46 Forensic dentistry
Often the cause of death cannot be arrived at by examination of the
remains of the decedent. Just as a clinical physician must take a medical his-
tory prior to performing a physical examination, the medical examiner must
have investigative information regarding the circumstances of death prior to
reaching a conclusion. Review of past medical history, consideration of the
presentation of the decedent at the time of death (sudden collapse, complaints
of symptoms), and other factors are of equal importance to the autopsy and
other examination techniques. It is for this reason that an adequate investiga-
tive team is required to assist the medical examiner in gathering initial and
follow-up information.
Forensic pathology, like any field in medicine, is not an exact science.
There are degrees of uncertainty in any cause of death determination, and
the degree of likelihood necessary to make a cause of death statement varies
from case to case. It is a matter requiring considerable professional judgment
and experience, and is very difficult to quantify in most cases. The phrase
“beyond a reasonable doubt” is a legal term referring to conclusions by a
criminal trial judge or jury, but it has no place in the lexicon of the forensic
pathologist. Instead, medical examiners are often asked to render their opin-
ions to a “reasonable degree of medical probability.” Though even this phrase
is somewhat nebulous, it does at least recognize that medical determinations
invariably involve some degree of uncertainty. It is important to realize that
cause of death statements by a medical examiner are opinions, resulting from
consideration of myriad different factors and observations, generation of a
differential list of potentially fatal conditions or injuries, and selection of the
most likely candidate(s) for cause of death from that list. When explaining
this opinion to attorneys, families, juries, or any other group, the forensic
pathologist must make every effort to convey any degree of uncertainty, to
acknowledge other possible opinions, and to explain his or her rationale for
selecting one over another. To simply state an opinion dogmatically, leaving
no room for competing theories or argument, is incompatible with honest
forensic medical practice. This is perhaps best summarized in a well-known
statement by Dr. Paul Brouardel, a French physician of the late nineteenth
century: “If the law has made you a witness, remain a man of science.
You have no victim to avenge, no guilty or innocent person to ruin or save.
You must bear witness within the limits of science.” These “limits of science,”
and the application of various types of decision-making tools to forensic
sciences, would form the basis for a long discussion far beyond the scope of
this chapter. However, it is incumbent on every practitioner to understand
the limitations, degrees of uncertainty, and sometimes ambiguity of medico-
legal opinions and to readily acknowledge them when appropriate.
Sometimes a cause of death cannot be determined to a reasonable degree
of probability. This may reflect the fact that multiple possible causes of death
are present, and one cannot readily be chosen over another. It may also reflect