Measures are considered coercive if they are carried out against the patient’s wishes or in spite of his/her opposition. In medical practice, coercion can take several forms, their ethical and legal status ranging from «necessary» to «completely unacceptable».
In recent decades, the principle of patient autonomy has become widely accepted in medical ethics. At the same time, discrepancies between the patient’s choice and medically indicated measures can arise. In emergency situations – for example, acute agitation or postoperative delirium – where the patient (temporarily) lacks capacity, the question whether to use coercive measures often arises.
How can patient autonomy be respected in these situations? When is it ethically permissible or essential to take urgent medical measures if the patient has not consented or even actively resists? The guidelines «Coercive measures in medicine» published by the SAMS in 2015 provide a framework for resolving conflicts of this kind.
Since 2018, the editorial team of Primary and Hospital Care has illustrated the medical-ethical guidelines of the SAMS with case studies. In the second edition, the guidelines on coercive measures in medicine are discussed with a case study on hyperactive delirium (in French or in German). More case studies of other medical-ethical guidelines by the SAMS can be found here.
Revision of the guidelines
Developments in medical ethics and legislation have made it necessary to revise the «Coercive measures in medicine» guidelines from 2015. The SAMS and Central Ethics Committee (CEC) have received remarks and inquiries in recent years, indicating practical aspects that need to be considered from a medical-ethical perspective. To this end, the CEC has set up an interprofessional and interdisciplinary subcommittee.
The UN Convention on the Rights of Persons with Disabilities, which Switzerland ratified in 2014, has led to an intensive debate among experts and the public in recent years, including on coercive medical measures. At the heart of this debate lies the Convention’s call to replace the principle of «substitution» (e.g., through guardianship) with the principle of «assistance» as far as possible for people with disabilities. The CEC subcommittee will consider this issue in the revision of the guidelines, as well as the amendments to the Swiss Federal Child and Adult Protection Act currently under revision.
Aim and procedure
The use of coercion in medicine not only raises medical-ethical questions for healthcare professionals, but also has serious consequences for patients and their families. To understand all the ethical aspects at stake, the perspectives of those affected during and after coercive medical interventions must be taken into account. The subcommittee will therefore involve various stakeholder organisations, rather than a single patient or family representative, as is usually the case in CEC subcommittees.
The guidelines are designed to raise and maintain awareness of the fact that coercive measures of any kind constitute a serious infringement of personal rights and thus require ethical justification in each case. Compliance with procedural requirements in itself does not justify the use of coercive measures. Careful ethical reflection is essential in all cases, as is strict compliance with legal provisions and applicable guidelines.
The subcommittee has started its work on the guideline revision in December 2023. The process for drafting and revising SAMS guidelines is described in the following document.
Composition of the subcommittee
Prof. em. Dr. med. Dr. phil. Paul Hoff, Zollikon, Chair, Psychiatry und Psychotherapy
Beat Baumgartner, Spiez, Paramedics
Dr. med. Gabriela Bieri-Brüning, Zürich, Geriatrics/Inpatient long-term Care
Susanne Brauer, PhD, Zürich, Ethics
Dr. rer. cur. Christian Markus Burr, Bern, Psychiatric care/Research
Dr. med. Marianne Caflisch, Genève, Paediatrics
Anne Fishman-Bosc, MSc, Payerne, Intensive Care Nursing
Dr. rer. medic. Martin Fröhlich, Aarau, Intensive Care Medicine
Prof. em. Dr. Dr. h.c. Thomas Geiser, St. Gallen, Law
Dr. sc. med. Manya Hendriks, SAMW (ex officio), Ethics
Prof. Dr. med. Stefan Klöppel, Bern, Geriatric Psychiatry
Marcel Koch, Wittenbach, Curative Education
Dr. med. Patrick Köck, Bern, Child and Adolescent Psychiatry
Dr. med. Stéphane Morandi, Lausanne, Psychiatry and Psychotherapy/Psychiatry and Psychotherapy for Addiction
Dr. phil. Simone Romagnoli, Genève, Ethics/Nursing homes
Bianca Schaffert-Witvliet, Schlieren, ANP Medicine, Long-term Care
Prof. Dr. med. Manuel Trachsel, Basel, Ethics/Psychiatry
lic. iur. Judith Wyder, Bern, Federal Office of Justice, Law (Observer)
Ursina Zehnder, Zürich, Outpatient Care/Psychiatry