Thursday, May 8, 2008

Part Two: Dr. Ernest Cutz's Recommendations: Thinking Dirty V. Scientific Objectivity When It Comes To Sudden Unexpected Death of Children;




Dr. Ernest Cutz, a distinguished pathologist at the Hospital for Sick Children in Toronto, has drafted his personal recommendations for the Goudge Inquiry, which have been posted on the Inquiry's Web-site.

Dr. Cutz's views are well worth considering because he has been at the Hospital for several decades and is steeped in all aspects of the Pathology Department -including the Ontario Forensic Pediatric Pathology Unit.

This Blog continues our series on Dr. Cutz's submissions with his thoughts on the need to emphasize research aimed at preventing Sudden Infant Death Syndrome - rather then criminalizing parents and caregivers on the base of unsound sound.

Dr. Cutz addresses this recommendation to three of the systemic factors being explored by the Goudge Commission:

0: What is the approach that best balances the objective that no individual be wrongly accused of child abuse with the objective that children be protected from abuse?

0: What are the relative merits of “thinking dirty” or “thinking truth” or other alternatives? and,

0: How is scientific objectivity best maintained throughout the examination to avoid “tunnel vision” that merely seeks support for an a priori conclusion?

(In an earlier Blog, I recorded Dr. Cutz's disagreement with the controversial "think dirty" protocol released by then Chief Coroner Dr. James Young to all of Ontario's coroner's, pathologists and chiefs of police, on April 10, 1995. I have repeated this post below for the benefit of our readers who did not have the opportunity to peruse it; It ran under the heading: "Think Dirty"; Part One: Two Words At The Heart Of The Inquiry;")

"The (above) objectives can be achieved by the provision of correct pathologic diagnoses based on solid scientific foundations," recommendation begins;

"The acquisition of and advances in medical knowledge are dependent on robust scientific research that constantly evolves and progresses over time," it continues;

"The Inquiry has seen how this evolution in thinking occurs through exposure to the debate and recent changes in attitude with respect to the interpretation of findings relating to Shaken Baby Syndrome.

Similar changes in attitude and thinking have occurred in the areas of Sudden Unexpected Infant Death, Sudden Infant Death Syndrome, and related conditions.

For example, during the 1990s a prevalent, early view was that Sudden Unexpected Infant Death and Sudden Infant Death Syndrome occurred due to “positional asphyxia”, overlaying caused by co-sleeping, or homicide.

These views have not been substantiated by solid scientific evidence.

Now, the prone sleeping position and co-sleeping are recognized as risk factors but are not the actual cause of death in sudden Infant Death Syndrome;

Today we know that Sudden Infant Death Syndrome is a pediatric disease recognized by the World Health Organization as a distinct pediatric medical disease entity.

In addition, Sudden Infant Death Syndrome is not a uniform entity but rather a heterogeneous multifactorial disorder with variable triggering and potentiating factors.

This is as exemplified by the so-called “triple risk model”, i.e. Sudden Infant Death Syndrome occurs as a result of interactions involving (1) a vulnerable infant who possesses some underlining biological abnormality; (2) a critical period of development; and (3) an exogenous stressor such as maternal smoking, mild infection or an unsafe sleeping position.

Current thinking in this area, which reflects recent advances in molecular medicine, indicates that an underlining biological abnormality in large proportion of Sudden Unexpected Infant Deaths and Sudden Infant Death Syndrome cases may, in fact, be due to genetic or molecular disorders (i.e. defects in cardiac or neuronal ion channels, etc.) that are now detectable by modern techniques of molecular pathology.

Notwithstanding these changes, confusion between what are risk factors for Sudden Infant Death Syndrome and what is the actual cause of death in Sudden Infant Death Syndrome persists in certain forensic circles.

Individuals in these circles continue to identify the cause of death in Sudden Infant Death Syndrome cases as being, for example, co-sleeping, which is inaccurate and misleading.

If Sudden Infant Death Syndrome was due to this simple explanation, how could one explain the fact that babies have slept in these situations for many years, but only some die while many do not?

Identifying a baby’s sleep environment as the sole factor responsible for the infant’s death gives only part of the explanation and leads to feelings of guilt and, potentially, to wrongful accusations of parents and caregivers.

Given the importance of accurately identifying and describing cause of death, it is problematic that there is currently very limited or non-existent scientific research on Sudden Unexpected Infant Death and Sudden Infant Death Syndrome;

This is partly due to the fact that the mandate of the Chief Coroner's Office which oversees all pediatric forensic cases, does not include research into medical diseases and because the current legislation and all agreements between the Chief Coroner's Office and the Hospital for Sick Children (including the most recent Ontario Pediatric Forensic Unit agreement)... explicitly forbid the use of tissues for medical research.

Furthermore, it is my view that research scientists are discouraged from pursuing basic research into Sudden Infant Death Syndrome since it remains under a cloud of suspicion and subject of criminal investigation.

To overcome the obstacles surrounding the use of tissues for research individual parental consent can be obtained or a legislative change, similar to that of the State of California, which authorizes and mandates research into Sudden Unexpected Infant Death and Sudden Infant Death Syndrome could be made.

Consequently an “Ontario Center for the study of Sudden Infant Death Syndrome/Sudden Unexpected Infant Death, based on the San Diego Sudden Infant Death Syndrome/Sudden Unexpected Infant Death Research Project database model, should be established at HSC with collaboration projects that include other Ontario pediatric academic centers that perform autopsies on Sudden Infant Death Syndrome/ Sudden Unexpected Infant Death cases.

Funding for the Center should be provided by the Ministry of Long Term Health;

Further, to encourage research in Sudden Unexpected Infant Death and Sudden Infant Death Syndrome, targeted, competitive, peer-reviewed research grants into Sudden Unexpected Infant Death and Sudden Infant Death Syndrome in a form of “Request for Application” should be issued by the Government of Ontario and by the Federal Government through Canadian Institute of Health Research/Institute of Child Health.

The resulting research is important because it would define protocols and methods for molecular diagnoses of disorders underlying Sudden Unexpected Infant Death and Sudden Infant Death Syndrome (for example, the specific channelopaties affecting the cardiovascular or nervous systems).

These new diagnostic tests could provide objective scientific evidence that would be exculpatory in contentious cases of infant death.

The tests would be analogous to DNA tests used currently in the criminal justice system.

When, if at all, should the terms “Sudden Infant Death Sndrome" and "Sudden Unexpected Infant Death" be used in a post mortem report?

These terms are well established and widely accepted in Pediatric clinical and pathology practice.

There is no compelling reason to not to use them in a post-mortem report.

The definition and terminology related to Sudden Infant Death Syndrome and Sudden Unexpected Infant Death has been the subject of a recent review and update by an international panel of experts comprised of paediatric and forensic pathologists with extensive experience in Sudden Unexpected Infant Death Syndrome;

The panel also included pediatricians and an epidemiologist.

It is important to use the correct terminology with respect to Sudden Unexpected Infant Death and Sudden Infant Death Syndrome so that accurate statistics are generated to monitor the incidence and trends of Sudden Unexpected Infant Death and Sudden Infant Death Syndrome as well as to ensure that well-defined groups of cases are used in research studies.

My recommendation is to adopt the use the criteria and definitions outlined in the above publication in Ontario.

c) With advances in Sudden Infant Death Syndrome research it will be possible in the future to render specific pathological diagnoses which will have the effect of removing ambiguity as to the cause and manner of death.

This will reduce the number of cases that today are designated as “undetermined” or “unascertained”.


Here is the earlier Blog on which articulates Dr. Cutz's disagreement with the controversial "think dirty" protocol released by then Chief Coroner Dr. James Young to all of Ontario's coroner's, pathologists and chiefs of police, on April 10, 1995:



Two words, containing only three syllables lie at the heart of the Goudge Inquiry: "Think Dirty."

They are contained in a protocol issued by former chief coroner Dr. James Young to all coroners, pathologists, and chiefs of police in Ontario on April 10, 1995.

The policy was ultimately dropped by Dr. Barry McLellan, Dr. Young's successor, after he became Chief Coroner in April, 2004;

The protocol read:

"Unfortunately, in this day and age, child abuse is a real issue, and it is extremely important that all members of the investigative team "Think Dirty."

They must actively investigate each case as potential child abuse, and not come to a premature conclusion regarding the cause and manner of death until the complete investigation is finished, and all members of the team are satisfied with the conclusion."

During the nine years the protocol remained in effect, these words communicated through "think dirty" slides that were used in presentations to coroners throughout the province and other members of the death investigation teams.

The obvious danger of the new policy was that it could be interpreted as requiring local coroners and pathologists to act like police officers instead of as impartial doctors and scientists.

There was also a risk that it could encourage pathologists and prosecutors to feel that they were required to search for criminality behind every death of a child.

A risk that it could turn most innocent death of a child into a murder with all of the horrific consequences, to loving parents, families and caregivers that we have seen thus far at the Goudge Inquiry - especially since Dr. Young's new policy was introduced at a time of heightened public fear over child abuse and pressure on the authorities to do something about it.

At the very least, this Bloggist wonders if the new policy may have validated Dr. Charles Smith's suspicious approach to his work in his own mind - when he still had years of work to accomplish.

In fact, Dr. Young testified that he got the idea from a cop, adopted it, and used it in his own presentations.

Dr. Young told the Inquiry that the "Think Dirty" approach was formulated during a period of world-wide concern "that pediatric deaths weren't being properly investigated."

"(We) were very aware and there were discussions, again, at any forensic meeting about the difficulties in investigating pediatric deaths, and the fact that they -- children died of different things than adults did; and the very difficult job of sorting out metabolic disorders, SIDS, cases of Shaken Baby, cases of
subtle -- suffocation, of subtle child abuse, and dating of injuries, you know, to make sure that what was attributed to the death was -- was relevant," he told Commissioner Goudge.

Young testified that the new protocol was simply intended to remind people to look out for signs of criminality during the course of their investigations.-

Young stressed that, " It was not -- absolutely not, and it was never contemplated or discussed at any meeting I ever attended where the phrase was used, to mean that make cases -- make cases criminal matters when they aren't.

But he agreed with Commission Counsel Mark Sandler that, "with the benefit of -- of what we've learned since, it might be advisable for the Chief Coroner's Office to -- to develop another phrase to communicate the same sentiment."

The new policy troubled Dr. Ernest Cutz, a distinguished pathologist and researcher at the Hospital for Sick Children.

Dr. Cutz is one of the world's leading authorities on the Sudden Infant Death Syndrome (SIDS);

Cutz told the Inquiry he found the concept of "thinking dirty" inappropriate because he interpreted as saying, "you are implying guilt up front, and, you know, until proven otherwise."

"I use the balanced approach," he said. "Looking at the facts and evidence, you know, regardless of what the motto is."

Cutz said that it made sense to be alert to the possibility of criminality in those relatively few cases where there had been a history with law enforcement or involvement with a Children's Aid Society.

However, he objected to the protocol because, "too heavy on the side of the forensic" as contrasted with the function of "Looking (at) what is the cause of death and...what what are the diseases and mechanism underlying it."

Doctor Cutz noted that he had voiced his objections to the protocol to the late Dr. Larry Becker, Head of the Pathology Department, but was not aware if Dr. Becker passed his objections on to the Chief Coroner's Office.

He said, however, that he had seen reference in correspondence to a meeting at ended by senior officials of the Chief Coroners Office, including Dr. Bernard Chiasson, at which Dr. Becker raised his own concerns about the policy.

On January 21, 1997, Dr. Cutz wrote a letter to Dr. Chiasson at the Chief Coroner's Office requesting a meeting to discuss information he had received from Dr. Becker that the Coroner's office was considering removing himself and a colleague from the rotation for performing medico-legal autopsies at the hospital.

The transcript of Dr. Cutz's testimony on this subject reads as follows:

MS. JENNIFER MCALEER: (Commission Counsel); And what -- what else did Dr. Becker tell you?

DR. ERNEST CUTZ: Well, you know, he said that, you know, if -- if I want any -- any sort of explanation as to the reasons and/or, you know, what -- what -- how can one mediate the situation, I have to -- to see Dr. Chiasson.

MS. JENNIFER MCALEER: And did you, in fact, meet with Dr. Chiasson --

DR. ERNEST CUTZ: Yes, I did.

MS. JENNIFER MCALEER: -- to discuss this issue?


MS. JENNIFER MCALEER: And what -- what was your recollection of those discussions?

DR. ERNEST CUTZ: Well, I sort of outline in my letter here that, you know, the -- my experience at doing these cases at the Hospital for Sick Children and
outlining my, you know, experience in the different kinds of conditions which include, you know, natural deaths as well as -- as well as cases of child maltreatment or suspected homicide. And I bring to his attention one (1)
particular illustrated case to show that I have the same level of concern and erudition in carrying out pathology investigations, and I give -- give him example of it.

MS. JENNIFER MCALEER: Well, did Dr. Chiasson explain to you why -- well, first of all, did he verify what Dr. Becker had told you, that there was a
prospect that you and Dr. Wilson would be removed from the roster doing medicolegal work? Did he tell you that was something they were considering?

DR. ERNEST CUTZ: Well, when I asked for the meeting I said, This is what I'd like to discuss with him. So he didn't sort of say, you know, You're going to
be removed. But, you know, we were discussing the -- the situation.

MS. JENNIFER MCALEER: And what was your understanding as a result of your letter and your meeting with Dr. Chiasson? Did you continue to perform
medicolegal autopsies?

DR. ERNEST CUTZ: Yes, I did.

MS. JENNIFER MCALEER: And was your performance of those medicolegal autopsies restricted in any way?

DR. ERNEST CUTZ: No, it wasn't restricted. I continued, as before, doing the non- homicide cases. You know, when I asked as to what the reasons were for removing me, it was sort of very vague. Something saying I was soft on crime, and I didn't collab-- or cooperate with the police which came to me as a 1 total surprise.

MS. JENNIFER MCALEER: Okay. So who said you were soft on crime?

DR. ERNEST CUTZ: Dr. Chiasson. Or there was a perception of.

MS. JENNIFER MCALEER: And do you know what the basis of that perception was?

DR. ERNEST CUTZ: He didn't explain, didn't give examples.

MS. JENNIFER MCALEER: And -- and the second reason was because you had difficulty communicating with the police?

DR. ERNEST CUTZ: No, that I did not cooperate with the police, which came as a total surprise, as I don't recall any incident. I was most cooperative at all instances with the police. I had no reason to -- so it came as a total surprise to me.

MS. JENNIFER MCALEER: And did Dr. Chiasson explain to you what the basis of that concern was --

DR. ERNEST CUTZ: He said he has -- he has no specific examples.

MS. JENNIFER MCALEER: Okay. Did you discuss this issue with Dr. Smith?


MS. JENNIFER MCALEER: And after -- after this point in time, Dr. Cutz, you did continue to do medicolegal autopsies?

DR. ERNEST CUTZ: That's right. I thought the meeting with Dr. Chiasson was useful because we cleared the air, you know, this -- this -- to see what
the problems were. And, you know, actually I -- I -- part of the letter was -- you know, I gave him the breakdown of all the cases I did in the past five (5)
years, which was two hundred, twenty-five (225) cases, and -- and show him that, you know, it -- major portion were pediatric disease, which is no way anybody would have diagnosis outside of a pediatric centre. Okay. So -- so we -- we rendered a very valuable service to -- to making the right diagnosis for
the families. Okay. And then I show him the percentage of cases which went to inquests, which went to -- okay, which -- in every instance I was involved, a correct diagnosis was made, the crime was pursued, the crime was prosecuted and the person was jailed for -- for the crime.

For his part, Dr. Chaisson testified at the Inquiry that he had concerns about Dr. Cutz's and his colleague's "attitude over forensics."

Pressed by Commissioner Goudge over what he meant by their "attitude over forensics" Dr. Chiasson replied:

"From a pediatric pathology perspective, they were not insignificant, and -- and it wasn't simply the number of -- of cases as -- as much as my perception that when it came to cases they -- they weren't really as apprised at looking at injuries and the potential significance of -- of injuries as, was my view of, Dr. Smith, who was clearly interested in pediatric forensic pathology and -- and, you know, whose focus was in that - - that area."

The good news is that Dr. Barry McLellan put the "think dirty" protocol to rest when he became chief Coroner.

"(My) own teaching in recent years has been that it's important to keep an open mind. But, I can tell you that "think dirty" slides and the phrase "think dirty" was removed from many of the standard presentations that we were giving to members of the death investigation team".

"When I redid the presentation that the coroner's office gives as part of the major case management course, that was taken out of the course," McLellan explained.

"So, I can't say that there has been a specific effort to send out a communication saying, Don't think dirty, but the approach has been different through our educational courses, through our new courses for coroners, and the emphasis is to keep an open mind. And, as such, you know, we'll end up with the best quality of death investigation."

I will give the last word for this posting to Dr. Michael Pollanen, Ontario's Chief Forensic Pathologist, who told the Ontario Court of Appeal in the Mullins-Johnson case that new guidelines effectively tell Ontario's pathologists and coroners: "Don't think dirty; Think objectively. Think truth."