Your patient is dead; the family is gathered. And there is one last thing that you must ask about: the autopsy. How should you go about it? You could do it offhandedly, as if it were the most ordinary thing in the world: "Shall we do an autopsy, then?" Or you could be firm, use your Sergeant Joe Friday voice: "Unless you have strong objections, we will need to do an autopsy, ma'am." Or you could take yourself out of it: "I am sorry, but they require me to ask, Do you want an autopsy done?"

What you can't be these days is mealy-mouthed about it. I once took care of a woman in her eighties who had given up her driver's license only to get hit by a car—driven by someone even older—while she was walking to a bus stop. She sustained a depressed skull fracture and cerebral bleeding, and, despite surgery, she died a few days later. So, on the spring afternoon after the patient took her last breath, I stood beside her and bowed my head with the tearful family. Then, as delicately as I could—not even using the awful word—I said, "If it's all right, we'd like to do an examination to confirm the cause of death."

"An autopsy?" a nephew said, horrified. He looked at me as if I were a buzzard circling his aunt's body. "Hasn't she been through enough?"

The autopsy is in a precarious state. A generation ago, it was routine; now it has become a rarity. Human beings have never quite become comfortable with the idea of having their bodies cut open after they die. Even for a surgeon, the sense of violation is inescapable.

Not long ago, I went to observe the dissection of a thirty-eight-year-old woman I had taken care of who had died after a long struggle with heart disease. The dissecting room was in the sub-basement, past the laundry and a loading dock, behind an unmarked metal door. It had high ceilings, peeling paint, and a brown tiled floor that sloped down to a central drain. There was a Bunsen burner on a countertop, and an old-style grocer's hanging scale, with a big clock-face red-arrow gauge and a pan underneath, for weighing organs. On shelves all around the room there were gray portions of brain, bowel, and other organs soaking in formalin in Tupperware-like containers. The facility seemed run-down, chintzy, low-tech. On a rickety gurney in the corner was my patient, sprawled out, completely naked. The autopsy team was just beginning its work.

Surgical procedures can be grisly, but dissections are somehow worse. In even the most gruesome operations—skin-grafting, amputations—surgeons maintain an attitude of tenderness and aestheticism toward their work. We know that the bodies we cut still pulse with life, and that these are people who will wake again. But in the dissecting room, where the person is gone and only the carcass remains, you find little of this delicacy, and the difference is visible in the smallest details. There is, for example, the simple matter of how a body is moved from gurney to table. In the operating room, we follow a careful, elaborate procedure for the unconscious patient, involving a canvas-sleeved rolling board and several gentle movements. We don't want so much as a bruise. Down here, by contrast, someone grabbed my patient's arm, another person a leg, and they just yanked. When her skin stuck to the stainless-steel dissecting table, they had to wet her and the table down with a hose before they could jerk her the rest of the way.

The young pathologist for the case stood on the sidelines and let a pathology assistant take the knife. Like many of her colleagues, the pathologist had not been drawn to her field by autopsies but by the high-tech detective work that she got to do on tissue from living patients. She was happy to leave the dissection to the P.A., who had more experience at it anyway.

The P.A. was a tall, slender woman of around thirty with straight sandy-brown hair. She was wearing the full protective garb of mask, face shield, gloves, and blue plastic gown. Once the body was on the table, she placed a six-inch metal block under the back, between the shoulder blades, so that the head fell back and the chest arched up. Then she took a scalpel in her hand, a big No. 6 blade, and made a huge Y-shaped incision that came down diagonally from each shoulder, curving slightly around each breast before reaching the midline, and then continued down the abdomen to the pubis.

Surgeons get used to the opening of bodies. It is easy to detach yourself from the person on the table and become absorbed by the details of method and anatomy. Nevertheless, I couldn't help wincing as she did her work: she was holding the scalpel like a pen, which forced her to cut slowly and jaggedly with the tip of the blade. Surgeons are taught to stand straight and parallel to their incision, hold the knife between the thumb and four fingers, like a violin bow, and draw the belly of the blade through the skin in a single, smooth slice to the exact depth desired. The P.A. was practically sawing her way through my patient.

From there, the evisceration was swift. The P.A. flayed back the skin flaps. With an electric saw, she cut through the exposed ribs along both sides. Then she lifted the rib cage as if it were the hood of a car, opened the abdomen, and removed all the major organs—including the heart, the lungs, the liver, the bowels, and the kidneys. Then the skull was sawed open, and the brain, too, was removed. Meanwhile, the pathologist was at a back table, weighing and examining everything, and preparing samples for microscopy and thorough testing.

Despite all this, the patient came out looking surprisingly undisturbed. The P.A. had followed the usual procedure and kept the skull incision behind the woman's ears, where it was completely hidden by her hair. She had also taken care to close the chest and abdomen neatly, sewing the incision tightly with weaved seven-cord thread. My patient actually looked much the same as before, except now a little collapsed in the middle. (The standard consent allows the hospital to keep the organs for testing and research. This common and long-established practice is now causing huge controversy in Britain—the media have branded it "organ stripping"—but in America it remains generally accepted.) Families can still have an open-casket funeral, and most do. Morticians employ fillers to restore a corpse's shape, and when they're done you cannot tell that an autopsy has been performed.

Still, when it is time to ask for a family's permission to do such a thing, the images weigh on everyone's mind—not least the doctor's. You strive to achieve a cool, dispassionate attitude toward these matters. But doubts nevertheless creep in.

One of the first patients for whom I was expected to request an autopsy was a seventy-five-year-old retired New England doctor who died one winter night while I was with him. Herodotus Sykes (not his real name, but not unlike it, either) had been rushed to the hospital with an infected, rupturing abdominal aortic aneurysm and taken to emergency surgery. He survived it, and recovered steadily until, eighteen days later, his blood pressure dropped alarmingly and blood began to pour from a drainage tube in his abdomen. "The aortic stump must have blown out," his surgeon said. Residual infection must have weakened the suture line. We could have operated again, but the patient's chances were poor, and his surgeon didn't think he would be willing to take any more.

He was right. No more surgery, Sykes told me. He'd been through enough. We called Mrs. Sykes, who was staying with a friend, about two hours away, and she set out for the hospital.

It was about midnight. I sat with him as he lay silent and bleeding, his arms slack at his sides, his eyes without fear. I imagined his wife out on the Mass Pike, frantic, helpless, with six lanes, virtually empty at that hour, stretching far ahead.

Sykes held on, and at 2:15 a.m. his wife arrived. She turned ashen at the sight of him, but she steadied herself. She gently took his hand in hers. She squeezed, and he squeezed back. I left them to themselves.

At two-forty-five, the nurse called me in. I listened with my stethoscope, then turned to Mrs. Sykes and told her that he was gone. She had her husband's Yankee reserve, but she broke into quiet tears, weeping into her hands, and seemed suddenly frail and small. A friend who had come with her soon appeared, took her by the arm, and led her out of the room.

We are instructed to request an autopsy on everyone as a means of confirming the cause of death and catching our mistakes. And this was the moment I was supposed to ask—with the wife despondent and reeling with shock. But surely, I began to think, here was a case in which an autopsy would be pointless. We knew what had happened—a persistent infection, a rupture. We were sure of it. What would cutting the man apart accomplish?

And so I let Mrs. Sykes go. I could have caught her as she walked through the I.C.U.'s double doors. Or even called her on the phone later. But I never did.

Such reasoning, it appears, has become commonplace in medicine. Doctors are seeking so few autopsies that in recent years The Journal of the American Medical Association has twice felt the need to declare "war on the nonautopsy." According to the most recent statistics available, autopsies have been done in less than ten per cent of deaths; many hospitals do none. This is a dramatic turnabout. Through much of the twentieth century, doctors diligently obtained autopsies in the majority of all deaths— and it had taken centuries to reach this point. As Kenneth Iserson recounts in his fascinating almanac, "Death to Dust," physicians have performed autopsies for more than two thousand years. But for most of history they were rarely performed, and only for legal purposes (if religions permitted them at all—Islam, Shinto, and the Greek Orthodox Church still frown on them). The Roman physician Antistius performed one of the earliest forensic examinations on record, in 44 B.C., on Julius Caesar, documenting twenty-three wounds, including a final, fatal stab to the chest. In 1410, the Catholic Church itself ordered an autopsy—on Pope Alexander V, to determine whether his successor had poisoned him. No evidence of this was found.

Even in the nineteenth century, long after church strictures had loosened, people in the West rarely allowed doctors to autopsy their family members for medical purposes. As a result, the practice was largely clandestine. Some doctors went ahead and autopsied hospital patients immediately after death, before relatives could turn up to object. Others waited until burial and then robbed the graves, either personally or through accomplices, an activity that continued into the twentieth century. To deter such autopsies, some families would post nighttime guards at the grave site—hence the term "graveyard shift." Others placed heavy stones on the coffins. In 1878, one company in Columbus, Ohio, even sold "torpedo coffins," equipped with pipe bombs rigged to blow up if they were tampered with. Yet doctors remained undeterred. Ambrose Bierce's "The Devil's Dictionary," published in 1906, defined "grave" as "a place in which the dead are laid to await the coming of the medical student."

By the turn of the century, however, prominent physicians such as Rudolf Virchow, in Berlin, Karl Rokitansky, in Vienna, and William Osler, in Baltimore, began to win popular support for the practice. They defended it as a tool of discovery, one that was used to identify the cause of tuberculosis, reveal how to treat appendicitis, and establish the existence of Alzheimer's disease. They showed that autopsies prevented errors—that without them doctors could not know when their diagnoses were incorrect. Most deaths were a mystery then, and perhaps what clinched the argument was the notion that autopsies could provide families with answers—give the story of a loved one's life a comprehensible ending. Once doctors had insured a dignified and respectful dissection at the hospital, public opinion turned. With time, doctors who did not obtain autopsies were viewed with suspicion. By the end of the Second World War, the autopsy was firmly established as a routine part of death in Europe and North America.

So what accounts for its decline? It's not because families refuse—to judge from recent studies, they still grant that permission up to eighty per cent of the time. Doctors, once so eager to perform autopsies that they stole bodies, have simply stopped asking. Some people ascribe this to shady motives. It has been said that hospitals are trying to save money by avoiding autopsies, since insurers don't pay for them, or that doctors avoid them in order to cover up evidence of malpractice. And yet autopsies lost money and uncovered malpractice when they were popular, too.

Instead, I suspect, what discourages autopsies is medicine's twenty-first-century, tall-in-the-saddle confidence. When I failed to ask Mrs. Sykes whether we could autopsy her husband, it was not because of the expense, or because I feared that the autopsy would uncover an error. It was the opposite: I didn't see much likelihood that an error would be found. Today, we have M.R.I. scans, ultrasound, nuclear medicine, molecular testing, and much more. When somebody dies, we already know why. We don't need an autopsy to find out.

Or so I thought. Then I had a patient who changed my mind.

He was in his sixties, whiskered and cheerful, a former engineer who had found success in retirement as an artist. I will call him Mr. Jolly, because that's what he was. He was also what we call a vasculopath—he did not seem to have an undiseased artery in him. Whether because of his diet or his genes or the fact that he used to smoke, he had had, in the previous decade, one heart attack, two abdominal aortic-aneurysm repairs, four bypass operations to keep blood flowing past blockages in his leg arteries, and several balloon procedures to keep hardened arteries open. Still, I never knew him to take a dark view of his lot. "Well, you can't get miserable about it," he'd say. He had wonderful children. He had beautiful grandchildren. "But, aargh, the wife," he'd go on. She would be sitting right there at the bedside, and would roll her eyes, and he'd break into a grin.

Mr. Jolly had come into the hos- pital for treatment of a wound infection in his legs. But he soon developed congestive heart failure, causing fluid to back up into his lungs. Breathing became steadily harder for him, until we had to put him in the I.C.U., intubate him, and place him on a ventilator. A two-day admission turned into two weeks. With a regimen of diuretics and a change in heart medications, however, his heart failure reversed, and his lungs recovered. And one bright Sunday morning he was reclining in bed, breathing on his own, watching the morning shows on the TV set that hung from the ceiling. "You're doing marvellously," I said. I told him we would transfer him out of intensive care by the afternoon. He would probably be home in a couple of days.

Two hours later, a code-blue call went out on the overhead speakers. When I got to the I.C.U. and saw the nurse hunched over Mr. Jolly, doing chest compressions, I blurted out an angry curse. He'd been fine, the nurse explained, just watching TV, when suddenly he sat upright with a look of shock and then fell back, unresponsive. At first, he was asystolic—no heart rhythm on the monitor—and then the rhythm came back, but he had no pulse. A crowd of staffers set to work. I had him intubated, gave him fluids and epinephrine, had someone call the attending surgeon at home, someone else check the morning lab-test results. An X-ray technician shot a portable chest film.

I mentally ran through possible causes. There were not many. A collapsed lung, but I heard good breath sounds with my stethoscope, and when his X-ray came back the lungs looked fine. A massive blood loss, but his abdomen wasn't swelling, and his decline happened so quickly that bleeding just didn't make sense. Extreme acidity of the blood could do it, but his lab tests were fine. Then there was cardiac tamponade—bleeding into the sac that contains the heart. I took a six-inch spinal needle on a syringe, pushed it through the skin below the breastbone, and advanced it to the heart sac. I found no bleeding. That left only one possibility: a pulmonary embolism—a blood clot that flips into the lung and instantly wedges off all blood flow. And nothing could be done about that.

I went out and spoke to the attending surgeon by phone and then to the chief resident, who had just arrived. An embolism was the only logical explanation, they agreed. I went back into the room and stopped the code. "Time of death: 10:23 A.M.," I announced. I phoned his wife at home, told her that things had taken a turn for the worse, and asked her to come in.

This shouldn't have happened; I was sure of it. I scanned the records for clues. Then I found one. In a lab test done the day before, the patient's clotting had seemed slow, which wasn't serious, but an I.C.U. physician had decided to correct it with vitamin K. A frequent complication with vitamin K is blood clots. I was furious. Giving the vitamin was completely unnecessary—just fixing a number on a lab test. Both the chief resident and I lit into the physician. We all but accused him of killing the patient.

When Mrs. Jolly arrived, we took her to a family room where it was quiet and calm, with table lamps instead of fluorescent lights and soft, plump chairs. I could see from her face that she'd already surmised the worst. His heart had stopped suddenly, we told her, because of a pulmonary embolism. We said the medicines we gave him may have contributed to it. I took her in to see him and left her with him. After a while, she came out, her hands trembling and her face stained with tears. Then, remarkably, she thanked us. We had kept him for her all these years, she said. Maybe so, but neither of us felt any pride about what had just happened.