A wolf in sheep's clothing: a critical look at the ethics of drug takingBMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7419.856 (Published 09 October 2003) Cite this as: BMJ 2003;327:856
- Iona Heath, general practitioner (firstname.lastname@example.org)1
- Caversham Group Practice, Kentish Town, London NW5 2UP
The Department of Health's Medicines Partnership is encouraging a shift away from the concept of drug compliance, with its tacit assumption of obedience and coercion, to one of concordance. However, Iona Heath argues that this is, at best, misguided and, at worst, simply window dressing
In 1997 a report of a working party of the Royal Pharmaceutical Society of Great Britain acknowledged that prescribing is “a technically difficult, and morally complex, problem” and that compliance is an ethically dubious aspiration.1 The report proposed the use of a new term—concordance—which was intended to describe the creation, during the process of prescribing, of an agreement that respected the beliefs and wishes of the patient.2 The intention of the working party was to foster a distinct change in culture in the relation between prescribing and drug taking and between patient and prescriber. The intention was honourable, but the initiative seems to be foundering.
Compliance is indeed a pernicious concept which devalues patients and leaves the hubris of doctors dangerously exposed. It derives from the foundation of medical science within a modernist rationality, which seeks to identify general rules that can be applied to standardised situations. However, in the care of patients, doctors attempt to apply general rules to particular individuals in situations that are never standard and where there is no single right answer. When doctors exploit their power and claim a monopoly of relevant knowledge, the autonomy, dignity, and even legal rights3 of patients may be compromised. This inappropriate use of power is reflected in the concept of compliance, which embodies the belief that “doctor knows best” and implies that patients' responsibility is simply to follow medical advice.
The Medicines Partnership
In 2002 the Department of Health responded to the recommendations of the Royal Pharmaceutical Society's report by endorsing the concept of …