Non-Compliance after a Kidney-Pancreas Transplantation – A Narrative Case-Analysis Involving Different Patient-Physician Relationships and Ethical Frames

Background: Non-compliance is one of the most frustrating causes of long-term allograft failure. Despite the frequency of this phenomenon, the clinical-psychological approach has not yet been standardised. Aim: To describe the use of a narrative approach based upon the identification of the best patient-physician interaction model and of the best ethical framework, in the clinical management of a non-compliant pancreas-kidney graft patient. Methods and results: The case: a 30 year-old woman, diabetic since adolescence, recipient of a preemptive kidney-pancreas transplant. No psychological or behavioural problem had been observed or reported before transplantation. After the graft, a benzodiazepine addiction was diagnosed (withdrawal syndrome). She experienced two rejection episodes (low Cyclosporine levels), and discontinued steroids (Cushingoid appearance). She repeatedly refused psychological help and wanted to be managed by her physicians only. The three tested models were: parental-paternalistic (the "static model" according to Hippocrates and the "dynamic model" according to Moses Maimonides); self-determination of the patient; and therapeutic alliance. The four classic principles of the ethical approach (beneficium, non maleficium, autonomy and justice) and the narrative approach were also applied. Due to her psychological fragility, a paternalistic approach was chosen as the basis for the relationship. Furthermore, due to the problems in defining her "autonomy", and considering her benzodiazepine abuse, an integrated, dynamic, narrative, ethical approach was chosen. Pragmatic solutions required frequent clinical controls, as a means to supervise compliance. Despite occasional wide swings in her Cyclosporine A levels, she is presently well compensated, working full-time and free from further major non-compliance or drug-abuse episodes. Conclusion: While this case raises several unanswered questions such as the practical classification of autonomy, competence and compliance, the definition of the setting of the patient-physician relationship and the systematic discussion of different ethical approaches may help the clinician to tailor interventions and to find adequate, tailored solutions.