Del paternalismo a la autonomía relacional: Una revisión integrativa sobre los dilemas éticos en la adherencia de enfermedades crónicas en atención primaria
Palabras clave:
bioética, autonomía personal, paternalismo, adherencia al tratamiento, atención primaria de salud, enfermedad crónicaResumen
Introducción: El manejo de las enfermedades crónicas no transmisibles en la Atención Primaria de la Salud (APS) enfrenta una tensión fundamental entre el principio de beneficencia médica y la autonomía del paciente. Históricamente, ha predominado un modelo paternalista centrado en el «cumplimiento», que a menudo ignora la capacidad de agencia del individuo. El objetivo de esta revisión fue analizar la evidencia sobre los dilemas bioéticos entre autonomía y paternalismo, y su impacto en la adherencia terapéutica.
Métodos: Se realizó una revisión integrativa de la literatura siguiendo el marco de Whittemore y Knafl. Se realizaron búsquedas en PubMed, Scopus y literatura gris para estudios publicados entre 2015 y 2025 que vincularan dimensiones bioéticas con resultados clínicos en diabetes e hipertensión. Los datos se sintetizaron temáticamente.
Resultados: El análisis identificó una transición conceptual necesaria desde la autonomía individual hacia la «autonomía relacional». Se halló que el paternalismo se manifiesta clínicamente como «inercia terapéutica» y mediante el etiquetado estigmatizante de pacientes («difíciles»), lo cual exacerba las inequidades en salud. Por el contrario, las intervenciones basadas en la toma de decisiones compartida y el apoyo a la autonomía se correlacionaron positivamente con mejoras en el control glucémico (HbA1c), la presión arterial y la satisfacción del paciente, al fomentar la motivación intrínseca.
Conclusiones: El respeto a la autonomía no compite con la eficacia clínica, sino que es un prerrequisito para ella. La práctica en APS debe superar el paternalismo por omisión y adoptar modelos de concordancia que integren los determinantes sociales, validando al paciente como un socio activo en el cuidado de su salud.
Referencias
Berlowitz DR, Ash AS, Hickey EC, Glickman M, Friedman R, Kader B. Hypertension management in patients with diabetes: the need for more aggressive therapy. Diabetes Care [Internet]. 2003 Feb;26(2):355–9. Available from: http://dx.doi.org/10.2337/diacare.26.2.355
Cryer MJ, Horani T, DiPette DJ. Diabetes and hypertension: A comparative review of current guidelines. J Clin Hypertens (Greenwich) [Internet]. 2016 Feb;18(2):95–100. Available from: http://dx.doi.org/10.1111/jch.12638
Alharbi NA, Alkhawaji YA. Use and effectiveness of digital adherence tools. Saudi J Med Pharm Sci [Internet]. 2023 Mar 9;9(03):155–62. Available from: http://dx.doi.org/10.36348/sjmps.2023.v09i03.003
Hassan Y, Al-Temimi AA, Ramli R, M. Saad MF, A. Aziz N. Difficulties facing the patients and extra burden for healthcare providers by non-adherence to the medications - A comprehensive review. Ind J Pharm Educ [Internet]. 2019 Nov 11;53(4s):s487–99. Available from: http://dx.doi.org/10.5530/ijper.53.4s.143
Klok T, Kaptein AA, Brand PLP. Improving adherence in paediatric respiratory disease. Breathe (Sheff) [Internet]. 2013 Jun;9(4):268–77. Available from: http://dx.doi.org/10.1183/20734735.002513
Veatch RM, Haddad A, Last EJ. Autonomy [Internet]. Veatch RM, Haddad A, Last EJ, editors. Oxford University Press; 2017. Available from: http://dx.doi.org/10.1093/med/9780190277000.003.0007
Woods S. Respect for persons, autonomy and palliative care. Med Health Care Philos [Internet]. 2005;8(2):243–53. Available from: http://dx.doi.org/10.1007/s11019-005-2506-y
Sherwin S, Winsby M. A relational perspective on autonomy for older adults residing in nursing homes: A relational perspective on autonomy for older adults. Health Expect [Internet]. 2011 Jun;14(2):182–90. Available from: http://dx.doi.org/10.1111/j.1369-7625.2010.00638.x
Bryant L, Martini N, Chan J, Chang L, Marmoush A, Robinson B, et al. Could the polypill improve adherence? The patient perspective. J Prim Health Care [Internet]. 2013 Mar 1;5(1):28–35. Available from: http://dx.doi.org/10.1071/hc13028
Ebrahimi H, Sadeghian E, Seyedfatemi N, Mohammadi E, Crowley M. Contextual factors affecting autonomy for patients in Iranian hospitals: A qualitative study. Iran J Nurs Midwifery Res [Internet]. 2016 May;21(3):261–70. Available from: http://dx.doi.org/10.4103/1735-9066.180388
Lewis J. Does shared decision making respect a patient’s relational autonomy? J Eval Clin Pract [Internet]. 2019 Dec;25(6):1063–9. Available from: http://dx.doi.org/10.1111/jep.13185
Ali DH, Kiliç B, Hart HE, Bots ML, Biermans MCJ, Spiering W, et al. Therapeutic inertia in the management of hypertension in primary care. J Hypertens [Internet]. 2021 Jun 1;39(6):1238–45. Available from: http://dx.doi.org/10.1097/hjh.0000000000002783
Wiener RS, Koppelman E, Bolton R, Lasser KE, Borrelli B, Au DH, et al. Patient and clinician perspectives on shared decision-making in early adopting lung cancer screening programs: A qualitative study. J Gen Intern Med [Internet]. 2018 Jul;33(7):1035–42. Available from: http://dx.doi.org/10.1007/s11606-018-4350-9
Sun M, Oliwa T, Peek ME, Tung EL. Negative patient descriptors: Documenting racial bias in the electronic health record: Study examines racial bias in the patient descriptors used in the electronic health record. Health Aff (Millwood) [Internet]. 2022 Feb;41(2):203–11. Available from: http://dx.doi.org/10.1377/hlthaff.2021.01423
Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs [Internet]. 2005 Dec [cited 2025 Nov 27];52(5):546–53. Available from: http://dx.doi.org/10.1111/j.1365-2648.2005.03621.x
Fernández-Ballesteros R, Sánchez-Izquierdo M, Olmos R, Huici C, Ribera Casado JM, Cruz Jentoft A. Paternalism vs. Autonomy: Are they alternative types of formal care? Front Psychol [Internet]. 2019 Jun 28;10:1460. Available from: http://dx.doi.org/10.3389/fpsyg.2019.01460
Williams GC, McGregor HA, Zeldman A, Freedman ZR, Deci EL. Testing a self-determination theory process model for promoting glycemic control through diabetes self-management. Health Psychol [Internet]. 2004 Jan;23(1):58–66. Available from: http://dx.doi.org/10.1037/0278-6133.23.1.58
Lee V, Kowalski J, Liu M, Thayer B. Impact of discharge medication reconciliation across a five-hospital health system. J Healthc Qual [Internet]. 2022 Mar 23;44(4):194–200. Available from: http://dx.doi.org/10.1097/JHQ.0000000000000335
Farisi MA. Faktor-Faktor yang Mempengaruhi Ketaatan Minum Obat pada Penyakit Kronik. Jurnal Ilmiah Universitas Batanghari Jambi [Internet]. 2020 Feb 5;20(1):277. Available from: http://dx.doi.org/10.33087/jiubj.v20i1.883
Shay LA, Lafata JE. Where is the evidence? A systematic review of shared decision making and patient outcomes. Med Decis Making [Internet]. 2015 Jan;35(1):114–31. Available from: http://dx.doi.org/10.1177/0272989x14551638
Khunti K, Gomes MB, Pocock S, Shestakova MV, Pintat S, Fenici P, et al. Therapeutic inertia in the treatment of hyperglycaemia in patients with type 2 diabetes: A systematic review. Diabetes Obes Metab [Internet]. 2018 Feb;20(2):427–37. Available from: http://dx.doi.org/10.1111/dom.13088
Boland L, Graham ID, Légaré F, Lewis K, Jull J, Shephard A, et al. Barriers and facilitators of pediatric shared decision-making: a systematic review. Implement Sci [Internet]. 2019 Jan 18;14(1):7. Available from: http://dx.doi.org/10.1186/s13012-018-0851-5
Arao T Sr, Okada Y, Kurozumi A, Tanaka Y. A comparative study on the efficacy and safety of dose escalation of luseogliflozin in type 2 diabetes mellitus patients with poor glycemic control. Cureus [Internet]. 2023 Feb;15(2):e35393. Available from: http://dx.doi.org/10.7759/cureus.35393
Lee HJ, Jang S, Lee JY, Ah YM, Lee MK, Jang S, et al. Development of a multidisciplinary medication management program in nursing homes: protocol for a randomized controlled trial : Multidisciplinary medication management in nursing homes: Multidisciplinary medication management in nursing homes. BMC Geriatr [Internet]. 2024 Mar 4;24(1):218. Available from: http://dx.doi.org/10.1186/s12877-024-04844-2
Federman AD, Cook EF, Phillips RS, Puopolo AL, Haas JS, Brennan TA, et al. Intention to discontinue care among primary care patients: Influence of physician behavior and process of care. J Gen Intern Med [Internet]. 2001 Oct;16(10):668–74. Available from: http://dx.doi.org/10.1111/j.1525-1497.2001.01028.x
Williams GC, Lynch M, Glasgow RE. Computer-assisted intervention improves patient-centered diabetes care by increasing autonomy support. Health Psychol [Internet]. 2007 Nov;26(6):728–34. Available from: http://dx.doi.org/10.1037/0278-6133.26.6.728
Saposnik G, Oh J, Terzaghi MA, Kostyrko P, Bakdache F, Montoya A, et al. Emotional expressions associated with therapeutic inertia in multiple sclerosis care. Mult Scler Relat Disord [Internet]. 2019 Sep;34:17–28. Available from: http://dx.doi.org/10.1016/j.msard.2019.05.029
Geskey JM, Kodish-Wachs J, Blonsky H, Hohman SF, Meurer S. National documentation and coding practices of noncompliance: The importance of social Determinants of health and the stigma of African-American bias. Am J Med Qual [Internet]. 2023 Mar 1;38(2):87–92. Available from: http://dx.doi.org/10.1097/jmq.0000000000000112
Gajda R, Knechtle B, Gębska-Kuczerowska A, Gajda J, Stec S, Krych M, et al. Amateur athlete with sinus arrest and severe bradycardia diagnosed through a heart rate monitor: A six-year observation-the necessity of shared decision-making in heart rhythm therapy management. Int J Environ Res Public Health [Internet]. 2022 Aug 19;19(16):10367. Available from: http://dx.doi.org/10.3390/ijerph191610367
Appelbaum PS. Patients who refuse treatment in medical hospitals. JAMA [Internet]. 1983 Sep 9;250(10):1296–301. Available from: http://dx.doi.org/10.1001/jama.250.10.1296
Al-Wathinani AM, Barten DG, Alsahli H, Alhamid A, Alghamdi W, Alqahtani W, et al. The right to refuse: Understanding healthcare providers’ perspectives on patient autonomy in emergency care. Healthcare (Basel) [Internet]. 2023 Jun 15;11(12):1756. Available from: http://dx.doi.org/10.3390/healthcare11121756
Mechem CC, Kreshak AA, Barger J, Shofer FS. The Short‐term Outcome of Hypoglycemic Diabetic Patients Who Refuse Ambulance Transport after Out‐of‐hospital Therapy. Academic Emergency Medicine [Internet]. 1998 Aug 28;5(8):768–72. Available from: http://dx.doi.org/10.1111/j.1553-2712.1998.tb02502.x
Descargas
Publicado
Número
Sección
Licencia
Derechos de autor 2025 Andrea Paola Britos Gómez, Alcides Chaux
Esta obra está bajo una licencia internacional Creative Commons Atribución-NoComercial-SinDerivadas 4.0.
