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Trainer AH, Goode E, Hoskins CN, Wheeler JCW, Best S. Calibrating variant curation by clinical context based on factors that influence patients' tolerance of uncertainty. Genet Med 2023; 25:100982. [PMID: 37724515 DOI: 10.1016/j.gim.2023.100982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 09/05/2023] [Accepted: 09/11/2023] [Indexed: 09/21/2023] Open
Abstract
PURPOSE Shared decision making manages genomic uncertainty by integrating molecular and clinical uncertainties with patient values to craft a person-centered management plan. Laboratories seek genomic report consistency, agnostic to clinical context. Molecular reports often mask laboratory-managed uncertainties from clinical decision making. Better integration of these uncertainty management strategies requires a nuanced understanding of patients' perceptions and reactions to test uncertainties. We explored patients' tolerance to variant uncertainty in 3 parameters: (1) relative causal significance, (2) risk accuracy, and (3) classification validity. METHOD Deliberative forums were undertaken with 18 patients with predictive testing experience. Uncertainty deliberations were elicited for each parameter. A thematic framework was first developed, and then mapped to whether they justified tolerance to more or less parameter-specific uncertainty. RESULTS Six identified themes mapped to clinical and personal domains. These domains generated opposing forces when calibrating uncertainty. Personal themes justified tolerance of higher uncertainty and clinical themes lower uncertainty. Decision making in uncertainty focused on reducing management regret. Open communication increased tolerance of classification validity and risk accuracy uncertainty. Using these data, we have developed a nascent clinical algorithm integrating molecular uncertainty with clinical context through a targeted communication framework. CONCLUSION Maximizing test utility necessitates context-specific recalibration of uncertainty management and communication.
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Affiliation(s)
- Alison H Trainer
- Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Department of Medicine, University of Melbourne, Melbourne, VIC, Australia; Department of Genomic Medicine, Royal Melbourne Hospital, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia.
| | - Erin Goode
- Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Department of Genomic Medicine, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Cass N Hoskins
- Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Department of Genomic Medicine, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Jack C W Wheeler
- Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Department of Genomic Medicine, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Stephanie Best
- Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia; Victorian Comprehensive Cancer Centre Alliance, Melbourne, VIC, Australia; Australian Genomics, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
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Forrest LE, Tutty E, De Silva AP, Petelin L, Ruscigno A, Purvis R, Monohan K, Kentwell M, Sexton A, Stafford L, James PA. Personalising genetic counselling (POETIC) trial: Protocol for a hybrid type II effectiveness-implementation randomised clinical trial of a patient screening tool to improve patient empowerment after cancer genetic counselling. Trials 2023; 24:712. [PMID: 37941026 PMCID: PMC10631179 DOI: 10.1186/s13063-023-07723-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 10/10/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Genetic counselling aims to identify, and address, patient needs while facilitating informed decision-making about genetic testing and promoting empowerment and adaptation to genetic information. Increasing demand for cancer genetic testing and genetic counsellor workforce capacity limitations may impact the quality of genetic counselling provided. The use of a validated genetic-specific screening tool, the Genetic Psychosocial Risk Instrument (GPRI), may facilitate patient-centred genetic counselling. The aim of this study is to assess the effectiveness and implementation of using the GPRI in improving patient outcomes after genetic counselling and testing for an inherited cancer predisposition. METHODS The PersOnalising gEneTIc Counselling (POETIC) trial is a hybrid type 2 effectiveness-implementation trial using a randomised control trial to assess the effectiveness of the GPRI in improving patient empowerment (primary outcome), while also assessing implementation from the perspective of clinicians and the healthcare service. Patients referred for a cancer risk assessment to the conjoint clinical genetics service of two metropolitan hospitals in Victoria, Australia, who meet the eligibility criteria and consent to POETIC will be randomised to the usual care or intervention group. Those in the intervention group will complete the GPRI prior to their appointment with the screening results available for the clinicians' use during the appointment. Appointment audio recordings, clinician-reported information about the appointment, patient-reported outcome measures, and clinical data will be used to examine the effectiveness of using the GPRI. Appointment audio recordings, health economic information, and structured interviews will be used to examine the implementation of the GPRI. DISCUSSION The POETIC trial takes a pragmatic approach by deploying the GPRI as an intervention in the routine clinical practice of a cancer-specific clinical genetics service that is staffed by a multidisciplinary team of genetics and oncology clinicians. Therefore, the effectiveness and implementation evidence generated from this real-world health service setting aims to optimise the relevance of the outcomes of this trial to the practice of genetic counselling while enhancing the operationalisation of the screening tool in routine practice. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry registration number 12621001582842p. Date of registration: 19th November 2021.
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Affiliation(s)
- Laura E Forrest
- Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre, Locked Bag 1, A'Beckett St, Melbourne, Victoria, 3008, Australia.
- Parkville Familial Cancer Centre & Genomic Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia.
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia.
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.
| | - Erin Tutty
- Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre, Locked Bag 1, A'Beckett St, Melbourne, Victoria, 3008, Australia
| | - Anurika P De Silva
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
- Methods and Implementation Support for Clinical and Health (MISCH) research Hub, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Lara Petelin
- Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre, Locked Bag 1, A'Beckett St, Melbourne, Victoria, 3008, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council New South Wales, Camperdown, Australia
| | - Amy Ruscigno
- Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre, Locked Bag 1, A'Beckett St, Melbourne, Victoria, 3008, Australia
- Parkville Familial Cancer Centre & Genomic Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Rebecca Purvis
- Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre, Locked Bag 1, A'Beckett St, Melbourne, Victoria, 3008, Australia
- Parkville Familial Cancer Centre & Genomic Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Katrina Monohan
- Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre, Locked Bag 1, A'Beckett St, Melbourne, Victoria, 3008, Australia
- Parkville Familial Cancer Centre & Genomic Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Maira Kentwell
- Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre, Locked Bag 1, A'Beckett St, Melbourne, Victoria, 3008, Australia
- Parkville Familial Cancer Centre & Genomic Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Adrienne Sexton
- Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre, Locked Bag 1, A'Beckett St, Melbourne, Victoria, 3008, Australia
- Parkville Familial Cancer Centre & Genomic Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Lesley Stafford
- Parkville Familial Cancer Centre & Genomic Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Melbourne School of Psychological Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Paul A James
- Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre, Locked Bag 1, A'Beckett St, Melbourne, Victoria, 3008, Australia
- Parkville Familial Cancer Centre & Genomic Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
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Frigon MP, Lavoie M, Emond MJ, Bouchard L, Poitras ME, Tremblay K. Family planning decisional needs assessment for recessive hereditary disorders: Insights from carrier couples and professionals. PATIENT EDUCATION AND COUNSELING 2022; 105:2537-2545. [PMID: 34872805 DOI: 10.1016/j.pec.2021.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 11/15/2021] [Accepted: 11/24/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Carrier couples of recessive diseases face an important decision-making process regarding their familial planning that can become a significant source of discomfort and potential regrets. To date, no study has described the decisional needs of carrier couples of Leigh syndrome French-Canadian type, hereditary tyrosinemia type 1, hereditary motor and sensory neuropathy with or without agenesis of the corpus callosum and autosomal recessive spastic ataxia of Charlevoix-Saguenay undergoing family planning decision-making process. Our study aimed to describe the decisional needs of carrier couples according to the Ottawa Decision Support Framework. METHODS A qualitative descriptive study was conducted. Qualitative individual and joint couple interviews were performed among 39 carrier individuals and 11 health and social care professionals. RESULTS Carrier couples' decision-making process is complex, and their decisional needs include, among others, sufficient knowledge about the disease and the reproductive options, personal values and available support. Increased decisional conflict was observed among carriers of diseases associated with low morbidity and mortality. CONCLUSION Family planning decision-making is an evolutive deliberative process that requires appropriate shared decision-making to insure decisional comfort. PRACTICE IMPLICATIONS Carrier couples family planning decision-making process needs to be better supported.
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Affiliation(s)
- Marie-Pier Frigon
- Medicine Faculty, Université de Montréal, Montréal, QC, Canada; Department of Pediatrics, Université de Sherbrooke, Sherbrooke, QC, Canada; Community Genomic Medicine Centre & Biocluster ECOGENE-21, Saguenay, QC, Canada
| | - Mélissa Lavoie
- Department of Health Science, Université du Québec à Chicoutimi, Saguenay, QC, Canada; Groupe de recherche interdisciplinaire sur les maladies neuromusculaires, Saguenay, QC, Canada
| | - Marie-Josée Emond
- Department of Health Science, Université du Québec à Chicoutimi, Saguenay, QC, Canada
| | - Luigi Bouchard
- Department of Medical Biology, Centre intégré universitaire de santé et de services sociaux du Saguenay-Lac-Saint-Jean, Saguenay, QC, Canada; Department of Biochemistry and Functional Genomics, Université de Sherbrooke, Saguenay, QC, Canada
| | - Marie-Eve Poitras
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, QC, Canada.
| | - Karine Tremblay
- Medicine Faculty, Université de Montréal, Montréal, QC, Canada; Department of Medical Biology, Centre intégré universitaire de santé et de services sociaux du Saguenay-Lac-Saint-Jean, Saguenay, QC, Canada; Department of Pharmacology-Physiology, Université de Sherbrooke, QC, Canada.
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Allen KA, McInerney-Leo AM, Gamble N, Wurf G, Boyle C. The ethical protection of genetic information: procedure analysis for psychologists. CLIN PSYCHOL-UK 2021. [DOI: 10.1080/13284207.2021.1985376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Kelly-Ann Allen
- School of Educational Psychology and Counselling, Faculty of Education, Monash University, Melbourne, Australia
- The Centre for Wellbeing Science, The Melbourne Graduate School of Education, The University of Melbourne, Parkville, Australia
| | - Aideen M McInerney-Leo
- Dermatology Research Centre, The University of Queensland Diamantina Institute, The University of Queensland, Woolloongabba, Australia
| | - Nicholas Gamble
- School of Educational Psychology and Counselling, Faculty of Education, Monash University, Melbourne, Australia
| | - Gerald Wurf
- School of Educational Psychology and Counselling, Faculty of Education, Monash University, Melbourne, Australia
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Jamal L, Schupmann W, Berkman BE. An ethical framework for genetic counseling in the genomic era. J Genet Couns 2020; 29:718-727. [PMID: 31856388 PMCID: PMC7302959 DOI: 10.1002/jgc4.1207] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 11/29/2019] [Accepted: 12/03/2019] [Indexed: 01/08/2023]
Abstract
The field of genetic counseling has grown and diversified since the profession emerged in the early 1970s. In the same period, genomic testing has become more complex, profitable, and widespread. With these developments, the scope of ethical considerations relevant to genetic counseling has expanded. In light of this, we find it helpful to revisit how ethical and relational variables are used to inform genetic counseling practice. Our specific focus is on whether, and to what extent, it is ethically acceptable for genetic counselors to make normative recommendations to patients. This article builds on prior literature that has critiqued nondirectiveness, a concept that has influenced and constrained the modern profession of genetic counseling since its origin. In it, we review scholarly efforts to move beyond nondirectiveness, which we believe privilege patient autonomy at the expense of other important values. We then argue that genetic counselors should favor a more explicit commitment to the principles of beneficence and non-maleficence, as well as a broader understanding of autonomy and the relational variables that impact genetic counseling. Finally, to translate our arguments into practice, we present a framework of six considerations that genetic counselors should take into account when deciding whether it is ethically acceptable, or even desirable, to make recommendations to patients in certain areas of their work.
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Affiliation(s)
- Leila Jamal
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD
- National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD
| | - Will Schupmann
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Benjamin E. Berkman
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD
- National Human Genome Research Institute, NIH, Bethesda, MD
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Laberge AM, Birko S, Lemoine MÈ, Le Clerc-Blain J, Haidar H, Affdal AO, Dupras C, Ravitsky V. Canadian Pregnant Women's Preferences Regarding NIPT for Down Syndrome: The Information They Want, How They Want to Get It, and With Whom They Want to Discuss It. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:782-791. [PMID: 30738740 DOI: 10.1016/j.jogc.2018.11.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 10/22/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This study sought to assess Canadian pregnant women's and their partners' preferences for information about non-invasive prenatal testing (NIPT). METHODS Pregnant women and their partners across Canada were surveyed as part of the Personalized Genomics for prenatal Aneuploidy Screening Using maternal blood (PEGASUS) study. RESULTS A total of 882 pregnant women and 395 partners participated. Women preferred being informed by a physician (77.2%). They preferred getting information ahead of time, except for information about resources for families with Down syndrome, which they preferred getting with test results. More than half thought that written consent is important (63.7%) and could decide whether to do NIPT on the day they received the information (54.9%). Women preferred to be informed of results by telephone (43.7%) or in person (28%), but they preferred in person if they were considered at high risk for Down syndrome on the basis of the results (76%). The partner was the person whose input was considered most important (62.6%). Partners' preferences were similar, except that partners tended to want information later (at the time of the test or with the results) and felt that their opinion was not considered as highly by health professionals. CONCLUSION Canadian women want information about NIPT early, in person, by a knowledgeable physician. Partners also want to be informed and involved in the decision-making process.
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Affiliation(s)
- Anne-Marie Laberge
- Department of Pediatrics, Université de Montréal, Montréal, QC; Service de génétique médicale, Centre hospitalier universitaire Sainte-Justine, Montréal, QC; Centre de recherche du Centre hospitalier universitaire Sainte-Justine, Montréal, QC.
| | - Stanislav Birko
- Bioethics Program, Department of Social and Preventive Medicine, School of Public Health, Université de Montréal, Montréal, QC
| | - Marie-Ève Lemoine
- Bioethics Program, Department of Social and Preventive Medicine, School of Public Health, Université de Montréal, Montréal, QC
| | | | - Hazar Haidar
- Institute for Health and Social Policy (IHSP), McGill University, Montréal, QC; Centre de recherche en éthique (CRÉ) de l'Université de Montréal, Montréal, QC
| | - Aliya O Affdal
- Bioethics Program, Department of Social and Preventive Medicine, School of Public Health, Université de Montréal, Montréal, QC
| | - Charles Dupras
- Institute for Health and Social Policy (IHSP), McGill University, Montréal, QC; Centre de recherche en éthique (CRÉ) de l'Université de Montréal, Montréal, QC
| | - Vardit Ravitsky
- Bioethics Program, Department of Social and Preventive Medicine, School of Public Health, Université de Montréal, Montréal, QC
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Molina F, Dehlendorf C, Gregorich SE, Kuppermann M. Women's preferences for and experiences with prenatal genetic testing decision making: Sociodemographic disparities in preference-concordant decision making. PATIENT EDUCATION AND COUNSELING 2019; 102:595-601. [PMID: 30502029 PMCID: PMC6421100 DOI: 10.1016/j.pec.2018.10.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 09/24/2018] [Accepted: 10/26/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To investigate women's preferred approach to prenatal genetic testing decision making and assess concordance between preference and experience. METHODS We conducted a secondary analysis of data from two randomized trials conducted between 2007-2012. Survey items assessed participants' preferred approach to decision making and whether they experienced a preference-concordant decision process. Logistic regression estimated relationships between patient characteristics and these outcomes. RESULTS 56% of women preferred autonomous decision making, 39% preferred shared decision making, and 5% preferred a provider-driven approach. Only 57% experienced preference-concordant decision making. On bivariate analysis, black women, Spanish-speaking Latinas and women with less education were less likely to experience this outcome than white, more educated women. Numeracy and preferring a provider-driven approach fully mediated observed disparities in preference-concordant decision making for most participants, except for Spanish-speaking Latinas, who were still less likely to have experienced this outcome after accounting for these factors. CONCLUSION Numeracy, preference for provider-driven decision processes, and language barriers were key drivers of disparities in preference-concordant decision making. PRACTICE IMPLICATIONS Given the values-sensitive and quantitative nature of prenatal testing decisions, nuanced counseling and interventions to address language barriers, numeracy gaps, and decision-making preferences are needed to tailor counseling to patient's backgrounds and desires.
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Affiliation(s)
- Fabiola Molina
- Department of Medicine, Brigham and Women's Hospital, Boston, USA
| | - Christine Dehlendorf
- Department of Family & Community Medicine, University of California, San Francisco, San Francisco, USA; Department of Obstetrics, Gynecology & Reproductive Sciences and Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, USA
| | - Steven E Gregorich
- Department of Medicine, University of California, San Francisco, San Francisco, USA
| | - Miriam Kuppermann
- Department of Obstetrics, Gynecology & Reproductive Sciences and Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, USA.
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Musayón-Oblitas Y, Cárcamo C, Gimbel S. Counseling for improving adherence to antiretroviral treatment: a systematic review. AIDS Care 2018; 31:4-13. [PMID: 30309239 DOI: 10.1080/09540121.2018.1533224] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
One-on-one counseling can be an effective strategy to improve patient adherence to HIV treatment. The aim of this systematic review is to examine articles with one-on-one counseling-based interventions, review their components and effectiveness in improving ART adherence. A systematic review, using the following criteria was performed: (i) experimental studies; (ii) published in Spanish, English or Portuguese; (iii) with interventions consisting primarily of counseling; (iv) adherence as the main outcome; (v) published between 2005 and 2016; (vi) targeted 18 to 60 year old, independent of gender or sexual identity. The author reviewed bibliographic databases. Articles were analyzed according to the type of study, type of intervention, period of intervention, theoretical basis for intervention, time used in each counseling session and its outcomes. A total of 1790 records were identified. Nine studies were selected for the review, these applied different types of individual counseling interventions and were guided by different theoretical frameworks. Counseling was applied lasting between 4 to 18 months and these were supervised through three to six sessions over the study period. Individual counseling sessions lasted from 7.5 to 90 minutes (Me. 37.5). Six studies demonstrated significant improvement in treatment. Counseling is effective in improving adherence to ART, but methods vary. Face-to-face and computer counseling showed efficacy in improving the adherence, but not the telephone counseling. More evidence that can determine a basic counseling model without losing the individualized intervention for people with HIV is required.
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Affiliation(s)
- Yesenia Musayón-Oblitas
- a Departamento Académico de Enfermería, Instituto de Medicina Tropical Alexander von Humboldt , Universidad Peruana Cayetano Heredia , Lima , Perú
| | - Cesar Cárcamo
- b Departamento de Salud Pública , Universidad Peruana Cayetano Heredia , Lima , Perú
| | - Sarah Gimbel
- c Department of Family and Child Nursing, Department of Global Health , University of Washington , Washington , DC , USA
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Metcalfe SA. Genetic counselling, patient education, and informed decision-making in the genomic era. Semin Fetal Neonatal Med 2018; 23:142-149. [PMID: 29233487 DOI: 10.1016/j.siny.2017.11.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Genomic technologies are now being applied to reproductive genetic screening. Circulating cell-free DNA testing in pregnancy for fetal chromosomal abnormalities is becoming more widely used as a screening test, and expanded carrier screening for autosomal and X-linked recessive conditions for more than a hundred conditions is available to couples for testing before and during pregnancy. These are most typically available as a commercial test. The purpose of reproductive genetic screening is to facilitate autonomous reproductive choices. Previous studies would suggest that many women do not make informed decisions about prenatal genetic screening, and the introduction of genomic technologies has generally added to the ethical debate. Appropriate pre-test genetic counselling is recommended, and healthcare providers should include information that is balanced, accurate and up-to-date, comprising written and/or e-learning tools, as well as providing psychosocial support so that couples consider the pros and cons of being tested and can make informed decisions.
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Affiliation(s)
- Sylvia A Metcalfe
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Parkville, Victoria, Australia.
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Laurino MY, Leppig KA, Abad PJ, Cham B, Chu YWY, Kejriwal S, Lee JMH, Sternen DL, Thompson JK, Burgess MJ, Chien S, Elackatt N, Lim JY, Sura T, Faradz S, Padilla C, Paz ECDL, Nauphar D, Nguyen KN, Zayts O, Vu DC, Thong MK. A Report on Ten Asia Pacific Countries on Current Status and Future Directions of the Genetic Counseling Profession: The Establishment of the Professional Society of Genetic Counselors in Asia. J Genet Couns 2017; 27:21-32. [PMID: 28699126 DOI: 10.1007/s10897-017-0115-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 05/23/2017] [Indexed: 11/26/2022]
Abstract
The Professional Society of Genetic Counselors in Asia (PSGCA) was recently established as a special interest group of the Asia Pacific Society of Human Genetics. Fostering partnerships across the globe, the PSGCA's vision is to be the lead organization that advances and mainstreams the genetic counseling profession in Asia and ensures individuals have access to genetic counseling services. Its mission is to promote quality genetic counseling services in the region by enhancing practice and curricular standards, research and continuing education. The PSGCA was formally launched during the Genetic Counseling Pre-Conference Workshop held at the 11th Asia-Pacific Conference on Human Genetics in Hanoi, Viet Nam, September 16, 2015. The pre-conference workshop provided an opportunity for medical geneticists and genetic counselors from across 10 Asia Pacific countries to learn about the varied genetic counseling practices and strategies for genetic counseling training. This paper provides an overview of the current status and challenges in these countries, and proposed course of unified actions for the future of the genetic counseling profession.
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Affiliation(s)
- Mercy Y Laurino
- Department of Pediatrics, College of Medicine, University of the Philippines Manila, Manila, Philippines.
- Cancer Prevention Program, Seattle Cancer Care Alliance, 825 Eastlake Ave East Suite 210, Seattle, WA, 98109, USA.
| | - Kathleen A Leppig
- Group Health Cooperative, Seattle, WA, USA
- Department of Pathology, University of Washington, Seattle, WA, USA
| | - Peter James Abad
- Department of Pediatrics, College of Medicine, University of the Philippines Manila, Manila, Philippines
- College of Nursing, University of the Philippines Manila, Manila, Philippines
| | - Breana Cham
- Department of Pediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yoyo Wing Yiu Chu
- Department of Pediatrics and Adolescent Medicine, Queen Mary Hospital, Hong Kong, SAR, China
| | - Saahil Kejriwal
- Institute for Public Health Genetics, University of Washington, Seattle, WA, USA
- Strand Life Sciences, Bengaluru, India
| | - Juliana M H Lee
- Asia Genomics Pte Ltd, Kuala Lumpur, Malaysia
- Genetic Counseling Asia, Kuala Lumpur, Malaysia
| | - Darci L Sternen
- Department of Laboratories, Seattle Children's Hospital, Seattle, WA, USA
| | | | - Matthew J Burgess
- Clinical Genetics Service, Austin Health, Heidelberg, VIC, Australia
| | - Shu Chien
- Genetic Consultation Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Jiin Ying Lim
- Department of Pediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Thanyachai Sura
- Department of Medicine, Ramathibodi Hospital Medical School, Mahidol University, Bangkok, Thailand
| | - Sultana Faradz
- Master's Program in Genetic Counseling, Diponegoro University, Semarang, Indonesia
| | - Carmencita Padilla
- Department of Pediatrics, College of Medicine, University of the Philippines Manila, Manila, Philippines
- Institute of Human Genetics, National Institute of Health, University of the Philippines Manila, Manila, Philippines
| | - Eva Cutiongco de-la Paz
- Department of Pediatrics, College of Medicine, University of the Philippines Manila, Manila, Philippines
- Institute of Human Genetics, National Institute of Health, University of the Philippines Manila, Manila, Philippines
| | - Donny Nauphar
- Faculty of Medicine, Swadaya Gunung Jati University, Cirebon, Indonesia
| | | | - Olya Zayts
- School of English, The University of Hong Kong, Faculty of Arts, Hong Kong, SAR, China
| | - Dung Chi Vu
- National Hospital of Pediatrics, Hanoi, Viet Nam
| | - Meow-Keong Thong
- Department of Pediatrics, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Hill M, Oteng-Ntim E, Forya F, Petrou M, Morris S, Chitty LS. Preferences for prenatal diagnosis of sickle-cell disorder: A discrete choice experiment comparing potential service users and health-care providers. Health Expect 2017; 20:1289-1295. [PMID: 28504327 PMCID: PMC5689222 DOI: 10.1111/hex.12568] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2017] [Indexed: 01/29/2023] Open
Abstract
Background Non‐invasive prenatal diagnosis (NIPD) for sickle‐cell disorder (SCD) is moving closer to implementation and studies considering stakeholder preferences are required to underpin strategies for offering NIPD in clinical practice. Objective Determine service user and provider preferences for key attributes of prenatal diagnostic tests for SCD and examine views on NIPD. Method A questionnaire that includes a discrete choice experiment was used to determine the preferences of service users and providers for prenatal tests that varied across three attributes: accuracy, time of test and risk of miscarriage. Results Adults who were carriers of SCD or affected with the condition (N=67) were recruited from haemoglobinopathy clinics at two maternity units. Health professionals, predominately midwives, who offer antenatal care (N=62) were recruited from one maternity unit. No miscarriage risk was a key driver of decision making for both service users and providers. Service providers placed greater emphasis on accuracy than service users. Current uptake of invasive tests was 63%, whilst predicted uptake of NIPD was 93.8%. Many service users (55.4%) and providers (52.5%) think pressure to have prenatal testing will increase when NIPD for SCD becomes available. Conclusions There are clear differences between service users and health professionals’ preferences for prenatal tests for sickle‐cell disorder. The safety of NIPD is welcomed by parents and uptake is likely to be high. To promote informed choice, pretest counselling should be balanced and not exclusively focused on test safety. Counselling strategies that are sensitive to feelings of pressure to test will be essential.
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Affiliation(s)
- Melissa Hill
- Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Eugene Oteng-Ntim
- Directorate of Women's Health, Guy's and St Thomas' Foundation Trust, London, UK.,King's College London, London, UK
| | - Frida Forya
- Fetal Medicine Unit, University College London Hospitals NHS Foundation Trust, London, UK.,Institute of Women's Health, University College London, London, UK
| | - Mary Petrou
- Institute of Women's Health, University College London, London, UK.,Haemoglobinopathy Genetics Service, University College London Hospitals NHS Foundation Trust, London, UK
| | - Stephen Morris
- Department of Applied Health Research, University College London, London, UK
| | - Lyn S Chitty
- Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Fetal Medicine Unit, University College London Hospitals NHS Foundation Trust, London, UK
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12
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Forbes Shepherd R, Browne TK, Warwick L. A Relational Approach to Genetic Counseling for Hereditary Breast and Ovarian Cancer. J Genet Couns 2016; 26:283-299. [PMID: 27761849 DOI: 10.1007/s10897-016-0022-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Accepted: 09/12/2016] [Indexed: 11/26/2022]
Abstract
Ethical issues arise for genetic counselors when a client fails to disclose a genetic diagnosis of hereditary disease to family: they must consider the rights of the individual client to privacy and confidentiality as well as the rights of the family to know their genetic risk. Although considerable work has addressed issues of non-disclosure from the client's perspective, there is a lack of qualitative research into how genetic counselors address this issue in practice. In this study, a qualitative approach was taken to investigate whether genetic counselors in Australia use a relational approach to encourage the disclosure of genetic information from hereditary breast and ovarian cancer (HBOC) clients among family members; and if so, how they use it. Semi-structured qualitative interviews were conducted with 16 genetic counselors from selected states across Australia. Data collection and analysis were guided by a basic iterative approach incorporating a hybrid methodology to thematic analysis. The findings provide indicative evidence of genetic counselors employing a relational approach in three escalating stages--covert, overt and authoritative--to encourage the disclosure of genetic information. The findings lend credence to the notion that genetic counselors envision a form of relational autonomy for their clients in the context of sharing genetic information, and they depart from individualistic conceptions of care/solely client-centered counseling when addressing the needs of other family members to know their genetic status.
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Affiliation(s)
- Rowan Forbes Shepherd
- Research School of Biology, Australian National University, Canberra, ACT, Australia.
- Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia.
| | - Tamara Kayali Browne
- Research School of Biology, Australian National University, Canberra, ACT, Australia.
- Centre for Applied Philosophy and Public Ethics, Charles Sturt University, Canberra, ACT, Australia.
| | - Linda Warwick
- ACT Genetic Service, ACT Health, Canberra, ACT, Australia
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13
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14
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Wessels T, Koole T, Penn C. 'And then you can decide'--antenatal foetal diagnosis decision making in South Africa. Health Expect 2015; 18:3313-24. [PMID: 25523442 PMCID: PMC5810738 DOI: 10.1111/hex.12322] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2014] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Decision making is integral to genetic counselling and the premise is that autonomous decisions emerge if patients are provided with information in a non-directive manner. The pivotal activity in antenatal diagnosis counselling with at-risk pregnant women is decision making regarding invasive procedures. This process is not well understood in multicultural settings. OBJECTIVE This study examined multicultural genetic counselling interactions with women of advanced maternal age (AMA). It aimed to investigate the participants' orientation towards the amniocentesis decision. DESIGN Data were collected during 14 video-recorded consultations between six genetic counsellors and 14 women of AMA in a genetic counselling clinic in South Africa. The design was qualitative and conversation analysis was used for analysis. RESULTS Analysis revealed that counsellors used several strategies to facilitate discussions and decision making. However, the invitation to make a decision regarding amniocentesis was not perceived as being neutral. Both the counsellors and the women appeared to treat the offer as one which should be accepted. This resulted in a paradox, as strategies intended to allow neutral discussion seem to achieve the opposite. It is suggested that these results may be linked to the local health-care setting. CONCLUSION The results suggest that the understanding of decision-making processes and enhancing autonomy may require a more detailed investigation into psychosocial, political and historical factors in the local health-care setting. Models of practice as well as the training of genetic counsellors need to be sensitive to these influences. A closer examination of interactional variables may yield new and relevant insights for the profession.
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Affiliation(s)
- Tina‐Marié Wessels
- Division of Human Genetics and the Health Communication Research UnitUniversity of the WitwatersrandJohannesburgSouth Africa
- Health Communication Research UnitUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Tom Koole
- Health Communication Research UnitUniversity of the WitwatersrandJohannesburgSouth Africa
- Communication and Information ScienceRijksuniversiteit GroningenGroningenThe Netherlands
| | - Claire Penn
- Communication and Information ScienceRijksuniversiteit GroningenGroningenThe Netherlands
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15
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Hill M, Johnson JA, Langlois S, Lee H, Winsor S, Dineley B, Horniachek M, Lalatta F, Ronzoni L, Barrett AN, Advani HV, Choolani M, Rabinowitz R, Pajkrt E, van Schendel RV, Henneman L, Rommers W, Bilardo CM, Rendeiro P, Ribeiro MJ, Rocha J, Bay Lund IC, Petersen OB, Becher N, Vogel I, Stefánsdottir V, Ingvarsdottir S, Gottfredsdottir H, Morris S, Chitty LS. Preferences for prenatal tests for Down syndrome: an international comparison of the views of pregnant women and health professionals. Eur J Hum Genet 2015; 24:968-75. [PMID: 26577044 DOI: 10.1038/ejhg.2015.249] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 09/06/2015] [Accepted: 10/23/2015] [Indexed: 12/12/2022] Open
Abstract
Non-invasive prenatal testing is increasingly available worldwide and stakeholder viewpoints are essential to guide implementation. Here we compare the preferences of women and health professionals from nine different countries towards attributes of non-invasive and invasive prenatal tests for Down syndrome. A discrete choice experiment was used to obtain participants' stated preference for prenatal tests that varied according to four attributes: accuracy, time of test, risk of miscarriage, and type of information. Pregnant women and health professionals were recruited from Canada, Denmark, Iceland, Israel, Italy, the Netherlands, Portugal, Singapore, and the United Kingdom. A total of 2666 women's and 1245 health professionals' questionnaires were included in the analysis. Differences in preferences were seen between women and health professionals within and between countries. Overall, women placed greater emphasis on test safety and comprehensive information than health professionals, who emphasised accuracy and early testing. Differences between women's and health professionals' preferences are marked between countries. Varied approaches to implementation and service delivery are therefore needed and individual countries should develop guidelines appropriate for their own social and screening contexts.
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Affiliation(s)
- Melissa Hill
- Genetics and Genomic Medicine, UCL Institute of Child Health and Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Jo-Ann Johnson
- Department of Obstetrics & Gynecology, University of Calgary, Calgary, Alberta, Canada
| | - Sylvie Langlois
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Hyun Lee
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Stephanie Winsor
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Brigid Dineley
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Marisa Horniachek
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Faustina Lalatta
- Clinical Genetics Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Luisa Ronzoni
- Clinical Genetics Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Angela N Barrett
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Henna V Advani
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Mahesh Choolani
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ron Rabinowitz
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Centre, Jerusalem, Israel
| | - Eva Pajkrt
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Rachèl V van Schendel
- Department of Clinical Genetics, Section of Community Genetics, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Lidewij Henneman
- Department of Clinical Genetics, Section of Community Genetics, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Wieke Rommers
- Department of Obstetrics and Gynecology, Fetal Medicine Unit, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Caterina M Bilardo
- Department of Obstetrics and Gynecology, Fetal Medicine Unit, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | | | | | - José Rocha
- CGC Genetics, Porto, Portugal.,IINFACTS, CESPU, Porto, Portugal
| | | | - Olav B Petersen
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Naja Becher
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Ida Vogel
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Vigdis Stefánsdottir
- Department of Genetics and Molecular Medicine, Landspitali University Hospital, Reykjavik, Iceland
| | - Sigrun Ingvarsdottir
- Landspitali, National University Hospital, Reykjavik, Iceland.,Department of Midwifery, Faculty of Nursing, University of Iceland, Reykjavik, Iceland
| | - Helga Gottfredsdottir
- Landspitali, National University Hospital, Reykjavik, Iceland.,Department of Midwifery, Faculty of Nursing, University of Iceland, Reykjavik, Iceland
| | - Stephen Morris
- Research Department of Applied Health Research, University College London, London, UK
| | - Lyn S Chitty
- Genetics and Genomic Medicine, UCL Institute of Child Health and Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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16
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Cura JD. Respecting Autonomous Decision Making Among Filipinos: A Re-emphasis in Genetic Counseling. J Genet Couns 2015; 24:213-24. [DOI: 10.1007/s10897-015-9823-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 01/12/2015] [Indexed: 11/30/2022]
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17
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Genetic Counseling for Indigenous Australians: an Exploratory Study from the Perspective of Genetic Health Professionals. J Genet Couns 2014; 24:597-607. [PMID: 25348084 DOI: 10.1007/s10897-014-9782-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 09/29/2014] [Indexed: 10/24/2022]
Abstract
Indigenous populations are thought to have particularly low levels of access to genetic health services, and cultural issues may be a contributing factor. This article presents the findings of the first study of genetic health service provision to Indigenous Australians. This qualitative study aimed to identify elements of culturally-competent genetic health service provision in Indigenous Australian contexts. Twelve semi-structured interviews were conducted with genetic counselors and clinical geneticists from around Australia who had delivered services to Indigenous Australians. Participants were asked to describe their experiences and identify any collective cultural needs of Indigenous clients, as well as comment on specific training and resources they had received or used. Interviews were audio-recorded and transcribed with thematic analysis conducted on the data. The findings show that participants were reluctant to generalize the needs of Indigenous peoples. Some participants asserted that Indigenous peoples have needs that differ from the general population, while others felt that there were no collective cultural needs, instead advocating an individualized approach. Being flexible and practical, taking time to build rapport, recognizing different family structures and decision-making processes, as well as socio-economic disadvantage were all identified as important factors in participants' interactions with Indigenous clients. Indigenous support workers and hospital liaison officers were seen as valuable resources for effective service provision. The implications of this study for training and practice are discussed.
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18
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Client Views and Attitudes to Non-Invasive Prenatal Diagnosis for Sickle Cell Disease, Thalassaemia and Cystic Fibrosis. J Genet Couns 2014; 23:1012-21. [DOI: 10.1007/s10897-014-9725-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 04/09/2014] [Indexed: 10/25/2022]
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19
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Abstract
OBJECTIVE End-of-life decision-making is difficult for everyone involved, as many studies have shown. Within this complexity, there has been little information on how parents see the role of doctors in end-of-life decision-making for children. This study aimed to examine parents' views and experiences of end-of-life decision-making. DESIGN A qualitative method with a semistructured interview design was used. SETTING Parent participants were living in the community. PARTICIPANTS Twenty-five bereaved parents. MAIN OUTCOMES Parents reported varying roles taken by doctors: being the provider of information without opinion; giving information and advice as to the decision that should be taken; and seemingly being the decision maker for the child. The majority of parents found their child's doctor enabled them to be the ultimate decision maker for their child, which was what they very clearly wanted to be, and consequently enabled them to exercise their parental autonomy. Parents found it problematic when doctors took over decision-making. A less frequently reported, yet significant role for doctors was to affirm decisions after they had been made by parents. Other important aspects of the doctor's role were to provide follow-up support and referral. CONCLUSIONS Understanding the role that doctors take in end-of-life decisions, and the subsequent impact of that role from the perspective of parents can form the basis of better informed clinical practice.
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Affiliation(s)
- J Sullivan
- Children's Bioethics Centre, Royal Children's Hospital, , Melbourne, Victoria, Australia
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20
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Deans Z, Hill M, Chitty LS, Lewis C. Non-invasive prenatal testing for single gene disorders: exploring the ethics. Eur J Hum Genet 2012. [PMID: 23188047 DOI: 10.1038/ejhg.2012.250] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Non-invasive prenatal testing for single gene disorders is now clearly on the horizon. This new technology offers obvious clinical benefits such as safe testing early in pregnancy. Before widespread implementation, it is important to consider the possible ethical implications. Four hypothetical scenarios are presented that highlight how ethical ideals of respect for autonomy, privacy and fairness may come into play when offering non-invasive prenatal testing for single gene disorders. The first scenario illustrates the moral case for using these tests for 'information only', identifying a potential conflict between larger numbers of women seeking the benefits of the test and the wider social impact of funding tests that do not offer immediate clinical benefit. The second scenario shows how the simplicity and safety of non-invasive prenatal testing could lead to more autonomous decision-making and, conversely, how this could also lead to increased pressure on women to take up testing. In the third scenario we show how, unless strong safeguards are put in place, offering non-invasive prenatal testing could be subject to routinisation with informed consent undermined and that woman who are newly diagnosed as carriers may be particularly vulnerable. The final scenario introduces the possibility of a conflict of the moral rights of a woman and her partner through testing for single gene disorders. This analysis informs our understanding of the potential impacts of non-invasive prenatal testing for single gene disorders on clinical practice and has implications for future policy and guidelines for prenatal care.
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Affiliation(s)
- Zuzana Deans
- Department of Community Based Medicine, Centre for Ethics in Medicine, University of Bristol, Bristol, UK
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21
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McGillivray G, Rosenfeld JA, McKinlay Gardner RJ, Gillam LH. Genetic counselling and ethical issues with chromosome microarray analysis in prenatal testing. Prenat Diagn 2012; 32:389-95. [PMID: 22467169 DOI: 10.1002/pd.3849] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Molecular karyotyping using chromosome microarray analysis (CMA) detects more pathogenic chromosomal anomalies than classical karyotyping, making CMA likely to become a first tier test for prenatal diagnosis. Detecting copy number variants of uncertain clinical significance raises ethical considerations. We consider the risk of harm to a woman or her fetus following the detection of a copy number variant of uncertain significance, whether it is ethically justifiable to withhold any test result information from a woman, what constitutes an 'informed choice' when women are offered CMA in pregnancy and whether clinicians are morally responsible for 'unnecessary' termination of pregnancy. Although we are cognisant of the distress associated with uncertain prenatal results, we argue in favour of the autonomy of women and their right to information from genome-wide CMA in order to make informed choices about their pregnancies. We propose that information material to a woman's decision-making process, including uncertain information, should not be withheld, and that it would be paternalistic for clinicians to try to take responsibility for women's decisions to terminate pregnancies. Non-directive pre-test and post-test genetic counselling is central to the delivery of these ethical objectives.
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Affiliation(s)
- George McGillivray
- Royal Women's Hospital, Melbourne, Victoria, Australia; Victorian Clinical Genetics Services, Royal Children's Hospital, Melbourne, Victoria, Australia.
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22
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Enhancing family communication about genetics: ethical and professional dilemmas. J Genet Couns 2012; 22:16-21. [PMID: 22833230 DOI: 10.1007/s10897-012-9514-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Accepted: 06/06/2012] [Indexed: 10/28/2022]
Abstract
When a new genetic condition is diagnosed within a family, genetic counselors often describe a sense of responsibility towards other at risk family members to be appropriately informed about their status. Successful communication of genetic information in families is contingent on many factors. While a small number of probands directly state their intention not to inform their relatives, many who do intend to communicate this information appear to be unsuccessful for a wide range of reasons and may benefit from follow up support from a genetic counselor. Drawing on the reciprocal-engagement model (REM) of genetic counseling practice we explore how enhancing family communication about genetics raises a number of ethical and professional challenges for counselors-and describe how we resolved these. A subsequent manuscript will describe the counseling framework we have developed to enhance family communication about genetics.
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23
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Hickerton CL, Aitken M, Hodgson J, Delatycki MB. "Did you find that out in time?": new life trajectories of parents who choose to continue a pregnancy where a genetic disorder is diagnosed or likely. Am J Med Genet A 2011; 158A:373-83. [PMID: 22140089 DOI: 10.1002/ajmg.a.34399] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Accepted: 10/31/2011] [Indexed: 11/08/2022]
Abstract
The availability of tests to detect genetic conditions prenatally has expanded considerably in recent decades. These advances allow women and couples choices; the choice of whether or not to undergo prenatal screening or diagnosis and therefore the choice whether to continue or terminate a pregnancy. Following prenatal testing many people choose to terminate an affected pregnancy, however little is known about the experiences of parents who choose to continue such a pregnancy. This exploratory qualitative study involved in-depth interviews with five mothers and four fathers who experienced a pregnancy where a genetic diagnosis was, or could have been, detected prenatally. Transcripts of the interviews were analyzed using thematic analysis. While the participants' experiences of genetic diagnoses and prenatal choices varied, findings revealed three major categories triggering new life trajectories for all of these parents: knowledge of reproductive risk and receiving a genetic diagnosis; adapting to diagnosis and new life path; and attitudes to prenatal diagnosis and disability. Parents reported that while dealing with their own attitudes and getting on with their "new world," positive and negative attitudes of others impacted on these parents' experiences. A conceptual model arising from the major themes is offered as a way of thinking about this paradigm. Parents who continue a pregnancy where a genetic condition is detected or suspected prenatally, can be supported appropriately by health professionals while adjusting to their new life path.
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24
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Hodgson J, Weil J. Talking about disability in prenatal genetic counseling: a report of two interactive workshops. J Genet Couns 2011; 21:17-23. [PMID: 22037895 DOI: 10.1007/s10897-011-9410-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2010] [Accepted: 09/08/2011] [Indexed: 11/25/2022]
Abstract
Women are commonly offered testing in pregnancy to determine the health of their baby. An important component of informed decision-making about prenatal testing is provision of relevant, accurate, meaningful information concerning the conditions that are being tested for--many of which, such as Down syndrome, are associated with a varying degree of physical and intellectual disability. A range of health professionals, including genetic counselors, may provide information and support throughout the testing process, but available data suggest that discussion of disability is frequently absent or limited. To investigate genetic counselors' perceptions of this situation and identify potential barriers to discussion we facilitated interactive workshops at the 2007 National Society of Genetic Counselors Annual Education Conference (NSGC) and the 2008 European Meeting on Psychosocial Aspects of Genetics (EMPAG). Working groups identified relevant psychosocial issues and impediments to discussion (NSGC) or used a two-part scenario to promote discussion (EMPAG) and reported findings in notes and a closing plenary discussion. Inductive content analysis revealed that participants considered informed decision making to be a major reason for presenting information about disabilities in prenatal genetic counseling and endorsed the value of including information about daily life with Down syndrome and other disabilities. However, they identified three broad types of impediments to such discussion: counseling issues concerning the most appropriate manner to discuss disability under the complex circumstances of prenatal genetic counseling, less than optimal training and experience in addressing these issues, and perceived limitations in the participants' knowledge and understanding of life with disability. Our analysis of the responses from the workshop participants and additional thoughts on these issues have led us to develop recommendations for further research, training and clinical practice.
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Affiliation(s)
- Jan Hodgson
- Genetics Education and Health Research, Murdoch Childrens Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia
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25
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Practice guidelines for communicating a prenatal or postnatal diagnosis of Down syndrome: recommendations of the national society of genetic counselors. J Genet Couns 2011; 20:432-41. [PMID: 21618060 DOI: 10.1007/s10897-011-9375-8] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Accepted: 05/12/2011] [Indexed: 01/08/2023]
Abstract
Down syndrome is one of the most common conditions encountered in the genetics clinic. Due to improvements in healthcare, educational opportunities, and community inclusion over the past 30 years, the life expectancy and quality of life for individuals with Down syndrome have significantly improved. As prenatal screening and diagnostic techniques have become more enhanced and widely available, genetic counselors can expect to frequently provide information and support following a new diagnosis of Down syndrome. This guideline was written for genetic counselors and other healthcare providers regarding the communication of a diagnosis of Down syndrome to ensure that families are consistently given up-to-date and balanced information about the condition, delivered in a supportive and respectful manner.
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26
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Sheets KB, Best RG, Brasington CK, Will MC. Balanced information about Down syndrome: what is essential? Am J Med Genet A 2011; 155A:1246-57. [PMID: 21548127 DOI: 10.1002/ajmg.a.34018] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2010] [Accepted: 03/07/2011] [Indexed: 11/06/2022]
Abstract
The purpose of this study was to explore the perspectives of genetic counselors and parents of children with Down syndrome to define essential information for the initial discussion of a new diagnosis. We compared information given in both prenatal and postnatal settings, and also aimed to distinguish differences between the informational needs of parents and the information genetic counselors provide. Online surveys were distributed to members of the National Down Syndrome Congress, National Down Syndrome Society, and National Society of Genetic Counselors. Participants included 993 parents of children with Down syndrome and 389 genetic counselors. Participants rated 100 informational features about Down syndrome as Essential, Important, or Not Too Important for inclusion in the first discussion of the diagnosis. Responses identified 34 essential informational items for the initial discussion of Down syndrome, including clinical features, developmental abilities, a range of prognostications, and informational resources. Healthcare providers should consider incorporating these items in their initial discussion of a diagnosis in both prenatal and postnatal settings. Statistically significant differences between parent and genetic counselor responses illustrate that information is valued differently and that parents appreciate information about the abilities and potential of people with Down syndrome, as opposed to clinical details. Balancing clinical information with other aspects of the condition, as well as a better understanding of the information parents consider most important, may enable healthcare professionals to more effectively satisfy families' informational needs following a new diagnosis of Down syndrome.
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Affiliation(s)
- Kathryn B Sheets
- Division of Medical Genetics, Duke University Medical Center, Durham, North Carolina 27710, USA.
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27
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Quillin JM, Bodurtha JN, McClish D, Wilson DB. Genetic risk, perceived risk, and cancer worry in daughters of breast cancer patients. J Genet Couns 2011; 20:157-64. [PMID: 21132457 PMCID: PMC4870590 DOI: 10.1007/s10897-010-9336-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Accepted: 11/08/2010] [Indexed: 10/18/2022]
Abstract
This study explored relationships between worry, perceived risk for breast cancer, consulting a genetic counselor, having genetic testing, and genetic risk for women whose mothers had breast cancer. Analyses involved data from a community-based phone survey of women whose mothers had breast cancer. Participants were categorized as having low, intermediate, or high genetic risk based on their reported family history, in accordance with an accepted classification scheme. The Lerman Breast Cancer Worry Scale measured worry, and participants reported their perceived lifetime likelihood of breast cancer, risk compared to others, and chance from 1 to 100. ANOVA, chi-square, and multiple regression analyses were conducted as appropriate. One hundred-fifty women participated. Mean age was 38 years, and 81% were Caucasian. Fifty-two women had low, 74 had intermediate, and 24 had high genetic risk for breast cancer. There were no significant differences in worry or perceived risk by hereditary risk category. Most high-risk women (91%) had not spoken with a genetic counselor, and no one had previous genetic testing. These findings suggest perceived risk, worry about breast cancer, and use of expert consultation do not match the genetic contribution to risk. There is a need for effectively stratifying and communicating risk in the community and providing tailored reassurance or referral for high-risk assessment.
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Affiliation(s)
- John M Quillin
- Department of Human & Molecular Genetics and Massey Cancer Center, Virginia Commonwealth University, 1101 E. Marshall St, Richmond, VA 23298-0033, USA.
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Tsouroufli M. Routinisation and constraints on informed choice in a one-stop clinic offering first trimester chromosomal antenatal screening for Down's syndrome. Midwifery 2010; 27:431-6. [PMID: 20947230 DOI: 10.1016/j.midw.2010.02.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2009] [Revised: 02/01/2010] [Accepted: 02/20/2010] [Indexed: 11/16/2022]
Abstract
OBJECTIVE to explore routinisation and constraints on informed choice in a one-stop clinic offering first trimester antenatal chromosomal screening for Down's syndrome. DESIGN recordings of booking appointments and pre-screening consultations in both a community and a hospital clinic setting. SETTING one antenatal clinic site in the UK offering first trimester nuchal translucency screening in combination with maternal serum screening. PARTICIPANTS 57 taped clinical consultations involving pregnant women and midwives and health-care assistants (HCAs). FINDINGS midwives and HCAs expected women to make informed decisions about screening for Down's syndrome. However, midwives' attempts to maintain the normality of pregnancy and avoid discussions about potential scenarios, as well as their emphasis on the high accuracy rate of first trimester screening have routinised first trimester antenatal screening for Down's syndrome. Also, a general expectation in the clinic to take up screening and the constrained service context in which midwives and HCAs work had implications for women's informed choices. KEY CONCLUSIONS directive information combined with lack of purposeful dialogue with pregnant women have constrained the process of information-giving about antenatal screening for Down's syndrome. IMPLICATIONS the provision of information about antenatal screening for Down's syndrome is a challenging role for midwives. Changes in midwifery practice resulting from continuing education as well as less constraining service contexts could improve the quality of information about antenatal screening for Down's syndrome.
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Affiliation(s)
- Maria Tsouroufli
- School of Medicine Health Policy and Practice, University of East Anglia, Norwich NR4 7TJ, UK.
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Menezes MA, Hodgson JM, Sahhar MA, Aitken M, Metcalfe SA. “It’s Challenging on a Personal Level”—Exploring the ‘Lived Experience’ of Australian and Canadian Prenatal Genetic Counselors. J Genet Couns 2010; 19:640-52. [DOI: 10.1007/s10897-010-9315-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Accepted: 07/07/2010] [Indexed: 10/19/2022]
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What Do Genetic Counselors Learn on the Job? A Qualitative Assessment of Professional Development Outcomes. J Genet Couns 2010; 19:371-86. [DOI: 10.1007/s10897-010-9289-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2009] [Accepted: 02/17/2010] [Indexed: 10/19/2022]
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Hodgson JM, Gillam LH, Sahhar MA, Metcalfe SA. “Testing Times, Challenging Choices”: An Australian Study of Prenatal Genetic Counseling. J Genet Couns 2009; 19:22-37. [DOI: 10.1007/s10897-009-9248-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2009] [Accepted: 07/17/2009] [Indexed: 11/29/2022]
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van den Berg M, Timmermans DRM, Kleinveld JH, van Eijk JTM, Knol DL, van der Wal G, van Vugt JMG. Are counsellors' attitudes influencing pregnant women's attitudes and decisions on prenatal screening? Prenat Diagn 2007; 27:518-24. [PMID: 17367105 DOI: 10.1002/pd.1720] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES It is generally recognised that choices concerning treatment or screening should be people's own, autonomous decisions. However, in the context of genetic counselling, many studies found that counsellors deviate from nondirectiveness, or that subjective norm influences behaviour. The present study aimed to investigate whether prenatal counsellors (midwives, gynaecologists) influence pregnant women's decisions and their attitudes regarding prenatal screening. It was hypothesised that uptake rates and attitudes would be associated with the counsellor's attitude toward prenatal screening. METHODS Pregnant women attending their midwifery or gynaecology practice were asked to fill out postal questionnaires before and after they were offered prenatal screening for Down syndrome. Their prenatal counsellors also filled in a questionnaire. These questionnaires assessed attitudes toward prenatal screening and background variables. The study sample consisted of 945 pregnant women, being guided by 97 prenatal counsellors. RESULTS Multilevel regression analyses revealed that neither uptake rates, nor attitude toward prenatal screening were significantly predicted by counsellors' attitudes toward prenatal screening. CONCLUSION It is suggested that the advice these pregnant women were reported to have received, should rather be interpreted as an indication of shared decision-making and social support than of social pressure and undesired influence.
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Affiliation(s)
- Matthijs van den Berg
- EMGO Institute, Department of Public and Occupational Health, VU University Medical Centre, Amsterdam, The Netherlands.
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Zutlevics T. Should ART be offered to HIV-serodiscordant and HIV-seroconcordant couples: an ethical discussion? Hum Reprod 2006; 21:1956-60. [PMID: 16772283 DOI: 10.1093/humrep/del082] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Increasingly, fertility clinics are offering their services to human immunodeficiency virus (HIV)-serodiscordant couples where the woman is seropositive. In the case of HIV-seroconcordant couples, there remains a general reluctance to provide treatment. This attitude to seroconcordant couples is reminiscent of that once widely held towards serodiscordant couples when the risk of vertical transmission rates in pregnant women was greater than 1-2%. Due to recent advances in HIV clinical care and assisted reproduction technique (ART) procedures directed at reducing the risk of viral transmission during gamete transfer, where good healthcare is available, the current risk rate has fallen to 1-2%. This article deals with the ethical arguments of those who remain opposed to offering HIV-serodiscordant and HIV-seroconcordant couples access to ART. Until these arguments have been addressed, clinics providing ART to such couples cannot be assured that their practices are ethical.
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Affiliation(s)
- Tamara Zutlevics
- Women's and Children's Hospital, Research Institute, Adelaide, Australia.
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