Madam, - Dr Deirdre Madden's report on post-mortems has at last provided a clear authoritative account of autopsy practice in Ireland and its context over the past 30 years (The Irish Times, January 19th).
The facts contrast with the sensational and often unbalanced media reporting. Dr Madden found that post-mortems were performed in line with best international practice and that the autopsy has a major role in continued medical progress.
So what was the problem? Dr Madden pinpointed an information gap between what doctors knew and what relatives were told. She determined that the grief and anguish suffered by parents was caused by the failure of doctors to communicate openly. Contrasting letters on this page illustrate the background to this communication gap. Charlotte Yeates (January 27th) poignantly recalled the death of her daughter. She was devastated to learn later that her child's organs had been retained without discussion with her. Donald Weir (January 30th) illustrated the difficulties of detailed discussions with the recently bereaved.
This information gap had already been identified in 2000, when, shortly after the controversy began, the Faculty of Pathology introduced guidelines to provide transparency and detailed information to relatives; the guidelines were adopted universally, and the autopsy moved from "professional paternalism" (Dr Madden's term) to fully informed consent. This was not easily done. It required an intense effort by hospital staff to produce information leaflets and documents (one hospital now uses a suite of more than 30 forms, information letters and leaflets, in relation to autopsy matters) and many hospitals found that it was necessary to employ bereavement counsellors to explain details to relatives. It also came at a price. Informed consent requires that detailed information must be provided before consent can be given. While many relatives welcomed such information, others have been upset and disturbed to receive necessarily graphic details at a sensitive time; such discussions have also troubled many doctors. Autopsy rates have fallen drastically. It has become very clear that providing graphic information to the bereaved is far from being a simple matter.
An important part of Dr Madden's report is the introduction of the concept of authorisation. This process, recently developed in Scottish law, provides a course midway between the extremes of professional paternalism and informed consent. It would allow relatives, if they wished, to authorise an autopsy and organ retention having received as little or as much information at they want (currently with informed consent they must be provided with all the information, however distressing). This new thinking both highlights the complexity of the information gap and provides a better means of bridging it. The Faculty of Pathology hopes that with this important report all interested parties can co-operate to move forward, to develop the necessary legal framework, and to reinstate the autopsy to its important role in medical practice. - Yours, etc,
Dr D. SEAN O'BRIAIN,
Dean, Faculty of Pathology,
Royal College of Physicians of Ireland,
Dublin 2.