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Abstract

No death should go unexplained is what has been proved as a golden rule in preventing lot many future deaths in medical science. Medical autopsy done in unexplained death has helped to unravel many secrets and subsequently protected many lives. Western countries like the USA and many European countries practice medical autopsy and have successfully done favour to their citizens. India is at a juncture where it cannot avoid medical autopsy in the name of cultural, religious and legal framework anymore. We will present our argument in this article in favour of the same. For the purpose of this article, we have done a review of literature, websites of WHO, United Nations and COVID Dashboard to understand the present scenario in India. Once we could understand this, we could come up with a solution to improve the current scenario.

Keywords

Medical autopsy virtual autopsy sudden unexplained death verbal autopsy

Introduction

India since independence has been trying to make health policy which was centred on providing basic healthcare to its public. It has been working slowly and steadily up the ladder in healthcare, taking baby steps. While doing so for the first 60 years of its independence it gave more focus to public health care facilities, medicines, nutrition, sanitation and so on. While basic needs were taken care of, research and development and up gradation of healthcare were never prioritised. For legal needs, post-mortems are performed in every country. But this post-mortem is more for solving the case and is done only when the law permits. The last two decades have shown that we need to now break the shell and move ahead in all these neglected fields which also include medical autopsy. In India, religion takes precedence when someone dies and so thinking or talking of taking the body for medical autopsy itself creates an environment of argument and restlessness among the people. But the moot question is, ‘Why avoid a scientifically proven technique to solve the unexplained death?’ Even during the COVID pandemic and events post-COVID where there is an increase in the percentage of unexplained deaths, the importance of medical autopsy has been established.

Historical Background

It would have started way earlier but as early as 1,500, the church asked for an autopsy on conjoined twins to find if they had the same soul or not.1 Almost all detailed books of pathology, histopathology and anatomy exist because then people thought of doing autopsies and finding out the truth about many diseases that were the cause of suffering in the world. As early as 1800, Mr Karl Rokitansky has performed more than 30,000 autopsies and has helped others perform 75,000 autopsies which led to the largest database of pathological findings.^{1, 2} The reason for performing autopsies on unexplained deaths can easily be understood by the fact that in 1912 Mr Richard Cabot after studying 3,000 autopsy reports concluded that more than 50% diagnoses made were incorrect.¹ In 1951, when the Joint Commission of Hospital Accreditation came into existence it made a revolutionary criterion. It is said that to have good quality hospital care and accurate death audit, a hospital should have a minimum of 20% of medical autopsy.

A Helping Hand

In the medical fraternity not, a single soul will deny the fact that autopsy and dissection have provided us with insight into the human body in the form of anatomy and pathology. Throughout the globe, the first year of dissection classes has helped shape doctors with invaluable knowledge about the human body. In all the countries where it is allowed, medical autopsy has become the backbone of research in unexplained death where they use direct observation of the pathology, radiology and biochemistry reports, molecular biology and tissue histopathology to unravel the reasons behind the death. With the advent and propagation of transplants, cadaver transplants have saved millions of lives across the globe.³ Every court of law in the world relies completely on good forensic evidence provided by the autopsy or post-mortem. The last decade has even seen an increase in virtual autopsy which is saving a lot of time and may help overcome the religious and cultural barriers.

A Death

A human can die broadly in two ways. It can be an unnatural death due to accidents or homicide. He or she can die naturally because of known or unknown reasons. In case of unnatural deaths law permits and even asks for post-mortem to get the reason of death on paper as forensic evidence to prosecute. Here since it is enforceable and hence there is no resistance from any corners be it religious or cultural. In case of natural death, a person may die for a known reason like due to a disease he or she is suffering from or acutely he suffers from. He or she may die in a hospital or outside hospital. The death in the hospital in majority of the time is observed by the doctor and hence largely the cause is determined and noted on the case paper. Mostly doctors are sure about the cause of death. The reasons behind death outside the hospital may not be known but when a person is brought to the hospital, the history of the patient helps in determining the cause of many such deaths. And so, in all such cases, medical autopsy is not required even in countries which do such autopsy regularly.

The grey area is for deaths of undetermined cause, be it in hospital or outside hospital. There are many deaths that happen in hospitals where even after all diagnostic tools and expert reviews reason for suffering and eventually death is not clear. Such unexplained death is an emotional burden for the families as they always want an answer for the reasons for suffering and death. It is an academic burden on treating doctors to know if they missed something, if they could have done better to manage the patient and above all whether they can learn from this undetermined death to save another life. It is also important for hospitals which target to provide good quality of care whereby every death audit helps to improve the same.

In death which happens outside hospitals where there is suspicion, in many countries post-mortem is performed to ascertain the absence of foul play. However, the overall rate of such autopsies is also very low across the spectrum.⁴ In law, such cases which are brought dead are to be considered medico-legal but due to religious and cultural beliefs and lack of legal will, the majority of cases are sent back without even reporting in the hospital database.^{4, 5} This has led to a probable change in population of world then we will find substandard death certificates which mislead the overall death registry.

Another aspect of death and the diagnosis provided by the doctor is an observation that has been made ever since 1912. From Mr Richard Cabot² to the Norwegian study published in 2012⁶ it is clear that more than 50% time the diagnosis mentioned on the death certificate by the practitioner is found to be wrong on autopsy reports. This has a repel effect on all the death registries of the world as a whole. WHO since 1948 has defined the underlying cause of death and the format of recording it.⁷ It is followed internationally and because of the uniformity mortality statistics are widely used for medical research, monitoring of public health, evaluating health interventions and planning and follow-up of health care.^8–11 So if the death registry has an underlying cause of death which is not right then statistics will misguide nations and humanity as a whole in the wrong direction.^9–13

From 2005 there has been a shift in recording the underlying cause of death. It is centralised whereby software integration is used. The aim of this exercise is to improve the metrics which can provide the accurate reasons behind the deaths and non-fatal diseases.¹⁴ It combines the underlying cause of death provided by the death certificate and autopsy if provided. In such cases either it provides a combined underlying cause or a single cause whereby autopsy is given priority.^{6, 14}

Lack of medical autopsy and its effect on health data: Medical science for centuries has learned lots of valuable lessons from medical autopsy data and findings.¹⁵ This data is segregated into various forms like ranking of disease-causing mortality,16 similar ranking in children, pregnant females, epidemiological studies, infectious disease-causing mortality ranking, cancer-causing mortality ranking and so on. It also helps the research fraternity to decide on the priority of research and development in markers of early detection, drug discoveries and ways to prevent such diseases. Such death registries^{5, 17} also help local, national and global authorities plan their health initiatives and budgets.

WHO and various national authorities have been working hard to rectify the errors in death certificates through adopting various updates in software collecting death registry data, combining death certificates with medical autopsy and also now adopting virtual autopsy techniques.^{14, 18–21} This whole exercise of having a robust death registry is to categorise the common cause of death, cause of death (single or multiple factors) and preventable cause of death, death related to abuses and environmental changes and death due to lack of health infrastructure which includes healthcare facility and also manpower. This helps every country and even WHO to plan for public health programmes, to allocate money for the programmes and to direct the research personnel to work on such diseases.^{16, 22}

Data from India changes the whole scenario: To understand the importance of accuracy of death registry and subsequently, its utility we need to know the five most populous countries. They are India, China, the United States of America, Indonesia and Pakistan.²³ If we add Europe then its total population as a whole will put it in third position before the USA.²⁴ But if we follow the data and probable change in population of world then we will find the following reality. The population of Europe and China is going to decline in the next two to three decades, of the United States of America and Indonesia is going to remain more or less stable whereas India is going to remain at peak as the largest population for at least next 50 years.^{23, 24} So, it is clear that data emerging from India are going to affect the world at large and also India itself.

If we look at data from the death registry; Russia, the United States of America, the United Kingdom, India and China record above 75% share of deaths being registered.²² When death is registered, a cause is given for that death. USA, Russia and a few other countries give this cause in their death registry almost 100%22 but this may be due to lack of training and lack of knowledge about the ICD (International Classification of Disease) system India records the cause of death in only 10% cases.²² So, this makes it amply clear that only a small fraction of the population lives in countries where the death registry is up to the mark. However, the majority of the population lives in countries where there is a poor death registry.²² Now majority of the guidelines for diagnosis of disease, management protocol and research topics are made by the countries that are minority in nature and ironically this is/had to be followed by the most populous countries. So, it is necessary for the rest of the world that India on an urgent basis should adopt the robust death registry system. This will require teaching medical practitioners International guidelines of mentioning death according to the International Classification of Diseases (ICD).^{22, 25} There has to be an addition of verbal autopsy in various scenarios of unexplained death which includes multiple contributing factors.^{18, 19} There have to be coordinated efforts to start medical autopsies in India. The policymakers will have to take the lead and frame a policy of medical autopsy.²⁶ To save time and prevent surgical procedures in many of the autopsies even virtual autopsy is need of the hour.²⁷

COVID Pandemic: Medical Autopsy Changed Everything

COVID was caused by to novel virus so the disease pathology, clinical manifestations and management were not defined. Initial days it was managed as interstitial pneumonia and acute respiratory distress syndrome (ARDS).²⁸ There were no defined guidelines for management, patients were given symptomatic treatment and as they deteriorated doctors across the world used treatment protocols defined by their hospitals or that they knew by experience. But the deterioration kept increasing and so did the death rate. If we go by data COVID-19 started in December 2019, by the end of April 2020 almost 3 million people across the globe were affected by it and approximately 210,000 have died of it.²⁹ This was looking dangerous as the mortality was even higher than the seasonal flu.³⁰ So, there was a need for urgent research to find the actual pathogenesis of the ongoing pandemic. The most perplexing part was that the countries that had set protocols for autopsy refrained from doing the same on deaths related to COVID.

Though it was almost five months of the onset of the pandemic worldwide there were only three reported articles which described the autopsy findings in death in COVID patients.^{31, 32} Once the medical autopsy findings came, doctors and scientists got real insight into the characteristics of COVID-19 and its pathogenesis.³³ With this new insight provided because of autopsy, it was clear that COVID-19 had multiple pathogenesis of inflammatory disease, acute respiratory distress syndrome, coagulopathy and multi-organ disease. This was assisted by various biomarkers like C reactive protein, D-dimer.^{34, 35} Because of this investigation various phases of COVID-19 were decided and so was the treatment protocol.

India also saw devastating effects during COVID-19 and the pattern followed by COVID-19 was different from the rest of the world. The first wave lasted for months due to the strict lockdown policy of the government.^{36, 37} Since the legal requirement of ordering a post-mortem is clear in India where a post-mortem is done only if there is suspicion, for research purposes there is no proper infrastructure, the consent for performing an autopsy even if research is permitted is not forthcoming and due to fear of transmission to examiners medical autopsy is never performed for academic purposes. So, world was slowly catching up on medical autopsy during COVID times, and India was lacking behind. The first published data on medical autopsy on COVID deaths was done in late September 2020 in Rajkot.³⁸ Another such study was done at Bhopal but published in 2022.³⁹ After this the second wave was the deadliest of all which was called as delta wave throughout the world. It caused complete collapse of the healthcare system in India. It was a rapid rise and rapid fall wave in India. During this worst phase, India saw more than 20 million cases and about 4 lakh deaths.⁴⁰ Along with the delta wave simultaneously India faced epidemic of mucormycosis in COVID patients.^41–43 It was clear till now that India was seeing different patterns in both waves than the whole world. There were little to no minimal reports of mucormycosis in world other than India. It is a firm belief that medical autopsy would have been of great help in finding out the pathogenesis of this combined attack on India. There was a lack of knowledge regarding this coexistence of two infections and their pathogenesis due to a lack of autopsies. This led to delayed detection of mucormycosis and so delayed treatment.⁴⁴

Surge in Sudden death: Research is impossible without medical autopsy.

Sudden unexplained death is known to be the leading cause of death across the world. Globally the cases are almost in the range of 0.6–0.8 per 100,000 population.^{45, 46} The definition of sudden death is provided by the World Health Organisation, which defines them as sudden, unexpected, natural deaths either within one hour of symptom onset or, if unwitnessed, within 24 hours of having been last seen alive and symptom-free.^{47, 48}

In India post-COVID, this surge in sudden death in young adults has been attributed to post-COVID complications or COVID-19 vaccine complications.⁴⁹ It is also attributed only to cardiac causes leading to this death either as myocardial infarction or cardiac arrest.⁴⁹ Pre-COVID all the data suggested that there are multiple reasons behind sudden death46 but to find the real reasons the best option is autopsy. This autopsy is a combination of verbal autopsy and medical autopsy.^50–53 When the matter is of children and young adults, knowing the real reason behind unexplained death is utmost importance to plan an investigation, preventive strategy and also treatment strategy.⁵⁰

Final Argument

In modern healthcare, it is very clear that nothing can be taken for chance in healthcare. If the technology is available then it should be used to ascertain the real cause behind any medical catastrophe. This always helps from various points of view like epidemiological data, social/cultural issues/prevention plans, national health policy and finally hierarchy of research.

By having a proper death registry, ranking of mortality factors can be known and hence research in those areas can be prioritised. India needs to understand the importance of registry and its utility considering its vast population. If the data that originates from a country like India is not correct or half correct then the final global data will also be same. In that case, the future planning of research and development will be in wrong direction. Another point to understand is that India is relatively a young country and so next few decades there will rise in population and also health-related problems. So, correcting this death registry will make India research-centric. This data in the death registry also helps in formulating the guidelines for treating various chronic diseases which should also be India-centric. But for all this medical autopsy what is needed.⁴ Without a medical autopsy the death registry as proven in past will be inaccurate.

During the COVID pandemic refraining from doing medical autopsy led to an increase in morbidity and mortality due to no clear-cut guidelines for management of the disease. When the autopsies were done in some of the developed countries it proved a guiding factor in knowing the pathogenesis of the disease. But in India, since there is no legal clause, lack of proper infrastructure, lack of forensic examiners and religious/cultural issues^{54, 55} it was not in the policy to perform autopsy.⁴ Over a period of time very minimal research has happened in medical autopsy even during the pre-COVID era. A real medical autopsy will need collaboration with molecular biology testing, toxicological screening and histopathological examination.^{56, 57} But looking towards the threats of pandemics we are going to face in future we need an urgent policy shift towards medical autopsy and the same will require development of infrastructure where such autopsy can be performed, expert manpower for performing this autopsy properly and pathology/radiological backup to provide with accurate diagnosis.^{2, 58, 59} One thing is for sure by neglecting medical autopsy human race tends to loos! as morbidity and mortality increase.

Sudden unexplained death is a burden that is faced by every nation and India is not protected. In fact, looking at the young population, an epidemic of sudden unexplained death is a catastrophe.⁶⁰ The most important aspect in this category of death is that the majority of people do not reach the hospital alive. So, the data or death registry will not mention deaths that happen outside a hospital or at home. But to ascertain the correct cause of such death microscopic, macroscopic and toxicological findings are of utmost importance. This is possible only through medical autopsy. Along with medical autopsy if verbal autopsy is also used then the results are accurate. This will always help society at large to prevent such events in young people.⁶¹

Solution

Every country in the world has a facility for post-mortem to solve crime. However, a medical autopsy requires various things.

Policy: Government of India will have to come up with policy amendments where medical autopsy is allowed to doctors in case of undetermined death.

Religious/cultural awareness: The biggest hurdle that even developed countries face is getting consent from the relatives for the autopsy. It is considered a sign of disrespect to the dead if autopsies are done. The same is true for the Indian population. Even in the case of crime or suspected crime, many a time people frown upon in name of post-mortem. But a larger section of people has to realise that doing medical autopsy in cases of undetermined death will help them get the answers about their relatives and will bring emotional closure.

Infrastructure: Hospitals, both private and government will have to establish infrastructure for the autopsy. Joint Commission International and NABH (National Accreditation Board for Hospitals) will have to add riders for performance of medical autopsies to improve quality care and proper death audit.

Pathology and radiological backup: This is the most essential infrastructure backup required for accurate medical autopsy. Biochemistry, molecular biology, histopathology and toxicology are required for diagnosis. Along with this radiology backup of X-rays, CT scans, MRI and 3D imaging are needed for results.

Manpower: Even though all the above are available, expert forensic examiners are most important in this whole exercise. To train them the first thing that is required is to increase the education facilities across the country. The term ‘autopsy’ derives from the Greek ‘autopsia’ meaning ‘to see for oneself’ and for this, an expert forensic examiner is required.

Combine various autopsies: Medical autopsy, verbal autopsy and virtual autopsy are various types of autopsy available to us. All have their own pros and cons. India is a vast and diverse country. In an urban setup where the population is receptive to medical autopsy, it can be performed. But if there are cultural and religious issues then virtual autopsy can be performed as surgical methods can be avoided by this. In remote places and rural areas where there is a shortage of infrastructure then verbal autopsy can be performed.

Conclusion

Autopsies, for centuries, have helped mankind in solving the secrets of human bodies. For centuries it has solved crimes and helped the law punish the guilty. In modern times the use of medical autopsy should be mandatory to unravel various undetermined causes of morbidity and mortality. Advancements in autopsy like virtual autopsy and utilising the age-old methods of medical autopsy and verbal autopsy will help countries like India to draft its health policy which includes epidemiological surveys, public health care and medical guidelines to prevent and treat diseases and research and development. It is an urgent need for the country and also for the world that India urgently upgrades its policy and infrastructure for medical autopsy.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Ethical Approval and Informed Consent

Not applicable.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

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