Preliminary test with chlorindazone DS for zinc in Sintox residue

So-called exit bags are voluminous, transparent plastic bags, each with a collar to go round the neck, and a Velcro fastening. In conjunction with the consumption of sleeping pills, the bags are recommended as an aid to commit suicide by organizations in favour of "humane death". It is reported on four such suicides by elderly people between 79 and 87 years of age. In two of these cases, there was assistance in committing suicide, one corresponding to a suicide protocol from the Swiss organization for euthanasia, EXIT. In two cases, detailed instructions for committing suicide were found. The morphological findings were not very specific in any of the cases. If the plastic bags are removed by a third party, this type of suicide may remain undetected even after performance of an autopsy. Exit bags tend to be used by older people with either real or feared life-threatening illnesses, in suicides which have usually been planned for some time. From the criminological point of view, the possible active participation of other persons in pulling the covering over the head can often not be proved. Assisting a suicide, in the sense of giving instructions on how to accomplish it, is not punishable in German law.     

Current issues in medical liability

Currently, liability discussions are being dominated by AIDS and the legal problems associated with birth and death. The introduction of routine AIDS tests without the knowledge of those concerned is disputed heatedly and, in fact, may well constitute bodily assault and render those responsible liable to prosecution. In AIDS cases, the apparent breach of the Hippocratic oath of secrecy by Physicians can be justified on the grounds of both the extraordinary circumstances prevailing and conflicting duties. The transmission of AIDS could give rise to prosecution for causing bodily injury or manslaughter. The drawing up of a law to protect embryos is designed to establish legal constraints in the fields of reproduction and gene technology. In reframing section 168 StGB, which provides protection to the dead embryo, legislators assume that the head of a medical clinic is the lawful custodian of the corpse of a person who has died in his institution. This should help to resolve many of the problems arising from post-mortem examinations. The questions of euthanasia and medical assistance in cases of suicide were raised at the 1986 Conference of German Lawyers. Whereas medical treatment that could be considered as interference with the natural process of dying may be withdrawn in the case of irreversible terminal suffering, active euthanasia, i.e. the deliberate killing of a terminal patient, was rejected. With regard to noninterference in a suicide attempt by a third party, the free decision of the person wishing to commit suicide should be respected. In general, however, the maxim in dubio pro vita should be respected and where any doubt exists, an attempt should be made to save the person's life.     

Therapeutic response to assisted suicide request

The authors review the first publicly reported case of legal assisted suicide in the United States and discuss possible clinical responses other than assistance in suicide. Psychiatric observers have noted that acceptance of assisted suicide or euthanasia as a medical option has resulted in loss of knowledge about how to respond to suicidal ideation in the seriously ill. The authors discuss specific therapeutic interventions that may be appropriate for seriously ill patients requesting suicide.     

Emotional and psychological effects of physician-assisted suicide and euthanasia on participating physicians

This is a review and evaluation of medical and public literature regarding the reported emotional and psychological effects of participation in physician-assisted suicide (PAS) and euthanasia on the involved physicians. MATERIALS AND METHODS: Articles in medical journals, legislative investigations and the public press were obtained and reviewed to determine what has been reported regarding the effects on physicians who have been personally involved in PAS and euthanasia. RESULTS AND DISCUSSION: The physician is centrally involved in PAS and euthanasia, and the emotional and psychological effects on the participating physician can be substantial. The shift away from the fundamental values of medicine to heal and promote human wholeness can have significant effects on many participating physicians. Doctors describe being profoundly adversely affected, being shocked by the suddenness of the death, being caught up in the patient's drive for assisted suicide, having a sense of powerlessness, and feeling isolated. There is evidence of pressure on and intimidation of doctors by some patients to assist in suicide. The effect of countertransference in the doctor-patient relationship may influence physician involvement in PAS and euthanasia. CONCLUSION: Many doctors who have participated in euthanasia and/or PAS are adversely affected emotionally and psychologically by their experiences.     

Detection of medical examiner cases from review of cremation requests

Title 9, Chapter 19, Article 3 of the Arizona Administrative Code requires all bodies that are to be cremated must have the death certificate reviewed by a county medical examiner. In Tucson, AZ, and surrounding Pima County, all cremation requests are submitted to the Forensic Science Center, where the death certificates are reviewed by one of 5 board-certified forensic pathologists. In 2002, there were 5557 cremation requests, and in 2003 there were 5662 cremation requests. Of these requests, 670 (12.1%) and 447 (7.9%) death certificates were flagged for further investigation in 2002 and 2003, respectively. Eventually, 47 cases (0.8% of total, 7.0% of flagged cases) were accepted as medical examiner cases in 2002, and 43 cases (0.8% of total, 9.6% of flagged cases) were accepted as medical examiner cases in 2003. In 2002, the majority of cases were handled as a records review; however, 4 cases were brought in for autopsy and 1 was certified after an external examination only. In 2003, all cases were certified via a records review. The manner of death in all but 3 of these deaths was certified as accident, with complications of remote trauma being the most common proximate cause of death. The 3 most common injuries were complications of fractured pelvis or femur (15 in 2002, 22 in 2003), head injury due to fall (18 in 2002, 8 in 2003), and complications of remote motor vehicle accident (3 in 2002, 6 in 2003). The other 3 deaths included 2 homicides, 1 in each year, and 1 suicide in 2003.     

Private thoughts of public representatives: assisted death, voluntary euthanasia and politicians

Assisted death and voluntary euthanasia have received significant and sustained media attention in recent years. High-profile cases of people seeking assistance to end their lives have raised, at least in the popular press, debate about whether individuals should be able to seek such assistance at a time when they consider their suffering to be unbearable or their quality of life unsatisfactory. Other recent developments include a number of attempts to legislate on the issue by the minor parties in Australia and the successful enactment of legislation in a few overseas jurisdictions. However, despite all of the recent attention that has focused on assisted death and voluntary euthanasia, a discussion of the adequacy of existing laws has not made it onto the political agenda of any of the Australian State or Territory governments. This is in spite of the fact that the private views of the majority of our elected Members of Parliament may be supportive of reform. This article explores the role of politicians' views and, as a case study, considers the opinions expressed by a number of Queensland Members of Parliament. In light of the views of these politicians and those of members of the public, as well as considerations arising from current medical practice, the article argues that there is a need for open political debate on assisted death and voluntary euthanasia. The article also suggests ways that such a debate may be achieved while minimising any political impact on governments that are prepared at least to consider this issue.     

Asphyxial suicide by inhalation of helium inside a plastic bag

Asphyxial suicide by placing a plastic bag over the head, especially in combination with inhalation of gases, is a rarely described method of committing suicide. This article reports a case of suicidal asphyxiation by inhaling the inert gas helium inside a plastic bag. A 64-year-old man probably followed the instructions described in an article about committing suicide written by a medical practitioner from Zürich. This form of suicide is recommended by right-to-die groups and in the internet as a certain, fast, and painless suicide method. Additionally, it leaves only seldom externally visible marks or pathomorphological findings on the body. If the plastic bag and other auxiliary means are removed by another person, the forensic death investigation of cause and manner of death may be very difficult. Therefore, the death scene investigation and the inquiry ordered in the environment of the deceased are very important.     

Suicide classification--clues and their use. a study of 122 cases of suicide and undetermined manner of death

In order to identify clues to forensic pathologist's classification of suicide, the forensic files of 100 consecutive cases of suicide, and 22 cases of undetermined manner of death, were analysed. Some specific causes of death, suicidal communication and other circumstantial evidence suggesting suicidal intent explained all but three classifications. Problematic cases concerned death by poisoning and by submersion, alcohol-dependent persons and subjects with positive blood alcohol concentration at autopsy. Guidelines to support the police investigation as well as the medico-legal examination can probably reduce the number of undetermined cases in cases of possible suicide.     

Suicide by electrocution with low-voltage current

Three cases of suicide by electrocution with low-voltage current were observed in five years (1994-1998) by medical clinical forensic examiners of an Emergency Forensic Unit of the Paris suburb among 2,000 external death examinations. The cases involved one woman, aged 72 and two men, aged 38 and 41. In the last two cases, electric burns were retrieved under bared electric wires, placed on the arms or fingers in order to realize a hand-to-hand electric circuit involving the heart muscle. In the other case, the electric circuit between mouth and foot also involved the heart muscle. Household low-voltage current delivered (220 V in France) had a sufficient strength to induce local muscular paralysis and heart fibrillation. In the three cases, blood samples taken have retrieved very high levels of muscular enzymes (CPK, LDH) correlated to the mechanism of electric death. The rareness of suicide by electrocution and its forensic characteristics are detailed in order to help the clinical forensic examiners, prosecutors, and police officers concerned by such death examinations.     

Asphyxial suicide with helium and a plastic bag

Suicide by helium inhalation inside a plastic bag has recently been publicized by right-to-die proponents in "how to" print and videotape materials. This article reports a suicide performed according to this new and highly lethal technique, which is also a potentially undetectable cause of death. Toxicology information could not determine helium inhalation, and drug screening did not reveal data of significance. The cause of death could be determined only by the physical evidence at the scene of death. Helium inhalation can easily be concealed when interested parties remove or alter evidence. To ensure that their deaths are not documented as suicide, some individuals considering assisted suicide may choose helium methods and assistance from helpers. Recent challenges to Oregon's physician-assisted suicide law may increase interest in helium instead of barbiturates for assisted suicide.     

Forensic medical specificity of death in atypical sexual behavior: asphyxiophilia, autoerotism

The diagnosis of death of autoerotic asphyxia has not been virtually stated by Russian forensic medical expert. All such cases were interpreted as mechanical asphyxia entailing suicide, and "accidental" or "fatal" death. The authors observed, during the recent 5 years, 10 lethal cases in different-type autoerotic practice. Strangulation asphyxia was the death cause in 7 cases. Compression asphyxia, inhaling of glue vapor and electric shock caused death, each in one case. Death of asphyxia seizes to be exceptional; it is rather a regular phenomenon in the present-day life, which needs a proper research from 2 standpoints--etiopathogenesis, and forensic medical diagnosis.     

A case of suicide disguised as natural death.

A case report describing the suicide of a physician classified initially as a natural death. Faced with the vehement protest of the family of the deceased the magistrate decided to request a 'preventive' forensic autopsy. Forensic investigations revealed the cause of death as being a pentobarbital intoxication and the circumstances favoured the hypothesis of a genuine suicide. This case illustrates that the tendency of magistrates to request or not an autopsy is related to their experience or intuition.     

大学生自杀态度的研究

本文应用自杀态度问卷,采用随机抽样的方法取样,对98名大学生进行问卷调查。结果表明大学生对自杀态度总体上保持中立或矛盾的态度;在对自杀者家属的态度上存在性别差异;大学新生对安乐死持肯定、认可、理解和宽容的态度,高年级学生对安乐死则持矛盾或中立的态度。了解大学生对自杀的态度,为自杀早期预防工作提供理论依据和信息支持。提醒全社会充分认识大学生带来的社会负面影响,最大可能的降低大学生自杀率。     

Forensic pitfalls

The lives of forensic psychiatrists are complicated and subject to stressful experiences because they have elected to interact with a social system very different from their own. This article presents discussion of these frequently troublesome areas commonly encountered by forensic psychiatrists in trying to respond to the law's requests and needs without sacrificing their medical integrity: (1) legitimate definition of expertise; (2) reasonable medical certainty; (3) generally accepted standard of care. They are explored with emphasis on the exercise of self-assessment by the involved forensic psychiatrists lest their incautious application of knowledge and expertise become pitfalls of their own making.     

Suicidal Shotgun Wound Employing a Shotgun Barrel,a Shotgun Shell,and a BB*

Abstract: A vast majority of firearms‐related suicides involve the conventional use of a properly functioning, intact firearm. Occasionally, forensic investigators encounter a case wherein the firearm suicide victim employs some form of unconventional use of a weapon, or utilizes an unusual weapon type. In this case report, the authors present an unusual case in which a man committed suicide by using a shotgun shell, a shotgun barrel (separate from the rest of the gun), and a BB. Some confusion as to the cause and manner of death was present during the initial scene investigation. Examination at autopsy revealed the cause of death to be a shotgun wound of the chest and prompted further scene investigation. Therefore, this case serves as another example of the importance of cooperation between scene investigators and forensic pathologists when investigating a death. A review of suicidal firearm cases using unconventional means and/or firearms is presented.     

The alleged distinction between euthanasia and the withdrawal of life-sustaining treatment: conceptually incoherent and impossible to maintain

Richard Epstein, in his book Mortal Peril, supports euthanasia and assisted suicide and rejects the distinction between them and withdrawal treatment. In this essay, Professor Orentlicher argues that Epstein is correct in finding no meaningful moral distinction between euthanasia and treatment withdrawal, examines the reasons why the distinction has persisted in American jurisprudence, and explains why the distinction has eroded. Epstein also concludes in his book that there is no constitutional right to euthanasia or assisted suicide. Professor Orentlicher's response is that constitutionality is not the appropriate inquiry; rather, the better question is whether to recognize a right to assisted suicide once a right to euthanasia in the form of terminal sedation already exists. He answers this question in the affirmative, arguing that assisted suicide enhances patient welfare and reduces risks of abuse in a world with euthanasia.     

Level of agreement between opinions of medical examiner investigators and forensic pathologist medical examiners regarding the manner of death

To evaluate the level of agreement between medical examiner investigators' opinion of the manner of death and what the manner of death was as certified by forensic pathologist medical examiners (MEs), we reviewed the case records stored in a database of all deaths reported to the office of the medical examiner in Fulton County, Georgia. Of 15,771 deaths reported to the office during a 10-year period, a difference exists in 1908 cases. In 900 natural deaths, the investigators recorded 135 accident, 10 homicide, 10 suicide, and 745 undetermined manners of death. In 755 accidental deaths, the investigators recorded 16 natural, 8 homicide, 13 suicide, and 718 undetermined manners of death. In 107 homicides, the investigators recorded 12 natural, 8 accident, 0 suicide, and 87 undetermined manners of death. In 70 suicides, the investigators recorded 9 natural, 9 accident, 3 homicide, and 49 undetermined manners of death. In 61 deaths classified as undetermined, the investigators recorded 25 natural, 13 accident, 17 homicide, and 6 suicide manners of death. In 15 deaths, the discrepancy exists due to an apparent error in the database information. This study confirms a high concordance between investigator and ME opinion regarding manner of death but also documents the need for case review and autopsies by forensic pathologists to confirm the investigators' opinion of the manner of death, determine the manner of death when the investigator selects undetermined, and on occasion, refute the investigators' opinion regarding the manner of death.     

Suicide in a patient with undiagnosed periarteritis nodosa

Surveys of medical examiners' records have shown that as many as one-third of suicide victims have serious physical illnesses. We report the case of a 56-year-old woman who committed suicide by drug overdose. At autopsy, she had severe widespread periarteritis nodosa, which had been unsuspected during life. The identification of treatable physical illness in suicide victims is important in suicide prevention, yet such illness may be overlooked after death unless a forensic autopsy is performed.     

Complex Suicide by Self‐stabbing and Drowning: A Case Report and a Review of Literature

Sharp force injuries and drowning are methods exceptionally combined in complex suicides. We report a challenging case of complex suicide by self‐stabbing and drowning that illustrates the difficulty in discriminating between homicide and suicide in such circumstances of death. The corpse of a young man was found submerged in a river, stabbed nine times with two wounds that had penetrated the thorax and had caused lung injuries and a hemopneumothorax. The postmortem and histological examinations were consistent with a death caused by drowning, but the manner of death still remained undetermined. Police investigation finally concluded to a suicide, although no suicide note had been left and the victim had no underlying diagnosed mental disorder. The parameters that may help distinguish suicide from homicide at the autopsy should be interpreted in light of a thorough forensic investigation to determine the exact manner of death in such a case.     

Withholding and withdrawing of life support: a medicolegal dilemma

The developments in medicine in general and the technology of life support in particular have provided the means of maintaining organ function for prolonged periods of time. However, there are many situations where life-sustaining treatment in an intensive care unit (ICU) may lead to a death with lingering and suffering of the patient, as well as burdening their family. Although often equated, withholding and/or withdrawing life-prolonging treatments that allow the patient to die needs to be differentiated from the physician-assisted suicides and euthanasia that involve the active ending of life. There is a difference between an unintended but accepted consequence of forgoing therapy and an intended result of death from suicide or euthanasia. The present-day physicians view most patient deaths as an inevitable process secondary to disorders unresponsive to treatment and/or multiple organ dysfunction syndromes. The large majority of patients dying in ICUs today succumb not after cardiopulmonary resuscitation, but rather, after the forgoing of life-sustaining treatment. Such approach has frequently caused families, institutions, and conservators of patients to resort to judicial fiat for resolution.