The forensic or medicolegal autopsy. Friend or foe?

The major issue in questioning the performance of general pathologists doing medicolegal or forensic autopsies is that they are very often without a firm basis for performing this task. With minimal training in medical school and minimal exposure during their residency, practicing general pathologists, although expected or even forced to do these cases, may face criticism after their performance in a case. The necessity for teaching forensic medicine and pathology in medical schools is obvious, and the necessity of there being more forensic pathology exposure in residency training programs in the United States and overseas is also obvious. Medical educators are responsible for all phases of medicine being taught to medical undergraduates and graduates and must be pressured to support the practice of all kinds of medicine in American communities, including legal or forensic medicine, in those cases in which questions arise that lead to the performance of postmortem examination.     

Tissue donation: ethical guidance and legal enforceability

The legal and ethical framework regulating the use of tissue donated for medical research in Australia provides clear direction on the appropriate use of donated tissue in many instances. However, this article argues that the current framework may be inadequate to address some of the problems that may arise from misuse of such tissue. It argues that the Human Tissue Acts do not provide a sufficiently broad system of regulation and require updating. It also notes that as much of Australian research practice is regulated through ethics guidelines, which do not have the status of law, in some cases this approach may fail to provide remedies for those whose tissue is used inappropriately.     

Competence to give informed consent for medical procedures

This study shows that referrals to psychiatry for evaluation for competence to give informed consent generally were made on patients who refused medical treatment. In this sample of referred patients, the only patients found to be incompetent to give informed consent were those with organic brain syndromes. No one with either schizophrenia or depression was found to be incompetent. It is possible that schizophrenic and depressed patients may generally be competent to give informed consent to medical treatment. This finding might be true notwithstanding the fact that many such patients have been found in other studies to be incompetent to consent to voluntary psychiatric treatment. For example, a patient may have delusions that others can read his mind and thoughts, but he still can understand that he needs dialysis for renal failure. Alternatively, it may be relatively rare that an emergency procedure is necessary before a patient's psychosis can be brought under control and consequently internists and surgeons themselves may prefer to wait. The significance of the results is unclear. Because of active interest in the doctrine of informed consent for psychiatric and medical patients by both physicians and attorneys and the few studies within this population, there is a strong need for more study regarding competence to give informed consent. Further study is especially important for psychotic patients for whom psychiatric consultation is not requested.(ABSTRACT TRUNCATED AT 250 WORDS)     

The fetus as a patient: emerging rights as a person?

Dramatic scientific breakthroughs in medical technology have revolutionized the physician's diagnostic prowess in the art of obstetrics. Scientific procedures now reveal previously undetectable secrets about the womb's tiny inhabitants. In the last few years, perinatologists have not only demonstrated the ability to discern fetal abnormalities of an extraordinary variety, but also have become increasingly successful in correcting many of these defects in utero. This article identifies the potential medicolegal conflicts that may arise as fetal surgery becomes an accepted medical practice. It begins by surveying the legal rights of unborn persons with a particular emphasis on the role of viability in determining those rights. The article will then examine the concept of viability as developed by the Supreme Court in Roe v. Wade and later abortion decisions and concludes that the current judicial deference to the medical community in determining viability is adequate for balancing rights in the abortion context. However, conflicts among physicians and between the other and her unborn child that may arise in the fetal surgery context suggest that viability may be an adequate benchmark for resolving such conflicts. The article concludes with a recommendation to reform the current method of resolving the critical question of when a fetus becomes viable.     

Determination of the Lewis blood group substances in stains of forensically relevant body fluids

Forensic investigations often demand a clear definition of secretor status. Lewis-typing of secretion stains may help to verify non-secretor results and to identify mixtures of secretions from Le (a-b-) persons and secretors (or non-secretors). Furthermore it gives an additional check on secretor status, determined by ABO-grouping. Few problems may arise, when testing prepared saliva or semen stains. Therefore our interest was focussed on the possibility of Lewis-typing in stains appearing in forensic case work such as cigarette tips, stamps and envelope flaps, semen stains and vaginal swabs, nasal secretion, sweat and urine stains. All stains with the exception of sweat and urine were successfully Lewis-typed. In saliva stains Lewis substances could be determined even after 5 years and in semen stains for at least up to 40 days.     

Must the Surgeon Take the Pill? Negligence Duty in the Context of Cognitive Enhancement

Recently, attention has turned to the possibility of enhancing human cognitive abilities via pharmacological interventions. Known as ‘cognitive enhancers’, these drugs can alter human mental capacities, and in some cases can effect significant improvements. One prime example is modafinil, a drug used to treat narcolepsy, which can help combat decreases in wakefulness and cognitive capacity that arise due to fatigue in otherwise healthy individuals. In this paper, we respond to calls in the philosophical and ethical literature that surgeons and other medical professionals should be morally obliged to take cognitively enhancing drugs. We examine whether surgeons who make fatigue‐related errors during patient care might be considered legally obliged to enhance themselves. We focus on liability for a failure to medicate, and conclude that it is highly unlikely that surgeons will be legally obliged to address their fatigue through the use of cognitive enhancing drugs.     

Changes in Fingerprints Depending on Physiological Factors

The aim of the study was to determine the effect of gender, body mass index, and time on the width of friction ridge impressions in fingerprints and the content of sweat and sebum forming the print. The research showed that the friction ridge impressions of women are significantly wider than those of men, and this tendency persists throughout the existence of the print. The differences may result from the anatomical structure of the skin, as well as from the use of protective products such as creams, which are used more often by women. The width of friction ridge impression is similar in underweight and overweight people, but greater than in those with normal body weight, and the amount of sweat and sebum increases with body weight. The passage of time significantly reduces both the width of the friction ridge impression and the content of sweat and sebum secretions in the print.     

Drug abuse's smallest victims: in utero drug exposure

The social and economic impact of drug use on our global population continues to increase leaving no geographical, social or cultural group untouched. The National Institute on Drug Abuse (NIDA), in one of the few large surveys of maternal abuse, found that 5.5% of mothers reported taking an illicit substance during gestation. These figures certainly are underestimates due to the stigma of drug use during pregnancy and the accompanying legal, ethical and economic issues. Although drugs of choice and routes of administration vary by country, exposure of our most valuable resource, our children, to the developmental effects of drugs is an enormous problem. In utero drug exposure can have a severe impact not only on the development of the fetus, but also on the child during later stages of life. More than 75% of infants exposed to drugs have major medical problems as compared to 27% of unexposed infants. The cost of treating drug-affected infants was twice the cost of non-affected infants. Obstetrical complications including placental insufficiency, miscarriage, intrauterine death, and increased incidence of infectious and sexually-transmitted diseases are higher in the drug-abusing mother. Treatment for pregnant addicts should be a high priority for our governments. Increased awareness and improvement in our understanding of drug abuse in the medical, legal and social realms will enable us to reduce the barriers to treatment for this important population.Accurate identification of in utero drug exposure has important implications for the care of the mother and child, but can raise difficult legal issues. Society discourages prenatal care with the infliction of harsh criminal penalties. Maternal drug use during pregnancy can be monitored with urine, sweat, oral fluid and/or hair testing. Detection of in utero drug exposure has traditionally been accomplished through urine testing; however, the window of detection is short, reflecting drug use for only a few days before delivery. Monitoring exposure through testing of alternative matrices, such as neonatal meconium and hair, offers advantages including non-invasive collection and detection earlier in gestation. There are many unresolved issues in monitoring in utero drug exposure that urgently require research. These can be divided into research to definitively differentiate drug exposed and non-drug-exposed fetuses, determine the most efficient methods to routinely monitor women's drug use, and determine how these drug test results relate to neonatal and maternal outcomes. Research in this area is difficult and expensive to perform, but necessary to assess accurately drug effects on the fetus. By increasing our understanding of the physiological, biochemical and behavioral effects of gestational drug exposure, we may ultimately provide solutions for better drug prevention, treatment and a reduction in the number of drug-exposed children.     

Gender expectations and their impact on black female offenders and victims

The purpose of this study is to investigate the relationship between failure to register (FTR) as a sex offender and subsequent recidivism (N = 2,970). No significant differences were found between the sexual recidivism rates of those who failed to register and compliant registrants (11% vs. 9%, respectively). There was no significant difference in the proportion of sexual recidivists and nonrecidivists with registration violations (12% vs. 10%, respectively). FTR did not predict sexual recidivism, and survival analyses revealed no significant difference in time to recidivism when comparing those who failed to register (2.9 years) with compliant registrants (2.8 years). Results fail to support the supposition that sexual offenders who fail to register are more sexually dangerous than those who comply with registration requirements. The punitive emphasis on registration enforcement may not be justified and might divert limited resources away from strategies that would better facilitate public protection from sexual violence.     

Blood typing of blood stains on sweat stains by the iso-agglutinins detection method

When a blood typing is made for mixed stains of sweat and blood, erroneous results may be obtained. The reason is that the blood group substance in the sweat is detected at the same time as that in the blood. In this paper the typing of the blood stain on the sweat stain is carried out by the detection of isoagglutinins which may give additional information to the forensic serologist.     

Recent status of the medical examiner system in Japan: demographic variation of medicolegal deaths in Hyogo Prefecture and uncertainty in medicolegal investigations conducted by medical practitioners.

The medical examiner system has been steadily abolished in Japan. Instead, medicolegal investigations are entrusted by the police to medical practitioners, who are not permitted to perform autopsies. The necessity for the medical examiner system was assessed through inquest records in Hyogo, one of the three prefectures which still have medical examiner systems. Standardized mortality ratios (SMRs) for accidents and suicides were negatively associated with population density, being high in rural areas with a large proportion of elderly citizens, while the SMR for natural deaths was high in urbanized areas and associated with the proportion of inquests to total resident deaths. The high proportion of inquests, however, did not always mean that inquest records were of good quality. Significant differences in the quality of medicolegal investigations seemed to exist between medical examiners and medical practitioners. That is, in order to certify the cause-of-death, medical examiners performed autopsies in about half of their cases, while only 2% of medical practitioner cases were subjected to autopsies. Medical practitioners, who certified the cause-of-death as "heart failure" without advising an autopsy, were regularly entrusted with inquests. It is likely that the causes-of-death for medicolegal cases may be questionable since more than 85% of all medicolegal deaths were investigated by medical practitioners, which may cause inaccuracy in at least 3-7% of mortality statistics. It is necessary to educate medical practitioners concerning the importance of mortality statistics and ICD and on the validity of autopsies, in order to obtain accurate mortality statistics from medicolegal cases.     

High Resolution Imaging of Latent Fingerprints by Localized Corrosion on Brass Surfaces

Abstract:  The Atomic Force Microscope (AFM) is capable of imaging fingerprint ridges on polished brass substrates at an unprecedented level of detail. While exposure to elevated humidity at ambient or slightly raised temperatures does not change the image appreciably, subsequent brief heating in a flame results in complete loss of the sweat deposit and the appearance of pits and trenches. Localized elemental analysis (using EDAX, coupled with SEM imaging) shows the presence of the constituents of salt in the initial deposits. Together with water and atmospheric oxygen—and with thermal enhancement—these are capable of driving a surface corrosion process. This process is sufficiently localized that it has the potential to generate a durable negative topographical image of the fingerprint. AFM examination of surface regions between ridges revealed small deposits (probably microscopic "spatter" of sweat components or transferred particulates) that may ultimately limit the level of ridge detail analysis.     

Electronic fetal monitoring: physician liability and informed consent

Electronic fetal monitoring (EFM) has been criticized as ineffective, unsafe and costly. Despite existing controversy regarding the risks involved in using EFM, this monitoring procedure continues to be widely employed. In many jurisdictions, in fact, the use of EFM during labor may be considered the customary practice. This Article analyzes the medical and legal issues arising from a physician's use of or failure to use EFM. The Author argues that EFM subjects the mother and the fetus to risks which may be avoided if auscultation, a less intrusive monitoring technique, is employed. The "customary practice" standard of care, the ordinary negligence standard of care, and the "best judgment" and "duty to keep abreast" standards of care are compared and applied to the physician's decision to use EFM. The Author contends that physicians who employ auscultation may not be liable for failing to use EFM; however, physicians who use EFM despite the evidence of its risks may be liable for failing to "keep abreast" or to use their "best judgment" or for negligence. Finally, the Author contends that both physicians and their patients are best protected when the physician elicits the mother's informed consent to employ a particular monitoring technique during labor.     

Segmental Hair Analysis—Interpretation of the Time of Drug Intake in Two Patients Undergoing Drug Treatment

The present study involved segmental testing of hair in two clinical cases with known dosage histories. Hair analysis confirmed the first patient's exposure to the prescribed sertraline and citalopram for several months. Citalopram was generally distributed along the hair shaft in accordance with the drug ingestion period. By contrast, “false” positive results were observed for sertraline in distal hair segments, corresponding to a period of no sertraline exposure, which may indicate incorporation from sweat or sebum, which transport the drugs along the hair surface. The second patient received various drugs during her treatment for brain cancer. Metoclopramide, morphine, oxazepam, paracetamol, sumatriptan, tramadol, and zopiclone, which had been part of the therapy, were all detected in the proximal hair segment. The results of these two cases indicated that results—especially concerning the time of drug intake—must be interpreted with caution and allow for the possibility of incorporation from sweat or sebum.     

The role of clinical forensic medicine in cases of sexual child abuse

The work of specialists in forensic medicine in those cases of child abuse that result in the killing of a child is defined and well known. It is less well defined in cases of (suspected) sexual abuse. The cases presented show the difficulties that arise if medical doctors and prosecutors are uncertain about the procedures that have to be followed or do not appreciate the value of objective findings. It is concluded that knowledge about necessary examinations by physicians, police officers and prosecutors has to be promoted in order to improve handling and (legal) outcome of these cases.     

从法医角度看医疗纠纷及其产生的原因与防范

从医疗纠纷鉴定人角度研究医疗纠纷,为相关机构防范医疗纠纷提供思路。医疗纠纷是多种原因引起的,一般采用诉讼方式解决。法医在医疗纠纷的解决中扮演重要角色。在医疗纠纷鉴定中要判定诊疗行为对患者造成的损害后果,判定诊疗行为是否存在医疗过失,判定医疗过失与损害后果之间的因果关系．正确地进行死因分析和证据的取舍认定。在引起医疗纠纷的原因中,以技术性、责任心、医患交流不足等方面的原因居多。医护人员应提高自身的业务水平、责任心及服务质量;加强医患交流,建立畅通的医患沟通渠道;增强自我法律防护意识,建立健全的医疗规章管理制度。     

Medical devices; exception from general requirements for informed consent. Interim final rule

The Food and Drug Administration (FDA) is issuing this interim final rule to amend its regulations to establish a new exception from the general requirements for informed consent, to permit the use of investigational in vitro diagnostic devices to identify chemical, biological, radiological, or nuclear agents without informed consent in certain circumstances. The agency is taking this action because it is concerned that, during a potential terrorism event or other potential public health emergency, delaying the testing of specimens to obtain informed consent may threaten the life of the subject. In many instances, there may also be others who have been exposed to, or who may be at risk of exposure to, a dangerous chemical, biological, radiological, or nuclear agent, thus necessitating identification of the agent as soon as possible. FDA is creating this exception to help ensure that individuals who may have been exposed to a chemical, biological, radiological, or nuclear agent are able to benefit from the timely use of the most appropriate diagnostic devices, including those that are investigational.     

Jewish Perspectives on the Use of Preimplantation Genetic Diagnosis

This article presents an analysis of the ethical considerations raised by preimplantation genetic diagnosis (PGD) from a Jewish perspective. It weighs the Jewish imperatives to pursue good health against a number of harms that may follow from the expanded use of PGD technology, including increased medical risk to the mother, the destruction of embryos and possible emotional harm to the child born from this procedure. It pays special attention to the potential harms that may befall those in society who do not have access to PGD or who choose not to employ it.     

Bundaberg and beyond: duty to disclose adverse events to patients

Although much excellent work has been done in Australia and elsewhere to improve the safety and quality of health care provision, the practice of medicine is inherently risky--adverse events sometimes occur. In Australia, practical guidelines for the open disclosure of adverse events to patients have been developed and are being implemented. State and Territory medical boards have recently adopted Codes of Conduct which include disclosure provisions, although the Australian Medical Association's Code of Ethics does not yet contain express patient disclosure provisions. There is a dearth of authority concerning legal obligations to disclose known or suspected adverse events. Although many Australian jurisdictions have introduced statutory protection for those who apologise or express regret to patients following an adverse event, there is no corresponding express statutory disclosure obligation, unlike in some parts of the United States. The Bundaberg experience illustrates the complex ethical, practical and legal issues which arise in this area.