The Psychological Autopsy: A Useful Tool for Determining Proximate Causation in Suicide Cases Douglas Jacobs, MD and Marci Klein-Benheim, PhD This overview article examines the applications of the psychological autopsy method in determining proximate causation in suicide cases. The article reviews the history of the psychological autopsy and describes its procedure and how it has proved helpful in explicating proximate causation. The five standards cur- rently used by the courts to determine proximate causation in suicide cases are described, as are a variety of applications of the psychological autopsy method, including its application to workers' compensation cases, product liability cases, and medical malpractice cases. In particular, issues of prediction and protection are addressed. Finally, there is a discussion of an application of the psychologi- cal autopsy to criminal cases. The article concludes with a discussion of the is- sues raised in the use of the psychological autopsy during expert testimony and the considerations that should be addressed by an expert witness contemplating the use of the psychological autopsy method. Until recently, suicide was treated in a Nineteenth century psychiatry was influ- number of Western societies as both im- enced by such religious concepts, viewing moral and culpable. According to English suicide as a sign of moral and mental common law, for example, an individual weakness as well as a felony.2 who committed suicide warranted punish- Modern legal thinking, however, has ment for his act; his property was confis- moved away from blaming the person cated by the crown and a stake was driven who committed suicide for his death. For through his heart at burial.' The criminal- instance, in 1961, all sanctions against a ity of suicide was tied to church doctrine, person who attempted or committed sui- the belief that man's life is not his own.2 cide were abolished in ~n~1and.lThis change reflected the belief that criminal Dr. Jacobs is assistant clinical professor of psychiatry, law could not deter a person who wanted Haward Medical School, Boston, and Executive Direc- to commit suicide. The suicidal person tor, National Mental Illness Screening Project, Welles- ley Hills, MA. Dr. Klein-Benheim is a research associate was no longer viewed as a culpable per- with a consulting firm in Fairfax, VA. Address corre- spondence to: Douglas Jacobs, MD, One Washington son to be handled by the legal system, but St., Suite 304, Wellesley Hills, MA 02181-1706. rather as a troubled person to be handled Bull Am Acad Psychiatry Law, Vol. 23, No. 2, 1995 165 Jacobs and Klein-Benheim by the mental health system.' That is, the to be a concept that attempts to define, by person who committed suicide was con- means of many factors, when a defen- sidered to have a mental disorder; and, dant's liability will be limited, even where under certain conditions, was not deemed the fact of causation is clearly estab- responsible for his death. Legal liability ~ished.~ for suicidal deaths was instead shifted to In fact, there seem to be at least five those whose actions "caused" the suicide standards used by the courts to determine or failed to protect the potential suicide whether proximate causation exists in sui- from self harm.3 cide cases. The first, the "substantial fac- Legal liability for suicidal deaths is still tor test," holds that an individual's con- focused on the actions of others, or exter- duct is a legal cause of harm if hidher nal forces, that have a temporal relation- conduct had a substantial, as opposed to ship to the suicide. The question that negligible, effect in bringing about that arises, however, is whether there is actu- harm.4 In other words, liability will be ally a causative relationship to the sui- limited to those cases in which the defen- cide. Indeed, the law demands that in dant's conduct was a substantial factor in order for an individual to be held liable producing the suicide.'> The second test, for the suicide of another, there must be a the "but for test," states that the injury reasonable connection between the indi- would not have happened but for the de- vidual's actions or omissions and the sui- fendant's negligence.4 That is, recovery cide. This connection is usually dealt with will be allowed if the suicide would not by the courts in terms of what is called have occurred without the injury.' Al- "proximate cause" or "legal cause," with though the "substantial factor test" and the word "proximate" derived from Fran- the "but for test" are not synonymous, cis Bacon, who, in 1630, stated: "Injure they are often lumped together because, non remota causa, sed proxima, spec- to satisfy the "substantial factor test," it tatur." ("In law, not the remote cause, but must be shown that the injury would not the nearest is looked to.")4 have happened "but for" the defendant's However, there are few concepts in the negligence and that the negligent act was entire field of law that have called forth so important in bringing about the injury more disagreement and/or confusion than that reasonable people would regard it as the concept of proximate ca~sation.~Al- a cause and thereby attach responsibility though the legal periodical output on to it.4 A third test of proximate causation proximate causation throughout the past is foreseeabilityl, 4; that is, recovery will century has been prodigious,4 Prosser be denied because the suicide was an un- (1950) has noted that "proximate cause foreseeable consequence of a negligently remains a tangle and a jungle, a palace of inflicted injury.' Finally, recovery will be mirrors and a maze, and the very bewil- allowed if the decedent did not know the dering abundance of the literature defeats nature of his actions, or knew the nature its own purpose and adds its smoke to the of his actions but was unable to control fog."5 In general, proximate cause seems them because of mental illness.' Indeed, 166 Bull Am Acad Psychiatry Law, Vol. 23, No. 2, 1995 The Psychological Autopsy as Gutheil et aL7 note, whether a person is personal documents; police, medical, and competent (i.e., has the capacity for self- coroner records; and first-person ac- protection and the ability to give informed counts, either through depositions or in- consent) is also considered in suicide terviews with family, friends, coworkers, cases. school associates, and physicians.9 One of On the issue of causation, the plaintiff the major contributions of psychological has the burden of proof, and must show autopsies "has been to introduce the psy- that it is more likely than not that the sui- chosocial context into decisions about the cide resulted from the cause he posited.4 cause of death since examination of post- This will depend heavily upon the opin- mortem remains tell only what lesions ion(~)of experts in the field of suicidol- the patient died with, not what he died ogy; in applying a sequence of events test, from." '' what may appear to be a cause and effect Studies have shown that there are cer- relationship may be discredited scientifi- tain commonalities to suicide completers. cally. Indeed, as schwartzl has noted, Indeed, RO~" found that persons who courts "camouflage with the use of the commit suicide are likely to be unmar- talisman 'proximate cause' the difficult ried, unemployed, living alone, and de- cause in fact question before them: how pressed. Clark and or ton-~eutsch'~ important from the psychiatric viewpoint found that suicide completers are twice as was the defendant's act in bringing about likely to be male, almost always qualify the suicide?" In this article, we will illus- for a psychiatric diagnosis, and more trate how suicidologists can help deter- often than not communicate intent. San- mine proximate causation in such cases. born et a1.13 found that the protoypical Particular attention will be paid to the im- suicidal individual is not currently em- portance of a technique known as the psy- ployed, is experiencing acute stress and chological autopsy. frustration in areas apart from work, and has an alcohol problem. Moreover, such The Psychological Autopsy risk factors for suicide have been found ~hneidman,' in collaboration with the to vary by age group. Adolescent suicide Los Angeles Suicide Prevention Center completers often have a history of phy- and the Los Angeles Medical Examiner's sical and sexual abuse, parental psy- Office, coined the term psychological nu- chiatric problems, and commit suicide in topsy to refer to a procedure used to clas- the context of an acute disciplinary cri- sify equivocal deaths. An equivocal death sis14, 15., elderly suicide completers often is a death in which it is not immediately have a history of chronic or terminal dis- clear whether a person committed suicide ease. 16 or not (e.g., drug-ingestion deaths, single- Psychological autopsies review the car accident deaths). The psychological specifics of the death and the decedent for autopsy method entails reconstructing a suicide risk factors. ~hneidman,' for ex- biography of the deceased through psy- ample, has identified 14 areas for inquiry chological information gathered from in psychological autopsy studies. These Bull Am Acad Psychiatry Law, Vol. 23, No. 2, 1995 167 Jacobs and Klein-Benheim areas include: (1) identifying information act or to discover what led up to it."8 That (e.g., age, marital status, religious prac- is, they have helped determine why a per- tices, occupation); (2) details of the death; son had chosen suicide, in terms of their (3) brief outline of the victim's history motivation, personal philosophy, and psy- (e.g., previous suicide attempts); (4) death chodynamics, and why a person had history of the victim's family (e.g., family committed suicide at a particular time.