Compliance is not allBMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7125.151 (Published 10 January 1998) Cite this as: BMJ 1998;316:151
- Marshall Marinker, Visiting professora
Editor—Bamforth is correct in spotting the wrong preposition in the quotation from Franz Kafka.1 In the course of some enthusiastic technical editing of my article, Kafka was omitted and restored only as the result of my last minute appeal on the telephone.2 Somehow BT (the telecommunications company), my diction, and the technical editor's hearing conspired to substitute the offending preposition. Bamforth's summary of Kafka's story, however, usefully warns us of the contrast between professional empathy (a cornerstone of concordance) and uncontrolled transference (the fate of Kafka's fictional doctor). In the working party report that I referred to, the correct translation of Kafka's quotation appears, as Bamforth gives it.3
In their letter Milburn and Cochrane express three reservations about concordance.4 Firstly, they observe that drug trials demand high levels of compliance to establish effectiveness and dose. In clinical practice half of patients with chronic conditions fail to achieve this compliance. Does this mean that the results of these trials can be of help only to (an unpredictable) half of the population of patients to be treated? The singleminded pursuit of compliance may provide proof of effectiveness but seems unable to deliver reliable benefit.
Secondly, they claim that cognitive analytic psychotherapy has helped to improve patients' compliance. If as a consequence the patient is able to benefit more fully from the treatment then he or she does so as an active partner. Psychotherapy aims to empower, not control, the patient. Surely this is an argument not for compliance but for concordance.
Thirdly, they remind us that threats to the public health (posed, in their example, by non-compliant patients with open pulmonary tuberculosis) demand nothing less than strict compliance with drug treatment, in the public interest. There are similar examples from forensic mental health. Nothing in the concept of concordance asserts the necessary primacy of individual autonomy over the needs of society.
In setting out our agenda of research, training, and public awareness, our working party was only too aware that we were not providing definitive answers to the problems caused by non-compliance in medicine taking. Rather, we wished to suggest a more productive way of asking the questions