Paying Our Last Respects: The Neonatal Autopsy as Continuing Care and Ethical Obligation

Abstract

After completing this article, readers should be able to: 1. List the benefits of a postmortem examination. 2. List possible reasons for the decline in autopsy rates. Ethical discussions of autopsies usually center around consent: how it must be requested, who may give it, or limitations on the procedure . All of these issues should concern us, but the real ethical issue about autopsies is that the procedure itself is not being done. The worldwide trend of falling autopsy rates (1) involves the United States; hospital rates of 60% in the 1950s fell to 12% in the early 1990s and less than 5% in nonteaching hospitals. (2) The average United States hospital rate of autopsies was 50% in the 1940s and 38% in 1973. (3) A review in 1983 at an adult teaching hospital documented a 75% rate in 1960, 71% rate in 1970, and 38% rate in 1980. (4) Although neonatal autopsy rates have maintained a higher level than those of adults, (5) they too are falling. In Scotland, rates began to decline in 1994. (6) In Wales, some rates fell below 50%, with neonatal perioperative autopsy rates at 45%. (7) The rate in one Australian center was 43% (8) and 39.7% in another. (9) In the United States, one study documented a decline in neonatal autopsies from a range of 63% to 81% down to 52% (10), and a 10-year series from 1984 through 1993 demonstrated a decrease from 71.2% to 47.7%. (11) Must we again defend the value of the autopsy? This “final audit” provides the ultimate guarantee of quality control, and nothing can substitute for it. It discloses diagnoses not made premortem, discovers nosocomial infections not diagnosed in life, and confirms or denies the accuracy of multifarious diagnostic techniques, both simple and complicated, both old and new. …