[Hepatitis B vaccination and multiple sclerosis: from medical uncertainty to compensation for victims]. / Vaccination hépatite B et sclérose en plaques: de l'incertitude médicale à l'indemnisation des victimes.

Cases of multiple sclerosis appearing after a mass hepatitis B vaccination program can lead to claims for compensation. The legal jurisdiction under which such claims will be examined depends on whether the vaccination was carried out as part of a mandatory program (implying liability of the State or employers) or in application of recommendations (implying responsibility of the vaccine manufacturer). In the literature, there is no evidence demonstrating a statistically significant relationship between anti-hepatitis B vaccination and the onset or exacerbation of multiple sclerosis, questioning even the notion of compensation. The analysis of the jurisprudence shows that, in a first period, the scientific uncertainty of a link between vaccination and onset of multiple sclerosis precluded any compensation to victims. Subsequently, judicial and administrative courts ignored this scientific uncertainty, which enabled them to examine claims for compensation by adopting a presumptive reasoning based on specific criteria and different regulations depending on the legal jurisdiction. According to the French high courts (Cour de cassation and Conseil d'État) scientific causality and legal causality do not necessarily have to be consistent, such that medical uncertainty should not be an obstacle to compensation for victims.

[Is the court-ordered treatment indication by the expert based on a medical diagnosis?]. / L'indication d'injonction de soins repose-t-elle sur un diagnostic médical ?

UNLABELLED: Court-ordered treatment was created in 1998, as part of a law against sexual offense recidivism. The creation of court-ordered treatment is based on the premise that many offenders have psychiatric disorders. If the court-ordered treatment is appraised as an effective way to prevent recidivism by the lawmaker, the preeminent role of psychiatry, in the prevention of recidivism has generated controversy in the psychiatric community. Few studies have been conducted on court-ordered treatment in France, and have concerned epidemiological measures. Court-ordered treatment leads to an extension of the expert's mission. In order to prevent recidivism, the interest of a treatment is a new part of the expert's mission. PURPOSE: The main purpose of this study was to assess the kind of diagnosis reported by the forensic psychiatrist who considered the court-ordered treatment as appropriate. METHOD: We led a descriptive and retrospective study among the experts' reports of 68 subjects followed by three psychiatrists. We categorized each diagnosis found in the experts' reports in reference to DSM-IV-TR axis I and axis II. As the expert has no obligation to refer to the DSM-IV-TR, we also considered the "no DSM-IV-TR categorized disorder" as a category. The primary outcome was the proportion of each diagnosis category in experts' reports, in which the forensic psychiatrist agreed with the indication of a court-ordered treatment. RESULTS: We analysed 123 experts' reports in which the mission was to diagnose a mental disorder and to assess the need for a court-ordered treatment. The expert agreed with the need for a court-ordered treatment in 112 reports. In those reports the diagnosis was "no disorder" in 27% of them, "no DSM-IV-TR categorized disorder" in 26% of them, "axis II disorder" in 24% of them, "axis I disorder" in 19% of them, and "association of an axis I and an axis II disorder" in 4% of them. DISCUSSION: The diagnoses were heterogeneous. Their associations with the need for a court-ordered treatment seem to be contradictory when considering the association between "no mental disorder" and "need for a court-ordered treatment" found in 27% of the reports. These paradoxical results led us to question the meaning of mental disorder and treatment.

Sexual assault and MDMA: the distinction between consciousness and awareness when it comes to consent.

In France, the term chemical or drug-assisted submission is usually defined as the rendering of a person vulnerable by the surreptitious administration of an active substance with the purpose of prejudicing the person or his/her possessions. If the harm is sexual assault, establishing the victim's submission involves both proving that a dangerous substance was administered, providing material evidence of the infraction (the assault), i.e. the detection of traces in a physical examination and samples, and proving the absence of consent. We report the case of a woman who was sexually assaulted after having been surreptitiously administered methylenedioxymethamphetamine. In this special case, the woman remained in a state of vigilance (conscious) throughout, so there is doubt about whether or not she consented. In other words, the ability to consent is debatable.

[Psychiatric autopsy: its uses and limits in France]. / L'autopsie psychiatrique.

RATIONALE: Within the framework of an evaluation program for the prevention of suicide in Brittany conducted by the academic department of psychiatry (University of Rennes, Brittany, France), we have addressed the issue of the potential usefulness of psychological autopsy as a tool for the better comprehension of suicide risk factors. METHOD: We reviewed the appropriate literature in 30 articles found amongst those obtained from the "Medline" database. These articles were selected according to the quality of their methodology. For the Medline data retrieval search, the following keywords were used: "psychological autopsy", "psychiatric autopsy", "psychological autopsy and methodology", "psychiatric autopsy and methodology". This review's objective was to determine, firstly the nature and the content of psychological autopsies, secondly to evaluate their use as a methodological tool to assist the comprehension and prevention of suicide. Finally, it was also to assess its feasibility for use in France. RESULTS: The majority of the published studies using psychological autopsy for the evaluation of suicide expertise came from Scandinavian or Anglo-Saxon countries. Schneidman [Schneidman ES. The psychological autopsy. Suicide Life Threat Behav 1981;11:325-40], whose aim was to clarify the causes of sudden death related to psychological circumstances, focused on suicidal intentions and the symptoms exhibited. He coined the term: "psychological autopsy". Gradually, the definition of psychological autopsy has evolved and is now being used for the evaluation of death by suicide with a single goal in mind: to retrospectively identify any suicidal predictive and risk factors available at the time of the event. At present, no unequivocal definition of "psychological autopsy" has been put forth. However, this formerly only descriptive procedure is now becoming more analytical in nature (comparison of psychiatric profiles between pre- and postmortem assessments, research on precipitating factors, comorbidity studies...). Presently, it corresponds to a methodological tool to be used essentially for case reports that vary a great deal and do not permit cross-comparisons with other case-studies. For the past fifteen years, case-control studies in this field have become more frequent with various choices of control groups: healthy subjects with no psychiatric history, as well as attempted suicides, with or without a psychiatric history. Partial standardization of autopsy procedures is now possible with some data extracted from police inquiries, medical charts, or data gathered following interviews with the deceased patient's relatives. CONCLUSION: In the aggregate, the literature review showed that the aims of psychological autopsy include understanding and prevention of suicide in a population-based sample. It seems difficult to generalize with results from other population references. In France, the use of psychological autopsy as a standardized tool for the assessment of suicidal behaviors would be difficult, due to the complexity of the procedures involved: data coming from external sources, such as medical sources, is nearly impossible to obtain. Practitioners would be required to overcome administrative rules and regulations, plus incurring the high costs of such procedures. They must also take into account ethical considerations that make such interviews with the deceased patient's relatives difficult to obtain. Be this as it may, the French Ministry of Health is presently attempting to find a solution in order to alleviate the all too frequent problem of suicide in the population at large and to promote suicide prevention in France.

Fatal aluminum phosphide poisoning.

A 39-year-old man committed suicide by ingestion of aluminum phosphide, a potent mole pesticide, which was available at the victim's workplace. The judicial authority ordered an autopsy, which ruled out any other cause of death. The victim was discovered 10 days after the ingestion of the pesticide. When aluminum phosphide comes into contact with humidity, it releases large quantities of hydrogen phosphine (PH3), a very toxic gas. Macroscopic examination during the autopsy revealed a very important asphyxia syndrome with major visceral congestion. Blood, urine, liver, kidney, adrenal, and heart samples were analyzed. Phosphine gas was absent in the blood and urine but present in the brain (94 mL/g), the liver (24 mL/g), and the kidneys (41 mL/g). High levels of phosphorus were found in the blood (76.3 mg/L) and liver (8.22 mg/g). Aluminum concentrations were very high in the blood (1.54 mg/L), brain (36 microg/g), and liver (75 microg/g) compared to the usual published values. Microscopic examination revealed congestion of all the organs studied and obvious asphyxia lesions in the pulmonary parenchyma. All these results confirmed a diagnosis of poisoning by aluminum phosphide. This report points out that this type of poisoning is rare and that hydrogen phosphine is very toxic. The phosphorus and aluminum concentrations observed and their distribution in the different viscera are discussed in relation to data in the literature.

Increasing rate of sexual assaults by adults appearing before the Assize Court of Rennes, France, during 1987-1997.

In this paper, we analyse all the sentences handed out by the Assize Court of Rennes in France, in the last decade. A recent increase in the number of sexual offences has been observed. An increase in the number of cases of incest has also been noted. This paper analyses the sex ratio, the age of the victim, the association with other violence and the relationship between the victim and his or her aggressor. The outcomes of the trials are discussed.

[Trends in indications for therapeutic abortion. Statistical study of 20 years]. / Evolution des indications de l'interruption therapeutique de grossesse. Statistiques sur 20 annees.

PIP: 2 conditions are necessary for a therapeutic abortion: a medical indication of the threat to the mother's health posed by the pregnancy or the risk of incurable malady in the fetus, and the obtaining of clear consent from the woman, who has been duly advised of the risks. Medical indications for therapeutic abortion have preceded legal dispositions. An 1850 vote after animated debate at the French Academy of Medicine approved therapeutic abortion if no other treatment could save the mother's life, but the practice was not precisely codified until promulgation of a decree in 1955. The physician was to obtain the opinions of 2 consultants. Despite a few therapeutic abortions for fetal indications, a public debate on the issue did not arise until the thalidomide crisis of 1962. The 1975 and 1979 laws permitted therapeutic abortion if the pregnancy posed a grave threat to the mother's health or there was a strong probability that the fetus would be afflicted by a grave disorder recognized as uncurable at the moment of diagnosis, 179 records of therapeutic abortions performed from 1964-82 showed that the average age of the woman varied from 29 to 33 years from 1964 to 1973 and thereafter declined to 27-28 years by 1982. The declining age is directly related to the widespread use of sonography. The average gestation at time of therapeutic abortion has been about 19 weeks since 1964. None of the 20 therapeutic abortions performed from 1964-70 were for fetal indications, while in 1982 only 6 of 24 indications involved maternal risk and the other 18 included 2 cases of German measles, 2 of anencephalie, 3 of trisomy 21 and 1 of trisomy 18, 3 of spina bifida, 4 of coelosomies, and 3 of hydrocephalies. Therapeutic abortions for maternal indications are becoming proportionately less frequent because more of the conditions posing threats to maternal health during pregnancy are amenable to treatment, while improved contraceptive methods offer greater protection against pregnancy and improved methods of prenatal diagnosis of fetal morphologic, enzymatic, or chromosomal anomalies incompatible with a normal life. The availability of therapeutic abortion poses medicolegal problems, especially concerning the right of the fetus to be born.^ieng

[Judicial decisions after reporting cases of shaken baby syndrome. Sentences and compensation]. / Traitement judiciaire des cas de « bébés secoués ¼. Aspects répressifs et indemnitaires.

BACKGROUND: Shaken baby syndrome (SBS) is defined by the association of intracranial hemorrhage and retinal hemorrhage in infants under 2 years of age, with no obvious external trauma. This syndrome leads to frequent neurological sequelae. Therefore, these infants can claim compensation for damage if sequelae are directly and irrefutably linked to the trauma. Data on the judicial treatment are for the most part inexistent in the medical literature, the reason for which this study was conducted. POPULATION AND METHODS: We conducted a retrospective study over a period of 10 years. We included all cases of SBS reported to the High Courts of the Ille-et-Vilaine department (Rennes and St Malo). The cases were listed from the archives of the Department of Medical Information, the Specialized Unit for Abused Children and Forensic Department at the Rennes University Hospital. We were able to look the judicial cases up after receiving agreement from the prosecutors of the two courts. RESULTS: Of the 34 cases included, 12 could not be used (lost, ongoing, destroyed, transferred to another court), 16 led to an order of dismissal or to no further action because of an unknown perpetrator, insufficiently described offense, or insufficient evidence. Six authors were sentenced. It was the father (n=5) or the childminder (n=1). All perpetrators had confessed to part or all of the charges brought against them. Five children received compensation: three by the civil court and two by the commission of compensation for victims of an offense. CONCLUSION: Most cases led to no conviction and no compensation. The identification by the physician of the person responsible for the lesions in SBS does not mean that the perpetrator will be convicted because of the strict application of criminal law. The nomination of an administrator representing the infant could resolve the lack of compensation.

[Tuberculosis and refusal of treatment: resorting to legislation on serious health threats]. / Tuberculose et refus de soins: recours à la législation sur les menaces sanitaires graves.

INTRODUCTION: Clinicians are regularly confronted with the question of refusal of treatment from patients with tuberculosis. For several years, the French public health authorities have been studying the possibility of compelling treatment or isolation, but no plan has been implemented even though European and American experiences have shown the effectiveness of restrictive measures. BACKGROUND: Neither the statutory exceptions to the principle of consent to medical treatment nor the conditions of implementation of "required care" allow legally binding measures against patients refusing care or isolation. VIEWPOINTS: The legislation on serious health threats has recently been applied to the situation of a refusal of treatment in the context of tuberculosis. It allowed the patient to be ordered to observe prescribed care and the possibility of forced isolation in the event of breach of this order. CONCLUSIONS: The legislation on serious health threats is a response to the question of refusal of treatment from patients with tuberculosis. However the opinion of the legal authority as to its necessity and proportionality to the risk remains unknown.

[Case of death occurred after an injection of aetoxisclerol. The responsibility of the product should be discussed]. / L'aetoxisclerol accusé à tort d'entraîner une mort subite.

A 35-year-old woman has suffered from faintness with cardiovascular failure at the end of a sclerotherapy session for varix management. The injected product was Aeloxisclerol (DCI lauromacrogal 400). The death came up very quickly. The autopsy didn't reveal any traumatic lesion. The anaphylactic choc could be ruled out. Macroscopically, the heart showed a right ventricular dilatation. The toxicological analysis didn't reveal any medicinal substances. Histology showed the presence of lipid degeneration of all the right-ventricle wall The discussion is carried out on the role played by this previous health-state on the onset of death, and also on the incidence of sclerotherapy using this product. and the onset of death. We are carrying out this discussion by taking in mind the nature of the product injected and the information available in the literature concerning the lipid degeneration of cardiac muscle. Quickly after this case, the AFSSAPS (The French Agency for Sanitary Security of Health Products) has emitted an written alert which correlates with the requirements of principles of precaution although it is not founded on the totality of investigation results done for this medicolegal case.

[Responsibility of poison control center physicians]. / Responsabilité du médecin répondeur d'un centre anti-poisons.

Rennes's Poison Control Centers as a public medical department associated with an emergency care unit for poisoned patients, is also endowed with a role in toxicological information. In this regard, doctors are working as health officers in the respect of professional ethics. Administrative courts will therefore have to consider suits opposed to poison control doctors. The contract linking the doctor to his counterpart is a benevolence contract. The validity of his oral advice was defined by the Cour de Cassation. The potential evaluation of a fault will be modulated by the particular circumstances of data collection and hence its uncertainty. However, Poison Control Centers must be best organized so that their answers to queries are given by a toxicology-qualified staff. The doctor will also have to provide assistance to those people in danger by adequate help. Despite the ambiguity of some calls which he has to face, the doctor in a Poison Control Center does not seem to be involved by the Law on suicide.