The Conventional Autopsy still has an Important Role
in Modern Medicine
RACHNA BAJAJ
INTRODUCTION
Human dissection has historically been carried out in search for humours, worms,
miasmas and divine spells to explain what caused illness and death.1 However, as
‘scientific’ thinking advanced, there was a desire to understand disease based on the
empirical evidence obtained from post-mortem examinations.1 This gave birth to one of
the most important gold standards of diagnosis, a great tool for medical audit and
probably the best teaching method of medicine – the autopsy.
The words ‘autopsy’, ‘necropsy’ and ‘post-mortem examination’ are synonymous with
each other and refer to the investigation of the human body involving an external
examination followed by the dissections of the head, thorax and the abdomen. The word
autopsy literally means ‘to see for oneself’. Autopsy rates in the United Kingdom (UK)
currently stand at 21.9%,2 out of which only 0.4% are not requested by a coroner and the
most common request for an autopsy occurs in cases of unexpected deaths where the

First Year Medical Student, The Royal Free and University College Medical School, University College
London, Gower Street, London WC1E 6BT, United Kingdom
Rachna Bajaj
1
cause is not apparent.34 Autopsies are also carried out for determination of manner of
death, evaluation of ante-mortem and post-mortem diagnosis, epidemiological purposes,
survey outbreaks, medical audit, research, teaching, forensic purposes and to
enlighten/reassure families or inform then of hereditary diseases.5
Despite the well-recognised importance of autopsies in twenty-first century medicine,
there has been a huge decline in autopsy rates across the world, causing concern amongst
the medical community. Factors that have contributed to the decline include distaste of
the procedure in both the physicians and the relatives, lack of financial incentives,
increased faith in imaging technologies, fear of litigation, lack of importance of the
autopsies in the teaching curriculum and poor communication skills on part of the
requesting physicians.6,7 Moreover, even if the clinicians do request for an autopsy, many
do not receive the autopsy report or that there are several delays in receiving the report.8
For example, in a study conducted by Whitty9 et al in the north east Thames region, it
was found that autopsy results were conveyed to general practitioners in only 47% of the
cases. This has caused an immense loss of learning opportunity and fostered an attitude
of apathy in physicians towards autopsy as a tool for learning. Organ retention scandals at
Alders Hey Hospital10 and the Bristol Royal Infirmary11 have been implicated as
contributing causes of the autopsy’s decline in the UK.
This essay henceforth aims to demonstrate the importance of the conventional autopsy to
modern medicine and will then discuss some methods of its revival in current medical
practice. It will also address the challenges posed to the conventional autopsy by modern
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The Conventional Autopsy still has an Important Role in Modern Medicine
techniques such as endoscopy, Magnetic Resonance Imaging (MRI), Computed
Tomography (CT) scans and angiography and highlight the importance of necropsy in
clinical discovery.
THE VALUE OF THE CONVENTIONAL AUTOPSY IN MODERN
CLINICAL PRACTICE
Teaching
As Moore and Dalley12, authors of the highly acclaimed anatomy text, ‘Clinically
Oriented Anatomy’, describe, ‘ You will remember some of what you hear, much of what
you read, more of what you see and almost all of what you experience and understand
fully’. This is essentially the main reason why autopsies are such a powerful tool in
medical teaching. They allow a student to experience the information in a textbook.13
Sir William Osler, a renowned physician of the 19th century, placed the autopsy at the
centre-stage of medical education.14 In fact, despite being a busy physician he carried out
more than one thousand autopsies and used his findings to explain the pathologic basis of
disease in his book called ‘The Principles and Practice of Medicine’.14 Osler’s textbook
reflects the intimate link between autopsies and medical knowledge. A strong grasp of
pathology, together with the ability to learn from the wrong ante-mortem diagnosis lays
the foundation to make a great diagnostician, he believed.14
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The Conventional Autopsy still has an Important Role in Modern Medicine
Hill and Anderson15 have also outlined the value of the autopsy to students. Autopsies
allow students to grasp pathology in clinical contexts.15 The knowledge of the
physiological processes in disease states is better illustrated with autopsies.15 Necropsy
sessions also provide the opportunities to learn anatomy and sharpen skills of
observation.15 The sessions are useful in impressing upon students that many conditions
often remain undetected despite extensive diagnostic tests and that multiple pathologies
add to diagnostic difficulty.16 This may familiarise students with uncertainty created by
imperfect diagnostic procedures.16 The autopsy sessions provide opportunities to discuss
subjects like death certification, forensic pathology, appropriate attitudes towards deaths
and communication skills essential for giving bad news or seeking consent for
autopsy.7,17 These skills are enhanced in a realistic, interactive environment rather than
solely from an inanimate medical textbook.15-17 Not surprisingly, medical students who
took part in the survey conducted by University of Manchester found that autopsies are
valuable in medical education even though about 17.6% disliked the offensiveness of the
procedure18.
However, since the autopsy rates even in teaching hospitals in the UK are below 5%,19
there are too few opportunities for medical students to gain reasonably from the autopsy
experience.15 Moreover it has been reported that there is not sufficient time to include
autopsies in the teaching timetable even though curriculum planners consider autopsies to
be valuable to medical education.15
Clinical Audit
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The Conventional Autopsy still has an Important Role in Modern Medicine
A lot of literature advocates the use of autopsies for the purposes of clinical audit even
though many clinicians consider the autopsy worthless in providing novel information
relevant to the advancement of medicine.20 Audit in medical contexts, as defined by the
Royal College of Pathologists (RCP), is a process of methodically and critically
appraising the quality of patient care.21 This involves assessing diagnostic procedures,
treatments, resource utilization and clinical outcomes.21 The purpose of audit is to
identify weaknesses in the system and recommend actions to overcome them.21 For
clinical audit to be meaningful, it is essential that autopsy rates, the quality of reporting
and conducting the autopsy are high.20,21 Only autopsies involve the thorough assessment
of all clinical-pathologic aspects. Clinicians on the other hand diagnose only the
conditions that they suspect. Hence, autopsies are considered useful in verifying the
accuracy of ante-mortem diagnosis, death certificates, examining suitability of medical
treatment and investigating perioperative deaths.20
 Verification of ante-mortem diagnosis
A discrepancy rate as high as 40%5,22 approximately exists between the ante-mortem and
the post-mortem diagnosis. An investigation by University of Pittsburgh23 revealed that
the discordance rates were 35% in 1938,24 39% in 1959,25 43% in 1974,26 and 47% in
198327. This seems to indicate that there has been no progress despite the great leaps in
diagnostic technology over the decades. Moreover, a sizable percentage of the diagnostic
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The Conventional Autopsy still has an Important Role in Modern Medicine
errors fall into the Goldman class I and II categories (7-13% and 15-25% respectively)28,
which are defined below along with the Goldman class III and IV categories.
Box 1 – The box defines the classification created by Goldman29 pertaining to diagnostic
errors obtained from the comparison between ante-mortem and post-mortem diagnosis.
Class I - a serious pathology, which if diagnosed while the patient was alive could
have led to cure and thereby possibly have extended survival
Class II – a serious disease which even if diagnosed in life would not have influenced
the treatment or care plan.
Class III – non life threatening diagnosis linked to an incurable disease but not
immediately responsible for death
Class IV – other types of non life threatening diagnosis
In the past, the discordance rates between post-mortem and ante-mortem diagnosis were
as high as 77% for spinal tuberculosis, 61% of cirrhosis and 26% for lobar pneumonia. 30
These results however were attributed to limitations in the diagnostic methodology
instead of incorrect evaluation by the responsible clinicians. Eventually, diseases such as
spinal tuberculosis became rare as medicine advanced.20 Despite the progress, studies
have consistently shown that the discrepancy rates remain significant. 20
Goldman29,31 et al evaluated the value of autopsies in the 1960s, 1970s and the 1980s,
and found that approximately 10% of the 100 randomly chosen autopsies in each of these
decades revealed a serious diagnosis. The study also revealed that an additional 12% of
the autopsies revealed class II diagnostic errors. It was concluded that many cases
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The Conventional Autopsy still has an Important Role in Modern Medicine
remained undiagnosed despite the high dependence on CT scans, ultrasound and
radionucleotide scans around 1980s. It is believed by some doctors that these discrepancy
rates could be an overestimate because patients were selected for autopsies due to
uncertainty about the ante-mortem diagnosis.20 Moreover Goldman et al published their
study 1983, which will be considered outdated by today’s standards. Are the results still
valid today? Kaveh32 et al who published their study 20 years later have estimated that a
major error rate and a class I error rate in a modern US institution could vary from 8.4%
to 24.4% and 4.1% to 6.7% respectively. These figures indicate ranges which correspond
to autopsy rates ranging from 100% (rate at which there is no clinical selection) to 5%
(the US national average).
The need to establish an exact cause of death of their newborn is highly important for
parents who will be able to use this information to plan future pregnancies and take
certain precautions. Gordjin33 et al report that the perinatal autopsy is highly valuable as
it reveals additional findings or detects the wrong clinical diagnosis in 22% to 76% of the
cases.
Studies have also shown that the accuracy of clinical diagnosis does not improve even if
clinicians feel certain about their diagnosis. For example, in Edinburgh, clinicians were
shown to be wrong 1 out of every 4 times even when they felt ‘fairly certain’ about their
diagnosis.34 The discrepancy rates also did not improve even when the length of stay in
hospital was increased.35
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The Conventional Autopsy still has an Important Role in Modern Medicine
Even though most of the literature highlights the usefulness of necropsies for verification
of clinical diagnosis, Forsythe36 et al have published a study that contrasts this widely
held belief. In their study they autopsied 102 of their patients who died in their trauma
centre. Out of these patients none was observed to have a class I error and there was only
1 case in which an unavoidable technical error occurred. Hence it was concluded that
autopsies were not useful for adding to the trauma peer reviewed quality assurance
process.
A serious setback that the conventional autopsy faces is that at present no study has been
able to correlate high autopsy rates with a decreased discrepancy rate.
21,37
Despite this
glaring fact, discrepancy rates are considered an important measure of quality care.
Lassiue38 et al and the RCP21 believe that if this link is proved, the importance of
autopsies to modern medical practice will be irrefutable.
 For verification of death certificates
Many countries issue death certificates without the need of an autopsy. This may lead to
significant errors in epidemiological statistics which could have far-reaching impacts on
resource allocation, public health policies, and the ability to monitor outbreaks and detect
environmental/occupational hazards. For instance, it has been reported that death
certificates in the USA are inaccurate in 25 to 56% of the cases.20 In the UK, this figure is
estimated to be around 30%.20
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The Conventional Autopsy still has an Important Role in Modern Medicine
 Investigating perioperative deaths
The importance of necropsies with regards to the investigation of perioperative deaths
was emphasized in the report published in 1990 by the National Confidential Enquiry
into Perioperative Deaths (NCEPOD).8,20 It was commented that the low autopsy rates
were to be ‘deplored’ because the autopsy was a ‘useful investigation’ for numerous audit
purposes of which NCEPOD was only one of a kind.8 Recommendations were made to
increase the quality of information stored in medical records and increase post-mortem
rates.8 Consultants were urged to become keen in seeking consent from families about the
autopsy because it was discovered that in only 20 out of 417 autopsies studied20, were the
consultant personally involved. It was also noted during the enquiry that in less than half
of all autopsy cases were the surgeons informed of the autopsy date and time20.
 Assessing the suitability of medical treatment
Underwood20 reports that the cause of death in many cancer patients is often attributed to
their illness rather than to the damaging effects of the cancer treatment. He explains that
pathologists sometimes face situations in which the patient was given strong cancer
treatment and yet there was actually no evidence of a tumour being present in the body
when it was autopsied. He argues that it is essential to assess if toxic treatments have
been appropriately applied especially when the consequence of these treatments can be
fatal.
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The Conventional Autopsy still has an Important Role in Modern Medicine
THE CONVENTIONAL AUTOPSY VERSUS TECHNOLOGY
CT scans and MRI
It has been widely debated that advances in diagnostic technology have rendered the
conventional autopsy redundant especially when technology can provide us most of the
answers that we need. For example, the conventional autopsy has been challenged by the
advent of virtopsy (image-guided autopsy).39 This is a technique which involves the use
of CT scans, MRIs and minimally invasive biopsy to investigate the cause of death. The
virtopsy has the advantage of being a quicker and less invasive method in comparison to
the conventional autopsy.39,44 It also proves useful in circumstances where relatives are
unable to consent to a full autopsy due to religious/personal reasons. 39,44
It has been argued that because it has been possible to have a high degree of resolution
with a three dimensional reconstruction, virtopsy can eventually replace the conventional
autopsy.39 This belief however seems to be questioned in a study40 comparing the use of
MRI autopsy with the conventional autopsy. In this study, 10 MRI autopsies were
performed in cases of non-forensic sudden unexpected adult deaths. Four radiologists
were required to report their findings independently on all 10 cases. In only one case out
of the ten were all the radiologists able to state the same cause of death as that discovered
by the conventional autopsy. In four cases, none of the radiologists were able to point the
correct cause of death even though they discovered important features. A problem in
distinguishing between the post-mortem clots of thrombus and oedema from
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The Conventional Autopsy still has an Important Role in Modern Medicine
inflammatory exudates was reported. It was hence concluded that it was better to carry
out the imaging techniques whilst the patient was alive as this was more cost effective.41
Investigations performed by Patriquin42 et al support the conclusions of the
abovementioned study.
In a research done at Nottingham University, 70 patients were clinically diagnosed using
MRI to have suffered anterior circulation stroke syndrome.43 However, when autopsies
were conducted only 49 of the 70 patients were correctly diagnosed, whereas 6 were
misdiagnosed and 15 were misclassified. The implications of these findings are that
errors due to misdiagnosis will not have been taken into account in clinical trials and the
results could be confounded. This will mean that the therapy for strokes will be
misapplied in patients who have been misdiagnosed.
In another similar pilot study as described above, the conclusions were that radiological
investigations provided certain details which were not found out during the autopsy and
the autopsy provided certain details that were not apparent from radiological
investigations.44 This study henceforth advocated that more research needs to be done to
improve imaging techniques for pathology purposes, evaluate the sensitivity and
specificity and also assess cost effectiveness. Research carried out by Whitby45 et al,
Woodward46 and Brookes47 also report findings that propose the use of MRIs as
substitutes for the conventional autopsy.
Endoscopy
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The Conventional Autopsy still has an Important Role in Modern Medicine
Laparoscopic autopsy is also challenging the place of the conventional autopsy in modern
medical practice.48 The sensitivity and the specificity of laparoscopic autopsy is 91% and
94% respectively for the diagnosis of intra-abdominal lesions.49 This technique allows
one to accurately map certain types of wounds that lack sharpness and are deep, and
thereby opening new possibilities in the field on forensic medicine.48,49 Thoracoscopy
also offers alternatives to investigate bleeding into the pleural cavity and assess injuries
of the diaphragm. Like virtopsy these techniques also have the advantages of being less
invasive and can circumvent the issues of consent and religious reservations.
Needle Necropsy
Another technique with has attempted to replace the conventional autopsy is the needle
necropsy. However this approach has limitations because some organs and lesions are
relatively inaccessible.50,51 Studies have reported that the sensitivity of needle necropsy
compared with the conventional autopsy could be 67%, 48% and 43%.52,53,54 Hence
attempts have been made to perfect this technique. Farina51 et al have considered the use
of ultrasonography, also known as echopsy, to improve the way samples are collected.
Despite the more advanced manner of sample collection, only 83% concordance rate was
observed when measured against the conventional autopsy. The technique is of limited
value in the detection of pulmonary thromboembolism, diseases of heart valves and small
carcinomas.51 The advantage of ultrasonography combined with needle necropsy
however is that it is cheap, easy to perform and more acceptable to relatives. Perhaps it
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The Conventional Autopsy still has an Important Role in Modern Medicine
may also prove to be a more suitable alternative with the new threat from infectious
diseases.51 This approach is suitable for discovering diseases not diagnosed in life as well
unlike MRIs and CT scans.51
Post-mortem Coronary Angiography
Post-mortem coronary angiography is regarded to be superior to the conventional autopsy
as it is better able to determine the extent of deposition of fatty plaques in the coronary
artery.55 This is because in conventional autopsy, stenosis of the coronary arteries is
determined after sectioning them.50 Errors are introduced depending on the type of
sectioning chosen. High calcification of the arteries will cause these errors to be large.50
Moreover, the pathologist will not be able to re-examine the heart after the post-mortem
unless the whole of the coronary artery is preserved for histological purposes.50 Postmortem angiography conversely is a more precise and reproducible technique for
assessing the degree of stenosis and detecting acute thrombotic coronary occlusion.
Moreover, post-mortem clots do not pose a problem as they hardly ever lodge in coronary
arteries. Weman56 reports that the sensitivity was 100% for discovering anastomotic and
graphed stenosis. Indeed, it was difficult to observe these findings using the conventional
autopsy.
THE AUTOPSY AND DISCOVERY
Specific diseases where autopsies have proven to be particularly useful in the elucidation
of diagnosis are metastatic neoplasms31 and Alzheimer’s disease. Burton22,31
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The Conventional Autopsy still has an Important Role in Modern Medicine
pointed out that more than three out of four of the liver cancers are revealed only at the
autopsies. The diagnosis of Alzheimer’s disease is also only confirmed conclusively after
the necropsy of the brain. This is because the clinical method of diagnosing Alzheimer’s
involves excluding all other possibilities for the symptoms observed.
The autopsy has also enabled the discovery of many new diseases ever since it has been
used for medical purposes. Examples include the West Nile virus and Creutz-felt Jacob
Disease (CJD) and Alzheimer’s disease.57 Autopsies are also important for research and
development of surgical techniques. The technique of open heart surgery for example
was perfected with the help of autopsies.57 In the future, Goldman58 believes that the
autopsy will remain an important tool to diagnose the diseases of old age. It is possible
that more new and exotic diseases will be discovered as the life expectancies of
populations increase. A relatively reasonable rate of autopsies is required in the future if
medical knowledge and advancement is desired.
REVIVAL
The NCEPOD inquiry recommends that communication between clinicians and
pathologists needs improvement and the autopsy report needs to be promptly sent to the
relevant clinicians. Smith and Zumwalt59 recommend that a video should be created for
relatives to emphasize the value of the autopsy. Nurses and clergy could be deployed to
seek consent instead of clinicians as this has proven to increase rates. Roberts60
recommends that more clinically relevant information should be provided in autopsy
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The Conventional Autopsy still has an Important Role in Modern Medicine
reports to generate an interest for autopsies in clinicians. Haque61 et al suggest that the
fears of legal repercussions need to be allayed if it is hoped that rates should rise again.
Seeking the support of the hospital administrations61, arranging financial incentives62,
setting compulsory government targets and improving public acceptance63 may help
autopsy rates to climb again. It has also been suggested that students may be allowed to
learn from coroner’s autopsies in face of declining hospital autopsies.64
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