The Mental Mechanisms of Patient Adherence to Long-Term Therapies: Mind and Care

221 Pages·2015·4.481 MB·English

by  Gérard Reach (auth.)

P&M118
Philosophy and Medicine
Gérard Reach
The Mental
Mechanisms of
Patient Adherence
to Long-Term
Therapies
Mind and Care
Philosophy and Medicine
Volume 118
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Gérard Reach
The Mental Mechanisms
of Patient Adherence
to Long-Term Therapies
Mind and Care
1 3
Gérard Reach
Avicenne Hospital
and Paris 13 University
Sorbonne Paris Cité
Bobigny
France
Translation by Nastya Solovieva, edited with the assistance of Jeff Engelhardt and John Meyers
ISSN 0376-7418 ISSN 2215-0080 (electronic)
Philosophy and Medicine
ISBN 978-3-319-12264-9 ISBN 978-3-319-12265-6 (eBook)
DOI 10.1007/978-3-319-12265-6
Translation from the French language edition: Pourquoi se Soigne-t-on, Enquête sur la Rationalité
Morale de l‘Observance, © Le Bord de l‘Eau 2007. All rights reserved.
Library of Congress Control Number: 2014954601
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‘O Socrates, Gorgias is deceiving you, for my art is concerned
with the greatest good of men, and not his.’ And when I ask,
Who are you? He will reply, ‘I am a physician’. What do you
mean, I shall say. Do you mean that your art produces the
greatest good? ‘Certainly’ he will answer, ‘for is not health the
greatest good? What greater good can men have, Socrates?’
Plato, Gorgias
For neither does the man who is ill become well on those terms,
although he may, perhaps, be ill voluntarily, through living
incontinently and disobeying his doctors. In that case it was
then open to him not to be ill, but not now, when he has thrown
away his chance, just as when you have let a stone go it is too
late to recover it; but yet it was in your power to throw it, since
the moving principle was in you.
Aristotle, Nicomachean Ethics
You will see, I will try to show you, how generally speaking the
principle that one must take care of oneself became the princi-
ple of all rational conduct in all forms of active life that would
truly conform to the principle of moral rationality.
Michel Foucault, The Hermeneutics of the Subject
I am a sick man. I am a wicked man. An unattractive man.
I think my liver hurts. However, I don’t know a fig about
my sickness, and am not sure what it is that hurts me. I am not
being treated, and never have been, though I respect medicine
and doctors. What’s more, I am also superstitious in the extreme;
well, at least enough to respect medicine…No, sir, I refuse to
be treated out of wickedness. Now, you will certainly not be
so good as to understand this.
Dostoyevsky, Notes from the Underground
“He” has two antagonists; the first presses him from behind,
from his origin. The second blocks the road in front of him. He
gives battle to both. Actually, the first supports him in his fight
with the second, for he wants to push him forward, and in the
same way the second supports him in his fight with the first,
since he drives him back. But it is only theoretically so. For it
is not only the two antagonists who are there, but he himself as
well, and who really knows his intentions? His dream, though,
is that some time in an unguarded moment—and this, it must be
admitted, would require a night darker than any night has ever
been yet—he will jump out of the fighting line and be promoted,
on account of his experience in fighting, to the position of um-
pire over his antagonists in their fight with each other.
Franz Kafka, Aphorisms
The force that presses “Him” from behind and the force that
blocks Him from the front are the forces of the past and future.
Hannah Arendt, The Life of the Mind:
Thinking, 1971
To Isabelle
To our children and grandchildren
Foreword
In books on medicine, one generally wonders why one is sick, and how one can
look after oneself. One more rarely wonders why one does not take care of one-
self, and almost never why one does take care of oneself. The reason is simple:
Isn’t good health a desirable result in itself? If a patient visits a doctor, isn’t it in
order for the doctor to take care of him/herself? If one claims to need treatment,
isn’t it to be provided? Under these conditions, how is it possible for a patient
to go to the doctor but nevertheless not take care of him/herself? Yet, there is a
plethora of cases in which patients do not follow doctors’ prescriptions—patient
nonadherence.
This situation is reminiscent of a well-known philosophical paradox, the
Socratic paradox:
(1) If somebody wishes X more than Y, and believes that doing A is the best
means for him/her to obtain X, and is free to do A, then he/she will do A;
(2) A person wishes X more than Y;
(3) The person does not do A.
Socrates supported the idea that situations such as (3), in which the agent acts
against what he/she considers to be the best measure, are impossible because the
agent can only be ignorant of what is good, or of what he/she considers best in
these cases. “No one is voluntarily malevolent,” which is only another manner of
stating (1):
(1') Somebody who knows what is good or virtuous to do cannot help but do
what he/she considers good or virtuous.
Somebody who goes against (1) is what the Greeks called an akratès:
Somebody who does not control herself, or what Romans would refer to as
incontinent: Those who can say, according to the famous formula Video meli-
ora, proboque deteriora sequor (I see what is best, but I do the worst). Socrates
(and perhaps Plato) denied the possibility of akrasia. Aristotle, on the other hand,
accepted it, claiming that what occurs in the mind of the incontinent individual
is undoubtedly a form of bad reasoning: Either he/she does not grasp one of the
ix
x Foreword
premises of the practical reasoning well, or does not infer the conclusion correctly.
The reasoning in (1)–(3) should obviously be held as follows:
(1*) X is more desirable than Y;
(2*) Doing A will enable me to obtain X;
(3*) I do A.
But assuming that akrasia exists, why doesn’t the agent in these cases do A?
A frequent answer, which is not incompatible with the Socratic answer, consists
in saying that he/she is in the grips of a desire or of such a strong compulsion at
the time when he/she would normally be on the verge of doing A. This simply
amounts to thinking that he/she “does not control him/herself anymore,” and can-
not help him/herself. However, it is clear that neither the Socratic answer nor what
one can call, according to the American philosopher Donald Davidson, the “prin-
ciple of Medea” (“I know indeed what evil I intend to do. But stronger than all my
afterthoughts is my fury.”) gives an explanation for this kind of behavior. If the
agent does not know what is good for him/her, he/she is not akratic, but only an
ignorant person; and if the agent knows it, but does not do it, one does not under-
stand why he/she adopts this irrational behavior.
The authorities in charge of public health are often faced with this kind of
dilemma vis-à-vis certain behaviors such as drinking alcohol before driving or
cigarette smoking. They clearly oscillate between pedagogy (Socratic informa-
tion campaigns to inform bad people where the good is) and the pure and simple
constraint (increases in the price of cigarettes, prohibition). Everyone remembers
having seen on the TV medical experts despaired to see that drivers do not do
what they should judge to be best, namely not to drive after consuming alcohol. If
the results of the recent campaigns are very significant, can’t there exist a pathway
between Socrates and Medea?
Many descriptions of akrasia and weakness of will are provided in philoso-
phy and other literature (in psychoanalytic literature, less so, undoubtedly partly
because it uses other names). A vast psychological, medical, economic, sociologi-
cal, and anthropological literature exists on various irrational behaviors related
to akrasia, such as addiction. The phenomenon of patient adherence has been the
object of several publications in the field of health psychology. But never, to my
knowledge, had this phenomenon been considered originating from the discus-
sions of contemporary philosophers of the mind concerning practical reasoning,
the psychology of beliefs and desires, the moral psychology of motivation, and
theories of rationality until Professor Gérard Reach’s remarkable book, which
displays originality in taking these discussions seriously and applying them, with
great understanding, to the analysis of the patient-physician relationship. The
result is impressive because it represents, to my knowledge, the first true meet-
ing between clinical medicine and the analytical philosophy of the mind and of
agency, and for this reason, the model he proposes is of great value for both doc-
tors and philosophers.
A number of works on patient adherence presuppose that the fundamental goal
is to achieve adapted behavior on behalf of the patient who does not take care of
him/herself, without really considering his/her failure to follow a given step of the