Patient Prefer Adherence. 2008 Feb 02;2:7-19.
A novel conceptual framework for understanding the mechanism of adherence to long term therapies.
Patient preference and adherence
Gérard Reach
Affiliations
Affiliations
- Department of Endocrinology, Diabetes and Metabolic Diseases, Avicenne Hospital, Assistance Publique-Hôpitaux de Paris, and Laboratory of Pedagogy of Health, EA 3412, University Paris 13, CRNH-Idf, Bobigny, France.
PMID: 19920939
PMCID: PMC2770416
Abstract
The World Health Organization claimed recently that improving patient adherence to long term therapies would be more beneficial than any biomedical progress. First, however, we must understand its mechanisms. In this paper I propose a novel approach using concepts elaborated in a field rarely explored in medicine, the philosophy of mind. While conventional psychological models (eg, the Health Belief Model) provide explanations and predictions which have only a statistical value, the philosophical assumption that mental states (eg, beliefs) are causally efficient (mental causation) can provide the basis for a causal theory of health behaviors. This paper shows that nonadherence to long term therapies can be described as the medical expression of a philosophical concept, that is, weakness of will. I use philosophical explanations of this concept to suggest a mechanistic explanation of nonadherence. I propose that it results from the failure of two principles of rationality. First, a principle of continence, described by the philosopher Donald Davidson in his explanation of weakness of will. This principle exhorts us to act after having considered all available arguments and according to which option we consider best. However, patients conforming to this principle of continence should rationally be nonadherent. Indeed, when patients face a choice between adherence and nonadherence, they must decide, in general, between a large, but delayed reward (eg, health) and a small, but immediate reward (eg, smoking a cigarette). According to concepts elaborated by George Ainslie and Jon Elster, the force of our desires is strongly influenced by the proximity of reward. This inter-temporal choice theory on one hand, and the mere principle of continence on the other, should therefore lead to nonadherence. Nevertheless, adherence to long term therapies is possible, as a result of the intervention of an additional principle, the principle of foresight, which tells us to give priority to mental states oriented towards the future.
Keywords: causal theory of health behaviors; chronic diseases; inter-temporal choice; patient adherence; philosophy of mind; principle of foresight; weakness of will
References
- Nebr Symp Motiv. 1980;27:195-259 - PubMed
- Psychol Psychother. 2005 Mar;78(Pt 1):95-111 - PubMed
- Am Psychol. 1990 Aug;45(8):921-33 - PubMed
- BMC Med Inform Decis Mak. 2002 Nov 25;2:8 - PubMed
- Diabetes Res Clin Pract. 1998 Jan;39(1):23-9 - PubMed
- Pediatr Transplant. 2006 May;10(3):323-30 - PubMed
- Patient Educ Couns. 2005 Jan;56(1):98-103 - PubMed
- J Heart Lung Transplant. 1996 Jun;15(6):631-45 - PubMed
- Diabet Med. 2005 Apr;22(4):415-20 - PubMed
- Arch Intern Med. 2000 Nov 27;160(21):3278-85 - PubMed
- Am J Epidemiol. 2007 Aug 1;166(3):348-54 - PubMed
- J Clin Nurs. 2001 Sep;10(5):618-27 - PubMed
- Presse Med. 2000 Nov 18;29(35):1939-46 - PubMed
- Ann Fam Med. 2004 Jan-Feb;2(1):26-32 - PubMed
- Med Care. 1975 Jan;13(1):10-24 - PubMed
- Soc Sci Med. 1998 Feb-Mar;46(4-5):461-5 - PubMed
- Diabetes Care. 1997 Feb;20(2):215-8 - PubMed
- Diabetes Care. 1999 Apr;22(4):635-9 - PubMed
- Diabetes Care. 1990 Apr;13(4):441-3 - PubMed
- J Exp Anal Behav. 1974 May;21(3):485-9 - PubMed
- J Consult Clin Psychol. 1983 Jun;51(3):390-5 - PubMed
- Health Educ Monogr. 1978 Spring;6(2):107-17 - PubMed
- BMJ. 2006 Jul 1;333(7557):15 - PubMed
- Diabetes Care. 2004 May;27(5):1218-24 - PubMed
- BMC Womens Health. 2004 Aug 25;4 Suppl 1:S5 - PubMed
- Public Health Nutr. 1999 Jun;2(2):209-15 - PubMed
- Int J STD AIDS. 2007 Jan;18(1):28-32 - PubMed
- J Am Board Fam Pract. 2005 Jul-Aug;18(4):262-70 - PubMed
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