In the case of a sudden and unexpected death, an autopsy has become a mandatory public health and legal investigation to ensure that any disease threat—or more typically, wrongful death—does not go uninvestigated. A variety of organizational schemas exist to accomplish this in the United States. At the heart of these schemas are inherently two systems, the medical examiner system and the coroner system (Hanzlick & Combs, 1998). While it was previously important to speak of the differences between these two systems, these differences are narrowing as medically trained forensic pathologists are becoming the core of both. In earlier coroner systems, individuals of various backgrounds—undertakers, sheriffs, and farmers— served as the lead investigators in forensic death investigations. In the present day, this elected position still exists in rural areas; however, if there is a questioned death, most coroners have easy access to a district medical examiner or forensic pathologist with specialized training to thoroughly investigate a death. Famed pathologists DiMaio and DiMaio (2001) describe the duties of the death investigation system in their comprehensive overview of forensic pathology:
- To determine the cause and manner of death
- To identify, if the deceased is unknown
- To determine the time of death and injury
- To collect evidence from the body that can be used to prove or disprove an individual’s guilt or innocence and to confirm or deny the account of how the death occurred
- To document injuries or lack of them
- To deduce how the injuries occurred
- To document any natural disease present
- To determine or exclude other contributory or causative factors to the death
- To provide expert testimony if the case goes to trial (p. 1)
While this list is comprehensive, it ignores the most fundamental roles both medical examiners and coroners play in public health and epidemiology (Hanzlick & Parrish, 1996). For example, medico-legal investigation may uncover environmental hazards, poisons, or communicable diseases that have the potential to harm others. In this case, medical examiners or coroners can warn the appropriate authorities to take proper action to prevent harm. They also monitor trends in disease and drug overdose over time to fuel public health and drug abuse research.
Forensic pathology centers on the autopsy process. This process serves to answer two questions: What is the cause and the manner of death? The cause of death is the injury/condition or set of primary and secondary injuries/ conditions that result in and contribute to the death in question. For example, myocardial infarction (heart attack), liver failure, asphyxia, alcohol poisoning/overdose, gunshot wound, blunt force trauma, and emphysema can be causes of death. The manner of death consists of only a few categories: natural, homicide, suicide, accident, and undetermined/unclassified. This determination takes the circumstances surrounding the death, including the activity of the decedent just before death, and blends it with the findings at autopsy, toxicology reports, medical history, and police narratives among other sources to categorize the individual into one of these pathways of death. This is the most subjective part of the autopsy process, and is only finalized at the end of the forensic death investigation—typically a few days before the certificate of death is printed.
The controversies in this discipline are by and large localized to disagreements over the cause and manner of death in particular investigations—and since the determination of the cause of death can be documented and preserved for years past autopsy, these disagreements are quite limited. It is the manner of death that can be the most controversial, second only to outright malfeasance and malpractice. As this determination has bearing on life insurance policies, criminal and civil trials, and individuals’ reputations, challenges are relatively frequent in today’s society.