KOMMONSENTSJANE – SCALIA AUTOPSY DECISION DIVIDES PATHOLOGISTS

Scalia Autopsy Decision Divides Pathologists
By LAWRENCE K. ALTMAN, M.D.

FEB. 20, 2016
WASHINGTON — Should an autopsy have been performed on the body of Justice Antonin Scalia?
When a Texas justice of the peace certified that the 79-year-old Supreme Court justice had died from natural causes, questions immediately erupted. No autopsy had been performed, and the certification had been made without even an examination of the body. The unexpected death of a divisive public figure during an acerbic presidential campaign set off conspiracy theories and demands from political commentators that a pathologist perform an autopsy before Justice Scalia’s burial on Saturday to prove no foul play was involved.

Texas officials said they had obeyed the wishes of the Scalia family in not authorizing an autopsy after the justice was found Feb. 13 in his bed at a West Texas ranch, cold, pulseless, his hands almost folded on top of the sheets as if he were taking a nap. His doctor said he had chronic cardiovascular disease, and witnesses described a scene typical for death from heart disease.

An estimated 326,000 people of all ages experience cardiac arrest out of a hospital in the United States each year, and 90 percent of them die, according to the American Heart Association.

In many cases, autopsies are not performed on their bodies, because of family wishes, religious objections and other factors, including the expense of the procedure (often not covered by insurance) or the lack of available forensic pathologists to perform them. But some people argue that in the case of a prominent government official, the public has a right to know.

Three forensic pathologists interviewed separately were divided in their opinions about the handling of the death of Justice Scalia. Two — Dr. Michael M. Baden, a former chief medical examiner in New York City, and Dr. Vincent J. M. Di Maio, a former chief medical examiner in San Antonio — said officials had done what is usual for many individuals who die if their doctors have attested they had potentially fatal ailments.

“What you have is an elderly man found dead in bed, and if he was not on the Supreme Court everyone would say, O.K., and nothing more would happen,” Dr. Di Maio said. “It is only who he was that makes it a big deal. You can make an argument that they should have done an autopsy, but the only reason you would do it is he is a Supreme Court judge.”

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Times Coverage on Antonin Scalia

Recalling Scalia, a Literary Stylist Who Scorned ‘Jiggery-Pokery’Feb. 16, 2016

What Would Scalia Want in His Successor? A Dissent Offers CluesFeb. 16, 2016

Potential Nominees Obama May Consider to Fill Antonin Scalia’s SeatFeb. 15, 2016

Antonin Scalia, Justice on the Supreme Court, Dies at 79Feb. 14, 2016

Justice Antonin Scalia: His Life and CareerFeb. 14, 2016

How Long Does It Take to Confirm a Supreme Court Nominee?Feb. 13, 2016

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Related Coverage

Washington Pauses for Justice Antonin Scalia’s FuneralFEB. 20, 2016

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How Scalia’s Death Could Affect Major Supreme Court Cases in the 2015-16 TermFEB. 14, 2016
Recalling Scalia, a Literary Stylist Who Scorned ‘Jiggery-Pokery’FEB. 15, 2016
“If you are over 60 and are found dead in bed, most medical examiners’ offices don’t do an autopsy unless there is some obvious trauma,” Dr. Di Maio said.

A third, Dr. George D. Lundberg, a former editor of the American Medical Association publication JAMA, said the handling was “almost unbelievable.” An autopsy should be mandatory “when a politically prominent person dies unexpectedly, and especially if unobserved,” said Dr. Lundberg, who now works for CollabRx, a Rennova Health company.

In most unexplained deaths, if a personal physician attests that the deceased had an ailment that can be lethal, a justice of the peace or medical examiner usually will release the body without sending it to a medical examiner, unless officials suspect foul play or an accident. But if a police officer or funeral director sees a bullet or knife wound or sign of injury, they will call it to the medical examiner’s attention, which “happens, but rarely,” Dr. Baden said.

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“A family in the United States has an absolute right not to have an autopsy under these circumstances unless there is enough suspicious reason for a medical examiner to intervene, but that did not happen in the jurisdiction where Justice Scalia died,” said Dr. Baden, who is also a former chief forensic pathologist for the New York State Police and now has a private forensic pathology practice.

More than 90 percent of deaths in the United States are from natural causes and do not become medical examiner cases, Dr. Baden said.

Most sudden deaths result from a fatal heart rhythm that develops in ventricles (the heart’s lower chambers) damaged by atherosclerosis. In recent years, doctors have become increasingly convinced that many sudden deaths are not so sudden but come after warning signs or symptoms that may be overlooked in the days just before death.

Justice Scalia, a tennis player, went to his doctor on the Wednesday and Thursday before his death for a shoulder injury, according to The Associated Press. Pain in a shoulder can be heart-related. The A.P. reported that Justice Scalia had an M.R.I. of his shoulder and was told that the problem was from rotator cuff damage. Because Justice Scalia was too weak to endure surgery, his doctor advised rehabilitation.

A relatively small number of autopsies are performed in Texas because of a lack of forensic pathologists. “We do not have enough to do the cases we should do,” Dr. Di Maio said, explaining that about 500 forensic pathologists are practicing in the United States and that an estimated 1,500 are needed in the country. He said that in areas where there were no medical examiners, particularly in rural areas, certifying a death was a secondary job for a justice of the peace.

Without an autopsy, there is no way to know the specific cause of Justice Scalia’s death. Among the possibilities are a heart attack and a stroke or pulmonary embolus. Justice Scalia recently returned from travel to Asia. One problem that sometimes occurs after long airplane flights is pulmonary embolus, a formation of a blood clot in a leg from which a piece breaks off and travels in the blood to the lungs to cause sudden death.

In the absence of a full autopsy, Dr. Baden said, officials could obtain critical information even from an embalmed body by inserting a needle into the heart or a tube into the bladder to perform toxicology tests on blood and urine for evidence of toxins. Sophisticated testing could distinguish drugs and chemicals from those in embalming fluid. It is not known if officials performed such tests in Justice Scalia’s case.

Although Justice Scalia’s body could have appeared relaxed and asleep without showing any external signs if he had been poisoned, a natural cause is the most plausible explanation for his death, Dr. Baden said.

Officials in Washington have said little about the circumstances of Justice Scalia’s death. To tamp down rumors and speculation, officials at the United States Marshals Service on Friday provided the first timeline of their role in Texas. Federal marshals provide protection for justices on some of their out-of-town trips, but Justice Scalia declined it for the Texas hunting resort. Wade Drew, a spokesman for the Marshals Service, said a deputy marshal from western Texas arrived at the ranch about 2:30 p.m. on Feb. 13, after the body had been found. At least three Marshals Service employees guarded the body as it was taken to a funeral home in Texas and then returned to Washington.

“Our folks never indicated that anything seemed amiss or unusual, but that wasn’t our role,” he said. “We weren’t there to make any determination like that, so I’m not going to be drawn into that.”
Eric Lichtblau contributed reporting.

A version of this article appears in print on February 21, 2016, on page A21 of the New York edition with the headline: Pathologists Are Divided on Decision Not to Conduct an Autopsy. Order Reprints| Today’s Paper|Subscribe
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About kommonsentsjane

Enjoys sports and all kinds of music, especially dance music. Playing the keyboard and piano are favorites. Family and friends are very important.
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