key: cord-0686970-jj8xd5z9 authors: Parekh, Utsav; Kanchan, Tanuj title: COVID-19 instigates resurgence of ‘needless autopsies’ issue in India date: 2020-07-16 journal: J Forensic Leg Med DOI: 10.1016/j.jflm.2020.102028 sha: 61d48d89d84733f1acaa1ffb75a13394abe87892 doc_id: 686970 cord_uid: jj8xd5z9 COVID-19 has swamped the entire world and turned into a pandemic. Its high contagiousness compelled authorities to categorize all autopsies as ‘high risk’ considering the risk of exposure to the healthcare workers. In India, the Criminal Procedure Code authorizes investigating police officer to hold an inquest into suspicious deaths. The present article draw attention towards the ‘needless autopsies’ in times of COVID-19 and emphasizes on causes and recommendations. COVID-19 has swamped the entire world and turned into a pandemic. Its high contagiousness compelled authorities to categorize all autopsies as 'high risk' considering the risk of exposure to the healthcare workers. In India, the Criminal Procedure Code authorizes investigating police officer to hold an inquest into suspicious deaths. The present article draw attention towards the 'needless autopsies' in times of COVID-19 and emphasizes on causes and recommendations. Wuhan, the capital of Hubei, China, reported the first case of coronavirus disease 2019 (COVID-19), which causes serious respiratory illness in human. 1 Its causative agent belongs to coronavirus family, like SARS-CoV and Middle East Respiratory Syndrome (MERS), and has been named as severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). 2 Expeditiously, COVID 19 outbreak spread across China and swamped the entire world, unfolding into a pandemic. The Advisory Committee on Dangerous Pathogens within the Health and Safety Executive has categorized SARS-CoV-2 as a HG3 (hazard group 3 organisms). 3 SARS-CoV-2 is transmitted via respiratory droplets through inhalation or contaminated surfaces. The effect of this highly contagious virus was such that, almost all the affected countries went into a lockdown, limiting movements of the entire population. Autopsies have been categorized as 'high risk' for the risk of exposure to health care workers (HCWs). 4 Considering the infectivity rate (R 0 ) of the disease, even the handling and performance of the last rites of the infected body are being regulated with due infection prevention and control measures. Section 174 of the Code of Criminal Procedure (CrPC), India, authorizes the investigating police officer to hold an inquest into suspicious, and unnatural deaths. 5 'Unnatural deaths' include death resulting from suicides, homicides, accidents, animal attack, and occupational mishaps etc. In India, sudden deaths, without any certified cause of death are labelled as medicolegal, and autopsy is conducted to find the cause of death. In India, under the aegis of aforesaid Section 174 CrPC, innumerable cases are referred for medico-legal autopsy that should be considered as highly needless. The term 'needless autopsy', encompasses the hospitalized unnatural as well as natural deaths where cause of death can be certified by the treating doctor. The mechanism and pathophysiology is well-understood in deaths occurring in hospital due to head injuries, injuries to other vital organs, multiple fractures, burns, etc., following an act of homicide, suicide or an accident. Such cases, though designated as MLC at the time of hospital admission, have well documented clinical case records, even the course following trauma, and the cause of death. In all such cases, it is deemed unnecessary to conduct autopsy to find the cause of death, which is already well-established and documented by the treating doctor. Reasons for carrying out such needless autopsies emanates from the reluctance and resistance at various levels. Despite of the provisions in the law, unwillingness of the investigating police officer to waive off medicolegal autopsy in cases where cause and manner of death are wellestablished beyond any doubt, is believed to be the main reason for carrying out needless autopsies. Besides, the reluctance of the emergency medical officer or the treating doctor to provide an obvious cause of death, and instead registering the case as medicolegal leads to needless autopsies being carried out. Lack of adequate medicolegal knowledge and defensive attitude of the doctors, may be one of the reasons for increasing number of cases being labelled as medicolegal. Whatever being the reason, abide by the legalities in India, many such cases have to undergo autopsy examination for no valid reasons. The issue of needless autopsies has been deliberated in one form or another 6-8 , and it was even raised in the state assembly of Maharashtra, India. 9 Observations of a project undertaken to curtail the number of post-mortem examinations based on Section 174 CrPC with respect to burn injuries revealed that autopsy on burn cases did not add anything to what was already known based on the treatment records of the deceased. 8 Consequently, all these efforts end up in wastage of manpower, resources, and exposing the HCWs to unnecessary risk of infections etc. In one of the studies, forensic experts across India expressed that the exercise of carrying out medico-legal autopsies in hospital deaths is often unnecessary. 7 However, COVID-19 outbreak has led to the resurfacing of the long ignored issue of 'needless autopsies' in India. COVID-19 confirmed deaths are considered as natural in India and abroad, 10 that being so, the question of performing medicolegal autopsies do not arise. Henceforth, guidelines from the Government of India mention that no invasive autopsy technique should be adopted in confirmed COVID 19 cases. 11 While the in-hospital deaths under medical care due to COVID-19 are considered as non-medicolegal, the suspected COVID-19 death or latent status brought dead to hospital are often labelled by emergency doctors as medico-legal case (MLC); police are intimated and the body is sent for post-mortem examination to ascertain the cause of death. The same may sometimes happen in death of patients with ILIs (Influenza Like Illnesses)/ SARI (Severe Acute Respiratory Illness). Considering the high transmission rate of the COVID-19, and community spread, there is likelihood that the victims of unnatural events (homicides, suicides and accidents) brought for autopsy were suffering from COVID-19. In absence of mandatory pre-autopsy testing, confirmation of the COVID 19 status of all bodies brought for autopsy in itself is a distant reality. Autopsies are considered as aerosol generating high risk procedure, and lack of infrastructure, infection control measures, and personal protective equipment (PPE) make the matters even worse. Thus, in order to save the HCWs from acquiring the infection, deliberations are focusing on switching over to non-invasive or minimally invasive autopsy techniques or performing partial autopsy or even no autopsy at all. 1, [11] [12] [13] The most significant move to protect the HCWs, however, lies in avoiding the 'needless' autopsies, thereby minimizing the chances of unnecessary exposure to SARS-CoV-2. Besides, this is likely to reduce the existing load of autopsies on the resource limited medicolegal facilities 14 during these challenging times. There can be no justification for risking the life of a healthcare worker for a non-justifiable cause of performing unnecessary autopsies. It would not be incorrect to say that 'needless autopsies' are not only a futile exercise, and waste of manpower and resources, it exposes the HCWs to a number of infections. Besides, it also amounts to unnecessary mutilation of the body, and disregard for the dead. Though the issue of 'needless autopsies' has been deliberated in the past, 6-9 never was it taken so seriously, as during the COVID-19 pandemic. Considering the facts of the matter, exemption of post-mortem examination in all cases with well-established cause and manner of death based on the hospital Autopsy practice relating to possible cases of COVID-19 (2019-nCov, novel coronavirus from China 2019/2020) secondary autopsy practice relating to possible cases of COVID-19 Director General's remarks at the media briefing on 2019-nCoV on 11 February 2020. secondary director General's remarks at the media briefing on Health and Safety Executive Advisory Committee on Dangerous Pathogens. The Approved list of biological agents. secondary the Approved list of biological agents Guidelines on rational use of personal protective equipment. EMR Division, Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India Legislative department. Government of India India and the problem of "needless autopsies Forensic medicine experts' opinion on medico-legal autopsies in hospital deaths: a questionnaire survey A retrospective analysis of project undertaken to curtail the number of post-mortem examinations based on Section 174 CrPC with respect to burn injuries Question raised in Maharashtra assembly on Dr Khandekar's report on "unnecessary postmortems Chief Coroner's Guidance, Advice and Law Sheets. Courts and tribunals judiciary EMR Division, Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India Autopsy practices in suspected COVID-19 cases: scenario from India. Forensic and Legal Medicine A roadmap to the safe practice of Forensic Medicine in the COVID-19 pandemic COVID-19 outbreak: A testing time for medicolegal facilities in India The authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers' bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript that could inappropriately influence (bias) our work. Authors declare no conflict of interest.