By George D. Lundberg, MD

“This is the place where death delights to help the living,” - Giovanni Morgagni, circa 18th century. His words remind us of the purpose of studying the deceased: to inform and aid the living. Yet, in modern America, that “delight” is fading.

The Scalia Case: A Study in Systemic Failure

Think what you wish about the politics and persuasion of Supreme Court of the United State Justice Antonin Scalia, but his 2016 death remains a stark case study in systemic failure. His sudden, unexpected, unwitnessed death at a West Texas hunting lodge made national news, and yet it went largely uninvestigated.

A 79-year-old man who had just returned from a vigorous trip to Hong Kong saw his physician with complaints of a head cold and shoulder pain. His physician completed his examination, ordered tests, and provided treatment. Two days later, that patient was found dead — but no autopsy was performed. If you were that physician, would you not want to know what happened?

The absence of an autopsy didn’t just raise questions about the cause and manner of his death but exposed the inconsistent and often inadequate state of death investigation outside of major metropolitan areas in the United States.

The Value of an Autopsy

As I originally wrote in 1998, there are 11 reasons why autopsies have traditionally been performed:

Shortly after Justice Scalia’s passing in 2016, I used these 11 reasons for autopsy as a teachable moment to demonstrate the value of an autopsy. His case places into stark relief the difference one finds for death investigation based on the geography in which the death occurs, because there is no national standard for death investigation.

Two recent books provide great insights into death investigation in America and how it grew from the historically deeply flawed coroner system to an advanced scientific discipline of forensic medicine.

Bruce Goldfarb’s companion books, 18 Tiny Deaths: The Untold Story of the Woman Who Invented Modern Forensics and OCME: Life in America’s Top Forensic Medical Center, provide a compelling, two-part narrative on the evolution — and subsequent struggles — of scientific forensic death investigation in America.

18 Tiny Deaths introduces us to the pioneering spirit of Frances Glessner Lee, the “mother of forensic science.” Her meticulous Nutshell Studies — elaborate, miniature crime scene dioramas — were not just instructional tools for homicide investigators; they were a powerful catalyst. By demonstrating the need for precise, objective, scientific observation, Lee’s work directly supported the movement to replace the ancient, politically appointed, and medically unskilled coroner system with professional medical examiner offices.

The second book, OCME (Office of the Chief Medical Examiner), focuses on the Maryland medical examiner system, which emerged as the global gold standard — a direct intellectual descendant of the scientific rigor Lee championed. Goldfarb expertly traces how the Maryland office, benefiting from social momentum and strong leadership, became the undeniable model for modern death investigation.

However, the narrative is not a lasting one.

Why the Autopsy Is Vanishing

Sadly, autopsies have become almost nonexistent for most current American physicians and hospitals. In the 1940s and 1950s, autopsies were performed for 50% of all hospital deaths. The average annual autopsy rate from 2003 to 2020 is only 3.6%.

In OCME, Goldfarb highlights how, through a confluence of modern challenges — including severe underfunding, wildly escalating caseload, and conflicting political pressures — this highly respected medical examiner system gradually lost its dominant, leadership position. Critically, he pinpoints two key missteps by the CME involving one high-profile case (the investigation into the death of Freddie Gray) and one expert testimony (Derek Chauvin’s trial) which damaged public trust and contributed to the loss of globally recognized stature of the office and the CME.

Together, these books are a sobering study on how scientific excellence, though capable of transforming public institutions, is always vulnerable to political, economic, and social currents.

Resurrecting the Autopsy

To prevent autopsies from vanishing from medical practice completely, we must consider systemic reforms.

First, we must implement a national standard for death investigation in order to eliminate the “geographic lottery” of the current system. Then, we should phase out the lay-coroner system in favor of medically trained, board-certified forensic pathologists in all jurisdictions.

We also must provide a funding infrastructure to support this practice. Autopsies are expensive and typically not covered by insurance or Medicare, meaning hospitals must absorb the cost. Not only should there be federal funding for forensic autopsies, but Medicare should provide direct reimbursement for hospital autopsies to incentivize quality control and medical education.

In 1984, I wrote, “Autopsy is the one place where truth can be sought, found, and told without conflicts of interest.” I believe this statement still holds true. Without taking concrete steps to secure autopsy’s place in medicine, we risk losing the one place we can search for truth. If we fail to investigate death, we ultimately fail to protect the living.