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Abstract
Many neurogenetic conditions are inherited and therefore diagnosis of a patient will have implications for the patient's relatives and can raise ethical issues. Predictive genetic testing offers asymptomatic relatives the opportunity to determine their risk status for a neurogenetic condition, and professional guidelines emphasize patients' autonomy and informed, voluntary decision making. Beneficence and nonmaleficence both need to be considered when making decisions about disclosure and nondisclosure of genetic information and test results. There can be disclosure concerns and challenges in determining whose autonomy to prioritize when a patient makes a genetic testing decision that can reveal the genetic status of a relative (e.g., testing an adult child when the at-risk parent has not been tested). Ethical issues are prominent when genetic testing for neurogenetic conditions is requested prenatally, on minors, adoptees, adult children at 25% risk, and for individuals with psychiatric issues or cognitive impairment. Neurogenetic conditions can result in cognitive decline which can affect decisional capacity and lead to ethical challenges with decision making, informed consent, and determining the patient's ability to comprehend test results. The ethical implications of genetic testing and emerging issues, including direct-to-consumer genetic testing, disclosure of secondary findings from genomic sequencing, and use of apolipoprotein E testing in clinical and research settings, are also discussed. Resources for information about genetic testing practice guidelines, insurance laws, and directories of genetics clinics are included.
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Affiliation(s)
- Wendy R Uhlmann
- Departments of Internal Medicine and Human Genetics, University of Michigan Medical School, Ann Arbor, MI, United States; Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, Ann Arbor, MI, United States.
| | - J Scott Roberts
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, United States; Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, Ann Arbor, MI, United States
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Abstract
The clinical integration of prenatal genetic technologies raises a series of important medical and ethical considerations for patients, families, health care providers, health care systems, and society. It is critical to recognize, understand, and address these issues in conjunction with the continued development of new prenatal genetic screens and tests. This article discusses some of the lead ethical issues as a starting point to further understanding their ramifications on patients, families, communities, and health care providers.
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Cowley L. What can we Learn from Patients' Ethical Thinking about the right 'not to know' in Genomics? Lessons from Cancer Genetic Testing for Genetic Counselling. BIOETHICS 2016; 30:628-35. [PMID: 27523581 PMCID: PMC5031190 DOI: 10.1111/bioe.12272] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 03/12/2016] [Accepted: 05/25/2016] [Indexed: 06/06/2023]
Abstract
This article is based on a qualitative empirical project about a distinct kinship group who were among the first identified internationally as having a genetic susceptibility to cancer (Lynch Syndrome). 50 were invited to participate (42 were tested; eight declined genetic testing). 15, who had all accepted testing, were interviewed. They form a unique case study. This study aimed to explore interviewees' experiences of genetic testing and how these influenced their family relationships. A key finding was that participants framed the decision to be tested as 'common sense'; the idea of choice around the decision was negated and replaced by a moral imperative to be tested. Those who did not follow 'common sense' were judged to be imprudent. Family members who declined testing were discussed negatively by participants. The article addresses what is ethically problematic about how test decliners were discussed and whether these ethical concerns extend to others who are offered genetic testing. Discussions showed that genetic testing was viewed as both an autonomous choice and a responsibility. Yet the apparent conflict between the right to autonomy and the moral imperative of responsibility allowed participants to defend test decliners' decisions by expressing a preference for or defending choice over responsibility. The 'right not to know' seemed an important moral construct to help ethically manage unpopular decisions made by close family who declined testing. In light of this research, the erosion of the 'right not to know' in the genomic age could have subtle yet profound consequences for family relationships.
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Hofmann B. Incidental findings of uncertain significance: To know or not to know--that is not the question. BMC Med Ethics 2016; 17:13. [PMID: 26873084 PMCID: PMC4752786 DOI: 10.1186/s12910-016-0096-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 02/04/2016] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Although the "right not to know" is well established in international regulations, it has been heavily debated. Ubiquitous results from extended exome and genome analysis have challenged the right not to know. American College of Medical Genetics and Genomics (ACMG) Recommendations urge to inform about incidental findings that pretend to be accurate and actionable. However, ample clinical cases raise the question whether these criteria are met. Many incidental findings are of uncertain significance (IFUS). The eager to feedback information appears to enter the field of IFUS and thereby threaten the right not to know. This makes it imperative to investigate the arguments for and against a right not to know for IFUS. DISCUSSION This article investigates how the various arguments for and against a right not to know hold for IFUS. The main investigated arguments are: hypothetical utilitarianism, the right-based argument, the feasibility argument, the value of knowledge argument, the argument from lost significance, the empirical argument, the duty to disclose argument, the avoiding harm argument; the argument from principle, from autonomy, from privacy, as well as the argument from the right to an open future. The analysis shows that both sides in the debate have exaggerated the importance of incidental findings. Opponents of a right not to know have exaggerated the importance of IFUS, while proponents have exaggerated the need to be protected from something that is not knowledge. Hence, to know or not to know is not the question. The question is whether we should be able to stay ignorant of incidental findings of uncertain significance, if we want to. The answer is yes: As long as the information is not accurate and/or actionable: ignorance is bliss. When answering questions that are not asked, we need to think twice.
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Affiliation(s)
- Bjørn Hofmann
- Norwegian University of Science and Technology, Gjøvik, Norway. .,Centre for Medical Ethics, University of Oslo, PO Box 1130, Blindern, N-0318, Oslo, Norway.
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Sandford E, Burmeister M. Genes and genetic testing in hereditary ataxias. Genes (Basel) 2014; 5:586-603. [PMID: 25055202 PMCID: PMC4198919 DOI: 10.3390/genes5030586] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 06/25/2014] [Accepted: 07/01/2014] [Indexed: 12/19/2022] Open
Abstract
Ataxia is a neurological cerebellar disorder characterized by loss of coordination during muscle movements affecting walking, vision, and speech. Genetic ataxias are very heterogeneous, with causative variants reported in over 50 genes, which can be inherited in classical dominant, recessive, X-linked, or mitochondrial fashion. A common mechanism of dominant ataxias is repeat expansions, where increasing lengths of repeated DNA sequences result in non-functional proteins that accumulate in the body causing disease. Greater understanding of all ataxia genes has helped identify several different pathways, such as DNA repair, ubiquitination, and ion transport, which can be used to help further identify new genes and potential treatments. Testing for the most common mutations in these genes is now clinically routine to help with prognosis and treatment decisions, but next generation sequencing will revolutionize how genetic testing will be done. Despite the large number of known ataxia causing genes, however, many individuals with ataxia are unable to obtain a genetic diagnosis, suggesting that more genes need to be discovered. Utilization of next generation sequencing technologies, expression studies, and increased knowledge of ataxia pathways will aid in the identification of new ataxia genes.
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Affiliation(s)
- Erin Sandford
- Molecular & Behavioral Neuroscience Institute, University of Michigan, Ann Arbor, MI 48109, USA.
| | - Margit Burmeister
- Molecular & Behavioral Neuroscience Institute, University of Michigan, Ann Arbor, MI 48109, USA.
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Wedderburn S, Panegyres PK, Andrew S, Goldblatt J, Liebeck T, McGrath F, Wiltshire M, Pestell C, Lee J, Beilby J. Predictive gene testing for Huntington disease and other neurodegenerative disorders. Intern Med J 2013; 43:1272-9. [DOI: 10.1111/imj.12176] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Accepted: 03/18/2013] [Indexed: 11/26/2022]
Affiliation(s)
- S. Wedderburn
- Western Australian Department of Health; Neurosciences Unit; Perth Western Australia Australia
| | - P. K. Panegyres
- Western Australian Department of Health; Neurosciences Unit; Perth Western Australia Australia
- Neurodegenerative Disorders Research Pty Ltd; Perth Western Australia Australia
| | - S. Andrew
- Western Australian Department of Health; Neurosciences Unit; Perth Western Australia Australia
| | - J. Goldblatt
- King Edward Memorial Hospital; Perth Western Australia Australia
| | - T. Liebeck
- Western Australian Department of Health; Neurosciences Unit; Perth Western Australia Australia
| | - F. McGrath
- Western Australian Department of Health; Neurosciences Unit; Perth Western Australia Australia
| | - M. Wiltshire
- Western Australian Department of Health; Neurosciences Unit; Perth Western Australia Australia
| | - C. Pestell
- Western Australian Department of Health; Neurosciences Unit; Perth Western Australia Australia
| | - J. Lee
- Western Australian Department of Health; Neurosciences Unit; Perth Western Australia Australia
| | - J. Beilby
- Molecular Genetics; PathWest; Queen Elizabeth Medical Centre; Perth Western Australia Australia
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Bui TH, Raymond FL, Van den Veyver IB. Current controversies in prenatal diagnosis 2: should incidental findings arising from prenatal testing always be reported to patients? Prenat Diagn 2013; 34:12-7. [PMID: 24214820 DOI: 10.1002/pd.4275] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 10/29/2013] [Accepted: 10/29/2013] [Indexed: 01/15/2023]
Affiliation(s)
- The-Hung Bui
- The Karolinska Institute, Center for Molecular Medicine, Clinical Genetics Unit and Center for Fetal Medicine, Karolinska University Hospital, Stockholm, Sweden
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Cruz-Mariño T, Velázquez-Pérez L, González-Zaldivar Y, Aguilera-Rodríguez R, Velázquez-Santos M, Vázquez-Mojena Y, Estupiñán-Rodríguez A, Reynaldo-Armiñán R, Almaguer-Mederos LE, Laffita-Mesa JM, Tamayo-Chiang V, Paneque M. Couples at risk for spinocerebellar ataxia type 2: the Cuban prenatal diagnosis experience. J Community Genet 2013; 4:451-60. [PMID: 23673432 DOI: 10.1007/s12687-013-0147-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 05/03/2013] [Indexed: 12/19/2022] Open
Abstract
Cuba reports the highest worldwide prevalence of spinocerebellar ataxia type 2 (SCA2) and the greatest number of descendants at risk. A protocol for genetic counseling, presymptomatic testing, and prenatal diagnosis of hereditary ataxias has been under development since 2001. Considering that the revision of the experience with prenatal diagnosis for SCA2 in Cuba would enable comparison of ours with international findings, we designed a descriptive study, based on the retrospective revision of the medical records belonging to the 58 couples that requested their inclusion in the program, during an 11-year period (2001-2011). Most of the participants in the prenatal diagnosis program were known presymptomatic carriers, diagnosed through the presymptomatic testing in the same period of study, for an uptake among them of 22.87 % (51 out of 223). In 28 cases, the fetuses were carriers, 20 of these couples (71.43 %) decided to terminate the pregnancy; the rest continued the pregnancy to term, this resulting in a predictive test for their unborn children. A predominance of females as the at-risk progenitor was observed. Except for a slightly lower average age, the results attained in the Cuban SCA2 prenatal diagnosis program resulted similar to the ones reported for Huntington disease in other countries. It is necessary to have easy access to the Cuban program through its expansion to other genetic centers along the island. Future research is needed to evaluate the long-term impact of both the predictive testing in unborn children and the selection of other reproductive options by the at-risk couples.
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Affiliation(s)
- Tania Cruz-Mariño
- Center for the Research and Rehabilitation of Hereditary Ataxias, Holguín, Cuba,
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MacLeod R, Tibben A, Frontali M, Evers-Kiebooms G, Jones A, Martinez-Descales A, Roos RA. Recommendations for the predictive genetic test in Huntington's disease. Clin Genet 2012; 83:221-31. [PMID: 22642570 DOI: 10.1111/j.1399-0004.2012.01900.x] [Citation(s) in RCA: 140] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Revised: 05/08/2012] [Accepted: 05/22/2012] [Indexed: 01/27/2023]
Affiliation(s)
- R MacLeod
- Genetic Medicine, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK.
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Paneque M, Sequeiros J, Skirton H. Quality assessment of genetic counseling process in the context of presymptomatic testing for late-onset disorders: a thematic analysis of three review articles. Genet Test Mol Biomarkers 2011; 16:36-45. [PMID: 21819246 DOI: 10.1089/gtmb.2011.0023] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Presymptomatic testing (PST) is available for a range of late-onset disorders. Health practitioners generally follow guidelines regarding appropriate number of counseling sessions, involvement of multidisciplinary teams, topics for pretest discussion, and follow-up sessions; however, more understanding is needed about what helps consultands effectively and the impact of amount and quality of genetic counseling on the psychosocial sequelae of PST for late-onset disorders. We conducted a thematic analysis of three review articles on quality of the genetic counseling process, aiming at (1) exploring current evidence; (2) identifying quality assessment indicators; and (3) making recommendations for genetic counseling practice in late-onset disorders. We undertook a systematic search of 6 relevant databases: 38 articles were identified and 3 fitted our inclusion criteria; after quality appraisal, all were included in the review. The number of sessions, time spent, consultation environment, follow-up, and multidisciplinarity were identified as variables for quality assessment. Research on counseling in the context of genetic testing in familial cancer tends to be related to outcomes and indicators for quality assessment, while research concerning other late-onset diseases is mainly focused on the psychological impact of the test results. The quality and content of the overall process in noncancer late-onset diseases is insufficiently articulated. Despite the fact that PST for Huntington disease and other degenerative conditions has been offered for more than 20 years, good methodological approaches to assess quality of genetic counseling in that context remain elusive. This restricts improvement of the protocols for genetic services and, in general, healthcare for the at-risk population.
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Affiliation(s)
- Milena Paneque
- Center for Predictive and Preventive Genetics-CGPP, Institute for Molecular and Cell Biology-IBMC, ICBAS, University of Porto, Porto, Portugal.
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Janvier A, Barrington K. Letter to the editor. Paediatr Child Health 2011; 16:430. [PMID: 22851900 PMCID: PMC3200396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023] Open
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