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M. Gagnon, J.D. Daniel, A. Guta “Treatment Adherence Redefined”

October 14, 2012 Leave a comment

Gagnon, Marilou; Jacob, Jean Daniel; Guta, Adrian 2012. Treatmend adherence redefined: a critical analysis of technotherapeutics. – Nursing Inquiry (Epub ahead of print).

The development and implementa-tion of technotherapeutics are suggestive of particular tactics of governmentality that concern issues of individual conduct (i.e., treatment adherence), which are also known to inter-fere with the production of a healthy population. (2)

Direct methods may include direct observation by healthcare pro-viders (i.e., pharmacist) or objective measurements of drug concentrations in blood or urine. Thus, these methods not only require the presence of a healthcare provider who will record treatment adherence, but imply that individuals who deviate from the prescribed treatment will be automatically identified. In this sense, direct methods allow for healthcare providers to keep track of adherence via objective measure-ments (i.e., number of visits at the pharmacy, number of pills taken, and serum concentration) and intervene directly when individuals fail to take their treatment as prescribed. (3)

Recent advancements in technology now enable healthcare providers (and researchers) to monitor adherence indirectly via an electronic system capable of recording, for example, when medication bottles are opened (smart pill bottles) or when pumps are activated. Indirect methods such as this one have created new possibilities for healthcare providers to objectively monitor adherence at a distance and intervene directly when individuals fail to take their treatment as prescribed. (3)

By adding a digestible sensor to a standard pill capsule, the sensor undergoes an activation process within the stomach fluids and sends digital signals to the implantable microchip located under the skin of individuals who undergo prolonged treatments. For Proteus Biomedical, this device offers significant advantages for healthcare providers because it is capable of tracking the date and time of pill ingestion, recording drug-related information (i.e., type, dose, and place of manufacture), and measuring physiological parameters (heart rate, blood pres-sure, weight, blood glucose, body temperature, and respira-tory rate). This prototype is set to record information, generate feedback in real time for those involved in adher-ence work (including healthcare providers, patients, family members, and relatives), and promptly signal when a treat-ment is not being taken as prescribed. (3)

We will examine how this instrument of surveillance is, in fact, an anatomo-political instrument that exerts a hold over individual bodies and reconfigures individual behaviors in accordance with a pre-determined set of clinical objec-tives. (3-4)

By adherence work, we mean the broad range of activities through which healthcare providers, family members, rela-tives, and patients themselves look after treatment uptake to achieve optimal clinical outcomes. What becomes evident is that the need to closely monitor treatment adherence, and ensure those who deviate from the prescribed treatment are identified in a timely fashion, has led to the development of a new panoptic machine. (5)

Here, it is important to recognize that the efficiency of the panop-tic machine can be explained by the fact that surveillance not only makes individuals aware that they are being watched, but it makes them engage in self-surveillance during times of deviance; or, before misconducts or faults (such as non-adherence) even take place (Holmes 2001). (5)

Theideahereistousethisnewandpreviously unavailable knowledge to sanction individuals who demon-strate poor adherence while validating those performances that meet expectations. From this perspective, it is believed that individuals will be motivated to adopt prescribed con-ducts, habits, and attitudes when they are confronted with their performance (optimal or not) and positioned in rela-tion to the norm. (5)

Bio-politics, explains Foucault (1990), is closely tied to surveillance and the production of knowledge about pop-ulations. In fact, the birth of bio-politics is said to coincide with the introduction of new techniques to study and closely monitor biological occurrences at the population level (Fou-cault 1990). (6)

Bio-politics stands for the administration of life as a col-lective reality (Lemke 2011) and the management of issues known to interfere with life processes. It is concerned with issues that can be documented, measured, and aggregated on the level of populations – but, also, with calculations of possible and probable risks (Gordon 1991). To this end, bio-political interventions take on the semblance of solutions to discrepancies uncovered in the process of gathering infor-mation about populations or in the process of calculating risks within the collective body. (6)

We locate the development and growth of technotherapeutics at the intersections of bio-politics, and what Clarke et al. (2003) have termed biomedicalization. (7)

[Biomedicalization] …is characterized by its greater organizational and institu-tional reach through the meso-level innovations made possible by computer and information sciences in clinical and scientific settings, including computer-based research and record-keeping. The scope of bio-medicalization processes is thus much broader, and includes conceptual and clinical expansions through the commodification of health, the elaboration of risk and surveillance, and innovative clinical applications of drugs, diagnostic tests, and treatment proce-dures (Clarke et al. 2003, 165). Clarke AE, JK Shim, L Mamo, JR Fosket and JR Fishman. 2003. Biomedicalization: Technoscientific transforma-tions of health, illness, and U.S. biomedicine. American Sociological Review 68: 161–194. (7)

Tech-notherapeutics brings together three major forms of risk identified in neoliberal societies; insurance risk, epidemio-logical risk, and case management (Dean 2010). These three conceptions of risk are less concerned with individual adher-ence than with managing shared health costs, the spread of disease, and keeping individuals who pose a risk connected to regulatory systems. Risk assessment is no longer an indi-vidual matter, but now accounts for whole groups and their practices, and the social risk they pose in relation to health and disease, life and death. (7)

Overall, we understand technotherapeutics as serving to both disci-pline individual bodies and also to regulate whole groups of people deemed to constitute a threat to the collective body. In this sense, we consider that adherence work is above all a political project that endeavors to achieve optimal disease management (through surveillance and discipline), reduce the financial burden of treatment non-adherence on health-care systems, and serve to further marginalize and differenti-ate ‘at-risk groups’ because of their unwillingness or inability to conform. (7)

Returning to the bio-political goal of ‘making live’ and ‘letting die’, we understand that the populations deemed ‘hard to reach’ and ‘vulnerable’ – gay and other men who have sex with men, sex workers, injection drug users, and aboriginal people – have been historically constructed as ‘risky’ and dangerous. In this particular context, technotherapeutics would allow for healthcare providers to gather previously unavailable information about these populations and use this information to intervene directly with patients who deviate from prescribed treatments; not for theirbenefit,but to make sure they do not affect those who the state would ‘make live’ (otherwise useful and productive bodies). (8)

On one hand, technotherapeu-tics are being introduced under the premise that they can improve the therapeutic management of chronic conditions, maximize clinical outcomes, facilitate communication with healthcare providers, and individualize the care provided to those who undergo prolonged treatments. (9)

On the other hand, the development and implementation of technothera-peutics suggest particular tactics of governmentality that can-not be overlooked. (9)