Raisonnement médico-légal dans la détermination de l’incapacité totale de travail : une étude qualitative à l’unité médico-judiciaire de l’Hôtel-Dieu de Paris

Objectives

In French forensic medical units, medical doctors are requested to assess the functional impact of violence on its victims and to determine a total incapacity for work (ITT). Specific to French criminal law, with significant consequences in the judicial field, this practice is highly heterogeneous with considerable differences depending on the center and the assessor. The objective of this qualitative study was to describe the assessment methods of practitioners in the forensic medical unit at the Hôtel-Dieu Hospital in Paris, where both forensic practitioners and psychiatrists contribute to the evaluation of total incapacity for work.

Materials and methods

Semi-structured individual interviews were conducted with four forensic medical practitioners and four psychiatrists. The questionnaire addressed the evaluation methods and tools, the impact of the kinds of violence and their possible chronicity, as well as the rationale for a dual-evaluation by both a forensic practitioner and a psychiatrist.

Results

In the absence of consensual tools, practitioners tend to take into account the judicial consequences of their assessment of total incapacity for work, while striving to establish an internal coherence between a fact, an injury and its functional repercussions. The osteoarticular system is given as a model, with determined durations of bone healing, while the field of psychotraumatology lacks a similar data set and requires the practitioners to aim to relate the traumatic impact on the daily consequences reported by patients. Forensic practitioners and psychiatrists differ in the extent to which they take into account the plaintiffs’ grievances and the assessment of chronic violence cases. The former tend to determine an incapacity for work based on a clinical lesion, either assessed during their own clinical exam or reported in a former medical certificate, while the latter establish an incapacity for work grounded in the functional consequences reported by patients, especially in cases of psychotraumatic symptoms (sleep disorders, avoidance symptoms, and social interaction limitations, for example) following a physical or sexual assault. A dual-assessment is seen as an efficient way to ensure that the psychological impact of violence is taken into account. However the question arises of the systematic recourse to a psychiatrist or another professional trained in the field of psychotraumatology. The assessment and the clinical symptoms are specific and require appropriate training. Medical certificates are also considered to be judicial material with a broader implication than the sole determination of total incapacity for work. In reporting griefs and the circumstances of the events which have an impact on the clinical situation of the patient, the practitioners also provide qualitative data that a judge may take into account.

Conclusions

This exploratory study describes certain methodological principles used by forensic practitioners and psychiatrists and the inter-specialty variability in the determination of total incapacity for work. It reflects a common expectation for consensual practices based on non-binding indicators. In civil expertise, tools and methodological principals are delineated and discussed, with scales and psychometric instruments which could usefully be relayed to practitioners in forensic medical units dealing with the evaluation of total incapacity for work, a notion that remains specific to French criminal law and whose evaluation standards may also be discussed with practitioners in the judicial field.