Medicolegal Death: A Look at Cultural, Scientific, and Ethical Principles

In the media, many see the ideals of Medicolegal Death Investigations portrayed through TV shows involving crime and justice.  While a show like Bones may inspire many to believe that the system is often clear-cut and one that ultimately brings justice, there are many principles and issues that surround the field.  Having a deeper understanding of the different elements that work in today’s medicolegal system could prove beneficial in addressing some of the controversial topics faced in our modern era.  Since the early implementation of medicolegal systems, there have been many inconsistencies and changes made.

As described by Daniel J. Spitz in Medicolegal Investigation of Death, medicine and law have been dated as far back to the Egyptian era. Medicolegal investigations have been performed by coroners since the 9th  and 10th century in England, initially presented under the reign of King Richard I.[i] Once colonists became settled, coroners, elected officials who take the responsibility to determine the cause of death within the county level.[ii]   were introduced to the colonies to help with medical needs. Coroners were replaced by medical examiners in the late 1800s, where they were identified as physicians who performed autopsies for coroners.[iii]  The first official medical examiner system was created in New York City in 1918, and gradually spread across the United States, replacing coroners. Although the idea of the medical examiner system was created, its definition varies in qualifications and training, as seen by the coroner vs. medical examiner discrepancy. After centuries of coroners used as the primary source to investigate deaths, there has been a push for medical examiners, who tend to have more skills than coroners. Medical examiners, who are trained in pathology, examine bodies to determine death and can focus either in a county, district, or state. Although medical examiners are seen as more trained and knowledgeable, the state decides to determine how it is defined.[iv] Death investigators may also assist with the investigations as well, dealing more with the legal aspects. These investigations are not controlled in a hospital setting, rather are investigated in laboratories and scenes by medical examiners and coroners.

Early depictions of coroners and their facilities.[v]

After the initial creation of the field, the medicolegal system developed and is the major contributors in the investigation of deaths of individuals and helps determine how people have died. By 1954, an act known as the Model Post-mortem Examinations Act was created to serve as a guideline for the states to create their own laws.[vi]  It was proposed to set up offices, laboratories, and those involved in criminal justice, as well an Armed Forces Medical Examiner System that helps identify remains after natural disasters. In attempt to define the medicolegal jurisdiction, the Model Post-mortem Examination Act of 1954 states that deaths that were from violence, with a potential public health threat, not by a known disease, inmates, or from occupational disease or injury, can be reported to the medical examiner and coroner.[vii] Today, the deaths medicolegal investigations specify on are still unexpected or violent death, such as homicides, suicides, unintentional injuries, drug-related deaths, and others. These deaths are investigated because of the legality and public health implications.[viii]

The development of county medical examiner systems peaked in the 1980s, but have declined immediately after, leading to the system we know today. Unlike the Uniform Determination of Death Act, there are no national death investigation laws, meaning the state determines what laws are needed, thus creating different systems for coroners and medical examiners.  The lack of doctors trained in this field makes it hard to conduct all death investigations in the United States. Not as many physicians are hired because it is a higher pay than having untrained people follow through with the death investigations.  This will be further explored later.

As a comparison of the inconsistencies between states, North Carolina has a county-based system where there are medical examiners located everywhere, and need training and experience in the field.[ix] Compared to Michigan, each county has a physician medical examiner, meaning they have more training and are licensed. New Mexico has only one office, known as the Office of the Chief Medical Investigator [OCMI], where all medicolegal death investigations are conducted.  While inconsistencies exist, most medicolegal investigations occur in similar manners.

The process of medicolegal investigation is as follows. After the incident has occurred, the policeman arrives to see what happened and the ambulance arrives. The policeman is in charge of calling the medical examiner’s office to speak with the death investigator and is assigned the case, where the investigator will observe the scene. After taking notes about the scene and position of the body or surroundings, the investigator interrogates witnesses and takes the body to the morgue. A form is given to the medical examiner or pathologist to determine whether or not to conduct an autopsy. If the body requires an autopsy, the body is observed and then the family and officer is notified. A coroner would complete the full investigation and contact the family if needed.

Though they are not tasked with performing live medical procedures, coroners are still expected to bring a wide breadth of medical and anatomical knowledge.[x] Generally, these services are provided in cases of unexpected deaths, as mentioned previously, including, but not limited to: suicide, violent deaths, and deaths during surgical procedures. Therefore, it should come as no surprise that bodies can be found under different stages of decay for example. Because of the wide range of scenarios in which a body can be found, some deaths may be easier to investigate than other deaths. The cause of death in a controlled environment such as an operating room could be easier to find than the cause of death of a body suddenly found in the desert. Therefore, in order to determine the causes of these deaths, toxicologists and forensic pathologists will run tests on the body and present information to the medicolegal investigator, who compiles the information. Medicolegal investigators often work independently from law enforcement, while still engaging in legal affairs, in order to lessen bias.

Before the medical staff begin the autopsy, the medical examiner should provide them with information pertaining to the body’s identity. This includes basic identifiers such as “age, gender”, as well as “medical history”, and “circumstances of death.”[xi] In cases where the decedent cannot be identified, DNA testing can be a useful resource to figure out some crucial components of the decedent’s identity. According to Sanchez et al., “around 5-10%” of deaths requiring scrutiny by a medical examiner will be “classified as sudden unexpected deaths.”[xii] Though the case can be closed after this decision, the results can be unsatisfactory for both families and law enforcement. Thus, Sanchez et al. advocates for increased usage of gene sequencing in order to identify potential cardiac problems that may have led to the “sudden unexpected death.”[xiii]

 

A typical medical examination room in which identity, cause of death, etc., would be scrutinized.[xiv]

Basic information helps the medicolegal examiner and toxicologist contextualize their subsequent findings. During a toxicology investigation, tissues and fluids will be collected for analysis and will undergo “2-stage testing” composed of an initial screening to identify foreign chemicals, as well as an analysis to quantify the foreign chemicals. Many different factors will influence the results of a toxicology test, including but not limited to: food, other medications, and the degradation of certain chemicals in a specific timeframe.[xv] Food and medications can alter interactions between certain chemicals and the human body.[xvi] This presents a unique challenge to toxicologists, as different results will be acquired from different people. Though the deduction process is based on the toxicologist’s skill and the machinery available to perform analyses, strict national guidelines can introduce a more uniform process.

Examiners should be able to interpret medical results in order to deliver accurate and unbiased information to law enforcement, lawyers, judges, families, and even insurance companies. Accurate medical results are crucial in court cases and insurance claims. Though toxicology is important, not many medicolegal examiners are able to acquire their own lab. According to an infrastructure assessment performed by the National Association of Medicolegal Examiners (NAME), only “37% of medical examiner offices have their own toxicology laboratories.”[xvii] Offices without their own toxicology laboratories must request assistance from state or federal crime laboratories. In some cases, offices will contract a third party toxicology laboratory to perform much-needed analyses. Outsourcing the toxicology work creates a lag in which the body could wait weeks or even months before being tested. Even then, sometimes the toxicology reports may be incomplete. This creates problems for families, who may not be able to grieve for their departed, as well as law enforcement and court systems. Thus, it is evident that the scientific elements of the medicolegal death investigation system have many implications on legal and ethical issues.

 

Toxicology labs require extensive equipment and materials which are not always readily available to every ME office.[xviii]

As with any other medical procedure, one performed after death is very important.  David Spain writes that “Medicolegal investigation of death, in the past decade, has assumed an increasingly important role extending far beyond the immediate investigation of suspected homicide, suicide, or accidental death.”[xix]  Today’s complex issues such as the ease of malpractice with optimized technology, minority groups and violent deaths (police brutality), and others all call to question many ethical, legal, and moral concerns surrounding the field of medicolegal death and its investigations.

Before even diving into the ethical issues surrounding the actual investigations done, it’s important to note who is actually conducting the examinations.  As mentioned before, the first major concern for the public today is the ethical issue of medicolegal examiner qualifications.  Depending on state regulations, either county coroners, county medical examiners, or a mix of both will undergo death investigations.[xx]  With the weight and importance that investigations have on legal implications and convictions, there is rightful concern surrounding the quality of these medicolegal investigators and the accuracy of their rulings for cause of death, etc.  Yet despite the importance of these investigations, there is a lack of standardized qualifications for medical examiners and coroners who engage with the deceased.  Diane Kelsall and her colleagues argue that “there is no accreditation system for coroner or medical examiner offices, no national standards for the investi­gation or classification of death, no nationally recognized train­ing program or credentialing system for coroners and medical examiners, and no agreement on common outcome measures against which to evaluate performance.”[xxi] Her concern has merit considering that in coroner systems, the only requirements for a coroner to be elected are that the candidate must live in the county/state for a specified number of years.  There is no training, additional education, or certification required.  In contrast, medical examiners are usually licensed physicians that practice medicine, and are appointed by county officials.[xxii]  The wide spectrum of death investigators can cause concern regarding the differing quality of service between the deceased.

 

This map shows the varying systems used between states, from coroner or ME exclusive systems to mixed ones.[xxiii]

An ethical issue that can potentially arise from lack of medical experience or qualifications is that regarding errors during the course of the investigation.  While sufficient qualifications may not always be the cause of error, there are questions concerning whether or not these errors warrant acknowledgement.  Dwayne Wolf addresses this “gray area,” stating that “When the error is significant but did not lead directly to the patient’s demise, the questions may arise regarding the obligations of the medical examiner to disclose the error to the clinicians or to the family.”[xxiv]  For example, a male with a pacemaker is found incapacitated, and resuscitative measures are taken as he is transported to a hospital.  Due to “pulseless electrical activity,” resuscitative measures were terminated, and it was determined that cause of death was toxicity of a combination of drugs.  Yet, an interrogation of a pacer-defibrillator technician revealed that after resuscitation effort ceased, there were ventricular arrhythmias that triggered internal shocks from the defibrillators.  While this did not cause the death of the patient, the ethical question on whether or not the ME should report these findings and inform the family remain.  Generally, because this was not the cause of death, it would not be reported on the death certificate or autopsy report.[xxv]

Therefore, the ethical issue of full disclosure is one that continues to be debated today.  Some argue that the ME has a “duty to uphold ethical standards of professional practice, which include to not misrepresent data upon which conclusions are based.”[xxvi] If an ME decides to disclose these findings, there is usually confusion as to who to report them to.  An option is to open dialogue with the quality director of the institution of the physician who was in charge of treating the deceased.  While informing the physicians of the findings will not change the cause of death or the outcome of the deceased, initiating conversation and spreading awareness of the incident may build trust and help prevent any future issues.

Finally, just as transparency and trust would be beneficial between physicians and MEs, the same can be said about the representation of information in trials and convictions.  Praveen Yadav outlines the basic standards for medicolegal investigators giving their testimonies, stating that, “Laboratory results together with the expert’s opinion that interprets them must never be falsified, trimmed, tailored or otherwise modified to suit a third party, be the motive political, military, racial, financial or any other.”[xxvii]  As clear-cut as this may seem, there’s room for moral and ethical dilemmas in the courtroom.  Some investigators misrepresent the degree of their educational degree or professional status by associating their eligibility for higher certification as actually obtaining it.  Exaggerations in experience are often a tactic to intimidate cross-examination efforts.[xxviii] On the contrary, some investigators and scientists battle the task of ethically presenting interpretations of data in a way that is objective and understandable to the jury.  The use of medical jargon, complicated scientific concepts, and confusing evidence could lead to deception, especially to jurors who are unaware of those things.  This is a result of lack of courtroom training of medical examiners and coroners.[xxix]  Perhaps the largest ethical and moral difficulty faced by investigators is remaining objective.  Yadev writes, “They must not forget that objectivity is their main attribute and that they must examine all the angles before reaching conclusion.”[xxx] This could be difficult to do if, for example, the examiner knows that he/she is defending a murderer.

Some evidence provided by coroners/MEs can be confusing to a lay-person of a jury.[xxxi]

Overall, there are many ethical and moral issues that intertwine with legal implications, such as conviction of crimes.  Understanding these in conjunction with the history/development, and scientific practices of the medicolegal system does raise concern, especially as social issues and controversial turmoil continue to plague the Earth.  However, awareness of the many working parts and concerns of the system can help initiate dialogue about ways to improve issues and ameliorate the quality of medicolegal investigations.

 

Meredith Hou

Yaeelin Merino-Velasquez

Quynh Nguyen

 

NOTES

[i] Spitz, Werner U., Daniel J. Spitz, and Russell S. Fisher. Spitz and Fishers Medicolegal

Investigation of Death: Guidelines for the Application of Pathology to Crime Investigation. Springfield, IL: Charles C. Thomas, 2006.

[ii] “What is a Coroner?” How to Become a Crime Scene Investigator. Accessed April 07, 2019.

https://www.crimesceneinvestigatoredu.org/coroner/

[iii] Hanzlick, Randy. Death Investigation: Systems and Procedures. Boca Raton: Taylor & Francis, 48-60 2007.

[iv] Hanzlick, Randy. Death Investigation: Systems and Procedures.Boca Raton: Taylor & Francis, 35 2007

[v] “Office of Butterworth & Sons, Undertakers,” from brochure Seattle and the Orient (1900). https://justiceforraymond.wordpress.com/2012/07/25/who-regulates-coroner-medical-examiners-and-their-facilities/

[vi] National Conference of Commissioners on Uniform State Laws, “Model Post-Mortem Examination Act.” 9-14 Aug. 1954, https://netforumpro.com/public/temp/ClientImages/NAME/3301a8d5-4f77-4f70-92e9-ebec0b7598a8.pdf.

[vii] National Conference, “Model Post-Mortem Examination Act.”

[viii] [5] Kelsall, D.,M.D.M.Ed, & Bowes, M. J., M.D. (2016). No standards: Medicolegal investigation of deaths. Canadian Medical Association. Journal, 188(3), 169. doi: http://dx.doi.org/10.1503/cmaj.160041

[ix] Hanzlick, Randy. Death Investigation: Systems and Procedures.Boca Raton: Taylor & Francis, 92-95 2007.

[x] “Who Are You Calling a Death Investigator?” PBS. Accessed April 09, 2019. https://www.pbs.org/wgbh/frontline/article/who-are-you-calling-a-death-investigator/.

[xi] Basso, Cristina, Margaret Burke, Paul Fornes, Patrick J. Gallagher, Rosa Henriques de Gouveia, Mary Sheppard, Gaetano Thiene, and Allard van der Wal. “Guidelines for autopsy investigation of sudden cardiac death.” Virchows Archiv 452, no. 1 (2008): 11-18.

[xii] Sanchez, Olallo, Oscar Campuzano, Anna Fernández-Falgueras, Georgia Sarquella-Brugada, Sergi Cesar, Irene Mademont, Jesus Mates et al. “Natural and undetermined sudden death: value of post-mortem genetic investigation.” PLoS One 11, no. 12 (2016): e0167358.

[xiii] Sanchez et al. “Natural and undetermined sudden death: value of post-mortem genetic investigation.”

[xiv] Autopsy Table, unknown author, https://www.wisegeek.com/what-is-a-medical-examiner.htm

[xv] Skopp, Gisela. “Postmortem toxicology.” Forensic science, medicine, and pathology 6, no. 4 (2010): 314-325.

[xvi] Skopp, “Postmortem toxicology.”

[xvii] Graham, M. A., F. B. Jordan, and V. W. Weedn. “Preliminary report on America’s medicolegal offices. The National Association of Medical Examiners. 2004.”

[xviii] Toxicology Lab, unkown author, https://www.news5cleveland.com/news/local-news/cleveland-metro/cuyahoga-countys-medical-examiner-office-uses-dna-to-identify-bodies-solve-sex-crimes-cold-cases

[xix] Spain, David M, “Medicolegal Investigation of Death: Guidelines for the Application of Pathology to Crime Investigation.” JAMA, 1973;226(13):1574. doi:10.1001/jama.1973.03230130062041

[xx] Pearsall, Beth, “Improving Forensic Death Investigation.” National Institute of Justice, no. 267 (March 3, 2011): 30-33. Accessed April 4, 2019. https://www.nij.gov/journals/267/pages/investigation.aspx.

[xxi] Kelsall, Diane, M.D.M.Ed and Matthew J. Bowes M.D, “No Standards: Medicolegal Investigation of Deaths.” Canadian Medical Association, Journal 188, no. 3 (Feb 16, 2016): 169. doi:http://dx.doi.org/10.1503/cmaj.160041. http://libproxy.lib.unc.edu/login?url=https://search.proquest.com/docview/1768826205?accountid=14244.

[xxii] Ernst, Mary Fran, “Medicolegal Death Scene Investigation.” AccessScience (McGraw-Hill Education, 2009). https://doi.org/10.1036/1097-8542.YB090131.

[xxiii] Death Investigation State-By-State, unknown author, https://www.npr.org/2011/02/03/131242432/graphics-how-is-death-investigated-in-your-state

[xxiv] Wolf, Dwayne A., et al, “Ethical Considerations on Disclosure When Medical Error Is Discovered During Medicolegal Death Investigation.” The American Journal of Forensic Medicine and Pathology, 38, no. 4 (December 4, 2017): 294. doi:10.1097/PAF.0000000000000343.

[xxv] Wolf, “Ethical Considerations,” 295.

[xxvi] Wolf, “Ethical Considerations,” 295.

[xxvii] Yadav, Praveen Kumar. “Ethical Issues Across Different Fields of Forensic Science.” Egyptian Journal of Forensic Sciences, 7, no. 1 (July 18, 2017): 2. Accessed March 30, 2019. doi:10.1186/s41935-017-0010-1.

[xxviii] Yadav, “Ethical Issues,” 2.

[xxix] Yadav, “Ethical Issues,” 2-3.

[xxx] Yadev, “Ethical Issues,” 3.

[xxxi] Former Chief State Medical Examiner Gary Dale Testifies, Kurt Wilson, Missoulian, https://helenair.com/missoula/news/local/forensic-pathologist-will-no-longer-do-work-for-montana-county/article_05559668-76af-530c-9257-d64480a6d228.html

 

3 Comments

  1. It’s a striking problem to me that the standards for medical examiners varies so wildly between the states. I think it would be a good idea to do an analysis of how competent each state is when it comes to investigating deaths. By not having a standard across the board, the possibility of misconduct. What would be decided in one state could be different in another. A national standard would be very beneficial. For example, EMTs have different protocols to follow based on what county they’re in, but in order to function as an EMT they a national standard that they must adhere to. A similar system could instill more faith in these aspects of the medicolegal system.

  2. I learned a lot from this post but I am curious about who decides whether or not an autopsy will be performed? Do the police or death investigators decide or does the individuals family? Before reading this post, I never really thought about autopsies and their complexity. Now I’m wondering whether or not we have any autonomy over if an autopsy is performed or not once we die.

  3. I’ve also seen movies where the fact that the medicolegal investigation is not clear-cut or required the coroner to be a devil’s advocate were a plot element.

    In one movie, the coroner had to determine the cause of death as part of another police investigation. The coroner assumed the wife had a heart attack on her own, though the cause of her heart attack was in fact because her husband had opened her blood pressure pill capsules and filled them up with 4x the regular amount,

    In the second film, there was some qualification of the death (like, showed signs of trying to escape), and because the coroner couldn’t sign off on it, the case couldn’t get elevated and the (underfunded) local police department didn’t get the resources it needed for that cases. But, like the article says, objectivity is the coroner’s goal.

    “They must not forget that objectivity is their main attribute and that they must examine all the angles before reaching conclusion.” This could be difficult to do if, for example, the examiner knows that he/she is defending a murderer.

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