‘… we still have to care for them, we still have to care for the body, we still have to make sure they’re clean, we still have to make sure that they’re not in a terrible state, we have to make sure that they’re not damaged, just like you would a live patient. So you still have a care because that is somebody, do you know what I mean?’ (APT 1)
In this article, I tackle and extend understanding of the role of care in the autopsy stage of medico-legal death investigation. Traditionally, much academic engagement with this early stage of death investigation has focused on reporting medical research. These important contributions inform the methods and findings of pathologists. However, there has been scant socio-legal attention paid to medico-legal autopsies.Footnote 1 I extend understanding by demonstrating the presence and importance of care for the dead during these death investigations, in doing so highlighting how these benefit both the dead and the living. The article provides a new and important contribution to several fields, including socio-legal studies, medicine and death studies.
My central purpose is to argue that we should “care about the care of the dead’. I emphasise two reasons for this that are especially important in a medico-legal context. First, the dead matter, both intrinsically and because of their value to the living. This is equally true across a range of death work contexts, whether that be (non-exhaustively) in mortuaries, the funerary sector or in the use of remains for research or display. Second, more instrumentally, acting with care for the dead is salient because the ability of the coronial process to operate relies on societal acceptance of these disruptive processes. I argue that the work of Anatomical Pathology Technologists (APTs) is essential to enacting this care, and yet their role remains largely hidden from public view. I find evidence of an ethics of care in the work of APTs, and in demonstrating this I extend ethics of care to relationships with the dead as well as the living. I also contribute new understandings of the way that coronial justice can, and should, gain legitimacy.
Drawing on original interview data, I evaluate the role of APTs in medico-legal death investigation. By initially locating the medico-legal autopsy within the context of the coronial process, I highlight the technical, apparently limited, goals of the law and the focus on the evidential value of the deceased body. APTs play a role in the ‘technical’, both directly, by exercising practical skills (such as evisceration)Footnote 2 and by maintaining a physical environment that is necessary for autopsies to take place. This I describe as a form of ‘mundane’ or ‘mandated’ care. However, while the law may seem to assign only technical value to the autopsy, I demonstrate that care ‘bleed[s] into the spaces between the manuals of instruction’.Footnote 3
This may be because of the social and historical context against which legal demands, such as the regulatory framework developed by the Human Tissue Authority, have been developed, or because both technical skill as mandated care and more traditional care are basic and simultaneous tenets of the APT role. That is, even at this more overt and surface level, care is essential if the legal questions are to be answered while meeting the social function of justice in the context of death investigation. It is therefore rare that the technical is not limited by, or interpreted in the context of, the social and relational. I argue that this melting together of care and technical skill is central to how APTs practise and understand their role, and I note that with this comes a perceived duty to act as a gatekeeper against excessive or unjustified medical investigations.
The lens of ethics of care becomes especially important when we consider the identity of APTs. I demonstrate this by considering three examples from my data, which illustrate the commitment to the practice of care among APTs. These are the tendency of APTs to self-define as ‘nurses for the dead’, practices which recognise the interwoven needs of the deceased and the bereaved, and the drive to do the ‘right thing’. I argue that APTs practise care, at least in part, because they are driven by an emotional commitment to it, seeing care as valuable independent of what may be required of them by law and regulation. By performing care ‘well’, they are also enacting self-care. Therefore, care is both something that APTs practise and is often considered by them to be a virtue. This sense of care transcends strict legal obligations, whether these obligations are between different people with roles in death investigation and between employer and employee.
We are thus reminded of the complexity of the webs of interests which inform our interactions with (medicalised) deceased bodies. Recognising this also highlights the importance of legal context in determining what happens to the dead, and that it is not only the dead that are affected by the demands of medico-legal death investigation. Rather, it is the living, whether they are the bereaved or those who enact the demands of law (like APTs), who live with its consequences. As such, I hypothesise that the care identified here is important both due to its relational significance (for society and individuals), and because it has instrumental value in increasing public acceptance of a distressing but essential process if the coronial process is to obtain the information it requires. Put another way, medicine and law are not purely didactic processes; instead, I argue that multifarious forms and enactments of care are necessary to achieve coronial justice.
1. Methods
This article draws on interviews with twenty-five APTs carried out between 2019 and 2023. The APTs worked in mortuaries across England. To gain access, I downloaded a list of mortuaries with licences for post-mortem work from the Human Tissue Authority (HTA) website.Footnote 4 I then entered their details into a spreadsheet and generated a random selection of seventy (of 194) establishments to contact. Quite often the name of the mortuary manager was not available online, so I obtained this information by phoning the establishment. This had the additional benefit of establishing a rapport and also yielded some useful information, for example, plans to close some establishments, or that they only carried out consented post-mortems (otherwise known as hospital post-mortems) and were therefore not relevant establishments for this research. Letters were sent with a project summary to the remaining establishments inviting participation. Participants were drawn from those establishments that responded positively.
Once contact had been made, interviews took place at a location convenient for the APTs, most commonly in an office at the mortuary. The interviews were semi-structured and qualitative. Written consent for the recording and use of their data was provided by each participant. My schedule concentrated on the role of the APTs, and their interactions with the deceased body, the bereaved and other professionals involved in death investigation. Interviewees were given space to raise issues and to voice their own priorities and experiences. The interviews, lasting an average of an hour, were recorded and transcribed. The data were loaded into qualitative data analysis software, NVivo, and coded using grounded theory to identify themes and practices of interest.
The interviews produced a vast amount of interesting and original data, casting light on the role, attitudes and practices of this group. The project was designed as a scoping study; the data gained achieved that and more. The sample was large and diverse enough to provide new and important insights and highlighted previously undisclosed practices that shape the treatment of both the dead and the living in circumstances triggering a medico-legal death investigation.
To maintain anonymity this article contains no demographic information. However, I would note that among my respondents I did not identify any significant impact of gender or age. Given the specific and public nature of some of the cases described by APTs, I have taken care to redact any quotes to ensure that the location – and therefore the identity – of the mortuary where the APT worked, is not compromised.
2. Care and the dead
In this section I set out my understanding of ethics of care and why it is relevant to medico-legal death investigation. This forms the basis for the discussions which follow, in which I argue that care is omnipresent throughout the work and contribution of APTs in facilitating medico-legal autopsies.
My starting premise is that care is about relationships. As Kittay has argued, ‘An ethics of care is one in which the embodied existence of each, in both our unique individuality and in our material connectedness to one another, is never eclipsed’ (Kittay Reference Kittay2019). Kittay shows that care exists within webs of often unequal relationships. We see that care involves an attitudinal shift from the self to the needs of others, while simultaneously not demanding that the caregiver sacrifice themselves (Noddings Reference Noddings1984). Individuals are embedded within relationships, not only with each other but with the broader community and society, and our sense of self is developed in light of these relationships. This centring of relationality encourages care to be practised in ways that recognise how another person experiences their life. This is only possible when we approach others with compassion and empathy.
As is so often the case with theory, the role and boundaries of ethics of care are contested. It is, for example, widely acknowledged that care is a slippery concept and that the vagueness of ‘care’ could lead to it being all-encompassing (Abbots et al. Reference Abbots, Lavis and Attala2016). My purpose here is not to define care, nor does my argument depend on a bounded definition of it. Care can take several forms, including ‘caring about’ as an emotion or disposition toward someone, ‘caring for’ as a form of labour or physical work and care as a social relationship (Tronto Reference Tronto1998; Buse et al. Reference Buse, Martin and Nettleton2018). I would argue that care practices involve recognising the complexity of others (DeFalco Reference DeFalco2020) and responding to their needs and relationships. I also recognise that care can be practised without being driven by a normative ethic of care. Thus, while I identify much of the work of APTs as practising care, I would argue that this can, and does, both co-exist with and can be independent of ethics-driven care.
Perhaps a bigger challenge is between whom the relationship exists. The bereaved are living persons with whom embodied relationships are shared. They can express their needs and desires, even if circumstances make them dependent on others, which might lead to APTs practising care toward them. However, I would also argue that we share relationships with the deceased body, and that the embodiment of the living will be affected by interactions with the bodies of others, whether they are living or not (Jones Reference Jones2020). Theorising care of the dead is different from that of the living, because the care is not being performed to enable the now deceased person to flourish (as care was originally conceived in Tronto’s (Reference Tronto1998) original account of ethics of care). In response to this, I would argue that care is not, and does not always need to be, oriented toward helping (living) humans to flourish. Rather, care for the deceased body represents both care for the now deceased person and for the still living. This involves drawing on information regarding the deceased person’s preferences in life (via official sources, and/or the bereaved) and on generalised beliefs regarding how bodies should be treated. In addition to caring for the living, these forms of care respond to the vulnerability of the dead, who cannot communicate their needs or preferences but still require subjective and personalised care. It is also about injecting care into technical processes. In doing so, care may potentially limit the way in which law and medicine are applied to the deceased body. Care, then, is practised and valued because of the social and relational context in which bodies, death, law and medicine exist.
In the next two sections I separate out two categories of care: mandated technical care and a more traditional sense of ‘caring for’ skin to that seen across ‘caring professionals’ such as nursing. I argue that even in the technical and mundane care bleeds into the process. Care therefore, I suggest, can simultaneously promote the technical and the ethical/social.
3. Technical work and mundane care: evidence in context
In this section, I consider the acts and skills necessary to achieve objective medical and/or legal requirements. These need to be understood against a context of legally mandated – and controlled – investigations into some deaths. That is, when a person dies, legal processes are triggered, which, depending on the circumstances, will take one of several routes (Home Office, 2024). My focus here is only on deaths which are the subject of a coronial investigation.
While anyone can refer a death to the coroner, typically this will occur when, following review by a Medical Examiner, a registered medical practitioner feels unable to certify the death (Home Office, 2025), or those attending the scene of a death, for example, emergency service personnel, consider that the circumstances of the death are such that it is deemed to be unexpected or suspicious. Under section 1(2), Coroners and Justice Act 2009 (CJA2009), a death must be subject to an ‘investigation’ where the coroner ‘has reason to believe that (a) the deceased died a violent or unnatural death, (b) the cause of death is unknown, or (c) the deceased died while in custody or otherwise in state detention’.Footnote 5 The CJA2009 provides the legal framework and justification for medico-legal autopsies. It forms the basis for the technical demands for ‘facts’ to be obtained during autopsies, and marks the shift of control over the deceased body from the bereaved to the state.
One way to gain evidence to inform the investigation is to order a post-mortem examination. A ‘post-mortem’ can mean many things. Among these are computerised tomography (CT) scans, minimally invasive post-mortems, external examinations only, full invasive post-mortems and everything between (Ministry of Justice 2009, 2022).Footnote 6 In this article, I am primarily referring to invasive post-mortems, although many of the issues identified are relevant wherever the coroner takes control of the body. While these decisions are being made, and following any autopsy, the body needs to be stored and the bereaved or other legally nominated person must be kept informed.
APTs have a wide-ranging role which includes, non-exhaustively, receiving newly deceased persons (including identity checks), coordinating with coroner’s officers and police, evisceration and reconstruction,Footnote 7 supporting pathologists during the autopsy, maintaining bodies in the mortuary and managing contact with bereaved people, including facilitating viewings and liaising with funeral agencies. It is impossible to detail all the work that APTs do, although elements are described in more detail throughout this article.
While the CJA2009 provides the primary statutory framework for coronial death investigation, it is worth noting that much of the work of APTs is impacted by the regulatory standards and the oversight of the HTA (Human Tissue Authority 2023). The HTA sets standards regarding the storage and use of bodies and body parts, as well as a system for monitoring the treatment, condition and identification of the deceased. These standards are monitored and enforced via a system of inspections, upon which an establishment’s licence to carry out post-mortem work depends.Footnote 8 However, it is worth noting that, as indicated by the tasks outlined above, alongside assisting the pathologists carrying out post-mortems which inform legal processes, APTs play a fundamental role in the care of the deceased, and often a considerable amount of their time is directed to dealing with deceased persons who are not the subject of an autopsy. Even if there is an autopsy, APTs must still deal with (or, indeed, ‘care for’) the body and bereaved before and after the autopsy. The reach of their role and the identity associated with it will therefore always be cast more widely than simply the technical acts involved in autopsy work.
It follows, therefore, that the intended beneficiary of the APT’s work is not only the coroner and/or legal process, but instead shifts between a complex picture of science, social and legal goals. I suggest that these porous boundaries are essential to both the potential success of these legal processes and to the well-being of the APTs. To make this argument, more needs to be said about those tasks which may initially appear mundane. At this juncture it is also important to introduce what I term ‘mandated care’, by which I mean care that is required by regulatory frameworks such as those provided by the HTA.
I draw on the work of Rees, who has identified a ‘care-custody paradox’ in the work of Health Care Practitioners (HCPs)Footnote 9 with police (Rees Reference Rees, Harper, Kelly and Khanna2015, Reference Rees2023). Rees demonstrates that forensic medicine and care can lead to ‘co-produced routines and activities that meet their care and evidence collection objectives, and as a result, rather than existing in a state of role-conflict, they can perform forensic work unproblematically’ (Rees Reference Rees2023, p. 60). Rees is not alone in these findings; Mulla compellingly outlined the duality of care in evidence collection from sexual violence survivors in the USA (Mulla Reference Mulla2014). Comparing my data with Rees’s highlights the differences in balancing care and the demands of forensic evidence collection when working with the dead, as opposed to the living. APTs do not have the complication of dealing with a potentially non-compliant living person, or the complexity of the demands that the ‘patient’ be able to contribute personally to the legal process following (or as a result of) their work (such as being fit for an interview). Instead, they must balance other external factors such as the interests and experiences of the bereaved. Being mandated for the purpose of evidence collection does not, however, render technical acts devoid of care. Thus, I argue that they do not need to exclude each other, but rather that care can be found in, and at the same time as, mandated acts.
3.1 Formal technical role
As I outlined briefly above, while the duties of each APT vary,Footnote 10 most will be required to carry out several technical functions. These are externally mandated, whether by the HTA (Human Tissue Authority 2023), the coronial and criminal justice processes (for example, relating to the permission/requirement to retain materials, as set out in s.19 and s.20 of the Police and Criminal Evidence Act 1984 and s.11 of the Human Tissue Act 2004, or in NHS regulations such as those issued by the Care Quality Commission 2016 and by Wilson and White Reference Wilson and White2011). Non-exhaustive examples include identification checks, condition checks, moving and preparation of the dead, assisting the pathologist with the external examination, removal of organ blocks, liaising with coroner’s officers and funeral directors, being a ‘second pair of eyes’ to assist the pathologist in the post-mortem, evisceration and reconstruction of the body.
This is reflected in APT 20’s description of their role in death investigation as follows:
‘So, it’s to make sure the ID is correct in the first place. Three points of ID. So, you know, we definitely got the right person. The doctor’s got ultimate like responsibility over post-mortem. I’m there to assist. You know, so what they want, you know, we’re there to provide. So, and if we do see anything, you know, we just tell the doctor. If I see anything, yeah, that I’m uncomfortable with or when I get into the body, like, say, there’s peritonitis or there’s just something that needs – the doctor needs to look at, I stop, because there’s job limitation … But, you know, for the coronial ones, it’s prep, you know, eviscerating the bodies and doing all that reconstructing.’
These requirements might be seen as minimal standards designed to ensure processes which meet the need for legally acceptable evidence. For example, to answer the questions set forth in the 2009 Act, coroners rely on processes which identify the correct body and preserve the integrity of evidence (for example, this may be compromised by rough handling of a body, allowing deterioration through poor storage or poor dissection techniques). To achieve this, the APTs (and the pathologists they assist) must adhere to the standards set by both medicine and law (I include regulations and guidelines as a form of law).
It would be possible to achieve technically acceptable outcomes without practising anything other than mandated care. For example, the ‘anatomists’ of the nineteenth century arguably behaved with disregard for the value of the deceased person (Hurren Reference Hurren2004; Richardson Reference Richardson2001/Reference Richardson1988). They may, or may not, have been meticulous in their technical methods but this was distinct from any care for the deceased or bereaved. As I discuss below, care which is primarily directed at accurate knowledge generation may demand different practices to that which is for the body or memory of the person. But in the case of early dissections, the lack of care to the person via their body may have reflected ‘who’ the bodies were – that is, where post-mortem dissection was part of a criminal penalty and/or bodies were obtained via ethically dubious means, as was the case for the ‘resurrectionists’ who were infamously paid to obtain bodies for dissection (Hurren Reference Hurren2016; Richardson Reference Richardson2001/Reference Richardson1988). This historical context is relevant to the resistance of the APTs to being viewed as ‘slab men’.Footnote 11
This duality of function was evident when, during interviews, APTs noted the need to assist pathologists in finding evidence to support the legal process (whether that be simply finding the cause of death, or more detailed forensic evidence), while also being clear that the purpose of the medico-legal death investigation was primarily to benefit the bereaved. The complexity of interests and goals being served by coronial justice is thus much greater than the tests set out in the Coroners and Justice Act 2009 might imply.
For example, APT 10 told me:
‘I think you need to have a post-mortem for the family and also for that person, you know, if somebody’s died from a particular thing then I think the family have got a right to know why that person has died and I think that’s more important than statistics.’
One of the best ways to understand the consequences of failure to recognise the importance of this fragile balance is to examine what happens when things go wrong. The 2021 case of Brennan Footnote 12 demonstrates this. Here, multiple failures to properly store the deceased body, such that it became (badly)Footnote 13 decomposed, undermined the medico-legal system’s ability to accurately ascertain evidence because the organs were too deteriorated. The condition of the body caused significant distress to the bereaved family (Jones Reference Jones2023).Footnote 14 Thus, there was a failure to practise basic care, signifying a breakdown in the normative and technical/regulatory frameworks that ought to guide APTs. The consequences of this undermined the ability of a medico-legal autopsy to contribute to a forensic death investigation and led to unnecessary distress on the part of the bereaved.
It is not hard to find further examples of lack of care in, or around, the mandated autopsy. We only need to look to the HTA’s records of Reportable Incidents (HATRIs) to understand the scope for this. For example, between 2021 and 2025 there were four reported instances of ‘human error’ leading to the wrong body being autopsied; in the same period there were fifty-six instances of the ‘short-term release’ of the wrong body and 242 reports of a body being ‘accidentally’ damaged (Human Tissue Authority 2025). It is easy to see how instances such as theseFootnote 15 could both negatively impact the effectiveness of the post-mortem to address the legal questions in the CJA2009 and cause considerable distress to the bereaved. This was also the case prior to the creation of the HTA, for example as seen in the removal of hands from the deceased as part of identification processes following the sinking of the Marchioness in the River Thames (Clarke Reference Clarke2000).
While the care that I am referring to is required in autopsy work, as I noted at the outset the importance of caring for the dead extends to all death work sectors. It is not my purpose here to evaluate these but recent outcry regarding the exposure of failures of care in the funerary (Jones Reference Jones2024b, Reference Jones2025) and wider mortuary sector,Footnote 16 for example, highlights the intersectoral importance of care for the dead. The promotion of good technical care may therefore have the side effect of advancing emotional care of the bereaved.
Indeed, some rules such as those requiring consent for the retention of tissue, or identity checks prior to a body being viewed (which can be found in HTA Code B), speak less to the need to collect evidence and more explicitly to social and historical context. Whether that be the discomfort with the history of anatomical dissection, or more recently, the outcry following various organ retention scandals (Department of Health 2002; The Royal Liverpool Children’s Inquiry Report 2001; McGuinness and Brazier Reference McGuinness and Brazier2008), understanding the importance of care for the deceased body and body parts underscores the need for rules regulating the treatment of the deceased body because it is a matter of public concern. APTs were generally in favour of regulation, although they were sometimes frustrated by the additional administrative burdens that had accompanied this. These are therefore examples of ‘mandated care’, which may or may not overlap with the care that APTs would otherwise practise.
3.2 Reconstruction: the interwoven nature of the care
In this section, I take the example of the reconstruction of a body to further demonstrate these intermingled goals and consequences. In regulatory terms, the HTA requires post-mortem establishments to have in place policies which set out ‘practices relating to evisceration and reconstruction of bodies’ (Human Tissue Authority, HTA, Code B, GQ1, a(iii), 2017). Further, GQ3 requires that ‘APTs should be trained in reconstruction techniques to ensure that the appearance of the deceased is as natural as possible’. Accurate evisceration promotes the evidence collection required by the legal process, but technically, there is no need to reconstruct the body following this, or certainly not in a way beyond those demanded by public health considerations. This skill is part of the basic competencies of an APT, with recent qualification frameworks (AAPT 2024a; APT Careers) setting out both basic and advanced reconstruction competencies.Footnote 17 It is widely understood to be an important facet of the APT role, but the justification for this comes from the socioethical rather than technical (medical or legal) need. We could see instrumental value here too in terms of social acceptance, but I believe that APTs often go beyond what would be required by the rules designed to maintain that.
The skills and time required to reconstruct a body following an invasive post-mortem, but where there is no other damage to the body (for example, following a sudden unexpected death of an adult with no significant decomposition or fragmentation), are vastly different from more complex cases (for example, a young child or death following major physical trauma).Footnote 18 The former is largely a matter of placing the organs back in the body, cleaning and neatly stitching the body. Reconstruction following trauma is a different matter, and I found considerable variation in the practice reported. Before expanding on that point, I would note that APTs rarely reported being motivated by meeting minimum or mandated requirements.
APT 2 explained:
‘… the stitching stuff was one of the first things I learnt when I was here. It was kind of the first contact I had in the post-mortem room with the deceased. And it’s part of my job that I just really love maybe because of the caring, the mix between the care and technical … I would hate the thought that someone had not been reconstructed well or properly and I think it’s the last thing you’re doing for that person other than obviously looking after him afterwards if they’re still here.’
APT 4 extended this, highlighting the interwoven nature of the care and interests at play by linking even basic reconstruction to the experiences of the bereaved, combined with professional pride and a belief in the intrinsic worth of each deceased person:
‘We do a lot of teaching with the hospital because we know that some nurses have said to families, “They’re going to have an autopsy, you don’t want to go see them after that”, so we go to them and say, “Why wouldn’t they?” because if anything, we’ve had a chance to wash them and comb their hair the way it would be and they look much more peaceful after the post-mortem and it’s hard to explain but it’s nice that families have got that opportunity to come and do that and spend time with them, rather than wait for the funeral service.’
Where a body had been disrupted, this link to the experience of the bereaved was even more significant. The extract from APT 6 below shows how the APTs simultaneously care about the person who died, the families and themselves as human professionals:
‘It’s not a written policy here but we will always try and put people back how they were, irrespective of how badly damaged they are. I took an advanced human reconstruction course back in 2003 I think it must have been, and that allows me to use some specialist skills and knowledge, some specialist chemicals like waxes and building materials, to get people back together after they’ve had a traumatic death … The patient’s head was squashed about two inches flat, I spent the best part of two and a half days putting him viewable. He didn’t have any family, nobody came and saw him, but it was what I wanted to do, I thought it was important for him to be back as he should be, given the condition that he was in; it was important to me and it’s important to all of us as technical staff that we do our absolute best for people and for the people’s families.’
This kind of reconstruction goes well beyond stitching, it requires the application of extensive and advanced technical skills. However, resources are finite, and as APT 13 told me:
‘… as a manager, I have to weigh up the amount of time and effort compared to the likelihood of that person being viewed, so if someone has been hit by a high speed train, with the best will in the world you could spend five, six hours – they are still not going to be in a condition, they might be identifiable as a human, but not as a person’.
We can see that technical skills are exercised for a range of reasons: these may be linked to external rules but, as with much of the post-mortem sector, these are vagueFootnote 19 and leave considerable room for interpretation. Where moral concepts, such as treating people, alive or dead, with respect or maintaining dignity are prescribed,Footnote 20 there is little detail regarding how to achieve this beyond basic standards regarding, for example, not damaging bodies. These various legal and regulatory frameworks serve different masters, which may sometimes overlap or be mutually beneficial. Legislation sets a floor of minimum standards and tends to focus on procedures that can be specified. Professionals such as APTs often aspire to and achieve higher, and the less codifiable aspects of human relationships, as well as the more subtle and complex ethical considerations that can be at play within that, feature more clearly in consideration of professionalism than of legality. The professional identity of APTs is linked to care as well as technical skill, something which might be contrasted with the ‘over-excited’ pathologist that APT 4 identifies (above). As such, at least minimal care is deemed necessary, but the reason for that is because bodies matter, not because the technical process relies on it.
3.3 Gatekeeping: preventing unnecessary investigations
The fact that many APTs reported personal interest in, and enjoyment of, the exploration of anatomy was secondary to its value to the bereaved and society. As such, the value of, and justification for, the decision to carry out the medico-legal autopsy was in the way it benefitted others, including being necessary to provide answers to legal questions.Footnote 21 There were, however, limits; the common example being an elderly patient who, by virtue of their age, would have many comorbidities and for whom the cause of death was linked to the deterioration that is appropriately associated with old age. A typical example was:
‘She’d lived until she was 105. She died peacefully at home. There’s no getting away from the fact that a post-mortem is a very invasive procedure; it just didn’t seem right to have lived that long, been relatively healthy and then to have one of the – probably the biggest medical procedure you could have at the very end, that just didn’t sit right.’ (APT 2)
There was also a sense in which APTs considered themselves gatekeepers by preventing unnecessary acts being done to the deceased body. They were cynical that the devoid-of-emotion processes, which can be perceived to underpin law and medicine, could alone justify the destructive acts involved in invasive autopsies. Drawing on Moore, we can therefore summarise that the ‘central contrast between care and justice is that justice aims at universality, which can only be achieved through abstract reasoning; whereas, care is particularistic, with the self-defined in the context of particular social relationships to others which situate her morally’ (Moore Reference Moore1999, p. 3). They are therefore practising care by representing the interests of those whom they, and others, hold power over – that is, the dead.
APT 4 told me:
‘I think our role is generally to look after the person throughout the process, it’s debatable how much we can look after a deceased person, but we are looking after them in the fact that we are I guess, preventing anything happening to them that shouldn’t happen in our view. And obviously there’s what shouldn’t happen from a regulatory point of view, but there’s also what shouldn’t happen from a an APTs own opinion, I guess that is opinion. You know, it’s a moral opinion there, but I think we see ourselves; I certainly see myself as being a protector of the deceased from sometimes pathologists who may get a little bit excited and want to do things that aren’t. It’s difficult because this it’s not really for me to say what’s necessary and what’s unnecessary, but if you’ve got a pathologist who wants to do a dissection I know will affect the way that deceased can be viewed, and I know of another way to do it that might not affect the way, then I feel it, you know, my duty to say, well, do it this way … I think it’s our job to make sure that nothing untoward happens’.
An invasive post-mortem is destructive, and because of the breadth of their role before, during and after the autopsy, the APTs are the ones who are most confronted with the humanness of the deceased person. The vexed question of who coronial death investigation is ‘for’,Footnote 22 remains outside the scope of this article, suffice to say that the agendas and interests identified by the APTs underscore the complexity of this question. Nevertheless, by practising care, the APTs distance themselves from the lure of curiosity and ensure that relationality and the social value of the dead are a relevant consideration at this early stage of death investigation.
Returning to Rees’s analysis of the custody suits, the paradox I find is different. The dead are vulnerable and need to be cared for precisely because they are dead. APTs are in a relationship of responsibility toward the dead, which makes the dead particularly vulnerable to APT action and, in fact, dependent on APTs for any care that they receive while in the mortuary. By extension, the bereaved are also dependent on the APTs if it matters to them that the dead are respected and cared for through coronial processes. This leads to a complex set of goals being pursued synchronously. On the one hand, the body is medicalised, with technical processes applied to it to obtain evidence which serves the purpose of a legal investigation.Footnote 23 On the other, the deceased person and their body are cared for in ways that are not necessary if the only goal is the reliable collection of evidence (Mulla Reference Mulla2011).Footnote 24 With HCPs, the complexity is introduced by the living (whether this is the police or other), but for APTs the bereaved and the APT’s own emotions and normative commitment to ‘good care’ complicate matters. A better parallel might exist between HCPs and pathologists, who have a more boundaried role in these post-mortems,Footnote 25 but considering that is both a substantively different and a larger task than can be considered in this article.
Thus far, I have demonstrated how interwoven the experiences of the APTs, the deceased and the bereaved are. In all cases, the webs of relationships and the social nature of our lives inform the decisions made. This reflects an ethics of care which, as I discuss in the next section, is central to the identity and purpose of APTs.
4. Ethics of care: APT identity and purpose
In this section, I demonstrate how, in the context of the autopsy stage of medico-legal death investigations, a framework which foregrounds care is essential if we are to appreciate our obligations toward – and relationships with – the deceased body, the bereaved and the wider community. Doing this facilitates understanding of how the deceased are treated when an autopsy is required and provides the foundation for associating care with the role played by APTs in facilitating these autopsies. This develops and demonstrates my argument that mandated care and other more traditional forms of care do not exist separately. In doing so, I extend the application of ethics of care by demonstrating the ways in which care is embedded in the wider role and professional identity of APTs.
4.1 The nursing analogy
Many APTs described their role to me by appealing to a nursing analogy.
APT 19:
‘… the primary role of an APT is to take care of them as a nurse would take care of her patient on a ward. So, you have a similar protective, caring nature and that you’re supposed to, you know, make sure that they have everything they need, as in you’re getting the correct person because they can’t speak for themselves.’
In the medical context, an ethics of care is often associated with nursing. Nursing is said to rely on a closeness to the patient and their family. This is claimed to improve the well-being of the patient by locating them and their needs by reference to relational context and embodied interactions (Edwards Reference Edwards and Edwards1996; Sandelowski Reference Sandelowski2000). This can be contrasted with the Western biomedical ‘care’ provided by doctors, which has traditionally been driven by belief in medicine as (rational, objective) science. The ‘medical’ approach risks objectifying patients as biological entities over their subjective needs and experiences.
Nursing highlights the issue of dependency, whereby a nurse’s role is to assist another in activities (including dying) that they could, in other circumstances, do for themselves. This leads van de Weele et al. (Reference van der Weele, Bredewold, Leget and Tonkens2021, p. 2) to argue that ‘… dependency is foundational to nursing and caring, it also makes the caring relationship morally charged. Given that care implies dependency, it implies asymmetry too’. Some caring relationships may be reciprocal, and often care is routine, but where care is based on dependency there is also a power imbalance which demands responsibility on the part of the carer. We can quickly see that ethics of care is not just a description of a practice but can provide a moral compass guiding the enactment of power. I would argue that in the case of APTs, we see not only care being practiced but also norms of commitment to caring that are signalled in their social interactions and internalised in their sense of identity. There is an underlying assumption that this care is good. ‘Good’ care involves understanding the needs of the (deceased) ‘patient’ (a term that many APTs insisted on using when referring to the deceased; see Jones Reference Jones2021). While not explicitly linked by APTs in this way, the commitment to medicalised language corresponds with the nursing analogy and drive for recognition as professionals (AAPT 2024b).
The analogy with the medicalised living body was also highlighted by APT10:
‘I mean there’s some [deceased bodies] that it’s impossible to do anything with but I think we’ve got a duty within our role and as a person to actually make that person as complete as possible, you know, you’re doing your job but I mean you wouldn’t send somebody down to A&E and say, okay, well, I’ll take your line out and not put a dressing on it, you know, because to me part of that completing the job is to actually finish what you’ve started and that’s my role.’
The care described above is both routine (keeping a body clean, covered and stored properly) and specific to the individual deceased person because each deceased will present differently when first arriving in the mortuary. Both practices are informed by a commitment to care as valuable notwithstanding that the recipient is dead.
In my next example, I delve further into the complexity of the relationship webs involved and how these inform its provision. We see that the practice of care is adapted to each individual, by reference to their social and relational self, while also being extended beyond the deceased to those who are emotionally invested in their welfare.
4.2 Intersections of care: the deceased and the bereaved
Whether dead or alive, we have seen that basic welfare needs, such as being clean, are perceived by APTs to be universal. This assumption is socially and culturally located, but importantly these do not prompt an individualised approach to the care of deceased bodies.Footnote 26 However, the care practised by many APTs is both relational and individualised. This link was made explicit by APT 2 when I questioned what they meant by ‘looking after them’.
IJ: ‘“Looking after the people” being the living people?’
APT2: ‘No, the deceased. Yeah, I think having that connection with the family it always … it’s more significant, I think.’
Common examples of these intersecting interests related to storage and viewing. Take the situation described by APT 5:
APT 5: ‘…we had one lady that said – she said, “I know it sounds strange, but my husband is really scared of the dark” so we put a torch with him and just that one little thing, if it helped her that little bit, then we will do things like that.’
IJ: ‘Comfort knowing that you’d actually done that?’
APT5: ‘Well of course it is for – not just for her, it’s for the patient as well of course, even though they may or may not know about it, it’s still part of patient care.’
Other examples included putting a favourite teddy in the fridge with the deceased person (especially, although not exclusively, when the deceased was a child) playing music the deceased enjoyed during the autopsy (as informed by the bereaved). These acts take mundane or primarily technical processes and inject them with care. They involve emotion and compassion, adapted to the specific needs and circumstances of both the dead and the living (acknowledging that these often overlap).
APTs often emphasised that presenting the deceased for viewing by the bereaved was an important act of care for those who are grieving. They also maintained that being presented in a particular way (neatly reconstructed, with washed hair and so on) was important to maintain the dignity of the deceased person, whether or not they were to be viewed by bereaved parties.
APT 8: ‘So, you want to try your best to preserve them so that they look nice, so that if the family want to say goodbye, they can. But also, so that by the time that they have their funeral, you know, cremation, burial, whatever, they’re not essentially, you know, a rotting green soup. Which sounds really horrendous, but that is what all happens to all animals, us included, I mean. So, you’re trying to kind of keep what we would consider dignity as keeping them to look their best and not let them essentially rot as best as possible. But it’s also about keeping them covered. You know, if you were a live person, you wouldn’t like to be just sitting in the hospital with no gown on and everybody just looking at you as you’re naked. That’s considered dignity for a living person and it’s the same for a dead person. And that’s to me is the same. So, you try to offer the same level of, you know, consideration of their individual.’
APT 15: ‘It’s just nice to give them a nice wash down, make them more presentable, even if they’re not going to viewed by family. It’s just nice that they’re in their final moments that they’re nice and clean, presentable, and they’re going to go off respectable … I think it’s nice for the deceased … like that’s how they’re going to be the last image on earth’.
APT 25: ‘It’s giving them a bit of closure, isn’t it, that they’ve been here and they’ve been taken care of as a relative. So, it’s having kind of that closure for them, that they are safe, they are well looked after. I mean, we even lock up on a night and say goodbye when the fridge drawers are closed, you know, everything’s closed, lights will go on in a morning, it’s good morning.’
The deceased are cared for because they are ‘still a person’ with an enduring right to dignity. This emphasises the humanness of the dead body. APTs reported that care would be extended to the deceased whether or not their body was to be viewed by the bereaved, but that the bereaved were commonly intended beneficiaries because these practices of care would make viewing the body less traumatic for them. Many APTs meet the bereaved and directly confront their grief; this contact with the bereaved cannot therefore be discounted as a significant driver of many practices of care extended to the deceased body. It is impossible for APTs to deny the social and relational importance of the deceased body (and person), and the way their work interacts with that. There is a clear sense of overlapping interests. This is testament to the depth and complexity of our social lives, making it impossible to separate the ‘lives’ of the living from those of the dead (Danely Reference Danely2019).
4.3 Doing the right thing (which is good for everyone)
I have argued above that care is often practised in particular ways by APTs, because they understand this to be the morally right thing to do, whether or not this coincides with mandated care. Doing a ‘good job’ can also indicate a professional identity (e.g. APT 23: ‘it’s also obviously for myself as well because I get pride out doing my job’). Concurrently, the same care advances the interests of the deceased and the bereaved. The APTs implicitly see themselves as part of this network of relationships. Take, for example, how APT 21 explained their motivations to reconstruct a body neatly following a post-mortem:
‘… I’m doing it to create an end result that is palatable for the family or as palatable as it can be for the family. But I’m also doing it so that the person who I’m reconstructing is not in that exposed state … I’m also doing it for me because undoubtedly if I’ve done a good job, I feel better about it …’
Moreover, as APT 13 told me: ‘It is that link to remembering that what we are doing affects other people and that they are other people too, they are not just bodies.’
The trauma caused by delay and loss of control over the deceased body places additional moral duties on the APTs. I would argue that we should not discount the importance of emotions in informing decision-making. Van Reenen and van Nistelrooij argue that ‘a care-ethical approach takes notice of the uniqueness and particularity of every situation and considers vulnerability, corporality, and emotions as important sources of moral knowledge’ (van Reenen and van Nistelrooij Reference van Reenen and van Nistelrooij2019, p. 1164). Emotions are arguably shaped by socially shaped learning and personal reflection on experience, and practice may, of course, reflect some habituation. Nevertheless, we see care being practised because it is understood to be a ‘good’ thing to do. For example, a body being clean is ‘nice’ and required as a basic standard, but this is given effect by reference to how APTs would want the bodies of their family to be treated. This draws on emotions, as does the ‘pride’ involved in neat reconstruction, or tailoring actions to the express or implied emotional needs of the bereaved. The technical minimums are consistent with achieving these goals.
The medico-legal process has the potential to be fraught with emotion, distress and inconsistency. Nowhere is this more apparent than in the work of APTs. When making decisions, the APTs must balance the rules (the need to collect evidence, regulations relating to storage, consent, and so on) and their deep sense of the social life and importance of the dead.
Many APTs related their acts of care back to their own emotional and relational environment. For example, APT 3 told me that:
‘It’s probably not even for them, it’s probably for us. It’s probably for us, it probably gives me assurance that when I die someone might be looking after my body in a nice way.’
Similarly, I found that APTs often reflected on how they would want their loved ones to be treated, or how they wished to improve upon the care they had experienced as bereaved individuals:
‘I seen my dad and I thought I can do a better job than this person’ (APT 23).
As such, APTs are emotionally invested not only because they are confronted with the distress of the bereaved, but also because they empathise. Several APTs told me that they would not want their own family members to undergo an autopsy:
‘It’s quite a brutal process … I wouldn’t want my family having an autopsy’ (APT 5).
While the dead may not be able to reciprocate, the APTs can therefore still benefit personally from providing care, both in terms of personal satisfaction and also by assuring themselves that care will inform decisions and practice, relating to the treatment of the dead, including those that they love and themselves. This might be viewed as a form of self-care (Engster Reference Engster2007; Kittay Reference Kittay1999; Schuchter and Heller Reference Schuchter and Heller2018) although this was never reported to be the sole or primary driver. This element of reciprocity in the face of their own mortality is not a significant aspect of APTs’ public (including professional) identity, but it is important in showing that the empathy lying behind some care can be self-orientated.
5. Conclusions: why we should care about care of the dead
Context is everything, and here it is a legal justice process which creates the need for much of the care discussed. Whatever the purpose served by the coronial process, it does not exist in a vacuum. People die from a multitude of causes, in a range of circumstances. Among other things, these can include mistakes, neglect, self-harm and homicide. Each death has consequences beyond the legal: lives are lost and changed, communities and relationships fractured. Cultures and faiths may find themselves at odds with the demands of death investigation. For example, both the Jewish and Islamic faiths require the prompt disposal of an ‘intact body’ (Jones, Reference Jones2018; Campbell, Reference Campbell1998). Despite increased availability and use of CT scanning, partly in attempts to avoid invasive procedures in these cases, invasive procedures and some delay cannot always be avoided. In such cases, duties toward the dead, or toward the legal rules or professional codes may clash with the APTs’ ability to extend some forms of care to the living family members.Footnote 27
The process of medico-legal death investigation causes disruption – both physically to bodies and to norms of body disposal. These, in turn, impact on the lives of several groups of people. I have focused on APTs and, to a lesser extent, the bereaved, but this is not to underestimate the wider impact on others including pathologists, hospital bereavement support, funeral agencies, coroners’ officers and the police. Drawing on my original data, I have argued that it is important to understand the particular role of APTs. Only by examining this hitherto relatively hidden, but important, role can we grasp the ways in which the dead are cared for at this stage of the medico-legal process.Footnote 28
APTs must extend care to both the dead and the living, and in doing so adapt to each individual circumstance. The importance of care is not limited to the experiences of others. Rather, the identity of APTs, and indeed the development of their own autonomy, is grounded in their relatedness to others and informs how they treat others. Care is interwoven throughout the practices and identities of APTs, even where the care is mundane or primarily directed at the exercise of technical skill. We see that the regulations set out by, for example, the HTA, ensure that a body is treated in such a way that the evidential demands of the legal process are not undermined (or, indeed, advanced) while simultaneously recognising the social significance of the deceased body, and its historical treatment by medicine and law, by demanding care in the enactment of law. Like APTs, these legal instruments therefore do more than facilitate evidence collection and legal findings; they ensure that these goals are not pursued in socially or morally unacceptable ways. There is a real danger in these caring roles remaining relatively hidden. As Mol et al. have argued, ‘if care practices are not carefully attended to, there is a risk that they will be eroded’ (Mol et al. Reference Mol, Moser, Pols, Mol, Moser and Pols2010, p. 7).
Against the rather different context of fitting a chair for those with physical disabilities, Winance argued that ‘To care is to tinker, i.e. to meticulously explore, “quibble,” test, touch, adapt, adjust, pay attention to details and change them, until a suitable arrangement (material, emotional, relational) has been reached’ (Winance Reference Winance, Mol, Moser and Pols2010, p. 111). The tinkering done by APTs may be less overt than that by the salesman fitting a chair to a living person in consideration of their carer, but it is just as intricate. The APTs adjust their care by balancing technical skill and knowledge with meeting the needs of the deceased, the bereaved and themselves. This recognises the webs and relations involved in care, and that care may be concurrently exercised in many directions.
The beneficiaries of this ethics of care are not only the individuals directly involved. I would theorise that the legal process may depend on these non-mandated acts. Without such care, it is possible that we would see the evaporation of public acceptance of the state’s power to not only control deceased bodies but also mandate that they be subject to autopsies. We only need to look to the public outcry when the mistreatment, or callous, treatment of the dead has been exposed to appreciate the depth of the widespread public importance of the deceased body. The relationships engaged in are ones of varying levels of dependency and unequal power; it is against this background that care is both a practice and can be argued to be a moral necessity. Given their role in interacting with both the deceased and the bereaved, we should not underestimate the importance of APTs in facilitating acceptance of medico-legal death investigations.
There could be a temptation to perceive a hierarchy of care whereby some acts of care, such as putting a torch with the body of a person who in life was afraid of the dark, are considered less important than the ‘proper’ care demanded by rules, for example those relating to temperatures for body storage. I would argue that both are important, as each recognises the importance of dead bodies as symbols of living people. These are not just bodies; they are the bodies of people. That said, resources are limited, and it is legitimate to set priorities regarding the care that is given. In a care cost-benefit-style calculation, we might therefore conclude that the cost (in crude time/resource terms) of putting a teddy in the fridge is minimal, but with real benefits for the bereaved as well as the APTs’ sense of self. On the other hand, timely and intricate reconstructions of badly disrupted bodies which are unlikely to be viewed could fall on the other end of the spectrum.
While these findings are illuminating, there is a need for some caution. First, care is not necessarily unproblematic. What is caring for one person might not be for another. Caregiving is not always wanted or appreciated and may in some respects be oppressive. This danger is amplified when dealing with the dead because they have no way to communicate preferences. Care of the dead is enacted on the basis of generalisations and information from others. Putting aside the dead themselves, there is a danger that APTs make assumptions about the priorities of the bereaved (in relation to the appearance of the deceased, for example). This could cause unintended distress.Footnote 29 Care, like the relationships central to it, is complex, and it is not always possible to separate the good and bad.
As always, there is scope for more work. In particular, a comparison with the role played by pathologists in this process would facilitate a deeper understanding of the impact of the role, authority and responsibility. In his work, Rees concludes that ‘Medicine and law are co-dependent, and forensic medics must not embody one role alone (therapeutic or evidential) as physicians have done in the past; instead, they must draw from both medical and legal registers’ (Rees Reference Rees, Harper, Kelly and Khanna2015, p. 158). Whether this holds true in the context of medico-legal autopsies remains to be tested. That is, of course, another, different project, but one which I hope to return to in due course. There is also scope to more deeply examine the drive for professionalisation by some APTs, questioning both what this means for the way that care is valued in terms of identity and reward. Finally, I have briefly considered the conflicts that can arise in this area. Two pressing concerns are the need to ration care in response to finite resources and the implications of religious demands to avoid invasive autopsies, for the outcomes of death investigations, for the deceased and for the bereaved.
It seems only right that the final word goes to an APT, so I close with the words of APT 3:
‘When someone dies do you stop caring? No, you don’t. We have to just, the way you’re still respectful, you still treat them with, you know, with respect and it’s a dignified approach but you just, it’s got a slightly different take on it. You’re not asking, “Are you comfortable? Are you embarrassed? Are you, is this, you know …” all those things you’re … you’re still providing all of those things but it’s in a slightly different format’.
Acknowledgements
With thanks to the anonymous reviewers, whose encouragement and suggestions no doubt improved the paper. Even greater gratitude is owed to Marie-Andrée Jacob, Vikki Entwistle and Paul Wragg, as well as colleagues who have commented on presentations, for their time and counsel in the initial drafting of this piece. To the APTs who I can’t name, you know who you are: my thanks to you for all you do and have shared with me. Last, but by no means least, to Katie Rodda, whose work and endless positivity have given me hope. Apologies to those omitted – this is a reflection of my goldfish brain and not a reflection on how much I value you.
Funding statement
The research was funded by a British Academy/Leverhulme Grant (Ref SRG1819\191442).
Competing interests
None.
Open access
