Post-mortem examinations often include autopsies. The purpose of this dissection of the corpse is to establish the cause of death and the pathological processes involved. The pathologist strives to acquire reliable information concerning the nature and cause of the disease, and perhaps to investigate the medical procedures used on the patient. The initial autopsy incision opens the entire body in a "Y" shape. It begins below one shoulder, continues under the breasts, and extends up to the corresponding point under the other shoulder. This incision is then joined by another in the midline extending down toward the pubis, to complete the "Y." The scalp incision begins under one ear, extends across the top of the scalp and ends behind the other ear. The organs are removed and studied to the extent of each individual autopsy requirement. It should be noted that the standard autopsy permit form in the Autopsy Manual published by the United Hospital Fund of New York includes, as a matter of course, authorization for "the retention of such parts and tissues as the hospital staff may consider necessary for diagnosis."
Consent from next of kin is required for autopsy. Such consent may be given by the legal custodian of the body who is responsible for the burial, usually the husband or the wife. If there are more than one "next of kin" (and the interpretation of that phrase is elastic) and controversy arises, the hospital may forego autopsy or elect the most amenable relative as "the" next of kin.
In truth, however, it may be fairly surmised that the cause of death is accurately known in most cases, and only rarely is this a medical mystery. From experience with modern medical procedure, it is evident that autopsies are most frequently recommended in order to enable medical students and internes to study and practice by dissection and observation of the corpse. Many articles in medical journals have asserted that recent progress in patho-physiological science has made possible the reliable determination of cause of death without an autopsy. It is now held by many authorities that, with some exceptions, autopsies are no longer considered as vital as they once were.
Nonetheless, it appears that the percentage of autopsies is still considered one of the best indices of the standard of medical practice in hospitals. For this reason the Joint Commission on the Accreditation of Hospitals requires the maintenance of a satisfactory autopsy percentage. The United Hospital Fund standard manual urges obtaining consent in every possible case. "Indeed," says the Autopsy Manual, "when permission is not obtained, the physicians in attendance should be expected to account reasonably for such failure."
Hospital administrative staffs outdo themselves in perfecting techniques of extracting consent. Arguments are offered to counter typical family objections-some of these often untrue, and far below the high ethical practice the public has come to expect of the medical profession. One such argument often advanced is, "There are on record authoritative statements from religious leaders of all faiths indicating that nowhere is there any justification for opposition to autopsies on religious grounds." It is unfortunate that the religious sensibilities of traditional Jews should be so cavalierly dismissed by such misleading statements. Although there are notable exceptions to the rule, there is definite religious objection to autopsy.
Even though the motive of medical study is a worthy one, Jewish tradition forcefully rejects autopsies performed for teaching medical students, because this violates a higher principle: that of mutilating the body of the deceased. Jewish law is governed by several basic principles:
First, man was created in the image of God, and in death his body still retains the unity of that image. One may not do violence to the human form even when the breath of life has expired. Judaism demands respect for the total man, his body as well as his soul. The worthiness of the whole of man may not be compromised even in death.
Second, the dissection of the body, for reasons that are not urgent and directly applicable to specific existing medical cases, is considered a matter of shame and gross dishonor. As he was born, so does the deceased deserve to be laid to rest: tenderly and lovingly, not scientifically and dispassionately, as though he were an impersonal object of some experiment. The holiness of the human being demands that we do not tamper with his person.
Third, we have no permission to use his body without his own express desire that it be used, and even then it is questionable whether the person himself may volunteer to mutilate the image in which he was created. Certainly, where the deceased in his lifetime gave no express permission, even his children have no rights of possession over his body. Thus, we have no moral right, except for the cases to be mentioned, to use the body of the deceased by offering it as an object for study.
Autopsies are indeed valid in certain unusual cases, and these are exceptions to the general prohibition. While the possibilities of religiously-permitted autopsies are listed below, a competent rabbinic authority must be consulted in every case:
A) Cases which fall under the jurisdiction of governmental authorities. Here the decision must be made by the Medical Examiner. For convenience and clarity, such hospital cases can be divided into two groups
GROUP 1. Cases with impelling legal implications in which an autopsy is usually performed by the Medical Examiner, and in which permission for autopsy is never requested by the hospital physician.
Examples of such cases are:
a. Death by homicide or suspicion of homicide.
b. Death by suicide or suspicion of suicide.
c. Death due solely to accidental injury. d. Death resulting from abortion.
e. Death from poisoning or suspected poisoning, including bacterial food poisoning.
GROUP 2. Cases in which the Medical Examiner may decide that it is not necessary for him to do an autopsy as part of his post-mortem investigation.
Examples of such cases are:
a. Death occurring during or immediately following diagnostic, therapeutic, surgical, and anesthetic procedures, or following untoward reactions to medication.
b. Death occurring in an unusual or peculiar manner, or when the patient was unattended by a physician, or following coma or convulsive seizure the cause of which is not evident.
c. Death resulting from chronic alcoholism, without manifestation of trauma.
d. Death in which a traumatic injury was only contributory, and in which the trauma did not arise out of negligence, assault, or arson, such as a fracture of the neck resulting from a fall at home and contributing to the death of an elderly person, or accidental burns occurring in the home.
B) Cases of hereditary diseases, where autopsy may serve to safeguard the health of survivors.
C) If another known person is suffering from a similar deadly disease, and an autopsy is considered by competent medical authority as possibly able to yield information vital to his health.
D) In cases where the deceased specifically stipulated that an autopsy be performed there has been much rabbinic disagreement. The circumstances must be investigated on an individual basis, and only an informed, highly competent religious authority may decide.
Even in cases where the rabbis have permitted the postmortem, they have always insisted that:
Any part of the body that is removed must thereafter be buried with the body, and that it be returned to the Chevra Kadisha for this purpose as soon as possible.
The medical dissection must be performed with utmost respect for the deceased, and not handled lightly by insensitive personnel.
Because these matters are of great religious concern, questions on post-mortem examinations must be answered by a competent rabbi who is aware of both the medical requirements and the demands of the tradition. In addition, some forms of autopsy, such as the removal of fluid or blood only, or the insertion of an electric needle, may be considered permissible in many instances. The decision to perform an autopsy should not be made by the physician, no matter how close he is to the family and how reputable a doctor he may be. The prohibition is of a moral-religious nature, and permission should be obtained from an authority on religious law after consultation with medical authorities.
The procedure of embalming was instituted in ancient times to preserve the remains of the deceased. Preservation was desired for many reasons:
1. For sanitation purposes--the assumption being that the fresh remains were a hazard to health;
2. For sentimental reasons--the family feeling that it wanted to prevent deterioration of the physical body as a comforting illusion that the deceased still lived; and
3. For presentability--to avoid visible signs of decay while the deceased was being viewed by the public prior to the funeral service.
It is worthwhile to analyze the three reasons in order to determine their validity today. First, however, it should be clear that there is no state law in the United States that requires the deceased to be embalmed, except when it is to be carried by public conveyance for long distances.
Is there a sanitary purpose for embalming? From all available evidence, the unembalmed body presents no health hazard, even though the deceased may have died from a communicable disease. Dr. Jesse Can, quoted in The American Way of Death by Jessica Mitford, indicates that there is no legitimate sanitation reason for embalming the deceased for a funeral service under normal circumstances.
Do reasons of respect and love warrant embalming to preserve the remains as long as possible? Many relatives feel, naturally, that they wish to hold on to their beloved in his human form as long as possible. If this is the major purpose of the embalming, several points should be taken into consideration:
1. The body will keep, under normal conditions, for 24 hours, unless it has been dissected. If it was kept refrigerated, as is the standard procedure, it will unquestionably keep until after the funeral service.
2. The body must eventually decompose in the grave. Under optimum conditions, even were the embalming fluids to retard the deterioration of the outer form for considerable length of time, reliable reports of reinterments indicate that the remains soon become sickening to behold and totally unnatural, as a consequence of the embalming.
3. Sentiment should attach to the person as he lived his life, as he appeared during the years of good health, not to the corpse as it appears while entombed. The deceased himself undoubtedly would want his loved ones to remember him as he was during the peak of his lifetime.
The prohibition of embalming for the purpose of viewing the deceased is considered in a separate chapter later in the book.
In the entire procedure of embalming today there is great confusion. There is not general public knowledge as to the methods of embalming, and certainly very little is known of "restoring," or cosmetology, a term used by the funeral industry for propping, primping, berouging, and dressing the remains to be placed on view. There is little doubt that if the family were aware of the procedures they might be too horrified to request it. A detailed description is available in Jessica Mitford's The American Way of Death.
The guiding religious ideal in regard to embalming is that a person upon his demise should be laid to rest naturally. There should be no mutilation of his body, no tampering with his remains, and no handling of the body other than for the religious purification. Disturbance of the inner organs, sometimes required during the embalming procedure, is strictly prohibited as a desecration of the image of God. The deceased can in no wise benefit from this procedure. So important is this principle, that Jewish law prohibits the embalming of a person even where he has specifically willed it.
It is not a sign of respect to make lifelike a person whom God has taken from life. The motive for embalming may be the desire to make of the funeral a last gift or a lasting memorial, but surely mourners must realize that this gift and this memorial are only illusory. The art of the embalmer is the art of complete denial. Embalming seeks to create an illusion, and to the extent that it succeeds, it only hinders the mourner from recovering from his grief. It is, on the contrary, an extreme dishonor to disturb the peace in which a person should be permitted to rest eternally.
It is indeed paradoxical that Western man, nourished on the Christian concept of the sinfulness of the body, which is considered the prison of the soul, should, in death, seek to adorn it and make it beautiful. Surely, the emphasis on the body in the funeral service serves to weaken the spiritual primacy and traditional religious emphasis on the soul.
There are, however, several exceptions to the general prohibition of embalming. These are:
1. When a lengthy delay in the funeral service becomes mandatory.
2. When burial is to take place overseas.
3. When governmental authority demands it.
In these cases, all required because of health regulations, Jewish law permits certain forms of embalming. Rabbinic authority must be consulted to determine the permissibility of embalming and the method to be used. One method frequently used is freezing. This is an excellent modem, clean method of preserving, also recommended by Dr. Jesse Carr, Chief of Pathology at San Francisco General Hospital.
The injection of preservative fluid, without the removal of the organs of the body, frequently has been used. If the blood has been released from the veins it should be collected in a receptacle, which should then be buried with the body. Bloodied clothes, worn by those killed accidentally or by violence, should be buried with the body. The blood is considered part of the human being and even in death they are not to be separated. As time goes on, and our knowledge of chemistry advances, other methods may be developed which Jewish law may consider legitimate.
The foregoing paragraphs are only general guidelines, and do not offer specific dispensation. Specific cases require individual attention and special permission from competent religious authority.