Health ethics and legal medicine for health officer students (1)

HEALTH ETHICS AND LEGAL MEDICINE
By kaleab T.(MPH)

Table of Contents
• UNIT ONE Background and Rationale
 Background
 Rationale of Ethics
• UNIT TWO Health Ethics
• UNIT THREE Existing Health Laws in Ethiopia
• Public Health Proclamation

UNIT ONE Background and Rationale
 Background
• Ethics is the philosophical study of the moral value of human
conduct and the rules that govern it.
• The practical manifestations of ethics relates to
 codes of normative behaviour for society and
 an awareness of issues within society that have moral
importance

UNIT ONE continue…
• Ethics particularly associated with specific groups in society that
are deemed to have societal responsibility.
• Professions are among such groups.
• professions have a prestigious, powerful and trusted place in society
and both the public and the law expect high standards of conduct

• Rationale of Ethics for Health Workers
• The mandate to assure and protect the health of the public is an
inherently moral one.
• It caries with it an obligation to care for the well being of others and
it implies the possession of an element of power in order to carry
out the mandate.
• The general conduct of public health practice concerns the
professionals, individuals and the community at large.

• Ethical issues often arise as a result of conflict among competing
sets of values, such as, in the field of public health, the conflict
between the rights of individuals and the need of communities.
• The code of ethics for public health will clarify the distinctive
elements of public health and the ethical principles that follow
from or respond to those distinct aspects..

• The concerns of public health are not fully consonant with those of
medicine, however, thus we can not simply translate the principles
of medical ethics to public health.
 For example, in contrast to medicine, public health is concerned
more with populations than individuals, and more with
prevention than with cure
 In the context of Health Service extension programme (HSEP)
the ethical issues include equity, justice, equality and human
rights.
• These ideals should continue to be of primary importance in
providing Health service extension programme (HSEP).

• Health education, nutrition, basic hygiene and sanitation, family
health, immunization, prevention and control of HIV, TB, malaria
and first aid are major areas of focus in HSEP.
• Unless all these elements are provided adequately and continuously
without interruption, HSEP will have no meaning. There are no
priorities in these, and they must be offered as complete package.
• It is highly unethical to keep people ignorant about the causes,
control and prevention of diseases, about a healthy life style, and
about the social and community responsibilities of the people.
 Yet this is exactly what happens in the absence of public health
education.

UNIT TWO Health Ethics
 Ethics and Morality
 Health ethics have common features in different countries.
 However, each country adopts certain modifications according to
prevailing local culture, religious beliefs, social norms and
standards of public health practice.
 In Ethiopia, the need for modification of code of ethics is based on
current beliefs, standards of public health practice and religious
concepts.

UNIT TWO continue…
 Definition of Ethics and Morality
• The word ethics is derived from the Greek ethos, which means
custom or culture, a manner of acting or constant mode of
behaviour.
• Thus, Health ethics may be defined as a code of behaviour
accepted voluntarily, within the profession as, opposed to laws,
regulations and directives issued by official body or scientific
study of morality.
• It teaches us how to judge accurately the moral goodness or
badness of human action.

 Morality
• Definitions:- Morality is the science concerned with the distinction
between right and wrong.
• A moral act is one that is carried out with at least some degree of
knowledge and freedom, proceeding from man’s rational nature.
• A moral act (a human act which involves some principles of moral
law), which is in conformity with moral law, is called good but if
opposed to moral law, it is called bad.
• An act which is done with full knowledge and full freedom of choice is
a perfect moral act while an act in which both knowledge and/or
freedom is/or deficient is called an imperfect moral act.

• An act, which may be either good or bad but carried out with good
intentions, is referred to a positive moral act.
• On the contrary an act which entails omission such as an offence
committed by neglect of duty, is called a negative moral act.
• Factors, such as ignorance, emotion, violence and habit, that may
lessen human knowledge or freedom, may result in hindrance to
accountability.
 Public Health Ethics
 concerns the professionals, individuals and the community at
large.
 Focus on the mandate to assure and protect the health of the
public-which is inherently moral one.

 Importance of Ethics
• To help health professional identify moral and ethical issues
• To know what is right and wrong about what should and should not
be done for and to client
• To know and respect the issues of human rights, personal and civic.

 Basic Ethical Principles (General)
• There are five widely accepted ethical principles as put forward by
Thiroux, 1995.
 The Principle of Autonomy
• This principle means that people, being individuals with individual
differences must have a freedom to choose their own ways and
means of being moral with the framework of the other four
principles.
• Respect for autonomy involves respecting another persons rights
and dignity such that a person reaches a maximum level of
fulfillment as a human being.

• In the context of health care this means that the relationship
between client is based on a respect for him or her as a person and
with individual rights.
• Rights in relation to health care are usually taken to include
• The right to information
• The right to privacy and confidentiality
• The right to appropriate care and treatment

 Beneficence (doing good)
• Frankena (1963) suggests that beneficence means doing or
promoting good as well as preventing, removing and avoiding evil
or harm.
• E.g. Giving clients clean needles, condoms and provide
information about emergency first aid to reduce the risks of HIV
infection or accident.
 Non-mal eficence (doing no harm)
 Non-mal eficence holds a central position in the tradition of
medical ethics and guards against avoidable harm to subjects.

 Justice (fairness)
• This principle states that human being should treat other human
being fairly and justly in distribution goodness and badness among
them.
• In other words justice should include
• Fair distribution of scarce resources
• Respect for individual and group rights
• Following morally acceptable laws
• The principle of truth telling (honesty)
• At the heart of any moral relationship is communication.
• A necessary component of any meaningful communication is
telling the truth, being honest

UNIT THREE
• Existing Health Laws In Ethiopia
• Source of Enforcement of Laws and Procedures
• There exist two basic arguments as to the procedure necessary to
promulgate health legislation in this country.
• A major body of public health advisors believe that compliance
with public health requirements can never be obtained by force.
• The proponents of this case argue that health standards can only be
introduced into the community through persuasion and education.

UNIT THREE continue…
• The other argument is that of enforcement.
• If several cases are presented in which particular members of the
community are fined for being in violation of the existing law,
• there is the possibility that the remainder of the community will
become immediately aware of the existing rules the danger of
failing to comply with them, and the necessity of following the
directions.

• The enforcement of public health legislation requires excellent
judgment.

• general characteristics of public health legislation.
• Analysis of Legislation
• 2/31 (1943) L. 25: Sanitation Rules
• The law is directed toward the public enforcement authority rather
than the individual. The law does not seem to hold the individual
responsible but merely requires the public enforcement authority to
take remedial action. Therefore, there is some doubt about the
validity of enforcement of this law in local communities.
• Disinfestation and vaccination:. The power to order the
vaccination of any persons for vaccine preventable diseases.
• Disposal of Refuse: They prohibit the burning or disposal of
refuse in any public street or public place; require the removal of
night soil from buildings; demand removal of dead animals within
twenty-four hours; and prohibit the disposal of any or carcass in
any street, public place or water source..

• 2.11 (1943) L. 26: Rabies (Control) Rules:
• The Legal Notice allows the commissioner of police to destroy any
dog with out a mark or identification or any dog with a mark of
identification but appearing to suffering from rabies. The law is
reasonably explicit but it dose not provide for woreda Health
Office enforcement. The regulation and enforcement of it by law is
governed by the police commissioner; and therefore, will not be a
part of the woreda Health Office enforcement; practices and
procedures.
• 6/12 (1947) P. 91: Public Health Department
• Proclamation 91 sets up the respective duties and responsibilities
of the Ministry of Health in its sub-divisions.

 104: Quarantine Rules
• This Legal Notice control the entrance of infective persons,
vehicles merchandise and baggage into Ethiopia. It has no
substantial application within the provinces as it appears to
regulate only border problems and therefore, would not be
applicable for use by health center staffs. In general, this
legislation governs the quarantine of persons, and the quarantine
of merchandise baggage
 10/1 145: Woreda Health Office Rules
• In particular, the Woredas Health Office is required by section
five to report to the Kantiba if any condition exists which is
dangerous to public health; the Kantiba is thus granted authority to
refrain from granting a new license to a new applying
establishment in which there exist violation of any provision of
any health legislation..

• 10/1 (1950) L. 146: Water Rules
• Legal Notice 149 combines a series of separate provisions, which
together are designed to prevent impure and unhealthy water from
reaching the public.
• The Food Laws: (1) prohibit offering to the public food
unsafe or unfit for human consumption (2) food
contaminated with human waste material as dangerous to
public health; (3) define certain foods as unsafe for human
consumption: (a) meat without stamp of public municipal
slaughter house; (b) milk from animals having tuberculosis
infections, abortion, or anthrax cases; (c) other food declared
unsafe by the HW; and (d) vegetables irrigated with water
containing human excrement;

• 10/1 (1950) L. 148. Refuse Rules
• All private households and business enterprises are required by this
Legal Notice to keep all garbage and refuse in bins and containers.
• In general, the rules require; (1) garbage to be deposited daily in
municipal garbage in containers on the premise: (2) containers to be
easily cleaned and that they be maintained in good condition with
tight fitting lids capable of excluding flies and rats; (3) the non
accumulation of putrescible material which may breed flies.

• 10/1 (1950) L. 149: Vaccination Rules:
• This legal notice requires all parents to have their children
vaccinated at the public clinics maintained by the municipal/Public
Health service. The requirements are concise and specific and
should be enforceable with little difficulty.
• 10/1 (150) L.150: Disposal of Dead Bodies
• This legislation requires the Kentibas to designate cemeteries or
burial places. It further sets up the duties of the cementer officers
and the rules and regulations of the burial procedure. Only article
three places some duty on the surviving relation to make sure that
the body is buried with decency before but not later than twelve
hours after death.

• 10/3 (1950) L. 151 Venereal Disease Rules
• The legislation in this area does not begin to meet the basic
problems inherent in this major public health problem.
• The rules set forth in this Legal Notice are clearly not pervasive to
provide the power necessary to restrict and control the practice of
prostitution and the spread to venereal disease.

 10/12 (1951) L. 156: Communicable Disease Rules
• This legislation sets forth specific and enumerated communicable
diseases which it divides into classes. The legal Notice is designed
to find and eradicate disease with complete protection to citizens in
the epidemic or endemic areas. The regulations of this Legal
Notice are primary directed toward the Health Officials in charge
of the area in question
 N. 18/6 (1959) 0.22: Malaria control and prevention:-
• The primary thrust of this order is directed to ward the actions of
the malaria control and prevention, section ten provides that any
person who visits any provision of the order or regulations issued
there under provided cordance. With the provisions of article 785
of the penal code of Ethiopia of 1957.:

• Article 503 - Spreading of Human Diseases
• Spreading of human diseases intentionally or negligently is
punishable
• Where the offender intentionally transmitted grave diseases as
epidemic, the punishment is rigorous imprisonment not exceeding
five years, if necessary in addition to fine.
• Where the offender has acted through negligence, the punishment
is simple imprisonment not exceeding one year, or fine
• Article 504 - Spreading of Epizootic Disease
• Article 505 - Propagation of Agricultural or Forest Parasite
• Article 506 - Contamination of Water
• Article 507 - Contamination of Pastureland

 Public Health Measures
• Disregard of the measures prescribed by law for the prevention,
limit or arrest of a communicable disease is punishable
• In cases of intentional disregard, the punishment is simple
imprisonment not exceeding two years or fine, and where the
offender has acted by negligence he is punished with
imprisonment not exceeding six months, and with a fine not
exceeding one thousand Birr.
 Article 509 - Production, Making, or Distribution of
Poisonous or Narcotic Substances
• Production, making, transforming, importing, exporting or
transporting, acquiring or receiving, storing, offering for sale or
distribution or procuring for another, poisons drugs, or narcotic
substances, without lawful authority is punishable act.

 Article 514 - Endangering the Health of Another by
Alcoholic Beverage or highly fermented Liquor
/Very alcoholic is punishable;
 Article 515 - Endangering by Mental Means or
Practices
 Endangering the health of another by inducing in him/her a
state of hypnosis, trance or catalepsy or any other changes or
suspension of his/her conscious faculties is punishable with
simple imprisonment not exceeding three months or fine, with
the prohibition of professional practice, if necessary, where the
offense is repeated…

• Article 518 - Unlawful Exercise of The Public Health
Professions
• A making of treatment of sick persons in any form for remuneration,
whether the treatment is by consultation, by selling of remedies or
any other medical or curative activities are punishable with simple
imprisonment or fine.
• Casual advice, aid, or services rendered in cases of urgency or in an
emergency or out of kindness or devotion and free of charge … do
not come under this provision. (is not punishable)..

• Article 520 - Refusal to Provide Professional Aid
• Any person lawfully entitled to render professional attention and
care, who, contrary to his duty and without just cause, refuses, to
provide his services in a case of serious need, whether from
indifference, selfishness, cruelty, hatred, or contempt, or for any
other similar motive is punished with fine, in the event of repetition
of the offense simple imprisonment not exceeding one month may
be passed.
• The punishment may be up to one year where the offender is under
an obligation, professional or contractual, medical, to go to the
victim's aid or lend him assistance.
• Manufacture of food stuffs, products for human consumption –in
such a way as to endanger public health or importing receiving,
storing, offering for sale or distributing such injurious products is
punishable with simple imprisonment for not less than three
months, or with rigorous imprisonment not exceeding five years

• A severe sentence (punishment) is passed where the offender
discharges special duties of supervision or control in an
undertaking of public interest belonging to the state, or let out to
concession by the state or in cases of the deliberate manufacture…
• The Criminal Procedure Code of 1961
• These articles are intended to protect the rights of defendant
charged with violation of the article of the penal code of 1957..
This article prohibit the police from arresting any individual
without a warrant unless the person arrested is reasonably
suspected of having committed an offence punishable with
imprisonment for not less than one year.
• Public health Proclamation
• Federal Negarit Gazeta of Federal Democratic Republic of
• Ethiopia Proclamation NO. 2002/2000
• Public Health Proclamation Page 1274

 Public Health Proclamation
• NOW, Therefore, in accordance with Article 55(1) of the
constitution of the Federal Democratic Republic of Ethiopia, it is
hereby proclaimed as follows:
 Public Health
 8. Food Quality Control
• 1) It is prohibited to prepare, import, distribute, or make available
to consumers any food which is unhygienic, contaminated,
unwholesome or mislabeled and does not meet the standards of
food quality..
 9. Food Standard Requirements
• Any person engaged in any activity of selling, producing for sale,
storing, preparing or preserving of any food intended for human
consumption shall meet the standards set by the Ministry.

• 10. Water quality control.
• 1) It is prohibited to give water supply service from springs, wells
or through pipes unless its quality is verified by the Health
Authority.
• 11. Occupational Health Control and Use of Machinery
• 1) Any employer shall ensure the availability of occupational
health services to his employees.
• 12. Waste Handling and Disposal
• 1) Any person shall collect waste in a especially designated place
and in a manner which does not affect the health of the society.

• 13. Availability of Toilet Facilities
• 1) Any institution or organization providing public service has the
obligation to organize clean, adequate and accessible toilet
facilities for its customers.
• 2) Any city administration is responsible to provide public toilet
and ensure its cleanliness.
• 14. Control of Bathing Places and Pools
• 1) No person shall provide a public bathing place or swimming
pool service unless authorized by appropriate health authority.

• 15. Disposal of Dead Bodies
• 1) It is prohibited to bury or burn a dead body or human remains in
the places other than that are allowed for such burial or burning.
• 16. Controls at Entrance and Exit Ports
• 1). Any passenger coming to Ethiopia or leaving Ethiopia is
obliged to take vaccination required for international passengers
and to show his certificate whenever requested by the concerned
health offices and, where suspected of any communicable disease,
to cooperate for medical examination.
• 17. Communicable Diseases
• I) Any person who happens to know the existence of
communicable disease in his/her vicinity has the duty to report
immediately to the nearest health service institution.
• The institution receiving the report has to take the necessary
measures and report to the appropriate health authority.

 18 The Requirement of Health Permit and
Registration Before
 Resumption and After Completion of Construction
• 1) Any person constructing buildings for public services has the
obligation to get the necessary permit from and get registered by
appropriate health authority beginning from planning to the
completion of his construction in accordance with the regulations
and directives issued pursuant to this Proclamation.
• 2) Any person constructing houses, production facilities, and
public service enterprises, or institutions has the duty to include
toilet facility.

UNIT FOUR
 Medical law and ethics
• Medical ethics are the moral principles that govern the practice of
medicine by doctors and other health care practitioners.
• Basic principles of medical ethics are usually regarded as being:
 a) Respect for patient autonomy
 b) Not inflicting harm on patients
 c) a positive duty to contribute to the welfare of patients and
 d) Justice or fair treatment of patients.

UNIT FOUR CONTINUE…
 Patient autonomy
• The principle of patient autonomy recognizes the capacity of
mentally and legally competent patients to think and decide
independently, to act on the basis of their decisions, and to
communicate their wishes to doctors and other health care
practitioners.
• This is in line with the right to freedom and security of the person
in accordance with the provisions of the Constitution.

 Not inflicting harm on patients (‘non-maleficence’)
• The principle of not inflicting harm on patients is based on the idea
that doctors and other health care practitioners should not
deliberately inflict harm on their patients.
• The principle is used to justify, for example, the difference between
killing and letting die (active and passive euthanasia), or
withholding or withdrawing life-sustaining treatment.
• When dealing with patients or health care user’s health care
practitioners are governed by ethical principles and the law.
Breaches of ethical rules may result in disciplinary action by
employers and professional bodies.
• Breaches of the law may result in similar disciplinary action as
well as criminal or civil legal action against the health care
practitioners concerned.

 Contributing to the welfare of patients
(‘beneficence’)
• The principle of contributing to the welfare of patients requires
doctors and other health care practitioners to help patients further
their health interests.
• This not only requires providing patients with the benefits of the
treatment concerned, but also requires a balancing of the benefits
that may be received from the treatment against any possible harm
which may result from such treatment.
• For example, in cases of withholding or withdrawing life-
sustaining treatment it is necessary to weigh the chances of
success should such treatment be instituted or continued, against
the probable costs or risks to the patient.

• Justice or fairness
• The principle of justice or fair treatment of patients requires that
doctors and health care practitioners should treat all patients
equally irrespective of race, gender, colour and ethnic origin.
• In other words there should be no unfair discrimination against
patients

• Ethical and legal obligations
• Ethical obligations are based on the moral principles that underpin
the practice of the different health care professions.
• A breach of such principles in themselves may not necessarily lead
to legal action where they have not been given the force of law by
publication in a statute.
• Some of these moral principles may be incorporated in the ethical
rules of the different professions.
• For example, regulations passed by the health professions council
concerning the rules of conduct for medical practitioners and
dentists impose certain obligations on such practitioners.
• Although medical and dental practitioners breaching these rules
may be disciplined by the council, their conduct may not
necessarily result in legal action in the courts..

 EQUALITY OF TREATMENT
• Health care practitioners should treat all patients equally.
• The ethical principles of autonomy, not inflicting harm,
contributing to the welfare of patients and justice and fairness
would seem to require doctors, other health care practitioners, and
where applicable, the professional bodies concerned, to become
advocates for their patients where the latter’s constitutional human
rights are being violated.
• This duty has also been clearly set out in certain international
declarations and codes of ethics.
• The principle of autonomy requires medical personnel to ensure
that their patients’ constitutional and common law human rights to
freedom and security of the person are respected.

 Medical malpractice and professional negligence
• A breach of an ethical principle or of an ethical rule or regulation
promulgated by a professional council may be used to establish
medical malpractice or professional negligence even though the
breach itself may not constitute a crime or civil wrong.
• In order for a civil wrong to be proved it would have to be shown
that the health professional’s conduct was also a breach of a legal
obligation.
• For example, if the doctor or other health care practitioner
negligently caused the death of a patient by breaching an ethical
rule he or she may face a criminal charge of culpable homicide or
a civil action by the deceased’s dependents.

 International Codes of Ethics
• Doctors are specifically enjoined by the International Code of
Medical Ethics, the Declaration of Tokyo (dealing with prisoners
and detainees), and Regulations in Time of Armed Conflict, to
stand up for the rights of their patients by putting the patient’s
interests first, before those of anyone else.
 Relationship between practitioner and patient
• The relationship between health care workers and patients may
take the form of a contract or a duty of care imposed by the law
because of the special relationship between health care workers
and patients.

• The contract between health care practitioners and
patients
• A patient who consults a doctor or other health care practitioner in
private practice enters into a contractual relationship with the
practitioner but the latter also owes the patient a duty of care (see
below ‘medical malpractice’).
• However, a patient who goes for medical treatment by the staff at
a hospital or health care establishment enters into a contract with
the relevant hospital authority, e.g. a private or provincial hospital
authority.
• The hospital authority will be contractually liable for the negligent
conduct of its employees, but staff doctors and other members of
staff will also be liable in their personal capacities.

• In the doctor-patient relationship the contract usually takes the
form of an implied agreement that the doctor will diagnose the
patient’s complaint and treat the person in the normal manner
according to generally accepted medical procedures.
• Any procedures to be used by the doctor should first be discussed
with patient and the necessary consent to treatment obtained.
• If a doctor departs from his or her patient’s express instructions, or
fails to treat a patient for no good reason, the doctor will be guilty
of a breach of contract and may be denied the right to claim a fee.
.

• Once treatment has commenced the doctor may not abandon a
patient, but if the treatment has been completed the agreement ends
and the doctor need no longer attend to the patient.
• Patients must also perform their part of the agreement by making
themselves available for treatment

• Is there a duty to treat?
• The Constitution provides that everyone has the right to have
access to health care services which the state must provide within
its available resources.
• Therefore in the case of state run health care facilities health care
practitioners are required to treat everyone who presents and
qualifies for treatment.
• This does not apply to privately run facilities except in the case of
emergency medical cases.
• In the case of emergency medical treatment nobody may be
turned away by either Public or private facilities.

• In this context the Constitutional Court has defined an
‘emergency’ as ‘a dramatic, sudden situation or event which is of
passing nature in terms of time’.
• Apart from emergency situations there is generally no duty on a
private doctor to treat a person who is not his or her patient. This
is because in law there is usually no liability for a mere omission.
• However a duty to act will be imposed by the law where the
circumstances are such that society would regard the failure to act
as unlawful (e.g. where somebody pushes another into a river and
does not rescue the person).
• There may however be a contractual duty, for example, a casualty
officer at a state hospital is obliged to treat patients brought in for
treatment.

• Assessing the failure to treat
• According to Strauss in Doctor, Patient and the Law, when
determining whether or not the failure to treat by the doctor is
unreasonable the court will probably take into account the
following factors:
 a) The doctor’s actual knowledge of the patient’s condition
 b) The seriousness of the patient’s condition
 c) The professional ability of the doctor to do what is asked
 d) The physical state of the doctor, for example, the doctor may
have been physically exhausted at the time
 e) The availability of other health care practitioners, or nurses
or paramedics
 f) The interests of the other patients of the doctor, and
 g) Considerations of professional ethics.

• The bus accident
• A doctor works in a mission hospital in a rural part of the country
where the incidence of HIV-positive people is very high. She
leaves to drive to the city on the weekend to attend her son’s
wedding. As she is off duty and expecting to relax she leaves
behind her medical bag which contains universal precautions
against HIV infection.
• While she is still in the high risk area, an hour’s drive away from
the mission hospital, she comes across a bus accident with bodies
lying scattered in the road. She is feeling overworked, and also
needs to hurry to reach the city in time for her son’s wedding.
• She decides not to stop but uses her cell phone to call the mission
hospital with a request that they send help immediately.
• Three people die from loss of blood which could have been
prevented had she stopped and assisted.

• 1. Did the doctor act ethically? Why or why not?
• 2. Did the doctor act legally? Why or why not?
• Consent, in medical cases, means that a patient:
• a) Has knowledge of the nature or extent of the harm or risk
• b) Appreciates and understands the nature of the harm or risk
• c) Has consented to the harm or assumed the risk and
• d) Understands that the consent is comprehensive, i.e. extends to
the entire procedure, including its consequences.

• The person giving the consent must be legally capable of doing so
(e.g. not a minor or insane person). The consent will only be valid
if the act consented to is in accordance with public policy (e.g. not
consent to reckless medical experiments). Patients may consent
expressly to treatment, (e.g. in words or in writing), or by conduct.
• Consent generally takes the form of a request made by a patient
for a specific treatment or operation, and is usually in writing.
• Failure to obtain a proper informed consent may result in the
doctor being sued for assault (e.g. where the doctor knowingly
fails to get a consent) or invasion of privacy (e.g. where a blood
test is done without consent).

 Consent by spouses
 One spouse has no right to compel the other to undergo an
operation against his or her will or even to submit to a medical
examination
 Consent in the case of minors
 A minor is usually regarded as a person under the age of 21 years
who requires the consent of his or her parent or guardian to enter
into certain legal agreements.
 CONSENT
 Consent generally takes the form of a request made by a
patient for a specific treatment or operation, and is usually in
writing.

 Circumstances where consent of parent or guardian is not
required
• a) Minors over 18 years of age are competent to consent, without
the assistance of a parent or guardian, to the performance of any
medical operation.
• b) Minors over the age of 14 years are competent to consent to
medical treatment.
• c) If the parents or guardian cannot be found, or refuse permission
for treatment or an operation to a minor under the age of 14 years,
the Minister of Health may, if satisfied after due inquiry that the
treatment or operation is necessary, consent to it instead of the
parents or guardian of the child.

• d) If the medical superintendent of a hospital is of the opinion that
an operation or medical treatment is necessary to preserve the life
of the child or to save the child from physical injury or disability,
and that the need is so urgent that there is no time to postpone the
operation or treatment for the purpose of consulting the person
who is legally competent to consent to such operation or medical
treatment, the superintendent may give the necessary consent.

• Persons who may consent on behalf of mental patients
• The persons who may consent are listed in order of priority as
follows:
• a) The curator appointed by the court to the person or property of
the patient and
• b) The patient’s spouse, parent, major child or brother or sister.

• Consent to research
• . The Guidelines on Ethics for Medical Research published by the
Medical Research Council (MRC) provides that patients should
not only know that they are participating in research but should
also consent to such participation.
• It has been suggested that consent on behalf of mentally ill or
defective patients should only be sanctioned in respect of
therapeutic research. Consent to non-therapeutic research on
mentally ill and defective patients should only be allowed if it
involves no risk or danger to the subjects.
• The MRC Guidelines suggest that consent should only be given
on behalf of mentally ill or defective persons for therapeutic
research that will benefit them directly. However, an ethics
committee may sanction non-therapeutic research if it is
convinced that the research is acceptable, and it is specifically
directed at patients who might be incompetent.

• Informed consent and material risks
• A Consent will only be ‘informed’ if it is based on substantial
knowledge concerning the nature and effect of the act consented
to. Because of the technical nature of most forms of medical
treatment and surgical operations, there is a duty upon the
practitioner to inform the patient in a language he or she can
understand about the procedures to be followed, the risks involved
and their consequences. A doctor is obliged to warn a patient of
‘material risks’ inherent in the proposed treatment.

• RESEARCH
• Patients should not only know that they are participating in
research but should also consent to it.
• There is a duty upon the practitioner to inform the patient
about the risks involved.
• What are material risks?
• A risk is material if:
• a) A reasonable person in the patient’s position, if warned of the
risk, would regard it as important, and
• b) The medical practitioner should reasonably be aware that the
patient, if warned of the risk, would regard it as important.

• Thus a doctor need not tell the patient about all the remote risks,
but should at least mention the probable and possible risks of
harm, particularly where they are serious.
• Usually doctors inform their patients about their diagnosis but this
is not an absolute rule. For example, where the information
concerning the diagnosis or the potential effect of treatment may
have an extremely harmful effect on the patient which will
undermine the treatment, the doctor may be justified in not
informing the patient of the diagnosis. Where, however, the
patient insists that his or her consent is dependent upon being
given a diagnosis of the condition, such diagnosis must be made
known to the patient otherwise the consent will not be legal. The
doctor must weigh up the risk of inhibiting treatment against the
need to obtain an informed consent.

• Medical treatment without consent in cases of emergency
• Where a person whose life or health is in serious danger as a result
of injury, disease or ill-health is unable to give consent to medical
treatment or an operation he or she may be given emergency
treatment provided it is not against the patient’s will.
• No to blood
• A doctor at a provincial hospital is treating an eight year old boy
who requires a blood transfusion. For religious reasons his parents
are not prepared to give consent.
• • What should the doctor do?

• EMERGENCIES
• Emergency treatment may be given without consent provided
it is not against the patient’s will.
• When is emergency treatment justified?
• According to Strauss such treatment is justified where:
• a) There is an emergency
• b) The patient is or has been unable to communicate
• c) The treatment is not against the patient’s will, and
• d) The treatment is in the best interests of the patient.
• Where an operation is extended to save the patient’s life while he
or she is unconscious and unable to consent, the defence of
necessity will also succeed.

• Confidentiality
• Depression vs information
• A doctor has diagnosed her patient as suffering from cancer. She
knowsb that her patient is subject to bouts of depression and that if
she informs the patient that she is suffering from cancer, she will
go into a deep depression that will undermine the treatment.

• • Should the doctor reveal the diagnosis in order to obtain an
informed consent to treat the condition?
• Patients discuss intimate and personal details about themselves
with health care workers and have a right to expect that their
disclosures will remain in confidence.
• If this was not the case patients would be frightened into non-
disclosure and this would greatly inhibit their treatment. A breach
of such confidence may result in an action for invasion of privacy
or defamation. The ethical rules of the Health Professions
• Council provide that there is an ethical duty on doctors not to
divulge information about their patients without the latter’s
consent
• if they are over 14 years of age, or the written consent of their
parents or guardians if they are minors under 14 years of age. In
the

• Risk of amputation
• A doctor informs the parents of a 14-year-old girl suffering from
cancer that she will need superficial radium treatment which may
result in minor pigmentation changes to her arms and legs. The
parents sign a consent to such treatment .together with such other
or additional operations and treatments necessarily incidental
thereto..
• The superficial treatment does not work and she now requires
deep radium treatment which may result in shortening of the
limbs and the risk of their amputation.
• • Does the doctor require a further consent or is the original
consent sufficient? Why or why not?

• CONFIDENTIALITY
• There is an ethical duty on doctors not to divulge information
about their patients without the latter’s consent.
• When confidentiality may be breached
• There is a professional duty on doctors to maintain confidentiality
unless:
• a) A court of law orders them to make a disclosure, (e.g. in a
paternity dispute)
• b) An Act of Parliament requires them to make a disclosure, (e.g.
reporting child abuse in terms of the Child Care Act of 1983)
• c) There is a moral or legal obligation on the doctor to make a
disclosure to a person or agency that has a reciprocal moral or
legal obligation to receive the information, (e.g. where a patient
threatens to kill someone), or d) The patient consents to the
disclosure being made.

• Confidentiality and evidence in court
• A doctor may be ordered by a court of law to give evidence
concerning treatment of a patient. A doctor who discloses such
information when ordered to do so by a court cannot be held
liable for breaching the confidentiality rule. If the doctor refuses
to comply with a court order he or she may be prosecuted for
contempt of court.
• The courts have exercised a discretion as to whether they will
permit a medical witness to refuse to give evidence. For example,
in criminal cases the courts have admitted evidence by a
psychiatrist concerning whether an accused was mentally able to
understand what he or she was doing when the crime was
committed, but have refused to admit evidence to prove that what
the accused said to the psychiatrist conflicted with what he or she
had said in an earlier statement to a magistrate.

• Confidentiality and HIV-positive or AIDS patients
• Generally patients who are HIV-positive or suffering from AIDS
are entitled to have their right to confidentiality respected.
However, if they are a threat to the health and life of others it may
be necessary to disclose their HIV or AIDS status.
• The Health Professions Council requires doctors to breach the
confidentiality rule in cases where their HIV-positive patients, or
patients suffering from AIDS, put other health care practitioners
or the patient’s spouse or sexual partner at risk. In such cases the

• HIV/AIDS
• Doctors may be required to disclose HIV status.
• WHEN CONFIDENTIALITY MAY BE BREACHED:
• • Court order
• • Act of Parliament
• • Moral or legal obligation
• • Consent by patient
• BREACHING CONFIDENTIALITY
• A doctor who unlawfully breaches the confidentiality rule may
be sued for breach of contract, defamation or invasion of
privacy.

• The selfish lover
• A doctor is consulted by a patient who has been diagnosed as HIV
positive.
• The patient is married but is having sexual intercourse with
another woman with whom he is having an affair. The doctor
advises the patient that the latter should tell both his wife and the
other woman that he is HIV-positive and to ensure that
precautions are taken. For religious reasons the patient is not
prepared to use a condom. He also does not wish to inform his
wife because she may divorce him, and does not want the other
woman to know in case she ends their relationship.
• • What should the doctor do?

• Medical malpractice and professional negligence
• Medical malpractice consists of wrongful acts on the part of
doctors and health care workers which cause injuries or harm to
patients.
• Such acts may be done intentionally or negligently. Where
malpractice is done intentionally the wrong doeser directs his or
her will to do the wrongful act and knows at the time that the
conduct is wrongful.
• Where the malpractice is negligent the wrongdoer does not do the
act intentionally, but fails to act like a reasonable doctor or health
care practitioner would have acted in similar circumstances.
• Most medical malpractice takes the form of professional
negligence.

 Professional negligence
• A doctor or other health care practitioner is expected to exercise
the degree of skill and care of a reasonably skilled person in his or
her field.
• In deciding reasonableness the court will have regard to, but is not
bound by, the general level of skill and care possessed and
exercised by members of the branch of the profession to which the
person belongs.

• MALPRACTICE
• Medical malpractice consists of wrongful acts on the part of
doctors and health care workers which cause injuries or harm
to patients.
• Greater skill and care is expected of a specialist than a general
practitioner, and is also required where more complicated medical
procedures are used.
• A doctor will be negligent if he or she undertakes work which
requires specialist skill which the doctor does not have.

 DOCTOR NEGLIGENCE
• If the doctor is in a position to intervene in order to prevent
harm, and fails to do so, he or she may also be liable for
negligence.
 Legal and ethical aspects of HIV/AIDS
• A person who intentionally or negligently infects another with
HIV/AIDS may be liable to criminal or civil sanctions. In such
situations health personnel, hospitals and patients may be held
liable for infecting people with HIV/AIDS. The Constitution
protects HIV/AIDS survivors against unfair discrimination.

• Murder and culpable homicide
• A person who unlawfully and intentionally infects another with
HIV/AIDS which results in the latter’s death will be guilty of
murder.
• A person who recklessly infects another with HIV/AIDS, not
caring whether or not that other person contracts the disease and
dies will also be guilty of murder if the person dies. A person who
intentionally or recklessly exposes another to HIV/AIDS without
infecting them may be guilty of attempted murder.
• A person who negligently infects another with HIV/AIDS which
results in the latter’s death may be found guilty of culpable
homicide.

• Negligence means that the person foresaw the likelihood that he
or she would infect another with HIV/AIDS but did not take any
steps to prevent such infection from occurring.
• For instance, an HIV/AIDS survivor who has sexual intercourse
with a person without using a condom and without warning that
person, with the result that the person contracts the disease and
dies will be guilty of culpable homicide.

 Assault
• A person who unlawfully and intentionally infects a person with
HIV/AIDS or threatens to infect them with HIV/AIDS will be
guilty of assault if the person is still alive.
• A person who intentionally or recklessly infects another with
HIV/AIDS may be guilty of assault where the victim has
contracted the disease but has not died
• A person knowingly suffering from HIV/AIDS who does not
warn a sexual partner that he or she has the disease and has
intercourse with that person will be guilty of assault if that person
becomes infected with the disease.

• MURDER
• A person who unlawfully and intentionally infects another
with HIV/AIDS which results in the latter’s death will be
guilty of murder.
• ASSAULT
• A person knowingly suffering from HIV/AIDS who does not
warn a sexual partner and has intercourse with that person
will be guilty of assault if that person becomes infected.

• Civil actions
• There are two types of civil actions which may arise from
• a) Intentional or negligent acts which result in physical injuries or
death, and
• b) Intentional acts which result in infringements of a person’s
dignity, privacy or reputation that cause sentimental damages.
• NEGLIGENCE
• Health care practitioners who negligently or intentionally
infect others with HIV/AIDS will be liable in a criminal or civil
action depending on the circumstances

• DISCRIMINATION
• The Constitution requires that the state should not
discriminate unfairly against people living with HIV/AIDS.
• NOTIFICATION So far AIDS has not been made a notifiable
disease. Because of the fear of driving it underground.
HIV/AIDS: ‘communicable’ but not ‘notifiable’
• HIV/AIDS is a ‘communicable disease’ like cholera and
chickenpox and must be reported to the Regional Director of
Health. So far it has not been made a ‘notifiable disease’ because
of the fear of driving it underground. Scarcity of medical
resources gives rise to a number of ethical and legal dilemmas for
health care professionals and institutions.

• Medical ethics and scarce medical resources
• The general rule regarding the provision of health care services in
an environment of reduced medical resources is that the ethical
rules of the health care professions cannot be compromised. Health
care practitioners will be expected to maintain their ethical
standards even in an environment of reduced resources. Failure to
do so may result in disciplinary action by the relevant health care
professional board or council.
• Furthermore, if the breach of ethics results in an invasion of a
patient’s constitutional or common law rights the health care
practitioner may also face legal action. Decisions about reducing
the resources available to health care practitioners and their
patients are usually made by public health authorities and the
managers of health care institutions.

• Legal and ethical aspects of scarce medical resources
• Health care practitioners will be expected to Maintain their
ethical standards even in an environment of reduced
resources.
• NO COMPROMISE
• The general rule is that the ethical rules of the health care
professions cannot be compromised.

 Reduced services and patients’ rights
• If a patient’s treatment will be affected by a shortage of resources
at a medical facility the patient has a right to be informed. Patients
must be provided with sufficient information about the treatment
and options available so that they can give an informed consent.
• Private patients who are referred to state hospitals because their
medical aid or financial resources have run out are not entitled to
better treatment than other state-aided patients. They must be
treated in the same way as other state-aided patients who are being
treated within the state’s available resources.

• REDUCED SERVICES
• If a patient’s treatment will be affected by a shortage of
resources at a medical facility the patient has a right to be
informed.
• Legal and ethical aspects of Dual loyalty
• Dual loyalty situations arise where health care practitioners may
be employed by the state or a private institution to treat patients
and conflicts of interest arise between the interests of the
employers and those of the patient. This may result in the
obligations of the health care professional to the patient coming
into conflict with those to a third party.
• In countries with repressive governments where the third party is
the state (e.g. prisons, police or military) this often involves
human rights violations, as occurred to Steve Biko during the
apartheid era.

• International ethical codes
• International ethical codes require complete loyalty to patients and
imply that such loyalty should extend above the interests of third
parties. It does not matter whether a patient is a dangerous
criminal, detainee, prisoner, gangster, terrorist, unpopular political
activist or wartime enemy, once a patient-health care practitioner
relationship is established, the interests of the patient must come
before those of the state or anyone else.
• The World Medical Association’s Declaration of Geneva of 1948
(the modern Hippocratic Oath) requires doctors to pledge that ‘the
health of my patient shall be my first consideration’. It also states
that a doctor shall provide medical services in ‘full technical and
moral independence’. The World Medical Association’s Code of
Medical Ethics of 1983 likewise states that ‘a physician shall owe
his patients complete loyalty and all the resources of his science’

Legal medicine
• History and Development of Clinical Forensic Medicine
• Forensic medicine, forensic pathology, and legal medicine are terms
used interchangeably throughout the world.
• Forensic medicine is now commonly used to describe all aspects of
forensic work rather than just forensic pathology, which is the branch
of medicine that investigates death.
• Clinical forensic medicine refers to that branch of medicine that
involves an interaction among law, judiciary, and police officials,
generally involving living persons.

• ATTENDANCE AT COURT
• Courts broadly consist of two types: criminal and civil.
• A doctor may be called to any court to give evidence.
• The doctor may be called to give purely factual evidence of the
findings when he or she examined a patient, in which case the doctor
is simply a professional witness of fact
• or to give an opinion on some matter, in which case the doctor is an
expert witness.

• Evidence in court is given on oath or affirmation.
• THE DUTIES OF EXPERT WITNESSES
• The essential requirements for experts are as follows:
• Expert evidence presented to the court should be seen as the
independent product of the expert
• Independent assistance should be provided to the court by way of
objective unbiased opinion

• An expert witness in the court should never assume the role of
advocate.
• Facts or assumptions on which the opinion was based should be stated
together with material facts that could detract from the concluded
opinion.
• An expert witness should make clear when a question or issue falls
outside his or her expertise.
• If the opinion was not properly researched that should be stated with
an indication that the opinion is provisional.

• If after an exchange of reports an expert witness changes an opinion,
the change of view/opinion should be communicated to the other
parties

• How to prepare a report
• The report
• The report must clarify who has prepared its content.
• This is important as it identifies the scope of the expertise being provided.
• It should include the use of appropriate letterhead and a comprehensive
resume, encapsulating the training and expertise of the author of the report.
• Without such a resume, the expertise, and hence value, of the report may be
disputed with the potential for its rejection by the adjudicating authority.
• The purpose and circumstances resulting in the provision of the report
should be stipulated.

• This includes identifying how, when, where and why the report was
prepared.
• It should include a description of the patient at the time of any
consultation.
• It is important to explain to the patient that this is a legal medicine
consultation, not a therapeutic provision of service.
• The patient’s informed consent, or refusal to proceed, should be
documented in a brief statement in the report.
• Also include the date of the consultation, who else is present, and the
nature of the relationship of that person to the patient.

• Legal medicine has evolved as a specialty area in medicine (rather
than law) and relates to the application of medical expertise to the
administration of the law.
• Legal medicine often requires the provision of a report by the general
practitioner.

• Code of conduct
• Most jurisdictions have established a code of conduct relating to
expert legal medicine reports.
.
• The report must contain a formal statement attesting to the fact that
the report writer has read the relevant code of conduct, applicable to
the jurisdiction in which the report relates and referable to the matter
under review.
• It must also include a formal acceptance of that code of conduct.

• Supplementary reports
• A summary of the supplementary reports assists the reader to
prioritize their content and value.
• The author recommends placing this material within an appendix
(identifying each report by author, expertise of author and date of
preparation), followed by an efficient content summary.

• The more detailed the history and examination, the more protected is
the report writer from difficult cross-examination (should they be
called as a witness to appear in court).
• The opinion is the most critical component of the report.

• The opinion should be limited to the expertise of the person providing
it.
• That is, should the expertise of a specific consultant be required (eg. a
neurologist) this should be identified and the GP should refrain from
providing a specific neurological opinion.

• Legal medicine reports
may be organized under
the following headings:
 introduction
(preamble)
 presenting
symptom(s)
 history of the present
illness
 injury/injuries
sustained
 subsequent
management
 personal history
 current complaints
 physical examination
opinion

• author resume
• code of conduct
• references (when cited), and
• an appendix summarising any additional information that was supplied
specifically for the purpose of preparing the report.
• History of the present illness
• Supplementary reports, which provide additional information
regarding the present illness, are often included in the request for the
report.
• In order to minimise bias the author recommends reading these after
meeting the patient.

• This history is no different to any other medical history and should
include:
• presenting symptom(s)
• history of the present illness
• injury/injuries sustained
• subsequent management
• personal and social histories, eg. smoking, alcohol consumption,
medications, past medical history, past surgical history,
• employment history (where relevant) and family history (where
appropriate)
• a list of the current complaints at the time of the consultation.

• Physical examination
• Once a detailed history has been secured, then a targeted physical
examination should ensue.
• This implies specific examination of the relevant parts of the body
related to whatever caused the critically appraised as to its value in
the overall assessment of the patient.

• The role of the expert witness in the
• Adversarial legal system
• All too often expert witnesses are described as “hired guns”1 whose
“expertise” is sold to the highest bidder.
• They are considered biased and a blight on the legal process which
relies upon their contribution to assist the court.
• Experts provide the court with the advantage of technical
knowledge that is not widely available to a lay community.

• THE EXPERT AS A WITNESS IN COURT
• The only unequivocal duty that the expert must respect is to answer
truthfully any question posed by any officer of the court, be it the
lawyer leading the evidence, the opposing lawyer cross-examining
that evidence or the judge seeking clarification.
• While the expert should attend court with a properly formed and
reasoned opinion, it does not necessitate unconditional adherence to
that opinion.

• Deaths in Custody
• In considering any death associated with detention by officials of
any state, caused by whatever means, each state will define,
according to its own legal system, the situations that are categorized
as being “in custody”

• Lack of police action, or “care,” has also been responsible for
deaths in custody.

• INVESTIGATION OF DEATHS IN CUSTODY
• No standard or agreed protocol has been devised for the
postmortem examination of these deaths, and, as a result, variation
in the reported details of these examinations is expected.

• DEATHS RELATED TO THE PHASES OF THE CUSTODIAL
PROCESS
• numerous phases of the custododial process can be identified,
• the types of death that can occur during each of these phases, six
main groups can be identified based on the reported causes of
death.
• The groups are
• • Natural deaths.
• • Deaths associated with accidental trauma.
• • Deaths related directly to the use of alcohol.
• • Deaths related to the use of other drugs.
• • Deaths associated with self-inflicted injury.
• • Deaths associated with injuries deliberately inflicted by a third
party.

• Acute alcohol intoxication or the deleterious effects of drugs are,
inmost cases, likely to have a decreasing effect because they are
metabolized or excreted from the individual’s body.
• Therefore, they are most likely to cause death in the postarrest and
early detention phases, and it is important to note that their effects
will be least visible to those with the “duty of care” while the
individual is out of sight, detained within a cell, particularly if he or
she is alone within that cell.

• Similarly, the effects of trauma, whether accidentally or
deliberately inflicted, are most likely to become apparent in the
early phases of detention,
• and it would only be on rare occasions that the effects of such
trauma would result in fatalities at a later stage,

• Conversely, death resulting from self-inflicted injuries is unlikely
to occur in the prearrest and arrest phases of detention but it can
and does occur when the individual is placed in a cell and is not
under immediate and constant supervision.
• On the other hand, deaths from natural causes can occur at almost
any time during the arrest and detention period.

• CAUSES OF DEATH
• Natural Causes
• deaths result in from natural causes while in police custody fall
into the groups of disease processes that are commonly associated
with sudden natural death in the community
• The most common cause of death in the community, and of
sudden death particularly, is cardiac disease,
• and within this group, those deaths recorded as resulting from
ischemic heart disease or coronary atheroma are the most
common..

• Although there is a clear increase in the incidence of this cause of
death with age,
• it is important to remember that a small percentage of people in
the younger age groups, most commonly those with
hypercholesterolemia and hyperlipidemia, may also have
significant coronary artery disease

• Deaths may be preceded by the development of classical cardiac
chest pain, or it may present with sudden collapse and death
without warning.

• Current research is now focusing on a genetic basis for many other
sudden cardiac deaths in the younger age groups.

• prolonged QT intervals) can sometimes be diagnosed in life by
electrocardiogram;
• The examination for these specific gene markers in any sudden
death in police custody must now be considered in the absence of
other causes of death.
• Myocarditis and rheumatic heart disease are rare causes of death in
young individuals, although such deaths may occur without any
prior indication of a disease process in individuals in police
custody and elsewhere.

• Pulmonary emboli can cause sudden death or may present as
dyspnea and chest pain.
• It is most unusual for deep venous thrombosis of the leg veins to be
present in a young active male; .
• Central Nervous System
• The stress associated with arrest and detention in custody may also
have significant effects on the cerebrovascular system and may, in
susceptible individuals, precipitate intracerebral hemorrhage by the
rupture of congenital or acquired aneurysms or vascular
malformations.

• It is less likely that these intracranial hemorrhages will result in
sudden death, but they may result in sudden unconsciousness,
which ultimately leads to death.
• As with the heart, the possibility that an infectious process within
the central nervous system (CNS) is the cause of sudden collapse
and death must be considered.

• Endocrine
• Diabetes mellitus should raise similar concerns to those associated with
epilepsy because poorly controlled diabetes occasionally may be the
direct cause of sudden death and, through its association with an
increased incidence of arterial disease,
• it is a major factor in the development of coronary artery disease in the
younger age groups.
• At postmortem, consideration must be given in all cases of sudden death
in a young individual, particularly when there is a history of diabetes
mellitus, to the sampling of the vitreous humor to determine the blood
glucose level at the time of death.
• The samples must be taken as soon after death as possible to avoid
postmortem use of the intraocular glucose yielding erroneous results

• Other Causes
• There are many other natural disease processes that could
theoretically lead to sudden collapse and death.
• Among them is asthma, a disease that is usually unlikely to lead to
sudden death if adequately treated and supervised but that may, if
untreated and unsupervised and in stressful circumstances, result in
the individual being found dead in their cell.
• Other disease processes include the development of hemoptysis,
from tuberculosis or pulmonary malignancy, or hematemesis, from
peptic ulceration or esophageal varices, which can be life
threatening and may, because of the bleeding, be considered to be
the result of trauma rather than a natural disease process.

• Accidental Trauma
• It is clear that determining whether trauma is the result of an
accident may depend on the “eye of the beholder.” For example, it
is impossible at postmortem to determine
• if the injuries were caused by a fall from a window during arrest,
were the result of an accidental fall, an intended jump, or a
deliberate push from that window because the points of contact
during the descent and the contact with the ground will result in
the same injuries whatever the initial “cause.”

• The site and significance of the injuries that are present will
depend on the descriptions of the events before, during, and after
the arrest.
• Contemporaneous photographs are always extremely helpful in
these circumstances.

• ALCOHOL- AND DRUG-RELATED DEATHS
• Alcohol
• Alcohol is one of the most commonly used drugs in the world. The
small ethyl alcohol molecule can pass easily through the blood–
brain barrier to the
• CNS where it has direct suppressant affects on the whole of the
CNS. At low concentrations, the specialized cells of the cerebral
cortex are affected, but as the concentration increases, the
depressive effects involve the higher areas of the brain, resulting in
increasingly disinhibited behavior.
• Still higher levels of alcohol result in the depressant effects
involving the lower levels of brain function, including the vital
cardiorespiratory centers in the midbrain and the medulla,
predisposing the intoxicated individual to cardiorespiratory
depression or arrest.

• The anesthetic effects of alcohol may also result in deaths from
asphyxiation.
• Drugs
• Drug use is now so ubiquitous in Western society that any
examination of a potential detainee by a forensic physician must
include a careful evaluation of drug use whether in the past or
recently.
• The failure to identify a drug abuser who then suffers from
withdrawal while in custody is just as potentially life-threatening
as the failure to continue a detainee’s prescribed medication.

• A full drug screen on blood and, if available, urine is imperative.
Some laboratories will also examine samples of bile and/ or liver to
detect evidence of previous drug abuse.
• The management of acute drug intoxication is a matter of clinical
judgment, but with adequate medical care, it is unlikely that,
except in exceptional circumstances, drug intoxication alone will to
lead to sudden death in custody.

• DELIBERATE INJURIES
• Baton Blows
• Blows from a baton are usually easily identified because forceful
blows produce the classic “tram line”-type injuries on the skin.
• “Tram line” injuries are typical of a blow from a linear blunt
object; the areas of the skin that are most traumatized are not those
at the middle of the site of contact where the skin is most evenly
compressed but rather at the margins on the contact site where the
stretching and distortion of the skin and, hence the damage to the
underlying tissues, including the blood vessels, is most
pronounced.

• A linear object will, almost by definition, have two such margins,
which runparallel, and a blow from such an object results in two
linear parallel bruises; hence, the terminology “tram line.”
• Blows from a baton may also result in deeper bruising, nerve
damage, and fractured bones.
• The deeper injuries tend to reflect the use of greater force, but it is
not possible to correlate with any degree of certainty the amount of
force needed to cause a particular injury in any individual.

• Neck Holds
• Pressure on and around the neck is well-known to be a potentially
lethal action
• Death can be caused after compression of the neck by any one of
four mechanisms or by any combination of two or more of the
following:
• Airway obstruction by direct compression of the larynx or trachea or
by the pressure on the neck raising the larynx upward and causing
the superior aspect of the pharynx to be occluded by the tongue
base.
 This can be achieved by pressure of a forearm across the front of
the neck, sometimes called the “choke hold.”

• Occlusion of the veins in the neck
• Compression or occlusion of the carotid arteries.

• The pathological examination of deaths associated with
compression of the neck requires a detailed and careful dissection
of the neck structures

• The finding of injuries to the muscular, cartilaginous, vascular, or
neural components of the neck must be interpreted in the light of
the restraint events, the actions of the restrainers, and the
subsequent resuscitation, if any. Pressure on the neck to maintain an
airway after cardiac or respiratory arrest may result in bruising,
which could be confused with pressure before or, indeed, causing
that arrest.
• Therapeutic insertion of cannulae during active resuscitation by
paramedics or in the hospital commonly leads to marked
hemorrhage in the neck that, although it is unlikely to be confused
with bruising caused by a neck hold, may mask any bruising that
was present.

• Pressure on the neck is not, of course, the only mechanism
whereby an individual may suffer anoxia or asphyxiation.
• Any action that partially or completely occludes the mouth and/or
the nose will result in difficulty in breathing and may result in
asphyxiation.

• Homicide
• There have been numerous cases where individuals have been
murdered in the cell by another inmate.
• Such deaths are most commonly associated with blunt trauma, but
strangulation, stabbing, and other methods may be employedif
suitable weapons are available.
• It is also evident that individuals have been deliberately assaulted
and killed by police officers during arrest and detention.

• SELF-INFLICTED INJURIES
• The methods used are variable but reflect the materials available
to the individual at that time.
• Hanging
• To effect a hanging suicide, the individual must have two things:
an object that can be made into a noose and a point on which to tie
it.
• In addition, the individual must be able to place his or her body so
that his or her body weight can be used to apply pressure to the
neck via the noose.

• Ligature Strangulation
• Because the possibility of suspension is reduced by the changes in
theV design of the cells, the possibility of other forms of self-
asphyxiation are likely to increase.
• Self-strangulation by ligature is considered to be possible but
difficult because the pressure has to be applied to the neck in
these cases by the conscious muscular effort of the hands and
arms,
• it follows that when consciousness is lost and the muscular tone
lessens, the pressure on the ligature will decrease, the airway
obstruction and/or the vascular occlusion will cease, and death
will generally be averted.

• Incised Injuries
• All prisoners should be carefully searched before incarceration,
and any sharp objects or objects that could be sharpened must be
removed.
• Death from deep incised wounds to the neck or arms can occur
quickly. Even if the individual is found before death has occurred,
the effects of profound blood loss may make death inevitable,
despite resuscitation attempts.

• Drugs
• When considering the possibility of suicide using drugs while in
police custody, the two key factors are, once again, evaluation and
searching.
• Traffic Medicine
• Driving a motor vehicle is a complex task requiring a reasonable
level of physical fitness, accurate perception, and appropriate
judgment.
• All these factors can be affected by drugs and alcohol, greatly
increasing the risk of accidents. Many medical conditions (and
their treatments) may impair fitness to drive and are considered
first.

• MEDICAL ASPECTS OF FITNESS TO DRIVE
• Licensing requirements depend on the type of vehicle driven, with
more stringent requirements for commercial purposes and
multiaxle vehicles.
• it is the motorist’s responsibility to inform the licensing authority
of any relevant medical conditions.

• Drivers have a legal responsibility to inform the licensing authority
of any injury or medical condition that affects their driving ability,
and physicians should take great pains to explain this obligation.
• Occasionally, especially when dealing with patients suffering from
dementia, ethical responsibilities may require doctors to breach
confidentiality and notify patients against their will or without their
knowledge
• Requirements vary in different countries and in different
jurisdictions within the same country.

• Cardiovascular Diseases
• Several studies have demonstrated that natural deaths at the wheel
are fairly uncommon and that the risk for other persons is not
significant

• Epilepsy
• Epilepsy is the most common cause of collapse at the wheel,
accounting for approx 30% of such incidents.
• Restrictions vary from country to country.

• Withdrawal of antiepileptic medication is associated with a risk of
seizure recurrence.
• Patients who stop taking antiseizure medication and then cause an
accident may face future civil
• liability and possibly even criminal charges if they cause physical
injury

• Diabetes
• Diabetes may affect the ability to drive because of loss of
consciousness from hypoglycemic attacks or from complications of
the disease itself (e.g., retinopathy causing visual problems or
peripheral vascular disease causing limb disabilities).
• However, the risk of hypoglycemia differs greatly among insulin-
requiring diabetics, and today most insulin-dependent diabetics use
self-monitoring devices to warn them when their blood glucose
levels are becoming too low.

• Vision and Eye Disorders
• The two most important aspects of vision in relation to driving are
visual acuity and visual fields.
• Visual acuity may simply be defined as the best obtainable vision
with or without spectacles or contact lenses.
• Most countries require a binocular visual acuity greater than 6/12
for licensing purposes.

• Ethical Considerations
• Although it is generally a patient’s responsibility to inform the
licensing authority of any injury or medical condition that affects
his or her driving, occasionally ethical responsibilities may require
a doctor to inform the licensing authorities of a particular problem.
• If a patient has a medical condition that renders him or her unfit to
drive, the doctor should ensure that the patient understands that the
condition may impair his or her ability to drive.
• If the patient is incapable of understanding this advice (e.g.,
because of dementia), the doctor should inform the licensing
authority immediately

• Before disclosing this information, the doctor should inform the
patient of the decision to do so, and once the licensing authority
has been informed, the doctor should also write to the patient to
confirm that disclosure has been made

• ALCOHOL AND DRIVING
• Metabolism of Alcohol
• Alcohol is absorbed through the stomach and duodenum.
Absorption depends on many factors, including sex and weight of
the individual, duration of drinking, nature of the drink, and
presence of food in the stomach.
• Alcohol dehydrogenase in the gastric mucosa may contribute
substantially to alcohol metabolism (gastric first-pass metabolism),
but this effect is generally only evident with low doses and after
eating.

• Effects of Alcohol on Performance
• Alcohol affects mood and behavior, causing euphoria (which is
particularly significant in risk taking) but also depressing the
central nervous system (CNS).
• Even at low doses, there is clear evidence that alcohol impairs
performance, especially as the faculties that are most sensitive to
alcohol arethose most important to driving, namely complex
perceptual mechanisms and states of divided attention.

• The Criteria for Determination of Death
• An individual presenting the findings in either section A
(cardiopulmonary) or section B (neurologic) is dead. In either
section, a diagnosis of death requires that both cessation of
functions, as set forth in subsection 1, and irreversibility, as set
forth in subsection 2, be demonstrated.
• A. AN INDIVIDUAL WITH IRREVERSIBLE CESSATION OF
CIRCULATORY AND RESPIRATORY FUNCTIONS IS DEAD.
• 1. CESSATION IS RECOGNIZED BY AN APPROPRIATE
CLINICAL EXAMINATION.
• Clinical examination will disclose at least the absence of
responsiveness, heartbeat, and respiratory effort.
• Medical circumstances may require the use of confirmatory tests,
such as an ECG.

• 2. IRREVERSIBILITY IS RECOGNIZED BY PERSISTENT
CESSATION OF FUNCTIONS DURING AN APPROPRIATE
PERIOD OF OBSERVATION AND/OR TRIAL OF THERAPY.
• In clinical situations where death is expected, where the course has
been gradual, and where irregular agonal respiration or heartbeat
finally ceases, the period of observation following the cessation
may be only the few minutes required to complete the examination.
• Similarly, if resuscitation is not undertaken and ventricular
fibrillation and standstill develop in a monitored patient, the
required period of observation thereafter may be as short as a few
minutes

• When a possible death is unobserved, unexpected, or sudden, the
examination may need to be more detailed and repeated over a longer
period, while appropriate resuscitative effort is maintained as a test of
cardiovascular responsiveness.
• Diagnosis in individuals who are first observed with rigor mortis or
putrefaction may require only the observation period necessary to
establish that fact.
• B. AN INDIVIDUAL WITH IRREVERSIBLE CESSATION OF ALL
FUNCTIONS OF THE ENTIRE BRAIN, INCLUDINGTHE
BRAINSTEM, IS DEAD.
• The "functions of the entire brain" that are relevant to the diagnosis are
those that are clinically ascertainable.
• Where indicated, the clinical diagnosis is subject to confirmation by
laboratory tests as described below.
• Consultation with a physician experienced in this diagnosis is advisable.

• 1. CESSATION IS RECOGNIZED WHEN EVALUATION
DISCLOSES FINDINGS OF a AND b:
• a. CEREBRAL FUNCTIONS ARE ABSENT, AND . . .
• There must be deep coma, that is, cerebral unreceptively and
unresponsively. Medical circumstances may require the use of
confirmatory studies such as EEG or blood flow study.
• b. BRAINSTEM FUNCTIONS ARE ABSENT.
• Reliable testing of brainstem reflexes requires a perceptive and
experienced physician using adequate stimuli.
• Pupillary light, corneal, oculocephalic, oculovestibular,
oropharyngeal, and respiratory (apnea) reflexes should be tested.
• When these reflexes cannot be adequately assessed, confirmatory
tests are recommended.

• Adequate testing for apnea is very important. An accepted method
is ventilation with pure oxygen or an oxygen and carbon dioxide
mixture for ten minutes before withdrawal of the ventilator,
followed by passive flow of oxygen.
• (This procedure allows PaC02 to rise without hazardous hypoxia.)
Hypercarbia adequately stimulates respiratory effort within thirty
seconds when PaC02 is greater than 60 mmHg.
• A ten minute period of apnea is usually sufficient to attain this level
of hypercarbia. Testing of arterial blood gases can be used to
confirm this level. Spontaneous breathing efforts indicate that part
of the brainstem is functioning.
• Peripheral nervous system activity and spinal cord reflexes may
persist after death. True decerebrate or decorticate posturing or
seizures are inconsistent with the diagnosis of death.

• 2. IRREVERSIBILITY IS RECOGNIZED WHEN EV ALUATION
DISCLOSES FINDINGS OF a AND b AND c:
• a. THE CAUSE OF COMA IS ESTABLISHED AND IS
SUFFICIENT TO ACCOUNT FOR THE LOSS OF BRAIN
FUNCTIONS, AND. . .
• Most difficulties with the determination of death on the basis of
neurologic criteria have resulted from inadequate attention to this
basic diagnostic prerequisite.
• In addition to a careful clinical examination and investigation of
history, relevant knowledge of causation may be acquired by
computed tomographic scan, measurement of core temperature,
drug screening, EEG, angiography, or other procedures.

• b. THE POSSIBILITY OF RECOVERY OF ANY BRAIN
FUNCTIONS IS EXCLUDED, AND . . .
• The most important reversible conditions are sedation,
hypothermia, neuromuscular blockade,.
• c. THE CESSATION OF ALL BRAIN FUNCTIONS PERSISTS
FOR AN APPROPRIATE PERIOD OF OBSERVATION
AND/OR TRIAL OF THERAPY.
• Even when coma is known to have started at an earlier time, the
absence of all brain functions must be established by an
experienced physician at the initiation of the observation period.
• The duration of observation periods is a matter of clinical
judgment, and some physicians recommend shorter or longer
periods than those given here

• Except for patients with drug intoxication, hypothermia, young
age, or shock, medical centers with substantial experience in
diagnosing death neurologically report no cases of brain functions
returning following a six hour cessation, documented by clinical
examination and confirmatory EEG.
• In the absence of confirmatory tests, a period of observation of at
least twelve hours is recommended when an irreversible condition
is well established. For anoxic brain damage where the extent of
damage is more difficult to ascertain, observation for twenty four
hours is generally desirable.
• In anoxic injury, the observation period may be reduced if a test
shows cessation of cerebral blood flow or if an EEG shows
electrocerebral silence in an adult patient without drug
intoxication, hypothermia, or shock.

• Confirmation of clinical findings by EEG is desirable when
objective documentation is needed to substantiate the clinical
findings.
• Electrocerebral silence verifies irreversible loss of cortical
functions, except in patients with drug intoxication or hypothermia

 Complicating Conditions
• A. Drug and Metabolic Intoxication
• is the most serious problem in the determination of death,
especially when multiple drugs are used.
• Cessation of brain functions caused by the sedative and anesthetic
drugs, such as barbiturates, benzodiazepines, meprobamate,
methaqualone, and trichloroethylene, may be completely
reversible even though they produce clinical cessation of brain
functions

• B. Hypothermia
• Criteria for reliable recognition of death are not available in the
presence of hypothermia (below 32.2 oC core temperature).
• Hypothermia can mimic brain death by ordinary clinical criteria
and can protect against neurologic damage due to hypoxia. Further
complications arise since hypothermia also usually precedes and
follows death.
• If these complicating factors make it unclear whether an individual
is alive, the only available measure to resolve the issue is to
restore normothermia.

 C. Children
• The brains of infants and young children have increased resistance
to damage and may recover substantial functions even after
exhibiting unresponsiveness on neurological examination for
longer periods than do adults.
• Physicians should be particularly cautious in applying neurologic
criteria to determine death in children younger than five years.
 D. Shock
• Physicians should also be particularly cautious in applying
neurologic criteria to determine death in patients in shock because
the reduction in cerebral circulation can render clinical
examination and laboratory tests unreliable.

• Toxicology is the study of how natural or man-made poisons cause
undesirable effects in living organisms.
 What is Toxicity?
• The word “toxicity” describes the degree to which a substance is
poisonous or can cause injury.
• The toxicity depends on a variety of factors: dose, duration and
route of exposure , shape and structure of the chemical itself, and
individual human factors.

• What is Toxic? This term relates to poisonous or deadly effects
on the body by inhalation , ingestion , or absorption, or by direct
contact with a chemical.
• What is a Toxicant? A toxicant is any chemical that can injure
or kill humans, animals, or plants; a poison.
• The term “toxicant” is used when talking about toxic substances
that are produced by or are a by-product of human-made
activities.
• For example, dioxin (2,3-7,8-tetrachlorodibenzop-dioxin
{TCDD}), produced as a by-product of certain chlorinated
chemicals, is a toxicant.

• What is a Toxin?
• The term “toxin” usually is used when talking about toxic
substances produced naturally.
• A toxin is any poisonous substance of microbial (bacteria or other
tiny plants or animals), vegetable, or synthetic chemical origin that
reacts with specific cellular components to kill cells, alter growth
or development, or kill the organism.
• What are Toxic Effects? This term refers to the health effects that
occur due to exposure to a toxic substance; also known as a
poisonous effect .

• B. The Field of Toxicology
• Toxicology addresses a variety of questions.
• For example, in agriculture, toxicology determines the
possible health effects from exposure to pesticides or the
effect of animal feed additives, such as growth factors, on
people.
• Toxicology is also used in laboratory experiments on
animals to establish dose-response relationships.
• Toxicology also deals with the way chemicals and waste
products affect the health of an individual

• C. Sub-disciplines of Toxicology
• The field of toxicology can be further divided into the following
sub-disciplines
• Environmental Toxicology is concerned with the study of
chemicals that contaminate food, water, soil, or the atmosphere.
• It also deals with toxic substances that enter bodies of waters such
as lakes, streams, rivers, and oceans.
• This sub-discipline addresses the question of how various plants,
animals, and humans are affected by exposure to toxic substances.

 Occupational (Industrial) Toxicology is concerned with health
effects from exposure to chemicals in the workplace.
• Occupational diseases caused by industrial chemicals account for
an estimated 50,000 to 70,000 deaths, and 350,000 new cases of
illness each year in the United States (1).
• Regulatory Toxicology gathers and evaluates existing
toxicological information to establish concentration-based
standards of “safe” exposure.
• The standard is the level of a chemical that a person can be
exposed to without any harmful health effects.

 Food Toxicology is involved in delivering a safe and edible
supply of food to the consumer.
 During processing, a number of substances may be added to
food to make it look, taste, or smell better.
 Fats, oils, sugars, starches and other substances may be added
to change the texture and taste of food

• Clinical Toxicology is concerned with diseases and illnesses
associated with short term or long term exposure to toxic
chemicals.
• Clinical toxicologists include emergency room physicians who
must be familiar with the symptoms associated with exposure to a
wide variety of toxic substances in order to administer the
appropriate treatment.
• Descriptive Toxicology is concerned with gathering toxicological
information from animal experimentation.

 Forensic Toxicology is used to help establish cause and effect
relationships between exposure to a drug or chemical and the
toxic or lethal effects that result from that exposure.
 Analytical toxicology identifies the toxicant through analysis
of body fluids, stomach content, excrement, or skin
 Mechanistic Toxicology makes observations on how toxic
substances cause their effects.

 Classification of Toxic Agents
• Toxic substances are classified into the following:
• A. Heavy Metals Metals differ from other toxic substances in that
they are neither created nor destroyed by humans.
• Their effect on health could occur through at least two
mechanisms: first, by increasing the presence of heavy metals in
air, water, soil, and food, and second, by changing the structure of
the chemical.
• For example, chromium III can be converted to or from chromium
VI, the more toxic form of the metal.

 B. Solvents and Vapors Nearly everyone is exposed to
solvents.
 Occupational exposures can range from the use of “white-out”
by administrative personnel, to the use of chemicals by
technicians in a nail salon.
 When a solvent evaporates, the vapors may also pose a threat
to the exposed population.
 C. Radiation and Radioactive Materials Radiation is the release
and propagation of energy in space or through a material
medium in the form of waves, or the stream of particles from a
nuclear reactor (

 D. Dioxin/Furans Dioxin, (or TCDD) was originally
discovered as a contaminant in the herbicide Agent Orange.
Dioxin is also a by-product of chlorine processing in paper
producing industries.
 E. Pesticides The EPA defines pesticide as any substance or
mixture of substances intended to prevent, destroy, repel, or
mitigate any pest.
 F. Plant Toxins Different portions of a plant may contain
different concentrations of chemicals. Some chemicals
made by plants can be lethal.
 For example, taxon, used in chemotherapy to kill cancer
cells, is produced by the yew plant.

 G. Animal Toxins
 These toxins can result from venomous or poisonous animal
releases.
 Venomous animals are usually defined as those that are capable
of producing a poison in a highly developed gland or group of
cells, and can deliver that toxin through biting or stinging.
 Poisonous animals are generally regarded as those whose
tissues, either in part or in their whole, are toxic.

• H. Subcategories of Toxic Substance Classifications
• All of these substances may also be further classified according to
their:
• Effect on target organs (liver, kidney, hematopoietic system),
• Use (pesticide, solvent, food additive),
• Source of the agent (animal and plant toxins),
• Effects (cancer mutation, liver injury),
• Physical state (gas, dust, liquid),
• # Labeling requirements (explosive, flammable, oxidizer),
• Chemistry (aromatic amine, halogenated hydrocarbon)

• Toxicological Information Sources
• A. The Agency for Toxic Substances and Disease Registry
(ATSDR) ATSDR is part of the U.S. Department of Health and
Human Services.
• It was created by Congress in 1980 to provide health-based
information for use in the cleanup of chemical waste disposal sites
mandated by the Comprehensive Environmental Response,
Compensation, and Liability Act (CERCLA).

• B. The United States Environmental Protection Agency (EPA)
• EPA is responsible for a number of activities, including enforcing
federal laws designed to protect human health and the
environment.

 Euthanasia, Assisted Suicide & Health Care Decisions
• The words “euthanasia” and “assisted suicide” are often used
interchangeably.
• However, they are different and, in the law, they are treated
differently.
• “Euthanasia” is defined as intentionally, knowingly and directly
acting to cause the death of another person (e.g., giving a lethal
injection). “

• Assisted suicide” is defined as intentionally, knowingly and
directly providing the means of death to another person so that the
person can use that means to commit suicide (e.g., providing a
prescription for a lethal dose of drugs).
• Withholding and withdrawing medical treatment and care are not
legally considered euthanasia or assisted suicide.
• Withholding or withdrawing food and fluids is considered
acceptable removal of a “medical treatment.”

• While euthanasia for infants (infanticide) was not new, Dutch
doctors were now explaining that it was a necessary part of
pediatric care.
• Also in 2004, Holland’s most prestigious medical society
(KNMG) urged the Health Ministry to set up a board to review
euthanasia for people who had “no free will,” including children
and individuals with mental retardation or severe brain damage
following accidents.
• Currently, euthanasia is a medical treatment in the Netherlands
and Belgium.
• Assisted suicide is a medical treatment in the Netherlands,
Belgium and Oregon.

• A FAMILY AFFAIR
• In December 2005, ABC News’ World News Tonight reported,
“Anita and Frank go often to the burial place of their daughter
Chanou…. Chanou died when, with her parents’ consent, doctors
gave her a lethal dose of morphine…. ‘I’m convinced that if we
meet again somewhere in heaven,’ her father said, ‘she’ll tell us we
reached the most perfect solution.’”
• In Oregon, some assisted-suicide deaths have become family or
social events.
• Oregon’s law does not require family members to know that a
loved one is planning to commit suicide with a doctor’s help.

 TWO PILLARS OF ADVOCACY
• Wherever an assisted-suicide measure is proposed, proponents’
arguments and strategies are similar.
• Invariably, promotion rests on two pillars: autonomy and the
elimination of suffering.
 Autonomy
• Autonomy (independence and the right of self-determination)
is certainly valued in modern society and patients do, and should, have
the right to accept or reject medical treatment.
• The rationale is that when, where, why and how one dies should be a
matter of self-determination, a matter of independent choice, and a
matter of personal autonomy.

 Elimination of suffering
• The second pillar of assisted-suicide advocacy is elimination of
suffering.
• During each and every attempt to permit euthanasia and assisted
suicide, its advocates stress that ending suffering justifies legalization
of the practices.
• Thus, the rationale given by euthanasia and assisted-suicide
proponents for legalization always includes autonomy and/or
elimination of suffering.

Health ethics and legal medicine for health officer students (1)

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