Genomics and justice: mitigating the potential harms and inequities that arise from the implementation of genomics in medicine

Ethical Considerations in Psychiatric Genomics

The ethics of psychiatric genetics and genomics is an emerging field, distinct from general genetics. Key ethical concerns include the implications for personhood and identity, the dual perception of psychiatric conditions as both afflictions and integral aspects of identity, and the unique vulnerabilities of affected populations regarding informed consent. The multifactorial nature of psychiatric disorders, characterized by complex genetic and environmental interactions, further complicates ethical considerations. This paper explores ethical issues in psychiatric genomic research, clinical applications, and prevention efforts, emphasizing the need for a multidisciplinary approach and the importance of context sensitivity, particularly in low-and-middle-income countries.

Nursing strategies to address health disparities in genomics-informed care: a scoping review

OBJECTIVE

The objective of this review was to map the available global evidence on strategies that nurses can use to facilitate genomics-informed health care to address health disparities to inform the development of a research and action agenda.

INTRODUCTION

The integration of genomics into health care is improving patient outcomes through better prevention, diagnostics, and treatment; however, scholars have noted concerns with widening health disparities. Nurses work across the health system and can address health disparities from a clinical, research, education, policy, and leadership perspective. To do this, a comprehensive understanding of existing genomics-informed strategies is required.

INCLUSION CRITERIA

Published (qualitative, quantitative, mixed methods studies; systematic and literature reviews; and text and opinion papers) and unpublished (gray) literature that focused on genomics-informed nursing strategies to address health disparities over the past 10 years were included. No limitations were placed on language.

METHODS

The review was conducted in accordance with the JBI methodology for scoping reviews. A search was undertaken on May 25, 2023, across 5 databases: MEDLINE (Ovid), Embase, Cochrane Library (Ovid), APA PsycINFO (EBSCOhost), and CINAHL (EBSCOhost). Gray literature was searched through websites, including the International Society of Nurses in Genetics and the Global Genomics Nursing Alliance. Abstracts, titles, and full texts were screened by 2 or more independent reviewers. Data were extracted using a data extraction tool. The coded data were analyzed by 2 or more independent reviewers using conventional content analysis, and the summarized results are presented using descriptive statistics and evidence tables.

RESULTS

In total, we screened 818 records and 31 were included in the review. The most common years of publication were 2019 (n=5, 16%), 2020 (n=5, 16%), and 2021 (n=5, 16%). Most papers came from the United States (n=25, 81%) followed by the Netherlands (n=3, 10%), United Kingdom (n=1, 3%), Tanzania (n=1, 3%), and written from a global perspective (n=1, 3%). Nearly half the papers discussed cancer-related conditions (n=14, 45%) and most of the others did not specify a disease or condition (n=12, 39%). In terms of population, nurse clinicians were mentioned the most frequently (n=16, 52%) followed by nurse researchers, scholars, or scientists (n=8, 26%). The patient population varied, with African American patients or communities (n=7, 23%) and racial or ethnic minorities (n=6, 19%) discussed most frequently. The majority of equity issues focused on inequitable access to genetic and genomics health services among ethnic and racial groups (n=14, 45%), individuals with lower educational attainment or health literacy (n=6, 19%), individuals with lower socioeconomic status (n=3, 10%), migrants (n=3, 10%), individuals with lack of insurance coverage (n=2, 6%), individuals living in rural or remote areas (n=1, 3%), and individuals of older age (n=1, 3%). Root causes contributing to health disparity issues varied at the patient, provider, and system levels. Strategies were grouped into 2 categories: those to prepare the nursing workforce and those nurses can implement in practice. We further categorized the strategies by domains of practice, including clinical practice, education, research, policy advocacy, and leadership. Papers that mentioned strategies focused on preparing the nursing workforce were largely related to the education domain (n=16, 52%), while papers that mentioned strategies that nurses can implement were mostly related to clinical practice (n=19, 61%).

CONCLUSIONS

Nurses in all domains of practice can draw on the identified strategies to address health disparities related to genomics in health care. We found a notable lack of intervention and evaluation studies exploring the impact on health and equity outcomes. Additional research informed by implementation science that measures health outcomes is needed to identify best practices.

SUPPLEMENTAL DIGITAL CONTENT

A French-language version of the abstract of this review is available: http://links.lww.com/SRX/A65 .

Distinct positions of genetic and oral histories: Perspectives from India

Over the past decade, genomic data have contributed to several insights on global human population histories. These studies have been met both with interest and critically, particularly by populations with oral histories that are records of their past and often reference their origins. While several studies have reported concordance between oral and genetic histories, there is potential for tension that may stem from genetic histories being prioritized or used to confirm community-based knowledge and ethnography, especially if they differ. To investigate the interplay between oral and genetic histories, we focused on the southwestern region of India and analyzed whole-genome sequence data from 156 individuals identifying as Bunt, Kodava, Nair, and Kapla. We supplemented limited anthropological records on these populations with oral history accounts from community members and historical literature, focusing on references to non-local origins such as the ancient Scythians in the case of Bunt, Kodava, and Nair, members of Alexander the Great's army for the Kodava, and an African-related source for Kapla. We found these populations to be genetically most similar to other Indian populations, with the Kapla more similar to South Indian tribal populations that maximize a genetic ancestry related to Ancient Ancestral South Indians. We did not find evidence of additional genetic sources in the study populations than those known to have contributed to many other present-day South Asian populations. Our results demonstrate that oral and genetic histories may not always provide consistent accounts of population origins and motivate further community-engaged, multi-disciplinary investigations of non-local origin stories in these communities.

Taking the risk. A systematic review of ethical reasons and moral arguments in the clinical use of polygenic risk scores

Debates about the prospective clinical use of polygenic risk scores (PRS) have grown considerably in the last years. The potential benefits of PRS to improve patient care at individual and population levels have been extensively underlined. Nonetheless, the use of PRS in clinical contexts presents a number of unresolved ethical challenges and consequent normative gaps that hinder their optimal implementation. Here, we conducted a systematic review of reasons of the normative literature discussing ethical issues and moral arguments related to the use of PRS for the prevention and treatment of common complex diseases. In total, we have included and analyzed 34 records, spanning from 2013 to 2023. The findings have been organized in three major themes: in the first theme, we consider the potential harms of PRS to individuals and their kin. In the theme "Threats to health equity," we consider ethical concerns of social relevance, with a focus on justice issues. Finally, the theme "Towards best practices" collects a series of research priorities and provisional recommendations to be considered for an optimal clinical translation of PRS. We conclude that the use of PRS in clinical care reinvigorates old debates in matters of health justice; however, open questions, regarding best practices in clinical counseling, suggest that the ethical considerations applicable in monogenic settings will not be sufficient to face PRS emerging challenges.

Genomics-informed nursing strategies and health equity: A scoping review protocol

OBJECTIVE

The objective of this scoping review is to map the available evidence on strategies that nurses can use to facilitate genomics-informed healthcare to address health disparities.

INTRODUCTION

Advancements in genomics over the last two decades have led to an increase in the delivery of genomics-informed health care. Although the integration of genomics into health care services continues to enhance patient outcomes, access to genomic technologies is not equitable, exacerbating existing health disparities amongst certain populations. As the largest portion of the health workforce, nurses play a critical role in the delivery of equitable genomics-informed care. However, little is known about how nurses can help address health disparities within the context of genomics-informed health care. A review of the literature will provide the necessary foundation to identify promising practices, policy, and knowledge gaps for further areas of inquiry.

INCLUSION CRITERIA

We will include papers that explore strategies that nurses can undertake to facilitate genomics-informed care to address health disparities.

METHODS

This review will be conducted using JBI methodology for scoping reviews. We will search electronic databases including MEDLINE (OVID), EMBASE, Cochrane Library, PsychInfo, and CINAHL for quantitative and qualitative studies, systematic reviews and grey literature. Theses, books, and unavailable full-text papers will be excluded. The search will be limited to papers from 2013 and beyond. Two reviewers will screen titles and abstracts followed by full-text and disagreements will be resolved by a third reviewer. We will use a data extraction tool using Microsoft Excel and analyse data using descriptive statistics and conventional content analysis. Findings will be presented in the form of evidence tables and a narrative summary. We will report findings using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR).

DISCUSSION

Genomics will continue to transform all aspects of health care across the wellness continuum from prevention, assessment, diagnosis, management, treatment, and palliative care. The identification of nursing strategies to address health disparities will build the foundation for policy and practice to ensure that the integration of genomic technologies benefits everyone.

The role of polygenic risk scores in breast cancer risk perception and decision-making

Polygenic risk scores (PRS) have the potential to improve the accuracy of clinical risk assessments, yet questions about their clinical validity and readiness for clinical implementation persist. Understanding how individuals integrate and act on the information provided by PRS is critical for their effective integration into routine clinical care, yet few studies have examined how individuals respond to the receipt of polygenic risk information. We conducted an embedded Ethical, Legal, and Social Implications (ELSI) study to examine if and how unaffected participants in a US population breast cancer screening trial understood and utilized PRS, as part of a multifactorial risk score combining traditional risk factors with a genetic risk assessment, to make screening and risk-reduction decisions. Semi-structured qualitative interviews were conducted with 24 trial participants who were designated at elevated risk for breast cancer due to their combined risk score. Interviews were analyzed using a grounded theory approach. Participants understood PRS conceptually and accepted it as one of many risk factors to consider, yet the value and meaning they ascribed to this risk estimate varied. Most participants reported financial and insurance barriers to enhanced screening with MRI and were not interested in taking risk-reducing medications. These findings contribute to our understanding of how PRS may be best translated from research to clinical care. Furthermore, they illuminate ethical concerns about identifying risk and making recommendations based on polygenic risk in a population screening context where many may have trouble accessing appropriate care.

Addressing the challenges of polygenic scores in human genetic research

The genotyping of millions of human samples has made it possible to evaluate variants across the human genome for their possible association with risks for numerous diseases and other traits by using genome-wide association studies (GWASs). The associations between phenotype and genotype found in GWASs make possible the construction of polygenic scores (PGSs), which aim to predict a trait or disease outcome in an individual on the basis of their genotype (in the disease case, the term polygenic risk score [PRS] is often used). PGSs have shown promise for studying the biology of complex traits and as a tool for evaluating individual disease risks in clinical settings. Although the quantity and quality of data to compute PGSs are increasing, challenges remain in the technical aspects of developing PGSs and in the ethical and social issues that might arise from their use. This ASHG Guidance emphasizes three major themes for researchers working with or interested in the application of PGSs in their own research: (1) developing diverse research cohorts; (2) fostering robustness in the development, application, and interpretation of PGSs; and (3) improving the communication of PGS results and their implications to broad audiences.