The role of advance directives in preventing compulsory placement and coercive measures in Switzerland: a need to review present practice

Summary

In Switzerland, where individual self-determination and self-responsibility are strong values, coercive measures are still very present in the care of individuals with mental health conditions. In 2022, over 18,000 cases of compulsory care placements were recorded – one of the highest rates in Europe [1]. The Swiss Academy of Medical Sciences (SAMS) is reviewing its guidelines on coercion to better support practice. The present viewpoint aims to contribute to such efforts by focusing on the role of advance directives in preventing unwanted compulsory placement and coercive measures.

Advance directives support individuals to document treatment preferences in anticipation of future incapacity. There is, though, differentiation between psychiatric and non-psychiatric cases: while treatment refusals for somatic conditions are typically considered binding, the preferences expressed in psychiatric advance directives can be overridden following compulsory placement. This creates a double standard that undermines self-determination for individuals with mental health conditions.

The present article advocates for uniform legal standards that would grant psychiatric advance directives equal binding force. It explores the validity of common arguments against doing so, suggesting that objections often rely on inconsistent or ethically flawed reasoning. The piece lays out arguments in support of modifying policy on psychiatric advance directives, suggesting that comparably binding directives might enhance patient autonomy, reduce the harm of coercive interventions, promote goal-concordant care, strengthen oversight, and address discriminatory policy.

As the Swiss Academy of Medical Sciences revisits guidelines on coercive practices, it is a good moment to consider the potential value of binding psychiatric advance directives as tools to uphold patient autonomy and contribute to broader efforts to reduce the harm of coercive practices.