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Sunday, Nov. 2, 2008
Pondering the process of filling in the final page of a person's life
In the late 1980s, the mother of a close female friend of ours in Tokyo went into hospital for a hysterectomy. This is major, if fairly routine, surgery.
However, the operation didn't go well and she needed a blood transfusion. Our friend's husband and some of his colleagues rushed to the hospital to give blood — but in vain. Our friend's mother, only 56 years old, died of what the hospital deemed to be heart failure.
Both my wife and I were of course saddened and shocked, and we urged our friend to have an autopsy conducted on her mother's body to establish beyond doubt why she had died.
"She was so young to die of heart failure," my wife said to our friend. "And, after all, she went into hospital for something completely different."
But our friend resigned herself to her mother's death and had her cremated without inquiring further. No autopsy was performed.
A mere 20 years ago, hospitals in Japan played their patients' karute (medical records) very close to their chest. With few exceptions, patients and their families did not have free access to records. The "right to know" had been usurped by the paternalistic notion that "it's better for you if you don't know." In effect, medical matters were nothing to do with those they affected.
While hospitals and doctors in Japan are nowadays much more open and forthcoming when it comes to medical records and information, this country still has the lowest rate of autopsies in the developed world. Consequently, the determination of cause of death is largely left to hospitals and doctors. In many cases, however, this may not satisfy the next of kin, and conducting an autopsy may then be the only way to determine the true cause.
There are basically two kinds of autopsies. Clinical autopsy exists to determine cause of death when no suspicious circumstances are suspected. Forensic autopsy is performed in cases of death investigated by the police or other authorities.
Only 2.7 percent of people in Japan who die what is thought to be a natural death get an autopsy. In Europe, that figure is between 20 and 30 percent, while Hungary has the highest autopsy rate in the world, at 49 percent.
There are about a million deaths every year in Japan — approximately 80 percent of them in hospital or overseen by a doctor. In 20 percent of all deaths, the cause is not known.
As for forensic autopsy, this is performed on fewer than 10 percent of cases investigated by police in Japan. Forensic autopsies, or autopsies otherwise conducted for legal purposes, are paid for by the national or prefectural government, while clinical autopsies are not. (A clinical autopsy costs about ¥250,000, which is not covered by insurance.)
But the staggering fact in this context is that approximately one in four autopsies in the world reveal a major error in the diagnosis of cause of death. This alone would indicate the importance of an autopsy when even a shadow of doubt as to cause of death exists.
Some recent cases in Japan markedly underscore the need for autopsy.
There's that of a deceased woman who was about to be cremated but was given an autopsy after a man confessed to raping her. The autopsy revealed that this had occurred, and the man was arrested.
Then there was a man who died of what the hospital said was heart failure. After being given an autopsy at the request of his family, it was found that a nail had been driven into his heart with a nail gun, and his death was judged a suicide.
And what about the scandalous case of the death of 17-year-old sumo wrestler Takashi Saito, which makes the clearest case for autopsy. He died in June 2007 after taking part in a training session. Police, however, declined to request an autopsy, but Saito's father viewed his son's heavily bruised body and ordered one. Two autopsies were conducted and the conclusion was reached that Saito's death was the result of "multiple traumatic shock." This led to the arrest of sumo stablemaster Junichi Yamamoto and three wrestlers.
As reported in The Japan Times on Feb. 8, 2008, Yamamoto is alleged to have struck Saito in the head with a beer bottle and to have ordered the three others to beat him with a metal baseball bat.
Many Japanese people traditionally believe that a body should be as pristine as possible upon "leaving this world." For that reason, they shun autopsy, even if it might shed light on the true cause of a loved one's fate.
But a recent advance in technology — autopsy imaging, or Ai — now enables autopsies to be performed without invasion of the body. Ai is postmortem-computed tomography, by which a body is scanned in its entirety to discover cause of death. This type of virtual autopsy also aids in drug research, particularly in the study of toxicity of drugs used in cancer therapy.
These days, perhaps surprisingly, some hospitals in Japan are welcoming autopsies. There are cases in which bereaved family members may believe some form of malpractice may have occurred, and in such instances the best way for a hospital to clear itself legally may be to conduct an autopsy and prove the cause of death to be natural. The most thorough method, of course, is to conduct both an Ai autopsy and a pathology autopsy. Ai is unlikely, for instance, to uncover a tiny hole in the skin where an injection may have been administered.
In March this year, a committee formed by the Japan Medical Association issued a report advising government to make Ai autopsy mandatory in cases of suspected child abuse, when abusive parents would likely be reluctant to accede. This is a report whose advice must be followed.
There is an old saying that "You can always make a correct diagnosis, but you have to wait until the autopsy."
Our friend back in the '80s did not want to pursue an investigation into the cause of her mother's death. She will never know what really killed her.
Peace of mind and justice constitute good enough reasons to encourage the increased use of autopsy in Japan. The final page of a person's life should not be left blank.