A wolf in sheep's clothing: a critical look at the ethics of drug taking
BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7419.856 (Published 09 October 2003) Cite this as: BMJ 2003;327:856
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Editor,
Heath’s excellent paper on concordance is very timely (1). The new GP
(GMS) contract, due for launch in April 2004, will link GP performance to
pay. This is no new concept, for we have been receiving immunisation and
cytology target payments since 1990, but in the new GMS contract, GPs will
receive payment for prescribing drugs for diabetes, ischaemic heart
disease, hypertension and others chronic diseases. That these conditions
are often laboratory or clinical entities without symptoms at the time of
their discovery further muddies the water. Here we have to perform a
double sell; first there is the hump of the explanation of the disease to
overcome, with its murky concept of insurance against what may or not
happen, then the drugs.....
Part of the trouble is that patients and doctors are stuck inside the
“cure” paradigm, a paradigm underpinned by consumption and multi-national
profiteering. Patients often buy into this whilst doctors, who should know
better, too frequently turn inexpertly towards the single barrel of
prescription because they have been led to believe they have nowhere else
to go. Where there is acute illness with its pressure of symptoms and
sense of urgency, there may exist a raw form of concordance in which we
are as it were, of the “same heart”, i.e. patient’s request and doctor’s
assessment/treatment are in equilibrium. But transfer this to chronic
disease management and your problems really begin.
I do not relish the challenge of this new contract. The public will
perceive us even more as self-serving and this will threaten our most
priceless tool, the therapeutic relationship.
Jim Hardy
(1)Heath, I. A wolf in sheep’s clothing: a critical look at the
ethics of drug taking. BMJ 2003; 327:856-8
Competing interests:
None declared
Competing interests: No competing interests
In her thoughtful critique of medicines concordance, Iona Heath
argues that we should abandon the term because, while ‘compliance’ is
honest in its coercive intentions, ‘concordance’ conceals this coercion
under the cosmetic of soft words (1).
When we introduced the idea of a concordant consultation we did try
to avoid the danger against which Heath perceptively warns. We said of
‘compliance’ that in resolving the conflict between the doctor’s
perspective and that of the patient, the doctor’s task seemed to be “...to
bring the patient’s response to the doctor’s diagnosis and proposed
treatment as far as possible into line with what medical science
suggests.” This we contrasted with concordance in which the response to
such conflict was to form “...an alliance in which the most important
determinations are agreed to be those that are made by the patient.” (2)
The conflicts between what medical science suggests, and what the patient
wishes, can not be resolved by concordance. They can, however, be managed
in a non coercive and sensitive way .
Heath is also right to warn about the dangers of translating evidence
from sound clinical trials into rules for sound individual practice. Even
were doctors to have a priori evidence of individual effectiveness and
appropriateness, the patient’s priorities, her ways of solving the risk-
benefit equation inherent in every prescription, would remain of the first
importance.
It is my personal view that concordance proposes nothing less than a
re-think of our measures of clinical outcome. These new outcome measures
must somehow encompass not only the expected clinical benefit, but the
patient’s sense of the illness, her judgement of the relative risks of
taking, and not taking, medicines, her self image, and what she feels she
can bear.
Whether or not the term concordance survives in the medical lexicon
is less important than that its original intentions should survive in the
practice of doctors.
(1) Heath I. A wolf in sheep's clothing: a critical look at the
ethics of drug taking. BMJ 2003;327:856-858 (11 October)
(2) Royal Pharmaceutical Society of Great Britain. From compliance to
concordance: achieving shared goals in medicine taking. London: RPS, 1997.
Competing interests:
None declared
Competing interests: No competing interests
Therapy concordance in Parkinson's Disease
We would like to comment on the concordance issues discussed by Heath
(1) which makes critical reference to the Medicines Partnership programme,
in which a key area of study is education of patients with Parkinson's
disease (PD) by community pharmacists. So little is known about patient
compliance in PD that defining the baseline should precede interventions
to 'improve' compliance. We know that in a very small numbers of patients
with advanced PD (case series numbering 1 to 5 patients, total n=32)
excess levodopa consumption occurs, possibly through compulsive mechanisms
(2). We suspect that in early PD, mild symptoms and an absence of
individual dose responses, coupled with patient concerns about longer-term
side-effects and failing efficacy (both linked to motor complications) may
lead the patient to omit prescribed doses, but this is an unpublished
area. Healthcare professionals initially need a better understanding of
how and why the PD patient takes their medication. Some evidence for this
will come from pharmacy refill data (as in the Medicines Partnership
project) and this should be used to inform the prescriber as well as the
pharmacist and patient. Additional compliance measurement techniques
should be considered (3). Until we have such data, the design,
implementation, and interpretation of the effect of education programmes
for PD patients is premature. Presently, therapy management decisions and
attempts to inform the patient are often based on an erroneous
understanding of patient beliefs and behaviour. In other disease areas,
increasing patient knowledge takes enormous effort for marginal if any
gain achieved, and this is ill-sustained in chronic disease (4). Improved
concordance appears a laudable aim, but taking tablets as per instruction
should not be assumed to lead to health gain (5). The interplay is much
more complex since efficacy is pitched against side-effects, and in
addition concordance involves culture, personalities, illness beliefs, and
comorbidities (depression and cognitive failure being especially
significant in PD). The initial goal in this joint patient-professional
approach is to increase mutual understanding of how these factors interact
on the prescription and uptake of prescribed PD drugs.
Katherine Grosset, General Practitioner, Shettleston Health Centre,
Glasgow G32 7JZ [Katherine.Grosset@gp46081.glasgow-hb.scot.nhs.uk]
Donald Grosset, Consultant Neurologist, Institute of Neurological
Sciences, Glasgow G51 4TF [d.grosset@clinmed.gla.ac.uk]
References
1. Heath I. A wolf in sheep's clothing: a critical look at the
ethics of drug taking. BMJ 2003;327:856-8.
2. Lawrence AD, Evans AH, Lees AJ. Compulsive use of dopamine
replacement therapy in Parkinson's disease: reward systems gone awry?
Lancet Neurol. 2003;2:595-604.
3. George CF, Peveler RC, Heiliger S, Thompson C. Compliance with
tricyclic antidepressants: the value of four different methods of
assessment. Br.J.Clin.Pharmacol. 2000;50:166-71.
4. McDonald HP, Garg AX, Haynes RB. Interventions to enhance patient
adherence to medication prescriptions: scientific review. JAMA
2002;288:2868-79.
5. Haynes RB, McDonald H, Garg AX, Montague P. Interventions for
helping patients to follow prescriptions for medications.
Cochrane.Database.Syst.Rev. 2002;CD000011.
Competing interests:
None declared
Competing interests: No competing interests