Swiss Academy of Medical Sciences (SAMS), Bern, Switzerland
The Swiss Academy of Medical Sciences (SAMS) welcomes this opportunity to respond to the article by Merlo et al.  and would like to use it, first of all, to express its appreciation: firstly, to the hospital staff of the canton of Ticino, which was struck by the full force of the first wave of the pandemic, and from whose experience hospitals throughout Switzerland subsequently benefited; secondly, to the authors of the study, which is extremely valuable for the work of the SAMS. In addition, we hope that the following comments will help to clarify certain questions raised by the article.
The so-called “triage guidelines” elucidate Section 9.3 (“Resource scarcity and triage”) of the medical-ethical guidelines on “Intensive-care interventions” published in 2013, which also form part of the Code of the Swiss Medical Association (FMH). This guidance was prepared at the suggestion of, and in collaboration with, the Swiss Society of Intensive Care Medicine (SSICM). The study conducted in Ticino relates to version 2 of the “triage guidelines”, published on 24 March 2020. In more recent versions, the experience of the first wave has been taken into account (latest revision: version 3.1, published on 17 December 2020, cf. sams.ch/intensive-care).
Legal force of SAMS guidelines
All the medical-ethical guidelines issued by the SAMS are in accordance with existing legislation; nonetheless, they do not in themselves have legal force. The “triage guidelines” are addressed to healthcare professionals working in intensive care units (ICUs). In a triage situation, treatments that are medically indicated and desired by patients cannot, for reasons of resource scarcity, be offered to everyone. This is a highly stressful situation for all concerned. Under such conditions of resource scarcity, decision-making needs to be as fair as possible; this is the purpose of the SAMS guidelines. They are to be understood not as a rigid checklist, but as a source of guidance. Decisions will always also be influenced by the team’s training and experience. Every triage remains a decision based on the individual case.
Increasingly paternalistic decision-making
According to the physicians interviewed in the study, the medical-ethical principles of autonomy and beneficence were downgraded in favour of the principle of equity. The raising of this topic is to be welcomed and merits further discussion. It reinforces the conviction of the SAMS that the question of autonomy in medicine should be further pursued, and that dialogue on the questions of advance directives and advance care planning should be promoted independently of the current situation. Another point deserving reflection is how the shared decision-making approach, which seeks to take appropriate account of all the key medical-ethical principles (respect for autonomy, beneficence, equity, non-maleficence), can remain applicable even in extreme situations.
Raising awareness among healthcare professionals and society
The SAMS and the SSICM realise that, while the guidelines are addressed to ICU professionals, they involve fundamental principles – ultimately, questions of life and death – and are thus of the utmost relevance to society as a whole. This was demonstrated by the vigorous public debate on the guidelines conducted via the media. In line with its motto “For science, medicine and society”, the SAMS believes that one of its core responsibilities is to draw the attention of the public also to sensitive and controversial topics, and to contribute to a broad debate on these matters.
No financial support and no conflict of interest relevant to this article was reported.
lic. théol., dipl. biol. Sibylle Ackermann, Department Ethics, Swiss Academy of Medical Sciences (SAMS), House of Academies, Laupenstrasse 7, CH-3001 Bern, s.ackermann[at]samw.ch
1 Merlo F, Lepori M, Malacrida R, Albanese E, Fadda M. Physicians’ acceptance of the Swiss Academy of Medical Sciences guidelines “COVID-19 pandemic: triage for intensive-care treatment under resource scarcity”. Swiss Med Wkly. 2021;151:w20472. doi:. http://dx.doi.org/10.4414/smw.2021.20472
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