Teaching of Legal Medicine - 'Perugia Document'

TEACHING OF LEGAL MEDICINE to medical undergraduate students
The 'Perugia document' as modified in Cologne in JULY 1992

From the first few days after qualification, the practitioner of Medicine is of necessity exposed to tasks and problems during the course of the daily professional duties which require substantial medicolegal knowledge to be dealt with proficiently and satisfactorily. The scope of this document is to produce GUIDELINES of a MINIMUM STANDARD as a basis for the undergraduate curriculum in Legal Medicine. Varying nuances of emphasis would be required in individual countries to take into account differences in local practice, custom and legislation.

The major topics in Legal Medicine to be highlighted in undergraduate teaching are the following main headings:
1. Thanatology and Forensic Pathology
2. Clinical Forensic Medicine
3. Medical Law and related Jurisprudence.

All doctors are required to attend patients who have died and are confronted inescapably with the certification of the fact, the manner and the cause of death, with the certification of the time of death and with the external examination of cadavers to assist with such certification. Even in those countries where these obligations are only partly in existence for non-specialists, all doctors will be involved in the initial investigations of the deceased and in reaching prompt decisions as to whether suspicious circumstances are present and as to the necessity for further investigations by the authorities. Due to the medical practioner's participation in the earliest phases of this decisionmaking process, he plays an important part in the elucidation of homicides and in the initial aspects of the investigation of violent non-natural deaths, the most frequent cause of death in the younger age groups. The doctor has an obligation to ensure that death certification is accurate so that true statistics and mortality data can be maintained. All such duties are of paramount importance to both society in general and individuals in particular. The medical practitioner should be fully familiar with his duties relating to the reporting of deaths and to the issue of appropriate certification necessary for the legal disposal of the remains. To enable the medical practitioner to cope with such tasks, basic theoretical as well as applied knowledge in these fields is required at the undergraduate period of instruction.
1.1 Thanatology
Deaths with definitions and criteria for different modes of death, agonal phenomena, types of death, cadaveric (post-mortem) changes, signs of death, tissue death, brain-death -external examination of the deceased, procedure, determination of the fact of death, changes associated with unnatural death, certification of the mode and cause of death, implications for society and the individual -legal nature and possession of the corpse, legal pre-requisites for autopsy and for collecting diagnostic, therapeutic and teaching material.
1.2 Forensic Pathology
Forensic Traumatology -legal definitions and causalities, especially relative to homicides, suicides and accidents - general forensic pathology especially the principles of patho-mechanics, intra-vital reactions, principles of special laboratory investigations -blunt force trauma, lesions to skin, bones, internal organs, soft tissues and their mode of occurrence -injuries by sharp objects; types of lesions especially regarding mechanism of injury -gun-shot wounds; physical parameters relevant to these types of injury and the medical sequelae -the patho-physiology of mechanical asphyxia, suffocation, mechanisms of death, findings on external examination, strangulation and its subvarieties, other types of suffocation -drowning especially causes of drowning, manner of death and differential diagnoses -road traffic accidents and other transportation incidents, mechanisms and patterns of injury, biomechanics and principles of accident reconstruction from the medical findings -other causes of injury: thermal, electrical, physical, irradiation -sudden unexpected deaths in adults and children, causes of death, medico-legal differential diagnoses Familiarity with injury patterns as related to specific incidents should enable a distinction to be made between self-inflicted, accidental, second-party inflicted and natural disease both in the living person and in the deceased.

Close inter-relationships are encountered in most clinical disciplines between certain medical disorders and complaints, and the medico-legal interest and aspects directly related to them. The medical practitioner plays a key role in assessing these crucial situations and in critically determining such matters of interest to the patient as healing, residual disability, protection and the implementation of the law. Injury patterns in the living differ only quanitatively from those observed in deceased patients where the implications are also essentially similar. Items involved are:
2.1 Injury due to physical, chemical, mechanical, thermal and other related causes
Most of the modern 'epidemics', which are occurring with increasing frequency, are due to such causation and they often involve multiple casualties. In addition to the medical diagnoses and treatment of such conditions, several forensically based questions need to be addressed, sometimes even prior to the institution of appropriate treatment: -the nature of the injury: weapons and/or mechanisms involved -the mode of occurrence: accidental, suicidal or due to assault -the legal implications of diagnoses and potential sequelae e.g. in the battered child syndrome, in attempted suicide.
2.2 Other types of disorders involving acute and chronic injury to the person
Batered child and spouse syndromes, abuse of the elderly -sexual offences -attempted suicide, substance maluse and addiction, accidents, attempted homicide -human rights infringements such as torture and maltreatment of individuals. All these topics involve important decisions directly connected with the primary diagnosis or the differential diagnosis. Although it would fall to the specialist to give expert and definitive opinions, decisions and actions will by necessity be taken in the earliest phases of such investigations by the first doctor to be consulted. This doctor in turn has to ensure that procedural matters such as documentation, evidence sampling and preservation, evaluation, etc. are appropriately carried out, and that a referral is channelled to the more appropriate experts. If no specialist is available, it is the sole evidence and opinion of this doctor that would be available for consideration by the appropriate legal authorities.
2.3 This section would also include
a. bodily harm especially its forensic evaluation, documentation, degrees of severity, sampling of evidence b. sexual offences including legal definitions, genital and extra-genital findings, their importance for reconstruction of the incident, sampling of evidence, documentation c. maltreatment of children, the battered baby syndrome and other syndromes, definitions, medical criteria, child protection, legal and social welfare institutions to be involved d. abortion including definition, conditions for legal abortion, methods of legal and illegal abortion, complications, peri-partum causes of death e. forensic toxicology; modes of drug administration and absorption, masked administration of poisons, acute poisoning of forensic interest (carbon monoxide, cyanides, alcohol, insecticides, herbicides, opiates, heavy metals); chronic intoxications, findings in the living and deceased; drugs and driving f. forensic alcohology: ethanol absorption, distribution, metabolism and excretion, medico-legal implications of intoxication (driving, criminal responsibility, addiction, interaction with other drugs) g. drug misuse: types of drugs, legal definitions and sanctions, environmental factors (e.g. crime), modes of administration, interactions, abuse of solvents h. medico-legal implications of mental disease, certification, decreased criminal responsibility due to disease (especially mental illness) and intoxication i. medically related aspects of forensic biology (e.g. DNA profiling, paternity testing, seminal analysis j. medico-legal aspects of assisted and artificial reproductive methods.

The emphasis of this part of the curriculum should be directed towards a full consideration of the rights of the patient, the application of all legislation pertinent to the practice of medicine and a full review of the professional duties and responsibilities of the medical practitioner. A familiarity with applied medical jurisprudence and medical law is essential as well as a broad outline of the legal system and the constitution of the Courts. This would include: authorisation to practice medicine, legal framework of practice, fitness to practice, patient's rights. Application of therapeutics, authorisation for prescribing, limitations and prohibitions, duties of treatment, euthanasia -consent to treatment, informed consent and its limitations to invasive diagnostic and therapeutic procedures relevant to the civil and penal systems, legal pre-requisites, limitations and exceptions -problems regarding minors, the unconscious patient and the mentally ill or retarded patient -disease notification -medical liability, especially relative to the civil and penal systems, guidance on evidence, medical negligence -medical duties in emergencies, legal demands, assessment of testamentary capability -professional confidentiality, data protection relative to the civil and penal codes; employers and social institutions; access to records, exceptions, confidentiality with relatives, the State, and the Courts -provision of legally valid, competent and precise certification to State authorities, the Courts, private bodies and institutions and to the patient as an individual -trials of treatment, responsibilities in human medical or therapeutic experimentation.