CORONERS/MEDICAL EXAMINERS

AND THE PRODUCTION OF "MANNER OF DEATH" STATISTICS

Trudy Knicely Henson

A Dissertation

Submitted, to the Graduate College of Bowling Green State University in partial fulfillment of the requirements for the degree of

DOCTOR OF PHILOSOPHY

June 1978 © ,-v 1978

Trudy Knicely Henson

All Rights Reserved li

ABSTRACT

The official statistics for manner of death (natural, accidental,

suicide, and homicide) are used hy social scientists in a variety of

ways. Despite their widespread use, however, the statistics are often

criticized for a number of weaknesses. A review of social science

literature and preliminary interviews and observations among the

coroners and medical examiners who produce the statistics indicated that much of the bias in official statistics could be attributed to role conflict and role strain.

Several methods were used to collect data about medicolegal officials, the role strain and/or conflict they experience, and the structural and personal mechanisms they use to resolve strain and conflict. These included: l) observation in two coroners’ offices;

2) examination of case records; 3) focused interviews with coroners and medical examiners; and M a mail survey of a national sample of medicolegal officials.

The research was directed at an analysis of the coroner/medical examiner role with attention to the ways in which its various components might affect the production of manner of death statistics. To accomplish that goal the medicolegal role was examined on three levels: l) role requirements as dictated by state laws; 2) the role as defined by officials themselves; and 3) the actual role performances of coroners and medical examiners. Attention was given to those factors likely to affect the quality of official death statistics—the complexity of the official's role, the amount of role commitment, interaction with iii -f

role partners such as police, legislators, and medial personnel, and the existence and resolution of role conflict and role strain.

The data support the assertion that manner of death statistics are biased, but they indicate that the error is more often a result of role strain and conflict than of intentional misclassification.

Officials reported that budgetary restrictions, insufficient personnel, lack of proper training and skills, and conflicting expectations from role partners are factors which interfere with their role per­ formances and contribute to inaccuracies in manner of death verdicts. Il I ?>•,

"A single death is a tragedy, a million deaths is a statistic."

—Joseph Stalin IV

ACKNOWLEDGEMENT

The completion of a study such as this is never due solely to

the efforts of one person. Throughout the project a number of people

provide invaluable support and assistance.

I would like to thank Dr. Charles McCaghy and the other members

of my committee—Drs. Del Hilyard, Steve Cernkovich, Peggy Giordano,

and Don McQuarie—for their support and cooperation from the beginning

of the research. To my husband, Gary, I owe a special thank you for his moral support and encouragement.

A portion of the financial burden of the project was relieved by

grants from the Sigma Xi Scientific Research Society of North America and the Bowling Green State University Graduate College. The Bowling

Green Sociology Department also provided supportive resources during the survey phase of the study.

Finally, I wish to express my deepest appreciation to all those medicolegal officials and personnel who gave so freely of their time and knowledge throughout the study. Although all of these people had crowded schedules and many responsibilities, they were very helpful. Without their cooperation the project could never have been completed.

To all these people and many others who provided support, encouragement, and time, thank you. V

TABLE OF CONTENTS "

CHAPTER Page

I INTRODUCTION...... 1

II REVIEW OF LITERATURE...... 8

Weaknesses of official statistics...... 8

Previous studies of coroners/medical examiners...... 16

Theoretical approach...... 21

Summary...... 27

III METHODOLOGY: SAMPLES, STRATEGIES, AND TECHNIQUES...... 30,

Terminology...... 30

Samples...... 33

Research methods...... 39

Summary...... 1+9

IV MEDICOLEGAL ROLE REQUIREMENTS: THE HISTORY AND STATE LAWS...... 50

History of the medicolegal office...... 50.

Laws...... 57

Discussion...... 83

Summary...... 90

V THE MEDICOLEGAL ROLE AS PERCEIVED BY CORONERS AND MEDICAL EXAMINERS...... 92

The purpose of the office...... 92

Responsibilities to role partners...... 95 vi

CHAPTER Page

Qualifications and selection...... 101.

Motivation...... Ill

Summary...... 113

VI THE MEDICOLEGAL ROLE: PERFORMANCE, CONFLICT, AND STRAIN...... Il6

Role conflict and role strain...... 117

Individual characteristics and the medicolegal role...122

Performances of individual offices...... 132

Role performance in the occupation in general...... 152

Manner of death statistics and role strain/conflict...156

VII CONCLUSIONS AND SUGGESTIONS FOR USERS OF MEDICOLEGAL STATISTICS...... 1Ô7

Legal role requirements...... 167

Perceived role requirements...... 169

Role performances evaluated...... 170

Suggestions for users of official statistics...... 172

Suggestions for future research...... 173

Summary...... 175

REFERENCES...... 176

APPENDIX I: MAIL SURVEY QUESTIONNAIRE...... 182

APPENDIX II.: INTERVIEW LETTER...... 191

APPENDIX III: INTERVIEW SCHEDULE:S AMPLE QUESTIONS...... 193

APPENDIX IV: QUESTIONNAIRE COVER LETTERS...... 195

APPENDIX V: STANDARDS FOR MODERN MEDICOLEGAL SYSTEMS AS OUTLINED BY THE NATIONAL ASSOCIATION OF MEDICAL .'EXAMINERS...... 199 VI1

LIST OF TABLES

TABLE Page

3.1 Interview sample by type of system, population, and rural-urban character...... 37

3.2 Description of survey respondents by type of system, type of jurisdiction, and respondent’s educational background...... 39

U.l Summary of state laws regarding the medicolegal office and officials...... 75

5.1 Qualifications for medicolegal office as viewed by questionnaire respondents...... 103

6.1 Age distribution of mail survey sample...... 123

6.2 Distribution of survey sample by years in office..... 12H

6.3 Other titles held by medicolegal respondents in the mail survey...... 125

6.U Facilities and staff available to officials...... 135

6.5 Percentage of offices routinely ordering autopsies in selected cases...... 137

6.6 Respondents' evaluations of their role performances in obligations to role partners...... 1^0

6.7 Frequencies with which role partners pressure officials to change a suicide...... 148

6.8 Respondents' evaluations of frequency of r ' mistakes at various steps in the medicolegal handling of cases...... 15^ Vili

LIST OF FIGURES

FIGURE Page

4.1 Typology of state medicolegal systems including title of office, method of selection, and quired qualifications...... 82 7

Chapter I

INTRODUCTION

Death is an universal phenomenon. This fact in itself makes death

an object of interest. Beyond that, however, death is significant

because of its effect on individuals, groups, and society.

Few people attain such a degree of fame that their individual

deaths are lamented by the world, or even by one society. And few people lead lives of so little significance that their passing touches no one. Individual deaths vary in degree of impact on others, but

each one has an effect on the social network in which the deceased was once an actor.

Beyond the micro-level of individual social networks, death in the aggregate is significant in its impact on whole societies. It is a major factor in population trends, and because of this it affects the economy, the government, and the quality of life in a society.

Considering its significance in social life, it is surprising that for most of human history few records of death have been kept. Systematic compilation of statistics on causes and rates of occurrence of death is a relatively recent phenomenon. In the United States, annual collection of death statistics did not begin until 1900. At that time ten states were included in the project. Complete coverage was not achieved until

1933. Today most developed countries maintain death registration systems, but many underdeveloped countries still have only minimal registration of deaths (Petersen, 1975; Shryock, 1976). Prior to the establishment 2

of modern registration systems, the only records of death were those

kept by a family, or lists compiled for limited areas and purposes by

town officials, clergymen, and the like. In those days, the social

impact of death on a family or small community was recognized, but its importance to the larger society was given little consideration.

The emphasis on reason and rationality which resulted from the upheavals of the French and Industrial Revolutions gave rise to a number of new sciences. Among these were the social sciences, such as sociology, which undertook to study patterns of human life. The initiation of death registration systems and the development of methods of statistical analysis provided these new sciences with additional tools in their quest for understanding. Eventually the statistical analysis of official records became a standard practice among researchers interested in death and its implications.

Today the accuracy of rulings on cause and manner of death is no longer only of interest to limited social networks. In contemporary society vast sums of money are spent each year on programs of research and prevention for various types of deaths. Frequently, the analysis of official death statistics by social scientists and statisticians pro­ vides the justification for allocating funds, developing support programs, redirecting research, and even counseling families which have experienced a loss.

The extensive use of official death statistics has often been accompanied by criticism: of their weaknesses. Customarily a research report employing such data begins with a review of these general weaknesses. Just as often the criticism is followed with rationalizations for the use of official records in that particular case. Despite ready 3

acknowledgement that problems exist in the use of official death

statistics, researchers have made little effort to pinpoint the exact

nature of these problems. This lack of interest seems to contradict

all the concern expressed over the shortcomings of the data.

Obviously, acceptance of the status quo will not improve the

official statistics. Even action by social scientists directed at

improving and/or standardizing official procedures and forms would

probably have little effect. However, if more were known about the

weaknesses of particular statistics, it might be possible to adjust

for some of the error. It is to this end that the present study is

addressed.

Critics of the official statistics frequently point out that one

weakness in these data is that they are not compiled for social science

research, but for purposes of justifying budgets, explaining actions

taken, and the like. Those who generate the original statistics on

manner of death (natural, accidental, suicide, or homicide) are not

sociologists or psychologists, but coroners and medical examiners.

These officials then pass their decisions along to other officials

at the local and state bureaus of vital statistics. It is usually

from vital statistics offices and publications that the researcher

obtains his aggregate data. Coroners and medical examiners are seldom trained in social research. Medical examiners must, by definition, have medical training and some states require coroners to be either physicians or lawyers. Other states do not stipulate particular educational qualifications, and nearly anyone of legal age may become coroner. As a result, coroners may be physicians or lawyers or 4

morticians, sales people, or coal miners, depending on the degree of

selectivity in a state’s laws. And, not only does training vary, hut

laws regarding the operation of the office and duties of the official

also differ from state to state, and even within a state.

In recent years there have been efforts by various states to

tighten the qualifications for coroner or medical examiner positions.

Proponents of new, more rigorous qualification requirements contend

that medical training, and especially forensic pathology, eanbles

officials to make more consistently accurate determinations of the

manner of death. If this assumption is correct, changes in state policy and practice should be translated into more reliable statistics.

Even if they do not become more accurate, major changes in qualifications

and procedures will probably be reflected in the statistics generated.

Also, differences in medicolegal systems from state to state and changes within a state might account for some of the difference researchers find when comparing statistics over 'time or from place to place. If researchers are aware of the differences and changes in the role of coroners and medical examiners and the consequences for manner of death statistics, they might take precautions to minimize the error which would result from pooling data or comparing statistics from jurisdictions which are not comparable.

In the following study it is assumed that researchers and statisticians will continue to rely on official statistics as in­ formation sources about rates of death by both cause and manner.

It is further assumed that attempts should be made to construct a more accurate description of the social environment in which coroners 5

and medical examiners produce these statistics. Such information

could he useful in several ways. First, those using the statistics

might he able to reduce error by exercising some selectivity in their

use of the data. Second, those responsible for regulating the qual­

ifications of coroners and medical examiners and their work might gain

insights into ways to improve the operation of these offices. Finally,

a descriptive analysis of the office and its incumbents would add to

the pool of existing studies of work roles—a resource which Is used

to expand our understanding of the social dimensions of occupations.

The initial research plan for this study was to discover and

describe the processes used by medicolegal officials to arrive at

a classification of manner of death. It was soon obvious, however, that such a goal was too ambitious for this study with its limited personnel, time, and financial resources. Preliminary research also

indicated that examination of the coroner/medical examiner role itself

—its clarity, conflicts, and requirements—would be vital for any study of the classification process.

With these limitations in mind, the following discussion is directed at an analysis of the coroner/medical examiner role with attention to how its various components might affect the production of manner of death statistics. To accomplish this goal the coroner/ medical examiner role is discussed on three related levels: l) role requirements as dictated by state laws; 2) the role as defined by its occupants; and 3) the actual role performance of coroners and medical examiners. Within this framework attention is given to those factors which are likely to affect the quality of official death statistics. 6

These include: the complexity of the official's role, the amount of

role commitment, interaction with role partners, and the existence

and resolution of role conflict.

The following chapters include a review of literature and a

summary of the research methodology, as well as the presentation and

analysis of data collected relevant to the coroner/medical examiner

role. Chapter II is devoted to a review of literature dealing with

the weaknesses of official statistics, expecially manner of death

statistics. It also includes a brief discussion of those role

concepts which are used in the analysis of the occupation and the

structural and personal mechanisms used to resolve role conflict and

role strain.

Chapter III describes the research techniques and strategies

used in data collection. The rationale for various techniques is

explained, along with a discussion of the actual research process and

and description of the different research samples.

The historical development of the coroner's office, and sub­

sequently the position of medical examiner, is discussed in Chapter

IV as background for the presentation of a summary of present state laws defining the office. The history and laws are the focus of the

analysis of the role's requirements as presented in this chapter.

Chapter V is dedicated to the definitions of the coroner/medical examiner role as preceived by its occupants. These role definitions are compared and contrasted with those defined by law and those held by individual role actors.

The third level of analysis, role performance, is presented and discussed in Chapter VI. Particular emphasis is given to the actors' 7

evaluations of their performances and possible tactics for role conflict resolution.

Finally, Chapter VII is a summary of the role of coroner/ medical examiner. It also focuses on specific weaknesses in official manner of death statistics and possible precautions which might lessen error in statistical analysis of these statistics. 8

Chapter II

REVIEW OF LITERATURE

The use of official statistics in studies of death long ago became accepted practice in the social sciences. This is particularly true of studies of suicide, which have a long history in Western society. During the period 1822-1883 a number of systematic analyses using official statistics of suicide were conducted by such European researchers as

Legoyt, Falret, Quetelet, Wagner, Masaryk, and Ferri (Giddens, 1965).

In 1897 Emile Durkheim contributed another such study. Durkheim's

Suicide (1951) combined the official suicide statistics with sociological theory in an attempt to explain why official rates of suicide varied from place to place and time to time. Since its original publication

Suicide has become a classic and, despite the existence of earlier studies, many contemporary sociologists engaged in suicide research take Durkheim's work as their starting point.

Weaknesses of Official Statistics

Despite the praise Durkheim's work has received, however, re­ examination of the theories proposed in Suicide is often accompanied by numerous criticisms of his study. These criticisms generally focus on the weaknesses inherent in the use of official statistics on manner of death. Interestingly enough, many of the same criticisms were recog­ nized by those writing prior to Durkheim and continue to be raised by contemporary researchers in evaluating their own methodology and data. 9

De Guerry in 1935 5 de Boismont in 1856, Rumsey in 1875, and Legoyt in

l88l all questioned the reliability of such data (Douglas, 1967: 171-

172). More recently Gibbs (1968), Porterfield (1968), Labovitz (1968),

Douglas (1967; 1971), Breed (1963), Bradshaw (197^)» and others have

also criticized the use of official statistics as a data source for the study of suicide and/or homicide.

In addition to criticisms aimed specifically at the use of official statistics on manner of death, Douglas (l97l)s Cicourel (196^; 1968), and Kitsuse and Cicourel (1963), among others, have pointed to problems accuring to the use of official records in general. Regardless of the subject matter involved, official statistics are compiled for purposes other than social science research. Added to this, the reality re­ presented by these statistics must be filtered through a bureaucratic organizational structure, complete with constraints imposed by unique personalities, circumstances, and organizational requirements, all of which introduce additional sources of bias. As Cicourel (196U; 36-7) points out:

Most of the data that sociologists honor as "given," therefore., are largely the product of bureaucratically organized activities, for example, census bureaus, vital statistics bureaus, correctional agencies, welfare agencies, and business agencies. The multi­ tudinous perceptions and interpretations that went into the assembly of such data are invariably lost to the reader or user of such materials. The quantitative features must be accepted as fiat. The fact that even factual data are subject to per­ ceptions and interpretations which may vary with the actor's biography, the occasion of recording, the explicit or implicit rules empoyed for deciding the sense of the objects or events categorized, and the stated language and unstated meanings which were relevant to the particular observer, means that these are variables to consider in assessing the relevance and importance of such data. 10

Concerning suicide in particular, error may be introduced from a

number of sources. One possible source of error is a result of pooling

data compiled by various coroners or medical examiners. Although in­

dividual coroners and medical examiners may not share the same definition

of what constitutes a suicide, the statistics from their individual

reporting areas are frequently grouped together (Douglas, 1967; Gibbs,

1968; Labovitz, 1968). In addition to the common categories of manner of death—natural, accidental, suicide, and homicide—the death classi­

fication scheme common in the United States includes a cagegory labeled

"undetermined," which is used when there is some doubt as to the exact manner of death. Under the British coroner system, on which our own was based, a death must be unequivocally recognized as a suicide before it can be ruled as such (Atkinson, 1975: 1^3). Headley (1975) reports that this same standard is recommended by Jewish law, and the same criterion is used in the United States (Houts, 1967: 28o). This policy means that, for the sake of reliability, officials in charge of categorizations should also use the same criteria to determine what constitutes conclusive evidence that a particular type of death has occurred. There is evidence that this is not the case, however. Instead, a ruling of suicide by one coroner might have been a ruling of accidental death or undetermined manner had a different coroner with different de­ finitions and criteria been responsible for the verdict. A possibility of error exists, therefore, when the determinations from different coroners'- offices are pooled without insuring standardization of de­ finitions and decision-making criteria.

The likelihood that coroners and medical examiners share the same 11

definitions and evidence criteria is further complicated by a lack of uniformity in training. Each state has its own laws governing selection and qualifications of persons to fill the coroner or medical examiner position (Kornblum and Fisher, 1972; National Municipal League, 1975;

Department of Health, Education and Welfare, 1978). Some state positions require a medical degree in forensic pathology. Some require only that the office holder have a medical degree, with specialty unspecified.

Still other states have no particular qualication requirements; thus the position may be filled by a forensic pathologist, a family practi­ tioner, a lawyer, a mortician, or someone with neither medical nor legal background. In addition to this variation in training, in some states the office is appointive and career-oriented while in others it is elective and, therefore, political. This combination of variations in training and in selection has prompted the criticism that the statistics from jurisdiction to jurisdiction within and among states are not comparable and that many deaths may be misclassified, particularly where the official has no medical background and is elected (Childs,

1976).

Official qualifications aside, manner of death statistics may also be subject to error because there is a lack of knowledge about the circumstances leading up to the death (Labovitz, 1968; Gibbs, 1968) and/ or because the investigation of the death stopped at a point where the information collected fit the official's "map" for a particular category of death (Atkinson, 1975). Information which does not "fit" may be reinterpreted in light of the other data (Douglas, 1971). As

Bradshaw (1974) points out, exhaustive investigation, including 12

fingerprinting of the death scene, is not carried.out in all cases of violent death. A hanging body with a note nearby which does not ex­ plicitly state an intent to die, but which could be so interpreted, will probably be categorized as a suicide. This label is due more to the coroner's definition of the situation that hangings are usually suicides and suicide notes are a positive indication of intent to die than to conclusive objective evidence that the death Is actually a suicide (Atkinson, 1975)-

In cases of suicide, the deceased may deliberately have set out to confuse the determination of manner of death so as to avoid stig­ matizing his family or to insure that insurance policies will pay his survuvors. (Some policies carry a clause invalidating the agreement in case of suicide.) Even if the victim does not attempt to conceal his intentions, relatives and friends who happen on the scene before, and even after, the official investigators arrive may destroy or conceal evidence which would lead to a suicide verdict (Helpern, 1977:

Labovitz, 1968; Douglas, 19^7; Gibbs, 1968).

In the case of homicides, those causing the deaths have a particularly good reason for manipulating the evidence to conceal the true manner of death and arranging for a verdict other than homicide. In addition to cases of mislabeled homicide there may be undetected cases where the victims' bodies are never located and possibly not even missed, so that a death of any sort is never acknowledged (Mannheim, 19^5: 109; Havarad, i960).

Finally, the official charged with classifying the death may find that he is subject to pressure from the family of the deceased 13

to suppress or change a verdict. The family may wish.to prevent

unpleasant publicity and/or stigma, or to obtain financial benefits

in the form of insurance payments for a ruling of natural death, or

double indemnity payments if the verdict is "accidental" death

(Douglas, 1967; 1971; Gibbs, 1968; Labovitz, 1968). The pressure on

the official may be particularly intense if the family is an influential

one in the community (Breed, 1963). Douglas (1967) has pointed to

the possibility that part of the difference between rural and urban

suicide rates may be traceable to intentional misclassification by

rural coroners. In rural areas the coroner is likely to know the

deceased and/or his family and may be reluctant to return a verdict of

suicide, when a verdict of natural or accidental death would make

things easier for.the family. Misclassifications, rather than fewer

suicides, may account for at least some of the difference in rural

and urban rates. In addition to rural-urban differences, several

authors have suggested a problem of under-reporting in areas where

suicide is socially or legally disapproved, such as in Catholic

countries (Breed, 1963; Labovitz, 1968; Weiss, 196U; Hendin, 196U;

Stengel, 1973).

Although the official statistics from a given jurisdiction may include some inaccuracies, the prospect of additional error arises when computations are made on data for which statistics from several different areas have been pooled. Bradshaw (197^) reports finding errors in recording when county records of death are transferred into the statewide record system. For each re-recording and totaling of the number of deaths in a particular category there is the possibility 14

that some are missed or counted incorrectly. Bradshaw also found that

some deliberate recoding of cases may occur. For instance, vital

statistics personnel at the state level may operate under formal or

informal guidelines which consider children under a certain age

incapable of committing suicide. If the coroner/medical examiner at

the local level uses a lower cut-off age for capability, the state

level coder will simply recode any young suicides, possibly as

accidental deaths. The same situation is encountered at levels

above that of the state: the Division of Vital Statistics does not

recognize suicide for children under eight years old, while at the

international level, the World Health Organization does not count

any death as a suicide if the victim is under age fifteen (Horn, 1973).

That rates of manner.of death are inaccurate is an evaluation with which most researchers would concur, but there agreement ends. Gibbs

(1966) concludes that the actual rates may be either higher or lower than official statistics suggest, and that the actual amount of error is in question. Breed (1963) cites several reasons to believe that there is under-reporting of suicides, but then adds that there is also some possibility that over-reporting occurs—e.g., accidents ruled as suicides—although he admits that there is little support for that contention. Most writers seem to agree with Dr. Harvey Resnik of the

Center for Studies of Suicide Prevention and Louis Dublin that the official rates are much lower than the actual occurrences. Here again is the question of degree of error. While Dublin (1963) proposes that the rates are probably 25 to 33 per cent lower than actual occurrence,

Resnik (Pollack, 1971: 32) contends that the official statistics may 15

represent only half the number of actual suicides. Also, close

analysis often reveals that such estimates are themselves highly

speculative.

A review of the criticisms of official manner of death statistics

could leave one with a feeling of hopelessness. Indeed, at least one

writer (Hindess, 1973) suggests that following the logic of critics

such as Douglas (1967) and Cicourel (196U; 1968) leads to the necessity

of totally abandoning official statistics. Douglas and Cicourel both

point to the use of assumed knowledge and tacit understandings by

officials in the construction of their statistics. In order to under­

stand the process involving the application of such background criteria

in the categorization process, they suggest the use of trained ob­

servers to provide descriptions of the process. Hindess argues that

the trained observer would also be using assumed knowledge and tacit

understanding. He contends that a logical extension of the original proposal would involve a second observer to record the process of the

first, and so on, ad infinitum. In other words, any categorization, whether by officials, sociologists, or whomever, involves the use of background assumptions.

Furthermore, Hindess points out that the criticisms of official-

statistics usually imply that there are "real” categories which, once discovered and described, would result in "real" rates of a particular behavior. Thus, present suicide statistics are only approximations of the "real" rate of suicide. Presumably, with more information .about the actual behavior and intent of the deceased we could accurately classify the death as a suicide or not a suicide. 16

Hindess suggests. that there are no "real" categories. (See also,

Douglas, 1967.) The use of categories is an artificial device designed

to create order. The best we can hope to do is establish "relevant"

categories. The problem is that official statistics which are based

on irrelevant categories are of little use for describing a particular

society or phenomenon. Regarding suicide, we can not expect to know

the intent of the actor in every case, even the actor himself might

have trouble with that. The best we can do is use relevant categories

and relevant criteria for classification.

Hindess does not suggest that critical attention to official

statistics is unnecessary or even unfruitful. While he does dismiss

the possibility of perfect categorizations, he also maintains that

users of official statistics should strive to eliminate as much

error as possible, and proceed from there. Perfection may be unattain­

able, but we could improve our product.

Previous Studies of Coroners/Medical Examiners

The thesis of the present study is that one of the directions we

might take to eliminate error when using official statistics involves

understanding the officials themselves—their selection, qualifications,

and role performances.

Up to the present time, few studies have examined the role played by the coroner or medical examiner in generating official statistics.

Medical journals include many articles written by or for those officials, but these tend to deal with medical information used in determining the

cause of death (e.g., suffocation, drowning, et cetera), the length of time since death occurred, and the like. The few social science studies 17

of the operation, of the coroner’s office and the process of categori­

zation include those hy Fahey and Palmer (.1971 ) 3 Douglas (.1971)»

Bradshaw (1974), and Atkinson (1968; 1969; 1971; 1975; forthcoming).

Fahey and Palmer focused on the Cook County, Illinois coroner's

office and its role in the criminal justice system. They gave particular

attention to the use of juries in coroner's inquests. Fahey and Palmer

concluded that the Cook County Coroner's Office was not functioning as

the law intended. Its operation was highly political and the impartiality

of the coroner's jury in inquest proceedings was a myth.

Douglas studied the medicolegal system in California with emphasis

on the process of reaching a verdict as to manner of death.. He focused

on the correspondence between legal policy regarding the operation of medicolegal offices and the.common-sense constructions of definitions

and procedures by the officials themselves. He found that most coroners

and medical examiners assumed there were laws governing their offices, but that they were not able to specify what these were. Instead, they

acted on their own assumptions of what they should do and how. More­ over, he found that these common-sense constructions of definitions and procedures varied considerably from one official to another. As a result, a death in one jurisdiction might be classified as a suicide, while a similar death in another jurisdiction would be recorded as an accident.

Bradshaw investigated the categorization process as it existed in a major midwestern city in the early 1970's. He especially focused on the generation of official records by the coroner's office and related offices. He concluded that "If the results of this research 18

are accurate, then those who use .official statistics on .suicide in

order to generate.theory, test propositions, or plan programs can

place confidence in the figures obtainable from, the death certificate"

(Bradshaw, 197^: 190). Bradshaw cautioned, however, that differences

do exist between coroners' records and those available from the Office

of Vital Statistics. Personnel in the latter office sometimes recode

deaths already categorized by the medicolegal official.

Atkinson's research involved death categorization in the British

coroner system. He described the process used by coroners to fit known

information together into a logical explanation, or map, of what

happened and why. Atkinson (1971) concluded that officials construct

different cognitive maps for the various categories of manner of death.

In a particular case, the official will reach a preliminary judgement

about the death and then look for evidence which makes the death fit his map. He (1969) also found that coroners' maps include general­

izations about which categories of people are most likely to commit suicide. Since our own coroner system is based on the British system, the Atkinson study should be considered relevant to the present study.

Although it might seem that these four studies have covered the subject, there is still a need for more research. First, the Fahey and Palmer study and Bradshaw's research were limited because of the focus on only one office. The extent to which their findings can be generalized is, therefore, questionable. The Fahey and Palmer-research was apparently aimed at supporting a move for reform of the particular office under study. In addition, there are indications that the Cook

County operation was unique in its frequent use of coroner's inquests 19

and the relatively permanent membership of individuals, on inquest

juries. Many states, specifically those with, medical examiner systems,

do not use the inquest process to make medicolegal decisions. In those jurisdictions which still provide for a coroner's inquest, the option is used infrequently. Finally, the Fahey-Palmer study no longer accurately describes Cook County. Their research and that of other critics resulted in the abolition of the coroner system in Cook

County. It has been replaced by a medical examiner system—the only one currently operating in Illinois.

Bradshaw's research in a single office has not been published, and so is limited in readership and availability. In addition, the office in which Bradshaw did his research was unique in many ways.

The coroner in question, though elected, had held the office for several decades. His operation was larger and better staffed than any in that state, and even than most in the country. He served as coroner full time, while most other coroners in that state were part- time coroners with full-time medical practices. His support staff included several forensic pathologists in full-time employment with the office. Toxicology, histology, and trace evidence labs were included on the premises of the coroners' office and the heads of toxicology and trace evidence were nationally known and respected, as was the senior pathologist. The shortcoming of Bradshaw's study resulting from his use of only one coroner's office is compounded by the uniqueness of the office studied. While his description does provide some insights into the categorization process, it would be impossible to generalize many of his findings. This is especially true since so 20

many coroners' offices do.not have the facilities and expert personnel which accounted for much of that office's operation and figure so

importantly in the categorization process.

Douglas' description provides glimpses into the categorization process, but his report is rather brief. His discussion does provide

some evidence of the variability of official determination of manner of death, however. It should be noted that Douglas was not trying to provide a complete description of the office. His discussion is only part of a larger book on social rules and is used in an illustrative manner.

Atkinson's study, while not limited to one office, has thus far only appeared in fragments in short articles, although a full account of the work is in press. Also, his work involved the British system and may not be completely applicable to the American system. The

United States' system was originally based on the British, but it is reasonable to assume that the two have diverged since then. Indeed, a recent presentation by Her Majesty's Coroner Dr. David Paul (1974) points out some of the differences between the two systems. One of these is that inquests are still used extensively in England. Also,

British coroners are appointed, they must be trained in either medicine or law, and they are independent of both local and federal government.

The contrast with the present American system is apparent when one compares these characteristics with those specified by the various state laws outlined in Chapter IV. Despite these structural differences, however, Atkinson's study may well be more relevant for American sociologists than any of the others mentioned, because he focused on 21

decision-making processes and criteria in some detail. These.descriptions

could he used as guides for further study of particular offices or

systems in this country.

Finally, none of the previously mentioned studies dealt with a

medical examiner system and possible differences in approach and results

between the two systems. (Douglas, 1971 did. include some mention of

such systems in his study.) This omission is of increasing importance

as more and more states change from coroner to medical examiner systems.

The present study attempted to cover a variety of different offices nationwide, including both the coroner and medical examiner types of

systems.

Theoretical Approach

The following discussion from the present study's findings uses concepts associated with role theory as the organizational focus.

Throughout the research process certain concerns and behaviors of coroners and medical examiners recurred. These were first noticed during the observation phase and were further articulated during the subsequent interview and questionnaire phases. It eventually became apparent that most of these recurring themes could be classified as instances of role conflict and conflict resolution.

The data from observation, interviews, and questionnaires clearly suggest that role conflict and related structural and personal mechanisms for alleviating the conflict have important consequences for the statistics produced by coroners and medical examiners.

Previous research on occupations of various types has found the role conflict concept very useful for explaining behavior and 22

constructions, of reality , among occupational group members (e.g., Gross

et al., 1965; Ritzer, I968; Quinney, 1962;. Wardwell, 1952; 1955;

McCormick, 1956). The usefulness of the concept is sometimes clouded

by a confusion of the terms "role conflict" and "role strain," however.

Distinctions between role conflict and role strain are not always

clear, nor do various authors agree on their definitions. Landis

(1977: 70) defines role strain as a "...situation in which there are

differing and conflicting expectations regarding one’s status or

position," and role conflict as a situation in which "...a person

occupies several statuses or positions that have contradictory role

requirements." Other writers (c.f., Biesanz and Biesanz, 1973: 176;

Biddle and Thomas, 1966: ho, 62) propose that role strain involves a

feeling of difficulty in fulfilling role obligations, while role

conflict includes both differing expectations for one role or for two or more roles for which expectations are incompatible. In this case the difference is merely one of degree. A third category of writers makes no attempt to distinguish between the two concepts, and may actually use only one of them to refer to differing expectations and to difficulty in meeting these for one or several roles (c.f., Shaw and Costanzo, 1970; Denisoff and Wahrman, 1975: 152-59).

The most commonly used of the three approaches seems to be that in which strain and conflict are differences of degree of difficulty in meeting expectations, regardless of whether the tension is within one role or involves several roles. Those who have used this definition do, however, allow for a distinction between conflict within a role and that between roles. The former is referred to aS intra-role conflict 23

and. the latter, as inter-role conflict. . This notation has been used,

extensively by other writers . (c.f., Biddle and Thomas, 1966; Gross

et al., 1965; Ritzer, 1968), and it eliminates some of the confusion

by making explicit reference to the distinction. In the interest of

clarity the intra-role and inter-role convention will be observed

in the following discussion. "Role strain" will be used to designate

the feeling of difficulty in fulfilling role obligations.

Directly related to the existence of role conflict is the clarity

of role requirements and consensus about these among role partners.

As Lofland (1976: 137) has pointed out,

Roles differ in the degree,.of their formality and social articulation. At the most extreme of articulate formalization, abstractness, and impersonality, roles are embodied in codes of law specifying who can occupy the role, what the performance requirements are, and what constitutes grounds for removal.... At the opposite extreme, many roles are inarticulate, concrete, and highly personal.

Although each state has statutes setting forth the duties and qualifications of its coroners and/or medical examiners, these laws are often vague. This vagueness is further complicated by two addi­ tional factors. First, the occupation is undergoing changes in de­ finitions and standards in many states, and second, the coroner/ medical examiner role has not been a focus of attention, even among its role partners. As a result, the public and those occupational groups which work with coroners and medical examiners—police, ambulance attendants, public officials, and the like—may be uncertain what the coroners/medical examiners do and what their rights and obligations are in relationships with them. Under these ambiguous conditions, role theory would predict role conflict. 2U

The literature indicates that role conflict,.role strain, and

their resolution can he viewed at either a.structural or a personal

level. Although some consideration will he given to both of these

levels, this discussion will emphasize structural demands and responses

and the role bargining and negotiations which occur within such

frameworks.

Robert Merton's (1957) discussion of role-sets and social-

mechanisms articulating role-sets provides a framework for analyzing

role conflict and its resolution for the coroner/medical examiner

role. That every social status involves an associated role is one

of the "truths" routinely taught in introductory sociology classes.

In reality, every social status involves not just one role, but an

array of roles. This multiplicity of roles is the result of the

necessity of interacting with a variety of role partners, each with

his own definition of the strategic role (Lofland, 1976) and its

requirements. Merton (1957: 110) defines this role-set as'"...that

complement of role relations in which persons are involved by virtue

of occupying a particular social status."

The existence of role-sets creates the potential for intra-role

conflict because differences in position among role partners and between role partners and the occupant of the strategic role lead to differences in interests, sentiments, and expectations (Merton, 1957)-

If the social structure is to endure, it must produce mechanisms which lessen these conflicts among partners' expectations. Societies develop norms which help to prevent some of this conflict (Webster, 1975: 122-2U)

Merton describes six structural mechanisms which lessen conflict 25

resulting from the existence of a role-set.

(1) Different.statuses are given different levels;of importance.

In conflict situations, particularly those Involving inter-role conflict, the performance of some roles takes precedence over others.

(2) There are differences in power among the members of a given role-set. Those with more power are able to exert pressure to have their expectations fulfilled at the expense of those with less power.

(3) The occupant of the strategic role is protected from some role conflict by the mechanism of insulation of role-activities from observation by members of the role-set. Interaction with particular set members may be intermittent or the actual performance may occur in backstage settings (Goffman, 1959) from which set members are normally excluded.

(i) If set members are unaware of conflicting expectations, the role occupant is left to cope with the conflict himself. If set members are made aware of the conflict, however, it is then their burden to resolve it by clarifying expectations one way or another.

In this case the role occupant might even use the awareness of con­ flict to his advantage,setting one role partner against another.

(5) Because those who occupy a particular status face similar problems, mutual support associations may develop among status occupants. When this particular structural mechanism exists, the association acts as a social support for its members and may even initiate attempts at role clarification and conflict resolution.

(6) Finally, status occupants experiencing role conflict may abridge their role-set, breaking relations with role partners whose 26

support is not essential to the role performance. Despite.the existence

of a number of structural mechanisms for lessening role.conflict,

some conflict may he left unresolved. Merton refers to this as

"residual conflict." Residual conflict may still he potent enough

to prevent the role-system from operating at full efficiency.

Obviously not all attempts to resolve role conflict are structural.

Some analyses of role conflict have focused on inidividual attempts to resolve the conflict or strain. Such attempts may also be directed

at resolving residual conflict. William J. Goode (i960) has described a number of mechanisms for reducing role strains. Goode (i960: 483) describes role relations as "...a sequence of ’role bargains,’ and as a continuing process of selection among alternative role behaviors, in which each individual seeks to reduce his role strain." Goode describes six individual strategies for reducing role strain: compartmentalization, delegation, elimination of role relationships, extension, obstacles against indefinite expansion of one's role system, and barriers against intrusions.

Compartmentalization involves breaking the role into smaller parts based on l) location and context or 2) urgency. These parts can be separated and ranked. Delegation is simply shuffling less vital aspects of the role performance onto someone else. Elimination of role relationships is more or less the same as Merton's "abridge­ ment" mechanism. Again, elimination.is restricted to nonessential role relationships and thus, has only limited utility. Extension is the practice of increasing one's role relations so that the status occupant can legitimately plead "lack of time" as an excuse for failing to 27

perform some aspects.of the.role. Obstacles against indefinite,

expansion of the role system involve the necessity .of certain re­

strictions on the system in order to meet existing role requirements.

Finally, barriers against intrusion are techniques to prevent others

from activating a role relationship. These include such ploys as hiring a secretary to act as a gatekeeper or including a "free" day in the work week when one can not be disturbed by his role requirements and role partners.

Summary

Critics mention several sources of bias in official statistics of manner of death. These include l) pressures from others to falsify verdicts; 2) bureaucratic goals imposed on the official; 3) varying definitions and cognitive maps used for classification; lack of sufficient information about a case; and 5) variations in the training and skills of officials. Interview and observation data collected during the preliminary phases of this study revealed that coroners and medical examiners were also concerned about these issues—structural constraints and the expectations of role partners. To varying degrees all of the officials included in the initial interviews expressed the idea that one or more of these factors affected their ability to perform their medicolegal roles. Questionnaire responses from a national sample of coroners and medical examiners were consistent with those received in interviews.

These structural constraints and role expectations produce role conflict and/or role strain for a medicolegal official. The restraints placed.on a coroner or medical examiner by state medicolegal statutes 28

involve definitions .of the role and qualifications for the position.

State.or local officials.control the budget which influences, the kind

and amount of investigation each case will receive. Role partners with

a variety of interests hold different and often conflicting expectations of the official.

The structural and personal mechanisms used by officials to relieve conflict and strain have implications for the accuracy of the statistics produced. An insufficient operating budget may require the official to assign different priorities to different kinds of cases. Cases with high priorities (e.g., possible criminal cases) might receive extensive investigation, while low priority cases (e.g., apparent natural deaths of elderly persons) receive little more than a cursory external examination. The demands of a victim's family that the official rule the death accidental rather than a suicide conflict with the public's expectations that the verdict will be accurate and impartial. A lay coroner who lacks forensic training is faced with the need to buy autopsy and other medical investigative services necessary to determine or verify the cause and manner of death. At the same time he is constrained by a low budget and the conflicting expectations of county commissioners that he should minimize expenditures and never make mistakes.

The choices a medicolegal official makes in role strain and role conflict situations affect his verdicts which become the official statistics of manner of death and cause of death. Examination of these role conflicts and role strains and the ways in which they are resolved is an important step toward more complete understanding of the nature of the weaknesses in official statistics. Such understanding could 29

make it possible to.adjust for some of the'bias in the.statistics

and reduce error resulting from their use in social science research. Chapter III

METHODOLOGY: SAMPLES, STRATEGIES, AND TECHNIQUES

The data reported and analyzed in the following chapters were collected by a variety of methods from a number of different sources.

This chapter is divided into three main parts. The first section includes definitions of special terminology and position titles. The second section describes the samples used at different points in the study. It also includes the rationale for selecting the samples. The third part of the chapter describes the research methods used and a rationale and evaluation of each.

Terminology

As previously mentioned, the present study focused on coroners and medical examiners and their roles in the production of manner of death statistics. An early goal of the research was to discover the difference between coroners and medical examiners and the type of system in which each operates. Although this distinction is basic to much of the debate about medicolegal systems, preliminary research indicated a lack of consensus among officials about what constitutes a coroner system as opposed to a medical examiner system.

According to Webster's Dictionary (1967: 509), a coroner is

"a public officer whose principal duty is to inquire by inquest held in the presence of a jury into the cause of any death which there is reason to suppose is not due to natural causes." A medical examiner 31

is described, as

a usually appointed public officer who must be trained in medicine and whose functions are to make postmortem exam­ inations of the bodies of persons dead by violence or suicide or under circumstances suggesting crime, to investigate the cause of their deaths, to conduct autopsies, and sometimes to initiate inquests. (Webster's Dictionary, 1967: 14-02)

The reality is not as simple as these difinitions indicate, however.

Specific variations from state to state are examined in some detail

in Chapter IV, but some generalizations can be made here.

In practice, coroners are usually elected officials. Although

some states require coroners to be licensed, practicing physicians,

many impose no restrictions on candidates for the office other than

citizenship and legal age. In some states the coroner position is

incorporated into some other office (e.g., sheriff, county prosecutor),

with the coroner role being secondary. Most coroner systems provide

the legal justification for inquests, but in practice many coroners

never hold an inquest while others use this procedure infrequently.

Coroners, therefore, are usually elected officials who may or may not

have medical training and who are charged with the investigation of

sudden, unexpected, or violent deaths. They may order autopsies to

be performed and may hold inquests into the circumstances surrounding

a death (Kornblum and Fisher, 1972; National Municipal League, 1975;

Department of Health, Education, and Welfare, 1977).

The dictionary definition of "medical examiner" is much closer

to reality than is that of "coroner." Medical examiners are usually

appointed and must have medical degrees. The medical examiner position is usually regarded as a career, whereas the elected coroner 32

is subject to re-election. Medical examiners do conduct postmortem

examinations and perform autopsies on the bodies of those who die

suddenly, unexpectedly, or violently. However, medical examiners

seldom initiate inquests. In fact, many states with medical examiner systems no longer allow for inquests, or they allocate the power to initiate inquests to legal officers such as county attorneys. In some instances the medical examiner position may be part of another position, such as public health officer.

In addition to the differences in qualifications, selection, and power to initiate inquests, organizational characteristics of coroner and medical examiner systems also differ. Usually coroners are more or less autonomous and are responsible for a relatively small area, such as one county. Each coroner, being an elected county official, is independent of a larger medicolegal system. Although in some states (e.g., Iowa, Michigan) medical examiners have similar autonomy, it is not unusual to find centralized medical examiner systems. In the latter situation a chief medical examiner has ultimate control of an entire state. Local medical examiners are responsible to the Chief

Medical Examiner who usually has specialized training in forensic pathology, a medical specialty which relates medical facts to legal cases. As will become clear in the next chapter, the situation is further complicated in states which mix both systems. In a few states

(e.g., California, New York) some communities have medical examiner systems while others use the coroner system. Kentucky exemplifies another variation in which elected county coroners are backed up by a medical examiner system under which the state is divided into fourteen regions. 33

An umbrella term, "medicolegal officer" is also used in the

following chapters. This term, meaning "of or relating to both

medicine and law" (Webster’s Dictionary, 196?: 1^02) is used to

refer to both coroners and medical examiners.

"Manner of death" refers not to the medical cause of death

(e.g., strangulation, loss of blood, et cetera), but to the way in

which the victim met his death.Manner is usually categorized as

one of the following: natural, accidental, suicide, homicide, or

undetermined. Further attention is given to definitions of these

terms in a later chapter.

Samples

Two separate samples were used for different phases of the

research—one for interviews and the other for a mail survey. The

interview group was a convenience sample. Twenty-seven focused

interviews lasting on the average of an hour to an hour and a half

constituted the first part of the research plan. Although inter­

views with a random sample of medicolegal officers from across the

United States would have been preferable, limited financial support

forced a different approach. However, efforts were made to include

offices which differed in size, location (rural-urban, region of the

country), and type of system.

1 Although the accuracy of both "cause" and "manner" statistics is in question, social scientists utilize manner statistics more frequently than those for cause. Cause is also often reflected in the ruling on manner. In order to avoid the increased complexity of dealing with the physiological aspects of cause and because cause includes a multiplicity of possible categories, the present discussion will center primarily on manner of death statistics, rather than on both cause and manner statistics. 34

Initial interviews were conducted, with coroners from both rural

and urban counties in Ohio. Since Ohio law stipulates that coroners

must be licensed, practicing physicians, all these respondents were

medically trained. Of the thirteen jurisdictions included in this

series of interviews, most were located in the western portion of the

state in accordance with the criterion of convenience.

From the Ohio interview sample, two offices were chosen as sites

for more extensive interviews and observation of the operation of the

office and the official. Both of these offices were located in urban

areas, but the scale of their operations was quite different. One

office (Office A) encompassed a large full-time staff including p forensic pathologists, toxicologists, and trace evidence technicians,

in addition to the coroner. The office itself included a morgue,

autopsy facilities, and the appropriate laboratory facilities, as

well as administrative offices.

The other office (Office B) was much smaller. It was staffed by

a part-time coroner, two administrative assistants, and two field in- o vestigators who collected evidence, secured property, and the like.-1

2 Trace evidence technicians process clothing, blood stains, weapons, and the like to provide information to supplement that collected by the pathologist during the postmortem examination and autopsy.

Although the coroners in both cases were on call twenty-four hours a day, seven days a week, one engaged in another occupation at the same time. In this study, "full time" refers to officials whose sole or main occupation is the medicolegal role. A part-time officer is one who has another occupation (e.g., private medical practice) and who handles medicolegal cases as they arise. This latter case usually characterizes less populous counties in which there are not enough medicolegal cases to justify paying the officer a full-time salary. In some states these officers are paid on a per case basis. 35

During the observation period this office handled only administrative

details. Since no autopsy or laboratory facilities were included on

the premises, area hospitals provided these services when needed. In

this regard, the office, though in an urban area, was similar to

operations in many rural counties in Ohio. (This office was preparing

to enlarge its staff and facilities. Facilities for autopsies and

laboratory work were being added, and the addition to the staff of

a forensic pathologist was planned for 1978.)

It might also have been beneficial to include a rural office in

the observation sample, but certain practical considerations eliminated

that possibility. Rural officers usually engage in coroner duties

on a case by case basis. That would necessitate spending many hours

in the setting waiting for relevant action. Also, rural officers

usually do not have a separate coroner’s office. In Ohio they

frequently operate from their medical practice offices and adminis­

trative, postmortem, and laboratory services are performed in

separate, scattered locations. Coroner functions may be performed between hospital rounds and medical office hours or late at night.

These features limit the ease and efficiency of observation and an observer would obtrude on the physician’s routine.

In addition to the thirteen interviews conducted in Ohio, officials in twelve other states and the District of Columbia were interviewed.

Officials for those interviews were selected on the basis of one of two criteria. One category included officials who represented juris­ dictions in states bordering Ohio. In those cases the interview and round-trip drive could be accomplished in one day. That category 36

accounted for three states (Michigan, Indiana, Kentucky) and four

interviews. The other category included jurisdictions which the

researcher planned to visit or he near in the course of other

activities (e.g., professional meetings, vacations). Since data

collection was carried out over a period of about fifteen months,

several such trips resulted in interviews with officials from nine states and the District of Columbia. Three midwestern (Illinois,

Nebraska, Minnesota), three southern (Virginia, North Carolina,

Georgia), and three northeastern states (New York, Pennsylvania,

Maryland) made up this category. Table 3.1 presents a breakdown of' the jurisdictions by type of system, population, and urban or rural character. Character was determined by population density and whether or not the jurisdiction was dominated by a city of 200,000 or more according to the 1970 Census of Population.

The mail survey sample included 900 medicolegal officers repre­ senting all fifty states in the United States. The initial plan was to survey all those medicolegal officials who were not interviewed.

However, a preliminary check of the number of coroners and medical examiners indicated that there were at least 3,000 medicolegal jurisdictions in the United States. Since some of these jurisdictions included several part-time officers, the actual number of officials was more than 3,000. Limited financial support and the cost of producing and mailing the questionnaire made a total survey of such an extensive population prohibitive.

Before the sample was drawn, a letter requesting a list of all coroners and/or medical examiners was sent to the Secretary of State 37

TABLE 3.1: Interview Sample by Type of System, Population of Jurisdiction, and Rural-Urban Character

System Populationa Character

1. Coroner 21,826 Rural 2. Coroner 30,813 Rural 3. Coroner 33,071 Rural 4. Coroner 36,949 Rural 5. Coroner 60,696 Rural 6. Coroner 60,983 Rural 7. Coroner 61,217 Rural 8. Coroner 88,704 Mixed Urban-Rural 9. Coroner 89,722 Rural 10. Coroner 111,144 Rural 11. Medical Examiner 119,172 Rural 12. Medical Examiner 154,364 Urban 13. Coroner 280,455 Rural 14. Coroner 389,455 Urban 15. Medical Examiner 472,835 Urban 16. Coroner 483,594 Urban 17. Medical Examiner 607,592 Urban 18. Coroner 608,413 Urban 19. Medical Examiner 620,409 b 20. Medical Examiner 756,510 Urban 21. Coroner 923,205 Urban 22. Medical Examiner 960,080 Urban 23. Coroner 1,720,835 Urban 24. Medical Examiner 1,949,996 Urban 25. Medical Examiner 2,670,368 Urban 26. Medical Examiner b b 27. Coroner c c

a Population from U.S. Bureau of Census, 1970 Census

Person interviewed was head of a state system.

c Five coroners from one state were informally interviewed at once about their state's system. Two represented urban counties and three were from rural counties. This was counted as one interview. 38

for each state. The total number of medicolegal jurisdictions in­

dicated by these lists was 3,015. The mean number of jurisdictions

per state was sixty. Budget and personnel limitations combined with

scientific considerations resulted in the decision to sample 30 per

cent of the jurisdictions. To insure that all states were adequately

represented, the mean number of jurisdictions per state (sixty) was

divided by one-third. The resulting figure (twenty) was the number

of jurisdictions to be included per state.

Eleven of the fifty states involved fewer than twenty jurisdictions

each. In those cases, an official in each jurisdiction received a

questionnaire. To select the sample from each of the remaining

thirty-nine states, each jurisdiction in a state was numbered

chronologically, beginning with "one." (The lists usually arranged

officials alphabetically by counties.) In a few cases particular

jurisdictions were unique (e.g., major cities). To insure their

inclusion, those jurisdictions were automatically chosen for the

sample. Eleven jurisdictions were chosen this way. The remaining

respondents were selected by drawing numbers from a table of random numbers until the desired sample size was reached. (Officials who participated in the interview phases were eliminated.) The resulting list was then checked to insure that all regions of the state and both rural and urban jurisdictions were included. The final list included 897 names. Before the survey was completed, however, three names were added in an attempt to collect data for key areas from which the original sample member had not responded.

The final sample included 900 names. Of these 900, exactly ^00 39

officials responded. After adjusting the total number of questionnaires

mailed to take into account twenty forms which were returned as

"undeliverable," the response rate was 45.5 per cent. Table 3.2

provides a breakdown of respondents by type of system, type of juris­

diction, and respondent's educational background. The frequencies

represent responses to questions 1, 9, and 57 on the questionnaire

(see Appendix I).

TABLE 3.2: Description of Survey Respondents by Type of System, Type of Jurisdiction, and Respondent's Educational Background.

— * - - Characteristic Number in Sample

System: Coroner 234 Medical Examiner 166

Jurisdiction: Urban 26 Suburban 24 Rural 246 Other 3 Mixed 76

Education: Less Than High School 2 High School 29 Some College 23 Mortuary Science Degree 42 Bachelor's Degree 18 Master's Degree 3 Medical Degree (MD/DO) 244 Law Degree 17 Other 16

Research Methods

The order in which the following methods are presented does not necessarily indicate the order in which they were actually used in the 40

research. As is true of many studies, several techniques were some­ times used in the same time period.

Initial interest in medicolegal officials and statistics stimulated by the criticisms of official statistics in suicide literature led to a search of library materials for descriptions of a coroner's office.

This approach proved to be less fruitful than any other part of the research process, however. As indicated in Chapter II, there was little material available on the subject, apart from technical journals and books meant for medicolegal officers.

A search of state laws was somewhat more helpful. The review of laws began with actual statutes and was meant to provide background for initial interviews in Ohio. Early in the interview stage a respondent mentioned a volume which included medicolegal laws for all fifty states (National Municipal League, 1975). This report provided an easily understandable review of the relevant statutes. Later, two additional reviews were discovered. One of these (Kornblum and

Fisher, 1972) was prepared by medicolegal officers and the other

(Department of Health, Education, and Welfare, 1978) was written by a research firm under contract to the United States' Government.

These three sources served as a cross-check on each other, and the

1978 publication updated the other two.

The first interview with a coroner was conducted in the fall of

1976. For this interview and each subsequent one, a letter was used to initiate contact. The letter briefly outlined the purpose of the research and requested an interview with the official (see Appendix

II). In many cases the introductory letter was followed by a telephone 4i

call to set up a specific appointment. The remaining officials

answered the request with a letter.

Whenever possible the letter appeal included reference to a

colleague of the officer in question. In an early interview one

of the respondents asked which officials were included on the

interview list. When several names were mentioned he commented that

he knew those persons and that he would allow his name to be mentioned

in contacts with them. During subsequent interviews respondents

were asked about possible connections in other cities. These

questions not only revealed an informal network of medicolegal

officials, but also smoothed the way for later requests for interviews

Interviews were conducted over a period of about fifteen months.

Early interviews focused on basic information about the purpose and

operation of the office. They also included numerous questions about

terminology and medical procedures. Once an understanding of some

of these basic aspects was developed, the interviews were directed

more toward the respondent’s attitudes and relationships with others

in his role set. Basic questions about the purpose and operation of

the office were included in all the interviews, but these became less time consuming as basic medical and legal terminology became part of the research vocabulary.

Although the interview phase covered a period of fifteen months,

few interviews were conducted in the first nine months. During that time only three coroners and one medical examiner were interviewed.

The remaining interviews took place in the final six months of the

data collection process. That schedule allowed time to develop focused questions and interviewing techniques. 42

The interview phase constituted a major part of the data collection

process. Because of the need to secure meaningful data, it was impor­

tant to know as much as possible about medicolegal roles and procedures

before conducting the majority of the interviews. The first four

interviews provided a great deal of the necessary background information.

Since two of these officials consented to observation in their offices,

there was also opportunity to supplement their initial interviews with

additional questions at a later time.

The interviews covered a list of basic questions, but some sessions

were more structured than others. All the respondents in this phase

were well-educated and experienced at answering questions. Each

interview began with the interviewer reminding the official of the

nature of her study and outlining the types of questions to be asked.

Questions about the official's educational background and professional

affiliations were followed by inquiries about his medicolegal respon­

sibilities and policies. Additional questions covered relationships with role set members and problems faced by coroners or medical

examiners. Appendix III includes a sample interview schedule. In

some cases the respondent's answer to one question lead him auto­ matically to others. In these cases the interviewer allowed the

respondent's discussion to flow freely and only occasionally inter­

jected a question for clarification or redirection. Other respondents waited for individual questions to guide the interview.

Although a few interview questions were rather specific, most were more general. Also, each interview included an opportunity for the official to add information which he thought would be of interest 43

or importance for understanding his role and problems.

As previously indicated, the interview phase used a convenience sample of coroners and medical examiners. Of those contacted, only one refused the interview request. He wrote that his jurisdiction was so small that he did not have anything of importance to con­ tribute. Since several other jurisdictions of about the same size were included in this phase, no further attempt was made to include this official. Two other officers, both part-time coroners with medical practices, were dropped after several attempts to arrange an interview. Each of these officials was willing to participate, but schedule conflicts could not be resolved. Overall, respondent cooperation was excellent.

To avoid as many potentially biasing variables as possible, an effort was made to standardize the approach and techniques from interview to interview. A specific appointment was made for each interview. All but two interviews were conducted in the respondent’s office. One coroner requested a meeting at this home on his day off and the other scheduled the interview for his. lunch hour in a nearby restaurant.

In most cases only the official and the researcher were present during the interview. The coroner's wife was present during the one home interview and three coroners invited staff members to participate and provide additional information. Separate interviews with pro­ fessional staff members (forensic pathologists, toxicologists, and trace evidence technicians) were encouraged and conducted in one office

None of the interview sessions were recorded on tape. During an 44

early interview, the medicolegal official expressed a certain amount of distrust of the news media. That was a result of incidents in which media personnel had quoted comments which were made "off the record." Because many of the officials were elected and because several of the questions dealt with possibly sensitive issues, a tape recorder might have inhibited responses. Notes were taken by hand and later transcribed.

To minimize the possibility of variable reactions to the re­ searcher, an attempt was made to present a standardized impression from interview to interview. This included the use of conservative dress and make-up, punctuality for interviews, and the like.

Following each interview, the respondent received a letter of thanks with a promise of a summary of the findings after the completion of the study.

One interview differed from the others in several ways. During a free period at a meeting of the International Association of

Coroners and Medical Examiners, five coroners from one Midwestern state agreed to an informal group interview. Because this interview was not arranged in advance and involved several coroners, the ques­ tioning was less organized and focused than in the other situations.

The group interview dealt more with general practices in that one state and provided little information about specific offices, except insofar as they differed from the norm.

As previously mentioned, the data collection strategy also included a limited amount of observation in two coroners’ offices.

One week was spent in Office A (the larger office) observing the 45

operation of the organization and interviewing personnel at all levels.

This included administrative and laboratory work, as well as autopsies

and external postmortem examinations. A typical day in this office

began with a review of all new cases since the day before followed by

autopsies in those cases which required them. The pathologist spent

the remainder of the work day reviewing details of cases, analyzing

tissue slides and lab reports, counseling relatives of deceased

persons, giving court testimony when necessary, conducting research,

and completing a variety of other duties.

Observation in Office B, the smaller office primarily concerned with administrative detail, was conducted over a period of approximately

one year. The early stages involved spending a number of hours each week in the setting. Later, as other aspects of the research became more demanding, less time was committed to this office.

Although the range of activities was rather limited in Office B, it did provide a good opportunity to ask questions and observe the legal phase of the coroner’s role. Relatives of deceased persons visited or telephoned the office, the coroner spent one day a week there signing out cases and arranging investigations and medical workups, and legal documents concerning a coroner's case originated in that office. It was possible to observe the staff at work and to learn how a coroner could coordinate a medical practice with his medicolegal role.

Cooperation from the coroners and staff members was excellent.

They provided full access to all areas of the operations, to personnel, and to documents and files. The only stipulation made in either case 46

was that individual cases not he identified in research reports or

private conversations outside the office. The researcher was even

allowed to hear discussions of case details which were to he with­

held from the news media until police investigations were completed.

During the observation stage it was also possible to examine

a large number of case files in a coroner’s office. These files

contained autopsy protocols and laboratory results, the coroner’s

notes, police reports, and reports from the coroner's field!

investigators, as well as the official coroner's verdicts. From

those documents additional information was obtained about the operation

of the office. A review of two specific types of cases—drownings

and carbon monoxide deaths—provided an indication of the kinds of

clues the coroner used to make manner of death determinations.

In addition to the interviews and observation in coroners' offices, attendance at the annual meeting of the International

Association of Coroners and Medical Examiners (IACME) in June, 1977 provided another opportunity to observe the officials and learn more about their roles. The membership of this organization is composed of medicolegal officials, mostly coroners, from the United States,

Canada, and Mexico. (Another organization, the National Association of Medical Examiners, attracts many of the medical examiners.) Each year the IACME sponsors a one-week seminar for its members. During the seminar members hear speakers on a variety of topics and have a chance to discuss their own problems and concerns. The group also holds a business meeting and acts as a support organization for its members. The 1977 program included presentations on Legionnaire’s 47

Disease, child, abuse, the Sudden Infant Death Syndrome, forensic

anthropology, trace metal detection techniques, and the like. One

group of speakers discussed the relationship between medicolegal

officers and role set members such as county prosecutors, sheriffs,

and the Federal Bureau of Investigation. Other speakers outlined procedures for handling air crashes and disasters such as the 1977

Beverly Hills Supper Club fire in Kentucky.

The IACME meeting provided an opportunity to learn more about the technical side of the medicolegal role and to talk to a number of officials informally. The questions and comments made by members during the sessions also indicated their attitudes toward role partners and the kinds of concerns the officials had about their roles and role performances.

The final phase of data collection involved a national mail survey. The questionnaire (Appendix I) was constructed on the basis of data collected from all the previously mentioned techniques. It was designed to elicit information about the particular official and his office, and about state policies. It included both forced-choice and open-ended questions.

The first mailing to sample members included a lengthy cover letter

(Appendix IV), the questionnaire, and a prepaid return envelop. The cover letter outlined the research project and promised respondents a summary report at the conclusion of the study.

The body of the letter was mass produced on bond stationary, but the name and address of the official and the salutation were individually typed at the top. Address labels were also individually typed and each 48

letter was signed by hand in blue ink. The questionnaire was reduced

and printed on both sides of 8 1/2 x 11 inch paper. These packets were sent by first-class mail with a metered stamp. The first 711

questionnaires were mailed in early September. The remaining ques­ tionnaires were mailed later because not all names and addresses were known in time to include them.

Whenever possible, the questionnaire was addressed to a specific official by name. Names could not be acquired for seven states, even after several attempts. For those states the questionnaire was addressed to the county coroner or medical examiner in care of the courthouse at the county seat. Interestingly, the return rate for these states was comparable to that for states in which names and specific addresses were used.

As questionnaires were returned, the respondent's name and identification number were checked on a master list. A follow-up letter (Appendix IV) was mailed in early October. That letter was mass produced on bond paper with the signature and a general salutation. It was mailed at a bulk rate.

A second follow-up letter and another copy of the questionnaire completed the mailings. These were also sent at the first-class rate and were mailed early in November. Again, the body of the letter was mass produced on bond paper, the address and saluation were individually typed, and each letter was signed by hand. Persons who had already returned a questionnaire were not included in either follow-up. 49

Summary

The design for this study utilized a variety of research methods.

The review of state statutes formed the basis for a summary of state policies regarding the medicolegal role and provided background for later phases of the research.

Ideally, all contacts withihe officials would have involved personal interviews which would have allowed probing and the collection of detailed information. Although the actual number of interviews was limited, these and the data collected by observation form the basis of this study. They also provided the necessary information for con­ structing the questionnaire used in the mail survey.

Archival data—coroner files and annual reports—provided additional insights into the operation of a medicolegal office and the process of producing manner of death statistics.

Finally, a mail survey was the only possible way to reach a large number of coroners and medical examiners and include each state with a limited budget of time and money. Although the questionnaire did not allow for probing, it did include both forced-choice and open- ended questions. Most of the respondents who participated completed the entire form and many also returned additional information about their state systems or individual offices.

Overall, the combination of research techniques allowed for data collection at several levels and provided a range of information. The scope and relevance of these data will be revealed in the following chapters. 'So

Chapter IV

MEDICOLEGAL ROLE REQUIREMENTS: THE HISTORY AND STATE LAWS

The discussion presented in this chapter focuses on legal, role

requirements for coroners and medical examiners in all fifty states

in the United States. A brief summary of the history of these

positions provides the background for a review of state laws which

define the qualifications and responsibilities of medicolegal

officials. State statutes represent official policy regarding the

office. Chapters V and VI include data regarding the role perceptions

and performances of coroners and medical examiners.

History of the Medicolegal Office

To understand the present medicolegal system in the United States,

one must look to the history and origins of medicolegal interest in

death and the causes and circumstances which lead to it. Because

early American coroners' offices were patterned after those in England,

a history of the office in the United States must also include a

summary of the orgins of the English medicolegal system.

Long before the office of coroner was created, there was

interest in the manner in which a person died. Fisher (1973) reports that even before the birth of Christ forensic medicine was sometimes called upon to determine whether or not a death was suicide.

Suicide was condemned in many early societies and penalties were imposed on the victim or his family. In some cultures people believed 51

that suicide victims were possessed by evil spirits and the living

tried to protect themselves from those spirits. Many cultures

defined suicide as an offense against their god or gods. Penalties

for suicide varied. Goods and property might be seized, or the

victim might be denied funeral rites or burial in sacred ground.

The ancient Romans treated soldier suicides as desertions. In some

societies the bodies of suicide victims were buried at a crossroads

or burned along with their homes and possessions.

By the Tenth Century suicide was forbidden by English common

law. In 1184 the Council of Nimes condemned suicide, thus including

it under canon law. At that time a determination of the manner of

death was based primarily on investigation of the circumstances of

death with little or no attention to medical examination of the body

itself (Fisher, 1973).

There is some controversy over the exact date on which the office

of coroner was established. Some believe it was instituted in 1194

and others estimate that it existed prior to that time (Paul, 1974;

Encyclopedia Britannica, 1926). Fisher (1973) reports that the

Charts of Privilege show a grant of the coroner's office made by

King Athelstane to a nobleman named St. John of Beverly in 925-

Regardless of when it was first established, the purpose of the office was to safeguard the interests of the Crown in felony cases. From the beginning the coroner's office was closely associated with that of sheriff in English practice. Both held investigative powers and the coroner substituted for the sheriff whenever necessary

(Posner, 1975). The coroner was also charged with the responsibility 52

of acting as a check on corrupt practices of the sheriff. The sheriff

was to act as a representative of the King—collecting taxes, main­

taining order, and securing property which belonged to the Crown.

The immense powers of the office and the lack of supervision made it

easy for the sheriff to redirect some of the wealth from the King to

himself. The coroner was appointed to prevent the sheriff from

cheating the King out of money and property. A coroner was elected

by freeholders in his county. Only a lawful and discreet knight

was allowed to hold the office. (Knighthood itself required ownership

of a certain amount of land.) The title "coroner" derives from the

office holder's status as keeper of the pleas of the Crown. "Crown"

was formed from the Latin word "corona" and "coroner" is a corruption

of either "coronator" or "crowner" (Posner, 1975; Fisher, 1973).

The original duties of the coroner were to (l) hold inquests,

(2) inspect wounds and arrest the accused if those wounds were likely

to be fatal, (3) attach or arrest witnesses or suspects, and (4) safe­

guard land and other property which belonged to the Crown under

circumstances of death such as suicide (Fisher, 1973).

By the Fourteenth Century the knighthood requirement for coroners was dropped, but ownership of land was retained as a requirement in

English law until 1926. Land ownership was designed to insure that the

coroner would have an income and would, therefore, be able to handle

cases for anyone in his jurisdiction, not just the wealthy. It was also intended to prevent temptation to steal from the Crown.

Although the office was originally an honor given to a very reputable knight, it soon fell from honor as unqualified, corrupt 53

individuals were selected. Payment of fees to the coroner, a practice

which had originally been forbidden, became common. Since a salary

was not legislated for the office until i860, fees consituted the only

income a coroner received for his services (Paul, 1974; Fisher, 1973).

The office of coroner in the United States, like many other

official positions, was transported from England and included duties

similar to those performed by British coroners. On January 29, 1637

the Governor of Maryland appointed Thomas Baldridge of St. Mary’s to

be coroner and sheriff. He was authorized to carry out all the same

duties as any sheriff andccoroner in England (Fisher, 1973). But as

Paul (1974) reports, the evolution of the office was frozen in time

for a long period in America while it continued to evolve in England.

Remnants of the old English institution, complete with elected

coroners, fees, and a close relationship with the sheriff are still

found in many states today. England, meanwhile, has moved to an

appointive system in which the coroner must be qualified in law or medicine. Inquests are still used extensively in the English system

(Paul, 1974; Fisher, 1973; Encyclopedia Britannica, 1926), but are used infrequently in the United States.

Although forensic medicine was being practiced-at about the same time that the office of coroner was established, it was not developed by coroners. An early Chinese handbook, the Hsi Yuan Lu published in

1250, contained guidelines for conducting postmortem examinations.

Among other topics, it included descriptions of methods for determining whether a person found in the water had drowned or died before entering the water (Fisher, 1973). 51!

The written record of European forensic medicine begins with the

Bamberg Code of 1507 and in 1530 a more extensive code was issued by

Emperor Charles V. In the Sixteenth Century Ambrose Pare, Fidelis, and Zacchia used autopsies as a basis for research on a variety of topics including sexual assault, child smothering, bullet and stab wounds, asphyxiation, and the like. Michaelis and Bohn at the

University of Leipzig gave the first formal lectures in forensic pathology and in 1807 a chair of legal medicine was established at the University of Edinburgh. Still, much of the development of medicolegal practice took place in the pragmatic atmosphere of the

Scotland Yard organization where pathologists and toxicologists were faced with the necessity,of providing answers for investigating officers in criminal cases (Fisher, 1973).

Although autopsies in medical schools were performed as early as

1647 in the United States, medicine was not officially connected with the coroner's office until decades later. In i860 a Maryland law gave the coroner or his jury the right to call in a physician in cases of violent death. Eventually a physician was appointed as coroner in the city of Baltimore. In 1877 Boston adopted a medical examiner system, but only to investigate violent deaths. New York City's medical exami ner office was established in 1915 and the chief was given the right to order autopsies when necessary. The first statewide medical examiner system was established in Maryland In 1939- lb is in these medical examiner systems that the office of coroner and the skills and knowledge of forensic pathology were combined. 55

Despite the trend toward establishment of medical examiner offices,

many states retain coroner systems which in many ways resemble those

originally established in the United States. In recent years some

effort has been made to change this situation. Organizations such

as the National Municipal League encourage state legislatures to

standardize qualifications for medicolegal officials and to include

medical training as a requirement for the office. In 1974 the

National Association of Medical Examiners (NAME) prepared a set of

standards for medicolegal systems (see Appendix V). The Preface

to "Standards for Inspection and Accreditation of a Modern Medicolegal

Investigative System" states that the Standards were created "...for

the purpose of improving the quality of medicolegal investigation of

death in this country." In the Introduction to this publication,

Dr. Ali Z. Hameli, Chief Medical Examiner for Delaware and the 1974

President of the National Association of Medical Examiners advised,

They [the Standards] are set forth to improve the status of official investigation of death in the U.S.A. It would be immaterial, of course, whether the system or its director is called Medical Examiner or Coroner. The most important factor, however, is that an efficient system should require a governing law that would mandate the selection of the Chief Medicolegal Officer based on his professional qualifications and not on election or political patronage (National Association of Medical Examiners, 1974).

Although the framers of the Standards recognized that some juris­ dictions would have to modify the model system to allow for unique conditions, they proposed a basic outline for a modern, scientific office. The Standards require the chief medicolegal officer to be a physician certified in forensic pathology who is appointed on the basis of his qualifications. The office itslef should be independent 56

of other governmental agencies. Additional requirements specify the type of support personnel (e.g., toxicologists, histologic technicians,

deputy medical examiners) and physician structures needed for an effective operation. (See Appendix V for the Standards governing the system, staff, and physicial structure of a medicolegal office.) The

Standards Committee further proposed that such a system would he impractical for small jurisdictions. In these cases they suggested that several such jurisdictions should combine their needs and resources to establish one office.

As is evident in the following summary of state laws, the suggested

Standards have been adopted in some form by a number of states or jurisdictions within states. Many other states still operate under non-medical coroner systems, however. State legislators in these states may believe that their systems work well, or they may not be willing to spend the money and time necessary to establish a medically- based system. In some cases, morticians' organizations or local political-officials oppose attempts to change the laws. The proposed

Standards bar morticians from acting as coroners and eliminate local political control of the office.

At the present time there is a great deal of variation in official policies regulating coroners and medical examiners. In addition to variation among states, separate jurisdictions within a particular state may also have different policies. Regardless of whether one system is "better" than another, the wide variation among systems_ contributes to confusion about the role and its purpose among specific role-set members and the public. It also increases the possibility of reliability error in the production of manner of death statistics. 57

Laws

The organization of medicolegal systems and qualifications for

personnel vary from state to state and within states. At one extreme

are centralized state medical examiner systems which require certified

pathologists to head the system and physicians to serve as local

medical examiners. At the opposite extreme are states which, allot the

medicolegal function to lay coroners elected in each county.

State medicolegal statutes constitute the official definition of

the medicolegal role. Those legal provisions form the basis of the

structure within which a coroner or medical examiner must work and

resolve role conflicts and strains which may arise. Lack of clarity

in the legal definition of the office may itself be a cause of some

strain or conflict. Legal provisions for financing the office determine

the amount of money and personnel available to the official and, there­

fore, indirectly influence the kinds of investigation various cases

receive. The following review emphasizes the differences in systems

from jurisdiction to jurisdiction. These differences would be

expected to produce differential conditions of role strain and role

conflict and differential responses to these within the structural limitations imposed by the laws.

The following descriptions summarize medicolegal statutes for each state and provide more insights into the range and type of differences from jurisdiction to jurisdiction. The discussion includes the type of system used, selection of officials, qualifi­ cations for the office, and general comments about each system.

Information for these descriptions was compiled from,the following 58

sources: A Compendium of State Medicolegal Investigative Systems

(Kornblum and Fisher, 1972); Coroners: A Symposium of Legal Bases

and Actual Practices (National Municipal League, 1975); Death

Investigation: An Analysis of Laws and Policies of the United States,

Each State and Jurisdiction (Department of Health, Education, and

Welfare, 1978); state laws; and personal communications with officials

in several states. The reader should bear in mind that these

descriptions are based on information for 1977« Systems are continually

revising their laws, so some changes may have been made since these

data were collected.

Alabama—Coroners are elected in each county for a term of four

years. There are not statutory requirements for the office. The

coroner may call in a physician to examine a body externally. If a

decision can not be reached without it, the coroner may authorize a

physician to perform an autopsy. Coroners take statements from witnesses in deaths suspected to have resulted from unlawful means.

These statements are passed on to a judge or solicitor for that

jurisdiction and he authorizes an inquest, if necessary. (Responses

to the mail survey indicate that officials in Montgomery and Jefferson

counties are appointed.)

Alaska—A combination of coroners and medical examiners operates

in Alaska, although coroners hold most of the power. District judges and magistrates serve as ex officio coroners. These officials are elected and serve indefinite terms. Physicians are appointed by the

Commissioner of Health and Social Services to fill one year terms as medical examiners. The coroner may order an inquest and the medical 59

examiner reports to the coroner.

Arizona—A medical examiner system operates in Arizona. County

medical examiners are appointed by county supervisors for indefinite

terms. They must be licensed physicians who are certified in path­

ology and skilled in forensic pathology. If the supervisors in a

particular county find these requirements impractical, they may

appoint a physician who is not a qualified pathologist.

Arkansas—A 19&9 law authorized a state medical examiner system,

but the constitutional office of county coroner still exists, as well.

Coroners are elected in each county for two year terms. There are

no qualifications required for this office, and the existence of a

medical examiner system has limited the powers of the coroner. A

State Medical Examiner is appointed by the State Medical Examiner

Commission for an indefinite period. He must be a United States’

citizen and a physician licensed to practice in Arkansas. He must also have three years of post graduate training in pathology and one year of experience in medicolegal work. The State Medical Examiner appoints physicians to act as assistant medical examiners.

California—Home rule is a popular policy in California and as a result the state has a mixture of county coroners and county medical examiners. Several counties (e.g., Los Angeles and Santa Clara) have appointed forensic pathologists to head medical examiner systems. A number of other counties use physician coroners, and some smaller, sparsely populated counties have lay coroners. Medical examiners must be physicians specialized in pathology and are appointed by the county board of supervisors. Coroners are elected and must at least 60

be eighteen years old and residents of the county in which they are

elected. Some counties combine the coroner's office with that of

some other elected official such as the sheriff or prosecutor. Local

laws provide for inquests to be held at the discretion of the medical

examiner or coroner.

Colorado—County coroners are elected. They must be qualified

electors and residents of their respective counties for one year prior to election. The coroner is empowered to engage a licensed physician to conduct autopsies and postmortem examinations. Several counties have elected physicians to serve as coroners. The coroner may hold an inquest to determine the manner of death.

Connecticut—A state medical examiner system was legislated in 1969 and coexists with a county coroner system. The Commission on Medico­ legal Investigations appoints the medical examiner to an indefinite term. Coroners are appointed for three year terms by the judges of the Superior Court. The medical examiner must be a United States citizen and a licensed physician with four years of post graduate training in pathology and as much background in forensic pathology as the Commission feels is necessary. Coroners are attorneys who are residents of the county of appointment. The medical examiner system has taken over many medicolegal responsibilities in Connecticut, leaving the coroner with little power.

Delaware—In 1955 legislation authorized a medical examiner system to operate under the Department of Health and Social Services. The office of coroner was not abolished until 1971, however, and Kornblum and Fisher (1972) report that coroners attempted to abolish or 6l

undermine the medical examiner's office between 1955 and 1971« As a

result of this coroner opposition, the system lost several chief

medical examiners prior to the appointment of Dr. Ali Hameli in 1964.

The chief medical examiner must be a licensed physician who is

certified in pathology. Preference is given to forensic pathologists.

Local medical examiners must be physicians. The chief is appointed to

a ten year term by the Secretary of Health and Social Services. He

may also be reappointed when his term expires. The medical examiner

is primarily responsible for medical investigations. Criminal

investigations are handled by the Attorney General's office.

Florida—Prior to 1970 Florida had a haphazard system in which

each county designed its own system. In 1970 legislation established

a district medical examiners system involving physicians trained in

pathology. Medical examiners for the twenty-one districts are

appointed by the Governor from a list of names provided by the state

Medical Examiners Commission.

Georgia—Some Georgia counties use elected coroners and others have

medical examiners. There are no special qualifications for coroners.

Medical examiners, who must be physicians or pathologists, are selected

by the director of the state crime lab and the director of the

Department of Public Health. Autopsies are performed by licensed physicians of pathologista and are required in certain cases. One

Georgia medicolegal official indicated that these are not always done, however. (Some counties do not budget sufficient funds to cover the necessary autopsies.) Coroners have the power to hold inquests to

determine the cause and manner of death. Georgia is one of the states 62

in which county systems vary from those with elected, lay coroners

in some small counties to one in Fulton County (Atlanta) which has a

medical examiner qualified in forensic pathology who operates within

a modern medicolegal facility.

Hawaii—Honolulu city and county have an independent medical

examiner system which has been in operation since 1961. The medical

examiner must be a qualified state physician. In the remaining counties—

Hawaii, Maui, and Kauai—the elected chief of police is ex officio

coroner. He is supported in the medicolegal office by a qualified coroner’s physician who is a pathologist.

Idaho—County coroners are elected for two year terms and must be twenty-one years old, citizens of the United States, and residents of the county for a minimum of one year. Coroners are allowed to hold inquests and may use physicians to perform medical investigations for cause and manner of death.

Illinois—Cook County (Chicago) adopted a medical examiner system in 1977 after years of investigating allegations of corruption in the coroner's office. The Cook County Medical Examiner is appointed and qualified in pathology. All other Illinois counties retain the coroner system, although each county may change the office by referendum.

Coroners are elected to four year terms and do not have to meet any special qualifications. Physicians are used to perform autopsies and other necessary medical procedures. Illinois coroners are empowered to hold inquests and many make use of this power. The coroner’s office is no.’longer a constitutional one. This change may mean that other counties will follow Cook County's example and introduce a medical 63

examiner system in the future.

Indiana—Any qualified elector and county resident may he elected

to a four year term as county coroner in Indiana. Coroners may serve

only eight years out of every twelve, however. Police assist the county

coroner in investigations and hoard certified pathologists perform autopsies. Most coroners in Indiana are either physicians or morticians.

Iowa—In 1970 Iowa instituted a medical examiner system. At the

state level a licensed physician with special knowledge of forensic pathology is appointed by the Governor. The state examiner serves in a consultant and service capacity for county medical examiners who are licensed physicians and surgeons or osteopaths. County examiners are appointed to two year terms by the county supervisors who consult a list of qualified physicians provided by county medical and osteopathic societies.

Kansas—A district coroner system operates in Kansas. These coroners must be licensed physicians and surgeons who are residents of Kansas. They are appointed by district judges from a list provided by the appropriate medical society and they serve four year terms. An inquest is required if the death is unlawful or by unknown cause.

Autopsies are performed by qualified medical personnel.

Kentucky—A two-tiered system exists in which each county of the 120 counties elects a coroner who is supported on request by one of fourteen district medical examiners. Coroners must be twenty-four years of age or older, state residents for two years, and county residents for one year. Medical examiners are physicians who are appointed by and serve under the Department of Human Resources. 64

Inquests are permitted. Medical examiners have little power and are

subject to the county coroner. Although some counties have physician

coroners, other coroners are coal miners, morticians, radio station

managers, and the like.

Louisiana—Each parish elects a physician coroner for a four

year term. Orleans parish's coroner is elected in the state general

election. Coroners' juries have been abolished and inquests are

seldom used. Forensic laboratories are available in several locations

throughout the state. An unusual feature of the Louisiana office is

that the coroner is required by law to be the "principal examiner of

patients to be committed to mental institutions" (DeLee, 1970: 101.).

Maine—In 1929 Maine adopted a medical examiner system under a

chief medical examiner. The Governor appoints the chief to a seven

year term and the chief appoints county medical examiners who serve

at his pleasure. The chief must be a physician or osteopath certified

in forensic pathology. County medicolegal officers must be licensed physicians and residents of Maine. Autopsies are performed by the

chief or his deputies.

Maryland—Maryland has one of the few state medical examiner systems which is considered to be a model for other states. This system, instituted in 1939, involves a chief medical examiner and his deputies located in Baltimore and a network of county-level medical examiners.

A commission in the Department of Postmortem Examiners appoints the chief and the county officials. The chief examiner must be a physician who has had two years of post graduate work in pathology. County examiners are licensed physicians. 65

Massachusetts—The original medical examiner system in Massachusetts

was founded in 1877- The medical examiner and associate medical exam­

iners are appointed to seven year terms by the Governor. They must

be "discreet" persons "learned in the science of medicine." In the

past Boston has had the only pathologist medical examiner, while

county medical examiners have been physicians. As a result of the

well-publicized Mary Jo Kopechne case, a bill was passed to establish

a chief medical examiner for Massachusetts (Curran, 1970).

Michigan—Independent county medical examiners were authorized by legislation in 1969. These officials are appointed by the county board of supervisors and must be licensed physicians and county residents

In Wayne County (Detroit) the medical examiner is a forensic pathologist who is supported by a full-time medicolegal staff. In many other counties the medical examiner is also the county health officer.

Counties with fewer than 50,000 residents may appoint a physician, a dentist, a registered nurse, or a mortician as medical examiner.

The system is not centralized or standardized and there is minimal communication among the various county examiners.

Minnesota—Counties may choose a coroner or a medical examiner system. Many county coroners are physicians, since the law requires a person who has had academic courses in pharmacology, surgery, pathology, toxicology, and physiology. Some small, sparsely populated counties experience difficulty in locating a physician to fill the office, however, and may rely on a mortician. Coroners are elected or appointed to four year terms. Medical examiners are licensed physicians appointed by a county board of supervisors. The county 66

sheriff provides, investigative services for a medical examiner.

Hennepin County (Minneapolis) has a complete, full-time medicolegal

office and a medical examiner who is certified as a forensic pathologist

and appointed by a Medical Examiner Board. (Saint Paul has a coroner

system.) A coroner may order an inquest in his county, but the county

attorney, rather than the medical examiner, holds inquest powers in medical examiner counties.

Mississippi—County coroners are elected to four year terms in

each county and must be qualified electors who acknowledge the existence of a Supreme Being. If the coroner is not a doctor, he is required to hold inquests and may request assistance from a physician. Physician coroners need not hold inquests. The local sheriff and the highway patrol provide investigative support on request. Recently, Mississippi added legislation to provide a state medical examiner appointed by the Governor from a list of qualified physicians with certification in forensic pathology. The list is to be provided by the Mississippi

State Medical Association and the Mississippi Association of Pathologists

Missouri—Some counties elect coroners and others appoint medical examiners. The difference is largely dependent on county population.

Coroners must be United States’ citizens, twenty-one years old, state residents for one year, and county residents for six months. Medical examiners are licensed physicians appointed by the governing board of a county. The Chief Medical Examiner of St. Louis County is a forensic pathologist.

Montana—Coroners are elected in each county for four year terms.

The coroner must be twenty-one years old, a state citizen and a county 67

elector. Inquests are held at the request of the county attorney and

physicians perform autopsies and other medical procedures.

Nebraska—Kornblum and Fisher (1972) describe the Nebraska system

as "antiquated and primitive." The county attorney is ex officio coroner

and there are no formal requirements for the office. Investigation is

often delegated to the sheriff and a coroner’s physician is appointed

to perform medical investigations when needed. Inquests are required

by law in deaths by unlawful, means, but in reality these are seldom

held. In at least one county (Douglas) a pathologist performs the

necessary autopsies.

Nevada—A justice of the peace serves as ex officio coroner in most parts of Nevada. Townships constitute medicolegal jurisdictions and there are no formal requirements for office, although each county has the power to establish qualifications and term of office by local ordinance. Inquests are required in certain cases, unless waived by a district judge or attorney. In Douglas County (Minden) the health officer serves as coroner and Clark County (Las Vegas) has a medical examiner who is a forensic pathologist. Clark County accounts for approximately half the state's population.

New Hampshire—New Hampshire's county medical referees are essentially medical examiners. Referees are appointed by the Governor and his council to five year terms. Each referee must be a licensed physician. Autopsies are conducted by trained pathologists and must be ordered by the county attorney or Attorney General. Inquests are also held on the order of the county attorney or Attorney General. 68

New Jersey—In 1967 a state medical examiner system was adopted.

The state medical examiner must be a licensed physician and qualified

forensic pathologist. He is appointed by the Governor for a five

year term. County medical examiners are licensed physicians who are

appointed to five year terms by the county boards of freeholders.

Autopsies are performed by the state examiner and his assistants or

the county examiner, if he is a forensic pathologist. County examiners

report to the state medicolegal officer.

New Mexico—A statewide system of district medical investigators

is headed by a state medical investigator who is a licensed physician

trained in pathology and forensic pathology. District officers must

be physicians. The Board of Medical Investigation employs the state

investigator and he, in turn, appoints district investigators. This

is essentially a state medical examiner system.

New York—New York, like California, follows a policy of home rule

for counties and, consequently, it also has a mixture of county coroners

and county medical examiners. With the exception of Lewis County where the district attorney is ex officio coroner, counties elect coroners to a three year term of office. There are no requirements for the

coroner and a coroner's physician is appointed by the board of

supervisors if the coroner is not a physician. The board in each county may abolish the office of coroner, subject to permissive referendum, and establish a medical examiner system. A medical examiner must be a county resident and licensed physician whom the board feels is qualified to perform autopsies.

In 1915 Hew York City provided legislation for a medical examiner 69

system, and in 1918 the first metropolitan medical examiner was appointed hy the hoard of supervisors. The New York City system includes the counties of New York, Kings, Queens, Richmond, and the

Bronx. The chief medical examiner is a forensic pathologist. As a result of home rule differences, New York state's medicolegal offices range from an internationally recognized, modern medicolegal system in New York City to small county systems with lay coroners.

North Carolina—A statewide medical examiner system under the

Department of Human Resources has recently become operational in

North Carolina. At one time the only qualifications required of a coroner in this state were that he believe in God and have never participated in a duel (Childs, 1976). Under the present system the chief medical examiner is a forensic pathologist and county examiners must be physicians. The chief is appointed and appoints county officers who report to him at the central office in Chapel Hill.

North Dakota—Counties of less than 8,000 population elect lay coroners who are empowered to conduct inquests. Licensed physician coroners are appointed for two year terms by the board of county commissioners in counties of more than 8,000. Physician coroners do not hold inquests.

Ohio—County coroners are elected officials and must be physicians licensed to practice in the state for at least two years prior to election' to four year terms. The type of office varies from county to county in Ohio. Cuyahoga and Hamilton counties (Cleveland and

Cincinnati respectively) support full-time operations staffed by forensic pathologists. In many of the smaller counties the coroner 70

is only needed part-time. In these cases he often has a full-time

medical practice, as well.

Oklahoma—In 1961 a state medical examiner system was established

under the control of the Board of Medicolegal Investigation. The

chief of the Oklahoma medicolegal system must be a United States’

citizen, a licensed physician trained in forensic pathology, and a

diplomate of the American Board of Pathology. County examiners are physicians or osteopaths. The Board of Medicolegal Investigation

appoints the chief medical examiner who then appoints county examiners

Oregon—This is a rather complex state system involving several layers of medical examiners and support staff. The state, medical examiner is a forensic pathologist appointed by the Administrator of the Oregon Health Division. The state examiner appoints physicians as deputy state medical examiners in large counties. In smaller counties (less than 200,000 population) he appoints physicians as district medical examiners. Assistant district medical examiners are appointed by the district examiner and approved by the district attorney. Their qualifications are set by the State Medical Examiner

Advisory Board. Finally, the district medical examiner appoints deputy district medical examiners. The qualifications for this position are set by the district examiner and the district attorney.

These deputies are charged with investigating the circumstances of a death and are often law enforcement officials. They may not order autopsies or embalming or certify a death. In Oregon the district attorney may order an inquest when he feels one is appropriate.

Pennsylvania—Elected county coroners provide medicolegal 71

services throughout the state, except in Philadelphia city and county

Philadelphia has an appointed medical examiner who is a forensic

pathologist. The Allegheny County (Pittsburgh) coroner is a forensic

pathologist, but this is unusual in Pennsylvania as there are no

formal requirements for the office in the various counties.

Rhode Island—A centralized state medical examiner system is in

operation here. The chief medical examiner is a licensed physician

and pathologist with training in forensic pathology. He is appointed by the Governor. Assistant medical examiners are appointed by the

chief and must be physicians. The chief and his assistants operate

from a central office. The medical examiner has inquest powers.

South Carolina—State law provides for medical examiners in

counties of 240,000 or more and coroners in the smaller counties.

Medical examiners must be skilled physicians or pathologists and are employed by the Medical Examiner Commission. There are no special qualifications for coroners. They are elected for four year terms and have inquest powers.

South Dakota—County coroners are elected for two year terms.

There are no special qualifications for the office. Inquests are required in certain cases. If the coroner is a physician, he may perform autopsies.

Tennessee—Since 196l Tennessee has had both county coroners and a state medical examiner system. Coroners are elected for two year terms by justices of the peace, but they have little power.

The chief medical examiner must be a physician and preference is given to certified pathologists with training in forensic pathology. 72

County medical examiners are physicians.. The chief is appointed

by the Commissioner of public health. County courts elect county

medical examiners.

Texas—Texas also has a mixed system under which some counties

have elected coroners and others have appointed medical examiners.

Counties of 500,000. or more with no reputable medical school must

have a medical examiner. Other counties may choose to establish

medical examiner systems, but if they retain a coroner system the

justice of the peace is ex officio coroner. Medical examiners must

be licensed by the State Board of Medical Examiners and, if possible,

have training in pathology, toxicology, histology,,, and other medico­

legal sciences. Medical examiners are appointed by the commissioners

court in a county. Almost half the population of Texas is covered

by medical examiners.

Utah—In 1965 a state medical examiner system was established.

The chief of this system must be a licensed physician and qualified

pathologist. He is appointed by the Director of the Utah Division of

Health. County commissioners appoint physicians to serve as county

medical examiners.

Vermont—A state medical examiner system was established in 1953

The State board of health establishes such qualifications as it

decides are necessary for the chief medical examiner. The chief

examiner appoints regional medical examiners who must be licensed physicians or osteopaths.

Virginia—Virginia instituted a state medical examiner system

in 1946. The chief medical examiner is appointed by the State health 73

commission and must be a licensed physician and skilled pathologist.

The state is subdivided into four districts with a deputy medical examiner in charge of each. Deputies are also pathologists. At the local level licensed physicians are appointed by the chief as medical examiners for each city and county. (Virginia has separate city and county governments.) Local examiners serve three year terms.

Washington—Qualified electors may run for the office of coroner.

Counties of a certain class elect the coroner directly. In other counties the elected county attorney is ex officio coroner. King’s

County (Seattle) has had an appointed medical examiner since 1969.

Coroners have inquest power.

West Virginia—Legislation authorized a state medical examiner system in 1963, but adequate funds were not provided for implementation of the system. The medical examiner system has been activated only recently. The chief is a licensed physician and qualified pathologist who is appointed by the Commission on Post Mortem Examination. This commission also appoints licensed physicians to serve as county medical examiners for three year terms.

Wisconsin—Counties have either coroners or medical examiners and there are no formal qualifications for either office. Medical examiners are usually physicians, however. Coroners are elected for two year terms. Medical examiners are appointed by the county board of super­ visors. Inquests may be ordered by the district attorney or the coroner or medical examiner.

Wyoming—County coroners are elected for four year terms. There are no specific qualifications for the office. Coroners have inquest power. 74

District of Columbia—A medical examiner system was enacted by

Congress in 1970. The medical examiner must be a licensed physician and board certified pathologist. He is appointed by the Commission of the District of Columbia.

Table 4.1 is a brief review of these state systems relative to the type of system, manner of selection of officials, and their qualifications. Figure 4.1 is a typology of the state systems described in the preceding review of laws and summarized in Table

4.1. The systems are categorized as centralized or decentralized and then described in terms of the characteristics of the system— title of the office, method of selection and qualifications of the official. TABLE 4.1: Summary of State Laws Regarding the Medicolegal Office and Officials

State Type of Office Selection Qualifications

ALABAMA County coroners Elected None listed

ALASKA Mixed: coroners and District magistrates or Coroner—none medical examiners judges are ex officio M.E.—physician coroners. M.E. appointed

ARIZONA County medical Appointed Physician, certified in path­ examiners ology .with skills in forensic pathology

ARKANSAS Mixed: state medical •M.E. appointed M.E.—U.S. citizen, physician, examiner, county Coroner-- elected 3 years pathology, 1 coroners year medicolegal work. Coroner—none

CALIFORNIA Mixed: county medical M.E. appointed M.E-»—physician, specialized in examiners and county Coroner elected pathology coroners Coroner—varies from physician to no requirements.

COLORADO County coroners Elected Qualified elector and county resident

CONNECTICUT State medical ex­ Both appointed M.E.—U.S. citizen, physician, aminer and county 4 years pathology coroners Coroner—attorney, county resident —3 DELEWARE State medical Appointed Chief M.E.—physician, certified examiner pathologist, esp. forensic pathology. TABLE 4.1: continued

State Type of Office Selection Qualifications

FLORIDA District medical Appointed Physician pathologist examiners

GEORGIA Mixed: county Elected Coroner—none coroners and M.E“.—licensed physician or county medical pathologist examiners

HAWAII Mixed: Honolulu M.E. appointed M.E-- qualified physician medical examiner, Coroner elected Coroner—chief of police is others coroners ex officio coroner

IDAHO County coroners Elected 21 years old, U.S. citizen, 1 year resident of county

ILLINOIS County coroners, Coroner elected Coroner—none except Cook County M.E. appointed M.E.—physician and pathologist which has medical examiner

INDIANA County coroners Elected Qualified elector and county resident

IOWA State and county Appointed State—physician with forensic medical examiners pathology knowledge County—physician or osteopath

KANSAS District coroners Appointed Licensed physician and surgeon -q o\ TABLE 4.1: continued

State Type of Office Selection Qualifications

KENTUCKY. Mixed: district Coroner elected Coroner—24, state resident for medical examiners, M.E. appointed 2 years, county resident county coroners for 1 year. M.E.—physician

LOUISIANA Parish coroners Elected Physicians

MAINE State medical Appointed Chief M.E.--physician or osteo­ examiner system path certified in forensic pathology County M.E.—physician and state resident

MARYLAND State medical Appointed Chief M.E.—physician and examiner system pathologist County M.E.—physician

MASSACHUSETTS Medical- examiners Appointed "Discreet persons'^ "learned in the science of medicine"

MICHIGAN Independent county Appointed Physicians, except in counties medical examiners of less than 50,000 population

MINNESOTA Mixed: county coroners Coroner elected Coroner—usually physician or county medical or appointed M.E.—physician; Hennepin County examiners M.E. appointed M.E. is certified forensic pathologist

MISSISSIPPI County coroners and Coroner elected Coroner—qualified elector who state medical examiner M.E. appointed acknowledges a Supreme Being MsE.— forensic pathologist TABLE U.l: continued

State Type of Office Selection Qualifications

MISSOURI Mixed: county coroners Coroner elected Coroner—21, U.S. citizen, 1 or county medical ex­ M.E. appointed year state resident, aminers 6 months county resi­ dent . M.E.—licensed physician

MONTARA County coroners Elected 21, state citizen, county elector

NEBRASKA County coroners Elected County attorney is ex officio coroner

NEVADA District coroners, Coroner elected Coroner—justice of the peace except Clark County M.E. appointed is ex officio coroner which has medical M.E__ forensic pathologist examiner

NEW HAMPSHIRE County medical Appointed Physician referees

NEW JERSEY State medical Appointed State M.E.—physician and examiner system qualified forensic pathologist County M.E.—physician

NEW MEXICO State medical Appointed Chief—forensic pathologist investigator system District—physician

NEW YORK Mixed: county coroners Coroner elected Coroner—none or county medical M.E. appointed M.E.—physician co examiners TABLE 4.1: continued

State Type of Office Selection Qualifications

NORTH CAROLINA State medical Appointed Chief—forensic pathologist examiner system County—physician

NORTH DAKOTA County coroners Population 8,000 or Less than 8,000—none less, elected; 8,000 More than 8,000—physician or more, appointed

OHIO County coroners Elected Licensed physician

OKLAHOMA State medical Appointed Chief—U.S. citizen, licensed examiner system physician and forensic pathologist and diplo- mate of ABP County—physician or osteopath

OREGON State medical Appointed Chief—forensic pathologist examiner system Deputy state & district— physician

PENNSYLVANIA County coroners, Coroner elected Coroner—none except M.E. in M.E. appointed M.E.—forensic pathologist Philadelphia

RHODE ISLAND State medical Appointed Chief—forensic pathologist examiner system Assistants—physicians

SOUTH CAROLINA Mixed: county coroners Coroner elected Coroner—none and county medical M.E. appointed M.E.—physician or pathologist examiners —-4 VO SOUTH DAKOTA County coroners Elected None TABLE i+.l: continued

State Type of Office Selection Qualifications

TENNESSEE Mixed: county coroners Coroner elected Coroner—none and state medical Chief M.E. appointed Chief M.E.—pathologist examiner system County M.E. elected County M.E.—physician

TEXAS Mixed: county coroner Coroner elected Coroner—justice of the peace or county medical M.E. appointed is ex officio coroner examiner M.E.—physician

UTAH State medical Appointed Chief—pathologist examiner system County—physician

VERMONT State medical Appointed Chief—established by State examiner system board of health Regional—physician

VIRGINIA State medical Appointed Chief and deputies—pathologist examiner system Local—physician

WASHINGTON County coroners, Coroner elected Coroner—elector; in some countie except King's County M.E. appointed county attorney is ex has M.E. officio coroner M.E.—pathologist

WEST VIRGINIA State medical Appointed Chief—pathologist examiner system County—physician

WISCONSIN Mixed: county coroners Coroner elected None—M.E. is usually..physician, and county medical M.E. appointed but not formally required examiners co o TABLE 4.1: continued

State Type of Office Selection Qualifications

WYOMING County coroners Elected None

DISTRICT OF Medical examiner Appointed Physician and certified COLUMBIA pathologist

co H 82

FIGURE 4.1: Typology of State Medicolegal Systems Including Title of Office, Method of Selection-, and Required Qualifications.

Centralized System Decentralized System

TITLE: Medical Examiner3 Coroner or Mixed—both coroners and medical examiners or Medical Examiner

SELECTION: Appointed Coroner—elected^ Medical Examiner—appointed0

QUALIFI­ CATIONS: Physician3 Coroner—lay or physician Medical Examiner—physician^- a One exception, Connecticut has both coroners and medical examiners, but coroners have little power. Coroners are lay people.

Kansas appoints physician coroners. North Dakota appoints physician coroners in counties of over 8,000. Minnesota coroners are elected or appointed.

Georgia elects both. Tennessee elects medical examiners.

3 Michigan counties of less than 50,000 may use lay medical examiners. 83

Discussion

This overview is not meant to provide detail on all aspects

of the laws governing the selection of medicolegal officers and the

operation of their offices. Further details on the laws specifying

operation of the office and access to records are available in the

Health, Education, and Welfare (1978) report, Death Investigation.

As in the case of other laws, some medicolegal legislation still on the books has become outdated and is no longer adhered to. Whenever possible, adjustments were made for this circumstance, but some such laws may have been included in this report and those on which this summary was based.

The preceding review of state laws is rather brief and does not include all the differences from state to state. Statutes also define the duties of the office and specify which cases shall be within the jurisdiction of medicolegal officials. In some states they also re­ gulate relations between the coroner or medical examiner and law enforce­ ment officials in regard to authority and notification procecedures.

In general, medicolegal officers have authority in all deaths by violence and in cases of sudden, unexpected death when the deceased has been in apparent good health prior to his death. Any suspicious or unusual circumstances surrounding a death usually cause the case to be referred to the coroner or medical examiner. Also, deaths occurring when the deceased was not under a doctor's care are usually defined as medicolegal cases. In some states the definition of a medicolegal case is rather vague and general. Other states specify a list of types of deaths which must be referred to the coroner or medical 84

examiner. In the latter case the list may include some or all of the

following: industrial accidents, sudden infant deaths, suicides,

drownings, automobile fatalities, deaths while under hospital anesthetic,

deaths within a specific period after admission to a hospital (e.g.,

twenty-four hours), deaths of jail inmates, any. body which Is to be

cremated, or bodies which are to be shipped out of state for burial.

Some states even specify how recently the deceased must have been

seen by a doctor to be considered "under the care of a physician."

Many states' laws require that the medicolegal officer view each

body at the scene of death. In reality this is often delegated to

representatives of the official (e.g., field investigators) or police

or ambulance attendants. As noted in the summaries, inquests may be

required in certain cases by some states, but these are not always

held.

Autopsy powers also vary. Some officials have discretionary

autopsy powers, others are required to do autopsies on certain cases,

and some are forbidden to conduct or order autopsies in certain cases

or without consent from specified officials or relatives of the

deceased. De facto limitations on the number of autopsies performed often result from budgetary restrictions.

Some states limit the term of office, particularly for coroners, but in many states re-election is nearly automatic. This is especially true when the elected coroner must be a physician. The responsibility, twenty-four hour call, and low pay do not attract many candidates.

Medicolegal officers do not pronounce death, as commonly believed, but they do sign death certificates unless the deceased was under a 85

doctor’s care and died of natural causes. In these cases the attending physician signs the death certificate. Access to medicolegal records is defined hy state law, just as is access to other government documents

The variety in laws and systems among and within states can have a number of consequences for the role performances of medicolegal officials, and some of these will be discussed more fully in Chapter

VI. A brief description is also included here, however, to provide the reader with some understanding of how the legal role requirements contribute directly and indirectly to the development of role conflict and ultimately to the production of official death statistics.

One relevant feature of medicolegal laws in a number of states is that they are changing. As was illustrated by the situation in Delaware referred to earlier in this chapter, revisions in the law which decrease the power of some officials in favor of others have the potential of creating conflict between the two groups. In Delaware the coroners who were losing power opposed the new medical examiner system. Although they did not succeed in abolishing the system, their opposition was disruptive enough that several chief medical examiners quit as a result of the difficulties created.

Elected coroners have been in existence long enough to have some traditional authority in addition to their legal authority. Many— both lay and physician-coroners are firmly entrenched on the local political scene and can combine their own personal power with that of highly placed political colleagues to resist a change in the law or subvert a new system after it is established.

The individual coroner’s loss of a job is also combined with the 86

loss of a local political office. While the coroner’s political cronies

might he expected, to resist having one less party member in power, they

might also perceive the change as a harbinger of movements to abolish

other locally elected offices, including their own. In response to a

question about the possibility of a change from elected county to

appointed regional medicolegal officials in his state, one coroner said,

"I don't think it will go that way. Elected officials, the 'courthouse

crowd' as we call them, would resist because their jobs might be next."

A number of states have attempted to reduce opposition to a new, appointive medicolegal system by providing for both an elected coroner and an appointed medical examiner in the same jurisdiction. While this compromise has been successful in a few states, it does not always work.

If the coroner lost power to the medical examiner, the new official may begin his duties with at least one role partner (coroner) who resents his presence. That resentment might also be shared with political, colleagues of the old coroner who are role partners of the medical examiner (e.g., sheriff, county attorney, local judges) and who are in a position to increase the medical examiner's problems.

Even if this kind of personal conflict does not exist, a change in the laws affecting the medicolegal office may lead to a period of con­ fusion. If the law is vague, the office must be structured by its incumbent. More specific laws are also subject to interpretation. The adjustment of actual practices to implement the law also includes re­ cruiting personnel to staff the system. If the change is from lay coroners to a statewide medical examiner system with county medical examiners, it may take some time to find qualified physicians in each 87

county who are willing to assume a medicolegal role. This was one of

the difficulties faced in North Carolina and West Virginia following

a change in their systems.

Jurisdictions which have both a county coroner and a county medical

examiner or states which have a tiered system of county coroners and

regional medical examiners, face the possibility of conflict over

dividing the responsibility. Unless statutes are very specific and/or

the officials are very compatible, a dual or tiered system may lead to

squabbles over who has power to do what. This kind of situation not

only makes the medicolegal role difficult to perform, but also adds to

the burden on role partners. The police, ambulance and rescue squad

attendents, and the like may be caught in the middle and experience

role strain.

Role partners may also experience difficulty in their role per­

formances vis-à-vis the medicolegal official when a law changes, even

if it does not entail a dual or tiered system. Adjusting to a new

official and new regulations and procedures can be disruptive in

itself until new patterns of interaction are established. Many of

the officials interviewed for this study reported an initial period

of confusion and sometimes conflict with supporting role partners.

Some of the problems resolved themselves after patterns of interaction

developed. Others were not resolved until the official exerted his

authority, set down explicit policies, and educated his role partners through memoranda, lectures, and reprimands.

In jurisdictions where the medicolegal role was combined with that of some other position, there was also the potential for role conflict 88

or role strain. That situation was most likely to he encountered when

there was a lay coroner. A common combination was county sheriff and

coroner or county attorney and coroner. Since the sheriff and county

attorney are identified with the state and, usually the prosecution,

the impartiality of the coroner’s role is threatened when one of these

two offices is combined with the medicolegal role. Also, the coroner

may sometimes be called upon to investigate a death in which the state,

county, or sheriff is a suspect. A suspicious death in a county or

state nursing home or mental hospital or the death of a jail inmate

often comes under the coroner’s jurisdiction. The death of a crime

suspect resulting from a confrontation with police would also be a

medicolegal case because it would involve violence and sudden death.

A combined office also jeopordizes the credibility of the medico­

legal report. As one lay coroner said, "Making the sheriff a coroner

is like giving him a license to kill." Curran (1971) stresses the

need for credibility of the office as one of the major reasons for

establishing a professional, nonpolitical medicolegal system. He writes that as a result of

The polarization of political activity and the resort to violence in protest movements...[and]...the growing distrust and hostility toward the American system of justice and law enforcement... [iindependent.,' highly qualified, professional medicolegal systems are required to deal with these issues. (Curran, 1971: 30-31)

In support of his position, Curran cites the differences in public reactions to two similar cases. In one case a member of a youth gang, the Young Lords, died in a New York City jail. The report of the respected medical examiner's office in that city was accepted by 89

y

the public and the city.was exonerated of blame. The death of a

young black male in an Augusta, Georgia jail produced very different

results. The medicolegal response was late, and violence followed.

As a result, five more blacks were killed. Although the coroner

reported that some of these people had been shot in the back, he

did not order autopsies because he said each one cost $100. and the

county could not afford that. As might be expected, a great deal

of hostility developed between the public and law enforcement officials

and public trust was further weakened.

The authority to order or perform autopsies is another important

area of difference among laws. Some states give the medicolegal

officer relatively unlimited discretionary power to order what he

judges to be the appropriate postmortem examinations. These states

usually have a medical examiner system or, at least physician coroners.

In some jurisdictions, the official's autopsy powers are restricted to

cases in which the family does not object, the county attorney first

approves the request for an autopsy, or some other limitations as

specified by law. In other cases the law does not specifically state

what powers the official does or does not hold. Both ambiguity and

specific restrictions may hamper an official's role performance. One

coroner reported that he never ordered an autopsy unless he was certain

he could defend his decision as both "prudent and knowledgeable."

Some coroners expressed a feeling of role strain in regard to autopsies because the county budget limited them. As one said, "If I run out of

money before the end of the fiscal year, I simply can't order any more

autopsies." Another official, a physician-coroner faced with a similar 90

situation, had resolved the strain by.telling his county's commissioners

that he would be prudent in ordering autopsies. But he also said that

if they did not agree to pay for all those he did order he would resign.

Since the county was small and rural with few physicians, the commis­

sioners agreed to his terms.

Finally, the variation in powers, qualification requirements, and duties makes it difficult for medicolegal officials to pool their power

in an effective occupational organization. This means that the con­ flict resolution function of a mutual support organization has not been developed to its full potential. There are at least two medico­ legal organizations which cross state boundaries (NAME arid IACME), but many officials belong to neither one, and some indicated they were not even aware of the existence of such groups. In many states there are state organizations which attempt to perform support and education functions, and some appear to be rather successful at this

(e.g., Ohio State Coroner's Association). Not all states have active groups, however, and in some states the home rule options which result in a wide range of systems hinder the formation and success of such organizations.

Summary

The numerous variations among and within state systems and the recent tendency for the laws to be changed are potentially disruptive of medicolegal role performances. Disruption may be the result of ambiguity or it may stem from structurally induced role conflict or role strain. The effects on role performance may also affect the manner of death statistics produced by medicolegal officials. If 91

the official is restricted by law or finances in ordering autopsies, some cases which should receive such postmortem attention might not, and the death might he incorrectly recorded as a result.

Conflict between medicolegal offices or with other role partners may result in similar failures in the determination of death. Evidence may be destroyed intentionally or accidentally, the chain-of-evidence requirements in criminal cases might be violated, and so forth. In jurisdictions where the medicolegal office is highly political or where two official positions are combined, pressure might be brought to bear on the official to give a verdict before tests are completed or to provide an "acceptable," but incorrect verdict. Although death statistics are aggregate data, individual cases affected by individual role performances make up the aggregate.

Following a discussion of role perceptions in Chapter V, Chapter

VI involves a more detailed look at the role performances of coroners and medical examiners, including how role conflicts and role strains are diminished or resolved. Chapter V

THE MEDICOLEGAL ROLE AS PERCEIVED BY CORONERS AND MEDICAL EXAMINERS

To better understand why an actor performs his role in a certain way, one might first ask how he perceives the role. This is especially true of a role such as that of medicolegal.officer which involves a variety of different responsibilities. A coroner or medical examiner who places a high priority on the public health functions of his office might perform his role quite differently from one who emphasizes its legal functions.

The discussion presented in this chapter focuses on the definitions of the medicolegal role as perceived by occupants of coroner and medical examiner positions. It includes data on the purpose of the office, perceived responsibilities to a variety of role partners, motives for accepting the office, and qualifications believed necessary to effectively perform the role.

The Purpose of the Office

Questions about the purpose of medicolegal offices were included in both the interview and survey phases of data collection. Some answers indicated that the actor had given a great deal of thought to a "philosophy" of his role. Other respondents cited the legal definition of the purpose of their office.

Few respondents perceived the role merely in terms of processing dead bodies so that the required death certificate might be filed. 93

However, three persons (less than 1 per cent)-*- defined their purpose

as simply providing statistical data. Many officials (46 per cent)

focused on determining the cause of death and/or the circumstances of

death.

Respondents also emphasized the public health aspect of the

office and cited the need to uncover health hazards which might affect

the general public, or genetic disorders which would be of interest

to surviving family members. An emphasis on the legal aspects of the

office was indicated by those who reported that the purpose of the office was to detect homicide and other criminal acts or to aid in the prosecution of criminals. Approximately 2 per cent of those who completed the questionnaire combined the public health and legal functions in answers which stressed protecting the public's interest.

These officials mentioned protecting the public from disease, safety hazards, and criminals.

Although many respondents mentioned only one aspect of the office, a number (21 per cent) cited several functions of the office. These usually included both the legally defined purpose of the office and humanitarian concerns such as counseling family members and representing the interests of the deceased. As one official wrote, the coroner is

"an ombudsman for the dead." The "ombudsman" concept was also included by a physician coroner whose perception of his medicolegal role covered a variety of functions:

1 Percentages refer to responses to the mail survey, unless otherwise indicated. 94

To act as a "medical ombudsman" for the community; to determine the cause and manner of death in violent, sudden, suspicious, unexpected, unexplained, medically unattended, and other con­ troversial cases, and supply that information to legitimate interested parties, civil and criminal courts, and other official agencies; to protect the physical health and well- being of the citizens of the community; to act as a medical- legal resource center; to teach legal medicine to medical and law students, and on a postgraduate level, to physicians and attorneys.

As might be expected, the responses given by interviewed officials to "purpose" questions tended to be more detailed than those from the mail survey. Many in this sample stressed the benefits of medicolegal investigations for the living. One official described the coroner’s office as a facility to "study the dead to help the living." He explained that the office is important because it deals with human life and helps to administer justice. To him it is a "monument to life" and one which offers comfort to the living. He also pointed out the need to educate the public about the work done in a medicolegal office so that they will be willing to support it financially. He perceived the office as both an arm of the criminal justice system and a public health office. In the latter respect he emphasized that

"Public health is purchaseable," and in a public health capacity the coroner's office is "not a house of the dead, not a stopping off place on the way to the cemetary, but a house of the living."

Those who completed the questionnaire were asked to rank eight possible functions of a medicolegal office, from that function which was most important to the one which was least important. (See question

29, Appendix I.) Respondents were also given the alternative of eliminating any function which, in their judgment, was not important. 95

Many officials rated the functions instead of ranking them, hut in

general the function which was given most importance was to "Make

accurate determinations of manner of death." Assisting the police in thèir investigations was also perceived as very important.

Participating in medical research and cooperating with news media to keep the public informed were functions which rated as very low in importance. Respondents from smaller offices generally reported that they did not participate in medical research at all. In small offices or those which are understaffed there is a lack of time and personnel for this function. And, as discussed in Chapter VI, many medicolegal officials consciously avoid contact with the media, especially newspapers

Responsibilities to Role Partners

Closely related to perception of the purpose of a medicolegal office is the perception of responsibilities to various role partners of the coroner or medical examiner. Questions regarding these responsibilities were included in both interviews and the questionnaire.

(See Appendix I, question 28.) Role partners specifically included in the questions were the public, the family of a deceased person, police, the prosecutor in a criminal case, and the defense attorney In a criminal case.

A few officials felt that they had no responsibility to the public, but most expressed the opinion that they should serve the public in a variety of ways. These included being truthful about findings; pro­ viding information about public health concerns, criminal cases, and cases involving public figures; acting as a representative of the deceased, and educating the public. 96

Some coroners and medical examiners reported initiating or cooper­

ating in campaigns to decrease the number of preventable deaths by

educating the public or working with appropriate local, state, or

federal agencies. A local safety bureau might be notified about a particularly dangerous traffic intersection, or an industry warned

about a safety hazard. A past Chief Medical Examiner of New York City, the late Milton Helpern, was involved in one such campaign to reduce preventable deaths (Helpern, 1977: 174—183). After handling a number of cases of carbon monoxide poisoning resulting from faulty gas appliances, Dr. Helpern contacted local health department officials.

He also wrote articles about the hazard for the medical press. As a result of his warnings, an inspection program was initiated. Faulty appliances were either repaired or discarded and the number of such deaths was reduced.

Coroners and medical examiners also expressed the opinion that accurate determinations of manner of death allow them to serve the public by exposing criminal, activity (e.g., homicide, child abuse).

In contrast, there are instances when an apparent homicide is found to be an accident or a natural death. Therefore, the medicolegal official's responsibility to the public involves both aiding the prosecution of criminals and preventing prosecution when there has been no crime.

A number of respondents mentioned a responsibility to .inform the public in cases involving public figures. In this regard two cases were mentioned, both involving the politically prominent Kennedy family.

The first case was the assassination of President John F. Kennedy.

Volumes have been devoted to the investigation of Kennedy's death and 97

in most of these some of the uncertainty surrounding the death has

been attributed to the medicolegal handling of the case. Several

officials remarked that the case was poorly handled from a medicolegal

standpoint in several regards. First, the body was removed from Dallas

even though it was properly the jurisdiction of the medical examiner

there to perform the autopsy. Second, those who performed the autopsy

were not actively engaged in forensic pathology. Several respondents

felt that case would have more properly been assigned to nationally

recognized forensic pathologists familiar with gunshot wounds. And

finally, the public was not fully informed of the results of the inves­

tigation. During the interview phase of data collection, several

officials also expressed concern over the number of members of their

own profession who' presumed to provide the public with an interpretation

of the death based on that information which was released. They felt

such behavior was unprofessional and that the available data were not

sufficient for sound medicolegal judgements.

The second case mentioned in regard to informing the public was the

Kennedy-Kopechne case in which Mary Jo Kopechne drowned after a car

driven by Senator Edward Kennedy plunged into a river. In this instance,

many medicolegal officials reported that the case was not handled

properly by the Massachusetts' medical examiner in charge. As a result,

the public was not served with relevant information and Senator Kennedy's

reputation was damaged. A prompt, complete medicolegal investigation

might have resolved many unanswered questions and either fixed the blame or exonerated the Senator. As Curran (1970) reports, the publi­

city which resulted from that one case did lead to a re-examination of 98

Massachusetts' medicolegal statutes and the introduction of a hill to

modernize the state's system.

Finally, many officials pointed out that the coroner or medical

examiner is often the only person available to represent the deceased.

It is up to the medicolegal official to prevent an accident from

being incorrectly labeled as a suicide or to insure that homicide does

not go undetected. One official described the postmortem examination

as "talking to the dead." The evidence provided by the body must

answer such questions as what happened, who was involved, when did the

victim die, and where did death occur.

Most respondents also felt a responsibility to the deceased's

family. Many reported that explaining the death—cause and/or manner—

to the victim's family was an important part of their role. In an

article entitled "The Forensic Pathologist—'Family Physician' to the

Bereaved," Dr. Lester Adelson (1977: 1586) reports:

The emotional impact of death is magnified enormously when it occurs unexpectedly. It is, as it has been phrased, "like being struck by lightning on a sunny day." The grief-stricken, shocked family needs and deserves accurate information and comprehensible explanations, sympathetically and patiently imparted by a knowledgeable physician. In many cases, the survivors' sorrow is compounded by an erroneously assumed burden of guilt for the sudden death.

Officials perceived a responsibility to explain autopsy findings, to

help a family deal with the guilt and stigma of suicide, and to

counsel parents who have lost a child to sudden infant death syndrome.

In addition to counseling the family, some officials felt a

responsibility to protect the family's privacy and others reported helping the family to process insurance claims. A number of respondents, 99

usually from small, rural districts, explained that they often downplay

suicides to protect the family. One coroner occasionally withholds a

verdict on the grounds that the investigation is not complete. At a

later date, after newspaper reporters have lost interest in the case,

he can routinely process a verdict of "suicide" without the publicity

which accompanies such a ruling at the time of death.

Although families often object to autopsies, some families request

this postmortem procedure. Several officials commented that they feel

a responsibility to do autopsies in such cases, even if they themselves

do not find it necessary to reach a verdict. Some low income families

could not afford to pay for a hospital autopsy. Others may want to

know what the victim’s health was like at the time of death. Or in

accidental death of a pregnant female, the family may want to know what

sex her child would have been.

Their position in the criminal justice system brings coroners and medical examiners into frequent interaction with the police. Most medicolegal officials must deal with more than one law enforcement

office if a jurisdiction includes seperate city and county police

forces, and often several offices. In addition to local police, certain

cases involve the state police and possibly even the Federal Bureau of

Investigation. In many jurisdictions, especially where there are elected coroners, the medicolegal officer has authority over the local police. However, most officials report a cooperative relationship with police, rather than superior-subordinate one.

Coroners and medical examiners perceived their responsibility to the police as one of assistance in the investigation of death by 100

providing a cause of death and scientific medical information. Also,

in the event that the police do not recognize that a death involves

criminal action, the medicolegal official advises them of the prohahle

manner of death and the need for further investigation. In return,

the official expects the police to provide whatever investigative

support he requires to reach an accurate determination of cause and

manner of death.

In regard to prosecution and defense attorneys in criminal cases,

most of those questioned felt that they had the same responsibility

to both—to provide impartial facts, to cooperate in the investigation,

and to give impartial, expert testimony in court proceedings. Two

questionnaire respondents felt that they had no responsibility to the

prosecutor and eleven said they had none to the defense attorney.

In general, a number of respondents felt more of a responsibility to

the prosecutor than to the defense attorney. Some wrote that they

provided information to the defense only "as required by law" or

"as ordered by the court." Among the interview sample, several coroners

identified with the police and prosecutor in a criminal case. As one

coroner commented, "It’s interesting to me to be like Sherlock Holmes

and work with the police and their investigation." One might expect this kind of adversary relationship to be especially prevalent in states where the county attorney is also ex officio coroner. One such official reported that this did not present a problem for him, however. But a lay coroner in another state expressed the opinion that a conflict of interest was certain to occur whenever the coroner was also the sheriff or county attorney. 101

Qualifications and Selection

Other important elements of the medicolegal position which ultimately influence role performance are the method of selecting the official and the qualification requirements for the office. Selection procedures may influence an official's perception of loyalty priorities and his qualifications will determine whether he can perform the medicolegal procedures himself or whether he must delegate them to someone else.

Forty-eight per cent of the questionnaire sample and 63 per p cent of the interview sample were elected officials. Fifty per cent of the questionnaire sample and 38 per cent of the interview sample were appointed to their medicolegal positions. In response to question

21 on the mail survey, "In your opinion, should your position he an elected or appointed one?", coroners were more likely to say it should he elective and medical examiners clearly thought it should he appointive

Fifty-eight per cent of the coroners thought the office should he elective and 37 per cent believed it should be appointive. Those favoring election expressed the opinion that the public should have the right to choose public officials and many felt that appointments were too political. Ninety-seven per cent of the medical examiners believed that the office should be an appointed position. They supported their opinion by arguing that the public is not well enough informed to judge medical qualifications and that appointment would insure a qualified official and keep the office free from political pressure.

Since medical examiners are nearly always appointed, their responses

2 Two per cent of the questionnaire sample did not answer the question. 102

to this question supported the status quo. Coroners, although nearly always elected, showed some tendency to support a change to an appointive office. Some of those coroners who favored appointment over election also favored a change to a medical examiner system, even though it would mean they themselves would he ineligible for the position. A few of these held the coroner position by virtue of having been elected to another office, such as county attorney.

It is also interesting that some respondents on both sides supported their choice of method of selection by saying it was less political than the alternative. Although it may be easy for the reader to imagine how an elective office might be subject to political pressure, many elected officials felt that appointment was more political than election. Few questionnaire responses elaborated on how appointment of a medically trained person to fill a medically- oriented position could be considered political, but the subject did arise in interviews with elected physician coroners. Probing revealed that they seldom considered that the office might require any particular specialized medical training. Most assumed that there would be a number of persons who possessed medical degrees from which to choose.

They believed that the choice would be made on the basis of friendships between a particular doctor and the political party in power, as is true of many patronage-type positions. Most assumed that the decision would be made by elected politicians and did not consider the possibility that a committee or board of professionals representing various disciplines and/or political orientations might make the decision. Furthermore, few of these respondents thought; of the job 103

as a full-time, careér-oriented position. Since most of the physician

coroners and lay coroners play the medicolegal role on a part-time

basis, it is logical to assume that they were using their own position

as a frame of reference. This is especially true of those who

completed the questionnaire, since the question referred to "your

position."

Questions 22, 23, and 26 on the mail survey sought information

about the respondents' perceptions of qualifications for a medicolegal position. Question 26 specifically asked for "ideal" qualifications.

As shown in Table 5-1, the majority of respondents thought that the

chief medicolegal officer in a jurisdiction should have a medical background. However, a large number also believed that a lay person could be a good medicolegal officer with the proper support facilities.

TABLE 5-1: Qualifications for Medicolegal Office as Viewed by Questionnaire Respondents

Question Always Usually Sometimes Seldom Never % % % % ' %

22. In your opinion, c should the chief medicolegal officer of a jurisdiction have a medical back­ ground (e.g., M.D. or D.O.)? W=378 70 15 11 3 1

23. Could a lay person be a good medicolegal officer if he/she had access to the appro­ priate medical and testing resources? 9 26 28 21 16 N=370 104

The apparent discrepancy in responses to these two questions may

he largely attributed to the wording of the questions. The "should"

in question 22 may be construed as requesting information about ideal

conditions. It also specifies the "chief" medicolegal officer as

the focus of the question. Question 23 does not specify the chief

official and could, therefore, apply to deputy officers, or local

officials in a state system headed by a "chief" medicolegal official.

The use of the word "could" in the question removes the connotation of ideal circumstances and replaces them with an element of possible

restrictions on available personnel, funds, and the like.

That somewhat conflicting responses might have resulted from

differences in the wording of questions 22 and 23 is supported by the response pattern to question 26 which requested an opinion about

"ideal" qualifications. Sixty-nine per cent of those responding

(sample=343), specified that medical qualifications would be the ideal for medicolegal officials. Of these, some specified certification in forensic pathology and others mentioned only a medical degree.

Thirty-one per cent felt that the ideal situation would involve an official who was trained in several areas, including medicine, law, and law enforcement. One such response emphasized the com­ plexity of the role by citing the following "ideal" qualifications:

To have risen to the rank of at least Lt. as a homicide in­ vestigator. To have a B.A. in business administration. To be a board certified pathologist (forensic). To have worked within a major medical legal system for at least five years. And naturally, to be under 40 years of age. [A lay deputy coroner] 105

Another respondent conveyed much the same range of required knowledge,

hut attempted to describe more realistic requirements.

l) A coroner should serve a term of at least one year as a police officer; 2) Should have an associate degree in criminal justice at minimum; 3) Should serve at least one year as an assistant to a forensic pathologist, in some large city's Coroner's Office; 4) Should attend a short course of any approved or accredited mortuary science school for the purpose of understanding what basically is the mortician profession; 5) If public relations is not a part of the criminal justice course at college, I feel it is necessary at least one semester be taken on public relations, press relations, etc. Ideally we would be looking somewhere of [sic] the vicinity of about a five-six year course.

I guess I could summarize this course in what I would call reality, not ideally, by stating after a man was elected to the office, or possibly before he was elected, he probably should possess an associate degree in criminal justice or some related field. After being elected in November, there is about six weeks that I feel he should be involved par­ ticularly in population area such as we have with some medical examiner, coroner's office such as Los Angeles, or some large city where he would spend-a couple-weeks in basically all branches that he would be dealing with when he would be coming back to ______[this state]. Basically a couple weeks with the police department, homicide investigation unit, with the Coroner's office dealing with nothing but autopsies, a couple weeks out in the field, dealing with the fa.nri lies and then probably a couple weeks in addition with the County Attorney's office. After he has been in office a couple years, go to something where it would be more formalized training of specialty-type training. [From an elected, lay coroner]

Among the other "ideal" qualifications listed by respondents were

"A suspicious nature and a medical degree."

"A good course in public relations."

"Watch '.Quincy' regularly."

"Integrity."

"Willingness to serve and to learn."

Some officials differentiated between qualifications for coroners and medical examiners or between a chief medical examiner and deputy 106

examiners. Others distinguished between officials in rural and urban

areas. Many respondents qualified their answers with remarks about

the practicality of these ideals in their own states or locales.

Financial restrictions and the size of the average case load were

frequently cited as reasons why an ideal situation could not become

reality.

The perception of the office held by coroners and medical examiners

is in direct contrast to what they perceive to be the public image

of the office. In response to question 49, "In general, do you believe

that the public is aware of what your office does and why?", forty-five

per cent of the questionnaire sample said "yes." Fifty-five per cent

felt that the public was not aware of the medicolegal role and its

purpose.

Responses to a similar question during the interview phase of

the research included some elaboration of the "yea" answer. Most of

these officials felt that the public was aware of the existence of

a coroner or medical examiner and knew that the office was somehow

responsible for dead bodies, but that many people were unclear about

the purpose of the office and powers of the official. The public was also perceived as being unaware of the complexity of the office.

People who had had personal contact with the office were considered

exceptions. In a few cases a local newspaper had printed a feature

story on the official which enlightened the public. One medical

examiner said several of his neighbors commented that they had read about him in the paper and that they never knew that he did

so many things. 10?

Since late 1976 the public has had another source of information about the coroner/medical examiner role—a weekly television series called "Quincy." Quincy, played by Jack Klugman, is a medical examiner on the staff of a metropolitan medicolegal office in

California. Although nearly all the medicolegal officials included in this study expressed the opinion that "Quincy" was an unrealistic portrayal of their profession, they did not agree about the effect the program might have on their occupation. Of the 372 people responding to question 54, 31 per cent reported that they had never watched the program. (Several reported that they had never even heard of it.)

Nine per cent reported watching "Quincy" regularly, 35 per cent watched occasionally, and 25 per cent seldom watched the show. Because so many respondents were familiar with this television series, it was used to indirectly solicit perceptions of the medicolegal role.

Respondents' evaluations of Quincy's behavior indicated their feeling about the importance of various aspects of the medicolegal role and the proper way of handling them.

Of those who had seen the program, and a few who had only heard about it, 42 per cent reported a favorable opinion of it. They described "Quincy" as good entertainment and probably beneficial to the public image of medicolegal offices. The following sampling of favorable responses is characteristic of this category.

"Good show. Technically d.k. Good public relations."

"Very good—Has done more to tell public what we do than any other activity. Programs based on fact—fancy added."

"I feel the show will inform the public as to the coroner/ medical examiner responsibilities, as did the program. 'Emergency' for better EMS services nationwide." 108

"Wish I had his crystal hall. I enjoy comedy."

"I pick up things at times."

"I feel it is a great asset to our office, even the blunders that are made help me."

"It is a good program. It is close to reality. It helps coroners examine all avenues. I enjoy it."

Twenty per cent expressed a negative opinion of the program, calling it distorted, unrealistic, and possibly detrimental to the occupation.

Many of these respondents had watched the program only once or had only heard about it from others. Their comments included the following:

"Quincy and Marcus Welby have too much time to solve their prob­ lems—I don't "

"Pure baloney. No relation to reality. I personally don't care much about it as entertainment and never sit long enough to see an entire program. My wife watches it."

"Disgusting. I haven't seen him sitting on the Bench but I'll not be surprised to see him try to be both Judge & Executioner. I feel this program gives the public a poor image of what I am trying to do."

"It does not benefit coroners but does a disservice to them. Quincy goes far beyond the scope of his duties and enters into fields in which he has no jurisdiction. He takes over the duties of the prosecuting attorney or the defense attorney etc. The public then assumes all coroners should do the same."

"Unrealistic. Very poor quality. Saccharin. Medically inaccurate." •

"I think it is trash! I don't believe it helps anybody."

"Think it is way over dramatized and Quincy is usually out of place in his activities. Not those of a real examiner."

"Lousy acting, no reality and nonbeneficial. I don't enjoy it as entertainment."

"It creates some difficulty as it leads audience to believe things can be determined quickly in laboratories which actually are time consuming to those of us; who do not have facilities."

"Utterly stupid. Terrible mis=service to forensic pathology." 109

A third group gave the series mixed reviews. Many in this group thought the program was entertaining and glamorized the profession, hut that it was also distorted and unrealistic. The following is a sample of the "mixed" reviews given the show by a number of respondents.

"More fantasy than fact, however I'd like to be in his shoes. About as close to real life as James Bond is to the CIA."

"Quincy presents a coroner who is the most dedicated person in his profession and a standard by which we should strive for [sic]. Realistically the time he puts in on one case isn't available and I don't have the facilities."

"I do not find that it is particularly close to reality, but I believe it will benefit coroners and medical examiners generally as it will increase the public awareness of their function. It . does show somewhat the political situation which may be involved in a coroner who Is appointed by a political system."

"Not too close to reality—There are not Forensic Pathologists that have the time to do what Quincy portrays as being his work, performing autopsies by himself at odd hours of the night??? There is a good message within all the Show Biz style of the program. The film director and editor should be more careful with details. The program is watched by compulsive, minute detailed observers (Forensic Pathologists). Example: Quincy goes into a home for an interview wearing one pair of pants and comes out the door wearing a different pair."

"Quincy, in contrast to the 'real' m.e., tends to play detective and does not remain within his province of scientific investigator Quite good entertainment."

"We have a saying—'B.S., but makes a good story.' It is to coroners what 'Emergency' is to emergency services about America: There aren't that many Julie Londons and Jack Klugman's to go around."

"No reality to me—however, I am not aware of how a coroner's office operates in a large city."

"Although it is quite 'far out,' it does help to erase the 'Edgar Allen Poe and dungeon' image that has been created in the past. I think that people feel more comfortable knowing that their coroner/medical examiner is professional and clinical." 110

Interviews with coroners and medical examiners also touched on

"Quincy." In the earlier interviews the official was asked for his opinion of the show. It soon became apparent, however, that a

specific question was not necessary. In all the remaining interviews the coroner or medical examiner brought up the subject spontaneously.

Interview reactions were similar to those recorded on the questionnaire. Some were favorable, some were not, and many had mixed feelings. Many officials reported that they did not tune in the show themselves, but that family members—especially wives— watched it regularly. One official remarked that the first few episodes resulted in a cross-examination by his wife. In the early segments Quincy was portrayed traveling around with a very attractive female companion. Their relationship caused the real coroner's wife to ask what really went on at all those medicolegal seminars her husband had been attending. A medical examiner complained that the "disgusting" thing aoubt Quincy was that "he's always right."

Although opinions about the "Quincy" series did vary, the majority of respondents believed that the program was making the public more conscious of the medicolegal office. Few felt that it would have a completely detrimental effect on the profession and many envied the time and facilities available to the fictional medical examiner. The existence of a few rural, lay coroners who saw "Quincy" as a realistic portrayal of a large urban medicolegal office indicates that some of these officials are isolated from the occupation in general and that their understanding of the reality of a metropolitan office is as uninformed as that of much of the general public. Ill

The negative comments about Quincy focused on his expansion

of the role to include work which is in reality the province of

police and the courts. Quincy also invades the jurisdictions of

other medicolegal officials—-crossing both county and state lines

on his own initiative. Coroners and medical examiners do not have

authority to invade each other's territory unless called in by the

authorized official or by one of the parties in a court case. In

such cases the visitor is invited to give "expert" testimony.

Criticisms such as these indicate that medicolegal officials perceive

their roles as fitting into a network of role partners—police, courts-r-

and geographically restricted to a particular jurisdiction.

Motivation

All of the respondents in this study were actively engaged m

the operation of a medicolegal office and this experience very likely

shaped their perception of the coroner/medical examiner role. In an

attempt to gather data about their perceptions of the role prior to

assuming it, officials were asked why they originally became coroners

or medical examiners. (The reader should remember that these answers were probably also influenced by experience in the office, but many

answers indicated that the official had only a vague perception of the role before accepting his position.) Twenty-eight per cent of the mail survey respondents said that they thought the job sounded interesting. Seven per cent acquired the position, usually coroner, as a result of being elected or hired for some other position, such as sheriff or county attorney. Another 3 per cent felt that they 112

indirectly obtained the job as part of another occupation. As one

mortician-coroner wrote, "Whoever owns the funeral home is the coroner."

A number of officials (20 per cent) took the job because "Someone

had to do it," or "I was the only doctor available." Twelve per cent

became medicolegal officials to perform a civic duty or to help out

someone else. In the latter case, a number reported being asked by

political party representatives to run for the office so the opposing

party would not control it. A few commented that they had originally

agreed to help out part-time or for a few months until someone could

be found for the position but no one ever came to relieve them. One

official, Dr. Z_____ , who had held the elective coroner's office since

194-3, related a story of the latter type. When the previous coroner

was called up for military duty during World War II, a representative

of the Republican party asked Dr. Z____ to take the office to keep

it "in the party." When the previous coroner was discharged from

service, Dr. Z____ asked him to resume the office, but he refused.

Z____ , a practicing osteopath, decided to stay on after that because

he found the political aspect of the job interesting and because the

coroner's work "gets me away from the humdrum of my practice."

Interviews revealed that many medically trained officials came

to full-time medicolegal work accidently. As one said, "I got lucky."

He had planned a career in obstetrics and gynecology, but while taking

recommended courses in pathology he became interested in forensic

pathology. Another medical examiner specialized in hospital pathology, but decided he was "too extroverted" for that field and preferred a

job which involved public contact. Several other medical examiners 113

first experienced medicolegal work while serving as military doctors.

They later pursued this interest by specializing in forensic pathology.

Finally, a few officials became acquainted with the profession while engaged in required medical studies or moonlighting for a medicolegal official during medical school.

Interviews and questionnaire data indicate that medically trained, career-oriented coroners and medical examiners had a relatively clear conception of the medicolegal role prior to entering it, although they may not have chosen it as a specialty originally. Elected physician-coroners, lay coroners, and a few part-time medical examiners were less likely to understand the role prior to assuming it.. This was especially true of those who acquired the coroner or medical examiner position as a secondary function of another position such as county attorney, sheriff, or public health officer.

Summary

Despite the variety in training, type of office, size of juris­ diction, and legal requirements of their offices, there were some similarities in the role definitions held by coroners and medical examiners. In keeping with the legal definitions of their role, most officials included the determination of cause and manner of death as a primary function of the office. Some also included protecting public health, detecting,criminal acts, and providing scientific information to the public—functions which are specified by‘law in some states.

In addition to the legal role requirements, however, most officials also included services to the family of the deceased in 114

their roles. Explaining medical and investigative findings to the

family and counseling those who felt shame or guilt was assumed to

be an important part of the role. This was further emphasized by

the number of officials who included compassion, patience, and public

relations skills in their lists of ideal qualifications for the office

Most medicolegal officials also perceived themselves as being

a part of the criminal justice system. They suggested that they

should cooperate with police in investigations and provide expert

information and testimony to the prosecutor, and usually the defense attorney, as well. Attitudes expressed by officials toward the television series "Quincy," further supported the idea that the coroner/medical examiner was a member of a criminal justice team, and not the only player. Although a few defined their roles as being aligned with the prosecution, others expressed a desire to serve justice impartially by helping to convict the guilty and exonerate the innocent. Many also characterized themselves as "the last friend of the deceased."

Although there was a difference of opinion about how medicolegal officials should be chosen, there was a great deal of consensus that ideally they should have medical training. In reality, however, most recognized that such a requirement might be unrealistic in some juris­ dictions. In those cases, the respondents indicated that a lay person could fill the role, if appropriate medical and testing facilities were available.

Finally, the respondents were split on their opinion of whether or not the public was informed about the medicolegal role. Even 115

those who stated that the public was informed often qualified their

answers, however, by saying they were not well informed. A number

of these officials reported spending a portion of their time trying

to remedy this situation by lecturing to civic groups and school

classes. Many felt that "Quincy" was also a help in this regard.

Chapter IV reviewed legal role requirements; the discussion presented in this chapter concerned the role definitions held by occupants of medicolegal positions. Chapter VI focuses on the actual performance of the coroner or medical examiner role as reported by the actors. In addition to their evaluations of their performances, attention is given to role conflicts and role strains which occur and to the structural and personal mechanisms for resolving these. Chapter VI

THE MEDICOLEGAL ROLE: PERFORMANCE, CONFLICT, AND STRAIN

The following discussion focuses on the performance of the

medicolegal role by coroners and medical examiners. The data used in

this chapter deal with two general aspects of the role: l) role

performance and evaluation of that performance by the actors and

2) role conflict and/or strain and its resolution. The analysis of

these two general topics is conducted on three levels—the individual

actor, the individual office, and the occupation as a whole.

On the first level, the discussion focuses on characteristics

of medicolegal officers as individuals. A description of these

officials by age, education, organizational training, and the like is

followed by a discussion of the potential these characteristics have

for producing role conflict or role strain. Various structural and personal mechanisms used by the officials to reduce strain and conflict are also included.

Role performance vis-a-vis the organization and practices of particular offices constitutes the second level of analysis. It includes descriptive data and officials' evaluations of the performances of their own offices. This is followed by a discussion of role strain and conflict experienced during the role performances and, again, structural and individual mechanisms, employed to resolve these.

On the third level the performance of the occupational group as 117

a whole is described as it was evaluated by respondents. At this level the discussion focuses primarily on the possibility of inaccurate verdicts in medicolegal cases in general. The accuracy of suicide statistics received specific attention in this regard.

The chapter concludes with a discussion of the possible conse­ quences of role conflict/strain and their resolution for official statistics on manner of death. It is suggested that inaccuracy in these statistics is more likely to be the result of structural constraints than of intentional misclassification by the officials themselves.

Before beginning a discussion of the findings, a review of role theory and role conflict/strain and their resolution is appropriate.

Role Conflict and Role Strain

Chapter II provided a brief discussion of the role terminology used in this presentation and outlined the mechanisms for role conflict and role strain resolution as proposed by Merton (1957) and Goode (i960), respectively.

Each social status of position includes an associated complex of behaviors called a "role." The role involves both expected or required behavior (role requirements) and actual behavior by the actor (role performance.) Role requirements may be formal or informal. In this study the relevant social status was that of coroner or medical examiner. The role included behavior expected and executed by persons occupying that status.

Each status and its associated role is part of a larger social network including other related statuses and roles. Also, individual 118

actors may hold more than one status at one time. Because a particular

status is related to other statuses and a given status occupant usually

has multiple statuses, situations may arise in which it becomes diffi­

cult or impossible to fulfill all of one's role requirements (inter­

role conflict), or there may be conflicting expectations for a single

status (intra-role conflict.) The latter results from the necessity

of interacting with persons in a variety of related statuses—one's

role partners. Not all role partners are related to a status occupant

in the same manner. For instance, some are one's superiors, some are

subordinates, and others are equals. Different role partners expect

different things from the actor and these expectations are not always

compatible. Consequently, to fulfill one role partner's expectations

the actor may have to violate another's. The array of behaviors

expected by one's role partners constitutes a role-set. The inability to fulfill all role expectations associated with a particular role is role conflict.

Role strain is very similar to role conflict and, as mentioned earlier, the distinction between the two is often unclear. In this discussion, however, role conflict refers to a situation in which role expectations are in opposition, while role strain involves the actor's feeling that fulfilling role obligations is difficult. The amount of stress produced for the actor would be greater under a condition of role conflict than under role strain.

Role strain may occur in situations where the actor's resources— time, money, personnel—are limited and conformity to the role expec­ tations of all his role partners threatens to use more resources than 119

he commands. Both conflict and strain may arise as a result of a

lack of articulation of role requirements or a lack of consensus

among role partners in regard to the requirements.

As both Merton (1957) and Goode (i960) pointed out, role conflict

and role strain occur with enough frequency that society could not

function without some sort of resolution mechanisms. Each theorist

proposed a number of mechanisms which are used to resolve such

situations. Although their lists exhibit a certain amount of overlap,

Merton and Goode differed on the level at which coping mechanisms operate. Merton defined the problem as a structural one and Goode

focused on the individual.

Merton (1957) cited six separate conflict resolution mechanisms.

They were: l) hierarchy of statuses; 2) power differences among role partners; 3) insulation of role activities; 4) observability of con­ flict by role partners; 5) mutual support organizations among status occupants; and 6) abridging the role-set. These were discussed more fully in Chapter II. In general, structural allowances for one or more of these mechanisms function to reduce role conflict and permit actors to carry out their roles in a more or less acceptable fashion.

Goode recognized the occurrence of similar problems as a result of multiple statuses and multiple role partners for one status. He assumed that role performances involve a series of role bargains during which "...a continuing process of selection [takes place] among alternative role behavior, in which each individual seeks to reduce his role strain" (Goode, i960: 483). Goode’s mechanisms were 120

individual efforts at coping. These were also discussed in Chapter

II and include l) compartmentalization of expectations and partners;

2) delegation of responsibilities; 3) elimination of role relations;

4) role extension; 5) obstacles to role extension; and 6) intrusion barriers.

The following discussion presents a description of medicolegal role performances which were evaluated by the actors themselves.

Coroners and medical examiners must interact with a variety of' role partners and, as discussed in Chapter IV, the formal role requirements are seldom clearly outlined. As a result, the actors and their partners must negotiate the particulars of their performances. In addition to the potential for conflicting expectations from multiple role partners whose demands and power vary, medicolegal officers occupy other social statuses. For many of these officials the multiple statuses include at least one occupational role in addition to the medicolegal position. This increases the possibility of inter-role conflict compounding the problems caused by intra-role conflict.

While the existence of such conflicts and the mechanisms for resolution are interesting in themselves, their importance in this study is related to the effects they have on role performance. More specifically, how might role conflict, role strain, and the resolution mechanisms affect the production of manner of death statistics? Are different types of mechanisms used by different officials'depending on their training, selection, budgets, and so forth?

Previous research has also focused on similar conflict and/or 121

strain situations in other occupations. Wardwell (1952;. 1955)

studied role strain among chiropractors. Chiropractic was classified

as a marginal profession in which role strain was produced hy the low

status of the occupation and the lack of training and licensing in

medical skills and privileges. Wardwell noted a trend toward more

rigorous training as one possible solution for the strain. He also

described occupational organizations for chiropractors. These

organizations attempted to influence licensing legislation and provide

occupational support for their members.

In his study of the nursing profession, Corwin (l96l) described role conflict resulting from two aspects of the nursing role—the nurse as professional and the nurse as bureaucratic office holder.

He found that the type of nursing program in which one was trained

(degree or diploma) tended to determine the amount of conflict experienced. The nurses in Corwin’s study minimized such conflict by emphasizing one aspect of their role over the other.

Quinney (1962; 1964) described a similar conflict for pharmacists confronted with professional and business aspects of their role. Again, resolution involved emphasizing one aspect at the expense of the other.

Some pharmacists chose to play the businessman role and others stressed the health care professional aspects.

Gross, Mason, and McEachern (1965) focused on role conflicts as perceived by school superintendents. Members of that occupational category were faced with conflicting demands from role partners resulting from a lack of consensus in regard to proper role per­ formance. Three of the four specific role conflict situations 122

studied (personnel management, teachers' salary negotiations, and

budget recommendations) involved intra-role conflict. The fourth

situation—allocation of time between community activities and one's

family—was an instance of inter-role conflict. The study indicated

that school superintendents used different techniques to resolve

different conflicts. Conflicts connected with personnel management were resolved by emphasing a professional stance or a practical policy.

Salary allocations involved either abridging the role-set by shifting the responsibility to the school board or attempts at developing a

compromise between role partners. In budget negotiations the super­ intendents often took advantage of the lack of role consensus and redefined their roles to included negotiation and sales tactics. In the inter-role conflict situation the actors stratified their different roles, permanently or temporarily, so that one took precedence over the other.

In the present study questions about the effect of role conflict and strain and their resolution on official statistics or about the variation in solution mechanisms used can not be answered with certainty on the basis of data collected. However, the data do indicate the general direction of the answers and Chapter VII includes suggestions for further research which might result in more specific answers.

Individual Characteristics and the Medicolegal Role

Exactly 400 officials responded to the mail survey. Of these,

58.5 per cent (234) were coroners and 4l.5 per cent (166) were medical examiners. Forty-eight per cent of the respondents were elected 123

officials and 50 per cent were appointed.1 As shown in Table 6.1, most of the officials were between forty and seventy years old. Very

few were younger than thirty or older than seventy.

TABLE 6.1: Age Distribution of Mail Survey Sample, N=394

Age ■ Number of Respondents $ of Sample

20-29 years old 13 3

30-39 years old 62 16

40-49 years old 102 26

50-59 years old 115 29

60-69 years old 83 21

70-79 years old 15 4

80-87 years old 4 1

Most of. the officials surveyed had served a number of years in their medicolegal positions. The data in Table 6.2 indicate that the majority had served more than one but fewer than twenty years.

The educational background of officials ranged from less than a high school education to advanced degrees in law and/or medicine.

Slightly fewer than 1 per cent had less than a high school degree,

7 per cent were high school graduates, 6 per cent had some college education, 5 per cent held Bachelors' degrees, less than 1 per cent had obtained a Master's degree, 4 per cent had law degrees, 11 per cent held degrees in mortuary science, and 4 per cent had acquired some other specialized training. The largest group, 62 per cent,

1 Two per cent did not respond to this question. 124

graduated in medicine or osteopathy.

TABLE 6.2: Distribution of Survey Sample by Years in Office, N=394

Years Served Number of Respondents °lo of Sample

Less than 1 year 21 5

1- 9 years 194 49

10-19 years 112 28

20-29 years 50 13

30-39 years 15 4

40-69 years 5 1

Eighty-six per cent of the respondents held another job in addition to their medicolegal position and of these, 8l per cent were engaged in the other job full time. Only 24 per cent of the respondents were full-time coroners or medical examiners. Table 6.3 is a breakdown of these other positions. Doctors and funeral directors accounted for over half of those holding both a medicolegal position and another job.

The majority of respondents showed an interest in learning more about the medicolegal role by seeking additional training in relevant subjects. Although few respondents had taken college or police courses for medicolegal actors, 70 per cent had attended workshops, seminars, professional meetings, and the like to broaden their backgrounds and/ or keep them up to date on new procedures and regulations. Many of these also indicated that they regularly read medicolegal books, journals, and articles. Despite the large number of respondents who had sought some sort of additional training for their medicolegal roles, only 59 per cent of the sample reported belonging to any 125

occupational organization for coroners and/or medical examiners.

(Eight per cent did not respond to the question and 34 per cent

reported that they held no such memberships.) Since the organizations

available usually offer seminars, workshops, and other educational

services to members, it was expected that those who were motivated to

expand their knowledge would join one or more organizations.

TABLE 6.3: Other Titles Held by Medicolegal Respondents in the Mail Sample, N=344.

Title Number of Respondents % of Sample

Medical Doctor or Osteopath 166 48

Funeral Director/ Mortician 63 18

Teacher (medical school, etc.) 15 4

Attorney 16 5

Public Health Officer 17 5

Sheriff/Policeman 6 2

Other (Magistrate, miner, 6i 18 businessman, etc.)

Thirty-five per cent of those who responded indicated membership in only one organization, usually a state coroners’ or medical examiners group. There was also reason to believe that some who reported a state membership belonged to a group other than a medicolegal one. In several cases where the state organization blank was checked, it was known to the researcher that no such organization existed in that state.

Also, several respondents who checked that response or the "other" 126

category specified by name an organization related to another occupation

rather than the medicolegal role.

Some of those from states without medicolegal organizations in­

dicated membership in one of the national organizations such as the

International Association of Coroners and Medical Examiners (IACME),

which seems to attract mostly coroners, or the National Association

of Medical Examiners (NAME). Fifty-three per cent of the sample be­

longed to IACME and 58 per cent belonged to NAME. One state, Nebraska, was somewhat unique in that none of its fifteen respondents belonged

to any medicolegal organization. This may be accounted for by the

nature of the office there, however. In Nebraska the county attorney

is ex officio coroner. The coroner role is secondary and these officials would be expected to choose law-oriented organizations over medicolegal ones.

In addition to the 35 per cent of the respondents who reported membership in only one medicolegal organization, 16 per cent reported two memberships, 6 per cent had three, and 2 per cent listed four.

Only one respondent reported memberships in as many as five medico­ legal organizations.

Finally, as discussed in Chapter V, the respondents were motivated to enact the medicolegal role by a number of different factors. Some took the position out of interest and some felt it expedient for nonmedicolegal reasons. Others said they had been drafted into the position by a local political party or because the job required a physician. One lay coroner wrote, 127

It was simply a matter of need. I work on an ambulance service, many times the wait for the County Coroner to arrive was as much as two hours. Before we could be released to leave the sean [sic] the body had to be inspected by the coroner. By my being coroner a rulling [sic] could be made much sooner and the ambulance re­ leased for other duties.

Another lay coroner described his recruitment as follows:

[I] was told that only work was to sign death certificates— was swimming instructor at the time and figured this wouldn't use up too much time. What an education I've had since!

Several respondents reported taking the position, often an elected one, because the incumbent had not been doing a good job or was corrupt.

Considering only the personal characteristics such as training, perception, and so forth which individual medicolegal officials bring to their roles, there is potential for role strain and role conflict.

In reality, respondents from both the interview and mail survey samples reported experiencing such strain and/or conflict.

Thirty-seven per cent of the survey sample responded "yes" to question 4-7, "Do you ever feel that it is impossible for you to ful­ fill all the responsibilities of your office?" Twelve per cent of these respondents cited lack of personal training and experience as the main reason for their affirmative answers. Several of those in the interview sample suggested the same reason. Physician coroners in rural counties were most often concerned about their lack of training in forensic medicine and how it might hinder a medicolegal investigation

This particular role strain situation was often resolved by delegating the more technical functions of the office to someone else.

In many cases, state laws either allowed or required delegation of autopsy and other medical duties to a qualified physician. One attorney coroner even reported delegating responsibility for signing 128

death certificates to his autopsy physician.

In counties with small case loads or budgets it was common

practice to assign various aspects of a case to outside facilities.

Simple toxicology and autopsies were handled by local hospitals and

laboratories on a per case basis. Local law enforcement personnel were used for investigative work. In more difficult or unusual cases tests were run by state police or crime laboratories or sent to the

Federal Bureau of Investigation. Some officials whose counties were near jurisdictions with more elaborate medicolegal facilities sent special cases to that office.

It was also accepted practice to call in a more experienced colleague from another county or state to consult on a case. This practice was reportedly used only in difficult cases, however. When this occurred the public was not always informed. As one official explained, "We don’t like all that publicity." He felt that publi­ cizing the use of well-known consultants would call undue attention to the case and possibly interfere with the investigation.

The 59 per cent who belonged to occupational organizations could also use those associations to help reduce strain and conflict.

Officials desiring additional skills attended training sessions and seminars. In some cases state organizations were used to lobby for changes in the office’s structure which would eliminate conflict.

Inidviduals reported that role conflict as well as role strain resulted from personal characteristics. A rather obvious source of conflict was inter-role conflict which sometimes resulted from holding another job in addition to the coroner/medical examiner position. 129

This inter-role conflict occurred in several ways. Combining a full­

time job with a medicolegal position which required being on call

twenty-four hours a day placed heavy demands on one's time. Then

too, the medicolegal call sometimes came at a time when the other

job required one's attention. Physician coroners reported being

called on a medicolegal case in the middle of office hours or hospital rounds.

A second instance of inter-role conflict results when the two positions involve a conflict of interest. A mortician coroner faces possible economic conflict of interest. A county attorney or sheriff who is coroner is in a position to experience a conflict of legal interests. As coroner, a mortician often has the power to assign a body to a funeral home pending notification of next-of-kin or if no relatives are located. As a mortician he stands to benefit economi­ cally from taking all such cases to his own funeral establishment.

An impartial coroner, however, would be expected to assign cases more or less equally to all the funeral homes in his area.

Although there is some role conflict for the mortician coroner, legal officials and law enforcement officers who are also charged with medicolegal duties face potentially more serious inter-role conflict.

As mentioned in .Chapter V, these officials must balance the prosecution functions of one position with the impartiality expected of the medicolegal official. Also, as a result of affiliations with state and county government and the sheriff's responsibility for appre­ hending and holding suspected law violators, these dual-role officials may be suspected of covering up deaths for which they might be held 130

responsible. Since even supposedly impartial coroners are sometimes

accused of cover-ups, those officials who are doubly responsible to the public are particularly vulnerable.

Inter-role conflict resulting from occupation of two positions was resolved or lessened in several ways. Some officials resorted to the use of a hierarchy of responsibilities. This was particularly true of those who became coroner as a result of holding another public position such as county attorney. The primary job received full attention and the secondary, medicolegal role was supported with whatever resources were left over. The same sort of compromise was used by some who held a full-time job in addition to the part- time medicolegal position.

Respondents, especially in the interview sample, also reported easing this type of inter-role conflict by bringing it to the attention of relevant role partners. This mechanism served to shift the burden of the solution to others or it was used to direct the focus of controversy from the medicolegal official to an argument among his role partners. In the first instance, county commissioners or state legislators may be forced to resolve the conflict by hiring addi­ tional help for the official. Or they may revise the whole system to introduce another official who is not subject to inter-role con­ flict, for instance creating a position for a full-time medical examiner to replace an ex officio coroner. In the second instance, role partners at various levels may be pitted against one another by the medicolegal official who redirects criticism of his performance.

The official can plead for understanding by explaining that he is 131

only doing his job or that he knows it is a bad situation, but the

state or county people set up that way.

The individual's motives for assuming a medicolegal position

may also result in role conflict, both intra- and inter-role conflict

The ambulance attendant quoted earlier seemed to be more interested

in freeing an ambulance for other cases than in making an accurate

determination of death. In that case, arranging role demands in a

hierarchy probably resolved any conflict he might have felt.

Those who were drafted for the job by friends , political

colleagues, or the local medical association might not have been par­

ticularly interested in the job or might even have felt unqualified

for it. In those cases the occupant's behavior might not measure

up to his role partner's expectations. Bradshaw (1974) found that

some officials resolved this type of conflict by delegating certain

duties. In his study one coroner was not particularly interested

in his medicolegal role and minimized it by delegating responsibility

and abridging the role-set by declining certain types of cases.

Another official maximized his role in terms of both involvement and

number of cases because he was interested in the work. In summary,

the medicolegal officer may experience both role strain and role

conflict as a result of a variety of factors. Many of those who lacked specialized training in forensic medicine reported that it was sometimes difficult to perform their duties properly. In such cases they could often resolve the strain by delegating duties to someone else.

Role conflict resulted from occupying conflicting statuses, 132

especially two occupational statuses. The problem was of special

interest when one role was required, to function as a check on the

other, such as coroner and sheriff. One resolution mechanism in

these cases was stratifying the positions so that one was given more

importance than the other. Other officials made role partners aware of the conflict and left it to them to resolve the situation.

An official’.s motivation for assuming the medicolegal role also sometimes produced role conflict. Those who reported they sought the position out of interest or a sense of civic responsibility were able to maintain that motivation in performing the role. Some of those who originally accepted the position at the urging of someone else later developed an interest and retained the position for that reason.

Those who took the position at another's urging and retained it for that reason often relegated the medicolegal role to one with low priority and assigned much of the work to others. The same was often true of those who acquired the role as a part of another office.

Medicolegal organizations were used by some officials to provide additional training and information on new practices in the occupation

In some cases state organizations functioned as lobby groups to persuade legislators to tighten regulations or revise the system so that strain and/or conflict were reduced.

Performances of Individual Offices

As previously mentioned, the organization and sophistication of offices represented in this study covered a broad spectrum. At one 133

end were small operations which were not even housed in a separate

physical location, hut which constituted one drawer in a file cabinet

of a physician coroner's medical office or a mortician's funeral

home. An official of one such office said, "Around here the coroner's

office is a phone booth." Autopsies and necessary tests were per­

formed at local hospitals or state facilities and the coroner's

position was considered part time.

At the other end of the continuum were those offices which occupied modern, well-equipped facilities and included a staff of forensic

pathologists and a variety of specialized technicians. The head of

these operations was a full-time medicolegal officer and most or

all of the staff were also employed there full time.

Of those offices included in the interview phase, 4l per cent

(sample=27) were classified by the researcher as falling at the large, well-equipped end of the continuum. Forty-one per cent were small operations. Fifteen per cent were ranked somewhere between the two extremes. (The remaining 3 per cent were accounted for by the one group interview. Since the five offices represented in that interview varied in size and organization, no attempt was made to classify them.)

For the purposes of this study, offices included in the interview phase were described as large, intermediate, and small on the basis of several criteria. Large offices were housed in separate medicolegal quarters, usually a whole building. They had facilities for a morgue, autopsies, and laboratory work. The staff in large offices was mostly composed of full-time employees and included at least one foren­ sic pathologist. All but one of these offices were located in large metropolitan areas. The intermediate offices were also located in metropolitan

areas, hut these areas were somewhat smaller than those character­

istic of the first category. Three of the intermediate offices

occupied separate quarters of their own, hut two of these were only

administrative offices. Autopsies and laboratory work were done by

local hospitals and laboratories. One coroner's office was part of

a county prosecutor's office, but the medical and chemical work was

done in one central location supervised by a pathologist. One

separate facility included both administrative offices and medico­

legal facilities, but it was much smaller in scale than those

operations in the first category, tThe medical examiner in that

office was the only full-time staff member.

Small offices were headed by part-time coroners or medical

examiners, all of whom pursued a second occupation on a full-time

basis. The offices themselves were not housed separately, but

shared facilities with the official's other occupation. These

offices were located in predominately rural counties. Autopsies

and simple chemical work ups were conducted at area hospitals.

Difficult cases were often sent to a state facility or a larger medicolegal office in a nearby jurisdiction.

Offices represented in the questionnaire phase were described

in terms of the facilities available and the number of full- and part time employees. Table 6.4 describes the facilities and types of personnel available: to the officers. It was compiled from responses to question 46 on the mail survey form. The responses indicated that clerical staff was the feature most likely to be available in 135

an office and trace evidence facilities were least often found in medicolegal offices. This service was available to 85 per cent of the offices, however, if they chose to use it.

TABLE 6.4: Facilities and Staff Available to Officials

Service or Available in Available, not Not Staff Position Office in Office Available N % $ %

Clerical Staff 48 31 21 340

Morgue Facilities 32 56 12 358

Autopsy Facilities 31 65 4 36l

Field Investigators 28 52 29 355

Hospital Pathology 22 74 4 353

Histology 20 68 12 342

Forensic Pathology 16 74 10 346

Statistician 10 . 50 4o 330

Toxicology 8 88 4 358

Trace Evidence Lab 4 85 11 352

Although only l6 per cent had forensic pathologists in the office itself and only 22 per cent had hospital pathologists, three fourths of the officials reported that at least one of these was available for medicolegal cases. Twenty-five per cent of the 380 respondents reported that necessary autopsies were performed by forensic pathologists and

38 per cent indicated that hospital pathologists performed their autopsies

Twenty-six per cent of the offices used both and 6 per cent indicated that some other arrangement was made. In the latter case, the autopsy 136

was usually performed by a physician who then sent tissue and other

biological samples to a pathologist.

Field investigators represented the category which was least often

available and 29 per cent reported not having such personnel. It is

likely that most of these officials used state and local law enforcement

personnel for investigative work.

Another indication of the size of those offices included in the mail survey was the number of full- and part-time employees in the

office. Sixty per cent of the 36l respondents indicated that they had no full-time staff members. Thirty-one per cent reported one through

five full-time staffers. Three per cent had six to nine full-time people, 2 per cent had ten to nineteen, 3 per cent had twenty to fifty,

1 per cent had over fifty but less than seventy-five, and two respon­ dents reported that the size of the full-time staff varied.

Forty-one per cent of 36l respondents reported having no part- time staff. Forty-six per cent reported one through five part-time people. Seven per cent employed six to nine part-time staff members,

4 per cent reported ten to nineteen, and 1 per cent had twenty to fifty. One person reported seventy-one part-time employees and one had over one hundred, but those offices were part of a hospital setting.

In response to question 43, 64 per cent of those who responded reported that autopsies were always complete autopsies, rather than partial ones. (Complete autopsies involve both brain and body trunk.)

Thirty-six per cent reported using partial autopsies. During the interview phase one forensic pathologist indicated that complete autopsies were not always necessary, but that making them routine 137

eliminated some errors and resulted in fewer conflicts with family

members over what procedures should be done in a specific case.

In certain types of cases autopsies were routinely ordered to

verify the cause of death. The number and kind of cases routinely

autopsied varied with size of the office, its budget, and possible

research interests of staff members. Table 6.5 is a breakdown of

some of the kinds of cases routinely autopsied.

TABLE 6.5: Percentage of Offices Routinely Ordering Autopsies in Selected Cases, R=35O

Type of Case Autopsy Routine r

Suspected Homicide 97

Suspected Sudden Infant Death Syndrome 82

Industrial Accident Victim 51

Suspected Suicide 49

Auto Accident Victims 29

Other 29

The table indicates that suspected homicides were routinely autopsied by nearly all the offices and most offices routinely autopsied infant

deaths which were suspected to have been caused by Sudden Infant Death

Syndrome. Respondents were split on the handling of suspected suicides and industrial accidents. Less than one third of the officials reported that automobile accident victims were routinely autopsied.

In addition to autopsies some officials held inquest powers which could be used to investigate a death. Sixty-six per cent of the sample 138

reported that they had the power to order an inquest. Thirty-one

per cent did not have such powers and 1 per cent were unsure what

power they had. (-Two per cent did not respond.) Of those 277

respondents with inquest power, 72 per cent used that power less

than ten times in 1976. Seven per cent held between ten and twenty

inquests and 7 per cent held more than twenty but fewer than seventy-

six. Two per cent held over 100 inquests and 2 per cent did not know how many inquests were held in 1976.

In regard to the use of inquests in a medicolegal investigation, the system in the United States evolved in a different direction from that in England. The English system places more emphasis on the use of inquests than does the United States' system (Atkinson, 1973). It may be understandable that a physician coroner would not want to become involved in what is essentially a legal procedure, and it would be expected that inquests would be used extensively by attorney coroners

But one attorney coroner reported that he and his colleagues preferred not to use inquests because1'"... it gives the defense an advantage in preparing his court case." Prosecution evidence and witnesses would be revealed at an inquest which would allow a defense attorney to preview the state's case. An inquest usually also requires a coroner's jury which must be paid. The additional burdens of locating jury members and paying them are dispensed with when no inquest is held.

Despite numerous negative evaluations of the inquest procedure, it does have some advantages. One coroner said that some of his colleagues in other counties use it "...to take the pressure off themselves." If a case is controversial or the verdict is likely to 139

be unpopular, the coroner can reduce the pressure directed at him by

ordering an inquest and leaving the verdict up to a jury of citizens—

delegating part of his performance. One coroner threatened to call an

inquest to make public information which he felt the local authorities were attempting to hide (The Daily Sentinel-Tribune, 1976).

Chapter V included a discussion of the medicolegal role and its requirements as perceived by the incumbents of coroner and medical examiner positions. It included their analyses of the importance of responsibilities to various role partners. Question 30 on the mail questionnaire asked respondents to evaluate their own performances in regard to these responsibilities and role relations. Table 6.6 summarizes their evaluations for eight areas of responsibility. Re­ sponses are grouped by medicolegal title held by the respondents.

As the table illustrates, most of the respondents in both categories evaluated their offices as average or above on all but one factor— medical research. In regard to public health, advising the prosecutor, assisting police, making accurate determinations, advising the defense attorney, and medical research there was little difference between evaluations from coroners and those from medical examiners. Medical examiners gave themselves somewhat lower evaluations than coroners on dealing with family members and cooperating with the news media.

Overall the medical examiners were less likely to report an excellent performance, but evaluated themselves positively. Few members of either medicolegal category reported "very poor" performances and most such responses were given in regard to medical research.

In regard to those responsibilities which were perceived by TABLE 6.6: Respondents’ Evaluations of Their Role Performances in Obligations to Role Partners

PERFORMANCE EVALUATION (1) (2) (3) (4) (5) Excellent Good Average Poor Very Poor X N RESPONSIBILITIES 1° % % % % l) Protect Public Health Coroners 34 35 20 5 7 2.15 197 Medical Examiners 31 37 26 5 1 2.09 152

2) Advise Prosecutor in Criminal Case Coroner 42 43 14 1 0 1.76 202 Medical Examiner 4o 43 15 3 0 1.82 152

3) Explain Cause of Death to Victim's Family Coroner 50 40 9 1 0 1.6l 211 Medical Examiner 39 4l 18 0 0 1.82 155

4) Assist Police in Investi­ gation Coroner 50 40 8 1 1 1.63 207 Medical Examiner 47 4l 12 0 0 1.67 155

5) Make Accurate Determination of Manner of Death Coroner 52 33 14 0 0 1.64 209 Medical Examiner 44 37 18 0 0 1.76 155

-HPrt o TABLE 6.6: continued

PERFORMANCE EVALUATION (1) (2) (3) (4) (5) Excellent Good Average Poor Very Poor X N RESPONSIBILITIES 1' % $ % 1°

6) Advise Defense Attorney- in Criminal Case Coroner 23 35 30 10 2 2.33 198 Medical Examiner 27 4o 26 6 1 2.15 153

7) Cooperate with News Media in Informing Public Coroner 23 43 24 7 3 2.24 205 Medical Examiner 19 32 39 7 3 2.44 153

8) Participate in Medical Research Coroner 15 l4 28 16 27 3.27 197 Medical Examiner 7 14 31 29 19 3.40 147

H -p- 142

respondents to be most important—accurate determinations and assisting

the police (see Chapter V)—the officials evaluated themselves well.

They also evaluated their cooperation with the news media higher than

was expected in light of the low ranking it received in Chapter V when

the officials ranked responsibilities to role partners (see question

29, Appendix I.) Medical research was perceived as one of the least

important responsibilities and performances in that area were given

low evaluations. Although the comparison of perceived importance and

adequacy of performance was interesting, one important question could

not be answered with this data: Did perceived importance lead to

behavior adjusted for its priority, or did performance influence

perceived importance?

Responses to a number of questions about the operation of individual

medicolegal offices indicated that officials experienced both role strain

and role conflict as a result of the organization and resources of their

offices. Forty-two per cent of those who responded to question 4? re­

ported that they sometimes felt it was impossible to fulfill all the

responsibilities of their role. As reported earlier, 12 per cent blamed personal characteristics (e.g., lack of training) for the feeling of

role strain. Seventy-seven per cent of the group which experienced role strain attributed the difficulty to structural characteristics of the office. The most common complaint in that category involved too

few staff members and too much work. Twenty-eight per cent cited this deficiency alone. Other complaints included lack of sufficient funding, too few autopsies and too little investigation of cases, all of which could probably be traced to too much work for too few people. 143

Although no specific questions were included to ascertain which

strain resolution mechanisms were used by these officials, extraneous

comments written on questionnaires and comments made by respondents in

the interview sample indicated two possibilities. One involved Goode’s

(i960) compartmentalization mechanism. Officials did what they could when a case arose and tried not to deal with the overall problem. That approach could result in a variable policy of investigation and post­ mortem examination depending on the prominence of a particular case, availability of funds and personnel, and time.

A second mechanism which was suggested was delegation. Officials pressed community and state resources into service for investigation, chemical work ups, and autopsies when they or the staff were unable to handle the whole role performance. The use of that mechanism was limited for many, however, by the availability of funds to pay for extra services.

The role strain experienced by some officials as a result of insufficient funds and personnel had reached the role conflict level for others. In response to question l6, "Do you believe that the operating budget for your office is sufficient?", 27 per cent gave negative answers. Twenty-eight per cent of these believed that the shortage was severe enough to affect their ability to make accurate rulings. Sixty-four per cent of that group cited insufficient ' personnel and/or facilities to conduct the necessary medicolegal investigations and tests as the cause of the problem. In other words., their role partners expected them to make accurate determinations, but did not supply the necessary resources. 144

Coroners and medical examiners attempted to resolve this intra­

role conflict in one of several ways. Some devoted their energies

to making their role partners aware of the conflict in the hope that

those with the expectations would resolve the situation. One vehicle

of awareness used hy all of those interviewed was the annual budget

request. Since most of those submitting budgets were allowed to

include^verbal or written rationales for budget increases there was

some opportunity to educate role partners. One medical examiner re­

ported that he took the county commissioners on a guided tour of his

antiquated facility to convince them of the need for larger, better

equipped quarters. He was successful.

In addition to the efforts of individual coroners or medical

examiners, medicolegal associations, especially at the state level, were also used to make the appropriate role partners aware of conflict and pressure them for a solution. One such organization was able to convince legislators to restrict the office to physicians and then to increase the annual salary of coroners to a level commensurate with the responsibility and work involved.

Role conflict also resulted from conflicting definitions of role relations and role powers between coroners and medical examiners and their various role partners. In most cases the medicolegal official had to rely on a variety of role partners to notify him of the existence of a new case. In response to question 15, 23 per cent of those who answered said that some cases which should have been referred were not.

Among those role partners who were guilty of not referring appropriate cases were police, ambulance attendants, hospitals, and private physicians 145

Police and ambulance personnel were named by only 1 per cent of those who specified the guilty parties. Hospital personnel were named by

27 per cent and private physicians by 56 per cent.

One physician coroner in the interview sample reported that both an ambulance service and a hospital had violated the established re­ ferral procedures. The ambulance driver frequently crossed county lines and brought dead accident cases from another county, violating jurisdictional norms and failing to notify the coroner before disturbing the scene. One hospital had, on several occasions, waited several hours before notifying the coroner of a case and then only called when they

"had bodies left over." Other cases were improperly signed out by hospital physicians. All of those in the interview sample reported having had problems in this area at sometime. The usual method of resolution was to make the role partner aware of the situation and, since most of the offenders were status subordinates, the medicolegal official was able to use the authority of his position to develop consensus about the division of responsibility, at least in practice.

One medical examiner was so effective that he began experiencing the reverse problem—many unnecessary referrals.

One category of role partners which received a great deal of criticism: and blame for role conflict was the news media—newspapers in particular. Officials perceived that their responsibilities to these role partners had a low priority and they did not evaluate their own performances vis-a-vis the media as high as they did for most of the other aspects of the role.

Despite their complaints, however, only 35 per cent of the 146

questionnaire respondents considered news media coverage of medico­

legal cases inaccurate and only 11 per cent considered the media

unfair in their treatment of the medicolegal office. All hut three

respondents in the interview sample expressed a dislike of all or

some newspaper personnel, however.

The complaints cited against reporters always included the problem

of being misquoted, but officials also felt that reporters expected them to provide more details than they could or should, and that

sensationalized reporting was detrimental to the official, the victim's

family, and police investigations. One coroner said that he always

refused to deal with young, inexperienced reporters, but another

coroner felt that young reporters took greater care to be accurate than did older reporters. The medical examiner in one large city with two newspapers reported a neutral relationship with one paper and open hostility with the other. He refused to provide any infor­ mation to the latter because they had sensationalized reports and misquoted him so frequently in the past.

A very few officials, such as the last medical examiner, resolved role conflict with media personnel by abridging the role-set--he excluded reporters as role partners. Media representatives were helpful to officials in some cases, and media enemies were powerful foes in public disputes. Newspapers and television were used by officials to help identify unknown bodies and develop evidence. They also participated in publicity campaigns designed to reduce preventable deaths. As hostile role partners the media focused public criticism on medicolegal officials and blocked attempts to change the office or

- 1 147

its facilities. One metropolitan newspaper was probably instrumental

in delaying the acquisition of physicial facilities and trained per­

sonnel to upgrade the local coroner's office. The newspaper editor

used his editorial page as a forum to arouse public sentiment against

the necessary budget expenditures (Toledo Blade, 1976).

Other effective mechanisms employed by coroners and medical

examiners in their dealings with media role partners included delegation

of duties and insulation of role activities. Requests for information,

particularly in criminal cases, were referred to the appropriate law

enforcement agency or to the county attorney. Such an approach relieved

the medicolegal official of responsibility for deciding what information

to release and lessened the probability of misquotations of medicolegal

opinions.

Since much of their work occurs in restricted areas (e.g., autopsy

room, laboratory) and is more technical than the average lay person can

comprehend, medicolegal officers are somewhat insulated from probing

reporters. Such insulation also contributed to the reduction of role

conflict.

Some of the same mechanisms used by coroners and medical examiners

to reduce role conflict with reporters were also used to resolve con­

flict with the family of the deceased. As noted in the review of literature, a frequent criticism of official death statistics was that medicolegal officials were subject to pressures from the deceased's

family or their representatives to avoid unpleasant verdicts such as

suicide. All of those officials interviewed for this study reported

at least one instance in which a family member or representative had l48

attempted to persuade them to change a ruling. (Family representatives

included friends, lawyers, and religious officials.) Table 6.7 is

the distribution of responses to question 4l on the questionnaire.

TABLE 6.7: Frequencies with Which Role Partners Pressure Officials to Change a Suicide Verdict

FREQUENCY PER YEAR

SOURCE OF PRESSURE Never 3 or less 4-6 7-9 10+ N % 1» % 1° %

Family 4o 48 6 l 4 357

Family Representatives 51 39 6 1 3 329

Religious Officials 85 13 l 0 1 317

Insurance Investigators 86 12 2 0 0 321

Others 87 12 1 0 0 199

Police 91 8 1 0 0 320

Of those who responded to the question, 63 per cent reported that they had experienced pressure from someone in one or more cases (sample=

378). Most of the reported attempts were made by the family members or family representatives. Respondents felt that such efforts were prompted by the possibility of stigma attached to a ruling or by the potential for monetary gain if the death were not ruled as a suicide.

Thirty-one per cent of the respondents emphasized the stigma factor and 17 per cent singled out monetary factors. Thirty-nine per cent mentioned both factors. The remaining 13 per cent cited emotional and religious factors or misguided friendship.

Officials used a variety of mechanisms to reduce role conflict 149

resulting from pressures to change verdicts to "help" the family versus the expectations of other role partners that verdicts should he accurate.

Thirty-two per cent of 1?2 respondents relied on a variation of the mechanism of power differences among role partners. These officials were typified by the comment, "I tell them I have to call 'em like I see them. It's my job." That implied that a role partner, or partners with more power expected an objective verdict.

Fourteen per cent reported that they used the delegation method and referred further action or comment to someone else. Fifty-four per cent of these referred the matter to the county attorney or head of a state medicolegal system or suggested the complainant request an inquest. Forty-six per cent of those who used the delegation method delegated the responsibility to the complainant himself. In those cases the official advised the person making the appeal to produce new evidence and the case would be reopened and reinvestigated.

One per cent of the respondents reported attempts to abridge the role-set by ignoring such appeals. This was more an individual mechanism than a structural allowance, however, since medicolegal officials were defined as public servants.

The most frequently used coping mechanism reported was a variation of making role partners aware of conflict. Fifty-three per cent of those who responded to this question reported that they tried to explain the case to the family and make them aware of the necessity to rule the death a suicide. The following response illustrates a common approach to this series of questions. 150

I feel that most families have a fear, particularly the rel­ atives, of the gossip surrounding the death. Socially, they do not want to he labeled as haying a suicidal member in their family. Feelings of guilt. If the coroner rules it as some­ thing else it would be more acceptable to them. In my ex­ perience it has been family representatives who have made the greatest perssures to change the ruling or prevent it, and at times family friends. The immediate family never pose much problem, as I usually spend a great deal of time with these families explaining and discussing with them and feeling them out. It is usually the well meaning family representative waiting outside that wants to change things and poses the greatest problem.

If there is no doubt that the case is suicidal (suicidal note or witnesses), I am not persuaded in the least and explain to the individuals that although the information is public in­ formation and the coroner’s office is open to inspection, I will do my utmost to play down the suicidal aspects. I explain to them that legally I must rule in this manner -and I try to counsel them as best I can. Those cases which are questionable, where there is room for doubt, I may put down undetermined and then hassle with the state department of vital statistics, who wants a more accurate determination.

Officials also indicated that families sometimes objected to the performance of autopsies. When the law dictated an autopsy the official used that as a rationale to resolve conflict—indicating that another role partner had higher power. He was further protected by the in­ sulation of his role activities from public view. When the procedure was not legally required, the family's wishes were usually honored.

In summary, medicolegal officials reported experiencing role strain and/or role conflict as a result of the structural characteristics of individual offices. Role strain was usually attributed to shortages of financial and staff support which, meant extra work and minimizing expenditures. Coping-mechanisms included compartmentalization of activities and delegation of duties when financially feasible.

For some, financial shortages were severe enough to cause role conflict. In those cases the demands of role partners so far exceeded 151

resources that it was impossible to.fulfill all expectations.

Officials sought to relieve such conflict by increasing role partners’

awareness of the conflict in an effort to resolve the situation. In

some cases, occupational associations served a support function and

even attempted to influence legislation which would alleviate the

conflict.

Three categories of role partners reportedly contributed to intra­

role conflict for coroners and medical examiners. These were occu­

pational groups who were in a position to refer cases to the official

(e.g., police, ambulance attendants, private physicians, et cetera); media personnel, especially newspaper reporters; and family and friends

of the deceased.

The first group sometimes failed to refer the appropriate cases.

This occurred as a result of a lack of consensus in the definition of medicolegal jurisdiction or because referral would slow down other procedures or deprive the role partner of revenues (e.g., ambulance fees). These situations were resolved by educating partners about the role and its authority.

The perception that media role partners made unfair demands, misrepresented role performances, and/or hindered proper performances lead to the use of several conflict resolution mechanisms. A few officials attempted to eliminate reporters as role partners. That tactic had potentially negative consequences, however, so most officials either delegated role relations to some other official

(e.g., police, county attorney) or relied on the insulation of the role setting to minimize contacts with reporters. 152

Pressure from families or friends of the deceased to change

rulings was combated in several ways. Those role partners were

sometimes referred to other officials or reminded of power differences

among role-set members. Again, a few officials attempted to abridge the role-set, but that mechanism was used infrequently. The most common approach involved explaining the situation and findings in detail. That resulted in increased awareness of the conflict situation which the request created.

Role Performances in the Occupation in General

In addition to questions about their own role performances, officials were asked to evaluate certain aspects of the performance of the occupational group overall. Each respondent was asked several questions about the role of a medicolegal position in the career plans of most officials in his state. (See questions 24, 25, and 27 in

Appendix I.) Other questions dealt with the evaluation of role performances.

Only two per cent of 379 questionnaire respondents reported that the coroner or medical examiner position in their state was always or usually used as a stepping stone to higher political office. Nine per cent said that it was sometimes used for that purpose. Eighty- nine per cent reported that it was seldom or never used for political advancement.

Sixty-three per cent of 359 responding reported that the medicolegal position was usually a career in their state. Since so many of the respondents were part-time coroners or medical examiners this should probably be interpreted as a long-term position often held in addition 153

to another occupational position. Another 24.per cent indicated that

the position was sometimes a career. Only l4 per .cent felt that it was seldom or never a career.

Respondents were also asked to indicate at what point in a career one was likely to become coroner or medical examiner. Sixteen per

cent of 320 respondents believed the office was acquired early in one's

career. The majority (63 per cent) placed acquisition at mid-career.

Only 7 per cent reported that the office was usually acquired late in one's career. Another’l4 per cent could not identify a particular period, but indicated that it varied. The general opinion expressed was that the office was usually not a stepping stone for higher office and that the officials usually acquired the position in mid-career and retained it for a long period of time. These responses were fairly consistent with the data on age and length of time in office presented earlier.-

Question 30 asked respondents to evaluate occupational performances in regard to the frequency with which certain kinds of mistakes were made which led to inaccurate rulings. Table 6.8 includes a breakdown of those responses. Data were also compared by-the type of official reporting (coroner or medical examiner), but no significant differences were discovered.

As the table indicates, officials were less likely to report frequent mistakes than to claim infallibility. The most common choice was the middle-ground answer "occasionally."

Another series of questions was directed at perceptions of the accuracy of suicide statistics. Questions 38 through 40 dealth specifically 154

TABLE 6.8: Respondents’ Evaluations of Frequency of Mistakes at Various Steps in the Medicolegal Handling of Cases

FREQUENCY

Frequently Occasionally Never N STEP % %...... $

Failure to Refer Case to Medicolegal Officer 12 58 30 333

Decision Not to Autopsy 12 71 17 344

Misinterpretation of Biological Evidence at the Scene 7 80 13 333

Misinterpretation of Death Scene Evidence 6 82 12 341

Misinterpretation of Autopsy Findings 1 47 52 333

Misinterpretation of Toxicology Findings 1 48 51 331 with suicide statistics and officials who produce inaccurate suicide statistics.

Only 19 per cent of 329 respondents reported that suicide statistics were accurate. Seven per cent thought that they were over-reported and

74 per cent agreed with critics of the statistics who said that suicides were under-reported. Those who considered the statistics inaccurate were in disagreement over whether the inaccuracy was intentional or the result of mistakes. Thirty-six per cent believed the incorrect verdicts were made intentionally and 54 per cent said they were caused by mistakes. Ten per cent said both factors were responsible.

Intentional misclassifications were usually reported to be the result of a variety of pressures (21 per cent) or of a desire to help 155

the victim's family (58 per cent). Mistakes were thought to he

caused by the lack of training (6 per cent), or improper information

from toxicology tests, field investigations, or autopsies (63 per

cent). Three per cent of the cases were considered too difficult to

classify accurately because of the condition of the body or an

exotic cause of death.

When asked which officials were most likely to make errors in

their rulings, respondents gave a variety of answers. Untrained,

inexperienced officials were listed by 13 per cent of the 206 respon­

dents. Another 17 per cent said lay officials, 12 per cent cited

elected coroners, 2 per cent said compassionate officials. Twenty-

eight per cent listed police, medical people and officials who were

"lazy," "stupid," or "weak." Three per cent gave multiple answers

and 22 per cent said it was impossible to generalize.

Responses to these evaluation questions indicate that officials

perceive some role conflict and strain for the occupational group

as a whole. The sources of strain and conflict were much the same as

those reported for individual cases and offices: lack of training

and experience, insufficient funds for staff and facilities, and

pressures from role partners. Three officials in the interview

sample reported knowledge of cases in which pressure for a particular verdict was applied by an organized crime group. More frequently, however, the pressures were from family and friends of the victim.

Although no specific questions were asked at this level about coping mechanisms, it is assumed that they were the same as those cited by

individuals in similar circumstances. 156

Manner of Death-Statistics and .Role Strain/Conflict .

It is unlikely that any medicolegal system would produce

statistics which were 100, per cent accurate. The determination process

is subject to a certain amount of random error. In addition to the

possibility of random human error and weaknesses in the technology

used to make manner of death determinations, medicolegal officials

must cope with role strain and role conflict in their attempts to

carry out role expectations and requirements.

Cicourel's (1964) contention that statistics are produced in

bureaucractically organized settings is true for most offices. That

is even more the case when the statistics reach a state bureau of

vital statistics, where local verdicts may be changed. This is espe­

cially true for suicide rulings for young children or "undetermined"

verdicts. The verdict must conform to the vital statistics categories

and medicolegal officials indicated that the statisticians have

little tolerance for the ambiguity inherent in verdicts such as

"undetermined" and "unclassified."

The study’s findings also support the criticism that data are

often pooled even though they represent different definitions of a

particular type of death. The questionnaire used in this study

included items requesting information about the definitions for two

classifications—suicide and undetermined manner of death. Responses

support the contention that different officials use different defini­ tions. Twenty-nine per cent defined suicide as taking one’s own life

and stressed that the evidence of such an act must be extremely clear.

Thirty-eight per cent indicated that any act which involved the intent 157

to die was suicide. One per.cent would not rule .suicide without a

suicide note or witness. Two respondents indicated that the researcher

should know the definition or could look it up in a dictionary. The

remaining respondents defined the act with such comments as "self-

destruction," "self-inflicted death," and other variations of that

same idea.

The definitions given by officials for suicide do not vary to a

considerable degree, except for the 1 per cent who rely on a note or

witnesses, but the definitions are only general guidelines. A more

rigorous examination would include specific criteria used in different

types of deaths (e.g., carbon monoxide, drowning, and so forth.) One

such criterion is the age of the victim. Respondents indicated a wide

range of ages as the lowest age at which suicide would be ruled. At

the lower end, two officials specified an age of two years. Five per

cent specified mid- to late teens (fifteen through eighteen), 2k per

cent said early teens (twelve through fourteen), and 18 per cent

specified late preteens (nine through eleven.) The remaining respon­

dents gave ages between two and nine years, or over eighteen or said

it would depend on the evidence. The variation in responses to this

question is an indication that the cognitive maps used to distinguish

suicides do differ.

Officials were also asked to indicate when a verdict of undeter­ mined manner would be used. Sixteen per cent replied that such a verdict was never or only rarely used. Forty-nine per cent used that ruling as a type of "pending" notation until an investigation or laboratory tests were completed. Four per cent used the undetermined .158

manner for cases of decomposed or skeletonized bodies for which

evidence was unavailable. Seven per cent used undetermined when

the cause of death was unclear. Eight per cent used it when the

verdict could not be accurately distinguished between suicide and

an accident, or homicide and an accident. A researcher interested in

the statistics for undetermined manner would be foolish to assume that

all officials defined that category in the same way.

The questions are: Do role strain, role conflict, and the mechan­

isms used to resolve these contribute to inaccuracies in manner of

death statistics? Is systematic bias built into the statistics for

individual jurisdictions resulting from the use of coping mechanisms?

If so, does the amount of error vary from jurisdiction to jurisdiction, or is it relatively constant across the country? The data do not

answer all of these questions, but they indicate what the answers might be.

Interview and questionnaire respondents indicated that errors in manner of death determination were made, but only occasionally.

Since the. investigation process involves a number of steps, errors are possible in any or all of them. Respondents attributed most of the mistakes to strain and conflict caused by insufficient budgets, personnel, and postmortem examination.

Shortages of funds o'r personnel for autopsies result in situations in which certain types of cases, usually potential criminal cases, have higher priority than others. Suicides and accidental deaths are given lower priority for autopsies than are homicides.. Apparent natural deaths have the lowest priority. None of the officials 159

included in the study ordered autopsies in all cases referred to the

medicolegal office. Such a practice was not practical and none of

the officials felt that it was necessary. One medical examiner believed

that ideally any death other than an obviously natural disease should

be autopsied, but he indicated that such standards were not financially

practical.

In addition to assigning a case for autopsy on the basis of its

perceived type, the victim's age was a factor mentioned by those in

the interview group. As one coroner said, "People under forty don't

just die as a matter of course." Young people usually die suddenly

and unexpectedly and autopsies are performed, while death for an older

person is treated more routinely. Two physician coroners and a medical

examiner reported the use of a verdict of natural death caused by

cardiac arrest as a routine procedure in cases of death for older

persons when there were no suspicious circumstances or signs of

violence. As one said, "When we don't know the cause there is a tendency to rule it cardiac arrest—it's true, but we still don't know the cause." Heart disease becomes what one official called "a waste basket diagnosis." (He felt that many.coroners in his state, both lay and medical, use "Sudden Infant Death Syndrome" as a waste basket diagnosis.)

During a presentation toethe International Association of Coroners and Medical Examiners in 1968 Dr. Raymond Brandt (1968: 230) said

"In some jurisdictions if you're over 50 you've got a coronary whether you like it or not." While many such rulings are no doubt made with a certain amount of informed professional judgement, such classifications i6o

sometimes result from ignorance. Thompson (1976: 129.) quoted Dr.

Jachimczyk, Houston medical examiner, as having said, in reference

to the previous lay coroner system in that city, "Without a doubt, a

lot of fatal heart attacks were brought on £>y undiscovered ice pick

wounds in the chest." One medical examiner interviewed in connection

with the present research cautioned that anyone using medicolegal

statistics for research should "take time to learn the local bias."

Whenever an official is restricted from ordering postmortem

examinations on lower priority cases because of a lack of funds or

personnel, there is a chance of error in the statistics- And the

correct priority of a case is not always obvious before an extensive

examination, but there may be pressure to forego such a procedure to save money. The official often must choose between satisfying those who control the purse strings and his perceived duty to provide

an accurate verdict. Every person interviewed had a story about a homicide which almost went undetected, either in his own jurisdiction or in someone else's. (See also Houts, 1967 and Helpern, 1977-)

Since insufficient resources tend to be a chronic rather than a periodic problem, it is likely that certain "priorities" are informally built into the structure of each office. The consistent lack of attention to certain kinds of cases would contribute to biased statistics

Within the structural limits imposed by finances, facilities, and personnel, the medicolegal official must cope with personal character­ istics which threaten to limit the accuracy of verdicts. Much of the debate over the most effective type of system—coroner or medical examiner—focuses on the qualifications of the incumbent. As indicated, l6l

respondents opinions differed on the importance .of medical training,

and a few specified a particular type of training as more desireahle

than others. As one physician, coroner explained,

Most of the coroner’s cases don't amount to a damn. Just check it, sign the death certificate, and let the attorneys handle the estate as usual. Any ten cent clerk could handle that. Then comes along that case that is really vital.

In such "vital" cases is a specially trained official needed to make

an accurate determination, or will any medical degree do?

Those forensic pathologists interviewed tended to agree with one who said, "Most doctors are not trained to think along medicolegal lines." Another felt that most physicians were not trained to he sus­ picious or to recognize indications of foul play. Lay coroners were considered by this group to be least accurate in such cases. Even those systems which utilized physicians for the medical procedures came under attack by some who felt that the scene investigation should also be conducted by a medically trained official. A medical examiner explained, "Cases are screwed up not at the morgue, but at the scene."

She said that lay coroners often miss important biological evidence at the scene (e.g., unnatural position of the body, contradictory patterns of position and fixed lividity, and the like.) Inaccurate information in the scene report may then point subsequent investigation and interpretation in the wrong direction.

The qualifications which medicolegal officials must have are fixed by law and are, therefore, part of the structural limitations of the system. It may be argued that the law fixes only a lower limit on qualifications and that persons with more specialized training 162

could be hired. The expectations held by the position’s role partners

minimize that possibility, however. Administrators usually prefer to

expend as little as possible for medicolegal services and the public

tends to hold the office in low esteem. In the view of one coroner,

"Coroner is next to dogcatcher in the public's mind." Another said,

"The coroner has always been low man on the totem pole and usually the

one with the most education."

If role partners are not willing to support the office with the

appropriate respect and income, the position will not attract qualified

people. If, as the head of a state system said, "The quality of your

certification is going to be in direct proportion with the quality of

the people and facilities," such an attitude on the part of role partners will be detrimental to quality performances.

Those who must hold another occupational position to supplement the medicolegal salary may lack the necessary time to devote to the part-time coroner or medical examiner position. In that case duties are either delegated or not performed, thus increasing the possibility of.errors in determining the cause of death.

But even in jurisdictions employing a forensic pathologist, duties such as scene investigation are often delegated to lay inves­ tigators. The official must decide in each case whether it is necessary to visit the scene personally or whether it can be delegated to someone else. Since it is easier to delegate scene investigation than to delegate his medical and administrative duties, conflict is resolved by assigning the scene to a subordinate who is often a lay person.

When facilities and personnel are limited, the coroner or medical 163

examiner may also be forced to delegate autopsy and chemical analysis

details to an outside facility. Even those who consistently used the

same outside facility for tests, autopsies, and so forth expressed

some displeasure with the system. Respondents claimed that hospital

doctors and technicians often tried to avoid getting involved with

medicolegal cases because they might be required to make time-consuming

court appearances.

Those who used several different facilities or who were forced

to send samples some distance faced additional problems. In one case

certain hospitals consistently held up autopsy reports for weeks or

even months before sending them to the coroner. Another reported,

"Few things in my professional life have been so bewildering and dis­

maying as toxicology. Samples and reports are often lost in the mail,

tests are done incorrectly, and orders are misunderstood." One

coroner complained that evidence sometimes deteriorated or was lost

in shipment. The problem of "sending out" for autopsy and toxicology work increased the possibility of error in the final analysis.

Medicolegal officials must also rely on certain role partners to bring the appropriate cases to their attention. If there is a lack of consensus between the official and his partners about which cases to refer, errors may occur. Since most coroners and medical examiners hold considerable authority they are usually in a position to pressure role partners into complying with their definitions in such cases.

But before the official can apply pressure, he must be aware that cases are not being referred.

The data indicate that financial restrictions and low qualification l6h

standards are perceived as contributing to error in manner of death

statistics, but another factor which critics of the statistics often

cite as a source of error is pressure from role partners. None of

the respondents denied the existence of such pressure, but there was

some disagreement about its consequences.

Coroners and medical examiners reported pressure from a variety

of role partners. The most frequently mentioned category was the

family of the deceased, but others were also mentioned. They included:

local administrators and politicians, religious officials, insurance

officials, organized crime figures, the public, news reporters, and

the office of vital statistics.

Local administrators, politicians, the public, and news reporters

were accused of pressuring the official for a quick decision. In such

cases the official had to decide between satisfying those demands and

waiting for complete results to provide more accurate information.

Respondents indicated that many inaccuracies were the result of

hurried decisions based on inadequate information.

The office of vital statistics was reportedly guilty of pressuring

the official for a specific ruling rather than a verdict of "undeter­

mined" or "unclassified." One coroner reported that vital statistics

personnel sometimes classified the death themselves when the coroner

or his physician was-unable to do so. Bradshaw (1974) found that

verdicts from individual offices were sometimes changed when they

reached the state vital statistics recorders.

Organized crime groups were accused by some of trying to pressure officials to rule certain deaths as accidents or natural deaths rather 165

than homicides. One official reported that he ran for the office of

coroner at the urging of friends because the previous coroner had been

"a bagman" for local crime figures and had obligingly ruled certain

deaths to please his superiors. Although their techniques differ,

insurance investigators have also been guilty of attempting to influence

a medicolegal verdict to protect their investment. In regard to in­

surance benefits to survivors, the company loses less on a suicide or

a natural death than on an accident.

Family and friends of the deceased most frequently challenge the

officials' verdict, particularly in suicide cases. No one involved in

this study admitted changing a verdict to please the family, but all

of the interview sample and approximately 50 per cent of the question­

naire respondents expressed the opinion that other medicolegal officials

do succumb to pressure on occasion. The officials expressed compassion

for the families but indicated that they would only change a verdict if new evidence warranted it. A forensic pathologist expressed the common position:

As far as the coroner's office is concerned it would only change a statistic, but I have to uphold the legal system. It has more impact for the family, insurance agency, et cetera in a particular case, but it also has long range significance for society. Death is a delicate time in a person's life when they've lost somebody they love, but the coroner has to go with the evidence.

The question which remains to be answered is why do so- many officials believe that others give in to pressure if they themselves do not? 166

Summary

The conclusion reached by this researcher is that systematic

error exists in manner of death statistics. The data indicate that

the bias is not a result of intentional misclassification of deaths,

but of the role strain and role conflict created by the role require­

ments and expectations. Some of the most common sources of strain

and conflict are: l) lack of training and experience; 2) insufficient budgets to finance the necessary medicolegal operations and provide

an adequate, trained staff; 3) and pressures from role partners to provide verdicts too quickly or to play the role in such a way that the investigation is hampered or the decision made more difficult.

The evaluations made by several members of the interview sample support the idea that there is more than random error in manner of death statistics. One said, "A lot of the country is still inadequately served and therefore the statistics generated are less valuable."

Another reported, "The only thing you can be sure about from official statistics is the number of cases handled." And one cynic classified the statistics produced in some states as "garbage, pure garbage."

The extensive variation in legal requirements, size, organization, and complexity of available facilities, and individual backgrounds all influence the accuracy of the statistics produced. Although the quality of manner of death statistics probably varies from jurisdiction to jurisdiction, it should be possible to decrease some of the error when using those statistics. Chapter VII includes a summary of the sources of error and some suggestions for minimizing it in studies which utilize official statistics. Chapter VII

CONCLUSIONS AND SUGGESTIONS FOR USERS OF MEDICOLEGAL STATISTICS

It is common practice for social scientists to criticize the accuracy of official manner of death statistics which they use to study suicide, homicide, and other categories of death. Critics explain that the statistics are produced by bureaucratically organized operations and the available information about the death is often in­ adequate and always shaped by the perception and interpretitive pro­ cesses of individual officials. They also contend that medicolegal officials are subject to pressures from others to falsify their verdicts to avoid stigmatizing the victim's family or to allow them to collect insurance benefits which might otherwise be withheld.

The data collected for the present study indicate that these criticisms are valid to some extent. While some critics imply that the bias in statistics is the result of intentional misclassifications by officials, the findings reported here indicate that error is more likely unintentional and a consequence of role strains and conflicts.

Legal Role Requirements

Chapter IV included a review of medicolegal role requirements prescribed by the laws of each state. While social scientists treat all manner of death statistics as if they were produced by similar organizations, each state defines the office and its role in a different way. In addition to the variation among states, systems 168

and types of officials algo vary within gt at eg. In the debate ..over

the type ..of system, required to. produce accurate., statistics and re­ liable services two extremes are described. Critics place systems

involving part-time lay officials who command few support facilities at the least desireable end of a continuum. Full-time systems staffed by forensic pathologists with well-equipped facilities constitute the most desireable operation. In some states both types of systems operate.

Legal role requirements contribute to the potential for role strain and role conflict in a number of ways. Systems which require no special qualifications for office are often staffed by officials who experience role strain because they lack the skills to conduct the appropriate medicolegal procedures and investigation.

Statutes governing role performance are often vague and lead to situations in which status occupants and their role partners hold different definitions of the role and its purpose. Role conflict arises when the official's attempts to perform the role according to his perception are blocked or hampered by lack of cooperation or opposition from role partners. Since they have little contact with a medicolegal officer in their daily lives, the public and their legislative representatives are often hesitant to authorize enough financial support to staff and equip the office properly. But when a case is controversial or directly affects the individual citizen the official is expected to have all the answers. As one medical examiner commented, "Most people don't give a damn about this place until it hits home." The vagueness and dissensus surrounding the 169

role require that many Qfficials..must continually engage in .role

bargining with their role partners.

In some cases state.laws build additional conflict potential

into the situation by authorizing a tiered system or a dual system.

Under a tiered system local lay coroners are supported by specially

trained medical examiners at the state level. Local officials may

be required to refer certain cases to medical examiners, or referral

may be left to the coroner’s discrétion. In either case the initial

investigation and determination is left to the local officer. Officials

who feel threatened by the state level professionals or who do not

want to be bothered by formalities to refer a case may choose to

minimize utilization of that resource.

As illustrated by the Delaware experience, attempts to change a

system and incorporate both, coroners and medical examiners may result

in a power struggle which is detrimental to both officials. Political parties and occupational groups such as morticians who traditionally

controlled the office under the lay coroner system may bring consider­

able pressure on legislators to subvert attempts to professionalize the medicolegal role.

Perceived Role Requirements

Chapter V focused on the medicolegal role as defined by its incumbents. The data indicate that officials themselves do not all share the same interpretation of the purpose of the office or the way in which the role should be played. Some give high priority to accurate determinations of manner and cause of death, but others emphasize the public health aspect, assisting the victim's family, 170

or supporting the police or prosecutor in criminal cases. It can

he assumed that the official’s perception of role priorities affects

the kinds of statistics produced. When accurate determinations are

ranked low and assisting the victim’s family is high, the official

would he more likely to succumb to pressures to falsify verdicts in

favor of the family. To that official the verdict is only a statistic

but the individual family is immediate and dependent on him.

The data also indicate that most medicolegal officials consider

themselves part of the legal and/or public health complex, however.

From that perspective the accurate determination of manner of death

is a public trust and a vital part of the role. Although most officials

expressed the opinion that others sometimes falsify verdicts, none

admitted to such a practice themselves. On the basis of self-report

data it can be concluded that intentional misclassifications of

deaths are rare.

Role Performances Evaluated

The evaluations of their role performances provided by respondents

and discussed in Chapter VI include the perception that medicolegal

manner of death statistics involve both random and systematic error.

Seventy-four per cent of the questionnaire respondents reported that

suicides were under-reported and another 7 per cent believed that

suicides were over-reported. There was disagreement about whether the

error was intentional or the result of mistakes in rulings, however,

and a variety of factors were cited as responsible for the error.

Lack of training and experience and/or support facilities were mentioned by both sides. Officials also listed lack of understanding 171

and support from role partners and pressures to.provide quick verdicts

or to falsify verdicts as the cause of errors.

In regard to the criticisms of officials reviewed in Chapter II,

it appears that many of them are valid, at least to some extent. The

personnel who record death verdicts in state bureaus of vital statistics

may accidentally or intentionally change the classifications of deaths.

Coroners and medical examiners are restricted by bureaucratic organ­

izational structures, and data are often pooled even though they

represent different definitions of a particular type of death.

Although survey responses indicate that most officials use

similar definitions of suicide, the use of the category "undetermined"

varied greatly from respondent to respondent. Some used it only as a temporary "pending" classification, while others used it in cases where the manner of death was unclear for some reason. In addition, the similarity of definitions of "suicide" should not be interpreted . to mean that all officials agree on the criteria used for such determinations. More study of officials' cognitive maps might be useful for a more complete understanding of the determination process.

Critics also suggest that medicolegal officials make some rulings without complete information.. The respondents in this study were in agreement with that position. Insufficient information and lack of funds for necessary postmortem tests were cited by the officials as causes of inaccurate rulings. Some officials included misinterpretation of available information as another possible source of error, particu­ larly for officials who lack the expertise to interpret medical reports and evidence. 172

In regard to.the consequences of pressures from role partners,

respondents admitted that pressures were exerted and that it probably

affected the verdicts, but not in their own experiences. It is

possible that officials accept the assumption that others falsify

reports when in reality that seldom occurs. It is also possible

that some officials who succumb to pressures themselves did not admit

it, but assumed if they had done so others would also. The data do

not provide conclusive evidence to support or reject the critics’

claims in this case.

In summary, there is reason to believe that there is both random

error and bias in the statistics for manner of death. The evidence

indicates, however, that the kind and amount of bias varies from

jurisdiction to jurisdiction.

Suggestions for Users of Official Statistics

Official death statistics are an easily accessible data source for social scientists and it is doubtful that the possibility of error will dissuade their use. Researchers who prefer to minimize the error resulting from use of these statistics might consider taking a few precautions.

If statistics are to be compared across jurisdictions or over time, one might attempt to control for structural variables which would possibly contribute to error. Three factors have potential for producing differences in statistics—size of the medicolegal office, availability of trained personnel and testing facilities, and the type of system in operation and the qualifications of its central official. The researcher could limit comparisons to similar 173

types of operations or to.systems which have been.stable over time.

One might also consider background research In the target

offices to determine what reporting biases exist. It would be helpful

to know that all victims over sixty are listed as natural deaths due

to cardiac arrest unless there is evidence of foul play. If the

coroner or medical examiner believes that fifteen is the youngest age

for suicide, that perception will affect his verdicts.

Finally, the statistics used in a research project should come

from the same source level. If vital statistics personnel routinely

reclassify some deaths it would be wise to obtain data for different

jurisdictions from either vital statistics or the medicolegal office itself. If one jurisdiction's data comes from a vital statistics office and the other from the coroner’s or medical examiner’s office some additional error may result from the different definitions involved

Suggestions for Future Research

Those who are interested in the inaccuracies in manner of death statistics might consider research projects focused on the consequences of specific differences among organizations and officials. One possibility would involve a comparison of statistics between coroner systems and medical examiner systems. To avoid regional variables, the comparison could utilize a longitudinal approach comparing statistics for a jurisdiction which switched from one system to another.

Such a research project would necessarily involve an accurate description of the system in each time period. In some cases a system which only requires a lay coroner may in reality be run by a physician 174

coroner. Or the lay coroner may be supported by a trained pathologist.

Legal changes in the type of system might only mean that the physician

coroner assumes a new title—medical examiner--or the previous lay

coroner's pathologist may move up to the medical examiner position.

In such cases the system only appears to change. In reality, personnel

change titles and little more. The researcher should also remember

that the name of the system—coroner or medical examiner—reveals little

about the structure. Some coroners are appointed, full-time,

specially trained officials. Some medical examiners are part-time officials with a medical background, but no specialized forensic knowledge.

Another possible project would involve examination of the cognitive maps used by medicolegal officials to reach their verdicts. Atkinson

(l97l) provides some description of the way in which such a study might proceed. A specific type of death which is equivocal (e.g., carbon monoxide poisoning, drowning) could be the focus of research aimed at distinguishing cognitive maps and their use.

Those interested in role conflict might consider studying the bargining process which occurs between the medicolegal official and his role partners. What devices are used to control the situation and how do perceptions of role priorities influence the outcomes?

The debate over the efficiency of various systems and social changes from state to state provide additional subjects for research.

Research could be conducted on the national level or be confined to social change in a particular state. What factors influence legis­ lators to consider a change? Which influence techniques are most 175

effective? What roles do state and national medicolegal organizations

play in. the change process? Who opposes changes, why, and how? Once

changes are made, do former opponents accept defeat or do they hinder

implementation and operation of the new system?

Summary

The data indicate that official manner of death statistics are

subject to both random and systematic error. The bias involved in

systematic error appears to vary from jurisdiction to jurisdiction and is related to several structural factors which contribute to role strain and role conflict for the coroner or medical examiner.

Structural factors may also contribute to inadequate role performances when laws do not specify specialized training for the official and/or rewards for role performance are not sufficient to motivate qualified persons. Resolution of strain and conflict involves giving some activities priority over others and the actor is frequently engaged in role bargining to acquire the resources needed to perform his role, and to resolve other pressures. The systematic bias is, therefore, more likely the result of structural variables than of conscious falsification, and the degree of bias would be expected to vary from jurisdiction to jurisdiction in relation to the type of structure in operation. REFERENCES

Adelson, Lester 1977 "The Forensic Pathologist—'Family Physician' to the Bereaved." JAMA 237: 1585-88.

Atkinson, J. Maxwell 1968 "On the Sociology of Suicide." Sociological Review 16: 83-92.

1969 "Suicide and the Student." Universities Quarterly 23: 213-224

1971 "Societal Reactions to Suicide: The Role of Coroners’ Definitions." Pp. 165-191 in Cohen (ed.), Images of Deviance. Harmondsworth, England: Penguin.

1973 "Suicide, Status Integration and Pseudo-Science." Sociology 7: 437-445.

1975 "Some Cultural Aspects of Suicide in Britain." Pp. 135-158 in Farherow (ed.), Suicide in Different Cultures. Baltimore: University Park Press.

Forth- Suicide and the Social Organization of Sudden Death. London: coming Macmillan.

Biddle, Bruce J. and Edwin J. Thomas (Eds.) 1966 Role Theory: Concepts and Research. New York: Wiley.

Biesanz, John and Mavis Biesanz 1973 Introduction to Sociology (2nd Ed.). Englewood Cliffs, N.J.: Prentice-Hall.

Bradshaw, Alfred 1974 The Social Construction of Suicide Rates. Unpublished doctoral dissertation, Syracuse University.

Brandt, Raymond A. 1968 "Degree of Suspicion." Proceedings of the International Association of Coroners and Medical Examiners, pp. 218-231. Anaheim, California.

Breed, Warren 1963 "Occupational Mobility and Suicide Among White Males." American Sociological Review 28: 179-188. 177

Childs, Richard S. 1976 "Best States for a Murder." Manuscript included in personal communication.

Cicourel, Aaron V. 1964 Method and Measurement in Sociology. New York: The Free Press.

1968 The Social Organization of Juvenile Justice. New York: Wiley.

Corwin, Ronald G. 1961 "The Professional Employee: A Study of Conflict in Nursing Roles." American Journal of Sociology 66: 6o4-6l5•

Curran, W. J. 1970 . "Law-Medicine Notes: Medical-Examiner System in Massachusetts." New England Journal of Medicine 282: 556-557.

1971 "Medicolegal Investigational Systems: New Demands in the I97O’s'." New England Journal of Medicine 284: 30-31.

DeLee, Stuart 1970 "The Coroner System in Louisiana." Pp. 101-103 in Proceedings of the International Association of Coroners and Medical Examiners. St. Paul, Minnesota.

Denisoff, R. Serge and Ralph Wahrman 1974 An Introduction to Sociology. New York: Macmillan.

Douglas, Jack D. 1967 The Social Meaning of Suicide. Princeton: Princeton University Press.

1971 American Social Order. New York: The Free Press.

Dublin, Louis I. 1963 Suicide: A Sociological and Statistical Study. New York: Ronald Press.

Durkheim, Emile 1951 Suicide. John G. Spaulding and George Simpson (trans). New York: Free Press.

Encyclopedia Britannica 1926 "Coroner." Pp. 187-188 in Encyclopedia Britannica Voi. 7-8. New York: Encyclopedia Britannica.

Fahey, Richard P. and Deborah J. Palmer 1971 "An Inquest on the Cook County Coroner." Evanston, Illinois: Chicago Law Enforcement Study Group. 178

Fisher, Russell 1973 "History of Forensic Pathology and. Related Laboratory Sciences." Pp.. 3--10 in W. Spitz and R. Fisher, (eds.), Medicolegal Investigations of Death: . Guidelines for the Application of Pathology to Crime Investigations. Spring- field, Illinois: Charles C. Thomas.

Gibbs, Jack P. 1966 "Suicide." Pp. 281-321 in R. Merton and R. Nisbet (eds.), Contemporary Social Problems (2nd Ed.). New York: Harcourt.

1968 Suicide. New York: Harper & Row.

Giddens, Anthony 1965 "The Suicide Problem in French Sociology." British Journal of Sociology XVI: 3-18.

Goffman, Erving 1959 Presentation of Self in Everyday Life. Garden City, N.Y.: Doubleday.

Goode, William J. 1960 "A Theory of Role Strain." American Sociological-Review 25: 483-496.

Gross, Neal, Ward S. Mason, and Alexander McEachern 1965 Explorations in Role Analysis: Studies of the School Superintendency Role. New York: Wiley.

Havarad, J. D. J. i960 The Detection of Secret Homicide. London: Macmillan.

Headley, Lee 1975 "Jewish Suicide in Israel." Pp. 215-230 in Farberow (ed.), Suicide in Different Cultures. Baltimore: University Park Press.

Helpern, Milton 1977 Autopsy. New York: St. Martin's.

Hendin, Herbert 1964 Suicide and Scandinavia. New York: Grune & Stratton.

Hindess, Barry 1973 The Use of Official Statistics in Sociology: A Critique of Positivism and Ethnomethodology. London: Macmillan.

Horn, Yvonne 1973 "Children Who Want to Die." PTA Magazine 68: 18-21. 179

Houts, Marshall 1967 Where Death Delights: The Story of Dr. Milton Helpern and Forensic Medicine. New York: Coward-McCann, Inc.

Kitsuse, John I.- and Aaron V. Cocourel 1963 "A Note on the Uses of Official Statistics." Social Problems 11: 131-139.

Kornblum, Ronald N. and Russell S. Fisher 1972 A Compendium of State Medicolegal Investigative Systems. Baltimore: Maryland Medical-Legal Foundation.

Labovitz, Sanford 1968 "Variation in Suicide Rates." Pp. 57-73 in Gibbs (ed.), Suicide. New York: Harper & Row.

Landis, Judson 1977 Sociology: Concepts and Characteristics. Belmont, California: Wadsorth.

Lofland, John 1976 Doing Social Life: The Qualitative Study of Human Inter­ action in Natural Settings. New York: Wiley.

Mannheim, Hermann 1965 Comparative Criminology. New York: Houghton Mifflin.

McCormack, Thelma 1956 "The Druggist’s Dilemna: Problems of a Marginal Occupation." American Journal of Sociology 49: 208-224.

Merton, Robert K. 1957 "The Role-Set." British Journal of Sociology 8: 106-120.

National Association of Medical Examiners 1974 "Standards for Accreditation of a Modern Medicolegal Investigation System." Wilmington, Delaware: National Association of Medical Examiners.

National Municipal League 1975 Coroners: A Symposium of Legal Bases and Actual Practice. New York: The National Municipal League.

Paul, David M. 1974 "Matters Forensic." Carolina Forensic Bulletin 1-5: 1-11.

Petersen, William 1975 Population, (3rd Ed.). New York: Macmillan.

Pollack, J. H. 1974 "I Want Out, Teens Who Threaten Suicide." Today's Health 49: 32-34. 180

Porterfield, Austin L. 1968 "The Problem, of Suicide.". Pp. 31-56 in Gibbs (ed.), Suicide. New York: Harper & Row.

Posner, Curtis E. 1975 "Prosecutor's. Relation to the Coroner." Presentation to the Ohio State Coroner's Association Annual Seminar. Toledo, Ohio.

Quinney, Earl Richard 1962 Retail Pharmacy as a Marginal Occupation: A Study of Prescription Violation. Unpublished doctoral dissertation, University of Wisconsin.

1964 "Adjustment to Occupational Role Strain: The Case of Retail Pharmacy," Southwestern Social Science Quarterly 44: 367- 376.

Ritzer, George 1968 Commitment, Professionalism, and Role Conflict. Unpublished doctoral dissertation, Cornell University.

Secord, Paul F. , Carl Backms,n, and David Slavitt 1976 Understanding Social Life. New York: McGraw-Hill.

Shaw, Marvin and Philip Costanzo 1970 Theories of Social Psychology. New York: McGraw-Hill.

Shryock, Henry et al. 1976 The Methods and Materials of Demography. Condensed Edition by Edward G. Stockwell. New York: Academic Press.

Stengel, Erwin 1973 Suicide and Attempted Suicide. Maryland: Penguin.

The Daily Sentinel Tribune 1976 "Coroner Hints Inquest in Fostorian’s Death." Bowling Green, Ohio, September 23.

The Toledo Blade 1976 "Why the Push for a Morgue?" Toledo, Ohio, April 28.

Thompson, Thomas 1976 Blood and Money. Garden City, N.J.: Doubleday.

United States Department of Health, Education, and Welfare 1978 Death Investigation: An Analysis of Laws and Policies of the United States, Each State and Jurisdiction. Washington: Health, Education, and Welfare. I8l

Wardwell, Walter 1952 "A Marginal Professional Role: The Chiropractor." Social Forces 30;. . 339-348.

1955 "The Reduction of Strain in a Marginal Social Role." American Journal of Sociology 6l: 16-25.

Webster, Murray 1975 Actions and Actors: . Principles of Social Psychology. Cambridge, Massachusetts: Winthrop.

1967 Webster's Third New International Dictionary of the English Language, Unabridged. Springfield, Massachusetts: G. & C. Merriam.

Weiss, Hilda 1964 "Durkheim, Denmark and Suicide: A Sociological Interpretation of Statistical Data." Acta Sociological I: 264-278. APPENDIX I

MAIL SURVEY QUESTIONNAIRE 183

Coda Number

OCCUPATIONAL SURVEY: CORONERS AND MEDICAL EXAMINERS

You are requested to give your naze at the beginning of this survey. This will he used to facilitate « I

ding off returned questionnaires and to lighten the burden of fcllov-up letters. Your naze vill 4 >

l _ he used for any other purpose. Most data vill he given in aggregate fere in the final report.

Nans (please Print) ...... , . . / .

1.. Title______. ______

2. State and county/region of jurisdiction , ,

3. Is your position as coroner/medical exaaaner elective . appointive_____ , or other(specify)_____

• • ...... ?

U. Are . . ..

5. Eov long have you been coroner/medical examiner?______;.______. .

6. Were you associated vith a coroner's/medical examiner's office prior to assuming your present position? Yes No

If so, in vhat capacity and »•hers? , - , .

Per hcv long? ______,______, .______. .

7. Is your present position full-time or part-time_____?

S. Do you-hold any other occupational position or title? Yes___ _ No_____

If so, vhat is It? . . , • . . -

Is this fulltime or part-time ?

9. Please indicate the highest educational level (or levels) attained.

Institution Degree Year Completed

10. If you are a forensic pathologist, vhere and under vhom did you do that residency?

11. Eave you had any additional training since becoming coroner/medical examiner? (including seminars, vorishops, etc.) Yes_____ No

If so, vhat type of training? 184

- 2 -

12. Of which occupational organizations are you a member?

______none American Academy of Forensic Science ______International Association of Coroners and Medical Examiners ______National Association of Medical Examiners ______your state coroner/medical examiner organization other (please specify)______.

13. Why did you choose to become coroner/medical examiner?

lU. Approximately what percentage of all deaths in your Jurisdiction are referred to your office in the average year?______,...... -

15. In your opinion, should more deaths have been referred to your office? Yes_____ No_____

If yes, who is most responsible for not referring cases on which you should rule?

16. Do you believe that the operating budget for your office is sufficient? Yes_____ No_____

If not, does this ever affect your ability to make accurate rulings on manner of death? Yes____ _ Ho

Why or why not?

17. How is a coroner's/medical examiner's case defined in your jurisdiction? 185

_ ■? _

18. Are you authorised to held inquests? Yes_____ No_____

If so, how s=sy did you hold in 1976?

1?. What do you believe is the purpose of the coroner's/medical examiner's office?

20. How long has the present system (coroner or medical examiner? been used, in your jurisdiction?

21. In your opinion, should your position be an elected or appointed_____one?

Why?

Always Usually Sometimes Seldom Never (1) (2) (3) (U) (5) 22. In your opinion, should the chief medico­ legal officer of a Jurisdiction have a medical background (e.g., M.D. or D.O.)?...... ( ). ,..( ?...... ( )...... ( )...... ( ?

23. Could a lay person be a good medico­ legal officer if he/she had access to the appropriate medical and testing resources?...... ( ). ...( )...... ( ?...... ( )...... ( ?

2ù. In your state, is the coroner/medical . examiner position a stepping stone to higher political office?...... ( ). ...( )...... ( )...... ( ).....( ?

25. In your 3tate, is the coroner/medical examiner position a long-term job for the person holding ohe position?...... ( ). )...... ( )...... ( )...... ( )

26. Ideally, what should be the gu»'1 iftrst.-jons for the person holding the coroner/medical exeminer position 186

- ¡* -

27- In your state, at what point in a career does one usually become coroner/ medical examiner?

beginning of career mid-career late career

28. Many people believe the coroner/medical examiner has responsibilities to various audiences. What do you believe is your responsibility to the following?

the public:

the family of the deceased:

the police:

the prosecutor in a criminal,case:

the defense attorney in a criminal case:

29. Please rank the following responsibilities of your office from most important to least important. ( l=most important to 8=least important; lC=not important)

______protect public health

______advise prosecutor in criminal case

______explain cause of death to victim's family

______assist police in investigation

make accurate determination of manner of death

advise defense attorney in criminal case

cooperate with news media in keeping the public informed

______participate in medical research

30. How effective do you think your office is in meeting each, of these responsibilities?

Excellent C-ood Average Poor Very Poor

Protect public health...... ( ) ( ) ( )....( ) ( ) Advise prosecutor in criminal case...... ( ) ( ) ( )....( ) ( ) Explain cause of death to victim's family...... ( ) ( ) ( )•-..( ) ( ) Assist police in investigation...... ( ) ( ) ( )....( ) ( ) Make accurate determination of manner of death...... ( ) ( ) ( )•-..( ) ( ) Advise defense attorney in criminal case...... ( ) ( ) ) ( ) Cooperate with news media in informing public...... ( ) ( ) ) ( ) Participate in medical research...... ( ) ( ) ) ( )

i 187

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Assuming that some mistakes are made in rulings on marnp-r of death, how often ia the following stages Of the process are mistakes likely to be made?

St are Frecuent.lv Occasionallv If ever

Misinterpretation of death scene evidence...... ( ) ( ) ( ) Misinterpretation of biological evidence at scene...... ( ) ( ) ( ) Decision net to refer case to medico-legal officer...... ( ) ( ) ( ) Decision not to do an autopsy...... ( ) ( ) ( ) Misinterpretation of autopsy findings...... ( ) ( ) ( ) Misinterpretation of toxicology findings...... ( ) ( ) ( )

In your opinion, why ar mistakes of this kind made?

32. When sisclassifieations are made, what type of official do you think is likely to make them? (e.g., medical or lay official, urban or rural, etc.)

33. Under what circumstances is the manner of death classified as "Undetermined"?

3A If you were to make an error in dessi ficaticn I manner of death, would you prefer to er in the rBT-ofTt-'cn of undetermined. __ or a specifi pannar ?

Why?

35« How do you define "suicide"? 188

- 6 -

36. What is the youngest age at which you would rule a death as suicide?

37. In your experience, are there certain categories of people who are high risks for suicide? Yes

If so, who are they?

38. Do you believe the number of cases ruled as suicide nationwide Is accurate_____ , over-reported___ or under-reported_____?

39. In your opinion, do some coroners/medical examiners rule suicides as due to some other manner of death? Yes No_____

If so, is the miscl'assification more likely to be intentional or a mistake ?

Under what circumstances is this likely to happen?

UO. What type of official is most likely to make such misclassifications?

Ul. Has anyone ever tried to convince you to rule a suicide as something else? Yes No____

If so, approximately how many times per year do the following try to influence you?

Never 1-3 times b-6 times 7-9 times 10 or more

Family...... ( ). Family representatives. Police. Insurance investigators...... ( . )...... ( )...... ( P.eligious officials.... .( Other (please specify)_ ....(

.( )• .( ). .( )•

Why do you think they do this? (Please specify which group you are referring to) 189

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-2. now do you handle these situations?

¡*3. Are autopsies ordered by your office always complete autopsies? Yes_____ No_

When autopsies are done/ordered by your office, who performs then? -

______forensic pathologist hospital pathologist ______other (please specify

1*5- Are there certain categories of death for which you routinely order autopsies? Yes No

If sc, please check those which are routinely autopsied:

______suspected sudden infant death syndrome ______suspected honicide suspected suicide ______auto accident victim industrial accident victim ______other (please specify)______— k6 the following list check column A for those services or facilities which ere available in office; column 3 for those which are available, but not in your office; and column C for ‘ aoz available to you. (A) (3) (C) c; rrrice/Facility Available in Available, not Not office in office available

Field investigator...... ( )...... ( )...... ( ) Toxicology...... ( )...... ( )...... ( ) Forensic Pathology...... ( )...... ( )...... ( ) Hospital Pathology...... ( )...... ( )...... ( ) Trace evidence lab...... ( )...... ( )...... ( ) Statistician...... ( )...... ( )...... ( ) Clerical Staff...... ( )...... ••( )...... ( ) Histology...... ( )...... ( )...... ( ) Morgue Facilities...... ( )...... ( Autopsy Facilities...... ( )...... (

1»7. Do you ever feel that it is impossible for you to fulfill all the responsibilities cf your office? Yes_____ No______' ' "

Explain?

i-8. Do you believe that the raws media are accurate'in. their reporting of your cases? Yes_____ . No io* In general, do you believe that the public is aware of vhat your office does and why? Yes_____ No

50. Do you believe that the news media are fair in their treatment of your office? Yes_____ No_____

51. Sow cany fulltime employees does your office Include? ......

52. Sow many part-time employees does your office include?______' ______,______- . 190

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53. Who do you consider to he the top three medico-legal officers in the United States at this time?

Briefly, what criteria cid you use in making these choices?

51*. Eow often do you watch the television program "Quincy, M.E."?

regularly ______occasionally______seldom______never

If you have seen it, what is your opinion of the program? (e.g., how close to reality is it, will it benefit coroners/medioal examiners, do you enjoy it as n-.a-rt-, etc.)

55. What is the approximate population of the area you serve?______

56. What is the approx:mane size (land area) of the area you serve?______;______■

57. Would your jurisdiction best be described as urban suburban______, rural______, or other(explai

58. Is your office a subdivision of a centralised state system? Yes____ _ No

59« Is your office independent_____ or part of a larger department(e.g., public health)______?

60. Eow many deaths (total) occurred in your Jurisdiction in 1976?______.

61. Eow many cases were referred to your office in 1976?______.______

62. Eow many oases were accepted by ycur office in 1976?______■ ______,______

63. Eow many cases were autcpsied by your office in 1975?______.

6u. Of those cases accepted in 1976, how many were ruled

a. Natural______

b. Accidental^______

c. Suicide

d. Eonicide______

e. Undetermined

( ) Please check here if you wish to receive a copy of the summary report. (This will probably not. be available before summer 1978)

TEAM YOU FOR YOUR COOPERATION APPENDIX II

INTERVIEW LETTER 192

Department of Sociology Bowling Green State University Bowling Green, Ohio 43403 (419) 372-2294 September 1, 1977

Dr. John Doe Office of the Coroner Middletown, Ohio 43987

Dear Dr. Doe:

As a graduate student in the Sociology doctoral program at Bowling Green State University, I am currently engaged in a study of coroners and medical examiners as an occupational group. The project includes a comparison of state laws governing qualifications, duties, and selection of these officials in each of the fifty states; a national survey of coroners and medical examiners in regard to job descriptions, training, et cetera; and a series of interviews with medicolegal officers in various cities and counties.

At present I am involved in the interview segment of the project. Some of those interviewed include Drs. Gerber, Adelson, and Hirsch in Cleveland; Dr. Harry Mignerey in Toledo, Dr. Russell Fisher in Baltimore; and Dr. Page Hudson in Chapel Hill, North Carolina.

In choosing coroners for these interviews, I am attempting to include officials in a variety of types of areas around Ohio. For this reason, I am requesting your help. Would you be willing to grant me an inter­ view to discuss how your office operates and how you organize and carry out your duties?

I recognize that your schedule is busy. However, since I must set up other interviews around the state, would it be possible for you to talk with me for a little while at your convenience on October 7? I have no particular preference as to time, so any appointment you could work into your schedule would be fine.

All the interviews conducted thus far have been very successful. I will look forward to receiving your response to my request and hope we will be able to meet on the 7th of October.

Sincerely;

Trudy Knicely Henson Graduate Teaching Fellow m

APPENDIX III

INTERVIEW SCHEDULE : SAMPLE QUESTIONS 194

1. How long have you been coroner here?

2. What kind, of educational background and training did you have prior to assuming this position?

3. Why did you-choose to become a coroner?

4. Do you belong to any organizations which are designed for coroners?

5. How is your office organized? How many people do you have working for you and who is responsible for what?

6. Do you use field investigators and if so, what kind of training do they have and what do they do?

7. Who does autopsies for this office?

8. Where do you have toxicology done?

9. Do you have access to trace evidence laboratories and technicians?

10. Do you feel that the budget for your office is sufficient?

11. Does the public in this jurisdiction know who you are and what the function of this office is?

12. Do you ever get pressure from anyone to rule in a certain way or to change a verdict?

13. How do you handle such pressure?

14. Do you ever use "undetermined" as a classification for manner of death? When? About how often?

15. If you were in a position which might involve making a mistaken ruling on manner of death, would you rather err by calling it "undetermined" or by ruling it as a specific manner such as homicide, suicide, natural, or accident?

16. When autopsies are conducted are they always complete?

17- What percentage of your cases are autopsied?

18. How are your relations with the police? the courts? the news media?

19- Have you ever seen "Quincy, ME"? What do you think of it?

20. Do you have any special problems as a coroner in a small county (or a large urban area)?

21. Do you think the manner of death statistics from around the country are accurate or under- or over-reported? APPENDIX IV

QUESTIONNAIRE COVER LETTERS.­

ORIGINAL MAILING

FIRST FOLLOW-UP

SECOND FOLLOW-UP 196

Department of Sociology Bowling Green State University Bowling Creen, Ohio 43403 (419) 372-2294 September 8, 1977

Dr. David Smith, Coroner Jefferson County Courthouse Middletown, Iowa 50313

Dear Dr. Smith:

In the past a number of occupational groups such as lawyers, physicians, and police have been studied by social scientists. Researchers have made little effort to explore the work done by coroners and medical examiners, however, despite its obvious importance to the public as well as the health professions. Consequently, I am asking for your cooperation in what I believe will be an important first national study of your profession.

Ideally, all the data for this national study would be gathered in per­ sonal interviews. Financial and time considerations, however, have limited the number of such interviews. Therefore, to ensure that all states and types of systems are represented, I would greatly appreciate your cooperation in completing the enclosed questionnaire. A prepaid envelope is also enclosed for your convenience.

In preparation for this research, I have interviewed coroners and medical examiners in several states, observed the operation of two metropolitan coroners' offices, and attended a seminar for coroners and medical examiners. The enclosed questionnaire, then, consists of areas and concerns which I perceive as important to an understanding of your profession. Some of the answers requested will be used to make comparisons among states and systems, while others are designed to answer questions about the system in a particular state.

If you would be willing to answer part but not all of the questions, please do so. A totally complete form is preferred, but I would rather have some answers than none. Obviously a high response rate is necessary for the research to be of greatest utility and accuracy. Your cooperation is needed to achieve this.

The response to requests for interviews and other help has been very gratifying. So much interest has been expressed in the results that a written summary of the research will be provided to those who request it by checking the indicated space on the completed questionnaire. Thank you for your help in making this project a success. I will look forward to working with you through your response.

Sincerely;

Trudy Knicely Henson Teaching Fellow 197

Department of Sociology Bowling Green State University Bowling Green, Ohio 43403 (419) 372-2294 October, 1977

Dear Sir:

A few weeks ago questionnaires were mailed to a national sample of coroners and medical examiners. Although many of these have been returned, a number have not.

Due to the expense involved, questionnaires were not mailed to all coroners and medical examiners. Instead, a small sample was used for each state. It is very important that those who received forms fill them out so that each state is adequately represented. With your help, the research will present a more accurate picture of the occupation.

I realize that there are many demands on your time, but your cooper­ ation would be greatly appreciated. If you have not already done so, please take a few minutes to fill out and return the questionnaire.

Sincerely;

Trudy Knicely Henson Teaching Fellow 198

Department of Sociology Bowling Green State University Bowling Green, Ohio 43403 (419) 372-2294

November, 1977

Dr. David Smith, Coroner Jefferson County Courthouse Midland, Iowa 50313

Dear Dr. Smith:

Several weeks ago questionnaires were mailed to a number of coroners and medical examiners across the country. More recently a follow-up letter was mailed to those who had not yet responded.

As a result of the follow-up letter, several people wrote to say that they had riot received the original letter and questionnaire. Others misplaced the form before finding time to fill it out. In order to include those of you who misplaced or never received the original questionnaire, a copy is included with this letter.

The completed questionnaires received have been very enlightening. Several of you have indicated an interest in the research. Some even feel that the findings could be useful for improving the coroner/medical examiner systems in their own states. Although these returns have been encouraging, the total number of questionnaires returned is still rather low. The goal of the research is to develop an accurate description of the many variations in training of officials and operations of state and local systems. In order to realize this objective I need your help. If you have not already returned your questionnaire, please do so now. Your assistance will be greatly appreciated. Thank you.

Sincerely;

Trudy Knicely Henson Teaching Fellow APPENDIX V

STANDARDS FOR MODERN MEDICOLEGAL SYSTEMS AS OUTLINED BY THE NATIONAL ASSOCIATION OF MEDICAL EXAMINERS 200

STANDARDS

FOR

INSPECTION AND ACCREDITATION OF

A MODERN MEDICOLEGAL

INVESTIGATIVE SYSTEM

SPONSORED

BY

NATIONAL ASSOCIATION OF

MEDICAL EXAMINERS

PREPARED

BY

LESLIE LUKASH, M.D., CHAIRMAN FRANK P. CLEVELAND, M.D. ALI Z. HAMELI, M.D. RONALD N. KORNBLUM, M.D. HENRY SIEGEL, M.D. . WERNER U. SPITZ, M.D. WILLIAM Q. STURNER, M.D..

FIRST EDITION OCTOBER, 1974 MODEL LAW FOR OFFICIAL MEDICAL-LEGAL INVESTIGATION OF DEATH

1. The Office of the Chief Medical Examiner or Coroner shall be established and maintained in such a manner that it provides for the necessary facilities and personnel in accordance with the nationally recog­ nized and recommended standards.

2. The Office shall be an independent agency.

3. The intent of the governing law shall preclude any political interference in the selection and appoint­ ment of the staff or the operation of the Office.

B. Appointment

1. The Chief Medical Investigating Officer, whether being called Chief Medical Examiner or Coroner, shall be ap­ pointed with tenure by the appointing authority. He (or she) shall be a certified pathologist skilled in Forensic Pathology. He shall organize, operate and direct the Office.

2. The Chief Medical Examiner or Coroner shall name and appoint, with the approval of the supervisory author­ ity, qualified professional, technical, clerical and other staff of the Office. The staff shall be directly responsible to the Chief Medical Examiner or Coroner.

C. Investigation of Death

The Chief Medical Examiner or Coroner shall have the author ity:

1. To investigate and certify any death that falls in the following categories:

a. Criminal violence

b. Suicide

c. Accident

d. Suddenly when in apparent good health

e. Unattended by a practicing physician

f. Suspicious or unusual circumstances

g. Abortion

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h. Poisoning

i. Diseases constituting a threat to public health

j. Disease, injury or toxic agent resulting from employment

k. Death associated with diagnostic or therapeutic procedures

l. In any prison or penal institution

m. When in legal custody

n. When a body is to be cremated, dissected or buried at sea

o. Unclaimed bodies

p. When a dead body is brought into a new medicolegal jurisdiction without proper medical certification

2. To take charge of the dead body upon mandatory and direct notificiation of such death. He or his duly authorized representative shall respond to the scene. The dead body shall not be disturbed unless permission is granted by the Medical Examiner or his designee.

3. To conduct an investigation of circumstances surrounding the death.

4. To conduct all necessary examinations of the dead body which could include performance of any autopsy and re­ tention of whatever tissues and biological specimens that he deems are necessary.

5. To take possession of any object or article which, in his opinion, may be useful in establishing the identity of the deceased and/or the cause and manner of death.

6. To reduce his investigation and findings in writing and shall keep such records in his Office.

: and have the power of subpoena.

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PERSONNEL

A medico-legal investigative system (Medical Examiner's or Coroner's Office) shall be under the supervision of a physician, who shall be a certified pathologist skilled in Forensic Pathology, capable to meet the professional, super­ visory and administrative requirements of such an office. The Medical Examiner's and/or Coroner's Office shall be staffed with sufficient personnel for the proper fullfill- ment.of all functions of the department.

INTERPRETATION

The chief medico-legal investigative officer, who may be called Medical Examiner, Coroner, or by some other title, must be a certified pathologist, experienced in Forensic Pathology, and preferably certified by the American Board of Pathology in Forensic Pathology, or at least be Board-eligible. When he is not continuously available, the services of a qualified staff pathologist or consulting pathologist should be retained. In all instances, the official in charge should assume an effec­ tive working relationship with the local medical community, the police department, the prosecutor's office, as well as funeral directors and other related disciplines. He should also establish an active part in teaching and training pro­ grams to promote and ascertain the highest standard of his de­ partment.

A sufficient number of professional, technical and other personnel to conduct the work required by a medico-legal office should be available.

EXPLANATORY NOTES

In order to consider the staff for adequate operation of a medico-legal investigative system, a working unit is hereby established as a guideline. 200 complete autopsies plus ap­ proximately 300 post-mortem examinations limited to external examination of the body and collection of blood, urine and/or other biological speciments are considered one unit for the purpose of this definition. Medico-legal systems with multi­ ple units have the same basic needs, however, utilization of personnel increases proportionately. (Unit Table) It should also be recognized that the component of the unit system may vary in individual jurisdictions, i.e. State, County, City or district.

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A. Essential Features of a working unit (no provisions have been included for vacation ana sick leave of the per­ sonnel) :

1 - Chief Medical Examiner/Coroner - He shall be a cer­ tified pathologist, skilled in Forensic Pathology. He shall be capable of assuming the professional as well as administrative activities required by the office. To promote and maintain optimal standards of all phases of his department the Chief Medical Examiner/Coroner should establish an effective working relationship with all interrelated disci­ plines to meet the requirements of the criminal justice system and should conduct and participate in teaching, training and research.

When the Chief Medical Examiner/Coroner is not con­ tinuously available, he should lie represented by a Deputy Chief Medical Examiner. The Deputy Chief Medical Examiner should preferably possess similar qualifications as the Chief Medical Examiner/Coroner.

2 - Toxicologist - He shall be a person holding an earned degree from an accredited institution with a chemical, toxicological or pharmaceutical science as his major subject. (i.e. Ph.d. plus one year or M.S. plus three years or B.S. plus five years in Forensic Toxi­ cology work)

B. Personnel, Technical & Non-Technical must be properly qualified. The technical personnel must use methods of high quality to provide optimal laboratory and technical services and must meet certain nationally recognized re­ quirements for certification (e.g. ASCP) The following shall be considered as a guideline for one unit.

1 - Administrative assistant to help the Chief Medical Examiner or Coroner in the administration of the department.

1 - Certified laboratory technologist.

1 - Histologic technician with experience in embedding, cutting and staining of tissues, including special stains, as required for the routine operation of any surgical pathology laboratory. 1 - Medical photographer, or use of one, as would be ap­ plicable for medico-legal operations incorporated in larger pathology departments (such as medical schools or county hospitals, or the like).

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1 - Medical secretary for routine typing or a secretary with experience in typing medical records.

1 - Clerk for record keeping, statistics and time keeping.

1 - Autopsy Room technician.

1 - Custodial worker.

3 - Investigators (24 hrs. coverage). It is recommended that the Medical Examiner’s Investigators (lay In­ vestigators) have a college degree, or a background in police science or equivalent. The lay Investiga­ tor should meet the qualifications established by the Chief Medical Examiner. Eventually a graduation from a school for Medical Examiner’s Investigators (to be established) will be advocated to take the place of the above requirements.

3 - Attendants (24 hrs. coverage) to assist in body transport unless ambulance service is provided.

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PHYSICAL STRUCTURE

The Medical Examiner's or Coroner's Office shall have sufficient space, equipment and facilities for the perfor­ mance of the required number of medicolegal investigations of death with optimum accuracy, precision, efficiency and safety.

INTERPRETATION:

Facilities must be available and under the supervision of the Medical Examiner or Coroner for the performance of adequate medicolegal autopsies and investigations of death with sufficient accuracy and detail to meet the requirements of the jurisdiction served. The facilities, equipment and instruments should be appropriate for the work required and must be maintained in satisfactory working conditions. The working conditions should be conducive to the optimum per­ formance of personnel and equipment.

A system shall be established for the transportation and handling of bodies with due consideration for the soli­ citude of the bereaved and concern for the public welfare. Facilities should be available for adequate storage and re­ frigeration of bodies, sufficient space should also be avail­ able for storage of tissues, clothing and other evidence.

The autopsy room should be large enough to handle the usual case load and should be furnished with the proper in­ struments and equipment necessary for the performance of a complete autopsy. Facilities should be available for fluro- scopy, X-ray and photography.

Laboratory facilities with adequate space and equipment should be provided for processing histology sections. A toxicology laboratory should also be available which has the capability of performing accurate and reliable tests for drugs and poisons. Provisions should also be made for micro­ biology, serology and chemistry either within the Medical Examiner's Office or at a convenient reputable facility.

An office with sufficient space and facilities for ad­ ministrative and clerical personnel should also be available. Adequate space and facilities should be provided for storage and handling of records and statistics.

EXPLANATORY NOTES:

Autopsy Room: The autopsy room should have the space, facilities and equipment to adequately handle the usual case load. The

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lighting should be sufficient to allow proper identification of lesions. Ventilation should be sufficient to minimize discomfort and the facilities and equipment should be designed to minimize health hazards to personnel working in the area. The instruments and equipment should be of good quality and properly maintained and of the type which will permit the performance of a complete autopsy. Space should be provided for photography, both for whole bodies and for specimens and other evidence that may be removed from the body.

The receiving area should be designed to facilitate the expeditious handling of bodies into and out of the morgue. Refrigerated storage space should be sufficient to accomo­ date the number of bodies usually present. Additional storage space should be available to accommodate the victims of mass disaster.

Space should be provided for the storage of tissues, clothing, personal effects and other evidence which may be discovered on or about the body. Admission to this area should be limited to authorized personnel only and it should be designed to maintain security and the integrity of the chain of custody.

A separate room,I isolated from the rest of the building and with an independent ventilation system, is desirable for the storage and handling of decomposed bodies.

In addition, a separate area, out of view of the autopsy room and receiving area, should be available for the viewing of bodies by the next of kin. This area should be kept as clean and as congenial as possible.

X-Ray and fluoroscopy equipment should be installed in a convenient location in the autopsy room. This equipment must be located in a properly shielded room and must adhere to the radiation safety procedures recommended by State and Federal governments.

LABORATORIES: Laboratory space should be available for the processing of routine histology sections. Special staining methods must be available to meet the diagnostic requirements of the institution. Wet tissue and paraffin blocks must be clearly and adequately labelled and sufficient space available so they can be properly stored. Microscopic slides should also - be adequately and clearly labeled and stored in such a fashion as to facilitate retrieval.

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A toxicology laboratory should be provided which has the capability of performing accurate and reliable tests for drugs and toxic substances. The laboratory should be able to perform tests for alcohol, barbiturates, carbon monoxide, salicylates, tranquilizers, alkaloids, chlorinated hydrocarbons, heavy metals, solvents, stimulants, sedatices, insecticides and related drugs and chemicals. This labora­ tory should be provided with the required space, equipment, instruments, reagents and glassware necessary to perform these tests. The procedures should be performed by ac­ cepted methods and monitored to insure quality control. The laboratory should be designed to insure maximum safety to the personnel working in it and should have sufficient storage space for properly labeled tissues and body fluids. The laboratory records must be kept in an orderly fashion and designed to guarantee the chain of custody of evidence and for ease to retrieval of data.

PHOTOGRAPHY:

Adequate equipment, including cameras, lenses and lights should be provided to take good quality photographs. Space and facilities should be available for a darkroom for devel­ oping and printing photographs. Negatives should be clearly labelled and properly stored. A file of color transparencies of interesting and unusual cases should be maintained for teaching purposes and case conferences.

ADMINISTRATIVE OFFICES:

Adequate office space and facilities for administrative and clerical personnel should be provided to handle the usual case load. This area should be separate from the autopsy room so that it may be freely accessable to those who have legitimate business with the office. A record room should be provided which has sufficient space for the storage and handling of records. This area should be organized in such a way as to provide easy access to current case material. Office space should also be provided for the compilation of statistics. Space for a library-conference room is also desirable. Facilities and equipment should be provided for investi­ gators who conduct on-the-scene investigations and who make the initial inquiry into the circumstances of each death. Investigators should be available 24 hours a day and 7 days a week. They should be provided with properly equiped and maintained vehicles for transportation to and from the scene of death. Adequate provision must be established, under the direction of the medical examiner, for transportation of bodies to the morgue.

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ANCILLARY SERVICES:

Ancillary services such as microbiology, serology and chemistry should be available either within the Medical Examiner’s office or from a conveniently available reputable laboratory. Facilities for research are also desirable. The services of a Crime Laboratory should also be available.

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