9
You Only Die Once—
But Did You Intend It?
The Forensic Psychiatrist As Sleuth
Doubt is not a very pleasant condition, but certainty
is absurd.
—Voltaire
Was It Really Suicide?
Vincent W. Foster, Jr.
On Tuesday, July 20, 1993, as White House Counsel Vincent W. Foster, Jr., walked out of his office in the west wing of the White House,
he told his secretary to help herself to some M&M’s candy left on his
lunch tray. He then drove his car to Virginia, taking the George Washington Parkway to a scenic and secluded spot in Fort Marcy Park, and
shot and killed himself.
In many ways, Foster was a modern version of “Richard Cory” in
the poem by E.A. Robinson. As a corporate lawyer in Little Rock, Arkansas, Foster had earned professional acclaim and was earning
$300,000 per year. But in Washington, D.C., at the side of the Clintons, life was different for him, and difficult. In the week before his
death, he was worried about a possible congressional investigation
into the White House travel office. His connection to that discredited
office had been condemned by such newspapers as The Wall Street
Journal. Foster sought the names of psychiatrists but feared that his
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sessions with them might be taped. He talked to his wife about resigning and returning to Little Rock, to their former, comfortable life. On
Friday, July 16, Foster confided to his sister that he was fighting depression. She gave him some names of psychiatrists to call in Washington.
He attempted to reach one of the psychiatrists twice but failed to make
contact.
Foster took a getaway weekend, which seemed to refresh him, because back in his White House office he appeared rejuvenated. On the
day before his death, he called his family physician and obtained antidepressant medication, but to the very end, Foster exhibited few outward signs of mental distress.
Foster’s death roiled Washington. He left no suicide note and had
not spoken to anyone about suicide. People who knew him were
gripped with utter disbelief. How could a man of such stature and apparent stability, a man whom President Clinton called “the rock of
Gibraltar,” have killed himself? Foster’s judgment and intellect had
been so respected by his White House peers that he was considered a
potential Supreme Court nominee. The park officer who found Foster’s body commented that his slacks were creased, his white shirt was
starched, and every hair on his head was in place.
Foster’s injured professionalism has been advanced as the single
cause of his death, but as a forensic psychiatrist I reject that explanation as too simple. Stock ideas about suicide have no place in a true
understanding of this complex subject. At best, the broadest statement
that can be made about suicide is that its goal is to escape intolerable
and excruciating mental pain and problems of living, considered to be
solvable only by self-destruction.
The specific circumstances of every apparent suicide are unique
and must be thoroughly investigated. In Foster’s case, the more plausible explanation is an unrecognized and untreated psychiatric disorder. On June 30, 1994, Whitewater Special Counsel Robert Fiske, citing conclusive forensic evidence, officially determined that Foster’s
death was a suicide. The report describes his severe depression and
symptoms of panic. Consumed by depression, he could not eat or
sleep. Panic caused his heart to pound and his stomach to boil. He
could not concentrate.
I have seen patients who have tolerated depression for years but
who could not tolerate both depression and panic. It is one thing to
feel depressed and hopeless, but life can become intolerable when one
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is also constantly terrified. The combination of severe depression and
debilitating panic attacks likely proved fatal for Vincent Foster. Both
disorders are associated with an increased risk of suicide. It is particularly tragic because both conditions usually can be effectively and simultaneously treated with antidepressants. But it is likely that conspiracy theories will proliferate because definite answers are themselves
improbable in apparent suicides.
Vincent Foster’s death was quickly judged a suicide. So, too, for a
time, were the deaths of two other notables, Marilyn Monroe and
Robert Maxwell. On August 5, 1962, at 4:30 A.M., the Los Angeles police found Marilyn Monroe dead in her home. The cause of her death
was unknown, but some considered it a suicide. On November 4,
1991, publishing tycoon Robert Maxwell’s naked body was found
floating in the calm waters off Grand Canary Island. Similarly, some
considered Maxwell’s death a suicide. But were these really suicides?
Let us first examine the facts of these two deaths.
Marilyn Monroe
On that morning in 1962, Marilyn Monroe was found lying nude, face
down, with a sheet pulled over her body. Her habit was to sleep naked.
No suicide note was found. The night before her death, no disturbance had been heard by her neighbors, who knew her and considered her a good neighbor. On the morning after her death, an autopsy
was conducted by Deputy Coroner Thomas Noguchi, M.D. Five days
later, the Los Angeles coroner rendered a preliminary judgment that
Monroe had died of a possible barbiturate overdose. On August 17,
that judgment was amended to probable suicide. Ten days later, the
coroner issued his final judgment, saying that Monroe died of acute
barbiturate poisoning that followed an overdose.
The coroner’s decision was based on toxicologic analysis, for no
external signs of violence to the body were found. Blood analysis revealed 8 mg of chloral hydrate, a non-narcotic sedative, and 4.5 mg of
pentobarbital, a sedative barbiturate. A much higher concentration
(13 mg) of pentobarbital was found in the liver. It was theorized that
the chloral hydrate may have interfered with the metabolizing of the
pentobarbital and increased the pentobarbital’s lethal potential.
Many drug bottles were found at Monroe’s bedside table, some
full, others half-empty. One bottle contained antihistamines for a sinus
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condition. An empty canister, dated August 3—only 2 days before her
death—had previously contained twenty-five 100-mg pentobarbital
capsules. There were also ten 500-mg capsules of chloral hydrate, and
the remainder of a 50-capsule bottle dated July 25 and refilled on July
31st, which had been prescribed by Monroe’s longtime psychiatrist,
Dr. Ralph Greenson.
Dr. Greenson spoke with a suicide prevention team that the coroner had assembled to compile a psychological profile of Monroe at the
time of her death. This was done so the coroner could more judiciously consider whether there had truly been a suicide. Neither Dr.
Greenson nor Monroe’s caretaker, Eunice Murray, believed she had
deliberately taken her life. Other evidence assembled by the team
showed that Monroe had not been mentally unbalanced or physically
dependent on drugs. Her drug intake was considered to be light to medium. Pressed to make a decision—as one member later admitted—
the team concluded that Monroe had either committed suicide or had
made a suicide gesture that had turned lethal. The coroner’s office was
reportedly anxious to have the investigation completed, to issue a
death certificate, and to put the Monroe matter behind them.
Because the controversy over her death has continued to this day,
that last aim was never achieved. The haste with which the suicide investigation was conducted almost ensured that the case would, at least
in the mind of the public, remain open. It has been reported that Dr.
Noguchi and other forensic experts familiar with the facts at the time
did not believe that Marilyn Monroe committed suicide. For example,
they had learned that Monroe had made positive plans for the future.
Also, the difference in drug levels in the blood and liver suggested that
she had lived many hours after ingesting the pentobarbital. Further,
the forensic experts cited the fact that no trace of the drugs had been
found in her stomach or duodenum. To them, this meant that a lethal
dose of pentobarbital could not have been taken by mouth or by injection. (An examination of the body with a magnifying glass concluded
that there were no needle marks.)
In a biography of Monroe, author Donald Spoto examined carefully and rejected all the fanciful theories that contend Monroe’s death
was ordered because she “knew too much” about the Kennedy family.
However, Spoto was convinced that her two caregivers, an attendant
and Dr. Greenson, were accomplices in her death. He theorized that
they could not tolerate Monroe’s emerging independence and capac-
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197
ity to achieve happiness apart from them. Spoto believed that Dr.
Greenson had become so enmeshed in Monroe’s life that her plan for
imminent departure to a new life was an intolerable rejection of him,
one that impaired his professional treatment of her. Spoto contended
that the chloral hydrate enema ordered by Dr. Greenson for Monroe
capriciously imperiled her. There is no evidence, however, that Dr.
Greenson consciously attempted to harm Marilyn Monroe.
Was Marilyn Monroe’s death a suicide, murder, or an accident?
We may never know, because there was no opportunity to do a complete forensic psychiatric autopsy or postmortem evaluation drawing
on how she lived her life in the days and weeks prior to her death.
Robert Maxwell
A few days before Robert Maxwell’s death, he had suddenly ordered
the captain of his yacht to sail for Madeira and Tenerife Island, off the
northwestern coast of Africa. The captain reached Grand Canary Island and sailed around it, since Maxwell had decreed no particular
course. At approximately 5 A.M. on that morning in 1991, Maxwell
called the bridge to complain that his room was too cold. Then, unseen by anyone, he made his way up to the deck and either fell,
jumped, or was pushed to his death. Was it suicide? An accident?
Murder? Or natural causes? The answer was not an academic matter,
for if it could be determined that Maxwell’s death was accidental, his
family could collect $36 million from his life insurance.
Maxwell had been a billionaire, the exuberant wielder of enormous power through his newspapers and other businesses, and
through statesmen whom he had befriended. Given Maxwell’s previously demonstrated ability to rebound from personal scandals and
business disasters, suicide seemed out of character for him, although
he—much more than Marilyn Monroe—seemed to have had reasons
for committing suicide. Adversity had always inspired him. He
seemed to crave challenges. Many who knew him, however, came to
the conclusion that his death was not an accident, or by natural causes,
such as cardiac arrest either before his fall into the ocean, or by the
shock of the water. They believed he had committed suicide to avoid
complete personal disgrace and jail that might await him upon his return to England. Outraged bankers and members of his own corporate board were scheduled to confront him about the disappearance of
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corporate assets and monies from pension funds. These intimates believed that for Maxwell, who desperately sought the respect of people
in high places, the humiliation that would have followed revelations
about the disappearing assets would have been unbearable—and,
therefore, pushed him to a shame suicide.
Some believed that Maxwell had not died at all and that the body
identified by family members was that of someone else. The Spanish
authorities who recovered the body refused to do a dental plate comparison. They could not use fingerprints on file because the files were
too old. The autopsy that they performed was suspect because it described the corpse as having chestnut-colored hair, when Maxwell’s
was gray and dyed jet black. Other people—members of Maxwell’s
family—advanced the theory that Maxwell had been murdered by a
treasonous crew member or by a frogman assassin.
What was known about Maxwell’s personality gave rise to these
and other theories because he was an enormously complex man of
myriad contradictions, capricious behaviors, mood swings, and dark
corners of mind. Some intimates thought he possessed multiple personalities; one, a former editor, believed him to have had as many as
20, each struggling with the others for control.
Evidence that Maxwell lived in a fantasy world of some sort was
not hard to find. He had invented his background, his name, and parts
of himself. Born Jan Ludwik Hock, he changed his name at various
times to Leslie DuMaurier, James Maxwell, Ian Maxwell, and finally
Robert Maxwell. He told people that he had been with the Czech underground in World War II, fighting the Nazis. But his tales were unsubstantiated and also at odds with the facts of the underground activity in the area of Czechoslovakia where he had lived at that time.
Maxwell once refused to be interviewed by a Jewish magazine, asserting that he had joined the Church of England, but later claimed that
the conversion was only a prank played on a journalist.
The most likely theory of Maxwell’s death is that he killed himself
because he was at a point in his life where the final identity that he had
created for himself was about to be destroyed. The idea of Maxwell having multiple personality disorder also provides a theory if, in fact, Maxwell suffered from this disorder. It was not beyond possibility that because of the extreme stress of events, a murderous alter personality could
have emerged and killed Maxwell. The explanation of his death could
also be a lot simpler: a Spanish pathologist took note of the fact that Max-
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199
well’s stomach contained a barely digested banana and surmised that he
could have slipped on a banana peel and fallen to his death.
Suicide, Accident, Murder, or Natural Death?
Enter the Forensic Psychiatrist
What happened in the deaths of Vincent Foster, Marilyn Monroe, and
Robert Maxwell—that despite the availability of sophisticated scientific analyses, the intent to suicide has not been definitively established
but also cannot be definitively dismissed—is often true of suicides. Although most suicides are intentional, some are not, as I explain later
in this chapter. What appears to be a suicide, even if unintended, may
be murder. For example, preliminary results of a recent forensic examination on the exhumed body of germ warfare researcher Frank R. Olson appear to contradict government conclusions that he jumped to
his death in 1953 from a Manhattan hotel after unwittingly taking
LSD in a CIA experiment. This recent finding at last verified the suspicion, long held by Olson’s family, that he was murdered.
Murder Masquerading as Suicide
Murder masquerading as suicide is not rare. It is less likely to occur
with a public figure or celebrity, however, because close scrutiny may
uncover the deception. Murder masquerading as suicide is more likely
to remain unsolved when the individual murdered has a history of
mental illness.
Angela, a 36-year-old married but separated woman, was found hanging naked in her bedroom closet by her landlord. Her knees were approximately 4 inches off the floor. The police found no signs of a
struggle in the apartment, and no suicide note. Angela had told
friends and coworkers that she was taking a few days off to put the
finishing touches on a novel she was writing. A manuscript was found
on her desk. She did not have significant financial problems.
The body was cut down so as to preserve the knot made for the
noose. Fingerprints were obtained but were inconclusive. The forensic pathologist retained by the prosecution opined in her report that
the death was suspicious. She noted that suicide by hanging is not a
preferred method for women. The slipknot that was used contained
clumps of the deceased’s hair tangled within the knot. The forensic
pathologist stated that persons who hang themselves usually do so
with a simple slipknot that is not intertwined with their hair. The slip-
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knot is tied first and then the noose is placed over the head without
entangling the hair in the knot. The rope around Angela’s neck was
on a horizontal plane, as if it were tightened first before any strain was
applied. The forensic pathologist explained that a diagonal misplacement is more pronounced in suicides. The rope’s impression on
Angela’s neck was not as pronounced as seen in hanging deaths.
Moreover, the forensic pathologist observed that women who kill
themselves do not ordinarily do so in a naked state. Furthermore, it
could not be determined whether Angela sustained any trauma to her
body because of advanced bodily decay. There was no evidence of a
sexual assault. Blood analysis did not indicate evidence of drugs or alcohol. The pathologist concluded that Angela was murdered.
The defense’s forensic pathologist’s report states that it is not uncommon for hair to become entangled in a noose, that no conclusions
should be drawn from the knots used, and that his experience was
that women hang themselves in various states of undress. Also, the
angle of the ligature was an equivocal piece of evidence. This pathologist concluded that Angela’s death was a “garden-variety” suicide.
After further investigation, the police learned that Angela’s husband, age 49, a retired military officer, had a police record for spousal
abuse. After 10 years of marriage, Angela was planning a divorce. A
year prior to her death she had obtained a protective order against her
husband for stalking. Witnesses testified that Angela was afraid of being stalked again by her husband, who had once threatened to kill her.
She had begun a new romantic relationship at work. Angela had told
friends that her husband said that he would kill her rather than “give
her up” to another man. Neighbors provided sworn statements that
they had heard loud, angry voices and the sound of furniture falling
over at about the time of Angela’s death. One witness saw the husband’s car in the parking lot and observed him entering the apartment
building where Angela lived at around the time of her death. Hair
samples found in Angela’s apartment matched those of her husband.
The husband was questioned but denied any knowledge of Angela’s death. He claimed that he had not spoken to his wife in more
than a year. He stated that she had an extensive psychiatric history,
and had attempted suicide on several previous occasions. His alibi
was that he was out of town attending a regatta during the time his
wife had died, but the alibi could not be substantiated.
Because of the suspicious circumstances, the district attorney requested a postmortem psychiatric assessment to determine the presence or absence of suicide risk factors at the time of Angela’s death.
Witness statements and medical and psychiatric records were obtained and reviewed. The records indicated that she had developed
bulimia nervosa at age 17. The breakup of a romantic relationship had
resulted in depression, superficial wrist cutting, and a brief hospitaliza-
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201
tion at age 19. A maternal grandmother had attempted suicide during
a postpartum depression. The inpatient psychiatrist had made a diagnosis of Angela as having an adjustment disorder with depression.
Angela had married at age 26 after graduating from college with
a master’s in business administration. Because of psychological and
physical abuse by her husband—a particularly violent beating—she
then sought outpatient treatment. Her physical injuries included six
fractured ribs and a facial fracture. Her husband was arrested, briefly
jailed, and ordered to attend a treatment program for wife abusers.
Angela’s new psychiatrist diagnosed dysthymic disorder (chronic depression). He noted that Angela had experienced brief flurries of unbidden suicidal thoughts after being assaulted, but had no suicidal intent or plan. As a way of medicating her marital stress symptoms, she
occasionally drank wine excessively. She received 3 years of psychiatric treatment, which ended 1 year before she obtained the protective
order.
Further information of note came from Angela’s parents, who revealed that she was about to receive a $500,000 inheritance from an
aunt who had recently died. Angela and her husband knew of this bequest. Angela’s husband was a secondary beneficiary of the inheritance as long as the couple remained officially married.
The estranged husband was indicted for second-degree murder,
convicted, and sentenced to life in prison.
Did You Intend It?
An individual may have no intention of dying when he or she makes
a suicide gesture—the sole purpose of the gesture may be as a cry for
help or to bring about a desired result, in a relationship or in the external world.
Friedrich Nietzsche, in Beyond Good and Evil, said, “The thought of
suicide is a great consolation: by means of it one gets successfully
through many a bad night.” For some very disturbed patients, the freedom to terminate one’s own life is a fundamental solace. It is conservatively estimated that 30,000 people kill themselves each year. In fact,
the actual figure is likely much higher. The World Health Organization estimates that nearly a million people around the globe take their
lives each year, The same organization also estimates that 10 to 20 million people attempt suicide each year. Almost everyone has thought of
suicide at one time or another, usually when seriously depressed or
during a difficult personal crisis. Although there is quite a spectrum of
intent among those who have contemplated suicide, often only a fine
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line exists between those who think about suicide and those who actually commit it.
In my clinical experience, patients may be suicidal for just seconds,
minutes, or hours. Other patients have been seriously suicidal for days,
weeks, months, years, or much of their lives. Sometimes a quirk of fate
makes the only difference in whether a person survives a suicide attempt.
One of my patients, prior to coming to me for treatment, survived a massive overdose of pills that she took as she lay in a bathtub full of water. It
was in the middle of winter. The water rapidly cooled as she lost consciousness, lowering her metabolism enough so that she survived until
the next day, when she was discovered by her housekeeper. Having attempted suicide once and failed, she never again had the urge to harm
herself. However, of those who do commit suicide, anywhere from 9%
to 33% have made previous attempts. It is estimated that 8 to 25 suicide
attempts occur for every completed suicide. Between 7% and 12% of patients who make suicide attempts commit suicide within 10 years, which
means that attempted suicide is a significant risk factor for suicide.
In the United States, the statistics on suicide provide some hard
facts. The rate of suicide in the general population in 2005 was 11 per
100,000 people per year. The rate has remained steady for many
years. For persons with schizophrenia, mood disorders, or those who
abuse alcohol or drugs, the rate soars to 180 per 100,000. In one study,
the leading methods of suicide were
• Firearms, 60% (males 65%, females 40%)
• Hanging, 14% (males 15%, females 12%)
• Gaseous poisons, 10% (males 8%, females 11%)
• Solid/liquid poisons, 9% (males 6%, females 27%)
• All other methods, 7% (males 6%, females 10%)
The family and friends of suicide victims are at increased risk of
suicide themselves. They are also more vulnerable to physical and
psychological disorders. Suicide intent is frequently an issue in criminal cases in which it must be determined if the victim was murdered
or committed suicide. In civil litigation, determination of intent is necessary to recover death benefits under insurance policies, in legal actions involving workers’ compensation benefits, in malpractice claims,
and when suicide is alleged to be the result of injurious actions by third
parties. The most insidious tangle is in regard to insurance benefits.
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203
Insurance companies that suspect suicide may invoke a policy’s exclusionary clause to deny responsibility to pay benefits, whereas the deceased individual’s estate may contend that the death was accidental
and not suicide. Stakes regarding suicide intent can be as large as the
$36 million riding on the cause of Robert Maxwell’s death.
Why Naked Suicide?
Legend has it that when Cleopatra committed suicide by allowing the
bite of an asp, she was naked. A famous painting of Cleopatra’s death
reveals an obvious erotic theme. Both Marilyn Monroe and Robert
Maxwell were naked when discovered dead, she in her bed, he floating
in the ocean. There is little mystery about Monroe’s naked state, since
she was known to sleep in the nude. Why Maxwell was naked when
he died is a mystery, and the authorities seemed to take little note of it
in their autopsy. They should have. As an expert witness in a number
of suicide cases in litigation, I found that in approximately 5% of my
cases, the individual committed suicide naked. Even so, attorneys and
other experts in most of the cases showed little interest in the fact of
the suicide’s nakedness. Only in one case did it make a difference; the
attorneys for the defense in a suicide malpractice case postulated that
the patient was found hanging naked as the result of an autoerotic asphyxia gone wrong. The case was settled.
Most naked suicides are fraught with psychological meaning, if
that meaning can be divined. The professional literature has little data
on the topic. Most information is anecdotal, coming from individuals
who have attempted suicide naked, but survived. The reasons given
reflect highly individual psychodynamics in each instance. I have
asked a number of experienced psychiatrists for their interpretation of
naked suicide. Many spontaneously recited Job 1:21: “Naked came I
out of my mother’s womb, and naked shall I return.” Other psychiatrists postulated that naked suicide symbolizes a new beginning, a rebirth and cleansing or a sloughing off of an intolerable world. Naked
suicide challenges the forensic psychiatrist’s sleuthing abilities.
Mysterious Deaths: The Psychological Autopsy
The psychological autopsy originated in 1958, from the Los Angeles
Suicide Prevention Center, to assist the Los Angeles County Medical
Examiner’s Office in distinguishing drug overdoses from suicides. The
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basic principles for performing the psychological autopsy were established, as was its goal: the psychological autopsy is a procedure that
assists in the classification of equivocal deaths, where the manner of
death is unclear. A lack of standardization of the psychological autopsy
procedures is a significant limitation on the practice, raising admissibility issues in criminal and civil cases.
Forensic psychiatrists are experts who understand the pertinent legal issues as they apply to psychiatric cases before the court. They
translate psychiatric principles into the language of intent as it is defined by the legal system. Forensic psychiatry is a recognized subspecialty of psychiatry, and specialists can earn board certification. Years
ago, forensic psychiatrists were known primarily for their work with
criminals. Today, they also consult on a wide variety of administrative,
legislative, and civil law matters, some of them involving suicide.
The forensic psychiatrist is frequently called upon in insurance litigation to evaluate suicide intent, sometimes by the plaintiff—the estate that is bringing the suit—and sometimes by the defendant—the
insurance company. Although, as Oliver Wendell Holmes once observed, “Even a dog knows the difference between being tripped over
and being kicked,” the forensic psychiatrist’s job in establishing suicide
intent can be a complex, daunting task. The basic problem comes
from the fact that psychiatry and law have views that differ in trying
to understand the conundrum of suicide intent. Psychiatric theories of
behavior tend to be deterministic; that is, they say that the individual
contends with psychological forces that are often beyond his or her
control. On the other hand, legal theories are based on the belief that
humans have free will—that they are not deterministic. In evaluating
suicide intent, therefore, the forensic psychiatrist must keep both understandings in mind, adapt psychiatric principles to the legal framework, and perform what is, in essence, a psychological autopsy.
The intentional injury exclusion of insurance policies is designed to prevent enrichment for immoral or illegal acts that have been performed
by a competent individual. Competency itself is vague and complicated.
When is someone competent, and when not? It is necessary in individual suicide cases to determine whether the victim intended to end
his or her life. Approximately 90% to 95% of all those who commit suicide are suffering from a mental disorder. In a given case, did the individual understand that the self-destructive act would end his or her
physical existence or was he or she not able to understand that?
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One factor affecting the legal definition of intent is the presumption
against suicide that is maintained in many jurisdictions. This presumption is a legal restatement of the common belief that the instinct for
self-preservation in a rational person renders suicide improbable.
This, of course, is not always true. So-called rational suicides occur, for
example, among individuals who have terminal illnesses.
In elderly persons or persons suffering from chronic or terminal illnesses, deciding when a contemplated suicide is rational can be a very
tricky business. I have been asked to assess elderly persons who were
refusing food, water, and essential medications. In a number of instances, the elderly person’s caretaker assumed that the patient had decided that he or she has lived long enough and has made a rational decision to die. Yet a majority of these persons were depressed and, in
reality, were committing silent suicide. Their response to antidepressant medications was often rapid and gratifying.
Evidence of intent is generally derived from two basic sources. The
first is from the persons who knew the individual’s behavior and desires
for some time prior to the moment of death—such as family members,
friends, neighbors, coworkers, and treating physicians. The second
source is forensic, and is provided by experts and based on the development of all relevant information about the individual at or around the
time of death. In an insurance claim contest, this latter information will
be given by forensic psychiatrists, who attempt to determine the most
likely psychological reason or cause for the insured person’s death.
In doing our forensic psychiatric work in an equivocal suicide case,
we attempt to reach a detailed understanding of the deceased person’s
life because the way a person lived has a bearing on how and why he
or she died. The key to the establishment of intent, then, depends on
the establishment of motive. What could have been the reasons for
wanting to die, that is, to have an intent to commit suicide? A terminally ill patient who refuses further medical treatment may seem to be,
but is not necessarily, committing suicide. He or she may not intend
to die, but rather, to live free of useless, burdensome, or painful medical treatments. Especially in regard to the elderly and chronically ill,
the forensic psychiatrist must distinguish between suicide and the desire not to prolong the process of dying. Suicide notes may establish a
motive, but such notes are found in only about one-third of all cases.
To reconstruct the psychological life of an individual who is suspected of having committed suicide is to perform a psychological
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autopsy. In systemic risk assessment, forensic psychiatrists thoroughly
examine the person’s lifestyle, circumstances, and the feelings, thoughts,
and behaviors that existed during the days and weeks prior to death.
This permits a better understanding of the psychological events of those
last weeks and the circumstances that might have contributed to the
death, considering both suicide risk and protective factors. Table 9–1 is
a conceptual model of suicide risk assessment used in assessing suicidal
patients and in determining whether a person committed suicide or died
of other causes. Other models of suicide risk assessment are available,
but none have been tested for reliability and validity.
In a psychological autopsy, what we look for are ways to evaluate
the ability of the deceased to conceive, plan, and execute suicide, and to
evaluate that within the legal concept of intent. A failure in any one of
these three basic phases of mental functioning may indicate that the
deceased lacked the mental capacity to intend suicide. However, the
presence of ability to conceive, plan, and execute suicide does not necessarily ensure that the deceased had sufficient mental capacity to intend suicide. For example, one could conceive and plan violent acts
with the greatest diligence and execute them with remarkable elegance, and still be mentally deranged by delusions and thereby be considered as lacking the mental capacity to fully intend a violent act. In
some jurisdictions, the presence in the deceased of serious mental illness may negate any finding of intent. In other jurisdictions, even if the
person has been totally psychotic, he or she can still be determined to
have had suicide intent. If the psychotic individual did not understand
what he or she was doing, would that mean intent was absent? For example, was there intent to die if a person on LSD was convinced that
he or she could fly off a building and not be harmed? In that instance,
I would conclude that the intent was not to commit suicide.
Complex and nuanced medical-psychiatric issues are often present
in determining intent to commit suicide. The psychiatrist who only
treats patients, or who seldom thinks along the lines necessary for forensic evaluation, has a tendency to overidentify with the family of the
bereaved and give a judgment that favors the family over the insurer.
Forensic psychiatrists, trained in clearly separating the treatment component from the role of evaluator, are more able to minimize or to
avoid emotionally biased conclusions in litigation.
It is important to evaluate the person’s state of mind in relation to
the legal question at hand, for example, to evaluate intent to commit
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TABLE 9–1.
Systematic suicide risk assessment:
a conceptual model
Assessment factorsa
Risk
Protective
Individual
Distinctive clinical features (prodrome)
Religious beliefs
Reasons for living
Clinical
Current attempt (lethality)
Therapeutic alliance
Treatment adherence
Treatment benefit
Suicidal ideation
Suicidal intent
Suicide plan
Hopelessness
Prior attempts (lethality)
Panic attacks
Psychic anxiety
Loss of pleasure and interest
Alcohol/drug abuse
Depressive turmoil (mixed states)
Diminished concentration
Global insomnia
Psychiatric diagnoses (Axis I and Axis II)
Symptom severity
Comorbidity
Recent discharge from psychiatric hospital
Impulsivity
Agitation (akathisia)
Physical illness
Family history of mental illness (suicide)
Childhood sexual/physical abuse
Mental competency
(continued)
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TABLE 9–1.
Systematic suicide risk assessment:
a conceptual model (continued)
Assessment factorsa
Risk
Protective
Interpersonal relations
Work or school
Family
Spouse or partner
Children
Situational
Living circumstances
Employment or school status
Financial status
Availability of guns
Managed care setting
Demographic
Age
Gender
Marital status
Race
Overall risk ratingsb
aRate
risk and protective factors present as low (L), moderate (M), high (H),
nonfactor (0), or range (e.g., L–M, M–H).
bJudge overall suicide risk as low, moderate, high, or a range of risk.
Source.
Adapted from Simon and Hales 2006. Used with permission.
suicide as defined in the insurance policy signed by the deceased and
by the laws of the jurisdiction. The legal context evaluates motive, intent,
and act in regard to a particular happening. In clinical psychiatric contexts, it is conception, planning, and execution that must be assessed, and the
two sets of notions are only roughly similar. Here, as in other clinicallegal contexts, an imperfect fit exists between psychiatry and the law.
Conception (Motive)
How, when, and why the idea of attempting or completing suicide
arises in a person must be critically analyzed, especially in a court case.
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Was it a sudden and impulsive act, or was it planned in considerable
detail? Was the suicide committed in a fit of rage or during a bout of
drunkenness? Was the suicide the outgrowth of depression or schizophrenia? Can one find evidence of a plan to commit suicide, say, in the
fact that an individual was mired in financial problems and might hope
by death to provide for his or her family through insurance death benefits? Consider the following case:
A 57-year-old chairman of the board of a once successful manufacturing company, which he had built up through years of hard work, is
facing difficult choices. Business reverses and intense competition
have brought on a crisis. Banks are demanding payments on loans
that are overdue and are refusing to refinance those loans. The chairman sinks his personal fortune into the company in the fight to keep
it afloat. He takes a substantial cut in his own salary. His wife of 28
years is worried, because in all that time, she has never seen him so
upset. He seems “panicked” about their personal finances.
The couple’s three children are in college, and he wants to keep
them there. He himself never had the benefit of a college education.
He cannot bear the thought that if the financial situation continues to
worsen, he might not be able to pay the balance of their tuitions. He
hints to his wife and friends that he has a plan to improve his financial
situation. At work, he seems to function without difficulty. He does
not seek out a mental health professional, nor does he seem to coworkers to be depressed.
One morning, the chairman works until 11 A.M. and then departs
in his car for a meeting in another part of town. The weather is clear.
En route to that meeting, and traveling at 80 miles per hour, his car
strikes a bridge abutment. He dies instantly in the crash.
Police examination of the scene reveals no skid marks from his car.
No other vehicles were involved in the crash. It could not be established that there were any pre-crash mechanical problems with his car.
An autopsy finds equivocal evidence that he had had an acute heart
attack. No suicide note is found. The death certificate states that the
cause of death is natural. The workers’ compensation insurance carrier, however, conducts its own investigation and concludes that the
death was a suicide. It refuses to pay out on his policy.
The forensic psychiatrist retained by the family of the deceased,
and charged with the task of performing a psychological autopsy,
does not automatically accept the death certificate finding, nor does
she reject it. Death certificates frequently do not address the matter of
suicidal intent or lack of it. The death certificate is a document whose
purpose is to provide vital statistical data. It is not based on the totality
of evidence that may later become available. The forensic psychiatrist
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cannot simply accept the postmortem finding of a possible heart attack either, because it is not in keeping with the weight of the other
evidence. For instance, it was discovered that shortly before his death,
the deceased had put all of his affairs in order.
The forensic psychiatrist’s examination of the chairman’s life reveals a man who was very disciplined and who rarely acted impulsively. He led a quiet life, had conservative habits and tastes. No history of alcohol abuse, drug abuse, or gambling was present. Family,
financial stability, and occupational success and gratification are no
longer protective factors against suicide.
The workers’ compensation law in the deceased’s state reads that
the insurer could refuse to pay compensation “if the injury or death
resulted from the person’s intent to injure or kill himself.” The forensic psychiatrist concludes that despite the absence of evidence of a
mental disorder such as depression or psychosis, the preponderance
of the available evidence (more likely than not) showed that the chairman had intended to kill himself, in a suicide staged as an accident, to
provide financially for his family. The chairman’s conception or motive
for killing himself was likely the result of his declining financial status
and the perception that further decline would produce dire consequences for his family. His plan was to cause his death through a
staged accident and thereby enable his family to cash in on his large
insurance policy. Execution of the plan of suicide was carried out by
crashing the car into the bridge. The three conditions required to find
intent to suicide were thus met. The forensic psychiatrist presented
her findings to the family. They discharged her and decided to seek
another expert opinion.
In the matter of conception or motive, there are suicides that are
not motivated or not intended. Some people who suffer from brain
disorders may be considered unable to conceive or to have a motive
for suicide, but they occasionally randomly or impulsively kill themselves—or others. Trauma to the head or drug and alcohol intoxication can cause acute brain dysfunction accompanied by the unleashing
of violence. The resulting acts, even when directed against the impaired person, may not meet the legal criteria for intent to commit suicide, in part because it is so obvious that the other two conditions,
planning and execution, have not been met.
Certain “suicides” are also just as clearly not intended, although
they involve no physical brain disorder. For example, a person may
plan a suicide gesture. The motivation may show the intent is only a
cry for help or the desire to manipulate a situation or another person,
but, through miscalculation, the suicide gesture may result in death.
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Miscalculations also occur in other kinds of death that initially may appear to be suicides, such as in autoerotic asphyxia. This is an attempt
by young men to enhance sexual pleasure by decreasing the flow of
oxygen to the brain. If miscalculated, it can result in death by hanging,
even though the real motive was only to produce a heightened sexual
experience while masturbating.
Planning (Intent)
One can conceive the idea of suicide but fail in the intent or planning
of it. Persons driven by impulse, by psychosis that produces a break
with reality, or by intoxicants may have lost the ability to plan a violent
act, even though they have thought about it for some time. The event
may still happen, however, even if it is not actually planned. Intoxicants may destabilize the person and prematurely precipitate a violent
act. For example, consider this case:
A 33-year-old minor league baseball player harbors a grudge against
a former major league coach. The player has often been heard by
other players to threaten physical harm to that coach, who he feels has
thwarted the player’s major league career. One evening, while intoxicated with alcohol and cocaine, he takes a baseball bat and bludgeons
to death a different person, the coach of an opposing minor league
team, and then fatally shoots himself.
Citing the intentional-injury clause of the player’s team liability insurance, the carrier disallows payment to the deceased coach’s family.
Litigation follows. The forensic psychiatrist conducts interviews with
players from both teams, which reveal that the murdered coach was
liked and admired by the player who killed him. Postmortem blood
analysis of the player reveals the presence of cocaine and a blood alcohol level of 0.23 (intoxicated).
In this case, forensic psychiatric analysis reached the conclusion
that the player’s toxic mental state, brought on by cocaine and alcohol,
had caused the release of a violent act against an unintended victim.
This indicated the inability to plan. The murder-suicide, then, was unintended; it was, instead, an impulsive act.
Another case illustrates a different cause for failure of intent:
A 28-year-old depressed, devoutly religious woman, a week after the
birth of her first child, awakes to intense command auditory hallucinations. She writes a note to her husband: “God commanded me this
morning to bring myself and the baby to Him immediately. God said
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we will not die but live forever. I must obey God. I know you will understand.” Leaving the note for her husband, she gathers their child
in her arms and jumps from the 18th-story apartment.
Forensic psychiatric examination reveals that the woman had a stable personality prior to the birth of the child, but that a severe psychotic depression emerged after childbirth. The suicide note clearly indicates an acute postpartum psychosis. Having a newborn child was
not a protective factor against suicide in this instance, as it is in many
others. The psychiatrist reports to the court that in this instance, the
planning phase of suicide was nonexistent because the woman heard
the auditory hallucinations that compelled her to act immediately.
Such command hallucinations can be extremely powerful psychotic
symptoms that can force action in the here and now. Another factor
that affects the psychiatrist’s understanding of the case is that women
who intend suicide often do not use a method of suicide that will leave
them disfigured. They choose a method that does not involve smashing themselves on the ground. This testimony is challenged by the opposing expert as not having any scientific merit. The court rules that
the deceased did not intend suicide because when she jumped, she did
not want or expect to die.
Execution (Act)
An individual may be able to conceive and to plan a violent act, but
the way in which the violence is manifested may indicate impairment
of the individual’s capacity to execute. Unintentional death, bizarre actions, and the inability to delay or to control behavior are strong indicators of the presence of severe psychiatric disorder. Consider the following case:
A divorced rancher squanders his inheritance, runs into financial difficulties, and is in danger of losing his ranch. His older brother, by
contrast, has invested his portion of the inheritance wisely and has accumulated considerable wealth. The two have had a falling out. The
wealthy brother refuses to lend money to the rancher brother. The
rancher conceives the idea of killing the brother’s beloved wife and
then shooting himself. This is no idle fantasy, for the rancher has been
in frequent fights throughout his life and has a reputation for violence.
The rancher waits until the brother is out of town on business and
sets out to do the deed. He drinks three martinis before he goes. He
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also leaves a note detailing his intentions. The note contains rambling
comments about past grievances against the brother but also mentions “the good times” with him. The rancher hopes that he will
change his mind about killing the sister-in-law before he arrives at her
home. On his way to kill his sister-in-law, the rancher is involved in a
minor automobile accident. An altercation develops. The rancher
shoots and kills the other driver, and then kills himself.
The estate of the slain driver brings a claim against the rancher’s
excess liability insurance policy. This policy contains an exclusionary
provision, which denies coverage for bodily injury or property damage “intentionally” caused by, or at the direction of, the insured.
The forensic psychiatrist interviews friends, acquaintances, and
employees of the deceased rancher. He also culls the available records.
The rancher’s history of intense envy and ambivalent feelings toward
his brother are revealed, as are his spendthrift and impulsive-spending
ways. School, military, and police records demonstrate years of alcohol intoxication and fights. His blood-alcohol content at the time of
death was 0.15 (intoxicated). Few, if any, protective factors against suicide existed, especially abstinence from alcohol.
The psychiatrist concludes that the rancher had the mental capacity to conceive and plan a violent act but lacked the capacity to execute the plan in the way that he had intended. As the rancher drove
to his sister-in-law’s house, the psychiatrist testified, his envy and rage
were so great that the minor accident and altercation in which he was
involved, combined with the alcohol that he had ingested, ignited the
violence prematurely toward an unintended victim and himself.
The court decides to apply a narrow view of intent and makes a
determination that the murder-suicide was the result of the altercation
that came out of the accident. The court ruled that the rancher had
known that he was firing a gun at the other driver and had wished to
bring about a fatal result. The ambivalent feelings expressed in the
note, the court opined, meant that the deceased might have changed
his mind about his original target. The court’s decision, therefore, was
to uphold the injury exclusion clause of the policy and to deny payment to the family of the deceased driver of the second car.
Is Every Suicide a Murder?
As the various cases in this chapter make clear, the forensic psychiatrist’s role in the retrospective assessment of lethal acts is a difficult and
arduous task. It is also one in which the psychiatrist’s judgment is not
the final word. The law is pragmatic. It only requires testimony of
“reasonable medical certainty,” but reaching any sort of certainty is often hard to do. The evidence is often conflicting, and it is up to the
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court to decide what weight to give to each part of it. Moreover, the
legal determination of whether a suicide occurred may depend heavily
on criteria of intent applied by the courts. Ultimately, psychological interpretation of the web of facts and fantasy surrounding a mysterious
death is an art based on a science, and art is a subjective undertaking.
It is left to the courts to make the legal determination of suicide, accident, or murder.
In the world of the psychiatrist, distinctions are not and cannot be
clear-cut. Violent rage reactions can change direction in a second. A
person’s murderous rage that erupts against someone else may, at the
very last moment, be turned upon himself. Conversely, at the last second, a person who intends suicide may turn murderous rage outward
and kill someone else. Or both things may happen: after committing
a murder, and as part of the same violent act, the murderer may turn
the same murderous impulse against himself or herself.
Many years ago, Karl Menninger, the famous American psychoanalyst, observed that almost every suicide is a murder. The recognition that murderous rage can go either way—directed outward or
inward—is critically important in assessing the last mental stage in suicide and in murder. Suicide is often attempted or completed among a
welter of unclear, confusing, and ambivalent feelings. In fact, only one
thing about suicide is clear: the intent to kill oneself is hardly ever
absolute.
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