British Columbia Drug and Poison Information Centre (BC DPIC)

"Postmodernism does not accept one source of 'truth'." ~ Anna Kata, McMaster University, 2010

In the 1950's, a child's birthday party was often celebrated by a stay-at-home Mom and a working Dad with home-made cake and paper birthday cards.  Today such an event is just as likely to involve a single working Mom, a child conceived through IVF, a bought cake, electronic cards and a Skype session with the grandparents. Medicine has also changed: in the old days a child with a fever would have been treated with ASA, and a physician's prescription of an antibiotic would have been followed unquestioningly. Today ASA is not given to children because of concerns over Reye's syndrome, and the parents would probably check the internet before calling the doctor. What has happened?

A bit of philosophy

In La Condition Postmoderne, his 1979 commentary on Western society since WWII, Jean-Francois Lyotard examined how our understanding of knowledge has changed in the computer age.¹   He defined postmodernism as "incredulity toward meta­narratives", with meta-narratives being grand narratives; the principles within a society that determine what is considered truth.² Lyotard concluded that postmodern society has rejected grand narratives in favour of many smaller narratives.

For science, postmodernism has meant a questioning of scientific objectivity and scientific facts. Thalidomide is a relevant example for pharmacy. Prior to 1960, the scientific narrative stated that drugs could not cross the placenta and harm a developing fetus. The birth defects caused by thalidomide refuted that model. As stated by Gray in a 1999 article in Lancet, postmodern society is suspicious of science.³ He wrote, "postmodern society has different priorities - concern over values as well as evidence, preoccupation with risk rather than benefit, and the rise of the well-informed patient".

This is not a refutation of evidence-based medicine. Rather, Gray considers that today's medical decisions are based on "opinion = evidence + value". Evidence is required, but the values of individuals are also involved. Postmodernism postulates the existence of multiple realities, not a single objective reality or grand narrative. Paradoxically, while science has been downgraded, technology is highly valued in society today.⁴ It has been suggested that "relativism is a radical turning away in disappointment from the unfulfillable demand of certainty" as promised by science in the earlier modern era.⁵

The glass half full: a new Global Patient Safety Network

On one hand, postmodernism is a positive force in healthcare because of its emphasis on safety and the patient. Canadians can be proud of a new global patient safety website to reduce medical harm (www.globalpatientsafetyalerts.com). The Canadian Patient Safety Institute launched this freely accessible site in February 2011 to provide easy access to safety alerts from 22 international, national and regional organizations. Sources include Hong Kong, England, Wales, Australia, Canada and the US. Searching for advisories related to insulin, for example, pulls up an otherwise obscure report from the Winnipeg Regional Health Authority of an incident involving the inappropriate use of insulin syringes, calibrated in units, to measure doses in millilitres.

Another positive postmodern innovation has been the inclusion of patients in the reporting of adverse drug events. Previously, reports were mainly made by healthcare professionals, with less credibility attributed to reports from patients. A new website from Health Canada turns this around, strongly encouraging participation by patients in the documentation of medication errors. The website, www.safemedicationuse.ca recognizes that patients are knowledgeable about the adverse drug reactions they have experienced, and removes the barrier of having to report through a healthcare professional. Newsletters in lay language are provided on the website or through free email subscription. Evocative recent newsletter titles include: "Angeliq Drug Samples Mistakenly Provided as Birth Control"; and "Mix-ups Between Spouses' Medications Could be Harmful".  Recommendations address hazardous systems and situations both in the home and in healthcare settings.

Patients for Patient Safety Canada, with the motto "Every Patient Safe", is a grass roots organization that comes at the issue from yet another angle, upholding the need for transparent disclosure of adverse events, and promoting the inclusion of patient perspectives in patient safety research.

Patients and their families who have experienced an adverse event in healthcare generally want to participate in these programs to ensure that what happened to them does not happen to anyone else.

The glass half empty: can a postmodern patient be well-informed?

Does more information help or hinder?  That is a very postmodern question in itself. It can be argued that if you are trying to find a needle in a haystack, it doesn't help to make the haystack bigger. For drugs, the proliferation of websites available to the lay public creates confusion, given the variety of sources and diversity of information.

It is not just the amount of information that is a problem; misleading information is a major concern. Anna Kata from McMaster University has provided an excellent example of health misinformation on the internet in her research into websites devoted to the "anti-vaccination movement".⁶ The anti-vaccination websites contained some startling misinformation: on 88 per cent of the sites, alternative medicines including homeopathic products and acupuncture were considered to be superior to vaccination; and all of the anti-vaccination websites stated that vaccines are poisonous and that vaccines cause illnesses such as autism. Conspiracy theories were suggested, that vaccinations are motivated by profit, or by attempts to sterilize the population. Some information was outdated. For example, the controversial link between vaccines and autism has been found to be spurious, but this is not clarified on many of the websites.⁷ Unfortunately such controversies serve only to increase postmodern suspicions of science.

Postmodern emphasis on scepticism and safety may also be creating excessive fear, and fear of the harms of medications can lead to a reduction in their use as patients are unable to put risk information into perspective.⁸

What's a pharmacist to do?

Postmodern scepticism reduces confidence in experts, making it difficult for pharmacists to guide patients through the maze of health information.  Realizing that technology will be given precedence over science, encourage the use of the websites that make it easy for patients to report adverse drug reactions and medical errors. But also go beyond technology and maintain the human element of personal contact, addressing not just the evidence but also the personal values of the individual patient.

Written by Barbara Cadario BSc (Honours), BScPhm, MSc, BC Drug and Poison Information Centre

References

1. Aylesworth, Gary, "Postmodernism", The Stanford Encyclopedia of Philosophy (Winter 2010 Edition), Edward N. Zalta (ed.), URL = <http://plato.stanford.edu/archives/ win2010/entries/postmodernism/>.
2. Halbert M. Lyotard: the Postmodern Condition. In: Performativity, Cultural Capital, and the Internet. http://userwww.service.emory.edu/~mhalber/Research/Paper/pci­lyotard.html
3. Gray JAM. Postmodern medicine. The Lancet 1999;354(9189):1550-1553.
4. Forman P. (Re)cognizing postmodernity - helps for historians - of science especially. Ber.Wissenschaftsgesch. 2010;33: 157-175.
5. Bell, David. Is truth an illusion? Psychoanalysis and postmodernism. Int J Psychoanal (2009) 90:331-345.
6. Kata A. A postmodern Pandora's box: Anti-vaccination misinformation on the internet. Vaccine 2010;28:1709-1716.
7. Immunization Safety Review Committee. Immunization Safety Review. Vaccines and Autism. Available from: URL: http://books.nap.edu/openbook.php?record_id=10997. Accessed January 21, 2011.
8. Jones KW. Medication risk must be balanced with benefit, not fear. Ann Pharmacotherapy 2010;44:737-9.

©2012 B.C. Drug and Poison Information Centre

A version of this document was published in BCPhA's The Tablet. 2011; 20(2): 12-13.