That isn’t what happened. Dror and and his six co-authors, four of whom are medical examiners themselves, were subjected to acrid, unusually personal vitriol from colleagues across the country. NAME went particularly hard after Dror, who is not a medical examiner. The group’s president and executive director sent an official complaint to Dror’s then employer, University College of London. After an investigation, the university determined that Dror had done nothing wrong.
The reaction from medical examiners was so unhinged that the Journal of Forensic Sciences’ editor published an unusual note chastising the critics for their lack of decorum and collegiality.
Critics of the study seemed particularly irked by the racial component. “They keep saying we called them racist,” Dror says. “But the study was never about detecting racism. It was to measure how bias can affect a manner of death determination. We used race as one variable because it’s well established that the deaths of Black children are far more likely to be classified as homicides.”
“I was disappointed by the reaction, but I wasn’t surprised,” says Carter. “I’ve seen medical examiners say things like, because of the color of the decedent’s skin, they couldn’t tell if there were bruises. Which is just incredible. When I’d tell that story to explain why representation of nonwhite people is important, they would just shut down. They didn’t want to hear it. They just hear that as you calling them racist. So now you have a study finding that racial stereotypes can influence manner of death determinations. I can’t say I’m surprised that they don’t want to hear that, either.”
Dror and Neufeld speculate that the unusually unruly response stems from the fact that medical examiners aren’t accustomed to being proven wrong. “Doctors who work with the living get constant feedback for how they’re doing. If a patient doesn’t improve, you know to change the course of treatment,” Neufeld says. “But when you work with the dead, you don’t get that kind of feedback.”
“Unless there’s DNA testing involved, there’s rarely a ground truth in forensic science to tell a medical examiner when they’re wrong,” adds Dror. “So I think what we’ve seen with the reaction to the study is a profession being told for the first time that they can be wrong. And they don’t want to hear it.”
Critics filed eight complaints against Dror and his co-authors. All have since been dismissed. The Journal of Forensic Sciences initially sent the study to three peer reviewers, all of whom approved it for publication. After the wave of criticism, the journal sent the study to a fourth statistician. That statistician too found nothing wrong with the study.
Dror has since collaborated with other researchers and medical examiners to publish two additional studies on cognitive bias in forensic pathology. In the first, medical examiners were given identical autopsy reports, but half were accompanied by a police report suggestive of suicide, while the other half were given one suggestive of homicide. The medical examiners were far more likely to give a manner of death determination that matched the police reports. The final study, published in September, showed that when police give medical examiners just one theory of the crime, they’re likely to agree with that theory. Providing more than one theory changed their analysis.
The reaction to these subsequent studies has been less intense, but Dror says the criticism had an impact. “The response has made my medical examiner colleagues extremely skittish,” he says. “They want to water down the language in these subsequent studies, not because it’s wrong or overstated but because they don’t want their colleagues to come after them. One has asked that his name be redacted. It isn’t that he doesn’t agree with the results. He is afraid of retaliation. It’s definitely had a chilling effect.”
For all the protests, legislation, racial reckoning, and backlash inspired by George Floyd’s death, the most lasting—and perhaps improbable—legacy may be to have exposed and even helped correct the problems with how in-custody deaths are investigated in the U.S.
After the Sweasy memo first appeared in defense filings in August 2020, George Floyd’s family hired two outside medical examiners to conduct their own autopsy. Those doctors concluded that Floyd died of asphyxiation caused by pressure applied by Chauvin, and that his death was indeed a homicide.
That review provoked a bizarrely defensive—but perhaps revealing—response from the National Association of Medical Examiners. In a public statement, NAME discouraged obtaining second opinions for forensic autopsies. It was a strange stand to take—second opinions and peer review are a core tenet of science and medicine. Given the historic use of manner of death determinations to cover up racial violence, it was also inexplicably tone-deaf. After a flurry of public criticism, NAME retracted the statement.
The group has since hired Carter to head up a diversity and inclusion program to educate medical examiners on sickle cell trait, excited delirium, and other matters white medical examiners may encounter when conducting autopsies on Black people. Carter says she had long advocated such a program, but until the 2020 protests, she’d received little support.
One of the most vocal critics of the first Dror study was Brian Peterson, who at the time was chief medical examiner for Milwaukee. He was the lead signatory of the most prominent letter to the editor of the Journal of Forensic Sciences—the one that inspired a note from the editor. Peterson also attacked the studies’ authors in particularly personal terms on the NAME listserv. In one especially odd—and perhaps revealing—email to the group, Peterson wrote, “Is there anyone in our profession that has not, at one point or another, quipped about ‘spinning the wheel of death’ and picking one?”
“I don’t even know how you respond to that,” says Carter. “It’s such an embarrassingly cavalier thing to write about what we do—about the decisions we make that can send people to prison.”
Peterson was also a consultant for Chauvin’s defense, though he didn’t ultimately testify at the trial. Peterson himself has a controversial history with in-custody deaths. A decade ago, he issued a contentious diagnosis about another Black man who died with a police officer’s knee on his back, even as that man complained that he couldn’t breathe. Though Peterson and his office did ultimately classify that death as a homicide, he attributed the death to sickle-cell trait, a condition he speculated might have been brought on by the man’s decision to flee and resist police officers. Last fall, Peterson either retired or was fired from his position in Milwaukee, depending on whom you believe. He then stopped showing up for court hearings in pending cases, including the highly publicized trial of a police officer accused of killing a 25-year-old Black man with a choke hold.
Another prominent critic of the study was David Fowler, the former state medical examiner in Maryland. Fowler actually testified for Chauvin’s defense, and his testimony was so controversial that the Maryland attorney general appointed a panel to conduct an unprecedented review of Fowler’s work on in-custody deaths.
That review is ongoing. But last year, attorneys for the Maryland ACLU said they had found dozens of cases in which someone died while under some sort of restrictive police restraint, after which Fowler’s office ruled the death “undetermined.” In some of those cases, “the decedent had been Tased, pepper sprayed, subject to police baton strikes, prone restraint, or other uses of force.”
Critics like Dror say that while those sorts of determinations could be the product of a personal bias in favor of exonerating police, they’re more likely due to systematic bias.
“If you bring in a homeless person who was beaten to death by a street gang and covered in bruises, most medical examiners will quickly rule that a homicide. But if the same homeless person was beaten by police, they’ll run the gamut of tests. If you look hard enough, you can always find some other condition that might have contributed to death,” Dror says. In some jurisdictions, Dror says, in-custody deaths are required to undergo more tests as a matter of policy.
This is where diagnoses like “excited delirium” come into play. Despite dubious origins and little support in clinical and academic research, the condition caught on after the company formerly known as Taser spent millions to promote it among coroners and medical examiners. It posits that people apprehended by police who are intoxicated, high, or panicked, or who have ailments like heart disease or genetic conditions like sickle cell trait, can go into cardiac arrest and die when restrained or apprehended by police, through no fault of the police.
Excited delirium isn’t recognized by either the American Medical Association or the American Psychiatric Association—and after 2020, both groups explicitly recommended against its use. But it has been used to exonerate hundreds of police officers for in-custody deaths, and it’s disproportionately invoked in Black and Latino deaths. Chauvin’s attorneys managed to work it in at his trial, but the judge in the 2022 trial of two other officers barred them from claiming it was a factor in Floyd’s death. (Tellingly, excited delirium diagnoses are all but nonexistent outside a police context, and nearly all involve some sort of restraint.)
Even if excited delirium were a real condition, it shouldn’t affect a manner of death determination. “A homicide is a homicide,” says Carter. “A prosecutor can decide later that it was a justifiable homicide like self-defense. But if the person would still be alive if not for the police officer’s actions, it’s a homicide.”
Floyd’s death and the resulting protests prompted more skepticism of these sorts of deaths across the country.
In early November, as part of a settlement to the lawsuit related to the ACLU investigation, the state of Maryland agreed to sweeping changes to shield medical examiners from pressure by police and prosecutors.
But there have been changes elsewhere too. After Floyd’s death, authorities in Colorado reopened an investigation into the death of Elijah McClain, a healthy, 23-year-old Black man who died after police stopped him, threw him to the ground, and restrained him. Paramedics forcibly injected McClain with ketamine after officers at the scene claimed he may have been suffering from excited delirium.
After consulting with police, the county coroner classified McClain’s manner of death as “undetermined” and speculated that he may have died of excited delirium brought on by an undiagnosed mental health condition. Citing the coroner’s report, the local district attorney then cleared the officers of wrongdoing.
In the summer of 2020, Colorado Governor Jared Polis appointed a special prosecutor to reinvestigate McClain’s death. A grand jury subsequently found that police officers had no probable cause to stop McClain. The autopsy report was then amended to say McClain died of “complications of ketamine administration following forcible restraint.” One officer has since been convicted of manslaughter. Another was acquitted.
The 2020 protests also prompted scrutiny of police tactics like hog-tying and restraint chairs. They spurred reexamination of other in-custody deaths in Colorado, Utah, Oakland, and Illinois and inspired a critical academic review of the research police and prosecutors cite when they claim there’s no risk to restraining suspects while they’re lying face down.
Floyd’s death was also likely a factor in a nationwide reassessment of excited delirium. After years of criticism from medical professionals, NAME finally disavowed the diagnosis in March. In October, a panel for the last holdout medical organization—the American College of Emergency Physicians—voted to withdraw its endorsement of the seminal medical paper upon which the diagnosis is based. A week later, the California legislature voted to ban coroners from citing excited delirium as a cause of death.
But critics like Neufeld urge a more substantive change. They say the Dror studies demonstrate why the U.S. should join the rest of the world and bar medical examiners from testifying about manner of death in court—an opinion shared by Dror’s medical examiner co-authors, Melinek and Arden. Dror himself is on the fence on the issue, but believes that medical examiners should be required to notify prosecutors and juries when a manner of death determination was influenced by nonmedical information.
Some have suggested the U.S. adopt one of the less adversarial models of expert testimony used in Europe, but such a radical departure from the current system seems unlikely. Instead, Dror and other critics who study cognitive bias have pushed for a process called linear sequential unmasking, in which a medical examiner first conducts an autopsy and makes only medical observations, then carefully factors in any external information as necessary. Advocates of this process say it separates objective, medicine-based observations from the more subjective conclusions.
Dror says for this reason he was especially baffled by one critic of his study, in particular: Andrew Baker. “It’s interesting that Baker would be one of our biggest critics,” Dror says. “The most charitable interpretation of his actions in the Floyd case is that he did exactly what I recommend.”
At Chauvin’s trial, Baker testified that he avoided watching the videos of Floyd’s death because he didn’t want to bias his conclusions. “It wasn’t until after he saw the video that he concluded Chauvin’s actions contributed to Floyd’s death. He made preliminary medical observations first, then factored in the nonmedical information as necessary,” Dror says. “This is exactly how it should be done.”
The ease with which the deaths of young Black men like Cameron and McClain were initially dismissed—and with which others continue to be dismissed today—evokes the ugly racial history of death investigation in the U.S., one in which clear lynchings were classified as “undetermined,” “accidental,” “suicide,” or “natural causes,” rulings that foreclosed any further criminal investigation.
When I first saw the coroner’s report speculating that Elijah McClain’s death might have been caused by an “undiagnosed mental illness,” I recalled a particularly chilling quote from one of those cases, which a young Black woman gave to the journalist John Howard Griffith back in 1954. “We couldn’t even count the bullet holes in my brother’s head,” she said. “But they called it heart failure.”