After the Diagnosis

Living a rich, full life with chronic illness.

"Ask Your Doctor"

To take, or not take, medication

I had a patient, seventy-five years old, whose kidney disease had been stable for many years. Since lowering blood pressure is one way kidney doctors relieve stress on the filtering mechanism of the kidney, at our most recent appointment, I prescribed an antihypertensive to help maintain his function. The man turned to me in some distress and said, "Do I have to take this for the rest of my life?"   

Patients don't like medication--except for the ones who do.  People have strong reactions to the idea of drugs, depending on the particulars of their history and temperament, and sorting out these factors is a key part of practicing good medicine.  Without patient participation, "compliance" can easily feel like coercion.

People aren't entirely wrong to fear medication.  We live in a drug-happy society, where there is supposedly a cure for every ill, a pill for every occasion.  (Just watch TV for a minute, and check out those "ask your doctor" ads.)  But a drug that works is also a drug that changes the body's physiology, and the line between a therapeutic and a toxic dose is a fine one.    Side effects-evidence of some degree of toxicity-are an almost inevitable feature of taking medication.  Take the case of blood pressure medication: many of my patients with severe renal insufficiency are on high doses, which present the possibility of very low pressures that could lead to dizziness, weakness, nausea, even blackouts.   Patients have to do their own cost-benefit analysis in these cases: how much discomfort and uncertainty are they willing to tolerate in their daily lives to preserve the long-term function of their kidneys?  In my own life, I've had struggles with taking enough insulin to cover my meals because the sensation of hypoglycemia is so unpleasant and threatening.  A sugar that bottoms out deprives the brain of needed glucose and can lead to unconsciousness, even death, so I've always erred on the side of higher sugars, despite the potential complications stemming from poor control.  For me, having a reliable brain and a sense of minute-by-minute safety has allowed me to have the active life I wanted as a physician and a traveler.  That's the deal I've made with my illness.

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But there are people who strike opposite bargains: they're more than willing to suffer side effects in order to feel they're doing the right thing, the healthy thing.  Though daily life may be precarious, at least their kidney-or heart, lung, liver, pancreas-- is doing okay.  Some people would much prefer to pop a pill than change a habit.   When the first studies came out suggesting cholesterol was a key factor in heart disease, a flurry of dietary recommendations followed-only to be pretty much cast aside when statins became available.  A rigid diet was no match for a cholesterol-lowering drug, which let you have your cake and eat it. 

So when your doctor prescribes a medication, a frank talk about those costs and benefits might be in order.  Trying a drug, weighing side effects, tweaking dose or brand, looking at non-pharmaceutical approaches-these are the things that can make the difference in successful treatment.  Knowing who you are, and what most matters to you, is helpful information when you contemplate that little pill. 

 

 

 

Julian Seifter, M.D., is a professor at Harvard Medical School, and the chair of the Ethics Committee on Human Research at Brigham and Women’s Hospital in Boston.

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