Ronald L. Goldman's family cried as Dr. Lakshmanan Sathyavagiswaran, the Los Angeles County chief coroner, described how Mr. Goldman's killer taunted his victim with knife cuts to the throat before severing his jugular vein.
Dr. Lakshmanan theorized that Mr. Goldman was gravely wounded early in the struggle and his assailant held him from behind while making swiping wounds on his throat. Eventually, the killer slashed Mr. Goldman's throat and sliced his aorta.
For eight days, Dr. Lakshmanan laboriously laid out his gruesome evidence in the O. J. Simpson trial. The fact that his testimony lasted that long is an awesome acknowledgment of the power that coroners, pathologists and medical examiners have in murder cases.
Among court witnesses, to be sure, coroners and medical examiners are more equal than others.
But inadvertently, Dr. Lakshmanan's testimony picked the scab on a problem that has been festering in America's criminal-justice system.
Just how reliable is the testimony given by coroners and medical examiners "to a reasonable degree of medical certainty"?
At the start of his testimony Dr. Lakshmanan promptly acknowledged autopsy errors by Dr. Irwin Golden, the deputy medical examiner.
But, he hastily added, these mistakes were irrelevant to the final conclusions in the case.
Still, prosecutors announced, they would not call Dr. Golden as a witness. This prompted the defense to suggest that Dr. Golden's mistakes so embarrassed the prosecution that they were hiding him.
Interviews with more thanthree dozen coroners, medical examiners, forensic pathologists, legal experts and people who have been victimized by the system paint a disturbing picture of a process that is, at best, woefully inadequate; at worst, often inept.
"We're still living in the dark ages" when it comes to death investigations, says Dr. Michael Baden. "It's a national disgrace."
Dr. Baden, director of the New York state police forensic sciences unit, has been retained by the Simpson defense team as an expert witness.
Dr. Werner Spitz, the former chief medical examiner for Wayne County, Mich., and a consulting forensic pathologist near Detroit, estimates that up to 70 percent of the country is poorly served by its system for investigating unnatural deaths.
Of the nearly 2.2 million deaths reported in the United States in 1992 almost 7 percent, or nearly 143,000 deaths, were classified as unnatural, according to the U.S. Department of Health and Human Services' Division of Vital Statistics.
The importance of a proper death investigation cannot be overestimated, up to and including the possibility that it could lead to a criminal prosecution.
A death certificate can either compound a family's grief or bring peace of mind. It is used to resolve a range of legal issues, from insurance coverage to death benefits to civil liability.
The idea that a doctor should be in charge of the process of certifying deaths only took root in the 20th century.
Yet only a handful of states and large U.S. urban areas with
medical-examiner systems require that death investigations be conducted by board-certified or board-eligible forensic pathologists -- specialists with advanced training that enables them to analyze traumatic injuries, such as those from gunshots, stabbings, poisons or blunt force.
Maryland is among a handful of states that require a medical examiner to be a doctor. In North Dakota the requirement applies only to counties with more than 8,000 people. And Louisiana makes an exception for parishes in which no doctor is willing to serve.
As a result a disproportionate number of coroners are actually funeral-home directors who have fallen into their line of work because they happen to be in the business of transporting bodies.
Sheriff's deputies, school bus drivers and tow-truck operators also have served as coroners. So have gas station attendants, bar owners, jewelry salesmen and accountants.
Small wonder that in one Kentucky county every four years the hardest-fought race is the one between the same two rival funeral directors who want to be coroner. The winner's funeral parlor gets all the coroner's business.
Many coroners operate on a shoestring budget, which forces them to cut corners whenever and wherever they can. Too many rely for autopsies on hospital pathologists, who are trained to study the ravages of disease, not to reconstruct how somebody died.
"Asking a hospital pathologist to do an autopsy on the victim of a violent death is like asking a dermatologist to perform brain surgery," Dr. Baden says.
Medical-examiner systems come with their own set of problems, not the least of which is the shortage of highly skilled personnel.
Of the nearly 671,000 doctors currently licensed to practice in the United States, fewer than 3 percent, or 17,149 doctors, are specialists in pathology, according to the American Medical Association.
Only 435 are board-eligible forensic pathologists, of whom 335 are board-certified. Not all forensic pathologists work full time. At least 12 states don't employ any at all.
One reason there aren't enough qualified professionals to go around is the work, which can be both dirty and demanding. Medical examiners are on call 24 hours a day. Their caseloads are often crushing. Manyof their offices are chronically understaffed and ill-equipped. They must spend a lot of time in court. A medical examiner's relatively poor pay doesn't help.
Nobody knows how many murders go undetected, how many killers go free, how many innocent people are convicted of a crime that never occurred or how many suicides are covered up in deference to the next of kin.
"It probably happens more often than we know of, or would like to think," says Dr. Boyd Stephens, San Francisco's chief medical examiner. "But if everything's not done properly in the beginning, nobody's usually ever going to know whether a mistake was made or not."
Kenneth Reno knows all too well what can happen when something goes wrong. In 1991 the Detroit-area man spent nearly six months in jail awaiting trial for a double murder he didn't commit.
One night Mr. Reno was watching television with his 21-year-old daughter, Robin, when his dentures broke on a popcorn kernel. His wife, Carlynne, was asleep in bed. He went to the store to get some glue. He returned a half-hour later and found his wife dead and his daughter mortally wounded.
Each had been stabbed more than a dozen times.
When Mr. Reno asked his daughter who'd stabbed her, he said, she replied, "Tommy . . . Tom Collins."
When Mr. Reno asked who Collins was, he said Robin identified him as "a friend of" the father of her 2-year-old daughter."
Moments later Mr. Reno's daughter died.
The next day Mr. Reno was charged with two counts of murder. He was prosecuted mainly on the strength of an autopsy report that said his daughter's vocal cords had been cut, rendering her incapable of speaking.
Despite the autopsy report, Dan Less, the Wayne County assistant prosecutor, had doubts about Mr. Reno's guilt.
It didn't make any sense for Mr. Reno to make up the story because the whereabouts of the man he had accused could easily be checked out.
The autopsy report on Mr. Reno's wife provided another clue that something was amiss. It said the woman had still-intact natural teeth, but Mr. Less knew the victim had false teeth, which had been knocked out during the attack.
So the prosecutor asked four out- side experts, including a throat specialist, to review the autopsy report and the victim's larynx, which had been preserved as evidence.
All four concluded that Robin Reno's vocal cords had not been cut, making Mr. Reno's story all the more credible.
Six months later, Tom Collins, the man Robin had identified as her assailant, was arrested for a burglary. Eventually he confessed to the killings and was sentenced to life in prison.
While the system's shortcomings may be all too obvious, a solution is more elusive.
Some forensic pathologists suggest giving medical examiners civil-service status or allying them more closely with medical schools, which have a strong tradition of independence.
Some advocate setting up regional forensic-science centers that offer continuing education and the services of an expert. Some propose creating a private system that operates on a fee-for-service basis.
But nearly all agree on some basic needs. These include:
* Higher salaries to lure more bright young doctors into the field.
* A uniform set of national standards to govern the profession.
* Better training for employees to minimize the potential for error.
* Improved funding to ensure that each investigation gets the attention it deserves.
In the wake of the Simpson trial's highly publicized testimony, this is one area of the criminal justice system that will surely come under more scrutiny.
Hopefully, this will aid a nationwide effort to find much-needed solutions.
Mark Hansen is a reporter for the ABA (American Bar Association) Journal, from which this article is adapted.