Timmermans-ASR-Suicide - Suicide Determination and the Professional Authority of Medical Examiners Notes

Introduction

• Stefan Timmermans' study examines suicide determination by medical examiners and its impact on official statistics.
• It addresses the accuracy of suicide rates, professional authority of death investigators, and challenges to this authority.
• The article contributes to the sociology of professions by analyzing how professional groups maintain authority despite external criticism.
• In 1996, suicide was the ninth leading cause of death overall and the third leading cause of young people age 15-24.
• Surgeon General David Satcher issued a call to action in 1999 to prevent suicide, noting underreporting in official statistics.
• A 2002 Institute of Medicine report also acknowledges inaccuracies and limitations in official suicide statistics.
• Emile Durkheim identified that official statistics might be less than completely accurate but considered the overall suicide rate sufficiently proximate for his analysis

Accuracy of Suicide Statistics

• Disagreement exists regarding the accuracy of official suicide statistics.
  • Some researchers (minority) claim systematic bias.
  • The majority asserts that errors are minimal and not systematic.

Role of Death Investigators

• Death investigators, increasingly medical examiners, classify deaths and determine cause and manner of death.
• Medical examiners are certified as forensic pathologists.
• The study analyzes if increased professionalization has made suicide determination less equivocal.

Perspectives on Suicide Accuracy

• The literature on suicide accuracy has two views.
  • A minority claims suicide determination is biased (Douglas).
  • The majority states that suicide might be underreported, but the data are sufficiently accurate (Pescosolido and Mendelsohn).
• Douglas (1967) critiques sociologists' reliance on statistics, highlighting that suicide statistics reflect government definitions and assumptions.

Countervailing Factors and Pressures

• Researchers suggest inaccuracies due to:
  • Equivocality of suicide.
  • Legal, administrative, and procedural variations across locales.
  • Pressures of relatives to avoid stigma.
• Some studies find negligible effects of administrative and legal guidelines, while others hypothesize their importance.
• Relatives may influence death investigators to avoid social, religious, legal, or financial stigma.

Medical Examiners and Professional Authority

• Allegations of suicide inaccuracy challenge professional authority.
  • They presume scientific incompetence and preoccupation with private needs.
• Professional authority resides in presenting death investigations as accurate and valid and shaping cultural understanding of suicide.
• Professionals aim to acquire jurisdiction over a contested area of expertise.

Theories of Professional Power

• Two theories explain suicide underreporting:
  • Countervailing Powers (Light): Lack of suicide accuracy instigates counter-reaction structurally limiting authority of death investigators.
  • Professional Dominance (Freidson): Professions maintain autonomy over work content, preventing charges of suicide underreporting from undermining authority.
• Freidson dismisses organizational change and third-party incursions, emphasizing control and discretion over work.

Factors Influencing Professional Authority

• The grounds for professional authority of suicide determination depend on:
  • Whether death investigators classify deaths according to professional standards.
  • Who constitutes the audiences of their determinations.
  • What impact these audiences, particularly relatives and public health officials, have on the detection of suicide.

Jurisdiction of Medical Examiners

• The U.S. death investigation system has undergone changes to strengthen the professional status of death investigators.
• Coroners, who convened juries of lay people to issue verdicts about the cause and manner of death, are being replaced by medical examiners.
• Medical examiners are physicians, usually board-certified forensic pathologists, who conduct investigations, autopsies, and lab tests.
• Manner of death categories: natural death, accident, homicide, suicide, or undetermined.
• Medical examiners promise to bring medically and scientifically validated skills to the job, to increase the objectivity of death investigation.

Medical Examiners vs. Coroners

• Medical examiners differ from coroners in their claim of superior knowledge based on scientific expertise.
• Forensic pathologists are trained and certified in multiple nonmedical sciences and traditional medicine.
• Their decisions are informed by evidence gathered firsthand in postmortem investigations.

Methodology

• Ethnographic research was conducted in a medical examiner's office over three years.
• Full access was granted to investigative files, meetings, and autopsies, with guaranteed confidentiality and anonymity.
• 225 autopsies were observed, and files of 70 suicide deaths were reviewed.
• Data were analyzed systematically using the principles of grounded theory.

Medical Examiner's Office

• The research site reflects the "gold standard" of death investigation.
• Medical examiners resisted pressures to speed up determinations and preferred to have a backlog rather than certify a death based on sloppy research.

The Equivocality of Suicide

• The equivocality of suicide is mainly a problem of locating suicidal intent posthumously.
• A suicide is only routine in light of the professional prerogative to gather certain kinds of evidence.
• Medical examiners apply a probabilistic decision-making rule to satisfy their evidentiary standard.

The Problem of Suicidal Intent

• The U.S. Centers for Disease Control and Prevention (CDC) circulates Operational Criteria for Determination of Suicide.
• To classify a death as suicide, the death investigator needs to establish that the death is self-inflicted and intentional.
• Intentionality can be established from verbal or nonverbal expressions or inferred from implicit evidence.
• Last-second changes of intent are common in suicides.

Evidence of Suicide

• Generally, medical examiners provide support for suicide from seven different sources:
  1. Witness reports
  2. Suicide notes
  • Only 20 to 35 percent of presumed suicides contain notes.
  1. Suicide guidelines
  • A clear indication of suicidal intent corresponds to the suicide directions in Derek Humphry's Final Exit (2003).
  1. Previous suicide attempts
  2. Testimonials
  • Relatives and health care professionals report suicide threats.
  1. Life crises
  • Pathologists look for any indication of a recent crisis, such as relationship problems.
  1. Mode of dying
  • Evaluated based on desperation, painlessness, deadliness, aesthetics, symbolism, and cultural appropriateness.

The Routine Suicide

• In routine suicides, the evidence overwhelmingly points to suicidal intent.
• The police officer reports a suicide.
• The scene investigator describes a likely suicide in the scene report.
• Pathologists tailor their investigations to documenting a suicide.
• Evidence is not predetermined and can indicate suicidal intent only if a professional perspective allows one to look for it, find it, and interpret it.

The Routine Non-Suicide

• Counterpart of the routine suicide.
• Certain deaths are rarely considered suicidal because they have all the characteristics of a natural death, a homicide, or an accident.
• Suicides may be easier to miss when they appear as natural deaths and lack the trauma that alerts death investigators to the possibility of suicide.
• Poisonings and overdoses are thus likely underreported.
• Elderly people are the most likely to take their own lives.

The 51 Percent Rule of a Medicolegal Suicide

• Medical examiners work inductively, building a case for suicide from diverse pieces of evidence.
• The decision-making rule underscores how medical examiners' scientific expertise is mediated by their roots in the dual areas of medicine and criminal justice.
• Medical examiners positively demonstrate a manner of death.

Case: Guy Dubos

• Guy Dubos was found dead in his apartment with suicide notes.
• Dubos's relatives stated that they did not believe that he caused his own death.
• Toxicology results come back negative.
• Cause of death: undetermined following complete autopsy and toxicologic evaluation.
• Manner of death: undetermined.
• Later the cause of death has been changed to