The neurological determination of death: what does it really mean?

The recent Canadian forum's recommendations regarding "neurological determination of death" claim to have determined a "Canadian definition, criteria, and minimum testing requirements for neurological determination of death." In this review the problems with this statement are discussed. The criterion of neurological determination of death does not fulfill the definition of death, because there is continued integration of the organism as a whole. The tests for neurological determination of death do not fulfill the criterion of neurological determination of death because they do not show the irreversible loss of all critical brain functions. The forum has provided no coherent argument for why neurological determination of death should be considered death. I suggest that one cannot invoke expert opinion to clarify a criterion of death, and tests for this criterion of death, without a clear concept of what death is. The forum has clarified tests for what they call "neurological determination of death," but this is not death itself; rather, it is a neurologically devastating state. Whether this state of "neurological determination of death" is enough to justify the morality of harvesting organs prior to death is the real question. A potential solution to this question is discussed.     

Is organ procurement causing the death of patients?

This article offers a philosophical foundation for the Uniform Determination of Death Act as it first examines death per se, and then examines brain death and the non-heart beating donor criteria for determining death. The author suggests that many of the debates over death can be bypassed by changing the terms of the debate: what matters is not whether death is a process or an event, but death as a state. Understanding death as a state allows us to determine death in a functional manner that is compatible with the needs of law and medicine. The second part examines objections that arise from ignoring or rejecting the distinction between killing and letting die and the principle of double effect. By clarifying the lines between life and death, on the one hand, and between intentionally killing and unintentionally hastening death, on the other, the author hopes to restore a sense that the proposals to drop the dead donor rule are radical recommendations to cross lines we have never crossed before.     

The Whole-Brain Concept of Death Remains Optimum Public Policy

"Brain death," the determination of human death by showing the irreversible loss of all clinical functions of the brain, has become a worldwide practice. A biophilosophical account of brain death requires four sequential tasks: (1) agreeing on the paradigm of death, a set of preconditions that frame the discussion; (2) determining the definition of death by making explicit the consensual concept of death; (3) determining the criterion of death that proves the definition has been fulfilled by being both necessary and sufficient for death; and (4) determining the tests of death for physicians to employ at the patient's bedside to demonstrate that the criterion of death has been fulfilled. The best definition of death is "the cessation of functioning of the organism as a whole." The whole-brain criterion is the only criterion that is both necessary and sufficient for death. Brain death tests are used only in the unusual case in which a patient's ventilation is being supported. Brain death critics have identified weaknesses in its formulation. But despite its shortcomings, the whole-brain death formulation comprises a concept and public policy that make intuitive and practical sense and that has been well accepted by many societies.     

Accuracy of cause of death determination without forensic autopsy examination

Medical examiners and coroners commonly determine cause and manner of death without an autopsy examination. Some death certificates generated in this way may not state the correct cause and manner of death. From the case files of the Department of Forensic Medicine in Sydney, Australia, the authors retrospectively reviewed investigative information of all cases in a 6-month period that were initially considered natural deaths (429). The authors, blinded to autopsy results, accepted 261 cases as appropriate for certification without autopsy and assigned a cause of death to each. Per standard local practice, all cases had been autopsied. The actual causes of death as determined by autopsy were then revealed and compared with the presumed causes of death. Most presumed and actual causes of death were cardiovascular (94% and 80%, respectively). The majority of presumed causes of death were listed as ASCVD as the cases lacked features of a more specific cardiovascular process. A large majority of cases had a presumed cause of death of ischemic heart disease based on individual case details. The actual causes of death demonstrated a large breadth of cardiovascular and noncardiovascular disease processes, even though ischemic heart disease accounted for 62% of deaths. The presumed cause of death was completely wrong in 28% of cases. A nonnatural manner of death was present in 3% of cases. This study demonstrates that experienced forensic pathologists may generate erroneous death certificates for cases that are not autopsied.     

Undetermined Manner of Death: An Autopsy Series

A manner of death may be ruled undetermined by the forensic pathologist when there is insufficient information about the circumstances surrounding the death to make a ruling. The aim of our study was to retrospectively analyze a series of autopsy cases that were classified as undetermined manner of death after complete investigations. In all, 48 cases were examined. In 23 cases (48%), the cause of death was determined. The most frequent cause of death was toxic death (n = 11). More than one manner of death was deemed conceivable for most cases (n = 39). The most frequent and the most probable manner of death was accident (n = 37). Homicide was not excluded in about 23% of the cases. Our study showed that the manner of death may remain undetermined despite an established cause of death, and even when two or more conceivable causes of death are considered. Our study pointed out that undetermined manner of death covers a wide range of situations and that homicide may be underestimated.     

我国死刑复核程序之完善刍议

死刑复核程序是为了保障死刑案件质量而设置的特别审判程序,具有鲜明的中国特色。为最大化发挥死刑复核程序的公正司法、防错纠错、保障人权的功能,贯彻落实"保留死刑,严格控制和慎用死刑"的死刑政策,死刑复核程序应当着力加以完善:第一,厘定死刑复核程序的审判性质,选择在现有框架内实现死刑复核程序诉讼化改革的路径,而不必进行三审制转变;第二,加快将法律援助辩护全覆盖至死刑复核程序,充分保障死刑被告人的辩护权;第三,坚持死刑案件在基本事实的证明上达到"唯一性"结论;第四,扩大最高人民法院对死刑复核案件的改判范围,实现公正与效率价值的合理平衡。     

Destiny of the Death Penalty in China in the Contemporary Era

This paper is a study on the abolishment of death penalty in China. The author first reviewed the ancient death penalty in China, looked at the history of death penalty from its evolution and reform, then examined the status quo of China’s death penalty, and brought forward a practical question of what course should the flourishing death penalty in China follow in the international trend of abolishing and restricting death penalty. In this regard, the author analyzed the conditions for abolishing death penalty from the perspectives of public opinion’s influence, choice of politicians, control of crimes and structure of criminal penalty. He also designed a course for China to restrict and abolish death penalty from the legislation setting and judicial restriction, expecting to find a practical way to abolish death penalty.     

Vaginal "fisting" as a cause of death

We describe the death of a young girl that resulted from the insertion of a clenched hand and forearm into her vagina during heterosexual activity. (The male homosexual practice of rectal fist insertion has been described previously.) We believe this death to be the first reported case of a "fisting" death due to vaginal fist insertion during heterosexual activity. This death is reported to alert forensic pathologists, medicolegal death investigators, and coroners aware of the role of aberrant sexual activity and its potential to cause death.     

检察机关对死刑复核程序法律监督的实务设计

现行死刑复核程序,具有不完整性和"封闭"性特征,丧失了司法权的特性,且缺乏外部监督与制约,极大地减少了法官发现冤案、错案的可能性,不利于保证死刑案件的实体公正。检察机关作为国家的法律监督机关,对死刑复核程序进行法律监督,具有法律依据、政策依据和法律文化传统依据,也是保障人权和保证司法公正的客观要求,是满足广大人民群众对死刑复核工作的新期待和维护我国国际形象的需要。可以针对高级人民法院适用的死刑复核程序和最高人民法院适用的死刑复核程序,设置相应的实务运作程序,实现检察机关对死刑复核的过程和结果的法律监督,及时发现和纠正违法的复核行为和错误的复核裁判,保障死刑的准确适用。     

自愿适用脑死亡标准的法律设计

自愿适用脑死亡标准是指根据完全民事行为能力人的真实意思表示，尊重其意愿，对其适用脑死亡标准作为死亡判断标准。自愿适用脑死亡标准具有自愿性、科学性和复杂性。预立自愿适用脑死亡标准意思表示制度对自愿适用脑死亡标准有一定的制度意义。     

通过程序控制死刑

如何控制死刑问题已经成为中国亟待解决的重大现实课题。从各国的实践来看,控制死刑主要包括实体控制与程序控制两种路径。尽管通过宪法或者刑法可以对死刑控制起到立竿见影的效果,但是,通过实体控制死刑,存在难以克服的局限性。相比较而言,通过程序控制死刑,则具有明显的优势。在中国目前无法全面废除死刑而实体控制又存在较大难度的情况下,通过程序控制死刑应是明智之举。     

Screening of milk aspiration in 105 infant death cases by immunostaining with anti-human alpha-lactalbumin antibody.

To determine the frequency and degree of milk aspiration in infant death cases, immunohistochemical examinations were performed on lung sections from 41 sudden death cases and 64 in-hospital death cases using anti-human alpha-lactalbumin antibody. Milk aspiration to some degree was detected in more than half of the sudden death cases and in about one-third of the in-hospital death cases. A semi-quantitative examination of the amount of aspirated milk was subsequently performed in the positive cases. The amount of aspirated milk in the sudden death cases was significantly higher than that in the in-hospital death cases. The frequency distribution of the amount of aspirated milk was similar in shape in both groups. In most cases, a very small amount of aspirated milk was detected. The aspirated milk was assumed to be a result of occasional gastroesophageal reflux or cardiopulmonary resuscitation. However, in five cases, much larger amounts of aspirated milk were found. In these cases, milk aspiration may have been an important part of the cause of death. We concluded that slight milk aspiration is not rare in infant death cases, and that in a few cases, the aspiration is lethal. An immunohistochemical screening test is available to perform a postmortem diagnosis in these cases.     

Is there progress in the autopsy diagnosis of sudden unexpected death in adults?

Sudden death is now currently described as natural unexpected death occurring within 1h of new symptoms. Most studies on the subject focused on cardiac causes of death because most of the cases are related to cardiovascular disease, especially coronary artery disease. The incidence of sudden death varies largely as a function of coronary heart disease prevalence and is underestimated. Although cardiac causes are the leading cause of sudden death, the exact incidence of the other causes is not well established because in some countries, many sudden deaths are not autopsied. Many risk factors of sudden cardiac death are identified: age, gender, heredity factors such as malignant mutations, left ventricular hypertrophy and left ventricle function impairment. The role of the police surgeon in the investigation of sudden death is very important. This investigation requires the interrogation of witnesses and of the family members of the deceased. The interrogation of physicians of the rescue team who attempted resuscitation is also useful. Recent symptoms before death and past medical history must be searched. Other sudden deaths in the family must be noted. The distinction between sudden death at rest and during effort is very important because some lethal arrhythmia are triggered by catecholamines during stressful activity. The type of drugs taken by the deceased may indicate a particular disease linked with sudden death. Sudden death in the young always requires systematic forensic autopsy performed by at least one forensic pathologist. According to recent autopsy studies, coronary artery disease is still the major cause of death in people aged more than 35 years. Cardiomyopathies are more frequently encountered in people aged less than 35 years. The most frequent cardiomyopathy revealed by sudden death is now arrhythmogenic right ventricular cardiomyopathy also known simply as right ventricular cardiomyopathy (RVC). The postmortem diagnosis of cardiomyopathies is very important because the family of the deceased will need counseling and the first-degree relatives may undergo a possible screening to prevent other sudden deaths. In each case of sudden death, one important duty of the forensic pathologist is to inform the family of all autopsy results within 1 month after the autopsy. Most of the recent progress in autopsy diagnosis of sudden unexpected death in the adults comes from molecular biology, especially in case of sudden death without significant morphological anomalies. Searching mutations linked with functional cardiac pathology such as long-QT syndrome, Brugada syndrome or idiopathic ventricular fibrillation is now the best way in order to explain such sudden death. Moreover, new syndromes have been described by cardiologists, such as short-QT syndrome and revealed in some cases by a sudden death. Molecular biology is now needed when limits of morphological diagnosis have been reached.     

Philemon and Baucis Deaths: Case Reports and Postmortem Biochemistry Contribution

The death of a person as a reaction to the death of another is known as Philemon and Baucis death and may represent a difficult challenge for pathologists, especially due to the decompositional changes that often characterized these situations. In this article, we describe two cases of Philemon and Baucis deaths, the first concerning a married couple and the second concerning a father and son. Postmortem investigations including radiology and biochemistry were performed. Based on the results of all investigations, deaths were attributed to natural causes. Third‐party involvement could be excluded in both situations. In one case, biochemical analysis results revealed potentially contributing causes of death. The reported cases emphasize the importance of correlating findings from different postmortem investigations to identify causes of death, precipitating conditions and predisposing disorders, thus allowing the conclusion of natural death to be reached and third‐party involvement to be excluded.     

当代中国死刑改革争议问题论要简

死刑改革是当代中国刑法改革过程中最受关注、最具现实意义且备受争议的重大问题。中国虽难以在短期内全面废止死刑,但却有必要将废止死刑纳入其政策内涵。在功利与人道之间,人道性应当成为我国死刑改革最主要的根据。我国应以无期徒刑作为死刑的立法替代措施,适时建立死刑赦免制度,公开死刑执行的数字,并于适当时机废止贪污罪受贿罪的死刑。     

“Knowledge and Death Penalty Opinion: The Marshall Hypotheses Revisited.”

This study tests the three hypotheses derived from the written opinion of Justice Thurgood Marshall in Furman v Georgia in 1972. Subjects completed questionnaires at the beginning and the end of the fall a semester. Experimental group subjects were enrolled in a death penalty class, while control group subjects were enrolled in another criminal justice class. The death penalty class was the experimental stimulus. Findings provided strong support for the first and third hypotheses, i.e., subjects were generally lacking in death penalty knowledge before the experimental stimulus, and death penalty proponents who scored “high” on a retribution index did not change their death penalty opinions despite exposure to death penalty knowledge. Marshall’s second hypothesis--that death penalty knowledge and death penalty support were inversely related--was not supported by the data. Two unexpected findings were that death penalty proponents who scored “low” on a retribution index also did not change their death penalty opinions after becoming more informed about the subject, and that death penalty knowledge did not alter subjects’ initial retributive positions. Suggestions for future research are provided.     

National Association of Medical Examiners position paper on the certification of cocaine-related deaths

The National Association of Medical Examiners Committee on Cocaine-related Deaths recommends that the following guidelines be applied in the process of documenting, interpreting, and certifying potential cocaine-related fatalities. The committee cautions that the investigation of any drug-related death requires a complete investigation of the circumstances of death, the death scene, and past medical history. It is also necessary to have the results of the forensic toxicological analysis and those of a complete forensic autopsy examination prior to formulating an opinion as to the cause and manner of death. Cocaine should be considered the underlying cause of the death when 1 or more of the following is true: (1). the circumstances surrounding the death can be associated with an acute cocaine exposure and there are no supervening causes of death; (2). the immediate cause of death is directly due to a readily identifiable mechanism or disease such as a gunshot wound or a stroke, yet the acute use of cocaine was the direct underlying cause of the trauma or the disease process; and (3). chronic cocaine use leads to a disease that results in an ultimately fatal pathologic process leading to organ injury and death. The committee further cautions that reported drug levels may not directly relate to the toxic or lethal effects of the drug upon the patient. These guidelines are intended for use by practicing medical examiners and physicians who certify drug deaths, as well as providing education tools for students.     

Initiation of formal death investigation procedures among the Northern Plains Indians: a necessary adjunct in the study of American Indian sudden infant deaths

The high rate of infant mortality among native peoples in the Aberdeen Service Area of the Indian Health Service (primarily North and South Dakota) prompted a multi-institutional study of this problem. The study investigators assumed that local coroners or medical examiners would be able to perform suitable death scene investigations. However, during the design portion of the study it became apparent that, with one exception, none of the participating Indian Nations had a death investigator or even a legal mandate to provide death investigation. To allow the study to go forward, and ultimately to better the community health within its service area, the Aberdeen Area Indian Health Service submitted a draft enabling coroner legislation/resolutions to the area tribes. By November of 1996, 6 of the 19 Indian Nations enacted enabling coroner legislation. To facilitate both the study and general death investigation within the area, the Aberdeen Area Indian Health Service since 1993 has held five 2-day death investigation training programs covering a variety of death investigation topics which were attended by 68 participants. Without further recognition of the need for tribal death investigation and additional funding, these gains in tribal death investigation will probably be transitory.     

慎用死刑的程序保障——对我国现行死刑复核制度的检讨及完善建言

死刑复核制度具有限制死刑的功能,也是“慎用死刑”的程序保障。现行死刑复核体制存在诸多弊端,应当将死刑复核权全部收归最高人民法院行使,如此可以有利于在全国范围内统一死刑的适用标准,有利于对被判决死刑(立即执行)的人的权利进行救济,也有利于最大限度地贯彻“少杀,慎杀”的死刑刑事政政策。为解决处理死刑复核案件的效率问题,可在全国设立若干最高人民法院分院负责这类案件的审理工作;同时还应当大力完善这一制度的具体规范,以保障其功能的充分发挥。     

Confidence in the death penalty and support for its use: Exploring the value-expressive dimension of death penalty attitudes

Recent media and political attention has raised public awareness of a number of issues surrounding the death penalty. Questions regarding innocence, fair trials, and equitable access to counsel and the appellate process are ubiquitous in coverage of the death penalty. Adequate information about public attitudes toward the death penalty in light of these issues is currently lacking. In 2002, as part of the annual Texas Crime Poll, questions were asked about confidence in the administration of the death penalty, support for the death penalty, and support for a moratorium. The results indicate that, although a majority of respondents support the death penalty, a substantial proportion lack confidence in its use and support a moratorium on executions. Of those lacking confidence and those supporting a moratorium, strong majorities maintain support for the death penalty (68% and 73%, respectively). These findings suggest that death penalty attitudes may be largely value expressive.