Lee Garth Vigilant & John B Williamson. Handbook of Death and Dying. Editor: Clifton D Bryant. Volume 1. Thousand Oaks, CA: Sage Reference, 2003.
On the evening of October 2, 1996, an AeroPeru Boeing 757, Flight 603, with 61 passengers and 9 crew members aboard, took off from Lima, Peru. Flight 603, however, did not make it to its final destination in Santiago, Chile. In fact, the aircraft and its passengers were doomed from the very moment of takeoff. Earlier that day, the airline’s maintenance crew had taped over the plane’s left-side static ports while they washed the fuselage of the plane, and, by mistake, they had failed to remove the protective covering after they were through. This seemingly insignificant oversight was actually a dangerous blunder, because with the plane’s static ports covered, the flight crew would be flying without essential information, such as altitude, wind speed, and temperature. From the moment of takeoff, the plane’s instruments were communicating the wrong airspeed and altitude, and, because Flight 603 was a night flight, the pilot and copilot were indeed “flying blind.” When the instruments falsely indicated excessive speed, the crew slowed the plane to a near stall, and when the altimeter falsely indicated that the plane’s altitude was too high, the crew compensated by dropping the elevation to a perilously low level. For nearly 30 minutes, as the cockpit voice recordings of Flight 603 indicate, the pilot and copilot struggled to make sense of the erroneous information the instruments were communicating (MacPherson 1998). Eventually, Flight 603 crashed into the ocean at more than 300 miles per hour, killing everyone on board. At impact, the plane’s altimeter read an altitude of 9,700 feet (MacPherson 1998).
This air disaster, and the 70 accidental deaths that resulted, was most certainly preventable. The flight crew should have caught the maintenance crew’s mistake during the visual check, the so-called walk-around, that the pilot and copilot perform as part of their preflight ritual. That we refer to this tragic event as an accident, and the resultant deaths as accidental, is particularly telling, especially given our knowledge of the determining cause.
By definition, accidental deaths are usually unforeseen, violent, and unexpected. Such deaths are unintended, the result of chance, and culpability is not a matter of simple assignment. But what does it mean to label a death an “accident,” really? Are there situational characteristics that are common to all accidental deaths? The problem of labeling any death an “accident” begins with the very implications that the word accident imbues. If the standard criterion for an accidental death is lack of intentionality, how is that to be determined after the fact? In essence, the ex post facto assumptions surrounding accidental mortality are always the same, irrespective of circumstance: (a) that the deceased did not want to die, (b) that the deceased did not intentionally bring death upon him- or herself, and, ultimately, (c) that the deceased may bear little if any responsibility for his or her own death and the deaths of others involved in the incident. These assumptions raise important thanatological questions for the very meaning of the word accident and its application to accidental mortality, questions that we address in this chapter.
We consider here several issues in the discourse on accidental mortality. We begin with an analysis of the various meanings and problematics of the phrase accidental death. We then consider the occurrence and causes of some of the major accidental death categories in the United States, before turning to an overview of the problem of labeling accidental deaths and special consideration of the notion of subintentional mortality. We conclude with a brief discussion of bereavement and grief recovery in the case of accidental death.
What is an Accidental Death?
If we label all of life’s unpleasant events as accidents, then we come to perceive ourselves as the playthings of fate and we cultivate a philosophy of carelessness and irresponsibility. — John J. Brownfain, “When Is an Accident Not an Accident?” 1962
When we refer to tragedies such as that of Flight 603 as accidents, we mean to imply that these were unintentional occurrences. Accidental deaths occur by chance, without intention or design, and are unexpected and unusual (DeCicco 1985:141). Accidents and accidental deaths are nondeliberate, unplanned, and undesirable occurrences. Yet we are less than precise, both legally and connotatively, when we employ the terms accident and accidental death to describe all situational outcomes that lack intentionality (Bennett 1987; Suchman 1961). For one thing, the term accident conjures the idea that the occurrence of death was unavoidable (Kastenbaum 2001), even if, as in the case of Flight 603, it was the result of human incompetence and error. For another, the very idea of an “accidental death” is troubling both legally and philosophically: In legal terms, it makes us less accountable for the culpability of our actions and choices when serious injuries and death are the end result; philosophically, it involves a certain level of “bad faith” (Sartre 1956), because by reducing death to fate and chance, individuals can deny any responsibility for the final outcomes of their choices and actions (Brownfain 1962, as cited in Thygerson 1977). We too often apply the label of “accidental death” to outcomes that were completely preventable, if not expected, and this is certainly the case with autocide and subintentional suicide (Tabachnick 1973).
Recognizing the verbal and conceptual slippage common to the application of the concepts of “accident” and “accidental death,” the medical sociologist Edward Suchman (1961) has sought to tighten the definitions of these labels even further. Suchman asserts that in deciding whether to label an event “accidental,” we should examine three particular conditions: (a) the degree of expectedness (Was the event unanticipated?), (b) the degree of avoidability (Could the event have been prevented?), and (c) the degree of intentionality (Was the outcome intended?) (p. 244). However, Suchman extends these conditions by outlining what he calls the “antecedents” or “symptoms” of accidents to constrict further the usage and application of the term accident. In determining whether an event might be considered an accident after it has met the aforementioned criteria, Suchman suggests, we should look at four additional factors: (a) the degree of warning (the less forewarning, the greater the likelihood of an accidental occurrence), (b) the duration of occurrence (the more quickly a phenomenon occurs, the more likely it is to be labeled an accident, because greater speed of occurrence reduces the likelihood and degree of control), (c) the degree of negligence (the more recklessness associated with the event, the less likely it is to be labeled an accident), and (d) the degree of misjudgment (the more misjudgments, the less likely the outcome is to be labeled an accident).
If we were to apply Suchman’s rules to the tragic example of Flight 603, the question of whether this event was an accident would undoubtedly be cause for debate. Certainly, the parameters of expectedness and intentionality are satisfied: No one expected, or intentionally planned, the tragic outcome that befell Flight 603. However, a close examination of the events of the day and of the cockpit voice recordings suggests some serious shortfalls. With regard to avoidability, this incident was completely preventable. Human error and oversight caused the crash of Flight 603. In addition to the inexcusable error of the maintenance crew, the flight crew neglected a crucial warning during the takeoff procedure. The first indication that something was wrong with the plane’s altimeter came immediately after takeoff, and the copilot brought the problem to the attention of his captain at that time (MacPherson 1998). In terms of degree of warning, had the pilot simply made the decision then to return to the airport, events would not have unfolded as they did. Moreover, there were other misjudgments; for example, upon realizing that something was wrong with the instruments, the crew should have disengaged autopilot for the duration of the flight. Finally, in terms of negligence, or dereliction of duty, if the pilot and copilot had performed their prescribed preflight visual inspection, they would certainly have noticed the masking tape covering the plane’s left-side static ports.
To refer to the crash of Flight 603 as “an accident” is to ignore many important details and to suggest that what happened was the result of fate or chance. As Kastenbaum (2001) so eloquently says:
It is a dangerous misrepresentation to classify as accidents fatal events that were shaped by human error, indigence, and greed. “Accident” implies that nothing could have been done to prevent the loss of life—thereby contributing to lack of prevention in the future. (P. 239)
Fate did not cause the crash of Flight 603; human negligence, oversight, and misjudgment did. Yet we use the concept “accident” ineptly to describe incidents caused by human error even when science itself does not recognize chance or fate as the causes of social occurrences and “accidents” (Hacker and Suchman 1963). Perhaps the label “accident” offers a measure of consolation to survivors while simultaneously protecting the injured or deceased from any liability for what their errors have wrought. Perhaps the concept “accidental death” reminds us that we are not always in control of the outcomes or proceedings in our lives, and this, for many, is comforting. Whatever the rationale for applying the concept of “accident” or “accidental death” to social outcomes, this much is certain: The label “accident” is an ex post facto admission of the built-in fallibility of human interactions and human choices. Nevertheless, this label often obscures the social antecedents that lead to death and serious injury: the human errors that account for 60% to 80% of all accidents (Perrow 1984). Thus, mindful of this phenomenon, in the next section we report not only on the epidemiology of accidental deaths but also on the causes of, and countermeasures taken to prevent, “accidental” mortality.
The Occurrence of Accidental Deaths: Causes, Solutions, and Countermeasures
Accidents have consistently ranked among the principal causes of death in the United States, yet, compared to the other leading causes of death for all age groups, such as heart disease, malignant neoplasms, and diabetes, accidental mortality receives scant attention. This might be due in part to the fact that “unintentional injury” statistics include many subcategories (see Table 2), but in any case, the impact of accidental deaths on society is undeniable. As Table 1 shows, in 2000 there were 93,592 unintentional deaths in the United States, making accidents the fifth leading cause of death and the leading cause of death for all Americans between the ages of 4 and 33 (Minino and Smith 2001). Moreover, accidental injuries and deaths place a tremendous strain on the nation’s economy through wage and productivity losses, administrative expenses, medical costs, property damage costs, and employer overhead. The National Safety Council (2002) has estimated that in 2000, the average cost of a single traffic fatality was $1 million, the cost for each unintentional death in the home was $780,000, and the average cost of each work-related death was $980,000.
It is certainly not a stretch to say that accidental death is a major social problem, yet Americans in general do not perceive it as such. Most Americans, especially the young, continue to underestimate their risks of dying from accidental causes (Glik et al. 1999). Perhaps this is because of a certain sense of invincibility, or because of a perception that accidents are fateful events over which individuals have little or no control. Whatever the reason, Americans tend to see other causes of death as potentially much more likely to affect them than accidental causes.
Iatrogenic Mortality: Medical Mistakes and Accidental Deaths
The statistical picture of the occurrence of accidental deaths in the United States neglects an entire category of unintentional mortality: accidental deaths due to medical mistakes. Such deaths are a major social problem, yet they are only now coming to public attention and under the purview of political scrutiny. Although reported figures are much debated and disputed by some (e.g., Hayward and Hofer 2001; McDonald, Weiner, and Hui 2000; Leape 2000), iatrogenic mortality, or deaths caused by doctor mistakes, accounts for between 44,000 and 98,000 deaths per year in the United States, a problem of epidemic scale (see Kohn, Corrigan, and Donaldson 2000). Yet, to date, nowhere in the statistics on accidental deaths compiled by the Centers for Disease Control and Prevention (CDC) do we find a category called “accidental deaths due to medical mistakes” (see Table 2).
If there were a category for these accidental deaths, iatrogenic mortality would surpass all other accidental mortalities on the list, including deaths caused by automobile crashes. Moreover, as Kohn et al. (2000) suggest in a volume produced for the Institute of Medicine, iatrogenic mortality could easily be among the 10 leading causes of death, surpassing accidental deaths (42,000), breast cancer (43,000), and AIDS (16,000). Finally, this accidental mortality type is a very expensive burden on the economy, with yearly costs between $17 and $29 billion. Among the many recommendations that Kohn et al. make for reducing the incidence of iatrogenic mortality are the following:
- The creation of research and pedagogical tools that might bring knowledge of this crisis to the medical forefront
- The creation of mandatory and voluntary error-reporting systems
- The raising of standards of care through the establishment of oversight organizations and professional groups
- The instillment, at the delivery level, of a culture of safety among health care practitioners
Motor Vehicle Accidental Mortality
Table 2 outlines the subcategories of unintentional deaths in the United States for all ages, all races, and both sexes for the year 1999. What immediately stands out in these CDC data on accidental injuries is that motor vehicles were involved in an astonishing 42% of all accidental deaths in 1999—three times as many accidental deaths as the next category on the list, falls. Motor vehicle-related accidents account for a huge proportion of all accidents in the United States and a rapidly increasing proportion of accidents globally (Grant and McKinlay 1986; Nantulya and Reich 2002; Peden et al. 2001; Roberts, Mohan, and Abbasi 2002). The scope of the problem is immense: In the United States, there is a traffic fatality every 12 minutes and a disabling injury related to motor vehicles every 14 seconds, making motor vehicle accidents the leading cause of death and injury for the young, with the 15-24 age group most affected (National Safety Council 2002; Lang, Waller, and Shope 1996; Williams and Wells 1995). The National Highway Traffic Safety Administration (NHTSA 2001a) reports that, on average, about 115 persons die each day in motor vehicle accidents. Yet it is important to note that the fatality rate for motor vehicle accidents in the United States is currently at an all-time low and continues to decline, with the exceptions of alcohol-related and motorcycle crashes (NHTSA 2001a). Even so, the number of automobile deaths, approximately 40,000 yearly, is still high.
The demographic picture of automobile fatalities in 2000 shows that 68% of those who died were males; that 16- to 24-year-olds—the age group with the largest number of crashes—were 24% of fatalities; that the intoxication rates of male and female drivers who died in crashes were 20% and 11%, respectively; and that the rates of seat belt use for male and female drivers involved in fatal crashes were 43% and 29%, respectively (NHTSA 2001a). Some researchers have linked the pronounced difference between males and females in motor vehicle death rates to socialization, asserting that males are socialized to engage in more risky, health-endangering practices than are females (Lang et al. 1996; Veevers and Gee 1986; Vredenburgh and Cohen 1996) and have increased driving exposure (Farmer 1997; Massie, Campbell, and Williams 1995). In addition to gender differences, some studies have found a relationship between social class ranking and accidental mortality risk, with higher death rates among the poor for most categories of accidental death, including automobile accidents (Baker et al. 1992; Hippisley-Cox et al. 2002; Nantulya and Reich 2002). But what factors account for the high number of “accidental” motor vehicle deaths in the United States each year?
It was Herbert Heinrich (1959) who initially proposed that as much as 85% of all accidental injuries and deaths in industry may be attributed to “unsafe acts” by individuals, and only 15% to “unsafe conditions.” This controversial statement started a long-standing debate—which is yet to be resolved fully—among safety management professionals (Hagglund 1980; Jeffries 1980). In hindsight, it seems that Heinrich should have applied his theory to automobile fatalities and injuries, and not to industrial accidents, because a statistical breakdown of the causes of motor vehicle crashes shows three things that lend support to his initial conclusion: (a) Most such “accidents” are in fact avoidable, (b) most involve a great many misjudgments, and (c) many are the results of gross negligence or “unsafe acts.”
Every automobile accident can be reduced to three possible causes: (a) environmental factors and driving conditions (i.e., weather and the state of the roadway), (b) automobile problems (which may be due to poor maintenance or equipment failure), and (c) problems with the driver (poor health, risky decision making, risky practices, and so on) (Haddon 1968; Haddon, Suchman, and Klein 1964; Tabachnick 1973). According to the NHTSA’s (2001a) statistical portrayal of motor vehicle accidents in the United States in 2000, the vast majority of all traffic fatalities in that year were due to driving while intoxicated or driving at excessive speeds (40% and 29%, respectively). Thus we can conclude that gross negligence and unsafe acts on the part of drivers—namely, driving while intoxicated and speeding—account for the vast majority of traffic fatalities in the United States.
The link between alcohol consumption and traffic fatalities is unquestionable (Brewer et al. 1994; Haberman 1987; Winn and Giacopassi 1993). According to the National Highway Traffic Safety Administration (2001a), there is, on average, an alcohol-related traffic fatality every 32 minutes; such deaths make up about 40% of the total traffic fatalities yearly. More than 1.5 million Americans were arrested for driving under the influence in 1999 (NHTSA 2001a); such drivers are at substantially greater risk of dying in automobile crashes than are drivers who are not so impaired (Brewer et al. 1994). In fact, the NHTSA (2001a) notes that in 2000, “about 1,400 fatalities occurred in crashes involving an alcohol-impaired or intoxicated driver who had at least one previous DWI conviction” (p. 12); these deaths represented 8% of all alcohol-related fatalities. According to the NHTSA (2001a), 30% of Americans will be involved in alcohol-related “accidents” at some point in their lives.
Alcohol-related traffic deaths are not the sole purview of intoxicated automobile drivers; intoxicated bicycle and motorcycle riders have many fatal accidents as well. In a study that looked at 1,711 fatally injured bicyclists age 15 years and older who were tested for alcohol, Li and Baker (1995) found that an astonishing 32% were positive for alcohol at the time of their deaths, and 23% were legally intoxicated. Among fatally injured motorcyclists in the year 2000, 28% were intoxicated when they died (i.e., they had blood alcohol concentrations of greater than 0.10) (NHTSA 2001a; Shankar 2001).
Excessive speed is another risk factor that contributes to the roughly 40,000 traffic fatalities yearly. According to the NHTSA (2001a), in 2000 speeding was a factor in 29% of all traffic fatalities, contributing to the deaths of more than 12,000 individuals. The NHTSA places the economic costs of speeding-related accidents and fatalities at around $27.4 billion per year. Speeding is a risky behavior especially associated with younger male drivers—that is, those in the 15-24 age group. In 2000, 34% of male drivers ages 15 to 24 who were fatally injured in crashes were speeding (NHTSA 2001a). The problem of speeding is even more severe among motorcyclists. In 2000, there were 2,862 motorcycle fatalities, representing 7% of all traffic deaths; 38% of those deaths were attributed to excessive speeds (NHTSA 2001a). In fact, the NHTSA (2001a) reports that a motorcycle riders is 18 times as likely as a passenger in an automobile to die in a crash. Finally, it is important to note that intoxication and speeding go hand in hand. The NHTSA (2001a) reports that 40% of all alcohol-related traffic deaths in 2000 involved drivers who were speeding; only 13% of sober drivers killed in automobile crashes for the same period had been speeding.
The third risk factor associated with traffic fatalities is seat belt and child restraint usage—or, rather, the lack thereof. According to NHTSA (2001b) figures, seat belts have saved approximately 135,000 lives since 1975; they saved 11,889 lives in 2000 alone. The use of child restraints (specifically designed for children under 5 years old) has saved 4,816 lives during the same period, 316 lives in 2000. In fact, the NHTSA asserts that the use of safety belts could have saved an additional 9,238 lives in 2000. Moreover, in a recent study on the effectiveness of seat belt usage in preventing accidental deaths in children ages 4 through 14, Halman et al. (2002) found that in the front seat of a car, an unbelted child was nine times more likely to sustain a fatal injury than was a belted child; in the rear seat, an unbelted child was twice as likely as a belted child to be fatally injured. Cummings et al. (2002) report that seat belt usage reduces the risk of accidental death in an automobile accident by 65%; that figure rises to 68% when seat belts are used in conjunction with air bags. These researchers also note that seat belts alone provide much greater protection against accidental deaths than do air bags alone; air bag use by itself provides only an 8% reduction in the likelihood of dying in a crash.
A final factor contributing to traffic fatalities is sleep deprivation (see Coren 1996a, 1996b, 1996c). Coren (1996c) estimates that sleep deprivation results in about 25,000 accidental deaths and 2.5 million disabling injuries each year in the United States. He notes that the impacts of sleep deprivation are most obvious during the shift to daylight savings time in the spring, when, as a nation, Americans lose an hour of sleep. In a study of traffic fatalities during the week following the shift to daylight savings time in the spring and the shift back to standard time in the fall, Coren (1996a) found a 6.5% short-term increase when daylight savings time began, but no measurable difference in fatalities when it ended.
What can society do to lower the number of automobile fatalities? This question is one that is growing in significance, not just in the United States, but around the globe. The World Health Organization estimates that by 2020, road traffic accidents will move from being the ninth leading cause of health care burden to the third leading cause, replacing such causes as HIV/AIDS, diarrheal diseases, war, and cerebrovascular disease (Peden et al. 2001). Currently, automobile crashes are the leading cause of injury deaths and the tenth leading cause of all deaths around the globe (Peden et al. 2001). Clearly, this social problem demands a treatment strategy with global reach.
Until now, the primary strategies that societies have employed to lower death rates from vehicular crashes have taken the forms of technological advances (safety restraints, air bags, and the like) and driver education. Although the employment of safety equipment has been particularly effective in reducing deaths from vehicular crashes, driver education has not. In fact, in a study of the effects of high school driver education, Vernick et al. (1999) found that such training did not reduce motor vehicle crash rates for young drivers. Rather, that early licensure, which is the goal of school-based driver education courses, was actually associated with increased risk of crash involvement. Vernick et al. suggest that society should look to other treatment strategies for reducing traffic death rates.
To date, the best treatment strategy has been the enforcement of traffic laws, because, at the end of the day, people continue to underestimate their risk of dying in an automobile crash (O’Neill and Mohan 2002; Williams, Paek, and Lund 1995). The National Safety Council (2003) has called for the primary enforcement of seat belt laws (which so far exist in only 18 states) and for the adoption by all states of graduated licensing policies that require individuals to go through three steps to licensure: a learner’s permit, then a provisional license, and then a full license. The most effective treatment strategies implemented thus far to reduce the numbers of motor vehicle-related deaths have been as follows: technological improvements in vehicle safety; strict traffic law enforcement; passage of safety laws such as mandatory helmet provisions for motorcycle riders, which result in near-perfect compliance in states that have them; and the lowering of the definition of “legally drunk” to .08 blood alcohol concentration in many states (see Mothers Against Drunk Driving 2002). Aside from these, very few strategies have proven to have any significant effects on the rates of motor vehicle-related accidental deaths.
Deaths Due to Accidental Falls
Falls are the second leading cause of accidental mortality in the United States, with more than 13,000 deaths in 1999 (CDC 2002). This mortality type overwhelmingly affects the elderly, accounting for 70% of accidental deaths to persons over 75 years of age (Fuller 2000). In 1999, about 9,600 persons over 65 years old died of injuries sustained in falls, making it one of the leading causes of accidental death among people in this age group (CDC 2002; Fos and McLin 1990). Moreover, accidental falls were responsible for more than 250,000 hip fractures in 1996, resulting in costs exceeding $10 billion (Fuller 2000).
Statistics on accidental falls show that men are more likely than women to die of falls. Some 60% of falling deaths occur at home, 30% occur in public places, and 10% occur in hospital settings (CDC 2002), and the causes of falling deaths vary by setting. For example, in hospital settings, one of the primary causes of falling is physiological disorientation and dizziness resulting from polypharmacy (i.e., the use of four or more medications) (Morse, Tylko, and Dixon 1987); when falls take place in work settings, a common reason is worker error, usually the misapplication of equipment or machine (Copeland 1989). The risk factors associated with falling injuries are very different for the young and the elderly: Accidental falls among the elderly are most often associated with what Stevens et al. (1991-92) refer to as intrinsic risk factors, or causes internal to the individual, such as chronic pain, musculoskeletal and neuromuscular diseases, and the presence of polypharmacy, whereas among the young, falling is most often attributed to extrinsic risk factors, such as environmental conditions or hazards and risk-taking behaviors. Given that the causes are different, the problems of falling among the elderly and the young demand different treatment solutions. For instance, for elderly persons, a few simple improvements in home design might reduce the potential for accidental falls (e.g., installation of slip-resistant surfaces in the bathroom or of wall-mounted light switches that the older person can reach without standing on a ladder) (for a more complete list of suggestions, see Rollins 2000). Because most of the accidental falls that affect younger adults occur at workplaces and are due to some combination of unsafe acts and unsafe working conditions, efforts to prevent such falls have largely focused on improving the effectiveness of communication of the risk of injury on the job (Haskins 1980; Lauda 1980; Reamer 1980). For young children, a simple prevention measure is the use on public playgrounds of “energy-attenuating surfaces” that absorb and cushion the impacts of falls. Parents can also help protect their children from life-threatening falls by keeping appliances and furniture away from open windows in their homes, especially in high-rise apartment buildings (Baker et al. 1992).
Accidental Suffocation
Mechanical suffocation and asphyxiation were responsible for some 5,503 accidental deaths in 1999, and many of these deaths were, for the most part, completely preventable. Moreover, this accidental death category largely affects children under 1 year old, who account for around 40% of the accidental suffocation deaths in the United States (Baker et al. 1992). Any small object in the vicinity of a child is potentially dangerous, as it can lead to accidental suffocation by ingestion. Foods such as popcorn, grapes, nuts, and hard candy all pose potential risks for children less than 1 year of age (National Safety Council 2002). Deaths in this category are not limited to the very young, however; individuals over 65 years of age have one of the highest accidental food-choking rates, with more than 2,500 deaths annually (Baker et al. 1992). Accidental suffocation is also a hazard for many farmers whose work takes them into large storage bins for grains. Suffocations in such bins have been increasing in number in recent years due to the facts that larger and larger grain facilities are being built and many operators of these facilities work alone (Loewer and Loewer 2002).
One of the most prevalent causes of accidental deaths under the suffocation and asphyxiation heading receives little public attention in the way of prevention strategies: death by accidental autoerotic asphyxiation. Autoerotic asphyxiation (the application of cerebral hypoxia through self-strangulation, self-hanging, or manual strangulation among sexual partners to enhance orgasm) takes the lives of more than 1,000 Americans yearly, representing close to 20% of all deaths by accidental suffocation (Byard and Bramwell 1991; Byard, Hucker, and Hazelwood 1990; Michalodimitrakis, Frangoulis, and Koutselinis 1986). It has been speculated that the true number of accidental deaths by autoerotic asphyxia might well be much higher than reported, both because it is easy to mistake such deaths for attempts at suicide or homicide and because some officials may systematically mislabel such deaths as suicides to allow the families of the deceased to avoid the social stigma attached to the act of autoerotic asphyxia. Statistics on deaths owing to accidental autoerotic asphyxia show that males are overwhelmingly more likely than females to be victims of this form of death, with a male:female ratio of about 50:1. The typical male victim is a solitary masturbator between the ages of 12 and 25 (Cooper 1996; Gosink and Jumbelic 2000).
The typical autoerotic death scenario involves a young male who employs a strangulation procedure to the neck, usually self-hanging from a standing or seated position, while masturbating. Unfortunately, when loss of consciousness accompanies hypoxia, the victim loses control over voluntary movement, and accidental death is likely to follow. Many practitioners of autoerotic asphyxia employ “safety devices” such as knives to cut their nooses or slipknots to protect against the possibility of accidental death by losing consciousness (Cooper 1996). These escape mechanisms often do not protect against the loss of consciousness, however, and because the practitioner is usually alone, the risk of accidental death is high.
As we have noted, accidental death by autoerotic asphyxiation has yet to receive the same kind of attention to prevention afforded other accidental causes of death, even though it accounts for nearly 20% of all accidental suffocations. Perhaps this is a result of the stigma that accompanies sexuality in general in the United States, and particularly sexual practices that many perceive to be deviant and dangerous.
Some Special Problems with the Label “Accidental”: Cases of Subintentional Selfdestruction and Disguised Suicide
We have already shown that the statistical picture of accidental deaths in the United States is incomplete because every year between 44,000 and 98,000 iatrogenic mortalities go uncounted. In addition to this issue, the statistical picture of accidental deaths is faulty in that it may include (a) incidents of subintentional self-destruction (i.e., cases that are neither suicide attempts nor strictly “accidental” deaths) and (b) cases of suicides disguised as accidents.
Subintentional self-destruction is death that results from practices that can reasonably be expected to lead toward death (Tabachnick 1975; Smith 1980; Shneidman 1973). Unlike suicide, where there exists in the mind of the person a clear intention to die, in subintentional selfdestruction the person lacks immediate (or sometimes any) intentionality about the possibility of death, despite the fact that his or her behaviors are reckless, making the possibility of accidental death omnipresent (Tabachnick 1975; Smith 1980). Consequently, if death is the final outcome of such a person’s actions, it does not conform to a strict definition of suicide because the individual lacked complete intentionality. Nor does such a death fit the parameters of an accident, because it was probably expected, was totally avoidable, and involved a great deal of misjudgment, negligence, and forewarning. Consider, for example, a man who sits on the wall of a balcony of a 10th-story apartment and then falls to his death. We naturally assume that this death was an accident, and maybe rightfully so because of the lack of intent, despite the reckless abandon involved in the behavior. Yet surely at some point the victim entertained the possibility of falling. Can we really call this an accidental death without violating the spirit of the concept “accident”?
Certainly, many of life’s events involve risk, some greater than others. But the more risk an action entails, the more likely a self-destructive outcome. Perhaps in some cases the label of “subintentional death” is more appropriate than “accident” because it speaks to the level of obvious risk the deceased chose to ignore. Other frequently cited behaviors that might be described as subintentionally self-destructive are parasuicide (where a person might make a false “suicide attempt” as a cry for help, but with no intention of dying); polydrug abuse; participation in high-risk activities, such as Russian roulette or speeding or driving recklessly under conditions that pose a clear danger; and failure to follow a doctor’s advice concerning life-saving medication (Lester 1988; Kreitman et al. 1969; Tabachnick 1975). To date, there are no consistently effective ex post facto mechanisms available that will allow us to differentiate subintentional self-destruction and unsuccessful parasuicide from true accidental or suicidal deaths (Peck and Warner 1995). Ironically, the situations that compel individuals to take part in subintentional selfdestructive behaviors are often the same as those that may be the impetus for suicide; they often include a sense of hopelessness, helplessness, alienation, and isolation (Cole 1988; Smith 1980).
The problem of suicides disguised as accidental deaths also confounds the statistical picture of accidental mortality in the United States (Schmidt et al. 1977; Lester 1990; Pokorny, Smith, and Finch 1972). Although it is debatable whether many disguised suicides are counted as accidental deaths in certain subcategories of causes of accidental deaths (Lester 1985), there appears to be strong evidence that deaths in motor vehicle crashes include a number of suicides. In a decade-long study at the Los Angeles Suicide Prevention Center on the self-destructive impetus behind many automobile crashes, Tabachnick (1973) found that 25% of the victims of single-car crashes in his sample were suffering from depression and expressed feelings of hopelessness and helplessness around the time of their “accidents.” In another study, Phillips (1979) found a peak in car accident fatalities (an increase of 31%) in California 3 days after a highly publicized suicide story ran in the news media. He concludes that vehicular suicides are probably included within the statistical picture of accidental vehicle deaths. In a replication of Phillips’s study, Bollen and Phillips (1981) found a 35-40% increase in motor vehicle fatalities on the third day after a publicized suicide story in Detroit, lending support to the third-day peak theory. These authors also conclude that vehicular suicides might well be hidden in the statistical picture of automobile deaths. Finally, Pokorny et al. (1972) conducted an intensive review of the personalities, emotional states, and social factors of individuals involved in crash fatalities and came to the conclusion that 4 out of the 28 fatalities they observed were likely suicides.
Bereavement and Recovery after Accidental Deaths
The unexpectedness, suddenness, and often violent character of accidental deaths compound the difficulties that the survivors of the deceased face in their bereavement and grief recovery processes. The survivors of loved ones who die accidentally do not have the periods of anticipatory grief that those who lose loved ones in other ways often experience. In cases of acute mortality, such periods of grief may last weeks, months, or years, and may enhance survivors’ coping abilities and bereavement recovery (Dane 1991; Hill, Thompson, and Gallagher 1988; Huber and Gibson 1990). The shock and traumatic emotions that accompany the news of accidental death, common features of this type of bereavement, might last for weeks (Hogan, Morse, and Tason 1996; Sanders 1982-83). Raphael (1983) lists four possible features of accidental deaths that can make survivors’ grieving process more intense than that associated with death from chronic or acute illness: (a) the possibility of an accompanying traumatic stress response because of the shocking and unexpected nature of the news that a loved one is dead, (b) the possibility that learning of the violent nature of the death may compound the survivor’s trauma and shock, (c) the possibility of seeing the loved one in a dehumanized state (e.g., attached to life-support machinery) before death, and (d) the possibility of the need to identify a body that may have been severely damaged by the accident. In fact, Reed and Greenwald (1991) found that the survivors of accident victims in their study experienced more shock and emotional distress than did the survivors of suicide victims.
In addition, there is the problem of guilt associated with accidental deaths. Especially among the parents of children who have died accidentally, self-blame and guilty feelings are common occurrences (Rosof 1994). In one study, Miles and Demi (1991-92) found that 78% of accident-bereaved parents reported feeling guilty for the deaths of their children, and Thompson and Range (1992-93) found that self-blame was more common among parents who had lost children to accidental death than among those who had lost children to suicide. According to Miles and Demi (1991-92), a signature feature of the guilt that accident-bereaved parents experience concerns death causation; that is, they think about how their parental decisions (to allow their children to drive or to go out at night, for example) might have inadvertently led to their children’s deaths. Because of the suddenness of accidental death, which freezes the relationship in time, such parents often also feel parenting guilt that stems from unresolved fights, emotional problems, or simply their fear that they did not say “I love you” frequently enough to their children (Miles and Demi 1991-92; Rosof 1994). Such feelings of guilt are not the sole province of parents of children who die in accidents, of course. Lehman, Wortman, and Williams (1987) found that 53% of the accident-bereaved spouses in their sample believed that if they had done something differently, their spouses would be still be alive.
Although the topic of bereavement in accidental death has received considerable attention in the thanatological literature, the issue of recovery, especially for the survivors of situations involving accidental deaths, has received only scant attention. In one of the few studies to date, Foeckler et al. (1978) interviewed drivers who had survived a collision involving a fatality; they found that one-third of their respondents reported experiencing depression, disturbed thinking, and other psychic pains that continued from a month to several years after the accident, and 55% reported personal crises in their lives directly related to their involvement in the accidental fatality. Lehman et al. (1987) looked at long-term effects on accident victims’ survivors and found that as many as 80% of the survivors in their sample continued to ruminate about the vehicle crashes that took the lives of their spouses and children even some 4 to 7 years later, and “appeared to be unable to accept, resolve, or find any meaning in the loss” (p. 218).
Detachment seems to be a signature feature of bereavement for the survivors of loved ones lost to accidental death, and this coping mechanism carries with it profound implications for close relationships. The survivors of those who die by accidental means often withdraw emotionally in the face of insurmountable grief and their inability to explain or make sense of the suddenness of the loss. This tendency toward detachment can have adverse effects on marital and other relationships. Sometimes, the sudden loss of a child through accidental death can create a “polarization effect” between the child’s parents, either strengthening or dissolving the marital bond (Lehman et al. 1989).
Men and women often experience the grief of accidental deaths differently. Men, for instance, have a stronger tendency toward detachment in sudden bereavement. As Reed (1993) notes:
Men tend to feel the loss as a void and seek solitude. On the other hand, women tend to feel the loss as isolation and seek support from others. Women may therefore be extra sensitive to the distance between spouses precisely at the time the man is seeking solitude. (P. 218)
These differences in styles of grieving naturally lend themselves to marital discord. So, then, what factors can affect recovery in the case of sudden bereavement? Or, to put the question another way, what can we do to make accidental death bereavement more bearable?
The grief that accompanies accidental death is intense and extremely painful, especially in cases where the survivors are unable to find meaning in the experience and where the level of survivor-victim attachment was high (Reed and Greenwald 1991). Religion can play an important role in assuaging the impact of such intense grief, and this is the first recovery resource that might assist the survivors of accidental death. According to Reed (1993), religion can help the suddenly bereaved through the grieving process in three ways. First, religious institutions provide crucial emotional support for the bereaved through friendship networks that mimic primordial ties. Second, religious beliefs often strengthen self-esteem in individuals by creating new self-awareness and building up self-worth (Reed asserts that the strongest predictor of bereavement outcome is the psychological resource of self-esteem). And finally, religion enhances “existential certainty” by offering meaning for seemingly meaningless deaths and by reassuring the bereaved of the certainty of an afterlife while giving meaning to life and living.
Friendship networks, which are an implicit part of membership in religious and other social institutions (as Reed notes), are important resources for the suddenly bereaved. Because the mourning process typically extends for 8 months or longer (Hardt 1978-79), detachment and communicative isolation are potential problems for the survivors of victims of accidental death. Sanders’s (1982-83) research on grief recovery points to the importance of support systems (friends, religious institutions, family members, and so on) that remain in place for months after an accidental death to counter the harmful implications of social isolation, alienation, and detachment so common to sudden bereavement. Long-term support systems are important resources for grief recovery in general, and in cases of accidental death their importance is magnified. With more than 95,000 accidental deaths each year in the United States, it is not a stretch to suggest that grief recovery is a feature that deserves further attention. More research on the range of factors that might assist survivors in coping with the grief of accidental deaths and on the problems that men’s and women’s differing styles of grieving pose for close relationships would be especially valuable.
Conclusion
Accidental death is a common feature of life, affecting tens of thousands of Americans yearly, yet the subject of accidental deaths does not receive nearly as much attention from the public as do the other leadings causes of death. Perhaps, as we have argued in this essay, the word accident is linked too closely with the idea of fate, and this impedes our understanding of the antecedents of “accidents” as well as our ability to arrive at effective treatment strategies to reduce the occurrence of accidental mortality. Edward Suchman (1961) understood this quandary well. He notes:
When the public is willing to accept the same type of preventive program for accidents as it demands for the communicable diseases, we may expect to witness tremendous gains in removing accidents from its current position as one of the major causes of death and disability. (P. 249)
Obviously, we have yet to achieve such a preventive program. Until we do, we can expect accidental deaths to remain a leading cause of mortality. Perhaps a name change is in order, from “accidental deaths” to “deaths by mistakes—human mistakes.” Perhaps such a change in terminology would help us to see accidental deaths as the problems of human error and fallibility that they are. Until we take that perspective, we will continue to make the dubious link between accidents and fate, ultimately denying the possibility of strategic human intervention to prevent the occurrence of untimely death.