As will be seen subsequently, the systems of death investigation in the United States are widely varied. However, they generally share a number of mission components in common. To paraphrase DiMaio and DiMaio, the various components of a death investigation system are as follows:
1. Determine the cause of death, and how the death came about
2. Identify the decedent
3. Determine the time of death and injury
4. Collect evidence from the body that may be useful in the police investigation
5. Document injuries that are present, or their absence
6. Deduce how injuries occurred
7. Document any natural disease present
8. Document or exclude any causative or contributory factors in the death
9. Provide testimony in court as needed
In spite of the widespread distribution and long history of the office of the coroner, as medical science and the understanding of death have become more complex, shortcomings of the system have became apparent. Most obvious is the fact that most coroner jurisdictions do not require a coroner to be a physician. Obviously, a nonphysical is in a poor position to render a medical opinion on the cause of death, a determination that is manifestly the practice of medicine. The likelihood of omissions or misinterpretations is increased in such jurisdictions where the responsibility for this duty is vested in someone other than a trained physician. Second, coroners are elected officials in the United States. The necessity of maintaining public electoral support has long been considered a potential impediment to the development and maintenance of absolute impartiality in death investigation by coroners.
Death investigators must often make very hard and controversial decisions that are difficult for families, local political forces, and others to accept. In theory, at least, an appointed official, as opposed to an elected one, can make such decisions without the fear of alienating a voting block necessary for his or her continued employment in the position.
Proponents of the coroner system respond that the nonmedical coroner functions as an administrator and quasi-judicial agent, and can employ physicians to perform examinations and make medical decisions under his or her directions. However, since the coroner retains ultimate authority for the investigation and determination of the circumstances and cause of death, the possibility that such an individual will exercise that authority to veto or influence the medical decision of an employed physician still remains. Some coroner proponents also point to the greater political authority of an elected official over an appointed one. And in fact, many coroners have utilized their political acumen and the public inquest to call attention to issues of public afety. But the final decisions in a death investigation should ideally be made by an appropriately trained and experienced physician, and no one else. Only he or she has the expertise in the cause and interpretation of disease and injury to make such medical decisions.
Other concerns by opponents of the coroner system relate to potential conflicts of interest for the lay coroner.
In many coroner settings, particularly in small towns or rural areas, the office of coroner will not be a full-time position, and the person holding the office will have other employment. The coroner may be a law enforcement officer, a funeral director, occasionally a practicing physician, or hold other employment completely unrelated to death investigation. In one state, the county sheriff serves as the ex office coroner of the county. The potential conflict of interest in such an instance is obvious, with the sheriff charged with the investigation of deaths that may be the result of an interaction of his or her officers with a decedent, such as an officer-involved shooting. Equally disturbing is the situation in which an inmate in a jail or detention facility operated by the sheriff is found dead.
No matter how impartial and honest the sheriff, any such investigation will always have at least the potential for impropriety or lack of impartiality.
If the coroner is a funeral director, there may be a potential conflict if the coroner stands to earn money by also arranging the funeral service of the deceased. In such cases there might be a tendency to avoid making any cause or manner of death determination that would alienate the next of kin. Some jurisdictions do require that the coroner be a physician. However, this is often little improvement over an untrained lay coroner. Most physicians have had practically no exposure to forensic pathology and death investigation, leaving them exceptionally ill-prepared to make determinations about cause and manner of death. Medical schools provide essentially no training in this area, and even most pathologists receive only a superficial introduction to the topic during their period of residency training. Most rarely or never perform autopsies in their practice. Without training and experience, such physicians are in a very poor position to properly examine complex cases or to identify subtle findings that may indicate foul play in what initially appears to be a natural death. In other cases, a physician might be the director or an employee of a medical facility accused of being responsible for the death of a patient. The death would then be investigated by the physician-coroner, with the attendant potential conflict of interest. Independence from other agencies must be considered an absolute requirement for optimal death investigation.
As early as 1928 the National Research Council stated bluntly that the office of coroner is anachronistic and "has conclusively demonstrated its incapacity to perform the functions customarily required of it."
The council went on to recommend the abolition of coroners' offices, replacing them with pathologist medical examiners. A recent report by the National Academy of Science also discusses inherent problems with the coroner system.
Partially because of these shortcomings with the coroner system, the medical examiner system came into being. The title of medical examiner is not a medical designation, but a governmental title, and it is defined differently by various jurisdictions (usually at the state level). But in the most basic sense, the medical examiner (ME) is a properly trained physician charged with the responsibility and authority to investigate deaths and to determine cause and manner of death in a particular jurisdiction.
One of the first attempts at bringing medicolegal death investigation under the authority of physicians came in Maryland in 1860, with laws requiring the coroner to obtain the assistance of a physician in the investigation of violent death.
Later, in 1890, physicians were appointed in Baltimore as "medical examiners" to perform autopsies requested by the coroner or other officials. In 1877, the Massachusetts General Laws established physician medical examiners in Sufolk County and the remainder of the commonwealth, appointed by the governor for seven-year terms. These physicians assumed the uties of the coroner, but only in the case of deaths known to have come about by violent means. These physicians also were not able to perform autopsies on their own authority, but required an order from another official, such as the district attorney, to authorize this procedure.
The first true medical examiner system was formed in New York City in 1918.
Tis change was driven largely by a report of corruption in the coroner system at that time by the city's commissioner of accounts. In the reformed system, the medical examiner took on all the investigative duties of the coroner, whose office was abolished. The ME was required to be a physician appointed by the city and had the responsibility and authority to investigate any death occurring by violent means, or suddenly and unexpectedly.
Deaths of prisoners or those not attended by physicians were also included in the medical examiner's jurisdiction. Other landmark facets of the New York system included civil service protection of the ME and the sole authority to decide what type of examination or investigation was necessary to certify the death. In the early years of this office, a toxicology laboratory was also added to the ME's office, establishing laboratory analysis as a critical component of eath investigation.
When discussing the office of medical examiner, it is necessary to define the term forensic pathology. The term forensic derives from the Latin word forensics for "before the forum," or relating to argument and discussion. Pathology is the study of disease, or a medical specialty devoted to the diagnosis of disease by laboratory means. Forensic pathology can be defined as the subspecialty of medicine devoted to the medical investigation of death. It is one of many omponents of the modern forensic sciences, and is a subspecialty of the medical specialty of pathology. In the United States, training in forensic pathology requires completion of a course of medical study, culminating in a doctor of medicine or doctor of osteopathy degree, completion of three or more years of residency training in anatomic pathology, completion of an accredited year of fellowship training in forensic pathology in an accredited training program (usually a large medical examiner's office), and passage of national certification tests in both anatomic and forensic pathology, administered by the American Board of Pathology. The physician can then use the title of forensic pathologist and is considered board certified in that field.
While not all medical examiner positions require the incumbent to be a forensic pathologist, many do, and it is highly desirable that all physicians involved in medicolegal death investigation be board-certified forensic pathologists.
The formation of an academic specialty of forensic pathology owes much to early chairs of forensic medicine established in Europe and Scotland, but the first endowed chair of legal medicine in the United States was established at the Harvard Medical School in 1937.
In this program, a training program for physicians was established, as well as programs for law enforcement officers and other investigators. Forensic pathology was first recognized as a medical subspecialty in 1959, when examinations were administered and the first cadre of physicians was certified as forensic pathologists.
Over the years, the medical examiner system has been refined somewhat to include some fairly standard elements. Ideally the medical examiner is:
1. A physician trained in the field of forensic pathology. This ensures that the highest possible level of expertise is brought to bear on the cases that come before the ME. Forensic pathologists working under the direction of a coroner should not be referred to as medical examiners, since the coroner is the actual official imbued with the authority to investigate and certify death, not a physician.
2. Appointed, not elected. In this way, the office of medical examiner becomes a professional position, not a political one, and the office holder is not concerned with currying favor with an electorate and periodically campaigning for reelection.
3. Protected by civil service laws. Ideally the ME cannot be dismissed without good cause (such as incompetence or dereliction), and then only after appropriate due process procedures have been followed.
This provides some protection for the ME, who must make decisions that might prove to be politically unpopular.
4. The sole authority for investigation and certification of deaths in his or her jurisdictional area, and is independent of law enforcement, prosecutorial, or judicial agencies. This ensures that the ME is independent and is an impartial witness for the truth in our adversarial legal system.
It also gives the ME full authority to perform any type of examination or investigation necessary to determine cause and manner of death, without seeking permission of families or other authorities.
Tough many medical examiners retain the authority to hold public inquests, such proceedings are rare in a modern ME system. Rather, the ME makes determinations based on a thorough investigation of the ircumstances of death, along with findings of a scientific examination by autopsy, toxicology, or other disciplines. Only a trained and experienced physician has the knowledge to obtain and analyze such data and to synthesize a rational cause and manner of death conclusion from it.
During the first half of the twentieth century, medical examiner systems progressively replaced coroner jurisdictions throughout the United States.
However, this replacement trend began to plateau in the mid-1980s, and new ME jurisdictions are now formed infrequently.
Currently about half of the population of the United States is served by a medical examiner, with the rest under the jurisdiction of a coroner. However, coroner offices outnumber ME offices by factor of five in the United States. The disparity is due to the fact that ME offices tend to be clustered in highly populated counties, such that a single office will serve a much greater population than the average coroner's office.
The country is served by a patchwork of different types of death investigation systems, and the type of system is generally determined on a state-by-state basis. At this time, the populations of twenty-two states are served solely by medical examiners, eleven by coroners, and seventeen by a combination of medical examiner and coroner systems. Even within these broad groups, there are many variations.
Some medical examiner states are under the authority of a statewide medical examiner. Others have authority vested at the regional or county level.
In some states, the coroner function is subsumed by other office holders. For instance, in Texas, justices of the peace perform coroner duties in counties without a medical examiner. In many California counties, the sheriff has coronial authority. For these reasons, it is difficult to effectively categorize medicolegal death investigation systems in the United States, as the various systems often have little resemblance to each other.