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Special article

Vol. 145 No. 5152 (2015)

Medical-ethical guidelines: Coercive measures in medicine

  • Swiss Academy of Medical Sciences
Cite this as:
Swiss Med Wkly. 2015;145:w14234


  1. On being incorporated into the Code of the Swiss Medical Association (FMH), SAMS guidelines become binding for all members of the FMH.
  2. Hereafter, the term “medical” is used in a broad sense to refer to the activities of physicians, nurses and therapists.
  3. The broad definition used here may lead to problems in those cantons which, on the basis of cantonal regulations, require a written order for every coercive measure.
  4. In a person with capacity who is involuntarily committed, federal law essentially permits a restriction of liberty, but not compulsory treatment. In contrast, compulsory treatment – including treatment of somatic disorders – is permitted under certain cantonal laws (cf., for example, § 26 of the Canton Zurich Patients Act, LS 813.13).
  5. Under Art 435 SCC, in emergency situations, compulsory treatment of involuntarily committed patients is also possible for the protection of third parties.
  6. In contrast to the broad definition used here, Art. 383 SCC, which is applicable for patients in residential and nursing institutions, only provides for measures restricting physical freedom of movement, i.e. mechanical restraints. Art. 383 SCC applies mutatis mutandis for involuntarily committed patients (cf. Art. 438 SCC). It should be noted, however, that while Art. 383 can only be applied in the case of patients lacking capacity, the provisions concerning involuntary committal (Art. 426 ff. SCC) are also applicable for patients with capacity.
  7. In the case of involuntarily committed patients, the term used in the child and adult protection law is not compulsory treatment, but treatment without consent (Art. 434 SCC). This does not, however, mean that any treatment undertaken without consent amounts to compulsory treatment in accordance with Art. 434. Consent is lacking, for example, in the case of medically indicated measures where, for reasons of urgency, information on the patient’s wishes cannot be obtained (e.g. because the patient lacks capacity and no relatives can be consulted) (Art. 379 SCC).
  8. Under the SCC, the following persons are entitled, in the following order, to act as representatives in medical matters: persons appointed in an advance directive or power of attorney; a duly authorised deputy; relatives and other close associates who regularly provide the patient with personal support (spouse or registered partner, person sharing the same household, offspring, parents, siblings). In the case of patients who are minors, the holders of parental responsibility are entitled to act as representatives.
  9. Cf. in particular Section 2.4. («Capacity»), where it is noted that incapacity must not be automatically inferred from failure to consent to a proposed procedure which is medically indicated.
  10. Formerly known as «involuntary custody».
  11. The requirements specified for the detention of persons admitted voluntarily are more stringent than those specified for involuntary committal; in particular, there must be a serious risk of harm to the patient or third parties which cannot otherwise be averted.
  12. In an emergency, Art. 435 SCC is applicable for the treatment of a mental disorder in an involuntarily committed patient. The urgency of treatment may be due to the need to protect the patient or third parties.
  13. Cf. Art. 438 SCC («Measures restricting freedom of movement»).
  14. Necessary and appropriate means that all alternative options must have been considered in advance and a coercive measure is the only appropriate way of averting the danger in question.
  15. Cf. Annex B, No. 3 («Documentation of coercive measures»).
  16. Delirium is an acute, typically fluctuating, disturbance of consciousness associated with a somatic or mental illness, characterised by attentional and cognitive deficits (impairments of memory, orientation, speech and abstract thinking) and psychomotor disorders (apathy, hypoactivity to hyperactivity). The acute onset and essential reversibility of delirium differentiate it from dementia.
  17. Cf. Art. 379 SCC («Urgent cases»).
  18. The revised Federal Act of 28 September 2012 on the Control of Communicable Diseases (Epidemics Act) is to come into force at the beginning of 2016. Under Art. 30 ff., (coercive) measures targeted at individuals can be ordered.
  19. It should be borne in mind that the accompanying partner may not be legally authorised to represent the mother and/or the newborn.
  20. The principles set out in the present guidelines are also applicable for forensic psychiatry; however, specific aspects which are only relevant in this area are not addressed here (cf. Section 4.6.). The term mental disorder is used in accordance with the terminology of the Swiss Civil Code and is based on the International Classification of Diseases (ICD-10) issued by the WHO.
  21. The physician’s responsibilities are decisive; thus, in this case, a medical head of department, for example, can assume the function of a chief physician. The responsibility specified in Art. 434 SCC should not, however, be assumed by the physician who prepares the treatment plan, but by a hierarchically superior physician.
  22. An appeal filed in accordance with Art. 450 ff. SCC represents a legal remedy against decisions ordering measures, as specified in Art. 439 SCC.
  23. Cf. Section 3.3. («Appropriate environment»).
  24. Cf. the UN Convention on the Rights of the Child (CRC), which has been ratified by Switzerland and forms part of Swiss law.
  25. Art. 296 ff. SCC («Parental responsibility»).
  26. In cases where parental responsibility is shared, the sole parent present can grant consent for treatment to the attending physician if this is consistent with the parents’ agreed division of duties. In the case of critical treatment decisions, the physician must make sure that both parents have been informed and agree to the proposed procedure.
  27. Minors with capacity also have the right to state their wishes in an advance directive (Art. 370 SCC).
  28. In the case of a patient with capacity, committal to a psychiatric hospital under Art. 314b SCC would essentially be possible, but treatment without consent under Art. 434 SCC would not.
  29. The authority can appoint a deputy to act as a representative in medical matters and, if necessary, can restrict parental responsibility in this area (cf. Art. 308 SCC).
  30. In cases of delirium, the principles set out in Section 4.1.3. essentially apply.
  31. It is necessary to distinguish different types of cases where medication is concealed: if a tablet is crushed with a mortar and pestle and mixed with food purely so as to facilitate administration to a patient with dementia who has difficulty swallowing, this does not represent a coercive measure. It is, however, coercive to conceal medication in order to deceive a patient who refuses to take a particular (e.g. antipsychotic) drug. It should be borne in mind that the efficacy of a drug may be affected if the mode of administration is altered.
  32. In serious cases, this may include notifying the competent authority.
  33. Cf. the SAMS medical-ethical guidelines «Medical practice in respect of detained persons» (2002, updated 2012).
  34. For example, under Art. 429 SCC, the cantons may designate physicians who, in addition to the adult protection authority, are authorised to order committal for a period specified by cantonal law.