death investigation systems 39official over an appointed one. And in fact, many coroners have utilized their
political acumen and the public inquest to call attention to issues of public
safety. But the final decisions in a death investigation should ideally be made
by an appropriately trained and experienced physician, and no one else. Only
he or she has the expertise in the cause and interpretation of disease and
injury to make such medical decisions.
Other concerns by opponents of the coroner system relate to potential
conflicts of interest for the lay coroner.20,21 In many coroner settings, particu-
larly in small towns or rural areas, the office of coroner will not be a full-time
position, and the person holding the office will have other employment. The
coroner may be a law enforcement officer, a funeral director, occasionally
a practicing physician, or hold other employment completely unrelated to
death investigation. In one state, the county sheriff serves as the ex officio
coroner of the county. The potential conflict of interest in such an instance
is obvious, with the sheriff charged with the investigation of deaths that may
be the result of an interaction of his or her officers with a decedent, such as
an officer-involved shooting. Equally disturbing is the situation in which an
inmate in a jail or detention facility operated by the sheriff is found dead.
No matter how impartial and honest the sheriff, any such investigation will
always have at least the potential for impropriety or lack of impartiality.
If the coroner is a funeral director, there may be a potential conflict if the
coroner stands to earn money by also arranging the funeral service of the
deceased. In such cases there might be a tendency to avoid making any cause
or manner of death determination that would alienate the next of kin. Some
jurisdictions do require that the coroner be a physician. However, this is
often little improvement over an untrained lay coroner. Most physicians have
had practically no exposure to forensic pathology and death investigation,
leaving them exceptionally ill-prepared to make determinations about cause
and manner of death. Medical schools provide essentially no training in this
area, and even most pathologists receive only a superficia l introduction to the
topic during their period of residency training. Most rarely or never perform
autopsies in their practice. Without training and experience, such physicians
are in a very poor position to properly examine complex cases or to iden-
tify subtle findings that may indicate foul play in what initially appears to
be a natural death. In other cases, a physician might be the director or an
employee of a medical facility accused of being responsible for the death of a
patient. The death would then be investigated by the physician-coroner, with
t he attendant potentia l conflict of interest. Independence from ot her agencies
must be considered an absolute requirement for optimal death investigation.
As early as 1928 the National Research Council stated bluntly that the
office of coroner is anachronistic and “has conclusively demonstrated its
incapacity to perform the functions customarily required of it.”^22 The council
went on to recommend the abolition of coroners’ offices, replacing them with