“We (medical examiners) certify on the basis of our own training, personal philosophy and mood,” wrote one of my colleagues during a contentious online debate about the “correct” manner of death classification for a complex case.
“To others outside our community, we appear not to know what we are doing, because we come to different conclusions for the same set of facts,” he concluded.
The source of the controversy was the death of a 38-year-old man, an “avid swimmer,” who had developed seizures after an unsuccessful suicidal gunshot wound to the head 18 years before he died.
This man was last seen swimming in “shallow water” in the Gulf of Mexico. “A few minutes later,” another swimmer found him floating face down and unresponsive.
All autopsy findings were consistent with drowning. No other potential cause of death – heart disease, for example – was found. There’s no way for an autopsy to determine if he’d had a seizure.
Investigators learned that the dead man hadn’t been suicidal in years. He’d suffered a witnessed seizure three days before his death.
Medical examiners base manner of death – natural, accident, suicide or homicide – on the proximate cause of death. We agree that the proximate cause is the disease or injury that initiates a chain of events, brief or prolonged, that leads to death. There’s no statute of limitations.
We apply the “but for” approach: “But for event A, events B, C, D, etc. would not have occurred.”
A majority of my colleagues were comfortable making the assumption that a seizure precipitated this drowning. Given that assumption, “but for” the self-inflicted gunshot wound, the seizure wouldn’t have occurred. “But for” the seizure, the man wouldn’t have drowned.
Because a suicidal gunshot wound initiated the chain of events leading to death, suicide would be the proper classification, some participants in the discussion thought. They weren’t bothered by the lack of current suicidal intent.
Others disagreed. They said since the man wasn’t suicidal when he died, it would be better to certify the death an accident. A determination of suicide would be unnecessarily upsetting for the family.
These folks admitted their reasoning lacked consistency, as they would use “but for” reasoning to certify the death a homicide if somebody else had fired the shot.
Some of my colleagues firmly sat the fence. They said a good argument could be made for either certification and declined to state what they’d actually do if presented with a similar case.
As my medical school professor said, “Hard cases are hard.”
Is it reasonable to base certification on an act committed half a lifetime ago and in another state of mind?
Should consistency be sacrificed for a family’s comfort?
Is it fair to ignore “but for” reasoning for delayed consequences of a suicidal gunshot wound but invoke “but for” reasoning with reasonable medical certainty if somebody else pulled the trigger?
When it’s a tough call, should “undetermined” always be the default certification?
It depends on your training, personal philosophy and mood.
chuser@durangoherald.com Dr. Carol J. Huser, a forensic pathologist, served as La Plata County coroner from 2003 to 2012. She now lives in Florida and Maryland.
