Aspects of medical ethics in forensic medicine

O. Teteris

Medical Academy of Latvia

<< Contents

From ancient times medical deontology has been one of the branches of medical ethics which evaluation juts into competence of forensic medicine expertises. Historical roots of medical deontology in Latvia juts into the 30ties of the past century - from the beginning of the foundation of forensic medical expertise institution, when founder of the Latvian University Forensic Medicine Institute (chair) in Latvia doctor of austrian origin, assistant professor F.Neureiter published book "Forensic Medicine and deontology of doctors" into the Latvian language.

Basic principles of medical ethics concerning medical practice and science should be discussed together with the peculiarities characteristic for each of the medical branch. Forensic madicine takes specific place among other medical branches, which is connected with the objects of medical research and co-operation dependance of the legislation normatives, stated in the Latvian Criminalprocessual codex and in the Latvian Republic Criminal Law. These normatives also afflict all specialisation doctors which are invited as experts in criminal and civil cases. At the same time there exist official instructions and regulations, which determines tasks, amount and service relationship for all of the employees of subordinate units of forensic medicine. Meanwhile it does not include ethical aspects, which are determined by Latvian Doctor Ethics Code, Hypocrate oath and International Doctors Ethics Code. This means that in justice doctors are subordinated to the normatives of legislation and ethics as well as to the official instructions (by-laws) at the same time.

Ethical concept incorporates wide range of questions related to the persons interrelation and attitude against things and processes in the social life, understanding ethics as behavior and politeness normatives, morality in the whole society and in the social groups as well as moral or conscience, "what I can" and "what I can not do", good and evil, attitute to the values of each separate person. Good characteristics of ethics point-of-view variety has been given by Mr. B.Sluckis "Theories as multi-coloured yarn. Good has 120 theories." Existing such variety of the attitude there has been advanced a theory: Nobody knows exactly what is morality. The most popular formulation: Ethics - study of the morality. Rene Dekart has formulated: "Ethics - study how to win passions". Simplicism theory has postulated: Morality is a fear of something not to happen. Sometimes ethics has been identified as morality. "Morality - ability to overcome passions. What is good and what is evil has been determined by morality, that is regulations with what man obtains community with God and secondly - together with people. Good unites people, evil - separates" (Benedictus Spinosa). Phylosophically ethics has been connected with God, mind and correctness of the behaviour. "Commandments are correct orders of reason. Justice is love of wise" (Gotfried Leibnic). It has been confirmed by the popular formulation of Immanuel Kant: "Against mankind in your own person or anyone elses always act as an aim and never as mean. Act so that your will maxima should always serve at the same time as a principle of general legislation." Mr. V. Sagatowsky deliberates similary: "Real morality - when person respects everybody: himself, other and society. To dominate over myself to respect others!" At the same time I. Kant admits that action of ethics puts restrictions: "All that has been done willingly and with joy could not be moral". Mr. J. Bentham objects: "In common comprehension moral is art to lead persons action to create the greatest sum of happiness".

Ourday comprehension of ethics has been related to the personality, social groups (ethics of science, business, etc.), professions (ethics of doctors), religion, international affairs, politics ("Political rotting always is connected with morality" (F. Engelss)), determing its attitude of each other, things and processes based on the basical principles advanced by ethics. Attitude against values has been formulated as moral normatives which reflects in different acts and declarations of legislation.

Moral normatives

Summarizing - these normatives solves question how to live better and to get along with each other.

At the end of 20^th century subject of ethics takes more important place in different situations of life: psychology, sociology, ecology, politics and economy, it has spread into different ethical specialisations. Medical ethics has become one of the branches of bio-ethics, but deonthology - sub-sector of medical ethics.

BIO - ETHICS

MEDICAL ETHICS RESEARCH ETHICS 

GUIDELINES OF SOCIAL POLITICS 

Practical questions and normatives of ethics as well as cases of disputes have been reviewed and decisions have been made in the instances of different levels:

Institutions of law enforcement and reference

Court

Talking about violations in medicine beside questions of deonthology in the different levels of its evaluation very often there have to be solved ethical questions of personal reciprocal communication which have intensified due to the medical commercialism and doctor's distance from the patient as well as spreading the diagnostical equipment proportion in diagnostics. At the end of 20^th century there have been changed questions to be considered in deonthology - due to the modern medical technology, transplantation, artificial impregnation, cloning, intensifying euthanasy, brain death and other questions, of which there have been adopted contradictory decisions in different countries. What time, such morality!

Evaluation of the ethics law violations. Mass information has actualised and publicated violations of ethics, which have to be evaluated by the founded commissions of ethics, honour or trade courts. The grave violations of ethical normatives such as offence of honour and respect have been judjed as a crime. It is very important to determine when there ends violation of ethics and when begins crime. In violation of ethics or crime (for example - paedophylus) person's reaction of public allegation is variable (from application to the general prosecutor for encroachment of honour and respect or to go on hunger strike up to unimportant reply).

At the 60-ties of 20^th century formed medical ethics defines the basic principles of the relationship in medicine: determining values, establishing normatives and formulating codes. Basic principles of ethics for every proffession are the following:autonomy, equality, objectivity, honesty, confidentiality, implementation of duties - control, responsibility, to avoid the conflicts - especially it is actual in medicine. As a part of medical ethics deonthology investigates connection between duties and rights of the medical stuff (study of proffessional duty), one of its cornerstone is to keep without prejudice principle. One time medical ethics trys to find ethics of responsibility.

Medical ethics takes special role in forensic medicine, because its attitude to the basic principles of ethics is influenced by the normatives of legislation. Ethical commission was founded at the Center of Forensic Medicine of Latvia, but one time forensic doctors have not got special ethical code.

QUESTIONS OF FORENSIC MEDICINE ETHICS

1. Questions of medical expertise. medical deonthology in the connection with investigation of criminal cases.

2. Reciprocal ethics of medical experts and clinicists in the cases of hospital mortality, in the conferences of pathological anatomy, in the court.

3. Reciprocal ethics of experts of forensic medicine and subject of the expertise.

4. Attitude towards dead body, relatives of the dead person.

5. Confidentiality of medical experts.

6. Reciprocal attitude ethics of medical experts and employees of law enforcement (police, prosecutor, judge, lawyers).

7. Reciprocal co-operation ethics of employees of forensic medicine.

8. Co-operation with mass media.

9. Research ethics.

10. Teaching ethics of forensic medicine.

While solving these questions frequently we have to derogate from Moral basic principles or to observe double effect (there is no good without evil). Regarding objects of the expertise self - determination of dead, victim or suspected have been restricted by legislation (paragraph 59 on compulsory expertises).

In case of hospital mortality if there has been discovered mistake made by clinicists mutual fellowship between experts of forensic medicine and doctors - clinicists has been restricted by the justice principles, because in case of criminal trauma there prevails presumption of innoscence (person who has made bodily injuries is not responsible for the mistakes made by medical staff). Certain consideration conflict of fellowship ethics and legal normatives rises while commissioning the forensic medicine doctor's professional activity in law violation cases where work of the doctors have been critised. In forensic medicine consideration of the principles of medical ethics should be related to: evaluation of wounds for victims or persons blamed for crime subjected to forensic expertise, should be unmerciful objective, which is not always acceptable for the victim itself. There does not work clinical principle - interests of the patient in the first place! If one of the basic principles in clinics is faith to the victim, in forensic medicine everything has been mistrusted and evaluated unmerciful objective. For medical experts as well as court there prevails the well known principle - "All doubts for the best of defendant!" In contradiction to the clinical doctors there does not function mutual principle of making good, even flowers or some other small gift by victim can be comprehended as rejection of medical expert. Aspects of medical ethics regarding deceased persons are connected with the restrictions foreseen in law "Deceased body protection" and in "Regulation of dead body forensic expertise order". Uncareful (anti-ethical) attitude to dead body is determined by the questions set by crime investigator, which sometimes demands certain distortation of dead body during the expertise. If during the scientific research of the tissues of dead body there is needed special permission of doctor's ethics commission, then during the forensic expertises deceased person becomes an object of the scientific research. Ethical and legislation normatives in other countries (not vice verse as it is our country) foreseen larger rights in the defence of dead body, which is demonstrated in the statistics of forensic authopsies. For example, in the Netherlands authopsy is made only in one of six cases with a cause of violance death, in Japan 5-6 times less than in Latvia. In the spheres of research and usage of the dead body confronts interests of the dead person itself or dying person, his relatives, law protection institutions, scientists, interested persons in the organ transplantations (recipients, their relatives, transpanthologist) and interests in connection with the adopted normatives of legislation, and moral (or religious), provoking moral conflict ("doublemoral") - antiethical action to deceased person and its relatives is ethical and human to organ recipients or development of the science. Confidentiality - as one of the basic principles of medicine has specially been pointed out in forensic medicine threating with criminal penalty. In such situation there is mistrusted honesty of the doctor and it has been asked additional legislative liability which is not ethical from the side of legislator. In the expertise of forensic medicine the involved doctors has been mistrusted their professional fairness, warning them of criminal liability already before the expertise - that they will not ungrounded avoid or deliberately give false medical conclusion. In such a case there should be discussed question on establishment of the Institution of sworn experts. From the other side comprehension of ethics normatives for each doctor has been determined by many factors: declarated normatives in the society, religious conviction, national traditions, family, level of general education, upbringing, heredity, professional and lifetime experience, financial conditions, moral or material interest.

Specific place takes evaluation of ethical aspect interrelations among doctors - forensic experts during the commission forensic expertises, where each doctor's personnal conviction is more important than the common point of view of the commission or acting like competitive experts,but one time we may observe influence of more experienced experts or subordination. In the same way it is impossible to reach fellowship point of view making repeated expertises, where there is evaluated rightness of the first expertise, because there is prevailing interests of victims and possible defendants. There is specification in common relationship between doctors' and employees of legal instances, where between legislation normatives, regulating formal side of the relationship, exists ethical normatives, determined by general ethical normatives of society and by peculiarities brought by the profession of these employees (different usage of ethical normatives, for example, regarding confidenciality on judge or lawyer etc).

As exciting source of information forensic medicine has always been in the intensified attention circle of mass media. But at the same time principle of confidentiality does not let society frankly receive information because medical expert is a person which is specially warned not to divulge it without permission. In this co-operation we can observe different professional ethics of one and the same question (journalist does not have ethics - information on all costs, policeman - choice of freedom to furnish information, medical stuff - compulsory silence). There is different comprehension on medical questions which are confidential for the doctors - for example to get sick with AIDS. For investigators and press it seems interesting information to be published which sometimes can be reason for suicide.

In the Baltic States converting and approximating processual and criminal codes to the legislation of EU very current are its ethical aspects for the experts of forensic medicine and demanding lots of them.Interesting seems question about autonomy of Institutes of Forensic medicine and autonomy of experts. In the Criminal law of Latvian Republic punishment on experts responsibility has been extenuated mostly foreseeing penalty. Very interesting seems discussion on statehood status of experts: State Expertise experts relates status of state clerk or expert is state reliability person or there should be established institution of sworn state experts. But in the State forensic medicine expertise centre controversial is question of by-laws which can include ethical aspects of this relationship between doctors, administration, secondary and junior medical stuff and other questions of forensic medicine ethics. Recently ratified instruction on duties of medical experts reminds legislation normatives which are identic to the previous (USSR) instructions. May be it is time to establish Ethics code for experts of the Baltic States or EU.

References

1. Criminal Law of Latvia, Riga, 1998, 300, 302, 304

2. Criminal Processual Code of Latvia

3. Ethics Code of Doctors

4. Ethics Code of Scientists

5. H. Fagerberg. Medical ethics. - Dimensions of ethics, Riga, 1997, p. 153-172

6. R. Holte. Where roots morality? - Dimensions of ethics, Riga, 1997, p. 9-71

7. I. Kant. Practical criticism of mind. Riga, 1988, p 27

8. V. Sile. Basic principles of medical ethics, Riga, 1999

9. A. Meikalisha. Law of Criminalprocess, Riga, 2000, p. 175