The evolving duty to disclose the presence of genetic disease to relatives

Understanding and addressing populations whose prior experience has led to mistrust in healthcare

BACKGROUND

Policy makers need to maintain public trust in healthcare systems in order to foster citizen engagement in recommended behaviors and treatments. The importance of such commitment has been highlighted by the recent COVID-19 pandemic. Central to public trust is the extent of the accountability of health authorities held responsible for long-term effects of past treatments. This paper addresses the topic of manifestations of trust among patients damaged by radiation treatments for ringworm.

METHODS

For this mixed-methods case study (quan/qual), we sampled 600 files of Israeli patients submitting claims to the National Center for Compensation of Scalp Ringworm Victims in the years 1995-2014, following damage from radiation treatments received between 1946 and 1960 in Israel and/or abroad. Qualitative data were analyzed with descriptive statistics, and correlations were analyzed with chi-square tests. Verbal data were analyzed by the use of systematic content analysis.

RESULTS

Among 527 patients whose files were included in the final analysis, 42% held authorities responsible. Assigning responsibility to authorities was more prevalent among claimants born in Israel than among those born and treated abroad (χ² = 6.613, df = 1, p = 0.01), claimants reporting trauma (χ² = 4.864, df = 1, p = 0.027), and claimants living in central cities compared with those in suburban areas (χ² = 18.859, df = 6, p < 0.01). Men, younger claimants, patients with a psychiatric diagnosis, and patients from minority populations expressed mistrust in health regulators.

CONCLUSIONS

Examining populations' perceived trust in healthcare institutions and tailoring health messages to vulnerable populations can promote public trust in healthcare systems.

What's the harm? Genetic counselor perceptions of adverse effects of genetics service provision by non-genetics professionals

Anecdotal accounts suggest some patients have experienced negative outcomes as a result of receiving genetics services from non-genetics providers, but empirical evidence of these incidents and their outcomes is limited. This study examined genetic counselors' perceptions of the occurrence of such incidents in the state of Minnesota. Twenty-five genetic counselors completed an on-line survey and 20 also participated in a semi-structured telephone interview. The interviewees recalled and described 37 specific incidents they perceived as having negative outcomes for patients and/or their families. Inductive and cross-case analysis revealed common themes including: adverse psychosocial effects, inadequate genetic counseling, genetic testing and screening errors, medical mismanagement, negative shifts in attitudes toward medical providers, and unnecessary use of health care resources. Commonly mentioned strategies for preventing/mitigating negative outcomes included: educational outreach and awareness programs for medical providers and the general public, standardized testing and screening processes, and implementing mechanisms for reporting and addressing adverse events. Additional findings, practice and policy implications, and research recommendations are discussed.

Physicians' perspectives on the uncertainties and implications of chromosomal microarray testing of children and families

Chromosomal microarray analysis (CMA) has improved the diagnostic rate of genomic disorders in pediatric populations, but can produce uncertain and unexpected findings. This article explores clinicians' perspectives and identifies challenges in effectively interpreting results and communicating with families about CMA. Responses to an online survey were obtained from 40 clinicians who had ordered CMA. Content included practice characteristics and perceptions, and queries about a hypothetical case involving uncertain and incidental findings. Data were analyzed using nonparametric statistical tests. Clinicians' comfort levels differed significantly for explaining uncertain, abnormal, and normal CMA results, with lowest levels for uncertain results. Despite clinical guidelines recommending informed consent, many clinicians did not consider it pertinent to discuss the potential for CMA to reveal information concerning biological parentage or predisposition to late-onset disease, in a hypothetical case. Many non-genetics professionals ordering CMA did not feel equipped to interpret the results for patients, and articulated needs for education and access to genetics professionals. This exploratory study highlights key challenges in the practice of genomic medicine, and identifies needs for education, disseminated practice guidelines, and access to genetics professionals, especially when dealing with uncertain or unexpected findings.

Implementation of genetics to personalize medicine

BACKGROUND

We stand on the verge of integrating individual genetic and genomic information into health care provision and maintenance to improve health, increase efficiency, and decrease costs. We are beginning to integrate information on inherited susceptibility, gene expression, and predicted pharmacogenomic response to refine our medical management.

OBJECTIVE

This article reviews the current utility of genetics and genomics in a wide array of clinical circumstances, considers the future applications, and defines some of the obstacles and potential solutions to clinical integration of genomic medicine.

METHODS

Using the search terms genetics, genomics, pharmacogenomics, newborn screening, long QT syndrome, BRCA1/BRCA2, maturity onset diabetes of youth, diabetes, hemochromatosis, coronary artery disease, copy number changes, genetic discrimination, and genetic education, the PubMed database was searched from January 2000 to March 2007 to identify pertinent articles. Search results were restricted to English-language and human studies.

RESULTS

Several areas of medicine have begun to incorporate genetics into clinical practice, including newborn screening and breast cancer risk stratification and treatment. Molecular genetic tests are, and will increasingly become, available for inherited arrhythmias, diabetes, cancer, coronary artery disease, and pharmacogenomics. However, there are many barriers to implementation, including the cost of testing, the genetic literacy of patients and health care providers, and concerns about genetic discrimination.

CONCLUSION

Genetics and genomics will be increasingly utilized in every field of medicine; however, health care providers and patients must have realistic expectations about its predictive power and current limitations.

Disclosures of Huntington disease risk within families: patterns of decision-making and implications

Patterns of disclosure of Huntington disease risk and genetic test results among family members are important, but have been underexplored. We interviewed 21 individuals in-depth - eight mutation-positive for HD, four mutation-negative, and nine not tested - for 2 hr each. Within families, critical questions arose of what, when, and to whom to disclose, and what to do post-disclosure. Interviewees wrestled with dilemmas of what to tell (e.g., suspicions vs. confirmed symptoms; initiation vs. completion of testing; partial vs. indirect information), how to disclose (e.g., planning in advance vs. "blurting out" information in arguments), and whether and how to tell extended family members. Questions arose of when to tell (i.e., to avoid disclosing "too early" or "too late"). Similarities and differences emerged related to types of relationships (e.g., parents telling offspring vs. offspring telling parents vs. siblings telling each other). Individuals often disclosed because of perceived duty to foster the health of their family members, enabling these others to pursue appropriate medical evaluation, if desired. Yet tensions arose because the information could burden these members, who also have rights to remain "in denial" if they wish and not discuss the topic or pursue testing. Post-disclosure, dilemmas emerged of whether and how much to encourage family members to pursue testing. These data shed important light on critical issues that have received little, if any, attention concerning what, how, and when disclosure occurs, and have key implications for at-risk individuals, genetic counselors, and other health care workers (HCWs), and for future research. At-risk individuals would benefit from considering these issues in advance. HCWs need to realize that these decisions are multi-faceted. Future research can explore whether, when, how, and how often HCWs raise these issues with individuals.

Communicating genetic information: a difficult challenge for future pediatricians

BACKGROUND

The role of the pediatrician as genetic counselor is ideal because pediatricians have medical knowledge and experience with genetic disorders (e.g. Down syndrome). Moreover, pediatricians can provide comprehensive care in a medical home to patients with genetic disorders. However, changes in the curriculum of the pediatric resident are necessary to address the future challenges of effectively communicating genetic information to patients. The objective of this study was to explore these challenges and make recommendations for training to adequately prepare pediatricians for their future role as genetic counselors.

METHODS

Three reviewers independently searched PubMed, OVID, and Medline databases to identify articles describing the challenges of communicating genetic information to patients, published from 1960 to December 2005. After the publications were identified and reviewed, four major areas of interest were identified in order to categorize the findings.

RESULTS

Twenty-five publications were identified during the literature search. From the review, the following categories were selected to organize the findings: (1) Inherent difficulties of communicating and comprehending genetic information; (2) Comprehension of genetic information by pediatricians; (3) Genetics training in residency programs; and (4) The effect of genetic information on the future role of pediatricians and potential legal implications.

CONCLUSION

Pediatricians and residents lack essential knowledge of genetics and communication skills for effective counseling of patients. The review indicated that successful communication of genetic information involves a number of important skills and considerations. It is likely that these skills and considerations are universally required for the communication of most complex specialized medical information. In the past, communication skills have not been considered a priority. Today, these skills have become a demanding professional and even legal obligation. However, the challenges involved in communicating complex medical information cannot be successfully addressed with universal, one-size-fits-all recommendations. Residency training programs require changes to adequately prepare future pediatricians for the growing challenge of communicating genetic information. Four important skills should be considered in the training of residents to improve the communication of complex information to patients. These skills are (1) discriminating, (2) understanding, (3) simplifying, and (4) explaining information.

[Diffusion of genetic testing in oncology: what criteria for regulation?]

Does gene testing indicate a switch from an histopathological to a molecular approach of human diseases ? Disease management in oncology is already improved by gene testing, at least for some specific cancers. It is however necessary to distinguish the analysis of genes specific to the tumour which gives clues about the fate of the tumours, from those unique to the patients, which gives clues about the future of the person. For the latter so-called germline mutations, wide scale gene-default screening would put pressure on resource allocation from the health care systems of developed countries. Currently the cost of detecting of 700 genes in the whole French population would exceed the whole health budget of the country for the next 10 years. Even if we can anticipate a dramatic decrease in the unit cost of these genetic tests in the future, their diffusion should not be controlled exclusively by technological and market forces. In this paper, we propose to discuss four main parameters for regulating these genetic tests, using as an archetypal example their application to cancer prevention and treatment: (1) which specific cancer disease is targeted by the test (prevalence, incidence, likelihood of cure with current therapeutics, number of years of life potentially saved...); (2) what are the characteristics of the genes tested and which level of evidence is required about the predictive value of the test; (3) what are the size and characteristics of the population who will be offered the test, and (4) which process and public control are necessary before market approval of the test and reimbursement of related expenditures by health care insurance schemes.

Guidelines for disclosing genetic information to family members: from development to use

This paper presents the existing legal frameworks, professional guidelines and other documents related to the conditions and extent of the disclosure of genetic information by physicians to at-risk family members. Although the duty of a physician regarding disclosure of genetic information to a patient's relatives has only been addressed by few legal cases, courts have found such a duty under some circumstances. Generally, disclosure should not be permitted without the patient's consent. Yet, due to the nature of genetic information, exceptions are foreseen, where treatment and prevention are available. This duty to warn a patient's relative is also supported by some professional and policy organizations that have addressed the issue. Practice guidelines with a communication and intervention plan are emerging, providing physicians with tools that allow them to assist patients in their communication with relatives without jeopardizing their professional liability. Since guidelines aim to improve the appropriateness of medical practice and consequently to better serve the interests of patients, it is important to determine to what degree they document the 'best practice' standards. Such an analysis is an essential step to evaluate the different approaches permitting the disclosure of genetic information to family members.

Should children and adolescents be tested for Huntington's disease? Attitudes of future lawyers and physicians in Switzerland

The objective of the study was to identify future lawyers' and physicians' views on testing children for Huntington's disease (HD) against parents' wishes. After receiving general information about HD, patient autonomy and confidentiality, law students and advanced medical students were shown an interview with a mother suffering from HD who is opposed to informing and testing her two children (aged 10 and 16) for HD. Students then filled out questionnaires concerning their agreement with testing. No significant differences were found between medical and law students or between students from different courses concerning the adolescent son. Three quarters of students thought that he should be told about his mother's disease, and 91% thought the adolescent son should have the opportunity of genetic testing for HD himself. However, significant differences were found concerning the 10-year old son, with 44% of law students and 30% of medical students in favour of testing the child for HD. Students raised some important ethical issues in their elective comments. In conclusion, we found highly positive attitudes towards informing a 16-year old of his mother's HD and offering to test him. These attitudes were not in tune with guidelines. Students did not consider several practical and ethical issues of genetic testing of children and adolescents. Specific education should ensure that attitudes are based on sufficiently detailed knowledge about all aspects of genetic testing of children to discourage pressures on persons at risk of HD.

[Identification and management of HNPCC syndrome (hereditary non polyposis colon cancer), hereditary predisposition to colorectal and endometrial adenocarcinomas]

BACKGROUND

The HNPCC syndrome (hereditary nonpolyposis colon cancer) is an inherited condition defined by clinical and genealogical information, known as Amsterdam criteria. In about 70% of cases, HNPCC syndrome is caused by germline mutations in MMR genes, leading to microsatellite instability of tumor DNA (MSI phenotype). Patients affected by the disease are at high risk for colorectal and endometrial carcinomas, but also for small intestine, urothelial, ovary, stomach and biliary tract carcinomas. HNPCC syndrome is responsible for 5% of colorectal cancers. Identification and management of this disease are part of a multidisciplinary procedure.

METHODS

Twelve experts have been mandated by the French Health Ministry to analyze and synthesize their consensus position, and the resulting document has been reviewed by an additional group of 4 independent experts.

MAIN RECOMMENDATIONS

The lack of sensitivity of Amsterdam criteria in recognizing patients carrying a MMR germline mutation led to an enlargement of these criteria for the recruitment of possible HNPCC patients, and to a 2-steps strategy, asking first for a tumor characterization according to MSI phenotype, especially in case of early-onset sporadic cases. The identification of germline MMR mutations has no major consequence on the cancer treatments, but influences markedly the long-term follow-up and the management of at-risk relatives. Gene carriers will enter a follow-up program regarding their colorectal and endometrial cancer risks, but other organs being at low lifetime risk, no specific surveillance will be proposed.

Ethical issues in the use of genetic information in the workplace: a review of recent developments

PURPOSE OF REVIEW

In the wake of the Human Genome Project, the pace of genetic discovery has quickened. New genetic tests and other molecular technology have had immediate and wide relevance to American and European workers. These tests have the potential to provide improved workplace safety and protect workers' health, but they also carry the risk of genetic discrimination including loss of employment, promotion, insurance and health care. Ethical safeguards are necessary if the benefits are to outweigh the adverse consequences of genetics in the workplace.

RECENT FINDINGS

This review examines the major policy statements issued in Europe and the USA from 2000 to 2005 pertaining to genetic issues in occupational health. Recent findings stress that genetic testing can only be utilized with worker consent and that the workers should control access to genetic information. Such testing is only justified when the information is required to protect the safety of the worker or a third party. The progress of occupational genetic technology should not be permitted to shift the responsibility for a safe working environment from the employer to the employee. Genetic discrimination in all forms is neither supported scientifically nor warranted ethically.

SUMMARY

Increasingly, occupational physicians and clinicians treating workers will be faced with potentially stigmatizing genetic information and there is an urgent need for education and research to expand and implement the recommendations of major governmental and professional policy statements.

To tell or not to tell: barriers and facilitators in family communication about genetic risk

Communication about genetic risk in families is an important issue for genetic counsellors. The objective of this study was to explore the barriers and facilitators in family communication about genetic risk. Semi-structured interviews were undertaken with patients in the Northeast of Scotland who had attended genetic counselling for risk of hereditary breast and ovarian cancer and Huntington's disease, and with some spouses/partners. The interviews confirmed that the issue of disclosure was a problem for some, and that there were generic communication issues common to both groups. Telling family members about genetic risk was generally seen as a family responsibility and family structures, dynamics and 'rules' influenced disclosure decisions. A sense of responsibility towards younger generations was also important. The level of certainty felt by a person in relation to his or her own risk estimate also influenced what he or she could tell other family members. Communication within a family about genetic risk is a complex issue and is influenced by both pre-existing familial and cultural factors and individuals' responses to risk information. If genetic counsellors understood how these factors operate in individual families they might be able to identify effective strategies to promote considered decisions and prevent unnecessary emotional distress.

Huntington's disease: do future physicians and lawyers think eugenically?

The availability of presymptomatic and prenatal genetic tests could give rise to societal pressures on persons at risk for Huntington's disease (HD). The objective of this study was to identify future lawyers' and physicians' views on eugenics and genetic testing for HD. Five-hundred and ninety-nine Swiss law students and advanced medical students from 11 courses received teaching about HD and patient autonomy. They filled out questionnaires after having seen an audio/video recording of an interview with an HD mutation carrier. Participation rates were 68-97%. Attitudes of future lawyers and physicians were significantly different for most questions: 73.2% of law students vs 39.4% of medical students agreed that society should do everything possible to diminish the frequency of HD, including non-governmental pressure on carriers to undergo systematic genetic testing and recommendation of sterilization; 94% of all students agreed to the systematic proposal of prenatal testing to all women at risk; and 83.4% of medical students, but only 40.3% of law students, agreed that the wishes of a person at risk not to have her/himself and future children tested must be entirely respected. More education is needed to discourage eugenic pressures and discrimination of persons at risk of HD and other genetic diseases.

Medical Geneticists' duty to warn at-risk relatives for genetic disease

A patient who refuses to notify their relatives of potential at-risk status brings a genetics provider to face conflicting ethical principles and ill-defined legal precedent. Genetics professionals' views on the disclosure of patient information to at-risk relatives have remained largely unexamined. Prior analyses have been limited to identifying factors contributing to genetics providers' self-predicted responses in hypothetical scenarios. Our group was the first to examine the clinical experience of genetic counselors with this issue [Dugan et al., 2003]. We report here results from our follow-up survey of medical geneticists who are members of either the American Society of Human Genetics and/or American College of Medical Genetics in an effort to identify their experiences in warning at-risk relatives and the factors driving their decision-making processes. Over two-thirds of medical geneticists surveyed (69%, 143/206) believe they do bear responsibility to warn their patients' relatives when found to be at-risk for genetic disease. One-quarter (25%, 31/123) of medical geneticists who faced the dilemma of a patient refusing to notify their at-risk relatives seriously considered disclosure to those at-risk relatives without patient consent. Only four respondents proceeded to warn at-risk relatives of their status. Whereas genetic counselors cited emotional issues as playing a primary role in their decision not to warn, medical geneticists identified patient confidentiality, eventual case resolution by other means, and legal liability as the major factors leading to non-disclosure in 76% of actual scenarios. Responsibilities of medical geneticists, genetic counselors, and non-genetics healthcare professionals facing this issue will need to be more clearly defined to provide optimal medical care within the bounds of acceptable practice.

Duty to warn at-risk relatives for genetic disease: genetic counselors' clinical experience

When a patient refuses to inform relatives of their risk for genetic disease, the genetic healthcare professional is faced with conflicting ethical obligations. On one side of the issue is the obligation to respect and protect patients' right to privacy. On the other side is the obligation to prevent harm and promote the welfare of the family members, which suggests a responsibility to warn at-risk relatives, even without the patient's consent. In an effort to examine the actual clinical impact of this issue, we conducted a pilot study that explored genetic counselors' experience with this conflict. A survey was developed and made available to members of the National Society of Genetic Counselors. Questions were either multiple-choice responses or open-ended. Almost half of respondents (119/259; 46%) had had a patient refuse to notify an at-risk relative. The most commonly cited reasons for refusal were estranged family relationships, altering family dynamics, insurance discrimination, and employment discrimination, respectively. Of these 119 counselors, 24 (21%) reported that they seriously considered warning the at-risk relatives without patient consent, and one actually did disclose. Three factors consistently made the counselors less likely to disclose: their patient's potential emotional reaction, the relationship between the relative and patient, and the chance that the relative could be aware of the disease by another means. These results suggest that while the conflict is often encountered in clinical practice, it is rare that the situation remains unresolved to the extent that genetic counselors actually consider warning at-risk relatives. However, when the situation was encountered, the counselors in this study reported a lower rate of disclosure without consent than would have been anticipated based on previous studies that used hypothetical situations. It may be that counselors do not recognize a duty to warn at-risk relatives as integral to their role and professional obligations.

Empowering primary care health professionals in medical genetics: how soon? How fast? How far?

Applications of genetics to the practices of medicine and public health are important today and will only become more compelling as our understanding of the human genome evolves. Because of a perceived lack of medical genetics professionals, it is generally believed that primary health care providers (PCPs) will need to assume prominent roles in delivering clinical genetics services. However, a number of studies indicate that most PCPs are neither well enough educated in genetics nor interested enough in becoming so to effectively contribute. Those who advocate empowering PCPs must be aware of potential problems with any approach thus far suggested for achieving this goal. Moreover, any analysis of this model must consider the potential ramifications for medical genetics professionals, patients, and families. In this article, we explore some of the unique features of the culture of medical genetics services and service providers. We discuss how important this culture is to clinical outcomes and the likelihood that its positive attributes would be preserved in a PCP model of medical genetics service delivery.

Disclosure of Huntington's disease to family members: the dilemma of known but unknowing parties

Predictive genetic testing presents unique issues in the legal and ethical debate concerning disclosure of information within the physician-patient relationship. A duty to disclose information to family members has been found when the disclosure is likely to result in the ability to mitigate the damaging effects of the disease. When evaluating the situation where a individual is at risk of Huntington's disease, the analysis must be different, as shown in this paper, and necessitates an ethical and legal examination of the consequences of receipt of the information on family members, those known but unknowing parties who are at risk of inheriting a genetic disease. This paper analyzes the potential legal duty of a physician to disclose or withhold genetic information from the family members of patients. Existing statutes governing genetic information do not directly address the interests of family members. Courts that have ruled on the duty to disclose medical or genetic information have analyzed these issues using traditional concepts of tort law. Yet the situation presented by Huntington's disease is unique and demands a different framework for analysis, given the late onset and lack of curative or ameliorative treatment. This paper also analyzes the ethical standards to be invoked when considering violating the privacy of a patient or a family member. The principles of autonomy and self-determination of family members are considered, versus the risk of harm and the privacy interest in not knowing potentially devastating information.

Uptake of hereditary breast/ovarian cancer genetic testing in a French national sample of BRCA1 families. The French Cancer Genetic Network

Due to the technical difficulties involved in identifying BRCA1/2 genetic mutations, the affected patients have to be investigated before testing can be made available to all the relatives at risk. Here, we studied the attendance rates at cancer genetic clinics (CGC) and the uptake of genetic testing in first/second degree relatives after the first BRCA1 mutated woman with cancer had been informed in the family. We carried out a survey on French cancer geneticists involved in breast/ovarian CGC, asking them to select their first three BRCA1 family records. Data collection was carried out retrospectively by telephone interview with a standardised closed item questionnaire. Considering only those families (n = 37) where the index case had been informed for at least 8 months at the time of the survey, the overall attendance at CGC of first/second degree relatives (n = 419) was 31.7% (n = 133) and the overall uptake of BRCA1 testing was 26.7% (n = 112). Among those who attended the CGC (n = 133), 84.2% (n = 112) requested genetic testing (95% confidence interval: 78-90.4%). Among the first degree relatives, the unaffected women who attended accounted for 59.8% and 51.2% requested testing after the index case had been informed. Women with cancer had a higher attendance rate (83.3%) than unaffected women (36.1%) (Odds Ratio (OR) = 8.86; p < 0.001) and first degree relatives (51.4%) than second degree relatives (17.9%) (OR = 2.87; p < 0.001); women (43%) also attended more frequently than men (16%) (OR = 3.97, p < 0.001). In French BRCA1 mutated families, female first degree relatives of the index patient show the most interest in genetic testing.

Disclosure to the family of breast/ovarian cancer genetic test results: patient's willingness and associated factors

Informed probands are key actors for disclosing genetic information to their relatives when a mutation has been identified in the family. The objectives were to study women's attitudes towards the family disclosure of positive breast cancer genetic testing results and to determine the predictive factors of the diffusion patterns observed. A national multi-center cross-sectional survey was carried out at five French cancer genetic clinics during a 1-year period. Self-administered questionnaires were completed after the consultation by 84.5% (398/471) of women attending breast cancer genetic clinics for the first time. Among the 383 respondents who had at least one living first-degree relative to inform, 8.6% would inform none, 33.2% would inform at least one of them, and 58.2% would inform all of them. The sibship would be the most frequently informed blood relatives, sisters in 86.9% and brothers in 79% compared with mother in 71.4%, children in 70.4%, and father in 64.9%. Women of the family would be more frequently informed than men (P < 0.05). After multivariate adjustment, age, the fact to be affected by cancer, the number of daughters, and the emotional disturbance due to cancer in a close relationship were the main determinants (P < 0.05) of the diffusion patterns observed. The first step of the relatives' attendance to genetic counseling and the proband's willingness to disclose breast cancer genetic tests results was high in this study and was clearly dependent on the women's personal and emotional characteristics.