Resuscitating the teaching autopsy
BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7418.803 (Published 02 October 2003) Cite this as: BMJ 2003;327:803
- James Underwood (jceu{at}sheffield.ac.uk), professor of pathology1
O'Grady rightly laments the exclusion of students from coroner's autopsies in New Zealand. With the worrying decline in the hospital autopsy rate, coroner's cases (about 90% of autopsies in the United Kingdom) are now the main opportunity for medical student teaching.
I am not aware of any similar restriction in the United Kingdom, and there is nothing in the Coroner's Rules 1984 that would automatically prohibit medical students, nurses, or police trainees from attending. Coroner's Rule 7(4) is relevant: “Nothing in the foregoing provisions of this Rule shall be deemed to limit the discretion of the coroner to notify any person of the date, hour and place at which a post-mortem examination will be made and to permit him to attend the examination.” Coroners are thus empowered to decide who may attend; this may be on an individual case basis or according to a general agreement between the pathologist and coroner.
Those attending autopsies must, of course, respect the medical confidentiality of the deceased and his or her family. They should also understand that information gleaned from the autopsy about the case is, in a sense, owned and controlled by the coroner. Furthermore, although students can attend as observers, pathologists can make examinations only that will contribute to determination of the cause of death. They cannot extend the autopsy dissection and examination solely to serve the learning needs of medical students.
Public concerns
The New Zealand situation has arisen because of legitimate public concerns about organ retention. However, banning students from autopsies ultimately risks worsening the discomfort of bereaved families. Relatives naturally turn to doctors and other healthcare professionals for help and advice when they are asked to consent to an autopsy or one is required by law. With coroner's autopsies now being the main opportunity for learning about the medical examination of the body after death, the new generation of doctors will find themselves struggling to explain a procedure they have rarely or never witnessed.
I share O'Grady's enthusiasm for the autopsy as a teaching medium. Zealous overinterpretation of coroner's legislation is not the only factor contributing to the moribund state of the teaching autopsy. Many mortuaries are dilapidated or poorly designed with inadequate viewing facilities. In the United Kingdom, perhaps autopsy education should feature in the training of preregistration and junior house officers, thus remedying the deficiencies of the undergraduate experience.
The root cause of the New Zealand situation is apparently a belief that bereaved relatives might resent students witnessing the autopsy. My experience of families deeply affected by organ retention is that their objection is not necessarily to what was done but that it had been done without their knowledge or, where required, their agreement. There will be exceptions, but bereaved people generally want some good to come from their grief. If medical students can learn from the death, it may be some consolation that future patients could benefit.
Footnotes
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Competing interests I am President of the Royal College of Pathologists and led the production of the college's guidelines on organ retention (2000). I am an observer on the Retained Organs Commission and am paid to do coroner's autopsies.