Medical Examiner vs. Coroner for Death Investigations

Frances Glessner Lee pioneered the study of forensic science and helped establish the first formal curriculum in the field at Harvard in the 1940s. She crafted the famous Nutshell Studies of Unexplained Death in which miniature doll houses were turned into crime scenes to aid in training forensic investigators. In a time when female students and young women were discouraged from entering any kind of scientific profession, Lee used her social skills, family wealth, and uncompromising dedication to revolutionize a field that was usually political, often corrupt, and always deeply rooted in the primal fear of death.

I recently read a fascinating biography of Frances Glessner Lee, which also delved into the history of forensic science. It’s entitled 18 Tiny Deaths: The Untold Story of Frances Glessner Lee and the Invention of Modern Forensics. The author is Bruce Goldfarb, executive assistant for Maryland’s chief medical examiner.

Goldfarb begins with a history of the coroner’s position, which dates back to the middle ages and remained until the 20th century a fairly simple inquiry, basically amounting to determining the person was dead and a quick answer to why he died, basically obvious guesswork. No investigation or autopsy deemed necessary.

Later, the coroner position became an easy reward for campaign contributors.  According to Goldfarb, in the mid to late 1800s, the reputation of coroners in Boston was as bad as everywhere else. A governor could appoint any number of coroners. Before the medical examiner office was established in 1877, Boston had 43 coroners. Suffolk County, NY, had more coroners than NYC, Philadelphia, New Orleans, Chicago, San Francisco, Baltimore, and Washington DC, combined.

The scandal that precipitated the end of the coroner system in Boston began when the body of a newborn baby was found in a trash can. One of Boston’s district coroners convened an inquest which returned a verdict of “death at the hands of a person unknown.” Each member of the inquest jury earned $2 and the coroner made $10. Then the baby’s body was dumped in another district for another coroner to hold another inquest, after which the body was dumped again. This happened four times until the public learned of this atrocity. The ensuing scandal ended the coroner system in Boston. In 1877, lawmakers there abolished coroners and inquests and placed a competent doctor in charge of death investigations.

Today, many jurisdictions still maintain the coroner system, in which the coroner is elected and may have no experience in medicine or forensic investigation. Other jurisdictions mandate a medical examiner who is appointed by the governor and must be a licensed physician with additional certification in forensic science and investigation. 

According to Goldfarb, every year, approximately 1 million sudden and violent deaths in the US are referred for forensic investigation. At least half of these unexplained deaths are never subject to a thorough inquiry by a qualified forensic pathologist.

This biography of a powerful woman emphasizes the importance of trained and educated investigators, rather than elected hacks, determining the how, why, and who of death.

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