Table Of ContentFORENSIC ASPECTS
OF HYPOGLYCAEMIA
FORENSIC ASPECTS
OF HYPOGLYCAEMIA
Vincent Marks
DM, FRCP, FRCPath, MAE
University of Surrey
Surrey, UK
CRC Press
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CONTENTS
Preface vii
About the Author xi
Introduction xiii
Acknowledgments xix
1 The Control of Blood Glucose in Health and Disease:
Hypoglycaemia 1
2 Petty Crime 27
3 Violence and Aggression 49
4 Accident and Negligence 67
5 Spontaneous (or Non-Iatrogenic) Hypoglycaemia 97
6 Driving Offences 119
7 Hypoglycaemia from Drugs including Insulin and
Sulphonylureas 147
8 Forensic Investigation of Hypoglycaemia 175
9 Factitious Hypoglycaemia and Suicide 227
10 Murder; Single Individuals 261
11 Munchausen by Proxy: Infanticide and Murder of
Children 293
vi contents
12 Murder and Attempted Murder with Insulin by Carers 321
13 Confessions 347
14 Frequently Asked Questions 359
15 Expert Witness 371
Index 375
PREFACE
Forensic medicine is the science that deals with the application
of medical facts and methods of investigation to legal problems
and criminal matters. Hypoglycaemia, which is the term used to
describe a low blood glucose concentration, is a common cause of
people appearing in court. It may be raised by the defence because
of the way it can change behaviour or by the prosecution because
it has been used as weapon.
Hypoglycaemia is not a disease but a consequence of it and can
lead to radical and always temporary changes in behaviour that can
turn a normally law-abiding citizen into a criminal. The only com-
mon cause of hypoglycaemia encountered in practice is insulin, the
best-known drug used for treating diabetes. Paradoxically, insulin
can, through its ability to produce hypoglycaemia, also be used as
a murder weapon.
Hypoglycaemia has many causes apart from the overtreatment
of diabetes with insulin, but, because overtreatment is so common,
it has led to confusion between hypoglycaemia and diabetes – its
exact opposite. Although the ways that hypoglycaemia affects peo-
ple are the same throughout the world, the ways the law deals with
it are different. This presents a problem in preparing a book deal-
ing with both the medical and legal aspects of hypoglycaemia and
this book concentrates solely on the medical aspects of the subject.
Glucose is the only sugar that circulates in the blood of mankind
in anything more than miniscule amounts. It is one of the two main
fuels used by the tissues to maintain their vital functions. In most
tissues – the nervous system being the most important exception –
fats and their partially oxidised metabolites, known as ketones, can
fulfill this function equally as well as glucose. It is therefore the
viii preface
nervous system that bears the brunt of any shortage of glucose sup-
ply, and all the adverse effects of hypoglycaemia are because of it.
In healthy people the concentration of glucose in the blood is
tightly controlled by a complex system involving the liver, the ali-
mentary tract and a number of hormones of which two, insulin and
glucagon, both produced in the pancreas, are far and away the most
important. The whole process of blood glucose control is referred
to as glucose homeostasis. When this goes wrong, it leads to either
an abnormally high concentration of glucose in the blood (hyper-
glycaemia) or, more rarely, to an abnormally low concentration of
glucose in the blood (hypoglycaemia). This book is concerned only
with hypoglycaemia, its effect upon brain function and how this
leads to conflicts with the law.
Hypoglycaemia, in contrast to diabetes, is comparatively uncom-
mon in the general population. Though known to exist from the
time it first became possible to measure glucose in the blood in the
late nineteenth century, almost nothing was known of its effects on
the body until insulin was first used for the treatment of diabetes in
1922. Within a year, it became apparent that the effects of hypogly-
caemia on a person’s well-being and behaviour were just as dramatic
as that of diabetes, but totally different.
Hypoglycaemia occurs most commonly in people undergoing
treatment for diabetes, either with insulin or one of the sulphonyl-
urea class of drugs in everyday clinical practice, but it can arise de
novo as a manifestation of many types of disease.
Signs and symptoms of hypoglycaemia are usually quite mild,
and people who use insulin to treat their diabetes recognise them
for what they are and can rapidly bring them to an end by eating
or drinking something sugary. Sometimes, however, it produces
changes in behaviour that bring the sufferer into contact with
the law. Offences can vary in intensity and severity from the use
of abusive language, petty theft and dangerous driving to mania-
cal homicide. Most jurisdictions accept that a person affected by
hypoglycaemia may be incapable of formulating intent to commit
a crime, leading to them being exonerated or having their offence
mitigated.
preface ix
There are other ways than misbehaviour in which hypoglycae-
mia plays a key role in cases that come before the courts. Failure
by professional health carers to recognise and treat it properly can
lead to charges of medical negligence, and both insulin and sulpho-
nylureas have been used as murder weapons, to enhance sporting
performance and for other criminal practices.
In the 95 years or so since the discovery of insulin, an exten-
sive literature on hypoglycaemia and the law has been published,
mostly in the biomedical and legal literature. There is, however,
no authoritative text designed to be read by both lawyers and bio-
medical personnel called upon to prosecute, defend or give expert
advice in civil, criminal or coronial cases in which hypoglycaemia
plays a key role.
This book largely summarises my experience of hypoglycaemia
spanning some 50-plus years and is an attempt to correct this defi-
ciency. I have used cases in which I have been personally involved
to illustrate some of the problems that arise in a forensic situation,
as well as drawn extensively on the published literature, as these
differ in many important respects from those experienced in the
everyday practice of medicine.
I have referred to the relevant scientific, medical and legal litera-
ture for the benefit of those who need it for their own professional
purposes without, I hope, interfering with the pleasure of those
reading the book out of interest or curiosity. Some of the names of
individuals and locations have been altered to protect the innocent.
