Historical Shifts in China’s Forensic Medicine Education and Service Mode Since 1949

Abstract

China (only China mainland included in this article) differs significantly from any other country of the world, in terms of its current system of forensic medicine, which could be generally characterized by “the three world’s firsts”: the world’s first to establish undergraduate degree in forensic medicine nationally, the world’s first to add forensic medicine division to police criminal investigation system nationally, and the world’s first to permit market-oriented forensic medicine services nationally. To understand how such an interesting system was developed, the important historical shifts in China’s forensic medicine education and service mode that have ever occurred since 1949 are analyzed in this article. Then the advantages and deficiencies of the current system are briefly discussed. Finally, principles for China’s future forensic medicine system are proposed.

Introduction

China has a long and rich history of forensic medicine that can date back to the Qin (also Chin) Dynasty (221-207 BC) or even earlier. For example, the bamboo slips (named Yumeng Qinjian) unearthed in December 1975 recorded Qin Lv (the Qin Law), Fa Lv Wen Da (the Legal Issues & Interpretations), and Feng Zhen Shi (Models for Sealing and Physical Examinations), in which some topics on forensic medicine and methods to inquest, inspect, or perform medicolegal examinations were mentioned or described (1). Another example is that the world’s earliest systematic book on forensic medicine Xi Yuan Ji Lu (the Washing Away of Wrongs) was edited by Song Ci (also Sung Tzu, 1186-1247) during Song Dynasty China, in which the structured methodology on investigations into death of different manners/causes were provided (2). It was such an influential book that it was used as the reference in all subsequent dynasties (Song, Yuan, Ming, and Qing Dynasties) and the Republican China, though partial contents prove to be unscientific from the contemporary point of view (3).

It was also in the Republican China (1911-1949) that the autopsy based modern medicolegal examination methodology became official. During this period of time, Professor Lin Ji who was later regarded as the father of modern Chinese forensic medicine established the China’s first forensic medicine institute and exerted all his energies to promote the application of modern forensic techniques and draft blueprint for China’s forensic medicine system (4). Detailed stories for this period of history were well depicted vividly in many Chinese works by modern Chinese forensic historian Huang Ruiting and also in the book Death in Beijing: Murder and Forensic Science in Republican China by American historian Deniel Asen.

After the foundation of the People’s Republic of China in October 1949, development of Chinese forensic medicine had to start over from the beginning because the forensic institute built by Lin Ji was almost destroyed during the war in 1937 and from then on only handful of people kept working in the field of forensic medicine. Nowadays, China has formed a forensic medicine system that is significantly different from either the typical university institute based forensic system in the European continent or the coroner/medical examiner system in the English speaking countries/regions. The current system in China generally has three distinctions that could be described as “the three world’s firsts”: the world’s first to establish undergraduate degree in forensic medicine nationally, the world’s first to add forensic medicine division to police criminal investigation system nationally, and the world’s first to permit market-oriented forensic medicine services nationally. How did such an interesting system come into being step-by-step after 1949? What are the advantages and deficiencies of the current system? To answer those questions, this article carefully studied the important historical shifts in China’s forensic medicine education and service modes that have ever occurred since 1949. Then brief comments on the current system were made by the author from a comparative point of view and finally a new system for the future is proposed.

Methods

Most references that are cited in the article on China’s forensic medicine history are mainly derived from the three most frequently used and the largest Chinese electronic literature databases, CNKI (5), WANFANG DATA (6), and VIP (7). In addition, two history books (in Chinese language) The World History of Forensic Medicine and Sciences by Jia Jingtao and The Development History of the Chinese Modern Forensic Medicine by Huang Ruiting are also included. Law and regulation information regarding Chinese forensic medicine are retrieved from Beida Fabao-Laws & Regulations Chinese Database (8).

The author has been studying forensic medicine (pathology) since the year 2008 and started a research The Comparative Forensic Medicine: the Comparative Study on World Forensic Medicine Paradigms as a PhD student from the year 2016. He was also one of the main contributors to the study Development Strategies for Chinese Forensic Medical Sciences (2017), a national study granted by Chinese Academy of Engineering. The author went to Switzerland for a 12-months study from October 2017 to October 2018 on forensic imaging (virtopsy) as well as forensic medicine systems in European countries. Therefore, in this article, the author will not only review historical opinions by other authors but also express some of his own understandings that are acquired during the abovementioned research period.

Results and Discussion

Historical Shifts in China’s Forensic Medicine Education and Service Mode

Historical shifts in China’s forensic medicine education

Preparation Stage (1949-1956)

When the People’s Republic of China was founded in 1949, the number of people who could keep on working in the field of forensic medicine was extremely limited which posed a big threat to the China’s judicial system. As “justice delayed was justice denied,” the justice system could not wait so many years as medical students would need for adequate education and training and became qualified forensic doctors. It was urgent, under such background, to develop a mechanism by which medical students could easily access to forensic medicine knowledge so that they could go to serve the justice system with the shortest delay. Naturally, medical colleges were considered to be the best teaching places. However, although “where to teach” and “whom to teach” had become clear, there were still no answers for many questions, such as “who teach,” “what to teach,” and “how to teach,” due to the vacancies of syllabus, textbooks, and teachers in forensic medicine at this stage. To fill those gaps, a series of targeted measures were taken. For example, the first and second Senior Forensic Teachers Training Programs were held by Lin Ji and others in 1951 and by Chen Dongqi and others (from Shenyang Medical College) in 1955 separately, by which means, the number of forensic teaching staff as well as teaching units at medical colleges soon increased. Other measures were that in 1950 the Medical Textbook Compilation Committee set a special group responsible for compiling forensic medicine textbooks, in 1954 the Ministry of Health promulgated the first teaching syllabus on forensic medicine (compulsory course) for all medical students and in 1955 a Russian forensic medicine textbook by Popov was translated into Chinese language being used as a trial textbook for all medical students. However, teams of forensic doctors could not be built in a day from medical colleges or schools, a more effective and immediate way of education and training was still indispensable. Fortunately, the forensic medicine institute destroyed in the war (1937) got reconstructed in 1951 and soon launched 3 short-term forensic training programs (1952-1956), through which approximate 400 “forensic doctors” went promptly to work for the judicial system that already could not brook any delay (9,10).

It could be concluded that this was a successful period for China’s forensic medicine education after 1949, especially when the significantly increased number of teaching units and staff and the presence of compulsory forensic courses for the first time in higher medical education system are considered.

Period of Backwardness (1957-1978)

The preparation stage had not lasted for a full decade when the so called “left-leaning” mistakes prevailed in China from 1957. As consequences of this, the compulsory forensic courses at all medical colleges were removed from their syllabus and the forensic teaching units were dismissed soon after 1959. What was worse, the reconstructed forensic institute was also hit which was at first merged into the public security system in 1959 and later was disbanded totally in 1960. Misfortunes did not come alone during this period. In 1966, the Cultural Revolution started resulting in national disorders and thereafter the education of forensic medicine went down to another lowest level in history. The tragedy lasted for almost one decade (1966-1976), and only when it completely ended was the whole country able to return to normal orders (11).

So during this period of time, there was not any progress in forensic medicine education. More precisely, it was an education backward phase for over two decades, because of the two major setbacks.

Healthy Development Stage of Undergraduate Degree Education (1979-2019)

Not until the new national policy “Reform & Open-up” was implemented in China in October 1978 did the whole society become invigorated and start to put all energies into developing every field of the country. In July 1979, the codification of China’s first Criminal Law and first Criminal Procedure Law were both accomplished. In the same year, the Ministry of Health requested all medical colleges to rebuild their forensic teaching units and staff. More importantly, taking into account that teaching forensic medicine as a compulsory course alone would not immediately fulfill the “crying needs” of the judicial system for large numbers of forensic doctors, the Ministry of Health made a decision to initiate a new forensic education mode: “the forensic medical undergraduate (bachelor) degree education mode (FMUDEM),” which had not existed before in China or elsewhere in the world. At the beginning (still in 1979), the trial of this creative FMUDEM started at only three medical colleges (namely Shenyang, Sichuan, and Zhongshan Medical Colleges), situated respectively in the northeast, southwest, and west of China, according to the China’s territory. From then on, high school graduates who met the required entrance examination scores could choose to study forensic medicine as their major at these three medical colleges. In 1982, a comprehensive research of the nationwide need for forensic doctors was requested by the Ministry of Education. This kind of research was conducted for the first time and the result was almost dumbfounding: as many as around 10 000 forensic doctors were needed nationwide; however, by the end of 1982, the total number of forensic medical students at the three abovementioned medical colleges and Shanxi Medical College (starting forensic medicine undergraduate degree in 1980) was not more than 250. So in 1983, the representatives on behalf of the Ministry of Education, the Ministry of Public Security, the Ministry of Justice, the Ministry of Health, the Supreme People’s Court, and the Supreme People’s Procuratorate convened a special meeting in Shanxi Province (where Shanxi Medical College located). The representatives of the Ministry of Education expressed their great worry about the huge gap between forensic doctors needed in the judicial system and the extremely weak capacity of the Chinese forensic medicine education, and therefore defined forensic medicine specialty as “duanban zhuanye” (meaning “the weakest-of-the-weakest specialty”) in China. The representatives at the meeting reached a consensus that it was urgent to further promote forensic medicine specialty in higher education, appropriate essential educational resources, compile professional forensic medicine textbooks, and add compulsory forensic courses to medical colleges. In 1984, the State Education Commission permitted 6 medical colleges to build forensic medicine department (FMD), each of which could admit 60 new high school graduates per year. In 1985, under the State Education Commission’s supervision, the compilation of 8 professional forensic medicine textbooks was finished. Finally in 1986, the State Education Commission added forensic medicine to the State Higher Education Specialty List. From then on, forensic medicine has existed at medical colleges as a formal medical specialty (Table 1) (12,13). By now, over 20 medical colleges (or universities) have the forensic medical specialty within their FMDs or forensic medicine schools (FMSs) and offer undergraduate degree education (Table 2). What’s more, most FMDs or FMSs are equipped with advanced laboratories, experienced forensic teaching staff, and affiliated Forensic Science Centers as practical training bases.

Table 1:

Important Events Regarding China’s Forensic Medicine Education and Corresponding Developmental Stages Since 1949 (11 -14).

Year	Events	Stages
1950	Foundation of Forensic Medicine Group within Medical Textbook Compilation Committee.	Preparatory
1951	First Senior Forensic Teachers Training Program.
1954	First forensic medicine teaching syllabus.
1955	Second Senior Forensic Teachers Training Program.
1959	Forensic Medicine Teaching Units at medical colleges/universities were dismissed due to “left-leaning” mistakes.	Backward
1966	The Cultural Revolution started.
1976	The Cultural Revolution ended.
1979	The Ministry of Health permitted the reconstruction of the teaching units and initiated the undergraduate degree in forensic medicine specialty in the higher education system.	Healthy
1983	The Ministry of Education defined forensic medicine as “Duanban Zhuanye” in Opinions on Higher Medical Education Reform.
1983	The National Higher Forensic Medical Education Forum was held by the Ministry of Education with the Ministry of Public Security, the Ministry of Justice, the Ministry of Health, the Supreme People’s Court and the Supreme People’s Procuratorate.
1984	Foundation of the National Forensic Medicine Textbook Compilation Committee.
1984	The Ministry of Health and the Ministry of Education agreed to set department of forensic medicine at 6 medical universities.
1985	First meeting of Forensic Medicine Education Supervisory Committee, requiring that eight textbooks be finished within 3 years.
1986	Forensic medicine was defined as the 6th medical category.
1996	Xi’an Jiaotong University initiated the first Forensic Medicine School.
2019	Over 20 medical colleges or universities have offered forensic medicine undergraduate degree education.

Table 2:

Universities/Colleges Offering Forensic Medicine Undergraduate Degree Education.

No.	Universities/Colleges	City/Province	Degree starting year	Department starting year	School starting year
1	China Medical University (15)	Shenyang/Liaoning	1979	1985	2000
2	Zhongshan University (16)	Guangzhou/Guangdong	1979	1984	NA
3	Sichuan University (17)	Chengdu/Sichuan	1979	1984	1999
4	Shanxi Medical University (18)	Taiyuan/Shanxi	1980	NA	2001
5	Fudan University (19)	Shanghai	1984	1984	NA
6	Kunming Medical University (20)	Kunming/Yunnan	1984	1988	2002
7	Xi’an Jiaotong University (21)	Xi’an/Shanxi	1985	1985	1996
8	Huazhong University of Science & Technology (22)	Wuhan/Hubei	1985	1985	NA
9	Wannan Medical College (23)	Wuhu/Anhui	1987	1986	NA
10	Suzhou University (24)	Suzhou/Jiangsu	2001	2008	NA
11	Henan University of Science & Technology (25)	Luoyang/Henan	2002	NA	NA
12	Wenzhou Medical University (26)	Wenzhou/Zhejiang	2002	NA	NA
13	North Sichuan Medical College (27)	Nanchong/Sichuan	2002	2002	NA
14	Nanjing Medical University (28)	Nanjing/Jiangsu	2003	NA	2005
15	Hebei Medical University (29)	Shijiazhuang/Hebei	2003	NA	2017
16	Zunyi Medical College (30)	Zunyi/Guizhou	2003	2008	2017
17	Xinxiang Medical College (31)	Xinxiang/Henan	2003	2013	2017
18	Xinjiang Medical University (32)	Urumchi/Xinjiang	2007	NA	NA
19	Chongqing Medical University (33)	Chongqing	2007	NA	NA
20	Central South University (34)	Changsha/Hunan	2013	2002	2005
21	Southern Medical University (35)	Guangzhou/Guangdong	2014	2008	2016
22	Hangzhou Medical College (36)	Hangzhou/Zhejiang	2019	NA	NA

Chinese forensic medicine has experienced a healthy and rapid development stage from 1979 to 2019. During these 40 years, continuing importance has been attached to forensic medicine specialty development at a national level (Table 1). Forensic medicine has become not only compulsory courses for all medical students but also a definite medical specialty in the national higher education system. In addition, many Forensic Medicine Teaching Units (FMTU) has developed into FMDs or even FMSs, and by the year 2019, more than 20 medical colleges/universities can offer forensic medicine undergraduate degree education indicating that the novel forensic medicine education mode has already become entrenched in the China’s higher education system (14).

Historical shifts in China’s forensic medicine service mode

Like any other country in the world, China’s forensic medicine service mode is largely influenced by the statutes, specifically, the medical or criminal law articles on death investigation and autopsy procedures. Generally speaking, China’s forensic medicine service modes have always been scattered since the foundation of the People’s Republic of China in 1949 except for the national disorder period (1958-1978). However, the multiple Jurisdiction at different historical stages were significantly distinct from each other, which could be classified into “Scattered Jurisdiction I (1950-1957),” “Scattered Jurisdiction II (1958-1978),” and “Scattered Jurisdiction III (2005-2019).” In addition, there was also a period of “Unified (Police) Service Provision (1958-1978)” which was between “Scattered Jurisdiction I” and “Scattered Jurisdiction II” (Table 3).

Table 3:

Major Laws/Rules or Events Influencing China’s Forensic Medicine Service Mode Since 1949.

Stages	Laws/rules or events	Key points/articles	Service mode
1950-1957	Interim Rules on Autopsy 1950	Autopsies were classified into “anatomical autopsy,” “pathological autopsy,” and medicolegal (forensic) autopsy. Cadavers that could be autopsied were strictly defined. Autopsied could be performed in forensic medicine service units (FMSU) within judiciary authorities, medical universities/colleges, and hospitals.	Scattered Jurisdiction I: FMSU scattered in the Police System, the Procuratorate System, the Court System, medical universities/colleges and hospitals.
	Rules on Autopsy 1957	Definition of the cadavers that could be autopsied expanded (45).
1958-1978	Left leaning mistakes and the Cultural Revolution	FMSU scattered in the Procuratorate System, the Court System, and medical universities/colleges and hospitals were dismissed.	Unified (police) Service Provision: only FMSU in the Police System survived.
1979-2004	Revised Rules on Autopsy 1979	Autopsies were clearly defined into three categories, followed by a clear definition of cadavers that could be autopsied within each category (46).	Scattered Jurisdiction II: FMSU scattered in the Police System, the Procuratorate System, the Court System, and medical universities/colleges.
	Criminal Procedure Law of the People’s Republic of China 1979	Article 74. If the cause of a death is unclear, a public security organ shall have the power to order an autopsy and shall notify the family members of the deceased to be present (47).
2005-2020	Decision of the Standing Committee of the National People’s Congress on the Administration of Judicial Authentication 2005	Article 3. The judicial administrative department of the State Council shall be responsible for the management of the register of authenticators and authentication institutions throughout the country. The judicial administrative department of a provincial people’s government shall, under this Decision, be responsible for registering the authenticators and authentication institutions, creating rosters and making announcements. Article 7. An authentication institution established by an investigating organ for the purpose of investigation may not accept the entrustment of the general public to make judicial authentications. No authentication institution may be established by the people’s court or judicial administrative organ (41).	Scattered Jurisdiction III: FMSU scattered in the Police System, the Procuratorate System, medical universities/colleges and market-oriented private companies.
	Registration rule for internal forensic medicine and sciences service units of the police system(May 1, 2020)	The internal FMSU of the police system will be supervised by a new internal department, namely “the Register Management Department of the Forensic Service Units” (48).
	Law of the People’s Republic of China on the Promotion of Basic Medical and Health Care (June 1, 2020)	It may have great influence on the development of forensic medicine as more autopsies could be encouraged to support basic medical studies (49).

Scattered Jurisdiction I (1950-1957)

After the People’s Republic of China was founded in 1949, increasing number of forensic cases appeared in the investigation, prosecution, or judge procedure. However, as the whole justice system was very new, the police, procurators, and judges regularly had difficulties in handling medicolegal evidence. In order to improve judicial efficiency, forensic medicine service units (FMSU) were directly added to all the above systems naturally, indicating that each system had “legal right” to order medicolegal autopsies and to use the forensic medicine service within its own system (or within its entrusted FMSU at medical colleges and hospitals) (37). So the typical characteristics for “Scattered Jurisdiction I” were:

1. The “legal right” to order forensic autopsies was widely scattered in the investigation, prosecution, and judge system.

2. Each system had its own internal FMSU by which forensic medicine service could be immediately provided.

Unified (police) Service Provision (1958-1978)

“Scattered Jurisdiction I” had not lasted a decade when “the left-leaning mistakes” and “the Cultural Revolution” occurred and almost caused the breakdown of the judicial system. The direct impact of such events was that the internal FMSU in the prosecutorial system and the judge system were totally removed (37). Since only FMSU within the police system survived, the characteristics for this period of time were:

1. The police system was the only authority that could order forensic autopsies.

2. It was also the only system that could use the internal forensic medicine service.

Scattered Jurisdiction II (1979-2004)

China has entered into a new era since 1979 and great changes have taken place, such as the accomplishment of the first Criminal Procedure Law of the People’s Republic of China, the restoration of FMSU in the prosecutorial system and the judge system and the significantly growing number of advanced FMSU at medical colleges or universities. At first thought, it seems that time had returned to “Scattered Jurisdiction I” which was characterized by the scattered “legal right” to order forensic autopsies in three systems and the existence of internal FMSU in each of these systems. In fact, “Scattered Jurisdiction II” differed from “Scattered Jurisdiction I” in two major aspects. First, according to the China’s first Criminal Procedure Law, only the police system was clearly empowered to order autopsy when the cause of death was thought to be unclear, indicating that the police system turned more dominant in conducting the forensic autopsy process or the medicolegal death investigations. Therefore, although FMSU were restored in the prosecutorial system and the judge system, they functioned more as forensic expert consultants, who were mostly responsible for reviewing the medical evidences submitted to the procurators (by the police) or presented to the judges (by both sides in the court). Another great change was that a considerable number of advanced FMSU (forensic medicine and science centers) appeared at medical colleges and universities, thanks to a large amount of education resources and funds being located to forensic medicine specialty. In addition, most young forensic doctors working inside the three systems were once students of these medical colleges or universities, so they very much trusted in their teachers’ capability in forensic medicine services and regularly brought medicolegal cases to medical college or university based FMSU. Therefore, during this period, more and more forensic autopsies were being transferred to medical college or university FMSU from the prosecutorial system, the judge system, and the police system (38,39).

We could see there was a significant mode shift from “Scattered Jurisdiction I” (1950-1957) to “Scattered Jurisdiction II” (1979-2004). The latter could be seen as an advanced Scattered Jurisdiction that was developed on the basis of “Scattered Jurisdiction I.” The characteristics of “Scattered Jurisdiction II” could be described as follow:

1. Legal responsibilities became more definite. The police system turned to be the real legal conductor of forensic autopsy process, while the other two systems mainly served as consultants of the procurators and judges, though they also had power to order medicolegal service in the latter stages.

2. Considerable cooperation appeared between medical college/university based FMSU and internal FMSU of the police, prosecutorial, and judge systems.

Scattered Jurisdiction III (2005-2019)

As “Scattered Jurisdiction II” lasted more than 2 decades, some new challenges were accumulated. The most controversial issues were the unnecessarily repetitive FMSU located in different systems and the absence of a unified system for supervising the quality of forensic medicine and science services. Here is a case to illustrate such problems.

CASE

On February 24, 2003, a 21-year-old female music teacher was found dead (naked) in her dormitory at a city primary school. By June 8, 2003, postmortem examinations had been performed for 3 times by the district, city, and province police bureau, separately, and consistent natural cause of death was given. However, the bereaved family was unsatisfied with results thus requiring more postmortem examinations. On July 3 and August 14, the 4th and 5th examinations of the deceased were carried out at 2 medical university based FMSU separately and their results were against the previous ones, claiming that no sufficient evidences supported the death caused by natural disease. On August 2, the Supreme People’s Court ordered the 6th postmortem examination and their result was that the death was caused by the development of her underlying diseases (rheumatic and coronary heart diseases) combined with a contributory factor (unusual sex behavior administrated by her boyfriend). Even though the bereaved family stopped requiring further postmortem investigations, the contradictory opinions still existed especially between the police system and others (40).

This was just a representative case in which postmortem examinations of a same deceased were performed at least twice but contradictory opinions or findings were given. As the number of similar cases was increasing nationwide, the capability and credibility of FMSU within the police, procuratorial, and judge systems were questioned or even challenged by the public.

To address such problems, on February 28, 2005, the National People’s Congress (the highest legal authority in China) issued a decision regarding the unified administration of forensic medicine and science services entitled Decision of the Standing Committee of the National People’s Congress on the Administration of Judicial Authentication. As it was made by the National People’s Congress, the decision had the same level of legal power as any other Chinese laws (41). The key points of this decision were as follow:

1. All FMSU were under supervision of the Ministry/Department of Justice, except for the internal ones within the investigation organs (police and prosecutor’s offices).

2. Legal basis for founding market based FMSU was provided.

3. Internal FMSU of the court system were dismissed.

4. Internal FMSU of the police system and the prosecutorial system survived for their extensive use in the criminal investigation process.

The practical results during this period of time indicated that the influence of the decision was tremendous. In 2005, nearly 4000 market based forensic medicine/sciences service units (FMSSU) were registered (providing at least one service item: clinical forensic medicine, forensic pathology, forensic psychiatry, DNA analysis, drug testing/toxicology, digital forensics, and forensic engineering) and this number increased to over 5000 in 2011. However, “the more the better” did not apply to this situation. Problems soon appeared when continuous vicious competition and frequent defective products were found in the forensic service market. So the experience learnt from these 6 years was that the market based forensic service system indeed could quickly attract large amount of capital investment in forensic industry but the administrative cost also significantly increased. To improve the forensic service market environment, an “admittance-and-exit mechanism” was implemented to raise the admittance standard for new FMSU and to eliminate the existing underdeveloped ones. By the year 2017, the number of FMSSU had declined to 4338, but there are still as many as 700 market based FMSU left. So up to now, the FMSU supervised by the Ministry of Justice are mainly market based (42 -44). While the internal FMSU of the investigation organs (the police system and the prosecutorial system) were not (and are not likely to be) under the supervision of the Ministry of Justice.

So compared with “Scattered Jurisdiction II (1979-2004),” “Scattered Jurisdiction III (2005-2020)” has the following distinctions:

1. Two camps have taken form. The Ministry of Justice supervises market or medical college/university based FMSU while the investigation organs (the police system and prosecutorial system) supervise their internal ones, separately.

2. Three major types of FMSU that are based on different backgrounds coexist side by side.

3. The internal FMSU of the police system (and the prosecutorial system) have wide cooperation with either the market based ones or the medical college/university based ones. While the market based FMSU have competitive relations with each other as well as with the medical college/university based ones.

4. The judge system no longer has the internal FMSU, so it has to entrust the market or medical college/university based FMSU when necessary.

Major Advantages and Deficiencies of the Current Forensic Medicine System

As described above, the most significant characteristics of current system are the forensic medical undergraduate degree education, the internal FMSU of the police criminal investigation system, and the market oriented FMSU. Advantages and deficiencies of the China’s forensic medicine system will be discussed based on these three aspects, separately.

The forensic medicine undergraduate degree education

That the number of forensic medical doctors (pathologists) is always insufficient is a common challenge worldwide. Great efforts were made in China’s history in order to establish a mechanism by which large numbers of forensic medical doctors can be quickly provided to the justice system. The earliest effort was to make forensic medicine compulsory courses at all medical colleges believing that medical students who had interest in forensic medicine may choose to work as forensic medical doctors for the justice system. However, the result turned out to be unsatisfactory. Then Forensic Medical Undergraduate Degree Education (FMUDE) started at three medical colleges. Not until a research on the nationwide need of forensic doctors was finished in 1983, was the FMUDE mode introduced to more medical colleges or universities. In addition, with sufficient education resources and funds at a national level, the FMTUs at these medical colleges or universities soon developed into FMDs in late 1980s and then into FMSs in late 1990s. Now, over 20 medical colleges/universities have FMD or FMS functioning as the cradles of forensic medical doctors, and each year about 1400 forensic medical students can graduate and go to work at the internal FMSU of the police system or the FMSU based on private companies. Therefore, the biggest advantage of the current forensic medical education mode is the great capacity to admit a sufficient number of high school graduates and to successfully guide them to work as forensic medical doctors after leaving medical colleges or universities.

On the other hand, the there are also some obvious deficiencies. As the whole FMUDE is only 5 years in length, the biggest challenge of this education mode is that the undergraduate students could hardly receive sufficient practical training, especially in forensic autopsy and forensic histopathology within such a short term. To overcome this problem, a 5-years-on-job training is required before a forensic medical student can apply for the qualification certificate. Unfortunately, the number of forensic autopsy cases performed in most FMSU especially the market based ones is very variable and limited (an example in Table 4). So the forensic medical doctors holding the qualification certificates are not always qualified indicating the training standard is much less strict than the one in typical continental European countries or USA.

Table 4:

Forensic Pathology Cases by 7 Regional FMSU of Dian Forensics Company in 2019.

Regional FMSU	Case number	Items
Beijing	12	Include a large proportion of postmortem external examination (most deaths due to traffic accident) a small proportion of full autopsy with external examination, histopathology and toxicology (e.g., deaths due to malpractice) a small proportion of diatom detection (e.g., in internal organs from drowning victims)
Hunan	52
Shanxi	64
Nei Mongol	120
Zhejiang	166
Jilin	113
Tianjin	402

Abbreviations: FMSU, forensic medicine service units.

The internal FMSU of the police system

Not like the internal ones in the prosecutorial system and the judge system, the internal FMSU of the police system has been there throughout all historical stages since it appeared after 1949. Currently, there are at least 3000 FMSU and estimated over 10 000 certified forensic medical doctors in the whole police system at a province, prefecture/municipal, county/district or township level, which represent the most important power in the current forensic medicine service system in China (50). Some advantages of the internal FMSU in the police system are obvious:

1. It has raised need for forensic medicine to a countrywide level and has brought forensic medical doctors to the public attention.

2. As a public security service unit of police system, it has direct access to sufficient financial allocation from the government to regularly advance their working conditions, facilities, techniques, and so on.

3. Forensic medical doctors are able go to death scene with the investigators immediately when deaths are reported to the police system, so they are privileged to more investigative power for collection of more raw data regarding the death.

There are also some major deficiencies:

1. The internal FMSU of the police system conduct death investigation but their core value is to serve for criminal cases. So only when the external postmortem examination shows signs of presence of crime will the autopsy be ordered by them, resulting in a very low autopsy rate in China (an estimated autopsy rate, 3‰-8‰).

2. The internal FMSU of the police system has cut forensic medicine into two halves: “unnatural-death forensic medicine” or “criminal forensic medicine” in the internal FMSU of the police system, and “natural-death forensic medicine” or “non-criminal forensic medicine” in market and medical college/university based FMSU. This is fatal to development of academic forensic medicine: Forensic professors at college/university FMSU have limited access to unnatural death case materials although they have great research interests in them, while the internal FMSU of the police system, due to numerous daily death scenes to go to, are too busy to design a research plan.

The market oriented FMSU

The market based FMSU is the second largest power, just next to those in the police system. The presence of private FMSU nationwide has aroused fierce discussions since 2005, due to their main interest in capital return. Other deficiencies of the market based FMSU include:

1. They cause vicious competition of forensic service market and may damage the judicial authority.

2. They breed bribery and corruption between the internal FMSU of the police system and the market based ones.

1. Their on-job training standard for forensic medical students is relatively low, compared with either the internal FMSU or the medical college/university based ones.

Some advantages of the market based FMSU cannot be overlooked, including:

1. Large amount of capital investment can be attracted to forensic medicine service industry.

2. They have more enthusiasm to improve their service standard in order to achieve more market share.

Principles for China’s Future Forensic Medicine System

“Comparative Forensic Medicine,” the comparative study of world’s existing forensic medicine system paradigms, will do nothing but give comprehensive reference data, useful tools for interpreting a specific problem or phenomenon faced in a country, and principles for making laws and policy decisions. A very brief summary of comparative forensic medicine systems by the author are given in Table 5, according to which principles for the new China’s future forensic medicine system are proposed, as follow:

1. It should be built on the modern values of forensic medicine including health promotion and death prevention and medicine research and improvement, as “court medicine” especially the “criminal forensic medicine” is just very small tip of the huge iceberg.

2. So the new system should be totally independent from any specific justice system, such as the police, prosecutorial, and judge systems.

3. Forensic medicine research, education, training, and service should be done at the same location with direct sufficient national level funding resources.

4. The number and distribution of new service entity should be strictly calculated according to the autopsy numbers at a specific province or city, in order to guarantee sufficient autopsy/histopathology training resources for forensic medical students and the required sample sizes for scientific researches.

Table 5:

Comparative Advantages and Deficiencies of World’s Forensic Medicine Systems.

System	Example	Advantages	Deficiencies
Coroner system	England and Wales	It has monopoly power to order autopsy. Cause-of-death oriented system results in a large autopsy number and practical training opportunities.	The academic nature of forensic medicine is weakened, so there are fewer forensic institutes. Without enough institutes, there will less education resources at universities, leading to insufficient number of forensic pathologists.
Medical Examiner System	Some States of United States	Decision-making power to order autopsy handed over to medical professionals reduces mistakes made by layman.	The number of forensic pathologists is insufficient due to very few forensic institutes or resources for university education.
University Institute Based System	Germany	Sufficient resources in both theoretical lecturing and practical training are available.	It has to face the great pressure to compete with other disciplines in academic output.
Hospital Forensic Medicine Unit Based System	France	Modern instruments (e.g., CT, MR) and medical technologies are available.	The system is relatively decentralized and practice standard can be variable among different forensic medicine units. Supervision of the system can be a problem.
National Institute Based System	Sweden	Infrastructure construction is supported directly from a national level. Practical training and research resources are sufficient. Supervision of the system is easier. A small number of forensic doctors are needed.	The system is relatively centralized and can be very busy. Time spent on education and training in forensic medicine may be hard to guarantee.

Author

Zhiyuan Xia PhD, MD, Institute of Evidence Law and Forensic Science, China University of Political Science and Law (CUPL)

Roles: Project conception and/or design, data acquisition, analysis and/or interpretation, manuscript creation and/or revision, approved final version for publication, accountable for all aspects of the work, principal investigator of the current study