1
|
Lyle K, Weller S, Samuel G, Lucassen AM. Beyond regulatory approaches to ethics: making space for ethical preparedness in healthcare research. J Med Ethics 2023; 49:352-356. [PMID: 35725300 PMCID: PMC10176337 DOI: 10.1136/medethics-2021-108102] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 05/23/2022] [Indexed: 05/14/2023]
Abstract
Centralised, compliance-focused approaches to research ethics have been normalised in practice. In this paper, we argue that the dominance of such systems has been driven by neoliberal approaches to governance, where the focus on controlling and individualising risk has led to an overemphasis of decontextualised ethical principles and the conflation of ethical requirements with the documentation of 'informed consent'. Using a UK-based case study, involving a point-of-care-genetic test as an illustration, we argue that rather than ensuring ethical practice such compliance-focused approaches may obstruct valuable research. We call for an approach that encourages researchers and research communities-including regulators, ethics committees, funders and publishers of academic research-to acquire skills to make morally appropriate decisions, and not base decision-making solely on compliance with prescriptive regulations. We call this 'ethical preparedness' and outline how a research ethics system might make space for this approach.
Collapse
Affiliation(s)
- Kate Lyle
- Clinical Ethics, Law and Society (CELS), Wellcome Centre for Human Genetics, University of Oxford, Oxford, UK
- Clinical Ethics, Law and Society (CELS), Primary Care, Population Sciences and Medical Education, University of Southampton Faculty of Medicine, Southampton, UK
| | - Susie Weller
- Clinical Ethics, Law and Society (CELS), Wellcome Centre for Human Genetics, University of Oxford, Oxford, UK
- Clinical Ethics, Law and Society (CELS), Primary Care, Population Sciences and Medical Education, University of Southampton Faculty of Medicine, Southampton, UK
| | - Gabby Samuel
- Clinical Ethics, Law and Society (CELS), Wellcome Centre for Human Genetics, University of Oxford, Oxford, UK
- Global Health and Social Medicine, King's College London, Strand, UK
| | - Anneke M Lucassen
- Clinical Ethics, Law and Society (CELS), Wellcome Centre for Human Genetics, University of Oxford, Oxford, UK
- Clinical Ethics, Law and Society (CELS), Primary Care, Population Sciences and Medical Education, University of Southampton Faculty of Medicine, Southampton, UK
- Centre for Personalised Medicine, University of Oxford, Oxford, UK
| |
Collapse
|
2
|
McDermott JH, Sharma V, Keen J, Newman WG, Pirmohamed M. The Implementation of Pharmacogenetics in the United Kingdom. Handb Exp Pharmacol 2023; 280:3-32. [PMID: 37306816 DOI: 10.1007/164_2023_658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
There is considerable inter-individual variability in the effectiveness and safety of pharmaceutical interventions. This phenomenon can be attributed to a multitude of factors; however, it is widely acknowledged that common genetic variation affecting drug absorption or metabolism play a substantial contributory role. This is a concept known as pharmacogenetics. Understanding how common genetic variants influence responses to medications, and using this knowledge to inform prescribing practice, could yield significant advantages for both patients and healthcare systems. Some health services around the world have introduced pharmacogenetics into routine practice, whereas others are less advanced along the implementation pathway. This chapter introduces the field of pharmacogenetics, the existing body of evidence, and discusses barriers to implementation. The chapter will specifically focus on efforts to introduce pharmacogenetics in the NHS, highlighting key challenges related to scale, informatics, and education.
Collapse
Affiliation(s)
- John H McDermott
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Evolution and Genomic Sciences, School of Biological Sciences, University of Manchester, Manchester, UK
| | - Videha Sharma
- Division of Informatics, Imaging and Data Science, Centre for Health Informatics, The University of Manchester, Manchester, UK
| | - Jessica Keen
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - William G Newman
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Evolution and Genomic Sciences, School of Biological Sciences, University of Manchester, Manchester, UK
| | - Munir Pirmohamed
- Department of Pharmacology and Therapeutics, Wolfson Centre for Personalised Medicine, University of Liverpool, Liverpool, UK.
- Liverpool University Hospital Foundation NHS Trust, Liverpool, UK.
| |
Collapse
|
3
|
Affiliation(s)
- John H McDermott
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University National Health Service Foundation Trust, Manchester, United Kingdom
| | - William G Newman
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University National Health Service Foundation Trust, Manchester, United Kingdom
| |
Collapse
|
4
|
McDermott JH, Mahaveer A, James RA, Booth N, Turner M, Harvey KE, Miele G, Beaman GM, Stoddard DC, Tricker K, Corry RJ, Garlick J, Ainsworth S, Beevers T, Bruce IA, Body R, Ulph F, MacLeod R, Roberts PL, Wilson PM, Newman WG. Rapid Point-of-Care Genotyping to Avoid Aminoglycoside-Induced Ototoxicity in Neonatal Intensive Care. JAMA Pediatr 2022; 176:486-492. [PMID: 35311942 PMCID: PMC8938898 DOI: 10.1001/jamapediatrics.2022.0187] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance Aminoglycosides are commonly prescribed antibiotics used for the treatment of neonatal sepsis. The MT-RNR1 m.1555A>G variant predisposes to profound aminoglycoside-induced ototoxicity (AIO). Current genotyping approaches take several days, which is unfeasible in acute settings. Objective To develop a rapid point-of-care test (POCT) for the m.1555A>G variant before implementation of this technology in the acute neonatal setting to guide antibiotic prescribing and avoid AIO. Design, Setting, and Participants This pragmatic prospective implementation trial recruited neonates admitted to 2 large neonatal intensive care units between January 6, 2020, and November 30, 2020, in the UK. Interventions Neonates were tested for the m.1555A>G variant via the rapid POCT on admission to the neonatal intensive care unit. Main Outcomes and Measures The primary outcome assessed the proportion of neonates successfully tested for the variant of all infants prescribed antibiotics. Secondary outcomes measured whether implementation was negatively associated with routine clinical practice and the performance of the system. The study was statistically powered to detect a significant difference between time to antibiotic administration before and after implementation of the MT-RNR1 POCT. Results A total of 751 neonates were recruited and had a median (range) age of 2.5 (0-198) days. The MT-RNR1 POCT was able to genotype the m.1555A>G variant in 26 minutes. Preclinical validation demonstrated a 100% sensitivity (95% CI, 93.9%-100.0%) and specificity (95% CI, 98.5%-100.0%). Three participants with the m.1555A>G variant were identified, all of whom avoided aminoglycoside antibiotics. Overall, 424 infants (80.6%) receiving antibiotics were successfully tested for the variant, and the mean time to antibiotics was equivalent to previous practice. Conclusions and Relevance The MT-RNR1 POCT was integrated without disrupting normal clinical practice, and genotype was used to guide antibiotic prescription and avoid AIO. This approach identified the m.1555A>G variant in a practice-changing time frame, and wide adoption could significantly reduce the burden of AIO.
Collapse
Affiliation(s)
- John H McDermott
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom.,School of Biological Sciences, Division of Evolution, Infection and Genomics, University of Manchester, Manchester, United Kingdom
| | - Ajit Mahaveer
- Newborn Intensive Care Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Rachel A James
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Nicola Booth
- Newborn Intensive Care Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Mark Turner
- Newborn Intensive Care Unit, Liverpool Women's Hospital, Liverpool, United Kingdom
| | - Karen E Harvey
- Newborn Intensive Care Unit, Liverpool Women's Hospital, Liverpool, United Kingdom
| | - Gino Miele
- Genedrive Diagnostics Ltd, Manchester, United Kingdom
| | - Glenda M Beaman
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom.,School of Biological Sciences, Division of Evolution, Infection and Genomics, University of Manchester, Manchester, United Kingdom
| | - Duncan C Stoddard
- DS Analytics and Machine Learning Ltd, Hammersmith, London, United Kingdom
| | - Karen Tricker
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Rachel J Corry
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Julia Garlick
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | | | | | - Iain A Bruce
- Hearing Health Theme Manchester NIHR Biomedical Research Centre, Manchester, United Kingdom.,Pediatric ENT Department, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Richard Body
- Emergency Department, Manchester University NHS Foundation Trust, Manchester, United Kingdom.,Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
| | - Fiona Ulph
- Manchester Centre for Health Psychology, Division of Psychology & Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Rhona MacLeod
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom.,School of Biological Sciences, Division of Evolution, Infection and Genomics, University of Manchester, Manchester, United Kingdom
| | - Peter L Roberts
- Market Access & Reimbursement Solutions Ltd, Liverpool, Merseyside, United Kingdom
| | - Paul M Wilson
- Alliance Manchester Business School, University of Manchester, Manchester, United Kingdom
| | - William G Newman
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom.,School of Biological Sciences, Division of Evolution, Infection and Genomics, University of Manchester, Manchester, United Kingdom
| | | |
Collapse
|
5
|
McDermott JH, Mahood R, Stoddard D, Mahaveer A, Turner MA, Corry R, Garlick J, Miele G, Ainsworth S, Kemp L, Bruce I, Body R, Ulph F, Macleod R, Harvey K, Booth N, Roberts P, Wilson P, Newman WG. Pharmacogenetics to Avoid Loss of Hearing (PALOH) trial: a protocol for a prospective observational implementation trial. BMJ Open 2021; 11:e044457. [PMID: 34135034 PMCID: PMC8211036 DOI: 10.1136/bmjopen-2020-044457] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION In conjunction with a beta-lactam, aminoglycosides are the first-choice antibiotic for empirical treatment of sepsis in the neonatal period. The m.1555A>G variant predisposes to ototoxicity after aminoglycoside administration and has a prevalence of 1 in 500. Current genetic testing can take over 24 hours, an unacceptable delay in the acute setting. This prospective-observational trial will implement a rapid point of care test (POCT), facilitating tailored antibiotic prescribing to avoid hearing loss. METHODS AND ANALYSIS The genedrive POCT can detect the m.1555A>G variant in 26 min from buccal swab. This system will be integrated into the clinical pathways at two large UK neonatal centres over a minimum 6-month period. The primary outcome is the number of neonates successfully tested for the variant out of all babies prescribed antibiotics. As a secondary outcome, clinical timings will be compared with data collected prior to implementation, measuring the impact on routine practice. ETHICS AND DISSEMINATION Approval for the trial was granted by the Research Ethics Committee (REC) and Human Research Authority in August 2019. Results will be published in full on completion of the study. TRIAL REGISTRATION NUMBER ISRCTN13704894. PROTOCOL VERSION V 1.3.
Collapse
Affiliation(s)
- John Henry McDermott
- Manchester Centre for Genomic Medicine, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Evolution and Genomic Sciences, The University of Manchester, Manchester, UK
| | - Rachel Mahood
- Manchester Centre for Genomic Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - Duncan Stoddard
- Manchester Centre for Genomic Medicine, Manchester University NHS Foundation Trust, Manchester, UK
- DS Analytics and Machine Learning Ltd, London, UK
| | - Ajit Mahaveer
- Neonatal Intensive Care Unit, Manchester University NHS Foundation Trust, Manchester, UK
| | - Mark A Turner
- Neonatal Intensive Care Unit, Liverpool Women's Hospital NHS Foundation Trust, Liverpool, UK
| | - Rachel Corry
- Manchester Centre for Genomic Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - Julia Garlick
- Manchester Centre for Genomic Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | | | | | | | - Iain Bruce
- Paediatric ENT Department, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Richard Body
- Emergency Department, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, Manchester, UK
| | - Fiona Ulph
- Division of Psychology & Mental Health, University of Manchester, Manchester, UK
| | - Rhona Macleod
- Manchester Centre for Genomic Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - Karen Harvey
- Neonatal Intensive Care Unit, Liverpool Women's Hospital NHS Foundation Trust, Liverpool, UK
| | - Nicola Booth
- Neonatal Intensive Care Unit, Manchester University NHS Foundation Trust, Manchester, UK
| | - Peter Roberts
- Market Access & Reimbursement Solutions, Manchester, UK
| | - Paul Wilson
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - William G Newman
- Manchester Centre for Genomic Medicine, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Evolution and Genomic Sciences, The University of Manchester, Manchester, UK
| |
Collapse
|
6
|
Lucassen AM, McDermott JH, Newman W. Using a biomarker acutely to identify babies at risk of serious adverse effects from antibiotics: where is the 'Terrible Moral and Medical Dilemma'? J Med Ethics 2021; 47:117-118. [PMID: 33335072 DOI: 10.1136/medethics-2020-107048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 11/24/2020] [Accepted: 11/29/2020] [Indexed: 06/12/2023]
Abstract
We thank Parker and Wright for engaging in this roundtable debate in such a spirited way. The 'Pharmacogenetic [test] to Avoid Loss of Hearing' (PALOH) Trial is the first time a genetic point of care test has been applied in the acute neonatal setting; therefore, it is not surprising that questions have been raised which require debate, discussion and clarification. Parker and Wright misattribute several assumptions to the roundtable authors, which we would like to clarify here. Since they raise wider questions about the PALOH trial itself, several of the roundtable discussants have made a joint response.
Collapse
Affiliation(s)
| | - John Henry McDermott
- Manchester Centre for Genomic Medicine, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Evolution & Genomic Sciences, University of Manchester, Manchester, UK
| | - William Newman
- Manchester Centre for Genomic Medicine, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Evolution & Genomic Sciences, University of Manchester, Manchester, UK
| |
Collapse
|
7
|
Parker J, Wright D. Terrible choices in the septic child: a response to the PALOH trial round table authors. J Med Ethics 2021; 47:114-116. [PMID: 33208480 DOI: 10.1136/medethics-2020-106807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/05/2020] [Accepted: 10/13/2020] [Indexed: 06/11/2023]
Abstract
In this response article, we challenge a core assumption that lies at the centre of a round table discussion regarding the Pharmacogenetics to Avoid Loss of Hearing trial. The round table regards a genetic test for a variant (mt.1555A>G) that increases the risk of deafness if a carrier is given the antibiotic gentamicin. The idea is that rapid testing can identify neonates at risk, providing an opportunity to prevent giving an antibiotic that might cause deafness. We challenge the assumption that a positive test unequivocally guides antibiotic choice because, aside from the risk of deafness, all antibiotics for neonatal sepsis are equivalent. We argue that this assumption is faulty and has particularly troubling moral consequences. We claim that giving an alternative to gentamicin is potentially providing inferior treatment and thereby may increase the risk of death. Parents and doctors are faced with a terrible choice as a result of positive point-of-care testing (POCT): give gold-standard treatment and risk deafness or give second line care and risk death. While we do not indicate an answer to this choice, what we do argue is that such a deep and difficult choice is one that may make parents wish genetic testing was never undertaken, and therefore, contra some authors in the round table, provides a reason to gain specific consent for POCT.
Collapse
Affiliation(s)
- Joshua Parker
- Medicine, Wythenshawe Hospital Education and Research Centre, Manchester, UK
| | - David Wright
- Paediatrics, Macclesfield District General Hospital, Macclesfield, Cheshire East, UK
| |
Collapse
|
8
|
Coulson-Smith P, Lucassen A. Using biomarkers in acute medicine to prevent hearing loss: should this require specific consent? J Med Ethics 2020; 46:536-537. [PMID: 32661073 PMCID: PMC7418599 DOI: 10.1136/medethics-2020-106106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 03/11/2020] [Indexed: 05/06/2023]
Affiliation(s)
- Peta Coulson-Smith
- Clinical Ethics and Law Southampton (CELS), Faculty of Medicine, University of Southampton, Southampton, UK
| | - Anneke Lucassen
- Clinical Ethics and Law Southampton (CELS), Faculty of Medicine, University of Southampton, Southampton, UK
| |
Collapse
|
9
|
Boyd K. Explanatory frameworks and managing randomness. J Med Ethics 2020; 46:493-494. [PMID: 32723775 DOI: 10.1136/medethics-2020-106673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Kenneth Boyd
- Biomedical Teaching Organisation, Edinburgh University, Edinburgh EH89AG, UK
| |
Collapse
|