The Right to Immediate Preservation: Addressing Legal Barriers Due to Death Investigation

Abstract

Contemporary human preservation technologies aim to preserve the structure of the body—and especially the brain—after legal death. Although it has not yet been demonstrated, some believe that this may act as a bridge to future medical technologies that could allow for the recovery of life, if this ever becomes feasible and humane. However, current death investigation practices impose two significant obstacles to high-quality preservation. The first and most common is ischemic delay—the period between legal death and initiation of preservation while the death is investigated, during which brain tissue progressively degrades. The second is involuntary autopsy, where tissue disruption can severely compromise preservation quality. Through analysis of legal precedents and the ethical principles of bodily autonomy, non-discrimination, and potential preservation of life, we argue that individuals should be allowed a way to prevent both ischemic delay and autopsy from affecting the quality of their preservation. We explore potential avenues to implement a right to immediate preservation, including administrative, legislative, and judicial approaches, aimed at balancing this right with the societal interest in performing death investigations. This narrative review has implications for individual autonomy, public policy, and the legal framework surrounding death investigation in the context of emerging preservation technologies.

1. Introduction

Human preservation is an emerging technology that aims to preserve individuals at the time of their legal death, with the goal of reviving them in the future, if this ever becomes technically feasible. Although unproven, some believe that structural preservation methods available today may offer a non-negligible chance of future revival, with at least a subset of long-term memories and other aspects of personal identity intact [1,2]. Also known as biostasis, brain preservation, or cryonics—terms we use interchangeably here—the primary focus of contemporary preservation efforts is to retain the information key to personal identity present in the intricate structures of the brain. The field is small, with approximately 450 people who have been preserved worldwide as of 2019 [3]. However, it is growing, with the number of people who have opted for preservation doubling approximately every 8–9 years [3]. Despite the increasing interest in preservation as a personal choice, state laws and regulations frequently prevent individuals from choosing this option rather than standard burial or cremation. This conflict is most evident in medicolegal death investigation practices, which are the focus of this narrative review.

Critical to any discussion of human preservation is a rigorous definition of what death is. Currently, legal death is typically defined by the moment of pronouncement by a healthcare professional, triggered in turn by either the irreversible cessation of circulatory and respiratory functions or the irreversible cessation of all brain functions, including the brainstem [4]. There is widespread dissatisfaction with this contemporary legal definition of death, as it relies heavily on the available medical technology and professional judgment rather than clear biological markers [4,5]. This technology-dependent definition is particularly problematic given that, historically, advances in medical instruments and resuscitation capacities have repeatedly shifted our understanding of when death occurs. It would be preferable for death to be defined in a more objective way that is not dependent upon the medical technology available at the time. Some scholars have proposed alternative criteria, such as the higher-brain standard, which defines death as when one becomes irreversibly unconscious, focusing on the loss of capacity for consciousness and mental activities [6]. This definition would represent a shift from the whole-brain standard of death toward criteria based on the potential for consciousness.

An alternative definition is information-theoretic death, which is the point at which all of the information content in a person’s brain that encodes their psychological identity—such as their long-term memories and personality—has been irretrievably lost [7,8,9,10]. Under this definition, death is conceptualized as a process where information degradation occurs progressively, rather than a binary event. Moreover, it is not the bodily functions but rather the preservation of brain-encoded information that determines death under this view. Theoretically, even if the physical brain were destroyed, a person would not be considered information-theoretically dead if all of their relevant neural information had been accurately captured and stored in another medium beforehand [9]. Proponents argue that certain preservation procedures may pause the dying process without causing information-theoretic death. In this paper, we do not critically examine the likelihood that preservation could be performed in a way that prevents information-theoretic death or that preserved people could ever be revived. Instead, we use as a starting point the hypothesis that there is a non-negligible chance that current preservation procedures might accomplish this, which has been thoroughly discussed elsewhere [2,11,12]. We also note that there are several previous articles on the topic that take a more skeptical stance on the feasibility and contemporary implementation of human preservation, which we invite the reader to consider as well [13,14,15]. Even for those deeply skeptical of the feasibility of human preservation, the analysis in this manuscript still stands as an argument about bodily autonomy and the right to self-determination, based on the sincerely held beliefs of those who do think that preservation might work.

It is important to acknowledge the inherently speculative nature of human revival following preservation. The approach of seriously considering hypothetical but plausible future scenarios has precedent in other fields. One example of this is the environmental precautionary principle, which has been enshrined in legislation worldwide, allowing for regulatory action despite scientific uncertainty when activities might pose potential irreversible harms to human health or the environment. The Rio Declaration explicitly states that “[w]here there are threats of serious or irreversible damage, lack of full scientific certainty shall not be used as a reason for postponing cost-effective measures to prevent environmental degradation” [16]. Similarly, recent legislation around the regulation of artificial intelligence (AI) safety demonstrates how legal frameworks can develop in response to purely speculative risks that have never occurred. For example, the European Union’s AI Act delineates a regulatory framework for AI systems based on the possibility of future risks, despite the absence of empirical validation for all of the potential harms [17]. While we recognize that the speculative possibility of human revival following preservation has significant differences from these examples, they illustrate how society can accommodate decision-making under uncertainty when key values like human life are at stake, alongside rigorous discussion about the underlying scientific principles.

In the United States, which is the primary focus of this review, preservation has been legally performed as an anatomical donation to a designated organization after legal death is pronounced. Depending on the manner of legal death, there may be a need for a death investigation. The purpose of a death investigation is to serve both public health surveillance and criminal justice interests. It involves an independent scientific investigation into the cause and manner of death to identify emerging public health threats and provide expert testimony to support the administration of justice [18]. Unfortunately, when a death investigation is deemed necessary, it can impose significant delays between the pronouncement of legal death and the initiation of preservation procedures. These delays can drastically reduce the quality of preservation, preventing individuals from accessing the high-quality preservation that may be necessary for them to have any chance of revival in the future. We note that this problem has previously been discussed [19,20,21,22]. However, to the best of our knowledge, our review is the first comprehensive discussion of the ways in which the death investigation process harms preservation quality, the legal and ethical problems this poses, and several ways in which these problems could possibly be addressed. We note that while there are many disagreements within the preservation community, such as in the importance of preserving the whole body or just the brain, or about which preservation method to use, avoiding the harms of death investigation is a topic relevant to all those who are sympathetic to the goals of human preservation.

There are two distinct but related ways that death investigation procedures can interfere with preservation: (a) ischemic delay and (b) involuntary autopsy. Ischemic delay refers to the time period between legal death pronouncement and when the preservation procedure can begin, during which the body remains under medical examiner or coroner jurisdiction for investigation. This delay, which can range from hours to days, leads to progressive degradation of brain tissue and impairment of mechanical perfusion even before any preservation attempt can be made. Separately, autopsy refers to the direct physical disruption of tissue through dissection and examination, which can cause severe structural damage beyond that caused by delay alone. While both issues are significant, ischemic delay is much more common, as it occurs whenever a death investigation is initiated, regardless of whether an autopsy is ultimately performed. Therefore, this review focuses primarily on the problem of ischemic delay.

2. Review Methods

To identify sources, we performed searches on Google, Google Scholar, and PubMed on relevant search terms across bioethics, law, forensic medicine, neuroscience, and other applicable fields. We supplemented this with case reports from preservation organizations to provide real-world context. We systematically identified all state implementations of the Uniform Anatomical Gift Act to identify key provisions relevant to human preservation, but otherwise did not employ a systematic methodology for selecting other sources. We acknowledge the potential limitations of this literature selection strategy, as the sources we chose may have been influenced by our authorial biases and not represent the full spectrum of perspectives on human preservation. As a result, we propose that future reviews could target specific sub-questions discussed in this narrative review with more systematic search methodologies, which may be beneficial as this emerging area of bioethics and legal inquiry develops.

3. Effects of Death Investigation on Preservation Quality

3.1. Ischemic Delay

The amount of time between the loss of blood flow to the brain and a resuscitation or preservation procedure is commonly known as the ischemic time. One way to estimate the currently recoverable duration of ischemic time is by examining the longest documented cases of successful resuscitation. For example, one case report describes resuscitation with recovery of neurologic function after 10 min of normothermic cardiac arrest [23]. In cases of cardiac arrest associated with accidental hypothermia, this window can extend to several hours, with one report documenting recovery after 7 h [24]. However, a key premise of human preservation is the potential for future improvements in recovery techniques. Preservation technologies are intended to serve as a bridge to these improved future recovery methods [2].

3.2. Effects of Delay on Brain Structures

In the absence of the ability to recover individuals using contemporary methods, microscopic examination of preserved brain structures provides a proxy measure of preservation quality. Although the exact structural requirements for information preservation remain debated, it is widely accepted in neuroscience that stable, long-term memories in the brain must be encoded in stable physical structures, rather than purely in dynamic electrical activity [25]. It is also well established that critical brain structures begin to decompose after blood flow stops, with degradation rates varying based on environmental factors, most critically the temperature [26,27]. A critical question is: What is the longest ischemic interval that still allows reliable preservation of key neural structures? Unfortunately, there are not yet clear answers to this question, due to uncertainty about which specific structures need to be preserved to maintain key information, and how quickly those structures degrade. In the absence of immediate preservation, rodent brain tissue has been reported to develop ischemic alterations visible on electron microscopy after as quickly as 30 s [28] or 100 s [29]. In human samples, where tissue collection is inevitably delayed, longer periods of ischemia are generally tolerated. However, this results in artifacts visible under electron microscopy, such as vacuolization, which have uncertain effects on information preservation [27]. Two cutoffs that have been used in the study of human brain tissue via electron microscopy are 4 h [30] or 4.5 h [31]. On the other hand, some case reports show that when a low but non-freezing temperature is maintained, brain tissue as seen on light microscopy can remain intact for more than a month, which belies any strong claims about the rate at which neural structures necessarily degrade [32,33]. Ultimately, without preservation, the brain eventually liquefies [34,35], destroying the microscopic structures that are thought to encode personal identity. Taken together, while the exact timeline is uncertain and may vary across individuals, it is clear that any ischemic time delay will cause degradation of potentially critical brain structures.

3.3. Effects of Delay on Perfusability

In addition to direct degradation of brain structures in the absence of blood flow, the other major problem with an ischemic delay is that it impairs vascular perfusion. Even a relatively short ischemic interval of 15 min can dramatically decrease brain perfusion quality, which is known as the “no reflow” phenomenon [36]. The brain appears to be particularly susceptible to perfusion impairment after ischemia [37]. Preservation procedures often rely heavily on perfusion, for example, to distribute cryoprotective agents through the brain. In this case, the regions of the brain that are not successfully perfused with cryoprotective agents will have ice formation, which is highly damaging to brain structures [38]. As a result, perfusion-based preservation procedures are expected to be of much lower quality as a direct result of any length of ischemic time delay.

3.4. Effects of Involuntary Autopsy

Our discussion has focused primarily on damage due to ischemic delay, which is the most common problem resulting from a death investigation. Of course, if an autopsy of the brain is performed, it is almost certain to involve significant further damage, including potential trauma to the brain on removal, trauma due to slicing of the fresh brain, exposure of the brain tissue to the degradative effects of oxygen, and other factors [39,40]. Even if the brain is not autopsied, but the vascular perfusion route is compromised during the autopsy, for example, due to dissection of vessels in the neck or chest, this could also lead to significantly worsened preservation quality.

In cases where a death investigation absolutely requires access to brain tissue, a millimeter-scale biopsy sample could potentially be taken in conjunction with the preservation procedure, if deemed strictly necessary. Based on neurosurgical findings, such a procedure is not expected to cause substantial damage to the information content of the brain [41].

4. Use of the Uniform Anatomical Gift Act in Human Preservation

The primary legal mechanism by which preservation organizations in the United States accept donations is through the Uniform Anatomical Gift Act (henceforth UAGA). Individuals interested in preservation may sign authorization paperwork for the UAGA with the preservation organization prior to legal death, authorizing the donation of their whole body or just their brain, for long-term preservation as a form of scientific research. The UAGA was introduced in 1968, and its use as a legal mechanism to allow human preservation began shortly thereafter [42]. Those interested in preservation generally do not believe that the preserved person is necessarily dead from an information-theoretic perspective [2]. Therefore, the use of the UAGA, which depends on the pronouncement of legal death, represents a pragmatic option, given current laws, although certainly not ideal from the perspective of preservationists.

The use of the UAGA in human preservation was legally affirmed by the California Superior Court in 1990 [43]. The court granted summary adjudication in favor of the preservation organization Alcor on multiple grounds, ruling that prohibitions on the registration of death certificates and issuance of disposition permits for individuals choosing cryopreservation: (1) impermissibly interfered with individuals’ rights to determine the disposition of their bodies; (2) invalidly interfered with the right to contract for lawful activities; and (3) arbitrarily rejected Alcor’s status as a donee under the UAGA. Judge Aurelio Munoz ordered the state to cease prohibiting death registrations and disposition permits for individuals directing their bodies to be cryopreserved through Alcor. This ruling established an important legal precedent for preservation organizations operating as donees under the UAGA framework.

Other cases since have also upheld the use of the UAGA for human preservation. In a Florida case in 2004, a court upheld Alcor’s status as an anatomical gift recipient despite being located in a different state, based on the UAGA’s reciprocity provisions, which recognize anatomical gift recipients authorized in other states [44]. In this case, the court also rejected an alleged deathbed revocation of the anatomical gift that was found not to meet statutory witness requirements and dismissed one witness’s affidavit of revocation because she stood to gain financially if the cryopreservation was prevented. This case demonstrates the robustness of UAGA protections for preservation arrangements. In a 2010 case in Iowa, the Iowa Court of Appeals ruled that cryopreservation arrangements qualify as anatomical gifts under the UAGA, even when payment is involved [45]. The court also ruled that the preservation organizations’ rights as a donee superseded the burial wishes of next-of-kin who were aware of, but disregarded, the legally deceased person’s preservation arrangements.

While these court cases have upheld the use of the UAGA for human preservation, we acknowledge important limitations in our analysis. First, the UAGA was originally designed for broad use in organ and tissue donation for transplantation, education, and research, rather than being specifically written for preservation with the speculative goal of future revival. Although preservation organizations have successfully operated under the UAGA for decades, the fit is imperfect, requiring careful navigation of statutory definitions and requirements. Second, we also acknowledge the potential for bias in the non-systematic selection of cases for our legal analysis, which warrants further review of the available case law and statutory interpretations. Future legislative action specifically addressing human preservation could resolve the underlying tensions by creating a tailored legal framework that better accommodates the unique ethical and practical considerations of this field.

5. Background on Death Investigation

5.1. History

The office of coroner originated in medieval England not as a medical role but as a financial one. Established in 1194, county coroners were elected officials tasked with protecting the Crown’s financial interests in deaths, which were a major source of revenue [46]. When someone died, various fees and property could be claimed by the monarchy, including the value of “deodands” (objects that caused deaths) and fines levied on communities for homicides or sudden, unexpected deaths. The English system was adopted by the early colonists in America. Beginning in the 19th century, the profession became increasingly medicalized as forensic medicine and toxicology emerged as important disciplines, particularly for investigating homicidal poisonings. The medical examiner system was first established to replace the coroner system in New York City in 1915, which is a concept that has since spread to many other areas of the United States [47]. While the system has evolved from its revenue-focused origins to a more scientific approach with the establishment of medical examiner offices in the early 20th century, the state’s authority over the disposition of bodies after death remains intact in most circumstances, now justified by a public interest in death investigation rather than revenue collection.

5.2. Medicolegal Death Investigation Pathway

Human preservation procedures cannot begin until legal death has been pronounced (Figure 1). According to the UAGA, the pronouncement of legal death needs to be performed by a healthcare professional who is independent of the organization receiving the anatomical gift. Who is qualified to pronounce death in a given circumstance is determined by state and local laws, but can include physicians, nurses, and paramedics. After the pronouncement of death, the healthcare professional must then decide whether the death needs to be reported to the medical examiner or coroner (MEC). The criteria for reporting deaths to the MEC also differ by jurisdiction. In Oregon, legal deaths that require investigation include those that occur under suspicious or unknown circumstances, result from the use of controlled substances or toxic agents, occur while in custody or incarcerated, or are related to diseases that may threaten public health (ORS 146.090).

Once a death is reported to the MEC office, their team reviews the case and determines whether to assume jurisdiction. In Oregon, initial death investigation decisions are made at the county medical examiner level. This initial decision-making process alone can result in substantial ischemic delays. If the county medical examiner office decides a scene response is needed, this means that investigators must travel to and examine the location of death, which may include documenting the environment, collecting evidence, interviewing witnesses, and conducting a preliminary examination of the body. These additional investigative steps can further extend the ischemic time by hours.

If jurisdiction is assumed by the MEC, a death investigation is initiated, potentially including external examination, toxicology testing, evidence collection, witness interviews, and medical record review. The MEC may also order an autopsy if deemed necessary to determine the cause and manner of death. The extent of the investigation depends on the case circumstances and MEC discretion. While the body remains under MEC jurisdiction, preservation procedures generally cannot proceed without approval. However, under the UAGA in many states, the MEC can authorize preservation activities to occur in parallel if they determine it is compatible with their death investigation process.

5.3. Current Scope and Implementation

According to a 2016 report, of the approximately 2.6 million people who die yearly in the United States, 30–40%, or approximately 1 million, of these deaths are reported to MEC offices [48]. On a national level, it has been previously reported that the percentage of cases in which the MEC office accepts jurisdiction ranges from 50% to 86%, while the ratio of accepted cases that undergo a complete autopsy ranges from 20% to 31% [48,49].

Some data from Marion County can also provide context about the relative proportion of people whose deaths are investigated. For example, in 2019, 2934 people died in Marion County [50]. The medical examiner’s office received reports for 983 (34%) of these individuals [51]. There was a scene response for 392 (40%) of these reports. Notably, a scene response does not always lead to accepting jurisdiction, and jurisdiction can be accepted without a scene response. Of the 605 non-ME cases in 2019 (deaths reported to the ME office where jurisdiction was not accepted), investigators still conducted scene responses for 128 (21%) of them. Conversely, of the 379 cases where the office did accept jurisdiction, 115 (30%) did not require a scene response. Overall, the medical examiner’s office accepted jurisdiction for 379 (13%) of all deaths in Marion County. These percentages have been consistent over the past several years (Figure 2). The percentage of total deaths leading to autopsy has averaged 1.87% (range: 1.43–2.34%) from 2006 to 2020 [50].

Determining the length of time that a death investigation takes is a tricky question. An autopsy itself takes from two to four hours to complete [52]. However, other factors often cause substantially more delay than the procedure itself, including transport of the body and waiting for the person who performs the autopsy. The Marion County website reports that autopsies are usually completed within 24–36 h after death [53]. If legal death occurs on an evening, weekend, or holiday, the delay could potentially be many hours or even days. Theoretically, the average time may not be as relevant for human preservation cases, but only to the extent that MEC offices are willing and able to expedite this process if the person whose body is under investigation desires to be preserved.

5.4. Variability Across Jurisdictions

Across the approximately 2400 MEC jurisdictions in the U.S., there is a huge amount of variability in their practices [48]. For example, MEC offices can be standalone or operate as part of a larger agency, including public health, law enforcement, district attorney, or forensic science. The governing agency has been found to have substantial effects on the case acceptance rate and the ratio of accepted cases that undergo autopsy [49]. MEC offices may be run by appointed medical examiners or elected coroners [54]. Legal requirements may also vary. For example, New York has passed legislation restricting autopsies in some circumstances for the purpose of religious freedom [47]. San Diego County has required medical examiners to perform the autopsy within 24 h of discovering the body [55]. In addition to these structural factors, the decisions of individual MECs can also strongly influence the outcome in a given case.

6. Procurement Organizations and Death Investigation

6.1. History

Modern organ and tissue transplantation emerged in the 1950s, with the first successful human organ transplant—a kidney between identical twins—performed in 1954 [56]. With these advancements in medical science came a need for standards and regulation. This included the first version of the Uniform Anatomical Gift Act, drafted in 1967, which was “based on the belief that an individual should be able to control the disposition of his own body after death” [57]. Standards for the declaration of brain death were also developed [58]. Establishing brain death criteria was crucial for organ transplantation because it enabled doctors to maintain organ viability via artificial life support while allowing for the procurement of organs from deceased donors [59]. Over the years, there has been some tension between the organ and tissue procurement community and MEC offices, whose missions can at times be in conflict [60]. This is especially true because the causes of death that tend to lead to death by neurologic criteria, such as traumatic brain injury, overlap with the types of death that frequently lead to a death investigation. However, the relationship between most MECs and organ and tissue procurement organizations has often been cooperative. For example, one source from the 1970s notes that the policy of the medical examiner in Dade County, Florida, was to cooperate with the transplant program [61]. They noted that the only possible denials they could imagine would be in a case in which the corpus delicti (i.e., physical evidence proving a crime occurred) was not able to be established by other means and would be destroyed by the transplant procedure, but that “we have never been presented with such facts nor, for that matter, can we envision the possibility of such” [61].

We recognize that organ transplantation has proven medical efficacy with immediate clinical benefits, while human preservation is based upon more speculative possibilities in the future. This analysis is not meant to equate the two. Instead, we examine the procedural frameworks and cooperative relationships that have developed over time between MECs and organ procurement organizations as a potential model for addressing similar logistical challenges, while acknowledging the significant differences in scientific certainty and immediate public health impact between these fields.

6.2. Medical Examiner Perspective

The National Association of Medical Examiners (NAME) has taken a clear position supporting cooperation between MECs and procurement organizations, issuing position papers in 2007 and 2014 on the topic [62,63]. NAME notes that with appropriate communication and cooperation, MECs can and should allow procurement in “virtually all cases” while still meeting their statutory obligations [62,63]. The 2007 NAME position paper referenced a review finding that there were no documented cases where organ procurement had interfered with criminal investigations, prosecutions, or autopsy findings [62]. Additionally, the 2014 NAME position paper points out that many MEC offices have “decades of zero or close to zero denials while still fulfilling their legal mandate and without having issues with subsequent legal proceedings”, demonstrating that broad cooperation is feasible [63]. The position papers make several practical recommendations applicable to any procurement organization. These include early notification to MECs before legal death where possible to allow for proper investigation planning, protocols for preserving and sharing specimens and evidence, and extensive photography during recovery. They note that procurement organizations must assist MECs by helping to preserve evidence and ensuring a proper chain of custody. They also strongly encourage the establishment of prospective agreements and protocols between MECs and procurement organizations.

6.3. Procurement Organization Classification

The Uniform Law Commission (ULC) is the organization that develops uniform laws for adoption by states. The Uniform Anatomical Gift Act (UAGA) was proposed by the ULC in 1968, with major revised versions in 1987 and 2006. These proposed laws were adopted by states to varying degrees—some states adopted them fully, while others adopted modified versions or retained earlier versions. One critical component of the UAGA, which varies by state depending on its implementation, is whether human preservation organizations qualify as procurement organizations. This classification is established through a chain of definitions in the most recent ULC UAGA: First, a “tissue bank” is defined as “a person that is licensed, accredited, or regulated under federal or state law to engage in the recovery, screening, testing, processing, storage, or distribution of tissue” [64]. Then, a “procurement organization” is explicitly defined to include tissue banks: “‘Procurement organization’ means an eye bank, organ procurement organization, or tissue bank”. Therefore, organizations recovering tissue for preservation, a type of scientific research, would be classified as procurement organizations. Notably, the Act also states “If the part is an organ, an eye, or tissue and the gift is for the purpose of research or education, the gift passes to the appropriate procurement organization”, further evidence that the authors of the UAGA intended for procurement organizations to also include organizations performing research. To assess whether all states have the same language in their implementation of UAGA, we classified each state’s implementation of UAGA and the most recent ULC version based on whether preservation organizations would be considered a type of procurement organization (Figure 3). We identified that all states had some version of this clause, although in two states (Illinois and New York) this classification is only possible if the preservation organization is accredited by the American Association of Tissue Banks.

6.4. Mandates for Cooperation with Procurement Organizations

The most recent ULC UAGA also establishes model provisions for MEC cooperation with procurement organizations. As with the other parts of the UAGA, states have implemented these provisions to varying degrees. Notably, the MEC authority to perform death investigations is not generally granted in the UAGA, but rather other state statutes [65]. For example, in Oregon, ORS 146.117 grants medical examiners the authority to order autopsies in “any death requiring investigation”, including the power to “remove and retain body tissues or organs… for the purpose of the legal or medical determination of the manner or cause of death”. The UAGA provisions about MEC cooperation and tissue recovery are thus layered on top, regulating the investigative authority of the MEC in cases where there is also an anatomical gift.

There are several key dimensions of MEC cooperation mandates across state UAGAs (Figure 3). The first is the basic requirement for MECs to cooperate with procurement organizations to maximize recovery opportunities. While most states include this general mandate, the strength and specificity of the requirement differ. A second key variation is whether MECs must enter into formal agreements with procurement organizations to establish protocols for cooperation. Some states mandate that MECs enter such agreements, which would ensure that clear procedures are in place before any conflicts arise. The statutes for other states, such as Oregon, stipulate that medical examiners “may enter into an agreement” with procurement organizations, to establish protocols when recovery might interfere with an investigation, but while such agreements are permitted, they are not necessarily required (ORS 97.980(6)).

Another significant variation is in the procedural requirements when MECs seek to deny recovery. The most recent ULC UAGA has provisions requiring MECs or their designees to be present at the planned procurement procedure to deny recovery. Some, but not all, states have adopted this. Where this provision is present, it requires that MECs can only decline procurement after observing the recovery procedure and finding specific concerns that would interfere with determining the cause or manner of death. Finally, most states specify that examinations must be conducted in a manner and timeframe compatible with the preservation of the anatomical gift. This is a critical statutory stipulation for human preservation. However, it is unclear how this requirement would be interpreted by medical examiners, preservation organizations, courts, and other stakeholders in the context of human preservation. It may depend upon the evolving state of the scientific evidence regarding ischemic delay and preservation quality.

6.5. Summary

The history of organ procurement organizations demonstrates that cooperation with MEC offices is both possible and beneficial. State UAGA implementations vary in key ways, particularly regarding the requirements for whether preservation organizations can qualify as procurement organizations and in the obligations of MECs to cooperate with them. These statutory variations create a complex legal landscape for preservation organizations seeking to minimize death investigation-related delays.

7. Death Investigation Interference in Human Preservation

7.1. History

There have been numerous documented cases in cryonics where death investigation procedures are thought to have significantly compromised preservation quality. We describe a few examples here, which is far from an exhaustive list. These cases are meant to show that interference due to death investigation is not theoretical, but rather a real problem that has affected and will continue to affect people’s choices over what happens to their bodies.

In 1992, Alcor member Michael Friedman, a 38-year-old attorney, was shot in the head by a disgruntled former client [66,67]. After the pronouncement of legal death, Friedman’s body was autopsied and his brain was removed from his skull by the medical examiner in order to extract the bullets. The Alcor team was able to negotiate for the medical examiner to expedite his autopsy, in exchange for paying overtime fees to the medical examiner’s office. They were also able to negotiate for them not to further section his brain into pieces. However, the ischemic delay before the preservation procedure could begin was still 26 h, which undoubtedly led to significant damage, in addition to the damage incurred due to extracting the bullets. In a tragic irony, Friedman had reportedly discussed with another cryonicist about filing a lawsuit just the day before his legal death—specifically about protecting murdered cryonics patients from mandatory autopsies.

In 2009, Alcor member Michael Miller, a 48-year-old disabled Navy veteran, was found legally deceased in his Tampa, Florida apartment, wearing a medical bracelet stating “no autopsy” [68,69]. Despite this, the medical examiner planned to perform a full autopsy, with the rationale that there was a “reasonable possibility” of accidental overdose that needed to be investigated. When Alcor was notified, they immediately began working with legal counsel to prevent or limit the autopsy. Alcor filed an emergency lawsuit, arguing that a full autopsy served no public interest and that Miller had religious objections as a Jewish man to bodily desecration. The legal proceedings stretched over a week, during which Miller’s body remained in the morgue cooler at 34 °F (1.1 °C). The judge eventually ruled against Alcor, upholding the medical examiner’s authority to perform the autopsy. However, after subsequent negotiations, the medical examiner agreed to perform only a limited autopsy that avoided brain dissection. The body was finally released to Alcor for preservation eight days after legal death was first pronounced. This case demonstrates that pursuing legal proceedings in an attempt to avoid autopsy can result in an extended ischemic delay. Furthermore, pursuing adversarial legal proceedings will almost certainly be perceived as hostile and decrease the likelihood of achieving cooperative solutions with medical examiners.

In 2020, a confidential 56-year-old Alcor member experienced an unattended legal death at his home in California [70]. This led to his death being investigated. Alcor provided documentation that the man’s wishes were to avoid autopsy, but an autopsy was performed on his body regardless. The man’s brain was sectioned during autopsy and his body was not released for preservation until the following day. In this case, the ischemic delay during death investigation, the damage from brain sectioning, and the inability to perform cryoprotectant perfusion all would be expected to dramatically damage the quality of preservation.

In 2024, a confidential 69-year-old Alcor member experienced an unattended legal death in Oregon that was not discovered for an estimated 7 days [71]. After being found during a welfare check, the person’s body was placed under medical examiner jurisdiction. Despite requests from the preservation organization, neither the medical examiner’s office nor the funeral home agreed to place the person’s body on water ice or dry ice to mitigate ongoing degradation. Due to the medical examiner’s office being closed for a holiday period and there being no way for Alcor to contact them, there was an additional delay of two days before the preservation procedure could begin. This case illustrates how even without an autopsy, an extended ischemic delay while a person’s body is under medical examiner jurisdiction can significantly compromise the quality of their preservation.

7.2. Religious Objection to Autopsy

The First Amendment currently provides little protection for religious objectors to autopsy. Under current constitutional law, laws of “general applicability”—like those providing generally for autopsy that do not favor or disfavor particular religious groups—are generally valid against individuals claiming the law infringes on their religious beliefs, unless the individual can show there was some specific animus or reason to think that a religious practice was being disfavored or singled out [72]. Applying this law, a federal judge in Rhode Island noted his “deep regret” that he could not provide any relief to a Hmong family who claimed that the medical examiner’s autopsy of their son infringed the son’s religious beliefs [73].

Because this constitutional principle has been seen by many to give insufficient room for religious exercise, both Congress and many states have passed laws that would permit some to successfully claim that law of general applicability must give way to religious exercise, unless the law serves a compelling interest and is the least restrictive way to further that interest. The current state of the law, then, is a patchwork: a majority of states have general statutes or state court decisions that would apply this heightened protection for those claiming interference with a right to freely exercise religion, but several states—including California and New York—lack such general protections [74]. At the same time, some states do offer narrower statutes providing some protection for those who object to autopsy on religious grounds (e.g., Cal. Gov. Code § 27491.43).

Although some states have passed religious objection to autopsy statutes, these statutes have significant limitations in the context of human preservation. The accommodations given in these statutes often have strict requirements, can be overridden by the MEC at their discretion, and stipulate that contesting the MEC’s decision requires legal proceedings that would extend the ischemic delay. For example, California’s provision kicks in only if the MEC receives a specialized “certificate” on this specific issue “that is signed and dated by the person in the presence of at least two witnesses” (Cal. Gov. Code § 27491.43(b)). Most people do not execute these documents in this form, and even if they were to do so, the MEC would need to be immediately presented with this certificate for it to even have any possible impact. As another example, a New Jersey statute requires a waiting period of 48 h so that the objecting party can institute court action to determine the necessity of the autopsy (NJ Rev Stat § 52:17B-88.3 (2017)). From a preservation quality perspective, negotiating a limited autopsy that avoids brain damage would likely be preferable to time-consuming legal battles. Additionally, while traditional religious objections often seek to prevent any postmortem examination, for example, to maintain bodily integrity, human preservation is distinct because it specifically requires immediate action and because there is usually a strong preference for preserving the brain rather than the rest of the body. As such, existing religious objection to autopsy statutes clearly do not adequately address the needs of individuals who desire to pursue preservation.

Beyond the specific state autopsy objection laws, some jurisdictions provide heightened religious freedom protections that apply to any government interference with religious practice. For instance, due to a specific federal law, prisoners in every state happen to benefit from heightened protection for religious exercise. Applying that standard, a federal judge in Tennessee prevented an MEC from performing an autopsy on a person who was on death row and had a sincere religious objection to autopsy [75]. However, the court still allowed the MEC to perform non-invasive examinations, such as photographs and non-invasive radiographs. While this case shows how broader religious freedom laws can prevent invasive procedures in some specific circumstances, even these stronger protections would not necessarily eliminate all ischemic delays in a way that would have satisfied someone whose ultimate interest was in preservation.

We also acknowledge that the idea of preservation is not well established with time-honored traditions and prior rulings, like many forms of religious objection to autopsy are. Instead, it is an unconventional approach that lacks the historical and cultural embeddedness of traditional religious practices. Indeed, individuals interested in preservation may have various religious beliefs unrelated to their preservation choices. This is another reason that religious objection frameworks are clearly an imperfect analog, highlighting the need for alternative legal and policy approaches.

7.3. Summary

Taken together, the status quo death investigation system is not working for many individuals who desire preservation. The preservation quality is frequently and dramatically harmed by ischemic delay, autopsy, or both. Religious objection to autopsy is often considered in this context but does not provide adequate protection. While successful preservation is sometimes possible with cooperative MECs, others may exercise their discretion in ways that prevent individuals from receiving their desired preservation procedures.

8. Ethical Analysis Regarding a Right to Immediate Preservation

8.1. Potential Preservation of Life

A core argument for allowing immediate preservation access at the time of legal death stems from its potential, however speculative, to allow people to live on in the future. There is a parallel with CPR in medical emergencies, in which consent is presumed so that it can be begun without delay, despite not always having a high probability of success [76]. Similarly, because denying immediate preservation access may permanently eliminate any chance of revival, there is an ethical imperative to enable this choice without state-mandated delays. Although there is certainly no scientific consensus that preservation could be successful, there is also no consensus that it will not be successful. For example, in one survey, experts in neuroscience provided subjective probability estimates averaging 40% that a brain preserved using one currently available method would retain sufficient information to theoretically decode at least some long-term memories [1]. The high proportion of non-trivial probability estimates in this survey indicates a state of genuine scientific uncertainty about preservation efficacy among experts, rather than a consensus rejection of it.

8.2. Bodily Autonomy

The ethical principle of bodily autonomy, a cornerstone of medical ethics, also provides a compelling justification for immediate preservation. Just as we have sovereignty over our bodies in life, this self-determination should extend to choices about our bodies after legal death, within reasonable limits. The key consideration is not whether preservation will ultimately succeed, but rather that individuals have a sincere belief that it might work and a genuine desire to pursue it. This aligns with well-established principles in medical ethics and law that respect a patient’s right to make decisions about their medical care based on their personal values and subjective beliefs, even when healthcare providers may disagree with those choices. As long as these decisions reflect an individual’s consistent values and are not the result of impairment, the medical system generally honors them. In accordance with this medical approach, individuals should be allowed to pursue preservation without barriers if they sincerely believe it offers a chance at future life, regardless of the views of others on its probability of success. In principle, this requires no action from authorities, only that they not create delays that could cause irreversible damage.

While bodily autonomy is a fundamental principle, it must be balanced against societal interests, particularly in cases where death investigation serves crucial public safety functions. For example, when evidence strongly suggests that a violent crime has occurred, but the cause and manner of death are uncertain, there may be compelling reasons to conduct certain autopsy examinations to prevent future crimes. In such cases, the goal from an ethical standpoint is to find a proportional solution that protects both individual and societal interests. Here, a focus on preservation of the structure of the brain may be especially important. First, the rest of the body, other than the brain, can be autopsied if it is deemed necessary. Regarding the brain itself, in forensic neuropathology, preservation of the brain is performed by chemical fixation, either via immersing the brain in fixative or (preferably) perfusion fixation through the cerebrovascular system [77]. Adequate fixation prior to examination is favored because examining the brain in its fresh state can reportedly lead to missing approximately 50% of lesions [77]. Chemical preservation via fixation is also a method used by some preservation organizations for the initial preservation of the structure of the brain [2]. After adequate fixation, further dissection of the brain could be performed in the least invasive way if judged strictly necessary for the public interest, such as removing foreign objects or more precisely identifying lesions. Dissection of the brain in the fixed state is likely to be much less damaging to brain structures compared to dissection of the unfixed brain. Fixation helps to decrease the immense time pressure and allows for examination of all of the evidence, detailed non-invasive imaging, and discussion between all relevant parties. This is a practical solution that would allow individuals to pursue their interest in the high-quality preservation of their brain, while still being equally good at investigating crimes.

It is also important to point out the broad bioethical literature that covers how bodily autonomy can be proportionately limited when important collective interests are at stake [78,79,80]. The government has numerous responsibilities in death investigation, including determining the cause and manner of death, compiling accurate data, contributing to legal proceedings, and safeguarding community health. Rather than arguing for absolute bodily autonomy, the appropriate approach is to seek proportionate solutions that respect the core of individual self-determination while preserving the state’s ability to serve these crucial public functions through death investigation procedures that offer reasonable accommodations.

8.3. Equality and Non-Discrimination

Finally, access to preservation should be available to anyone who desires it. However, current death investigation mandates create systemic inequalities in preservation access. While these policies serve important public health and safety purposes, they require reconsideration in light of emerging preservation technologies. For example, Oregon law (ORS 146.090) mandates the reporting of deaths of incarcerated individuals to medical examiners, which inevitably causes a delay in any preservation procedures they may have chosen. This creates a concerning disparity—incarcerated individuals face automatic barriers to high-quality preservation that others may be able to avoid, effectively denying them equal access to potentially life-preserving procedures. While incarceration necessarily restricts certain rights, it should not strip away an individual’s autonomy over the disposition of their body after legal death. This principle extends beyond incarceration to anyone whose death triggers mandatory investigation under current laws. At the same time, it is crucial that preservation remains a voluntary, informed choice free from coercion or undue influence, particularly for vulnerable populations. Any policy reforms must balance expanding access while protecting individual autonomy and genuine self-determination.

8.4. Summary

The ethics of death investigation have not yet received substantial study, despite its significant impact on individual autonomy, dignity, and other critical aspects of bioethics [81]. We propose that human preservation poses unique ethical challenges to current death investigation practices, requiring substantial yet balanced reforms. This presents a complex challenge of protecting individual choice in preservation while maintaining the essential public health and safety functions of death investigation. In the following sections, we examine several approaches to address these challenges while respecting both individual rights and the legitimate investigative interests of the state.

9. Administrative Approaches to Change

9.1. Case-by-Case Communication with MECs

The primary current approach for preservation organizations to mitigate the harms of death investigation is via ad hoc communication with MEC offices after legal death has been pronounced. For example, it has been recommended to try to convince the MEC not to perform an autopsy or to perform one that is more compatible with preservation, such as a virtual autopsy that uses noninvasive imaging technologies [82,83]. However, history has shown that while some MECs are sympathetic to preservation goals and have worked to expedite examinations or limit tissue sampling, this approach is fundamentally unreliable. Individual MECs may view preservation unfavorably for various reasons, and there is no way to predict their stance in advance. These discussions often occur under severe time pressure, sometimes after the death investigation has already commenced, with preservation organizations having little or no leverage beyond appealing to MEC benevolence. While these negotiations could potentially be improved through sharing best practices and better understanding MEC perspectives and constraints, more definitive solutions to the problem should also be pursued.

9.2. Individual Advance Directives

Individuals seeking preservation can create specific advance directives documenting their preferences for death investigation, in the event that this becomes necessary. One practical implementation of this approach that has been used is for individuals to carry wallet cards expressing their objection to autopsy, possibly citing religious objections, as medical examiners are familiar with this and it may have legal weight in some states [84]. Beyond objecting to autopsy, more comprehensive directives might request expedited death investigations and other ways to minimize ischemic delay. Preservation organizations could serve as neutral repositories for these directives, making them immediately available to MECs if needed. However, even in states with religious objection laws, medical examiners have the authority to perform autopsies when they feel that the circumstances warrant it, despite any such advance directives. While some MECs might voluntarily choose to respect these wishes, there would be no guarantee. Sometimes, as in the cases of Michael Miller in 2009 or the confidential Alcor member in 2020, such written preferences are simply ignored. Instead, meaningful reform might require legislative action—specifically, statutory recognition of death investigation-specific directives and defined circumstances for how MECs must accommodate the preferences of some individuals to pursue preservation.

9.3. Cooperative Agreements with MECs

One potential approach to mitigating ischemic delays is by establishing formal cooperative agreements between preservation organizations and MEC offices before any cases arise. This strategy follows the model used by organ procurement organizations, which have developed protocols with MECs to enable rapid organ recovery while still allowing MECs to fulfill their investigatory duties [62]. While some states mandate such agreements between procurement organizations and MECs through the UAGA, MECs in other jurisdictions may be willing to enter them voluntarily. These agreements could specify procedures for rapid communication, establish protocols for documenting procedures through video and photography, and outline strategies to minimize invasive examination of brain tissue. Most importantly, they could define circumstances for when preservation could proceed in parallel with investigation, particularly for brain-focused preservation protocols that would leave the rest of the body available for examination according to the needs of MEC offices. These protocols could also include provisions for cost-sharing by preservation organizations to enable rapid response capability, such as paying overtime fees for MEC staff members. While such agreements would require upfront investment and may need to be renegotiated in the future, they represent one of the most practical near-term solutions for improving access to high-quality preservation for people whose legal deaths are investigated. Indeed, cooperative agreements between MECs and procurement organizations ire the stated preference of the medical examiner community for addressing potential conflicts in the context of organ procurement [62].

It is critical for any such agreement to be cognizant of the potential liability of MECs and be designed in such a way as not to increase their legal risks. Such liability to MECs can arise in several ways, including: (1) performing autopsies outside statutory authority, particularly when the death does not clearly fall under investigative criteria; (2) negligent performance of autopsy procedures, such as removing body parts not necessary to the determination of the cause and manner of death; and (3) conducting an autopsy against religious objections without demonstrating a compelling necessity and without using the least restrictive means possible, such as non-invasive photography or radiological imaging [65]. Critically, the UAGA includes important liability protections, present in the UAGA implementation of all states (Figure 3). For example, a part of the Oregon UAGA statute (ORS 97.974) specifies that “A person who acts in accordance with ORS 97.951 to 97.982 or with the applicable anatomical gift law of another state, or attempts in good faith to do so, is not liable for the act in a civil action, criminal prosecution or administrative proceeding”. Because of these protections in the UAGA, a carefully designed cooperative agreement might help MECs manage and potentially reduce their liability risks in a potentially contentious situation.

10. Judicial Approaches to Change

10.1. The Right to Determine Medical Treatment

In Donaldson v. Lungren, Thomas Donaldson, diagnosed with a terminal brain tumor in 1988, sought constitutional protection for a right to undergo cryopreservation before the tumor caused extensive damage. The complaint made the argument that he had a privacy interest in determining the timing, means, and manner of his legal death [85,86]. His amended complaint to the California Courts of Appeal sought an injunction against criminal prosecution of those who participated in the premortem cryopreservation procedure, and also an injunction preventing the coroner from performing an autopsy on his body after legal death, which was made “in order not to destroy his chance of reanimation” [85]. The court rejected all of his claims. It found that he had no constitutional right to assisted suicide. The court also found that it could not prevent officials from performing their duties, including that it could not prohibit the coroner from conducting an autopsy. The court noted that the coroner is required to inquire into deaths involving suicide or homicide, including potentially taking custody of the body and examining it.

Donaldson’s attempt to avoid autopsy was not a major part of this case, and it was intertwined with the attempt to pursue cryopreservation prior to the pronouncement of legal death. This decision was also made before medical aid-in-dying became legal in California. The court indicated that such changes to the laws would be better addressed through legislation rather than judicial action. However, this deference to legislative solutions is questionable given the very small number of people seeking preservation, which is precisely the situation where judicial protection of individual liberty interests is most crucial, as minority rights are unlikely to gain sufficient political support for legislative reform. This would parallel other areas where courts have protected rights for individual autonomy despite limited public support.

If autopsy is considered a medical procedure performed by physicians, it stands to reason that the constitutional right to make medical treatment choices recognized by the Supreme Court should apply, even though the Court has been inconsistent in how it has applied this right across various contexts [87]. When patients and families are not allowed to refuse medical treatment, they generally have legal recourse to challenge such decisions, supported by a strong framework of due process to guard against insufficiently justified actions. However, no such framework exists to adequately safeguard the interests of those seeking preservation against the harms of death investigation, which must account for the immensely time-sensitive nature of preservation. Future constitutional challenges could specifically target unavoidable ischemic delays and brain tissue disruption, arguing that these practices are not narrowly tailored to serve state interests when less harmful alternatives, such as expedited processing and non-invasive imaging, exist. Ideally, such alternatives would allow the initial preservation procedure to be performed prior to the full investigation, which has the potential to dramatically mitigate ischemic damage. This approach would protect the core interest in high-quality preservation while avoiding broader challenges to medical examiner authority.

10.2. Judicial Intervention to Prevent Autopsy

One of the most significant precedents regarding judicial intervention to avoid autopsy came from the Dora Kent case in 1987–88 [88,89]. Upon her legal death from pneumonia in December 1987, Kent’s head was separated from the rest of her body, which is a standard preservation method used to optimize perfusion to the brain [90]. After her legal death was pronounced, no physician was present to sign the death certificate, which automatically made it a coroner’s case. While Kent’s head was initially allowed to remain preserved in liquid nitrogen as planned, the coroner took jurisdiction over the rest of her body and performed an autopsy. Though they initially confirmed pneumonia as the cause of death, they later reversed that position after detecting barbiturates in tissue samples through toxicology testing during the autopsy, even though such medications were a standard part of the cryopreservation protocol used after legal death. The coroner then demanded access to Kent’s cryopreserved head, launching a dramatic series of confrontations, including facility raids and staff detentions, when Alcor refused to disclose the location of the head to allow it to be autopsied, because that would severely compromise the preservation quality.

The legal battle culminated in a victory for preservation rights when Riverside County Superior Court Judge Victor Miceli issued a temporary restraining order, which was later made permanent, preventing the coroner from autopsying Kent’s cryopreserved head. The court was persuaded by declarations from forensic pathologists arguing that this autopsy would yield no useful information beyond what was already obtained from examining the rest of her body. Notably, while Judge Miceli explicitly stated he was not endorsing or acknowledging the possibility of revival following cryopreservation, because he did not know whether it was scientifically sound, he recognized that allowing autopsy would permanently foreclose any chance of future revival, however speculative that possibility might be [91]. The judge ruled that the coroner had failed to demonstrate a “reasonable expectation” that an autopsy of the head would provide essential evidence that could not be obtained through less destructive means [91]. Critically, Judge Miceli also established that coroners do not have unlimited discretion in conducting autopsies, stating “(the coroner) does not have unrestricted right in conducting investigations” [91].

This case highlights the challenging tensions between preservation organizations and death investigators when their respective duties come into apparent conflict. While the initial preservation occurred without explicit MEC approval, the court’s subsequent ruling established important principles about balancing the investigative needs of MECs against the autonomy of individuals who desire preservation. The case demonstrates that when presented with scientific evidence about the minimal potential benefits of autopsy, balanced against the permanent foreclosure of the potential for revival, courts can be persuaded to side with preservation organizations. It also suggests a potential pathway for compromise in some circumstances: in cases requiring death investigation, the head could be surgically separated and immediately preserved while allowing autopsy of the rest of the body, since brain tissue is the most critical for potential revival. Finally, the adversarial nature of this case highlights the need for clearer legal frameworks and cooperative agreements to prevent such conflicts from arising in the first place.

10.3. Protected Interest in the Timely Preservation of Anatomical Gifts

One potential legal strategy would argue that the UAGA creates a legally protected interest in the timely preservation of anatomical gifts that is safeguarded by constitutional due process, similar to how courts have recognized protected interests in government benefits and licenses. Standing could be established through both individual and organizational harm, due to the known risk that MEC delays will compromise their anatomical gifts, which has previously occurred in many documented cases. Rather than seeking case-by-case reviews that would exacerbate ischemic delay and thereby harm preservation quality, the proposed remedy would be to focus on prospective structural reform. Specifically, given the established scientific evidence that even brief delays cause degradation of brain tissue and impair vascular perfusion, courts could order MECs to implement cooperative agreements with preservation organizations that enable immediate preservation, particularly of brain tissue. After this initial preservation, any needed death investigation could still be performed. To ensure fairness and protect MECs who are acting in good faith to fulfill their statutory duties, any proposed remedies should include robust immunity provisions for MECs acting in compliance with these protocols. This balanced approach would recognize both the legitimate interests of individuals seeking preservation and the important public service role of MECs in death investigation.

11. Legislative Approaches to Change

Finally, legislative approaches could provide a systematic solution to minimize or prevent the interference of death investigation in preservation procedures while still respecting the investigative duties of MECs. The most viable legislative path forward is through amendments to the state implementations of the UAGA. Such amendments could strengthen mandates for MEC cooperation with procurement organizations, including preservation organizations. This effort could benefit from collaboration with other stakeholders, particularly organ procurement organizations, who share interests in preventing unnecessary MEC denials in jurisdictions where MEC cooperation is less reliable. States have previously amended their UAGA implementations for specific purposes, underscoring that this is possible with sufficient interest. For example, California amended its implementation in 2016 to address medical marijuana use in anatomical gift recipients (California Health and Safety Code § 7151.36). Because revisions to the UAGA have historically occurred approximately every 20 years, another possibility is that preservation organizations could engage with the ULC during the next revision cycle to advocate for model language addressing these concerns. Finally, one source has previously proposed amendments to UAGA specifically for preservation [19]. Based on the analysis in this review, we also provide example language for such an amendment focused on enabling immediate preservation while protecting death investigation interests (Box 1). However, we acknowledge that this is unlikely to be passed in the near term in the absence of increased societal and legislative interest.

Box 1. Proposed model language for state UAGA amendments to enable immediate access to preservation of the brain while protecting death investigation interests.

§—Anatomical Gifts for Human Preservation

When an anatomical gift is made to a procurement organization for the purpose of research in human preservation with the goal of potential future revival, if this ever becomes possible, and the case does or may fall under medical examiner jurisdiction:

(1)

The procurement organization may begin preservation procedures immediately after legal death is pronounced, without required authorization from the medical examiner;

(2)

The medical examiner retains authority to examine and sample non-brain tissues if necessary for their examination, as long as this does not materially damage the preservation of the brain;

(3)

If necessary, any examination of the brain after the preservation procedure must be performed through non-invasive means, such as by photography or imaging;

(4)

The procurement organization shall:

(i)

Notify the medical examiner that preservation procedures are beginning. The medical examiner shall be allowed to observe the procedures either in person or via videoconference, but preservation procedures shall not be delayed for any period of time to wait for such observation;

(ii)

Thoroughly document all procedures after the pronouncement of death through notes, photography, and video recording;

(iii)

Share all documentation with investigating authorities;

(iv)

Pay any reasonable costs associated with additional work required of the medical examiner’s office, including any required imaging;

(v)

Ensure that the individual who pronounces death is separate from the team that performs the preservation procedure;

(vi)

Have staff members available for testimony regarding the death investigation if requested;

(vii)

Preserve and document any evidence of potential criminal activity discovered during preservation procedures, maintaining chain of custody through proper labeling, secure storage, access logs, and documentation of transfer.

12. Balancing Individual Rights and State Interests

It is essential to remember that the state’s interest in conducting thorough death investigations stems from the several critical functions they provide, including protecting public health by identifying infectious diseases, documenting accurate vital statistics, and providing essential evidence for criminal and civil proceedings. These functions certainly cannot be dismissed lightly. Any proposal to modify the current system must ensure that these interests remain protected. This is why any approaches to change must include provisions for evidence collection, documentation, and information sharing that would maintain the state’s ability to fulfill these essential functions while minimizing ischemic delay. Moreover, any changes made would need to be closely monitored over time to ensure that there was no increase in undetected public health threats or compromised criminal investigations resulting from modifications in the investigation procedures.

There are also valid concerns about creating a precedent for opting out of standard postmortem procedures. If exceptions are made for preservation, this could potentially lead to requests for exceptions based on other preferences, creating a complex patchwork of customized approaches that might undermine the consistency and reliability of death investigation systems. However, this concern can be addressed by establishing clear, narrow criteria for when immediate preservation would qualify for specialized protocols. This is similar to how religious objections to autopsy are currently handled in many jurisdictions as specific exceptions, rather than wholesale revisions to the system. Furthermore, the number of individuals seeking preservation is small, which would limit the potential administrative burden of such accommodations. If it were to grow in the future, then regulatory frameworks could be reviewed and adjusted based on accumulated evidence and experience, ensuring that both individual interests and public health safeguards remain appropriately balanced.

It is also important to point out that MECs in the US already juggle demanding responsibilities in the face of substantial resource limitations, workforce shortages, and high rates of burnout among forensic professionals [92,93,94]. Any proposed changes must acknowledge this reality and avoid placing additional burdens on the individuals working in these already overburdened systems. Therefore, rather than assuming that MECs would simply be able to easily accommodate these changes in the absence of reimbursement for any additional work it may require, we propose a work- and cost-sharing model that already exists in state UAGA implementations. For example, Oregon’s UAGA specifically addresses this concern through two key provisions: first, it requires that “the procurement organization shall reimburse the medical examiner a mutually agreed-upon reasonable fee” if post-mortem examination occurs outside normal business hours (ORS 97.980(7)(d)); and second, it mandates that “the procurement organization shall cooperate with the medical examiner in any documentation of injuries and the preservation and collection of evidence prior to and during the recovery of the body part” (ORS 97.980(9)). This legal framework provides a practical template for how preservation organizations could take responsibility for facilitating the accommodations their enrollees seek, making implementation both financially and logistically feasible. The feasibility of these approaches is supported by the existing model of organ procurement organizations, which have successfully implemented similar collaborative frameworks with MECs without compromising death investigations, even in cases with concern for criminal activity [63].

Finally, the scientific uncertainty involved in human preservation raises legitimate questions about resource allocation, both in terms of the financial costs to implement specialized protocols and of the opportunity costs for MEC resources. The societal investment required to accommodate immediate preservation must be weighed against the uncertain nature of the potential benefits. In a pluralistic society, we believe that individuals should generally be permitted to pursue options aligned with their beliefs and values, provided they bear the associated costs and that reasonable accommodations can be made for them without compromising essential public functions.

13. Conclusions

Under current law, guaranteed access to rapid brain preservation—a requirement for high-quality preservation—is effectively prohibited in the United States. Medical examiner jurisdiction over investigated deaths creates mandatory delays that can severely compromise preservation quality, potentially eliminating any chance of future revival. This is particularly concerning given that a high percentage of legal deaths fall under investigative authority, especially for younger individuals, leaving individuals interested in preservation with no legal means to prevent ischemic delays that could directly cause their information-theoretic death. While death investigation serves important societal purposes, these laws were established without consideration of emerging preservation technologies. We have outlined several approaches for reform, from cooperative agreements between medical examiner offices and preservation organizations to judicial and legislative remedies, building on successful models from organ procurement. No government has provided scientific justification for these mandatory delays, yet they may permanently foreclose individuals’ desired chances at future revival, however speculative those chances may currently seem to some. As our understanding of death as a process rather than a moment continues to evolve, advancing the legal and ethical standing of human preservation options aligns with broader trends toward increased respect for bodily autonomy.