Dial One Yourself
The Economist — Friday, 1 January 1999
Nature abhors a vacuum. So do American entrepreneurs. Consider a firm called Autopsy/Post Services (1-800-AUTOPSY), founded in 1988 by Vidal Herrera. The frequency with which autopsies are performed in America has been falling steadily for over three decades, and Mr. Herrera has made his mark by leaping in to fill the void.
Many of his customers suspect foul play or malpractice. Others have medical questions that a hospital or insurance company would not pay to have answered. Mr. Herrera expects to perform roughly 800 autopsies this year; he has turned away thousands of others across the United States, and in other countries, because he could not handle them from his Los Angeles base. That problem will soon be over; in January, Autopsy/Post Services will begin selling franchises in 72 American cities and 16 countries.
The success of 1-800-AUTOPSY aside, public-health experts are alarmed by the falling number of conventional autopsies. In 1960, roughly one in two deaths in Chicago area hospitals was followed up with an autopsy; that rate is now about one in ten. Federal data collected since 1972 shows the same trend. Indeed, experts note that autopsy rates are falling around the world.
Autopsies can be used to determine the effectiveness of surgical procedures and drug treatments. They provide accurate vital statistics, teach medical students, uncover new diseases and spot old ones that may be spreading. All the while, they sniff out incompetent medical care and the odd murder that might have passed for a slip in the bathtub. George Lumberg, editor of the Journal of the American Medical Association (JAMA), points out that medical conditions such as toxic shock syndrome and congenital heart disease (as well as many others) were discovered by autopsy. Toxic shock has now been pretty much stamped out; congenital heart disease can be treated successfully with surgery.
An autopsy is perhaps the only way for the dead to speak to the living. Why are Americans listening less? One reason is cost. An autopsy can run up a bill from several hundred dollars to several thousand, depending on the methodology. In the days before the health-care system began slimming down, most insurance policies covered the procedure. If not, hospitals politely picked up the tab. No longer. As HMOs, insurance companies and hospitals struggle to distribute scare resources, they tend to favour the living over the dead. (State and local governments have the right to demand an autopsy in any case where foul play is suspected or the cause of death is unknown.)
Autopsy, like organ donation, is a difficult subject to broach with grieving families through the public good associated with both can help the grieving process). The attending physician is the logical person to suggest a post-mortem exam; yet all too often a doctor's primary concern is covering his own gluteus maximus. An autopsy may prove a doctor wrong, or even negligent.
Doctors with better intentions may simply believe that more sophisticated laboratory tests and imaging technology have made the autopsy redundant. Alas, they have not. A study by researchers at Louisiana State University Medical Centre used autopsies to determine that doctors missed 44% of cancerous tumors while patients were alive. Another study at the University of Pittsburgh found a 45% discordance between what clinical doctors diagnosed as the cause of death and what an autopsy later showed it to be.
In 1988, the JAMA ran an issue round the theme: “Declaring war on the non-autopsy”. So far, it has been more of a slow retreat. Last month, the Journal took up the torch once again. An editorial proposed a minimum autopsy rate as a condition for hospital accreditation and/or Medicare reimbursement. Meanwhile Mr. Herrera, looking ahead to a bulge of dying baby-boomers, foresees endless opportunities.