Cause of Death

Cause of death is a concept applied somewhat more strictly and precisely by

the medical examiner than by other physicians or the lay public.21 A number

of definitions of this term have been devised, but a simple one favored by the

author is “that disease, injury or event, but for which death would not have

occurred at the time it did.” In death certification, the first insult that begins

a cascading series of events leading to death is of primary interest. This is

referred to as the cause of death, or as the proximate cause of death. This is in

distinction to the subsequent resultant physiologic derangements caused by

this event. These derangements are often referred to as mechanisms of death

or the immediate causes of death.

For example, suppose an individual receives a gunshot wound that

injures the spinal cord and renders the victim quadriplegic. If, years later, he

or she succumbs to a urinary tract infection related to the paralytic bladder

caused by the spinal cord injury, the cause of death should be appropriately

certified as a “gunshot wound of the back,” or “urosepsis complicating

quadriplegia due to gunshot wound of back.” Many physicians, however,

would inappropriately list the cause of death as “urinary tract infection”

(a mechanism of death) without referencing the true cause of the condition,

the gunshot wound. The reasons for this are readily apparent, as most clinical

physicians are concerned with diagnosing and treating acute conditions that can be ameliorated by medical or surgical therapy. The medical examiner,

however, recognizes that the purpose of death certification is to provide statistical

information on primary causes of death, and that the lapse of time

between injury and death is of no importance in this documentation. 

Death Certification

A major common denominator in any modern death investigation system is

the documentation of death and the determination of its cause and manner,

also referred to as death certification. In early times, records of birth and

death were kept inconsistently, if at all, but in 1538, clergy in England were A major common denominator in any modern death investigation system is

the documentation of death and the determination of its cause and manner,

also referred to as death certification. In early times, records of birth and

death were kept inconsistently, if at all, but in 1538, clergy in England were death investigation systems

 function of governments instead of the church. This change was given further

 impetus during infectious epidemics of the nineteenth century, when it came

to be appreciated that it would be worthwhile to keep track of the numbers

of deaths occurring as an infectious contagion progressed.18 Subsequently,

governments around the world began to require registration and certification

of births and deaths. Modern death certification is a function of state

governments, and all jurisdictions in the United States have a common

requirement that the death of a person be officially documented, with attestation

of the cause and manner of death by a physician, medical examiner,

coroner, or other official. The document serving this purpose is referred to as

a death certificate, and requirements regarding its use and filing are set forth

by a state department of health, vital records, or equivalent.28 State deathcertificates tend to be fairly similar, as most are based on the U.S. Standard

Certificate of Death, which is in turn based on World Health Organization

recommendations. A typical state death certificate is shown in Table 4.2.

Many states are also moving toward a standardized digital death registration

process that promises to make gathering of demographic and epidemiologic

data much simpler and more effective. 

Modern American Death Investigation Systems

As will be seen subsequently, the systems of death investigation in the United

States are widely varied. However, they generally share a number of mission

components in common. To paraphrase DiMaio and DiMaio,21 the various

components of a death investigation system are as follows:

1. Determine the cause of death, and how the death came about

2. Identify the decedent

3. Determine the time of death and injury

4. Collect evidence from the body that may be useful in the police

investigation

5. Document injuries that are present, or their absence

6. Deduce how injuries occurred

7. Document any natural disease present

8. Document or exclude any causative or contributory factors in the death

9. Provide testimony in court as needed

In spite of the widespread distribution and long history of the office of

the coroner, as medical science and the understanding of death have become

more complex, shortcomings of the system have became apparent. Most

obvious is the fact that most coroner jurisdictions do not require a coroner

to be a physician. Obviously, a nonphysician is in a poor position to render

a medical opinion on the cause of death, a determination that is manifestly

the practice of medicine. The likelihood of omissions or misinterpretations is

increased in such jurisdictions where the responsibility for this duty is vested

in someone other than a trained physician. Second, coroners are elected

officials in the United States. The necessity of maintaining public electoral

support has long been considered a potential impediment to the development

and maintenance of absolute impartiality in death investigation by coroners.

Death investigators must often make very hard and controversial decisions

that are difficult for families, local political forces, and others to accept. In

theory, at least, an appointed official, as opposed to an elected one, can make

such decisions without the fear of alienating a voting block necessary for his

or her continued employment in the position.

Proponents of the coroner system respond that the nonmedical coroner

functions as an administrator and quasi-judicial agent, and can employ physicians

to perform examinations and make medical decisions under his or

her directions. However, since the coroner retains ultimate authority for the

investigation and determination of the circumstances and cause of death,

the possibility that such an individual will exercise that authority to veto or

influence the medical decision of an employed physician still remains. Some

coroner proponents also point to the greater political authority of an elected

death investigation systems 

The Coroner System

Though the cause of death was undoubtedly investigated in ancient times,

it was likely an ancillary duty of tribal elders, magistrates, priests, or other

authorities. The first instance of an official office charged with the investigation of death, as we know it today, was probably the English coroner.

Though officials with this responsibility are reported as far back as 871 A.D.,

in the time of Alfred the Great, the beginning of the coroner system in

England is generally taken to have been in 1194, with the publication of

the Articles of Eyre, the Eyre being a system of roving “circuit” justices in

England in the twelfth century. These itenerant judges traversed the land to

hear cases and dispense justice, but due to the long intervals between their

visits (an average of seven years), it was necessary to have local officials

perform careful investigations and keep records of offenses so that the cases

could effectively be brought before the justices when they finally did arrive.

Without proper records, many cases were never tried. This would not do, as

many of them involved production of revenues for the monarch, at that time

Richard the Lionhearted. Richard, a Norman king, was an absentee ruler

with a penchant for expensive foreign wars that placed a heavy strain on the

royal coffers. In addition to his travels and the need to equip large numbers

of troops, he also managed to become captured and imprisoned in Germany

during his return from the Holy Land in 1192. A huge ransom was required

to secure his release and return to England in 1194. These expenses created

an acute need for revenues, so no stone was left unturned in a desire to collect

all taxes and other dues to which the Crown was entitled under the law. There

were many such assessments, creatively applied in the name of law and order,

to enrich the king at the expense of his subjects.

It was customary at that time to seize the property of felons, and because

suicide was considered a crime against God, the property of those taking

their own lives was also forfeited to the Crown. Furthermore, villages were

penalized with a fine, or amercement, whenever a murder or other legal

infraction occurred in their jurisdictions, a punishment for allowing civil

disturbances to occur or for not properly following the complex system of

laws in the realm. Sometimes the victims of these murders were members of

the conquering Norman class who were unfortunate enough to find themselves

in the midst of local Saxons bent on revenge. To prevent having large

numbers of its Norman noblemen dispatched by the indigenous population,

the Crown levied a fine known as the lex murdrorum on the lord of any village

or territory in which a Norman was killed. And naturally this fine was passed

on to the populace in the form of a tax. Even the object actually causing a

death (referred to as a deodand) was subject to presentation to the Eyre, and

it could be confiscated in the name of the Crown because of its culpability in

the death or injury of a person. So if a person were injured or killed by a cart,

animal, or farm implement, this item would likely be appropriated by the

court, possibly depriving a farmer of the means of his livelihood. 

Early Death Investigation

The most primitive societies likely had a well-developed sense of the causative

relationship of trauma, old age, and illness to death, and early “investigations”occurred even in tribal societies to determine why a member of the family

group had died, though they were more likely to invoke superstition or

magical thinking instead of the “rational” methods employed by modern

societies.2–4 Early Mesopotamian civilizations, and those of ancient Egypt,

Greece, and India, had well-developed legal codes (the earliest being the Code

of Hammurabi, 2200 B.C.), and these laws often referenced medical issues,

such as duties of physicians, allowable fees, the viability of the fetus, and discussions

of injuries. These cultures also had well-developed medical systems,

but there is little or no reference in their extant writings to suggest that medical

practitioners were regularly involved in the investigation of death. Rather,

common sense and experience were applied by various officials, magistrates,

or priests in an attempt to explain why and how individuals died. Some of the

earliest death investigations probably involved deaths due to suicide, which

most societies have considered to be an unacceptable act for religious or

superstitious reasons.5 Taking one’s own life might result in denial of funeral

rites, reprisals against the decedent’s family, or other penalties, so a rudimentary

death investigation was necessary in such cases to determine if a death

was self-inflicted.

The earliest written documentation specifically related to formal death

investigation has been discovered in archaeological excavations in China.6

Here, bamboo strips unearthed and dated from the period of the Ch’in

Dynasty (221–207 B.C.) have been found inscribed with writings giving

instructions to civil servants charged with the examination of corpses who

died under suspicious circumstances.

Death investigation in ancient Athens was largely a private matter instead

of a concern of the state.7 As such, investigations by a governing body were

not consistent, and Greek physicians were apparently not involved in certification

or investigation of death, though there are reported instances of their

testimony in legal proceedings involving injury. 

Death Investigation Systems

Introduction

Throughout human history, the inevitability of death has inspired not only

a sense of fear, but also a paradoxical sense of fascination and curiosity. It is

no surprise then that the investigation of death has a long and varied history,

intimately involved with the rise and governance of human populations. The

sociologist Stefan Timmermans1 has noted that death is not an individual

event, but a social one, and every developed society has had an interest in the

phenomenon, be it from a legal or public health viewpoint in modern populations,

or as part of a mythic or superstitious worldview in earlier societies.

Beliefs about the phenomenon of death have also been inexorably linked to

religious systems throughout history.2–4 

Expert Testimony in Criminal and Civil Litigation

Forensic odontologists are frequently called to give sworn testimony in depositions

and courtrooms. The testimony may involve the previously mentioned

areas of dental identification, bitemark analysis, or age estimation. Dentists

participating in forensic casework should expect that at some point they will

be required to provide sworn testimony.

Forensic dentists also may be called to provide an opinion in standard

of care, personal injury, dental fraud, or other civil cases. These cases, as

with other forensic cases, require the evaluation of material and the development

of an opinion concerning the case. Dental experts are not hired guns,

or advocates for one point of view. Dental experts must be advocates for

the truth and endeavor to find that truth by the application of their special

knowledge and skills. The unwavering goal of the forensic dental expert must

be impartiality, thoroughness, and accuracy (see Chapter 16).