Adherence, compliance and concordance: an ethical perspective

Concordance has become the widely accepted gold standard of prescribing.In this article, the ethical underpinnings of adherence-related decision makingwill be analyzed. The goal of this article is to identify the ethical dimensionsof adherence-related decisions using core concepts of health care ethics. Itdraws on the principles of biomedical ethics, as presented by Beauchampand Childress (2009), core ethical concepts like paternalism and informedconsent, and considerations from relational ethics and care ethics. The articlestarts by outlining initial ethical reasons for attention to the phenomenon ofnon-adherence, in particular the ethical requirement of prevention of harm.The rejection of the notion of compliance is then discussed in the context ofthe problem of paternalism, as a conflict between the patients autonomy andthe prescribers view of what is in the patients best interest. Informed consentwill then be addressed as the standard solution to avoiding paternalism, as anattempt to facilitate the patients autonomous decision making. The elementsand practices of informed consent are discussed. A discussion of the notion ofconcordance highlights the importance of the therapeutic relationship betweenpatient and prescriber. In this context, relational ethics and care ethics becomerelevant to the extent that they identify important characteristics of a constructiveethical approach to this relationship.