More anthrax case questions

Questions about the FBI's case against popping up like mushrooms after a rain. There are too many to address in just one post. Meryl Nass's site has cataloged a number of them and Glenn Greenwald's latest installment others. We've weighed in a couple of times (here and here) and now want to add some additional thoughts about the official version of how the alleged anthrax attacker, Dr. Bruce Ivins, died.

Dr. Ivins was found unconscious at his home and taken to a hospital, where he died three days later. We don't know if he ever regained consciousness. Let's assume he didn't. There was no suicide note. In order to be buried legally there must be a death certificate filed with the State of Maryland. In the case of death by natural causes with an attending physician, the doctor fills it out. Sudden, unexpected or unattended deaths are referred to the state medical examiner (Maryland does not have a coroner system), whose task is to determine, as accurately as possible, both the cause and manner of death. The cause of death is usually written in narrative form (e.g., acute liver failure from overdose of acetominophen and codeine, coded later into an official International Code by a trained coder, called a nosologist). The manner of death is usually one of five categories: natural, homicide, suicide, accidental or undetermined. In order to fill in the certificate as accurately as possible the medical examiner may or may not perform an actual autopsy, i.e., physically dissect the body and also examine tissues microscopically. But there are other forms of post mortem examination, some as simple as examining the body and corroborating a judgment with police accounts, police reports or medical records. It is the medical examiner's option how thorough an investigation should be done.

In the Ivins case the chief medical examiner determined the cause of death was toxicity from an overdose of acetominophen and codeine and the manner of death was suicide. At that point the body could be released to the funeral home for final disposition. We still don't know if an autopsy was done, although it was announced at one point that one wasn't (meaning dissection and microscopic examination of tissues). Given the extraordinarily high profile of this case we wondered about this last week. The questions go to how the medical examiner was able to accurately determine both the cause and manner of death.

To be completely certain of the cause of death there would have to have been both a toxicology screen (which could have been done with blood samples only) and also clinical evidence that the cause of death was related to the alleged toxic agent. In the case of acetominophen and codeine this could either be respiratory arrest from an overdose of codeine or fulminant toxic hepatitis and liver failure from the acetominophen. If the codeine were combined with the acetominophen, as is usual, the likely mode of death would be liver failure. Clinical information from Ivins's hospitalization before death could be used to verify liver failure, for example, a record of sky high liver-associated enzymes. So the medical examiner could have made a plausible cause of death determination without a dissection of the body, although one would have thought in this kind of case one would have been done in any event. Maybe when he fell unconscious he hit his head and died of a subdural hematoma. Might there have been other toxins? Since we don't know what was asked for in a tox screen, that is a possibility. What about alcohol? Colleagues say Ivins was drinking heavily in the period before his death, so this is highly pertinent. Maybe there is more complete information than we have been given, but there is no mention anywhere how it was obtained -- if it was.

In particular, the combination of alcohol and acetominophen is highly pertinent to the other determination the medical examiner must make, the manner of death. Besides cause and manner, there is one other piece of information, not officially part of the birth death certificate (although sometimes found in the narrative portion) -- the circumstances of death. Essentially this means the reason for the manner of death. For example, "family dispute," "financial worries," "home foreclosure" or "failed love affair." In the Ivins case, the FBI has obligingly offered abundant information on circumstance, mostly uncorroborated and some highly speculative. One of the most frequently repeated "circumstance" items in news reports is that Ivins killed himself as the FBI was "closing in" on him and preparing to charge him with capital crimes. But his lawyer denies Ivins even knew he was a suspect in the case:

As the government pegs the blame for the 2001 deadly attacks on one Army biologist, the attorney for scientist Bruce Ivins says his client never knew he was "the suspect" in the attacks.

"We were never informed or advised that an indictment was imminent of him," attorney Tom DeGonia tells WTOP. DeGonia's broadcast interview is Ivins' lawyers' first interview since Ivins committed suicide.

Ivins, a Fort Detrick scientist, overdosed on acetaminophen. He died July 29, hours before he was set to meet with the government about the case. Even though Ivins had died, DeGonia and co-counsel Paul Kemp still met with the Justice Department that day. It was then, DeGonia says, the government offered up a reverse proffer -- its plans to seek an indictment against Ivins.

"It had never been made clear to him nor to us that he was 'the suspect,'" says DeGonia, Ivins' co-counsel. (WTOP News [Baltimore]; n/t MRK)

Could the "manner of death" designation of "suicide" be wrong? We will leave aside various conspiracy theories that it was a homicide because without an autopsy we have no way to judge this at the moment. But another more likely "manner of death" would be "accidental" because the combination of alcohol and acetominophen is known to be lethal in some people. Indeed there are many reports in the literature of a combination of a normal therapeutic dose (2 to 4 grams) combined with chronic alcohol ingestion leading to fatal fulminant toxic hepatitis (here is one citation among many possible). Without more information than we now have, at the very least we would expect the "manner of death" to have been classified "undetermined," especially as Maryland is one of a few states whose procedures favor this classification.

What difference does this make? Let's assume for a moment that in the wake of the bungled Hatfill investigation the FBI was considering other "persons of interest." If Ivins died accidentally they would be in a dilemma. Should they announce their case at that point? If in fact they waited to accumulate more solid evidence or they felt that they would never get beyond what they already had, or there were reasons to have someone, especially a lone, rogue scientist be the culprit, then fixing the manner of death as a suicide fit in to the narrative they were developing much better than an misadventure with Tylenol for a headache. "Suicide as the cops were closing in" is a much tidier and persuasive story.

But is it just a story?