By Aparajeya Shanker, Intern Physician
Written on the 19th of December, 2022
It has been a little over a year since I witnessed my first autopsy. On a cold autumn evening, as the sun’s rays glanced off the rooftops over Pleven, my fellow colleagues and I walked in solemn silence to the University’s basement, where the morgue is located. In the six years of staying in Pleven, most of us have known that the dark underbelly of the University’s basement was the preparing room of the cadavers that were sent upwards to the Department of Anatomy. In some ways, we can look upon this pathway of the dead as a sort of ascension, from the depths of the unknown to the sunlight of the known. Of course, the anatomy laboratory’s words Mortui Vivos Docent, “the dead teach the living”, add to this almost poetic metaphor.
For those of us in attendance, the autopsy was a difficult first experience. By this stage in our journey through medicine, we had seen it all, intensive care units, surgeries, anatomy dissections, other myriad illnesses and tragedies. However, the sight of the deceased on the cold mortar slab of the autopsy room is in its own right a rite of passage. It was explained to us that witnessing an autopsy was a rare occurrence, and indeed, scientific research corroborates this. The rates of autopsies have declined throughout the world. At this point in my reflection, I feel that it is necessary to illustrate what an autopsy is, and what it entails, but more importantly, why an autopsy is an almost indispensable tool in our understanding of health, disease and death.
What is an autopsy?
An autopsy is a clinical examination carried out post-mortem, that is, after death. An autopsy consists of an external examination of the body of the deceased, a note of all the external features that can observed by the naked eye, and is then followed by an internal examination. The internal examination consists of examining the internal organs, collecting specimens from the organs, examining the contents of the stomach, intestines, and the bladder. The examination also consists of examining and dissecting through the brain’s protective layers, the meninges, and examining the brain both externally and internally.
The observations from an autopsy are useful for issuing a certificate of the cause of death. This certificate of the cause of death illustrates two major factors about the death of a person, the direct events that lead to the death, and the second part is the list of risk factors that contributed to the illnesses that could have caused the death of the patient.
When is an autopsy performed?
An autopsy is generally performed when the death is caused either by trauma, or in “uncertain circumstances”. It is important to note, however, that different countries have different legal frameworks for when an autopsy should be performed. Deaths that occur in the hospital are also considered, in general, to come within the ambit of autopsies, however compliance to this varies. Often times, an autopsy is conducted when the circumstances surrounding the death of a patient are unknown or there is a suspicion of “foul-play”.
There is an important aspect of the autopsy that is often overlooked: its value in establishing cause of death, and its almost indispensable value as a tool in public health. Every country maintains (or should maintain) a list of the most common causes of death, and this list of causes of death comes primarily from autopsy data.
Why defend the autopsy?
Over the past few years, there has been a world-wide decline in the rates of autopsies. This decline has been attributed to many reasons, and although it is hard to quantify the exact reasons why, some reasons are more apparent. The improvement of noninvasive methods for clinical and pathological examinations, combined with better statistical methods may have reduced the need for the autopsy. Further, the greater involvement of patients and their relatives in medical decision-making could also be contributing factors in explaining the decline in the rates of autopsy around the world.
In countries like Bulgaria, where the population is low, and the available resources are limited, it is important to understand the value of the autopsy. There are factors why the rates of autopsies are low, patients’ families normally do not consent to an autopsy because they feel the need to grieve. This sacred aspect of death and grief are two factors which need to be treated with a sense of sensitivity. An autopsy is a difficult process, and the steps in an autopsy are difficult to convey to patients without them feeling a sense of unease. It is understandable to consider that someone’s loved one, on passing, could be subject to an examination that involves methods of dissection and examination. There is no denying that the autopsy is inherently a process which is perceived as macabre, as all things involving the dead are, to an extent.
I must mention, however, the value of the autopsy lies in learning. Throughout history we have come to understand much of life through death, the dead are the teachers of the living. At the risk of sounding grandiose, the Latin adage Mortui Vivos Docent, rings like a universal truth. To establish the cause of death, to establish a comprehensive understanding of the person’s masked illnesses, is to educate ourselves to build a foundation upon which we can truly prevent disease. Further, the truth is always a cause worth fighting for, even if the methods for establishing the said truth can, at first glance, seem morbid. When I remember my first autopsy, I do admit feeling a deeply unsettling sense of unease. The deceased was a man who was found in an abandoned field, the circumstances of his death were unknown, only the small parts of his medical history, that he suffered from schizophrenia and tuberculosis were known to us. He had no family or relatives left.
I saw in the man the remnants of a life lived in agony. It was later established, through the course of the autopsy, that he had died due to hypothermia, most likely caused by an acute psychotic episode that led him to taking an erratic course of action where he was found, in an abandoned field on a cold autumn morning. This man’s life, tragic or not, was not my judgement to make. My duties lay in understanding why he had died, and in doing so, understand ways from preventing this from happening to someone else. I had to come to terms with my own preconceived notions of guilt, sentiment, justice and judgement to focus on the more important idea that there was a way to prevent this from happening again.
Now, a year later, the value of an autopsy is more apparent to me. Much of what we do in medicine seems difficult because there is no denying that it is. Surrounding ourselves with the worst of the human condition, of death, suffering and disease is not an easy task. Studying medicine has been an important journey, and it is a career I would do again if I ever had to. In a few months, I will be given a license to practice, a diploma and the title of “Doctor of Medicine”, but more importantly, I will be given a charge, to protect the health of the communities I will serve, and it is in pursuit of that charge that I defend the autopsy, as a tool that will help my patients, and the patients of thousands of doctors around the world, even if the task of it is unpleasant.
The following is a list of references and suggested reading for anyone interested:
- In Defense of Clinical Autopsy and Its Practice in Cuba (https://pubmed.ncbi.nlm.nih.gov/28225544/)