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.     

Recent trends in suicides utilizing helium

Retrospective review of cases of suicide involving helium inhalation was undertaken at Forensic Science South Australia over a 25-year period from 1985 to 2009. No cases of helium-related suicides were identified in the first 15 years of the study, with one case between 2000 and 2004 and eight cases between 2005 and 2009. Australian data were also reviewed from 2001 to 2009 that showed 30 cases between January 2001 and June 2005, compared to 79 cases between July 2005 and December 2009, an increase of 163%. A review of Swedish data between 2001 and 2009 showed no cases between January 2001 and June 2005, compared to seven cases between July 2005 and December 2009. Thus, all three areas showed recent and striking increases in cases of suicide involving helium inhalation. Given the availability of helium and the recent promotion of this method of suicide, it is quite possible that this may represent a newly emerging trend in suicide deaths.     

The de-medicalisation of assisted dying: is a less medicalised model the way forward?

Although assisted dying has been most commonly presented within a medicalised framework, the notion of de-medicalisation is employed in this paper to suggest that there are emerging models of assisted dying in which some medical aspects assumed to be an integral part of the phenomenon are both challenged and diminished. The paper considers cases where relatives have facilitated a loved one's assisted suicide abroad, cases of assisted death in which the assistor in the actual suicide act is a non-medic, and the growing debate surrounding non-medical grounds for desiring death. In evaluating the potential impact of partial de-medicalisation on the assisted dying debate, the argument presented is that whilst a de-medicalised model could well contribute to a richer understanding of assisted dying and a better death for the person who is assisted, there are cogent reasons to retain some aspects of the medicalised model and that a completely de-medicalised model of assisted dying is unrealistic.     

Suicide in pregnancy

The difficulty in establishing the cause of death of a pregnant woman emphasizes the necessity for the careful gathering of evidence. Especially in the case of motor accidents along lonely stretches of road involving a solitary motorist the possibility of suicide should be taken into consideration. Since a televised suicide had apparently served as model for the method of suicide, mention has been made of the "Werther effect". A literature review reveals that little has been written on the subject-suicide during pregnancy.     

In the laboratory of the states: the progress of Glucksberg's invitation to states to address end-of-life choice

It has now been ten years since the Supreme Court handed down Glucksberg and Quill, rulings on laws that forbid "assisted suicide." In that time, normative and legal developments in the fields of law, medicine, and psychology have changed the landscape of the discourse on the choice of a mentally competent, terminally ill individual to choose to self-administer medications to bring about a peaceful death. Although the Court rejected petitioners' claims that state laws denying them the ability to end their terminal illnesses through self-administered medication violated the Constitution, it left states with the opportunity to experiment with legislation that would allow terminally ill individuals the choices they had previously sought through litigation. Oregon's experience with its Death with Dignity Act, which grants terminally ill, mentally competent individuals the choice to end their lives through self-administered medication, has proven that such laws provide comfort not only to those who, faced with the prospect of a horrible death from a terminal illness, choose to end their lives in a peaceful and dignified manner, but also to those to ultimately choose not to. Additionally, Oregon's experience shows that the fears that originally attended the "assisted suicide" debate are unfounded so long as proper procedures are in place. Because Oregon's Death with Dignity Act has proven both useful and harmless, this Article concludes that it is time for other states to follow Oregon's lead and enact their own legislation to allow their citizens an alternative to what otherwise could be a prolonged and painful death from terminal illness.     

Determination of questionable suicide as a homicide by studies of criminal stains

In a woman found dead with cuts on both arms in a domestic sauna plastered with blood were assumed next to a bleed to death. The question self-infliction or by a third party of arm injuries could not be decided. By investigation of blood traces only could be clarified the cause of death. The husband had strangled his wife and inflicted several cuts on both arms with a razor blade to simulate suicide. Afterwards, he also inflicted several cuts on himself with a razor blade with the intention of suicide. He survived these injuries.     

Death certification of "suicide by cop"

Death certification of "suicide by cop" is controversial among some medical examiners and coroners. We present five such deaths that were certified as suicides and discuss the medico-legal issues involved with these certifications. To certify such a death as a suicide, certain criteria should be met. Suicide by cop is a circumstance that involves competing intentional acts that may result in dichotomous determinations of the manner of death. Despite the absence of direct self-infliction, there is overwhelming evidence that these five individuals intended to end their own lives. Their use of an unusual method to accomplish this goal may inappropriately result in a reflexive certification of homicide. All of the decedents possessed weapons or a facsimile of a weapon. We present five instances of suicide by cop and contend that these types of deaths are best certified as suicides.     

Self‐Strangulation Through A Sphygmomanometer: An Uncommon Suicide

Suicide by asphyxia is quite a common event in forensic practice and may be implemented in different ways. The authors report a unique case of a 16‐year‐old youth who committed suicide by means of a standard mercury sphygmomanometer. This manner of suicide has never been described in the literature reviewed. A complete forensic investigation led to the conclusion that the cause of death was mechanical asphyxia, ascribed to self‐strangulation by means of an atypical item. The victim suffered from attention‐deficit/hyperactivity disorder (ADHD) syndrome and was assisted by support teachers. He had a solitary and depressive personality. The exceptional nature of this case suggests that sphygmomanometers may be regarded as possible means of self‐strangulation. The case also highlights the importance of managing patients with psychiatric or cognitive disorders; indeed, particular caution is required to keep them away from objects that, although apparently harmless, can become lethal.     

Autopsy Reenactment – A Useful Technique in the Evaluation of Adhesive Tape Asphyxia

A 19‐year‐old woman was found dead with her face and head wrapped in plastic adhesive tape in a cupboard beside an opened helium cylinder. Despite the alleged presence of a suicide message on a social networking website, the unusual circumstances raised the possibility at the time of autopsy of either accidental death from sexual asphyxia or homicide. A carefully monitored reenactment demonstrated, however, that the type of commercial adhesive tape that had been used did not cause complete airway obstruction and that it was possible to wrap a considerable length of tape around the head and neck with the breath held. All of the features at autopsy were, therefore, compatible with self‐infliction. Asphyxial death was attributed to the combined effects of smothering from tape and anoxia from helium, an extremely rare combination in young females.     

Unusual hanging deaths

Four unrelated hanging deaths involving young white males, all in enlisted status in the United States military, are presented. Taken in a military context, one scene served as a suicide note equivalent with the unmistakable message of extreme defiance toward military regulations. In two cases, the elaborate attire of the decedents could have lead to the misclassification of the manner of death if investigative information had not been considered. Extensive background investigation and review of medical records in the fourth case disclosed that the victim had an eight- to ten-year history of compressing his neck to cause unconsciousness. He left an extensive suicide note in which he concluded that "hanging would be good." Each case has certain unique features, as a group, the cases all demonstrate a continuum from obvious suicide to cases where the manner of death is, at first, equivocal.     

自杀的认定及其相关行为的刑法评价

刑法中认定自杀有主客观两方面要求。在主观方面,被害人不仅应当认识到并且意欲死亡结果发生,而且必须自愿地、也即自主决定地选择了死亡。对于自愿性的判断应当以有效承诺的主观要件为标准。重大的动机错误同样导致不能成立自杀。此外,被害人还必须客观上事实性地支配着直接导致死亡的行为,在将不可逆转地造成死亡结果的最后关键时刻自己控制着事态的发展。自杀本身并非刑事不法行为,教唆或帮助自杀、对自杀者不予救助或者过失导致他人自杀等自杀相关行为也不应受到刑事处罚。     

Extending the Practice of Physician‐Assisted Suicide to Competent Minors

In an effort to address the mental and physical suffering terminally ill patients endure, some states have either legalized or decriminalized physician‐assisted suicide—a practice commonly referred to as death with dignity. However, as the practice of physician‐assisted suicide becomes accepted among states, competent minors continue to be excluded from legislative and judicial decisions. Regardless of parental consent, states institute an age requirement of eighteen years old for participants of physician‐assisted suicide. This Note proposes that states amend their physician‐assisted suicide statutes to (1) remove any age restriction, (2) create a standard of competency that minors must meet to be eligible for physician‐assisted suicide, and (3) implement a procedure to determine whether a minor meets the competency standard.     

500 psychological autopsies

Five hundred psychological autopsies on equivocal (suicide versus accident) deaths were reviewed to ascertain which factors are significant in making the determination between suicidal and accidental deaths. Factors varied in relative importance according to the method used to cause death. Significant factors included life-style, recent stress, suicidal communications, previous self-destructive behaviors, history of depression, and obvious factors from the physical evidence such as large amounts of drugs in the blood. Although the court-provided decision guideline is "a preponderance of the evidence", in practice, the assembled evidence is often used to construct a "most credible" scenario to explain the death.     

An unusual mechanical asphyxia in a homicide-suicide case by smothering and strangulation

A very unusual homicide of 2 children by smothering and strangulation by means of a rubber adhesive band carried out by the mother who committed suicide by the same manner is presented. Smothering is supposed to be one major cause of death in child homicide. Suicide by smothering is relatively uncommon. Suicidal smothering by winding strips of adhesive tape around the head to cover the nose and mouth is an even rarer method recently described in literature. The circumstances of the crime and the macroscopic and microscopic evidence are discussed to reduce the potential for underdiagnoses or mistakes in such cases in which it may be difficult to establish whether suicide or homicide occurred.     

“Murder–Suicide” or “Murder–Accident”? Difficulties with the Analysis of Cases

Abstract: Homicide where a perpetrator is found dead adjacent to the victim usually represents murder–suicide. Two incidents are reported to demonstrate characteristic features in one, and alternative features in the other, that indicate differences in the manner of death. (i) A 37‐year‐old mother was found dead in a burnt out house with her two young sons in an adjacent bedroom. Deaths were due to incineration and inhalation of products of combustion. (ii) A 39‐year‐old woman was found stabbed to death in a burnt out house with her 39‐year‐old de facto partner deceased from the combined effects of incineration and inhalation of products of combustion. The first incident represented a typical murder–suicide, however, in the second incident, the perpetrator had tried to escape through a window and had then sought refuge in a bathroom under a running shower. Murder–accident rather than murder–suicide may therefore be a more accurate designation for such cases.     

Anomalous Anterior Papillary Muscle as an Autopsy Finding in Two Cases

Anomaly in the anterior papillary muscle (APM) is known to cause left ventricle outflow tract (LVOT) obstruction, and this rare congenital condition could be a cause of sudden cardiac death. This anomaly and its hemodynamic effects is similar to valvular heart disease. In our two described cases, in which cause of death was, respectively, hypertrophic cardiomyopathy and suicide by hanging, the cephalad portion of the left APM was inserted directly into the ventricular surface of the anterior mitral leaflet and chordae tendineae were absent in the area of the direct anomalous muscle insertion; the aberrant papillary muscle was very large and showed an exaggerated anterior displacement within the left ventricular cavity. The described anomaly is a cause of LVOT obstruction. This condition is considered to be rare, although incidence estimates do not exist. In the absence of other possible causes, this finding may indicate arrhythmia as being the immediate cause of death.     

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.     

Suicide by inhalation of carbon monoxide in a residential fire

Fire deaths are usually accidental, but atypical cases of homicide or suicide have been described. In suicide by fire, the only method reported by several authors consists of self-immolation. We present here the unusual case of an adult female who committed suicide by waiting in the living room after setting fire to her bedroom. The autopsy revealed smoke inhalation and the toxicological analysis revealed carboxyhemoglobin levels of 67%. Very few cases of suicide by fire not of the self-immolation type have been reported, and all have been anecdotal. A review of the literature is presented and a new term, "suicide by inhalation of carbon monoxide in a fire," is proposed for such cases.     

Death following acute poisoning by moclobemide

A fatality due to ingestion of a reversible inhibitor of monoamine-oxidase A (MAO-A) is reported. Moclobemide is generally considered as a safe drug far less toxic than tricyclic anti-depressants. However, severe intoxications may result from interactions with other drugs and food such as selective serotonin reuptake inhibitors (SSRIs), anti-Parkinsonians of the MAOI-type (e.g. selegiline) or tyramine from ripe cheese or other sources. In the present case, high levels of moclobemide were measured in peripheral blood exceeding toxic values reported so far in the scientific literature. The body fluid concentrations of moclobemide were of 498 mg/l in peripheral whole blood, 96.3 mg/l in urine while an amount of approximately 33 g could be recovered from gastric contents. The other xenobiotics were considered of little toxicological relevance. The victim (male, 48-year-old) had a past history of depression and committed one suicide attempt 2 years before death. Autopsy revealed no evidence of significant natural disease or injury. It was concluded that the manner of death was suicide and that the unique cause of death was massive ingestion of moclobemide.     

Toxicologic aspects of deaths due to falls from height

A prospective study of 161 victims of falls from height is reported. The aim was to determine the interest of systematic qualitative and quantitative toxicological analysis in such fatalities. The primary cause of death was suicide (84.5%), followed by accidents (7%) and homicide (1%). In the remaining 7.5%, cause of death was undetermined. In the suicides, there was evidence of psychotropic medicines in 57% of the observations, with a much higher proportion of benzodiazepines and antidepressants in women than in men. Quantitative toxicologic analysis showed overdosing on medication in 16 suicide victims, with toxic levels in 11 of these. Systematic qualitative and quantitative toxicologic analysis made a significant contribution to the diagnosis of suicide by revealing either an unknown psychiatric treatment or a toxic level.