Are brain tumors afflicting more elderly people now than in the past? Or is it simply that more tumors are being detected?
Why did a transplant patient do well for several weeks, then suddenly weaken and die?
Modern medicine can answer many questions while patients are still alive. But the ultimate tool for quality control in diagnostic techniques is the autopsy, an examination of the body of a deceased person in order to document any diseases or injuries and to determine the cause of death.
Autopsies are not performed after every death. In this country, the autopsy rate peaked at around 50 percent during the 1940s. Beginning in the 1950s there was a gradual decline, which accelerated so dramatically after 1970 that some observers began to worry that the medical system was being deprived of statistics and information necessary for public health and medical research.
Dr. John K. Boitnott, pathologist in chief at Johns Hopkins Hospital in Baltimore, says that the autopsy rate has now reached a plateau, in part because "the lack of interest had overshot itself." That's encouraging news.
Autopsies fell out of favor for several reasons. Perhaps the biggest cause stemmed from vast improvements in the ability of medical science to diagnose disease and to follow its course in the body.
Other factors contributed as well. Organizations responsible for accrediting hospitals relaxed their autopsy requirements.
Reimbursement of physicians became another problem. Pathologists, who perform autopsies, began charging professional fees for their diagnostic work rather than simply working on salary for a hospital. Since families are not charged for autopsies, pathologists may feel that they are not adequately compensated for the work.
Some people also blame the threat of malpractice suits for the decline in autopsies. In fact, some observers say that asking for an autopsy can be a sign of good faith on the part of a physician and, in fact, not asking for the procedure might be held against the physician in court.
Another problem is the human factor. Dr. Boitnott recalls his days as an intern before the advent of intensive care units. He was on duty 24 hours a day and he got to know the families of critically ill patients. When they died, he felt comfortable asking them for permission to perform an autopsy.
Now, doctors are less likely to know their patient's families, and asking for an autopsy becomes an awkward task. Sometimes, families may feel that since their loved one has been through so much, another invasive procedure just isn't fair.
But these objections are misguided and if hospitals did a better job of training physicians in dealing with families on such matters, more people would understand why autopsies can be an excellent idea.
Autopsies can be comforting for families who may otherwise be haunted with the question of whether everything possible was done. Dr. Boitnott says that only a small percentage of autopsies present "surprises," or information the physician would have wanted to know. Even then, the information may not have changed the treatment.
But the procedure can provide important information for medical research. For instance, transplant patients or AIDS patients may survive infection after infection only to succumb unexpectedly to something the physician did not expect and had no way of detecting. Finding out the exact cause of death can be helpful for treating other people, and that can give families a sense that something worthwhile came out of the death.
Families should also know that the procedure can provide valuable information for them by detecting infectious conditions like hepatitis or tuberculosis, inherited disorders like sickle cell or Huntingdon's disease, or even family tendencies such as coronary artery disease.