When a disease is rapidly life threatening or markedly reduces quality of life, the distinction between professional and personal outcomes is often neglected. However, personal outcomes obviously should be addressed for many relatively asymptomatic ("silent") diseases, especially those with a slow course and diseases in which symptomatic treatment may conceal a worsening of the underlying disease, such as asthma. Furthermore, even patients with extremely symptomatic or life-threatening diseases may choose not to treat them if they decide that the treatment would be worse than the disease, or even worse than dying, for them or their loved ones.
In the vignette that opens this chapter, Mr. Diehl is concerned about his ability to enjoy life. He does not experience symptoms from his hypertension. In fact, he doubts that he has hypertension, while he attributes symptoms that he does experience, e.g., impotence, to his medication. Trying to trump his quality-of-life concerns with clinical objectives may not succeed, especially if this is attempted by means of professional authority. He admits that he is not cooperating in his care as well as he could. His cooperation may well be necessary to obtain the professional objective of disease control.
In addition to producing clinical effects that are visible to patients, medicines may help patients to understand, interpret, or accept an illness. Drug therapy for depression is an example. People sometimes say, in effect, "I'm not crazy, I have a biochemical imbalance that can be corrected with medicine." This is also an example of a medicine being used to make legitimate an otherwise vague illness.
Some people take medicines mainly to follow doctor's orders. This applies not only to a patient in a paternalistic relationship, in which the patient may take his medicines regularly regardless of their desirable or undesirable effects, but also to some caregivers, nurses, and pharmacists who carry out doctors' orders without questioning the effect of the medicine on a patient.
Finally, from a negative perspective, patients may choose not to take medicines or may use them incorrectly because they cannot afford them, because they do not know (or accept) the correct method of use, because the medicine is incompatible with diet or other aspects of their lives, or because using them is inconvenient. There are many examples. "Three times a day after meals" does not mean the same thing to a middle-class matron as it does to a homeless person. The dietary needs of a diabetic may not fit well with budget or with menus planned by another. A schoolchild's need to use an asthma inhaler may be incompatible with his desire not to appear different, especially if school rules restrict his access, e.g., by requiring that medicines be left with the school nurse.
Employers may in turn value people's wellness and quality of life, because people with a higher quality of life tend to be more effective. Governments may value quality of life because it satisfies the electorate, and because populations with higher quality of life may be more effective citizens. The significance of health professions to a society may be greater than just keeping its population disease-free.
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