Describe the medicolegal aspects of death from starvation and neglect.

Definitions

• Causes — accidental: famine, entombment in a mine or after an earthquake, shipwreck, being lost or trapped; suicidal: hunger strike, and self-starvation in psychiatric illness; homicidal: deliberate deprivation of the helpless — infants, the elderly, the disabled and prisoners, which is the circumstance of medicolegal importance; and disease: oesophageal stricture or carcinoma, pyloric stenosis, malabsorption, malignancy, and anorexia nervosa
• Water is far more urgent than food — death from deprivation of water alone occurs in about 7 to 10 days, whereas a person with water but no food may survive 6 to 8 weeks. Survival depends on the initial body fat, the ambient temperature, activity and the availability of water
• Death occurs when about 40 to 50% of body weight has been lost

Clinical Features and Postmortem Findings

• Clinical progression — hunger and thirst, which subside after a few days; progressive weight loss and emaciation; weakness and lassitude; the skin becomes dry, wrinkled, inelastic and pigmented, and hangs in folds; the eyes are sunken and the face haggard with prominent bones; the abdomen is retracted or, in children, protuberant; the pulse is slow and the temperature and blood pressure fall; oedema of the legs appears from hypoproteinaemia; there is constipation with foul breath; and finally mental changes, irritability, hallucinations, apathy, coma and death, commonly precipitated by intercurrent infection
• External findings at autopsy — extreme emaciation with the skeleton prominent, the eyes sunken, the abdomen scaphoid, the skin dry, wrinkled, dirty and pigmented, and often bedsores; the body weight far below expected; and in the neglected, evidence of filth, verminous infestation and untreated wounds
• Internal findings — the body is almost devoid of subcutaneous and visceral fat; all organs are shrunken and pale (brown atrophy, with lipofuscin in the heart and liver); the stomach and intestines are contracted and empty, thin-walled and sometimes ulcerated; the gall bladder is distended with bile; the muscles are wasted; and the heart is small. There is often terminal bronchopneumonia
• Fat is lost in a definite order — the omentum and mesentery first, then the subcutaneous tissue, then the perirenal and finally the pericardial and orbital fat, which are lost last; the persistence of the buccal pad of fat in a child is a recognised finding

Medicolegal Aspects and Applied Aspects

• The essential question is whether the emaciation is due to disease or to deprivation, and this is answered by a complete autopsy with histology, excluding malignancy, tuberculosis, malabsorption, endocrine disease, HIV and chronic infection
• Supporting evidence of neglect — bedsores in a person who was able to be turned; filth and verminous infestation; untreated injuries or disease; evidence of confinement; the nutritional state of others in the same household; and the social circumstances
• Deliberate starvation of a helpless person is culpable homicide or murder, and neglect of a child or of a dependent elderly person is an offence in its own right; the Maintenance and Welfare of Parents and Senior Citizens Act 2007 and the Juvenile Justice Act create specific duties
• Hunger strike raises a distinct ethical problem — under the Declaration of Malta, a competent striker who refuses food must not be force-fed; the doctor's duty is to explain the consequences, to monitor, to treat when consciousness is lost if there is no valid advance refusal, and to maintain independence from the detaining authority
• Weigh the body and compare with the expected weight for age and height, and photograph the emaciation; a numerical record is far more persuasive than a description
• Take histology and toxicology in every case, and preserve material; the defence will be that the person had an undiagnosed illness, and only the microscopy answers it
• Consider chronic poisoning — arsenic and thallium produce progressive wasting and may be mistaken for starvation, and hair analysis will distinguish them
• Water matters far more than food — death follows deprivation of water alone in about a week, but a person with water may survive six to eight weeks without food
• Pericardial and orbital fat are lost last, so their absence indicates profound and prolonged deprivation rather than recent illness
• Assess the household; the nutritional state of other dependents in the same home is among the strongest evidence distinguishing poverty from selective neglect
• Bedsores in a person who could have been turned are evidence of neglect in themselves, independent of the nutritional findings
• Death is usually precipitated by infection — commonly bronchopneumonia — so the immediate cause of death may look unremarkable and the underlying starvation must be stated as the underlying cause
• Do not force-feed a competent hunger striker; the Declaration of Malta permits no exception, and the doctor must remain independent of the detaining authority
• Photograph and weigh the body, and compare against expected weight for age and height; a number carries far more weight in court than a description of emaciation