CHAPTER: 1.

FORENSIC MEDICINE: GENERAL CONSEDERATION

1. History of forensic medicine

2. Define forensic medicine/ Legal medicine/state medicine and Medical
jurisprudence.
3. Define Medical ethics, code of medical ethics and oath of medical
applicant
4. Duties of doctor in general, towards state and patients
5. Define Professional secrecy or medical confidentiality
6. Define privileged communication
7. Define Consent, types of consent
8. Define medical malpractice
9. Define professional misconduct
10. Define medical negligence
11. Define Malingering ( Shaming)
[Link] Euthanasia and its type
[Link] Inquest and types

HISTORY OF FORENSIC MEDICINE & TOXICOLOGY

 Ambroise Pere by surgical work laid the several plan for the development
of forensic medicine and regarded as the father of forensic medicine in 16th
century.

 Paolo Zacchia was the father of forensic Medicine

 The first publication on forensic medicine in UK was by William Hunter in the

18th century. His essays were on injuries found on murdered bastard children.

 The three great pioneers of forensic medicine

1. Johann Casper
2. Mathieu Orfila
3. Marie Devergie
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 They devoted their life in the study and development of forensic medicine as we
understand it today

 Locard is considered as a father of Indian forensic medicine or father of

modern forensic science and criminology. In 1910 he could analyze
evidence from crime scenes.

 Paracelsus, also known as the father of toxicology, he was a 16th century

physician, he introduced the use of chemical substances, such as minerals,
into medicine.

 The Father of Modern Toxicology was Matthieu Joseph Bonaventure

Orfila (1787-1853) He was a respected Spanish chemist and the physician,
The first comprehensive work on Forensic Toxicology was published in
1813 by Mathieu Orfila, The study and classification of toxic substances was
first systematized by Matthieu Orfila in the 19th century, he identify poisons
and search for antidotes and other means of treating toxic injuries. His work
emphasized the need for adequate proof of identification and the need for
quality assurance

 Hippocrates Father of Western medicine discussed the lethality of wounds and

contributed to the field of ethics in forensic medicine in 460 – 377 B C

 First medico-legal autopsy was conducted by the Roman physician “Antistius” who
examined the body of Julius Caesar after his assassination in 44 BC

 The first book on forensic medicine was published by Italian physician, Fortunato
Fedele In 1602.

 first recorded medico-legal autopsy performed in India was by Dr Edward Bulkley

in 1693 at Chennai on a suspected case of “ arsenic poisoning”

 Manusmriti was a famous treatise where rules for marriage, punishment for
adultery, incest and sexual offences were formulated. Manu was the first traditional
king and lawgiver in India

 Shusruta, Father of Indian Surgery gave the Shusruta Samhita in 200-300 AD.

 Dr. CTO Woodford is regarded as the first Professor of Medical Jurisprudence in

India.

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 DEFINITIONS

Forensic Medicine or Legal Medicine or State Medicine

Forensic Medicine: - It is a branch of medicine that deals with application of medical

knowledge and principle for justice to legal problem and proceedings. it is used by the legal
authorities for the solutions of legal problems by applying the medical knowledge in
deciding cases of injuries, unnatural death, murder, suicide, accidental, sexual offenses,
poisoning, burn, bomb explosion, drowning, narcotic drugs, weapons scientifically. So it is
define as the science of justice and art of justices.

Medical jurisprudence: (Science of law)

This subject concern with the knowledge of law in relation to the practice of medicine for
any medical practitioner.

It includes-

 Doctor-patient relationship,

 Doctor– Doctor Relationship

 Doctor – state relationship

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Forensic pathology -- special field of pathology dealing with the medico Legal
investigation of death concern with the sudden, unexpected, suspicious, Unnatural death.

 in this cases dead body submitted for full autopsy to determine the cause of death.

 In all such cases the doctor may have appear in a court of law as a expert witness
and on his evidence the court will assess the responsibility of the accused.

ETHICS:- Ethics is a branch of philosophy concern with way of living , human behavior
in society, what is right and wrong in human behavior or good and bad . Greek philosopher
and father of ethics Socrates I st recognize the need to define ethical concepts and
established a universal standard and way of living in the human society. In philosophy we
study Ideas and belief that tries to explain the meaning of life or give rules about how to
behave (love of wisdom).

MEDICAL ETHICS:- Medical ethics concerned with moral principles for the members of
the medical profession in their dealing with each other, their patients and the state. Ethical
behavior is self-imposed duty upon doctor. The aim is to maintain noble tradition of the
medical profession. The foremost importance of medical ethics is to develop a professional
and respectful relationship with patient during their treatment. Medical ethics promotes
health, wellbeing, and respect in medical profession. Ethics of patient care includes
following criteria’s-

 Autonomy or rights of patient

 Beneficence or helpfulness or promoting the well-being of others

 Nonmaleficience –It is the obligation of a physician not to harm the patient. E.g.-
stopping a medication known to be harmful or an intention to avoid harming or
injuring others

 Informed consent— It is a process in which written permission given by a patient

to a doctor for treatment or medical procedure with knowledge of the possible risks
and benefits

 Justice:- Justice is the ethical idea that people are to be treated impartially, fairly,
properly and reasonably by the law where harm is alleged. Types Justice in India: -
social, Economic, Political, and Legal justice all these forms are inter-related and
interdependent. Justice forms the foundation of a civilized society. (Father of
justice- justice Vaidyanathapuram Rama Krishna 1915- 2014, was a Indian judge
who became a pioneer of judicial activism.

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  Truth telling and promise keeping

 Help someone in need

E.g.;- A doctor should not criticize another doctor while dealing with patient. He should
not charge from patient who is under the care of another practitioner, he should not refuse to
give professional services on religious ground, he must remember his duty to the state in
relation to notifiable disease to the public &to give emergency care on the humanitarian
ground .

MEDICAL ETIQUETTE: These are the conventional laws or any rule agreed upon by
persons for the regulation of their conduct towards each other, it is a form of special law for
behaving in a traditional way and customs of courtesy (respect for other) which are
followed between members of same profession. A doctor should behave with his colleague,
as he would like to have them behave with him, e.g.- he should not charge another doctor or
member of his family for professional service.

CODE OF MEDICAL ETHICS/DECLARATION OF GENEVA

It is known as the declaration of Geneva by world Medical association (WMA) The

declaration of Geneva is one of the world medical association’s oldest policies adopted by
2nd general assembly in Geneva in 1948, It builds on the principles of the Hippocratic Oath,
& in now known as its modern [Link] is followed by medical council of India as the code
of ethics; The declaration of Geneva is an Oath for physicians that was 1st adopted by the
world medical association in 1948 and it was drafted by EGLANTYNE JEBB who was a
British social reformer. at the time of registration as a member of medical profession every
medical applicant shall submit the following written & signed declaration to the concerned
registrar. Any deviation in the declaration of medical practitioner during his medical
practice treated as unethical practice. At the time of registration all the doctors are self-
warned about certain unethical practices and disciplinary action by the State Medical
Council.

OATH OF MEDICAL APPLICANT OR DECLARATION OF GENEVA

 I seriously promise myself to given up (devote) my life to the service of humanity

 I will give respect & gratitude (thankfulness) to my teacher

 I will practice my profession with carefully & truthfully (dignity)

 The health of my patient will be my first consideration (my regard)

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  I will maintain the honor (regard) & noble traditions of the medical profession

 My college will be my brother

 I will not permit consideration of religion, nationality race, poverty, politics or social
standing to interfere between my duty and my patient.

 I will maintain respect for human life from the time of conception

 I will use my medical knowledge for humanity

DUTIES OF PHYSICIAN

At the time of registration all the doctors are self-warned about certain unethical practices
and disciplinary action by the SMC.

Duties of Doctors in general

-A physician should uphold the dignity and honor of his profession and render service to
humanity.

-A physician should try to improve medical knowledge and skills.

- Physician should maintain the medical record of his indoor patients for a period of 3 years
from date of commencement of the treatment.

-Physician should display registration number in his clinic as per SMC.

-Physician should prescribe drugs with generic names and ensure that there is rational
prescription and use of drugs.

-He should give equal and highest quality assurance in patient care.

-He should expose, without fear or favor, unethical conduct on the part of members of the
profession.

-Physician should clearly display his fees in his chamber or hospital.

-Physician should observe the laws of the country in regulating the practice of medicine.

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Duties of doctors towards the State

-He should assist the police in determining whether the case is of poisoning, accidental,
suicidal or homicide.

-Doctor is bound to give information of communicable diseases, births, deaths and outbreak
of an epidemic to public health authorities.

-The sick prisoners of war, enemy of nationality are to be treated without any adverse
discrimination.

- He should responding to emergency military services as and when require

Duties of doctors towards patients

-A physician should exercise reasonable degree of skill and knowledge to the patient.

- Physician should give proper information to his patient or attendants regarding use of
medicines, injections and diet.

-Physician should give a good prescription after proper diagnosis of diseases and should
avoid damage to health by wrong prescription.

-he should inform the side effects of the drug prescribed

- If the disease is contagious, physician should ask patient not to go close to any third
person.

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-If a patient is incapable to take care of themselves, doctor should arrange proper care

-Physician should explain the nature and extent of operation, and take consent of patient

- For proper diagnosis and further prognosis a doctor should advice for investigations like-
laboratorical, radiological, scopy, ultrasound, c t scan, MRI, etc. if needed

-He has moral, ethical and humanitarian duty to help the patient in saving his life.

PROFESSIONAL SECRECY/ MEDICALCONFIDENTIALITY

In professional secrecy, The doctor is obliged to maintain the secrets that he comes to know
concerning the patient in the course of a professional relationship, except when he is
required by the law and when the patient has consented for its disclosure

It is fundamental tenet that whatever a doctor sees or hears in his life of his patient must be
treated totally confidential.

It is a contract between a doctor and his patient in this contract the doctor keeps the secrecy
about the any serious disease of patient.

Principles that should be followed:

1. Physician should not answer any query by the third parties without the consent of the
patient

2. Physician should not disclose the illness until patient’s consent, in public body, except in
case of notifiable disease. e.g. – AIDS

3. No information of patient and its disease should be leaked without his/ her consent

4. Medical officers in Govt. service are also bound by code of professional secrecy, even
when the patient is treated free of cost.

5. An information about a dead person may only be given after obtaining the consent from a
relative.

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6. The medical examination of life insurance policy is a voluntary act by the examiner, and
consent to the disclosure of findings may be taken as implied.

7. A prisoner in police custody has right not to permit the doctor to discuss the matter of his
illness to any person.

PRIVILEDGED COMMUNICATION

It is a statement, made in good faith or bonafide upon any subject matter by a doctor to the
concerned authority having corresponding interest, due to legal, social or moral duty to
protect the interest of the community or of the state.

- It is an exchange of information between two individuals in a confidential relationship,

and exception to professional secrecy.

- Doctor should first assure/advise the patient to obtain his consent before notifying the
proper authority.

Examples:

1. A bus driver, pilot or ship navigator may be suffering from epilepsy, hypertension,
alcoholism, drug addiction, color blindness, or a teacher with tuberculosis, etc. In all these
cases there is duty of doctor to report the problem

2. If the doctor learns of a crime such as assault, terrorist activity, traffic offence or
homicidal poisoning by treating the victim, he is bound to report it to the nearest magistrate
or police officer.

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 CONSENT

A consent is voluntary/ willingly agreement or permission given by the patient for

examine, treatment or operation after understanding the advantage & risk involved &
consent is obtained by the doctor from patient. Doctor may be charged for negligence if he
fails to inform to patient before asking his consent to a particular operation or treatment.

TYPES:

1. Implied consent: when the patient presents himself at the doctor’s clinic, it is held to
imply that he is agreeable to be examined. This do not implies to the procedures more
complex than inspection, palpation, percussion and auscultation.

For other examination, like rectal and vaginal and withdrawal of blood for diagnostic
purposes expressed permission should be obtained.

2. Expressed consent: Express consent, sometimes known as general consent. In medical

field, most simple procedure require express consent. For example, a nurse may ask “ Can I
take your blood pressure?” than your reply is express consent it should be specifically stated
by the patient.

It can be:-

 Oral/ verbal consent: It is obtained for relatively minor examination or

therapeutic procedures in presence of attendant or nurse.
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  Written consent: t is to be obtained for all major diagnostic procedures,
General anesthesia, Operations.

3. Informed consent: It is a process in which written permission given by a patient to a

doctor for treatment or medical procedure with knowledge of the possible risks and benefits.
Informed consent involves a greater discussion and more information. To obtain informed
consent, a doctor must fully discuss a patient’s options and how a procedure will affect him.

For example, if a patient is considering a surgery, a doctor will explain the surgical
procedure, possible complications and other possible courses of action.

Doctrine of Informed consent

This doctrine implies as understanding by the patient of:

 His /her condition of illness

Purpose or necessity for further examination
 Natural course of condition and possible complication
 Nature of procedure or treatment proposed
 Risks and benefits of treatment
 Prognosis in the absence of intervention
 Duration and approximate cost of treatment
 Expected outcome and follow-up
 Information given to the patient should be in easy language
 There is no need to express remote risk which may frighten or confuse the patient.

Exceptions of informed consent

 Emergencies

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  Medical examination requested by a police officer of an arrested accused
under sec. 53

 Therapeutic privilege or advantage

 Medico-legal postmortems

 Psychiatric examinations or treatment by court order

 Use of placebo

 Prisoners

 Person suffering from disease under notified category

 Treatment of notifiable disease for greater community.

MEDICAL MALPRACTICE

The term “medical malpractice” covers all failures in the conduct of doctors, where it unhinges or
deranged upon their professional skills, ability and relationships

It is devided into two types:

1. Professional misconduct: It is also known as Infamous conduct

It is where the personal, professional behavior of a doctor falls below that which is expected
of a doctor or any conduct of a doctor which might reasonably be regarded as disgraceful as
judged by professional men.

The following acts of commission and omission which constitutes professional misconduct:

 Any unethical practice like- euthanasia, dispensing secret remedies , torturing the
patient

 If He doesn’t maintains medical records of the patient

 If he doesn’t display the registration number

 Physician found absent from his duties more than two occasions during inspection

 Providing misleading information to the MCI

 Do sex determination to terminate female foetus

 Issue false certificate for use in courts

 Supply and sell addiction drugs

 Perform illegal operation and abortion

 Disclose professional secrets

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  Refuse on religious ground Publish photographs/ case reports without patients
consent

 Undertake in vitro-fertilization or artificial insemination.

2. Medical negligence:

It is where the standard of medical care given to the patient is considered to be inadequate. It is
defined as absence of reasonable care & skill or willful negligence of a medical practitioner in
the treatment or operation of a patient which cause the bodily injury or death of the patient.

Negligence consist of two acts

 Act of commission: Doing something which is reasonable under the circumstances

would not do.

 Act of omission: Not doing something that a reasonable man under the circumstances
would do.

e.g. – Willful delay in operation, wrong side operation, wrong treatment, caesarian section
without need.

MALINGERING (SHAMING)

It is a conscious planned fabrication, to give a false appearance (feigning) or pretend to be

ill in order to escape duty or work and to achieve a specific goal or exaggeration of physical
or psychological symptoms designed to achieve a desired goal. People who had
psychosomatic complaints were probably malingering

Reasons:

 By soldiers or policemen to evade their duties.

 By prisoners to avoid hard work

 By businessmen to avoid business contracts

 By workmen to claim compensation

 By beggars to attract public sympathy

 By criminals to avoid legal responsibilities

Disease Feigned:

Ophthalmia, sciatica, diabetes, spitting of blood, vertigo, aphonia, epilepsy, ulcers,

rheumatism, lumbago, etc

 Patient can exaggerate their symptoms so usually sign and symptoms do not confirm
any known disease

 History of the disease should be taken from patient ad relatives

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  A complete examination is essential

 It can be diagnosed by keeping the patient under observation and watching him
without his knowledge

EUTHANASIA

(MERCY KILLING)

Euthanasia means producing painless death of a person who is suffering from hopelessly
incurable & painful disease & there is no further chances of living. In that condition patient
also wants death from painful incurable disease condition death is better than painful
diseased life.

Types –

1. Active euthanasia

2. Passive euthanasia

1. Active euthanasia:- It is positive merciful killing or act to end useless suffering it is an

act of Commission done by given lethal doses of opium ( inj. Morphine) / Barbiturate/ ( inj.
Pentothal sodium or other narcotic drugs to hasten death.

2. Passive euthanasia:- means discontinuing life sustaining measures and permits natural
death to severely defective new born infant. It includes act of omission.

 Voluntary euthanasia: - means at the will or the request of the person either
during illness or before, if complete incapacitation is expected.

 Involuntary:-where individual distinguish between life and death, any medical

killing is involuntary i.e. against the will of the person is compulsory. It is ethically,
morally and legally considered as a murder

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  Non-voluntary euthanasia: - Where an individual is incapable of perception and
feeling, and hence cannot decide or distinguish between life and death, such person
cannot give informed consent. E.g. it refers to cases of in persons with irreversible
coma or severely defective infants.

Reasons for euthanasia

 Patient should be allowed a dignified painless death, instead of prolonged torture of

the pain and disease.
 It may pose economical and psychological burden to the patient’s relatives
 Right to commit suicide
 Patient should not be forced to stay alive.

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 INQUEST

Inquest is an inquiry or investigation into the cause of death where death is apparently not
due to natural cause. It is conducted in the cases of unnatural suspicious death to find out
the cause of unnatural death.

It is done in the cases of:

 Sudden death
 Suicide, homicide and infanticide
 Death from accident, poisoning
 Unexplained death or death from burns
 Death under anesthesia or on operation table
 Death due to alleged medical negligence
 Death of convict in jail, police custody, mental hospital
 Dowry death
 Death due to an industrial disease.
Types of inquest: - There are two types of inquest held in India:

1. Police inquest

2. Magistrate inquest

Other types are:

 coroner’s inquest
 Medical examiner system
 Procurator fiscal

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1. Police inquest: - An inquest is a fact finding inquiry, which is held in the presence of a
police officer not below the rank of head constable to get four reliable answers

 First the identity of deceased

 Second the place of death

 Third the time of death

 Fourth the cause of death

In the any case of unnatural death police officer or investigating officer proceeds to the
place of death and hold enquiry into the matter of death. In the presence of respectable
persons of locality (panchas). investigate the case & write a report under section-174 , 175
criminal procedure court about cause of death & describe the appearance of body , wounds ,
fractures, bruises, staining and other marks of injury present on the body which are
mentioned in the report & the inquest report ( panch nama ) is signed by investigating
officer & by the witness ( panchas ) .In case of suspected cases or doubtful cases body sent
to hospital for postmortem examination ( autopsy ) & if there is no foul play is suspected &
the death is due to natural cause then the dead body is given or ordered for disposal by
relatives in the presence of witnesses by police office

2. Magistrate inquest: - This inquiry or investigation conducted by district magistrate,

executive magistrate, Tehsildar empowered by state Govt. Not held routinely but only
when especially indicated.

During inquiry held by magistrate parents, brother, sister, spouse of deceased, relatives
should be informed and to be present in the inquiry

Magistrate should forward the body for examination by a civil surgeon or any other doctor
appointed by state Govt. within 24 hours of death of a person.

It is done in following cases of death:-

 Death in prison
 Death in police firing
 Death in Borstal school ( the school of criminal below 18 years of age for juvenile
delinquent to provide technical education for job )
 Death in police custody & while police interrogation
 Death in psychiatric hospital
 Dowry death.
 In any case of death magistrate may conduct an inquest in addition to the police
inquest

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 Differentiation in between Police and Magistrate Inquest

S.N. Feature Magistrate Inquest Police Inquest

1 Investigating Inquest conducted by magistrate Conduct by police officer who is

officer who is qualified and experience not qualified in law or medicine

2 Informing Need not inform any one Need to inform Magistrate of the
magistrate area any one

3 Types of Can hold inquest in all the cases Cannot hold inquest in cases of
cases handled of suspicious death death in custody, jail, police
firing or dowry death.

4 Witnesses Police helps the magistrate Panchas help is require chosen at

doesn’t require signature of the random to sign the report
witness

5 Value of No value not admissible in court Valuable and admissible in court

statements
made by
witness

6 Warrant for Can issue warrant for the Cannot issue warrant, but can
arrest accused arrest accused in cognizable
offence

7 Exhumation Can order a body to be exhumed Cannot order

8 Autopsy doesn’t send dead bodies for Send dead body for autopsy
autopsy

9 Analysis of Can order chemical analysis of Cannot order

viscera viscera

10 Quality of Superior to police inquest Inferior to Magistrates inquest

investigations

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