External challenges for specialists dealing with forensic autopsies

Introduction

The role of forensic medicine specialists or forensic pathologists is crucial in delivering justice to the deceased and their bereaved families by performing forensic autopsies in cases of suspected natural and unnatural deaths. Conventional autopsies provide reference standards in establishing the cause of death ¹ but they face significant challenges relating to their infrastructure, facilities, manpower, experience and required departmental support.

In addition, there are further external challenges due to widespread misconceptions and stigma surrounding forensic autopsies. In particular, as to its invasion of the deceased's body and concern regarding any mutilation or disfigurement. Further, some autopsies may be resisted if the cause of death is already known following chronic hospitalisation and the deceased has suffered. ² In addition, there is fear of delay in funeral proceedings and there may be sociocultural and religious issues. ^{1 , 3}

There is plenty of English medical literature on challenges surrounding clinical autopsies in developed countries. ^{4 , 5} In India, forensic autopsies are more commonly practised than clinical ones but only a few studies examine the attitudes and perceptions of the deceased's relatives in such cases ^{6 , 7} and there is a dearth of literature on external challenges faced by practitioners performing forensic autopsies. This study aimed at investigating these and any association between the external challenges and sex, age, place of residence, and number of bystanders present at the time of autopsy.

Materials and methods

This two-year, cross-sectional, observational study was conducted in the Mortuary of the AIIMS, Bhubaneswar between August 2020 and July 2022. The study population included the consenting on-duty staff of the Dept of Forensic Medicine and Toxicology (FMT). The Faculties and Resident doctors of the Departments of Pathology and FMT conducting the Pathological & Foetal autopsies were excluded. The universal sample size was adopted to include all medico-legal autopsy cases during the study period. The Institute Ethics Committee (IEC) approval was obtained before it commenced.

The faculties and residents were briefed using a participant information sheet, and informed consent from the participants was obtained before each autopsy. The data was collected using a pre-formulated questionnaire that the respondents completed after each autopsy. The data collected were entered into the Microsoft Excel sheet, and statistical analysis was done using SPSS software for Windows, version 20. Categorical variables were presented as percentage or proportions, and the association between the categorical variables was analysed using Chi-square test and Fisher’s exact test wherever appropriate, and level of statistical significance was set at p < 0.05.

Results

From 674 post mortems conducted during the study period, 610 questionnaires were received from the participants and included. The data showed that nearly three-quarters of the deceased were males (72.1%, n = 440), and about 40% were young adults, followed by middle-aged adults (32.6%) (Table 1). Almost 98% of the autopsied cases were Hindus in our centre who were more commonly from the lower middle-income group (40.3%). About half of the cases (46.4%) brought to our centre were determined to be accidental deaths, followed by suicides (30%), after police/magistrate inquest and complete autopsy. The deceaseds' homes were at a distance from the mortuary of 5 to 50 km and 51 to 100 km in more than two-thirds (34.8 and 34.3%, respectively) and over half of the deceased (52.6%) were accompanied by two to five relatives, followed by five to 10 relatives (29%) (Table 1).

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Table 1.

Basic characteristics of the autopsied individuals.

	Percentage(%)	Number (n = 610)
Age
0–18 y	7	43
19–35 y	39.2	239
36–54 y	32.6	199
>55 y	21.1	129
Sex
Male	72.1	440
Female	27.9	170
Religion
Hindu	98.2	599
Muslim	1.6	10
Christian	0.2	1
Socioeconomic status
Upper	5.4	33
Upper Middle	13.4	82
Middle	20.8	127
Lower Middle	40.3	246
Lower	20	122
Type of case
Accident	46.4	283
Suicide	30	183
Homicide	4.6	28
Others	19	116
Distance
<5 km	6.4	39
5 to 50 km	34.8	212
51 to 100 km	34.3	209
>100 km	24.6	150
Number of accompanying relatives
<2	4.1	25
2 to 5	52.6	321
5 to 10	29	177
>10	14.3	87
Any external challenges faced?
Yes	20.5	125
No	79.5	485

Notably, forensic medicine specialists faced external challenges in about one in five autopsies (20.5%, n = 125). In particular, demands to minimise the procedure (n = 65) and to conduct the autopsy at an inappropriate time (n = 58) were reported to be the most common. Demands not to perform the autopsy (n = 6) were less frequent. Sociocultural challenges, arising from an autopsy on bodies belonging to a specific religious community (Muslims 4/6), and ethical challenges, such as a request to provide false information (n = 1), were also seldom noted in this study. Most challenges were encountered before the autopsies commenced (n = 119). Further, most of the external challenges originated from the extra-institutional source (n = 87) rather than intra-institutional (n = 30). Of note, while the higher authority (n = 16) and staff of the institution (n = 16) were responsible for the primary source of intra-institutional challenges, relatives of the deceased (n = 65) were the most common source of extra-institutional challenges.

Most importantly, there was a statistically significant association observed between the external challenges and the deceased's religion (Pearson χ² = 9.98, p = 0.007), socioeconomic status of the deceased (Pearson χ² = 12.29, p = 0.015), number of relatives accompanying the deceased (Pearson χ² = 13.95, p = 0.003), and distance of the deceaseds' residence from the mortuary (Pearson χ² = 8.380, p = 0.039) (Table 2). Further, a statistically significant association was observed between age and demands to minimise the autopsy procedure (Pearson χ² = 7.999, p = 0.046), the religion of the deceased (Fisher’s exact = 9.304, p = 0.010), socioeconomic class of the deceased (Pearson χ² = 11.715, p = 0.020) and manner of death (Pearson χ² = 10.000, p = 0.019). Demands to conduct an autopsy at an inappropriate time were statistically linked with the distance of the deceased's residence (Pearson χ² = 13.029, p = 0.005) and the number of relatives accompanying the deceased (Pearson χ² = 15.472, p = 0.001) (Table 3).

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Table 2.

Relationship between external challenges and basic characteristics.

	External challenges (n = 125)		p value
	No	Yes
Age
0 to 18 y	35	8	.960
19 to 35 y	188	51
36 to 54 y	158	41
>55 y	104	25
Sex
Male	252	88	.628
Female	133	37
Religion
Hindu	480	119	.007 a , b
Muslim	4	6
Christian	1	125
Socioeconomic status
Upper	27	6	.015 a
Upper Middle	55	27
Middle	99	28
Lower Middle	198	48
Lower	106	16
Number of accompanying relatives
<2	18	7	.003 a
2 to 5	270	51
6 to 10	139	38
>10	58	29
Distance of the residence
<5 km	27	12	.039 a
5 to 50 km	159	53
55 to 100 km	175	34
>100 km	124	26
Type
Homicide	23	5	.776
Suicide	149	34
Accident	220	63
Others	93	23

a

Note: p < .05 was considered statistically significant.

b

Fisher’s exact test applied.

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Table 3.

Significant associations between case characteristics and perceived external challenges.

	Demand to minimise autopsy procedure		Pearson Chi-square value	p value
	No	Yes
Age
0–18 y	40	3	7.999	.046 a
19–35 y	220	19
36–54 y	178	21
>55 y	107	22
Religion
Hindu	538	61	9.304 b	.010 a
Muslim	6	4
Christian	1	0
Socioeconomic status
Upper	31	2	11.715	.020 a
Upper Middle	65	17
Middle	114	13
Lower Middle	221	25
Lower	114	8
Manner of death
Accident	242	41	10.000	.019 a
Suicide	172	11
Homicide	27	1
Others	104	12
	To conduct autopsy in inappropriate time
	No	Yes
Distance
<5 km	29	10	13.029	.005 a
5 to 50 km	192	20
51 to 100 km	193	16
>100 km	138	12
Number of accompanying relatives
<2	22	3	15.472	.001 a
2 to 5	302	19
5 to 10	158	19
>10	70	17

a

Note: p < .05 was considered statistically significant.

b

Fisher’s exact test applied.

Discussion

Most external challenges arise from prevailing stigma and misconceptions surrounding autopsy; for example, there will be an undue delay in handing over the body for cremation, disfiguration and considerable fees (both legal and illegal) to complete the autopsy. While there may be some delays this should be clarified to the relatives in advance to avoid agitation.

Fear of mutilation or disfigurement of dead bodies remains a significant concern for the bereaved families. ^{1 , 7 , 8} In particular, autopsies on children and individuals belonging to certain religions, for example Muslims and Jews, frequently arouse considerable objection ⁸ and can pose a substantial challenge to forensic medicine specialists in misinformed, conservative societies like India. Further, the need for complete invasive autopsies is becoming debatable in light of modern advancements in diagnostic capabilities. Minimally invasive autopsies such as virtual autopsy, needle autopsy and laparoscopic autopsy ⁹ can assist practitioners while virtual autopsies through post-mortem computed tomography (PMCT), magnetic resonance imaging (MRI) and post-mortem computed tomography angiography (PMCTA) are increasingly utilised along the conventional autopsies in developed countries (e.g. Switzerland and Australia). ³

By contrast, a conventional autopsy is the only method invariably practised in nearly all Indian mortuaries save for a few institutes where conventional autopsies are supplemented with virtual autopsies. Since the acceptance rate among the deceased's families is usually higher for minimally invasive autopsies than conventional autopsies, ² such alternatives should be considered while keeping in mind that there are limitations associated with them, which prevent them from being considered as complete replacements for conventional autopsies, despite many advantages. ^{1 , 3}

In India, forensic autopsies are generally carried out without unnecessary delay, during daytime under natural light, and in government or government-approved mortuaries by authorised registered medical practitioners. However, in most post mortem centres, the requisition for autopsies is received only up to 4 pm. ¹⁰ Bodies received after 4 pm are usually subjected to post mortem the following day. Hence, the deceaseds' families, already devastated by their loss, demand an autopsy beyond office hours to avoid prolonged agony due to waiting until the next day. In such circumstances, practitioners may be forced directly or indirectly to complete a post mortem after 4 pm or at night. This study's findings are that the demand to conduct an autopsy after hours was the second most common challenge (n = 55) faced by staff.

Only a few states in India, such as Karnataka and Gujarat, permit autopsies after sunset. ¹⁰ In the remainder, night autopsies are not routinely allowed except during law-and-order situations. In light of this, the Ministry of Health and Family Welfare, Govt. of India issued a memorandum to conduct night autopsies wherever feasible with proper infrastructure and lighting, without dilution of evidentiary value, with video recording (if necessary) in all mortuaries. ¹¹ While the priority is given to encouraging the post mortem for organ donation even during night hours, the memorandum excludes suicide, homicide, rape and decomposed bodies during this period. ¹¹ This move by the government is welcome and may alleviate many external challenges faced by forensic practitioners and also benefit the people concerned, provided the limitations are explained before implementation.

One of the interesting findings from this study is association between demands for a late autopsy and the distance of the deceased's residence from the mortuary (p = 0.005). This is most likely resulting from both extremes of distance, near and remote. Further, the demands to conduct an autopsy at an inappropriate time were also statistically linked with the number of relatives accompanying the deceased (p = 0.001). Since death is a very sensitive and emotional issue, occasional outbreaks of violence against doctors and healthcare establishments by a mob in India do occur. These mobs usually involve relatives of the deceased, bystanders of other patients, and other miscreants (often stirred up by local politicians) soon after an unexpected death. ¹² Interestingly, no incidents of violence against forensic pathologists or the mortuary staff were reported in our study, barring a few incidents of intrusion into the mortuary by relatives (n = 2). This is likely due to the very low number of deaths alleged to be from medical negligence in our Institute.

Conclusions

The results of this novel study indicate substantial external challenges faced by forensic medicine specialists, with most arising from relatives' demands to minimise the procedure of a conventional autopsy and/or conduct it at an inappropriate time, especially late in the evening. These results highlight the importance of amending relevant laws and frequent training programs for law enforcement agencies to avoid unnecessary complete autopsies in bodies where the cause of death is known and no foul play suspected. Modern advancements such as minimally invasive autopsies, especially virtual autopsies, should be embraced to mitigate the challenges posed by invasive conventional autopsies. In addition, this study stresses the need for more trained forensic experts and mortuary staff with the requisite infrastructure to enable round-the-clock forensic autopsy services in India. Our study may pave the way for future studies analysing the applicability of minimally invasive autopsies, such as virtual autopsies, to overcome the challenges posed by conventional ones. Anonymous studies involving forensic medicine specialists from across the country are urgently needed to assess the prevalence and nature of the complex challenges they face.