The absence of a law or specific legal provision mandating autopsies in unnatural deaths and cultural beliefs and family sensitivities are hampering autopsies in Bhutan and in the process investigation of death cases in Bhutan.
In the absence of a specific legal provision, law enforcement often has to go by the wishes of the family.
In a homicide case in Phuentsholing the RBP initially requested for an autopsy team from Thimphu, but halfway the team had to come back as the family did not want any autopsy done.
Even when autopsies are conducted, they are done in a limited manner and this can backfire at times in court proceedings in crime cases where the report must be beyond reasonable doubt.
A Forensic Specialist said that in the Namgay Dolkar case the extensive external injury marks were itself enough to show that she had died due to strangulation especially since the bruise marks were formed before her death.
There were bruises formed before her death on the lower left jaw, both sides of the neck, shoulder, upper chest, left hand and inner thigh.
It says the bruises, abrasions and wounds on the neck showed different patterns suggesting several forms of inflicting mechanisms were present like manual strangulation, ligature marks (strangulation using some cord or rope), scratches, etc.
The report says the laceration of the inner lip and lower lips with bruises surrounding it suggests the deceased was also smothered around the mouth with reasonable force.
It said although the body was retrieved from the river the features suggestive of drowning were not present, however, the possibility of drowning could not be excluded (rare cases of dry drowning with little amounts of water).
The person who did the autopsy was called to court twice and both times he confirmed that death had happened asphyxia due to the fatal pressure on her neck.
However, the defense picked up on the sentence that ‘the possibility of drowning could not be excluded’ to try and downplay the entire forensic report.
If the autopsy had cut in Namgay’s body and examined her lungs to completely rule out drowning then the defense would have no argument left, but in Bhutan the practice is not to go for such full-fledged autopsies. There were no specific instructions from the police to do so and moreover cultural sensitivities and practices would be involved.
The specialist said that for many cases such as the Pamtsho murder case, the external examination finding itself was sufficient to determine the cause of death. There was DNA evidence backed up by a confession that closed the case.
It becomes trickier in a case like that of Namgay Dolkar when there is no DNA evidence and no confession and a strong defense legal team making the forensic report all the more important.
What is an Autopsy?
Autopsy also commonly known as post- mortem examination is the examination of a body after death. The aim of a post-mortem is to determine the cause of death and to evaluate any disease or injury present.
There are generally two main types of autopsies.
Clinical autopsy or academic autopsy where the forensic medicine specialist or pathologist conducts the clinical autopsies with the consent obtained from the deceased’s relatives. It is conducted to identify undiagnosed conditions, understand medical complications and for educational purposes of medical students and professionals.
Medico-legal autopsy or forensic autopsy where forensic medicine specialist conducts autopsy upon the instruction of the legal authority responsible for the investigation of death.
Autopsy authority and legal issues
In Bhutan, the legal authority is with the Royal Bhutan Police (RBP) and Royal Court of Justice. It is conducted to determine the cause, manner, and circumstances of death, especially during investigating of homicides, suicides, and accidents, providing evidence for legal proceedings and in identifying victims of disasters or unknown individuals.
An autopsy involves a standardized process involving obtaining consent from next of kin, external examination, photography, and documentation of the body and belongings, internal examination of organs, taking samples for toxicology, microbiology, and microscopic analysis, closing and preparing the body and generating a detailed report summarizing findings and cause of death for medical or legal purposes.
For conducting forensic autopsy, just the instruction from the legal authority to perform the procedure is sufficient but this is easier said than done because in the absence of specific legal provisions and cultural sensitivity, family consent can make or break a case. For performing clinical autopsy, consent has to be sought from the family relatives.
The death investigation system in Bhutan is police-based system, whereby it is governed by the Police Act of Bhutan with no mention about the autopsy being mandatory.
The section 55 of Police Act of Bhutan which is for the death investigation system, just instructs the police to record all of the details of an unnatural death in the inquest form describing the circumstances and condition of the dead person. The examination is to be carried out jointly by the police and medical doctor, however, there is no specific mention about autopsy in any other legal provisions.
In Bhutan, cultural and religious beliefs, particularly Buddhist beliefs regarding the sanctity of the body and the importance of timely funeral rituals, often influence decisions against autopsies. Families believe that disturbing the body interferes with the deceased’s journey to rebirth and delays crucial ceremonies.
Autopsy capacity
For now, only the Jigme Dorji Wangchuck National Referral Hospital (JDWNRH) has a forensic department with forensic pathology services. There are forensic units in CRRH and ERRH whereby the forensic focal person manages the unit. In other dzongkhags, the medical officers are involved in providing the forensic services.
In the Department of Forensic Medicine and Toxicology, JDWNRH, there is a designated mortuary where the post mortem examination of dead body is carried out.
Currently, the mortuary is not fully equipped with necessary equipment. However, JDWNRH is in the process of refurbishing the existing mortuary with necessary equipment and tools as well as proper ventilation system, which can ensure safety, efficiency, and adherence to legal and ethical principles which is expected to be completed within this financial year.
There are 3 trained forensic specialists in JDWNRH supported by medical officers in each hospital throughout the country.
In the year 2024, the JDWNRH recorded 61 cases of death in which the Department of Forensic Medicine and Toxicology was involved in medico-legal death investigations. Out of these, three cases underwent forensic autopsy procedures.
However, all the autopsies conducted so far have been limited autopsies, wherein only the relevant part of the body is examined. For instance, if an injury is sustained in the head region, only the cranial cavity and its contents are explored. If the findings are sufficient to determine the cause of death, other regions of the body are not examined.
Importance of autopsies
The forensic specialist shared that autopsies are essential in Bhutan, as they play a crucial role in both medico-legal investigations and public health. While cultural and religious beliefs are deeply ingrained in our society, it is equally important to recognize the critical function autopsies serve in providing clarity and justice in cases of unnatural death.
The Forensic Specialist shared that an autopsy is important for several reasons, and he said, “Imagine you are trying to figure out why something went wrong with a machine, but you can’t see inside it. An autopsy is like ‘looking inside’ the body to find out what happened. Sometimes, people die unexpectedly or under unclear circumstances. An autopsy helps us find out exactly why someone passed away, whether it was due to an illness, an accident, or something else. This is important for families who want answers and for legal authorities to ensure that no foul play is involved.”
“In cases where a death might be suspicious, such as a murder or an accident, autopsies help provide evidence that can confirm the cause of death. This is important for the police and the legal system, as it can lead to justice for the deceased and their family. Autopsies also help us understand how diseases affect the body. For example, if there is a sudden death from a new disease, an autopsy can help doctors and health authorities figure out how the disease works and how to prevent it from spreading,” he added.
Further the forensic specialist shared that an autopsy helps doctors learn about medical conditions that were not obvious during a person’s life. This information can improve how doctors treat similar conditions in the future, helping save lives.
For some, cases police and family members don’t demand autopsy reports with satisfaction from the findings.
In USA autopsies are a must for unnatural deaths, unexpected deaths, deaths without a doctor present and public health threats.
In Australia an autopsy is ordered by a coroner when a death is unexpected, suspicious, or unnatural. This could be if the person was murdered, or if there is no clear cause of death.