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Public attitudes towards the autopsy in china
Pathology (1998) 30, pp. 92-94
PUBLIC ATTITUDES TOWARDS THE AUTOPSY IN CHINA WEI-QIANG ZHENG*, YIN-HUI FAN* AND ANGELA NGt
Department of Pathology, Second Military Medical University, Shanghai, China*, and Department of Pathology, University of Malaya, Kuala Lumpur, Malaysiat
Summary The autopsy rate in China has fallen within the last few years. The attitudes of the public have become an important factor for its decline. Attitudes towards autopsy were surveyed from 400 subjects residing in the 27 provinces of China. Among the 299 survey forms returned, 284 were completed correctly, the remaining 15 being incomplete. The response rate was 71 %. More than half of the responding members considered autopsy beneficial. However their perception of autopsy was quite inaccurate and prejudicial, lacking complete information. The two most frequent reasons for not accepting an autopsy were the lack of awareness towards the practice of autopsy and the wariness of body disfigurement after the autopsy was performed. It was suggested that the most appropriate way to change public perception of autopsy was through education. The primary tool for reaching the public was through the media. In addition, the approach to obtaining consent for autopsy should be improved.
now.! Hence, it is necessary to survey public awareness in order to improve the current state of affairs. MATERIALS AND METHODS A questionnaire was designed by a panel consisting of pathologists and non-medically qualified serving staff? Respondents were required to select a limited range of options (Tables 1-3). Some questions were accompanied by explanatory sentences. Space for additional comments was included at the end. A self addressed stamped envelope was also enclosed. A popUlation that covered 27 provinces of China and consisted of people with different levels of education was randomly selected in order to establish a survey that was representative of the general population in China. The sampling frame used was made from a random selection of
TABLE 1 Responses to the question "Do postmortems involve any of the following?" Response (%)
Key words: Autopsy, medical ethics, investigation, China. Accepted 28 October 1997
INTRODUCTION The autopsy rate in China has fallen within the last few years, even though the diseases discovered through autopsies have been and remain important.! Improved clinical practice from uncovered errors continues to be vita1. 2 The deterioration of the autopsy rate continues to fall, and is approaching fewer than 5% of deaths in our attached teaching hospital. Generally speaking, there are two main reasons for the recent decline in autopsy. First, the clinicians are requesting fewer autopsies, partly due to the cumbersome process of obtaining consent and sometimes the futile efforts in convincing family members or relatives. The pathologists are also increasingly reluctant to devote their time to perform autopsies because autopsy is not used as a criterion for evaluating their professional performance. Second, the negative attitude of the public towards autopsies is an important cause of the declining autopsy rates. Family members or relatives often reject the idea of an autopsy despite the promised money supplementation for funeral rites. Hospital administrators may be able to help resolve such contradiction. In particular, the physicians and medical students should be made more aware of the usefulness of autopsy. According to the literature in China, accurate public attitudes towards autopsy have not been investigated until
Getting permission from relatives in all cases Examining the outside of the body Examining the inside of the body Visible disfigurement of the body Delay of the funeral The way to solve the controversy for diagnosis
TABLE 2
Yes
No
Unsure
75.4 15.5 80.6 83.5 51.4 62.8
7.4 49.3 5.3 7.7 40.8 20.4
17.2 35.2 14.1 8.8 7.8 16.8
Responses to the question "For which of the following reasons do you think postmortems are needed?" Responses (%)
Postmortem is necessary for the departed To find out why people have died in hospital To find out why people die suddenly at home To teach medical students and doctors about diseases To find out if treatments work To learn surgical operations To obtain something which can be used to treat other patients
Yes
No
Unsure
28.5 69.4 65.1
66.2 23.6 27.8
5.3 7.0 7.1
71.1 58.9 19.0
10.6 34.2 25.7
18.3 6.9 55.3
28.2
47.2
24.6
TABLE 3 Responses to the question "Where have you learned about postmortems?" Source of information Television/radio Books/magazines/newspapers Friends or relatives Physicians
Numbers of respondents
%
197 192 61 27
69.4 67.6 21.5 9.5
Respondents could indicate more than one source if applicable.
0031-3025/98/020092-03 © 1998 Royal College of Pathologists of Australasia
CHINESE ATTITUDES TOWARDS THE AUTOPSY
TABLE 4 The comparison between different age groups with different levels of education for willingness to consent to autopsy (percentages given in brackets) N
Age < 40 years (n = 175 )
Age ;;. 40 years (n = 109 )
Primary school Secondary school College or university
78 140 66
12/33 (36.4) 22/98 (22.4) 31144 (70.5)*
8/45 (17.8) 13142 (30.9)
Total
284
Educated degree
65/175 (37.1)
11122 (50.0)**
32/109 (29.4)
* Statistically significantly different versus primary school group (p < 0.01).
*. Statistically significantly different versus primary school group (p < 0.05). 400 people between 18 and 84 yrs of age. The random subjects were provided by the registry bureau of the respective provinces. In general, questionnaires to subjects above 70 yrs old was limited to avoid the potential sensitivity towards such a questionnaire. Pathological jargon was avoided and common terms were used instead. For example, "postmortem" was used in place of "autopsy". Statistics
The Chi-squared test was used for data analysis. A p value of less than 0.05 was taken to indicate a significant difference between comparison of groups.
RESULTS A total of 299 survey foOlls were returned. Among those, 284 foOlls were completed and 15 were incomplete. The response rate was 71 %. The results in Table 4 show that there were no significant difference in number of respondents willing to consent to autopsy between those aged 40 years and above and those aged below 40 years. However significant differences were found when comparison was made between those with different education levels.
Questionnaire responses Most of the respondents considered that only anatomical pathologists carried out autopsies, while some believed that such work was carried out by forensic doctors. Most (75.4%) of the respondents thought that permission from relatives of the deceased was necessary for an autopsy in all cases and 62.8% regarded an autopsy as a way to solve the controversy between the relatives and the clinical physicians in the diagnosis of the cause of death. Seventeen per cent of the respondents accepted the fact that this was also a contribution to medical research. However, more than 50% of them thought an autopsy would result in visible disfigurement of the body, which they considered disrespectful for the departed although they understood its purpose (Table 1). A large number of respondents considered that autopsy was required to determine the cause of a sudden death, for example, in the case of myocardial infarction during sleep (Table 2). Some of the respondents thought autopsies could verify the accuracy of the advanced medical equipment such as Magnetic Resonance Computed Tomography (MRCT). The main sources of infoOllation on autopsies were from television and newspapers (Table 3), but there were also a few respondents who had never heard of an autopsy. Many respondents requested further details.
93
A surprising suggestion was that for persons who died in a hospital, the autopsies should be carried out in another hospital to justify the initial diagnosis without any bias.
DISCUSSION The decline in the autopsy rate is attributed to the waning interest of clinicians, pathologists, families of the deceased, and hospital administrators. 4 The respondents in this survey brought up a few reasons for the objection to autopsies. First, superstitious beliefs, especially among the older generation, had been the main reason for unfavourable attitudes toward autopsy. Second, the issue of religious prohibitions was raised by some of the city dwellers. While city dwellers generally have a higher level of education, they may be more sensitive to religious values. There was a trend for the less educated population to have a narrow view about autopsies and negative attitudes toward its practice. These problems need to be addressed but it would definitely require a long time before a change in attitude or behaviour could occur. This investigation indicated that the public had considerable appreciation for the nature and purpose of autopsy and its value to the medical advancement. However, their knowledge about autopsy was quite inaccurate and prejudicial. The primary means for reaching the public is through the media. A wide range of possible methods involving print, radio and television have been proposed elsewhere. 5 In China, the media have commonly associated autopsy with criminal investigations. This has led the general public to regard it as forensic work, and thus has incurred their prejudice. The most appropriate way to change public perception of the autopsy is through education, such as healthy propaganda and press instructed by the province (city) or even national administrators. 6 Attractive, factual and sensitively prepared pamphlets that convey scholarly infoOllation urging the public's participation in supporting research and infoOllation on current discoveries from autopsies can be distributed freely through social agencies, hospitals and clinicians. Special features should be prepared for publication in some specialized magazines aimed at the elderly and the less educated population. Due to their lack of education, they commonly resist new ideas and cannot grasp the true meaning or significance behind published infOlmation. Therefore, it is recommended that these groups, usually 'from the rural regions, should be given more explanation with great patience in order to gain their trust and understanding. Targeting newsletters in hospitals and 10ng-teOll care units, such as the unit for the teOllinally ill, can reach out to those directly involved who might be willing to support research in autopsy. The contribution of the autopsy to the improvement of medical treatment, prevention of diseases and advancement of medical research in such public, educational campaigns should be emphasized for the benefits of future generations. Obviously, these campaigns would be difficult to cany out if there was a lack of support from medical professionals. Thus, we recommend the appreciation of OsIer's famous dictum: To investigate the causes of death, to examine carefully the condition of organs, after such changes have gone on in them as to render existence impossible, and to apply such knowledge to the prevention
94
Pathology (1998), 30, May
ZHENG et al.
and treatment of disease, is one of the highest objects of the physician. 7 Many clinical departments have supported the practice of autopsy in recent years. Formal assessment of the attitudes of medical staffs toward autopsies has consistently shown strong support for it in principle. However, these attitudes are not supported in practice and clinical autopsy rates continue to decline. 8, 9 One must ask whether the problem can be rectified through the administrative policy of the hospital. 10 New bridges must be built between the funding agencies, the scholarly community, the administrators and the medical schools if autopsy is to be revitalized. So far, in our hospital, most autopsies were performed when a controversy arose in the clinical diagnosis or when the relatives showed doubts regarding the causes of death. Another factor that may influence the attitude of the public towards autopsy is the manner in which the consent for clinical autopsy is sought,u Permission for autopsy is often refused if the relationship between relatives and physicians is tense. We frequently receive requests not to disfigure the body, in particular the face during the autopsy. So far, there were hardly any complaints about disfigurement after restoration at the end of the autopsy. Sometimes, the option of a limited autopsy was performed as a compromise between the relatives and the physicians. For example, only thoracic autopsy was carried out if there was an opposition to some form of incision. 12 We must also make clear to the family that autopsy is not only used for confirming the clinical diagnosis but can also reveal the possibility of familial disorders, the knowledge of which could be useful when monitoring the living family members. These findings suggested the need to improve the procedure for obtaining consent for autopsies and the counselling of family members of the dying or the deceased. Today, few medical schools require students to attend an autopsy as part of their education. Medical schools need to expose students to autopsies and to educate them about
their benefits. Students need to be evaluated and rewarded for their skills and knowledge about autopsies as part of their overall medical education. 13 In conclusion, the future will be optimistic if the attitudes of both doctors and public can be slowly changed through the collaborative effort of all those directly and indirectly involved. ACKNOWLEDGEMENTS The authors are grateful to Professor Lai-Meng Looi, Associate Professor Phaik-Leng Cheah, Dr Beng-Beng Ong and Miss Wanda Seet Wan Tai for their kind advice and assistance in preparation for this manuscript. Address for correspondence: W-Q.Z, Department of Pathology, Faculty of Medicine, Second Military Medical University, Shanghai 200433, China.
References
1. Wang L, Guo S. A surveying on the recent issues of autopsy. Chin J Pathol 1989; 21: 383-6. 2. McPhee SI, Bottles K. Autopsy: moribund art or vital science? Am J Med 1985; 78: 107-13 3. Start RD, Saul CA, Cotton DWK, Mathers NJ, Underwood JCE. Public perceptions of necropsy. J Ciin Pathol 1995; 48: 497- 500 4. Roberts Wc. The autopsy: its decline and a suggestion for its revival. N Engl J Med 1978; 299: 332-8 5. Brown HG. Perception of the autopsy: views from the lay public and program proposals. Hum Pathol 1990; 21: 154-8 6. Hill R. Conference recommendations: The autopsy. Arch Parhol Lab Med 1984: 108: 512- 5 7. Cushing H. The life of Sir William Osier. 1st edn. New York: Oxford University Press, 1940; 85 8. Hill RB, Anderson RE. Pathologists and the autopsy. Am J Clin Parhol 1991 ; 95: (Suppl 1): S42-9 9. Start RD, McCulloch TA, Silicoks PB, Cotton DWK Attitudes of senior pathologists toward the autopsy. J Pathol 1994; 172: 81-4 10. Dever KJ. The changing role of the autopsy: a social environmental perspective. Hum Parhol 1990; 21: 145-53 1 L Scheidermann H, Grubn J. How and why to request an autopsy. Postgrad Med J 1985; 77: 153- 64 12. Brown HG. Lay perceptions of autopsy. Arch Parhol Lab Med 1984; 108: 446-8 13. Benbow EW. Medical students' views on necropsies. J Clin Pathol 1990; 43: 969-76
PUBLIC ATTITUDES TOWARDS THE AUTOPSY IN CHINA WEI-QIANG ZHENG*, YIN-HUI FAN* AND ANGELA NGt
Department of Pathology, Second Military Medical University, Shanghai, China*, and Department of Pathology, University of Malaya, Kuala Lumpur, Malaysiat
Summary The autopsy rate in China has fallen within the last few years. The attitudes of the public have become an important factor for its decline. Attitudes towards autopsy were surveyed from 400 subjects residing in the 27 provinces of China. Among the 299 survey forms returned, 284 were completed correctly, the remaining 15 being incomplete. The response rate was 71 %. More than half of the responding members considered autopsy beneficial. However their perception of autopsy was quite inaccurate and prejudicial, lacking complete information. The two most frequent reasons for not accepting an autopsy were the lack of awareness towards the practice of autopsy and the wariness of body disfigurement after the autopsy was performed. It was suggested that the most appropriate way to change public perception of autopsy was through education. The primary tool for reaching the public was through the media. In addition, the approach to obtaining consent for autopsy should be improved.
now.! Hence, it is necessary to survey public awareness in order to improve the current state of affairs. MATERIALS AND METHODS A questionnaire was designed by a panel consisting of pathologists and non-medically qualified serving staff? Respondents were required to select a limited range of options (Tables 1-3). Some questions were accompanied by explanatory sentences. Space for additional comments was included at the end. A self addressed stamped envelope was also enclosed. A popUlation that covered 27 provinces of China and consisted of people with different levels of education was randomly selected in order to establish a survey that was representative of the general population in China. The sampling frame used was made from a random selection of
TABLE 1 Responses to the question "Do postmortems involve any of the following?" Response (%)
Key words: Autopsy, medical ethics, investigation, China. Accepted 28 October 1997
INTRODUCTION The autopsy rate in China has fallen within the last few years, even though the diseases discovered through autopsies have been and remain important.! Improved clinical practice from uncovered errors continues to be vita1. 2 The deterioration of the autopsy rate continues to fall, and is approaching fewer than 5% of deaths in our attached teaching hospital. Generally speaking, there are two main reasons for the recent decline in autopsy. First, the clinicians are requesting fewer autopsies, partly due to the cumbersome process of obtaining consent and sometimes the futile efforts in convincing family members or relatives. The pathologists are also increasingly reluctant to devote their time to perform autopsies because autopsy is not used as a criterion for evaluating their professional performance. Second, the negative attitude of the public towards autopsies is an important cause of the declining autopsy rates. Family members or relatives often reject the idea of an autopsy despite the promised money supplementation for funeral rites. Hospital administrators may be able to help resolve such contradiction. In particular, the physicians and medical students should be made more aware of the usefulness of autopsy. According to the literature in China, accurate public attitudes towards autopsy have not been investigated until
Getting permission from relatives in all cases Examining the outside of the body Examining the inside of the body Visible disfigurement of the body Delay of the funeral The way to solve the controversy for diagnosis
TABLE 2
Yes
No
Unsure
75.4 15.5 80.6 83.5 51.4 62.8
7.4 49.3 5.3 7.7 40.8 20.4
17.2 35.2 14.1 8.8 7.8 16.8
Responses to the question "For which of the following reasons do you think postmortems are needed?" Responses (%)
Postmortem is necessary for the departed To find out why people have died in hospital To find out why people die suddenly at home To teach medical students and doctors about diseases To find out if treatments work To learn surgical operations To obtain something which can be used to treat other patients
Yes
No
Unsure
28.5 69.4 65.1
66.2 23.6 27.8
5.3 7.0 7.1
71.1 58.9 19.0
10.6 34.2 25.7
18.3 6.9 55.3
28.2
47.2
24.6
TABLE 3 Responses to the question "Where have you learned about postmortems?" Source of information Television/radio Books/magazines/newspapers Friends or relatives Physicians
Numbers of respondents
%
197 192 61 27
69.4 67.6 21.5 9.5
Respondents could indicate more than one source if applicable.
0031-3025/98/020092-03 © 1998 Royal College of Pathologists of Australasia
CHINESE ATTITUDES TOWARDS THE AUTOPSY
TABLE 4 The comparison between different age groups with different levels of education for willingness to consent to autopsy (percentages given in brackets) N
Age < 40 years (n = 175 )
Age ;;. 40 years (n = 109 )
Primary school Secondary school College or university
78 140 66
12/33 (36.4) 22/98 (22.4) 31144 (70.5)*
8/45 (17.8) 13142 (30.9)
Total
284
Educated degree
65/175 (37.1)
11122 (50.0)**
32/109 (29.4)
* Statistically significantly different versus primary school group (p < 0.01).
*. Statistically significantly different versus primary school group (p < 0.05). 400 people between 18 and 84 yrs of age. The random subjects were provided by the registry bureau of the respective provinces. In general, questionnaires to subjects above 70 yrs old was limited to avoid the potential sensitivity towards such a questionnaire. Pathological jargon was avoided and common terms were used instead. For example, "postmortem" was used in place of "autopsy". Statistics
The Chi-squared test was used for data analysis. A p value of less than 0.05 was taken to indicate a significant difference between comparison of groups.
RESULTS A total of 299 survey foOlls were returned. Among those, 284 foOlls were completed and 15 were incomplete. The response rate was 71 %. The results in Table 4 show that there were no significant difference in number of respondents willing to consent to autopsy between those aged 40 years and above and those aged below 40 years. However significant differences were found when comparison was made between those with different education levels.
Questionnaire responses Most of the respondents considered that only anatomical pathologists carried out autopsies, while some believed that such work was carried out by forensic doctors. Most (75.4%) of the respondents thought that permission from relatives of the deceased was necessary for an autopsy in all cases and 62.8% regarded an autopsy as a way to solve the controversy between the relatives and the clinical physicians in the diagnosis of the cause of death. Seventeen per cent of the respondents accepted the fact that this was also a contribution to medical research. However, more than 50% of them thought an autopsy would result in visible disfigurement of the body, which they considered disrespectful for the departed although they understood its purpose (Table 1). A large number of respondents considered that autopsy was required to determine the cause of a sudden death, for example, in the case of myocardial infarction during sleep (Table 2). Some of the respondents thought autopsies could verify the accuracy of the advanced medical equipment such as Magnetic Resonance Computed Tomography (MRCT). The main sources of infoOllation on autopsies were from television and newspapers (Table 3), but there were also a few respondents who had never heard of an autopsy. Many respondents requested further details.
93
A surprising suggestion was that for persons who died in a hospital, the autopsies should be carried out in another hospital to justify the initial diagnosis without any bias.
DISCUSSION The decline in the autopsy rate is attributed to the waning interest of clinicians, pathologists, families of the deceased, and hospital administrators. 4 The respondents in this survey brought up a few reasons for the objection to autopsies. First, superstitious beliefs, especially among the older generation, had been the main reason for unfavourable attitudes toward autopsy. Second, the issue of religious prohibitions was raised by some of the city dwellers. While city dwellers generally have a higher level of education, they may be more sensitive to religious values. There was a trend for the less educated population to have a narrow view about autopsies and negative attitudes toward its practice. These problems need to be addressed but it would definitely require a long time before a change in attitude or behaviour could occur. This investigation indicated that the public had considerable appreciation for the nature and purpose of autopsy and its value to the medical advancement. However, their knowledge about autopsy was quite inaccurate and prejudicial. The primary means for reaching the public is through the media. A wide range of possible methods involving print, radio and television have been proposed elsewhere. 5 In China, the media have commonly associated autopsy with criminal investigations. This has led the general public to regard it as forensic work, and thus has incurred their prejudice. The most appropriate way to change public perception of the autopsy is through education, such as healthy propaganda and press instructed by the province (city) or even national administrators. 6 Attractive, factual and sensitively prepared pamphlets that convey scholarly infoOllation urging the public's participation in supporting research and infoOllation on current discoveries from autopsies can be distributed freely through social agencies, hospitals and clinicians. Special features should be prepared for publication in some specialized magazines aimed at the elderly and the less educated population. Due to their lack of education, they commonly resist new ideas and cannot grasp the true meaning or significance behind published infOlmation. Therefore, it is recommended that these groups, usually 'from the rural regions, should be given more explanation with great patience in order to gain their trust and understanding. Targeting newsletters in hospitals and 10ng-teOll care units, such as the unit for the teOllinally ill, can reach out to those directly involved who might be willing to support research in autopsy. The contribution of the autopsy to the improvement of medical treatment, prevention of diseases and advancement of medical research in such public, educational campaigns should be emphasized for the benefits of future generations. Obviously, these campaigns would be difficult to cany out if there was a lack of support from medical professionals. Thus, we recommend the appreciation of OsIer's famous dictum: To investigate the causes of death, to examine carefully the condition of organs, after such changes have gone on in them as to render existence impossible, and to apply such knowledge to the prevention
94
Pathology (1998), 30, May
ZHENG et al.
and treatment of disease, is one of the highest objects of the physician. 7 Many clinical departments have supported the practice of autopsy in recent years. Formal assessment of the attitudes of medical staffs toward autopsies has consistently shown strong support for it in principle. However, these attitudes are not supported in practice and clinical autopsy rates continue to decline. 8, 9 One must ask whether the problem can be rectified through the administrative policy of the hospital. 10 New bridges must be built between the funding agencies, the scholarly community, the administrators and the medical schools if autopsy is to be revitalized. So far, in our hospital, most autopsies were performed when a controversy arose in the clinical diagnosis or when the relatives showed doubts regarding the causes of death. Another factor that may influence the attitude of the public towards autopsy is the manner in which the consent for clinical autopsy is sought,u Permission for autopsy is often refused if the relationship between relatives and physicians is tense. We frequently receive requests not to disfigure the body, in particular the face during the autopsy. So far, there were hardly any complaints about disfigurement after restoration at the end of the autopsy. Sometimes, the option of a limited autopsy was performed as a compromise between the relatives and the physicians. For example, only thoracic autopsy was carried out if there was an opposition to some form of incision. 12 We must also make clear to the family that autopsy is not only used for confirming the clinical diagnosis but can also reveal the possibility of familial disorders, the knowledge of which could be useful when monitoring the living family members. These findings suggested the need to improve the procedure for obtaining consent for autopsies and the counselling of family members of the dying or the deceased. Today, few medical schools require students to attend an autopsy as part of their education. Medical schools need to expose students to autopsies and to educate them about
their benefits. Students need to be evaluated and rewarded for their skills and knowledge about autopsies as part of their overall medical education. 13 In conclusion, the future will be optimistic if the attitudes of both doctors and public can be slowly changed through the collaborative effort of all those directly and indirectly involved. ACKNOWLEDGEMENTS The authors are grateful to Professor Lai-Meng Looi, Associate Professor Phaik-Leng Cheah, Dr Beng-Beng Ong and Miss Wanda Seet Wan Tai for their kind advice and assistance in preparation for this manuscript. Address for correspondence: W-Q.Z, Department of Pathology, Faculty of Medicine, Second Military Medical University, Shanghai 200433, China.
References
1. Wang L, Guo S. A surveying on the recent issues of autopsy. Chin J Pathol 1989; 21: 383-6. 2. McPhee SI, Bottles K. Autopsy: moribund art or vital science? Am J Med 1985; 78: 107-13 3. Start RD, Saul CA, Cotton DWK, Mathers NJ, Underwood JCE. Public perceptions of necropsy. J Ciin Pathol 1995; 48: 497- 500 4. Roberts Wc. The autopsy: its decline and a suggestion for its revival. N Engl J Med 1978; 299: 332-8 5. Brown HG. Perception of the autopsy: views from the lay public and program proposals. Hum Pathol 1990; 21: 154-8 6. Hill R. Conference recommendations: The autopsy. Arch Parhol Lab Med 1984: 108: 512- 5 7. Cushing H. The life of Sir William Osier. 1st edn. New York: Oxford University Press, 1940; 85 8. Hill RB, Anderson RE. Pathologists and the autopsy. Am J Clin Parhol 1991 ; 95: (Suppl 1): S42-9 9. Start RD, McCulloch TA, Silicoks PB, Cotton DWK Attitudes of senior pathologists toward the autopsy. J Pathol 1994; 172: 81-4 10. Dever KJ. The changing role of the autopsy: a social environmental perspective. Hum Parhol 1990; 21: 145-53 1 L Scheidermann H, Grubn J. How and why to request an autopsy. Postgrad Med J 1985; 77: 153- 64 12. Brown HG. Lay perceptions of autopsy. Arch Parhol Lab Med 1984; 108: 446-8 13. Benbow EW. Medical students' views on necropsies. J Clin Pathol 1990; 43: 969-76