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 making will be analyzed. The goal of this article is to identify the ethical dimensions of adherence-related decisions using core concepts of health care ethics. It draws on the principles of biomedical ethics, as presented by Beauchamp and Childress (2009 ), core ethical concepts like paternalism and informed consent, and considerations from relational ethics and care ethics. The article starts by outlining initial ethical reasons for attention to the phenomenon of non-adherence, in particular the ethical requirement of prevention of harm. The rejection of the notion of compliance is then discussed in the context of the problem of paternalism, as a conflict between the patient's autonomy and the prescriber's view of what is in the patient's best interest. Informed consent will then be addressed as the standard solution to avoiding paternalism, as an attempt to facilitate the patient's autonomous decision making. The elements and practices of informed consent are discussed. A discussion of the notion of concordance highlights the importance of the therapeutic relationship between patient and prescriber. In this context, relational ethics and care ethics become relevant to the extent that they identify important characteristics of a constructive ethical approach to this relationship.