- Email: [email protected]
Two regards on forensic expertises: Crisis of migrants and autopsies
Ethics, Medicine and Public Health (2016) 2, 156—158
Available online at
ScienceDirect www.sciencedirect.com
SYNOPSIS Two regards on forensic expertises: Crisis of migrants and autopsies Deux angles sur les expertises médico-légales : crise des migrants et autopsies Necessity of social anthropology collaboration during forensic expertises Recent bio-medical publications have pointed the fact that forensic practitioners have a key role to play at the occasion of the global management of the Near-East migrants crisis. First, this is from a global health point of view (mainly with infectious diseases problems) [1]. But a more specific forensic problematic arises, with the necessity of identification process for both living and dead individuals [2]. But, can forensic medicine work effectively alone during such procedures? As a matter of fact, a few months ago, a medical and anthropological consultation was put in place in a public hospital in western Paris (CASH de Nanterre, France); in interviews of 30 minutes to an hour, migrants seeking refugee status were subjected to a forensic expertise, i.e. an exhaustive description and interpretation of traumatic injuries acquired in their country of origin. This observation of injuries on migrants allows differentiating the ‘‘economic migrants’’ from subject asking to benefit from a political refugee status and/or religious (for whom the care is under the authority of the Human Right Protection). Furthermore, as recently stressed by the COP 21 in Paris, due to climate change there will soon be added to the two previous categories the environmental migrant and naturalization, the latest depending on the certificate resulting from this expertise. During this specialized forensic consultation, a dual outlook of medicine and anthropology is necessary. A differential diagnosis that would not be clear to other specialists can then be established from those two specialities. To help illustrate the value of multidisciplinary knowledge during interviews, below are 3 short examples of expertises: first, a 31-year-old Eritrean patient presenting hypertrophic scars related to the use of suction in a traditional medicine context, initially thought to be lesions due to repeated hits from the end of a Kalashnikov. Second, a 34-year-old Somalian subject presenting ritual face scarifications and lesions related to traditional medicine context (torso, limbs, knees), initially thought to be wounds induced by torture with a knife.
Figure 1. Palmar view of all finger pulps showing almost complete loss of fingerprints. Vue palmaire de la chair des doigts montrant une perte presque complète des empreintes digitales.
Lastly, a 30-year-old man, asylum seeker of Syrian origin, presenting for the management of injuries related to torture in his home country [3]. Many old scars were highlighted in the trunk and four limbs, consecutive to blunt force trauma and cigarette skin and mucous burning. On both hands, at the level of the ten finger pulps, we observed an almost complete loss of fingerprints (Fig. 1). The patient first invoked a result of prolonged contact with solvents, while working in the oil industry during a stop in Libya. Then he explained to have deliberately burned the fingertips with sulfuric acid to prevent its inclusion into a fingerprint database in the Southern European countries (Italy, Greece), preferring seeking refugee status in Northern Europe countries (France, Italy, Germany, United Kingdom) where the database system is different. From a clinical point of view, such acid burned fingers present as irregular and lacquered appearance loss fingerprints [4], strongly different from chemotherapy related fingerprints erasing in a context of hand foot syndrome [5,6]. Such lesions of self-mutilation may dramatically increase with the current crisis of migrants of Near Eastern origin. It further justifies, for some Western countries, the use of other types of anthropomorphic database (plantar fingerprint or finger), otherwise genetics [7]. . . even if economical and/or ethical limits may appear. As we can see, an expertise as a simple description and/or record of the traumatic lesions is not sufficient;
Synopsis it has to be accompanied by the meaning those lesions have, therefore complemented by a qualification or interpretation for which knowledge and experience in human science is mandatory. The main concern is practices problematization, medicine being at the crossroad of ethical and scientific norms and, in the present case, politic and legal norms. This leads to the question, in what way do these norms require cross-disciplinary knowledge, interdisciplinarity, and knowledge rooted in fundamental and human science? The present politics of massive reception of migrants coming from the Middle East makes the integration of social and human sciences, particularly anthropology, a necessity in the medicine today. In fact, the necessity to respect justice has to be part of the basic qualifications of a clinician confronted to such migratory movements, particularly through the observation of injuries but also through the ability to objectively interpret such lesions/injuries. For the latest analysis, not all the humanists’ fields carry the same sense and significance: it is not philosophy that can help, but rather signifier observation, including physical, when integrated to a specific meaning (contextualization) [8]. We are now past the pluricultural society and into a multicultural society (melting pot) with beliefs and rituals different from the occidental referential [9]. In front of a suffering body, we can then ask ourselves the question of translation: how to not betray what we are translating? Beyond anthropological or legalmedicine questions, this is a semiotic problem [10] or of reflective philosophy whom, beyond the ‘‘simple’’ words, touches phenomenology with a real cultural exactingness. In his practice, the doctor has for instance to distinguish what is ‘‘ritual’’ (culture, fate) from what is ‘‘togetherness’’ (secularism). The physician has to on one hand, acquire the knowledge related to the history of the population he is confronted to, and on the other hand, not necessarily adhere to the ideologies and past historical facts that contributed to their evolution. Knowledge is not belief. Nonetheless, to not stigmatize the migrants and look beyond appearances (especially what is shown in the media), anthropology (physical and social) seems indispensable to the best practice of medical expertises. Doctors are they afraid of autopsies? In a recent article in the Lancet, Turnbull et al. [11] presented a realist but catastrophic picture on the autopsy’s frequency downfall in occidental countries: autopsy rates were of 25% in the UK 30 years ago, yet the rate was 0.5% in 2013 (this substantial decline being noted throughout Europe, USA, and beyond). . . This state of affair is also seen in underdeveloped countries such as in SubSaharan Africa; where other priorities exist, beginning with the fight against infectious diseases and malnutrition/under nutrition [12]. Nevertheless, Turnbull et al. underestimate the professional’s lack of interest regarding the autopsy’s practice, seen as a waste of time and not an economic priority, or even as archaism [13]. The international development of bioethics laws has also played a major role in this decrease
157 of autopsies frequency caused by the time consuming administrative procedure requested prior to the actual act of the autopsy. Finally, the fear that diagnosis or therapeutic errors could be discovered during the autopsy, occasioning complaints or forensic procedures against health care providers, also has to be taken into account [14]. Beyond this remark on an autopsy’s diagnosis, there is a substantive inquiry questioning anatomical dissection during medical education: is it essential to see a dead body to be a good doctor? Are new technologies’ to learn body anatomy an effective substitute? [15]. Are respect of beliefs and religious oppositions legitimate concerns in the face of this rationally indispensable medical act? Are new generation of medical students more afraid of death than the others? Did they choose this speciality to better fight and understand death? In their regular practice, doctors seem to continuously live anticipating their own death. Traditionally, it is the doctors that close the eyes of the dead, but we are forgetting that in fact, it is the dead that are opening the eyes of the livings, starting with those of the doctors. It is for the living that autopsies are done, the dead bequeathing their truth to the common good, as a beneficial mission. Disclosure of interest The authors declare that they have no competing interest. References [1] Hargreaves S. Europe’s migrants face unacceptable humanitarian situation. Lancet Infect Dis 2016;16(1):27—8. [2] Cattaneo C, Tidball Binz M, Penados L, prieto J, Finegan O, Grandi M. The forgotten tragedy of unidentified dead in the Mediterranean. Forensic Sci Int 2015;250:e1—2. [3] Ahsan S. Providing medical relief in Syria’s conflict. Lancet 2013;381:523—4. [4] Fracasso T, Pfeiffer H, Pellerin P, Karger B. The morphology of cutaneous burn injuries and the type of heat application. Forensic Sci Int 2009;187:81—6. [5] Chavarri-Guerra Y, Soto-Perez-de-Celis E. Loss of fingerprints. NEJM 2015;372:e22. [6] Rovere RK, De Lima AS. Forbidden to drive. A new chemotherapy side effect. Klin Onkol 2015;28:370—2. [7] Milot E, Lecomte MM, Germain H, Crispino F. The National DNA data bank of Canada: a Quebecer perspective. Front Genet 2013;4:249. [8] Morin E. Penser global. L’humain et son univers. Paris: Robert Laffont; 2015. [9] Lough BJ, Sherraden MS, McBride AM, Xiang X. The impact of international service on the development of volunteers’ intercultural relations. Soc Sci Res 2014;46:48—58. [10] Eco U. A theory of semiotics. Indiana University Press; 1976. [11] Turnbull A, Martin J, Osborn M. The death of autopsy? Lancet 2015;386:2141. [12] Charlier P, Brun L, Hervé C. Medical students from Parakou (Benin) and West-African traditional beliefs on death and cadavers. Afr Health Sci 2012;12:443—5. [13] Xiao J, Krueger GR, Buja LM, Covinsky M. The impact of declining clinical autopsy: need for revised healthcare policy. Am J Med Sci 2009;337:41—6. [14] Scottolini AG, Weinstein SR. The autopsy in clinical quality control. JAMA 1983;250:1192—4. [15] Ruder TD, Flach PM, Thali MJ. Virtual autopsy. Forensic Sci Med Pathol 2013;9:435—6.
158
Synopsis P. Charlier a,b,∗,c , C. Dagenais-Everell d a
CASH, 92000 Nanterre, France b EA4569, Laboratory of Forensic Medicine and Medical Ethics, Paris-Descartes University, 45, rue des Saints-Pères, 75006 Paris, France c Section of Medical and Forensic Anthropology, UFR of Health Sciences (UVSQ), 78180 Montigny-Le-Bretonneux, France d McGill University, QC H3A 0G4 Montreal, Canada
∗ Corresponding
author.
E-mail address: [email protected] (P. Charlier) Received 12 December 2015; accepted 10 January 2016 Available online 20 February 2016 http://dx.doi.org/10.1016/j.jemep.2016.01.017
Available online at
ScienceDirect www.sciencedirect.com
SYNOPSIS Two regards on forensic expertises: Crisis of migrants and autopsies Deux angles sur les expertises médico-légales : crise des migrants et autopsies Necessity of social anthropology collaboration during forensic expertises Recent bio-medical publications have pointed the fact that forensic practitioners have a key role to play at the occasion of the global management of the Near-East migrants crisis. First, this is from a global health point of view (mainly with infectious diseases problems) [1]. But a more specific forensic problematic arises, with the necessity of identification process for both living and dead individuals [2]. But, can forensic medicine work effectively alone during such procedures? As a matter of fact, a few months ago, a medical and anthropological consultation was put in place in a public hospital in western Paris (CASH de Nanterre, France); in interviews of 30 minutes to an hour, migrants seeking refugee status were subjected to a forensic expertise, i.e. an exhaustive description and interpretation of traumatic injuries acquired in their country of origin. This observation of injuries on migrants allows differentiating the ‘‘economic migrants’’ from subject asking to benefit from a political refugee status and/or religious (for whom the care is under the authority of the Human Right Protection). Furthermore, as recently stressed by the COP 21 in Paris, due to climate change there will soon be added to the two previous categories the environmental migrant and naturalization, the latest depending on the certificate resulting from this expertise. During this specialized forensic consultation, a dual outlook of medicine and anthropology is necessary. A differential diagnosis that would not be clear to other specialists can then be established from those two specialities. To help illustrate the value of multidisciplinary knowledge during interviews, below are 3 short examples of expertises: first, a 31-year-old Eritrean patient presenting hypertrophic scars related to the use of suction in a traditional medicine context, initially thought to be lesions due to repeated hits from the end of a Kalashnikov. Second, a 34-year-old Somalian subject presenting ritual face scarifications and lesions related to traditional medicine context (torso, limbs, knees), initially thought to be wounds induced by torture with a knife.
Figure 1. Palmar view of all finger pulps showing almost complete loss of fingerprints. Vue palmaire de la chair des doigts montrant une perte presque complète des empreintes digitales.
Lastly, a 30-year-old man, asylum seeker of Syrian origin, presenting for the management of injuries related to torture in his home country [3]. Many old scars were highlighted in the trunk and four limbs, consecutive to blunt force trauma and cigarette skin and mucous burning. On both hands, at the level of the ten finger pulps, we observed an almost complete loss of fingerprints (Fig. 1). The patient first invoked a result of prolonged contact with solvents, while working in the oil industry during a stop in Libya. Then he explained to have deliberately burned the fingertips with sulfuric acid to prevent its inclusion into a fingerprint database in the Southern European countries (Italy, Greece), preferring seeking refugee status in Northern Europe countries (France, Italy, Germany, United Kingdom) where the database system is different. From a clinical point of view, such acid burned fingers present as irregular and lacquered appearance loss fingerprints [4], strongly different from chemotherapy related fingerprints erasing in a context of hand foot syndrome [5,6]. Such lesions of self-mutilation may dramatically increase with the current crisis of migrants of Near Eastern origin. It further justifies, for some Western countries, the use of other types of anthropomorphic database (plantar fingerprint or finger), otherwise genetics [7]. . . even if economical and/or ethical limits may appear. As we can see, an expertise as a simple description and/or record of the traumatic lesions is not sufficient;
Synopsis it has to be accompanied by the meaning those lesions have, therefore complemented by a qualification or interpretation for which knowledge and experience in human science is mandatory. The main concern is practices problematization, medicine being at the crossroad of ethical and scientific norms and, in the present case, politic and legal norms. This leads to the question, in what way do these norms require cross-disciplinary knowledge, interdisciplinarity, and knowledge rooted in fundamental and human science? The present politics of massive reception of migrants coming from the Middle East makes the integration of social and human sciences, particularly anthropology, a necessity in the medicine today. In fact, the necessity to respect justice has to be part of the basic qualifications of a clinician confronted to such migratory movements, particularly through the observation of injuries but also through the ability to objectively interpret such lesions/injuries. For the latest analysis, not all the humanists’ fields carry the same sense and significance: it is not philosophy that can help, but rather signifier observation, including physical, when integrated to a specific meaning (contextualization) [8]. We are now past the pluricultural society and into a multicultural society (melting pot) with beliefs and rituals different from the occidental referential [9]. In front of a suffering body, we can then ask ourselves the question of translation: how to not betray what we are translating? Beyond anthropological or legalmedicine questions, this is a semiotic problem [10] or of reflective philosophy whom, beyond the ‘‘simple’’ words, touches phenomenology with a real cultural exactingness. In his practice, the doctor has for instance to distinguish what is ‘‘ritual’’ (culture, fate) from what is ‘‘togetherness’’ (secularism). The physician has to on one hand, acquire the knowledge related to the history of the population he is confronted to, and on the other hand, not necessarily adhere to the ideologies and past historical facts that contributed to their evolution. Knowledge is not belief. Nonetheless, to not stigmatize the migrants and look beyond appearances (especially what is shown in the media), anthropology (physical and social) seems indispensable to the best practice of medical expertises. Doctors are they afraid of autopsies? In a recent article in the Lancet, Turnbull et al. [11] presented a realist but catastrophic picture on the autopsy’s frequency downfall in occidental countries: autopsy rates were of 25% in the UK 30 years ago, yet the rate was 0.5% in 2013 (this substantial decline being noted throughout Europe, USA, and beyond). . . This state of affair is also seen in underdeveloped countries such as in SubSaharan Africa; where other priorities exist, beginning with the fight against infectious diseases and malnutrition/under nutrition [12]. Nevertheless, Turnbull et al. underestimate the professional’s lack of interest regarding the autopsy’s practice, seen as a waste of time and not an economic priority, or even as archaism [13]. The international development of bioethics laws has also played a major role in this decrease
157 of autopsies frequency caused by the time consuming administrative procedure requested prior to the actual act of the autopsy. Finally, the fear that diagnosis or therapeutic errors could be discovered during the autopsy, occasioning complaints or forensic procedures against health care providers, also has to be taken into account [14]. Beyond this remark on an autopsy’s diagnosis, there is a substantive inquiry questioning anatomical dissection during medical education: is it essential to see a dead body to be a good doctor? Are new technologies’ to learn body anatomy an effective substitute? [15]. Are respect of beliefs and religious oppositions legitimate concerns in the face of this rationally indispensable medical act? Are new generation of medical students more afraid of death than the others? Did they choose this speciality to better fight and understand death? In their regular practice, doctors seem to continuously live anticipating their own death. Traditionally, it is the doctors that close the eyes of the dead, but we are forgetting that in fact, it is the dead that are opening the eyes of the livings, starting with those of the doctors. It is for the living that autopsies are done, the dead bequeathing their truth to the common good, as a beneficial mission. Disclosure of interest The authors declare that they have no competing interest. References [1] Hargreaves S. Europe’s migrants face unacceptable humanitarian situation. Lancet Infect Dis 2016;16(1):27—8. [2] Cattaneo C, Tidball Binz M, Penados L, prieto J, Finegan O, Grandi M. The forgotten tragedy of unidentified dead in the Mediterranean. Forensic Sci Int 2015;250:e1—2. [3] Ahsan S. Providing medical relief in Syria’s conflict. Lancet 2013;381:523—4. [4] Fracasso T, Pfeiffer H, Pellerin P, Karger B. The morphology of cutaneous burn injuries and the type of heat application. Forensic Sci Int 2009;187:81—6. [5] Chavarri-Guerra Y, Soto-Perez-de-Celis E. Loss of fingerprints. NEJM 2015;372:e22. [6] Rovere RK, De Lima AS. Forbidden to drive. A new chemotherapy side effect. Klin Onkol 2015;28:370—2. [7] Milot E, Lecomte MM, Germain H, Crispino F. The National DNA data bank of Canada: a Quebecer perspective. Front Genet 2013;4:249. [8] Morin E. Penser global. L’humain et son univers. Paris: Robert Laffont; 2015. [9] Lough BJ, Sherraden MS, McBride AM, Xiang X. The impact of international service on the development of volunteers’ intercultural relations. Soc Sci Res 2014;46:48—58. [10] Eco U. A theory of semiotics. Indiana University Press; 1976. [11] Turnbull A, Martin J, Osborn M. The death of autopsy? Lancet 2015;386:2141. [12] Charlier P, Brun L, Hervé C. Medical students from Parakou (Benin) and West-African traditional beliefs on death and cadavers. Afr Health Sci 2012;12:443—5. [13] Xiao J, Krueger GR, Buja LM, Covinsky M. The impact of declining clinical autopsy: need for revised healthcare policy. Am J Med Sci 2009;337:41—6. [14] Scottolini AG, Weinstein SR. The autopsy in clinical quality control. JAMA 1983;250:1192—4. [15] Ruder TD, Flach PM, Thali MJ. Virtual autopsy. Forensic Sci Med Pathol 2013;9:435—6.
158
Synopsis P. Charlier a,b,∗,c , C. Dagenais-Everell d a
CASH, 92000 Nanterre, France b EA4569, Laboratory of Forensic Medicine and Medical Ethics, Paris-Descartes University, 45, rue des Saints-Pères, 75006 Paris, France c Section of Medical and Forensic Anthropology, UFR of Health Sciences (UVSQ), 78180 Montigny-Le-Bretonneux, France d McGill University, QC H3A 0G4 Montreal, Canada
∗ Corresponding
author.
E-mail address: [email protected] (P. Charlier) Received 12 December 2015; accepted 10 January 2016 Available online 20 February 2016 http://dx.doi.org/10.1016/j.jemep.2016.01.017