The Future of Autopsy, what is the role of minimally invasive autopsy

and can it replace traditional autopsy?

Janey Rusk

Senior Project Advisor: Tina Hott

Abstract

Clinical autopsy rates are currently the lowest they have ever been resulting in less quality
control in hospitals. The lowering rate can be attributed to, family and religious objections. As
the autopsy rate drops the quality control goes down, possibly to a point where doctors are
unaware of their mistakes. The role of a minimally invasive autopsy is examined and determined
if it would have the ability to replace clinical conventional autopsies. The research used are
studies that test minimally invasive autopsies techniques and compare them to conventional
autopsy in their ability to diagnose the correct cause of death. This research suggests that
minimally invasive autopsy cannot currently replace conventional autopsy due to its inability to
diagnose common causes of death. Though there are few studies on minimally invasive autopsy
thus far, and study sizes have been relatively low. Further research needs to be done using larger
study sizes, and studies need to be done on alternate uses of minimally invasive autopsies and if
it is cost effective compare to conventional autopsy.

12th Grade Humanities

Animas High School

11 March 2019
 Introduction

In the United States, current hospital autopsy rates have dropped to a low as 0% to 10%

of cases. In the 1960s this rate was as high as 70%. Hospital autopsies or clinical autopsies are

used to investigate deaths in the hospital in order to learn more and improve care. These

declining rates do not include the rate of medico-legal autopsies which are done in cases of

suspicious or unknown cases. Autopsy involves a full external and internal examination of the

abdominal cavity, the brain may or may not be examined depending on the case. Autopsies are

often vital to understanding the cause of death of a person and recognizing if there was more that

could have been done in the case of hospitals. An autopsy can be used to inform doctors of their

mistakes so that they can better perfect their practice. With these falling autopsy rates, hospitals

and medical practices could become blind to errors.

This is why techniques are currently being developed for a minimally invasive autopsy

which would involve an external examination, MRI, CT, and possibly needle biopsy and CT

angiography. These methods might allow for a less invasive autopsy that families and clinicians

may be more open to in a hospital setting. These methods would not be used for investigative

autopsies where an autopsy is legally required. A minimally invasive autopsy is best used as a

preliminary screening to decide if a clinical conventional autopsy is necessary and to inform

public health.

Background Information

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 Autopsies were not regularly used in homicide investigations until the late 18th century

and forensic medicine was not taught in many medical schools until the 19th century. Evan

though forensic medicine was, and, is taught in medical schools by the 20th century many people

did not think the profession was academic and it went into decline. Autopsies today are used for

medicolegal cases, other investigations to gain medical knowledge from clinical autopsies and as

a learning tool for medical students. Though in recent years clinical autopsies and autopsies in

medical schools have been on the decline. The reason for the decline in hospital autopsies can be

attributed to families not providing consent, and it is not taught in medical schools due to a lack

of interest in the profession.

Because of the lowering rate of autopsies, the amount of medical examiners is falling in

turn, and will not be sufficient for the future of forensic medicine. According to the Scientific

Working Group on Medicolegal Death Investigation (SWGMDI), there are 500 full-time forensic

pathologists in the United States currently and only 55 in the UK. Only 2000 have been trained

in the US since 1959 and the minimum number of forensic pathologists needs to double in order

for the amount of completed medicolegal autopsies to reach its goal. This problem is exacerbated

by the fact that there are only 37 accredited forensic pathology programs out of 131 medical

schools. Out of 17,000 medical graduate students, only 30 to 40 will become forensic

pathologists. Out of those 17,000 students, few will even be exposed to autopsies and forensic

pathology at all. Also, in some reports faculty have been known to discourage forensic pathology

as a career. Students are also deterred from the career as it is one of the lowest paid medical jobs

with annual salaries from $100,000 to $200,000 compared to primary physicians median salary

around $202,000 and specialty physicians at $356,000. A final setback to forensic pathology as a

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career is the long exposure to violence and traumatic cases and exposure to media and court

systems is a deterrent for medical students.

The declining rate of both medical examiners and autopsies does not change the fact that

they are necessary and essential to medical studies. In this paper autopsies in a hospital setting

for quality control will be addressed. Medico-legal autopsies are important to investigations and

are the main use of autopsies today, the topic of minimally invasive autopsy does not apply well

in this situation. As for clinical autopsies, their main use is for quality control in hospitals and in

the public health sector. Public health is the study of disease prevention, prolonging life,

preventing death, and promoting health in communities and individuals. By using autopsies in

public health studies we can better see what is affecting the community and where the focus

needs to be. It is important to do autopsies on randomly selected cases in the hospital as they

provide information to doctors that can improve their practice. It provided families a sense of

closure in many cases, and in one study, “40% of 2479 autopsies revealed substantial

information about the patient's condition beyond what was known premortem” (Weustink, et. al.

898). This data shows how important it can be to have an autopsy performed. In those cases

where the knowledge found could have changed premortem treatments are cases in which

doctors can learn from the past in order to find ways to better provide care. This all connects to

public health and how autopsies can be used to improve it. Currently, collaborations between

public health offices and death investigators does not exist except in a few places.

Key Terms

CA: conventional/traditional autopsy

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MIA: minimally invasive/less invasive autopsy

Angiography: the x-ray examination of blood or lymph vessels by injecting a dye into the blood

and lymph vessels.

Clinical Autopsy: an autopsy done in hospitals to learn more about diseases and to ensure quality

control in a hospital setting.

Medicolegal Autopsy: also called a forensic autopsy is done in suspicious or unknown causes of

death, autopsies that fall under the classification of forensic are required by law.

Biopsy/Needle Biopsy: the removal of small tissue and blood samples in order to

microscopically examine them for diseases. This is usually done by a needle in a post mortem

setting from all major organs.

Research and Analysis

Religious Objections

Clinical autopsy has declined for two main reasons, the first being that families are

unwilling to consent for an autopsy to be done on a loved one and the second reason is, clinicians

not requesting an autopsy. The reason for family objections stems from religious views and view

it as mutilation of the body. Every major religion has reasons why an autopsy is not ideal

according to traditions and beliefs. These traditions range from burial traditions, belief in the

human spirit, fear of death and fear of loved ones being disrespected. Each religion has its own

reasons for autopsy reluctance though there are many similarities that can be found.

Islam

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 In Islamic religions, they have strict traditions that they follow regarding death and how a

body is prepared for burial regarding dress, body placement and how the deceased is buried. In

Muslim tradition, the body is buried as soon as possible without embalming, and the burial site

has to be within one to two miles of where the deceased passed away. Autopsy interferes with

almost all of these traditions. Autopsies themselves do not take long but the body is not usually

released until all the test and toxicology is done which can take up to a week, delaying the burial.

Also in more rural places, especially in countries where there are not many medical examiners

the body must be transported to an area where an autopsy can be done which could make it so

the body is not buried where it needs to be according to tradition. Burial delay has a big effect on

communities as they want the spirit of a person to be with God as soon as possible and delaying

that can cause distress.

Judaism

As for Jewish tradition, it is much the same in principle as that of Islamic traditions. They

believe that a dead body must be treated with respect and that no desecration of the body is

permitted. They also believe that the body should be buried the same day that the death occurred,

though they also believe that if the body is treated with respect then a delayed burial is not

forbidden if it is for the benefit of those who have survived the dead. They also have a principle

called pikuach nefesh which is the obligation to save a life, so if an autopsy could provide

information on a disease, and other medical knowledge that would result in future gain an

autopsy may be permitted.

Hinduism

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 Furthermore, in Hinduism, they contrast from the past two religions, as they believe in

cremation. They do object to an autopsy because they think it might disturb the soul on its way

into the next life. They believe that in the performance of an autopsy the soul might not be able

to be reincarnated and it will re-enter the body. Though they do object to autopsy some also think

that once the spirit moves on from the body, “the lifeless body has no karmic obligations, then it

may be okay”(Beal and Burton, 8). In general, Hindi tend to avoid autopsy, but if it is legally

required, they comply.

Buddhism

On the other hand, Buddhism does not have many objections to autopsy. Buddhists

believe that the body is but a shell for the spirit and that one should not be attached to it as it will

age and then you will die. They believe that once a person dies they are to be treated with the

utmost respect, and not be disturbed for three days after death before cremation. However, most

Buddhists agree that autopsies are a way to show compassion and respect to life, as they can

bring criminals to justice. They think that since the intention of an autopsy is not to harm the

person, it is acceptable as long as the spirit has left the body.

Catholicism

In addition to Buddhism, Catholics also do not have many objections to autopsies

currently. In the past, there has been much debate over autopsies and the dissection of the human

body in the Catholic church. In the year 1153, mutilation of the body was banned by the church

mainly to stop people from eviscerating the bodies of Crusaders when they were transported to

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Europe, though it affected anatomists too. By the late 1400s autopsies were allowed in medical

schools in order to teach students, as the church, “devalued the dead body in an era when the

thirst for new knowledge ruled.” Currently, this general belief still stands as Catholics generally

agree and allow for autopsies for use in medical education or organ transplantation which are

considered an act of charity to help others.

Native American

Next, Native American cultures tend to embrace the present and they do not discuss

death. Since views can change depending on which tribe a person is from as there are around 558

recognized tribes and over 100 who request recognition. Mostly they prefer natural ways and

home care. They believe that death is a natural part of life and they have rituals to ensure that a

spirit crosses over to the other side to be with ancestors. They tend to view autopsy as the

desecration of a body and they generally prefer not to have an autopsy performed.

Summary

In most religions and cultures, autopsies are seen as disrespectful to a body. Nevertheless,

they still accept that autopsies are sometimes necessary in the view of the law and in the

advancement of medical knowledge. In some religions, it is a choice of the deceased and they

respect those wishes. In most cases, on the other hand, most religions would prefer an autopsy is

not performed and that the loved one is treated according to tradition and with utmost respect.

Clinicians Objections

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 Since the improvement of public health and medical knowledge are the main reasons for

clinical autopsies, it is important for clinicians to understand this need. In medical school many

students today are not exposed to autopsies and do not understand the need for them. With the

rise of diagnostic technology, imaging techniques, and confidence in clinical diagnosis,

clinicians may think that autopsy is outdated. Some clinicians may believe that, “an autopsy is

unnecessary or they feel embarrassed to ask permission for such an “unpleasant”

procedure”(Weustink, et. al. 898) This view is prohibiting clinical autopsies from being done

which in turn can cause harmful medical mistakes to be buried.

However, despite these views, it has been shown that, “in a study of 99 autopsies, post

mortem findings provided information that would have changed management had it been

available premortem in 10%-13% of cases. Another study reported that two-thirds of the

undiagnosed conditions were considered treatable”(Weustink, et. al. 898). These cases show that

even with advanced diagnostic technology, the need for quality control using clinical autopsy is

necessary. If clinicians continue to forgo requesting autopsies and the clinical autopsy rate falls

even lower than the current rate of 0%-10% then it will cause medical practices to be blind to the

consequences of malpractice and omissions.

Public Health Implications

As stated, the lowering rate of clinical autopsy risks the chance of clinician being

unaware of mistake. Another consequence of lower rates is in public health and knowledge

around mortality statistics. These statistics can provide important information on common causes

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of death and could provide information that can be used in the public health sector to stop

disease epidemics before they happen;

“The data might be used to discern risk factors that are key to developing preventive

interventions. If the tissue is banked, it can be analyzed to characterize the natural history

of a new and emerging illness, such as those caused by hantavirus or HIV. Finally, ME/C

data can yield timely and specific information about an unfolding epidemic”(Sosin 38)

There are examples where this is the case and death information caused a change in a previously

unnoticed cause of death in children. Children were getting trapped in car trunks with no way to

get out, once these deaths were noticed it spurred an investigation. This investigation lead to

changes being made in the car manufacturing industry so that in cars made after 2001 there are

now interior trunk releases. If this investigation did not take place this change would never have

occurred, resulting in more child death. Currently the system is flawed and similar investigations

are not as common as they should be. Few states have programs that help public health workers

collaborate with medical examiners. For those who do not, public health officials may not be

able to access data that would help improve the health of a community.

How Can MIA Help?

Minimally invasive autopsy (MIA) is a technique that is currently being developed and

researched in order to possibly supplement or replace clinical autopsy in certain cases. In the

previous section it has been discussed why autopsy rates are falling and the consequences this

has. MIA is being developed because it is more acceptable to families as the deceased does not

get cut into, and because of this more families might be willing to allow for an autopsy. In some

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studies concordance between conventional autopsy (CA) and MIA is high enough that MIA was

concluded to be a sufficient substitute for CA. In one study they said,

“Furthermore, in the cases for which a pathologist and radiologist jointly predicted that

full autopsy was unnecessary, the concordance rate for cause of death or major pathology

was almost 100%. Thus minimally invasive autopsy could be a suitable alternative to

conventional autopsy for detection of cause of death or major pathological lesions in

selected cases for which an invasive post mortem examination is unacceptable”(Thayyil,

et al. Minimally invasive fetal, 229)

In this study, the autopsies were done on fetuses and children and the study was set up so that

forensic pathologists and radiologists examined the scanned images, then based off a set of

criteria they created then determined whether a CA was needed in that case. Then when a CA

was done they determined if the cause of death was the same as found in the MIA. Though this

study only looked at fetal and child deaths, this may not be applicable to adult deaths. Though

another study on MIA stated;

“further development of post-mortem biopsy and post-mortem angiography together

with MRI and MSCT will set new trends toward a minimally invasive autopsy. In

contrast to pre-autopsy cross-sectional imaging, a minimally invasive autopsy has the

potential to replace traditional autopsy in the future”(Grabherr, et. al. 6)

This study showed a promising approach to MIA by using biopsy and angiography, though it

does not mention the fallbacks to an MIA approach that other studies do. They do not compare

the scans to CA, all this study looked at was ways that scanning is currently being used to

supplement CA in some cases and how it may lead to MIA.

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MIA Limitations

While MIA is a useful tool it has many limitations that affect its ability to fully replace

the clinical autopsy. Though MIA sounds promising the fact that it does not have the ability to

diagnose certain causes of death makes it so it can not fully replace conventional autopsy. Most

studies mention that MIA has not been able to demonstrate cardiac diseases such as myocardial

infarction, endocarditis and ischemic heart disease which is the leading cause of death in the

world. Since MIA is not able to diagnose these diseases and others such as pulmonary embolism,

pneumonia, intestinal infarction, and intra-abdominal lesions, it can not replace CA. On study

said;

“the major discrepancy rate between consensus imaging and autopsy in the group for

whom autopsy was not necessary to confirm cause of death could be acceptable for

medicolegal purposes because it is similar to the error rate of clinical death certificates on

which most registered causes of death are based. However, because some disorders, such

as pulmonary emboli, could not be diagnosed, replacement of autopsy with imaging

would result in systematic errors in mortality statistics”(Roberts, et. al. 141).

This point is also made in many other studies. Though it is noted in this quote that the error rate

is close to that of CA meaning MIA could be used in place of CA, since some causes of death

cannot be diagnosed at all using MIA many errors would be seen. If MIA was used

systematically currently the statistics could not necessarily be trusted, especially by public health

workers who would rely on the statistics to make changes in communities.

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 Furthermore, the changes that a body undergoes during decomposition may cause

misdiagnosis of the cause of death. Many of the changes that occur can look similar to diseases

seen in live patients. Therefore if a radiologist is not properly trained, they may misdiagnose a

cause of death, but it may be contributed to decay. In the study by Tom Sutherland and Chris

O’Donnell, it discusses the changes that a body undergoes during decay and how this interferes

with a scan. One complication they note is, “postmortem blood clots render it challenging to

differentiate antemortem thrombosis and emboli”(Sutherland and O’Donnell 207). Antemortem

Thrombosis and emboli is when a clot forms in the blood before death. When a body decays

blood clots occur as the circulation cesses and iron in the blood clusters together and the

enzymes in the blood break down. It can be difficult to differentiate between a clot that formed

before death and one that formed after which can cause a misdiagnosis of the cause of death if

MIA is used. This study concludes by stating, “an appreciation of the artefacts associated with

dying and the post-mortem state is important as these are limitations of post-mortem CT, and if

not recognized can lead to misdiagnosis”(209). Indicating the radiologist that are doing this work

will need to understand how a body changes during death, as misunderstandings in this area

would cause mistakes to be made.

An important thing to note is that so far there has not been enough research done on the

topic of MIA. Also, the research that has been done thus far widely ranges in methodology. Each

study has different study sizes that are relatively small, the biggest study on adults being 182

cases, the smallest is 23 cases. Two studies note the need for bigger study sizes the best, one

saying, “building up practical experience of the MIA process across a wide range in settings,

including the whole age range from stillbirths to older adult deaths, different cultures and

12
religions, and urban and rural communities will be essential in defining the best practice and

determining what may be acceptable”(Byass 3). The other one saying that, “to establish a

feasible alternative to conventional autopsy and to increase consent to post-mortem

investigations, further research in larger studies groups is needed”(Blokker, et. al. 1159). Both

studies make the point that not enough research has been done and more needs to be done in

order to determine how MIA can be used.

The last limitation to MIA may be its cost. Few studies have looked at what the cost

would be if MIA were to replace CA. As it may depend on how MIA is used and if coroners

offices have access to their own radiology equipment or if they will rely on using hospital

equipment. From the studies that have looked at cost, both options have positive and negative

side effects. If coroner used hospital equipment this would mean that they could only use it after

hours in order to not interfere with the everyday functions of the radiology lab. This severely

limits when coroner can use these machine, though by doing this the cost will be far less as they

will not have to buy their own machines. If coroners were to have their own machines this would

drastically up the cost of MIA. Also so far studies are inconclusive as to how much MIA would

cost, one study saying, “The mean costs (in U.S. dollars) per patient of an MIA and a CA

(including brain autopsy) were $1497 ±148 (range, $1190-$1792) and $2274 ± 104 (range,

$2056-$2491), respectively”(Weustink, et. al. 901) over 700 dollars less than CA. while another

study stated, “Cost implications are also a concern; MRI in particular is more expensive than is

traditional autopsy. Further development of post-mortem imaging is needed and this

development must be based on careful consideration of comparisons between radiology and

autopsy”(Roberts, et. al. 142) More studies need to be done analyzing the cost-benefit of MIA

13
techniques, and how to minimize cost. Though much of that depends on how MIA will be used.

Will it be used as an alternative to CA or will it be used to supplement CA?

Uses of MIA

If MIA cannot be used to replace CA completely there are still ways that it could be

implemented in order to grow autopsy rates improve the quality of autopsies in general. MIA

could be used with CA to simply provide more information that may help to determine cause of

death, as it has been shown to be better at diagnosing certain cause than CA. MIA might also be

able to be used as preliminary screening before a CA autopsy is done possibly determining if a

CA is needed in that case.

In the case of using MIA to supplement CA the only issue that would be run into is

surrounding the cost as it would make the cost of autopsies go up. The benefit of using radiology

techniques with CA is that it can detect causes of death such a pneumothorax which is much

harder to detect using CA techniques. When trying to detect a pneumothorax in a CA “the first

opening of the pleural cavity is made under a layer of water in order to visualize escaping

air”(Weustink, et. al. 900). When this is done in an MIA the air pocket can be seen in the scan as

an artefact as a blank space where the air is, which is much easier and effective, as the method

described above can be difficult to execute. In the study by Ian S. D. Roberts et al. it was noted

that, “We used full autopsy as the gold standard for diagnosis, but this assumption might not be

valid. Imaging could be better that autopsy in the detection of some fractures, intracranial

pathologies, and pneumothorax”(141). If this is the case then if MIA were used alongside CA to

supplement and add data then the report would be more accurate and all-encompassing.

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 The second way that MIA may be able to be utilized is by using it as a screening for CA.

This would involve performing and MIA on all cases and then using a set of criteria and

systematic review of the resulting images and data to determine if a CA is needed. An MIA

would be done and reviewed by a team that is specially trained on MIA and the artefacts

associated with death, if they determine that a CA is needed to confirm cause of death then one

would be done. The study that for the most part tested this theory concluded that,

“major discrepancies between radiological and autopsy cause of death were reduced

when radiologists indicated that autopsy was not necessary. When radiologist confidence

was definite, the proportion of cases with major discrepancy compared to autopsy was

25% less than non-definite cases for CT, 37% less for MRI and 28% less for consensus

reports”(Roberts, et. al. 139).

Since discrepancy rates are much lower when criteria is set it may be plausible that as more

comprehensive criteria lists are made and more research is done that this becomes a use of MIA.

If this criteria is made and studied, then MIA could be used as preliminary screening to

determine if a CA is needed. This could reduce the number of conventional autopsies needed

while also boosting the number of overall autopsies done as more MIA’s are done. Though not

many studies on this alternative and method of MIA have been done so more research would

need to be conducted.

Discussion and Conclusion

As has been noted declining autopsy rates will cause cases of malpractice to go unnoticed

and for quality control in hospitals to be low or close to non-existent. The public health sector

15
will also be affected as death certificates may be wrong on the cause of death stated. This will

give people working to improve health in their communities skewed statistics that may not

benefit them in their jobs; as they will not know what people are actually dying from.

This is why MIA was created, to provide an alternative method to autopsy that people

will find more acceptable to help improve autopsy rates. Although this idea is good in concept its

much harder to make it an acceptable alternative to autopsy due to its shortfallings. Since MIA

cannot diagnose certain causes of death it will not be able to replace autopsy currently as,

“common causes of sudden death are frequently missed on CT and MRI, and, unless these

weaknesses are addressed, systematic errors in mortality statistics would result if imaging were

to replace conventional autopsy”(Roberts, et. al. 136). Also due to changes due to decomposition

misdiagnosis may occur when radiologist are unused to the artefact associated with death in

imaging.

Even though MIA cannot replace CA it may still have its uses. It is possible that as

technology improves then MIA may become a feasible replacement for CA, though currently,

that replacement is not possible. Roberts et al. states that, “However, because some disorders,

such as pulmonary emboli, could not be diagnosed, replacement of autopsy with imaging would

result in systematic errors in mortality statistics”(141) Also, MIA can be used with CA to gain

more information and to provide a better quality autopsy. Although MIA cannot replace autopsy,

it can also be used as a screening to CA. Where an MIA is done before each CA and based off a

set of proven criteria it would be determined if CA is necessary. Lastly Thayyil, et al. state,

“The PM MIA represents either an alternative nor an adjunct to traditional autopsy, but

an additional approach that may allow at least some important clinical information to be

16
 obtained. In this population the alternative is no form of examination at all and therefore,

to be regarded as useful, the PM MRI simply has to provide some additional diagnostic

information compared to no examination whatsoever”(Post-Mortem Imaging, 716).

PM is this case means postmortem, and since in many cases consent for autopsy cannot be

obtained in a hospital setting and that MIA could still be used to gain at least some information

regarding death. Though it could be worrying if this were to be how MIA is used as cause of

death could be diagnosed wrong causing statistics to be wrong.

In order to determine if MIA truly cannot replace CA and if any of the alternative uses

mentioned are possible, more research needs to be done. Study sizes so far have been small

ranging from 23-138 cases. Study methods also vary between studies.One study said, “until

adequate evidence on the accuracy and cost-effectiveness of such an approach is available, the

use of postmortem MR imaging as a replacement for conventional autopsy cannot be

recommended”(Thayyil, et. al. Post-Mortem Imaging, 718). In order to be certain on the results,

studies need to be done confirming the results of other papers and studies need to be consistent in

methodologies. Such as will MIA be both CT and MRI or will just one be used? Will biopsies be

used? Will angiography be used? These questions need to be answered and have reasons why

each of the techniques is used to make MIA more effective. Studies on cost-effectiveness also

need to be done to determine if MIA is cost effective.

Lastly, even though MIA has the potential to supplement CA and possibly replace it in

some cases if autopsy rates are to go back up to the 70% autopsy rate of the 1960s then the

public perception of the autopsy has to change. MIA is suspected to be more acceptable to

families as it does not require any mutilation of the body, but in more rural places where the

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technology is not available, CA will remain the gold standard. Also in the case of medicolegal

autopsies, it is doubtful that MIA will be accepted in the field due to the need for a more full

view of what happened for court cases. Autopsies will always be necessary in society, therefore

if knowledge about causes of death and mortality statistics is to grow, people and clinicians need

to understand the need and necessity of autopsies and request for one to be done.

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