Religions and the Autopsy

Different traditions, beliefs, and practices surrounding death are common to all cultures and religions, and they have resulted in conflict regarding anatomic dissections and postmortem examinations. Such views have even been thought to hinder scientific and medical discovery in past years. ^[1] People from more westernized or diverse environments tend to have less cohesive connections with traditions, religion, and beliefs, and have a greater acceptance of autopsies. In contrast, non-westernized cultural groups generally have more unified traditions, beliefs, and practices surrounding death, and they more frequently have religious objections to autopsy. ^[2]

Although cultural or religious beliefs are often cited as a reason for opposition to autopsy, most religions and cultures find autopsy acceptable on the basis of either the individual's beliefs or under what are deemed to be special circumstances. ^[3] Certain religions have objections to autopsy (eg, Islam, Judaism) in that bodily intrusion violates the sanctity of keeping the human body complete, despite those religious doctrines not strictly forbidding it. Instead, it is a matter of interpretation of these doctrines that have changed over time. ^[4] For example, the Prophet Muhammad stated that "to break the bone of a dead person is like breaking the bone of a living person," (Sunan of Abu Dawood) which has been extensively interpreted in the fields of autopsy and organ transplantation from the very literal (eg, the decedent being able to still feel pain) to the more figurative.

Christian Scientists do not outright object to autopsies, but they are not advocated. Buddhism, various Christian sects (eg, Anglican, Church of England, Church of Wales, Episcopal, Church of Scotland, Greek Orthodox, Roman Catholic, Baptist, Methodist), the Church of Jesus Christ of Latter Day Saints, the Free Church (Salvation Army, Quakers), and Jehovah Witness doctrines do not state an intrinsic objection to autopsies. ^[5] Hindus believe all organs must be returned to the body. Those who practice Sikhism believe that a funeral must not be delayed. Shinto, Taoism, and Confucianism do not prohibit autopsies. Not surprisingly, views about autopsies often parallel views about organ and tissue donation.

Religious objections to autopsy occur in both medicolegal- and hospital (clinical)-based autopsies. For clinical autopsies, the purpose is generally to investigate the cause of death and the extent of natural disease. Consent must be granted by the next-of-kin in order for an autopsy to occur. When permission for an autopsy is declined for any reason, including religious objections, the autopsy is not performed. This process is different in cases that fall under medicolegal jurisdiction, as the autopsy in these circumstances is used as a tool to investigate unnatural death.

The purpose of the medicolegal autopsy, which may or may not be part of a death inquest, can be to identify the decedent, document the nature and distribution of injuries, correlate whether the nature and distribution of injuries is consistent with a history or eyewitness account, reconstruct events related to the death, determine other diseases or injuries that may have contributed to the death, and collect trace materials that may help ascertain the manner and cause of death, as well as solve crimes. ^[6] In medicolegal cases, a death inquest and/or autopsy is ordered by a legal authority (most commonly a medical examiner or coroner) and permission from the next-of kin is not sought, although expressed opposition from the next-of-kin is considered on a case-by-case basis. A number of cases in which an autopsy was protested on religious grounds have been shown to have hampered or obstructed death investigations, including those of a suspicious nature. ^[7] Such challenges bring into question the age-old dilemma between autonomy for an individual (patient or family) against that of a paternalistic authority figure (justice and law enforcement). This has led to public policy and legislation restricting autopsies to cases in which there is a compelling public necessity, often requiring a court order to proceed in the least intrusive way possible. ^[1]

In the following sections, we aim to elucidate various cultural and religious beliefs surrounding the postmortem examination in hopes of helping the practicing pathologist and other healthcare professionals understand how these diverse viewpoints may influence the decision to perform an autopsy in both the clinical and legal settings.

Islamic religious practices are most prevalent in the Middle East, Northern and Western Africa, Central and South Asia, the Indian subcontinent, Malay Archipelago, the Balkan Peninsula, Russia, Europe, and China. Although the Qur'an (Koran) does not directly discuss autopsies or postmortem examinations, Islam contains many important doctrines that do.

When contemporary situations challenge Islamic law, scholars known as mufti are sought out to publish a fatwa. Fatwa are nonbinding legal opinions on the interpretation of Sharia (Islamic) law, and several can exist with regard to one issue. These interpretations, therefore, can range from more literal views of the laws to liberal, modern interpretations. ^[8] The main issues in Islam surrounding autopsies are not different from that of other religions: Autopsies delay burials, cause harm to the body, and remove body parts. The benefits, however, are also the same: Autopsies can lead to scientific advances and discovery of important medical diagnoses, enhance education, and establish cause of death, amongst many others. ^{[4, 9]}

Muslims undergo several rigid traditions following death. The eyes and mouth should be closed, and the limbs should be straightened. The body is washed and draped in a specific manner and is faced toward Mecca. Muslims are always buried without embalming and are never cremated. The deceased should be buried as soon as possible, usually within 24 hours, and the burial should be as close to the site of death as possible, preferably within 1-2 miles. Several family and community members travel to the deceased and participate in the mourning process. Family members do not eat until the deceased has been buried. Females traditionally do not attend funerals. ^[9]

The Sharia states that the importance of burial is to bring the dead closer to what God has prepared for him or her and to bring God's servant closer to Him. ^[8]  Postmortem examination would inevitably delay this and potentially render the body in a decayed state. ^[9] A rapid burial is also considered beneficial to the community: If the decedent was a “good” person, then it will be a good deed to hasten his or her journey to God; alternatively, it would behoove the community to free themselves of a “bad” person as quickly as possible. ^[8]

The Sharia encourages retaining the body in its original form and keeping it as close to the site of death as possible, both of which would be violated by the performance of an autopsy. Transporting the body to the laboratory may cause physical damage and move the body far from the site of death. It also allows time for natural decomposition of the body. The Sharia, however, contains a few exceptions. It explains that if a person had swallowed money belonging to someone else, it is acceptable to retrieve that money out of the decedent’s abdomen in order to pay his debt, thereby preventing harm to his heirs. Additionally, if a woman dies during pregnancy and the fetus is believed to be alive, some sects of Islam believe that it is appropriate to remove the fetus with an incision. ^[10]

There are also few reasons considered acceptable in delaying the burial, as cited from the well-known Egyptian scholar and politician Rashid Rida. His 1910 fatwa entitled "Postmortem Examinations and the Postponement of Burial” described that a risk of a hasty burial is that the person may not truly be dead. This, he realized, was especially true in the setting of drowning or being struck down during a storm. Therefore, he found it beneficial to wait on an official medical examination. Finally, it may take time to obtain camphor (kafur), which is the special turpenoid solution used to clean the body. Hence, Rida determined that there are reasons to postpone burial, leading to the expansion of his ideas to include medical examinations. ^{[8, 10]}

Maslaha is the Islamic principle of "public benefit." It states that when the benefits outweigh the damages, the beneficial approach should be taken. This has been widely interpreted and used to support the practice of autopsies. H. M. Makhluf's 1952 landmark fatwa explains that a doctor is only fully educated when he understands the body inside and out, thereby making human dissection necessary for thorough medical education. ^[10] Makhluf even went so far as to legitimize voluntary donation of bodies to science. Contemporary Islamic society is sensitive to criticism regarding lack of medical advancement and falling behind Western medicine; therefore, these arguments are taken seriously by the public. ^[8] However, some believe that animal autopsies should be sufficient.

The Fatwa Committee at al-Azhar of 1982 also based their allowances on maslaha: Autopsies should be permitted if medical students will learn from them, if justice prevails, and if contagious diseases are controlled. Still, the examination should only take place when necessary and include only relevant body cavities. For example, in the case of a forensic evaluation for potential murder, if the murderer confesses and is willing to take the proper punishment, then the autopsy is not necessary. ^[10]

Prior to the Fatwa Committee at al-Azhar, the Arab Republic of Syria determined situations in which a postmortem examination could be performed: if doctors believed that an examination would be socially useful and the decedent was not opposed when he was alive, or if three degrees of relatives did not oppose it. Additionally, the government could overrule objections by the family if the postmortem examination was used for scientific reasons or to prevent an epidemic.

• Egyptian law states that an autopsy can only be performed when there is belief that the death was caused by foul play.
• Saudi Arabian laws describe a rigid pathway, beginning with the doctor's requirement to report a death that is thought to have occurred unnaturally. The doctor must describe the wounds that led him to this belief and provide this information to a forensic expert, who will subsequently perform an external examination of the body and any accompanying objects (eg, clothing, personal effects). If the forensic expert deems that a full internal examination is necessary to identify the cause of death, he must then obtain permission from the authorities before proceeding.
• In Qatar, the permission of relatives is not necessary if an autopsy is performed for reasons of justice or pathologic diagnosis; however, authorization from the Sharia court is required for the latter as well as if an autopsy is performed for teaching purposes, in which case the family must also consent. A male doctor may not perform a postmortem examination on a female patient unless it is for teaching purposes or if no female doctor is available. ^[10]

It is generally agreed upon that an autopsy on an unidentified person following a severe accident is warranted and does not violate Islamic law. Additionally, when the law requires that an autopsy be performed, the Muslim should comply but inform the coroner's office so that arrangements can be made to proceed quickly. ^[11]  In Islamic countries, when consent from the family is needed, the order of priority is as follows ^[10] :

1. Father, son, mother
2. Brothers and sisters, wife, grandfather, grandsons
3. Cousins of paternal and maternal uncles

However, not all Muslim families agree on this subject. In 2007, a Muslim family in Fort Worth, Texas, attempted to halt autopsies performed on two family members who were killed in a car accident. ^[12] The judge ruled that the autopsies were required; they were performed by the medical examiner, who was also a Muslim.

Judaism is predominately practiced in Israel, North America, and Europe, and it is based on the Torah, which is known as "written law" and consists of the five books of Moses. The Torah is believed to have been written by God and given to the Jews at Mount Sinai. The Tanach, known to non-Jews as "The Old Testament," includes the Torah as well as two other important sections. The Talmud, known as "oral law," is a collection of rabbinic teachings. The Tanach and the Talmud are the central texts for current Jewish law, known as halacha.

Pikuach nefesh translates from Hebrew as "saving of human life." It is perhaps the most important commandment in all of Judaic law. Pikuach nefesh renders all other laws permissible if a life is saved. Jews, therefore, are obligated to do anything necessary to save another life, even if it means disregarding other Jewish laws, with some exceptions (eg, murder, suicide). Thus, the fact that autopsies can save other lives supersedes other prohibitions. Permitting autopsies, however, is not a sharply defined issue, and much debate surrounds desecration of the human body, delaying burial, and inability to bury the body in full. ^[13]

First, saving lives under the commandment of pikuach nefesh is open to interpretation. Some recommend that only autopsies that would save the life of a currently ill person should be permitted, whereas others believe that autopsies for future gain (medical advances) should be allowed as well. Rabbi Yechezkel Landau, an 18th century scholar, disagreed with the latter because of the slippery-slope phenomenon: If autopsies are permitted for future gain, there will be no end to the exceptions to the prohibitions. Now that we are in the age of technology, some rabbis admit that there is likely a person whose life may benefit from nearly any autopsy. Additionally, most rabbis would agree that autopsies performed to contain an epidemic may be permitted. Similar arguments based on pikuach nefesh have been made in the realms of organ donation and abortion. ^{[14, 15]}

Jewish persons believe that the dead body should be treated with respect. The prohibition to desecrate the dead is known as nivel ha'met ("desecration of the dead"). It is based on a passage from the Torah that describes the treatment of a hanged criminal: The corpse should not be left on the tree, and it should be buried the same day. Additionally, the Torah states that the human body must be respected because man was created in the image of God ("Let Us make man in Our image..." [Genesis 1:26]). It is accepted that the body itself is not a physical image of God, but rather the body contains the soul, or neshama, which was created in God's image. Therefore, the body remains holy even following death. ^{[15, 16]}

Rabbis have widely interpreted the definition of desecration and considered reasons why human dissection should or should not be a violation of the holiness of the body. Some base their conditions on the intent of the dissection. Others believe that any procedure done on a living person is not a desecration and, therefore, can be done on a dead body. Still others believe that a dissection started by a non-Jew can be completed by a Jewish physician. ^[17]

Jewish law prohibits benefiting from the dead. What defines a benefit, however, is also heavily debated. Medical education is commonly thought of as a benefit of human dissection, thus this is a point of controversy for Jewish people. Some rabbis believe that the act of watching an autopsy is not a benefit received from the dead body, whereas participating in the autopsy might be. Others say that the act of dissection is not a benefit, but learning and understanding are, and these are not derived from the cadaver. Although this subject propagates much philosophical debate, most rabbis agree that one may not receive financial compensation from an autopsy under this prohibition. ^[17]

Jews observe several traditions following death. The body should be laid on the floor, and it should never be left alone. To prepare for burial, the body is wrapped in a simple white cloth and placed in a simple coffin. The reason for this simplicity is so that the treatment of the body is the same regardless of the decedent’s socioeconomic status. Embalming, cremation, and open-casket ceremonies are forbidden. ^{[15, 16]}

The commandments k'vura (burial) and halanal ha'met (leaving the dead overnight) are the basis of rapid burial customs. However, the Talmud states that it is proper to delay burial "for the honor of survivors," which may include "to honor the dead” or “to bring a casket and shrouds." Furthermore, as long as no shame is brought to the deceased (such as a criminal hanging on a tree overnight would be), then delaying burial is not forbidden. Interpretation of the Talmud by Rabbi Shlomo Yitzhaki (known by the acronym Rashi, 1040-1105) also suggests that as long as no disrespect to the body is shown, delay of burial is permitted. The burial may even be delayed by several days if the reason is to increase the dignity and honor of the decedent. Therefore, in cases where an autopsy would honor the family or the patient, it may be accepted even though it violates rules regarding desecration of the body. Fulfilling the patient's expressed or assumed wishes would honor him or her and is therefore considered an acceptable reason for an autopsy if medically necessary. ^{[14, 15]}

The Jewish term olam ha-ba, or "the world to come," refers to the world following the Messiah. When the Messiah comes, it is said righteous people will be resurrected and allowed to live in the world where the righteous will "sit... and enjoy the radiance of God." (Talmud Berachot 17a). Participation in olam ha-ba is based on merit: Righteous people will achieve a higher level of peace, whereas wicked people will achieve a lower level, and they may need to undergo a short period (less than 12 months) of a purification process. Jews believe that this standard is held for people of all nations and religions. Following death, the soul (perhaps partially) leaves the body and enters heaven. When resurrection takes place, the soul will reunite with the body. Therefore, a complete burial is required by the Talmud. This fundamental Judaic principle has caused great debate regarding organ donation, donation of the body to science, and autopsy. Thus, if a dissection does take place, all fluids and body parts should be returned within the body cavity. This is particularly difficult in the setting of cadaver dissections for medical education. ^{[14, 15, 18]}

Jews believe that the body belongs to God, thus it is questioned whether the person has the right to decide what is done with it following death. ^[19] Although not encouraged in Judaism, many rabbis agree that if the person willed or sold their body to medicine, the autopsy should be permitted, as this means they did not view this as bodily desecration. Some, however, still implement conditions requiring inclusion of only body parts that would lead to an unknown diagnosis or in settings in which the amount of time until burial is limited (ie, prohibiting use in an anatomy class because this would delay burial by several weeks). There are many rabbis who agree that a Jewish person does not contain the right to donate his body in such a way. ^[17]

In more recent history, rabbis have debated whether autopsies should be permitted but did not reach a consensus. In 1922, admission requirements for Jewish students to Polish medical schools included providing Jewish bodies for anatomic dissections. Polish rabbis unanimously objected but autopsies continued to occur on Jewish bodies despite these rabbinic prohibitions. In Israel, the controversy about autopsies sparked a serious public and political uprising that lasted several decades. The opening of Hebrew University’s medical school was delayed for 22 years because of the issue of human cadaver dissection.

In 1947, Hebrew University opened Hadassah Medical School and asked the Chief Rabbinate to explore the idea of autopsy. An agreement between the Chief Rabbinate of the State of Israel and Hadassah Hospital stated that autopsies were not to be done routinely, because they were a desecration of the human body; however, they would be permitted under the following four conditions:

1. The autopsy is required by civil law
2. Three doctors agree that the cause of death cannot be determined without an autopsy
3. Three doctors believe that an autopsy will help save the lives of others with similar illnesses
4. There is a question of a hereditary disease that may affect living relatives

Additionally, autopsies for medical education were permissible as long as patients voluntarily donated their body for this purpose, and all organs and body parts were eventually buried. When Israel became a state in 1948, it adopted these conditions as laws. In 1953, the Israel Knesset (Parliament) passed the controversial Anatomy and Pathology Law, which expanded the allowance of autopsies and included organ transplantation.

The law of 1953 did not specify if the final decision to perform an autopsy was with the family or with the medical authorities. Therefore, a set of amendments was later added for this reason: If the deceased did not leave written consent for an autopsy, the next of kin may refuse; if no family is found, the community organization Chevra Kadisha, which helps prepare bodies for burials, may object to the autopsy; and if the body is unclaimed, it may be donated to medical education. Physicians were still able to proceed with autopsy if three doctors deemed that a diagnosis could not otherwise be made, but this led to accusations of physicians abusing this aspect of the law.

In 1962, the new deputy minister of health, Yitzhak Raphael, was given the responsibility of reviewing this law. After several committee and subcommittee meetings and hearings with myriad experts, the following recommendations were published:

• An autopsy can be performed to determine the cause of death if it will save lives or obtain organs for transplantation to a specific recipient(s)
• An autopsy will not be performed if the patient had expressed this choice during their life or if their specific relatives object to it; unless not establishing the cause of death may bring harm to the public or family, or if medical error may be the cause of death

Although these recommendations were not fully incorporated into law, medical professionals enjoyed the freedom that such guidance afforded them to perform autopsies without family consent.

To appease the public, the laws were rewritten in 1965 in an effort to balance the power of decision making. The revision was widely accepted in the medical community but disliked by religious factions. Hospitals continued to perform autopsies, overriding family members' wishes for various reasons. Public outcry continued with demonstrations and threats. In one case, the family of an autopsied patient stormed the hospital, causing both physical damage to the building and harm to hospital personnel. The Ministry of Health responded by spreading a circular that stated no patient who refuses an autopsy should be admitted to the hospital. In response, the Chief Rabbinate of Israel published a radical statement: "Autopsy in any form whatsoever is prohibited by the law of the Torah. And there is no way to allow it except in a manner of immediate danger to life...." He added that any autopsy must be approved by a rabbi. This extreme statement incited more uprisings among the Israeli public and in Jewish persons around the world. Although physicians suffered violent threats, they continued to perform autopsies against family wishes. People were afraid to be admitted to Israeli hospitals for fear of dissection. By the late 1970s, however, hospital practice had changed, autopsies were no longer being performed without family consent, and an amendment to the Anatomy and Pathology Law was passed. ^{[17, 20]}

In 2015, the High Court of Justice in England ruled against a coroner's wishes to perform an autopsy on an Orthodox Jewish woman, because her family believed that an autopsy would desecrate Jewish law. Coroners are now required to adhere to a family’s religious beliefs if certain criteria are met, such as if there is a possibility that a noninvasive procedure (eg, imaging studies, laboratory tests) could determine the cause of death. ^[21]

In general, autopsies are currently permitted by Jews. The overriding principle is pikuach nefesh, or the obligation to save a life. A life is considered one at hand, which in this age is any person all over the world, and it includes future relatives of the deceased who may benefit from knowledge about a hereditary disease. ^[20] Autopsies should be limited to only the relevant body parts, and care should be taken to return as much of the body as possible. Additionally, autopsies should be performed promptly to allow for a rapid burial. Some families may request that a rabbi preside over the autopsy.

The main practice of Hinduism is in the Indian subcontinent, Fiji, Guyana, Trinidad, Mauritius, Suriname, Bali, Australasia, Northern America, and Southeast Asia. Hinduism is more a philosophy than a religion, and it is believed to have originated around 3000 BC in the Indus Valley.

One of the central tenets of Hinduism is that of a unitary life force or Supreme Being called Brahman that has "no form nor shape, is timeless and eternal, and is believed to pervade everything (animate and inanimate)." ^[22] Hindus also believe in karma (actions leave an imprint on the mind and soul) and that humans are ignorant of the fundamental unity of the cosmos and should therefore seek actions that lead to enlightenment of the immortal soul, referred to as Atman or Self. Karmic actions are the driving force governing the Hindu belief in the rebirth and re-death cycle, with virtuous actions elevating the soul toward liberation (Moksha or Nirvana). For Hindus, the purpose of life is to exit this rebirth and re-death cycle and enter a state of Moksha. This liberated state is the ultimate state of enlightenment where the mind is tranquil and relieved of all individual desires and sufferings.

During death, the soul leaves the body but is still aware. Hindus thus believe that an autopsy may be disturbing to the soul ^[23] —with a disturbed soul having the potential to either reenter the body and not continue life or be reborn and manifest as evil. To circumvent this possibility and to appease the decedent’s soul, mourners pray and a funeral is held by a priest before cremation. Cremation is believed to help usher the soul into the next world or its rebirth into the next life. The ashes are then spread into a holy body of water. ^[24]  However, Brahmin Swami Bua (1889-2010) stated, "In the Vedic Age (c. 1500 – c. 500 BCE), dissection and mutilation of body were considered detrimental to the fulfillment of life. Yet, if we consider that once the spirit leaves the body, the lifeless body has no karmic obligations, then it [autopsy] may be okay." ^[25] In summary, Hindus disapprove of autopsies but comply if necessary by law. ^[26]

Buddhism, Jainism, and Sikhism grew out of Hinduism and hold some of the same fundamental beliefs, including those regarding cremation. Jains believe in karmic philosophy, with the goal being to attain freedom from a cycle of life, death, and rebirth. They believe that by practicing the right faith, knowledge, and conduct, the soul can attain liberation from mortal pleasures, materialistic possessions, and other sins. The Sikh belief is that the cycle of birth and rebirth is broken by living a virtuous and dutiful life through following the teachings of gurus (teachers), meditating on God at all times, and performing acts of service and charity. Jains and Sikhs have no intrinsic religious objection to the autopsy. Buddhism is discussed in the next section.

Buddhism consists of three major divisions with distinct practices and beliefs. Theravada Buddhism is practiced in Vietnam, Cambodia, Thailand, Laos, Burma, and Sri Lanka; Mahayana Buddhism is practiced in China, Japan, and Korea; and Vajrayana Buddhism is practiced in Tibet and Japan. In the United States, less traditional Buddhist practices include Soto Zen and Tibetan Buddhism, of which the largest groups are concentrated in the Chicago area.

Great cultural diversity exists throughout Buddhism, but all believe that illness and death are natural events and should not be feared and that relief of suffering and clarity of consciousness during the end of life are important. The Buddhist priest’s role is to assist the individual in making decisions in accord with his or her individual temperament, conditions, and understanding.

According to Buddhist theory, "Death occurs when the body is bereft of three things: vitality (ayu), heat (usma), and sentiency (viññana)." There is debate whether these criteria coincide with that of modern medicine. ^[27]  Buddhists believe that the body is a shell for the spirit. A main Buddhist teaching point is that one should not be overly attached to his or her body, as it will inevitably deteriorate with age and then cease to function. The spirit, however, remains following death and is reborn. Where it is reborn is dependent on the person's karma, which is a result of his or her past actions. ^[28]  Following death, the body should be highly respected so that the spirit can concentrate on achieving enlightenment. For this reason, the body should not be disturbed for 3 days or until a religious leader has determined that the soul has left the body. At this time, most Buddhists will be cremated. ^[23]

Because of the benefits of autopsies, such as educating medical professionals and determining diagnoses, Buddhists generally believe that autopsies are a form of compassion that help to preserve life. Bringing justice to a criminal is also honorable, so autopsies can be performed when there is a question of natural versus unnatural death. Although Buddhists believe that the body should be treated with great respect and it is not proper to desecrate the body, their views on autopsy parallel intent. The intent of a postmortem examination is not to harm the body and, therefore, not prohibited. ^[28]  Waiting until the soul has left the body is the only major contingency when performing an autopsy on a Buddhist. ^[23]

Christianity is the world’s largest religion, with an estimated 2.3 billion practitioners ^[29] within various sects predominating throughout Europe, the Americas, Oceania, Sub-Saharan Africa, and the Philippines.

Roman Catholicism

The Greek scientist Herophilos (335-280 BC) is accredited with performing the first human dissections. King Ptolemy, successor to Alexander the Great, granted permission for the performance of autopsies in his multi-religious city of Alexandria, Egypt. The autopsies were often open for viewing to interested persons.

Herophilos uncovered several imperative truths regarding human medicine. Although all his works have been lost, his ideas have lived on through anatomists such as Galen (also known as Aelius Galenus, 129-199 AD), whose principles dominated medicine for centuries. As a Roman physician and philosopher, Galen was not allowed to perform human dissection, thus his knowledge stemmed from dissections of monkeys in addition to Herophilos’s findings. However, he described a need for human dissection in his text On Anatomical Procedures.

Following 200 AD, religious and civil laws made autopsies unlawful. In 1153, during the Council of Tours in France, the Roman Catholic Church banned the mutilation of dead bodies. The aim was to prevent the common practice of eviscerating Crusaders' body parts for transport back to Europe but had negative implications for anatomists. Although extremely rare and still widely considered unacceptable, systematic autopsies were restarted during the 13th century in Italy, which the Vatican allowed. In 1316, Mondino de Luzzi (1270-1326) published the first modern anatomy text based on these autopsies.

Andreas Vesalius (1514-1564) corrected many of Galen's misunderstandings of medicine by conducting his own dissections on executed criminals. Of the several anatomy books he published, De Humani Corporis Fabrica is the most well known. In an era when thirst for new knowledge ruled, the Catholic Church shifted their belief to devalue the dead body and began to more openly accept the idea of autopsies. During the mid-16th century, new Protestant rule made it even easier for such postmortem examinations to occur. For example, in 1565, London’s Royal College of Physicians was granted permission to dissect human cadavers. ^[30]

The Renaissance continued to witness an exponential growth of medical advances—many attribute this to the invention of the printing press, which allowed for the spread of news without control by the Church. Galen’s On Anatomical Procedures was translated into Latin in 1531 and widely distributed, which was significant in helping to persuade the Catholic Church to permit autopsies.

On the other side of the world, an autopsy was performed for religious reasons in 1533. Conjoined twin girls were autopsied in Espanola (now the Dominican Republic) to determine if they had one soul or two. The girls had been individually baptized, and the postmortem examination confirmed that there were indeed two souls based on the finding of two complete sets of internal organs. ^[30]

Today, Catholics accept the value of autopsy and generally agree with its use for medical education, organ transplantation, and diagnostic determination. It is considered an act of charity to perform an autopsy to help others. ^[13]

Protestantism

The Bible's overall view of the human body is that of uniquity and divine inspiration, while acknowledging that it contains the limitations of physical matter. The Bible states that the body is made "of dust from the ground" and is a "tent" or "clothes" (Genesis 2:7, 2 Corinthians 5:1-5:5). Therefore, Christians believe that the body is a mortal housing for the soul.

In most sects, Christians believe that death is when the soul leaves the body based on the Biblical passages "...the body without the spirit is dead..." (James 2:26) and "… the dust returns to the earth as it was, and the spirit returns to God who gave it" (Ecclesiastes 12:7). ^[31] There are also many references to the afterlife throughout the Bible, including Matthew 8:11: “Many will come... and will take their places at the feast with Abraham, Isaac, and Jacob in the kingdom of heaven." ^[32]

God is considered to have taken away physical immortality when Adam and Eve sinned in the Garden of Eden. ^[32] The Bible acknowledges human decomposition in its statement "Unto dust thou shalt return" (Genesis 3:19). However, Christians strongly respect the dead body and undergo several rituals surrounding death, as set by the examples of the burials of Sarah and Abraham. ^[33] Although there are no specific limitations during autopsies of Christians, the body should always be handled with respect.

The religion of Jehovah’s Witnesses is based on the Bible, namely the New World Translation of the Holy Scriptures. The religion is ruled by a group of elders ("the Governing Body"), the origin of which is unclear. In the late 1800s, a group of students formed Zion’s Watch Tower Tract Society, which was the basis of the formation of Jehovah’s Witnesses. Witnesses bear similar basic ideas as other Christians about God and the Bible, however, they do not believe in Hell. They believe righteous souls are resurrected at the time of the Armageddon, of whom 144,000 will go to heaven and the remainder of the righteous will remain on an earthly paradise representing the Garden of Eden. Evil souls will be annihilated. ^[34]

Jehovah's Witnesses interpret death as a state of pure nothingness; that is, the dead pass out of existence (Psalm 146:4; Ecclesiastes 9:​5, 10). ^[35] No thoughts are perceived and no work is done. The dead are conscious of nothing. All future life for that person is based on a hope of resurrection. During resurrection, it is believed God will form a new body and soul for that person based on His memory.

Because the body is the creation of Jehovah God, the main obstacle for Jehovah's Witnesses regarding autopsies is mutilation to the body. A Jehovah's Witness should agree to autopsy when required by law, but the next of kin may request that no organs be removed and that the body be treated with care.

The prophet historian Mormon completed a book of golden plates containing the revelations of many prophets, including those of his son Moroni. The book was buried in Hill Cumorah, located in present day Manchester, New York, for several centuries until an angel appeared to Joseph Smith in 1823, instructing him to find the golden plates. Joseph Smith translated the golden plates to English as the Book of Mormon. In 1830, The Church of Jesus Christ of Latter-day Saints was founded in New York City. The Old and New Testaments as well as the life of Christ are also central to the Church of Latter-day Saints.

Mormons believe in three phases of life. Before the human form, we are spirit-children, followed by life as a human on Earth, and then eternal life with God. Following death, the body and spirit reunite to be resurrected into the afterlife. There are two forms of afterlife: Paradise for the righteous and Spirit Prison for the evil. Spirits from Paradise visit the Spirit Prison where they can teach the gospel; if the unrighteous repent, they may be able to move to Paradise. Therefore, the purpose of life on Earth is to prove that one is worthy enough to spend his or her afterlife in Paradise.

Death is considered an honorable part of life. Mormons are encouraged to be buried, although cremation is not forbidden. Regarding autopsies and organ transplantation, Mormons are invited to choose what will give them a feeling of peace and comfort. Most will ask the Lord for inspiration in these decisions. ^[36] The Encyclopedia of Mormonism (1992) states, "It is one of the methods whereby both those who die and those who examine them contribute to improving the quality of life and health of their fellow human beings." ^[37]

Christian Science is a belief system rooted in the idea that God's creations are spiritual rather than materialistic. Mary Baker Eddy wrote Science and Health with Key to the Scriptures (1875), a text that is now the central document of the religion. Her inspiration came while she was healing from an injury and read a passage in the Bible about the cures of Jesus. She believed that Jesus's way of healing could be continued in modern life.

Christian Scientists' views of health care set them apart from many other belief systems. They prefer to separate the physical from the spiritual in all aspects of life, believing in a specific form of prayer that is meant to spiritualize thought. There is no specific prohibition from using modern Western medicine, thus Christian Scientists can visit dentists for dental care and optometrists for vision care, as well as physicians to set broken bones or labor and delivery. ^[38] However, Christian Scientists are taught that it is best not to mix the two, as spiritual healing and material healing may counteract each other. They will first turn to prayer before attempting cure through medications or surgery. When seeking cure through modern medicine, Christian Scientists will often discontinue their involvement in spiritual healing.

Christian Scientists believe in an afterlife, with death being a continuation of the immortal spirit. In another book by Eddy (a chapter called "Is there no death?" in Unity of Good), she states, "Because God is ever present, no boundary of time can separate us from Him and the Heaven of His presence; and because God is Life, all Life is eternal." She goes on to state that "Human beings are physically mortal, but spiritually immortal." ^[39]

There are no specific rituals surrounding death. Funeral and burial matters are up to the individual's wishes. No prohibitions against autopsies exist for Christian Scientists, but in general they are averse to participating in Western medicine practices. Because God is believed to be the only true healer, Christian Scientists may not see the benefit of a postmortem examination. Autopsies should therefore only be done in special circumstances in accordance with the deceased person's wishes. ^[40]

Confucianism (China-Chinese folk religion) may be thought of as more of an ideology than a religion, with it having a tremendous impact on Chinese life and culture. Confucius (551-479 BCE) is considered a great scholar and sage who never claimed divinity. Temples built for Confucius are not places of worship but rather community centers for special occasions, especially Confucius's birthday.

Confucius handed down nine ancient Chinese works that are the basis of Confucianism. Jen is the ultimate principle translating to "love" or "humanity." Followers of Confucianism live by the ideal "do not do to others as you would not want done to yourself." In addition, charity, justice, propriety, wisdom, and loyalty are the five main principles to live by.

With regard to death, Confucius was often criticized for not discussing the matter. He believed that people should focus on the present day and not attempt to seek an afterlife; that one should lead a life with his or her own mission from heaven. Modern-day China remains nearly silent about death.

Burial is the custom for those who practice Confucianism. The body is washed and dressed in coarse clothes. Food and significant personal belongings are buried with the decedent in a coffin. A willow branch, representing the person's soul, accompanies the funeral procession and is then placed in the family’s altar where it installs the soul of the deceased. ^[41]

Some historians believe that the Chinese conducted autopsies before the time of Confucius, because their medicine was far more advanced than the other empires of the time. Confucius taught that the body is sacrosanct and touching the body under certain conditions is unholy, therefore autopsies are not in agreement with his teachings. Confucius also taught that bodies belong not to oneself but to one's parents. Taking care of the body is a way of showing respect for one's parents, thus any form of mutilation to the body is therefore not aligned with cultural values. The Tang Legal Code, China's earliest recorded law code, condemned the destruction of bodies.

In modern times, however, followers of Confucianism do not prohibit autopsy. ^[36] Despite this, the Chinese suffer from a serious shortage of bodies to dissect for medical education. In response, several agencies have enacted public outreach initiatives to teach the benefits of body donation. Some incentives have been started to show families that the gift of a body represents the giving of a life—for example, inviting the family to plant a tree on the campus of Nanjing University in China. The Education Center for Medial Ethics at Nanjing University also retains personal effects of the cadavers, such as letters and photos, which show the devoutly respectful nature of the gift. A large 2004 study on the thoughts of Chinese revealed that approximately one third of the population is willing to donate their bodies to medicine. ^[42]

Shintoism (Japan), Taoism (China-Chinese folk religion), and Shamanism also do not prohibit autopsies.

In the United States, at least 558 tribes/nations are federally recognized, with over 100 more having applied for recognition. ^[43] The primary religious or spiritual affiliation of Native Americans may be traditional or Christian, or they may practice no religion at all, depending on the individual or tribal affiliation. Spirituality is central to their identity, although belief systems differ widely among tribes/nations and geography.

It is believed that people and nature are interconnected, and all animate and inanimate (eg, water) forms of life are sacred and have a spirit. For some, illness is considered an imbalance among the spirit, the mind, the body, and social interactions. ^[44] Care of the body and attitudes surrounding death and dying also vary greatly, but there is a seeming preference for naturalness and home care. For some tribes (eg, Navajo), however, a cultural taboo surrounding death exists, ^[43] and some tribes gravitate toward avoiding discussion surrounding impending death and contacting the dying.

After death, some traditional practices include positioning the body in a certain manner and performing a purification process with sage or sweetgrass smoke. Most Native Americans believe that death is a natural part of the life cycle. Specific rituals are carried out with the intention of letting the spirit to safely cross over to the other side to join with ancestors. ^[45] Organ donation and autopsies are viewed as desecration of the body, and they are generally not desired.

For pathologists involved in the performance of autopsies, it is useful to have some understanding of the different cultural and religious beliefs likely to be encountered surrounding death and how those views may influence decisions about autopsy. The cultural and religious diversity of the population in the United States and abroad has increased in part due to the ease of immigration into various countries as well as the relative ease in accessing information through various communication channels. Certain rituals and practices surrounding death are common to all cultures and religions and are influential in whether or not an autopsy is performed. Although certain cultures and religions do not advocate for autopsies, most do not outrightly object. In general, most views about autopsy parallel attitudes about organ and tissue donation, which can vary not only by religion but also within religious sects and beliefs within different countries.

Religious objections to autopsy pose a particular dilemma for medical examiners and coroners in that such objections can be in direct conflict with laws to investigate certain manners of deaths. In most instances, strong consideration is given when there are objections to an autopsy, and autopsies are performed only in those cases with a clear and convincing reason. As a result of such conflict, some states have enacted legislation that restricts the power of the state to demand an autopsy, often requiring the courts to intervene in the decision to proceed. Several states have passed "religious objection" laws that grant the right for persons to attempt prevention of an autopsy by signing a certificate stating that the autopsy is contrary to their religious beliefs.

Whether it be in the clinical or medicolegal setting, by understanding the influence various belief systems have on autopsy, healthcare and other professionals involved in death proceedings will be better equipped to communicate with next of kin and appropriately perform postmortem examinations within the confines of specific religious and cultural contexts.