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Post-publication Peer Reviews to:
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![[Read P3R]](/icons/misc/sectionDOWN.gif){kind=icon}
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Intent and Manner are Different
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Bruce A. Hyma, M.D., Chief Medical Examiner Miami-Dade County, Emma O. Lew, M.D., Martha J. Burt, M.D., Kenneth D. Hutchins, M.D., Erik K. Mont, M.D., Reinhard W. Motte, M.D., Mark J. Shuman, M.D., Joseph H. Davis, M.D.
Send letter to journal:
bahyma{at}miamidade.gov Bruce A. Hyma, M.D., et al.
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The article by Schaechter, et. al.(1) suggests that medical examiners (ME) underreport unintentional firearm fatalities. The authors’ apparent goal was to increase the number of unintentional (accidental) gunshot deaths in children because "during a coalition meeting in Miami to reduce youth gun injury, several prevention partners protested a focus on unintentional gun deaths because no 'accidental' firearms deaths had been reported by the ME during the previous year." The authors compared the manner of death determined by the Miami-Dade County Medical Examiner to an “intent-based classification approach.”(2) While we appreciate the authors’ sentiment, their fundamental failure to recognize what manner of death classification represents and the methods by which deaths are certified has resulted in erroneous conclusions. Manner of death is classified by medical examiners for vital statistic purposes and represents the opinion of the certifier, based on the totality of evidence, of the probable (51% probability or greater) manner of death. As the authors correctly point out, because of the individuality of each death, opinions regarding manner of death occasionally vary. In firearm related deaths, the intents of the victim(s) and shooter(s) are often difficult to ascertain. We strive to engender consistency in our approach and utilize the National Association of Medical Examiners (NAME) guidelines(3), which are intent based. The erroneous statement that “intent is not uniformly considered in manner of death coding of firearm fatalities in Miami-Dade County” attributed to Dr. Davis is a misrepresenation of his comments. The Miami-Dade County Medical Examiner’s Office does uniformly consider intent in manner of death classification, but intent may not be uniformly considered in other parts of the country. The authors reclassified 22 ME intentional deaths as unintentional and cited two of their reclassified cases as illustrative examples. One case was that of “a 14 year-old boy who shot into the air to celebrate Independence Day but had the misfortune of the bullet falling back and striking his head.” Aside from the unlikelihood of such a scenario, the authors’ statement misrepresents both the terminal events and the physical evidence. The police report in this case indicates that the victim was shooting the gun in the air, but then placed the gun to his head, said, “Let’s play Russian roulette,” and pulled the trigger twice before the gun fired. The characteristics of the gunshot wound in the victim’s right temple are unequivocally those of a close-range entrance wound. The projectile traveled through the head from right to left, upward and slightly backward. The investigative information, wound characteristics and projectile’s pathway are not consistent with a falling projectile. According to the authors’ stated methods, the case should have been excluded from the analysis, “as determination of intent in [Russian roulette] fatalities remains controversial.” The second case cited by the authors was “an ME-coded homicide of a 3 -year-old boy by his 4-year-old sibling.” The determination of intent in such cases is subject to opinion regarding the ability of a child to comprehend the consequences of his/her actions. However, the NAME guidelines recommend classification of such cases as homicide except if the circumstances are not well clarified or the weapon is faulty/malfunctioning (pp.12-13; #26). The authors’ conclusions cannot be validated because they presented only these two specific case examples, one of which had gross factual and interpretive errors and the other of which was properly classified according to NAME guidelines. Furthermore, the authors’ obvious agenda, to prove that unintentional firearm fatalities in children are more common than Medical Examiner statistics suggest, is misguided and irrelevant. Guns are inherently dangerous. The shooting of a three year old child by a four year old child is a tragedy that can be prevented by conscientious adults, regardless of whether the manner is classified as homicide or accident. References: 1. Schaechter J, Duran I, De Marchena, Lemard G, and Villar ME. Are “accidental” gun deaths as rare as they seem? A comparison of medical examiner manner of death coding with an intent-based classification approach. Pediatrics, 2003; 111(4):741-4. 2. National Fatal Firearms Reporting System Workgroup. Uniform Data Elements Manual, Release 1.1. Available at http://www.hsph.harvard.edu/hicrc/nviss/documents/Uniform_Data_Elements.pdf 3. National Association of Medical Examiners. A guide for manner of death classification. First edition. February 2002. |
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Judy Schaechter, pediatrician University of Miami
Send letter to journal:
jschaechter{at}miami.edu Judy Schaechter
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I want to thank the Miami Dade County medical examiners for furthering the discussion of intent-based categorization of violent deaths. As discussed in the paper, and emphasized in their letter, the coding of violent death by intent can be a subjective decision making process. However, the differences reported in our article between medical examiner and public health coding of violent deaths primarily reflect a definitional issue. Public health traditionally makes a determination of intent from the underlying cause of death on a death certificate that reflects the International Classification of Diseases (ICD) used to code and classify mortality data from death certificates. Medical examiner/coroner consideration of intent in manner of death may vary on a case-by-case basis. In many cases, there may be a tension between the legal and public health concepts of intent. The confusion is clearly described in the National Association of Medical Examiners’ "A Guide for Manner of Death Classification," which proposes that “a singular definition and application of ‘intent’ does not work in the context of manner-of-death classification.”1 It is quite logical that the perspective of a medical examiner/coroner (and similarly, law enforcement) may differ substantially from that of public health because the two variables, intent and manner of death, are describing different concepts. The clinical coding conducted for this analysis might have been subject to bias. However, there was no presupposed agenda. Further, the paper in no way concludes that medical examiner coding of these deaths is flawed, or that medical examiners are responsible for making changes to the current situation. The public health and clinical communities should understand that those proportions of deaths that occur without any intent to harm may be categorized differently by medical examiner coding, when it complies with National Association of Medical Examiner guidelines, than they would expect with ICD coding, closer to the classification in the referenced article. It also needs to be recognized that the methods used by medical examiners/coroners to write cause-of-death statements can vary greatly across jurisdictions. Differences of opinion regarding the determination of intent have also been documented by Barber et al.2 and Hanzlick and Goodin.3 It is important to emphasize that the wealth of circumstantial information contained in medical examiner records provide a substantial enhancement to the current state of injury mortality surveillance that relies primarily on death certificate information. Currently available systems tell us nothing about where violent deaths occur, the types of weapons involved or the multiple factors leading up to these deaths. As the Centers for Disease Control and Prevention and others work toward a national violent death reporting system (http://www.hsph.harvard.edu/hicrc/nviss/about_parent_nvdr.htm), it is important that standardized definitions for violent death move forward. The clearer picture we get of why violent deaths happen will permit more effective prevention and intervention activities. The number of unintentional deaths in the sample surprised the authors. Careful attention to unintentional deaths, particularly those in the pediatric age range, seems warranted. Our only concern is to add to the body of information that clinicians and others can use to prevent death and injury, to keep children safe. 1. Hanzlick R, Hunsaker JC, Davis GJ. A Guide for Manner of Death Classification, 1st Edition. National Association of Medical Examiners, Feb 2002, available at www.thename.org/Library/MannerRev.pdf 2. Barber C, Hemenway D, Hochstadt J, Azrael D. Underestimates of unintentional firearm fatalities: comparing Supplementary Homicide Report data with the National Vital Statistics System. Injury Prevention. 8(3):252-256, September 2002. 3. Hanzlick R, Goodin J. Mind your manners: part III. Individual scenario results and discussions of the National Association of Medical Examiners Manner of Death Questionnaire 1995. Am J Forensic Med Pathol. 1997; 18(3):228-245. |
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Maria Elena Villar, Research Scientist Nova Southeastern University, Glendene Lemard
Send letter to journal:
mev{at}nova.edu Maria Elena Villar, et al.
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As co-authors on the referenced article, we would like to add to this discussion by addressing two points raised by Hyma et al. First, it is our understanding that we are all in agreement that manner of death coding is dependent on the opinion of the certifier and that “in firearm related deaths, the intents of the victim(s) and shooter(s) are often difficult to ascertain.” (Hyma et al) We are not suggesting that Medical Examiners/Coroners are not striving for consistency or are disregarding NAME guidelines. Instead our point is that due to the intrinsic difficulty in ascertaining intent, unintentional gun deaths in children are underreported. Second, we would like to respond to the statement that our purpose to demonstrate “that unintentional firearm fatalities in children are more common than Medical Examiner statistics suggest, is misguided and irrelevant.” In contrast, we believe that this is extremely relevant to policy makers and prevention practitioners. While suicide, homicide and unintentional firearm deaths share certain risk factors, they also have different implications for education and prevention. In a world where public perception guides policy, it is important to be clear about the strengths and limitations of the data used to inform research, which in turn informs public awareness. Finally, regarding the discrepancy pointed out by Hyma et al in the case that occurred during the Independence Day celebration, we have re- investigated our source of information and discovered three varying accounts of the incident. This further highlights our point that determining intent is not a clear-cut task and that the true incidence of unintentional firearm deaths is not easily determined and may be under- reported. |
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