A New Kind of Autopsy for 21st Century Medicine

To the Editor.—I read with interest Dr Laposata's¹  editorial. It is telling that the second paragraph of the editorial is largely written in first person. “I have so many questions . . . I need a different form of autopsy . . . I want to know more about . . . I would like to have had a small piece of liver . . .” This is telling, because we live in a society where patient autonomy is an ethical standard. Even in cases where medicolegal authority exists for autopsy, ancillary tests, especially genetic tests, still require consent of the next of kin.²  Because forensic autopsies are performed under legal authority rather than consent, one must be careful to avoid performing autopsies under the guise of medicolegal authority for academic interests. Answering clinical questions about the effects of treatment or patient genomics regarding treatment efficacy is generally outside the realm of forensic authority. The family's right to decline autopsy must be respected in the forensic setting just as in the academic setting.

Answering the family's questions, providing closure, and answering clinicians' questions about enhancements and improvements in treatment, efficacy and specificity of diagnostic tests, missed diagnoses, and misdiagnoses are, and have been “for more than a century,” what autopsy is about. Dr Laposata's “diagnostic and management autopsy” is really a traditional morbidity and mortality format where experts from various disciplines share case-based clinical findings and expertise, ideally supplemented with autopsy findings, with the goal of improving the quality of care. Autopsy pathologists (hospital and forensic) should be an integral part of these reviews, by any name.

The assertion that “coronary angiography findings render the anatomic findings moot” is curious, as Dr Laposata cites a National Academy of Medicine report on clinical diagnostic errors that were discovered only during “traditional autopsy.” This has been our experience as well, and we have seen many examples where antemortem radiology arrived at a wrong conclusion.³ 

Pathologists have been on the forefront of defining molecular abnormalities in sudden unexpected deaths in young individuals⁴  and infants⁵ ; in fact, the National Association of Medical Examiners has promulgated a position paper on retention of samples for genetic testing.⁶  Samples for testing pharmacogenomic sensitivities, genetic underpinnings of atherosclerosis, or sensitivity to antiplatelet and anticoagulant medications are all within the realm of what can be collected, stored, and later tested during a traditional forensic or hospital autopsy.

The key to gaining the most information from an autopsy, and for tapping into the vast clinical usefulness of forensic autopsies, is communication with the autopsy pathologist. A lack of communication will lead to practicing in a silo, where one may develop the erroneous perception that there must be something wrong with diagnostic tests happening outside the silo. Dr Laposata may well be surprised at the wealth of information and the collaborative environment offered by “traditional” autopsy pathologists. As long as appropriate familial consent is obtained, there are limitless possibilities to glean precisely the information Dr Laposata desires.