Manner of Death

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.