Assignment
of a manner of death is also a required part of the death certification
process.
Ostensibly, this is an attempt to classify the death as to the
circumstances
by which death came about; unfortunately, this classification
is often
problematic. There are five classical manner of death categories.21
•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
from
traumatic 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.
Some
jurisdictions also add additional categories, such as unclassified,
therapeutic
misadventure, etc., but these are not universal. The idea of a
manner of
death classification is an American invention,31 and the manner
of death
categories available for use in death certification are promulgated by
state vital
records departments. Physicians, medical examiners, and coroners
are bound to
and limited by these available choices.
The problem
with manner of death classification is that the “pigeonholing”
of complex
and disparate deaths into one of five (actually four) categories
is fraught
with problems. One difficulty in reproducibly assigning an
appropriate
manner of death category is the lack of agreement on definitions
for the
classification terms. The brief definitions listed above are quite rudimentary
and broad, and are subject to considerable and
substantive variationin various
jurisdictions. For example, a homicide is generally considered to
be a death
at the hands of another person, whereas suicide is death at one’s
own hands.
Yet a death due to a motor vehicle crash is generally classified
as an
accident, regardless of whether one or both of the drivers were at fault
or caused
the crash. If a hunter fires at a target he believes to be a deer, but
inadvertently
kills another hunter, many MEs will classify this death as a
homicide,
since the rifle was purposely fired at a target, which was struck and killed.
Others would consider it to be an accidental death since the
hunter did
not intend to kill a human being. Some jurisdictions require that
intent to
cause one’s own death be a factor in classifying a death as suicide.
Others
require only that the act leading to death be intentional, regardless
of whether
or not death was anticipated. For example, if a person is playing
Russian
roulette with a partially loaded revolver and dies of a gunshot
wound of the
head, many MEs would classify this as a suicide, without consideration
of whether
or not the player actually intended to die, or just was
engaging in
thoughtless, extremely risky behavior. Others would agree that
the death
represents a suicide, but largely because of the high inherent risk of
the
activity. Deaths due to acute intoxication by ethanol or other drugs are
usually
classified as accidents unless suicidal intent is evident. But deaths due
to the
chronic effects of the same drugs (cirrhosis, endocarditis, etc.) are typically
classified
as natural deaths. These are but a few of the inconsistencies
and
disagreements that may plague a manner of death determination.