Patient Adherence

Situation

While working at a health clinic at a homeless shelter, you discover

that F.C., a 64-yr-old man with tuberculosis (TB), has not been taking

his prescribed medications. He tells you that it is hard for him to get

to the clinic to obtain the medication, much less to keep on a

schedule. You are concerned not only about this patient, but about

the risks for the other people at the shelter, in the park, and at the

meal sites where he often visits.

Ethical/Legal Points for Consideration

• Adherence is a complex issue involving a person’s culture,

values, and beliefs, perceived risk for disease, availability of

resources, access to treatment, and perceived consequences of

failure to adhere to treatment.

• Advocacy for the patient and the community obliges you to

involve other members of the health care team, such as social

services, to aid in obtaining resources or support for the patient

to complete a course of treatment.

• Some cities and states have a stepwise legal process for managing

nonadherent TB patients.

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• Legally the constitutional right to control one’s own body may be

limited by state and federal obligation to protect public health

and safety. Most of these laws have provisions for the protection

of constitutional rights, such as right to counsel, right to least

restrictive alternative in terms of confinement setting, and right

to prompt judicial review.

• The federal government and many states have provisions for

quarantine, detention, and treatment. With the threats of

bioterrorism and the globalization of exposure to highly lethal

infectious diseases, it seems unlikely that the government’s

power to detain will be removed.

Discussion Questions

1. What alternatives of care can we offer to F.C.?

2. Under what circumstances, if any, are HCPs justified in

overriding a patient’s autonomy or decision making?