by Douglas Ankney

Bias influencing medical examiners’ manner of death determinations is sending innocent people to prison and exonerating guilty cops. In Mississippi, Rankin County Deputy Hunter Elward pleaded guilty in 2023 to federal charges related to his role in the horrific torture of two Black men by a gang of deputies calling itself the “Goon Squad.” The deputies broke into the men’s home, tortured and sexually humiliated them, and fired a gun inside the mouth of one of the men, leaving him with permanent disfiguring injuries. And in 2021, Elward was one of two deputies who witnesses saw kneeling on 29-year-old Damien Cameron for more than 10 minutes. Cameron died from the encounter. His face was swollen and bloodied, and there was bleeding in his neck.

Nevertheless, State Medical Examiner Staci Turner determined Cameron’s manner of death to be “undetermined.” But in the aftermath of the torture cases, Cameron’s manner of death was reviewed by three separate medical examiners. Each of them concluded that Turner erred in classifying Cameron’s manner of death as undetermined – each concluding that Cameron’s death was clearly a homicide. But because Turner had failed to classify the death as homicide, there was no ensuing investigation, and Elward was able to continue his criminal conduct under the guise of law enforcement.    

Medical examiners are called upon to make two determinations when performing an autopsy after a suspicious death: (1) the cause of death and (2) the manner of death. The cause of death, well rooted in medicine, generally is not disputed. Examples include blood loss (exsanguination), cardiac arrest, asphyxiation, blunt-force trauma, etc. But manner of death – the mechanism by which the death occurred – is a subjective determination that is much more consequential. Manner of death determinations include suicide, homicide, accident, natural causes, and undetermined. Generally, only when the manner of death is determined to be a homicide is there an ensuing investigation that may lead to a criminal prosecution.

Innocent parents, grandparents, siblings, and other caretakers have been sent to prison because a medical examiner determined a child’s death to be a homicide when it was not. The best example of this is the theory of “shaken baby syndrome.” Medical examiners routinely testified that particular symptoms observed during the autopsies of small children could be caused only by violent shaking, sending hundreds of innocent people to prison. Scientists outside the criminal justice system have proven that those same symptoms are caused by falls and illness. ProPublica and the Medill Justice Project have conducted studies that revealed child deaths are much more frequently classified as crimes in particular states and counties than others, suggesting the determining factor in those classifications is not science but the biased predilections of the medical examiners.

Conversely, guilty police officers have gone free because medical examiners failed to correctly determine the manner of death to be a homicide. The death in Colorado of 23-year-old Elijah McClain is a well-known example. McClain, a healthy Black man, was thrown to the ground by police and restrained. Police officers claimed McClain was suffering from “excited delirium,” and paramedics forcibly injected him with ketamine. The county coroner first consulted with police and then classified McClain’s manner of death as “undetermined,” speculating he “may have died of excited delirium brought on by an undiagnosed mental health condition.”

But after the killing of George Floyd, Colorado Governor Jared Polis appointed a special prosecutor to investigate McClain’s death anew. After a grand jury found that the police officers had no probable cause to stop McClain, the autopsy was changed to read that McClain died of “complications of ketamine administration following forcible restraint.” One officer was later convicted of manslaughter. According to Joye Carter, who was named director of the Washington, D.C., medical examiner’s office in 1992, there is “a pattern with in-custody deaths. There’s a knee-jerk desire to quickly clear these police officers. Some medical examiners bend over backwards to blame these deaths on race-based conditions like ‘sickle-cell trait’ or excited delirium.”

The U.S. is the last remaining country in the developed world where medical examiners testify about the manner of death. Like felony murder, it’s a holdover we inherited from England. Peter Neufeld, cofounder of the Innocence Project, explains: “Manner of death is not a medical determination. It’s a legal determination that necessarily involves processing nonmedical information. Why is a doctor in a better position to evaluate the veracity of a suicide note, the truthfulness of a police report, or the reliability of a witness identification? They aren’t. Medical examiners simply don’t have the training to make those calls.”

Adding to the problem, medical examiners frequently work within systems designed to make them biased. In many jurisdictions around the nation, the medical examiner’s office comes under the control of a law enforcement agency. The medical examiners and coroners report to police and/or prosecutors who often have invested interests in the outcomes of the autopsies, especially when the death occurred at the hands of the police.

In other jurisdictions, autopsies are contracted out to private pathologists. The financial arrangements create a strong incentive for the pathologists to fill the ears of law enforcement with what the officers want to hear in order to keep the referrals coming. Shockingly, in some jurisdictions, crime labs receive additional funding when someone is convicted.

And even in those jurisdictions where medical examiners are not directly connected or dependent upon law enforcement, they are generally viewed to be a component of the “prosecutor’s team.” And they often consult with the prosecution before beginning an autopsy. This contact opens the door to cognitive bias.

Neurologist Itiel Dror has published three studies in the Journal of Forensic Sciences on the cognitive bias of medical examiners. In his second study, medical examiners received identical autopsies reports. Half of them were accompanied by a police report suggesting suicide, and the other half accompanied by a police report suggesting homicide. The results revealed that the medical examiners were far more likely to make a manner of death determination that coincided with the police reports even though the information in all of the autopsy reports was the same.

The third study, published in September 2023, revealed that when medical examiners are given one theory of the crime, they are most likely to agree with that theory. But providing more than one theory changed their analysis. But it was Dror’s first study that brought the onslaught of backlash from medical examiners. Dror and a team of six researchers – four of whom were medical examiners themselves – asked 133 medical examiners to review an autopsy report of a child’s death and to make a determination of accidental death, homicide, or insufficient information to make a determination. The 133 participants were given identical autopsy reports. But half of the participants were told the deceased child was Black and died while in the custody of the mother’s boyfriend. The other half were told the child was white and died while in the care of his grandmother. Statistically, Black children are more likely to die from homicide, and grandmothers are less likely to kill a child than a mother’s boyfriend. But those facts should have no bearing in determining the manner of death in a particular case. Yet, the medical examiners given the scenario with the Black child ruled the death a homicide at a rate five times greater than those who were told the child was white.

Predictability is fundamental to the scientific method. A group of scientists applying established scientific principles to the same set of facts should reach the same conclusion. This failure among the medical examiners revealed the subjective nature of manner of death determinations.

One would think the medical examiners would be ecstatic at learning how cognitive bias affects their determinations, enabling them to take precautions to eliminate it from future autopsies. Instead, forensic pathologists from around the nation attacked Dror and his team.

“It was an extremely disturbing experience to be openly attacked by my colleagues, some of whom I thought were friends,” said Dr. Jonathan Arden, one of the study’s authors and former president of the National Association of Medical Examiners (“NAME”) as well as the former head of the crime lab in Washington, D.C. “We were attacked baselessly, inappropriately, in a public forum. I had to retain counsel, and ended up spending a substantial amount of time, money, and effort responding to these accusations.”

Dror said “we expected people to disagree with the study. But these are supposed to be scientists. You write a letter to the editor. These doctors make decisions that send people to prison. You’d think they’d welcome feedback that will help them minimize mistakes. Instead, they sent a clear message: Don’t criticize us. We’ll go after you. We’ll go after your career.” Dror and his six co-authors were attacked with personal vitriol. NAME’s President sent an official complaint to Dror’s employer at the time, University College of London, alleging improprieties in the manner the study was conducted. A subsequent investigation found that Dror had done nothing wrong. The attacks upon the researchers from the medical examiners were so bizarre that the Editor of the Journal of Forensic Sciences took the rare action of publishing a note chastising the critics for their “lack of decorum and collegiality.”

Carter said, “I was disappointed by the reaction, but I wasn’t surprised. I’ve seen medical examiners say things like, because of the color of the decedent’s skin, they couldn’t tell if there were bruises. Which is just incredible. When I’d tell that story to explain why representation of nonwhite people is important, they would just shut down. They didn’t want to hear it. They just hear that as you calling them racist. So now you have a study finding that racial stereotypes can influence the manner of death determinations. I can’t say I’m surprised that they don’t want to hear that, either.” Though, to be fair, race wasn’t the sole difference between the two groups in the study. The relationship of the caregiver to the victim (grandmother versus mother’s boyfriend) was also a difference, but just like race, that should not have any bearing on the manner of death determination in a specific case.

Perhaps another factor is the caliber of the people entering the medical examiner profession. Medical students are not beating down the doors to get careers in forensic pathology. Most medical schools don’t even teach it. The majority of medical examiners work in the public sector and earn significantly less money than physicians who work with living patients. State legislatures underfund medical examiners’ offices. As a result, the field has come to be viewed as a professional dumping ground for those who didn’t excel in medical school.

After a police-involved killing of a Black man in 1954, a young Black woman told journalist John Howard Griffith: “We couldn’t even count the number of bullet holes in my brother’s head. But they called it heart failure.” It appears that in the succeeding 70 years, little progress has been made in the medical examiner’s community.

Sources: The New Republic; Journal of Forensic Sciences