How medical examiners explain suspicious deaths.
Columbia University, New York, NY, USA
Postmortem: How Medical Examiners Explain Suspicious Deaths Stefan Timmermans takes us inside a present-day U.S. medical examiner’s office to examine the ways that medical examiners leverage and defend their pathological expertise in the routine process of determining cause and manner of death. Timmermans shows that the nature of their professional expertise deeply shapes the meanings ascribed to death and the ways that it becomes a more comprehensible and routine part of modern life.
In the six main chapters of the book Timmermans examines sites at which medical examiner expertise is solidified or challenged. The role of the postmortem is most straightforward in chapter one, in which Timmermans argues that the common postmortem diagnosis of coronary artery disease is one site at which medical examiners successfully shift the site of death investigation onto examination of pathological change in organs and tissues. In much of the rest of the book, the value of the postmortem is more ambiguous. In chapter two, Timmermans argues that in possible suicide cases medical examiners’ pathological expertise contributes relatively little, causing them to take a conservative interpretive stance based on medical evidence. In chapter three, Timmermans untangles the forensic evidence presented in the Louise Woodward shaken-baby syndrome case to examine the challenges which expert witnesses face during adversarial courtroom procedure. He uses the case to discuss various ways that medical examiners regulate their activities in the morgue to mitigate risks to their credibility.
Timmermans shows that medical examiners’ use of their pathological expertise must be negotiated with the interests and actions of other professionals involved in death investigation. Following this theme, in chapter four Timmermans examines the ways that technical “homicides” caused by medical and law enforcement professionals are classified as “natural”, “accidental”, or “suicide by cop”, reflecting the dependence of medical examiners on these groups and the inter-professional negotiations on which death classifications are based. In chapter five Timmermans argues that despite the ambiguity of pathological evidence in cases of infant death, medical examiners are given authority to interpret evidence more liberally in order to resolve ethically charged questions of care-giver culpability in the death. In chapter six Timmermans examines the ways that organ and tissue transplant interests effectively challenge the scientific authority and legal and ethical mandates of medical examiners. This too is a site at which medical examiners must defend the scientific and ethical value of the postmortem - especially when the lives of potential organ recipients are at stake. Throughout the chapters of the book, I was left wondering about medical examiners’ relations with coroners (who according to Timmermans are involved in cases for about half of the U.S. population). How do the activities of coroners and medical examiners cross paths in early twenty-first century death investigations? Given Timmermans’ multifaceted approach to questions of professional authority, this would no doubt be an interesting discussion. Such a discussion would also touch on questions of standardization and resource distribution in local death investigations, providing further context for Timmermans’ textured analysis of medical examiners.
While the postmortem is a key component of the professional identity of forensic pathologists, Timmermans shows that “forensic authority” is not just a question of the ability to produce “scientific” findings. For Timmermans, the authority which medical examiners possess in any given situation derives from and is contested across multiple fields: their ability to make death intelligible within the rubric of modern ideas about dying, the laws which give them a mandate to investigate certain kinds of deaths and, finally, their anatomic-pathological expertise. Medical examiners reach the peak of their authority when through these resources they achieve “cultural authority”, or the ability to have other actors accept the claims that they make.
This is a valuable approach to the modern history of forensic expertise. Ian Burney also has found that more than simply the “science” of the postmortem was at stake in debates over reform of the English inquest during the nineteenth and early twentieth centuries (1). Discussions about the kinds of experts who should be involved were framed in a modern political discourse of “public participation” versus centralized expert-based authority. The connections which Burney describes between new conceptions of medico-legal expertise and new ideas about separating the living and the dead on hygienic and ethical grounds also suggests that – as Timmermans argues – medico-legal authority and the way that a society manages death cannot be separated. Of course, the exact “composition” of forensic authority at the start of the twenty-first century is different. One difference, which Timmermans points out, is that the mid-twentieth century saw a decline in the prestige of the clinical autopsy in medical research and education. But given that much of Timmermans’ study revolves around the ways that medical examiners use their expertise in situations which would be highly ambiguous under any circumstances (for example, suicidal intent), the book taps into the much deeper ambiguities of making death meaningful which one suspects exist regardless of the type of medico-legal expertise being used.
Timmermans’ way of analyzing the professional authority of medical examiners is informed by science studies approaches which take the content or “practice” of scientific activity as an indispensible element in analysis of how different processes of knowledge-production work. Timmermans thus views the material practices of death investigation as sites at which knowledge-claims are made and contested. In Latourian terms, the negotiation of medical examiner authority is a political process in which knowledge-claims can be accepted, contested, or appropriated by other actors involved in death investigation such as prosecutors, defense counsel, families of victims, and organ transplant advocates. As discussed above, the resources of these struggles are not purely “scientific” (the scientificity of claims is in many ways a result of this process), but are variable. Timmermans is not the first scholar to use such an approach to examine the “hybrid” quality of forensic facts (3, 5, 7). Timmermans effectively uses this approach to interpret ways that medical examiners capitalize on the strength of their networks while ensuring that their findings remain durable under the scrutiny of other groups’ networks, such as those of the courtroom.
While Postmortem makes methodological contributions to the recent body of work which examines the social, legal, and political dynamics underlying conceptions of forensic expertise in different times and places (see 1, 2, 4, 6, 9), it also complements recent studies of the history of forensic medicine in the United States. This history has been examined by scholars like James Mohr, who documents the shift from early nineteenth-century interest in an activist “medical jurisprudence” to the rapid disintegration of the field and beginnings of the modern medical examiner system by the turn of the twentieth century (9). As in England, the medico-legal role of pathological expertise – as opposed to that of general practitioners – was not preordained or straightforward (1). Julie Johnson-McGrath has shown that pre-WWII forensic pathology education as well as debate during the 1950s within the pathology community over subspecialty certification was ambivalent about the legal and administrative skills which would differentiate the professional field of forensic pathology from clinical pathology (8). Timmermans’ account of present-day medical examiners resonates with Mohr’s description of the early tribulations of medical witnesses in court while showing how administrative and legal skills allow medical examiners to assert their authority beyond the morgue.
In summary, Postmortem provides a compelling account of the structural dynamics and material practices of modern forensic pathology. While the book engages with questions of professional authority and scientific practice grounded in sociology of expertise and science studies, Timmermans’ integration of theoretical discussion and compelling narrative description of cases and procedure makes the book an interesting read for anyone who wants to learn more about the work of medical examiners.
Daniel Asen is a doctoral candidate in modern Chinese history in the Department of History at Columbia University. His dissertation examines the establishment of modern forensic medicine in early 20th century China. He can be reached at: firstname.lastname@example.org.
1. Burney, Ian A.. Bodies of Evidence: Medicine and the Politics of the English Inquest, 1830-1926. Baltimore: The Johns Hopkins University Press; 2000.
2. Clark, Michael and Crawford, Catherine (eds). Legal Medicine in History. Cambridge: Cambridge University Press; 1994.
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4. Fahmy, Khaled. The Anatomy of Justice: Forensic Medicine and Criminal Law in Nineteenth-Century Egypt. Islamic Law and Society. 1999; 6(2): 1-48.
5. Fuchs, Stephan and Ward, Steven. What is Deconstruction, and Where and When Does it Take Place? Making Facts in Science, Building Cases in Law. American Sociological Review. 1994; 59(4): 481-500.
6. Golan, Tal. Laws of Men and Laws of Nature: The History of Scientific Expert Testimony in England and America. Cambridge: Harvard University Press; 2004.
7. Halfon, Saul. Collecting, Testing, and Convincing: Forensic DNA Experts in the Courts. Social Studies of Science. 1998; 28(5/6, Special Issue: Contested Identities: Science, Law and Forensic Practice): 801-828.
8. Johnson-McGrath, Julie. Speaking for the Dead: Forensic Pathologists and Criminal Justice in the United States. Science, Technology & Human Values. 1995; 20 (4, Special Issue: Constructivist Perspectives on Medical Work: Medical Practices and Science and Technology Studies): 438-459.9. Mohr, James C.. Doctors and the Law: Medical Jurisprudence in Nineteenth-Century America. Baltimore: The Johns Hopkins University Press; 1993.
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