Autopsies are vital for establishing causes of death, advancing medical research and training young doctors, despite religious, social and legal issues surrounding their use, claims a Review in this week’s edition of The Lancet.
The Review states that autopsies continue to reveal major pre-death diagnostic errors in around 30% of cases, and as such are vital for improving national mortality data on which health care strategies are based.
Dr Julian Burton and Professor Sir James Underwood, of The School of Medicine and Biomedical Sciences at The University of Sheffield, UK, studied the published views of doctors, pathologists, coroners and members of the public from around the world to establish whether the autopsy retains its importance in the 21st century.
They say: "Many doctors lack familiarity with autopsy practices, and are insufficiently aware of the benefits for not only bereaved families but also present and future patients."
Rates of autopsy in the UK fell from 42.7% in 1979 to 15.3% in 2001. But public attitudes (and, it follows, rates of consent) could become more positive if the benefits to the individual family and future patients were made more evident. For example, in Northern England, there is a 60% consent rate for late fetal and neonatal autopsy. Parents in these tragic cases said that autopsy had helped to explain what had happened and helped them come to terms with events – as well as helping them plan future pregnancies.
Many doctors feel that the decline in general UK autopsy rates is a combination of the increasingly onerous consent process, advances in pre-mortem diagnostic techniques and their own assumptions that family members will be against an autopsy.
Pathologists who carry out autopsies feel that the procedure teaches valuable lessons about the inherent uncertainty that persists in medical practice. Many also feel that autopsy is an integral part of training and development for both themselves and other doctors. But other pathologists feel that autopsy is an unpleasant, expensive and time-consuming task secondary to their primary duties of diagnosing disease in the living.
The role of the law is crucial in relation to autopsy rates. In the UK, coroners can request autopsies for any death they deem to be unexpected or unusual. But any autopsy or retention of tissues for education or research requires consent from the next of kin.
Yet in Hungary – where no consent is required for educational/research related autopsies, the 2001 autopsy rate was 68.9% - around four-and-a-half times the UK rate.
The complexities surrounding tissue retention are also covered in the Review, particularly those involving infant deaths. A full autopsy and tissue examination is needed before an unexpected death in infancy can be attributed to sudden infant death syndrome (cot death).
Since a small number of sudden infant deaths are subsequently be suspected to be caused unnaturally, many argue that tissue samples should be kept longer for subsequent review. However, once the coroner has concluded the inquest into the death, the legal requirements for retention of tissue samples end – and consent must be requested from next of kin for continued retention under the Human Tissue Act 2004.
The use of imaging autopsies – that is using MRI scans to establish cause of death - has been trialled in some cultures where family members object strongly to the dissection of the body. But some doctors believe that such autopsies are not as reliable as conventional autopsies, and thus it could be argued that family members who might have played a part in a death should not then be given any remit in how cause of death is determined.
The authors conclude: "Autopsy also continues to be vital for advancing our knowledge of diseases not readily accessible to biopsy, such as those of the cardiovascular and central nervous systems and especially those for which novel therapies are emerging."
Part of an accompanying Editorial reads: "Evidence shows that relatives are most likely to grant consent when clinicians strongly recommend autopsy. Addressing the barriers to clinicians seeking relatives’ consent will therefore ensure the valuable practice of autopsy lives on."
Journal
The Lancet