Theories of ethics and perception of symptoms: A diabetes perspective

This editorial delves into a hither to unexplored facet of diabetology. The aim of this communication is to encourage cross-discipline fertilization in this field, making it more robust and responsive to the needs of persons with diabetes.

Diabetes is a heterogenous disorder characterized by varied etiopathogenic mechanisms, associations, clinical presentations, and complications. This diversity is further enhanced by an equally wide array of therapeutic and diagnostic procedures. This diversity results in and gets reflected in variations in the clinical care. The fact that diabetes is not merely a biological entity, but a syndrome that perfectly fits the biopsychosocial health model, makes this metabolic disease and its management even more complex. This theory posits that psychological and social factors contribute to health and disease in tandem with biological determinants.[1]

In spite of enhanced understanding in the psychosocial modulators of diabetes, researchers and clinicians often find it challenging to explain variations in behavior of people with diabetes. Similarly, the management patterns followed by diabetes care professionals are, at times, difficult to understand and explain. People with diabetes exhibit varying attitudes and behavior patterns related to health-care seeking, acceptance of modern medical care, and adherence to prescribed therapy. While all these aspects of diabetes care can be understood through psychosocial explanations, some unique features of diabetology merit a wider, and even deeper, analysis.

The same biological abnormality underlying a disease often manifests differently symptomatically. In addition, similar symptomatology tends to get perceived differently across patients. Consequently, different patients tend to have different illness behavior.[2] Interestingly, patients with apparently similar disease parameters (viz., glucose control indicators, and duration of illness) can react differently to their illness experience. This variation is reflected in help-seeking behavior as well.[3] In context of diabetes, this variation is noted in both acute and chronic complications such as hypoglycemia and peripheral neuropathy. Symptoms of hypoglycemia are reported in contrasting manner by patients from different cultural and linguistic backgrounds. Similarly, symptoms of chronic complications such as peripheral neuropathy can be described by a seemingly never-ending list of adjectives.

This clinical heterogeneity is most obvious for hypoglycemia. Hypoglycemia, an integral component of diabetes, is characterized by a wide array of symptoms. Some individuals present with more “complaints per unit biochemical abnormality,” while others carry a noncomplaining attitude (reflected in “asymptomatic” presentation); in spite of major biochemical defects. Much of this paradox can be explained by biomedical dysfunction such as hypoglycemia unawareness and by psychosocial determinants such as personality traits and coping styles.[4] However, not all the variance noted in symptomatology perception fits existing “strait jacket” explanations.

Human attitudes and behaviors are shaped by an ongoing interaction of various biological, psychological, and environmental factors. Cognitive, psychodynamic, behavioral, and interpersonal paradigms are commonly used to explain these attitudes and behaviors. However, role of ethics in shaping these attitudes and behaviors remains rather unexplored. Ethical perspectives of illness behavior, and help seeking, find little, if any, application in clinical settings.

This editorial highlights certain theories of ethics, relevant to health care, which may explain the clinical paradoxes noted in diabetes care praxis. While being of special relevance to hypoglycemia, these theories can help understand patients' and physicians' attitudes and behaviors with regard to other aspects of diabetes care as well.

• References

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• 2 Pilowsky I. Abnormal illness behaviour. Br J Med Psychol 1969; 42: 347-351
• 3 Cornally N, McCarthy G. Help-seeking behaviour: A concept analysis. Int J Nurs Pract 2011; 17: 280-288
• 4 Kalra S, Kalra B, Agrawal N, Sahay R, Unnikrishnan A, Chawla R. Coping strategies in diabetes. Internet J Geriatr Gerontol 2010; 5
• 5 Conway P, Gawronski B. Deontological and utilitarian inclinations in moral decision making: A process dissociation approach. J Pers Soc Psychol 2013; 104: 216-235
• 6 Allmark P. Virtue and austerity. Nurs Philos 2013; 14: 45-52
• 7 Gillon R. Medical ethics: Four principles plus attention to scope. BMJ 1994; 309: 184-188
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