Adherence Labeling: Understanding the Origins, Limitations, and Ethical Challenges of "Diagnosing" Nonadherence.

Abstract

Promoting adherence to medical recommendations remains one of the oldest yet most persistent challenges of modern clinical practice. Although increasingly sympathetic to structural forces that affect health behavior, standard models frequently conceptualize nonadherence as a phenomenon of patient behavior, a self-evident quality belonging to patients that is responsible for a myriad of undesired outcomes. We contend, however, that this approach not only fails to consider the role of the clinician in the concept's origins in clinical encounters, but also has facilitated the use of adherence terms (eg, nonadherent, noncompliant, treatment resistant) as pejorative social labels to the detriment of the physician-patient relationship. Used without care, such terminology can alter the meaning assigned to patients' behaviors so that structural barriers to care such as poverty and systemic racism are reframed as problems of poor attitude or effort. This article explores the functions of adherence terms as social labels by reviewing their underlying logic in clinical settings and outlining pitfalls in the pathologization of nonadherence in research and practice. We propose the concept of adherence labeling-the assessment, classification, and dissemination of clinicians' perceptions of patients' adherence through social labels-as an alternative model to understand how adherence terms may inadvertently obstruct the care of marginalized patients.