A Medico Legal Autopsy Health And Social Care Essay

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The future role of the invasive autopsy in the investigation of deaths and possible alternatives.
Mohammed Saleh Madadin
Word count excluding references (9203 )
Declaration of Originality
Name: Mohammed Saleh Madadin
I certify that this dissertation is entirely my own work and free from plagiarism. I allocate joint copyright to the Society of Apothecaries.
Signed : Madadin , Mohammed Date : May 2013
Table of Contents
1. Abstract ………………………………………………………………
2. Introduction ………………………………………………………….
3. History of Autopsy ……………………………………………………
3.1 Early pre-historic…………………………………………………….
3.2 Middle Ages …………………………………………………………..
3.3 Modern or recent ages………………………………………………..
4. What is Autopsy (overview)………………………………………….
4.1 Definition …………………………………………………………
4.3 Types of Autopsy ………………………………………………….
4.4 Procedure of autopsy ……………………………………………….
4.5 Autopsy Report ……………………………………………………..
5. Roles of Autopsy………………………………………………………..
5.1 In Death investigations ………………………………………………
5.2 Other roles of Autopsy……………………………………………….
6.Legal status of Autopsy …………………………………………………
6.1 System & organization in UK……………………………………………
6.2 System & organization in other countries ……………………………….
7. Decline Rate of Autopsy …………………………………………………
7.1 Decline Rate of Autopsy in UK………………………………………..
7.2 Decline autopsy rate worldwide ……………………………………….
7.3 Reasons for autopsy rate decline ………………………………………
7.4 Societies attitude toward autopsy………………………………………
8. Alternatives for Autopsy……………………………………………………..
8.1 Role of Imaging technique in Diagnosis…………………………………..
8.2 imaging Radiology as Alternatives to autopsy ...............................................
8.3 Using imaging in Forensic settings ………………………………………..
8.4 Reliability of the Imaging Autopsy…………………………………………
8.5 medico legal questions ………………………………………………………
9. Summary & Conclusions ……………………………………………………….
Post mortem is Latin meaning ‘after death’. The post mortem examination carried out to elucidate the cause of death is known as an autopsy. The autopsy has been practiced since time immemorial but its role has been changing in recent times and its practice carried out for different reasons. In the past, the study of disease was the motivation for carrying out an autopsy but the current objectives are mainly to determine the cause and approximate time of death of the individual together with other important related facts.
Two types are practiced, namely hospital and forensic autopsy . Forensic autopsy is an essential part of the investigation into an unexplained death as it can often pinpoint the exact cause. The organization of the investigation into the death of an individual and the autopsy in different countries may often follows different systems; the judicial, medical examiner and coronial systems are the commonest. For the last few decades there has been a clear decline in the autopsy rate , There are many reasons for this decline but perhaps one of the most important is the attitude of the general public towards autopsy. This attitude towards both death and autopsy depends on different societies, religious backgrounds, and ingrained beliefs that consider the autopsy to be an unacceptable disfiguration of the dead body. at the same time, remarkable developments of imaging techniques have also led to a decrease in the rate of conventional invasive autopsies as diagnosis became more accurate . For these reasons, imaging techniques are an excellent alternative to the traditional autopsy in many but certainly not all cases. Studies that have evaluated the reliability of radiology in medico-legal investigations have revealed many advantages as well as limitations in the use of this methodology and concluded that a number of medico-legal questions need to be addressed. At the present time, further research and studies on imaging autopsy need to be carried out to increase its accuracy, solve current problems and answer the medico-legal questions raised by the new methodology. An imaging autopsy can certainly help to enhance the diagnostic yield of a traditional autopsy, and eventually may well commonly replace it in the future, in the near future.
Word count excluding references (9203 )
A medico-legal autopsy performs a very important role in the investigation of death. However, there are major societal objections centered mainly on the invasive nature of conventional autopsy especially with the advent of advanced, non-invasive diagnostic techniques such as radiological imaging radiology. of the present research is on the future of invasive autopsy versus the rapidly developing non-invasive alternatives. how forensic autopsy used in current practice evolved throughout history, and describes the objectives and roles of the procedure either in forensic settings or other roles. An explanation will be given about the legal status of the autopsy in the UK and selected other countries. In addition, a review of the attitudes towards autopsy held in these countries together with the views of various religions will be documented.
The main aims are to consider alternatives methods to invasive autopsy, their accuracy and reliability, and indeed the future role of conventional forensic autopsy. An extensive literature search has been carried out to determine current worldwide practices. Several research articles have studied the efficacy, outcome expectancies and future of imaging autopsy while others have investigated the specific use of novel imaging techniques that could help in medico-legal investigations of death. Although difficulties in legal issues related to the imaging autopsy was encountered as few literatures discussed the issue and different legal systems worldwide made it more difficult but some legal questions addressed in this research.
This overwhelming conclusion is clarifying the current situation of imaging autopsy and the fact that more research needs to be carried out into imaging autopsy methodology to ensure that the non-invasive autopsy will become a valuable, medico- legal alternative to the conventional invasive autopsy.
History of Autopsy
The role of autopsy has changed over time. Attitudes toward dead bodies have evolved, and many factors have led to the performance of different acts toward dead bodies in the past, including religious beliefs and cultural and geographical backgrounds. Past acts and practices involving dead bodies included mummification, burials, cremation, or even using dead bodies in arts.1
Early Pre-historic
In ancient times, a procedure for examining animal organs, such as the liver, was practiced, called hepatoscopy; this was known to be practiced in 3500 BC in Babylon. Also, examination of slaughtered animals for signs of disease was practiced in the Talmudic period, and ancient Egyptians practiced mummification.2
Hippocrates, who lived between 468 and 377 BC, was the first real physician because he was the first to posit that disease resulted from natural causes and is not due to a spiritual origin. His thoughts and ideas determined the progress of scientific medicine later on. However, despite this naturalistic philosophy, autopsy did not play a role immediately but acquired a major role in pathology 1,800 years after Hippocrates’ time.3
In early medical theory, anatomy had no or A very small role. Anatomical knowledge continued to increase slowly in ancient times and had a minute influence on medical theory.1 During that early period, embalming was practiced in Egypt, and because the cutting of dead bodies was not prohibited, dissection of the dead was practiced in Alexandria and in the Greek world in the 3rd century; no human dissections were performed in the Greek world prior to the third century. Erasistratus, an anatomist and physician who lived between 310 and 250 BC, did dissections and made observations about the effects of disease.2,3
Middle Ages
Data and information about autopsy are scarce for this period, but some references show an interest in autopsy. Also there is some evidence that autopsy-related activities were carried out in England in the 13th century, according to a manuscript dating from about 1290.4 Cetto Singer determined that dissections were being done in Italy between 1266 and 1275 and that the earliest dissections were medico-legal.3,4 In pathology, the system of Galen was still employed. Galen was a Roman physician (131-200 AD) who carried out dissections on animals and extrapolated the anatomical findings to humans.5
Modern or Recent Ages
During the 15th century, autopsies were done with more consideration for pathology, In the 16th and 17th centuries, many autopsies were done, and pathology made significant advances as the role of autopsy continued to advance. In the 18th century, new developments, thoroughly linked to the French Revolution, introduced new changes to pathology and the conduct of autopsies because battlefields produced more practice and more experiments were done.1-5
Xavier Bichat, a French anatomist and physiologist (1771-1802), is referred to as the father of histology because he achieved a turning point in medical history. He focused the medical sciences toward pathology, anatomy, and physiology. He directed attention away from organs toward the components of organs (the tissues).6
The golden period of autopsy was the 19th and 20th centuries. Starting in the first half of the 19th century, other new developments greatly made revolution in medicine, and the basic or preclinical sciences underwent a sharp spurt. Further progress in physiology and chemistry led to great achievement, and more vital revolution was the development of the microscope. This development led to what we call cell theory, a direct outcome of microscopy, which introduced a whole new dimension to the study of disease. All of these developments led to further progress in autopsy.3
What is Autopsy? (Overview)
An autopsy is the dissection of a dead body. The word "necropsy" is more accurate in description, but "autopsy" is more widely used. In the U.K. and several other countries, the term "post-mortem examination" is commonly used, but it lacks accuracy, as it does not describe the scope of the examination, whether it is simply an external examination or an internal examination and dissection.7 The term "autopsy" originated from Greek word "autopsia," which means "self-examination" or "seeing by one’s own eye." In the Oxford English Dictionary, the definition is "dissection of a dead body."7
As I mentioned, autopsy has been practiced for long time for various reasons. In the past, the study of disease was the motivation to do autopsies, but for the current modern practice of forensic autopsy, the objectives are to determine the cause and time of death, to identify the body and document injuries, to obtain samples for further investigation, and for the purpose of teaching and education.8,9
Types of Autopsy
There are two types of autopsy:
Hospital autopsy: this type is carried out to diagnose, to determine cause of death, the study the extent of disease and therapies effects, and for education and research. It has great value in discovering undiagnosed conditions.10,11
Medico-legal or forensic autopsy: this type is carried in medico-legal cases, mainly to determine cause of death. It differs from a hospital autopsy with respect to consent, which is not needed to carry out a forensic autopsy.12
Autopsy Procedure
Autopsy procedures are almost uniform, although some differences in regulation exist in different regions and countries. The practice of medico-legal autopsy is organized and standardized by legislation and done under the instruction of the authorities. The published guidelines differ from country to country. The U.K. Royal College of Pathologists maintains the guidelines for practicing autopsy within the U.K., as well as coroner activities and rules.13 There has been an increase in interest to make international rules for the practice of forensic autopsy. For example, the European Council of Legal Medicine (ECLM) published Harmonization of the Performance of the Medico-Legal Autopsy.14
The steps of an autopsy include the pre-autopsy, which involves examining the circumstances, history, and hospital reports, scene reports, and any other available data. Then the examination includes an examination of the clothes, an external examination, dissection of the body and examination and dissection of the organs, the taking of samples, and restoration of the body. After that, laboratory tests such as toxicological and DNA tests.7,10
Autopsy Report
The autopsy results are summarized and written in a report called the autopsy report. The autopsy report is not only a description of the findings but also correlates the findings to the circumstances and history, investigation, and laboratory results and then gives an opinion. Many different formats of autopsy reports are used; some may be detailed reports, especially in teaching hospitals, while others are more focused. However, nowadays, almost all forensic pathology textbooks standardize the formula for writing an autopsy report, though with some flexibility and a little change from book to book.15
The Role of Autopsy
In Death Investigations
A forensic autopsy is an essential part of a death investigation, as it can reveal important information such as the cause of death , time of death, and manner of death and allow the collecting of samples for toxicological analysis and further investigations.7-12
Other Roles of Autopsy
Autopsy plays an important role in various ways, not just in death investigations. Autopsy has an important role in the diagnosis of undiagnosed clinical conditions, and it is also involved in the investigation of malpractice, in addition to education, as I will discuss in this section.
Autopsy is still use to confirm clinical diagnoses, despite the development of improved diagnostic techniques. A large meta-analysis study determined that about 30% of death certificates are incorrect and that about 50% of the autopsies performed discovered findings that were not diagnosed before the person died.16, These diagnoses include many clinical conditions, including tumors. Some previous studies17 have proved that the diagnosis of tumors by autopsy is still better than clinical diagnosis. Another clinical condition in which autopsy can play an important diagnostic role is cardiovascular disease, as autopsy diagnosis is more accurate than clinical diagnosis. Such discrepancies can lead us to question the validity of statistics derived from death certificates based on clinical diagnosis and the sensitivity of epidemiological studies that do not consider the limitations of using only clinical methods and do not depend on autopsy, which is more precise. Thus, autopsy yields increased accuracy of cardiovascular disease statistics as well.18
Autopsy also finds answers to unexplained clinical inquiries and is a major source of unexpected findings, and these finding will lead to improved clinical practice and knowledge.19,20 A previous study19 showed that 93% of clinically unsolved questions were resolved by autopsy. There are many conditions that lead to unexpected death and usually cannot be diagnosed clinically but can be diagnosed by autopsy, including emphysema, bronchopneumonia, pulmonary thromboembolism, and arteriosclerotic cardiovascular disease.20
We can conclude that autopsy is used as a quality assurance measure to verify clinical diagnoses. Almost all previous studies have shown a significant discrepancy between the main clinical and autopsy diagnoses and low sensitivity, specificity, and predictive values for diagnoses of causes of death and clinical diagnoses. Thus, the value of autopsy is clear with respect to clinical diagnosis.21
From its beginning, autopsy has been used in education. Today, it is used in teaching medical students at the undergraduate level as well as in pathology training at the postgraduate level. Autopsy plays a major role in teaching students the basics of pathology and clinical pathological relations. In addition, it is a perfect method for teaching human pathophysiology from gross findings and showing the mutual relationship of lesions in different organ systems. These are the basis for creative diagnostics in surgical pathology, and experience gained from post-mortem investigations allow the pathologist to identify new and unusual disease patterns. Autopsy is also considered a process by which medical students learn about medical uncertainties and how to deal with them. The current decline in autopsy rates negatively affects future doctors’ education.22-25
Autopsy can detect the cause and mechanism of death, and it provides help in lethal cases of medical malpractice. The role of autopsy in malpractice serves not only to detect cases or for diagnosis but also to prevent such malpractice cases. The percentage of autopsies due to malpractice claims varies widely between 1.9% and 20%.26
Legal Status of Autopsy
System and Organization in the UK
Medico-legal autopsy in the UK is under the jurisdiction of the coroner. A coroner is an independent judicial office holder, appointed and paid by the relevant local authority. A coroner is a lawyer or a doctor and sometimes is qualified in both professions. Coroners inquire into deaths due to unknown causes, unnatural deaths as a result for example of violence, and death in custody among others. The purposes of the coroner service is to first establish whether a coroner’s inquest is required, and if so, to establish the identity of the person who has died, and how, when and where that person came by their death. One aim of the coronial process is to assist in the prevention of similar future deaths, and to provide public reassurance.
In some cases a coroner may refer the death to the police for investigation on their behalf. Under some circumstances an independent body such as the Health and Safety Executive may instigate a separate investigation into a death.
Less than 50% of deaths are reported to the coroner. In many cases the deceased’s own doctor, or a hospital doctor who has been treating him or her during their final illness, is able to issue a Medical Certificate of the Cause of Death (MCCD) without reference to a coroner. Nevertheless, the coroner may still ask a pathologist to examine the body and carry out an autopsy if they have grounds to believe there were suspicious circumstances surrounding the death.
After the autopsy is completed, the coroner will normally issue the necessary authority to permit burial or cremation of the body, so that the funeral can be held, even though an inquest may be required.
The regulation of autopsies is under the auspices of The Royal College of Pathologists who stipulate guidelines on the practice of an autopsy. In 1998, The Royal College of Pathologists commissioned a new code of practice for the autopsy in the UK.13,27,28
Systems in Other Countries
The organization of death investigations and the autopsy in different countries generally follows one of 3 systems namely the judicial, medical examiner and coronial systems. Each of these systems will now be considered in turn.
Judicial System
Occasionally known as a ‘civilian’ system, the generic judicial (criminal investigation) system is used in the majority of the European Union countries, where an official is responsible for investigating a potential crime and initiating a prosecution if necessary. In most countries, the examining magistracy overseas judicial involvement and also takes responsibility for directing the investigation. In all countries that follow the judicial system, there is a requirement for the authorities to undertake autopsies even when the next of kin have not provided consent. However, they are usually only authorized where there is suspicion of crime surrounding the death. In these cases, forensic autopsy specialists perform the autopsy. 29
Medical Examiner System
In 1877, the first Medical Examiner System was established in the state of Massachusetts, USA. The system required that a physician, known as a medical examiner, replaces the coroner. Forensic pathologists, who establish the cause of death but generally do not inquire into the circumstances of the death, direct the Medical Examiner System. Within this system, forensic pathologists provide services to police and criminal investigation units, and undertake in-house autopsies and other scientific investigation services as required.30
Coronial System
The coronial system as discussed earlier is used in the UK and other countries, now known as those within the Commonwealth, and in the USA.29,30
Decline in the Autopsy Rate
Decline of the Autopsy Rate in the UK
The autopsy rate is defined as the ratio of the number of autopsies to the total number of deaths. Reporting of autopsy cases differs according to the practice of the particular institution and whether it is a hospital or forensic autopsy. During the last decades, there has been a clear decline in the autopsy rate, especially in hospitals. 31 The autopsy rate can vary according to the nature of the death, the sex and age of the individual, and may be susceptible to the influence of regional variations. 32
The number of deaths that occur each year in UK varies, somewhat; in 2010, the combined numbers of deaths in England and Wales was 230,600 while the figure was slightly less in 2011, being 222,371. Approximately 47% of all deaths are reported to the coroner and this percent has been fairly constant over the last few years. The percent of cases that underwent an autopsy from all deaths reported to the coroner was 46% in 2009, 44% in 2010 and 42% in 2011, percentage that is continuing to decrease year by year. 33
Decline in Autopsy Rates Worldwide
The decrease in the autopsy rate is not an exclusive feature of the UK but rather reflects a global international change. In the USA, the number of autopsies performed has decreased in recent years. In a comparison study between autopsy prevalence in 1993 and 2003, it was unequivocally demonstrated that there was a significant decrease in the autopsy rate year by year. 32
The current percentage of hospital autopsies in the USA today is around 6% while it was 30-40% in the 1960s. 34 In Australia, autopsy rate dropped by 50% between 1992 and 2003. 35 In Denmark, the percentage of autopsy cases was 45% in 1975 compared to only 16% in 1990 36. In France, the rate declined from 15.4% in 1988 to 3.7% in 1997. 37
Reasons for the Decline in the Autopsy Rate
There are many possible reasons responsible for the decline in the autopsy rate and some of these will be considered next.
One major reason is that there has been a shift in care; older and sick patients are dying in long-term facilities and/or in hospices where health professionals oversee their care. Another reason is cost constraints with stringent changes in healthcare coverage and reimbursements under constant review in the present economic circumstances; autopsies are no longer considered to be essential without good reason.
Surprisingly, there is a paucity of data available in the public domain detailing the true cost of an autopsy (including fixed and variable costs), although from the small number studies that have attempted to collate both fixed and variable costs, there is a great variability in the estimates. 38 The most recent published mean estimated cost per autopsy case in the USA was $1,275.00. Clearly, the actual cost of an autopsy depends on many variables, including the case loads, cost of personnel, space, materials and instrumentation, processing and ancillary testing. 39
It is noteworthy that the cost of an autopsy is generally not covered by managed care organizations or by third-party insurers as part of individual's healthcare plans. As a result, the cost of an autopsy may be passed on, somewhat incongruously, to the next of kin at the discretion of the hospital or the individual pathologist who performed the procedure. 38,39
Another of important reason for the decline in the autopsy rate is the increasing difficulty of obtaining consent from relatives. Notwithstanding the cost, there are many factors that lead a relative to deny consent for an autopsy. These factors include their perceptions and beliefs about death, religious objections and strong cultural beliefs that the body should not be ‘defiled’ after death. An excessive time lapse between the person’s death and being notified of it are also factors. A lack of direct feedback between the clinician overseeing the deceased and the pathologist may also prevent a routine autopsy from being carried out. 40 Another reason for the decreased autopsy rate is that advanced radiological and diagnostic techniques will most likely have pinpointed the likely cause of death when the patient was alive, but perhaps gravely ill. One further reason is a substantial decrease in the resources employed in medical schools for autopsy education for trainee doctors. Students increasingly have an insufficient knowledge of the role and value of an autopsy. Physicians who did not attend autopsies during their training also surprisingly tend ‘not to believe’ in the benefits of established method. 40, 41
Society's Attitude To Autopsy
The attitudes towards both death and autopsy differ between different societies, not only from society to society but also by demographics within the same society. As mentioned earlier, throughout history different attitudes towards autopsy have evolved and usually these attitudes have had a key role in decreasing the autopsy rate or indeed in leading to the demand for an alternative non-invasive form of autopsy. 31
When one considers the benefits of an autopsy, it must be with respect to the moral and societal culture and beliefs that are current. At the same time, it is important to let the next of kin know that sometimes an autopsy is obligatory according to the law of the land (suspicious death). Thus, a forensic autopsy can be carried out against the wishes of the immediate family. Unfortunately, it is a procedure burdened with a variety of misconceptions, myths and emotions by lay people, as well as by some physicians. 42 It goes without saying that sensitivity and great tact is required by the presiding physician when raising this highly emotive subject with the next of kin.
Public perception has played a major role in decreasing the autopsy rate worldwide. In a previous study, 59% of the population surveyed believed that an autopsy causes visible disfigurement of the body, and 69% believe that an autopsy will delay the funeral. 43
The corps belief by many people as it stands is that the dead body is the only ‘concrete symbol’ of the deceased integrity, the corpse being the ‘symbol’ of the dead person’s life. 31 The autopsy threatens this most powerful symbol in the eyes of some people, the central symbol in modern rituals of death. Particular family circumstances and some religions may require adherence to specific timing restrictions that can be honored only by expediting the autopsy, or by the performance of a limited examination. It should be remembered that autopsy, except under civil law requirements, is strictly prohibited within some major religions. 44 However, in modern societies the concept of the autopsy is easily understandable by most members of the community but many studies have also reported different beliefs in different countries According to a Swedish study 45, the large majority of people would theoretically permit an autopsy to be carried out on a close relative. This conclusion is supported by a study in the USA conducted on family members of a relative who died in hospital. These results may not, however, apply to forensic autopsies. 42
In one study, eighty-four responders replied to the question whether they had a positive, negative, or neutral attitude toward the performance of an autopsy on a relative’s body; 43% reported that they welcomed the fact that an autopsy would be performed. The main reasons for this acceptance was the desire to know the cause of death and that the circumstances of death were thoroughly investigated.Thirty-three (39%) of the responders had an indifferent attitude, and 18% were implacably opposed to an autopsy.42
In a Japanese study, 46 the majority of the general public indicated they believed an autopsy was necessary. However, in cases of unclear medical error, or an unclear cause and effect relationship between medical care and the patient’s death, the general public was much less likely to request an autopsy. In China, more than half of the responding members considered autopsy beneficial 47 but in Uganda family members who declined permission for an autopsy gave one common major for refusal of consent. The most frequent reason was ‘not wanting to delay the burial’, 59%. Other reasons included it was ‘not useful to know the cause of death’ (16%) and ‘being satisfied with the clinical cause of death’ (10%). Cultural and religious reasons were mentioned in 6% and 1% of the cases, respectively. 48
Islam, one of the youngest and largest of faiths, where Islamic law called Sharia is similar to Christianity and Judaism in that it contains subdivisions with different beliefs and practices. Neither the Quran nor the Hadith (the sayings and practices of the prophet Muhammad) addresses the issue of autopsy. But the Muslim jurist scholars, who give non-binding answers to questions not found in the ancient texts have allowed medico-legal autopsies to be performed under certain strictly defined conditions.49
In Islam, a body should be buried as soon as reasonably possible. However, if an autopsy is required by law (for example, in criminal death), the autopsy can be performed as soon as practically possible and the burial may be delayed. 49,50
In the Roman Catholic tradition, there is no law or edict that forbids autopsy. Devout Hindus always cremate their dead as burial is not allowed according to their traditions. In Hinduism, it is believed that autopsies are disturbing to the still-aware soul that has just separated from the body. Practicing Buddhists believe that the corpse is a temporary shell for the spirit and should be treated with great reverence so that the mind can concentrate on pursuing enlightenment; they also cremate their dead. Jewish law requires immediate burial, including all internal organs and the blood. It is believed that while the soul or spirit leaves the body upon death, it is nevertheless aware and conscious of its surroundings, until after its return to the earth. Any invasive procedure is seen as a desecration. Burial should therefore take place as soon as possible.51
After this review of different cultural and religious beliefs about body and autopsy, I can conclude that conventional autopsy is considered by many cultures to be disfiguring, invasive and disrespectful of the corpse. So this leads on to the fascinating question as to whether modern technology can provide an alternative non-invasive form of autopsy?
Alternatives to Autopsy
Role of imaging technology in diagnosis
Radiology is the branch of medical science that uses imaging technology and radiation to make diagnoses and treat disease. It has benefited greatly from advances in physics, electronic engineering and computer science. It is fair to say that during the last two decades, technological advances in radiology have revolutionized the practice of medicine, advances that have enhanced our potential to understand and manage disease. 52 In radiology, the ability to detect an anatomic abnormality is strongly related to the size and location of the abnormality. Thus, technological advances have enabled radiologists to detect smaller abnormalities in regions of the body inaccessible to conventional medical examination. 53 Advances in radiology may cause us to overestimate not only the prevalence of disease, but also the effectiveness of earlier diagnosis and the associated treatments. 52.53
However, this technological progress does not necessarily translate into better health or much lower costs as technology comes with a premium price. If clinicians and radiologists are not properly equipped with information and decision making tools to help them decide whom to test, how often to test them, and how to interpret the test results, technological progress may actually lead to more harm than good despite appearances to the contrary. 52,53
Today, the mainstream modalities that are widely used in hospitals and medical centers include radiography (X-ray), fluoroscopy, computed tomography (CT), ultrasound, magnetic resonance imaging (MRI), and positron emission tomography (PET) among others. 54 Medical images contain many structures including normal structures such as organs, bones, muscles, fat, and abnormal structures such as tumors and fractures. Segmentation is the process of identifying structures, both normal and abnormal, in the images and is fundamental to the interpretation of medical images. 54 The fantastic improvement in imaging techniques is a major reason to decrease the rate of conventional hospital autopsies. However, the question is raised can it be a suitable alternative to the well-established medico-legal conventional autopsy?
Imaging as an Alternative to an Invasive Autopsy
As discussed previously, many people have raised serious objections towards the routine use of autopsy; whatever the reasons there are always objections now matter how ill founded. The worldwide public objections to conventional autopsy, has led to the search for minimally invasive acceptable alternatives. Sophisticated imaging has the potential to be the basis of a minimally invasive alternative form of autopsy, that would be acceptable to many people. Many research articles published have focused on imaging as an alternative to conventional autopsy, and many practical projects have been initiated to realize this admirable goal.
For example in UK, religious factors and public pressure are becoming increasingly influential and this led to many studies investigating the role of MRI in replacing the well established autopsy. Indeed, it is interesting in the UK that the majority of postmortem work investigating the role of MRI on the deceased has so far been driven and paid for by the Jewish community in north Manchester. 55
Imaging autopsy can be defined as the use of different imaging techniques such as high-definition CT and or MRI scans of the deceased in addition to, or in lieu of, traditional autopsy. 56 It is perhaps worth briefly outlining the key features of the imaging modalities that will be investigated for potential useful roles in a non-invasive autopsy.
Computer Tomography (CT)
CT includes technologies such as high-resolution computed tomography (CT) scanning, which can capture several thousands of cross-sectional images of a cadaver in less than a minute and paves the way for the advancement of forensic autopsy procedures. 54
Magnetic Resonance Imaging (MRI)
MRI is a very powerful technique used in clinical radiology to visualize the internal structures of the body. It works by using the magnetic properties of hydrogen (present as water in most body tissues) and its interaction with both a large external magnetic field and radio waves to produce astonishing three-dimensional images of the human body in exquisite detail. 55
Ultra Sound (US)
Ultrasonographic techniques are relatively easy to learn and use. Ultrasonography is presently used in various resuscitative clinical scenarios and in the imaging of ultrasound-accessible anatomic structures. For example, US can be used for cardiac evaluation, determination of the sizes of tumors and other masses, abscesses, vascular structures, solid organ assessment and in monitoring the progress of the fetus during pregnancy. 56
Laparoscopic and thoracoscopic autopsies have previously only been performed on an experimental basis to determine their potential usefulness as a substitute for a conventional invasive postmortem examination. 57
After a traditional autopsy, imaging can subsequently be performed to obtain additional information regarding, for example, the skeletal musculature, and other anatomic structures that cannot be examined fully during the traditional autopsy. 56
Using Imaging in the Forensic Setting
Advanced imaging techniques have been employed for a number of years during forensic investigations. Radiological imaging has been used for medico-legal purposes in forensic practice as long ago as 1896. Martin and Arroio 58 showed the applicability of post-mortem radiographic techniques to identify bodies through comparative analysis of the cranial sinuses. In addition, numerous cases were reported in which the liver, heart, brain and bone injuries were investigated radiographically, revealing the possible causes of death and thus research subsequently increased apace. 59 By the 1990s, virtual autopsy programs had been developed in Switzerland and the USA. 56 A recently published study 60 by the Forensic Institute, Leicester, UK examined 8 different cases; 2 fire related deaths, 2 traffic deaths, 2 stabbing cases, 1 ligature to the neck death and 1 shotgun murder. Post-mortem full-body CT scans and the results of a full post-mortem forensic autopsy including results of an external examination and scene details, as well as toxicology results, retrieved without dissection where analyzed. However, histology results were not included in the non-invasive post-mortem CT report because histology was considered to be a more invasive examination and therefore was only included in the formal autopsy report. 60
Virtual Autopsy
The virtual autopsy or ‘Virtopsy’ a radical new approach to forensic imaging developed in Switzerland, that is fast winning converts in the UK and elsewhere. The term Virtopsy (Virtopsy Project, Zurich, Switzerland), is was derived from ‘virtual’ (Greek: virtus: effective) and ‘autopsy’ (Greek: autos: own + opsomei: to see) 61
The Swiss team, led by Professor Michael Thali, of the Institute of Forensic Medicine in Zurich, has gone one stage further, not only using X-ray imaging to create scalpel-free three-dimensional images of intact cadavers but also building a ‘Virtobot’ capable of carrying out precise post-mortem tissue sampling – and all without exposing pathologists to harmful radiation or bodily contaminants. In addition, the Virtopsy team can perform CT angiography, a procedure that entails injecting a contrast agent into blood vessels with a needle in order to reveal leaks and lesions that can easily be overlooked when conventional autopsy methods are employed.56,61
The main objection as raised about the application of virtual autopsy I'll discuss later is that the technology to allow it to be performed is not available in less developed countries, in which high-technological imaging devices are not easily justified priority for scientific investigations. Despite this caveat the bioethical issues related to the digital transfer of images is another surprising objection raised against the use of the virtual autopsy. However, like any new exciting development in science, there will always be scare mongers! The virtual autopsy is still being developed and refined and is sure to earn a well-deserved place alongside the traditional autopsy. 59
Advantages :
As highlighted earlier, the imaging autopsy can be applied to a broad range of forensic situations such as: thanatological investigations; carbonized and putrefied body identifications; mass disaster cases; age estimation; anthropological examinations and skin lesion analyses. CT scanning is undoubtedly a helpful supplement to the medico-legal autopsy. In traumatic cases the CT-scanner can produce very useful evidence and documentation, which is difficult to obtain by any other means. CT-examinations have proven useful in cases of intracranial hemorrhages, cerebral contusions and edema, splenomegaly, pelvic and extremity fractures. 63
In drowned bodies, CT information concerning the volume, density, size of the lungs, and the amount of liquid detected in them is greatly helping in the diagnosis of the cause of death. Furthermore, in cases of firearm projectile injuries, which are often difficult to examine during a conventional autopsy either because sometimes the bullet is ‘not in the body’, or has been diverted by an anatomical structure, or it can be in ‘hidden’ in unexplored body parts and ‘very difficult to find’ using gross pathological dissection methods. Therefore, knowing the location of the projectile before the autopsy is performed greatly facilitates the examination. 59,69
In hit and run cases, virtual autopsy can also be very helpful. For example, after an incident on a quite country road near Bern in 2007, where three-dimensional crime scene imaging was used to prove a motorist's culpability in the death of a cyclist. The three-dimensional reconstruction proved that the cyclist had been hit from behind and NOT from the side as the motorist had claimed. The imaging data also revealed that that the bicycle had been lifted, and thrown forward several metres, indicating that the driver had been speeding. 63 Thus there can be no doubt about the value of imaging. The imaging autopsy has also been found to be a very helpful and complementary tool in dental cadaveric examinations. 59
Micro-CT and micro-MR might be used to perform micro-Virtopsy on forensic tissue specimens prior to destructive sectioning. Routine histology specimens can then be taken from the various regions-of-interest identified on images acquired prior to invasive sectioning. This approach will reduce sampling errors and tissue processing times. It should be remembered however that magnetic resonance microscopy images do not reveal maps of cellular structures but rather maps of gross tissue morphology and composition. 64
Post-mortem radiological imaging is a potential alternative method of investigating the rather sensitive nature of perinatal loss such as still birth. The use of Multi-Detector CT (MDCT) permits a series images to be easily reconstructed in any plane, which greatly facilitates the interpretation of potentially complex anatomical deformities. 65
While the current focus is on the advantages of CT and MRI, one should not forget some of the special advantages of using US. Potential uses of US in the post-mortem setting include sonographic evaluation of various organs, pleural air and pleural effusions, cardiac and pericardial abnormalities (including pericardial tamponade), hemoperitoneum, and even skeletal injuries. 68
One of the great benefits of imaging autopsy are reviewable permanent digital images of the post-mortem imaging examination. Post-mortem images fall outside the scope of the Human Tissue Act 2004 (which applies in England, Wales and Northern Ireland); unlike the case for actual tissue samples and organs, images can be kept for audit and diagnostic review, even after the coroner’s authority has ended, with no legal requirement for consent for experts to view them. 66
Finally, medical and surgical education programs stand to benefit enormously from the more widespread use of imaging autopsy. Knowing why the patient died is key to our medical education paradigm. A proposed algorithm for the utilization of CT/MRI
autopsies in medical/surgical education has been previously published and explains the advantages. 67
If used as a pre-autopsy screen, imaging might avoid unnecessary invasive autopsies (e.g., for a ruptured aortic aneurysm), identify lesions difficult to diagnose by conventional dissection, and help to guide dissection by the identification of pathologies that obviously require further investigation. Therefore, imaging will ultimately reduce the number of invasive autopsies that need to be carried out.

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