The Cost of Not Looking

The Cost of Not Looking

This is how it all started. I was listening to an audible book, a German mystery novel, in which the inspector reminded himself that in Germany way too few autopsies are performed.  

That made me curious and so I started looking. 

I put out a question, to which the answer turns out not to be fictional at all: 

Are too few autopsies being performed in Germany? 

The answer is yes, and the reasons point toward a larger problem in how modern societies decide what is worth investigating.

Germany’s hospital autopsy rates are exceptionally low. A survey of German pathologists found rates of about 3.6% in 2013 and 3.4% in 2014.¹ A separate survey covering 2005 through 2014 found that the overall number of autopsies reported by participating German institutions fell by 30% in that decade.²

The United States has followed a similar trajectory. National data show that autopsies were performed in 19.3% of deaths in 1972, but only 8.5% by 2007.³ 

Hospital autopsy rates, once commonly reported around 40-60% before 1970, have fallen to a small fraction of that level.⁴

This decline is not explained by cost alone. Improved scans, laboratory tests, and other diagnostics encouraged physicians to believe they already knew why a patient had died. Hospitals lost accreditation incentives that once required a minimum share of deaths to be autopsied. Families may decline permission, doctors may be reluctant to request an examination, and institutions face a simple financial fact: a full autopsy costs money but does not generate the revenue that billable medical procedures do.¹⁴

Yet, to me, an autopsy is not merely an administrative formality. It is about why a person suddenly died, and nobody is interested in knowing why, solely based on financial reasons!?

After all, it is a final check on diagnosis, a source of public-health knowledge, and sometimes the only way to identify an unnatural death that has been made to look natural. Toxicological investigation is not automatically performed whenever someone dies. It depends on a death being referred for forensic examination, an autopsy being authorized, and the right tests being ordered.

That is important because some lethal acts leave little obvious external evidence. A death that appears to be from illness, an accident, or suicide may require a careful postmortem examination and targeted toxicology to reveal something else. The real danger is not that there is some magical “undetectable poison.” It is that, if nobody looks, no evidence is sought. The investigative capacity may exist, but it remains unused.

The first recorded forensic-style examination is often associated with Julius Caesar’s assassination in 44 BCE. His physician, Antistius, examined Caesar’s wounds and reportedly determined that, among 23 stab wounds, only one had been fatal.⁵ 

For centuries thereafter, dissection and autopsy were limited by cultural, religious, and legal taboos about disturbing the dead. Those objections have not vanished: families from several religious and cultural traditions may still object to autopsy on grounds of bodily integrity, burial requirements, or respect for the deceased.⁶

But in the modern era a new resistance has joined the old ones: the resistance of the balance sheet.

The United States is heavily policed in the name of public safety, yet its death-investigation system is understaffed and uneven. 

The country has a serious shortage of forensic pathologists; recent reporting estimates roughly 850 practicing specialists nationwide, hundreds fewer than needed.⁷ 

This means that many communities have limited access to expert postmortem investigation precisely when a death is ambiguous, unexpected, drug-related, violent, or potentially criminal.

The contradiction is hard to miss. 

Public money can be found for visible enforcement, surveillance, and punishment, while quieter systems that might establish what actually happened after a death, and reveal patterns of violence, poisoning, medical error, unsafe work, addiction, or neglect, are allowed to weaken.

The same contradiction appears in healthcare. Research on public-health interventions finds that prevention often produces substantial economic returns: one systematic review calculated a median return of $14.30 for every dollar spent, and an even higher median for nationwide interventions.⁸ Yet preventive care is chronically underfunded because the institution that pays today may not be the one that receives the savings tomorrow.

Economists call this “misaligned incentives” or the “wrong pockets problem.” Those terms describe the mechanism, but they can be too polite about the outcome. When a system declines to investigate suspicious deaths because investigation costs money, and declines to prevent illness because the long-term benefit appears on someone else’s ledger, the effect is not neutral. It shifts risk, suffering, and preventable loss onto ordinary people, while preserving short-term institutional revenue.

That is why “predatory capitalism” is not merely rhetorical language. It describes a system that treats the cost of looking as more real than the human cost of refusing to look. It treats prevention, care, and truth-seeking as expenses, while allowing the far greater costs of illness, premature death, violence, and uncertainty to be carried by families and communities.

The science exists. The tools exist. The question is whether we choose to use them, and whether we are willing to count the cost of looking away.

Corinne Wesley 

PS: This is not a story about a lack of science. It is a story about a lack of willingness to pay for truth itself, especially when the truth might expose harm, error, neglect, or the cost of decisions.

As autopsies and thorough death investigations have become less common in real life, forensic investigation has become one of the most popular forms of entertainment around the world. From the 1990s onward, and especially after CSI arrived, audiences have watched countless investigators examine bodies, preserve scenes, test evidence, and ultimately uncover the truth.

I am not claiming that the decline in real autopsies caused the rise of CSI-style crime fiction. But I find the contrast revealing. The less certain we can be that every suspicious death will receive serious scientific attention, the more eagerly we seem to watch fictional experts give it exactly that attention. On television, there is always a lab, an expert, enough time, and a determination to look beneath the surface. In real life, too often, there is not.

Perhaps the popularity of these stories reflects a hunger for what we are not reliably willing to provide: the assurance that somebody will look, that evidence will matter, and that hidden harm will not simply disappear into an official explanation.

Sources:

J. Waidhauser et al., “Can low autopsy rates be increased? Yes, we can! Should we?” Virchows Archiv (2021)

https://link.springer.com/article/10.1007/s00428-020-02884-8

M. Grassow-Narlik, M. Wessolly, and J. Friemann, “Autopsy rates in Germany,” Der Pathologe (2017), PubMed

https://pubmed.ncbi.nlm.nih.gov/28842753/

National Center for Health Statistics, “Autopsy Rates: United States, 2007”

https://www.cdc.gov/nchs/products/databriefs/db67.htm

“The Dying American Autopsy,” Policy Perspectives

https://policy-perspectives.org/2021/03/02/the-dying-american-autopsy/

“Julius Caesar’s Assassination and the Dawn of Forensic Autopsy”

https://simplyforensic.com/julius-caesars-assassination-and-the-first-recorded-forensic-autopsy/

“Religious Objections to Autopsies—A Virtual Solution?” Marquette University Law School

https://law.marquette.edu/facultyblog/2012/10/religious-objections-to autopsies-a-virtual-solution/

“Shortage of forensic pathologists is now critical,” STAT

https://www.statnews.com/2026/07/13/forensic-pathologist-shortage-medical-examiners/

R. Masters et al., “Return on investment of public health interventions: a systematic review,” Journal of Epidemiology & Community Health

https://jech.bmj.com/content/71/8/827