Coroners vs. Medical Examiners

Introduction

Hello everyone. Today I’d like to get into a discussion about the distinction between coroners and medical examiners. It’s not uncommon for people to use the two terms interchangeably, which is something that chafes a lot of medical examiners. Coroners have a set of responsibilities that overlaps that of the medical examiner, but the qualifications that one needs to hold this post are much different than those of a forensic pathologist. 

To start, let’s just call this whole system “death investigations.” Regardless of how states manage death investigations, the overall goals are the same:

• Determination of cause and manner of death
• Issuance of death certificates
• Thorough investigation in suspicious cases
• Reporting of the above to vital statistics agencies
• Cooperation with families, law enforcement, and jurisdictional legal authorities

Death investigation is governed almost entirely by state law. Different states define their death investigation systems in a variety of ways. The United States is a place that seems to resist standardization, and death investigation is certainly one of them. Some states have only medical examiners, some states only have coroners, and some states have a confusing mix of both. Here’s a map that shows the distribution of ME and coroner systems throughout the country. The data is garnered from the Centers for Disease Control. They have a pretty neatt interactive map you can check out here.

Some rough trends:

• Centralized state offices are found in:
  • Maine, New Hampshire, Vermont, Massachusetts, Delware, Maryland, Rhode Island, Virginia, West Virginia, North Carolina, Oklahoma, New Mexico, Utah, and Oregon
  • The District of Columbia has a centralized office akin to a state office
• Coroner-only states are clustered in the West, Midwest, and South. These tend to predominate in states with large rural areas.
• Michigan and Arizona have ME offices organized at the county level
• Florida has ME offices that match judicial circuits that may encompass several counties
• The rest is a mix of both.

Pretty confusing, right? Even that map doesn’t show the varied complexity of death investigation systems in the United States. For example, in certain parts of Texas, a third death investigation official, the Justice of the Peace can be found. This is an individual that has certain magisterial powers generally related to small-claims civil disputes, but can function as a de facto medical examiner in certain instances. In parts of California, Sheriff-Coroners are used. Let’s start this post by talking a little bit about coroners.

Coroners

A Brief History

I hope this does not shock most of the people reading this, but the United States is a country that grew out of the British colonization of North America. Early colonial society was based on British royal society, and as such, many practices in the United States can be traced back to English Common Law. One of these is the office of the coroner.

Early coroners had some law enforcement responsibilities that overlapped with those of sheriffs (another early English law enforcement designation found in the US today.) Their responsibilities to the Crown were primarily financial. They sought to protect the kingdom’s financial interests in criminal cases. They also had a variety of record-keeping duties. The most relevant duty that coroners assumed, and still have today, is that death investigation. If a body was discovered and that death was thought to be unnatural or suspicious in any way, one of supposed to contact the coroner. Again, the main interest of the coroner was to make sure that any debts or duties were paid to Crown upon notification of the death, but this responsibility is probably where modern coroner offices derive their authority and jurisdiction. 

Coroners followed colonists to the United States. The first US coroner was Thomas Bainbridge of what would become Maryland. He was appointed in 1637. The system persisted until the 20th Century. The first jurisdiction to abolish its coroner system and replace it with a medical examiner system was New York in 1918. Dr. Charles Norris was the first medical examiner to head this office. He and his colleague, Alexander Gettler, were really the first to apply scientific principles to death investigation in a systematic way. They probably also had the first functional forensic toxicology lab in the United States. Mr. Gettler produced a lot of novel ways of detecting various poisons during his career. A wonderful book that chronicles this time was written by Deborah Blum. It really is worth the read.

The system first spread from New York to Patterson, New Jersey. As graduates of these programs moved about the country, they brought the system with them. As this was happening, it became pretty obvious that medicolegal death investigation by trained practitioners was superior to that of common law established coroners. This culminated in the Model Post-Mortem Examinations Act of 1954.

The Model Act

The Model Post-Mortem Examinations Act recommended some standardization of autopsy practice. The goal of the act was pretty simple:

…to provide a means whereby greater competence can be assured in determining causes of death where criminal liability may be involved.

It basically set forth recommendations that have been most directly adopted by states that have a single, centralized ME office. The recommendation was to have a board called the Commission on Post-Mortem examinations that would be run by a Chief Medical Examiner and whose membership would include various officials on the medical and legal sides of death investigation. Of note, Section 11 of the Act abolished coroner’s offices and transferred their duties to the centralized agency. However, it still allowed for coroners to maintain some role in the death investigation process. That role just had to be established by and performed at the direction of the aforementioned Commission. This was to allow the establishment of official ME offices in states where the office of the coroner was constitutionally derived, which would require an amendment to change. Since the Act, many coroner systems have converted to ME systems up until about 1990. Little has changed since then. The reasons are way beyond the scope of this post, but I’ll leave you a link to a paper by Dr. Randy Hanzlick, the Chief Medical Examiner of Fulton County, Georgia. Unfortunately, it’s PubMed, so you may not be able to access it without a login. Right now, things seem to be pretty static on that front.

Now let’s make a quick comparison between coroners and medical examiners.

So You Want to be a Coroner…

The job requirements for coroners are pretty varied. Most commonly, coroners are elected positions and need to be some combination of the following:

• Resident of the jurisdiction for some specified amount of time
• Be somewhere between 18 and 25 years of age
• Some degree of education 
  • This can be as simple as a high school diploma, but most states require a college degree
• Some kind of continuing education on a yearly basis

…and that’s about it. A large number of states have no specific requirements at all for the job. As usual, the CDC is a great resource for large scale public health information in the US. They have a list of coroner requirements in every state here.

You’ll notice one pretty big omission here. Do coroners need any medical training? Generally no. In fact, in a lot of places, most of the actual training to be coroner occurs after the person has been elected or appointed. The exceptions are Kansas, Louisiana, Ohio, and Minnesota. In these states it is required that coroners are medical doctors, but they don’t have to be trained specifically in forensic pathology.

So how does the coroner obtain enough information to sign a death certificate? In most cases that relies on the same tools we’ve discussed in the introduction lecture. The two big ones would be review of relevant circumstantial information, including medical records, and autopsy examinations. Most of that work will be conducted by a forensic pathologist. So are coroners necessary? Let’s come back to question later. Before we do, however, let’s take a look a medical examiners and forensic pathologists.

Medical Examiners 

For the purposes of this discussion, I’m going to use medical examiner and forensic pathologist interchangeably. They are not totally equivalent terms, but they are close enough. The main quirk is that some states have statutorily defined positions called “medical examiners” that don’t require forensic pathology training. The big difference between medical examiners and coroners is qualifications and training. A medical examiner has:

• A medical degree
• Pathology residency (3 – 4 years)
  
• Forensic pathology fellowship (1 – 2 years)

It’s a lot more than a high school diploma and a week of training. Most people would agree that medical examiners are clearly much better suited to accurately determine cause and manner of death. The medical opinion of someone with medical training obviously carries more weight of that than an elected official. So why do we have coroners at all?

Conclusion

So we’ve arrived back at the question I posed before. Are coroners necessary? The answer is a little more complicated than a yes or a no. Unfortunately, there are just not that many medical examiners out there, which may come as a surprise. There are only about 500 practicing medical examiners in the United States and training programs produce around 30 to 40 new ones every year. Considering around 2.5 million people die in the United States each year, it is a lot of work for a relatively small group of people. There is a definite shortage in the US which leaves a lot of ground to cover in death investigations. Regardless of the logistical issues, deaths deserve the benefits of competent investigation, whether that means procuring evidence for criminal prosecution or closure for families. As long as the job is done competently and compassionately, I don’t really care how one gets there. There are great coroners like there are terrible doctors. Going forward, our national organization is going to undertake more public outreach in order to attract new people to our profession. Maybe one day that could be you! As always, if you have any comments of questions, let me know.