Forensic Medicine in Europe - Switzerland / Schweiz
Legal Medicine in Switzerland
P. Mangin, University Institute of Legal Medicine, Lausanne
V. Barras, University Institute of the History of Medicine and Public Health, Lausanne
The early history of legal medicine in Switzerland resembles that of all western European countries. Its roots are to be found in the Middle Ages, its customary laws and its specific social and sanitary organizations. Accounts of medical investigations can be found in the archives of most cities for that period in history. Surgeons, matrons, physicians and apothecaries all acted as early forensic experts in numerous cases of suspected infanticides, sorcery, bawdry, poisoning or any other bodily harm. At the end of the Middle Ages, every important city had its own official physician who would often let the activity of a medical expert earn its spurs as a valuable service to the community and justice. Such was the case for Felix Platter (1536-1614), a physician from Basel who is generally considered as the founding father of legal medicine in Switzerland (fig. 1). This claim to fame is based on the "Observations", a manuscript published in 1614 which describes a plethora of cases, including those of Platter's colleagues and predecessors, that the physician studied during his long career as a hospital doctor, medical examiner and public physician in the city of Basel. Platter's work abounds with medico-legal observations, including autopsies, evaluations and all types of reports made by physicians and surgeons to the justice. In the Modern Times, several other Swiss leading medical experts took interest in legal medicine and more generally in the ties that exist between the medical sciences and different legal activities, both in criminal and civil law. Even though it is too early to talk about the emergence of a new discipline in those times, different authors, including Albert de Haller (1708-1777), were already publishing a variety of case collections and treatises explaining the art of writing medico-legal reports and other dissertations.
The field of legal medicine, such as it is understood today, emerged at the end of the Enlightenment period. The sanitary and academic organization of the modern state, the advent of anatomoclinical localization methods, the discoveries in chemistry and the invention of many laboratory techniques and of their biological applications during the 19-th century all contributed to the birth of the new medical specialty. As demonstrated by the numerous writings published in books and specialized periodicals during that period of history, the Swiss medical examiners became interested in a variety of subjects , including penitentiary medicine, poisonings, toxicological examinations, criminal personalities, suicide, sexual perversions and responsibility in case of mental alienation.
The birth of the science of legal medicine coincided with the creation of the first public services of forensic medicine and forensic psychiatry. Because of the Swiss federalism, these services had to be organized at the level of the different cantons. At the same time and in practice, the strictly forensic tasks overlapped with the activities carried out by sanitary police and public hygiene authorities.
The changes also impacted the academic world: legal medicine began to be taught at the Law faculties of the different Swiss universities. Soon thereafter however, all scientific and teaching activities pertaining to legal medicine were gradually transferred to the five newly created or reorganized faculties of medicine, and in some cases even to independent urban institutions (in Locarno, St-Gallen or Chur). This was a general trend that affected all the different medical specialties that emerged in the second half of the 19-th century.
Several legal medicine university chairs and teaching programs were thus created within the various faculties of medicine: in Bern (Prof. Carl Friedrich Emmert in 1855, followed by Prof. Max Howald in 1903), in Geneva (Prof. Hippolyte-Jean Gosse in 1876, followed by Prof. Louis Mégevand in 1902 and Prof. François Naville in 1925), In Basel in 1882 (Prof. Ernest von Sury in 1890, followed by Prof. Adolf Streckeisen in 1895 and Prof. Salomon Schönberg in 1924), in Lausanne in 1890 (Prof. Jacques Larguier des Bancels, followed by Prof. Georges Spengler in 1904 and Prof. Paul Reinbold in 1922), and in Zürich (Prof. Hans Konrad von Wyss in 1895, followed by Prof. Heinrich Zangger in 1912 and Prof. Fritz Schwarz in 1941).
The academic recognition of the new field, which took place in most cases when the different Institutes of legal medicine were created, was not always an easy process. Nevertheless it did result in the conceptual and institutional separation of the different aspects of legal medicine that were traditionally dealt with by other specialties such as public hygiene, anatomy, pathology, surgery or even psychiatry.
The professionalization and institutionalization of legal medicine continued throughout the 20-th century. At the same time, the volume and the types of activities of all the Institutes increased significantly, causing an acute need for additional physical space at all locations. Legal medicine was clearly outgrowing its traditional boundaries, defined in the 19-th century by pathology and toxicology and sometime later also by genetics. Thus, the different institutes introduced a number of new specialties: physical anthropology, anti-doping laboratory analysis, penitentiary medicine, forensic psychiatry and traffic medicine. A milestone was reached in 1980 with the creation of the Swiss Society of Legal Medicine. Its objectives were clear from the onset: the encouragement and promotion of legal medicine at scientific and institutional levels and the development of a post-graduate training curriculum which would lay the basis for a Swiss Medical Association (FMH) Specialty Diploma, the central authority authorized to deliver medical diplomas. As illustrated by many recent historical developments, legal medicine today is a vibrant field, often at the center stage of social and political tensions, requiring constant adaptation to new circumstances in a rapidly evolving world.
There are currently six Institutes of legal medicine in Switzerland, located in Basel, Bern, Geneva*, Lausanne*, St-Gallen and Zürich (fig. 2). They are all administered by different cantonal authorities such as the cantonal government itself, the Department of Health and Social Affairs, the Department of Justice and Police or the Department of Education. Some cantons that do not have an institute of legal medicine (Grisons, Neuchâtel, Ticino, Zug) offer their judicial authorities a cantonal medical examiner that can conduct the necessary forensic investigations.
* Both institutes being about to merge into a single one under the responsibility of a unique director, ordinary professor of legal medicine a the faculties of medicine of Lausanne and Geneva.
A) The Institutes of legal medicine
1. A university status
The institutes of legal medicine of Basel, Bern, Geneva, Lausanne and Zürich operate under university status. The director of each institute is a medical doctor who must be an ordinary professor at the faculty of medicine of the university to which the institute is affiliated. He or she is also in charge of teaching legal medicine at both undergraduate and postgraduate levels.
The institute of legal medicine of St-Gallen has a hospital status. Nevertheless, it is headed by a medical doctor who is a member of the Faculty of Medicine of the University of Basel. The Institute's Director is responsible for undergraduate teaching of legal medicine at the University and is also in charge of post-graduate training at the Institute.
2. Structure :
The institutes, which are structured identically, always include a forensic medicine unit, a unit of traffic medicine, a laboratory of toxicology and forensic chemistry and a laboratory of forensic genetics.
The forensic medicine units are headed by a medical examiner. These units are active in three different domains: forensic pathology (on-site investigations, autopsies, external examinations, identifications), clinical forensic medicine (examination of victims of physical and sexual assault, abuse, age determinations, etc.) and forensic expert evaluations (medical malpractice).
The units of traffic medicine are in charge of assessing the driving capacities of individuals suffering from alcohol-related or drug-related problems, specific diseases or age-related psychomotor impairment. These units are headed by a medical doctor specialized either in internal medicine or in forensic medicine with an exception in Geneva where the head is a psychologist.
The toxicology and forensic chemistry units are usually headed by a forensic chemist. The tasks carried out include the determination of blood-alcohol levels, toxicological analyses of samples collected during autopsies or clinical examinations and analyses of samples in cases of suspected driving under the influence of illegal drugs or medication. The quality of the latter analyses, as well as that of blood-alcohol level determinations, is rigorously controlled by the federal government which delivers accreditation based on mandatory external quality control procedures. In addition, the laboratories are accredited according to the ISO17025 standard.
The forensic genetics laboratories, headed by a forensic geneticist, are responsible for analyzing biological traces, carrying out paternity tests and determining genetic fingerprints that are then added to the national registry at the Federal Police Office for Police in Bern. These activities are rigorously controlled by the federal authorities and require ISO17025 accreditation.
In addition to these common services, certain institutes also include the following specific units and laboratories:
-A medical law unit has been developed at the institutes in Geneva and Bern.
-A psychiatric assessment Unit exists at the institutes in Basel, Bern and Geneva.
-The institute in Lausanne includes a laboratory for doping analysis and a violence medicine unit.
-The institute in Bern offers the services of a forensic imaging unit and that of a forensic physics and ballistics center.
The different activities of the six Institutes are financed in part by the fees charged for the forensic services rendered and in part by funds provided by the relevant cantonal authorities.
The institutes' staff is composed entirely of employees. A number of professions are represented: physicians, biologists, chemists, psychologists, laboratory technicians and assistants, secretaries and administrators. In the case of university-affiliated institutes, the supervisory staff, the physicians, the chemists and the biologists usually hold a university degree.
B. Legal medicine outside of the Institutes
In the cantons of Grisons, Neuchâtel, Ticino and Zug the medical examiners have a different status:
·In Neuchâtel, he is considered as liberal professional
·In the other three cantons, they work as employees of the cantonal administration.
All the medical examiners in these cantons hold forensic medicine specialty Diplomas. As a rule, they have undergone training in one of the institutes of legal medicine in Switzerland and with which they collaborate on a regular basis, in particular with regards to the laboratory analyses that need to be conducted.
3. Forensic evaluations
In Switzerland, different organizations may ask an institute of legal medicine or an extra-institute forensic expert to carry out a forensic evaluation. In most cases, these evaluations are ordered by judicial and police authorities. Occasionally, federal authorities may also be involved. In addition, cantonal administrations may also request an evaluation of one's driving capacities. Finally, forensic evaluations may also be carried out on the request of private individuals or non-governmental organizations such as the IRCC, the WHO, the IOC or international sports federations.
The Swiss institutes of legal medicine do not conduct evaluations of bodily damage due to accidents or to any other cause when such assessments are requested by insurance companies. Instead, this particular task is carried out by other expert physicians (internists, rheumatologists, orthopedists, etc.).
Requests for forensic evaluations are usually addressed to the director of the institute. Once the evaluation is completed, the institution issues a bill for the services rendered. The situation is different for extra-institute experts that either bill their services directly or receive salaries as state employees.
Judicial evaluations are principally aimed at determining the cause of death of a victim, the possible involvement of a third party in a death and the nature of such involvement, as well as the date and time of death. The identification of victims and the characterization of traumatic lesions inflicted during any type of assault, including sexual assault, are also common requests.
Forensic investigations often require complementary forensic toxicological analyses, such as the determination of blood-alcohol levels at the time of the event of interest, regular monitoring in substance abusers and tests certifying the absence of alcohol consumption using the appropriate biological markers.
In more general terms and whenever possible, the institutes of legal medicine always ready assist the judicial authorities by offering their expert medical opinion so that justice may prevail. The issues at stake may concern medical liability, drunk driving and even forensic psychiatry when the institutes have the appropriate expert staff.
Finally, the institutes of legal medicine also play an important role in providing expert advice in medical law and ethics when such advise is requested by hospitals or private practitioners.
a) Undergraduate training
Forensic medicine is part of the mandatory courses taken by every medical student in Switzerland and is one of the subjects of the Federal Medical Diploma examination. Although the medical diploma is indeed federal, undergraduate education is organized independently by each faculty of medicine. Forensic medicine is thus taught in different ways in different universities. In some cases, the subject is addressed exclusively in ex cathedra lectures. In other cases, a more interactive format is offered: workshops designed for groups of 8 to 10 students. Each faculty is also at liberty to decide which specific topics should be included in the course and which specific format, practical or theoretical, is used during the final examination. At the same time, a certain level of homogeneity is guaranteed thanks to a common, nationwide list of learning objectives in forensic medicine.
As a rule, the teaching of forensic medicine in every faculty covers classical issues such as forensic pathology, forensic toxicology, forensic genetics, traffic medicine and medical law, and ethics.
Finally, it should be noted that in some cases, the academic members of the institute of forensic medicine also participate in the teaching offered to law students.
b) Post-graduate training
A specialist diploma in forensic medicine may be obtained after receiving a Federal Diploma in Medicine and attending a five year program, which includes four years of training in an institute of legal medicine and one year training in a clinical or non-clinical setting. During the training period at the institute, one of the four years can be devoted to studying forensic psychiatry, forensic genetics or forensic toxicology. This particular training can be accomplished in an accredited foreign institution.
The post-graduate training required to obtain a given specialty Diploma is defined by the Swiss Medical Association (FMH), a privately held non-profit institution where every recognized medical specialty is represented by two members nominated by peers. In the case of legal medicine, the requirements for obtaining a specialty Diploma are relatively complex. The successful candidate must be familiar with a number of different forensic methodologies as specified by the Swiss Society of Legal medicine. In practice, each candidate is required to carry out a specific number of forensic investigations including examination of bodies, external examinations and autopsies. The candidate must also be knowledgeable about forensic toxicology, in particular with regards to the interpretation of analytical results. He or she must be familiar with forensic genetics, including paternity testing, analysis of trace material and interpretation of results. There are also other requirements such as demonstrated active participation in psychiatric evaluations, the ability to conduct driving capacity assessments, evaluations of traumatic lesions in an assault victim, determination of blood-alcohol levels, age determination, evaluation of a potential medical error, and others.
The successful candidate is also expected to be knowledgeable about medical law and ethics and to participate in different scientific meetings in legal medicine.
When all of theses conditions are met, the director of the institute where the candidate has been trained issues a certificate testifying that all the prerequisites for a specialist Diploma have been met. The candidate must then pass a full-day examination. The morning session includes an autopsy in the presence of two experts, followed by a written autopsy report and its conclusions, In the afternoon, the candidate is first asked to conduct an evaluation of traumatic lesions, either by examining a live victim or analyzing previously collected data. A second evaluation follows. It may focus on another set of traumatic lesions, or address a different topic, such as forensic toxicology, forensic genetics or traffic medicine. The examination also includes a series of general questions about legal medicine pertaining to medical law, determination of blood-alcohol levels, paternity searches, driving ability, etc.
c. Continuing Education
Every specialist in legal medicine is required to maintain his knowledge through continuing education. Continuing education activities usually consist in attending congresses, seminars and other scientific meetings. Compliance with continuing education requirements is rigorously controlled on behalf of the FMH by the Society of Legal Medicine. Thus, every specialist must earn a certain number of continuing education credits every year.
Research activities in legal medicine are carried out for the most part within the university institutes. Indeed only these institutions can provide the technical framework, all the competent staff and the critical mass of investigations necessary to conduct quality research. Research is funded by national or international granting agencies such as the Swiss National Fund for Scientific Research, different Federal Departments ( Health, Justices, Transportation, Sports) and a number of private foundations. Institutional grants are allocated to specific projects on a competitive basis and using independent evaluators.
The institutes of legal medicine participate in a number of collaborative research projects.
At a national level, the institutes collaborate among themselves and also with the Lausanne School of Criminal Sciences, currently headed by Professor Pierre Margot. International collaborations involve a number of different institutions and laboratories abroad. In practice, medical and non-medical scientists employed by the Swiss institutes have many opportunities to undergo additional training abroad. Funding is provided either by research grants or within the context of sabbatical stays granted by the home institution.
Current research projects in Switzerland cover many different areas of legal medicine. In some cases, individual institutes have focused on specific research subjects leading to international recognition in very precise domains. Thus, the Institute in Bern is known for its research on forensic imaging and for its concept of Virtopsyâ. In Lausanne, diaphanoscopic analyses are a specialty. Forensic molecular biology is actively researched at the Institute in Zürich which also maintains the national registry of genetic fingerprints. Lausanne is also a center for anti-doping analyses. The institute in Geneva focuses on alternative matrices for toxicological analyses, while psychiatry and bioethics are strongholds in both Basel and Geneva.
6. The Swiss Society of Legal Medicine
The Swiss Society of Legal Medicine was founded on December 13, 1980 by the Directors of the Institutes of Legal Medicine. Its first president and founding father was Professor Hubert Patscheider, the Director of the Institute of Legal Medicine of St-Gallen. According to the Society's articles of association , its members may include both legal medical doctors and other professionals involved in forensic activities, such as chemists, biologists and psychologists.
The Society meets twice a year. The winter meeting always takes place in Bern and has a fairly standard agenda. Firstly, reports are made by the different commissions and experts that represent the Society vis-à-vis other learned societies or international organizations. Secondly, a number of administrative issues are addressed, such as changes in the articles of association, admission of new members, and approvals of the treasurer's financial statement and of the President's activity report. The summer meeting is organized by a different Institute every year and is more scientific in nature. Thus, the members can usually attend at least one presentation made by a Swiss or foreign invited speaker on a topic of interest to forensic scientists.
The Swiss Society of Legal Medicine is also active through its specialty commissions which represent different domains of legal medicine (forensic medicine, forensic chemistry and toxicology, forensic genetics, traffic medicine). The specialty commissions play two important roles. The first role consists in ensuring good practices in the specialty. This may be accomplished by coordinating different activities through institutional directives and by conferring specialty titles on the basis of ad hoc directives. The second role is to represent the specialty vis-à-vis the Swiss political authorities. Indeed, the political authorities often require expert opinions that the specialty commissions are capable of providing. One example is the revision of the law that sets the maximum allowable alcohol levels when driving a vehicle. Another example is the introduction of tests aimed at identifying drivers that use illegal drugs or dangerous medical substances. Some of the issues are extremely complex: directives aimed at properly defining death in the context of organ transplantation, construction of human tissue banks, ethical issues surrounding end-of-life treatments, and many others.
Our description of the Swiss Society of Legal Medicine would not be complete if we did not mention its central role in the training of forensic specialists. Not only is the Society responsible for defining the conditions necessary to obtain the specialty Diploma, it is also instrumental in ensuring lasting professional excellence through mandatory continuing education. Indeed, every physician with an FMH specialization in legal medicine must be able to demonstrate that he or she is maintaining and updating his or her knowledge by engaging in continuing education activities. Oral presentations or written publications in relevant domains as well as active collaborations with the official organizations in a given specialty constitute additional requirements. The overall control of continuing education is indeed possible and enforceable because the minimum number of credits that a physician must earn each year are determined for each given specialty.
7. The six Swiss Institutes of Legal medicine
Institut für Rechtsmedizin der Universität
Pestalozzistrasse 22, Postfach, CH-4004 Basel
Telephone : (0041 61) 267 31 11
Telefax : (0041 61) 267 39 07
E-mail : firstname.lastname@example.org
Director and Head Physician: Prof. Volker Dittmann, MD
Institut für Rechtsmedizin der Universität
Bühlstrasse 20, CH-3012 Bern
Telephone : (0041 31) 631 84 11
Telefax : (0041 31) 631 38 33
E-mail : email@example.com
Co-Director: Prof. Ulrich Zollinger, MD
Institut universitaire de médecine légale
Centre médical universitaire
9 avenue de Champel, CH-1211 Genève 4
Telephone : (0041 22) 379 56 16
Telefax :(0041 22) 789 24 17
E-mail : firstname.lastname@example.org
Director and Head Physician: Prof. Timothy Harding, MD
Institut universitaire de médecine légale
Rue du Bugnon 21, CH-1005 Lausanne
Telephone : (0041 21) 314 70 70
Telefax : (0041 21) 314 70 90
E-mail : IUML.Central@chuv.ch
Director and Head Physician: Prof. Patrice Mangin, MD
Institut für Rechtsmedizin am Kantonsspital
Rorschacherstrasse 93, CH-9007 St-Gallen
Telephone : (0041 71) 494 21 52
Telefax : (0041 21) 494 28 75
E-mail : email@example.com
Director and Head Physician: Prof. Thomas Sigrist,MD
Institute of Forensic Medicine, University of Zurich
Telephone : (0041 44) 635 56 11
Telefax : (0041 44) 635 68 51
Director and Head Physician: Prof. Michael Thali, MD, EMBA HSG
- H.J. Mallach, Geschichte der Gerichtlichen Medizin im deutschsprachigen Raum, Schmidt-Römhild Verlag, Lübeck, 1996.
- Michael Th. Mund and Walter Bär, Legal medicine in Switzerland, Forensic. Sci. Intern. 2004, 144, 151-155.
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