Knowledge and attitudes towards preimplantation genetic diagnosis in Germany

Assessment of attitudes towards the use of preimplantation genetic diagnosis in a single center in Riyadh, Saudi Arabia

In this cross-sectional study, we assessed the attitudes of the general public in Saudi Arabia regarding both medical and non-medical applications of pre-implantation genetic diagnosis (PGD). The study was conducted in King Abdullah Specialist Children's Hospital (KASCH) in Riyadh with a sample size of 377. Demographic information was collected, and attitudes towards applications of PGD were assessed using a pre-validated self-administered questionnaire. Out of the total sample size, 230 (61%) were males, 258 (68%) were married, 235 (63%) had one child or more, and 255 (68%) were older than 30 years of age representing the majority of participants. Only 87 (23%) of participants reported prior experience with PGD. Personally, knowing someone who had a prior experience with PGD was associated with higher attitude scores (more favorable attitudes towards PGD) (p-value = 0.04). The findings of this study indicate that our sample of Saudi individuals generally had a positive attitude towards the use of PGD.

Limitations, concerns and potential: attitudes of healthcare professionals toward preimplantation genetic testing using polygenic risk scores

Preimplantation genetic testing using polygenic risk scores (PGT-P) has recently been introduced. However, PGT-P has been met with many ethical concerns. It is therefore important to get insights into the perspectives of stakeholders regarding PGT-P. We performed a qualitative interview study on the views of healthcare professionals toward PGT-P. We conducted in-depth semi-structured interviews with 31 healthcare professionals working in the field of preimplantation genetic testing. The interviews explored the attitudes of healthcare professionals toward the technology of PGT-P, e.g., the validity, utility, limitations and potential benefits of PGT-P. We found that most healthcare professionals were concerned about the prematurity of introducing PGT-P into clinical practice. They had various ethical considerations, such as concerns related to validity and utility of PGT-P, limited embryos and options, and difficulties for prospective parents regarding comprehension and informed decision-making. Positive aspects were also identified, e.g., regarding reproductive autonomy and potential health benefits. Overall, most healthcare professionals considered that clinical implementation of PGT-P is premature. More comprehensive, longitudinal and inclusive studies are needed first, though these might not improve PGT-P enough to responsibly implement it. Healthcare professionals were also concerned that PGT-P could cause anxiety and create difficult choices for prospective parents. These perspectives and ethical considerations are crucial to consider for future guidelines and recommendations regarding PGT-P.

Reproductive issues in carriers of germline pathogenic variants in the BRCA1/2 genes: an expert meeting

BACKGROUND

Healthy individuals and patients with cancer who are carriers of germline pathogenic variants in the BRCA1/2 genes face multiple reproductive challenges that require appropriate counseling and specific expertise.

MAIN BODY

On December 5th-7th, 2019, patient advocates and physicians with expertise in the field of reproductive medicine, fertility preservation, and oncology were invited to "San Giuseppe Moscati" Hospital in Avellino (Italy) for a workshop on reproductive management of women with germline pathogenic variants in the BRCA1/2 genes. From the discussion regarding the current evidence and future prospective in the field, eight main research questions were formulated and eight recommendations were developed regarding fertility, fertility preservation, preimplantation genetic testing, and pregnancy in healthy carriers and patients with cancer.

CONCLUSION

Several misconceptions about the topic persist among health care providers and patients often resulting in a discontinuous and suboptimal management. With the aim to offer patient-tailored counseling about reproductive issues, both awareness of current evidences and research should be promoted.

Effects of religious orientation and state secularism on pre-implantation genetic diagnosis

This study aimed to test the associations of religious orientation (extrinsic, intrinsic, and quest) and secularism of state with individuals' attitudes towards the pre-implantation genetic diagnosis of embryos. Moreover, we tested the mediating effects of secularism of state on the relationship between religious orientations and attitudes towards this issue related to embryos. Participants were 312 Catholic Italians that completed a questionnaire containing measures of investigated constructs. Results showed that attitude towards pre-implantation genetic diagnosis negatively correlated with intrinsic religious orientation and positively with extrinsic religious orientation and secularism. Moreover, results indicated that secularism mediated the relationship between extrinsic and intrinsic orientation and attitude towards pre-implantation genetic diagnosis. Taking together these results indicate that real endorsement with religion is associated with the refusal of pre-implantation genetic diagnosis because intrinsic religious orientation is related to the desire for state laws to follow religious principles; on the other hand, the use of religion for utilitarian reasons is associated to the acceptance of pre-implantation genetic diagnosis in order to have a religious state and then maintain Catholics’ privileges.

Women's health providers' perspectives on preimplantation genetic testing

RESEARCH QUESTION

What are the perspectives of women's health providers on the use of preimplantation genetic testing (PGT) for common medical disorders?

DESIGN

A cross-sectional 15-question online anonymous survey was conducted of women's health providers specializing in general obstetrics/gynaecology, gynaecologic oncology and infertility at a tertiary care academic institution in Massachusetts, USA. Respondents could answer 'yes', 'no' or 'unsure' to each thematic question.

RESULTS

The survey was sent to 1060 providers and 240 providers responded (response rate 22.6%). Overall, 93% of respondents supported the use of PGT for the identification of genetic mutations which lead to childhood-onset disease, 83% supported the use of PGT for chromosomal aneuploidy screening, and 76% supported the use of PGT for cancer-related genetic disorders. Only 1.7% of respondents supported the use of PGT for non-disease-related indications, including sex selection and physical traits. Compared with general obstetrics/gynaecology providers, infertility specialists were more supportive of PGT. In total, 22.5% of respondents reported no prior knowledge of PGT.

CONCLUSIONS

In a sample of women's health providers across multiple different obstetrics/gynaecology specialties, there was overall support for the use of PGT for a variety of common indications. Infertility specialists were the most supportive, which may reflect the familiarity that these providers have with this procedure. There was an overwhelmingly non-supportive response for the use of PGT for non-disease-related indications. The percentage of medical professionals working in women's health without prior knowledge of PGT (22.5%) was higher than expected, identifying the need for more education regarding the availability and potential indications for this procedure.

The Effect of Values and Secularism on Attitude towards Pre-Implantation Genetic Diagnosis of Embryos

In this study we tested the associations of four high-order values (openness to change, self-transcendence, conservation, and self-enhancement, devised according to Schwartz’s model) and secularism of state with individuals’ attitude towards pre-implantation genetic diagnosis of embryos. Moreover, we tested the mediating effects of secularism of state on the relationship between values and attitude towards this issue related to embryos. Participants were 289 Spaniards who completed a questionnaire. Results showed that attitude towards pre-implantation genetic diagnosis was negatively affected by conservation and positively by self-transcendence. Moreover, results indicated that attitude towards a secular state positively correlates with attitude towards pre-implantation genetic diagnosis. Finally, results showed that secularism mediated the effects of conservation and self-transcendence, but not the effect of openness to change and self-enhancement on attitude towards pre-implantation genetic diagnosis. Taken together, results of this study suggest that people adopting values emphasizing the defence of the tradition reject pre-implantation genetic diagnosis because they want state laws to represent religious traditional values; on the other hand, people endorsing values emphasising the welfare of all accept pre-implantation genetic diagnosis because they want state laws to be free from religious values.

Professionals' knowledge, attitude and referral behaviour of preimplantation genetic diagnosis for hereditary breast and ovarian cancer

Hereditary breast and ovarian cancer caused by a BRCA1/2 mutation is the most frequent indication for preimplantation genetic diagnosis (PGD) in the Netherlands. The extent to which involved professionals are informed about this option, however, is unclear. The few available international studies mostly represent a limited range of professionals, and suggest that their knowledge about PGD for hereditary cancer syndromes is sparse and referral for PGD is based on limited understanding. A cross-sectional survey assessing awareness, knowledge, acceptability and PGD-referral for BRCA was completed by 188 professionals involved in the field of breast and ovarian cancer or reproduction. One-half of professionals were aware of PGD for BRCA, and most had a low to moderate level of knowledge. A total of 86% considered PGD for BRCA acceptable and 48% had referred patients with BRCA for PGD. Awareness and knowledge was higher among professionals who worked at a university hospital (compared with a general hospital). Knowledge of PGD was positively associated with discussing and referring for PGD, and PGD acceptability was associated with previous awareness. Although PGD counselling is the primary responsibility of the geneticist, other involved professionals may be gatekeepers as patients rely on them for raising awareness and referral.

Public Perceptions of Ethical, Legal and Social Implications of Pre-implantation Genetic Diagnosis (PGD) in Malaysia

Pre-implantation genetic diagnosis (PGD) became well known in Malaysia after the birth of the first Malaysian 'designer baby', Yau Tak in 2004. Two years later, the Malaysian Medical Council implemented the first and only regulation on the use of Pre-implantation Genetic Diagnosis in this country. The birth of Yau Tak triggered a public outcry because PGD was used for non-medical sex selection thus, raising concerns about PGD and its implications for the society. This study aims to explore participants' perceptions of the future implications of PGD for the Malaysian society. We conducted in-depth interviews with 21 participants over a period of one year, using a semi-structured questionnaire. Findings reveal that responses varied substantially among the participants; there was a broad acceptance as well as rejection of PGD. Contentious ethical, legal and social issues of PGD were raised during the discussions, including intolerance to and discrimination against people with genetic disabilities; societal pressure and the 'slippery slope' of PGD were raised during the discussions. This study also highlights participants' legal standpoint, and major issues regarding PGD in relation to the accuracy of diagnosis. At the social policy level, considerations are given to access as well as the impact of this technology on families, women and physicians. Given these different perceptions of the use of PGD, and its implications and conflicts, policies and regulations of the use of PGD have to be dealt with on a case-by-case basis while taking into consideration of the risk-benefit balance, since its application will impact the lives of so many people in the society.

Saving or Subordinating Life? Popular Views in Israel and Germany of Donor Siblings Created through PGD

To explore how cultural beliefs are reflected in different popular views of pre-implantation genetic diagnosis for human leukocyte antigen match (popularly known as "savior siblings"), we compare the reception and interpretations, in Germany and Israel, of the novel/film My Sister's Keeper. Qualitative analysis of reviews, commentaries and posts is used to classify and compare normative assessments of PGD for HLA and how they reproduce, negotiate or oppose the national policy and its underlying cultural and ethical premises. Four major themes emanated from the comparison: loss of self-determination and autonomy; loss of dignity through instrumentalization; eugenics and euthanasia; and saving life. In both countries, most commentaries represented a dominant position, with a few negotiated positions. We also highlight the decoding of a relatively less explored bioethical aspect of My Sister's Keeper's narrative, namely the meaning of euthanasia. We conclude by discussing how the findings relate to attempts of providing cultural explanations for the regulation of HLA-PGD.

Awareness and attitude regarding reproductive options of persons carrying a BRCA mutation and their partners

STUDY QUESTION

To what extent are BRCA mutation carriers and their partners in the Netherlands aware about preimplantation genetic diagnosis (PGD) and prenatal diagnosis (PND) as reproductive options and what is their attitude towards these options?

SUMMARY ANSWER

Awareness of PGD (66%) and PND (61%) among BRCA mutation carriers and their partners is relatively high and 80% and 26%, respectively, of BRCA carriers and their partners find offering PGD and PND for hereditary breast and ovarian cancer (HBOC) acceptable.

WHAT IS KNOWN ALREADY

Internationally, awareness of PGD among persons with a genetic cancer predisposition appears to be relatively low (35%) and although acceptability is generally high (71%), only a small proportion of mutation carriers would consider using PGD (36%). However, for HBOC, there are no studies available that investigated the perspective of individuals with a confirmed BRCA1/2 mutation and their partners about PGD and PND including demographic and medical correlates of awareness and acceptability.

STUDY DESIGN, SIZE, DURATION

A cross-sectional survey was completed by 191 participants between July 2012 and June 2013. Participants were recruited through patient organizations (88%) and the databases of two Clinical Genetics departments in the Netherlands (12%).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Male and female BRCA carriers and their partners completed an online survey, which assessed demographic and medical characteristics, and awareness, knowledge, acceptability and consideration of PGD and PND as main outcomes. Correlations between demographic and medical characteristics and the main outcomes were investigated.

MAIN RESULTS AND ROLE OF CHANCE

The majority of respondents were female (87%), of reproductive age (86%) and about half reported a desire for a child in the future. About two-thirds (66%) were aware of PGD and 61% of PND for HBOC. PGD knowledge was moderate (5.5 on a 9-point scale) and acceptability of PGD and PND for HBOC was 80% and 26%, respectively. A minority would personally consider using PGD (39%) or PND (20%). Individuals with a higher educational level were more likely to be aware of PGD (P < 0.001) and PND (P < 0.001) and persons with a more immediate child wish were more often aware of PGD (P = 0.044) and had more knowledge about PGD (P = 0.001). PGD acceptability was positively associated with knowledge about PGD (P = 0.047), and PND acceptability was higher among partners in comparison to carriers (P = 0.001). Participants with a history of cancer and with a higher perceived seriousness of breast and ovarian cancer were more likely to consider using PGD (P = 0.003 and P < 0.001 respectively) or PND (P = 0.021 and P = 0.017 respectively).

LIMITATIONS, REASONS FOR CAUTION

The response rate (23%) of participants invited by the clinical genetics departments was low, probably related to a simultaneous study that used a similar recruitment strategy within the same target group, which may have resulted in selection bias. Moreover, PGD knowledge was measured with an instrument that is not yet validated since to date such an instrument is not available in the literature. Finally, the cross-sectional design of this study limits us from drawing any causal conclusions.

WIDER IMPLICATIONS OF THE FINDINGS

Improvement of information provision remains needed, in order to timely inform all couples with HBOC about the available reproductive options and enable them to make a balanced reproductive decision. This may limit the risk of negative psychological impact due to decisional conflict and possible regret.

STUDY FUNDING/COMPETING INTEREST(S)

The Dutch breast cancer foundation Stichting Pink Ribbon (grant number 2010.PS11.C74). None of the authors have competing interests to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

Public opinions about human enhancement can enhance the expert-only debate: A review study

Human enhancement, the non-medical use of biomedical technologies to improve the human body or performance beyond their 'natural' limitations, is a growing trend. At the same time, the use of these technologies has societal consequences. In societal debates about human enhancement, however, it is mainly the voices of experts that are being heard, and little is known about the public's understanding of human enhancement. The views of the public can give valuable insights, and can, in turn, supplement experts' voices in political decision-making as has been argued before for other emerging technologies. This study presents a systematic literature review of current public perceptions and attitudes towards technologies for human enhancement. Results show that the public's view has not been assessed often. Studies originate mainly from western-oriented countries and cover a broad range of enhancement technologies. In the studies, the majority of respondents hold moderate to strong negative attitudes towards enhancement technologies for non-medical applications, although the type of technology influences these opinions. The study provides an overview of what is known about citizens' attitudes towards technologies for human enhancement.

Public perspectives on the use of preimplantation genetic diagnosis

PURPOSE

To study the perspectives of the United States population towards the use of preimplantation genetic diagnosis (PGD) in various clinical scenarios.

METHODS

Online cross-sectional population based questionnaire of a nationally representative sample according to age, gender, race/ethnicity, income, education and religion.

RESULTS

A total of 1006 completed the questionnaire with an overall response rate of 94%. A majority supported PGD for diseases fatal early in life or those causing lifelong disability (72.9 and 66.7%, respectively); only 48.0% supported PGD for diseases that manifest late in life. Respondents were more supportive of PGD for genetic diseases if they were aware of PGD prior to the survey (OR = 1.64; CI = 1.13-2.39). However, a small proportion were in favor of genetically-based trait selection: 21.1% supported PGD for sex selection, 14.6% for physical traits and 18.9% for personality traits. Compared to women, men were nearly two- to three-fold more supportive of PGD for sex selection (OR = 1.65; CI = 1.20-2.78), physical traits (OR = 2.38; CI = 1.60-3.48) and personality traits (OR = 2.31; CI =  .64-3.26). Compared to Caucasians, Asians (OR = 3.87; CI = 1.71-8.78) and African Americans (OR = 1.61; CI = 1.04-2.74) were more supportive of PGD for sex selection.

CONCLUSIONS

In a nationally representative sample, a majority supported PGD to identify early onset diseases. We noted significant variation in opinions by sex, race, and education. There was more support among those with prior knowledge of PGD suggesting that education about PGD may foster favorable opinions. This study identifies public knowledge and attitudes that may be used to shape future research hypotheses and clinical policies.

Comparison of attitudes regarding preimplantation genetic diagnosis among patients with hereditary cancer syndromes

Preimplantation genetic diagnosis (PGD) allows couples to avoid having a child with an inherited condition, potentially reducing cancer burden in families with a hereditary cancer predisposition. This study investigated and compared awareness and acceptance of PGD among patients with different hereditary cancer syndromes. Questionnaires were mailed to 984 adults with hereditary breast and ovarian cancer, Lynch syndrome, familial adenomatous polyposis, or multiple endocrine neoplasia type 1 or 2. Associations between clinical, demographic, and psychosocial factors and awareness and acceptance of PGD were examined. Of 370 respondents (38 % return rate), 28 % felt their syndrome impacted family planning, 24 % were aware of PGD, 72 % felt that PGD should be offered, 43 % would consider using PGD, and 29 % were uncertain. Family experience and syndrome-specific characteristics, such as disease severity, quality of life and availability of medical interventions as well as gender, family planning stage, and religiosity impact perceptions of the acceptability of PGD, though a high level of uncertainty exists. Hereditary cancer patients lack awareness of PGD despite feeling that PGD should be offered, highlighting the need for education on this topic. While we found attitudes about the acceptability of PGD to be generally similar to those reported in the literature and of genetics and ethics experts, we observed similarities and differences between syndromes that provide insight into why some hereditary cancer patients may find PGD more acceptable than others.

100 years Lynch syndrome: what have we learned about psychosocial issues?

In the care of patients with Lynch Syndrome (LS), a range of psychosocial issues are encountered, which significantly affect patient outcomes. A brief historical background of 'psycho-onco-genetics' (the domain where psychology, oncology and genetics meet) in relation to LS is presented, followed by an overview of important psychosocial issues identified in the past 20 years. The identification of mismatch repair genes in 1993-1994 made possible genetic counseling and testing for patients who had cancer and for potentially high-risk relatives without cancer. At that time, concerns were raised about the potentially negative psychosocial impact of predictive genetic testing. Since 1993, a large number of studies have been conducted to investigate the possible psychosocial benefits and limitations of such testing. This article presents an overview of: the uptake of and motivations for genetic testing, its psychosocial impact (e.g. psychological adaptation, impact on risk perception and self-concept, and concerns about, and experiences of, genetic discrimination), psychological screening instruments, adherence to and decision-making about preventive strategies, family communication, lifestyle changes, reproductive technology utilization, and professional psychosocial support needs of members of families with LS. Finally, challenges for the future are discussed, including population screening and genomic testing.

Ethical attitudes of German specialists in reproductive medicine and legal regulation of preimplantation sex selection in Germany

BACKGROUND

Because of its ethical and social implications, preimplantation sex selection is frequently the subject of debates.

METHODS

In 2006, we surveyed specialists in reproductive medicine in Germany using an anonymous questionnaire, including sociodemographic data and questions regarding ethical problems occurring in the practice of reproductive medicine. Most questions focused on preimplantation sex selection, including 10 case vignettes, since these enabled us to describe the most difficult and ethically controversial situations. This is the first survey among specialists in reproductive medicine regarding this topic in Germany.

RESULTS

114 specialists in reproductive medicine participated, 72 males (63%) and 42 females (37%), average age was 48 years (age range 29-67 years). The majority of respondents (79%) favoured a regulation that limits the use of preimplantation sex selection only for medical reasons, such as X-linked diseases (including 18%: summoning an ethics commission for every case). A minority of 18% approved of the use of sex selection for non-medical reasons (4% generally and further 14% for family balancing). 90% had received obvious requests from patients. The highest approval (46%) got the counselling guideline against a preimplantation sex selection and advising a normal pregnancy, if preimplantation sex selection would be allowed in Germany. The majority (67%) was opposed the personal use of preimplantation sex selection for non-medical reasons, but would think about it in medical cases. In opposite to woman, 14% of the men were in favour of personal use for non-medical reasons (p=0,043). 25% of specialists in reproductive medicine feared that an allowance of preimplantation sex selection would cause a shift in the sex ratio.

CONCLUSIONS

The majority of German specialists in reproductive medicine opposes preimplantation sex selection for non-medical reasons while recommending preimplantation sex selection for medical reasons, e.g. X-linked diseases like haemophilia.

High-risk consumers' perceptions of preimplantation genetic diagnosis for hereditary cancers: a systematic review and meta-analysis

Individuals carrying deleterious germline mutations placing them at increased risk for hereditary cancer syndromes (high-risk consumers) often have a great deal of fear and concern over transmitting mutations to their offspring, particularly conditions which are autosomal dominant. Preimplantation genetic diagnosis (PGD) is a procedure that can detect certain germline cancer predisposing mutations present in embryos. The objective of this review was to assess high-risk consumers' knowledge and perceptions of PGD for hereditary cancers. A systematic literature review was conducted through PubMed, Wiley Interscience, PsychInfo, and Cochrane Library databases to identify all articles assessing consumer knowledge and attitudes of PGD for hereditary cancer syndromes. We assessed heterogeneity and the robustness of findings through additional analyses according to study location, hereditary cancer type, and sample size. Thirteen articles remained eligible after the application of specific criteria. Results show a general low level of knowledge about PGD for hereditary cancers, moderate rates of acceptability among high-risk groups, and high levels of need for information about PGD. Individuals in specific risk groups such as those with a personal or family history of hereditary breast and ovarian cancer (HBOC) syndrome or familial adenomatous polyposis (FAP) may benefit from educational information from healthcare professionals about the use of PGD.

Knowledge, attitudes, and clinical experience of physicians regarding preimplantation genetic diagnosis for hereditary cancer predisposition syndromes

Approximately 5-10% of cancers are caused by an inherited predisposition. Individuals affected by hereditary cancer are often concerned about transmitting a predisposition to cancer to their children. Preimplantation genetic diagnosis (PGD) is a technology that allows embryos without a deleterious mutation associated with a hereditary cancer syndrome to be identified and implanted. The aim of this study is to assess the knowledge, attitudes, and clinical experience of physicians regarding PGD for hereditary cancer predisposition syndromes. Hereditary Breast and Ovarian Cancer (HBOC) and Familial Adenomatous Polyposis (FAP) are two hereditary cancer syndromes highlighted in this present study. A survey assessing physicians' attitudes, knowledge, and clinical practice was completed by a total of 373 gynecologic oncologists (GYN ONCs) and obstetrics and gynecologists (OB/GYNs). Physicians had a limited knowledge of PGD for hereditary cancer; however, physicians reported PGD was an appropriate option for patients with either HBOC or FAP. Although GYN ONCs were more likely to care for patients with hereditary cancer (P < 0.001), they were less likely than OB/GYNs to refer their patients to a PGD specialist (P = 0.004). While 80% of GYN ONCs and 91% of OB/GYNs would refer patients to a PGD specialist, clinical experience indicates that only 29% actually referred their patients. Since 68% of physicians had incorrect or limited knowledge of PGD for hereditary cancer, there is a need for additional education.

Preimplantation genetic diagnosis in Saudi Arabia: parents' experience and attitudes

BACKGROUND

Preimplantation genetic diagnosis (PGD) has been proposed as an alternative to prenatal diagnosis (PND). This study compares the attitudes towards PGD of four groups of parents in Saudi Arabia: two groups at genetic risk for different conditions but with no experience of PGD procedures and two groups who had experience, either of PGD or of in vitro fertilisation (IVF) for infertility.

METHODS

One hundred and eighty four participants attending the King Faisal Specialist Hospital and Research Centre (KFSH&RC) in Riyadh were interviewed using a semi-structured questionnaire: 49 had children affected by a haemoglobin disorder, 48 had children with non-syndromic deafness, 37 were attending the PGD service and 50 were attending IVF services for infertility.

RESULTS

Opinions in the two genetic groups were very similar: families were enthusiastic about PGD and relatively unconcerned about its technical limitations or the desirability of a confirmatory PND. The technical limitations of PGD and the moral status of embryos were of greatest concern to the PGD group. Waiting for the pregnancy result was the most commonly mentioned concern in the PGD and IVF groups.

CONCLUSION

PGD might be considered for a range of conditions in Saudi Arabia. However, it is not an easy option, and couples must be selected and counselled appropriately.

Christian lay understandings of preimplantation genetic diagnosis

Focus groups were used to analyse Christian lay public understanding of preimplantation genetic diagnosis (PGD), a relatively new biomedical practice. The paper explores how this often controversial genetic technology was contextualised and interpreted through the intersection of religious values and beliefs, secular and cultural knowledges, and lived experience and emotion. For the lay people in our study, PGD often created moral dilemmas that could not necessarily be resolved through Christian beliefs and teaching, but which required the expression of empathy and compassion. The findings emphasise the heterogeneity in individuals' interpretations of scientific issues and reinforce the need to consider public understanding of science and technology in terms of public concerns and meaning.

Conceptualizing couples' decision making in PGD: emerging cognitive, emotional, and moral dimensions

OBJECTIVE

To illuminate and synthesize what is known about the underlying decision making processes surrounding couples' preimplantation genetic diagnosis (PGD) use or disuse and to formulate an initial conceptual framework that can guide future research and practice.

METHODS

This systematic review targeted empirical studies published in English from 1990 to 2008 that examined the decision making process of couples or individual partners that had used, were eligible for, or had contemplated PGD. Sixteen studies met the eligibility requirements. To provide a more comprehensive review, empirical studies that examined healthcare professionals' perceptions of couples' decision making surrounding PGD use and key publications from a variety of disciplines supplemented the analysis.

RESULTS

The conceptual framework formulated from the review demonstrates that couples' PGD decision making is composed of three iterative and dynamic dimensions: cognitive appraisals, emotional responses, and moral judgments.

CONCLUSION

Couples think critically about uncertain and probabilistic information, grapple with conflicting emotions, and incorporate moral perspectives into their decision making about whether or not to use PGD.

PRACTICE IMPLICATIONS

The quality of care and decisional support for couples who are contemplating PGD use can be improved by incorporating focused questions and discussion from each of the dimensions into counseling sessions.

High risk men's perceptions of pre-implantation genetic diagnosis for hereditary breast and ovarian cancer

BACKGROUND

Pre-implantation genetic diagnosis (PGD) is an assisted reproductive technology procedure which provides parents with the option of conducting genetic analyses to determine if a mutation is present in an embryo. Though studies have discussed perceptions of PGD from a general population, couples or high-risk women, no studies to date have specifically examined PGD usage among men. This study sought to explore perceptions and attitudes towards PGD among males who either carry a BRCA mutation or have a partner or first degree relative with a BRCA mutation.

METHODS

A cross-sectional survey was conducted among 228 men visiting the Facing Our Risk of Cancer Empowered or Craigslist website. Eligibility criteria included men who self-reported they had been tested for a BRCA mutation or had a partner or first degree relative tested for a BRCA mutation. A 41-item survey assessed socio-demographic, clinical characteristics, PGD knowledge and attitudinal factors and consideration of the use of PGD. Differences in proportions of subgroups were tested using the Monte Carlo exact test for categorical data. A multiple logistic regression model was then built through a backward elimination procedure.

RESULTS

Although 80% of men reported being previously unfamiliar with PGD, after learning the definition of PGD, 34% of the 228 respondents then said they would 'ever consider the use of PGD'. Respondents who thought of PGD only in terms of 'health and safety' were almost three times more likely (OR = 2.82; 95% 1.19-6.71) to 'ever consider the use of PGD' compared with respondents who thought of PGD in terms of both 'health and safety', and 'religion and morality'.

CONCLUSIONS

As with other anonymous web-based surveys, we cannot verify clinical characteristics that may impact consideration of PGD use. Our findings indicate high-risk men need more information about PGD and may benefit from educational materials to assist them in reproductive decision-making.

A 'healthy baby': The double imperative of preimplantation genetic diagnosis

This article reports from a study exploring the social processes, meanings and institutions that frame and produce 'ethical problems' and clinical dilemmas for practitioners, scientists and others working in the specialty of preimplantation genetic diagnosis (PGD). A major topic in the data was that, in contrast to IVF, the aim of PGD is to transfer to the woman's womb only those embryos likely to be unaffected by serious genetic disorders; that is, to produce 'healthy babies'. Staff described the complex processes through which embryos in each treatment cycle must meet a double imperative: they must be judged viable by embryologists and 'unaffected' by geneticists. In this article, we focus on some of the ethical, social and occupational issues for staff ensuing from PGD's double imperative.

Ethical, legal and social implications of prenatal and preimplantation genetic testing for cancer susceptibility

With the progress in cancer genetics and assisted reproductive technologies, it is now possible for cancer gene mutation carriers not only to reduce cancer mortality through the targeting of surveillance and preventive therapies, but also to avoid the birth of at-risk babies through the choice of different means of reproduction. Thus, the incidence of hereditary cancer syndromes may be decreased in the future. The integration of cancer genetic testing and assisted reproductive technologies raises certain ethical, legal and social issues beyond either genetic testing or assisted reproductive technology itself. In this paper, the reproductive decisions/choices of at-risk young couples and the ethical, legal and social concerns of prenatal genetic testing and preimplantation genetic diagnosis for susceptibility to hereditary cancer syndromes are discussed. Specifically, three ethical principles related to the integration of cancer genetic testing and assisted reproductive technologies, i.e. informed choice, beneficence to children and social justice, and their implications for the responsible translation of these medical techniques into common practice of preventive medicine are highlighted.

Opinions concerning pre-implantation genetic diagnosis and sex selection among gynecologist-obstetricians in Brazil

OBJECTIVE

The aim of this study was to assess a sample of obstetrician-gynecologists on their technical knowledge of PGD as well as their views of PGD and sex selection (SS).

STUDY DESIGN

Cross-sectional observational study, carried out during a Congress on Gynecology and Obstetrics. A self-report questionnaire was offered to all professionals registered to attend the Congress and answers of 723 physicians were analyzed.

RESULTS

Of the participants, 436 (60.3%) were female and 287 (39.7%) were male; 517 (71.5%) had children. Regarding knowledge of PGD techniques, 63.2% had heard something about PGD and/or preconception SS. Concerning SS, physicians believed that SS is always the couple's choice (36.4%), should be the couple's choice only in specific situations (42.6%), or did not agree that SS should be a couple's choice (17.4%). A majority of the respondents were in favor of PGD and believed that pre-embryos with 6-8 cells are human life in potency.

CONCLUSIONS

In spite of a small percentage of gynecologists-obstetricians in Brazil had knowledge of PGD techniques, many of them recognized it to be a method to prevent genetic diseases and agreed with its use. The SS appears to be highly accepted for use in specific situations.

Designer babies on tap? Medical students' attitudes to pre-implantation genetic screening

This paper describes two studies about the determinants of attitudes to pre-implantation genetic screening in a multicultural sample of medical students from the United States. Sample sizes were 292 in study 1 and 1464 in study 2. Attitudes were of an undifferentiated nature, but respondents did make a major distinction between use for disease prevention and use for enhancement. No strong distinctions were made between embryo selection and germ line gene manipulations, and between somatic gene therapy and germ line gene manipulations. Religiosity was negatively associated with acceptance of "designer baby" technology for Christians and Muslims but not Hindus. However, the strongest and most consistent influence was an apparently moralistic stance against active and aggressive interference with natural processes in general. Trust in individuals and institutions was unrelated to acceptance of the technology, indicating that fear of abuse by irresponsible individuals and corporations is not an important determinant of opposition.

Testing the embryo, testing the fetus

This paper stems from an ethnographic, multidisciplinary study that explored the views and experiences of practitioners and scientists on social, ethical and clinical dilemmas encountered when working in the area of PGD for serious genetic disorders. We focus here on staff perceptions and experiences of working with embryos and helping women/couples to make choices that will result in selecting embryos for transfer and disposal of 'affected' embryos, compared to the termination of affected pregnancies following PND. Analysis and discussion of our data led us to consider the possible advantages of PGD and whether a gradualist account of the embryo's and fetus's moral status can account for all of these, particularly since a gradualist account concentrates on the significance of time (developmental stage) and makes no comment as to the significance of place (in-vitro, in-utero).

On new reproductive technologies and family ethics: pre-implantation genetic diagnosis for sibling donor in Israel and Germany

This paper discusses the policy debate and ethical discussion surrounding pre-implantation genetic diagnosis (PGD) for sibling donor (SD) in Germany and Israel. Based on an analysis of the regulations and ethical discourse concerning a unique form of new reproductive technology (NRT)--PGD for SD--we complement the scholarly discussion of NRTs in these countries, by pointing to an explanatory factor that has been so far neglected, namely the hegemonic notions regarding the ideal relationship between the generations, and the mutual obligations between different family members in Germany and Israel. We argue the fact that PGD (in general) and PGD for SD (in particular) have been banned in Germany, but were endorsed without hesitation in Israel, has to do with different perceptions of family ethics within the two societies. Furthermore, we argue that this factor contributes significantly to the more general understanding of German and Israeli policies regarding NRTs.

Facilitating choice, framing choice: staff views on widening the scope of preimplantation genetic diagnosis in the UK

In the UK, the Human Fertilisation and Embryology Authority (HFEA) is responsible for licensing preimplantation genetic diagnosis (PGD). To date, licenses have been issued for the testing of about 70 genetic conditions, drawing on three key 'ethical principles'. Following a public consultation, the HFEA has recently widened the scope for PGD to include susceptibility to late onset, lower penetrance conditions such as inherited breast cancer. As the numbers and types of conditions which can potentially be tested for rises, the question of how, and indeed what limits should be set is timely. Drawing on qualitative interviews and ethics discussion groups which took place prior to or during the HFEA consultation, this paper explores the views of staff working in or linked to one PGD Unit in the UK, as to how they saw these potential changes. The paper thus provides an opportunity to develop greater understanding of how staff working in a morally contentious, innovative area viewed the potential expansion of their work, prior to that expansion taking place. Key themes include 'drawing lines' on behalf of others, particularly with the current emphasis on individual reproductive autonomy; and balancing the invasiveness and possible risks of PGD treatment against the 'seriousness' of the condition. More broadly, the paper highlights the complexities involved in trying to develop general 'ethical principles' to govern the use of ever evolving reproductive technologies.

Views of BRCA gene mutation carriers on preimplantation genetic diagnosis as a reproductive option for hereditary breast and ovarian cancer

BACKGROUND

In May 2006, the UK Human Fertilization and Embryology Authority (HFEA) approved use of preimplantation genetic diagnosis (PGD) for lower penetrance, late onset cancer susceptibility syndromes such as hereditary breast and ovarian cancer (HBOC). This is the first report on views of BRCA gene mutation carriers on use of PGD for HBOC.

METHODS

Between December 2005 and February 2006, a postal survey of BRCA mutation carriers attending a Familial Cancer Clinic was undertaken.

RESULTS

Of 102 women sent questionnaires, 52 (51%) responded. Thirty-nine (75%) felt it was acceptable to offer PGD for HBOC. Fifteen (37.5%) of 40 who had completed their families would personally have considered PGD if it had been available. Only one of seven (14%) contemplating a future pregnancy would consider PGD. Eighteen (35%) wrote extensively about their concerns including increasing availability of effective treatment and good quality of life.

CONCLUSIONS

The majority of BRCA gene mutation carriers are supportive of offering PGD to others, thus endorsing the HFEA decision. However, most women would not consider it personally. Concerns raised highlight the need for regular HFEA reviews of the licensing criteria, as HBOC may cease to be a "serious life threatening illness" in the future.

Attitudes to prenatal and preimplantation diagnosis in Saudi parents at genetic risk

BACKGROUND

Prenatal diagnosis (PND) is only available for severe abnormality in Saudi Arabia, and preimplantation genetic diagnosis (PGD) has been proposed as a valuable alternative. The acceptability of PGD is unexplored, and may ultimately determine the value of this technology in Saudi Arabia. This study reports attitudes towards PND and PGD of Saudi couples offered genetic counselling following the birth of a child with a single gene or chromosomal condition.

METHODS

Thirty couples attending the King Faisal Specialist Hospital and Research Centre in Riyadh were interviewed using a semi-structured questionnaire. One couple had previous experience of PND and none had experience of PGD or IVF.

RESULTS

Eight of the 30 couples (27%) would only accept PGD; four (13%) only PND; three (10%) either technology; the remainder would accept neither test, or were unsure. The main concerns of those who would accept neither technology were related to personal religious views. Specific concerns about PGD related to the IVF procedure, the risk of multiple pregnancies, the chance of mistakes and the chance of not getting pregnant. A high proportion of couples (six out of seven; 86%) who had a child with thalassaemia expressed interest in PGD, and all would be prepared to use technology to avoid having an affected child. Views were more mixed for the other conditions.

CONCLUSION

PGD is acceptable to many couples and for some, it represents a valuable alternative to PND. However, parents' concerns are complex, and the acceptability of different reproductive technologies must be established on an individual basis.

Attitudes of patients, healthcare professionals and ethicists towards embryonic stem cell research and donation of gametes and embryos in Germany

Due to the Embryo Protection Act, creation of supernumerary embryos, as well as egg and embryo donation, is prohibited in Germany. Human stem cell research is regulated through the Act on stem cells that came into force in 2002. A cross-sectional survey of 101 IVF couples (n=202) in two fertility centres, and representative samples of healthcare professionals and ethicists (n=879), was carried out, and their attitudes towards embryonic stem cell research and donation of gametes and embryos compared. A clear majority of IVF couples favoured legalization of egg and embryo donation and embryonic stem cell research for various purposes. The willingness of couples to donate was related to purpose and to other independent influences. The majority of physicians voted for legalization of embryonic stem cell production from surplus embryos. Most human geneticists and obstetricians approved egg, but not embryo, donation to other couples. Ethicists and midwives were opposed to every kind of donation and research on surplus embryos. The IVF couples surveyed have positive attitudes towards donation and research using surplus embryos, whereas the healthcare professionals and ethicists are predominantly sceptical about most research activities destroying human embryos. This difference should be considered carefully in legal and ethical discussions on reprogenetics.

Attitudes towards sex selection for non-medical reasons: a review

Early non-invasive fetal sexing is widely available over the Internet, leading to concerns about its possible use for sex selection. The aim of this review is to summarise the results of surveys describing lay attitudes towards sex selection for non-medical reasons to help address or inform such concerns. A search of electronic databases and key journals was supplemented by an Internet search and citation-tracking. Twenty-one quantitative studies were identified. Most were conducted in the US, with five recent studies in the UK and Germany. Most studies found that, overall, people were not in favour of sex selection. However, this varied from 94 to 18%. People may hold more negative attitudes when the method of sex selection is specified, particularly if this involves termination of pregnancy (TOP). Attitudes towards the general availability of sex selection are less negative than those towards personal use. Attitudes were consistently negative in German surveys. Little is known of such attitudes outside the US, the UK and Germany, and how such attitudes may change as new sex selection technologies become available. Studies of use of early non-invasive fetal sexing for sex selection for non-medical reasons are needed to assess the extent to which concerns about usage are justified and to assist in debates on how these might be most appropriately addressed.

Social sex selection and the balance of the sexes: Empirical evidence from Germany, the UK, and the US

Preconception sex selection for nonmedical reasons is one of the most controversial issues in bioethics today. The most powerful objection to social sex selection is based on the assumption that it may severely distort the natural sex ratio and lead to a socially disruptive imbalance of the sexes. Based on representative social surveys conducted in Germany, the United Kingdom, and the United States, this paper argues that the fear of an impending sex ratio distortion is unfounded. Given the predominant preference for a "gender balanced family," a widely available service for social sex selection is highly unlikely to upset the balance of the sexes in Western societies.

What is the preimplantation embryo?

We present results from our 'bioethical field studies', which explore and compare the views of experts, patients and the general public on the beginning of human life and the status of the preimplantation embryo in Germany. Using a qualitative and quantitative multi-method approach, we found crucial differences in the categorization of the beginning of human life within the expert group (representative samples of human geneticists n=104, ethicists n=168, midwives n=294, obstetricians n=147, paediatricians n=166), and between expert and lay samples (IVF couples n=108, high genetic risk couples n=324, general population n=1017). The majority of lay respondents as well as paediatricians and obstetricians chose nidation, the moment when the implantation of the fertilized egg into the uterus takes place, as the crucial boundary that marks the beginning of human life, whereas the majority of (female) human geneticists, ethicists and midwives voted for conception as the decisive point in time. The views of all groups on the status of the preimplantation embryo differed from the assumptions underlying German legislation (Embryo Protection Act). Religiousness and religious affiliation, gender, attitudes towards disabled people, post-material values and a present desire for a child were identified as independent factors influencing attitudes towards the preimplantation embryo in the population sample. The results are discussed within a broader philosophical and social science perspective of constructivism versus essentialism, proposing a truly interdisciplinary approach to such bioethical core issues as new reproductive technologies and the status of the preimplantation embryo.

Reducing multiple pregnancy from assisted reproduction treatment: educating patients and medical staff

Multiple pregnancy, with its adverse outcomes, is a significant problem in assisted reproductive technology. Single embryo transfer (SET) is the only feasible solution for reducing the rate of multiple pregnancy. Many patients and some clinicians remain to be convinced that SET is a better clinical option. Adequate education, based on available evidence, is one important way to promote the use of SET.

PGD patients' and providers' attitudes to the use and regulation of preimplantation genetic diagnosis

Preimplantation genetic diagnosis (PGD) providers and patients have a vested interest in policy related to the use and regulation of PGD. To understand their experiences and attitudes, 32 in-depth interviews were conducted. Participants included 13 people at risk of transmitting a single-gene alteration to their children (10/13 had actually used PGD to try to have an unaffected child) and 19 PGD service providers (four nurses, five genetic counsellors, two reproductive endocrinologists, two geneticists, two physician-geneticists, two embryologists, and two laboratory directors). Virtually all participants supported the use of PGD to avoid severe, life-threatening genetic illness or to select embryos that are a tissue match for a sick sibling, but their attitudes varied significantly over the appropriateness of using PGD to avoid adult-onset genetic disease, to select for sex, or to select for other non-medical characteristics. There was disagreement within the PGD provider community about whether or not PGD is experimental. Participants were more concerned about overzealous government regulation of PGD creating barriers to access than potential abuses of the technology, and expected the PGD provider community to take the lead in ensuring that PGD is used for ethically appropriate purposes.

Ambivalent attitudes towards pre-implantation genetic diagnosis in Germany

BACKGROUND

Pre-implantation genetic diagnosis (PGD) is a modern technique in reproductive medicine which can be used to diagnose genetic disorders of an embryo. PGD is currently not legal in Germany, still there are debates being held regarding the issue of legalization. Both the internationally "accepted" indications and new or alternative approaches can lead to complex ethical dilemmas. The attitudes towards PGD have rarely been assessed in the general population.

METHODS

In our study, 2110 persons aged 18-50 years were interviewed about their attitudes towards PGD and related topics. We assumed that religion, world views and the evaluation of PGD would influence the attitude a person has towards this procedure.

RESULTS AND CONCLUSIONS

In our survey, the majority of respondents would agree to a restricted legalization of PGD in Germany. Our results also confirmed some of our assumptions but religion did not have the expected influence. The evaluation of costs and benefits of PGD and the feelings associated with this technique explained more of the final attitude whether PGD should remain prohibited in Germany or not. The agreement to a restricted legalization may be connected to an overall rejection of prohibitions made by the state concerning the individual reproductive autonomy.