Dying Autopsy

A trend worrying doctors

In the 3rd century B.C., the Greek anatomist Erasistratus noticed that the liver of a man dead of dropsy was as hard as stone but that of a man who had died of snakebite was soft. So physicians have long known that examining the dead could provide valuable information for the living. By the 20th century, the post-mortem examination, or autopsy (from the Greek for seeing with one's own eyes), had become a routine medical procedure. Yet since the end of World War II there has been a sharp reversal, and the autopsy itself appears to be dying. In 1950 nearly half of all patients who died in hospitals were autopsied. Now the figure has dropped to about 20%.

The autopsy is not performed merely to establish the cause of death. It is also of enormous importance in helping define the course of diseases and in evaluating the effectiveness of new therapies. Not the least of its benefits, especially if a child has died, is that it can lift a burden of guilt by showing that the family was in no way responsible.

If autopsies are so valuable, why are they being abandoned? For one thing, they cost from $500 to $1,200, which is usually borne by the hospital itself. For another, there is not much pressure to do them. In 1971 the Joint Commission on Accreditation of Hospitals dropped its recommendation that hospitals autopsy at least 20% to 25% of their deaths. Also, fewer families seem to be giving their consent, partly on the advice of morticians who see autopsies as a delay and hindrance to embalming.

Physicians too have become autopsy-shy. As Dr. William Masters, chief of anatomic pathology at Atlanta's Emory University Hospital, points out: "Medicine in general is more interested in the living, for whom it can perhaps still do something." And in an age of malpractice suits, doctors may also fear what an autopsy will reveal about their skills and judgment.

Some argue that because of new diagnostic tools like computerized X-ray scanners, the autopsy is now rarely needed to determine the cause of death. Says Ralph Greene, pathologist at Chicago's Portes Cancer Prevention Center: "Most autopsies these days are useless."

Many pathologists disagree. Says Dr. Nancy Warner of Los Angeles County-Southern California Medical Center: "Everyone is dead certain they know what a patient has, and on autopsy it turns out to be something else." Several studies have shown that in about 25% of autopsied cases, the post-mortem findings do not agree with the major clinical diagnoses made while the patient was alive. That does not necessarily mean that the doctor was careless, only that certain ailments, like cancer of the pancreas or bacterial infections in heart valves, are extremely difficult to diagnose. Thus, without verification by autopsy, the information on the death certificate--and, consequently, national disease statistics--are only informed guesses.

Beyond all this, the autopsy is a benchmark for medical performance. As Pathology Chief Dante Scarpelli of Chicago's Northwestern Memorial Hospital explains: "A careful autopsy is the very best quality control instrument." Or, more bluntly, it keeps the doctor from quietly burying his mistakes.

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