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Adherence, shared decision-making and patient autonomy

Abstract

In recent years the formerly quite strong interest in patient compliance has been questioned for being too paternalistic and oriented towards overly narrow biomedical goals as the basis for treatment recommendations. In line with this there has been a shift towards using the notion of adherence to signal an increased weight for patients’ preferences and autonomy in decision making around treatments. This ‘adherence-paradigm’ thus encompasses shared decision-making as an ideal and patient perspective and autonomy as guiding goals of care. What this implies in terms of the importance that we have reason to attach to (non-)adherence and how has, however, not been explained. In this article, we explore the relationship between different forms of shared decision-making, patient autonomy and adherence. Distinguishing between dynamically and statically framed adherence we show how the version of shared decision-making advocated will have consequences for whether one should be interested in a dynamically or statically framed adherence and in what way patient adherence should be assessed. In contrast to the former compliance paradigm (where non-compliance was necessarily seen as a problem), using observations about (non-)adherence to assess the success of health care decision making and professional-patient interaction turns out to be a much less straightforward matter.

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Notes

  1. 1.

    In taking this shift seriously we will also henceforth use the notion of adherence in the rest of the article, unless we are specifically referring to the traditional compliance paradigm.

  2. 2.

    Achieved through, e.g. professional consensus conferences or decisions by central quality assurance authorities.

  3. 3.

    Here it should be noted that 1–3 is about successfully exercising autonomy and 4–5 is about having certain abilities related to autonomy, hence they are expressed in terms of nouns and adjectives respectively and ontologically different.

  4. 4.

    The value of preference-satisfaction is a part of the value of self-realization since preference-satisfaction is a necessary condition for self-realization as used in this context.

  5. 5.

    I may, of course, also abstain from complete delegation of authority, but nevertheless choose to involve other people as advisors and discussion partners from whom I welcome also critical views on my own lines of reasoning.

  6. 6.

    Variations in this respect will describe the “field” within which others have a moral reason to respect a person’s autonomy (in the sense of abstaining from interfering with her decision making or execution of made decisions).

  7. 7.

    In addition to these nine variants, sharing may also take the form of a therapeutic measure in its own right, where the exchange and interaction between the patient and the professional in any of the versions 1–9 may serve the management of immediate psychosocial needs, such as reducing anxiety and feelings of uncertainty.

  8. 8.

    A further aspect of this is to what extent the patient also gives a promise to him- or herself in arriving at a certain decision (or in accepting a certain decision). If giving a promise to oneself could provide extra reason for sticking to the decision and not abandon it lightly to satisfy short term preferences, such a promise could turn out beneficial (as far as it goes).

  9. 9.

    Ideas in this direction is developed in a forthcoming paper by Christian Munthe, Lars Sandman and Daniela Cutas, that surveys the ethical implications of central ideas in shared decision making and person centered care.

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Acknowledgments

This work was supported by the Centre for Person-Centred Care (GPCC), University of Gothenburg, Sweden, http://www.gpcc.gu.se. GPCC is funded by the Swedish Government’s grant for Strategic Research Areas, Care Sciences [Application to Swedish Research Council no 2009:1088] and co-funded by the University of Gothenburg, Sweden.

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Correspondence to Lars Sandman.

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Sandman, L., Granger, B.B., Ekman, I. et al. Adherence, shared decision-making and patient autonomy. Med Health Care and Philos 15, 115–127 (2012). https://doi.org/10.1007/s11019-011-9336-x

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Keywords

  • Adherence
  • Compliance
  • Patient autonomy
  • Patient best interest
  • Shared decision-making