Forensic Medicine vs Forensic Pathology

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Forensic Medicine vs Forensic Pathology

PM&DC decision will promote the interests of private medical

Institutions rather than the interests of the public at large

Dr. Muhammad Maqsood

The subject of Forensic Medicine and Toxicology is once again for the umptieth time being challenged and an attempt is being made to undermine not only the subject but the legal framework of the country. Unlike any other subject taught in the medical curriculum, the teaching of Forensic medicine and its practice in the service of the public is dependent on the laws framed by the state. It is thus also referred to as state medicine. Ever since the private sector became involved in medical education in Pakistan, attempts have repeatedly been made to do away with the subject on different pretexts. Instead of getting involved in the establishment of this specialty in their institutions which is a pure public service to the common man, they have concentrated only on financially rewarding domains. It is pertinent to mention that across the border, a country that has a similar legal framework, the private medical institutions are involved in providing forensic medicine services to the public not only in the form of clinical forensic medicine but also in the conduction of autopsies at their institutions. In addition forensic science services are also being established thus contributing to public welfare.

In contrast no private medical institution in this country has even attempted to venture into this public service and have instead opted to try to jeopardize the subject trying to move it from the undergraduate to the postgraduate level or entirely doing away with it. This great urge has exposed the total lack of understanding of the history of development of the specialty in different parts of the world by the people who are trying to make such attempts.

The latest attempt has been made by the executive committee of the Pakistan Medical and Dental Council attempting to change its name from Forensic Medicine and Toxicology to Forensic Pathology in its meeting held in Karachi on 24th March 2015. At the present time the very legality of the PMDC and its executive committee is under question and even if accepted, the validity of the said meeting vis-a vis its quorum is also debatable. In spite of this; attempts at basic structural decisions are being made in an attempt to please the people who now control the council which has been relegated to a body watching commercial interests of the few rather than the interests of the public at large. In prudent bodies, such suggestions are first put before the professionals belonging to the subject for their views and suggestions for improvement, No such iota of an attempt was made while moving in the said direction.

Forensic Pathology is a nomenclature used in countries where the law of the land demands an autopsy to be conducted in any case where the last attending physician is unable to certify the cause of death. Therefore in these countries around 90% of the autopsies are conducted in cases of sudden natural deaths. In such cases the decision of cause of death is based on histopathology and therefore this change in nomenclature and this shift into the paradigm of Pathology. But let us be very clear that this change occurred after a change in the law of the states making it mandatory for autopsies to be conducted in sudden natural deaths. In all other countries in which autopsies are conducted in only deaths that are unnatural or due to violence, the nomenclature of forensic medicine holds true. It is also important to understand that a major public service by experts in forensic medicine is clinical forensic medicine or medico-legal certifications in cases of physical, sexual or toxic assaults, age and fitness certificates etc. This is an area in which countries that shifted to forensic pathology have been struggling for the last many decades. This is an area in which countries like Pakistan have an edge. Even if we accept that the quality of forensic medicine services in Pakistan need improvement; we should keep in mind that this specialty was established about half a century later than other specialties. In the past thirty years or so much has been done and, It can be very confidently said that the standards in the centers established in Academic institutions are comparable to other parts of the world. The problems still exist in peripheral health establishments but as more and more people are trained, it is an endeavor of the specialty to ultimately have all medico-legal work conducted by duly qualified and trained specialists. Its progress has been hampered by the uncertainty created every now and then by the regulatory body with people becoming reluctant to join one of the toughest of areas where opinions given have be defended in the court of law and are subject to challenge by an opposing counsel determined to find any lacuna in the reports issued. No other specialty has to undergo such microscopic scrutiny of its opinions.

It is also worth mentioning that there is hardly any qualified Forensic Pathologist in the country and training programs in Forensic Pathology are nonexistent. Neither do postgraduate programs in pathology have any exposure to autopsy work, medical or medico-legal. So instead of recognizing a subject that has become fairly established and is on its path to improving the system at par with international standards; attempts are being made to dismantle the system and move in a direction that is disconnected with the Law and culture of the society we live in. It reminds one of the saying “ Kawa Chala Hans Ki Chaal, Apni Chaal Bhi Bhool Gya.”

In view of the above facts, the National Assembly, Senate of Pakistan, the Honorable Supreme Court and High Courts have time and again issued directives to give the discipline its due status. Contrary to what is being attempted, the need of the day is to enhance teaching and training at the undergraduate level till such time that all posts where clinical forensic medicine or medico-legal autopsies are being conducted are manned by appropriately qualified and trained specialists.

The question is would anyone of the people taking this decision be ready to have an autopsy conducted on a near one or themselves if death occurs suddenly due to a natural cause just to get a report of coronary artery disease if death occurred due to ventricular fibrillation. The answer in case of nearly every citizen of this country will be in the negative.

Moreover about 2000 autopsies per million populations are carried out with the system being proposed. This is where the healthcare system is much more advanced compared to our country and the probability of unattended deaths is uncommon. These numbers would be manifold in our country where the regulatory body has as yet been unable to implement the certification of cause of death as envisaged by the world health organization. This would be a prerequisite before a forensic pathologist comes into play. With a population close to 200 million about 400,000 to 800,000 autopsies or even more would be required to be performed every year. With guidelines of about 300 autopsies per annum per forensic pathologist we would need 2000-3000 qualified and appropriately trained forensic pathologists in Pakistan to handle this work alone. How many exist at present is, none at all.

Given the above facts it seems the decisions are ill conceived, poorly thought out, whimsical and being made with no connection to the Law, culture or realities of the culture we live in or the society we have wowed to serve.