How America's broken autopsy system can mask police violence

Maanvi Singh
Photograph: Terray Sylvester/Reuters

“I can’t breathe.” With those words, George Floyd, Manuel Ellis and Elijah McClain each seemed to narrate their own deaths. Their autopsies told a different story. Floyd died of “cardiopulmonary arrest, complicating law enforcement subdual”, the report said. “An argument could be made” that drugs in his system were what killed Ellis, officials said. McClain’s cause of death was “undetermined”.

Among the many layers of institutional inequality excavated by a nationwide reckoning with racism in the US is a broken system of how and by whom deaths are investigated. In most states, officials who oversee autopsies are not required to have a medical degree. The departments responsible for investigating suspicious deaths often lack funding and oversight, and work closely with – if not under the supervision of – law enforcement. As a result, many deaths at the hands of police are never reported as such, or are minimized by diagnoses that blame the victim’s heart disease or mental illness rather than an officer’s boot or bullet.

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Last month, a group of physicians and psychiatrists signed a letter condemning the system wherein “autopsy reports are manipulated to bury police violence”.

“Black people are suffocating under the weight of anti-Black hatred. They cannot breathe,” their message, published in Scientific American, reads. “And even as they gasp for air, structural gaslighting operates to deny the truths of the causes of their suffocation.”

Inconsistencies and conflicts of interest

In the US, death investigations aren’t necessarily overseen by qualified professionals.

The process – a crucial element in the US criminal justice system – is regulated by a patchwork of often confounding, quirky rules and norms. While death inquiries in some communities are directed by medical examiners with medical degrees and board certification, most are overseen by coroners, who don’t necessarily have specialized training.

Only four states – Kansas, Louisiana, Minnesota and Ohio – require their coroners to be physicians, and only 16 states have laws specifying training requirements for the function.

In some communities the job is an elected position. In many it is directly tied to the sheriff’s department. In the state of Georgia, the mayor of any town with 5,000 or fewer residents is officially authorized to also serve as the coroner – and vice versa. Many county coroners in the state are funeral home directors and the position often allows morticians a first crack at selling funeral services to families. Pastors, handymen and plumbers have also been elected to the position.

In Colorado, where coroners are elected in all but one county, the only requirement to run for the office is a high school diploma and US citizenship. Once elected, coroners are expected to take a 40-hour course and obtain a basic-training certification within one year of taking office.

In cases of unnatural deaths, many local governments require autopsies to be performed by trained forensic pathologists. But ultimately it’s often the coroner – and not the pathologist – who decides whether to sign off on the final death reports.

That has been a consistent issue in most California counties, where the chief coroner and sheriff are one and the same. In 2017, two medical examiners employed by San Joaquin county in California resigned, alleging that the sheriff-coroner Steve Moore pressured them to change their autopsy results for deaths in police custody.

Efforts to fully disentangle death investigators from police in California have failed. A bill to simply keep law enforcement out of pathologists’ exam rooms when they were investigating deaths in police custody failed, and another to require large California counties to establish an independent medical examiner’s office was vetoed in 2018.

“There’s just real egregious conflicts of interest in investigating officer-related deaths, across the country,” said Justin Feldman, an epidemiologist at New York University who studies police violence. That is one reason officer-related deaths are underreported, he said.

In a 2017 study, Feldman and his colleagues found that the Guardian’s Counted project – which scoured local news reports to count victims of police shootings – was much better at reporting the total number of police-related deaths than the federal database that tallied up what was reported on death certificates. “We found that on the certificates, deaths were being reported typically as homicides – but not as police-related homicides,” Feldman said.

In cases where victims are choked, beaten or Tasered by law enforcement, investigators have even more leeway in how they might characterize the cause of death. Often, these deaths are described a result of “excited delirium” – a controversial diagnosis that is not recognized by the American Psychiatric Association, the American Medical Association or the World Health Organization. People with excited delirium are said to gain “superhuman strength” and become aggressive under the influence of drugs such as cocaine and methamphetamine. When they interact with law enforcement, they are said to struggle and collapse, essentially killing themselves.

“Even if it’s describing a real phenomenon, the term is often overused in certain types of cases to downplay the responsibility of police,” Feldman said. “When there’s any ambiguity, a medical examiner or coroner concert can just round it up to: no one is responsible, or it’s delirium, or maybe it’s a combination of factors.” Even when these cases are categorized as homicides, they are rarely listed as law-enforcement-related. “In that way, the George Floyd autopsy is an anomaly,” he said.

Misleading medical jargon

The Hennepin county medical examiner’s autopsy of George Floyd listed the cause of death as “cardiopulmonary arrest complicating law enforcement subdual, restraint, and neck compression”.

“Cardiopulmonary arrest just means death,” said Dr Roger Mitchell, the chief medical examiner of Washington DC. “It means his heart stopped beating – that’s a very technical way of saying it – due to neck compression.”

The odd, passive phrasing, implying that the death complicated actions taken by law enforcement, though technically accurate, “is completely damaging”, said Dr Jennifer Tsai, an emergency medicine physician at Yale who co-authored the letter condemning the autopsy system.

Moreover, Floyd’s autopsy listed several underlying health conditions, including heart disease and hypertension, and included a toxicology report that found levels of “cannabinoids, amphetamines, and fentanyl/metabolites” in his system – even though none of those factors appear to have caused his death.

A child runs past a mural at the George Floyd memorial outside Cup Foods in Minneapolis. Photograph: Leila Navidi/AP

Although the county autopsy ultimately squared with what a private investigation commissioned by Floyd’s family found – that his death was a homicide – the examiner’s report was extrapolated from in the charging document for the former officer Derek Chauvin to assert that “underlying health conditions and any potential intoxicants in his system likely contributed to his death”.

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Even if the practice of including medical information that isn’t directly relevant is common practice, Tsai said, “there’s character assassination in this process in describing the medical facts.” Medical reports often bolster narratives that the Black and Brown victims of police violence are large and threatening, and somehow also fragile, in such poor health that the slightest touch could kill them, she added.

The death investigations that followed three high-profile police killings in 2014 illustrate her point. The autopsy of Alex Nieto, whom San Francisco officers shot at more than 40 times, reported traces of cannabinoids in the young man’s system and came attached to years-old medical records revealing Nieto’s history of mental health struggles. That year, a toxicology report that accompanied the autopsy of Michael Brown, the 18-year-old shot by St Louis police, noted that Brown had marijuana in his body when he was killed. And although the medical examiner who performed the autopsy of Eric Garner, who died after a New York officer held him in a chokehold, testified that the officer’s use of force killed Garner, the officer’s lawyers fixated on Garner’s asthma, enlarged heart, hypertension and obesity. Eventually, the examiner agreed that even a bear hug could have killed the 43-year-old man.

“This is a pattern we see over and over again,” Tsai said.

Mitchell and three other board-certified medical examiners told the Guardian that while the Hennepin county report on Floyd was technically accurate, they wouldn’t have written it up the same way. “We need to be clear what we’re emphasizing in the diagnosis, and that emphasis should be intentional,” Mitchell said. “From what the world has seen, we know that George Floyd’s intoxication, or George Floyd’s heart condition, played absolutely no part in his death.”

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