Few Important Facts about Category of Hurt

I have already taken classes on medico-legal documents and category of hurt for a few clinical groups. During the discussions I found that 'hurt' and its 'categories' had confused most of those young minds. No body should feel disheartened for not being able to understand these concepts as, some would sarcastically say that  they are meant to be confusing. Anyway the truth is that most of the forensic medical experts, including me, still find categorisation of some injuries difficult.

Although it has now been well-established that the doctor should categorise the injury on MLEF (Medico-Legal Examination Form) initially and MLR (Medico-Legal Report) later (and in the high court as well), it is my understanding that the doctor's role really is only to describe the injury and the court should categorise the injury based on the information provided by the doctor.

[I have read in one of the judgement given by a well-known judge (I cannot remember the reference.) where he categorically says that the doctor's role (in expressing opinion not confined to category of hurt) is to describe the scientific criteria he used in his opinion to the court. So that they can form their own opinion using the same criteria used by the doctor. ]

Since the police, prosecutors (Attorney General's Department), defence lawyers and judges expect the doctor to categorise hurt we do not have an alternative but to acquiesce with their 'demand'.

On the other hand giving category of hurt on the MLEF may have a purpose. As you already know that it is a police form and the very brief information the doctor provides on it is used by the police in deciding the kind of action they are supposed to take with regard to the case.

Categorisation of hurt is a sort of a scale used in measuring the 'severity of an injury'. However, it is not the sole criterion used by the courts in sentencing a perpetrator of a crime. For instance, using a firearm to injure a person is considered  to be a serious offence, so much so that even if it has caused a mere abrasion the wrongdoer could be charged for attempted murder.

Although the 'hurt' is defined in the Sri Lankan Penal Code (SLPC) as 'bodily pain, disease of infirmity' (Section 310) all the different types of injuries designated as 'grievous hurt' are physical injuries and their sequelae. ('Hurt' constitutes physical injuries as well as poisoning, mental disorders, infections such as STDs etc. To cause hurt there needn't even be physical contact.)

When you look at MLEF and MLR carefully you would realise that the police and courts wants to know only an injury is 'grievous' or 'non-greivous' (forget about 'endagering life' and 'fatal in the ordinary course of nature' for the moment). They are not concerned with 'hurt' (all the diseases, bodily pains and infirmities of non-physical origin). Therefore the doctor is only required to deal with physical injuries with regard to MLEF and MLR especially in categorising injuries.

The grievous injuries are defined under the Section 311. And they also say that only the kinds of hurt given are grievous (The following kinds of hurt are only designated as grievous.) although there may be infinite number of injuries as it were. The doctor's job is to decide whether a given injury is grievous first. If not it is categorised as non-grievous. In other words, non-grievous injuries are injuries which are not grievous. It is a kind of funny logic isn''t it?

An inquisitive observer might wonder why injury endangering life', though it is one of designated grievous injuries, has been given a separate box in the MLEF. The reason behind this is that the law takes 'injuries endangering life' more seriously, for instance, than a mere fracture of a tooth crown for obvious reasons, though both are 'grievous injuries'. Therefore, depending on circumstances such as intention, motive and many others the prosecutor may decide to charge and a court may decide to sentence a person who is responsible for causing an 'innjury endangering life' for not causing 'grievous hurt' but for attempting to kill (attempted murder and culpable homicide). That is the reason why the police wants to know whether the injury is endangering life when the doctor says it is grievous.  

[What I am going to describe here is beyond your curriculum content. Therefore, these paragraphs (font colour is red) should only be read by those who are interested in seeking knowledge and understanding and not only in passing the exam.  

There is one more 'category of hurt' called 'injury likely to cause death' which does not appear in the MLEF or MLR as it comes under the offences of 'Culpable Homicide' (Section 293) and 'Murder' (Section 294). (A homicide can either be 'culpable homicide not amounting to murder', lesser offence, or 'murder', the ultimate offence, the punishment of which is 'death'.) 

However, there is no consensus among the medical and legal communities about its definition and even whether it is a separate category of hurt.

If a man dies after receiving injury, which is  fatal in the ordinary course of nature, the suspect may be charged for 'murder' (of course the other elements of the offence should be fulfilled such as 'intention' etc.). If he survives the suspect may be charged for 'attempted murder'. That's the reason why 'fatal in the ordinary course of nature is included in the MLEF.

In the same way if a man dies after receiving an' injury likely to cause death' the suspect may be charged for either 'culpable homicide not amounting to murder' or 'murder' depending on many other factors. If the man survives the suspect may be charged for either 'attempted culpable homicide' or 'attempted murder' again depending of many other circumstances.  

This is because 'injury likely to cause death' appears both in the law of culpable homicide (293) and murder (294) whereas injury fatal in the ordinary course of nature to cause death appears only in law of murder.

Therefore, one would wonder why the 'injury likely to cause death' does not appear on the MLEF and MLR when 'injury fatal in the ordinary cause of nature' has places in both of them. The only logical explanation is that the relevant authorities may consider 'injury endangers life' as equal to 'injury likely to cause death' when the victim is dead. ]

Inclusion of 'fatal in the ordinary cause of nature' is for obvious reasons. If a person inflicted an injury with intention on another person and that injury is 'suffiient in the ordinary course of nature to cause death he or she will be charged for 'murder' if the victim is dead or charged for 'attempted murder' if the victim is alive.

(We should not get too involved with 'legal concepts' and 'definitions'. We should understand the law only to the extent that gives us the understanding to execute our duty efficiently. We should always remember to stick to our discipline in terms of expression of opinion. Therefore unnecessary flirting with law should be discouraged.)

Categorisation of injuries to 'endangering life' an 'fatal in the ordinary course of nature'.

Categorisation in to 'non-grievous' and 'grivous' excluding 'endangering life' is relatively easy, I would say. The problems arises only when it comes to 'endangering life' and 'fatal in the ordinary course of nature.

When categorising injuries it should be remembered that we categorise only the 'injuries' and not the 'actions'. In order to understand this one must be aware of the difference between 'action' and its result, which in this case is an 'injury'. For instance, in a case of attempted manual strangulation the victim may present with finger nail abrasions and bruises on the neck. The category of injury is only non-grievous even if the action would have endangered the life of the victim. Only if the victim presents with bilateral florid petechial haemorrhages in the tarsal plates and conjunctivae the category of hurt would be 'endangering life'.

We can say that an injury endangers life when there is an existing possibility (threat to life) of death as opposed to 'potential' and 'imminent' threats. Every injury may have a potential threat to life if a serious complication develops such as tetanus on a nail prick. Injuries which have imminent threat to life are 'injuries fatal in the ordinary course of nature. Injury endanger life lies in between these two extremities so to speak.

If one analyses these two entities more carefully he/she would realises that 'injuries fatal in the ordinary course of nature' would also include the 'injuries endangering life'. In other words when an injury is fatal in the ordinary course of nature it would also endanger the life of the person. Therefore, when defining these categories one should understand that injuries endangering life are the injuries which only 'endangers life'.

 

Every injury to the human body has a 'potential' to cause death as a result of unforeseen or rare complication. For instance a 'nail prick' can be fatal if it is infected with tetanus. But a nail prick is just a non-grievous injury (not even a grievous injury). Whereas in the case of injury endangers life the dangerousness of the injury or possibility of it causing death is felt at the time of the doctor's examination. The doctor knows that the chance of death, however remote, is there, so much so that he/she will not let the patient discharged but keep under observation until the danger passes off even if no active intervention is planned.  For instance, a patient who is unconscious as a result of concussion will be kept under observation in order to prevent him from being asphyxiated or aspirated his own stomach contents even if the doctor would not attempt any active intervention. Would any doctor behave in the same way with a patient who has got a nail prick and come for a toxoid injection to the OPD?

Injuries fatal in the ordinary course of nature have a very high probability of death if not intervened actively ( will be fatal if prompt and proper care is not given.). The doctor will not keep the patient under observation as he would do in the case of the patient with concussion. He will have to do something actively (usually a surgery) to prevent a fatal outcome. For instance a patient with a stab injury to the heart what would the doctor do? Would he/she put him under observation or would he/she take him to the theatre and operate on him?

Injuries endangering life have a low probability of causing death by injury itself or giving rise to complications which might cause death e.g. head injury with concussion has a low probability of causing death by itself. It gives rise to complications such as aspiration or asphyxia very rarely.

Injuries fatal in the ordinary cause of nature have a very high probability of causing death by injury itself or giving rise to complications which might cause death e.g. stab injury to the abdomen causing perforation of the small intestines. Although small intestinal perforation does not cause death by itself it has a very high probability of being complicated by peritonitis and causing death as a result. Therefore, the category of hurt should be fatal in the ordinary course of nature.

If a non-grievous injury develops a complication and it puts the life of the patient in danger as a result it can now be categorised as 'endangering life' provided that the doctor has to specifically mention that the injury itself is 'non-grievos' but because of the complication it has now become 'endangering life' e.g. patient with nail prick who has developed tetanus.

When a doctor examines a patient with injuries and categorise hurt should he/she consider the patient as a whole or only the injury itself? For instance a cut injury which may not be fatal in the ordinary course of nature in a healthy individual will become such in a person with a bleeding disorder. It is my opinion that the doctor should only categorise the injury forgetting about the idiosyncratic factors. If it has become fatal in the ordinary course of nature or endangering life as a result of some other concurrent disease such as a bleeding disorder it should be mentioned in the remarks column. 

A decision as to whether an injury has a potential, existing of imminent threat to life is based on 'proabability'. No scientist would be able to calculate the probability of causing death of each and every type of injury with any mathematical certainty. (One would say this is based on 'inductive reasoning' rather than 'deuductive reasoning'. The best example of 'inductive reasoning' is 'All the swans we have seen are white. Therefore, all swans are white. This was held absolutely true until the European explorers re-discovered 'black' swans from Australia.) Based on past experiences of collective medical mind we calculate the probability of a given injury. Probably this may have given the categorisation of injury a vibrance which would have otherwise been a dull and dry mathematical calculation. This may be true for all branches of medicine. That is why it is regarded as more of an art than a science. 

 

Finally in categorising injuries especially to endangering life and fatal in the ordinary course of nature one should not be too dogmatic. Although medical experts have defined them in order to have a uniformity what matters is how the non-medical people including lawyers and more importantly the general public understand it. We can split hair on theses matters till the sun goes down but at the end of the day what counts is our ability to convince the lay public.

 

Priyanjith Perera

28/12/2012