Two of the most important functions of the medical examiner's or coroner's office are the determination of the cause and manner of death. Clinicians, lawyers, and the lay public often have difficulty understanding the difference between cause of death, mechanism of death, and manner of death. Simply put, the cause of death is any injury or disease that produces a physiological derangement in the body that results in the death of the individual. Thus, although differing widely, the following are causes of death: a gunshot wound to the head, a stab wound to the chest, adenocarcinoma of the lung, and coronary atherosclerosis.
The mechanism of death is the physiological derangement produced by the cause of death that results in death. Examples of mechanism of death would be hemorrhage, septicemia, and cardiac arrhythmia. One must realize that a particular mechanism of death can be produced by multiple causes of death and vice versa. Thus, if an individual dies of massive hemorrhage, it can be produced by a gunshot wound, a stab wound, a malignant tumor of the lung eroding into a blood vessel and so forth. The reverse of this is that a cause of death, for example, a gunshot wound of the abdomen, can result in many possible mechanisms of death, e.g. hemorrhage or peritonitis.
Medical examiners often have to review death certificates produced by clinicians. Not infrequently, the cause of death is listed as "cardiac arrest" or "cardiopulmonary arrest." Simply stated, this means that the heart stopped or the heart and lungs stopped. Experience tells us, however, that when any individual dies, the heart and lungs stop. These are not causes of death and, to a degree, are not even mechanisms of death. Yet, clinicians continue to list these diagnoses on the death certificate, and some government organizations accept them as causes of death.
The manner of death explains how the cause of death came about. Manners of death can generally be categorized as natural, homicide, suicide, accident, or undetermined. The authors also use the category "unclassified." Just as a mechanism of death can have many causes and a cause many mechanisms, a cause of death can have multiple manners. An individual can die of massive hemorrhage (the mechanism of death) due to a gunshot wound to the heart (the cause of death), with the manner of death being homicide (somebody shot the individual), suicide (they shot themselves), accident (the weapon fell and discharged), or undetermined (one is not sure what occurred).
The manner of death as determined by the forensic pathologist is an opinion based on the known facts concerning the circumstances leading up to and surrounding the death, in conjunction with the findings at autopsy and the laboratory tests. The autopsy findings may contradict or agree with the account of how the death occurred. Thus, if the story is that an individual shot himself and the autopsy reveals a gunshot wound to the back inflicted from a distance, obviously the account is incorrect. If, however, it is a contact gunshot wound of the temple, then the autopsy findings are consistent with the account. It must be realized that the manner of death can be changed if subsequent information that alters the circumstances surrounding the death is discovered. Thus, if we have an individual found with a contact gunshot wound to the temple, with no weapon present and no history of any suicidal threats, one might then conclude that this case is a homicide. If, subsequently, it turns out that the individual had embezzled half a million dollars from his company and was about to be indicted by the grand jury, and his body was found by his wife, who removed a gun and suicide note from the scene, the cause of death would be changed to suicide.
Just because a forensic pathologist makes a ruling as to the manner of death does not mean that it will be accepted by either families or other agencies. The author has ruled homicide in a number of cases that police agencies have written off as accidents. Sometimes, families will challenge a ruling and go to court to have the manner of death overturned. In most instances, the court will support the medical examiner. The medical examiner should not be upset if the court comes to a different ruling as to manner of death, because juries, especially in cases of suicide, are notoriously not impartial or objective. Thus, if a widow, challenging a medical examiner's ruling of suicide so that she can collect insurance, brings two or three young children to the trial, it would not be surprising if the jury should decide to rule the death an accident, no matter how much objective evidence had been presented to the contrary. Their reasoning is that the widow needs money and the insurance company has plenty of it.
Occasionally, there are cases in which the cause of death would ordinarily be considered natural, but the manner is homicide. Thus, we have the homeowner who surprises a burglar, engages him in a violent struggle, then collapses and dies of a heart attack. The mechanism of death is a cardiac arrhythmia and the cause of death is severe coronary atherosclerosis, but the manner of death is homicide, in that the arrhythmia was brought on or precipitated by the struggle. Some individuals will rule a case a homicide even if there is no physical struggle, just sufficient psychological stress to have precipitated the arrhythmia and death. This is very controversial.
In one case, what would ordinarily be considered a natural death based on cause of death was classified as a suicide. An elderly woman attempted to commit suicide by stabbing herself. She used a dull kitchen knife and could not break the skin. She then picked up a hammer and struck herself two or three times on the head, producing some minor contusions of the scalp. The stress of the attempted suicide precipitated a fatal cardiac arrhythmia due to severe coronary atherosclerosis. One of the authors ruled the cause of death to be coronary atherosclerosis and the manner suicide. Her family initially challenged this ruling. When the reasoning for the ruling was explained to them, much to the author's surprise, the family agreed that it was suicide. In another case, a young woman stood at the end of a pier, placed a gun to her chest, and pulled the trigger. The bullet struck her in the chest and she fell backward into the harbor. Her body was subsequently pulled out of the water by a police boat. At autopsy, she had a through-and-through gunshot wound of the left breast, with the bullet producing only soft tissue injury and not entering the chest cavity. The actual cause of death was drowning. The manner of death was ruled as suicide.
A manner of death is ruled undetermined when there is insufficient information about the circumstances surrounding the death to make a ruling, or, in some instances, when the cause of death is unknown. Thus, if one finds the skeletonized remains of a young adult male without evidence of trauma, one cannot say whether the manner of death was accident, homicide, or suicide, because the cause of death is not known. In other instances, there may be insufficient information concerning the circumstances surrounding the death to explain the manner of death. This situation often occurs in deaths due to drug overdoses. Thus, an individual dies as a result of an overdose of a central nervous system depressant drug. The individual has a long history of overmedicating, but, at the same time, has a history of attempted suicide. Is this a case of suicide or did the individual just take too much medication inadvertently, because that was his or her normal habit? Sometimes it is possible to differentiate on the basis of the metabolites of the drug present. Sometimes it is not.
An individual was found with a head injury, obviously due to a fall on the back of the head. There was suspicion, however, that the individual had been in a fight. Toxicological analysis revealed the deceased was intoxicated. Was there a fight and the individual was struck, fell backward, and hit his head, making the case a homicide? Or was there a fight in which the individual was not injured, walked away, and, while intoxicated, fell backward, striking his head, making the death an accident?
In some instances, based on the circumstances surrounding a death, a ruling as to the manner of death can be made without a cause of death. Thus, the decomposing body of a 32-year-old female was found in a ditch two miles from her burglarized house. She was clad in pajamas, barefoot (with the soles of her feet clean), and her hands were bound behind her back. An autopsy failed to reveal a cause of death. The cause of death was ruled undetermined; the manner homicide. The ruling as to manner was based on the circumstances surrounding the death and not the autopsy findings. In the autopsy report, it was suggested that she had either been strangled or smothered. The perpetrator was subsequently arrested and confessed to smothering her.
In addition to the usual classifications of manners of death, some forensic pathologists, ourselves included, use the term "unclassified." This refers to a death in which the cause and circumstances are known, but the death does not readily fall into any of the aforementioned categories. An example is the case of a woman who came into the hospital for an abortion. A hypertonic saline solution was injected; the woman went into labor and delivered a live 450-g infant. There were chemical bums of the skin due to the hypertonic saline solution. The child survived an hour and a half without mechanical assistance, then died. The death was obviously not a suicide, but was it a natural death, an accident, or a homicide? You can propose valid arguments for all three rulings. The manner of death was ruled unclassified. The authors also place in the unclassified category cases that some individuals call medical misadventure. Thus, a case of a perforated heart due to an intravascular catheter, and an air embolism complicating spinal fusion are classified as unclassified.
One must also understand that sometimes the classification of manner of death is based on tradition. Thus, if two people are "kidding around" with a gun and one individual points the gun at another and pulls the trigger, in some localities, this is classified as an accident, in others, as a homicide. An individual walking down the street is hit by an automobile; the driver stops. This is an accident. If the driver continues on his way, in a number of jurisdictions, this is classified as a homicide. If one drinks too much alcohol and dies of acute alcohol intoxication, this is an accident. If one drinks too much alcohol every day for 15 years and develops cirrhosis of the liver and chronic liver failure due to the alcohol, then the manner of death is classified as natural.
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