Monday, October 17, 2016

Mind Your Manners: Where Death Certification Ends and Prevention Begins

This article was originally published in Forensic Magazine. To read the original article click here (

The police pick up a 45 year old man, a robbery convict, for speeding. The arrest is a parole violation. The man has a history of smoking and substance abuse, and is obese. On his third day back in jail, he refuses to cooperate during a routine search of his cell. The corrections officers address this behavior problem by strapping the man into a restraint chair for several hours until he calms down. After he is released, he immediately starts a fight with another inmate. Once again the guards strap him into the restraint chair, for several more hours, until he is compliant. The man goes back in the chair twice more over the course of the next four days. After the final time, he stands up—and then, without a word, collapses. He's lying on the floor of the jail, unconscious. He is not breathing. The guards initiate CPR immediately, but after a few minutes the man is still not breathing and no longer has a pulse. The guards continue CPR until paramedics arrive ten minutes after the man's collapse. The medics declare him dead.

The forensic pathologist conducting the autopsy finds that the man has a large saddle pulmonary embolus and blood clots in both legs associated with the strap marks from the restraint chair. The cause of death is clear—pulmonary embolus. What's the manner, though? A blood clot traveled from the man's legs to his lungs. Obese smokers commonly develop dangerous blood clots, so should this be certified as natural? The man had been immobilized and showed signs of injury on his legs from the restraint straps, so is this death an accident? But, wait—his immobilization was forced. He had been restrained and injured at the hands of the guards. This prisoner's death should be a homicide. How about undetermined? Suicide is the only manner of death we would categorically discount.

Medical examiners and coroners agonize over manner of death all the time, and for good reason. The cause of death, the disease or injury leading to the lethal event, may be patently clear, but it's the manner of death that the family hears and that the press pounces on. Call an in-custody death such as this one a homicide, and the media will immediately pronounce that the police killed the inmate, even if the corrections officers were only following their training and jail protocol. Call an in-custody death accident or natural, and you might be accused of a cover up. Call it undetermined (a way of saying the death doesn't fully categorize into one manner or another) and no one is happy: You get branded as either unscientific or indecisive. Or both.

What is manner of death? It's a required part of the death certificate, a system of classification most often used for data analysis in the realms of public health and academic research. Every time you read an article that contains information about the ways people die, or compares types of deaths across geographic regions, the researchers likely started their analysis with publicly-available death certificate data, sorted by manner of death.

But manner of death has a social function as well, because, like it or not, we attach different moral value to different ways of dying, even when the mechanism is the same. In my experience, families who have lost a loved-one to a drug overdose don't object to the determination that the cause of death was by acute mixed drug intoxication as much as they object to my manner ruling that the overdose was an accident or a suicide, in some cases because of religious prohibitions against suicide. One Pennsylvania coroner has been in the news lately for classifying overdoses of illegal drugs as homicides, so that the drug dealers will be prosecuted for murder, even if the user injected the drugs himself in order to get high. Sounds like a good idea, right? Drugs are illegal and the dealers should be punished. The problem is, such an approach conflates the duties of scientific death classification with those of law enforcement. Our job is statistical and unbiased, and we need a uniform classification system in order to understand how people die in the real world, and to study regional differences. Coroners in jurisdictions surrounding this Pennsylvania county have avoided following suit with this reclassification of manner in drug deaths.

We in the forensic sciences must work to communicate with the police, the families of decedents, and with the public at large about the different manners of death, about the national standards used in classifying deaths, and about our decision-making process in arriving at a conclusion in each individual case. We must do so as part of our professional duty to public health in seeking to reduce our national burden of avoidable deaths. We spend a lot of time agonizing about the manner—but the determination of manner doesn't matter if we don't then do something to counsel the decedent's family, to explain what happened to the public, and to prevent this from happening again, if what happened was at all preventable.

Some jurisdictions will call our hypothetical case study of the prisoner with the embolus a homicide. Others might call it an accident. A few might even decide this was a natural death. Regardless, they will all be remiss if they stop with cause and manner. We coroners and medical examiners have an ethical duty to do more than just check a box on a death certificate and wait for the inevitable lawsuit. We have a duty to reach out to those in power to change the lethal environment by educating the jail staff and the corrections department managers who write the policies and procedures. If we don't reach out to other professionals in other county agencies, one man's avoidable death will repeat with others under similar circumstances. If we don't publicize it in the press, how will others learn from our experiences and adjust their policies accordingly, before the next death? The next time it happens, what will you do about it? Will you call it another homicide, another accident, another natural death? Whatever your answer, you will have a harder time explaining why another such corpse has come to a slab in the morgue, and why you didn't do anything to stop it getting there. We forensic pathologists are physicians working in the realm of public health. Our job—our duty—does not end with the death certificate.