Among patients with chronic illnesses such as heart disease, diabetes, renal disease and cancer, mental conditions such as depression and schizophrenia, as well as acute illnesses such as infections, patient adherence to both short-term and lifelong treatment regimens is a common problem (Graziottin et al., 2011). There are several barriers to patient compliance, namely insufficient knowledge about his or her own health condition, the perception that treatment leads to little or no positive effect, unrealistic expectations regarding outcomes, low self-efficacy in relation to self-management, increased frequency of medication dosing, depression, stress and anxiety, poor provider-patient relationship, lack of social support, inadequate finances, fear of treatment side effects, and incompatibility with cultural beliefs (Graziottin et al., 2011). In order to improve health outcomes, adherence to treatment must be enhanced. This issue, however, touches upon the ethical principles of autonomy, beneficence, nonmaleficence and justice and a deeper understanding can only be arrived at from examining the issue in light of these principles.
The principle of autonomy is anchored on the human right to self determination and essentially means being able to voluntarily make informed choices regarding medical treatment (Morrison, 2010). Patients may or may not agree with the treatment plan but agreement is formally documented through the signing of a consent form which represents a go signal for treatment to commence. Imposing treatment on the patient, treating without consent, threatening the patient to consent and providing deceptive information to obtain consent are violations of this principle which has corresponding legal consequences. In order to make choices, patients must be competent enough to make them (Morrison, 2010). That is, they must be in a developmental stage that they are able to comprehend given information and make independent choices. The obligation of the health care provider is to respect the patient’s right to autonomy and provide complete and truthful information that the latter needs in order to make his or her choices.
Specifically regarding the issue of noncompliance to treatment, the following barriers to adherence are the result of the inadequate fulfillment of health care professional obligations to provide information: insufficient knowledge about medical condition, perception that treatment leads to little or no positive effect, unrealistic expectations regarding outcomes, fear of treatment side effects, and incompatibility with cultural beliefs (Graziottin et al., 2011). Health care providers are in the best position to inform patients about their condition, the rationale of treatment, the expected outcomes, possible adverse events and their management and alternatives when treatment runs counter to cultural beliefs and practices. The barriers mentioned reflect unmet information needs. This implies that disclosure or patient education would have been either limited or delivered through ineffective means. At the same time, the barriers reflect how patient preferences may be ignored as when treatment is recommended even when these come into conflict with cultural beliefs. Often, such as situation contributes to poor provider-patient relationship as well.
A scenario of seemingly unmet information needs puts into question the patient’s capacity to make decisions regarding treatment and also implies that the traditional paternalistic relationship between provider and patient continues to be dominant. This paternalistic relationship defines the role of the provider as the one who, because of his expertise, defines what is best for the patient and the latter’s role is to passively comply (Sandman et al., 2012). Hence, the need to disclose may be done as part of routine protocols. At the same time, a paternalistic relationship of subservience on the part of patient fosters the kind of care where unnecessary treatments and tests are performed, a practice that has driven up the cost of health care and is the focus of current healthcare reforms (Kaufman, 2011).
However, there is a growing belief that patient autonomy in its full essence should be a guide to the provider-patient relationship. Thus, focus is shifting from passive compliance, defined as compatibility between patient behavior and medical advice, to active adherence defined as willful commitment to follow an idea (Sandman et al., 2012). Patient autonomy, when exercised in the context of adherence, requires that decision making be shared between patient and provider. Hence, the patient has a voice in matters concerning his health and his own perspective of what is best for him is considered. This requires the kind of disclosure and patient education that engenders active participation.
Beneficence and nonmaleficence, on the other hand, are about generating benefits and minimizing harm to patients (Morrison, 2010). Specific to the issue of patient noncompliance, harm arises from the direct physiologic effects of not having treatment such as delayed diagnosis of cancer metastasis because the patient refused to have his scheduled CT scans, and acute exacerbation of chronic heart failure or poorly-controlled diabetes because of missed drug doses. Often, the patient is blamed for these consequences. However, given the barriers to compliance as mentioned above and the recognition of this issue as a significant clinical problem in many clinical settings, it is not as easy to declare poor health outcomes from noncompliance as purely the result of irresponsible patient behavior.
Lastly, the principle of justice invokes fairness in patients’ access to health care even those services that aim to improve compliance with treatment or adherence management interventions (Morrison, 2010; Wood, 2012). Nursing staff, being in the frontline of care, are in the best position to deliver these interventions. However, a reality in many healthcare institutions is the shortage of nursing staff. In this labor situation, it is difficult to make patient education a priority when other pressing physiologic needs must be taken care of first. As such, access to interventions that help patients adhere to treatment may likely be limited and when compounded with difficulties in accessing primary health care, it is difficult to see how the ethical principle of justice can be applied.
In conclusion, the issue of patient noncompliance with treatment requires an evaluation of the current understanding and application of ethical principles in healthcare settings in light of the fact that these principles help provide the rationale for interventions that address the issue. However, while the obligations of healthcare professionals with regard to patient autonomy, beneficence and nonmaleficence are quite clear, the principle of justice is more difficult to apply to the issue of patient noncompliance. In dealing with the issue, a responsibility of the healthcare administrator is to plan and institute ethically-guided systems and processes promoting shared decision making and adherence to treatment so that ethical principles can be consciously applied in healthcare professional and patient relationships as well as in caring for patients. In a healthcare environment which emphasizes accountability, this issue requires a response which involves modifying the process of patient care to include ample time for patient education and adherence management. Securing the necessary human resources needs to be done so that this responsibility can be fulfilled.
References
Graziottin, A., Gardner-Nix, J., Stumpf, M., & Berliner, M.N. (2011). Opioids: how to improve compliance and adherence. Pain Practice, 11(6), 574-581
Kaufman, N.S. (2011). A practical roadmap for the perilous journey from a culture of entitlement to a culture of accountability. Journal of Healthcare Management, 56(5), 299-304
Morrison, E.E. (2010). Ethics in Health Administration: A Practical Approach for Decision Makers. Massachusetts, MA: Jones and Bartlett Publishers.
Nielsen, D. (2010). Patient education in groups increases knowledge of osteoporosis and adherence to treatment: a two-year randomized controlled trial. Patient Education and Counseling, 81(2), 155-160
Sandman, L., Granger, B.B., Ekman, I., & Munthe, C. (2012). Adherence, shared decision- making and patient autonomy. Medicine, Health Care and Philosophy, 15(2), 115-127
Wood, L. (2012). A review on adherence management in patients on oral cancer therapies. European Journal of Oncology Nursing, 16(4), 432-438
