The field of medical practice has evolved throughout the course of time as with the rapid developments. Thus, numerous ethical and legal challenges have arisen in the professional practice amidst all these developments.
Medico-legal cases (MLCs) are an integral part of medical practice that is frequently encountered by Medical Officers (MO). In the Civil as well as in the Armed Forces, the rate of MLCs is increasing. Proper handling and accurate documentation of these cases is of utmost importance to stray from legal complications and to ensure that the Next of Kin (NOK) get the entitled benefits. There are certain medico-legal issues which should be handled by every medical officers working in hospitals /non-medical units in accordance with the law of the land and directives issued by service headquarters. The aim of this article is to render general guidelines for Medical Officers (MO) of Armed Forces Medical Services (AFMS) while dealing with commonly encountered situations which fall within the medico-legal domain. These legal procedures vary state-wise as the law and order is a state subject. Thus, the Medical officers (MO) should be aware of these procedures in the particular state in which they are serving.
Legal issues in medical practice
A medico-legal issue comprises of injury or ailment where the attending physician after taking medical history and performing clinical examination
- considers that investigations by law enforcement agencies are warranted to ascertain circumstances and
- fix responsibility regarding the said injury according to the law.
Labelling a case under medico legal issue
(a) A case can be represented as a MLC by the Casualty medical officer/MO in charge of MI Room/ RMO/Duty Medical Officer (DMO)/MO in charge ward who is handling the case.
(b) Sound professional judgement, after a detailed history taking and thorough clinical examination should be done before the decision to label a case as MLC.
Examples of medico legal issues
An efficient professional judgement is important to decide the cases as MLCs. Many of these are shown as follows:
(a) Assault and battery, like domestic violence and child abuse
(b) Accidents like Road Traffic Accidents (RTA), industrial accidents etc.
(c) Trauma cases with suspicion of foul play
(d) Poisoning, Alcohol Intoxication
(e) Electrical injuries
(f) Un- diagnosed coma
(g) Burns and Scalds
(h) Chemical injuries
(j) Sexual Offences
(k) Criminal miscarriages
(l) Attempted suicide
(m) Asphyxia cases as a consequence of hanging, strangulation, drowning, suffocation etc.
(n) Unnatural deaths
(o) Death in the operation theatre
(p) Custodial deaths
(q) Death due to Snake Bite or Animal Bite
(r) Drug overdose
(s) Fire Arm injuries
(t) Drug abuse
(u) Dead brought to Accident and Emergency Dept /MI Room (Found dead) and deaths occurring within 24 hours of hospitalization without establishment of a diagnosis.
General Guidelines for dealing with Medico-legal cases
- In emergencies, firstly resuscitation and stabilization of the patient should be carried out and then the medico-legal formalities thereon. In all emergencies, the consent for treatment is implied.
- In any AFMS Health Care Establishment, emergency medical care will be conducted irrespective of their entitlement. Howsoever after the initial stabilization in non-entitled cases, patient may be transferred to the nearest Government hospital, and if imperative by service ambulance.
- Even if the episode did not happen recently, trauma cases will be marked as MLCs, if there is a suspicion of foul play. All injury cases to service personnel should be reported on IAFY 2006 (Injury Report) with the suitable classification for instance; trivial, moderately severe or severe.
- The personal particulars, identification marks, finger prints and particulars of the person accompanying the patient will be documented in the MLC register maintained by all MI Rooms and hospitals.
- The medico-legal documents should be preferably written in ball-point pen, avoiding overwriting and constructed in duplicate, with utmost care giving all necessary attributes. In case of any overwriting or correction, authentication with full signature and stamp of the MO should be done. Use of abbreviations should be refrained.
- As soon as a MLC is admitted the Commandant/ Commanding Officer (CO), Senior Registrar and equivalent in other hospitals should be immediately informed. A DMO report book maintained contain the particulars of the patient and a short summary of the case.
- Patient will be placed on SIL / DIL, when needed.
- If the address is available, NOK will be informed.
- Medico-legal documents should be thorough, complete and assessed as confidential records stored under safe custody to avoid interference. The case sheets, X-rays and investigation reports will be maintained diligently in the medical record section which should be given to the concerned authorities (Police Investigating Officer / Court / Court of Inquiry) as and when needed
- Due to the medico-legal nature of the case, prompt attention, correct triage and safe transfer of patient from one facility to another should be carried out in all cases and not deferred.
- In cases of bones / joints injuries, the perspective on severity of injuries should be given after the X-ray reports are acquired.
- The samples and specimens gathered for medico- legal purposes will be properly sealed, labeled and handed over to the investigating officer elaborated by the police. The Commandant/CO of the hospital will make sure that documents are kept in the custody of an assigned officer till the case is ultimately decided or cleared by police and judicial authorities.
- Evidence required to be preserved is related to the nature of a case. The below artefacts should be preserved in sealed envelopes in injury cases:
1) Each piece of evidence should be encircled and numbered with matching description in the case sheet for the cases of multiple tears, cuts or holes etc.
2) Clothing worn by patient showing evidence of injury like tears, bullet holes, cuts, blood stains etc.
3) Bullets retrieved from a body should be marked by etching an initial or a mark on the bottom prior preservation.
4) To establish the chain of custody in a court of law, all evidence collected should be introduced in medico-legal documents.
- The magistrate will be informed in cases where the patient desires to make a dying statement. The MO may note down the dying declaration himself in presence of two independent witnesses whose signatures are also attached in document when the Magistrate is unable to come and record a statement or where the MO thinks that he might not be able to reach the patient in time.
Ways to resolve ethical problems/ legal issues in critical care setting
- Assemble the relevant facts and spot the decision makers and stake holders
- Recognize the ethical problems. Incorporate others in the process and use consultation resources as appropriate
- Inspect the problem using ethical guidance and resources
- Deliberate about the action substitutes in light of guidance