Death Certification
A majorcommon denominator in any modern death investigation system is thedocumentation of death and the determination of its cause and manner, alsoreferred to as death certification. In early times, records of birth and deathwere kept inconsistently, if at all, but in 1538, clergy in England were required to keep aledger of births, deaths, and marriages in their parishes.
This customof registration persisted for many years, but gradually became a function of governmentsinstead of the church. This change was given further impetus during infectiousepidemics of the nineteenth century, when it came to be appreciated that itwould be worthwhile to keep track of the numbers of deaths occurring as aninfectious contagion progressed.
Subsequently,governments around the world began to require registration and certification ofbirths and deaths. Modern death certification is a function of state governments,and all jurisdictions in the UnitedStates have a common requirement that thedeath of a person be officially documented, with attestation of the cause andmanner of death by a physician, medical examiner, coroner, or other official. Thedocument serving this purpose is referred to as a death certificate, and requirementsregarding its use and fling are setforth by a state department of health, vital records, or equivalent.
State deathcertificates tend to be fairly similar, as most are based on the U.S. Standard Certificateof Death, which is in turn based on World Health Organization recommendations.
Many statesare also moving toward a standardized digital death registration process thatpromises to make gathering of demographic and epidemiologic data much simplerand more effective.
The reasonsfor death certification and investigation are several. First, as has been notedabove, a developed society has an interest in documenting the birth and deathof its citizenry in order to provide for transfer of estates, administration ofsocietal programs, payment of insurance settlements, etc.
The trackingof deaths from an epidemiologic viewpoint allows for better public healthsurveillance in a society, be it related to epidemic diseases or public safetyissues. As all purveyors of television crime dramas are well aware, adequate deathinvestigation and certification is required for the criminal prosecution ofdeaths due to the action or inaction of another person or institution. And finally, knowledge of the cause and manner of death is oftenof importance in allowing appropriate grieving and closure for the family andloved ones of a decedent.
In mostjurisdictions, deaths occurring solely by natural means may be certified byattending physicians. However, deaths due to trauma, intoxication, or unknown meansusually fall under the jurisdiction of the medical examiner or coroner, andmust be investigated and certified by that office.
In additionto the demographic documentation related to the decedent, such offices mustalso attempt to determine the cause and manner of death.
Cause of Death
Cause ofdeath is a concept applied somewhat more strictly and precisely by the medicalexaminer than by other physicians or the lay public.
A number ofdefinitions of this term have been devised, but a simple one favored by theauthor is “that disease, injury or event, but for which death would not haveoccurred at the time it did.” In death certification, the first insult thatbegins a cascading series of events leading to death is of primary interest.Tis is referred to as the cause of death, or as the proximate cause of death. Thisis in distinction to the subsequent resultant physiologic derangements causedby this event. These derangements are often referred to as mechanisms of deathor the immediate causes of death.
Forexample, suppose an individual receives a gunshot wound that injures the spinalcord and renders the victim quadriplegic. If, years later, he or she succumbsto a urinary tract infection related to the paralytic bladder caused by thespinal cord injury, the cause of death should be appropriately certified as a“gunshot wound of the back,” or “urosepsis complicating quadriplegia due togunshot wound of back.” Many physicians, however, would inappropriately listthe cause of death as “urinary tract infection” (a mechanism of death) withoutreferencing the true cause of the condition, the gunshot wound. The reasons forthis are readily apparent, as most clinical physicians are concerned withdiagnosing and treating acute conditions that can be ameliorated by medical orsurgical therapy. The medical examiner, however, recognizes that the purpose ofdeath certification is to provide statistical information on primary causes ofdeath, and that the lapse of time between injury and death is of no importancein this documentation.
Often thecause of death cannot be arrived at by examination of the remains of thedecedent. Just as a clinical physician must take a medical history prior toperforming a physical examination, the medical examiner must have investigativeinformation regarding the circumstances of death prior to reaching aconclusion. Review of past medical history, consideration of the presentationof the decedent at the time of death (sudden collapse, complaints of symptoms),and other factors are of equal importance to the autopsy and other examinationtechniques. It is for this reason that an adequate investigative team isrequired to assist the medical examiner in gathering initial and follow-upinformation.
Forensicpathology, like any field in medicine, is not an exact science.
There aredegrees of uncertainty in any cause of death determination, and the degree of likelihoodnecessary to make a cause of death statement varies from case to case. It is amatter requiring considerable professional judgment and experience, and is verydifficult to quantify in most cases. The phrase “beyond a reasonable doubt” isa legal term referring to conclusions by a criminal trial judge or jury, but ithas no place in the lexicon of the forensic pathologist. Instead, medicalexaminers are often asked to render their opinions to a “reasonable degree ofmedical probability.” Tough even this phrase is somewhat nebulous, it does atleast recognize that medical determinations invariably involve some degree ofuncertainty. It is important to realize that cause of death statements by amedical examiner are opinions, resulting from consideration of myriad differentfactors and observations, generation of a differential list of potentiallyfatal conditions or injuries, and selection of the most likely candidate(s) forcause of death from that list. When explaining this opinion to attorneys,families, juries, or any other group, the forensic
pathologistmust make every effort to convey any degree of uncertainty, to acknowledgeother possible opinions, and to explain his or her rationale for selecting oneover another. To simply state an opinion dogmatically, leaving no room forcompeting theories or argument, is incompatible with honest forensic medicalpractice. This is perhaps best summarized in a well-known statement by Dr. PaulBrouardel, a French physician of the lathe nineteenth century: “If the law hasmade you a witness, remain a man of science.
You have novictim to avenge, no guilty or innocent person to ruin or save.
You mustbear witness within the limits of science.” These “limits of science,” and theapplication of various types of decision-making tools to forensic sciences,would form the basis for a long discussion far beyond the scope of this chapter.However, it is incumbent on every practitioner to understand the limitations,degrees of uncertainty, and sometimes ambiguity of medicolegal opinions and toreadily acknowledge them when appropriate.
Sometimes acause of death cannot be determined to a reasonable degree of probability. Thismay reflect the fact that multiple possible causes of death are present, andone cannot readily be chosen over another. It may also reflect the fact thatnot every fatal condition has accompanying anatomic changes that can bediscovered on autopsy examination. The human body is in fact an electrochemicalmechanism, and many fatal physiological processes are not associated withdemonstrable anatomic alterations. When these processes cannot be inferred fromhistorical or investigative information, the cause of death may remainundetermined. It is the mark of a good forensic pathologist that thisconclusion is invoked whenever appropriate, without the attempt to form anunsupportable cause of death conclusion.
Mannerof Death
Assignmentof a manner of death is also a required part of the death certificationprocess. Ostensibly, this is an attempt to classify the death as to thecircumstances by which death came about; unfortunately, this classification is oftenproblematic. There are five classical manner of death categories.
Homicide:Death caused by the intentional actions of another person.
Suicide:Connotes a death due to one’s own intentional acts.
Natural:Death due to natural disease processes only, with no contribution fromtraumatic or external factors.
Accident:Death due to unforeseen traumatic or external factors.
Undetermined:The manner of death is not known or could not be determined.
Somejurisdictions also add additional categories, such as unclassified, therapeuticmisadventure, etc., but these are not universal. The idea of a manner of death classificationis an American invention, and the manner of death categories available for usein death certification are promulgated by state vital records departments.Physicians, medical examiners, and coroners are boundto and limited by these available choices.
The problemwith manner of death classification is that the “pigeonholing” of complex and disparatedeaths into one of five (actually four) categories is fraught with problems.One difficulty in reproducibly assigning an appropriate manner of deathcategory is the lack of agreement on definitions for the classification terms. Thebrief definitions listed above are quite rudimentary and broad, and are subjectto considerable and substantive variation in various jurisdictions. Forexample, a homicide is generally considered to be a death at the hands ofanother person, whereas suicide is death at one’s own hands. Yet a death due toa motor vehicle crash is generally classified as an accident, regardless ofwhether one or both of the drivers were at fault or caused the crash. If ahunter fires at a target he believes to be a deer, but inadvertently killsanother hunter, many MEs will classify this death as a homicide, since the rifewas purposely fired at a target, which was struck and killed. Others wouldconsider it to be an accidental death since the hunter did not intend to kill ahuman being. Some jurisdictions require that intent to cause one’s own death bea factor in classifying a death as suicide.
Othersrequire only that the act leading to death be intentional, regardless ofwhether or not death was anticipated. For example, if a person is playingRussian roulette with a partially loaded revolver and dies of a gunshot woundof the head, many MEs would classify this as a suicide, without considerationof whether or not the player actually intended to die, or just was engaging inthoughtless, extremely risky behavior. Others would agree that the deathrepresents a suicide, but largely because of the high inherent risk of theactivity. Deaths due to acute intoxication by ethanol or other drugs areusually classified as accidents unless suicidal intent is evident. But deathsdue to the chronic effects of the same drugs (cirrhosis, endocarditic, etc.)are typically classified as natural deaths. These are but a few of theinconsistencies and disagreements that may plague a manner of deathdetermination.
As ademonstration of this point, a survey consisting of twenty-three separate andvaried medical examiner case scenarios was sent to members of the NationalAssociation of Medical Examiners (NAME) in 1995.
The surveypresented the cases and asked the respondents to answer a variety of questions,particularly relating to manner of death determination.
Subsequently,a panel discussion was convened at a meeting of the National Association ofMedical Examiners in 1996 inwhich five well-known and respected forensic pathologists discussed theiropinions of the cases. The degree of discordance was striking in both thesurvey and the subsequent panel discussion. Complete agreement was reached inonly one case, and in some cases,the level of disagreement was such that no majority opinion was identified. Itis a fact that highly trained and experienced MEs frequently disagree on mannerof death classification. Tough it may be assumed that the use of a particularmanner of death classification schema is based on consistent scientificprinciples, it is in fact based more on local tradition and habit, and nationalconsistency has proven to be an elusive goal.
Anotherfactor causing difficulty in producing consistent manner of death classificationsis the exceptional complexity of various death processes. Each case is quite unique,with many facets of the death process being unknown, partially known, or merelyinferred. In such cases, it is extra ordinarily difficult to distill thiscomplexity into one of four or five categories, and if it can be done, some wouldconsider it to be of little practical use. After all, categorizing disparate anddissimilar types of deaths together into overly broad and artificial categoriesseems to be of questionable value.
In anattempt to better define the various manner of death categories, NAME publisheda booklet giving guidelines for death classification in 2003.
Itsmethodology has not, however, become universally adopted at this time, andvariations in manner of death classification continue to abound.
It is oftenthought by uninformed individuals that a medical examiner’s assignment ofmanner of death forms the basis for prosecution of crimes, insurancesettlements, and other legal matters. In fact, however, the manner of death classificationput forth by the medical examiner is not a legal opinion or criminal charge,nor is it binding to parties in civil disputes. It is, instead, a classificationscheme for use by state vital records agencies charged with gleaningepidemiologic data from death certificates. By way of illustration, considerthat if a driver causes a collision by virtue of his recklessness orintoxication, he may be prosecuted for manslaughter even though the medicalexaminer classifies the death as an accident. Conversely, if a police officershoots and kills a weapon-wielding felon, it will generally be classified as ahomicide by the medical examiner. But if the shooting is considered justifiable,no charges of murder or manslaughter may be brought against the officer. The beliefthat the medical examiner assigns criminal culpability when classifying mannerof death is incorrect, but it is often a source of misunderstanding. Because ofthese inconsistencies in the classical manner of death classification, someexperts would prefer to delete this system in favor of a greatly expanded andmore useful list of manner of death choices, or a more detailed and flexiblenarrative statement giving sufficient information so that the events of a deathare clear to those perusing the death certificate. However, since death certificationis driven by agencies other than medical examiners or coroners, the statutorilyprescribed manner of death classification scheme must be utilized. Itsshortcomings can be somewhat ameliorated if the forensic pathologist provides sufficientnarrative detail in the autopsy or investigation reports to clearly define thecircumstances of death to the extent that they are known, in spite of thelimitations of the concept of manner of death.
