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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 2  |  Issue : 2  |  Page : 85-90

Forensic Experts' Opinion Regarding Clinical Forensic Medicine Practice in Indonesia and Malaysia


1 Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
2 Department of Forensic and Medicolegal, Faculty of Medicine, Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
3 Department of Public Health, Faculty of Medicine, Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia

Date of Web Publication16-Jun-2016

Correspondence Address:
Hanusha Nair Gopalakrishnan
Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung.Sumedang Km. 21, Jatinangor, Sumedang, West Jawa
Indonesia
Yoni Fuadah Syukriani
Department of Forensic and Medicolegal, Faculty of Medicine, Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital, Bandung
Indonesia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2349-5014.184193

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  Abstract 


Clinical forensic medicine is a progressing branch. In Indonesia and Malaysia, there is inadequate information regarding this practice. It is always unclear about the job scopes and practitioners involved in this field. The study outlined in this article is aimed to explore the current clinical forensic medicine practice compared to existing systematic practice globally and hence analyzing for presence of difference in this practice between these two countries. A qualitative study was conducted by forensic experts in Indonesia and Malaysia from September to November 2015. In-depth interview was carried out to obtain data which were then validated using literature and legal documents in Indonesia and Malaysia known as the triangulation validation method. Data were presented in narrative form. In Indonesia, forensic pathology and clinical forensic medicine were approached as one whereas in Malaysia separately. This practice was conducted by a general practitioner in collaboration with other specialists if needed in Indonesia; whereas, in Malaysia, this practice was conducted by forensic pathologists or medical officers in the absence of forensic pathologists. Both Indonesia and Malaysia followed the continental regimen in practicing clinical forensic medicine. There was still a lack of involvement of doctors in this field due to lack of understanding of clinical forensic medicine. The current clinical forensic medicine practice has not developed much and has no much difference in both countries. The gap between the current practice with systematic practice cannot be justified due to the absence of one standardized code of practice.

Keywords: Clinical forensic medicine, Indonesia, Malaysia


How to cite this article:
Gopalakrishnan HN, Syukriani YF, Setiawati EP. Forensic Experts' Opinion Regarding Clinical Forensic Medicine Practice in Indonesia and Malaysia. J Forensic Sci Med 2016;2:85-90

How to cite this URL:
Gopalakrishnan HN, Syukriani YF, Setiawati EP. Forensic Experts' Opinion Regarding Clinical Forensic Medicine Practice in Indonesia and Malaysia. J Forensic Sci Med [serial online] 2016 [cited 2019 Oct 17];2:85-90. Available from: http://www.jfsmonline.com/text.asp?2016/2/2/85/184193




  Introduction Top


Forensic medicine practice is the utilization of the standards and practice of medicine to serve the needs of the justice system. A proper understanding about forensic medicine practice will lead to a great practice in this field. Without great practice, foul play will prosper. Forensic medicine practice is further branched into two disciplines which are forensic pathology and clinical forensic medicine.[1] Forensic pathology manages the examination of the dead whereas clinical forensic medicine manages the examination of the living individuals. In numerous parts of the world, these two orders are rehearsed together, in others separately.[1],[2]

In general, when it comes to the involvement of clinical forensic medicine practice, it is primarily involved with the procurement of medical guidance in the analysis of crimes and other misconducts where medical insights and skill are fundamental to assist the legal procedures. Without proper testimony and interpretation of the experts regarding injuries, closure about how an injury happened may be inaccurate. Such conclusions will influence the examinations and both criminal and civil trials.[1] Clinical forensic medicine is a term that has been globally used for the past two decades. The doctors of clinical forensic medicine have been given a variety of names as the years advanced, yet the term “forensic physicians” has been able to be more comprehensively recognized. However, there are practitioners who are incorporated in both clinical and pathological forensic practice worldwide. There are various perspectives where both clinical forensic medicine practice and forensic pathology practice override each other, and this is reflected in the history and advancement of the specialty overall and its present practice.[2]

The degree and scope of career of a forensic physician varies; many constrain themselves to particular aspects of clinical forensic medicine, such as sexual assault or child abuse. At present, the degree and scope of the specialty of clinical forensic medicine internationally are ill defined, unlike other medical specialties.[2] In Indonesia and Malaysia, there are no any clear policies involving the standardization of clinical forensic medicine practice. Hence, there is always a question about who are involved and being in charge in clinical forensic medicine practice and what the scopes of this practice are comprised. Thus, this research is carried out to explore the current clinical forensic medicine practice and the disparity compared to the existing systematic practice and hence analyzing for the presence of any difference in this practice between Indonesia and Malaysia.


  Methods Top


The design of this research is qualitative study using intrinsic case study method which is aimed to explore the current clinical forensic medicine practice in Indonesia and Malaysia compared to the existing systematic practice and hence to identify whether there is any difference in this practice between Indonesia and Malaysia. Population of this study was consisting of forensic experts in Indonesia and Malaysia. Two doctors from each country were interviewed. Each doctor from Surabaya and Malang was interviewed in Indonesia whereas in Malaysia, each doctor from Penang and Kelantan was interviewed. The inclusion criteria included forensic experts working in government hospitals of Indonesia and Malaysia, whereas the exclusion criteria included forensic experts who are not willing to participate in this research and absence of forensic experts on the day of the interview being carried out. This research was carried out from the month of September to November 2015 in Indonesia and Malaysia. Data analysis for this study was conducted in Fakultas Kedokteran Universitas Padjadjaran. Data validation was done using triangulation method which verifies the data obtained from the interviews using literature and legal documents related to clinical forensic medicine practice in Indonesia and Malaysia [Figure 1].[3]
Figure 1: Research workflow

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  Results Top


Based on forensic experts' opinion, in Indonesia, all general practitioners were competent enough to conduct clinical forensic medicine practice. There was no specification for it. When there was a requirement for the involvement of other specialists from a different field, the cases were referred to them. For example, when there is a victim of domestic violence case with psychological disturbances due to it, he or she is referred to a psychiatrist. Clinical forensic medicine practice in Indonesia consists of the producing of Visum et Repertum of living victims that were involved in cases such as domestic violence, sexual assaults, or child abuse in context with jurisdiction. At present, forensic pathology and clinical forensic medicine practice are not separated as two independent branches. It is still considered as a single entity. A forensic specialist has the ability to conduct both the practices when their involvement is required. Clinical forensic medicine practice was only carried out when there is a request from the police. If there were any clinical forensic medicine cases that were brought to hospitals without the requirement of police for Visum et Repertum, hence the examination is not conducted. These victims were dealt as normal patients. As mentioned by the experts, there is an international standardization by the World Health Organization (WHO) about operational procedure for clinical forensic medicine field which is then adopted into Pedoman Nasional Pelayanan Kesehatan (PNPK) in Indonesia, whereas the standardization for clinical forensic medicine practice competency in Indonesia is explained in Standar Kompetensi Dokter Indonesia (SKDI 2012). Clinical forensic medicine practice in this country followed the continental regime. Based on forensic experts' point of view, standardization is very important. With this, the minimal competency of a doctor to conduct this practice will be obtained. Thus, there will be not only a uniformity throughout the country about this field but also there will be a guidance for the doctors to look up and hold on to, by having a standardized practice to provide an excellent service in this field. According to the forensic experts, there were problems and conflicts present in this field. For example, general practitioners are more familiar with medical terminologies. However, when it comes to clinical forensic medicine, they are required to report their findings which will be aiding in jurisdiction. Therefore, due to the lack of understanding in this field, the reports made were still consisting of medical terms that were being used in it whereby the information needed for the jurisdiction is not only expected to be more factual but was also mentioned that the total number of forensic doctors were less than 200. There are still hospitals without a forensic doctor. Other than that, there were also weaknesses in the way how a doctor deals with clinical forensic cases. These victims were usually dealt as a normal patient due to the lack of understanding about this field by the doctors. Thus, to overcome these problems, general practitioners should have a better understanding regarding this field and also have a minimum understanding about the legislation or regulations in Indonesia. Re-education is also needed for the doctors so that they are well aware about clinical forensic medicine cases and their role as a doctor and a responsible citizen to report any cases that are presented to hospital in legal context [Table 1].
Table 1: In-depth interview responses

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In Malaysia, the situation is dualistic. This practice was usually conducted by the forensic pathologists whereby in the absence of forensic pathologists, medical officers in government hospitals are competent to conduct this practice. In this country, this practice involved the examination of the cases consisting of sexual assault, domestic violence, child abuse, violation by law organizations, and rape in legal context. Forensic pathology and clinical forensic medicine are an equable field in this country. Examinations were done by the doctors-in-charge upon the request from the police. Findings were documented and handed over to the police for the proceedings of jurisdiction. According to the forensic experts' opinion in Malaysia, there is no standardization worldwide. There are only three regimes that are followed globally which are consisting of coroner, continental, and medical examiner. There is also no any specific standardization that Malaysia has been following. However, in Malaysia, the practice was based on the continental regime where the examination was carried out on living victims upon the request from the police. It was also mentioned that standardization is very important as this allows a clear understanding about one's duty and responsibility that needs to be carried out in a well-organized manner. This also helps to prevent the confusion and misunderstanding within the doctors about their roles and duties. In Malaysia, clinical forensic medicine does not pertain to a single specific area. Under such circumstances, it is difficult to state about flaws and conflict of interest. However, there was not only a lack in the number of forensic experts involved in clinical forensic medicine field which was around less than twenty forensic pathologists throughout Malaysia but also lack of importance and priority was given for this field since it was a newly developed branch. Therefore, a clear definition about the specificity of this field is required to be further researched for a better understanding. The doctors need to be re-educated about this practice and the importance of their roles toward the community in order to enhance the general practitioners' interest in this field.


  Discussion Top


Clinical forensic medicine is a term that has been globally used for the past two decades, in defiance of the fact that the declaration has been being utilized at any rate taking after 1951 when the Association of Police Surgeons, now known as the Association of Forensic Physicians – a UK-based body – was at first established. The doctors of clinical forensic medicine have been addressed in many ways as the years advanced, yet the term “Forensic Physicians” has been able to be more comprehensively recognized. In wide terms, a forensic pathologist basically does not manage the living individuals, and a forensic physician usually does not deal with the demised.[2] However, in Indonesia, a general practitioner is the one who conducts this practice whereas in Malaysia is by a forensic pathologist.

The degree and scope of career of a forensic physician varies; many constrain themselves to particular aspects of clinical forensic medicine, for example, sexual assault or child abuse. Forensic physicians are specially positioned to deliver useful interpretation on some of the criminal and social problems present in many modern societies. These comprise cases of child abuse, rape, domestic violence, assault by law enforcement agencies, torture, and substance abuse. Clinical forensic services can also be used to support community welfare such as the safety of children, health care within the custodial system, evaluation of mentally ill or behaviorally distressed people, traffic medicine, and other various medicolegal services that may be demanded by government departments or agencies. Some forensic physicians may also be referred for the diagnosis of occupational disease and injury, or insurance medicine.[1] However, none of the forensic experts in Indonesia and Malaysia has mentioned about examination for substance abuse, traffic medicine, or evaluation of mentally ill or behaviorally distressed people. This shows that the job scopes in clinical forensic medicine practice are not applied in a wider range advanced both in Indonesia and Malaysia.

Clinical forensic medicine practice varies based on countries.[4] In numerous parts of the world, forensic pathology and clinical forensic medicine are rehearsed together, in others separately.[1],[2] At present, in Indonesia, it was said that both forensic pathology and clinical forensic medicine field are not separated as two independent branches but they are considered as one whereas in Malaysia both the fields are equable. Although they are an equable field, yet they are practiced together in Malaysia. Clinical forensic medical involves the examination and documentation of living victims in legal contexts.[1] Examinations on the victims of cases mentioned earlier are conducted only upon request from police in both Indonesia and Malaysia.[5] Physicians are normally requested to prepare reports for medicolegal reasons. This is explained in Pasal 133 in Kitab Undang-Undang Hukum Acara Pidana (KUHAP).[5] It is necessary to know the nature of the request and the criteria that are needed – a simple report of fact, a report on present illness and diagnosis after a medical examination, a professional view, or a combination of these.[6] Thus, practitioners must have a good knowledge of medical, legal aspects, which can be characterized as the utilization of medical science to the law within their own sovereignty.[1] These have become a problem in Indonesia as the general practitioners are well versed with medical knowledge. Hence, they tend to produce Visum et Repertum with medical terms which contradicts with the requirement from the police who needs the facts about the evidence that have been obtained through the examination. In Malaysia, such problems have not only been mentioned by the forensic experts that were interviewed but also in both these countries, examinations have been conducted on the victims who are brought to hospital with the request from the police. Thus, those victims who seek for medical examination and treatment without the request from police are dealt as regular patients. These leads to the exemption of certain cases from getting justification under legal jurisdiction as the police are unaware about these cases. Therefore, as a responsible doctor, one should manage all the patients cautiously with the possibilities of being a victim of certain crimes and report to the police if there are any.

Besides this, a practitioner may also be requested to attend to any court in order to provide evidence. The doctor may be requested to provide virtuously factual evidence of the discoveries when he or she assessed a patient, in which case the doctor is considered as a professional witness of fact, or to give an opinion on certain matters, in which doctor is considered as an expert witness. Sometimes, a doctor will be called to provide both factual and expert evidence. Some doctors have made a profession from providing expert opinions, and a few have brought the career into dishonor by being evidently biased or by providing opinion evidence that is scientifically unsupportable. Hence, the courts have now come up with guideline for expert witnesses, where the expert evidence provided to the court must be seen as the independent product of the expert. An independent assistance should be given to the court in a way of unprejudiced view regarding matters within the capability of the expert witness. An expert witness in the court should never undertake the role of an advocate. Facts or assumptions on which the view was based should be mentioned together with material facts that could detract from the decided opinion.[6],[7] In Indonesia and Malaysia, there are times where the doctors who were involved in this examination are called to be an expert witness in certain cases. This was explained in KUHAP that is in Undang-Undang Nomor 8 Tahun 1981 under Pasal 186 quoting “Keterangan ahli ialah apa yang seorang ahli nyatakan di sidang pengadilan,” which means that a statement given by a forensic expert during trial.[5],[7] In Malaysia, duty of a practitioner as expert witness is explained in Laws of Malaysia, Act 56, Evidence Act 1950 under Chapter 3, Section 45, which quotes that “When the court has to form an opinion upon a point of foreign law or of science or art, or as to identity or genuineness of handwriting or finger impressions, the opinions upon that point of persons specially skilled in that foreign law, science or art, or in questions as to identity or genuineness of handwriting or finger impressions, are relevant facts. Such persons are called experts.”[8] It was mentioned by Malaysian forensic experts that very limited cases had been required for the involvement of expert witness. Hence, most of the time, the doctors are only approached as a professional witness which causes doctors to be passive. However, this problem was not mentioned by the forensic experts in Indonesia.

Based on the interpretation of this study, it was mentioned by the forensic experts in Indonesia that there is a standardization internationally for clinical forensic medicine code of practice by the WHO whereas the forensic experts in Malaysia were certain that there is no international standardization. It was also quoted by the experts that Indonesia follows the standardization for code of practice that is written in PNPK, which was said to be adopted from the WHO. However, this becomes questionable since there is no any operational standardization that is available worldwide for this practice. There are only regimes that have been developed which was not only explained in a study conducted in Hong Kong [4] but also was mentioned that there is standardization for the competency of doctors involved in this field in Indonesia which is explained in SKDI 2012. The statement “Membuat surat keterangan medis seperti surat keterangan sakit, sehat, kematian, laporan kejadian luar biasa, laporan medikolegal serta keterangan medis lain sesuai kewenangannya termasuk Visum et Repertum dan identifikasi jenasah” in SKDI 2012 which explains that a general practitioner is competent to produce reports with findings for jurisdiction shows and supports the forensic experts statement that since 2012, Indonesia has standardized that all general practitioners are competent to conduct this practice.[9] In Malaysia, there has been no evidence regarding the standardization for the competency of doctors who are able to conduct this practice. Based on the forensic experts in Malaysia, there is also no any standardization nationally for this practice specifically. There is only Standard Operating Procedures of Forensic Medicine Service, which standardize the examination and management of dead bodies.[10] It was also learnt that in Indonesia, there is already standard operational procedure for examination of victims of women and child abuse cases which is known as the “Prosedur Standar Operasional Pelaksanaan Standar Pelayanan Minimal Bidang Layanan Terpadu Bagi Perempuan dan Anak Korban Kekerasan.” It explains the procedures and steps of examination, management of the victims, documentation of findings, and reporting of cases for advocations.[11]

Globally, clinical forensic medicine system can be branched into three definite regimes. The first is that the clinical forensic medicine is practiced by a group of nonforensic pathologist doctors who are mostly consisting of the forensic medical examiners, for example, in the United Kingdom and Australasia. The second regime is consisting of forensic pathologists practicing clinical forensic medicine practice, for example, like that of Continental Europe and Hong Kong. Finally, the third regime is that there is no any specific group of doctors who carries out clinical forensic medicine practice. Usually, the doctors who are working in Emergency Department are the ones who carry out this practice, for example, like that of the United States.[4] Based on the interview, it was explained by the experts that both Indonesia and Malaysia follows the continental regime. However, since there is an involvement of a wide range of doctors from different field based on the requirement in Indonesia, it contradicts with the information obtained from the journal of Clinical Forensic Medicine: Much Scope for Development in Hong Kong as this journal explained that continental regime consists of a group of forensic pathologists conducting this practice.

The limitation of this study is that very limited study has been conducted regarding clinical forensic medicine practice worldwide. Therefore, in this study, the comparison of this practice with various countries is insufficient. Hence, the disparity of this practice in Indonesia and Malaysia with systematic practice globally is not fully understood due to the inadequate studies conducted regarding clinical forensic medicine practice. Besides this, the period of time to conduct this research was also a factor of limitation. Due to this, only two doctors were able to be interviewed in each country. This is also because of the lack in availability of the doctors and unwillingness to participate in this research.


  Conclusion Top


There is a lack of development in current clinical forensic medicine practice in both countries. It was not only found that there is presence of inconsistency in the practice due to absence of standardization in both countries as there were even differences in the understanding and practice in this field in different parts within Indonesia and Malaysia, but it was also learnt that this practice does not differ much in both countries. There are only slight differences such as for the one who are responsible to conduct this practice, the competency and the problems that they are facing in this field. However, regarding the systematic practice, there is no any specific code of practice that has been followed globally. This field only has three definite regimes that have been guidance in this field worldwide. Therefore, it is difficult to justify the disparity between the current practices of clinical forensic medicine with the systematic practice globally. There is not only a lack of involvement of doctors in this field due to lack of exposure about clinical forensic medicine but forensic specialists are also giving a least amount of importance toward this field as it is a newly developed subdivision.

Therefore, a clear understanding and standardization regarding these fields needs to be studied and developed further to enhance an efficient delivery of service in this field. Besides this, an agreement has to be achieved among the forensic experts for the recognition of the importance of this field to be established independently in order to develop a standard operating procedure in this field and approved in advocate regulation. A new policy should not only be developed in Indonesia and Malaysia with the guideline of what are the cases to be treated as clinical forensic medicine cases and who are able to conduct this practice but also the statement regarding the competency of general practitioner to conduct this practice should be removed from SKDI 2012, as the experience and knowledge of a general practitioner is considered to be insufficient. This is because of the involvement of two different fields in this practice that are medical and legal system which requires an in-depth understanding and knowledge in it as it involves in judiciary judgments. Therefore, to overcome the reduction in quantity and quality of doctors involved in this field, training for a longer period of time should be conducted and given certificate to certify that they are competent enough to carry out this practice if they pass their examination after the training program is being conducted.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Cordner S, Wells D, Mckelvie H, Nageh MM, Linehan B. Ethical Practice in Laboratory Medicine and Forensic Pathology. Report No.: Series 20. Egypt: WHO Regional Publications, Eastern Mediterranean Series; 1999. p. 66.  Back to cited text no. 1
    
2.
Payne-James J. History and development of clinical forensic medicine. In: Stark MM, editor. Clinical Forensic Medicine. New Jersey: Humana Press Inc.; 2005. p. 1-36.  Back to cited text no. 2
    
3.
Creswell JW. Qualitative Inquiry & Research Design Choosing Among Five Approaches. 2nd ed. California: Sage Publications Inc.; 2007. p. 414.  Back to cited text no. 3
    
4.
Beh PS. Clinical Forensic Medicine: Much Scope for Development in Hong Kong. Vol. 7. The HK Medical Diary: Department of Pathology, Faculty of Medicine, the University of Hong Kong; 2002. p. 3-13.  Back to cited text no. 4
    
5.
Sudharmono SH. Kitab Undang-Undang Hukum Acara Pidana (KUHAP) Undang-Undang Nomor 8. Report No.: 76. Indonesia: Lembaran Negara Republik Indonesia; 1981. p. 81.  Back to cited text no. 5
    
6.
Palmer RN. Fundamental principles. In: Stark MM, editor. Clinical Forensic Medicine, a Physician's Guide. 2nd ed. New Jersey: Humana Press Inc.; 2005. p. 37-60.  Back to cited text no. 6
    
7.
Susanti R. Peran dokter sebagai saksi ahli di persidangan. Andalas Journal of Health 2013;2:101-4.  Back to cited text no. 7
    
8.
Law of Malaysia. Act 56 Evidence Act 1950. Malaysia: Commissioner of Law Revision; 2012. p. 114.  Back to cited text no. 8
    
9.
Mukti AG, Herman RB, Kusumawati W, Hernowo BS, Trisna DV, Aras I, et al. Standar Kompetensi Dokter Indonesia. Jakarta: Indonesian Medical Council; 2012. p. 102.  Back to cited text no. 9
    
10.
Sabrina, Karim A, Kadir JD, Bhupinder S, Shahidan, Azman K, et al. Standard operating procedures of forensic medicine services. Malaysia: Ministry of Health Malaysia; 2012. p. 83.  Back to cited text no. 10
    
11.
Kementerian Pemberdayaan Perempuan dan Perlindungan Anak Republik Indonesia. Prosedur Standar Operasional Pelaksanaan Standar Pelayanan Minimal (SPM) Bidang Layanan Terpadu Bagi Perempuan dan Anak Korban Kekerasan. Indonesia: Kementerian Pemberdayaan Perempuan dan Perlindungan Anak Republik Indonesia; 2010. p. 108.  Back to cited text no. 11
    


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