50 Forensic dentistrymedical examiner’s office or other medical facility for autopsy examination.
A key feature of any type of system is that the examinations performed by
the medical examiner or coroner’s pathologist are done under the author-
ity of the state, and as such, are not subject to approval of the decedent’s
next of kin, as are diagnostic hospital autopsies. A corollary of this authority
is that there can be no room in a medicolegal examination for objections
to the forensic pathologist’s examination on personal or religious grounds.
If the ME or coroner has the need to conduct an examination in order to
adequately investigate the death, then it should be done regardless of any
objections, though the examination techniques may be modified at the dis-
cretion of the autopsy physician to attempt to accommodate family beliefs.
Any attempt to infringe upon this prerogative compromises the system of
investigation significantly.
A medical examiner or coroner’s office must first determine whether a
case reported to the office falls under its jurisdiction. Jurisdictional criteria
vary according to law from state to state, but in general, deaths due to trauma
or intoxication, natural deaths occurring suddenly and unexpectedly, or those
due to un k now n causes fa l l under t he jurisdiction of t he ME or coroner. Ot her
types of death may not fall under ME or coroner jurisdiction, and need not be
examined by those offices.
Sometimes there is a need for autopsy examinations in cases that do not
fall under ME jurisdiction. At one time in the United States, the autopsy rate
of individuals dying in a hospital setting approached 50%. The autopsy was
viewed as a valuable diagnostic and quality assurance, and teaching tool, and
permission was sought from the patient’s next of kin to perform an autopsy
in most death cases. In cases not falling under a medical examiner or coroner
jurisdiction, permission is required of the next of kin to perform an autopsy.
In recent decades, however, the autopsy rate in this country has plummeted,
and now autopsies are performed infrequently in most hospitals, even in
teaching institutions. This is due to a multitude of causes.
First, there is an overreliance on modern diagnostic imaging techniques
and a belief that computed tomography and magnetic resonance imag-
ing scans will have discovered everything the autopsy might find. This is
proving to be a very erroneous belief, as most autopsy physicians can attest.
Imaging studies, in spite of their clinical utility, are poor substitutes for an
adequate postmortem examination. Molina et al. have documented signifi-
cant discrepancies between antemortem imaging findings and the autopsy,^32
which remains the gold standard of medical diagnosis. Second, the Joint
Commission on Accreditation of Health Care Organizations deleted the
autopsy requirement for hospital accreditation in 1971. This closely coincided
with the precipitous drop in autopsy rates nationwide, as hospitals are no
longer required to show a particular rate of autopsies in their institutions in
order to be accredited.^33 The autopsy is not covered by third-party payers,