Recent years have seen many different efforts to leverage digital technology to address the widespread issue of non-adherence to medication prescriptions. But critics, including many experts, argue they’re neither effective nor ethical.
Non-adherence is a serious problem worthy of creative and forward-thinking solutions. Studies have suggested as many as half of patients aren’t taking their medications correctly, according to The Verge. Between 25 and 50 percent of the time, patients don’t complete medication cycles, which in antibiotics can promote drug resistance, with effects that go far beyond the individual patient. Other research has shown non-adherence actually causes more than 100,000 deaths each year. And some estimates suggest non-adherence incurs costs in the US reaching between $100 and $300 billion annually. Roughly 66 percent of hospital readmissions have been linked to non-adherence.
But the nature of the problem means solutions are often fraught with ethical problems. Increasingly, these efforts are raising ethics and privacy questions that need to be addressed, and advancing technology that offers new options for monitoring patients is only making those ethical questions even more urgent and concerning. Where is the line between reminding, encouraging, and forcing patients to take medications? Given broader concerns over data privacy, is medical data safe from breaches and improper access? And what accessibility issues are at the root of the problem?
A recent development called “selfie medicine” uses phone apps to encourage patients to take their pills by requiring them to take a video of themselves swallowing the medication, which is then sent to their clinic where they’re monitored for compliance, according to The Verge. Many cities are already using this procedure for tuberculosis medication, and some clinics are using it to treat opioid addiction. Researchers are also looking into its use for hepatitis C treatment.
But simply adding the requirement to send the video isn’t likely to be enough. Studies have shown that patients with electronic pill bottles, which monitor compliance and send the results to a social support network like their family, don’t do any better than control groups without the monitoring. Research suggests that behavioral changes hinge on external consequences. But what would this look like with selfie medicine?
NYU bioethicist Arthur Caplan said to the Chicago Tribune:
“Is the doctor going to start yelling at me? Am I going to get a big accusatory speech? How will that interaction be handled?”
Monitoring could even allow insurers to refuse to pay for medication without evidence that it’s being taken properly.
Through all of the failed attempts at addressing non-compliance, reducing the price of pharmaceuticals has consistently been shown to be effective. But this is a knotty problem that many politicians have tried and failed to solve, including President Donald Trump, who campaigned on the issue. The solution would probably require radical changes in rules for manufacturers. These companies wield considerable political power and influence in the US, which pays more for drugs than nearly any other developed nation.
Perhaps our efforts to deal with non-compliance using technology are attempts to find a more convenient shortcut around a thorny political issue.
And as technology advances, these attempts have become increasingly questionable. Pharmaceutical companies have released “smart” pills that include computer chips to track adherence. In January, the first digital cancer pill was released, which transmits a signal when it reaches the stomach, allowing patients, as well as doctors and family members, to monitor the patient’s adherence. The manufacturer is now incorporating the same chip into dozens of other medications.
All computers can be hacked or could malfunction. In this era of data breaches, is there any substantial assurance that medical data from inside patients’ bodies will any safer than their information on social media?
These issues could become even more problematic if used for medications to treat mental health issues and disabilities. It could be a slippery slope from convenient reminders to coercing people to take medication against their will. This can even backfire. For example, the first smart pill approved by the FDA was for treatment of schizophrenia, which often includes paranoia relating to surveillance, and a distrust of doctors. Not only is asking these patients to swallow a computer chip unethical, but it could understandably exacerbate their condition.
According to Eric Swirsky, an expert in legal and ethical issues in healthcare and a clinical associate professor of biomedical and health information sciences at the UIC College of Applied Health Sciences, even the questions about privacy are missing the larger issue:
“We need to know if smart pills are going to actually improve patients’ lives, which is much more complicated than compliance or privacy. It is naive to think that this type of surveilled compliance with provider-recommended drug treatments will function like a magic pill. More likely, it will just challenge the ingenuity of patients.”
Swirsky cites research that shows the benefits of care from doctors that are prepared to carefully manage adherence issues.
“Smart pills are a dangerous reduction of the provider-patient relationship and there is no shortcut to improving patient adherence, which happens in a larger framework of home, work and clinical environments, not to mention perceptions and emotions. This technology dumbs down an issue that is often very complex in the hopes of quickly solving an expensive medical challenge.”
Non-adherence is a serious problem, with serious consequences. But these ethical and privacy questions are enough reason to move forward with caution. With the added possibility that we’re also avoiding grappling with root causes like the access and affordability issues and the need for care providers who can address the nuanced problems around adherence, these technologies might be doing an even greater disservice.