The United States has half the forensic pathologists it needs, so elected coroners with zero medical training sign off on cause-of-death determinations that send people to prison

The National Association of Medical Examiners estimates that roughly 800 forensic pathologists practice in the United States, while approximately 1,600 are needed. In 2024, only 58 newly boarded forensic pathologists entered the workforce, barely replacing those who retired or left. Death investigations in the U.S. are conducted by more than 2,000 separate medical examiner and coroner offices, and in many jurisdictions, the coroner is an elected official with no requirement for medical training. In some counties, the coroner is also the sheriff, the funeral director, or a farmer. These officials make determinations about cause and manner of death that become the foundation of homicide prosecutions, and their findings are presented to juries as medical evidence. When an unqualified coroner rules a death a homicide based on intuition rather than pathology, the entire downstream criminal case is built on that foundation. Prosecutors charge suspects based on the coroner's determination. Juries hear that an official determined the death was a homicide and treat it as established fact. If the cause of death was actually a medical condition, an accident, or natural causes, the wrong person may be charged, tried, and convicted of a crime that never occurred. The Innocence Project has documented that flawed death investigations contributed to wrongful convictions in cases where natural deaths were misclassified as homicides. A 2011 survey found that 82% of forensic pathologists reported facing pressure from politicians or family members to change their determinations about cause or manner of death. When the person making those determinations is an elected official who depends on votes, the pressure is not just professional but political. The shortage persists because forensic pathology is the lowest-paid medical specialty. Medical examiners in public offices earn substantially less than pathologists in hospital or private practice settings, let alone other medical specialties. Medical students carrying six-figure debt have little financial incentive to pursue a four-year residency in a field that pays less than half what they could earn in other specialties. The coroner system persists because it is embedded in state constitutions and county charters that would require legislative action to change. Rural counties cannot afford to hire board-certified forensic pathologists even if they wanted to. The result is a patchwork system where the quality of death investigation, and therefore the integrity of homicide prosecutions, depends entirely on the accident of where someone dies.