How Are Coroners and Medical Examiners Different?

John Oliver, the host of the HBO show "Last Week Tonight with John Oliver," unleashed a 22-minute monologue in May 2019 on the state of death investigations in the U.S. The bit focused largely on the people who handle unusual deaths: coroners and medical examiners.

Lots of people use those titles interchangeably, but they're not the same. Here's an explanation from a 2003 workshop held by the U.S. Institute of Medicine, now called the National Academy of Medicine:

"I think a lot of people have the misconception, from a death investigative standpoint, that it has to be one or the other," Watts explains. "My opinion has always been that it needs to be professionally trained death investigators regardless of what type of system you work, whether it's a coroner system or a medical examiner system."

Watts' 40-year career as a coroner includes time as a police officer and a emergency medical technician. Like some jurisdictions throughout the U.S. — but not all, as Oliver detailed in his piece — the Richland County coroner's office uses medical examiners (again, they're normally physicians) to actually conduct autopsies. Deputy coroners do the field work, including investigating the death scene, tracking down medical records and interviewing witnesses.

"We rely on the medical examiner, the forensic pathologist, to give us the medical reason the person dies," he says. "They determine the cause of death from a medical standpoint. We determine the manner of death through an investigative process."

Take, for an example, a gunshot victim. Is it a homicide? A suicide? An accident? Can it be determined?

"You cannot necessarily make that determination just from the autopsy process," Watts says. "You have to have skilled investigators in the field, death investigators, to help with that process to make sure that you come up not only with the proper cause of death, but also the proper manner of death."

According to the Centers for Disease Control and Prevention, states have a myriad of different systems to conduct death investigations. Some states use a centralized medical examiner system; some are county- or district-based; some mix in coroners in varying ways.

States have differing definitions of what a coroner or a medical examiner is, too. A medical examiner in West Virginia, for example, doesn't have to be a physician. In Georgia, someone can be both the mayor and the coroner if they live in a town of fewer than 5,000 people. The county attorney does the job of the coroner in Nebraska. Justices of the peace in Texas handle coroner duties.

States also have different requirements on what triggers an autopsy or a death investigation. All of it makes for a confusing and sometimes slipshod way that death is handled throughout the nation.

"On one side of the border you have a statewide medical examiner and competent death investigation," Ross Zumwalt, a medical examiner in Albuquerque, New Mexico, told a 2011 investigation by NPR, PBS and ProPublica. "The other side of the border may be a small county coroner with few resources and little training."

What's common, it seems, is this: Funding is a problem almost everywhere. And, largely because of that, it's extremely difficult to find qualified medical examiners or forensic pathologists (who can make good money outside of government work), and it's becoming harder to pay qualified people who know their way around the field. According to Watts, you need both.

"The medical examiner, or forensic pathologist, is one piece of the puzzle. The field investigators are the other piece of the puzzle," Watts says. "It's not an either-or. It should be an and."

A 2012 report by the Scientific Working Group on Medicolegal Death Investigation cited a number of reasons for the shortage of forensic pathologists. (Some estimate that fewer than 500 are practicing in the U.S.) Among the reasons: a lack of educational centers that teach the profession, lax funding to support that education, high dropout rates, tight budgets among states and counties, and the resultant low salaries that deter young people who may want to enter the field.

That shortage may be causing some disturbing problems. That 2011 NPR, PBS and ProPublica investigation found jurisdictions that were cutting back on autopsies when the cause of death seemed obvious. "There's no way that we can look at every case we should probably be looking at," Craig Harvey, a death investigator with the Los Angeles County Coroner's office, now retired, told NPR at the time. "When you only see one in every three cases, the possibility that a homicide's going to be missed are pretty great."

For Watts, who has been involved with more than 32,000 death investigations in his career, the systemic problems always come back to money. If states don't cough up enough to pay the right kind of experts, the problems will persist.

"The death investigation offices are usually the last ones to get funding," he says. "It's something that people either don't want to think about, try not to think about or won't think about, until it affects them, personally. And then everyone wants to know all the answers and exactly what happened."