South Carolina is not unique. Coroners are chosen by voters in most states. Many are not pathologists, or even doctors. That often leads to reporting of inaccurate information in cases of homicides and suicides. Now, an already inadequate system of death investigation has been “strained to its absolute limit” by the spike in overdose deaths from opioids, says Suzanne Bell, who chairs the Department of Forensic and Investigative Science at West Virginia University.
The word “coroner” derives from French and Latin roots referring to officers of the crown. Historically, Bell says, “the death investigator was more interested in sorting out taxes and inheritance” than worrying about the cause of death. Not much has changed. More than a third of Americans live in counties where coroners have to meet only minimal qualifications to hold office, or none at all, according to a 2009 National Academy of Sciences report.
That report, as well as a more recent study from the Obama White House, pleaded for raising the bar when it comes to coroner qualifications. Such calls have been made for a century or more, but generally lead to no action. “It’s very entrenched,” Kim Collins, president of the National Association of Medical Examiners, says of the practice of electing coroners. “Egos get involved, and the science gets pushed to the background.”
Collins notes that plenty of coroners do fine work, even if they lack medical training. The pertinent question is whether they have experience in death investigations. Recognizing homicides is obviously important, but determining the cause of death also matters when it comes to public health. Coroners and medical examiners are on or near the front lines when it comes to spotting outbreaks of infectious diseases, or determining whether new designer drugs are killing people.
In many cases, coroners may lack not only experience, but also the budgets to find out exactly what happened. In one Ohio county, with a population of 43,000, the county commission allocates funds to perform just three autopsies a year, according to a recent academic study. In the remaining cases, there are external examinations only, or deaths are certified based on the medical record. With opioid deaths, “people are saying we’ve gone over our budgets, we can’t afford autopsies,” says Collins.
Coroners in many states have come to recognize their limitations. The Arkansas Coroner’s Association now runs training courses that are more popular every year. “In Arkansas, we have made huge strides when it comes to death investigation,” says Kevin Cleghorn, the association’s president. But Cleghorn concedes that some coroners who have been in office for as long as 30 years refuse to be retrained, insisting on doing things the way they’ve always done them.
The problem isn’t only political, however. There just aren’t enough qualified pathologists to go around. If you’re a physician, there are other specialties that pay more and can lead to happier outcomes. “If everybody went to a medical examiner system tomorrow, we don’t have the pipeline established,” says Bell, the West Virginia professor. “Bless the people who do it, but I can see why it’s not the most appealing thing for everyone.”
