UNDER THE MICROSCOPE

Autopsia (Ancient Greek) — to see for oneself.

Most people think of autopsies only in terms of forensics, having been indoctrinated by television shows like “CSI.” Those are forensic autopsies, which determine causes of unnatural deaths — suicide, homicide, accidents, mass disasters, and the like. But medical autopsies that are done to determine the cause of natural deaths are just as important. 

Unfortunately, while forensic autopsies remain a valuable tool and are still widely done, medical autopsies are on the decline. I have already mentioned the mistaken notion of resurrection and other religious beliefs as reasons for the refusal to donate organs (Don’t bury good organs-Nov. 28, 2023). The same reasons are given for refusing a request for autopsy of a beloved family member who died in the hospital setting. 

The medical autopsy is a valuable tool for the medical profession and the patients who will benefit from the insights gained from autopsies, even in this modern age of CT scans and MRIs. There is up to 25 percent error rate in diagnoses uncovered in autopsies, of which at least 10 percent could have led to interventions that would have altered the treatment given and thus save lives. The insights gained can then be translated into changes in practice to benefit future patients with the same conditions.

In some instances, the autopsy can uncover hereditary conditions such as cancer and familial predisposition to early deaths due to heart attacks, such as a certain case I once had. 

A 35-year-old apparently healthy male suddenly collapsed and died while playing his regular game of basketball. The distraught family requested an autopsy to determine the cause of death. It turned out to be a fatal heart attack, brought about by severe blockage of the arteries supplying blood to the heart. On discussion of the autopsy findings with the family, it was revealed that an older brother had also died of a heart attack. The family has a hereditary condition of elevated cholesterol that hastens the hardening and blockage of arteries. The remaining siblings and close relatives were advised to undergo regular medical checkups and continuing medication for reducing cholesterol levels. Without that autopsy, they could be dropping dead one after another at a young age.  

There are other potential uses of autopsies: evaluating new therapies, studying familial diseases, discovering the reasons for failures of current therapies, preserving cancer tissues from different sites of a deceased patient to gain insights on why cancers spread to other organs (metastases), finding the cause of an infectious-disease outbreak that might cause another pandemic, and homicides and suicides occurring undetected.

With the falling autopsy rate, the training of future pathologists will be imperiled, causing future practitioners not to be proficient with autopsy techniques and to fail to appreciate the diseased organs. Indeed, pathologists who confine themselves to just diagnosing surgical specimens are not complete pathologists in the tradition of Virchow, Rokitansky, Morgagni, and Osler, pioneers in the field of pathology. 

Without autopsy exposure during training, pathologists who decide to subspecialize in forensic pathology face a huge handicap, for how can they discern the difference between natural and unnatural causes of death if they don’t understand the first?

If the autopsy is consigned to the dustbin of history, medical progress will be hampered. Physicians will continue to treat patients the usual way, which may have been shown to be ineffective or even detrimental to the patient without the feedback from autopsy findings. New therapies, especially for cancer, will not benefit from the hindsight of their effects as gleaned from post-mortem examinations of the failed cases. 

The oncologists (cancer specialists) will be plagued by unanswered questions on tumor evolution and heterogeneity, treatment resistance, immune evasion, and optimal drug-targeting strategies. Even the current practice of tissue banking is limited by the inadequate volume and sources of tumor tissues collected.

The practice of medicine is far from perfect. Despite outstanding progress in imaging and other sophisticated clinical investigations, autopsies maintain an important role in detecting diagnostic and therapeutic failures. Unusual presentations may lead to the wrong clinical diagnosis, and an autopsy can provide the answers that can save the life of another patient who presents with the same unusual symptoms in the future.

For the deceased patient’s family, the autopsy conference can help them process their grief, allowing closure by providing clarification of the underlying causes of death and alleviating their guilt over whether proper care was rendered to the patient.

If your doctor approaches you as a bereaved family member and asks to perform an autopsy on your next-of-kin, please remember the good it will do for your family, for the practice of medicine, and for all of mankind. Please sign the autopsy consent. Don’t let the autopsy die, for without it, this will be a less healthy world for all.