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OPENING REMARKS

Richard Bonnie

Death investigations are conducted under the authority of state law and local ordinances by either a coroner or a medical examiner, at a minimum, when homicides, suicides, unintentional injuries, deaths caused by drugs or toxic agents, and other deaths not clearly explained by natural causes are involved. Additionally suspicious and unattended deaths and deaths of public health importance might also fall under medicolegal jurisdiction. Official death investigations are reportedly opened in about 20% of annual deaths in the United States. The scope of the investigations, although somewhat variable, generally includes investigation of the scene of the death, collection of evidence, external examination of the body, an autopsy, tests of body tissues or fluids, and the completion of a death certificate that certifies the cause of death.

The purpose of this workshop is to review the system for conducting medicolegal death investigations by taking stock of the present, highlighting problems and issues of concern, and identifying priorities for discussion and possibly for a future IOM study.

There is little risk of dissent in pointing out that there is no such "system" of death investigations, in the same sense that there is no health care system in this country. Instead, the processes and structure of death investigations vary widely according to the



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2 OPENING REMARKS Richard Bonnie Death investigations are conducted under the authority of state law and local ordinances by either a coroner or a medical examiner, at a minimum, when homicides, suicides, unintentional injuries, deaths caused by drugs or toxic agents, and other deaths not clearly explained by natural causes are involved. Additionally suspicious and unattended deaths and deaths of public health importance might also fall under medicolegal jurisdiction. Official death investigations are reportedly opened in about 20% of annual deaths in the United States. The scope of the investigations, although somewhat variable, generally includes investigation of the scene of the death, collection of evidence, external examination of the body, an autopsy, tests of body tissues or fluids, and the completion of a death certificate that certifies the cause of death. The purpose of this workshop is to review the system for conducting medicolegal death investigations by taking stock of the present, highlighting problems and issues of concern, and identifying priorities for discussion and possibly for a future IOM study. There is little risk of dissent in pointing out that there is no such "system" of death investigations, in the same sense that there is no health care system in this country. Instead, the processes and structure of death investigations vary widely according to the

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characteristics and practices of distinct jurisdictions. The source of variation is not only state law but also local authority. Responsibility for death investigations rests at the county level for over 2,000 counties. Remarkably, for well over a century, there has been continuous concern about the lack of standardization in death investigations and about high rates of errors, whether real or perceived. Concern began to be expressed by progressive reformers over the last decades of the 19th century. Even the National Academy of Sciences weighed in—75 years ago. In 1928, the National Research Council’s Committee on Medical Legal Problems issued its report, The Coroner and the Medical Examiner (1928). The committee was made up of titans of the American legal and medical establishment of that era, including Roscoe Pound, dean of Harvard Law School, and John Henry Wigmore, dean of Northwestern Law School. The committee stated forcefully, in blunter terms than used today, that the coroner’s office is an anachronistic institution, predating the Magna Carta. The office "has conclusively demonstrated its incapacity to perform the functions customarily required of it.” The committee recommended that the office of coroner be abolished and be replaced by a well-staffed office of a medical examiner, headed by a pathologist. A key goal of the committee's recommendations was the professionalization of death investigation, with medicine as its center. That vision relied heavily on the training and credentialing capacities of what was becoming modern medicine. That effort has continues over the ensuing decades. The subspecialty of forensic pathology was recognized in 1959. The National Association of Medical Examiners (NAME) was established in 1966, and the country saw a gradual conversion of offices, from coroners to medical examiners, encompassing half the population. The goal of this workshop is to obtain a progress report on the transformation to a more professional systemnamely, whether the system exploits the full range of tools from medicine and other scientific disciplines, including the development of standardized protocols and access to high specialty technical services and laboratories, to reduce errors. The workshop also addresses this

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overarching theme: the capacity of the nation's legal institutions to take maximal advantage of rapidly developing scientific knowledge. The 1928 National Research Council Committee recommended that medical examiner offices in urban centers have the duty to furnish to the police, prosecutors, and the courts expert medical assistance at every stage of the investigation, prosecution, and disposition of criminal cases of any description. Furthermore, the committee said, cities should establish properly equipped medico-legal institutes under the control of the medical examiner that, as much as possible, would be affiliated with medical schools and universities. By taking such steps, the committee concluded, “the legal system would be better able to utilize the developing scientific knowledge and the information that all of scientific medicine is in the position to furnish to the forces of justice.” The vision of professionalism and affiliation with medical schools and universities was further developed in another special report 4 years later (1932). In 1932, a National Research Council committee reviewed medico-legal institutes that had been formed, especially in Europe. The committee hoped to use the medical examiner's office and the affiliated institutes to broaden the contribution of medical science to all criminal cases, including those involving nonfatal injuries. A key component of the relevant expertise would be scientific criminology that involved psychiatric assessments of criminal responsibility. In its broadest view, the committee’s vision was displacement of the process of adjudication altogether and the substitution, in some respects, of scientific inquiry for adversary litigation in the courtroom. Needless to say, that ambitious vision has not been realized, neither in relation to the crime nor to the criminal. For one thing, there is much less confidence today in the ability of science to solve all the problems of criminal adjudication, not to mention crime prevention and punishment. Today, perhaps, the promise lies more in molecular genetics than in clinical psychiatry, but the nation is still trying to find the best tools for putting science in the service of the law. In its own modest way, the judiciary is adding an important voice to the effort. Through the 1993 Supreme Court decision in the Daubert case1 and an 1   Daubert v. Merrell Dow Pharmaceuticals, Inc. 113 S. Ct. 2786 (1993).

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unending sequence of decisions in its wake, the courts are taking some steps to try to assure better science in the courtroom. Court decisions aiming to improve scientific testimony have implications not only for the work of experts investigating death but also for all the technical analyses and judgments on which medical examiners or coroners rely. The topics covered in this workshop are related to how a modern, professional, scientific system of medicolegal death investigation can diversify its role and increase its utility in connection with public health and surveillance. Examples include serving as a sentinel for unusual deaths, serving as a tool for quality improvement in the health care system, and, of course, dealing with the gravest contemporary concerns: bioterrorism and mass disasters.