© Springer International Publishing Switzerland 2015
Gérard ReachThe Mental Mechanisms of Patient Adherence to Long-Term TherapiesPhilosophy and Medicine11810.1007/978-3-319-12265-6_66. Medical Irrationality
(1)
Avicenne Hospital and Paris 13 University, Sorbonne Paris Cité, Bobigny, France
Abstract
Nonadherent patients are often conscious of their behavior but do not understand it: When asked why they did not stick to their diet, obese persons often do not try to hide their nonadherence but add with a sigh—“I know, I should, but I can’t help myself.’’ This perplexing human behavior has been described under the name of akrasia (literally lack of strength). Other philosophers have used the term incontinence , or weakness of will . In this chapter, I propose to describe nonadherence as a case of incontinent action. The definition of an incontinent action is that the agent intentionally performs an action that she herself does not consider to be the best—not an action that is considered bad by another. In short, the classic view of nonadherence was about disagreement between doctor and patient , whereas considering nonadherence as a case of akrasia places the disagreement between the patient and herself. Davidson suggested that there is a principle of continence : When one abides by this principle, one commits to using all the available information before acting (this is the ‘all things considered ’). Akrasia is the consequence of a failure of this principle . To explain how the exile of the principle of continence is possible, Davidson proposed the hypothesis of a divided mind. This partitioned mind hypothesis is applicable to clinical experience: For instance, there are pipe smokers who take the warning labels out of the tobacco boxes so that they do not have to ‘think’ about it, or perhaps because the labels confront their irrationality .
We have sought to better understand the paradoxical quality of patient nonadherence, and our seeking has led us to the field of philosophy of mind . Quite surprisingly, we were led to describe first the mental mechanisms behind adherence. Let’s turn now to the issue of patient nonadherence.
Why does a patient not follow the advice of her doctor even when she realizes that not doing so is bad for her? She should do it, not only from the doctor’s point of view (this is the classic definition of adherence) but also from her own point of view. Everyone involved, it seems, agrees that the treatment recommendation is a great idea—and yet the treatment never gets off the ground. Even though the patient has objective reasons to do it (she “sees something desirable in all actions that improve her health ; she believes that losing weight is this type of action ”), she still does not stay on the diet . The exasperated physician doesn’t know what to make of the patient’s behavior , which seems completely irrational . Some physicians distance themselves from these patients: “Come back when you’re ready,” they say.
What is so striking is that this exasperation is seldom lost on the patient , who is conscious of her behavior but does not understand it: When asked why she behaves in this strange manner, she does not try to hide the fact that she did not stick to her diet , adding with a sigh—“I know, I should, but I can’t help myself.’’
A simple explanation is that the patient lacks knowledge of the diet and what it requires of her. She may not know how to identify which foods have high cholesterol content, or she may not know how to count her caloric intake. She might be confused because her physician told her to reduce her cholesterol intake, but on the TV news she hears that there is “good cholesterol” too.
We already recognized that the lack-of-knowledge explanation often falls short, as even patients who are well-educated about their medical conditions have problems of adhering to therapy. The doctor who smokes is perhaps the simplest demonstration of the insufficiency of the “knowledge is power” approach to treatment planning. A more complicated example is that of diabetic women who find out they are pregnant and suddenly begin adjusting their insulin doses (or quit smoking , or stop using cocaine). It often is not even necessary to remind them of the knowledge they already have.
As noted previously, other explanations have utility, at least sometimes: A hidden fear or other psychological issue, denial of illness , lack of money or other resources , and so forth. The previous section highlighted how poor habit formation and/or insufficient willpower and resolution can affect adherence to treatment over the long run. However, these explanations do not give a full description of the paradoxical nature of patient nonadherence: How is it possible? Again, understanding nonadherence calls for a philosophical interpretation .
Gary Watson has described several distinct situations that facilitate what seems to be an irrational behavior (Watson 1977; Smith 2003). Consider a person who takes one drink too many, and as a result is unable to drive her car responsibly. Watson distinguishes three explanations for how the drinker got into this situation. The first is recklessness : The drinker knows what she is doing, thinks that the value of the drink is sufficient to take the risk of not being able to fulfill her obligations, and accepts the consequences: Since she could have evaluated the risk differently, her behavior is reprehensible, even more so because it is not at all irrational. She has simply sized up the situation in a way which may lead to harm to herself or to others. The second explanation is compulsion: This time , the drinker knows she should not drink, but she cannot resist the compulsive desire of the forbidden drink. She can size up the situation any way she likes, but she’s going to take the drink anyway.
Watson describes a third possibility: The person thinks it would be better not to drink, but in spite of this evaluation, or, even as a result of this evaluation, she drinks anyways. As opposed to the compulsive person, who is incapable of controlling herself, the third case is that of a person who could have decided to act otherwise, but did not. The reckless person throws caution to the wind, and drinks with a cavalier “to heck with it.” The compulsive person drinks regardless of what she is thinking (or not thinking). Watson’s third type drinks even though she knows it’s a bad idea, and has the ability to refrain.
Consider the Chinese proverb describing the psychological progression of alcoholism: “At first, the man takes a drink; then, the drink takes a drink; then the drink takes the man.” Perhaps these three stages are analogous to Watson ’s types? The “man takes a drink” is the reckless drinker; the “drink takes a drink” stage is when there is, as it were, a battle of wills between the man and the drink; and the final stage is the compulsive drinker, in which all willpower has been transferred from the man to the drink.1
Let us go back to patient nonadherence. We saw that not taking a pill, for instance, is a completely independent action . It is not the same as forgetting to take a pill; it is an action and not the absence of one. This has an important implication: If the patient knows, or rather thinks, that it would be better for her to take the pill (it is not a case of forgetting), and does not do it, then not only does she not perform the action she thinks is the best, but she also appears to choose the action she thinks is the worst, when she could have performed the best action. This description of patient nonadherence is strictly analogous to the third case in Watson ’s example of the person who takes a drink, where it is neither a decision of deliberate recklessness , nor a compulsion. As in the example of the person getting drunk, the choice is surprising.
6.1 Akrasia
The third type of person—the person who drinks despite her best judgment not to—Watson calls “weak .” This perplexing human behavior has been described before: Aristotle called it akrasia . Other philosophers have used the term incontinence , or weakness of will . Aristotle tells us that Socrates rejected the possibility that a person could knowingly act bad:
Socrates was entirely opposed to the view in question, holding that there is no such thing as incontinence ; no one, he said, when he judges acts against what he judges best – people act so only by reason of ignorance.
He then adds:
Now this view plainly contradicts the apparent facts, and we must inquire about what happens to such a man; if he acts by reason of ignorance, what is the manner of his ignorance? (Plato , Protagoras, 352b–358d; Aristotle , Nicomachaen Ethics, Book VII, 2, 1–2).
Aristotle devotes a large part of Book 7 of Nicomachean Ethics to akrasia , defined as a character trait which predisposes a person to intentional , non-compulsive behavior which at odds with his best judgment. The very existence of incontinent actions presents theoretical problems that have been analyzed by numerous contemporary philosophers , notably by Davidson , starting with the second Essay in Actions and Events and in Paradoxes of Irrationality; (Davidson 2001, 21–43; Davidson 2004, 169–189). There is also a recent collection of essays dedicated to it (Stroud and Tappolet 2003). The practical problems of incontinence have been grappled with by psychologists, theologians, physicians, law enforcement—indeed, any field which seeks to understand and shape human behavior.
6.2 Patient Nonadherence to Therapy as a Case of Akrasia
The concept of weakness of will — akrasia —may perhaps shed additional light on the problem of patient nonadherence.
Taking a medication is an action that can be considered desirable from the point of view of the physician who prescribed it, and to not take it is a typical example of nonadherence. But this concept of nonadherence is actually a reflection of the physician’s point of view. On the other hand, the definition of an incontinent action is that the agent intentionally performs an action that she herself does not consider to be the best—not an action that is considered bad by another. In short, nonadherence is about disagreement between doctor and patient , whereas incontinence is about disagreement between the patient and herself.
If my physician has advised me to take some pills as part of my treatment and I don’t do it, she can conclude that I am nonadherent to her advice. It may be that I do not think that taking the medication is, all things considered , best for me. I am refusing the prescription against medical advice. But if I do not take the medication even though I think it would be best to do so, my behavior is incontinent , akratic . Thus, to analyze the problem of nonadherence from the angle of akrasia , as I propose to do here, is to consider the patient ’s point of view. In other words, this analysis takes into account patient autonomy in the therapeutic relationship.
One may argue that perhaps “all things considered ” is an unreasonable expectation: Who is ever in the position of being aware of all pertinent aspects of a situation, let alone having the time and ability to consider all of them? Even the doctor , whom we like to imagine knows all that is relevant in a medical situation, does not have complete information; and what information he does have may be weighted differently than how the patient (or another doctor) might weight it. For instance, a patient might not be worried about long-term complications in quite the same way that her doctor is; can we really say that this patient’s choice to not adhere to treatment is akratic ?
Nevertheless, we can assess a patient ’s choices in light of the information she does possess (regardless of whether it is less, more, or different than what her doctor possesses, whether it is biased by the use of heuristics —consider Tversky and Kahneman ’s theories 1974). When her choice is at odds with the information, we can rightly call it akratic .
Indeed, here is the tricky point: Deciding whether an action is akratic may be seen as a judgment, and many people, being sensitive about this sort of thing, may tell us: “Who are you to judge?” Thus, it is important to emphasize that akrasia is about internal incoherence, and not about whether the patient is doing or not doing what she “ought” to do according to others: The conflict is between the patient and her own judgment, between the patient and herself. Thus, akrasia steps us into the realm of meanings and belief , and loosens the exclusive coupling between “hard facts” and “rational decision making”.
6.2.1 Philosophical Explanation of Akrasia
Incontinent actions are interesting from the philosophical point of view because they are difficult to understand. Davidson has analytically formulated the paradox of incontinent actions in three propositions (Davidson 2001, 23):
P1: If an agent wants to do x more than he wants to do y and he believes himself free to do either x or y, then he will intentionally do x if he does either x or y intentionally.
P2: If an agent judges that it would be better to do x than to do y, then he wants to do x more than he wants to do y.
P3: There are incontinent actions.
P1 and P2 together entail that if an agent judges that the first action is better than the other, and if she believes herself to be free to choose, then she will perform the action she judges to be the best. But experience shows that this is not the case: P3 affirms that there are truly incontinent actions. And that is why they are paradoxical : They should be impossible, since they contradict logic. Whence the typically philosophical question asked by Davidson in his 1970 paper: How is weakness of the will possible ?
The first way to explain it is to hold that when the agent acts incontinently, she does not control herself, that she is possessed by unknown forces that keep her from acting in accordance with her best judgment. It is not she who acts, and thus it is not an action . Or that her judgment, under the influence of passion, pleasure or desire is so distorted that she is no longer capable of understanding that the action she is performing is bad. But, as Davidson notes, these explanations either deny that an incontinent action is possible (since in the first case it is not the agent who acts), or they deny that the agent has intentionally chosen the bad action having compared the relative virtues of the two. But as we have already seen, there are many instances of incontinent action (including the action of not doing something) where these explanations fall short.
6.2.2 A Choice Between Two Actions
We can make sense of incontinence by introducing two notions; conveniently, these notions complete the description of an action . Let us consider an example. Suppose I desire to lose weight , and I think that I can do so by exercising. And yet I do not exercise ; I am ‘incontinent ’.
First, even if an action is considered in the form of a practical syllogism , it is obvious that this action would not exist in isolation. There would be in my mind many other syllogisms as well, and some would undermine the continent action. In our example, there may be something like this: “All action that assures my rest is desirable, I believe that not exercising is this type of action, so I do not exercise ”. This first explanation of the performance of an incontinent action can be seen as a moral conflict, a struggle between two opposing desires . But this explanation is not sufficient, because here, once again, the agent would not be responsible for her choice —she is merely the recipient of the outcome of the battle.
Davidson prefers another scenario, with three players: From the moment one has the choice between two actions, we can introduce a third component, which we can for now call the will; it decides in favor of one action or the other. It will choose the action with the strongest reasons (Davidson mentions “reason, morality , family, country” as reasons; for the case we are interested in, we can add the advice given by the physician) “based on all relevant considerations” (Davidson 2001, 35–36). But again, how can the agent rationally choose the one judged as the worst by reason? In other words, to use Davidson’s title, how is weakness of the will possible ? In the collection “Essays on Actions and Events ”, the essay on the weakness of will comes second, after the essay “Actions, reasons and causes”, proving how crucial this question was for the author.
The second factor to be taken into account is the possibility that both actions may have their reasons ‘for and against’, i.e., neither action is completely desirable. Davidson suggests that there are two types of judgments. The first type of judgment is an unconditional judgment, always exact, a judgment ‘sans phrase’: It unconditionally leads to action. The second is a conditional judgment: It does not tell us whether an action is the best in itself, but rather whether it is the best taking into account the circumstances. These arguments cannot be properly assessed in a void; they can be understood only in a given context. Davidson calls this a prima facie judgment. For instance, a rule such as ‘lying is wrong’ might be judged to be inapplicable if the lie in question is uttered to prevent needless embarrassment. So this type of moral judgment does not unconditionally lead to action: ‘So I do not lie’.
This can be analytically represented by an operator pf (x is better than y, r) where r is the reason why one thinks x is better than y. In this example, r is ‘this particular lie, a white lie’. Here the conditional, prima facie, evaluation leads me to lying, when if I had stopped at the unconditional evaluation ‘sans phrase’, ‘lying is wrong’, it would have lead me not to lie.
As Ruwen Ogien notes,
it is necessary […] that I interrupt, in a second, my conditional (prima facie) evaluation, otherwise I would be completely incapable of acting. So in a way I fix my absolute duty, which is a rough evaluation, an unconditional judgment. The prima facie duty is what precedes this decision to believe that the action will be more just than unjust (or good rather than bad), a decision that transforms a prima facie or conditional duty into an absolute duty (Ogien 1993, 72).
Davidson thus proposes that reasoning that stops at prima facie or conditional judgment “is practical only in its subject, not in its issue” (Davidson 2001, 39) and might not result in a corresponding action .
To explain incontinent actions, Davidson comes back to the notion ‘all things considered ’. An action is said to be incontinent if it is performed while the agent has a better reason to do something else (Davidson 2001, 40).
Definition: in performing x, the agent performs an incontinent action if and only if: (a) the agent performs x intentionally; (b) the agent believes there was another action she had the possibility of performing; (c) the agent judges that all things considered , it would be better to perform y rather than x.
This is the case for an action x that the agent performs for a reason r, but she has a reason r′ that includes r, and on the basis of which she judges some alternative action y to be better than x. Inversely, we may say that an action x is continent if x is done for a reason r, and there is no reason r′ (that includes r) on the basis of which the agent judges some action better than x. (Davidson 2001, 40)Related posts:
Introduction: The DoctorDoctor , Her PatientPatient , and Their Reasons
IntentionalityIntentionality
The Dynamics of IntentionalityIntentionality
Doctors’ Clinical InertiaClinical Inertia as Myopia
Time and Adherence: A Principle of Foresight
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
