Keywords

1 Introduction

Suicide is a global public health crisis influenced by religion, culture, social class of an individual, and income of the country. According to the World Health Organization (WHO), more than 700,000 deaths happened due to suicide in 2019 in the world with an age-standardized rate of 9.0 per 100,000 population (WHO, 2021). Additionally, about 10–20 suicide attempts happen for each suicide (WHO, 2014). It is the 4th leading reason of death among individuals aged 15–29 years (WHO, 2021). More than three-fourths (77%) of global suicides happen in low- and middle-income countries (LMICs) (WHO, 2021). In case of Bangladesh, the suicide rate widely varies among published articles such as WHO reports, NGO data, and police reports as the country is yet to establish a standard suicide reporting and surveillance system (Arafat, 2019). The WHO report published in 2021 estimated the age-standardized rate of suicide in Bangladesh as 3.9 per 100 000 population (WHO, 2021). In the majority of the cases, people rely on data available from the police that seems to be an underestimation of actual rates. At the same time, we do not know the exact proportion of underestimation. The detailed epidemiology of suicide in Bangladesh is discussed in the first chapter of this book (Kabir et al., 2023).

Bangladesh is a Muslim-majority country located in South Asia with about 170 million populations; among them, more than 90% are Muslims (World Population Review, 2022). Suicide is prohibited in Islam and it is a criminal offense in the legal system of the country. As per the current legal structure of the country, any unnatural death should be reported to the nearby police station. Subsequently, a postmortem or medicolegal autopsy is conducted to ascertain the manner of death, i.e., suicide or other unnatural deaths like accident or homicide. At this point, a significant portion of unnatural deaths is kept away from the medicolegal autopsy to avoid the legal procedure, disfiguration of the deceased body, and the potential harassment of police due to the criminal legal identity (Rahman et al., 2010).

2 Process of Suicide Declaration in Bangladesh

According to the code of criminal procedure in Bangladesh, the declaration of suicide, whether it occurs at home or at a hospital, rests with the police. As per the legal directives, the medicolegal autopsy procedure should be preceded by an inquest (preliminary investigation conducted by a police officer into the cause of death) report prepared by the police officer working as at least at the rank of sub-inspector of the concerned police station. In Bangladesh, postmortem is performed under the provision of three laws: (i) The Penal Code (1860), (ii) The Code of Criminal Procedure (1898), and (iii) The Evidence Act (1872) (Islam and Islam, 2003). The code of criminal procedures, 1898 (act no. V of 1898, 174(1) part V chapter XIV) describes the acts of the response of police regarding suicide, accidental death, or homicide. 174(1) (a) describes the response of police in case of death by suicide; 174(1) (b); and (c) describe the duties of police in case of homicidal, accidental, and suspicious deaths (Code of Criminal Procedure, 1898). This act has empowered the police officer in the presence of two or more witnesses (usually neighbors), shall make an investigation, and prepare a report regarding the apparent cause of death, unless otherwise directed by any rule where magistrate investigation is necessary. On the other hand, Section  176(1) describes inquiry should be performed by a magistrate into the cause of death in case of death in the custody of the police and in any other case mentioned in 174(1) (a) (b) and (c) (Code of Criminal Procedure, 1898). The magistrate inquiry is performed in exchange for or accompanied by the police investigation. That means, the process of suicide declaration follows the laws enacted proceedings. The police are the authority that should carry out the declaration of suicide primarily by visiting the scene of the crime and preparing an inquest report that is to be confirmed by autopsy. In case of death by suicide in a hospital, a police case should be filed and the death certificate and the dead body should be handed over to the police. The police then make an investigation that is called an inquest (Surathal in Bangla) report and mention the apparent cause of death. Subsequently, the deceased body is sent for medicolegal autopsy to the nearby establishments where forensic morgues are available (Islam and Islam, 2003). But if a person dies in the custody of the police, whether it is a natural or unnatural death, the inquest report is prepared by the magistrate and then the body is sent for autopsy. A copy of the inquest (surathal) report and challan (Government gazetted, tabulated form no. 5371) should be sent along with the dead body. On completing the medicolegal autopsy, the physician prepares an autopsy report (form no. 5372) with a carbon copy. The hand-written copy of the postmortem is sent to the police to be produced in the concerned court. The carbon copy is kept in the forensic medicine department or the records of the district hospital. After completion of the postmortem, the dead body is handed over to the family members to perform the rituals before burial. Based on the inquest report, postmortem report, and information obtained from the police investigation, the manner of death whether it is natural or unnatural (suicidal, homicidal, or accidental) is decided finally by the legal bodies instead of the doctors (Islam and Islam, 2003). Sometimes the family members try to take the dead body without performing an autopsy by submitting an application to the legal authority mentioning that they don’t have any complaints against anyone and will not file any case. In some other cases such as definite road traffic accident, police may hand over the body to the family members. It is important to note that ideally, all unnatural deaths should undergo a medicolegal autopsy as per the law of the country.

Manner of death means the circumstances which make the person die. It can be better understood if the circumstantial evidence, crime scene investigation, and information from the first-hand witness, family, and friends are available and cooperative. Such information helps the autopsy surgeon a lot during the time of autopsy to collect evidence from the body for related investigations, viscera for chemical analysis, and finally prepare an opinion regarding cause, mode, and manner of death. In case of hospital death, the treatment papers help forensic pathologists to gather information related to the death. Inference from circumstantial and supportive evidence and information and autopsy findings, the opinion regarding the manner of death can be given. However, it is important to note that medicolegal autopsy along with all the necessary investigations like microscopic examination, laboratory investigation, chemical analysis of viscera, and other related investigations (if done) may fail to provide inference regarding the cause and manner of death. This is called negative autopsy which is about 2–5% of all deaths brought to the morgue. Postmortem reports don’t mention the manner of death in the case of poisoning, falling from a height, jumping in front of moving objects, railway accident, electrocution, burning, and drowning. In the above cases, the manner of death is confirmed by the police investigation.

3 Current Status of Postmortem Facilities in Bangladesh

The word “postmortem” is derived from the word “post”, which means “after”, and “mortem” means “death”. It is also called “autopsy”, which is derived from the Greek words autopsia. “Autos” means “self” and “opis” means “view”. So autopsy means “the act of seeing for oneself”. The other name for an autopsy is a necropsy. An autopsy is a scientific dissection of a dead body in order to ascertain the cause of death. The procedure should be in a systematic and scientific manner with standard facilities for the related investigations. Inadequate facilities and poorly or untrained manpower are supposed to fail in revealing the fact.

There are eight divisions and 64 districts in Bangladesh. In the 64 districts, there are 37 public medical colleges. Among these medical colleges, 18 medical colleges are conducting autopsy under the department of Forensic Medicine and Toxicology as they have morgues to keep dead bodies (Table 1). Other newly established medical colleges are yet to be prepared for medicolegal autopsy though forensic medicine departments have been established without morgue facilities. Third-year students of these medical colleges have to visit the district hospital morgue for the purpose of hands-on training on medicolegal autopsy. Autopsies are conducted in public medical colleges having morgue facility by the department of Forensic Medicine and Toxicology. In other settings where there are no public medical colleges or morgue facilities, autopsies are performed by the doctors who are working under the responsibility of the district hospital superintendent (previously under a civil surgeon). Especially Residential Medical Officer (RMO) in the district hospitals perform an autopsy. Unfortunately, it has been seen that the physicians working in the district hospitals who are involved in postmortem lack the necessary expertise to conduct the medicolegal autopsy (Rahman et al., 2010). Usually, they are working in other disciplines of medical science and are called on to conduct postmortem. Therefore, the whole procedure is more dependent on the morgue attendants rather than the field experts. Moreover, there are no independent forensic, pathology, and toxicology labs supporting the process of medicolegal autopsies in medical colleges and district-level hospitals in Bangladesh. There was a chemical examiner’s office established in Dhaka, the capital city. Therefore, all the viscera/samples were to be sent to Dhaka (Rahman et al., 2010). Recently, two other chemical examiner labs in two other cities have been established. Autopsies are conducted during daylight hours in Bangladesh. Usually, no autopsy is carried out on that day when a dead body comes after 5 pm, and only in certain cases, if a state higher authority gives any special direction, the autopsy is done even at night. For example, an incident occurred in 2009, notoriously known as the “Bangladesh Rifles (BDR) mutiny” in which 57 army officers including the BDR director-general were brutally killed at BDR headquarter (Now known as BGB; Border Guard Bangladesh) by a group of rebellion BDR soldiers. In that case, postmortem examinations were carried out at night. But, normally when a body comes after 5 pm (scarcity of daylight), the dead body is received by the morgue attendant, papers are prepared, and the body is kept in the refrigerator/freezer for next day autopsy. Usually, the freezing facilities are available in the morgues of medical college hospitals only. In most of the district hospital morgues, this facility is currently not available, and in these facilities, postmortem examination is carried out the next day as early as possible and the body is handed over to the police for the purpose of burial.

Table 1 List of public medical colleges in Bangladesh having medicolegal activities
Full size table

As far as chemical labs are concerned, there are currently three labs working in Bangladesh: Dhaka (the capital city), Chattogram, and Rajshahi. Previously, there was only one chemical lab in Dhaka (Rahman et al., 2010). The second chemical analysis lab is established at Chattogram, a port and divisional city in Bangladesh. In January 2020, a third forensic laboratory including a chemical lab has been established at Rajshahi, a divisional city of Bangladesh by the Criminal Investigation Department (CID). Due to this expansion of chemical labs, chemical examiner’s reports are available earlier compared to the past. Along with the chemical labs, for the detection of criminals, fixation of paternity and maternity, and establishment of identity related with DNA test, two DNA labs are functioning at Dhaka also. One is the National Forensic DNA Profiling Laboratory (NFDPL), the first forensic DNA profiling lab established in 2006, which is located at the Nuclear Medicine building of Dhaka Medical College. The second DNA testing lab is working under the Bangladesh Policenamely Forensic DNA laboratory of Bangladesh Police, under CID at Dhaka. It started its journey as a project in 2011 and finally maintaining all the validating processes, it started a case sample examination in 2014. To broaden the services all over Bangladesh, now the government had set up a separate DNA Laboratory Management Department by gazette notification on 9 August 2020. After the gazette notification, divisional DNA screening laboratories are nowadays established and are working in Rajshahi, Sylhet, Barishal, Khulna, Rangpur, and Faridpur. These six centers collect and preserve DNA samples and send them to NFDPL.

In case of autopsy and medicolegal works, where any test related to confirming the cause of death or any medicolegal works, the forensic experts have to take help from the chemical examiner’s office, DNA Lab along with other departments such as radiology and imaging, microbiology, pathology, etc., which work independently. Noteworthy, due to the affiliation of various departments with poor collaboration and coordination, final reports by the forensic experts submitted to legal authority are time-consuming and delayed.

It is an unfortunate reality that there is a scarcity of forensic experts in Bangladesh due to its job nature, work environment, and benefits package. According to the Director General of Health Education Department Statistics (2 August 2022), only 22 forensic experts are now working all over Bangladesh with a vacancy of 65 posts. There are 103 posts of lecturers. Among them, 58 are filled and 45 are vacant. Despite this shortage of manpower, very few doctors show interest to build up a career in this field due to various reasons. Sometimes they have to perform these medicolegal works under undue pressure exerted from different corners for a favor. This creates a psychological burden as well as a feeling of lack of safety for a new doctor who has just started working in this field. Nonetheless, they have to perform all sorts of medicolegal works including autopsy without additional payment. On the other hand, they have to produce evidence as an expert witness in a court of law and have to travel frequently to different districts of Bangladesh. This goes on after retirement from government service till death which may contribute as a demotivating factor. Surprisingly, after retirement from government services, they have to continue it without any remuneration even if the travel expenses are delayed. In an unfortunate condition, it may even be unpaid. During the time of cross-examination by the lawyers, forensic experts face unwanted questions with no link to the case. These sort of questions are felt humiliating by the young doctors, especially the female doctors. As a result, young doctors feel better to avoid these unexpected situations. Bearing these pressures, forensic pathologists, who are working in public medical college have to maintain academic activities like teaching and also conducting exams. Additionally, doctors are more oriented toward private clinical practice which is a source of extra income that is also an important reason for showing low interest in forensic medicine career. Moreover, there is no post of forensic pathologist at the district level. So there are unmet needs for creating positions in the district hospitals as well as to fill up the present vacancies in the Forensic Medicine department of public medical colleges based on the workload and responsibilities. Moreover, there are chances of creating new positions for forensic experts in medical colleges according to the rules and regulations formulated by the Bangladesh Medical and Dental Council (BMDC).

It is a bitter truth we can admit simply in a way that when there is a scarcity of forensic experts, the mortuary facilities will also be far behind the standard level in the morgues of medical colleges as well as in the district hospitals in Bangladesh except a few (Islam and Islam, 2003). The poor and neglected conditions of dead bodies have been identified and criticized in previous reports (Bose, Arafat et al., 2021). We reported a complicated case of necrophilia performed by a morgue assistant at Shaheed Suhrawardy Medical College morgue, perhaps due to poor privacy of dead bodies, and wide access to the dead bodies by morgue assistants (Bose, Arafat et al., 2021). If we consider the standard morgue facility, we can point out the mortuary facilities ensured and recommended by the national pathology accreditation advisory council, Commonwealth of Australia. It is important for the safety of autopsy surgeons and assistants working in the mortuary (Australian Government Department of Health, 2013). The council depicts autopsy as level 1, level 2, and level 3 facility and high-risk autopsy which should be maintained for setting up a mortuary that comprises an autopsy theater, change room, and observation area. Level 1 facility indicates a mortuary where an autopsy suite is not available. This level includes postmortems that are conducted by external examinations with or without radiological support and percutaneous needle sampling. The level 2 facility contains an autopsy suite where infrastructure or manpower for high-risk autopsies are not available. The next level (Level 3) facility contains a mortuary with an autopsy suite along with infrastructure and expertise to conduct high-risk postmortems. The autopsies with the risk of hazards from infections, chemicals, biological or radiation matters are considered high-risk postmortems. Sirohiwal et al. mentioned the minimum facilities of mortuaries indicating the arrangements for receiving the deceased bodies, conducting postmortems, transferring the bodies after the medicolegal examination, postmortem observation gallery, and other basic needs for an office (Sirohiwal et al., 2011). The mortuaries should be well equipped to ensure the smooth smooth functioning of the team. It describes also the design of a mortuary for a secondary, tertiary level mortuary complex, and miscellaneous requirements (Sirohiwal et al., 2011). If we give an example of Dhaka Medical College morgue, the country’s most familiar and reliable hospital, the autopsy is still done with ancient equipment like hammer, chisel, knife, etc. As a result, it is time-consuming to complete an autopsy and hand over the bodies to the police and finally to the relatives of the victims.

4 Current Legal Structure and Decriminalization

Suicide ends one’s life by own choice. Likewise, in many other countries, attempted suicide or non-fatal suicide attempt is considered a punishable criminal offense in Bangladesh (United for Global Mental Health, 2021; Mishara and Weisstub, 2016). According to the review of Mishara and Weisstub (2016) among 192 countries and states, suicide is still illegal in twenty-five countries and it is punishable with jail sentences in additional twenty countries that implement Islamic or Sharia law. Individuals who attempt to take their own lives risk severe penalties for themselves and even their families. Punishments vary, with penalties ranging from 1 to 3 years of imprisonment and fines (United for Global Mental Health, 2021). In Bangladesh, already previously mentioned in chapter XVI, Section  309, penal code 1860 criminalizes attempted suicide. The law is as such, “whoever attempts to commit suicide and does any act toward the act of commission of such offense, shall be punished with simple imprisonment for a term which may extend to one year, or with fine, or with both” (The Penal Code, 1860). On the legal aspect, attempted suicide in our country is considered as a criminal offense and punishment is simple imprisonment extending up to one year with or without a fine. Nevertheless, there is no record of giving punishment for any non-fatal attempts. Basically, Bangladesh is bearing the legacy of criminal laws of the British Raj formulated more than160 years ago (Islam and Islam, 2003). One should bear in mind that criminalization along with social stigma makes suicidal attempts underreported and even the deaths are driven away to show it as other causes. Therefore, the data on suicidal rates and non-fatal attempts available in Bangladesh do not depict the actual picture. Logically, the question comes, if you don’t know the real picture of a problem, then how is it possible to formulate a solution to the event?

Nowadays keeping and addressing these problems in mind, academicians have started to raise their concerns and demand decriminalization of suicidal behavior which in turn will encourage the help-seeking by the victim for mental support without any legal harassment (Soron, 2019; Arafat and Khan, 2019; Arafat et al., 2019). As we know mental support, psychiatric evaluation, and counseling are the ultimate steps in order to prevent further attempts to die by suicide. Readily available and easily accessible mental health support to distressed and indicated persons has proven the preventive role in suicide prevention (Zalsman et al., 2016). However, no initiative has been identified to make policy-level changes to date.

Now we may have to face the question of whether decriminalization of suicide is equivalent to the legalization of suicide? Really it’s a matter of unwanted debate. Bhatti et al. describes it in a fantastic manner by differentiating decriminalization and legalization (Bhatti et al., 2021). Something that is being decriminalized doesn’t indicate it as a legal entity. Referring to the perspective of mental health professionals, the article upholds it in a way that decriminalization would not legalize suicidal behavior, instead, it will inhibit the legal steps for persons with suicidal behavior.

Another question may arise, whether decriminalization should create a positive impact on lowering suicide or not. This sort of question is just a model of argument rather than a solution. Because a person attempting suicide is already suffering mental pain and agony and punishment sanctioned on him/her would change nothing but prevent the said accused to seek help from others. Hence, it is a hard time to take the necessary steps to adjust or change the laws in a timely manner, to make it decriminalized which would create a space to seek consultation from others without the fear of jail.

In the South-East Asia region, suicide has been already decriminalized in Bhutan, Indonesia, the Maldives, Nepal, Sri Lanka, and Thailand (Arafat et al., 2020). Now we could get a look at the legal framework related to suicide that existed in the Indian subcontinent where Bangladesh, India, and Pakistan reside. In India, Section 309 Penal Code, 1860 criminalizes attempted suicide. This is as same as in Pakistan and Bangladesh described in Section 325 and 309, respectively. Ranjan et al. mentioned a judgment of 1985 by the Delhi High court as a landmark judgment (Ranjan et al., 2014). The court commented, “the continuance of Section 309 I.P.C. (criminalizing suicide) is an anachronism unworthy of a human society like ours.” This Indian Penal Code was commenced during the British empire in 1860 and it persisted in India, albeit, suicide has been decriminalized in the United Kingdom in 1961 (Ranjan et al., 2014). Suicide is criminalized in Pakistan as per Section 325 in the Pakistan Penal Code, 1860. It criminalizes attempted suicide with punishment (Mehtab et al., 2022; Pakistan Penal Code Act, 1860). After a long battle, India has stopped the effects of the law that criminalized attempted suicide in 2017 by formulating the Mental Healthcare Act. Yet, further steps are warranted to remove the Penal Code act in India. Like India, strong notions have been raised in Pakistan in favor of decriminalization that are yet to be accepted in the parliament of Pakistan (Mehtab et al., 2022; Behere et al., 2015).

5 Current Challenges and Way Forward

5.1 Criminal Status of Suicide

The law in our country acknowledges the suicidal attempt as criminal offense which is prevailing 50 years counting from 1971, the birth year of Bangladesh that started over 160 years ago in British regimen. It is clear that criminalizing suicidal attempt is not a way to mitigate the problems. Rather the law is deterring people to seek consultation and even to escape from the hospital without fulfilling the course of treatment just to avoid legal problems. So we will have to think again and again in order to stop suicide or suicidal attempts. Current criminal legal status hinders people to disclose suicidal behavior and help-seeking, which in turn increases the risk of further attempts and death by suicide. Therefore, attempting suicide should be decriminalized, which will help the victim for seeking necessary help for the management of further suicidal attempts without any fear of imprisonment and social stigma.

5.2 Modernization of Medicolegal Autopsy Facilities

There is a lack of modern mortuary and forensic experts in Bangladesh. Without modern facilities and experts, it is difficult to give an opinion on any unnatural deaths, especially in case of advanced decomposed, mutilated, and burnt bodies, where there is effacement of identities. Recently, we noticed that it took about a week to identify a body with cut-throat wound due to LSD intoxication (Bose, Ray et al., 2021). The traditional ways of performing an autopsy in case of unnatural deaths should be upgraded. Forensic expert should continuously be trained. For an instance, the traditional procedure of dissecting the dead body for confirmation of death in case of suicide can also be performed by psychological autopsy, that is, to ask the relatives, friends or roommates who were in close contact with the deceased about the habits, history of taking anti-depressant or anti-psychotic medications, suicidal thoughts, failure or frustration, etc., regarding any issue without dissecting the body. These will help us to follow the trend and pattern of suicide which in turn will facilitate the formulation of suicide prevention. But in any doubtful cases, we can dissect the body as well. Furthermore, related laboratory investigations such as toxicological, histopathological, and radiological facilities should be set up under the forensic departments in order to avoid undue delay in giving an opinion. In district hospitals, forensic consultants must be appointed for performing an autopsy. Rahman and his colleagues recommended setting up of medical examiner’s system through international support which could be tested in the country to assess its suitability in current decades (Rahman et al., 2010).

5.3 Human Resource in Forensic Medicine

The number of forensic medicine experts needs to be increased, and decentralizing the services may help the health and judicial systems manage autopsy cases with limited resources. Without adequately trained experts and supporting staff, further expansion and up gradation of forensic services cannot be expected. Adequate facilities should be ensured in such a pattern that young doctors spontaneously choose their careers in forensic medicine. Secondly, in addition to forensic medicine, adequate opportunities for forensic psychiatrists would expand the services. Adequate training (both national and international) should be arranged to ensure the continuous progression of expertise.

5.4 Proper Training and Benefits of Morgue Staff

Morgue staff (well known as Dom in Bangla) play a vital role in medicolegal autopsy. They are engaged in receiving the dead body, dissection, preservation of viscera, reconstruction, and finally handing over the body to legal authority. Surprisingly they are inheritably engaged in this profession; the legacy started from their families. But still, nowadays, they are not well trained as professional ones. They learn to handle autopsy cases only by seeing the procedure from their family members though they need to be scientifically well trained. That is why there is a lack of well trained mortuary staff. Moreover, their salary and remuneration are so undervalued that is really unacceptable. If we want to take initiatives for upgrading forensic medicine, we will have to have a holistic approach like morgue attendants should be properly trained up with ensuring full monetary benefit packages.

5.5 Well-Documented Liaison

Suicide prevention is everyone’s business (World Health Organization, 2014). Currently, the scattered and scantly prevention strategies are not harmonized in Bangladesh (Arafat and Khan, 2019; Arafat, 2018). Enduring liaisons between mental health professionals, forensic experts, journalists, and legal bodies are warranted to change the legal status, raise awareness, and improve medicolegal decisions.

6 Conclusion

There are undeniable roles of forensic medicine, forensic psychiatry, and legal bodies in suicide prevention that should not have any exception in Bangladesh. Death declaration, identification of suicides, and crafting laws and regulations affect help-seeking behavior and suicide prevention. Immediate initiatives are warranted to change the criminal status of suicidal behavior in Bangladesh. Additionally, both qualitative and quantitative improvement of forensic services should be prioritized. Adequate measures should be made to reduce postmortem dropouts so that the underestimation of suicide could be resolved. There is no alternative to an enduring collaboration among forensic medicine, psychiatry, police, media, and other stakeholders.