Abstract
Introduction
Expert opinions presented in legal proceedings should be scientifically accountable, which is known as evidence-based practice (EBP). Although forensic medical expert opinions ...are essential in legal proceedings, the methods used to formulate them are not always evidence based or based on standard methods. In forensic medicine, EBP has not been explicitly applied, including in Indonesia. One potential approach to formulate evidence-based expert opinions is called INtegration of Forensic Epidemiology and the Rigorous EvaluatioN of Causation Elements (INFERENCE). In addition, there is also no universal guideline for making forensic pathological reports. One prospective guideline is named the Principles of Evidence-based Reporting in FORensic Medicine-Pathology version (PERFORM-P).
Methods
This article describes the validation process of INFERENCE and PERFORM-P in Indonesia. This study uses a mixed method through three interrelated phases, i.e., (1) a cross-sectional survey to determine the characteristics of Indonesian forensic doctors and their current practice, (2) the adaptation and validation process of the two tools through a review by the Indonesian College of Forensic Medicine, and (3) a one-group pre–postintervention study to assess the validity and reliability of forensic medical expert opinions formulated using Indonesian-INFERENCE (i-INFERENCE) and reported using Indonesian-PERFORM-P (i-PERFORM-P).
Results and Discussion
In general, both tools received a positive reception and can potentially be used in the Indonesian setting with some additions/clarifications in the user manuals. Participants envision that both tools will be most useful in complex cases.
Conclusions
By obtaining the i-INFERENCE and the i-PERFORM-P, it is hoped that Indonesian forensic medical doctors are better equipped in analyzing and reporting complex cases, and the implementation of EBP can be improved.
Investigating causation is a primary goal in forensic/legal medicine, aiming to establish the connection between an unlawful/negligent act and an adverse outcome. In malpractice litigation involving ...a healthcare-associated infection due to a failure of infection prevention and control practices, the medicolegal causal analysis needs to quantify the individual causal probabilities to meet the evidentiary requirements of the court. In this paper, we present the investigation of the most probable cause of bacterial endocarditis in a patient who underwent an invasive procedure at a dental/oral surgical practice where an outbreak of bacterial endocarditis had already been identified by the state Department of Health. We assessed the probability that the patient’s endocarditis was part of the outbreak versus that it was an unrelated sporadic infection using the INFERENCE (Integration of Forensic Epidemiology and the Rigorous Evaluation of Causation Elements) approach to medicolegal causation analysis. This paper describes the step-by-step application of the INFERENCE approach to demonstrate its utility in quantifying the probability of causation. The use of INFERENCE provides the court with an evidence-based, transparent, and reliable guide to determine liability, causation, and damages.
The scope, roles, and tasks of forensic medicine and forensic medical experts currently vary widely between countries and legal systems, which has resulted in barriers to organization, standard ...setting, and quality assurance for practice in forensic medicine, including for reporting. The legal fact finder is thus confronted with variability in the quality, structure, and content of forensic medical reports. We sought to define and categorize the scope, methods, and practices that fall under the description of forensic medicine, the various issues encountered in current forensic medical practice, and the potential role of evidence-based practice in forensic medicine. We searched electronic databases and reviewed relevant articles, as well as conducting personal correspondences with forensic medical practitioners around the world, to obtain a description of current forensic medical practice. The terms forensic medicine, legal medicine, medical jurisprudence, medico-legal services, forensic pathology, and clinical forensic medicine are used with mixed interpretations in different countries. The systems and services rendered are not uniform either. The methods used by forensic medical practitioners are not always evidence-based, or based on standardized methods, and vary greatly between experts and centers. There are also no universally accepted guidelines to prepare a standard and admissible report. The lack of a uniform system in forensic medicine creates difficulties in assessing the development and performance of forensic medicine as a distinct discipline. To prepare evidence-based forensic medical reports, generally accepted guidelines are necessary.
A fundamental purpose of forensic medical, or medicolegal, analysis is to provide legal factfinders with an opinion regarding the causal relationship between an alleged unlawful or negligent action ...and a medically observed adverse outcome, which is needed to establish legal liability. At present, there are no universally established standards for medicolegal causal analysis, although several different approaches to causation exist, with varying strengths and weaknesses and degrees of practical utility. These approaches can be categorized as intuitive or probabilistic, which are distributed along a spectrum of increasing case complexity. This paper proposes a systematic approach to evidence-based assessment of causation in forensic medicine, called the INtegration of Forensic Epidemiology and the Rigorous EvaluatioN of Causation Elements (INFERENCE) approach. The INFERENCE approach is an evolution of existing causal analysis methods and consists of a stepwise method of increasing complexity. We aimed to develop a probabilistic causal analysis approach that (1) fits the needs of legal factfinders who require an estimate of the probability of causation, and (2) is still sufficiently straightforward to be applied in real-world forensic medical practice. As the INFERENCE approach is most relevant in complex cases, we also propose a process for selecting the most appropriate causal analysis method for any given case. The goal of this approach is to improve the reproducibility and transparency of causal analyses, which will promote evidence-based practice and quality assurance in forensic medicine, resulting in expert opinions that are reliable and objective in legal proceedings.
A review of causal inference in forensic medicine Meilia, Putri Dianita Ika; Freeman, Michael D.; Herkutanto ...
Forensic science, medicine, and pathology,
06/2020, Volume:
16, Issue:
2
Journal Article
Peer reviewed
Open access
The primary aim of forensic medical analysis is to provide legal factfinders with evidence regarding the causal relationship between an alleged action and a harmful outcome. Despite existing guides ...and manuals, the approach to formulating opinions on medicolegal causal inference used by forensic medical practitioners, and how the strength of the opinion is quantified, is mostly lacking in an evidence-based or systematically reproducible framework. In the present review, we discuss the literature describing existing methods of causal inference in forensic medicine, especially in relation to the formulation of expert opinions in legal proceedings, and their strengths and limitations. Causal inference in forensic medicine is unique and different from the process of establishing a diagnosis in clinical medicine. Because of a lack of tangibility inherent in causal analysis, even the term “cause” can have inconsistent meaning when used by different practitioners examining the same evidence. Currently, there exists no universally applied systematic methodology for formulating and assessing causality in forensic medical expert opinions. Existing approaches to causation in forensic medicine generally fall into two categories: intuitive and probabilistic. The propriety of each approach depends on the individual facts of an investigated injury, disease, or death. We opine that in most forensic medical settings, probabilistic causation is the most suitable for use and readily applicable. Forensic medical practitioners need, however, be aware of the appropriate approach to causation for different types of cases with varying degrees of complexity.
The COVID-19 pandemic has significantly impacted many aspects of life, including death care. International and national protocols have been implemented for the management of the dead. This study aims ...to determine the characteristics of decedents managed according to COVID-19 protocols in Indonesia and the quality of their death certificates. This study uses a descriptive, cross-sectional design. Secondary data of deaths with COVID-19 were taken from hospital death registries, medical records, and death certificates. Data were collected from nine referral hospitals and one funeral home in 6 cities in Indonesia. The majority of the decedents were male, Muslim, with a median age of 57. Most were treated in non-intensive isolation wards, and almost half had known comorbidities. Many were still awaiting the result of their confirmative PCR at the time of death. Almost all were managed compliant with the standard protocol, and most were buried in COVID-only cemeteries. There were still deficiencies in the completeness and accuracy of the death certificates. “COVID-19” was mentioned as a cause of death in only about half of the cases, with a wide variety of terms and spelling. Management of the dead protocols for bodies with COVID-19 can generally be implemented in Indonesia. The quality of the death certificates should, however, be continuously improved.
Pendahuluan: Kurangnya ahli dalam bidang kedokteran forensik di masa depan menjadi masalah serius di hampir seluruh dunia. Di Indonesia, keunikan posisi kedokteran forensik, yaitu di persimpangan ...antara bidang kedokteran dan hukum, menyebabkan peran dokter spesialis forensik masih dapat berkembang luas. Arah perkembangan bidang kedokteran forensik Indonesia di masa depan sangat ditentukan oleh para dokter forensik dan calon dokter forensik itu sendiri. Penelitian ini bertujuan untuk mengetahui motivasi para dokter dalam memilih spesialisasi kedokteran forensik dan pandangan terhadap pekerjaan sebagai dokter forensik. Metode: Penelitian ini bersifat observasional deskriptif potong lintang, menggunakan mixed methods, dengan responden dokter spesialis forensik dan peserta program pendidikan dokter spesialis (PPDS) Forensik di Indonesia. Hasil: penelitian menunjukkan bahwa 83% memilih bidang kedokteran forensik karena minat sendiri dan 51% karena menganggap kedokteran forensik merupakan spesialisasi yang menantang. Tidak adanya beasiswa, kurangnya dukungan instansi dan keluarga, kurangnya jumlah dan variasi kasus di berbagai sentra pendidikan, serta keterbatasan fasilitas pendukung dan pembiayaan layanan kedokteran forensik menjadi hambatan utama bagi para dokter forensik. Kaderisasi dan sosialisasi terkait pentingnya spesialisasi forensik dalam bidang hukum dan kedokteran perlu dilakukan untuk memenuhi kebutuhan dokter spesialis forensik di berbagai daerah di Indonesia. Kesimpulan: Koordinasi yang baik antara ahli forensik, Perhimpunan Dokter Forensik Indonesia (PDFI), organisasi profesi lainnya, dan stake holder terkait sangat dibutuhkan dalam mengatasi berbagai kendala yang muncul sehingga kedokteran forensik di Indonesia semakin berkembang.
Mogok kerja adalah tindakan pekerja secara bersama-sama menghentikan atau memperlambat pekerjaan sebagai akibat gagalnya perundingan atas tuntutan atau pelaksanaan hak normatif. Namun, profesi dokter ...dan tenaga kesehatan lainnya merupakan profesi yang luhur, yang memiliki kewajiban moral yang lebih “tinggi”. Paradigma populer di masyarakat adalah “Dokter tidak boleh mogok melayani pasien karena menyangkut jiwa manusia”. Aksi dokter mogok sesungguhnya melanggar berbagai prinsip dan hukum, termasuk kode etik dan sumpah Dokter. Kepentingan pasien (dan masyarakat) semestinya didahulukan dibandingkan kepentingan pribadi atau golongan. Selaku kaum intelektual, dokter seharusnya merasa memiliki bargaining power yang cukup sehingga tidak perlu mengambil jalan mogok kerja untuk menyampaikan aspirasinya. Jika, dan hanya jika, semua strategi musyawarah telah dilaksanakan dan gagal, maka mogok kerja mungkin dapat dipertimbangkan dengan ketentuan semua kasus gawat darurat tetap harus ditangani, mogok kerja bertujuan untuk memperjuangkan kepentingan pasien (bukan kepentingan pribadi atau golongan) sebagai tujuan akhirnya, dan semua dokter yang berpartisipasi yakin secara moral bahwa memang tidak ada jalan lain untuk memperjuangkan kepentingan pasien tersebut.
Sikap dan perilaku pasien terhadap berita buruk, misalnya diagnosis penyakit terminal ataupun kondisi medis buruk lainnya, harus ditangani secara khusus. Di balik kewajiban dokter untuk bersikap ...jujur dan mengedepankan autonomy pasien, prinsip etik beneficencedan non-maleficence menjadi pertimbangan dalam penahanan sebagian atau seluruh informasi yang dapat melemahkan psikis atau sik pasien. Selain itu, budaya patrilineal dan matrilineal di Indonesia yang masih kental juga mempengaruhi keluarga pasien saat turut serta membuat keputusan atas kondisi medis pasien. Prima facie dalam masalah ini perlu ditinjau dengan mempertimbangkan faktor budaya, kondisi sik dan psikis pasien, serta Kode Etik Kedokteran Indonesia (KODEKI) yang menjadi pilar dari pertimbangan etik kedokteran di Indonesia.
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