Midwestern State University CT Machines for Postmortems Awareness Essay

After reading this article, write a 3-4 paragraph discussion of the article. Should clinical CTs be used for autopsies? Be sure to discuss both the reasons for and against. Also discuss making this known to the public. Be sure to relate this to local values and opinions. Include 2 outside sources along with the article source. Be sure to cite your sources properly and include an APA formatted reference list at the end of your post.

Journal of Forensic Radiology and Imaging 11 (2017) 12–17
Contents lists available at ScienceDirect
Journal of Forensic Radiology and Imaging
journal homepage: www.elsevier.com/locate/jofri
Public awareness of the use of clinical CT machines for postmortems
⁎
T
Hiroshi Ikegaya , Stuart McLean, Tsunakuni Ikka, Yasuhiko Kakiuchi, Nozomi Idota
Department of Forensic Medicine and Medical Ethics, Graduate School of Medicine, Kyoto Prefectural University of Medicine, Japan
A R T I C L E I N F O
A B S T R A C T
Keywords:
Postmortem imaging
Postmortem CT
Clinical CT use
Public awareness
Background: Japan has one-third of the world’s CT machines and the highest number of CT devices per million
population. The lack of medical examiners to meet the needs of Japanese police authorities has therefore led to
requests that CT scanners be used for both clinical and postmortem examination. However, hospitals believe that
patients might feel uncomfortable with this dual use, so they usually advocate performing postmortem cases at
night and not informing patients of the dual use of CT scanners. In this study, we investigated people’s thoughts
about the dual use of CT scanners.
Methods: In this internet-based questionnaire study, we wanted to understand public opinion about postmortem
CT imaging. Specifically, we sought the opinions of the general public about the Japanese death investigation
system and the use of CT machines for both the living and the dead.
Results: More than 70% of respondents wanted postmortem examinations to identify the cause of death, but only
34% were aware that CT was used for this purpose. Moreover, only 13% knew that postmortem CTs were
performed at general hospitals using CT machines that are also used for patients, and 51.6% thought that
hospitals should inform patients that CT machines are also used for postmortem examinations.
Conclusions: There are no rules for the use of the clinical CT machines for postmortem examination in Japan.
However, we identified that half of our respondents wanted to be informed that hospitals use CT scanners to
examine both the living and the dead.
1. Background
insufficient. Against this background, Chiba University started using CT
for postmortem examination in 2006 [6], but it was found that some
patients requested that patient-designated CT scanners should not be
used for dead bodies. Although this does not affect the Forensic Department of Chiba University, which has a dedicated CT machine for
use exclusively for dead bodies, only 10 of Japan’s 80 medical universities have dedicated CT machines for postmortem use.
Japan has one-third of the world’s CT machines, with access to
101.28 CT machines per million population for clinical use. This is not
only the highest in the world but is also approximately double that of
Australia, which has the second highest rate [7]. Therefore, it is not
unreasonable that Japanese police authorities increasingly want access
to this resource when investigating the cause of death. However, hospitals tend to conduct postmortem CT imaging at night because many
people in conservative Japanese culture are uncomfortable with death.
To date, no study has investigated what Japanese people actually think
about using clinical CT machines for postmortem imaging.
In this qualitative questionnaire-based study, we investigated people’s thoughts about the use of CT scanners to image both the living and
In the death inquiry system in Japan, a police investigator is asked
to perform an external examination after a report is made to the police
[1,2]. If they suspect a crime, the body is then sent for a forensic autopsy at a university [3]. However, if no crime is suspected, it is usual
practice for police to ask a clinical doctor to issue a death certificate
showing a natural cause of death, and to release the body for cremation.
Although governmental autopsies are performed in some big cities [4],
the Japanese autopsy rate remains the lowest among developed countries, with autopsies conducted in fewer than 2% of all deaths [5].
In the late 1990s, there were numerous reports of previously overlooked murders and in-hospital deaths from possible medical misconduct. Over a 15-year period, the number of reported unnatural
deaths increased from about 70,000 to 170,000, while the number of
autopsies increased from about 5000 to 11,000. However, the government did not increase funding or resources for forensic medicine in line
with this increased demand, so the numbers of facilities and medical
doctors available for forensic autopsies have become increasingly
Abbreviations:CT, Computed tomography
⁎
Correspondence to: Department of Forensic Medicine, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kamigyo, Kyoto, Japan.
E-mail addresses: ikegaya@koto.kpu-m.ac.jp, ikegaya-tky@umin.ac.jp (H. Ikegaya), mclean@koto.kpu-m.ac.jp (S. McLean), ikka@koto.kpu-m.ac.jp (T. Ikka),
kakiuchi@koto.kpu-m.ac.jp (Y. Kakiuchi), idotan@koto.kpu-m.ac.jp (N. Idota).
http://dx.doi.org/10.1016/j.jofri.2017.09.001
Received 5 October 2016; Received in revised form 12 August 2017; Accepted 17 September 2017
Available online 20 September 2017
2212-4780/ © 2017 Elsevier Ltd. All rights reserved.
Journal of Forensic Radiology and Imaging 11 (2017) 12–17
H. Ikegaya et al.
Table 1
Profile of respondents.
Age
Male
Female
10–19
20–29
30–39
40–49
50–59
> 60
Total
5(1.9%)
24(9.3%)
69(26.7%)
100(38.8%)
43(16.7%)
16(6.2%)
257(100%)
8(3.3%)
75(30.9%)
89(36.6%)
52(21.4%)
14(5.8%)
5(2.1%)
243(100%)
the dead.
Fig. 1. Preference for method of examination after the unnatural death of a family
member by whether insurance would be affected. Respondents were asked about
what examinations should be performed if a family member were to die from an unknown
cause, where insurance would not be affected (upper). Next, respondents were asked what
examination should be performed if an accurate diagnosis of death would result in them
receiving an increased life insurance payment (lower). Before respondents answered, we
explained that autopsy and CT can reveal the cause of death in 80% and 30% of cases,
respectively [6].
2. Methods
We administered a questionnaire through an internet research corporation, Mixi Research Co. Ltd., which provides a service that can send
questionnaires to 430 million respondents who are registered with the
service. Respondents are then free to decide whether to participate in
the survey based on the survey title, but cannot see the survey contents
until they have accepted and started to answer. Survey administrators
have no access to respondents’ personal data. Moreover, company
policy prohibits surveys from including questions about matters contrary to good public order and requires that intellectual property and
personal information (e.g., race, creed, lineage, permanent domicile,
medical history, physical or and mental disorders, criminal records,
labor union membership, and sexual history) remain confidential.
Our survey contained 10 questions, with the order of answer choices
randomized. The questionnaire was sent on May 13, 2014, and responses were collected on the same day from the first 500 respondents
who answered all questions. Table 1 shows the respondents’ details.
These may not constitute a fully representative sample, however, so
care should be taken when generalizing the results of our study to
broader public opinion. Furthermore, generally internet service users
tend to be younger compared to hospital patients, and are therefore less
likely to hold conservative values. This may bias the results of our
study, and actual opinion on using hospital CT scanners on human remains among hospital users may be much lower than that reported
here. And there are only about 150 forensic doctors in Japan which
total population is 120 million. Therefore, it is very rare for them to
participate in this questionnaire study.
This study was published with the permission of the institutional
review board of Kyoto Prefectural University of Medicine (ERB-E-260).
We received no specific grant from any funding agency in the public,
commercial, or not-for-profit sectors.
an increased life insurance payment (Fig. 1, lower). Compared with the
response to the previous question, 14.6% fewer respondents (12.6%)
preferred no postmortem examination, and 20.6% more respondents
(39.2%) would want an autopsy (Fig. 1, lower). Thus, when life insurance payments were a factor, about 90% of respondents wanted
some form of examination to diagnose the cause of death.
3.2. Postmortem CT imaging at community hospitals
Only 34% of respondents were aware that postmortem CT imaging
was used for the diagnosis of unnatural deaths (Fig. 2). This is despite
the recently founded Autopsy Imaging Association [9] and the increased exposure in popular culture to postmortem CT imaging in the
plots of fictional stories. Moreover, only 13% of respondents knew that
postmortem images were taken at community hospitals using CT machines that are also used for living patients (Fig. 3). This is to be expected because hospitals are usually very sensitive to rumors about
their institutions, and in our experience, ensure that postmortem CT
imaging is scheduled at night when patients are not present. Hospital
staff also usually only accept human remains for CT imaging when they
are fully enclosed in body bags and hidden from patient view; similarly,
they do not usually accept severely decomposed bodies for CT imaging
because of the odor. Although we are aware that this occurs in Kyoto
Prefecture, it is likely that this may also happen in other prefectures.
3. Results and discussion
3.1. Need for examination of cause of death
Respondents were asked about what examinations should be performed if a family member were to die from an unknown cause, where
insurance would not be affected (Fig. 1, upper). Before respondents
answered, we explained that autopsy can reveal the cause of death in
80% of cases and that CT imaging can reveal the cause of death in 30%,
according to the report by Hayakawa et al.[6]. In total, 18.6% wanted
an autopsy, 54.2% wanted a CT scan, and 27.2% did not want an examination, indicating that more than 70% of people wanted some form
of examination to diagnose cause of death (Fig. 1, upper). This contradicts the previously held view that the autopsy rate was very low in
Japan relative to other economically developed nations because Japanese society is generally uninterested in diagnosing the cause of death
[8].
Next, respondents were asked what examination should be performed if an accurate diagnosis of death would result in them receiving
Fig. 2. Awareness of the use of CT imaging for postmortem examination. We asked
whether respondents were aware that postmortem CT imaging is used for the diagnosis of
unnatural deaths.
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Journal of Forensic Radiology and Imaging 11 (2017) 12–17
H. Ikegaya et al.
Fig. 5. Appropriate CT machines for postmortem imaging. We asked what was the
most appropriate machine for postmortem CT imaging.
Fig. 3. Awareness of postmortem CT imaging in community hospitals. We asked if
respondents were aware that the same CT machines were used to examine the living and
the dead.
factor in respondents’ acceptance of postmortem CT imaging. Overall,
responses were divided fairly equally for and against postmortem CT
imaging, probably because respondents were unaware of the conditions
surrounding the unnatural deaths.
Respondents were asked to indicate what is the most appropriate
machines for postmortem CT imaging (Fig. 5), and 59% responded that
there should be dedicated CT scanners for the dead. Only 5% of respondents thought that CT machines for patients at community hospitals should also be used for the dead. However, 36% of respondents also
thought that postmortem CT imaging should be conducted using the
machine closest to the site where a body is found, even if it is also used
for living patients.
Respondents were asked whether hospitals should inform patients
that postmortem CT imaging is performed using the same CT machines
used for living patients. (Fig. 6), and 51.6% thought that hospitals
should inform patients. Among these, 26.7% (13.8% of all respondents)
required a declaration of use because they did not want to use the same
facilities and 73.2% (37.8% of all respondents) simply wanted to be
informed of the dual use, but would not have an issue with using the
machine. Conversely, 48.4% of respondents felt it was unnecessary to
inform living patients; among them, 57.4% (27.8% of all respondents)
stated that they don’t think the hospital need to inform them the use of
CT machines with dead bodies. And 42.6% (20.6% of all respondents)
thought that they don’t want to know because they feel uncomfortable
in using of CT machines. In summary, about one-third of respondents
were negative about the dual use of CT machines and more than half
thought that hospitals should inform them about the use of CT scanners
for imaging human remains.
Patients are, therefore, unlikely to be aware that postmortem CT imaging is conducted at community hospitals.
We asked respondents to express their feelings about the use of CT
machines for living and dead bodies in community hospitals (Fig. 4). A
total of 28.2% of respondents thought it was acceptable if human remains remained in a body bag and 25.6% thought it was acceptable if
they were done at different times, but 26.8% did not want to have CT
imaging performed in a machine that had previously been used for
human remains, 25.6% of respondents thought it was acceptable if they
were not present, and 14.4% were uncomfortable and wanted the
practice to be discontinued. Only 17.4% of respondents thought that
postmortem CT imagining was important in death investigations and
should continue even if CT machines must be used for both living and
dead bodies, and 23.6% responded that they did not care whether CT
scanners were used for both living and dead bodies. Only 8.8% of respondents thought it was acceptable if the remains were not yet decomposed. These results show that the condition of the body is not a
3.3. CT machines preferred for future postmortem examinations
Presently, several universities have CT machines that are used exclusively to scan human remains, and some universities are trying to
acquire such machines, but this is difficult given their high cost.
Respondents were asked whether it is necessary to have CT machines
dedicated to postmortem examination in the future (Fig. 7). Only 12%
responded that hospitals should use existing CT machines used for patients and that dedicated CT machines were unnecessary. By contrast,
47% responded that postmortem CT examination should be done using
dedicated CT machines for postmortem examination, although 41%
thought that the CT machine closest to the body should be used. Given
that nearly half of the respondents wanted dedicated CT machines, it
may be necessary to increase the number of dedicated postmortem CT
machines in the future.
In Japan, only the police may request CT imaging to diagnose the
cause of death, and the government compensates hospitals for the expense. By contrast, clinicians, hospitals, and relatives cannot legally
Fig. 4. Respondents’ feelings about using the same CT machines for both the living
and the dead in the community hospitals. We asked respondents to express their
feelings about the use of CT machines for living and dead bodies in community hospitals.
Multiple choice was allowed. No single response predominated.
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Journal of Forensic Radiology and Imaging 11 (2017) 12–17
H. Ikegaya et al.
Fig. 6. Patients’ preference about what information should
be shared about the postmortem CT imaging in the hospital.
We asked whether hospitals should inform patients that postmortem CT imaging is performed using the same CT machines
used for living patients.
Fig. 8. Ability to request postmortem CT imaging. We asked if they should have the
right to request postmortem CT imaging.
current situation, and 50.4% believed that a patient’s physician should
have the right to request postmortem CT imaging. Furthermore, 80%
believed that family members should have the right to request postmortem CT imaging. Respondents’ views conflicted with the following
aspects of current practice in Japan: (a) that the police exclusively have
the right to request postmortem CT imaging, (b) that the diagnosis of
death or finding of a criminal cause of death should be made exclusively
through external examination, and (c) that clinical doctors and family
members do not have the right to demand CT imaging when diagnosing
the cause of death.
Fig. 7. Preference for CT machine use for postmortem imaging in the future. We
asked what CT machines should be used for postmortem exams in the future.
request postmortem CT imaging, even though it could provide important information for death certificates. Indeed, doctors have no
rights to request postmortem CT imaging if a death inspector, who is a
member of the police force, believes that it is unnecessary. This is unfortunate because police death inspectors are not medical doctors and
only study forensic medicine for a few months, so lack a doctor’s level of
medical knowledge. Further, the Japanese Police Agency only considers
criminality, not the diagnosis of cause of death, as sufficient justification for imaging: that is, they will only request postmortem CT imaging
when there is criminal suspicion.
In this study, respondents were asked if they should have the right
to request postmortem imaging (Fig. 8). Only 10.6% agreed with the
3.4. Fear of infection
In 2014, an outbreak of Ebola hemorrhagic fever occurred [10], and
it was identified that many deaths were caused by people touching
infected bodies at funerals [11]. Therefore, we recently checked the
safety of body bags for preventing contamination by infectious agents,
15
Journal of Forensic Radiology and Imaging 11 (2017) 12–17
H. Ikegaya et al.
using a full-size doll covered in invisible fluorescent paint to imitate
infectious agents. Police officers were told to place the doll in the body
bag without spreading the fluorescent paint. In our test, officers were
not able to place the doll cleanly in the body bag because of their lack of
specialized training when handling infectious agents. This raises concerns when police transfer bodies where the cause of death is suspected
to be an infectious disease, as infectious agents may spread to the CT
machines and other places with which they come into contact.
In 2016, a police officer was hospitalized with tuberculosis, and
source tracing revealed that he had recently transferred a dead body in
a bag from police custody to a university for postmortem CT imaging
and autopsy. Even though the CT machines were disinfected, 29 police
officers and university staff members were infected in that outbreak
[12]. If this happened in a community hospital, it could result in public
discontent about the use of CT machines for postmortem CT imaging.
CT machines are very expensive so it is difficult to increase the number
of CT machines designated for the dead, but our results indicate that the
public indeed wants dead people to be examined. So we must therefore
consider the risk of contamination by postmortem cases when a CT
scanner is used for both the living and the dead in community hospitals.
And we should perform external body bag disinfection and CT machine
cleaning mandatory everywhere.
Tsunakuni Ikka and Nozomi Idota critically revised the manuscript
for important intellectual content.
All co-authors have given final approval of the version to be published.
Availability of data and materials
The datasets used and/or analyzed during the current study are
available from the corresponding author on reasonable request.
Funding
This study was done with the aid of our university fund.
Questionnaire
Q1
Autopsy can reveal the cause of death in 80% of cases and that CT
imaging can reveal the cause of death in 30%, according to the report.
1) What examination should be performed if a family member is to die
from an unknown cause, where insurance will not be affected?
4. Conclusion
a) Autopsy
b) CT imaging
c) No need for examination
Japan has one of the lowest reported crime rates in the world [13].
In addition, the diagnosis of cause of death in cases not thought to be
criminal has never been a priority. Consequently, the human and infrastructure resources are inadequate for reducing the number of
overlooked criminal deaths [8]. Purchasing and maintaining a CT machine for cadavers alone in each prefecture would be financially problematic. However, the benefits to society of diagnosing the cause of
death should not be underestimated, and CT can help bridge the current
gap in service in Japan. Even though postmortem CT imaging is becoming a common tool in the diagnosis of cause of death, we must also
consider the low diagnostic efficacy of CT examination for this purpose
[14].
At present, there are no rules or regulations for postmortem CT
imaging in Japan, and it is not well known that postmortem CT imaging
is conducted with the same CT machines used by living patients. In this
study, we found that about half of respondents wanted to be notified of
this use, even though hospitals are not required to disclose this information. However, given patients’ perceptions of death and the possible health risks posed by dead bodies, we must ensure that we change
policy and disclose this usage. Ultimately, given the limitations of CT
examination and the inadequacy of autopsy provision, we must fundamentally reform the death investigation system in Japan.
2) What examination should be performed if an accurate diagnosis of
death will result in them receiving an increased life insurance payment?
a) Autopsy
b) CT imaging
c) No need for examination
Q2
Are you aware that postmortem CT imaging is used for the diagnosis
of unnatural deaths?
a) Yes.
b) No.
Q3
Are you aware that the same CT machines are used to examine the
living and the dead?
a) Yes.
b) No.
Declarations
Q4
What is your feeling about the use of CT machines for living and
dead bodies in community hospitals? Multiple choice is allowed.
Ethical approval and consent to participate
This study was published with the permission of the institutional
review board of the Kyoto Prefectural University of Medicine (ERB-E260).
a) Taking postmortem CT images is OK if the body is in a bag.
b) I do not care at all
c) Taking postmortem CT images is OK if taken when I am not present.
d) Postmortem CT should be discontinued, because it makes me uncomfortable.
e) Taking postmortem CT images is OK if not taken before my use.
f) Taking postmortem CT images is OK if the body is fresh.
g) Other
Competing Interest
Authors declare that they have no competing interests.
Authors’ contribution
Q5
What is the most appropriate machine for postmortem CT imaging?
Hiroshi Ikegaya made substantial contributions to conception and
design, acquisition of data, and analysis and interpretation of data.
Stuart McLean and Yasuhiro Kakiuchi were involved in drafting the
manuscript.
a) The CT machine closest to where the body is found even it is a
16
Journal of Forensic Radiology and Imaging 11 (2017) 12–17
H. Ikegaya et al.
machine for living patents.
b) CT machines for patients.
c) CT machines for dead bodies only.
b) Relatives
c) Physician in charge
d) Others
Q6
Do you think hospitals should inform patients that postmortem CT
imaging is performed using the same CT machines used for living patients?
References
[1] Article 21 of the Medical Practitioners’ Act.
[2] Article 229 of Code of Criminal Procedure.
[3] Article 168 of Code of Criminal Procedure.
[4] Article 8 of Act on Dissection and Preservation of Dead Body.
[5] J.A. Siegel (Ed.), Encyclopedia of Forensic Sciences, Academic Press, UK, 2000.
[6] M. Hayakawa, S. Yamamoto, H. Motani, D. Yajima, Y. Sato, H. Iwase, Does imaging
technology overcome problems of conventional postmortem examination? A trial of
computed tomography imaging for postmortem examination, Int. J. Leg. Med. 120
(1) (2006) 24–26.
[7] OECD Health Statistics. 〈https://data.oecd.org/healtheqt/computed-tomographyct-scanners.htm〉, 2013.
[8] B. Wallace, Japan’s police see no evil (November 09), Los Angeles Times, 2007.
[9] 〈https://plaza.umin.ac.jp/~ai-ai/〉.
[10] Team WHOER, Ebola virus disease in West Africa—the first 9 months of the epidemic and forward projections, New Engl. J. Med. 371 (16) (2014) 1481–1495.
[11] S.F. Dowell, R. Mukunu, T.G. Ksiazek, A.S. Khan, P.E. Rollin, C.J. Peters,
Transmission of Ebola hemorrhagic fever: a study of risk factors in family members,
Kikwit, Democratic Republic of the Congo, 1995. Commission de Lutte contre les
Epidemies a Kikwit, J. Infect. Dis. 179 (Suppl 1) (1999) S87–91.
[12] Police and hospital nearly year late in reporting detainee’s TB case to health authorities. APR 12, 2016. The Japan times.
[13] Editorial. Crime rate dips again in Japan. The Japan Times. January 25.
[14] R.Ian S.D. Roberts, Rachel E. Benamore, Emyr W. Benbow, Stephen H. Lee,
Jonathan N. Harris, Alan Jackson, Susan Mallett, Tufail Patankar, Charles Peebles,
Carl Roobottom, Zoe C. Traill, Post-mortem imaging as an alternative to autopsy in
the diagnosis of adult deaths: a validation study, Lancet 379 (9811) (2012)
136–142.
a) I want to know so that I can use a different machine.
b) I don’t want to know because I feel it uncomfortable.
c) I am fine using it, but want to know.
d) I don’t think the hospital need to inform me.
Q7
What CT machines should be used for postmortem exams in the
future?
a) CT machines for patients are OK.
b) We should use CT machines designated exclusively for human remains.
c) We should use the CT machine closest to where the body was found.
Q8
Who should have the right to request postmortem CT imaging?
a) Police only
17
Disscussion Board – Article Review
Course: RADS-4853-X11 Essentials Forensic Med Imagng Fall Semester 2022
Criteria
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48 points
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24 points
12 points
0 points
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Post shows a very
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student applied the
information to the
course and to the
real world.
The student analyzed
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questions asked of
the student were
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student applied the
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course and to the
real world.
The student analyzed
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questions asked of
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was not complete
and/or the questions
asked of the student
were not completely
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attempt to analyze
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answer the
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20 points
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The student posted
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some logical order.
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20 points
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are used to connect
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