Norbert Konrad, Birgit Völlm and David N. Weisstub (eds.)International Library of Ethics, Law, and the New MedicineEthical Issues in Prison Psychiatry201310.1007/978-94-007-0086-4_21
© Springer Science+Business Media Dordrecht 2013
21. Prison Psychiatry in Switzerland
(1)
Forensic Psychiatric Hospital, Psychiatric Hospital of the University of Basel, Basel, Switzerland
Abstract
Switzerland has some distinctive sociodemographic and geographic features which influence prison psychiatric services: The Swiss resident population is about 7.7 millions of which about 1.7 millions are foreigners, mostly from southern Europe and the Balkan states. The four official languages are Swiss German (63.7 %), French (20.4 %), Italian (6.5 %) and Rhaeto-Romanic (0.5 %). Switzerland is slightly smaller than the Netherlands; the population lives rather scattered in the 50 % of land which is habitable, forming 5 cities with more than 100.000 habitants, the largest agglomeration being Zürich with 1.1 million. A small fraction of the whole Swiss population live in remote alpine valleys, some of touristic interest, with ‘Juf’ at 2,126 m above sea level being the highest all-year inhabited commune of the Alps. Although Switzerland has probably one of the best public transportation services worldwide, a journey from west to east takes more than 8 h due to the complicated alpine geography. These geographic characteristics, with a location not only in the centre of the Alps but also in the centre of Europe with some of the most important transport hubs from south to north and vice versa passing through, contributed historically to the characteristics of the Swiss state: Since Roman times many different principalities fought for their independence against each other and the large surrounding empires. In 1291 the first small federation was chartered in the centre of the later Switzerland as a military alliance against Austria-Hungary. Other so called ‘cantons’ joined in until Napoleon finally not only defined Switzerland’s frontiers in the Vienna congress in 1814/15 but also figured as godfather for the first Swiss constitution with its grounding in the principles of the French revolution. Switzerland then survived almost unharmed the heavy turmoils of the two World Wars and even emerged in a strong position leading to wealth and a high degree of social security. The Red Cross became probably the most iconic symbol reflecting Switzerland’s early efforts to promote human rights from a politically neutral position, a position that continues today.
21.1 Introduction
Switzerland has some distinctive sociodemographic and geographic features which influence prison psychiatric services: The Swiss resident population is about 7.7 millions of which about 1.7 millions are foreigners, mostly from southern Europe and the Balkan states. The four official languages are Swiss German (63.7 %), French (20.4 %), Italian (6.5 %) and Rhaeto-Romanic (0.5 %). Switzerland is slightly smaller than the Netherlands; the population lives rather scattered in the 50 % of land which is habitable, forming 5 cities with more than 100,000 habitants, the largest agglomeration being Zürich with 1.1 million. A small fraction of the whole Swiss population live in remote alpine valleys, some of touristic interest, with ‘Juf’ at 2,126 m above sea level being the highest all-year inhabited commune of the Alps. Although Switzerland has probably one of the best public transportation services worldwide, a journey from west to east takes more than 8 h due to the complicated alpine geography. These geographic characteristics, with a location not only in the centre of the Alps but also in the centre of Europe with some of the most important transport hubs from south to north and vice versa passing through, contributed historically to the characteristics of the Swiss state: Since Roman times many different principalities fought for their independence against each other and the large surrounding empires. In 1291 the first small federation was chartered in the centre of the later Switzerland as a military alliance against Austria-Hungary. Other so called ‘cantons’ joined in until Napoleon finally not only defined Switzerland’s frontiers in the Vienna congress in 1814/15 but also figured as godfather for the first Swiss constitution with its grounding in the principles of the French revolution. Switzerland then survived almost unharmed the heavy turmoils of the two World Wars and even emerged in a strong position leading to wealth and a high degree of social security. The Red Cross became probably the most iconic symbol reflecting Switzerland’s early efforts to promote human rights from a politically neutral position, a position that continues today.
Politically Switzerland consists in 26 cantons and half-cantons with a higher degree of autonomy than, for example, the German federal states. Switzerland has one federal Penal Code (SPC) but up to 026 different codes of criminal procedures which will fortunately be converted in a single federal one in the next years. However, the cantons will retain responsibility for the enforcement of sentences. They have affirmed three concordats for this duty to share institutions for the execution of penal sentences and court ordered treatment as well the so called “concordat commissions for the assessment of offenders dangerous to the public”, whose role and functioning will be described in more detail later: The Swiss-German speaking part of Switzerland consists of two of those concordats whereas Latin Switzerland (Italian and French speaking cantons) form a third one. The health services are organised in a similar manner: In principle a duty of the communities, they delegate this to the cantons which provide services. Health insurance is mandatory and paid for those who cannot afford it by social welfare. While outpatient treatment is at the expense of health insurance, inpatient treatment is paid in half by social insurance and in half by the cantons. From 2012 onwards the largest share of Swiss people with basic insurance have free choice of hospitals throughout Switzerland which will enhance competition between hospital and cantons. All these factors contribute to the unique characteristics of Swiss prison psychiatric services.
21.2 Organisation of Prison Psychiatric Services
Switzerland has a relatively low prison population rate of 79 per 100,000 (Finland 60, Sweden 78, Germany 88, France 96, England and Wales 154, Israel 325, USA 748) (King’s College 2010) which itself consists of a relatively high share of prisoners on remand (30 %). Sentenced prisoners contribute 59 % to the prison population, detained asylum seekers 7 % and others 4 %. Switzerland has only one prison with more than 400 places (Zürich) and only a handful of institutions only with more than 200 places. This means that an important share of prisoners is placed in small to medium sized prisons, many of them having less than ten places and being managed by part-time staff.
Few cantons have prison medicine or prison psychiatric services, run either by the penal department, health departments or University departments. In the other cantons individual correctional institutions may have contracts with nearby hospitals, outpatient services or doctor surgeries. Most large prisons have specialized medical wards though none of them have 24/7 emergency medical services. Prisoners with somatic (and often also psychiatric) emergencies are therefore usually transferred to a special ward (“Bewachungsstation”) at the University Hospital of Berne which is under responsibility and run by staff from the prison services of the canton of Berne and offers 16 beds. A similar ward for the Latin-Swiss is at the University Hospital of Geneva (L’unité cellulaire hospitalière -UCH) with another 10 beds. Both wards have an extremely high capacity utilisation. For pure psychiatric emergencies the canton of Zürich has three high-security wards in its Forensic Psychiatric Centre “Rheinau” with a total of 27 beds.
Due to these diversities of service provision, it is quite difficult to summarise the system of prison psychiatry and to represent all clinical staff involved and safeguard their often very specific interests and to develop minimal standards for the provision of health care. Those are the aims of the Swiss Conference of Prison Physicians: This association was founded in 2004 after several years of loose congregation. Further aims of the association include quality assurance, continued education as well as annual scientific and corporate meetings (statutes as well as other information available online at http://files.chuv.ch/pediatrie/dpc_home/dpc_infos/dpc_infos_organisation/dpc_smpp.htm/). Similarly, forensic psychiatrists founded the Swiss Society of Forensic Psychiatry (http://www.swissforensic.ch) with one section each for the Swiss German and the Swiss Latin part as well as one for juvenile forensic psychiatry in 2006. It focuses on forensic psychiatric assessment and treatment, runs postgraduate courses and issues the certificate “Forensic Psychiatrist (SSFP)” to successful graduates of the curriculum, which is similar to the one of the German Medical Association (DGPPN). It is highly respected by courts and currently about 50 members are certified. Appreciating its originality and the urgent need for minimal standards especially in courtroom testimony, most probably the Swiss Board of Physicians (FMH) will introduce the subtitle “Forensic Psychiatry and Psychotherapy” officially and adopt the SSFP’s curriculum within the next few years. Both these two associations support prison psychiatrists as well as forensic psychiatrists in their duties, often complicated due to well-known challenges such as threats to confidentiality, blurry responsibilities, a lack of high-security inpatient treatment facilities and others.
21.3 Ethics and Guidelines
Switzerland ratified the European Convention on Human Rights 1974 (some amendments are still a matter of negotiations) and follows the Recommendation No. R (98) 7 of the Committee of Ministers concerning ethical and organisational aspects of health care in prison as well as the recommendation Rec(2006)2 on the European Prison Rules. Furthermore, the Swiss Academy of Medical Sciences published medical-ethical guidelines for medical activities with regard to detained persons in 2004 (Restellini et al. 2004). These show that Swiss prison psychiatrists struggle in their routine duties with similar ethical dilemmas as psychiatrists from other European countries (Elger Bernice 2008) such as the problem of confidentiality in their professional relation with prison staff, constrained therapeutic options or the use of coercive measures in cases of possible self-harm. One such example is discussed below.
Related posts:
Ethics Within the Prison System
The Evolution of Punishment and Incarceration
Overcrowded Prisons and Low Psychiatric Provision: The Situation of Mentally Ill Prisoners in Kenya
Psychiatric Treatment in the Detention Systems of Quebec: Trying to Merge Prison and Therapeutic Cultures
Application of the AMA Code of Medical Ethics to Psychiatric Practice in Correctional Facilities and Access to Psychiatric Care in the U.S.A.
Current Ethical Challenges in Prison Psychiatry in England and Wales
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