Is the French criminal psychiatric assessment in crisis?

The criminal psychiatric assessment in France seems to be facing growing criticism related to disagreements between experts and, on the other hand, a lack of interest of psychiatrists for the assessment. We start by explaining the current framework of the criminal psychiatric assessment in France, which differs from the assessment used in English-speaking countries, where Roman law applies. Then, we will describe the disagreements through a literature review and two clinical vignettes. Finally, we will try to understand the causes of discrepancies between experts and the reasons for a supposed lack of interest of the psychiatrists for the expertise. For this, we conducted a survey among the psychiatric experts. We individually questioned experts on the discrepancies and on their awareness of the expertise. We found that 75% of the experts we surveyed had already faced the divergent opinion of a colleague. In addition, the experts were divided on their conclusions related to the fictional scenario we gave them for an a priori assessment (a person with schizophrenia who was accused of murder), particularly in the specific contexts that we submitted to them. The main cause of disagreement between experts was the various schools of thought that influence the psychiatric experts in the forensic discussion and, therefore, the conclusions of a case. Moreover, the experts believed that the decrease in the number of psychiatric experts could be attributed to the adverse financial situation of the assessment, the considerable workload required, and the extensive responsibility that falls on the expert. Calling on a team of forensic experts to perform assessments seems to be the first solution to this crisis. Furthermore, if the experts were better compensated for the assessments, more people would want to undertake this work.

[Differences in psychiatric expertise of responsibility: Assessment and initial hypotheses through a review of literature]. / Divergences dans l'expertise psychiatrique de responsabilité : bilan et premières hypothèses à travers une revue de la littérature.

INTRODUCTION: Forensic psychiatric assessment regarding liability ensures a balance between justice and psychiatry. In France, criminal assessment is not contradictory. The psychiatric expert is commissioned by judges to determine whether or not the accused has a mental disorder and specify whether it affects discernment and control of actions at the time of offense. Its mission focuses on the mental element required to constitute an offense, and is structured around Article 122-1 of the Criminal Code. This article, composed of two paragraphs, distinguishes the framework of the abolition of discernment ­ a cause of non-imputability and therefore of a statement of lack of criminal responsibility due to mental disorder ­ and the framework of the alteration of discernment. Nowadays expertise seems to meet discomfort, with criticism focusing on possible differences among psychiatric experts, without specific studies having been conducted to confirm it. OBJECTIVES: Our objective was to identify the main points of disagreement between psychiatric experts and to propose explicative hypotheses. MATERIALS AND METHODS: For this, we carried out a literature review on PubMed, Science Direct and Cairn, and studied the report of the 2007 public hearing on forensic psychiatric assessment with contributions from different authors. The keywords were: forensic psychiatry, psychiatric court report, psychiatric expertise, differences among experts, legal responsibility, and discernment. We defined differences as disagreements between experts, or as a mismatch in conclusions and approaches of experts. RESULTS: The differences among experts concerned mainly forensic interpretation, i.e. the discussion of the relationship between pathology and offense, particularly in contexts that involve a larger forensic discussion, including interruption of medication, use of drugs, association with antisocial personality, premeditation, denial of facts, especially when the accused suffers from a mental illness (especially schizophrenia). For a finding of abolition of discernment, an expert must consider two requirements, one temporal (the mental disease must be active during offense) and the other causal that involves seeking a direct and exclusive relationship between the offence and the mental state, according to expert jurisprudence. Some experts do not comply with these two requirements or this jurisprudence, whence differences. There were also diagnostic differences and disputes relating to the concept of "alteration of discernment". Disagreements appeared to be related primarily to personal ideologies or different schools of thought that influenced interpretations and conclusions of experts, e.g. accountability as a therapeutic response for the psychotic person. Then, the lack of clarity of expert mission regarding necessary causal relationship ­ between any disease and crime ­ to demonstrate to conclude an abolition of discernment, could also contribute to differences. Moreover, time available to achieve the mission is too short and the expert would not devote enough time to an expert examination, which could lead to less good expertise and differences; especially as observed clinical examination in expertise is sometimes difficult, misleading, due to pathological reticence of accused mentally ill but also sometimes due to possible simulations. Finally, the low quality of some expert reports ­ due in part to the less well-trained experts, but also the particular conditions of achievement of expertise, especially in prisons ­ were mentioned by some authors as causes of differences. DISCUSSION: It appears from this review of literature that differences mainly concern forensic interpretation and are mainly explained by ideologies. This synthesis is a preliminary work prior to a study among psychiatric experts.

[Responsibility for prescribing and monitoring an act transfusion and safety blood transfusion]. / La responsabilité en matière de prescription et surveillance d'un acte transfusionnel et sécurité des produits sanguins.

The act to transfuse is a prescription following basic rules similar to drug prescriptions. If harm happens, potentially linked with this prescription, the harm's responsibility is borne by the physician, the paramedics, the care organization but by the supplier laboratory too. The setting of good practice rules consistent with science data at the time when the act is performed, the respect of the patient's rights and the quality of supplied products will be assessed during the expertise. Under restorative responsibility, it is necessary to previously establish a direct and certain causation between the litigious act and the harm to enforce the vicarious liability. Nowadays, legal precedents grant a larger protection to more and more numerous victims, enhancing the field of the fault with the appeal to assumption of fault. At the same time, the lawmaker himself promulgated objective conditions of compensation for many categories of victims of medical risk from which transfused people are part. The law of March the 4th of 2002 went one step closer devoting a new foundation of compensation: national solidarity.

[Prescribing medication in 2013: legal aspects]. / Prescrire un médicament en 2013: aspects légaux.

AIM: To describe the legal framework of medicine prescription in France in 2013. METHODS: With the assistance of lawyer and forensic pathologist, consultation (legifrance.gouv.fr), analysis, summary of French laws and rules surrounding drugs prescriptions to humans for medical purpose. RESULTS: Free medicine prescription is an essential feature of a doctor's action. To prescribe involve his responsibility at 3 levels: deontological, civilian and penal. Aim of the rules of medicine prescription is to preserve patient's safety and health. Doctors are encouraged to refer to recommendations and peer-reviewed publication every time the prescriptions go out of the case planned by law. CONCLUSION: Knowledge and respect of medicine prescription legal rules is essential for a good quality practice. Medical societies have a major role to improve medicine use among practitioners.

[No-fault medical accidents: review of two years' activity of the regional commission for the compensation of medical accidents of the Provence-Alpes-Côtes d'Azur region (PACA)]. / L'accident médical non fautif: bilan de deux années d'activité de la commission régionale de conciliation et d'indemnisation des accidents médicaux de la région PACA.

Compensation for victims of medical accidents identified as no-fault medical accidents (NFMA) will be financed by national solidarity: this is a major and innovative feature of the Law of March 4, 2002 relative to Patients' Rights. In this review, we analyse the decisions of the regional commission on compensation of medical accidents in the Provence-Alpes-Côtes d'Azur (PACA) region of France in 2004 and 2005, and we attempt to identify the prevalence of certain surgical procedures liable to result in NFMA and to define the concept of "unintended consequences" in the context of state of health of the patient and the predictable course of the malady. We hope to improve the medical information given to the patient and thereby the overall quality of management. NFMA was acknowledged in 57 claims, about 10% of all those received by the commission during this period. Nearly half of the claims were within the competence of the commission because of the existence of serious sequelae (Permanent Partial Disability) in 47%. No typical profile of age or gender emerged in the patients with NFMA. The majority of cases occurred after surgical procedures, in particular gastrointestinal surgery and orthopaedic surgery; 91% were planned procedures. We did not identify increased risk related to any given type of surgery, particular disease condition, or precise anatomic region. Complications were those usually observed such as neurological complications in vascular surgery or perforations in gastrointestinal surgery. The interpretation of NFMA has undergone an evolution during this two-year period. In 2004, previous poor health status precluded acknowledgment of a medical accident, the argument being that there was a predisposition to the complication which occurred. In 2005, compensation was based on a reduced Partial Permanent Disability score compared to the patient's previous health status. This became a means of measuring the impact of the medical complication on an already predictably unfavorable clinical course without medical intervention, and the legal aspect of the "ineluctable nature" of this course.

The regional commission for medical accidents and nosocomial infections set up by French law.

The regional commission for conciliation and compensation for medical accidents, iatrogenic diseases and nosocomial infections (commission régionale de conciliation et d'indemnisation des accidents médicaux, affections iatrogènes et infections nosocomiales, CRCI) offers victims of such events the possibility of obtaining compensation without recourse to legal proceedings. We suggest various points of view about this commission set up by the French law no. 2002-303 of 4 March 2002: the composition, role and competence of the CRCI; the place of the expert's report; the opinion pronounced by the CRCI and its outcome, the compensation of victims and, finally, interaction with other procedures.

Postmortem assessment of fetal diaphyseal femoral length: validation of a radiographic methodology.

Depending on the general condition of fetal remains, forensic specialists might face difficulties concerning age estimation. Reference tables and regression equations are helpful devices in this task, although they are generally applied for complete fetuses or fetal remains including soft tissues. However, the problem of age estimation stays for osseous remains, both for entire bones and ossified parts, since most of the reference tables come from ultrasonographic measurements, which are not easily reproducible on fetal osseous remains. Furthermore, the ultrasonographic measurements contain slight errors in comparison to the real anatomical ones. This study describes a radiographic protocol and a measurement technique that facilitate and improve bone measurements, and therefore, facilitate age estimation, too. A qualitative criterion, namely a clear-cut bony endplate, was defined and tested. Its reliability (repeatability and reproducibility) turned out to be good, showing nonsignificative differences to the threshold of 0.05, with average errors of 0.26 and 0.44 mm respectively. Moreover, concerning the test of eventual size differences between the right and left femurs showed a P value < 0.0001. The test of the qualitative criterion was based on the comparison of the radiographic in situ femur measurements and the radiographic measurements of the same bones after dissection. The results were satisfactory, since an average error of 0.58 mm was obtained, which did not give any significant differences to the threshold of 0.05. It was concluded that this methodology provides an easy and precise new measurement tool for forensic practice, and can allow us to establish some nonultrasonographic tables, which fit our population.