10 years of controversy, twists and turns in the Perruche wrongful life claim: compensation for children born with a disability in France.

Since March 1st, 2010, French citizens have been able to call on a new legal procedure for defending their rights: the priority preliminary ruling on issues of constitutionality (question prioritaire de constitutionnalité, QPC). If, during a trial, a citizen considers that a provision of the applicable law is inconsistent with the Constitution of the French Republic, he/she may request that the matter be referred to the Constitutional Council. One ofthe first QPCs concerned legislation related to the Perruche jurisprudence. In a ruling on November 17th, 2000, the French Supreme Court of Appeal had granted the child Nicolas Perruche the right to financial compensation for the material costs related to his physical disability (caused by congenital rubella). In response, Article 1 of the Patients' Rights and Quality of Care Act (passed on March 4th, 2002) prohibited the award of compensation to a child "just because he/she has been born [with a disability]", i.e. in "wrongful life" claims. Since the enactment of the Act, compensation in a case like Perruche may only be awarded to cover the parents' psychological suffering, rather than the child's status at birth. The application of this "anti-wrongful life claim" legislation has since been subject of heated debate. In a QPC ruling on June 11th, 2010, the Constitutional Council found that Article 1 of the Patients' Rights and Quality of Care Act was (with the exception of its transitional provisions) indeed consistent with the Constitution of the French Republic.

Sudden death caused by aortic dissection in a patient with polycystic kidney disease.

A 43-year-old man presented at the emergency medical unit with chest pain. The results of a clinical examination were normal, apart from sternum pain (without radiation) on palpation. The patient had no respiratory problems and the pain was relieved by paracetamol. The electrocardiogram, laboratory tests and chest X-ray were normal. However, the man was found dead the next morning. In the autopsy, we noted the presence of haemopericardium, aortic dissection (starting from the vessel's origin and extended to the aortic arch and on through the diaphragm), polycystic kidney disease and liver cysts. In adult autosomal dominant polycystic kidney disease (ADPKD) patients, the main causes of death are ruptured intracerebral aneurysms, coronary artery disease, congestive heart failure, valvular heart disease and ruptured abdominal aortic aneurysms. Aortic dissection is considered to be rare cause of sudden death in ADPKD sufferers. ADPKD can have serious consequences for the vascular system. The families of confirmed ADPKD sufferers must be informed and screened as early as possible, in order to prevent renal and cardiovascular complications.

Victims of assault: a Europe-wide review of procedures for evaluating the seriousness of injuries.

In France, victims of assault receive a medical certificate describing their injuries. This certificate must fulfil certain criteria because it plays a major role in the subsequent judicial proceedings--notably the establishment of a period of 'total incapacity for work', which determines the court in which the case will be heard. Determination of the duration of this period of incapacity is complex. We decided to review medical examination procedures for victims of assault in a number of other European countries (England and Wales, Belgium, Germany, Switzerland and Spain). Our study revealed that only in France do physicians have to make a quantitative assessment of injuries, which is supposed to reflect the extent of the injuries and the intensity of the violence--despite the difficulties this may pose. We discuss the relevance of this quantitative assessment.

[Dead children born: Current regulation, inscription to registry office differs]. / Décès périnatal : réglementation actuelle, inscription à l'état civil et devenir du corps.

From a juridical point of view, in France, we become a "person" only when we are born "living" and "viable". These two criteria are necessary, but the threshold of viability is not defined by the law. The general education of registry office leaned on a circular fixing a << threshold of viability >> itself based on a recommendation of the Worldwide Organization of Health (WHO). The fetus was considered as viable after a term of twenty-two weeks of amenorrhea or if it had a weight over or equal to 500 grammes. The inscription to Registry office differs, as well as the taking care of the body of the child, depending on whether he was born living, viable and living and not viable, dead and viable, or dead and not viable. In France, the civil officer established an act of child declared lifeless when the child was born living but not viable or when the child is death - born but viable. However, parents of not viable and born dead children, often close to the threshold of viability, also liked to acquire an act of lifeless child, to be able to organize funeral has child lifeless and to inscribe it in their family record book. The act of child declared lifeless allows to inscribe the child on the family record book if the parents wish and give to the families the delay of ten days to claim the body. By judgment of February 6th, 2008, the Supreme Court of appeal cancelled rulings where the threshold had been kept to refuse the deliverance of an act of lifeless child. Her Supreme court of appeal considers that law does not impose de threshold from which the recognition of the status of lifeless child would be possible. Since the decrees of August, 2008, there is no border anymore of minimum of term or weight. Consequently, the lifeless born children after an unprompted delivery or a medical break, the pregnancy can be inscribed on the civil record. On the other hand, it is not possible for the precocious wrong coat and the termination of pregnancy.

[Obstructive lung diseases in a French prison: results of systematic screening]. / Dépistage de l'asthme et de la bronchopneumopathie obstructive à la maison d'arrêt d'Amiens: étude préliminaire transversale.

BACKGROUND: French prisoners have health problems that have been inadequately treated before imprisonment. This population has insufficient access to the healthcare system. Addictive behaviours, particularly smoking, are widespread. The aim of the study is to evaluate the prevalence of airflow limitation by using a primary care screening method adapted for the correctional facility and its inmates. METHOD: The screening of airflow limitation using a mobile spirometer is carried out in inmates consulting the primary care unit (UCSA) of Amiens prison. Patients consulting the UCSA between 16 August and 17 October 2006 and providing their consent are included in the study. The criteria for exclusion are: a counter-indication for spirometry, poor compliance with the effort of forced expiry after eight efforts, as well as refusal to take part in the study. The descriptive statistical analysis includes all of the quantitative and qualitative variables. RESULTS: Among the 210 patients included in the sample, only five patients refused to take part in the study. Their mean age was 37 (range: 16-65) and 90% were men. Ninety percent of this population were active smokers. Sixty percent of these smokers would like to quit. The spirometry detected 11% undiagnosed airflow limitation: 11 prisoners suffered from chronic obstructive lung disease and 13 prisoners suffered from asthma. DISCUSSION: Given the relative youth and high risk nature of these diagnosed patients, the potential for the long or short term aggravation, and a growing recognition of the seriousness of exposure to tobacco, the authors suggest that the systematic screening of inmates for airflow limitation may be used to assist in detecting serious health issues. Along with new French antismoking legislation, this screening may enable primary care workers to better reduce smoking habits in prisons.

[Tuberculosis vaccination programs: where are we?]. / Comment en est-on arrivé à suspendre l'obligation vaccinale du BCG ?

The incidence of tuberculosis strongly dropped since the obligation of declaration and the vaccination generalized in the middle of the 20(th) century. Many countries suspended the obligatory character of vaccination, preferring to reserve it to populations at risk. France had preserved obligatory generalized vaccination, using an intradermal injection whose realization is difficult and produced many side effects. Since 2004, different opinions to the installation of a vaccination reserved to the populations at risk are favorable, in particular, those originating in a country with strong tuberculosis endemia. These opinions also recommend to reinforce the tracking of the subjects reached of tuberculosis. Mrs Roselyne Bachelot, Minister of Health, announced on July 11, 2007 the suspension of the obligatory character of the BCG from the child and the teenager with the profit of a strong recommendation of vaccination of the children most exposed to tuberculosis as of the first month of life. In parallel, a national programme of fight against tuberculosis 2007-2009 is launched.

[The genetic fingerprints file in France: between security and freedom]. / Les fichiers des empreintes génétiques en France: entre sécurité et liberté.

In France, the French National File Automated with Genetic fingerprints (FNAEG) is a bank automated by genetic data which is used in penal domain. It facilitates search of the authors of malpractices, or the missing people. Since 1998, it has enabled to resolve numerous criminal cases. An extension of the field of application has been observed. It is a confidential register which is subjected to numerous controls. Nevertheless, private character of the data and its functioning (criminal character of the refusal of taking, periods of answer, and problem of data's conservation) explain the important contesting of associations worried about the respect of personal freedoms.

[Passive smoking in France: science, law and judge's point of view]. / Le tabagisme passif en France: que dit la science, la loi, le juge?

INTRODUCTION: Passive smoking occurs as a consequence of exposure to indoor atmospheric pollution by tobacco smoke. Its effects on health are now scientifically established. BACKGROUND: The 1976 "Veil"'s law was the first law related to the fight against passive smoking. It introduced a first step towards respecting the rights of non-smokers in premises and public transport. In 1991, the law "Evin" augmented it. Health messages appeared on the cigarette packets and the law prohibited exposure to smoke in public places, except in the sites reserved for smokers. The right of non-smokers not to be exposed to tobacco smoke was recognized. In practice, 15 years later, the law is still not enforced, so that the health of non-smokers is still not effectively protected. PERSPECTIVES AND CONCLUSIONS: Tobacco smoke is the second most common carcinogen to which employees are exposed. Workers in bars, restaurants and night-clubs are particularly vulnerable and display significant increases in biological markers of exposure. On June 29th 2005, the "Cour de Cassation" recognized that an employee had the right to sue their employer for breach of contract because they did not effectively implement a general and absolute prohibition on smoking in their offices, thus recognizing a legal obligation on employers to prevent exposure to tobacco smoke. This decision opens a new frontline in the fight against tobacco, while waiting for new legislative or governmental action to protect non-smokers at work effectively.

[Informing patients in otorhinolaryngology: legislation, jurisprudence, and incidences in practice]. / L'information des patients en ORL: législation, jurisprudence et incidences sur les pratiques.

The law of March 4, 2002 is the pedestal of legal responsibility in medicine in France. This law resumed data stemming from the jurisprudence but innovated also by establishing for example the "confidant" person and the direct access of the patient to his medical file. This law established or strengthened the rights of the patients: respect for dignity, respect for refusal of care, right to end-of-life care, right to adequate analgesia, right to the respect for professional confidentiality but also right to the information. The obligation of information is justified by the respect for the autonomy of the patient and by the necessity of obtaining a free and lit assent. Information is not only a preliminary to the medical act; it has to be done before, during and after. In case of complication, it will be reinforced. The information has to deal with the necessity of the medical act, the expected benefits, the possible urgency, the consequences, the normally predictable frequent or severe complications, the alternatives and the predictable consequences in case of refusal. The oto-laryngologist can refuse to perform an act prescribed by a colleague that he considers useless or too dangerous as compared to the benefit expected. The surgical oto-laryngologist in private practice has to prove that he informed his patient and it is his (compulsory) malpractice insurance that financially compensates the patient in case insufficient information leads the patient to lose his or her chance to refuse treatment. If the surgical oto-laryngologist practices in a public hospital, the establishment has to bring this proof of sufficient information, and in case of litigation, the hospital must provide compensation. One will note that the more difficult it is to justify the medical act, the less the judges tend to tolerate insufficient patient information. If the indication of the act is indisputable from a medical standpoint, then legally there is usually no ground for litigation due to insufficient information except possibly emotional damage.

[Risk/benefit counseling in surgical practice: How? Why?]. / La discussion bénéfices/risques en pratique chirurgicale: pourquoi? comment?

A thorough discussion of the risks and benefits of proposed surgery is a legal obligation stemming from the code of the health service. A multidisciplinary discussion assembling all involved services best serves to balance the risks of a procedure against the hoped for benefit. A written précis should document this discussion in the patient's chart, both as a part of the patient record and also to refer to in case of eventual medico-legal dispute. While a personal oral discussion should take place with the patient, it should be fully documented. A copy of this informed consent can be sent to referring colleagues or to the patient. This document, by summarizing the elements of the risk/benefit discussion is a supplementary means to assure that the information was given and understood. The primary physician can refer back to it in ongoing discussions with his patient to be sure that the patient has full understanding and has opportunity to have his questions answered. This may require a supplementary office visit. If the referring physician cannot answer these questions, he may need to refer back to the surgeon.

[Suing the surgeon: what are procedures? How to conduct an assessment?]. / Mise en cause du chirurgien: quelles sont les procédures? Comment gérer une expertise?

Surgeons are particularly exposed to lawsuits. Most will be threatened or confronted with litigation several times during their career. The surgeon can be held directly and personally liable during a penal procedure. Civil jurisdictions oversee expert evaluation in cases involving self-employed and salaried surgeons in private practice. An administrative structure for expert evaluation is set up for surgeons working in the public sector. The law of March 4, 2002 has set up a new structure with commissions for reconciliation and compensation of medical accidents (CRCI); these apply to all surgeons. It is essential that the practitioner prepare himself fully, studying both the patient dossier and the pertinent medical literature in order to participate in an expert evaluation under the best circumstances and to justify the diagnostic and therapeutic measures taken. The surgeon may be accompanied by legal counsel and an expert medical witness, but he should not abdicate all responsibility for testimony to them; he, as the treating physician, has the fullest knowledge of the medical case and can best respond to the expert's interrogation. This behavior also demonstrates both responsibility and respect to the patient and his family.

[Is it necessary to found an exemption from the medical secrecy concerning the health of politicians?]. / Faut-il instaurer une dérogation au secret médical concernant l'état de santé des hommes politiques?

In its book " The great secrecy", Dr. Gübler revealed that President of French Republic, Franpois Mitterrand, had lied on his cancer as of his accession with the capacity. 1981 to 1994, Dr. Gübler was the personal doctor of the President of French Republic, deceased on January 8, 1996. The great secrecy was diffused on January 17, 1996. French Justice ordered the interruption of its diffusion on January 18, 1996. The recourse led to a compensation for family of President. However, the European Court of the Humans Right (CEDH), May 18, 2004, condemned France retaining that the general and absolute character medical secrecy could not attack the freedom of expression and to the right to knowledge by the Nation of the truth on health of its former President of Republic. The CEDH however approves initial prohibition but not the maintenance of this prohibition, 9 months later. The great secrecy remained interdict in France until 2004 and was republished at the beginning of 2005. Dr Gübler was condemned for violation of medical secrecy and was erased Order of the doctors, decision confirmed by the Council of State. This story started again the medical, legal and political debate around the medical secrecy concerning politicians. In September 2005, President of French Republic, Jacques Chirac, was hospitalized after a cerebral vascular accident. Communicate were regularly published on its health, but questions were asked concerning medical activity under these conditions.

[Study of litigation files leading to a definitive settlement over three years in the orthopaedic trauma ward in a public hospital]. / Etude de 16 dossiers de contentieux ayant abouti à un règlement définitif sur trois ans dans un service hospitalier d'orthopédie traumatologie.

OBJECTIVE: To know the future of appeals against a public establishment of health. MATERIAL AND METHODS: We studied 16 files of dispute having ended in a definitive payment over three years in the service of orthopaedics of the Amiens hospital (2001-2003). RESULTS: The majority of the plaintiffs are people (63%), and the average age is of 45,6 years (24 year/68 years). In 14 cases on 16, an expertise was done (7 on the initiative of the hospital and 8 on the initiative of administrative court). The opinion of the expert was followed in every case, except one. In the final, 5 patients (31%) received a compensation (3 with the administrative court and 2 after a love rule). Eleven patients (69%) were not indemnified (7 after demand with the administrative court 4 after demand of love rule). On the whole, 10 case was treated in the administrative court (62%) and 6 by the legal department of the hospital. Among cases settled by the service of dispute of the hospital, 2 ended in a love rule and 4 were classified. Among those treated by the court, 3 ended in a love rule and 7 were the object of a refusal.

[The law of March 4, 2002: how to implement it with regards to informed consent in radiology]. / La loi du 4 mars 2002: comment l'appliquer en matière d'information des patients en radiologie.

The duty of providing information to patients makes it possible to obtain an informed consent. Information must be complete and relate to the health of the patient and not only to the risks of a medical procedure. From jurisprudence initially, and then from the law of March 4, 2002, it is a right for patients. It is the physician's burden to prove that he or she informed his patient well. This provision raises difficulties in radiology because of the particular nature of this practice. The radiologist intervenes after a fellow-physician has prescribed the examination. This relation involves three individuals: the requesting physician, the radiologist and the patient. Both physicians have a duty to provide information. As such, should consultations with radiologists prior to specific invasive procedures be obtained? This article aims at clarifying the concept of informed consent in radiology, based on the law of March 4, 2002, examples of jurisprudence, and the recent regulation specific to radiology in the decrees of March 2003.

[Autopsies and surgical service]. / Autopsies et services de chirurgie.

The aim of autopsy is to define the causes of a patient's death by studying the gross and microscopic visceral lesions. It is in actual decline but nevertheless the post-mortem examination remains one of the basic tools for the assessment of medical care in hospital. The aim of this paper is to finalize the present French legislation of autopsy and to show its importance in surgical practice.

New French legislation governing organ removals for therapeutic and scientific purposes.

In France the general principles of organ donation are: consent, absence of financial gain, anonymity, advertising is prohibited, healthcare safety. As regards organ removals from living persons, a panel of experts is required to give approval. The recipient's spouse, brothers or sisters, sons or daughters, grandparents, uncles or aunts and first cousins may be authorised to donate organs, as well as the spouse of the recipient's father or mother. The donor may also be any person who provides proof of having lived with the recipient for at least two years. As regards organ removals from Deceased Persons for Therapeutic Purposes, removals may be practised if the deceased did not make known their refusal during their lifetime (this may be recorded in the national registry set up for this purpose). The doctor must not seek the family's opinion, but rather ensure that the deceased did not express opposition to organ donation during his lifetime. The rule of presumed consent should apply, unless there is any danger to the health of the general public. This paper describes and discusses in detail the new legislation and its relationship to existing French legal codes.

Alcohol, cigarette, and illegal substance consumption among medical students: a cross-sectional survey.

This study investigated addictive substance use by French medical students. A cross-sectional survey was distributed to 255 participants randomly selected from 1,021 second- to sixth-year medical students. Questionnaires were self-administered and included questions on sociodemographic characteristics, mental health, and alcohol (The Alcohol Use Disorders Identification Test [AUDIT test]), tobacco (Fagerstrom test), and illegal substance consumption (Cannabis Abuse Screening Test [CAST test]). The AUDIT scores indicated that 11% of the study participants were at risk for addiction and 21% were high-risk users. Tobacco dependence was strong or very strong for 12% of the participants. The CAST score showed that 5% of cannabis users needed health care services. Cannabis users were also more likely than non-users to fail their medical school examinations (89% vs. 39%, p<.01). One quarter of medical student participants (n=41) had used other illegal drugs, and 10% of study participants had considered committing suicide during the previous 12 months. Psychoactive substance consumption by French medical students requires preventive measures, screening, and health care services.

Postoperative bilateral vertebral artery dissection: a case report.

With the improvement of medical imaging and surgical techniques, surgery on cervical vertebral is more frequent. Some cases of complications of this type of surgery have been described. We report a case of postoperative bilateral vertebral artery dissection. It concerns a 58 year-old woman who suffered from a left cervico-brachial C6 neuralgia with paresthesiae of the thumb. She underwent discectomy at C5-C6 and C6-C7 followed by setting up intersomatic cages. In subsequent days, an irreversible coma developed. Supra-aortic echographic study revealed bilateral vertebral artery thrombosis. CT scan revealed ischemic lesions of the brain stem and cerebellum. Cerebral death was declared five days after the operation. Autopsy was performed to determine whether death was the consequence of the intervention. The cause of death was determined to be ischemic brain injury of the brain stem and cerebellum resulting from bilateral traumatic occlusion of the vertebral arteries caused by the surgery.

[Surgery and transfusion in Jehovah's witness patient. Medical legal review]. / Chirurgie et transfusion chez les patients témoins de Jéhovah. Mise au point médico-légale.

The religious convictions of the witnesses of Jehovah leads them to refuse transfusion of blood, of its major components and of blood sparing procedures breaking the physical contact between the patient and his blood. We recall the rules of good practice in case of elective surgery concerning exhaustive information of the patient within multidisciplinary team associating anesthetist and surgeon advised by the forensic pathologist. This consultation must, to our point of view, be concluded by a report which summarizes what is accepted or not by the patient. This report will be initialed by the patient. This consultation can never lead the physician to swear to never use a transfusion whatever the circumstances. In case of emergency if and only some conditions are met (everything was made to convince the patient, vital emergency, no therapeutic choice, therapeutic care adapted to the patient heath status), the physician can be brought to overpass the patient's will to not receive blood transfusion. Current jurisprudence has, to date, never recognized as faulty the physicians having practiced such transfusions whenever they took place within a precise framework.

[The person of trust, a new tool in the physician-patient relationship]. / La personne de confiance, nouvel outil de la relation médecin patient.

THE NOTION OF A PERSON OF TRUST: Introduced by the law dated March 4th 2002, the person of trust is there to accompany the patient in all his/her measures of care; this person is also conceived as an helper in medical decisions or when the patient participates in biomedical research protocols. DESIGNATION MODALITIES: Any adult, unprotected patient can designate a person of trust, whose intervention is not only limited to hospitalisation (the nursing staff are obliged to propose such a person), but can also intervene during care at home or at the doctor's. The designation is made in writing and can be revoked at any time. The person of trust can be a relative, a friend or even the treating physician. A SPECIFIC ROLE: The person of trust can be of help in medical measures in routine medicine when the patients needs to be accompanied, and in the case of diagnosis or serious prognosis, and when the patient is incapable of expressing him/herself.