Failure to Autopsy: The Otto Warmbier Case

Abstract

Coroner and medical examiner offi ces are charged with the medicolegal investigation of deaths to determine the cause and manner of death. We describe the recent high-profi le case of Otto Warmbier, who tragically died shortly after his return in a coma from North Korea and in which the coroner failed to conduct a complete autopsy, and failed to satisfy the needs of the local, national, and international communities.Medico legal death investigation offi ces, including both medical examiner and coroner offi ces, have a legal responsibility and duty to investigate deaths in the public interest for public safety and public health purposes. Although, they serve the families of the deceased as they can, their raison d'être and priority is service to the greater public good. Thus, they may conduct investigations and even autopsies over the objections of the nextof-kin. Full investigations include a complete forensic autopsy. The utilitarian public interest should, within the constraints of the offi ce resources, drive the decision of whether to autopsy or not. Failure to autopsy can sometimes constitute a breach of faith that the public entrusts in these offi ces. Empirically, this seems to be a greater problem in coroner jurisdictions than in medical examiner offi ces. Specifi cally, we believe the recent case of Otto Warmbier is such a case.