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To Die, By Mistake: Accidental Deaths
(Unedited Version: Published Article May Differ Slightly)
Lee Garth Vigilant, Ph.D.
Minnesota State University at Moorhead
Department of Sociology and Criminal Justice
Lommen Hall
Moorhead, MN 56563
And
John B. Williamson, Ph.D.
Boston College
Department of Sociology
McGuinn Hall
Chestnut Hill, MA 02467-3807
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To Die, By Mistake: An Introduction
“Accidents Will Happen.” –Elvis Costello
On the evening of October 2nd, 1996, an AeroPeru Boeing 757, flight 603,
with 61 passengers and 9 crewmembers, took off from Lima, Peru. Flight 603,
however, did not make its final destination to Santiago, Chile. In fact, the aircraft
and its passengers were doomed from the very moment of take-off. Earlier that
day, the maintenance crew had taped over the left-side static ports while
washing the fuselage of the plane, and by mistake, did not remove the protective
covering after the wash. This seemingly insignificant oversight was actually a
dangerous blunder because with its static ports covered, Flight 603 would be
flying without essential information like altitude, wind speed, temperature, and
the like. From the moment of take-off, its instruments were communicating the
wrong airspeed and altitude, and since it was a night-flight, the pilot and copilot
were indeed “flying blind”. When the instruments falsely indicated over-speed,
the crew slowed the plane to a near stall, and when the altimeter falsely
indicated too high an altitude, the flight crew compensated by dropping
elevation to a perilously low level. For nearly thirty minutes, as indicated by the
cockpit voice recordings of Flight 603 (MacPherson 1998), the pilot and copilot
struggled to make sense of the erroneous information that the instruments were
communicating. Eventually, Flight 603 crashed into the ocean at more than 300
miles per hour. All nine crew members and 61 passengers lost their lives. At
impact, the plane’s altimeter read an altitude of 9,700 feet. (MacPherson 1998).
3
As it turns out, this air disaster, and the 70 accidental deaths that resulted,
was most certainly preventable. The flight crew should have caught the mistake
by the maintenance crew during its 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 with knowledge of the determining cause.
By definition, accidental deaths are usually unforeseen, violent, and
unexpected (Webster 1986). These deaths are unintended, the result of chance,
where culpability is not a matter of simple assignment. But what does it mean to
label a death “an accident,” really? And, are there situational characteristics that
are common to all accidental deaths? The problem of labeling an accidental
death “an accident” begins with the very implications that the word accident
imbues. If the standard criterion for an accidental death is intentionality, how is it
to be determined after the fact? In essence, the ex post facto assumptions
surrounding accidental mortality are always the same irrespective of
circumstance: (1) that the deceased did not want to die; (2) that the deceased did
not intentionally bring death upon himself; and, ultimately, (3) that he may bear
little if any responsibility for his own death and the death 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 henceforth addressed.
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This essay considers three issues in the discourse on accidental mortality.
It begins with an analysis on the various meanings and problematics of the
phrase “accidental death”. Then it considers the occurrence and causes of some
of the major accidental death categories in the United States. Finally, it concludes
with an overview of the problem of labeling accidental deaths, with special
consideration given to the notion of subintentional mortality.
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 we refer to tragedies like that of Flight 603 as an accident, we mean
to infer that it was an unintentional occurrence. Accidental deaths occur by
chance, without intention or design, and are unexpected and unusual (DeCicco
1985: 141). Accidents and Accidental deaths are non-deliberate, unplanned, and
undesirable occurrences. Yet, there is quite a lot of slippage, 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, 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 because the
former makes us less accountable for the culpability of our actions and choices
when serious injuries and death are the end result, and the latter, because it
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involves a certain level of “bad faith” (Sartre 1956) since by reducing death to
fate and chance, individuals can deny any responsibility for the final outcome of
their choices and actions (Brownfain 1962). We too often apply the accidental
death label 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 accident and accidental death, the medical sociologist
Edward Suchman (1961) sought to tighten their definitions even further.
Suchman (1961: 244) believed that the application of the labels accident or
accidental death should conform to three necessary conditions: (1) the degree of
expectedness (was the accident unanticipated?); (2) the degree of avoidability
(could the accident have been prevented?); and finally, (3) the degree of
intentionality (was this outcome intended?). However, Suchman (1961) extends
these conditions by outlining what he calls the antecedents or symptoms of
accidents to further constrict the usage and application of the term accident. In
determining whether an outcome might be considered an accident after having
met the aforementioned criteria, Suchman (1961: 244) suggests four additional
requisites: (1) the degree of warning (less forewarning, the greater the likelihood
of an accidental occurrence); (2) the duration of occurrence (the more quickly a
phenomenon occurs, the more likely it is to be labeled an accident because it
reduces the likelihood and degree of control); (3) the degree of negligence (the
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more recklessness associated with the event, the less likely it is to be labeled an
accident); and lastly, (4) the degree of misjudgment (the more misjudgments, the
less likely the outcome is to be labeled an accident).
If we were to apply the aforementioned rules to the tragic example of
Flight 603, the question of whether the outcome was an accident would
undoubtedly be cause for debate. Certainly, the parameters of expectedness and
intentionality are satisfied: no one expected, nor 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. Yet, despite the inexcusable error of the
maintenance crew, and the oversight of the pilots, the flight crew did neglect a
crucial warning during the take-off procedure.
The first indication that
something was wrong with the altimeter came immediately after take-off, when
the copilot brought it to the attention of his captain (MacPherson 1998). In terms
of degree of warning, had the flight crew simply returned to the airport on first
caution, the events might not have unfolded as they did. Moreover, there were
misjudgments: the flight crew, upon realizing that something was wrong with
the instruments, should have disengaged autopilot for the duration of the flight.
Finally, in terms of negligence, or dereliction of duty, if the flight crew had done
their “walk around” as prescribed, where the plane is visually inspected, they
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would have certainly noticed the masking tape over the plane’s left-side static
ports.
To refer to the crash of flight 603 as “an accident”, is to ignore so many
important details and to suggest that it was the result of fate or chance. As
Kastenbaum
(2001:
239)
so
eloquently
expressed,
“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.” 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 fateful causes
to 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 the liabilities that his
error has 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 concepts
“accident” or “accidental death” to social outcomes, this much is certain: the
term “accident” is an ex post facto admission of the built-in fallibility of human
interactions and human choices.
Nevertheless, the label “accident” often
obscures the social antecedents that lead to death and serious injury: the human
errors that account for 60 to 80 percent of all accidents (Perrow 1984). Thus
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mindful of this phenomenon, the next section not only reports on the
epidemiology of accidental deaths, but
also on the causes of, and
countermeasures 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 (see Table 1), yet when compared to the other leading causes of
death for all age groups such as heart disease, malignant neoplasms, and
diabetes, accidental mortality receives only scant attention. This might be due to
the many subcategories that makeup the “unintentional injury” statistics (see
Table 2). Yet, the impact of accidental deaths on society is undeniable. In 2000,
there were some 93,592 unintentional deaths (see Table 1), making it the fifth
leading cause of death in the United States, 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 are a tremendous strain on the nation’s economy
through wage and productivity losses, administrative expenses, medical costs,
property damage, and employer overheads. Estimates for 2000 list the average
cost of a single traffic fatality at $1,000,000, the cost for each unintentional death
in the home at $780,000, and an average cost of $980,000 for each work-related
death (National Safety Council, 2000).
Table 1 goes about here
It is certainly not a stretch to say that accidental deaths are a major social
problem.
Yet, Americans do not perceive accidental deaths as such; and,
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especially among the young, continue to underestimate their risk of dying from
an accidental cause (Glik et al. 1999). Perhaps it is a sense of invincibility that
leads to us to underestimate our risk of dying by accident. Or maybe, as
previously discussed, it is the perception that accidents are fateful events that we
have little or no control over. Whatever the reason, we tend to see other
morbidities as potentially much more likely to affect us than accidental mortality.
Iatrogenic Mortality: Medical Mistakes and Accidental Deaths
The statistical picture on the occurrence of accidental deaths in the United
States neglects an entire category of unintentional mortality. Accidental deaths
due to medical mistakes are a major social problem. Yet, these deaths are only
now coming to public attention and under the purview of political scrutiny.
While much debated and disputed by some (Hayward et al. 2001; McDonald et
al. 2000; Leape 2000), iatrogenic mortality, or deaths caused by doctor mistakes,
makeup between 44,000 and 98,000 deaths per year in the United States, a
problem of epidemic scale (Kohn et al. 2000). Yet to date, nowhere in the CDC’s
statistical picture of accidental deaths do we find a category called accidental
deaths due to medical mistakes (see table 2). But 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,
Kohn and her colleagues (2000) suggest that 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
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also a very expensive burden for economy, with yearly costs between $17 and
$29 billion (Kohn et al. 2000).
Among the many recommendations that The Institute of Medicine (Kohn
2000) suggests to reduce the incidence of iatrogenic mortality, are the following:
(1) the creation of research and pedagogical tools that might bring knowledge of
this crisis to the medical forefront; (2) the creation of mandatory and voluntary
error-reporting systems; (3) raising the standards of care through the
establishment of oversight organizations and professional groups; and finally, (4)
at the delivery level, instilling a culture of safety among healthcare 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 from the CDC’s data on accidental injuries is that motor vehicles
(comprising an astonishingly 42% of all accidental deaths for 1999) are
responsible for three times as many accidental deaths as the next category on the
list, accidental falls.
Motor vehicle related accidents account for a huge
proportion of accidents in the United States and a rapidly increasing proportion
of accidents globally (Grant and McKinlay 1987; Nantulya and Reich 2002; Peden
et al. 2001; Roberts 2002). The scope of the problem is immense: there is a traffic
fatality every 12 minutes and a disabling injury every 14 seconds, making motor
vehicle accidents the leading cause of death and injury for the young, with the
15-24 age group most impacted (National Safety Council 2001; Lang et al 1996;
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Williams 1995). The National Highway Traffic Safety Administration (2001)
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 remain at an all time low, and continue to decline
with the exceptions of alcohol related and motorcycles crashes (NHTSA 2001).
Notwithstanding, the number of automobile deaths, approximately 40,000 cases
yearly, is still high.
Table 2 goes about here
The demographic picture of automobile fatalities in 2000 shows that males
were 68% of all deaths, that 16-24 year-olds —the age group most impacted by
crashes— were 24% of fatalities, that the intoxication rate of male and female
drivers who died in crashes were 20% and 11% respectively, and that the rate of
seat belt use among male and female drivers involved in fatal crashes were 43%
and 29% respectively (NHTSA 2001). Some researchers have linked the
pronounced difference in motor vehicle death rates to differential socialization
that lead males to assume more risky, health-endangering practices than females
(Lang et al. 1996; Veevers and Gee 1986; Vredenburgh et al. 1999), and to
increased driving exposure (Farmer 1997; Massie et al. 1995). In addition to
gender differences, some studies have reported an inverse relationship between
higher social class ranking and decreased 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 et al.
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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 were attributed to “unsafe acts”
by individuals, and only 15% to “unsafe conditions”. This controversial
statement started a long-standing —yet to be fully resolved—debate 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 the statistical breakdown of the
causes of motor vehicle crashes show three things that lend support to his initial
conclusion: (1) that most “accidents” are in fact avoidable; (2) that most involve a
great deal of misjudgments; and finally, (3) that accidents are often the result of
gross negligence or “unsafe acts”.
Every automobile accident can be reduced to three possible causes: (1)
environmental factors and driving conditions (namely, weather and the state of
the roadway); (2) automobile problems (poor maintenance or equipment failure);
and (3) problems with the driver (poor health, risk taking decisions/practices,
etc.) (Haddon 1968, 1964; Tabachnick 1973). The statistical portrayal of motor
vehicle accidents tells us that the vast majority of all traffic fatalities in the year
2000 were due to driving while intoxicated or driving at excessive speeds, 40%
and 29% respectively (NHTSA 2001). Gross negligence and unsafe acts, namely
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excessive speeding and driving while intoxicated, can account for the vast
majority of traffic fatalities in the United States.
The link between alcohol consumption and traffic fatalities is an
indubitable one (Brewer et al 1995; Haberman 1987; Winn and Giacopassi 1993).
According to the National Highway Traffic Safety Administration, there is, on
average, an alcohol related fatality every 32 minutes, representing about 40% of
the total traffic fatalities yearly. Over 1.5 million Americans were arrested for
driving under the influence in 1999 (NHTSA 2000), drivers who are at
substantially greater risk of dying in automobile crashes (Brewer et al 1995). In
fact, NHTSA data for 2000 notes that, “about 1,400 fatalities occurred in crashes
involving an alcohol-impaired or intoxicated driver who had at least one
previous DWI conviction,” representing 8% of all alcohol-related fatalities
(NHTSA 2000: 12). What’s more, at some point in their lives, 30% of Americans
will be involved in an alcohol-related “accident” (NHTSA 2000). Yet, alcoholrelated traffic deaths are not the sole purview of intoxicated drivers, but
intoxicated riders as well. A recent study by Li and Baker (1995) on 1,711 fatally
injured bicyclists age 15 years and older, who were tested for alcohol, revealed
that an astonishing 32% were positive for alcohol at the time of their deaths, and
23% were legally intoxicated. Moreover, 28% of fatally injured motorcyclists for
the year 2000 were intoxicated (Blood Alcohol Content > 0.10) at the time of their
death (NHTSA 2001; Shankar 2001).
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Excessive speeding is another risk factor that contributes to the roughly
40,000 traffic fatalities yearly. In 2000, excessive speeding took the lives of over
12,000 individuals, and was the cause of 29% of all traffic fatalities (NHTSA
2001). Moreover, the economic cost of speeding-related accidents and fatalities is
around $27.4 billion dollars (NHTSA 2001). Speeding is a risk factor that is
especially associated with younger male drivers in the 15 to 24 years age group.
In 2000, 34% of young male drivers, ages 15 to 24, who were fatally injured in
crashes were speeding (NHTSA 2001). The problem of speeding is even more
severe among motorcycle drivers. In 2000, there were 2,862 motorcycle fatalities,
representing 7% of all traffic deaths; and, 38% of those deaths were attributed to
excessive speeds (NHTSA 2001). In fact, the National Highway Traffic Safety
Administration (2001) reports that motorcycle riders are 18 times as likely as
passengers in automobiles to die in a crash. Finally, it is important to note that
taken together, intoxication and speeding go hand-in-glove. The National
Highway Traffic Safety Administration (2001) reports that 40% of all alcoholrelated deaths in 2000 involved drivers who were speeding, compared to only
13% of sober drivers killed in automobile crashes for the same period.
The third risk factor associated with traffic fatalities is seat belt and child
restraint usage –or, the lack thereof. According to NHTSA (2001) figures,
seatbelts have saved approximately 135,000 lives since 1975, and 11,889 lives in
2000 alone. Likewise, the use of child restraints (specifically designed for
children under five) has saved 4,816 lives during the same period, and 316 lives
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in 2000.
In fact, the NHTSA reports that safety belts could have saved an
additional 9,238 lives in 2000. Moreover, a recent study on the effectiveness of
seatbelt usage in preventing accidental deaths in children aged 4-14 found that
the odds of sustaining a fatal injury for an unbelted child in the front seat of a car
was 9 times higher than a belted child, and for an unbelted child in the rear seat,
the odds were 2 times higher than a belted one (Halman et al. 2002). According
to one study, seat belt usage reduces the risk of an accidental death by 65%, and
by 68% when used in conjunction with an airbag (Cummings et al. 2002). The
same study found that seat belts provide much greater protection against
accidental deaths than airbags alone, which only provided an 8% reduction in
the likelihood of dying in a crash (Cummings et al 2002).
A final contributing factor in the statistics on traffic fatalities is sleep
deprivation and its affect on accidental motor vehicle crashes (Cohen 1996a;
1996b; 1996c). Cohen (1996c) estimates that sleep deprivation results in about
25,000 accidental deaths and 2.5 million disabling injuries each year in the United
States. What’s more, the impact of sleep deprivation is most obvious during the
shift to daylight savings time in the spring, where, as a nation, we lose an hour of
sleep. Cohen (1996a) found a 6.5% short-term increase in traffic fatalities the
week following spring daylight savings time, but no measurable difference in
fatalities in the fall, when as a nation, we gain an hour of sleep. Cohen (1996a)
concludes that losing an hour of sleep in the spring with daylight savings time
results in a measurable short-term increase in accidental motor vehicle deaths.
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What can society do to lower the number of automobile fatalities? This
question is one that is growing in significance especially around the globe. The
World Health Organization estimates that by 2020, road traffic accidents will
become the third leading cause of disease burden, from its current position of
ninth, replacing such causes as HIV/AIDS, diarrhoel diseases, war, and
cerebrovascular disease (Peden 2001). Currently, automobile crashes are the
leading cause of injury-deaths and the tenth leading cause of all deaths around
the globe (Peden 2001).
Clearly, this social problem demands a treatment
strategy with global reach.
Until now, the primary strategies employed to lower the death rate in
vehicular crashes have been technological advances (safety restraints, airbags,
etc.) and driver education. While the former has been particularly effective in
reducing the likelihood of death in vehicular crashes, driver education has not. In
fact, a study by Vernick et al. (1999) found that driver education did not reduce
the motor vehicle crash rates for young drivers, and that early licensure, which is
the goal of school-based driver education courses, was actually associated with
an increased risk of crash involvement. The authors of that study (Vernick et al.
1999) suggest that society look to other treatment strategies in addition to traffic
education for reducing the death rate in crashes. And the best treatment strategy
to date is that of traffic laws and their enforcement –not driver’s educationbecause, at the end of the day, we continue to underestimate our risk of dying in
an automobile crash (O’Neil and Mohan 2002; Williams et al. 1995). The National
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Safety Council’s “Report on Injuries in America 2000” calls for the primary
enforcement of seat belt laws, which only 18 states currently have, and for all
states to adopt graduated licensing policies that include the three steps to
licensure: learner’s permit, provisional license, then full license. Technological
improvements in vehicle safety, strict traffic enforcement, laws such as
mandatory helmet provisions for motorcycle riders, which result in near perfect
compliance in states that have them, and efforts to lower the illegal drunk
driving limit to .08 percent of blood alcohol concentration for all states (see
MADD 2002), remain the most effective treatment strategies for reducing the
number of motor vehicle accidental deaths: aside from these provisions, very
little have been shown to significantly affect the rate of accidental deaths in
motor vehicle crashes.
Accidental Falling Deaths
Falling down is the second leading cause of accidental mortality in the
United States with over 13,000 deaths in 1999 (CDC 2002). It is a mortality type
that overwhelming affects the elderly, accounting for 70% of the accidental
deaths to persons over 75 years (Fuller 2000). In 1999, about 9,600 persons over 65
years old died of juries sustained in falls, making it one of the leading causes of
accidental death among people in this age group (CDC 20002; Fos et al. 1990).
Moreover, accidental falls were responsible for over 250,000 hip fractures in 1996,
with costs exceeding $10 billion (Fuller 2000).
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The statistical picture of accidental falls shows that men are more likely to
die of falls than women, that 60% of falling deaths occur at home, 30% in public
places, and that 10% occur in hospital settings (CDC 2002). Likewise, the cause
of falling deaths varies by setting. For example, in the hospital setting, one of the
primary causes of falling is physiological disorientation and dizziness from
polypharmacy, the use of four or more medications (Morse et al. 1987); while at
work, a common reason is worker error, usually the misapplication of equipment
or machine (Copeland 1989). Moreover, 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. refers to as intrinsic
risk factors, or causes internal to the individual, such as chronic pain,
musculoskeletal
and
neuromuscular
diseases,
and
the
presence
of
polypharmacy; while among the young, falling is most often attributed to
extrinsic risk factors, such as environmental conditions or hazards and risk taking
behaviors.
Both of these causes demand different treatment solutions.
For
instance, among the elderly, improvements in home design, such as the use of
wall-mounted lights that can be reached without standing on a ladder or
installing slip resistant surfaces in the bathroom, are but a few of the many
simple improvements that might reduce the potential of accidental falls (see
Rollins 2000 for complete suggestions). Likewise, since most of the accidental
falls the affect the young occur at work, and are due to some combination of
unsafe acts and unsafe working conditions, prevention efforts have largely
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focused on the gap in effective communication of the risk of injury on the job
(Haskins 1980; Lauda 1980; Reamer 1980). For young children, the use of
“energy-attenuating surfaces” at playgrounds that absorb and cushion the
impact of falls is a simple prevention measure; also, keeping appliances and
furniture away from open windows, especially in high-rise apartment buildings
(Baker et al. 1992).
Accidental Suffocation Deaths
Mechanical suffocation and asphyxiation were responsible for some 5,503
accidental deaths in 1999, many deaths that were, for the most part, completely
preventable. Moreover, this accidental death category largely affects children
under 1 year, who account for around 40% of the accidental suffocation deaths in
the United States (Becker et al. 1992). Any small object in the vicinity of a child is
potentially dangerous and can lead to an accidental suffocation by ingestion.
Foodstuffs, such as popcorn, grapes, nuts, and hard candy all pose a potential
risk for children less than 1 year of age (National Safety Council 2001). Mortality
from this category, however, is not limited the very young, as elderly individuals
over 65 years have one of the highest accidental food-chocking rates, with over
2,500 deaths annually (Becker et al. 1992). Accidental suffocations also pose a
hazard for many farmers working among large storage bins for grains, a problem
that has been growing in recent years due to the building of larger grain facilities,
and the fact that many operators work alone (Loewer and Loewer 2002). Yet,
one of the more prevalent categories of accidental deaths under the suffocation
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and asphyxiation heading receives little public attention by way of prevention
strategies: death by accidental autoerotic asphyxiation.
Autoerotic asphyxiation, or 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 et al.
1991; Byard et al. 1990; Michalodimitrakis et al. 1986). What’s more, the true
number of accidental deaths by autoerotic asphyxia might well be much higher
than reported because of the potential to mistake these deaths as suicidal or
homicidal attempts, or, to systematically mislabel them as suicides to avoid the
social stigma of dying from autoerotic asphyxia. The mortality picture of
autoerotic accidental asphyxia shows that males are overwhelmingly the victims
of this form of death, with a male to female ratio of about 50 to 1, and the typical
male victim a solitary masturbator between the ages of 12 to 25 years (Cooper
1996; Gosink 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 the loss of
consciousness accompanies hypoxia, the victim will lose control over voluntary
movement, and accidental death is likely to follow. Many practitioners of
autoerotic asphyxia incorporate “safety devices” such as knives to cut the noose
or slipknots to protect against the possibility of an accidental death by losing
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consciousness (Cooper 1996). But these escape mechanisms often do not protect
against the loss of consciousness, and since the practitioner is usually alone, the
risk of an accidental death is punctuated.
Accidental death by autoerotic
asphyxiation has yet to receive the same prevention-attention afforded to the
other accidental injuries, even though it accounts for nearly 20% of all accidental
suffocations. Perhaps this speaks volumes to the stigma that accompany
sexualities and sexual practices thought to be deviant and dangerous.
Some Special Problems with the Label “Accidental” Mortality: The Cases of
Subintentional Self-Destruction and disguised suicides
We have already shown the statistical picture on accidental deaths to be
incomplete because every year it leaves uncounted between 44,000 and 98,000
iatrogenic mortalities. But among other problems that exist with the statistical
picture of accidental deaths are (1) the possibility that it includes incidences of
subintentional self-destruction, cases that are neither suicidal attempts nor strict
“accidental” deaths, and (2) cases of suicides disguised as accidents.
Subintentional self-destructions are ill-defined deaths and practices that
lead towards death (Tabachnick 1975; Smith 1980; Shneidman 1973). These
practices if continued will eventually result in the death of the practitioner. Yet,
unlike suicide, where there exists in the mind of the person a clear intention to
die,
subintentional
self-destructive
behaviors
lack
immediate,
or
less,
intentionality about the possibility of death. In fact, the person may not have
complete intentionality despite the fact that her behaviors and choices are reckless,
making the possibility of an accidental death omnipresent (Tabachnick 1975;
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Smith 1980). Consequently, if death is the final outcome of her actions, it does not
conform to a strict definition of suicide because it lacks complete intentionality,
neither does it fit the parameters of an accident because it was probably
expected, totally avoidable, and involved a great deal of misjudgments,
negligence, and forewarning. Consider for example, the person who sits on the
balcony of 10-story apartment and then falls to 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, the possibility of
falling was certainly entertained in the victim’s mind at some point. Therefore,
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 involved, the more likely a self-destructive outcome.
Perhaps then, the label subintentional death is more appropriate because it
speaks to the level of obvious risk the person involved in the behavior chose to
ignore. Other frequently cited behaviors are parasuicide (where a person might
make a false “suicide attempt” as a cry for help, but with no intention of dying),
poly-drug abuse, high-risk activities like playing Russian roulette, excessive
speeding or reckless driving under conditions that pose a clear danger, and not
following a doctor’s advice on life-saving medication (Lester 1988; Kreitman
1969; Tabachnick 1975). To date, we have no consistently effective ex post facto
mechanism for differentiating sub-intentional mortality and unsuccessful
parasuicide from true accidental or suicidal deaths (Peck et al. 1995). Ironically,
23
the situations that compel individuals into subintentional self-destructive
behaviors are often the same the act as impetus for suicide: a sense of
hopelessness, helplessness, alienation, isolation, and the like (Cole 1988; Smith
1980).
The problem of suicides disguised as accidental deaths is the final area
that confounds the statistical picture on accidental mortality in the United States
(Chester et al 1977; Lester 1990; Pokorny 1972). While the number of disguised
suicides in certain subcategories of accidental deaths is debatable (Lester 1985),
there does appear to be strong evidence for them in motor vehicle crashes.
Norman Tabachnick’s (1973) decade-long research at the Los Angeles Suicide
Prevention Center on the self-destructive impetus behind many automobile
crashes found that 25% of the victims of single-car crashes in his study were
suffering with depression, and expressed feelings of hopelessness and
helplessness around the time of their “accidents”. In another study, Phillips
(1979) describes a third day peak in accidental fatalities after a publicized suicide
story. Phillip (1979) found that automobile fatalities in California increased by
31% three days after a highly publicized suicide story in the media, thus
concluding that vehicular suicides are probably included among the statistical
picture of accident vehicle deaths. In a replication of this study, Bollen et al.
(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,
while concluding that vehicular suicides might well be hidden in the statistical
24
picture of automobile deaths. Finally, Pokorny et al. (1972) in their intensive
review of the personalities, emotional states, and social factors of individuals
involved crash fatalities found that 4 out of the 28 fatalities observed were likely
suicides.
The Anatomy of Accidental Death Bereavement and Recovery
The nature of accidental deaths, that is, their unexpectedness, suddenness,
and, often, violent character, compounds the bereavement and grief recovery
experiences of survivors. The survivors of loved ones who die accidentally do
not have a period of anticipatory grief, that may last weeks, months, or years as
in the case of acute mortality, and which might enhance coping and bereavement
recovery (Dane 1991; Hill et al. 1988; Huber 1990). The shock and traumatic
emotions that accompany the news of the death might last for weeks, and is a
common feature of this type of bereavement (Hogan et al. 1996; Sanders 1982).
Accordingly, Raphael (1983) lists several features of accidental deaths that make
the grieving process more intense than chronic or acute illness, and these are: (1)
the possibility of an accompanying traumatic stress response because of the
shocking and unexpected nature of the news that a loved one is dead; (2)
learning of the violent nature of the death that compounds trauma and shock; (3)
seeing the loved one in intensive care in a dehumanized state before death; and,
(4) identifying a body that is often severely mutilated and damaged by the
accident. In fact, Reed et al. (1991) found that survivors of accident victims in
25
their study experienced more shock and emotional distress than survivors of
suicide victims.
Still, there is the problem of guilt, and this is especially associated with the
parents of children who died accidentally, where self-blame and guilty feelings
are common occurrences (Rosof 1994). In one study, 78% of accident bereaved
parents reported feeling guilty for the death of their children (Miles and Demi
1991), while another study found that blame was more common among parents
who lost children to accidental death than those who lost children to suicide
(Thompson and Range 1992). And for Miles and Demi (1991), a signature feature
of the guilt that bereaved parents experience concerns death causation; that is,
thinking about how their parental decisions might have inadvertently led to the
death of their children, for instance, their decisions to allow them to use the
automobile and to stay out late at night with friends.
And because of the
suddenness of accidental death, which literally freezes the relationship in time,
there is often parenting guilt that stems from unresolved fights, emotional
problems, or simply, not saying “I love you” frequently enough (Miles and Demi
1982; Rosof 1994). But feelings of guilt were not the sole province of parents.
Lehman et al. (1987) found that 53% of bereaved spouses believed that if they
had done something differently, their spouses would be still be alive today.
While 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 an accidental death, has
26
received only scant attention. One study, on drivers who survived a collision
involving a fatality, found that a third of the interviewees experienced
depression, disturbed thinking, and other psychic pains that continued from one
month to several years after the accident, while 55% of the respondents reported
a personal crises in their lives directly related to their involvement in the
accidental fatality (Foeckler et al. 1978). And for the victims’ survivors, Lehman
et al. (1987: 218) found that as much as 80% of their respondents were still
ruminating about the vehicle crashes that took the lives of their spouses and
children, and “appeared to be unable to accept, resolve, or find any meaning in
the loss,” and this, some four to seven years after the accident.
With regard to accidental death bereavement, detachment seems to be a
signature feature for the survivors of this type of mortality, one that carries with
it profound implications for close relationships. The survivors of loved ones
killed by accidental means often withdraw emotionally in the face of
insurmountable grief and the inability to explain, or make sense of, the
suddenness of the loss.
Moreover, this tendency toward detachment can
adversely affect marital relationships by creating a “polarization effect” where
the sudden bereavement either strengthens or dissolves the marital bond
(Lehman et al. 1989). Men and women experience the grief of accidental deaths
differently. Among men, there is a stronger tendency toward detachment in
sudden death bereavement, and this, according to Reed (1993: 218), is because
“Men tend to feel the loss as a void and seek solitude. On the other hand, women
27
tend to feel the loss as isolation and seek support from others. Women may
therefore be extrasensitive to the distance between spouses precisely at the time
the man is seeking solitude.” The varied styles of grieving, where men tend to
suppress communication on their feelings and where women seek comfort in
others and through emotional expressions about the meaning of the accidental
loss, naturally lends itself to marital discord. So then, what factors can affect
recovery in the case of sudden bereavement, or, stated otherwise, what can we
do to make our accidental death bereavements more bearable?
Grief from accidental death bereavement 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
1991). Here, religion plays an important role in assuaging the impact of intense
grief, and this is the first recovery resource that might assist the survivors of
accidental death.
Reed (1993) believes that religion enhances the grieving
process in cases of sudden bereavement in three ways. Religious institutions
provide crucial emotional support through friendship networks that mimic
primordial ties, and this encouragement is helpful to the bereaved. Moreover,
religious beliefs often strengthen self-esteem by creating new self-awareness and
by building up the self-worth of individuals, and for Reed (1993), the strongest
predictor of bereavement outcome is the psychological resource of self-esteem.
Finally, religion enhances “existential certainty” by offering meaning to a
seemingly meaningless death, and by answering questions on the uncertainty of
28
an after-life, while giving meaning to life and living (Reed 1993). Friendship
networks, an implicit part of membership in religious, or other social,
institutions, are also an important resource to the suddenly bereaved. Since the
mourning process typically extends for eight months or longer (Hardt 1978),
detachment and communicative isolation are potential problems for the
survivors of sudden bereavement. Research on grief recovery by Sanders (1982)
point to the importance of having support systems (friends, religious institutions,
families, etc.) that extend months after the funeral to counter the harmful
implications of social isolation, alienation, and detachment so common to sudden
bereavement. Having a long-term support system is an extremely important
resource in grief recovery, and its importance punctuated under the accidental
death context. With over 95,000 accidental deaths each year, it in not a stretch to
suggest that grief recovery is a feature that deserves much further attention,
especially more research on the range of factors that might assist survivors in
coping with the grief of accidental deaths, and the problems that the various
styles of grieving are posing for men and women in close relationships.
Concluding Remarks
Accidental deaths are a common feature of life that affects tens of
thousands of Americans yearly. Yet, taken together in all of its manifestations,
accidental deaths do not hold the same public sway as the other leadings causes
of death. Perhaps, as argued elsewhere in this essay, the word accident is linked
too closely with the idea of a fateful event, and this impedes our understanding
29
of the antecedents of “accidents”, and at arriving at effective treatment strategies
to reduce the occurrence of accidental mortality. Edward Suchman (1961: 249)
understood this quandary well when he said the following: “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.” Obviously, we’ve yet to achieve such as a preventive
program for accidental deaths, and until that time, we can expect accidental
deaths to remain a leading cause of mortality. Perhaps a name-change, from
“accidental deaths” to “deaths by mistake –human mistakes”, is in order.
Because until we come to see accidental deaths as a problem of human error and
fallibility, we will continue to make a dubious link between accidents and fate,
ultimately denying the possibility of strategic human intervention to prevent the
occurrence of untimely death.
30
References
Baker, Susan P., O’Neil, Brian, Ginsburg, Marvin J., and Guohua Li. The Injury
Fact Book (Second Edition). New York: Oxford University Press, 1992.
Bennett, Ross C. “Predictors in Accidental Deaths.” Transaction of the Association
of Life Insurance Medical Directors of America, Vol. 70 (1987): 46-53.
Bollen, Kenneth A. and David P. Phillips. “Suicidal Motor Vehicle Fatalities in
Detroit: A Replication.” American Journal of Sociology, No. 87, No. 2 (1981):
404-412.
Brewer, R.D., Morris, P.D., Cole, T.B., Watkins, S., Patetta, M.J. and C. Popkin.
“The Risk of Dying in Alcohol-Related Automobile Crashes Among
Habitual Drunk Drivers.” Journal of Safety Research, Vol. 26, Issue 2
(Summer) 1995.
Brownfain, John J. “When Is an Accident Not and Accident?” Journal of the
American Society of Engineers, (September 1962).
Byard, Roger W. and Nigel H. Bramwell. “Autoerotic Death: A Definition.”
Amrican Journal of Forensic Medicine and Pathology, Vol. 12, No. 1 (1991): 7476.
Byard, Roger W., Hucker, Stephen J. and Robert R. Hazelwood. “A Comparison
of Typical Death Scene Features in Cases of Fatal Male and Female
Autoerotic Asphyxia with a Review of the Literature.” Forensic Science
International, Vol. 48 (1990): 113-121.
Center for Disease Control And Prevention. “1999 United States Unintentional
31
Injuries, All Ages, All Races, Both Sexes.” Office of Statistics and
Programming, National Center for Injury Prevention and Control, CDC.
WISQARS (Web-based Injury Statistical Query and Reporting System),
2002. Source: http://www.cdc.gov/ncipc/wisqars/.
Cohen, Stanley. “Accidental Death and the Shift to Daylight Savings Time.”
Perceptual and Motor Skills, Vol. 83 (1996a): 921-922.
Cohen, Stanley. “Daylight Savings Time and Traffic Accidents.” New England
Journal of Medicine, Vol. 334 (1996b): 924.
Cohen, Stanley. Sleep Thieves. NY: Free Press, 1996c.
Cole, David A. “Helplessness, Social Desirability, Depression, and Parasuicide in
Two College Student Samples.” Journal of Counseling Psychology, Vol. 56,
No. 1 (February 1988): 131-136.
Cooper, A. J. “Auto-erotic Asphyxiation: Three Case Reports.” Journal of Sex &
Marriage Therapy, Vol. 22, No. 1 (Spring 1996): 47-53.
Copeland, Arthur R. “Accidental Deaths due to Falls at Work.” The American
Journal of Forensic Medicine and Pathology, Vol. 10, No. 1 (1989): 17-20.
Cummings, Peter, McKnight, Barbara, Rivara, Frederick, and David C.
Grossman. “Association of Driver Air Bags with Driver Fatality: A
Matched Cohort Study.” British Medical Journal, Vol. 324 (11 May 2002):
1119-1122.
Dane, Barbara O. “Anticipatory Mourning of Middle-Aged Parents of Adult
32
Children with AIDS.” Families in Society: The Journal of Contemporary
Human Services, Vol. 72, No. 2 (February 1991): 108-115.
DeCicco, Jack M. “Accidental Deaths: the Legal View.” Transaction of the
Association of Life Insurance Medical Directors of America, Vol. 68 (1985): 138147.
Farmer, Charles M. “Trends in Motor Vehicle Fatalities.” Journal of Safety
Research, Vol. 28, No. 1 (1997): 37-48.
Fuller, George F. “Falls in the Elderly.” American Family Physician, Vol. 61, No. 7
(April 1, 2000): 2159-2168.
Foeckler, Merle M., Garrard, Frances H., Williams, Catherine C., Thomas, Alice
M., and Teresa J. Jones. “Vehicle Drivers and Fatal Accidents.” Suicide and
Life-Threatening Behavior, Vol. 8, No. 3 (Fall 1978): 174-182.
Fos, Peter J., Carlen L. McLin. “The Risk of Falling in the Elderly.” Medical
Decision Making, Vol. 10 (1990): 195-200.
Glik, Deborah C., Kronenfield, Jennie J., Jackson, Kirby, and Weiyang Zhang.
“Comparison of Traffic Accident and Chronic Disease Risk Perceptions.”
American Journal of Health Behavior, Vol. 23, No. 3 (1999): 198-209.
Gosink, Paul D. and Mary I. Jumbelic. “Autoerotic Asphyxiation in a Female.”
The American Journal of Forensic Medicine and Pathology, Vol. 20, No. 3
(2000): 114-118.
Grant, Karen R. and John B. McKinlay. “Appropriate Technology Applied to a
33
Western Epidemic: The Case of Motor Vehicle Accidents.” Prevention in
Health Services, Vol. 5, No. 1 (Fall/Winter 1986): 29-55.
Haberman, Paul W. “Alcohol and Alcoholism in Traffic and Other Accidental
Deaths.” American Journal of Drug and Alcohol Abuse, Vol. 13, No. 4 (1987):
475-484.
Hacker, Helen A. and Edward A. Suchman. “A Sociological Approach to
Accident Research.” Social Problems, Vol. 10, No. 4 (Spring 1963): 383-389.
Haddon, William Jr., Suchman, Edward A., and David Klein. Accident Research:
Methods and Approaches. NY: Harper & Row Publishers, 1964.
Haddon, William Jr. “The Changing Approach to the Epidemiology, prevention,
and Amelioration of Trauma: the Transition to Approaches Etiologically
Rather Than Descriptively.” American Journal of Public Health, Vol. 58
(1968): 1431-1438.
Hagglund, George. “Causes of Injury in Industry –The “Unsafe Act” Theory.” In
Dan Petersen and Jerry Goodale (Editors) Readings in Industrial Accident
Prevention. NY: McGraw Hill, 1980.
Halman, Stephen I., Chipman, Mary, Parkin, Patricia C. and James G. Wright.
“Are Seat Belt Restraints as Effective in School Age Children as in Adults?
A Prospective Crash Study.” British Medical Journal, Vol. 324(11 May 2002):
1123.
Hardt, Dale V. “An Investigation of the Stages of Bereavement.” Omega, Vol. 9,
No. 3 (1978-79): 279-285.
34
Haskins, Jack. “Effects of Safety Communication Campaigns: A Review of the
Research Evidence.” In Dan Petersen and Jerry Goodale (Editors) Readings
in Industrial Accident Prevention. NY: McGraw Hill, 1980.
Hayward, Rodney A. and Timothy P. Hofer. “Estimating Hospital Deaths Due to
Medical Errors: Preventability is in the Eye of the Reviewer.” JAMA, Vol.
286, No. 4 (July 25, 2001): 415-420.
Heinrich, Herbert W. Industrial Accident Prevention: A Scientific Approach (Fourth
Edition). NY: McGraw-Hill, 1959.
Hill, Connie D., Thompson, Larry W., and Dolores Gallagher. “The Role of
Anticipatory
Bereavement
in
Older
Women’s
Adjustment
to
Widowhood.” The Gerontologist, Vol. 28, No. 6 (December 1988): 792-796.
Hippisley-Cox, Julia, Groom, Lindsay, Kendrick, Denise, Coupland, Carol,
Webber, Elizabeth, and Boki Savelyich. “Cross Sectional Survey of
Socioeconomic Variations in Severity and Mechanism of Childhood
Injuries in Trent 1992-1997.” British Medical Journal, Vol. 324 (11 May 2002):
1132-1134.
Hogan, Nancy, Morse, Janice M., and Maritza C. Tason. “Toward an Experiential
Theory of Bereavement.” Omega, Vol. 33, No. 1 (1996): 43-65.
Huber, Ruth and John W. Gibson. “New Evidence for Anticipatory Grief.” The
Hospice Journal, Vol. 6, No. 1 (1990): 49-67.
Jeffries, Jim. W. “Unsafe Acts VS. Unsafe Conditions.” In Dan Petersen and Jerry
35
Goodale (Editors) Readings in Industrial Accident Prevention. NY: McGraw
Hill, 1980.
Kastenbaum, Robert J. Death, Society, and Human Experience. Boston: Allyn and
Bacon, 2001.
Kohn, Linda T. and Molla S. Donaldson (editors). “To Err is Human: Building a
Safer Health System.” Committee on Quality of Health Care in America,
Institute of Medicine. Washington, D.C.: National Academy Press, 2000.
Kreitman, N., Phillip, A.E., Greer, S. and C.R. Bagley. “Parasuicide.” British
Journal of Psychiatry, Vol. 115 (1969): 747-748.
Lang, Sylvia W., Waller, Patricia F., and Jean T. Shope. 1996. “Adolescent
Driving: Characteristics Associated with Single-Vehicle and Injury
Crashes.” Journal of Safety Research, Vol. 27, Issue 4. (Winter 1996): 241-257.
Lauda, Robert. “A Communication Gap in Safety.” In Dan Petersen and Jerry
Goodale (Editors) Readings in Industrial Accident Prevention. NY: McGraw
Hill, 1980.
Leape, Lucian L. “Institute of Medicine Medical Errors Figures are not
Exaggerated.” JAMA, Vol. 284, No. 1 (July 5, 2000): 95-97.
Lehman, Darrin R., Lang, Eric L., Wortman, Camille B. and Susan B. Sorenson.
“Long-Term Effects of Sudden Bereavement: Marital and Parent-Child
Relationships and Children’s Reactions.” Journal of Family Psychology, Vol.
2 No. 3 (March 1989): 344-367.
Lehman, Darrin R., Wortman, Camille B., and Allan F. Williams. “Long-Term
36
Effects of Losing a Spouse or Child in a Motor Vehicle Crash.” Journal of
Personality and Social Psychology, Vol. 52, No. 1 (1987): 218-231.
Lester, David. “Accidental Death Rates and Suicide.” Ativitas Nervosa Superior,
Vol. 32, No. 2 (1990): 130-131.
Lester, David. “Toward a Theory of Parasuicide.” Corrective and Social Psychiatry
and Journal of Behavior Technology Methods and Therapy, Vol. 34(1988): 24-26.
Lester, David. “Accidental Deaths as Disguised Suicides.” Psychological Reports,
Vol. 56, Issue 2 (1985): 626.
Li, G. and S. P. Baker. “Alcohol in Fatally Injured Bicyclists.” Journal of Safety
Research, Vol. 26, Issue 4, (Winter 1995): 255-256.
Loewer, Otto Jr. and David H. Loewer. “Suffocation Hazards in Grain
Bins.” Document Fact Sheet AEN-39 of the Agricultural Engineering
Department, University of Kentucky, Cooperative Extension, 2002.
Source: The National Ag Safety Database
http://www.cdc.gov/niosh/nasdhome.html
MacPherson, Malcolm. The Black Box: All New Cockpit Voice Recorder
Accounts of In-Flight Accidents. NY: William Morrow & Company, Inc.,
1998.
MacDonaldson, Clement J., Weiner, Michael, and Sui L. Hui. “Death Due to
Medical Errors are Exaggerated in Institute of Medicine Report.” JAMA,
Vol. 284, No. 1 (July 5, 2000): 93-95.
Mothers Against Drunk Driving (MADD). “MADD Says Nation Must
37
Make the Drunk Driving Issue a Top Priority.” 2002. Online Source:
http://www.madd.org/news/
Massie, D.L., Campbell, K.L., and A.F. Williams. “Traffic Accident Involvement
Rates by Driver Age and Gender.” Accident Analysis and Prevention, Vol.
27, No. 1 (1995): 73-87.
Michalodimitrakis, M., Frangoulis, M. and A. Koutselinis. “Accidental Sexual
Strangulation.” The American Journal of Forensic Medicine and Pathology, Vol.
7, No. 1 (1986): 74-75.
Miles, Margaret S. and Alice S. Demi. “A Comparison of Guilt in Bereaved
Parents Whose Children Died By Suicide, Accident, or Chronic Disease.”
Omega, Vol. 24, No. 3 (1991-92): 203-215.
Minino, Arialdi M. and Betty L. Smith. “Deaths: Preliminary Data for 2000.”
National Vital Statistics Reports, Vol. 49, No. 12 (October 9, 2001): 1-40.
Morse, Janice M., Tylko, Suzanne J., and Herbert A. Dixon. “Characteristics of the
Fall-Prone Patient.” The Gerontologist, Vol. 27, No.4 (1987): 516-522.
Nantulya, Vinand M. and Michael R. Reich. “The Neglected Epidemic: Road
Traffic Injuries in Developing Countries.” British Medical Journal, Vol. 324
(May 11, 2002): 1139-1141.
National Highway Traffic Safety Administration (NHTSA). “Motor Vehicle
Traffic Crash Fatality and Injury Estimates for 2000.” Washington, DC:
U.S. Department of Transportation. Revised November 2001.
National Highway Traffic Safety Administration (NHTSA). “Traffic Safety Facts
38
2000:
An
Overview.”
Washington,
DC:
U.S.
Department
of
Transportation, 2001.
National Safety Council. “Report on Injuries in America, 2001.” NSC 2002.
Source: http://www.nsc.org/library/rept2000.htm
National Safety Council. “Estimating the Costs of Unintentional Injuries, 2000.”
Source: http://www.nsc.org/
O’Neil, Brian and Mohan Dinesh. “Reducing Motor vehicle Crash Deaths and
Injuries in Newly Motorising Countries.” British Medical Journal, Vol. 324
(11 May 2002): 1142-1145.
Peck, Dennis, L. and Kenneth Warner. “Accident or Suicide? Single-Vehicle Car
Accidents and the Intent Hypothesis.” Adolescence, Vol. 30, No. 118
(Summer 1995): 463-472.
Peden, M.M., Krug E., Mohan D., Hyder A., Norton R., MacKay, M., and C. Dora.
“Five-Year WHO Strategy on Road Traffic Injury Prevention.” Geneva:
World Health Organization, 2001. Ref: WHO/NMH/VIP/01.03. Source:
http://www.who.int/violence_injury_prevention/
Perrow, Charles. Normal Accidents: Living with High-Risk Technologies. NY: Basic
Books, 1984.
Pokorny, Alex D., Smith, James P. and John R. Finch. “Vehicular Suicide.” Life
Threatening Behavior, Vol. 2, No. 2 (Summer 1972): 105-119.
Raphael, Beverly, The Anatomy of Bereavement. NY: Basic Books, 1983.
Reamer, Fred. “Toward More Effective Communications in Safety.” In Dan
39
Petersen and Jerry Goodale (Editors) Readings in Industrial Accident
Prevention. NY: McGraw Hill, 1980.
Reed, Mark D. “Sudden Death and Bereavement Outcomes: The Impact of
Resources on Grief Symptomology and Detachment.” Suicide and LifeThreatening Behavior, Vol. 23, No. 3 (Fall 1993): 204-220.
Reed, Mark D. and Jason Y. Greenwald. “Survivor-Victim Status, Attachment,
and Sudden Death Bereavement.” Suicide and Life-Threatening Behavior,
Vol. 21, No. 4 (Winter 1991): 385-401.
Roberts, Ian, Hohan, Dinesh, and Kamran Abbasi. “War on the Roads.” British
Medical Journal, Vol. 342 (11 May 2002): 1107-1108.
Rollins, Gina. “Preventing the Fall: Designs on Building Safe Homes for the
Elderly.”
Safety
and
Health
(September
2000).
Online
Source:
http://www.nsc.org/issues/ifalls/falfalls.htm.
Rosof, Barbara D. The Worst Lost: How Families Heal from the Death of a Child. NY:
Henry Holt and Company, 1994.
Sanders, Catherine M. “Effects of Sudden VS. Chronic Illness Death on
Bereavement Outcomes.” Omega, Vol. 13, No. 3 (1982-83): 227-241.
Sartre, Jean-Paul. Being and Nothingness: A Phenomenological Essay on Ontology.
NY: Washington Square Press, 1956.
Schmidt, Chester W., Shaffer, John W., Zlotowitz, Howard I., and Russell S.
Fisher. “Suicide by Vehicle Crash.” American Journal of Psychiatry, Vol.
134, No. 2 (February 1977): 175- 178.
40
Shankar, Umesh G. “Motorcyclist Fatalities in 2000.” National Highway Traffic
Safety Administration, National Center for Statistics. (December 2001).
Washington, D.C.: U.S. Department of Transportation. DOT HS 809 387.
Shneidman, Edwin S. Deaths of Man. NY: Quadrangle, 1973.
Smith, D. F. “Subintentional Suicide Among Youth.” Health Education,
(September/October 1980): 44-45.
Stevens, Victor J., Hornbrook, Mark C., Wingfield, Darlene J., Hollis, Jack F.,
Greenlick, Merwyn R. and Marcia G. Ory. “Design and Implementation
of a Falls Prevention Intervention for Community-Dwelling Older
Persons.” Behavior, Health, and Aging, Vol. 2, No. 1 (1991/92): 57-73.
Suchman, Edward A. “A Conceptual Analysis of the Accident Phenomenon.”
Social Problems, (August 1961): 241-253.
Tabachnick, Norman. “Subintentional Self-Destruction in Teenagers.” Psychiatric
Opinion, Vol. 12, No. 6 (July 1975): 21-26.
Tabachnick, Norman (Editor). Accident or Suicide? Destruction by Automobile. IL:
Charles C. Thomas, 1973.
Thompson, Karin E. and Lillian M. Range. “Bereavement Following Suicide and
Other Deaths: Why Support Attempts Fail.” Omega, Vol. 26, No. 1 (199293): 61-70.
Veevers, Jean E. and Ellen M. Gee. “Playing it Safe: Accident Mortality and
Gender Roles.” Sociological Focus, Vol. 19, No. 4 (October, 1986): 349-360.
Vernick, J.S, Li, G., Ogaitis, S. MacKenzie, E.J., Baker, S.P. and A.C. Gielen.
41
“Effects of High School Driver Education on Motor Vehicle Crashes,
Violations, and Licensure.” American Journal of Preventive Medicine, Vol. 16
(1999): 40-46.
Vredenburgh, A.G. and H.H. Cohen. “High-Risk Recreational Activities: Skiing
and Scuba. What Predicts Compliance with Warnings?” Journal of Safety
Research, Vol. 27, Issue 2 (Summer 1996): 134-135.
Webster’s Third New International Dictionary of the English Language
Unabridged. Chicago: Encyclopedia Britannica Inc., 1986.
Williams, Allen F. and JoAnn K. Wells. “Deaths of Teenagers as Motor-Vehicle
Passengers.” Journal of Safety Research, Vol. 26, Issue 3 (Autumn 1995): 161167.
Williams, Allen .F., Peak, N.N., and A.K. Lund. “Factors that Drivers Say
Motivate Safe Driving Practices.” Journal of Safety Research, Vol. 26, Issue 3
(Autumn 1995): 198.
Winn, Russell G. and David Giacopassi. “Effects of County-Level Alcohol
Prohibition on Motor Vehicle Accidents.” Social Science Quarterly, Vol. 74,
No. 4 (December 1993): 783-791.
42
Table 1: The Fifteen Leadings Causes of Death in the United States, 2000
Rank
Cause of Death
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Heart Disease
Malignant Neoplasms
Cerebrovascular Diseases
Chronic Lower Respiratory Diseases
Accidents (Unintentional Injuries)
Diabetes Mellitus
Influenza and pneumonia
Alzheimer’s Disease
Nephritis
Septicemia
Intentional Self Harm (Suicide)
Chronic Liver Disease
Hypertension & Renal Disease
Pneumonitis due to Solids or Liquid
Assault (Homicide)
Source: Minino and Smith, 2001.
Number of Deaths
709,894
551,833
166,028
123,550
93,592
68,662
67,024
49,044
31,613
31,613
28,332
26,219
17,964
16,659
16,137
43
Table 2: Unintentional Injuries in the United States, 1999
Rank
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
Cause of Death
Number of Deaths
Motor Vehicle
40,965
Falls
13,162
Poisoning
12,186
Unspecified
7,459
Suffocation
5,503
Drowning
3,529
Fire/Burn
3,471
Natural/Environment
1,923
Other Land Transport
1,867
Pedestrian
1,502
Other Transport
1,408
Other Spec., Classified
1,310
Other Spec., (Not elsewhere classified)
955
Struck by or Against
894
Firearm
824
Machinery
622
Pedal Cyclist, Other
185
Cut/Pierce
74
Overexertion
21
-----------------------------------------------------------------------------------Total
97,860
Source: Center for Disease Control and Prevention, 2002.