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6 COMPARING MEDICAL EXAMINER AND CORONER SYSTEMS Advantages and Disadvantages of the Medical Examiner System Marcella Fierro There are numerous advantages of instituting a medical examiner system, especially a statewide system. Virginia’s statewide medical examiner system is decentralized: it has a chief administrative officer and four regional offices. Other statewide systems, such as those of New Mexico or Rhode Island, are centralized. The degree of centralization should be dictated by state geography, demographics, and ease of administration; but whether centralized or decentralized, medical examiner systems are highly desirable in comparison with coroner systems and mixed systems. The major advantages of a statewide medical examiner system are the quality of death investigations and forensic pathology services and their independence from population size, county budget variation, and politics. Certification of death is accomplished by highly trained medical professionals who can integrate autopsy findings with those from the crime scene and the laboratory. The professionals have core competency in assessing immediate and earlier medical history, interviewing witnesses, and physical examination. The recognized excellence of and confidence in a medical examiner system in Virginia
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have been vital for adjudicating the state’s death penalty cases and for prompt payment of insurance claims. Another major advantage of a statewide system is uniformity. Virginia’s uniformity comes from its statute covering types of cases automatically in the jurisdiction of the medical examiner. One example, set to take effect in 2003, is automatic referral of all deaths in state mental institutions. High-profile investigations had uncovered abusive practices in the handling of patients in those institutions, which resulted in preventable deaths. Automatic referral to medical examiner offices was instituted by the state legislature to promote more humane treatment and avoid abuses. Uniformity also covers credentialing, training, and continuing education of medical examiners and death investigators; coding of deaths; access to case files through archive and retrieval policies; criteria for exhumation and disposition of unclaimed bodies; and appeals processes. Those features benefit not only death investigations but also public health epidemiology and surveillance. Virginia’s office reports to the legislature each year on child fatalities, family violence, and domestic violence. The state office is striving to set up a new information-technology system that will permit greater access to its data; the goal is to develop a system with great utility not only for criminal prosecutions but also for epidemiologic and surveillance purposes. A final set of advantages of a statewide system are related to central administration. A statewide system like that in Virginia can have statewide guidelines for case management and death scene investigation. It also can have 24-hour consultation with any site in the state, which is an especially important feature for isolated areas with little experience. Furthermore, a large cadre of forensic pathologists (Virginia has 13) gives the state the flexibility to shift manpower in case of a mass disaster. Centralized administration can sustain the cost of central laboratories, and it can take advantage of economies of scale and purchasing power. Virginia’s centralized administration devotes personnel to writing grants, which can be extremely time-consuming. The growth of Virginia’s centralized system depended heavily on obtaining seed money from federal grants expressly for infrastructure. Virginia's system was awarded $8 million in 1970 to establish a forensic science laboratory and a DNA laboratory. The DNA databank, which stores data on 200,000 people, has proved
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valuable to law enforcement. Virginia’s centralized system was expensive to start but is inexpensive to sustain; it spends $0.79 per capita, which is less than many other jurisdictions spend. The first wave of infrastructure grants was discontinued decades ago, but Congress passed the Coverdell Act/National Forensics Science Improvement Act (NFSIA) in 2000. Still, the current appropriation level under the act is only about $5 million for all 50 states. When Virginia recognized that it would be eligible for less than $100,000 under the legislation, it decided that the funding was too meager to justify the cost of writing a grant application. A centralized medical examiner system also poses challenges. It requires strong leadership, attention to state budget priorities and competition with other public health and criminal justice programs, and human-resource management to ensure recruitment and retention of multiple types of professionals. An ideal statewide system has a medical examiner system to a medical school and subspecialty pathologists, forensic science laboratories and scientists, and public health systems and laboratories. Such proximity facilitates sharing of knowledge, system refinement, and access to new technologies. In addition to grants for infrastructure, the most efficient expenditure of federal funds would be for uniform data elements collected in a way that allows easy comparability across jurisdictions and that could be used by all coroners and medical examiners nationwide. Advantages and Disadvantages of the Coroner System Carl Parrott The major differences between coroners and medical examiners are embedded in the manner of their selectionby electoral process versus appointmentand their professional status. Coroners are elected lay people who often do not have professional training, whereas medical examiners are appointed and have board-certification in a medical specialty. The coroner system has advantages, but they are heavily outweighed by its disadvantages. [The speaker is a forensic pathologist who was elected coroner in Hamilton County, Ohio. His
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office is a regional facility that provides forensic services to surrounding counties on a fee-for-service basis. Services cover autopsies, examination of firearms, serology, toxicology, and others.] The major advantages of the coroner system concern autonomy, access to power, and the ability to represent the will of the electorate. As an elected official, a coroner has the power to make decisions and has equal footing with other local elected officials. That places the coroner in a strong position to withstand political pressures imposed by other elected officials and to compete vigorously for the office’s budget allocation. Furthermore, due to their English commonlaw origins, coroners also have subpoena and inquest powers. Finally, being an elected official resonates with American political culture, which views elected officials as the best representatives of a community’s needs and values. Two important disadvantages are that coroner systems are less likely to be medically proficient and that their structure often reflects piecemeal legislative reaction to inadequacies, rather than intelligent design. The coroner system is steeped in the vagaries of history rather than in a forward-looking, planned system that capitalizes on professional depth and knowledge. Coroner statutes are less specific about which types of cases are reported or investigated, and they tend to reflect the lowest common denominator in the qualifications of the office holder and the quality of investigations. The coroner may be deficient in knowledge and may have conflicts of interest; especially when funeral directors, prosecutors or sheriffs act as coroners. As elected officials, they cannot be dismissed for incompetence, except by the electorate after highly visible transgressions. Several coroners in Ohio are serving prison terms for Medicare fraud. The coroner position as derived from England is specifically a county official. The county nature of the coroner system is a fundamental flaw as applied to the U.S. because the jurisdictional base is often too small to support a modern medicolegal office. The result is that coroner systems vary widely, with many counties having only a part-time elected coroner with few resources for operations or even training. The creation of medical examiner systems permits governments to consider regional or state systems that can provide more uniform coverage in an efficient manner. Ohio counties vary by a factor of 30 in the number of autopsies they perform. The key
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determinant is the resources of the county, as opposed to the circumstances of the cases. Cities have far greater resources than rural areas. The homicide rate is higher in cities, but homicides are less frequent than injury and suicide deaths, which vary less between urban and rural areas (2002). Thus, the variability in circumstances of death between urban and rural counties cannot account for the enormous spending disparities. Other disadvantages are poorer quality of coroner investigations, poorer integration across jurisdictional boundaries, poorer information transfer, and poorer information-gathering. A coroner system can approximate the high quality of a medical examiner system, but greater impediments stand in the way. Discussion The discussion focused on the scientific and administrative advantages of medical examiner systems over coroner systems (Thomas Pearson). One key outcome of this workshop could be national endorsement of the abolition of the coroner system and endorsement of the establishment of greater professionalism through a medical examiner system (Ellen Clark). The endurance of the coroner system is best explained by voter inertia, lack of awareness of the problem, and high capital expenditures for system start up (Carl Parrott, Vincent Di Maio). Transformation in individual jurisdictions from a coroner to a medical examiner system will not solve the disparities within a state unless the commitment to reform is undertaken statewide through legislation (Carl Parrott). It is difficult for states to make such changes, because elected officials find it unpopular to promote removal of elected officials from office and state constitutional amendments may be required in some states even if a change might impact only one county (Randy Hanzlick). The NFSIA could be used by states to move to a medical examiner system (Randy Hanzlick). To be eligible for funding for infrastructure grants, a state is required to have accreditation or to show progress toward accreditation; financial incentives for accreditation and the possibility of sizable awards of infrastructure grants might give states sufficient motivation to transform their system (Marcella Fierro). Furthermore, NAME has formed a committee to
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work with the American Bar Association to determine how the 1954 model legislation could be updated with state systems to incorporate scientific advances of the last 50 years (Victor Weedn). Efforts to abolish coroner systems in Georgia were propelled by the Georgia Association of County Commissioners, which passed a resolution to eliminate the coroner offices on the basis of cost and inefficiency (however, the elimination of coroner offices has not been realized) (Kris Sperry).
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