would be able to learn from the body and do good in the world as a consequence.  It was really quite wonderful and moving.”  

Key interviewees: Sebastian Lucas, Irene Scheimberg, Miguel Reyes-Múgica, Derrick Pounder, Bill Bass, Juan Rosai, Dhiren Govender, Helen Wainwright, Francisco González-Crussí, Paola Domizio, James Ironside

See also: 
Life, death and the hereafter, History of Pathology, Legislation and Regulation

 

QUOTES

Elaine JaffeI mean, I didn't really look forward to doing an autopsy.  You'd walk in and you'd see this body in front of you and the first cut or so was kind of distasteful.  But then I'd get interested in it and I'd sort of lose myself – I'd just become engaged in what I was doing and all distaste for the blood and the smells and other unpleasant aspects of the autopsy disappeared.
 - Elaine Jaffe (USA)

 

Irene ScheimbergThe postmortem is the first and only time that that child – particularly if it's a very young baby – will be examined by a doctor.  We are that baby's doctors; we have a duty to them and to their families.  Because what we find will not only help the parents in their grief; it might also help them if there’s the possibility of the same problem occurring again in another child. So a perinatal postmortem is not just a closure; it's a closure and a continuation, because it helps families to carry on with their lives, and have more children.
 - Irene Scheimberg (UK)

Derrick PounderThose of us who do autopsies mainly do them for medico-legal reasons.  These are deaths in which there's a community interest in the investigation because, first of all, we want to investigate any possible crimes, but secondly because we want to prevent further deaths.  All of the public health measures in terms of carbon monoxide poisoning, seat belts, drink driving and so on -- all that derives from the investigation of fatalities... So [with seat belts, for example], it was the analysis of aggregated data from a large number of fatalities over a period of time.  First of all it was recommendations, and only later did it become legislation.
 - Derrick Pounder (UK)

Irene ScheimbergThe confidential enquiry into stillbirth and death in infancy found that ‘…in 70% of postmortems on children done by a non-paediatric pathologist, essential tests were omitted, and the diagnosis was deemed to be incorrect in approximately 20% of cases.  And these led to failure to recognise inherited conditions and on occasions led to inappropriate suspicion of harm.’  So the postmortem is very important for audit purposes also.
 - Irene Scheimberg (UK)

Irene ScheimbergAs I said, the most important purpose is for families.  But postmortems are an important element of teaching and training too.  Medicine doesn't only progress on big, wonderful discoveries that may bring people the Nobel Prize.  Medicine progresses little by little; it's like building a wall in which every little piece of knowledge is a new brick -- and pathology can give a lot of bricks to that wall, as well as helping families.
 - Irene Scheimberg (UK)

Sebastian LucasIn terms of the autopsy, two important things have happened.  One is that the consented autopsy rate has declined.  We now have one every fortnight asked for in this hospital... We used to do three a day!  That means that very few doctors here have ever asked for an autopsy, so they don't know how to ask for consent from the family.  And of course, because of Alder Hey, the consent forms have got longer.  Secondly, they've never seen an autopsy. 

...Then there's the coronial autopsy business, which is of variable quality and output.  And the problem is that too many of the doctors, senior and junior, have seen coronial autopsy reports which bear little or no relationship to the patient they thought they were looking after, and they've assumed all autopsies necessarily are bad, therefore they're not worth considering. 
- Sebastian Lucas (UK)

Miguel Reyes-MúgicaIn many autopsy rooms there is a statement in Latin that says something like, ‘This is a morgue, the place where death teaches or helps those that are still alive.’  And that’s exactly what came to my mind – the contribution this little baby, who was no older than two or three months, was making to her family and to humankind by letting us, with her personal experience (and there is nothing more personal than death), understand a disease process that can protect not only her family but many others, was huge. 
 - Miguel Reyes-Múgica (Mexico and USA)

I see autopsy as the most exhaustive, and final, medical exam that a doctor can provide for a patient.  I don’t see autopsy as something horrendous and macabre.  Yes, it’s not pleasant, I can tell you.  I don’t like it.  It’s just that I know how to do it fast, effectively, cleanly, and to get the most out of it.
 - Miguel Reyes-Múgica (Mexico and USA)

Juan RosaiDuring the Renaissance performing autopsies was the standard... People think that autopsies were only started in the 1800s, that for religious reasons they were not allowed before that.  Actually, they were so common in Florence during the Renaissance that Benivieni, in his book, commented about a case in which the autopsy was refused, and he was indignant... He wrote, ‘The autopsy was refused because of some superstition on the part of the family!’
Like today, the physician needed the consent of the family except in cases of doubtful death or epidemics.  For instance, when they had bubonic plague they would do autopsies on everybody to be sure that it was plague and not something else. 
 - Juan Rosai (Argentina, USA and Italy)

Dhiren GovenderI enjoyed doing autopsies a lot and I have my own views about them.  I feel we learn a lot of pathology, and a lot more clinical correlation -- applying pathology to the clinical scenario – when we do autopsies.  In surgical pathology we get a case; we report it; we go to multi-disciplinary team meetings; we present it.  There is some correlation with one diagnosis.  In autopsy you tie everything up.  It's a pity that we don't do that many autopsies any more.
 - Dhiren Govender (South Africa) 

[In the UK] they want to offer histopathology without autopsies so you can become a histopathologist.  I think the bigger picture is lost.  I think what we are tending to become is just diagnosticians – look down a microscope and not look at the whole disease.  And that's a problem, specially with trainees. You want them to get a big picture, because the pathogenesis, the way diseases are caused, is as important as looking down and saying OK, this is a cancer, or whatever.
 - Dhiren Govender (South Africa)  

Helen WainwrightOur registrars have to do 50 autopsies each... Groote Schuur [should have] an autopsy rate of about 20%.  We must be about 0.05%...We make up for it by offering our services to [the police department]...You've got to be quite a tough registrar to work there, as you see very unpleasant sights.
 - Helen Wainwright (South Africa) 

Francisco González-CrussiThe arrogance of the physicians...who think they can learn nothing from an autopsy... is another cause that has been much talked about… Yet serious studies [have shown that]… in spite of all the wonderful advances in technology, there were a significant number of cases where things that [physicians] didn't know were uncovered by the autopsy… So that's why I say the decline of the autopsy is negative. Not only that, there are new diseases that can only be known by securing tissues and doing all the studies that an autopsy allows…[And there are] new diseases created by the physicians with the new therapies!  New prostheses and organ transplants are giving rise to a new kind of pathology that didn't exist before…How can it be known?  Not only by biopsies; you really have to examine the whole organ.
 - Francisco González-Crussí (Mexico and USA)

Paola DomizioThe first time I did an autopsy on a child was very different... It was horrible, I remember, I really had to force myself to take the knife and make that cut... Children are always worse because you read the histories – I think that, compared to adults, it's the overwhelming feeling of sadness. But having said that, you do get used to it as well.  Because you know that the advantages at the end of the day and the benefits that it can bring – to parents, to the doctors who are looking after them, and to society in general – are actually quite great.   
- Paola Domizio (UK)

James IronsideAnd [the discovery of new variant CJD] shows the importance of actually performing an autopsy in patients like this with neurological diseases which are undiagnosed.  It makes a huge difference, particularly when a prion disease like that is diagnosed, because it does have wider implications in terms of health and safety...That work took years and... is a good example of using archives in a very constructive way to address an issue which was a real public health concern.
 - James Ironside (UK)

Chris Fletcher[The reason for declining autopsy rates] is a combination of social distaste; the belief that radiology has found things that only pathologists could find before, and a reluctance of the junior doctors who are around in the middle of the night to ask families...There's another thing too – health care has changed [in the USA], as has happened in England. If you or I were in hospital 20 years ago the young doctor -- you would see the same one day after day, so you knew and trusted that person.  Now it's a different one every eight hours and you don't form that bond.  They don't really know you or the family well enough to say, "Well, grandmother died, can we do an autopsy?’  In the old days, a week in hospital and you were just about family friends by the end, and that's all gone. 
 - Christopher Fletcher (UK and USA) 

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