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A novel conceptual framework for understanding the mechanism of adherence to long term therapies

机译：一个新颖的概念框架，用于理解长期治疗的依从性机制

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Abstract: The World Health Organization claimed recently that improving patient adherence to long term therapies would be more beneficial than any biomedical progress. First, however, we must understand its mechanisms. In this paper I propose a novel approach using concepts elaborated in a field rarely explored in medicine, the philosophy of mind. While conventional psychological models (eg, the Health Belief Model) provide explanations and predictions which have only a statistical value, the philosophical assumption that mental states (eg, beliefs) are causally efficient (mental causation) can provide the basis for a causal theory of health behaviors. This paper shows that non-adherence to long term therapies can be described as the medical expression of a philosophical concept, that is, weakness of will. I use philosophical explanations of this concept to suggest a mechanistic explanation of nonadherence. I propose that it results from the failure of two principles of rationality. First, a principle of continence, described by the philosopher Donald Davidson in his explanation of weakness of will. This principle exhorts us to act after having considered all available arguments and according to which option we consider best. However, patients conforming to this principle of continence should rationally be nonadherent. Indeed, when patients face a choice between adherence and non-adherence, they must decide, in general, between a large, but delayed reward (eg, health) and a small, but immediate reward (eg, smoking a cigarette). According to concepts elaborated by George Ainslie and Jon Elster, the force of our desires is strongly influenced by the proximity of reward. This inter-temporal choice theory on one hand, and the mere principle of continence on the other, should therefore lead to nonadherence. Nevertheless, adherence to long term therapies is possible, as a result of the intervention of an additional principle, the principle of foresight, which tells us to give priority to mental states oriented towards the future.
机译：摘要：世界卫生组织最近声称，提高患者对长期疗法的依从性比任何生物医学进步都更为有益。但是，首先，我们必须了解其机制。在本文中，我提出了一种新颖的方法，该方法使用了在医学中很少探索的领域-心灵哲学-中阐述的概念。传统的心理模型（例如，健康信念模型）提供的解释和预测仅具有统计价值，而心理状态（例如，信念）具有因果效率（精神因果关系）的哲学假设可以为以下方面的因果理论提供基础健康行为。本文表明，不坚持长期治疗可以被描述为一种哲学概念的医学表达，即意志的弱点。我用对此概念的哲学解释来提出对不遵守的机械解释。我认为这是由于两个理性原则的失败所致。首先，一种过失原则，由哲学家唐纳德·戴维森（Donald Davidson）在解释意志弱点时加以描述。在考虑了所有可用的论点并根据我们认为最佳的选择之后，该原则鼓励我们采取行动。但是，符合这种节制原则的患者应合理地坚持治疗。确实，当患者面临依从与不依从之间的选择时，他们通常必须在较大但延迟的奖励（例如健康）和较小但立即的奖励（例如抽烟）之间做出选择。根据乔治·安斯利（George Ainslie）和乔恩·埃尔斯特（Jon Elster）提出的概念，奖励的接近性强烈影响着我们欲望的力量。因此，一方面，这种跨时选择理论，另一方面，单纯的节制原则，应该导致不坚持。然而，由于附加原则即预见性原则的介入，仍可能坚持长期治疗，这告诉我们优先考虑面向未来的精神状态。

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