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Issues of Culture and the Role of Medical Examiner

Author(s): Christine Wilson Owens

Dr. Richard Harruff, Chief Medical Examiner, King County (Washington State), initiated a series of meetings with personnel from the Medical Examiner's office and representatives of immigrant communities. These meetings explored traditional beliefs and practices about death, suicide, autopsy, organ donation, religion, delivery of news, and burial. This interview with Dr. Harruff provides some background into the role of the medical examiner and some of the reasons he sought out this kind of information.

Why the Medical Examiner is Talking About Immigrant Cultures and Communities

The Medical Examiners are employees of the Public Health Department - Seattle and King County. The Health Department has a strong mission to be culturally competent and sensitive. In addition we believe that we can best serve families by being aware of their specific cultural attitudes surrounding death.

We have experienced certain difficulties that appear to be culturally based. It is not uncommon for families to oppose our performing an autopsy, based on cultural or religious attitudes. Other examples include situations in which many (dozens) of community and family members have appeared at the office expecting to participate in the ceremonial washing of the deceased. Although we have allowed this ceremony, the large number of people and the washing procedure itself disrupted our routine operations. The presence of so many family and community members, along with the emotional grieving, risked there being some misunderstanding regarding the business and authority of the Medical Examiner. In a similar way, when there is community or family opposition to autopsy (a legal prerogative of the Medical Examiner) and many people are present, conflicts may arise that compromise the duty of the Medical Examiner. Unfortunately we have no room in our facility to comfortably accommodate these ceremonial practices. Furthermore, the Medical Examiner, as a government body, needs to be mindful of the potential conflicts arising from supporting religious practices in a government facility.

We have achieved positive solutions to some of these cultural conflicts, such as the example of allowing religious, ceremonial washing of bodies in our office. We have done this by initiating meetings with community members to discuss means for recognizing potential conflicts and avoiding them before they occur. Specifically, with respect to the issue of ceremonial body washing, we now facilitate their being performed at another location.

Common Misperceptions About the Medical Examiner

It is necessary to dispel two common misperceptions: first, that the Medical Examiner performs autopsies for medical reasons like education and research, the same as the hospital autopsies; and, second, that the Medical Examiner disfigures or mutilates the body.

The truth is that Medical Examiner autopsies are actually done for legal reasons, rather than medical reasons. Also, the Medical Examiners are not only highly professional and respectful, but also very skillful in preserving the appearance of the body. Ordinarily all organs are returned to the body for burial.

What Information the Medical Examiner has for Leaders of Immigrant Communities

Mostly, knowledge about the Medical Examiner policies and procedures is specialized and the general public is not expected to know about them. The Medical Examiner considers it important to share information with community leaders and to establish a network of community leaders who can work with the Medical Examiner to avoid conflicts and establish policies that work for the community and allow the Medical Examiner to do their work.

For community leaders, it is important to know that death investigation is a legitimate governmental responsibility, conducted by procedures that are different from place to place. In King County the agency for conducting death investigation is the Medical Examiner's Office. It is important to inform leaders about the mission of the Medical Examiner, which "is to investigate sudden, unexpected and unnatural deaths in King County with the highest level of professionalism, compassion and efficiency and to provide a resource for improving the health and safety of the community consistent with the general mission of Public Health".

Communities should know that the Medical Examiner performs a service for the family by explaining the death of a loved one. It is important to distinguish the Medical Examiner role as separate from the Police. Community leaders should understand that the Medical Examiner cooperates with the Police, but does not answer to them.

In deaths having criminal implications, the Medical Examiner has a responsibility to the larger community. But, when a death is not a criminal matter, but a civil matter, the Medical Examiner serves the family by providing instrumental information for insurance claims and estate settlements, and also by providing information about why and how a loved one died.

The Medical Examiner avoids phone notification of death, when at all possible. A member of the Medical Examiner's Office will deliver the news in person or may rely on agreements with Police chaplains or volunteer agencies to make personal notification. Most times, steps are made to ensure that someone isn't left alone by themselves after receiving the news of a loved one's death. It is helpful to have community- specific contacts to facilitate this news delivery and grief support process. The exception to delivery of news in person occurs at times when the media may get to the family or next of kin before the Medical Examiner can.

The public community interests outweigh the family interests in a homicide case. In other cases where there may be a conflict of interest, for example when a death occurs on the job and both the employer and family have interest in the autopsy results, the Medical Examiner responds without bias and to objectively explain the cause of death.

As a medical record, the autopsy report is information that belongs to the family and to a limited number of official agencies specified by law. The death certificate is a public record which is distributed by vital statistics. Other parties may get access to the autopsy report only through specific legal processes. For example, if the family sues, making the case a legal matter, the autopsy report then becomes a legal record, which will be available to the opposing party. The Medical Examiner considers and respects family interest as much as possible, but legal considerations will be the decisive factor. Washington State Law strongly favors family privacy in protecting confidentiality of medical records.

Limited and Shared Resources for Working with Immigrants and Refugees

There are not really sufficient resources available for the Medical Examiner to interact optimally with immigrant families and communities. We are working with other groups to develop relevant resources because no funding is available to do it directly. The Police and Harborview Medical Center share resources, like interpreters, with the Medical Examiner. Often, the Medical Examiner cases are joint efforts with the Police who are also investigating the death.

Culture and Religion of Americans and New Americans Impact the Medical Examiner's Office

In general, Americans are more accepting of autopsies and more likely to lack cohesive connections with spirituality, religion, and cultural beliefs that may significantly impact Medical Examiner procedures performed at times of death. People who come from smaller and less diverse environments tend to have more unified schemes of beliefs and practices governing occasions like death. For many non-American cultural groups there will be more frequent religious issues than with ordinary Americans. The exceptions for Americans include Jewish, especially Orthodox Jewish, communities. Specifically, both Muslims and Jews have specific protocols for the time frame and handling of the body and are likely to oppose autopsies on religious grounds.

For the Medical Examiner all oppositions to autopsy are viewed equally, and family wishes are respected whenever possible. Most of the time, opposition to autopsy represents the family's wishes and is not based on formal religious doctrine. Opposition to autopsy is dealt with case by case. The Medical Examiner doesn't evaluate objections to autopsy by considering the motivation for the objection (e.g. culture, religion, ignorance). However, if the Medical Examiner knows about the motivation for the objection, and an autopsy needs to be done, appealing to the specific concerns of the family or community may help to accomplish the purposes of both the Medical Examiner and the deceased's family or community.

There are times that the Medical Examiner engages in religious ceremonies that generally aren't called for by Americans. For example, the Medical Examiner sometimes helps erect a small shrine with candles and incense and plays tapes of chanting for the families of a deceased Buddhist. Buddhists represent a group that the Medical Examiner accommodates fairly frequently by allowing simple religious ceremonies, such as shrines, to be on site. Sometimes, Latin American Catholics want a cross or other emblem left with the body. Native Americans may have feathers or sage left with the deceased. Rather than a specifically religious item, an American family may leave some sort of memorial token, for example, a granddaughter's drawing left with the body of a deceased grandfather.

Managing Time and Work Space Issues with Family and Community Needs

Out of consideration for the family, the Medical Examiner makes all efforts to perform the autopsy and release the body as quickly as possible - within 12 hours and certainly less than 24 hours - after a death comes under jurisdiction. The Medical Examiner can accommodate any family who requests more time in holding the body. For example, certain Buddhists have requested that their bodies be left undisturbed for up to three days, during which time the Medical Examiner holds the body in refrigeration, helps set up a shrine, and plays religious chants on a tape recorder alongside the body.

The exception to the rule of accommodating the family in this way is when the autopsy needs to be rushed because the death was a homicide and the police need as much information as soon as possible to track leads. Otherwise, there is rarely any rush to do the autopsy.

As mentioned previously, Muslim families, including Somali families along with their communities have performed ceremonial body washings in the Medical Examiner facility. In such cases, the potential disruption to Medical Examiner work caused by on-site body washings led the Medical Examiner and representatives of the Somali community to establish a plan for washing the body in another location. This plan means to facilitate both the Medical Examiner's maintenance of a professional and efficient work environment and also respect for the Somali community's traditional time schedule for body washing and burial.

Cultural and Community Information is Useful to Medical Examiners

It would be very helpful to have readily accessible information about immigrant communities' practices and beliefs concerning death. This information would be useful for King County Medical Examiners and likely for medical examiners elsewhere. Although other professionals dealing with death may also find the same information useful, many agencies, like the police, are accustomed to referring their questions to the Medical Examiner, making it even more important for the Medical Examiner to have available relevant and accurate information.

Interest in Informing Immigrant Community Leaders about the Medical Examiner

The main Medical Examiner interest is to connect and network with community leaders. The leaders could then assure their communities that the Medical Examiner is trying to provide a service for the families in the community and are not intentionally doing harmful things.