Ethics of prediction: genetic risk and the physician-patient relationship

Anticipating the ethical, legal, and social implications of human genome research: An ongoing experiment

Dr. Victor McKusick was a founding member of the joint NIH-DOE working group that designed the federal effort to address the ethical, legal, and social implications of the US Human Genome Project in 1989. A key feature of this effort was its commitment to anticipating genomics-driven questions before they became urgent practical dilemmas, by complementing the scientific effort to map and sequence the human genome with projects by a wide range of social scientists, humanities scholars, legal experts, and public educators designed to equip society with the foresight required to optimize the public welfare benefits of new genomic information. This article describes the origins of that experiment and the model of anticipatory science policy that it produced, as one piece of Dr. McKusick's extraordinary intellectual legacy.

Can you keep a (genetic) secret? The genetic privacy movement

This paper reviews the literature on genetic privacy, especially since 1995 and the first proposal for national genetic privacy legislation. Since that time, a majority of states have passed some form of genetic privacy legislation, and efforts to pass federal legislation are ongoing. Such new laws, however, remain untested in the courts and their effects are unclear. If they fail to provide additional protections against discrimination for most people, their most significant impact may be in their ability to either diminish or enhance the power of genetic information and to influence the way individuals view themselves and others. How does "genetic exceptionalism"--the idea that genetic information is different from other types of medical information--relate to "genetic essentialism"--the idea that we are to a large extent shaped by our genes? Anthropological views on genetics and personhood bring a new perspective to this ongoing debate. Implications for counseling practices are also explored.

Should genetic testing for BRCA1/2 be permitted for minors? Opinions of BRCA mutation carriers and their adult offspring

Although professional guidelines recommend against testing minors for adult-onset genetic conditions, the genetic testing of minors for BRCA1/2 alterations has been debated in the literature. To better understand the opinions of BRCA mutation carriers regarding the genetic testing of minors and the cognitive and affective processes underlying these opinions, we interviewed BRCA mutation carriers and their adult offspring who had learned of their parent's BRCA mutation. Semi-structured interviews were conducted with 53 parents and 22 offspring. In response to a closed-ended question, 52% (n = 39) of participants were opposed to the testing of minors. Responses to an open-ended question indicate that many participants (24%, n = 18) feel that testing could be permitted for some minor offspring. Psychological risks and the insufficient maturity of minors were frequent concerns of participants opposed to testing minors. The potential to impact health behaviors was frequently cited as a reason to support the genetic testing of minors. These preliminary results suggest that many BRCA mutation carriers and their adult offspring have concerns about, or are opposed to the genetic testing of minors. However, a significant minority in our study would support testing minors. Greater support for testing among offspring could indicate increasing requests for early genetic diagnosis. Further research is necessary to explore the risks and benefits of providing genetic testing to minors for adult-onset hereditary cancer syndromes in order to inform clinical practice and public policy and to ensure optimal psychosocial and medical outcomes for all members in families at risk for genetically determined disease.

Clinical genetics issues encountered by family physicians

PURPOSE

To describe the genetics-related clinical issues encountered by family physicians, and the medical problems they referred to genetics consultants.

METHODS

Questionnaires were mailed to a nationwide, random sample of 498 practicing family physicians, asking how many times in the past year they discussed genetic information about 19 familial or genetic conditions with patients and what proportion of the families with each genetic condition were referred for genetics consultation. Factor analysis was used to group the conditions.

RESULTS

The response rate was 38% (n = 190). Respondents were similar to non-respondents except that more were women. Most family physicians reported discussing the genetics of common cancers, cardiovascular disease, and Alzheimer's disease with two or more patients in the past year. Thirteen percent had referred families for genetics assessment of breast-ovarian cancer but only two made genetics referrals for cardiovascular disease or dementia. 25% to 50% of family physicians had addressed genetic issues in at least one family with hemoglobinopathy, a blood clotting disorder, hemochromatosis, mental illness, vision loss or deafness, chromosome abnormality, infertility or pregnancy loss, congenital anomalies, mental retardation, and neurofibromatosis. Most cases were not referred to geneticists. Of respondents, 23% said that genetics consultation is very difficult to obtain or unavailable and 18% listed ethical and social dilemmas related to pursuing genetic diagnosis.

CONCLUSION

Nationwide, family physicians address a variety of genetics issues with patients, most frequently consulting geneticists for perinatal conditions and familial cancers. Access to genetics consultation is more difficult in rural areas. These data may be used in organizing genetics services and in planning professional education programs for primary care clinicians.

Ethical issues arising from the participation of children in genetic research

With new tools derived from the Human Genome Project, genetic research is expanding from the study of rare, single gene disorders to the evaluation of genetic contributors to common, complex diseases. Many genetic studies include pediatric participants. The ethical concerns related to pediatric participation in genetic research derive from the study designs commonly employed in gene discovery and from the power accorded to genetic prediction in our society. In both family-based studies and large studies combining genetic and other health-related data, special attention should be placed on recruitment procedures, informed consent, and confidentiality protections. If data repositories are created for long-term use, we recommend re-consent of pediatric participants when they reach adulthood. In addition, the potential for disclosure of individual results should be considered as part of the institutional review of genetic studies, taking into account the validity of research data and the potential that such data could be used in health care. The potential for genetic results to pose harms of personal and group stigma is also a consideration. Because genetic information is often accorded special power in our society, careful attention should be paid to how genetic information is collected and used in research involving pediatric participants.

FACE facts: why human genetics will always provoke bioethics

Some people dispute the relative importance of issues in genetics and biotechnology for the future of bioethics, either because they think the problems are time-limited or because they give priority to issue of human rights and social justice in health care. In fact, the special historical standing of genetic issue s in bioethics reflects four overlapping sources of moral sensitivity which ar inherent in the stories that genetic science tells and raise paradigmatic justice concerns: the implications of new genetic knowledge for people's understanding of their familial roles, ancestral origins, community memberships, and ethnic affiliations. Beneath worries over "genetic privacy," "the therapeutic gap," and the "post-human," this constellation of basic wellspring which both insures and justifies a central place for genetics on the agenda of bioethics.

Dealing with the prenatal diagnosis of clefting: a parent's perspective

OBJECTIVES

Prenatal testing and information is available on an increasing basis for a variety of reasons. There are conflicting standards of care in the delivery of this type of evaluation and even more confusion around access to such services. As physicians and patients evaluate which tests will generate useful information with acceptable levels of risk, the rules of the game constantly shift. Presenting the situation from the viewpoints of both a professional and a parent, issues revolving around uncertainty and reassurance are evaluated. A description of the personal experience of the impact of the discovery of a cleft prenatally is provided.

CONCLUSIONS

Finally, efforts are made to raise questions about our motivations behind conducting prenatal testing and also developing some suggestions about how to support families better in our regular clinical work. A challenge is made to providers and patients to do more work prior to examination to explore how the unexpected will be handled. The dilemma about how to facilitate informed consent through full disclosure without overwhelming the patient is also discussed.

Home care and hospice ethics: using the code for nurses as a guide

In today's rapidly changing healthcare environment, home care and hospice nurses face complex ethical dilemmas. Many result from situations with two opposing, but equally reasonable, solutions. Understanding how and why ethical dilemmas arise helps nurses recognize the potential for an ethical dilemma and formulate justifiable solutions. This article, the first of a new ethics column in Home Healthcare Nurse, sets the foundation for the nurse's understanding of these dilemmas by applying the American Nurses Association's Code for Nurses with Interpretive Statements to real case studies.

The environmental genome project: ethical, legal, and social implications

The National Institute of Environmental Health Sciences is supporting a multiyear research initiative examining genetic influences on environmental response. Proponents of this new initiative, known as the Environmental Genome Project, hope that the information learned will improve our understanding of environmentally associated diseases and allow clinicians and public health officials to target disease-prevention strategies to those who are at increased risk. Despite these potential benefits, the project presents several ethical and social challenges. Of immediate concern is the protection of individual research participants. Other ethical issues relate to the application of research results and how study findings could affect social priorities. Clarifying these emerging areas of concern, many of which have not received adequate attention in the existing bioethics literature, is an important step toward minimizing potential research-related risks and defining research needs.

Ethical issues in genetic research: disclosure and informed consent

As research to correlate genetic status with predisposition to disease has accelerated, so has the concern that participation in such studies creates the risk of genetic discrimination and emotional distress. There is a need to broaden disclosure during the consent process to ensure that potential subjects understand these risks and other issues and to address them in the consent form. We describe the broad approach that we have taken in regard to disclosure and consent in gene mapping studies.