It's ‘back to school’ for genetic screening

A Genomically Informed Education System? Challenges for Behavioral Genetics

The exponential growth of genetic knowledge and precision medicine research raises hopes for improved prevention, diagnosis, and treatment options for children with behavioral and psychiatric conditions. Although well-intended, this prospect also raise the possibility-and concern-that behavioral, including psychiatric genetic data would be increasingly used-or misused-outside the clinical context, such as educational settings. Indeed, there are ongoing calls to endorse a "personalized education" model that would tailor educational interventions to children's behavioral and psychiatric genetic makeup. This article explores the justifications for, and prospects and pitfalls of such endeavors. It considers the scientific challenges and highlights the ethical, legal, and social issues that will likely arise should behavioral genetic data become available (or be perceived as such) and are routinely incorporated in student education records. These include: when to disclose students' behavioral and psychiatric genetic profile; whose genomic privacy is protected and by whom; and how students' genetic data may affect education-related decisions. I argue that the introduction of behavioral genetics in schools may overshadow the need to address underlying structural and environmental factors that increase the risk for psychiatric conditions of all students, and that the unregulated use of student behavioral genetic profiles may lead to unintended consequences that are detrimental for individuals, families and communities. Relevant stakeholders-from parents and students to health professionals, educators, and policy-makers-ought to consider these issues before we forge ahead with a genomically informed education system.

Population-based carrier screening for cystic fibrosis: a systematic review of 23 years of research

Cystic fibrosis is the most common severe autosomal recessive disease, with a prevalence of 1 in 2,500-3,500 live births and a carrier frequency of 1 in 25 among Northern Europeans. Population-based carrier screening for cystic fibrosis has been possible since CFTR, the disease-causing gene, was identified in 1989. This review provides a systematic evaluation of the literature from the past 23 years on population-based carrier screening for cystic fibrosis, focusing on the following: uptake of testing; how to offer screening; attitudes, opinions, and knowledge; factors influencing decision making; and follow-up after screening. Recommendations are given for the implementation and evaluation of future carrier-screening programs.

The ethics of screening for disease

Screening can identify individuals at increased risk of or in the early stage of a disease at a time when intervention can reduce the risk of morbidity and mortality. There are many ethical issues that have arisen as a result of screening. These can relate to the process of screening in general or to specific screening programs. Examples of the former include issues related to consent for screening, the utility of the screening tests employed and issues of funding of screening programs and equity of access to screening. Ethical issues related to three specific areas of screening are explored in more detail: reproductive screening, screening for disease with onset in adulthood and newborn screening. It is critical that ethical issues are considered in planning screening programs so as to ensure that the main focus of screening, preventing morbidity, is maximised. There are many lessons to be learnt from the many screening programs that have been conducted worldwide. No doubt new ethical issues will arise as new technologies and new treatments are developed, enabling screening for more conditions at lower relative costs.

"The Most Important Test You'll Ever Take"?: attitudes toward confidential carrier matching and open individual testing among modern-religious Jews in Israel

This article reports on attitudes of modern-religious Ashkenazi Jewish adults in Israel toward anonymous carrier matching for severe monogenic diseases by Dor Yesharim (the ultra-orthodox organization) and open individual carrier testing (through a medical center), examining how this important choice is being informed, communicated, made, and reflected on. Qualitative analysis of semi-structured interviews conducted with 23 modern-religious Ashkenazi Jews in 2009-2011 revealed social pressure to utilize Dor Yesharim; however, respondents considered its policy of advising against a marriage between partners who are carriers of the same genetic condition inappropriate for 'love marriages' where a couple's commitment may already be made. Confidential carrier testing was a stepping stone to open carrier testing for those advised not to marry. Respondents varied in their views on when open carrier tests should be conducted. Pre-implantation genetic diagnosis was considered religiously preferable to abortion; however most carrier couples opted for pre-natal testing and selective abortion, challenging stereotypes about the attitudes of religious Jews. It is discussed how carrier screening is contextualized and interpreted not just in terms of religious teachings, but in interaction with lay agency, personal experiences and knowledge of reproductive choices. We conclude by discussing the implications for the social analysis of the ethics of carrier screening in religious communities at risk.

Evaluation of a multi-disease carrier screening programme in Ashkenazi Jewish high schools

A screening programme for Tay Sachs disease (TSD) carrier status was introduced in high schools in Victoria, Australia in 1997, and was expanded to screen for six other genetic conditions common in the Ashkenazi Jewish population in 2008. The aim of this study was to evaluate the current programme and compare it with an evaluation of the programme when screening was offered for TSD alone. All students from Jewish high schools in Melbourne who offered the programme in 2009 were invited to participate in the study. A purpose-designed questionnaire explored the following domains: knowledge (disease and genetics), reasons for screening, anxiety, and predicted negative feelings if found to be a carrier. Two hundred and seventy-three students were offered screening, and 272 (99.6%) completed the questionnaire. Only two students chose not to have screening. Two hundred and seventy-one students were in the penultimate year of high school (99.6%) and 222 were of Ashkenazi Jewish descent (82.5%). The main reasons for choosing screening were the desire to know carrier status and convenience. Knowledge level decreased and negative feelings increased in the current cohort compared to that when screening was offered for TSD alone. We conclude that the current programme is efficient, although increasing the number of conditions resulted in a decrease in knowledge and increase in predicted negative feelings if found to be a carrier of one of the conditions. This has implications for multi-disease screening programmes that will increase in frequency as more conditions can be screened for and costs diminish.

Ethical considerations in choosing a model for population-based cystic fibrosis carrier screening

Cystic fibrosis (CF) carrier testing can be used to inform reproductive decision making, allowing carriers to avoid having a child with CF. A government-funded, population-based CF carrier screening program would allow greater equity of access to this test. The setting in which CF carrier screening is offered significantly affects the extent to which participants make well informed, voluntary decisions to accept or decline testing. Screening offered before pregnancy and in non-clinical environments better promotes participant autonomy than screening offered in the prenatal consultation.

Patient empowerment in clinical genetics services

Outcome measurement in clinical genetics is problematic because the patient benefits are difficult to measure. The aim in this qualitative grounded theory study was to develop a theoretical framework describing the patient benefits from using clinical genetics services. Seven focus groups and 19 interviews were conducted with patients, patient group representatives, and health professionals. Data analysis resulted in construction of a model of empowerment summarizing the patient benefits from using clinical genetics services. Empowerment is similar to the concept of perceived personal control (PPC), and a measure of PPC has been developed for use in evaluations of clinical genetics services. However, empowerment includes some benefits not captured by PPC related to empowerment of other at risk relatives, and future generations.

Heterozygote carrier testing in high schools abroad: what are the lessons for the U.S.?

The main value of carrier detection in the general population is to determine reproductive risks. In this manuscript I examine the practice of providing carrier screening programs in the school setting. While the data show that high school screening programs can achieve high uptake, I argue that this may reflect a lack of full understanding about risks, benefits, and alternatives, and the right not to know. It may also reflect the inherent coercion in group testing, particularly for adolescents who are prone to peer pressure. The problem of carrier screening in the schools is compounded when the condition has a predilection for certain groups based on race, ethnicity or religion. I examine programs around the world that seek to test high school students for Tay Sachs and Cystic Fibrosis carrier status. I argue that carrier programs should be designed so as to minimize stigma and to allow individuals to refuse. The mandatory school environment cannot achieve this. Rather, I conclude that screening programs should be designed to attract young adults and not adolescents to participate in a more voluntary venue.