LEGAL MEDICINE IN EUROPE-THE PAST AND THE FUTURE
Anthony Busuttil*
Busuttil A. Legal Medicine in Europe-The Past and the Future. Adli Tıp Bülteni, 1996; 1 (1 ): 6-10.
B ıı yazıda, tıp san atın ın b ilin e n e n esk i zam an lard an gü n ü m ü ze m a h k e m e le r v e h u k u k sistem in d e aldığı y er ve g elişm e le r k ro n o lo jik b ir y ap ıd a aktarılm ıştır. O rta çağ, R ö n esa n s ve so n rası d ö n e m le rd e tıp bilim in in h u ku ktaki rolü , adli tıp kav ram ın ın g e liş m e s i anlatılm ıştır. A vrupa Bir- liği'n in g e rç e k le şm e si ile y ak ın g e çm iş te adli tıp u zm an lık alan ın ın tan ın m ası v e bu u zm an lık alanı ile ilgili m ezu n iy et ö n c e si v e so n rası eğ itim p ro g ram ların ın Avrupa Birliği ü y esi ü lk e le rce stan d artlaştırılm asın a y ö n e lik ça b a la r, k o n u ile ilgili u lu slararası çalışm a gru pları v e uğraşları, h e d efle d ik leri am açlar, d ü z en led ik leri tem el b e lg e le rin a m a ç v e içerik leri tanıtılm ıştır.
“It may not be feasible to construct an internationally curriculum ivhich ivill meet the requirements laid down by the certifying and registering authorities in the different parts o f the world. This would not how ever stand in the way o f creating an internationally recognised qualification which may p r o v e acceptable; f o r specialist registration in many i f not most parts o f the world. ”
Prof. H.A Shapiro - V th. In tern ation al Meeting o f Forensic Sciences-E dinburgh-Septem ber 1972
T h e "art o f m ed icin e as p ractised by the p h y sician ” have p erm eated and infiltrated the cou rts and the p ractice o f law th rou gh o u t kn ow n historical tim es. This in flu en ce has b e e n w ell establish ed on the C ontinent o f E u ro p e fo r o v er tw o thousand years thou gh m ed ical in volvem en t in the law w as well enshrin ed in fo ren sic p ractice in C h inese, Persian, A rabic and oth er n o n -E u ro p ean civilisations well b efo re the G reco -R o m an era: fo r exam p le, papyri relating to the tim es o f R om an O ccu p atio n o f Egypt refer to the ad vice and o p in io n s sou ght from d octors by judges in reach in g the m ore ap p rop riate judicial
verdicts.
By the tim e that Ju stin ian , Eastern R om an Em peror d ied in N ov em ber 565 A D his fam e as a legislator and c o d ifie r had b e e n w ell e sta b lish e d - his Codex, Institutiones, Digesta a n d N ovellae to g eth er w ith the
Corpus Ju ris Civilis had co n so lid ated the w ork o f his p re d ece sso r T h e o d o siu s (3 4 6 - 395 A D ) w ho after b ein g p ro claim ed e m p e ro r ( w h ile in E ngland), had d o n e his utm ost to structure and catalo g u e Rom an Law; R om e w as in d eed the "caput m undi” in terms o f its co d e s o f law; Justinian in corp o rated into Rom an law m atters relating to a m ed ical im pute into legal m atters
O n ce establish ed as the official chu rch, the Holy See o f R om e particularly, thou gh not exclusively, in m atter in w h ich m orals and law cam e together, had a further m ajor im p act o n m ed ico -leg al m atters. St. A m brose o f Milan, co n sid ered as o n e o f the m ore em in en t “fath ers” o f the early C hurch, had a m ajor in flu en ce on the thoughts o f T h e o d o siu s and later em p erors. In su ch eth ico -leg a l m atters as insanity, prem ature births, virginity, w ou nd ing, im p oten ce, m edical m en w ere ask ed to testify.
T h e C h u rch ’s in flu en ce w as further established w ith the co n v o ca tio n o f the Fourth Lateran C ouncil by P o p e In n o cen t III in 1215 and the birth o f the “S acred ” Inq u isition to co u n te ract heresy and with it the establish m en t o f a new system o f evid en ce gathering and fo ren sic p ro ced u re; this overruled, on p ain o f e x c o m m u n ic a tio n fo r p riests, th e still prevailing a n te ce d e n t system o f trial “by o rd eal” T h e underlying principle w as that the ju dge had to b e absolu tely sure o f the guilt o f the a ccu sed b efo re he sen ten ced him , no m atter how this guilt w as actually establish ed and the co n fessio n o f the accu sed to the crim e elicited .
O th er p o p es co n tin u ed to have a m ajor influence R egiu s P ro fe sso r o f F o re n sic M ed icin e - U niversity o f E d in b u rgh
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in the n o n -e ccle siastical courts. For e x am p le G regory IX (1 1 4 8 - 1 2 4 1 ) p ro m u lg a te d th e C om pilatio D ecretalium w hich co n c e rn e d itself w ith such m atters as nullity o f m arriage, sexu al o ffe n ce s, the u se o f torture and crim es against the p erson . Jo h n XXII (1 3 1 6 -1 3 3 4 ) fro m h is stro n g h o ld in A v ign on p ro n o u n ced o n the criteria by w h ich leprosy should h e d iagnosed . G regory X II in 1582 is cred ited the legal ap horism the physician is to be believed in his own medical field "
T h e se innov ations tran sferred quite im percep tibly from ch u rch and C an on Law to the Civil and Criminal Courts in the legislatu res o f m ost o f the E uropean nations w h ich b o re alle g ian ce to the C hurch o f Rom e and that e n co m p a sse d m ost o f the E u rop ean courts. T h e rem arkab le e x ce p tio n w as that o f G reat Britain w h ere C o m m o n Law and Court system - w ith the e x ce p tio n o f the C o ron er's cou rts - have retained an adversarial rath er than inquisitorial system o f court p ro ced u re exp o rtin g this system to its co lo n ies, p ro tectorates, d e p e n d e n cie s and C om m onw ealth.
In th e la te r M iddle A ges and d u rin g the R enaissance, m ed ical e x p e rtise w as sou ght in the courts as requ ired, and it w as often th o se doctors co n n ecte d w ith the p ap acy at the Curia, or to cardinals and o th er high officials o f the chu rch, w ere d eem ed to b e the p erso n s b est suited to assist the courts. As universities co n so lid ated their status and autonom y, the ap p ren ticesh ip system o f learning m ed icin e w as su p p lem en ted by form al tuition in these seats o f learning. The M edical School o f Salerno in Sou thern Italy h ad b e e n w ell estab lish ed by the 9 th Century; The M edical S chool o f M ontpellier in France had fu n ction ed from 1137 . B o lo g n a had a m edical faculty in 1156 and gradually all the o th er universities in T u scany w ere e n d o w e d sim ilarly. Paris had its sep arate m ed ical faculty by 1273- In G reat Britain m edical facu lties to o k a lon g er period to b e co m e established : O xford had a sm all and indistinguished m edical faculty in 1303 and C am bridge a m edical faculty, o f e v e n lesser international rep u te, in 1350. M ost o f th e se cou rt p hysicians w ere also m onks trained in the cu rrent ce n tres o f m edical e x ce lle n ce th rou gh th e ir a b ility to read Latin; th ey also fu n ction ed as a p o th eca rie s and b loo d -letters.
This tradition ap p ears to have b e e n m aintained till w ell into the sev en tee n th century. Ind eed the sem inal w o rk o n legal m ed icin e, the nine-volu m e
Q uaestiones m edico-legales - w as that w ritten by P ao lo Z acch ias w h o w as th e principal p hysician o f P o p e In n o cen t X and later o f A lexand er VII; this
m agnum opus w as p u blish ed b etw ee n 1621 and
1666
.T his “ad h o c ” arran gem en t o f m ed ical involvem ent w ith the cou rts o f law p ersisted until the various
m ed ical fa cu ltie s a lso started to te a c h M edical Ju risp ru d en ce as a sep arate su b ject. C haussier, a prison d o cto r at D ijon started to teach this su b ject as a sep arate cu rricu lar entry in 1790; this e v en t w as closely fo llo w ed by the estab lish m en t o f chairs in the speciality o f M edical Ju risp ru d e n ce by the U niversities o f P aris (o c c u p ie d b y M a h o n ), o f S trasb o u rg (o c c u p ie d by F o d e re - c lo se ly a sso c ia te d w ith B on ap arte ) and o f M ontpellier, by the b egin n in g o f th e n in e te e n th ce n tu ry . In E d in b u rg h the first P rofessor o f “M edical Ju risp ru d e n ce and M edical P o lic e ” - w ith the latter a sp e ct o f the su b je ct d e v e lo p in g in to P u b lic H ealth M ed icin e - w as estab lish ed by Royal D e cre e in 1807 w ith the su b ject b ein g taught inform ally fo r several years prior to that. B erlin and V ienna also had p ro fesso rs teach in g this speciality at ab ou t the sam e tim e
M edical exp ertise w as also called fo r and firmly estab lish ed as a sin e qua n o n in co n n e ctio n w ith civil m atters su ch as co m p en satio n fo r injuries at w ork, indu strially-acquired d iseases, claim s in relation to in su ran ce p o licies etc.. In d eed in m ost o f Europe this asp ect o f fo ren sic m ed icin e -referred to as "M edicina S o c ia lis ”- h as o fte n b e c o m e o n e o f th e m o re p rom inent asp ects o f the speciality.
This diversity o f interests and cou rt system s, and the au ton om ou s d ev elo p m en t o f m edical curricula o f ea ch university resulted in a very individual and m arkedly disparate te ach in g o f F o ren sic M edicine as an undergradu ate and p ost-grad uate speciality in d iffe ren t co u n trie s an d in d iffe ren t u n iv ersities. Furtherm ore as m ed ical ad v an ces requ ired that the u ndergradu ate m ed ical cu rriculum co v ered new er and m ore directly clin ically-relev an t su b jects, such su b jects as im m u nology, clin ical g en etics, clinical b ioch em istry and m o lecu lar b io lo g y had to find sp a ce in the teach in g p rogram m es. O n e o f the co n se q u e n c e s o f this w as that less and less foren sic m ed icin e w as b ein g taught. T his co u p led w ith the increasing realisation that crim es such as in terrorism , drugs and prostitution do not re sp ect b ou n d aries and the increasing in cid e n ce o f m ultinational disasters led to P ro fesso r D on Luis Frontela Carreras o f Seville, Spain to call to g eth er in 1986 a m eeting o f several w ell establish ed nam es in the fo ren sic m edical field (m ostly p atho lo gists), to discu ss these m atters. A M anifesto w as put to g eth er and signed by the Seville W orking G roup (SEVILLE M A N IFESTO ) on the 6 th Se p te m b e r 1986, and rep resen tatio n s w ere m ade to the E u ro p ean C ouncil to p ersu ad e them to accep t the p rin cip les o f h arm o n isatio n o f p ractice and teach in g in this speciality.
O n e co n c rete result w as this w as the so-called Morris d o cu m en t (D o c .6 3 3 ) w h ich form ed th e basis o f a report from the C om m ittee o f Legal Affairs and
H um an Rights. It w as ad op ted by the Standing C om m ittee on b e h a lf o f the A ssem bly on the 28 th Ju n e 1991 in the Forty - Third Plenary Sessio n o f the C ouncil o f E u ro p e and issu ed as R ecom m en d ation 1159 (1 9 9 1 ) ”on the h arm onisatio n o f autopsy rules “ (se e A p pendix 1).
The Treaty o f the European Union w h ich w as signed in M aastricht on the 7 th February 1992 by the heads o f state and gov ern m en ts o f 12 E uropean nations rep resen tin g 370 m illion p e o p le, has three fu ndam ental a sp ects the estab lish m en t o f U nion Citizenship rights, co -o p e ra tio n in the justice and h o m e affairs, and the introd u ction o f a co m m o n secu rity p o licy . T h e treaty a lso e x p a n d e d the resp onsibilities o f the E u rop ean Court o f Ju stice with an ability to im p o se fines on m e m b er states not abid ing by its rulings. A central p o lice o ffice (E U R O P O L ) w as e sta b lis h e d to deal w ith in te rn a tio n a l drug traffick in g , frau d , "m o n e y lau nd ering”, and o th er seriou s international crim es. A central sch e m e fo r the e v alu atio n o f crim inal investigative w o rk w as e stab lish ed as w ell as crim e prevention program m es, joint training and research in fo re n sic te c h n o lo g y , jo in t crim in al reco rd s d ep artm ents and data bases.
An international organisation know n as TRI'YI (Terrorism , R ad icalism , Extrem ism a n d V iolence In tern ation al) has also b e e n establish ed in 1975 and op erates outw ith the con trol o f the EEA, it is also involved w ith p o licin g co -o p e ratio n . In addition to E u rop ean states o th er cou n tries (su ch as Austria, C an ada, M o ro cco , N orw ay, S w e d e n , USA and Sw itzerland ) attend this organisation as observers.
A cardinal p rin cip le o f the E u ropean Community,
presen t from its very in cep tio n , has alw ays b e e n the free m obility o f lab o u r w ithin its constitu ent cou ntries and this ap p lies to d octo rs as to anybod y else, and thus th ere is great sco p e , and indeed a necessity, for a m ed ical integration w ithin Europe. O n e o f the barriers that has b e e n put forw ard for the slow p ro gress fo r this is a certain d eg ree o f ig n oran ce as to how the E uropean Community, o r the
European E con om ic A rea as it is now know n, obtains its a d v ice o n m e d ica l m atters. The E u ropean Commission (EC ) that acts as the E u ro p ean Civil Service as w ell as its e x e cu tiv e body, deals with supplying this ad vice and drafting p ro p osals for com m unity legislation, w h ich are th en p assed on to the E u ro p ean P arliam ent m ad e up o f m em b ers rep resenting their individual cou n tries ele cte d every five years and are aligned acco rd in g to political affiliation. T h e EC is co m p o se d o f C om m ission ers ap p o in ted by the now 15 m em b ers states and they are b o u n d by o a th to act in d e p e n d e n tly o f g ov ernm ents and only in the interests o f the EEA as a
w h ole. T h e EC is served by 23 d irectorates general, n o n e o f w h om deal d irectly w ith health although individual d irectorates con trib u te to such health- re la ted m atters as re se a rc h a n d so cia l affairs.
D irectorate G en eral III has an Advisory Committee on Medical Training (ACMT)
Another tap root o f the Commission on matters medical is the UEMS (European Union o f Medical Specialists) w hich com p rises o f about 30 m o nosp ecialist s e c tio n s. T h e s e are b a se d on sp ecialities w h ich are officially re co g n ised by at least tw o thirds o f th e m e m b er states. U nfortunately in spite o f very intensive lo bb yin g, Legal M edicine is not constitu ted as a m o n o sp eciality as th ere is no official reco g n itio n by the sp eciality by the appropriate nu m ber o f m em b er states; it only has o b serv e r status in the P ath ology Su b co m m ittee (to g eth er w ith for ex a m p le Cytology and N eu ro p ath ology ).
T h e participation o f the Seville W orking Party in the C o n fe re n ce held in Perugia entitled La m ed icin a legale n ell'Europa C om m u n itaria b e tw e e n the 9-12 th O c to b e r 1991 led to the drafting o f a d ocu m en t con sid erin g undergrad u ate m ed ical tuition in this su b ject. In G erm any the sp eciality o f Legal M edicine is perhap s the strongest in E u ro p e b o th in relation to its a cad em ic and research ou tpu t, its full contribution to the m ed ical cu rricu lum and the strong association w ith s c ie n tific c o lle a g u e s w ith in th e sam e d ep artm ents and institutes o f Legal M ed icine. Thus th rou g h the e ffo rts o f o u r G e rm a n co lle a g u e s, particularly Prof. Dr. Med. B. B riu km an n and Prof. Dr. Med. A. Stak, a m eetin g w as called together, to w h ich all E u ro p e a n U n io n co u n trie s and all signatories to the E u ro p ean F ree T rad e A ssociation w ere invited w ith the individual d eleg ates being nom in ated by their resp ectiv e P rofessio n al B o d ie s or C o u n cils. The E u ro p ean C ouncil fo r Legal Medicine w as thus b orn and o v er the last tw o years the m em b ersh ip has b e e n co n so lid ated to include rep resentativ es from all the cou n tries in the £'£4. O bservers are invited from o th er E u ro p ean cou ntries so that co lle ag u es not in the EEA, and particularly the new er states, are kept ab reast o f d ev elop m en ts.
T h e establish ed aim s o f the ECIM are :
• the h arm onisatio n o f p ractice in relation to such m atters as autopsy, to x ico lo g y , m ass disaster investigation, training and accred itation .
• th e in te g ra tio n o f th e d iffe ren t fo re n sic su b sp ecialties particularly fo ren sic scie n ce and clinical m ed icin e w ith pathology.
• the c lo se r co n tact and in teractio n w ith the legal sp ecialities and specialists.
• international e x ch a n g e s at all levels in relation to training, sp ecialisation and research in the spirit o f the Treaty o f Rom e.
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• the supply o f a w ell-inform ed and authoritative m o u th p ie c e to n a tio n a l an d in tern atio n al organisations and to p o liticians fo r ob tain in g o p in ion s o n m atters relating to legal m edicine. T h ree m ajor d ocu m en ts have b e e n pro d u ced by the ECLM. T h e first w as the re-ed ition and re structuring o f the P eru gia d o cu m en t and it gives the basis for w hat is thou ght to b e the m inim um curriculum o f legal m e d icin e that sh ou ld b e taught to u n dergrad u ates . T h e seco n d d o cu m en t refers to
an elem en tary, c o n c ise bu t co m p reh en siv e autopsy p ro toco l w h ich is co n sid ere d to b e the basis o n w hich all m ed ico -leg al au top sies shou ld b e carried out. The third relate to w hat are gen erally co n sid ered to b e the attributes that w ould b e requ ired o f a sp ecialist in Legal M edicine.
T h e n ext m eeting o f the ECLM is due to b e held in London on th e 9 th D e c e m b e r o f this y ear w h ere n ew er h orizo n s will h op efu lly b e lo o k e d at and m ore integration and harm onisation are ach iev ed .
Appendix 1
COUNCIL OF EUROPE - Recommendation 1159 (1991)
"O n the h arm onisatio n o f autopsy ru les”1. T h e A sse m b ly c o n sid e rs it a n e ce ssa ry practice for au top sies to b e carried out in all Council o f E u rop e m e m b er states establish the cau se o f death for m ed ico -leg al or o th er reaso n s and to establish the identity o f the d eceased .
2. As the m obility o f the p opulation increases throughout E u ro p e and throu ghou t the w orld, the ad option o f uniform gu id elin es o n the w ay autopsies are to b e carried ou t and the w ay autopsy reports are to b e estab lish ed b e c o m e s im perative.
3. This is esp ecially so in the case o f m ass disasters, w h eth er natural o r not, w h ere they m ay be several hundreds o f victim s o f nu m erou s nationalities.
4. M oreover, it is b eliev ed that au top sies should b e carried ou t in all cases o f su sp iciou s deaths or w h ere there are d ou bts as to the cau se and that, if d on e system atically, they m ay m ore easily bring to light illegal ex e cu tio n s and m urders perp etrated by authoritarian states.
5. In te rn a tio n a lly re c o g n ise d and ap p lie d autopsy rules w ould th ere fo re con trib u te to the fight to p rotect hu m an rights, esp ecially such hum an rights as the p rohib ition o f torture and ill-treatm ent, and the right to life. H ere, the A ssem bly w e lco m e s the fact that the E u rop ean C o nvention for the P revention o f T orture and Inhu m an or D egrading T reatm en t or P unishm ent has b e e n ratified by tw enty ou t o f the tw enty-five C ouncil o f E u ro p e m e m b er states.
6. T h e A ssem bly reco m m en d s the follow ing to the C ouncil o f M inisters:
i. P rom ote the ad op tion o f harm onised and internationally re co g n ised rules on the w ay
au top sies are carried out and th e ad op tion o f a standardised m odel fo r au top sies;
ii. Sup port the p ro p osals that states w orld-w ide form ally a cce p t and im plem ent the ob ligation to carry ou t au top sies in all cases o f suspicious deaths;
iii. Invite the m em b er states to apply the In te rp o l g u id e lin e s o n d isa ste r victim identification;
iv. Invite th o se C ouncil o f Europe M em ber states w h ich have not yet d o n e so to ratify the C ouncil o f E u rop e A greem ent o n the T ransfer o f C orpses;
v. Invite the five C ouncil o f E urope m em b er states w h ich have not yet d o n e so to ratify the E u ro p e a n C o n v e n tio n fo r th e P rev e n tio n o f T orture and Inhu m an o r D egrading T reatm ent or Punishm ent;
vi. Draw up international rules to facilitate the form alities in su b p aragrap hs 6 i., ii., iii., iv., and v. from the adm inistrative (transport, crossing o f b ord ers, p o lice, e tc.) or legal points o f view .
Adress C o rresp o n d en ce and reprint requ ests to: Prof. D r.A nthony Busuttil F o ren sic M edicine Unit D ep artm en t o f Pathology T h e University o f Edinburgh M edical B uilding T ev io t P lace Edinburg EH8 9AG England
