What is an Equivocal Death?

• A woman says her boyfriend went for a walk in a state park and then he was found dead in the ocean.
• A king from centuries past dies from an undocumented cause.
• The death of an eccentric billionaire raises questions.
• A boy shoots his mother and claims it was an accident.

These cases, as different as they are, have something in common: the need for a psychological autopsy to get at the truth.   Also called psychiatric autopsy, retrospective death assessment, reconstructive evaluation, and equivocal death analysis, the term refers to a specific method used for examining a persons lifespecifically, the life of a dead person.

In death certifications, there are three important matters: the cause, mechanism and mode or manner of death.   The cause is an instrument or physical agent used to bring about death (a bullet, for example), the mechanism is the pathological agent in the body that resulted in the death (excessive bleeding), and the manner of death, according to the NASH  classification, is considered to be natural, accident, homicide or suicide.   Sometimes, although the cause and mechanism of death can be easily determined, the manner cannot.  This it is known as an undetermined death.

A medical autopsy determines the cause of death by examining the physical condition of the body.   In cases where the manner of death is unexplained and its not clear what happened, a psychological autopsy may assist the coroner or medical examiner in clearing up the mystery.

For example, as Elizabeth Biffl notes, someone falls from a plane and dies from multiple injuries.   She wore a parachute, but it did not open.  Did she fall from the plane, was she pushed, did she jump and the chute did not open, did she have a heart attack before pulling the cord, or did she jump and decide not to open the chute?  We know what caused her physical death but we dont have the larger picture.

The idea of a psychological autopsy is to discover the state of mind of the victim preceding death, because the results may be needed to settle criminal cases, estate issues, malpractice suits, or insurance claims. When the circumstances surrounding a death can be interpreted in more than one way (also called an equivocal death), psychologists can help to compile information retrospectively about behavior, psychological state, and motive in ways not as available to lawyers or medical examiners.

A man was found in a cemetery, lit on fire.   He died on the way to the hospital.  The cause was carbon monoxide and the mechanism was damage to his lungs from inhalation.  Initially, this incident was determined to be a suicide.  The man had a history of mental illness and he lived near the cemetery.  The assumption was that he went off his medication, had a psychotic break, and set fire to himself.  However, people who knew him insisted this was a hasty assumption.  Further questioning indicated that hed been harassed earlier that week by neighborhood bullies for being gay.  There was now a possibility that he had been murdered.  It was also possible that he had set fire to himself by accident.  It would require an investigator who could look closely into this mans psychiatric record, as well as reports from neighbors, to shift the balance toward one manner of death over another.

According to Lawrence Wrightsman, between 5 and 20 percent of deaths across the country that need to be certified are considered equivocal, but most of them are undetermined between accident and suicide, with the potential for homicide being less frequent.   It helps to know some statistics.  Among teenagers, Daniel  Fischer says, accidents are the leading cause of death, with homicide second and suicide third.  Yet it has also been noted that to save families grief, suicide in teenagers has been underreported.

In many cases, the manner of death matters.   Any family would rather know that the death of a 13-year-old was an accident instead of a suicide, and sometimes with older people, insurance payments depend upon it.  But does the psychological information really affect the person who makes the final determination?

In a 1986 study, nearly half of the countrys medical examiners (195 out of 400) were given scenarios from both typical and equivocal death cases to analyze.   Half of them received information from a psychological autopsy in addition to the standard information about the death scene.  This information did not influence decisions in typical cases, but in the equivocal cases it had a significant impact on determining the manner of death.  These results underscore the importance of gathering psychological information that could shed light on the circumstances surrounding the death.

If, for example, it was known that teenagers with mental illness or conduct disorders and antisocial tendencies have a higher than average suicide rate, this might affect an interpretation of ambiguous circumstances.   To determine intent, says Fischer, a complete and thorough psychological autopsy must be done.  Frustrated perfectionists, sexual abuse victims, and   kids with fragile emotions can show high rates as well.  A suicide overzealously reported can also trigger others, and Reiter and Parker indicate that suicides have been documented with children as young as three. 

However, there are also autoerotic incidents, in which men attempt maximum sexual gratification but can accidentally kill themselves.   These incidents often appear to be a suicide.  Suicide should be used as the manner of death only after an exhaustive and thorough investigation, says Fischer.  He notes how the interpretation of the death of a teenager who was hit by a train was helped along with notes in the victims trip planner, indicating that it was clearly an accident.

Lets look at one such case, where the manner of death was believed at different stages to have been a suicide, an accident, and a homicide, to see how difficult interpretations can sometimes be.