Justice Scalia: Why didn’t they perform an autopsy?

With the Supreme Court in the balance, every aspect of the unexpected demise of U.S. Supreme Court Justice Antonin Scalia has received intense scrutiny, from the cause of his recent death to the politically charged choice of his successor. An autopsy was not performed on the 79-year-old jurist, who was found dead in his room in a West Texas hunting resort, and that too has become a lightning rod for controversy.

This high-profile case provides an opportunity to shine some light on the practice of autopsies, and the pros and cons in circumstances like these. Pathologists, who specialize in the study of disease, are the physicians who perform autopsies. While I must emphasize that I do not know any of the details of Mr. Scalia’s health records or the events that transpired following his death (and I obviously don’t know the position of the pillows in his hotel room), there are some things that can be extrapolated.

Presidio County Judge Cinderela Guevera pronounced Scalia dead under “natural causes,” according to The Washington Post. A death that occurs outside a hospital falls under the jurisdiction of the local county – typically a coroner, who is an elected official, or an appointed medical examiner, usually a doctor, in a large metropolitan area like Cook County in Illinois. Autopsies performed by coroner’s or medical examiner’s offices are “forensic autopsies,” while those in hospitals, such as the ones I have performed, are “medical autopsies.” There are many similarities in the two autopsy types, but a forensic autopsy will further investigate certain possibilities.

For instance, a coroner or medical examiner further investigates cause of death if there is any indication that it occurred under unusual or unnatural circumstances, including “foul play,” such as shootings, or some sort of accident, such as a drowning or car crash. A 79 year old passing away in his sleep, while sad and untimely, may not necessarily trigger an autopsy, especially if the patient had significant prior medical conditions. Similarly, an autopsy may not be pursued if a 79-year-old man dies while shoveling snow if the patient had known coronary artery disease.

In making her decision, Guevera reportedly contacted Scalia’s doctor and learned about some of his chronic conditions. Presidio County District Attorney Rod Ponton later told the Associated Press that Scalia’s doctor wrote a letter to Guevera stating that the Supreme Court justice suffered from coronary artery disease, obesity, diabetes, chronic obstructive pulmonary disease, hypertension and sleep apnea. Scalia also had been a smoker, according to the letter.

One of the benefits of a forensic autopsy in an extremely high-profile case like this also may be to help rule out such things that conspiracy theorists speculate about.  Forensic autopsies differ from medical autopsies in that toxicology tests may be performed on blood or other body fluids to look for an overdose – or even for poisoning. A forensic investigation also would take into account any clues from the death scene.

An autopsy itself would not put all the conspiracy theories to rest — and one can’t help but think about John F. Kennedy in such instances — but it would have taken away one angle on them.

A patient’s family also has the opportunity to seek a private autopsy, and Mr. Scalia’s chose not to do that, according to reports. If a death occurs in a hospital, a family has the choice whether to request a medical autopsy, which would be performed by pathologists, pathology residents or pathology assistants there.

A reasonable presumption in a case of a septuagenarian, where the deceased was not ill at the time of death but had multiple chronic conditions, is that the cause of death was a cardiac event.  A myocardial infarction would be high on the differential diagnosis.

In both forensic and medical autopsies, pathologists scrutinize the organs of the body and sample postage stamp-sized portions of tissue that are made into slides which are later examined under a microscope. Unfortunately, autopsies are limited in their ability to pinpoint an MI as an acute cause of death because the tell-tale changes that cardiac muscle cells undergo after an MI typically are not microscopically identifiable until about 12 hours after the event. If a patient dies before then, those changes are halted in their tracks and are thus undetectable.

However, pathologists performing an autopsy can discover many of the predisposing conditions that suggest that an MI was a strong possibility. For example, are the coronary arteries hardened and occluded with atherosclerosis? Is there pre-existing scarring that suggests that an earlier MI occurred (perhaps one so small that the patient had not felt it)?

Similarly, if a patient dies of a fatal heart arrhythmia, there will be no sign at the autopsy that would point to it conclusively like an abnormal EKG taken before death.

An autopsy could, however, more definitively identify other common causes of acute deaths by natural causes. Pathologists performing autopsies follow a standardized procedure and would look for a pulmonary embolism, an aortic dissection or a cerebral hemorrhage.

In hospitals, autopsies are not performed as commonly as they were in the past as improving medical technology has made them less necessary. More precise lab tests and advanced diagnostic capabilities in radiology, such as CT scans which can detect cancers spread throughout the body, have taken much of the mystery out of why patients die.

Autopsies remain an important facet in the education of pathologists and pathologists-in-training undergoing lifelong learning in how diseases affect the human body. Even when the cause of death is not 100 percent conclusive, they can reveal insight into the condition of the patient that led to his demise.

In this case, with such a prominent patient, the autopsy may have been more revealing in what it did not find, as opposed to what it did find. In other words, the greatest benefit may have been simply in precluding the question: Why didn’t they perform an autopsy?

John Biemer, a former reporter, is a pathology resident.

Image credit: Shutterstock.com

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