Gérard ReachThe Mental Mechanisms of Patient Adherence to Long-Term TherapiesPhilosophy and Medicine11810.1007/978-3-319-12265-6_10

10. Conclusion: Adherence Generalized

Gérard Reach¹

(1)

Avicenne Hospital and Paris 13 University, Sorbonne Paris Cité, Bobigny, France

Gérard Reach

Email: gerard.reach@avc.aphp.fr

Abstract

Not conforming to the principle of foresight, described in this book (Chap. 7), leads to nonadherence. This principle, whose intervention would allow patient adherence, could be called on to help with all incontinent actions which may have potentially serious consequences for our future . This explanation would allow us to define adherence in a general sense, as acceptance to perform certain actions when we believe their consequences could positively influence not only our immediate, but also our long-term, future. Included among these actions is everything that concerns one’s health , but also being sober, buckling one’s seatbelt, crossing at the crosswalk, avoiding risky situations, and, for some, believing in an afterlife. In sum, the phenomena of adherence and nonadherence concern everything that is vital to us, as opposed to everything that leads us to death. Adherence and nonadherence emerge as the medical counterparts of Eros and Thanatos Freudian principles. Then what answer to give, at the end of this study, to the question: why do we take care of ourselves? We take care of ourselves, if we have a reason to do it, and the reason is the desire —the sustained intention —which confers priority status to the option of arriving healthy and safe at the end of our voyage. We take care of ourselves because it is natural for us to love ourselves just as it is natural to love our children. Here I follow Harry Frankfurt in his celebration of self-love, the highest thing of all, according to Spinoza.

Happy the man who, like Ulysses , has traveled well, or like that man who conquered the fleece, and has then returned, full of experience and wisdom, to live among his kinfolk the rest of his life .

Joachim du Bellay , Regrets

10.1 A Choice Between Two Actions

So, when I refused the cigarette you offered, I first respected the principle of continence that tells me to examine all the contents of the propositional attitudes pertinent to the question being asked. These contents are located in two domains, one where I keep those issues concerning the immediate present, the other containing those concerning the future . Next, I put to work my principle of foresight , which tells me to give priority to the arguments found in the domain concerning to the future. This is how a few years ago I was able to come to the realization that it was time to think about my health and once and for all stop smoking . This is a strong expression of the principle of foresight , consisting in making the right resolutions, as part of a habit . Habit, as we have seen, circumvents the need to repeat this exercise day after day, always running the risk , if failing to execute it, of falling off the wagon. No smoking…

And if, on the contrary, I accept your cigarette , it means that either my mind lacks the domain of the future (or that it is empty as far as this question is concerned), or that I do not have the principle of foresight , or that the principle is inhibited at the moment, as because of an emotion. The sulky character played by Sabine Azéma in Alain Resnais’s Smoking takes the packet of cigarettes left on the table after grumbling “what the hell”….

10.2 The Risk of Nonadherence

This example shows that the risk of nonadherence is serious. It is especially so when distant future rewards pale in comparison to immediate rewards. We can understand now what emerged at the beginning of our research, when I enumerated the determinants of patient adherence.

Let us take the example of a typical illness with a risk of nonadherence: A chronic asymptomatic disease requiring a boring preventive treatment, including lifestyle changes such as losing weight , exercising, not smoking . And let us consider first what is being proposed to the patient : The reward of all these tasks is not particularly attractive; it is abstract and often expressed as a negative (to avoid complications), and somewhat tragically, the benefits will never entirely accrue. It is like an insurance policy that one does not completely understand, though the premiums must be paid several times a day and there is no return on the money. As with insurance policies, the chances of the insured-against event happening are far from one hundred percent, and we can gamble on never needing it: Perhaps there will be no fire. (After all, the State requires insurance because this sort of reasoning is so compelling.)

And then there is the incontinent action . It consists of doing nothing, and its rewards (rest, no side effects from the medication , etc.) are immediate, concrete and often visible. The distinction between distant and immediate rewards is certainly not academic: It drives real behavior . We mentioned in the last chapter that Yaacov Trope and Nira Liberman suggested that our mental categorizations tend to give concepts pertaining to the future an abstract, central, important character, expressed for instance by the question: why; meanwhile, those concerning the immediate future are given a concrete, more accessorial, less important character, pertaining more to the question: how (Trope and Liberman 2003). As we have seen, when a desire is more likely to be satisfied sooner, the motivation to satisfy that desire is typically stronger. In this game, nonadherence has the deck stacked in its favor.

On the other hand, there are circumstances that intensify the motivations pertinent to more distant rewards. We have already mentioned how diabetic women suddenly manifest an extraordinary adherence the moment they decide they want a child, and particularly if they know they are pregnant. One can assume that the diabetic women are no longer acting only for themselves: They sacrifice immediate rewards for their child’s later health . But what is more, the object of desire , to bring the pregnancy to term without complications, is concrete and present to the mind. Here, the question is no longer how to avoid complications—a question which is abstract and negative—but how to have a healthy child—which is of course a more concrete and positive matter. Moreover, the payoff, though not immediate, is foreseeable (the woman’s due date) which adds to the concreteness of the reward for the required efforts.

Isn’t this particular aspect of the favorable influence of pregnancy on adherence explained by its uniqueness, among human actions, the birth of a child? Perhaps rather than seeing pregnancy as a special case, we can view it as a window on a deeper source of strength and motivations. We can quote Hannah Arendt ’s Human Condition:

The miracle that saves the world, the realm of human affairs, from its normal, “natural” ruin is ultimately the fact of natality, in which the action is ontologically rooted (Arendt 1998, 247).

10.3 Generalization of the Problem

Hannah Arendt gives a superb general description of the distinction between two types of rewards, an immediate and a distant one, as it emerges from our study of patient adherence:

Desire is influenced by what is just at hand, thus easily obtainable – suggestion carried by the very word used for appetite or desire , orexis, whose primary meaning, from orego, indicates the stretching out of one’s hand to reach for something nearby. Only when the fulfillment of a desire lies in the future and has to take the time factor into account is practical reason needed and stimulated by it. In the case of incontinence , it is the force of desire for what is close at hand that leads to incontinence, and here practical reason will intervene out of concern for future consequences. But men do not only desire what is close at hand; they are able to imagine objects of desire to secure which they need to calculate the appropriate means. It is this future imagined object of desire that stimulates practical reason; as far as the resulting motion, the act itself, is concerned, the desired object is the beginning while for the calculating process the same object is the end of the movement (Arendt 1978, 58).

In this book, I have likened patient nonadherence to a particular case of akrasia . And is it not rather an exemplary case of incontinent action , as a manifestation of irrationality , or rather, as I will now show, of a certain type of incontinent action?

For philosophers , following Davidson , irrationality manifests itself essentially in three forms: Incontinent actions, self-deception and wishful thinking. Among these types of irrationality, the essence of incontinent actions is precisely the fact that they concern actions, i.e., events that by definition have future consequences, inscribed in temporality.

Among these actions, we can distinguish two types: Those that have somewhat neutral consequences and those that concern one’s future . In Paradoxes of Irrationality, Davidson illustrates action of the first type with a story taken from Freud . It deals with a man who moves a tree branch lying in a park. Continuing on his way, he thinks that the branch might hurt someone and he is torn between two contradictory desires , to go home or to return to the park and put the branch back in its place. His best judgment tells him to go home. He performs the incontinent action of returning to the park to put the branch back in its place (Davidson 2004, 172–173). Obviously, the consequences of going home or of returning to the park are going to modify his immediate future, but it does not have important consequences for his future in general. It is an incontinent action of the first type where it is not necessary to engage the principle of foresight .

This principle, whose intervention would allow patient adherence, could be called on to help with all incontinent actions of the second type, which may have potentially serious consequences for the future . This explanation would allow us to define adherence in a general sense, as acceptance to perform certain actions when we believe their consequences could positively influence not only our immediate, but also our long-term, future. Included among these actions is everything that concerns one’s health , but also being sober, buckling one’s seatbelt, crossing at the crosswalk, avoiding risky situations, and, for some, believing in an afterlife. We see here again an analogy between health beliefs and religious beliefs: When one Googles the word “observance” (the French word used to speak about adherence to treatment) most references are to observance of religious practices rather than to therapeutic observance. Indeed, the term observance was first created in a religious context.

10.4 Defining Adherence by Its Explanation

In all science there is explanation and understanding; to explain, one must find an understandable link between the different elements one is to explain. (Descombes 2001, 58–66)

We have come back to the idea introduced at the beginning of this inquiry: All these actions—or their opposites—are not only analogous, but phenomenologically homologous and form, in a sense, a category.

We have often stressed that one must consider separately all the tasks of a medical treatment, each being an action that risks nonadherence, and that nonadherence often is not a general trait, but rather must be examined on a case-by-case basis. However, if clinical experience indeed shows that patients are not usually entirely adherent or nonadherent, it also suggests that phenomena of nonadherence are often linked. Take the example of diabetes : Diabetic patients who smoke usually have the poorest glycemic control (Gulliford and Ukoumunne 2001; Stenstrom and Andersson 2000). Non-smokers accept complex treatments more frequently (Perros et al. 1998). Smokers also come less often to consultations (Dyer et al. 1998). We observed a correlation between adherence to medication and the declaration that one fastens seatbelt in the rear of a car (Reach 2011).

It is while researching how these phenomena are homologous that we have progressively been led to postulate the existence of a principle of foresight , which explains them generally. According to George Ainslie , to act according to a principle means to decide at the moment of choice that the action is not isolated, but belongs to a category (Ainslie 1999, 69). We saw that for Robert Nozick , a principle is also a way of seeing an action as symbolically representing a group of actions of the same type, or of a related type, which could be equivalent to the concept of homology , advocated by Jon Elster .

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