Taxonomy
The term
forensic medicine is employed in the Netherlands, Belgium, Germany, France, Sweden, Norway, Egypt, Saudi Arabia, Turkey, Iran, Bangladesh, Japan, China, Indonesia, and Australia [
11‐
21]. The name is not used universally, however, and in other countries the term
legal medicine is used instead of
forensic medicine [
22‐
25]. Other terms with similar or overlapping meaning include
medical jurisprudence and
medico-legal services [
20,
26,
27]
. In some countries, including the USA and Canada
forensic medicine and
forensic pathology (i.e. medico-legal autopsy practice) are interchangeable, and there is no single formal designation for other applications of medical knowledge in a legal setting. In the UK and some other countries (including the USA, Canada, and India) the term
clinical forensic medicine is used to describe forensic services rendered by clinicians from various non-forensic disciplines (surgeons, emergency physicians, gynecologists, etc.) [
7,
28‐
31]. As a further taxonomic complication, opinions vary on whether
forensic medicine and
legal medicine are synonymous or whether they are two separate entities, with
forensic medicine relating to criminal law and
legal medicine concerned with civil and tort law [
32].
Due to the inconsistency of the terms used to describe similar practices, it is unsurprising that the scope and role of forensic medicine vary between countries. For the sake of consistency, in the following sections, the term forensic medicine will be used to refer to the discipline, and forensic medical practitioner will be used to designate the individual practicing within the discipline.
Scope and role of forensic medicine
The systems and services rendered by forensic medicine are not uniform and vary between countries. Generally, the different systems can be classified into two main categories of forensic medical service. The first can be labeled as the “integrated services” type [
18,
19,
33,
34]. In this type of service, the forensic medical practitioner conducts investigations of death and injury associated with suspected criminal acts. The service includes the conduct of medico-legal autopsy (i.e. forensic pathology practice), and the examination of living victims of physical and sexual assault, which are activities that fall under the umbrella term of clinical forensic medicine. The integrated services type of forensic medical practice may also include consultations pertaining to medical ethics and negligence, and the conduct of forensic laboratory examinations, such as those relevant to forensic serology or forensic genetics. To qualify as a forensic medical practitioner in an integrated system, medical doctors are required to undergo additional postgraduate or specialist education [
21,
25,
35], varying by country. The basic principles of forensic medicine may also be taught at the undergraduate level, particularly in countries that require all medical doctors to perform forensic medical examinations, if necessary, due to the shortage of specially trained forensic medical practitioners [
21,
25,
33,
36‐
38].
The second category of forensic medical services can be described as the “divided type” of service. In the divided service the variety of tasks provided by a single practitioner in the integrated system are handled by different practitioners within forensic medicine. Forensic pathologists, typically working within a medical examiner/coroner system (i.e. the USA, the UK, Australia, and New Zealand) exclusively handle death investigation, typically associated with the performance of an autopsy or external examination of a decedent [
3,
5,
39,
40]. Clinical forensic medical examinations, and sometimes medico-legal consultations as well, are conducted by general practitioners, police surgeons (a general practitioner with a particular assignment and contract with the police), or other relevant medical specialists (for example, a specialist in obstetrics and gynecology in cases of sexual abuse or emergency physicians for trauma victims). In the divided services system, clinical forensic medicine is not linked with forensic pathology and has variable recognition as a subfield within forensic medicine [
4,
6,
7,
26,
28‐
31,
41‐
43]. In countries with a divided services system principles and practice of forensic medicine are neither taught to medical undergraduates nor routinely provided as postgraduate education. The principles of forensic examination are either included in the curriculum of postgraduate training in relevant disciplines (emergency medicine, gynecology, nursing, etc.) or not at all [
6,
29]. Table
1 describes the types of forensic service system by country.
Table 1
Type of forensic medical services in different countries
| Australia and New Zealand [ 37, 64] |
Forensic medicine, as it is variously practiced, is a hybrid discipline, relying on principles drawn from a variety of core and adjunct disciplines, including medicine, and specifically pathology, pharmacology, and toxicology. In cases of injury resulting from mechanical trauma, principles of applied physics, including injury biomechanics and ballistics, are also used. Another adjunct discipline that is increasingly relied on in forensic medicine is forensic epidemiology, which applies population-based data and methods as a form of evidence-based causation analysis in forensic medicine [
78,
79]. In select cases, practices from disciplines more appropriately considered to be part of forensic sciences rather than forensic medicine are employed or relied on, including serology, genetics, dactylography (fingerprint analysis), forensic anthropology, and forensic odontology.
Current situation and practice of forensic medicine
Despite a long history of practice, with evidence of investigations dating back to early civilizations [
80], forensic medicine remains one of the least known and most misunderstood specialties of medicine. Forensic medicine, and forensic pathology in particular, is a comparatively rarely chosen profession [
39,
81], with many medical undergraduates considering it gruesome, outside of the clinical setting, and with long and unpredictable working hours and insufficient job appreciation compared to other specializations (monetary and otherwise). There are currently no data on the number of practitioners working in the field of forensic medicine, which may be due to the differences in the definitions used for forensic medical services, titles of practitioners, and the educational and practice systems in the countries listed in Table
1.
The wide variety of types of cases handled by forensic medical practitioners include, among others, cases of alleged murder/homicide, suicide, physical assault/abuse, accidental injury causation, sexual assault/abuse, poisoning, medical negligence claims, the cause of food and blood-borne illness, competency and dangerousness, and disaster victim identification. The annual number of criminal and civil investigations and cases that involve or require forensic medical expertise worldwide, much less in various countries is not known. This lack of data is despite the existence of WHO’s World Health Statistics that includes data regarding a variety of forensic-related health topics (e.g. road traffic injuries, violence, and substance abuse). The potential number of cases globally that are likely to involve forensic medical investigation based on data available in early 2016 is shown in Table
2 [
82].
Table 2
WHO world health statistics of forensic-related health topics (2016)
Death due to substance abuse (esp. alcohol) | 3,300,000 |
Death due to road-traffic injuries | 1,250,000 |
Non-fatal injuries due to road traffic accidents | 20,000,000 – 50,000,000 |
Homicide | 475,000 |
Suicide | 800,000 |
Along with the increase of public awareness regarding the role of forensic medicine in society, largely due to romanticized portrayals in popular media [
83‐
85], the demand for high-quality service is increasing. Despite the vital role of forensic medical expert opinion in the justice system, however, the methods used by forensic medical practitioners are not always evidence-based or based on standardized methods. Many forensic medical practitioners currently rely more on experience and individual customary practices in formulating their expert opinion [
10]. Furthermore, many operational principles and procedures used by forensic medical practitioners have not been standardized and therefore may vary greatly between experts and centers [
86].
The difference in available resources also contributes to the variety of services rendered. Some centers in high-resource countries complement conventional autopsy with post-mortem imaging techniques [
87,
88], while others have explored the usefulness of post-mortem biochemistry investigation in establishing the cause-of-death [
89]. On the other hand, resource-poor countries often resort to cheaper or simpler alternatives of the conventional autopsy, such as verbal autopsy [
90] or minimally-invasive autopsy [
91,
92]. Furthermore, forensic medical practitioners must also consider various non-medical factors, especially in settings or populations with a certain degree of aversion towards autopsy due to social or religious reasons [
3,
93,
94]
. This variation leads to difficulties in comparing and reviewing the performance and output of forensic medical service between nations and even between centers in the same country
.
There have been several efforts to initiate a harmonization of rules in forensic medicine, particularly forensic autopsies. One example is the 1999 European Harmonization of Medico-legal Autopsy Rules effort [
95], which was updated in 2014 [
96]. We were unable, however, to find publications about experiences in using, or the level of success of, the harmonized rules so far. Furthermore, although an accreditation/certification guideline for forensic pathology services exists [
97], it has limited scope, both regarding countries which implement it as well as the type of forensic medical services subject to accreditation.
Forensic medical expert opinions are provided in either oral or written forms. Generally, a written report contains the opinion of the expert on the issues involved in the case evaluation, as the core element of the involvement of the forensic medical practitioner in the case [
98]. Unlike clinical/hospital records, which are secondary to the medical procedure performed by the clinician (and are sometimes considered as “a necessary evil” [
98]) written reports are the primary product of forensic medical practice. They are also the principal means of communication between the forensic medical practitioner and legal practitioners as their customers.
The first published work about the methods to be adopted in preparing medico-legal reports was written in sixteenth-century France by Ambroise Paré [
80,
99], which was part of several volumes on the subject of forensic medicine. The development of forensic medicine in different parts of the world occurred at a different pace and through varied processes so that the reports produced by forensic medical experts also differ in scope and quality. A literature search using the keywords
forensic medical report, forensic medicine report, clinical forensic report, and
autopsy report revealed numerous samples of forensic reports, but no standardized guidelines regarding how to prepare a standard and admissible forensic medical report. Although an example of guidelines for an autopsy report exists [
100]
, the majority of publications are concerned with the writing of reports in forensic psychiatry/psychology, where the issue is the mental health state of the accused, criminal responsibility, community danger, and competence to stand trial [
98,
101‐
103]. There are various samples of customary examination forms produced by different agencies and institutions available on the internet, including forms for sexual assault victim examination and autopsy report forms. A list of some examples, and the search keywords used to find them, is available in the
Appendix.
There are countless variations in the format, content, and terms used in the reports [
86], not only between countries or centers but between experts as well. One element that is commonly missing from the reports is an explanation of the methods used by the expert to come to a conclusion, the justification for the use of the methods, and supporting references to scientific papers and databases. There is often a conclusory leap from the objective findings directly to the conclusion, without any explanation about the basis of the opinion rendered, or whether the said opinion is based on best-available evidence at all.