MEDICOLEGAL DEATH INVESTIGATION SYSTEM

Workshop Summary

Committee for the Workshop on the Medicolegal Death Investigation System

Board on Health Promotion and Disease Prevention

THE NATIONAL ACADEMIES PRESS
Washington, D.C. www.nap.edu



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MEDICOLEGAL DEATH INVESTIGATION SYSTEM Workshop Summary Committee for the Workshop on the Medicolegal Death Investigation System Board on Health Promotion and Disease Prevention THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Support for this project was provided by the Department of Justice. The views presented in this report are those of the WORKSHOP PARTICIPANTS and are not necessarily those of the funding agency International Standard Book Number 0-309-08986-7 (Book) International Standard Book Number 0-309-52642-6 (PDF) Additional copies of this report are available from the National Academies Press, 500 Fifth Street, North West, Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at www.iom.edu. Copyright 2003 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. Cover: Copyright Christel Gerstenberg/ CORBIS The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Shaping the Future for Health

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THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE FOR THE WORKSHOP ON THE MEDICOLEGAL DEATH INVESTIGATION SYSTEM RICHARD BONNIE (Chair), John S. Battle Professor of Law and Director Institute of Law, Psyschiatry, and Public Policy, University of Virginia, Charlottesville, VA DAVID KAYE, Regent's Professor, College of Law, Arizona State University, Tempe, AZ THOMAS PEARSON, Albert D. Kaiser Professor and Chair and Professor of Medicine, Department of Community and Preventive Medicine, University of Rochester, Rochester, NY KATHLEEN TOOMEY, Director, Division of Public Health, Georgia Department of Human Resources, Atlanta, GA ROBERT WALLACE, Irene Ensminger Steecher Professor of Epidemiology and Internal Medicine, Colleges of Public Health and Medicine, University of Iowa, Iowa City, IA Staff CAROLYN E. FULCO, Senior Program Officer GINA BATA, Research Assistant (until December 2002) HOPE R. HARE, Research Assistant A. WEZI MUNTHALI, Research Assistant DEEPALI PATEL, Sr. Project Assistant ROSE MARIE MARTINEZ, Director, Board on Health Promotion and Disease Prevention NORMA GROSSBLATT, Senior Editor Consultant MIRIAM DAVIS, Independent Medical Writer, Silver Spring, Maryland

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REVIEWERS This report has been reviewed in draft form by persons chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards of objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: MARGARET BERGER, Professor, Brooklyn Law School, Brooklyn, NY RANDY HANZLICK, Associate Professor of Forensic Pathology, Emory University School of Medicine, Chief Medical Examiner, Atlanta, GA CHARLES HIRSCH, Chief Medical Examiner, Office of the Chief Medical Examiner, New York, NY KURT NOLTE, Assistant Chief Medical Investigator, New Mexico Office of the Medical Investigator, Professor of Pathology, University of New Mexico School of Medicine, Albuquerque, NM VICTOR WEEDN, Principal Research Scientist, Director of Biotechnology and Health Initiatives, Mellon Institute, Pittsburgh, PA Although the reviewers listed above have provided many constructive comments and suggestions, they did not see the final draft of the report before its release. The review of this report was overseen by LAWRENCE GOSTIN, J.D., Professor of Law, Georgetown University, Professor of Public Health, Johns Hopkins University, Center for Law and the Public’s Health, CDC Collaborating Center Promoting Health Through Law, Washington, DC, who was appointed by the Institute of Medicine. Mr. Gostin was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the author committee and the institution.

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PREFACE On first glance, official identification of human remains and certification of the cause of death appear to be mundane endeavors that serve mainly private needs of families, insurers, and litigants. In truth, however, valid and reliable data on the circumstances and causes of deaths serve a variety of important public needs, including fair and accurate adjudication in criminal and civil cases, maintenance of accurate vital statistics, effective public health surveillance and response, advances in health and safety research, and improvement in quality of heath care. The combined task of collecting and interpreting information about circumstances and causes of death has traditionally been called medicolegal death investigation, terminology that reflects the interface of medical science with law and public policy. This "forensic" function has been performed for centuries in all societies, although not always by medical professionals. Concerns about the adequacy of medicolegal death investigation in the United States have been raised for many decades. The concerns have been voiced by all the constituencies that have a stake in the accuracy of data related to circumstances of death and in the official determinations based on them. For the criminal justice system, concerns about the adequacy of data about deaths merge with general concerns about all aspects of forensic science. Those concerns led the National Institute of Justice to ask the Institute of Medicine to conduct a workshop on the medicolegal death investigation system in the United States. IOM appointed a committee to plan the workshop with the advice and assistance of NIJ, staff of the Centers for Disease Control and Prevention, and other interested constituencies. The workshop was held on March 24-25, 2003, and this report summarizes the ideas and observations expressed at the workshop. Presentations and opinions expressed at the workshop demonstrated clearly that the current practices of medicolegal death investigation in

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this country are in substantial need of improvement. The workshop discussions also showed that accurate data on the circumstances and causes of death (and the identification of human remains) are, in the language of economists, a valuable public good and that much of their value accrues to the benefit of the nation as a whole. To rectify the many deficiencies of the system, it will be necessary to solve many problems, including fundamental issues of financing. The workshop was a starting point for further study and, I hope, for eventual reform. Richard J. Bonnie Chair

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TABLE OF CONTENTS 1   INTRODUCTION   1 2   OPENING REMARKS   3 3   OVERVIEW OF THE MEDICOLEGAL DEATH INVESTIGATION SYSTEM IN THE UNITED STATES   7 4   INFRASTRUCTURE AND TRAINING   12 5   PROFESSIONALISM, STANDARDS, AND QUALITY   19 6   COMPARING MEDICAL EXAMINER AND CORONER SYSTEMS   23 7   MEDICOLEGAL DEATH INVESTIGATION AND THE CRIMINAL JUSTICE SYSTEM   29 8   MEDICOLEGAL DEATH INVESTIGATION, PUBLIC HEALTH, AND HEALTH CARE   38 9   HOMELAND SECURITY AND EMERGENCY PREPAREDNESS   49 10   CLOSING REMARKS   61     REFERENCES   65 APPENDIX A   WORKSHOP AGENDA   67 APPENDIX B   PANEL MEMBERS AND INVITED SPEAKERS   71

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