1
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de Groot NF. A contextual integrity approach to genomic information: what bioethics can learn from big data ethics. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2024:10.1007/s11019-024-10211-0. [PMID: 38865053 DOI: 10.1007/s11019-024-10211-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/27/2024] [Indexed: 06/13/2024]
Abstract
Genomic data is generated, processed and analysed at an increasingly rapid pace. This data is not limited to the medical context, but plays an important role in other contexts in society, such as commercial DNA testing, the forensic setting, archaeological research, and genetic surveillance. Genomic information also crosses the borders of these domains, e.g. forensic use of medical genetic information, insurance use of medical genomic information, or research use of commercial genomic data. This paper (1) argues that an informed consent approach for genomic information has limitations in many societal contexts, and (2) seeks to broaden the bioethical debate on genomic information by suggesting an approach that is applicable across multiple societal contexts. I argue that the contextual integrity framework, a theory rooted in information technology and big data ethics, is an effective tool to explore ethical challenges that arise from genomic information within a variety of different contexts. Rather than focusing on individual control over information, the contextual integrity approach holds that information should be shared and protected according to the norms that govern certain distinct social contexts. Several advantages of this contextual integrity approach will be discussed. The paper concludes that the contextual integrity framework helps to articulate and address a broad spectrum of ethical, social, and political factors in a variety of different societal contexts, while giving consideration to the interests of individuals, groups, and society at large.
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Affiliation(s)
- Nina F de Groot
- Department of Philosophy, Faculty of Humanities, VU University Amsterdam, Amsterdam, the Netherlands.
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2
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Horton RH, Macken WL, Pitceathly RDS, Lucassen AM. Discussion of off-target and tentative genomic findings may sometimes be necessary to allow evaluation of their clinical significance. JOURNAL OF MEDICAL ETHICS 2024; 50:295-298. [PMID: 37339848 PMCID: PMC11103297 DOI: 10.1136/jme-2023-109108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/08/2023] [Indexed: 06/22/2023]
Abstract
We discuss a case where clinical genomic investigation of muscle weakness unexpectedly found a genetic variant that might (or might not) predispose to kidney cancer. We argue that despite its off-target and uncertain nature, this variant should be discussed with the man who had the test, not because it is medical information, but because this discussion would allow the further clinical evaluation that might lead it to becoming so. We argue that while prominent ethical debates around genomics often take 'results' as a starting point and ask questions as to whether to look for and how to react to them, the construction of genomic results is fraught with ethical complexity, although often couched as a primarily technical problem. We highlight the need for greater focus on, and appreciation of, the ethical work undertaken daily by scientists and clinicians working in genomic medicine and discuss how public conversations around genomics need to adapt to prepare future patients for potentially uncertain and unexpected outcomes from clinical genomic tests.
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Affiliation(s)
- Rachel H Horton
- Clinical Ethics, Law and Society, Wellcome Trust Centre for Human Genetics, Oxford, UK
- Centre for Personalised Medicine, St Anne's College, Oxford, UK
- Clinical Ethics, Law and Society, University of Southampton, Southampton, UK
| | - William L Macken
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
- NHS Highly Specialised Service for Rare Mitochondrial Disorders, Queen Square Centre for Neuromuscular Diseases, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Robert D S Pitceathly
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
- NHS Highly Specialised Service for Rare Mitochondrial Disorders, Queen Square Centre for Neuromuscular Diseases, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Anneke M Lucassen
- Clinical Ethics, Law and Society, Wellcome Trust Centre for Human Genetics, Oxford, UK
- Centre for Personalised Medicine, St Anne's College, Oxford, UK
- Clinical Ethics, Law and Society, University of Southampton, Southampton, UK
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3
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Abondio P, Bruno F, Passarino G, Montesanto A, Luiselli D. Pangenomics: A new era in the field of neurodegenerative diseases. Ageing Res Rev 2024; 94:102180. [PMID: 38163518 DOI: 10.1016/j.arr.2023.102180] [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: 09/07/2023] [Revised: 12/14/2023] [Accepted: 12/28/2023] [Indexed: 01/03/2024]
Abstract
A pangenome is composed of all the genetic variability of a group of individuals, and its application to the study of neurodegenerative diseases may provide valuable insights into the underlying aspects of genetic heterogenetiy for these complex ailments, including gene expression, epigenetics, and translation mechanisms. Furthermore, a reference pangenome allows for the identification of previously undetected structural commonalities and differences among individuals, which may help in the diagnosis of a disease, support the prediction of what will happen over time (prognosis) and aid in developing novel treatments in the perspective of personalized medicine. Therefore, in the present review, the application of the pangenome concept to the study of neurodegenerative diseases will be discussed and analyzed for its potential to enable an improvement in diagnosis and prognosis for these illnesses, leading to the development of tailored treatments for individual patients from the knowledge of the genomic composition of a whole population.
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Affiliation(s)
- Paolo Abondio
- Laboratory of Ancient DNA, Department of Cultural Heritage, University of Bologna, Via degli Ariani 1, 48121 Ravenna, Italy.
| | - Francesco Bruno
- Academy of Cognitive Behavioral Sciences of Calabria (ASCoC), Lamezia Terme, Italy; Regional Neurogenetic Centre (CRN), Department of Primary Care, Azienda Sanitaria Provinciale Di Catanzaro, Viale A. Perugini, 88046 Lamezia Terme, CZ, Italy; Association for Neurogenetic Research (ARN), Lamezia Terme, CZ, Italy
| | - Giuseppe Passarino
- Department of Biology, Ecology and Earth Sciences, University of Calabria, Rende 87036, Italy
| | - Alberto Montesanto
- Department of Biology, Ecology and Earth Sciences, University of Calabria, Rende 87036, Italy
| | - Donata Luiselli
- Laboratory of Ancient DNA, Department of Cultural Heritage, University of Bologna, Via degli Ariani 1, 48121 Ravenna, Italy
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4
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Kuiper JML, Borry P, Vears DF, Van Esch H, Cornel MC, Van Hoyweghen I. Dealing with ambivalence in the practice of advanced genetic healthcare: towards an ethical choreography. Eur J Hum Genet 2023; 31:1387-1392. [PMID: 37592172 PMCID: PMC10689481 DOI: 10.1038/s41431-023-01436-3] [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: 02/17/2023] [Revised: 07/06/2023] [Accepted: 07/17/2023] [Indexed: 08/19/2023] Open
Abstract
The implementation of next-generation sequencing (NGS) in diagnostic practice has stimulated ongoing debates on how to construct and perform "good" genomic care. Our multi-sited qualitative fieldwork at two large European centres for human genetics (CHGs) revealed tangible ambivalence in beliefs, norms, and actions in the enactment of NGS practices across sites stemming from differing expectations, interests, demands, and tensions. First, ambivalence was present around the boundaries of clinical diagnostic genetic care. The overlap between research and clinical work and diagnostics and screening led to ambivalence around "best" practices and norms concerning whom to offer NGS testing and how far to take testing. Secondly, the clinical value of NGS results, especially VUS and unsolicited findings, was ambivalently valued, resulting in an inconsistent approach towards these types of findings. Thirdly, ambivalence was recognized in applying guidelines in the reality of clinical practice. The ambivalence we encountered was often not made explicit or acknowledged, causing a failure to benefit from its possibility to encourage reflexivity and change. We propose to facilitate a more explicit ethical choreography [27], where ethics and science are developed iteratively whilst welcoming different perspectives and disciplines. Pulling experiences and practices of ambivalence into the light can help to understand the points of tension in the values and internal logic in care practices within the CHGs and facilitate a more informed, transparent, and consciously chosen direction for genetic care.
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Affiliation(s)
| | - Pascal Borry
- Centre for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Danya F Vears
- Centre for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Biomedical Ethics Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Melbourne Law School, University of Melbourne, Parkville, VIC, Australia
| | - Hilde Van Esch
- Center for Human genetics, University Hospitals Leuven, Leuven, Belgium
| | - Martina C Cornel
- Amsterdam UMC, Vrije Universiteit Amsterdam, Human Genetics and Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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5
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Watts G. Ambivalence in genomic healthcare provision, cure or symptom? Eur J Hum Genet 2023; 31:1346-1347. [PMID: 37789087 PMCID: PMC10689728 DOI: 10.1038/s41431-023-01467-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 09/14/2023] [Indexed: 10/05/2023] Open
Affiliation(s)
- Gabriel Watts
- Sydney Health Ethics, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia.
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Eichinger J, Zimmermann B, Elger B, McLennan S, Filges I, Koné I. 'It's a nightmare': informed consent in paediatric genome-wide sequencing. A qualitative expert interview study from Germany and Switzerland. Eur J Hum Genet 2023; 31:1398-1406. [PMID: 37773517 PMCID: PMC10689462 DOI: 10.1038/s41431-023-01468-9] [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: 01/23/2023] [Revised: 08/27/2023] [Accepted: 09/18/2023] [Indexed: 10/01/2023] Open
Abstract
The use of genome-wide sequencing (GWS) in paediatrics has added complexity to informed consent (IC) and pretest counselling because of the vast number and interpretation of potential findings, and their implications. However, empirical data from continental Europe on these issues remains limited. This study therefore aimed to explore the experiences and views of medical geneticists working with children in Germany and Switzerland regarding the challenges of obtaining valid IC in paediatric GWS. Qualitative interviews with 20 medical geneticists were analysed employing reflexive thematic analysis. In the interviews, many medical geneticists questioned the validity of parents' IC due to the enormous amount of relevant information given and the variety and complexity of the possible test outcomes. Key barriers identified included familial implications, administrative challenges and struggles with non-directiveness. Medical geneticists' suggestions for improvement included increasing the number of genetics professionals and better information material, which is crucial as GWS becomes a diagnostic standard in the early care pathways of children. An adjustment of aspirations from still existing ideal of traditional fully IC to appropriate IC seems to be needed. Such a more realistic and ethically sound adaptation of the requirements for IC can lead to better 'informedness' and improve the validity of the consent. This might also help reduce the moral distress for the medical geneticists involved.
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Affiliation(s)
- Johanna Eichinger
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland.
| | - Bettina Zimmermann
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
- Institute of History and Ethics in Medicine, TUM School of Medicine, Technical University of Munich, Munich, Germany
- Institute of Philosophy & Multidisciplinary Center for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Bernice Elger
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
- Center for Legal Medicine (CURML), University of Geneva, Geneva, Switzerland
| | - Stuart McLennan
- Institute of History and Ethics in Medicine, TUM School of Medicine, Technical University of Munich, Munich, Germany
| | - Isabel Filges
- Medical Genetics, Institute of Medical Genetics and Pathology, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Insa Koné
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
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Kohut K, Morton K, Hurley K, Turner L, Dale C, Eastbrook S, Gold R, Henwood K, Patton S, Punjabi R, White H, Young C, Young J, Bancroft E, Barnett L, Cable S, Connolly G, Coad B, Forman A, Hanson H, Kavanaugh G, Sahan K, Snape K, Torr B, Way R, Winchester E, Youngs A, Eccles D, Foster C. 'A good decision is the one that feels right for me': Codesign with patients to inform theoretical underpinning of a decision aid website. Health Expect 2023; 27:e13844. [PMID: 37705192 PMCID: PMC10768874 DOI: 10.1111/hex.13844] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 07/17/2023] [Accepted: 08/01/2023] [Indexed: 09/15/2023] Open
Abstract
INTRODUCTION Patient decision aids (PtDA) complement shared decision-making with healthcare professionals and improve decision quality. However, PtDA often lack theoretical underpinning. We are codesigning a PtDA to help people with increased genetic cancer risks manage choices. The aim of an innovative workshop described here was to engage with the people who will use the PtDA regarding the theoretical underpinning and logic model outlining our hypothesis of how the PtDA would lead to more informed decision-making. METHODS Short presentations about psychological and behavioural theories by an expert were interspersed with facilitated, small-group discussions led by patients. Patients were asked what is important to them when they make health decisions, what theoretical constructs are most meaningful and how this should be applied to codesign of a PtDA. An artist created a visual summary. Notes from patient discussions and the artwork were analysed using reflexive thematic analysis. RESULTS The overarching theme was: It's personal. Contextual factors important for decision-making were varied and changed over time. There was no one 'best fit' theory to target support needs in a PtDA, suggesting an inductive, flexible framework approach to programme theory would be most effective. The PtDA logic model was revised based on patient feedback. CONCLUSION Meaningful codesign of PtDA including discussions about the theoretical mechanisms through which they support decision-making has the potential to lead to improved patient care through understanding the intricately personal nature of health decisions, and tailoring content and format for holistic care. PATIENT CONTRIBUTION Patients with lived experience were involved in codesign and coproduction of this workshop and analysis as partners and coauthors. Patient discussions were the primary data source. Facilitators provided a semi-structured guide, but they did not influence the patient discussions or provide clinical advice. The premise of this workshop was to prioritise the importance of patient lived experience: to listen, learn, then reflect together to understand and propose ideas to improve patient care through codesign of a PtDA.
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Affiliation(s)
- Kelly Kohut
- School of Health Sciences, Centre for Psychosocial Research in Cancer (CentRIC)University of SouthamptonSouthamptonUK
- St George's University Hospitals NHS Foundation TrustLondonUK
| | - Kate Morton
- School of Health Sciences, Centre for Psychosocial Research in Cancer (CentRIC)University of SouthamptonSouthamptonUK
| | - Karen Hurley
- Stanford R. Weiss, MD Center for Hereditary Colorectal NeoplasiaCleveland ClinicClevelandOhioUSA
| | | | | | | | | | | | | | | | | | | | | | | | - Elizabeth Bancroft
- Cancer Genetics Unit and Academic Urology UnitThe Royal Marsden NHS Foundation TrustLondonUK
- Oncogenetics TeamThe Institute of Cancer ResearchLondonUK
| | - Lily Barnett
- St George's University Hospitals NHS Foundation TrustLondonUK
| | - Sarah Cable
- St George's University Hospitals NHS Foundation TrustLondonUK
| | - Gaya Connolly
- St George's University Hospitals NHS Foundation TrustLondonUK
| | - Beth Coad
- St George's University Hospitals NHS Foundation TrustLondonUK
| | - Andrea Forman
- St George's University Hospitals NHS Foundation TrustLondonUK
| | - Helen Hanson
- St George's University Hospitals NHS Foundation TrustLondonUK
| | - Grace Kavanaugh
- Division of Genetics and EpidemiologyThe Institute of Cancer ResearchLondonUK
| | - Katherine Sahan
- Nuffield Department of Population Health, The Ethox CentreUniversity of OxfordOxfordUK
| | - Katie Snape
- St George's University Hospitals NHS Foundation TrustLondonUK
| | - Bethany Torr
- Division of Genetics and EpidemiologyThe Institute of Cancer ResearchLondonUK
| | - Rosalind Way
- Division of Genetics and EpidemiologyThe Institute of Cancer ResearchLondonUK
| | | | - Alice Youngs
- St George's University Hospitals NHS Foundation TrustLondonUK
| | | | - Diana Eccles
- Faculty of MedicineUniversity of SouthamptonSouthamptonUK
| | - Claire Foster
- School of Health Sciences, Centre for Psychosocial Research in Cancer (CentRIC)University of SouthamptonSouthamptonUK
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8
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Abondio P, Cilli E, Luiselli D. Human Pangenomics: Promises and Challenges of a Distributed Genomic Reference. Life (Basel) 2023; 13:1360. [PMID: 37374141 DOI: 10.3390/life13061360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/02/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023] Open
Abstract
A pangenome is a collection of the common and unique genomes that are present in a given species. It combines the genetic information of all the genomes sampled, resulting in a large and diverse range of genetic material. Pangenomic analysis offers several advantages compared to traditional genomic research. For example, a pangenome is not bound by the physical constraints of a single genome, so it can capture more genetic variability. Thanks to the introduction of the concept of pangenome, it is possible to use exceedingly detailed sequence data to study the evolutionary history of two different species, or how populations within a species differ genetically. In the wake of the Human Pangenome Project, this review aims at discussing the advantages of the pangenome around human genetic variation, which are then framed around how pangenomic data can inform population genetics, phylogenetics, and public health policy by providing insights into the genetic basis of diseases or determining personalized treatments, targeting the specific genetic profile of an individual. Moreover, technical limitations, ethical concerns, and legal considerations are discussed.
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Affiliation(s)
- Paolo Abondio
- Laboratory of Ancient DNA, Department of Cultural Heritage, University of Bologna, Via degli Ariani 1, 48121 Ravenna, Italy
| | - Elisabetta Cilli
- Laboratory of Ancient DNA, Department of Cultural Heritage, University of Bologna, Via degli Ariani 1, 48121 Ravenna, Italy
| | - Donata Luiselli
- Laboratory of Ancient DNA, Department of Cultural Heritage, University of Bologna, Via degli Ariani 1, 48121 Ravenna, Italy
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9
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Lyle K, Weller S, Horton R, Lucassen A. Immortal data: a qualitative exploration of patients' understandings of genomic data. Eur J Hum Genet 2023; 31:681-686. [PMID: 37002328 PMCID: PMC10250296 DOI: 10.1038/s41431-023-01325-9] [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: 07/05/2022] [Revised: 01/30/2023] [Accepted: 02/21/2023] [Indexed: 04/03/2023] Open
Abstract
As ambitions to 'mainstream' genetic and genomic medicine in the UK advance, patients are increasingly exposed to information about genomic data. Unlike the results of many other medical investigations which are linked to the time of sample collection, genomic testing provides immortal data that do not change across time, and may have relevance for relatives and generations far beyond the patient's own lifespan. This immortality raises new ethical challenges for healthcare professionals, patients and families alike, such as ensuring consent for possible future interpretations; determining when genomic data are best sought (at birth, on illness etc) and reinterpreted; and balancing the confidentiality of patients and duties of care towards others. This paper reports on qualitative work exploring the perspectives of patients and relatives participating in genomic testing, and suggests that their engagements with this immortality are shaped by: the contrast between the simplicity of sample provision and information gathered; understandings of heritability; and notions of genomic data as a collective resource. We discuss the implications this holds for practice and argue that the immortality of genomic data must take a more prominent position in patient and healthcare professional interactions.
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Affiliation(s)
- Kate Lyle
- Clinical Ethics, Law and Society (CELS), Wellcome Centre for Human Genetics, University of Oxford, Oxford, UK.
- Clinical Ethics, Law and Society (CELS), Primary Care Population Sciences and Medical Education, University of Southampton Faculty of Medicine, Southampton, UK.
| | - Susie Weller
- Clinical Ethics, Law and Society (CELS), Wellcome Centre for Human Genetics, University of Oxford, Oxford, UK
- Clinical Ethics, Law and Society (CELS), Primary Care Population Sciences and Medical Education, University of Southampton Faculty of Medicine, Southampton, UK
- Centre for Personalised Medicine, University of Oxford, Oxford, UK
| | - Rachel Horton
- Clinical Ethics, Law and Society (CELS), Wellcome Centre for Human Genetics, University of Oxford, Oxford, UK
- Clinical Ethics, Law and Society (CELS), Primary Care Population Sciences and Medical Education, University of Southampton Faculty of Medicine, Southampton, UK
- Centre for Personalised Medicine, University of Oxford, Oxford, UK
| | - Anneke Lucassen
- Clinical Ethics, Law and Society (CELS), Wellcome Centre for Human Genetics, University of Oxford, Oxford, UK
- Clinical Ethics, Law and Society (CELS), Primary Care Population Sciences and Medical Education, University of Southampton Faculty of Medicine, Southampton, UK
- Centre for Personalised Medicine, University of Oxford, Oxford, UK
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10
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Tommel J, Kenis D, Lambrechts N, Brohet RM, Swysen J, Mollen L, Hoefmans MJF, Pusparum M, Evers AWM, Ertaylan G, Roos M, Hens K, Houwink EJF. Personal Genomes in Practice: Exploring Citizen and Healthcare Professionals’ Perspectives on Personalized Genomic Medicine and Personal Health Data Spaces Using a Mixed-Methods Design. Genes (Basel) 2023; 14:genes14040786. [PMID: 37107544 PMCID: PMC10137790 DOI: 10.3390/genes14040786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/15/2023] [Accepted: 03/22/2023] [Indexed: 03/30/2023] Open
Abstract
Ongoing health challenges, such as the increased global burden of chronic disease, are increasingly answered by calls for personalized approaches to healthcare. Genomic medicine, a vital component of these personalization strategies, is applied in risk assessment, prevention, prognostication, and therapeutic targeting. However, several practical, ethical, and technological challenges remain. Across Europe, Personal Health Data Space (PHDS) projects are under development aiming to establish patient-centered, interoperable data ecosystems balancing data access, control, and use for individual citizens to complement the research and commercial focus of the European Health Data Space provisions. The current study explores healthcare users’ and health care professionals’ perspectives on personalized genomic medicine and PHDS solutions, in casu the Personal Genetic Locker (PGL). A mixed-methods design was used, including surveys, interviews, and focus groups. Several meta-themes were generated from the data: (i) participants were interested in genomic information; (ii) participants valued data control, robust infrastructure, and sharing data with non-commercial stakeholders; (iii) autonomy was a central concern for all participants; (iv) institutional and interpersonal trust were highly significant for genomic medicine; and (v) participants encouraged the implementation of PHDSs since PHDSs were thought to promote the use of genomic data and enhance patients’ control over their data. To conclude, we formulated several facilitators to implement genomic medicine in healthcare based on the perspectives of a diverse set of stakeholders.
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Affiliation(s)
- Judith Tommel
- Health, Medical, and Neuropsychology Unit, Institute of Psychology, Faculty of Social and Behavioural Sciences, Leiden University, Wassenaarseweg 52, 2333 AK Leiden, The Netherlands
- Department of Psychiatry, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
- Correspondence: (J.T.); (D.K.)
| | - Daan Kenis
- Department of Philosophy, University of Antwerp, Rodestraat 14, 2000 Antwerp, Belgium
- Correspondence: (J.T.); (D.K.)
| | | | - Richard M. Brohet
- Department of Epidemiology and Statistics, Isala Hospital, Dokter van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | | | | | | | - Murih Pusparum
- VITO Health, Boeretang 200, 2400 Mol, Belgium
- Data Science Institute, I-Biostat, Hasselt University, 3500 Hasselt, Belgium
| | - Andrea W. M. Evers
- Health, Medical, and Neuropsychology Unit, Institute of Psychology, Faculty of Social and Behavioural Sciences, Leiden University, Wassenaarseweg 52, 2333 AK Leiden, The Netherlands
| | | | - Marco Roos
- Department of Human Genetics, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Kristien Hens
- Department of Philosophy, University of Antwerp, Rodestraat 14, 2000 Antwerp, Belgium
| | - Elisa J. F. Houwink
- Department of Family Medicine, Mayo Clinic, 221 Fourth Avenue SW, Rochester, MN 55905, USA
- Department of Public Health and Primary Care (PHEG), Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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11
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Horton R, Lucassen A. Ethical Considerations in Research with Genomic Data. New Bioeth 2023; 29:37-51. [PMID: 35484929 DOI: 10.1080/20502877.2022.2060590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Our ability to generate genomic data is currently well ahead of our ability to understand what they mean, raising challenges about how best to engage with them. This article considers ethical aspects of work with such data, focussing on research contexts that are intertwined with clinical care. We discuss the identifying nature of genomic data, the medical information intrinsic within them, and their linking of people within a biological family. We go on to consider what this means for consent, the importance of thoughtful sharing of genomic data, the challenge of constructing meaningful findings, and the legacy of unequal representation in genomic datasets. We argue that the ongoing success of genomic data research relies on public trust in the enterprise: to justify this trust, we need to ensure robust stewarding, and wide engagement about the ethical issues inherent in such practices.
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Affiliation(s)
- Rachel Horton
- Centre for Personalised Medicine, St Anne's College, University of Oxford, Oxford, UK.,Clinical Ethics, Law and Society, University of Southampton, Southampton, UK
| | - Anneke Lucassen
- Centre for Personalised Medicine, St Anne's College, University of Oxford, Oxford, UK.,Clinical Ethics, Law and Society, Wellcome Centre for Human Genetics, University of Oxford, Oxford, UK
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12
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Singh S, Cadigan RJ, Moodley K. Research-Related Stakeholders' Perspectives on Sociocultural Considerations in Biobanking Practice in South Africa. Biopreserv Biobank 2023; 21:81-89. [PMID: 35759422 PMCID: PMC9963473 DOI: 10.1089/bio.2021.0149] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background: Biobanking practice continues to proliferate in South Africa, yet little is known about how stakeholders engage with social, cultural, and religious considerations in this area of research. This study was undertaken to establish the perspectives of South African stakeholders (researchers, biobankers, clinicians, and research committee members) on sociocultural considerations in biobanking research. Methods: This in-depth exploratory study used semistructured face-to-face or Skype interviews with 25 purposively selected stakeholders involved in the biobanking-related practice. The study sample comprised biobankers, clinicians, researchers, postgraduate students in biobanking research, and research ethics committee members in South Africa. The interview focused on social and cultural challenges facing the biobanking practice in the country. Further probes included stakeholder perspectives on ownership and custodianship of stored biosamples. Thematic analysis was used to analyze the collected data. Results and Discussion: Several themes arose from the data analysis. These included respondents' perceptions of poor understanding of biobanking among research participants and communities; inconsistency in defining ownership and custodianship of biosamples; variability in respondents' understanding of cultural, religious, and social implications of biobanking; the notion of distrust; and building trust in biobanking. There were also inconsistencies in respondents' recognition of social, cultural, and/or religious influences on participant decision-making in biobanking research. Respondents highlighted that a general climate of distrust existed in the biobanking practice in South Africa. Conclusion: There is a need for greater stakeholder awareness of sociocultural considerations in biobanking practice in South Africa. One possible way to achieve this could be through the availability of training programs aimed at improving stakeholder understanding of the sociocultural context for biobanking practice in addition to greater efforts at community engagement with respect to all biobanking activities and research.
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Affiliation(s)
- Shenuka Singh
- Department of Medicine, Centre for Medical Ethics and Law, Faculty of Health Sciences, Stellenbosch University, Tygerberg, Cape Town, South Africa
| | - Rosemary Jean Cadigan
- Department of Social Medicine, Center for Bioethics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Keymanthri Moodley
- Department of Medicine, Centre for Medical Ethics and Law, Faculty of Health Sciences, Stellenbosch University, Tygerberg, Cape Town, South Africa
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13
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Singh S, Engel-Hills P. Invited Peer Commentary: Research Site Anonymity in Context. J Empir Res Hum Res Ethics 2022; 17:565-572. [PMID: 36394587 DOI: 10.1177/19401612221138478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Shenuka Singh
- Discipline of Dentistry, School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Penelope Engel-Hills
- Faculty of Health and Wellness Sciences, Cape Peninsula University of Technology, Western Cape, South Africa
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14
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Lynch F, Prentice T, Gillam L, Stark Z, Gyngell C. Rapid Genome Sequencing: Consent for New Technologies in the Neonatal Intensive Care Context. Pediatrics 2022; 150:190125. [PMID: 36443237 DOI: 10.1542/peds.2022-058222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/09/2022] [Indexed: 11/30/2022] Open
Abstract
The clinical utility of rapid genome sequencing (rGS) in critically unwell infants has been consistently demonstrated, and there are calls for rGS to be implemented as a first-line test in the NICU. A diagnosis from rGS can enable rapid initiation of precision treatment, making it potentially lifesaving. However, in many patients rGS leads to the diagnosis of severe and life-limiting conditions, prompting discussion with families about withdrawal of life-sustaining treatment. The complexity of information about rGS, together with the heightened emotions of parents in the NICU, poses significant challenges for informed decision making in this context. We present a case where both parents are unable to provide informed consent, and the treating team must decide whether to proceed with rGS. Our discussion highlights the important differences between genome sequencing and other types of genetic testing, and the crucial role played by pre-test counseling in facilitating informed consent and preparing parents for a range of possible outcomes. We then discuss the consent paradigms at play in NICUs; whereas admission generally comes with an understanding that the treating team will perform interventions thought to be in the best interest of the child, rGS is substantially different because of its long-term implications for patients and family members. Finally, we look at the ethical interplay between parental consent and the interests of the child. We conclude by showing how cases like this are resolved at our tertiary center and how they may be resolved differently in future.
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Affiliation(s)
- Fiona Lynch
- Murdoch Children's Research Institute, Melbourne, Australia.,Melbourne Law School, The University of Melbourne, Melbourne, Australia
| | - Trisha Prentice
- Murdoch Children's Research Institute, Melbourne, Australia.,The Royal Children's Hospital, Melbourne, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Lynn Gillam
- The Royal Children's Hospital, Melbourne, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Zornitza Stark
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia.,Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Melbourne, Australia.,Australian Genomics Health Alliance, Melbourne, Australia
| | - Christopher Gyngell
- Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Australia.,Melbourne Law School, The University of Melbourne, Melbourne, Australia
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15
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Nansumba H, Flaviano M, Patrick S, Isaac S, Wassenaar D. Health care users' acceptance of broad consent for storage of biological materials and associated data for research purposes in Uganda. Wellcome Open Res 2022; 7:73. [PMID: 38037644 PMCID: PMC10687383 DOI: 10.12688/wellcomeopenres.17633.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2022] [Indexed: 12/02/2023] Open
Abstract
Background: Implementation of appropriate informed consent has become a cornerstone for the use of biological materials and data from clinical care to use in research. During 2017-2018, the Ugandan National Biorepository has since sought prior informed consent for long-term storage and use of remnant clinical human biological materials, where a shortened informed consent form (ICF) was incorporated on the laboratory investigation form. This project aimed at determining the acceptability rate of broad consent from health care users (HCUs) for storage of biological materials and data for research purposes in Uganda. Methods: A cross-sectional study was conducted at three Primary Health Care Facilities. 500 HCUs above 18 years of age seeking health care at outpatient departments between March to December 2020 were invited to enrol. A shortened experimental ICF for this study was developed and attached to the Laboratory investigation form. Results: Overall the acceptability of broad consent for storage of biological materials and data was 86.2% [95% CI: 82.9%-88.9%]. Compared to participants who perceived that the informed consent information is understandable (OR=0.10, CI [0.03-0.32], participants who either partly or totally disagreed were significantly less likely to perceive information as understandable (OR=0.27, CI [0.15-0.46]. 226 out of 431 respondents that accepted storage of biological materials and data, majority (61.7%) preferred to receive feedback on results of relevance to their health. Conclusion: Acceptance of broad consent for storage of biological materials and data for future research purposes was high among HCUs. A shortened and simplified ICF may trigger discussions between participants and health care workers hence increase research participant understanding of study related materials in biobanking. This in turn could enrich ethically collected biobank resources for future research of public health relevance.
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Affiliation(s)
- Hellen Nansumba
- Central Public Health Laboratories (CPHL), Ministry of Health of Uganda, Kampala, Uganda
| | - Mugalula Flaviano
- Central Public Health Laboratories (CPHL), Ministry of Health of Uganda, Kampala, Uganda
| | - Semanda Patrick
- Central Public Health Laboratories (CPHL), Ministry of Health of Uganda, Kampala, Uganda
| | - Ssewanyana Isaac
- Central Public Health Laboratories (CPHL), Ministry of Health of Uganda, Kampala, Uganda
| | - Douglas Wassenaar
- South African Research Ethics Training Initiative (SARETI), University of KwaZulu-Natal, South Africa, Kwazulu-Natal, South Africa
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16
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Costa A, Franková V, Robert G, Macek M, Patch C, Alexander E, Arellanesova A, Clayton-Smith J, Hunter A, Havlovicová M, Pourová R, Pritchard M, Roberts L, Zoubková V, Metcalfe A. Co-designing models for the communication of genomic results for rare diseases: a comparative study in the Czech Republic and the United Kingdom. J Community Genet 2022; 13:313-327. [PMID: 35523996 PMCID: PMC9075921 DOI: 10.1007/s12687-022-00589-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 04/11/2022] [Indexed: 11/24/2022] Open
Abstract
The communication of genomic results to patients and families with rare diseases raise distinctive challenges. However, there is little evidence about optimal methods to communicate results to this group of service users. To address this gap, we worked with rare disease families and health professionals from two genetic/genomic services, one in the United Kingdom and one in the Czech Republic, to co-design that best meet their needs. Using the participatory methodology of Experience-Based Co-Design (EBCD), we conducted observations of clinical appointments (n=49) and interviews with family participants (n=23) and health professionals (n=22) to gather their experience of sharing/receiving results. The findings informed a facilitated co-design process, comprising 3 feedback events at each site and a series of meetings and remote consultations. Participants identified a total of four areas of current service models in need of improvement, and co-designed six prototypes of quality improvement interventions. The main finding was the identification of post-test care as the shared priority for improvement for both health professionals and families at the two sites. Our findings indicate the need to strengthen the link between diagnostics (whether or not a pathogenic variant is found) and post-test care, including psychosocial and community support. This raises implications for the reconfigurations of genomic service models, the redefinition of professional roles and responsibilities and the involvement of rare disease patients and families in health care research.
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Affiliation(s)
- Alessia Costa
- Engagement and Society, Wellcome Connecting Science, Hinxton, CB10 1SA, Cambridgeshire, UK. .,Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, SE1 8WA, UK.
| | - Věra Franková
- Department of Paediatrics and Inherited Metabolic Disorders, Charles University, First Faculty of Medicine and General University Hospital, Prague, Czech Republic. .,Institute for Medical Humanities, Charles University, First Faculty of Medicine, Prague, Czech Republic.
| | - Glenn Robert
- Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, SE1 8WA, UK
| | - Milan Macek
- Department of Biology and Medical Genetics, Charles University, Second Faculty of Medicine, and University Hospital Motol, Prague, Czech Republic
| | - Christine Patch
- Engagement and Society, Wellcome Connecting Science, Hinxton, CB10 1SA, Cambridgeshire, UK.,Genomics England, London, EC1M 6BQ, UK
| | - Elizabeth Alexander
- Manchester Centre For Genomic Medicine, University of Manchester, St Mary's Hospital, Manchester, M13 9WL, UK
| | - Anna Arellanesova
- Česká asociace pro vzácná onemocnění (ČAVO), Rare Diseases Czech Republic, Bělohorská 19, Praha 6, 169 00, Czech Republic
| | - Jill Clayton-Smith
- Manchester Centre For Genomic Medicine, University of Manchester, St Mary's Hospital, Manchester, M13 9WL, UK.,Division of Evolution and Genomic Sciences School of Biological Sciences, University of Manchester, Manchester, M13 9PL, UK
| | - Amy Hunter
- Genetic Alliance UK, London, EC2A 4NE, UK
| | - Markéta Havlovicová
- Department of Biology and Medical Genetics, Charles University, Second Faculty of Medicine, and University Hospital Motol, Prague, Czech Republic
| | - Radka Pourová
- Department of Biology and Medical Genetics, Charles University, Second Faculty of Medicine, and University Hospital Motol, Prague, Czech Republic
| | | | - Lauren Roberts
- Genetic Alliance UK, London, EC2A 4NE, UK.,Syndromes Without A Name (SWAN UK), London, EC2A 4NE, UK
| | - Veronika Zoubková
- Department of Biology and Medical Genetics, Charles University, Second Faculty of Medicine, and University Hospital Motol, Prague, Czech Republic
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17
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Weller S, Lyle K, Lucassen A. Re-imagining ‘the patient’: Linked lives and lessons from genomic medicine. Soc Sci Med 2022; 297:114806. [PMID: 35219975 PMCID: PMC8943276 DOI: 10.1016/j.socscimed.2022.114806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/07/2022] [Accepted: 02/10/2022] [Indexed: 11/17/2022]
Abstract
How ‘the patient’ is imagined has implications for ethical decision-making in clinical practice. Patients are predominantly conceived in an individualised manner as autonomous and independent decision-makers. Fields such as genomic medicine highlight the inadequacies of this conceptualisation as patients are likely to have family members who may be directly affected by the outcome of tests in others. Indeed, professional guidance has increasingly taken a view that genetic information should, at times, be regarded as of relevance to families, rather than individuals. What remains absent from discussions is an understanding of how those living through/with genomic testing articulate, construct, and represent patienthood, and what such understandings might mean for practice, particularly ethical decision-making. Employing the notion of ‘linked lives’ from lifecourse theory, this article presents findings from a UK-based qualitative longitudinal study following the experiences of those affected by the process and outcomes of genomic testing. The article argues that there is a discord between lived experiences and individualised notions of ‘the patient’ common in conventional bioethics, with participants predominantly locating their own decision-making within the matrix of linked lives in which they are embedded. In the quest to gain ‘answers’, many took an intra or intergenerational view, connecting their own experiences to those of past generations through familial narratives around probable explanations, and/or hopes and expectations for the health of imagined future generations. The article argues that a re-imagining of ‘the patient’, that reflects the complex and shifting nature of patienthood, will be imperative as genomic medicine is mainstreamed. How ‘the patient’ is imagined has implications for ethical decision-making. Genomic medicine shows the shortcomings of individualised notions of ‘the patient’. Instead, a ‘linked lives’ lens highlights the ensembles of relationships affected. Participants reported more collective inter/intra-generational views of patienthood. Re-imagining patienthood beyond the individual is vital as genomics is mainstreamed.
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Affiliation(s)
- Susie Weller
- Clinical Ethics, Law and Society (CELS); Wellcome Centre for Human Genetics, University of Oxford, UK; Clinical Ethics, Law and Society (CELS) - Southampton, Faculty of Medicine, University of Southampton, UK.
| | - Kate Lyle
- Clinical Ethics, Law and Society (CELS); Wellcome Centre for Human Genetics, University of Oxford, UK; Clinical Ethics, Law and Society (CELS) - Southampton, Faculty of Medicine, University of Southampton, UK
| | - Anneke Lucassen
- Clinical Ethics, Law and Society (CELS); Wellcome Centre for Human Genetics, University of Oxford, UK; Clinical Ethics, Law and Society (CELS) - Southampton, Faculty of Medicine, University of Southampton, UK
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18
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Samuel G, Lucassen A. The environmental sustainability of data-driven health research: A scoping review. Digit Health 2022; 8:20552076221111297. [PMID: 35847526 PMCID: PMC9277423 DOI: 10.1177/20552076221111297] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/14/2022] [Accepted: 06/15/2022] [Indexed: 11/15/2022] Open
Abstract
Data-Driven and Artificial Intelligence technologies are rapidly changing the way that health research is conducted, including offering new opportunities. This will inevitably have adverse environmental impacts. These include carbon dioxide emissions linked to the energy required to generate and process large amounts of data; the impact on the material environment (in the form of data centres); the unsustainable extraction of minerals for technological components; and e-waste (discarded electronic appliances) disposal. The growth of Data-Driven and Artificial Intelligence technologies means there is now a compelling need to consider these environmental impacts and develop means to mitigate them. Here, we offer a scoping review of how the environmental impacts of data storage and processing during Data-Driven and Artificial Intelligence health-related research are being discussed in the academic literature. Using the UK as a case study, we also offer a review of policies and initiatives that consider the environmental impacts of data storage and processing during Data-Driven and Artificial Intelligence health-related research in the UK. Our findings suggest little engagement with these issues to date. We discuss the implications of this and suggest ways that the Data-Driven and Artificial Intelligence health research sector needs to move to become more environmentally sustainable.
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Affiliation(s)
- Gabrielle Samuel
- Department of Global Health and Social Medicine, King's College London, London, UK
- Wellcome Centre for Human Genetics, Oxford University, Oxford, UK
| | - A.M. Lucassen
- Wellcome Centre for Human Genetics, Oxford University, Oxford, UK
- Clinical ethics, law and society (CELS) Faculty of Medicine, University of Southampton
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19
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Schmitz D, Henn W. The fetus in the age of the genome. Hum Genet 2021; 141:1017-1026. [PMID: 34426855 PMCID: PMC9160108 DOI: 10.1007/s00439-021-02348-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 08/16/2021] [Indexed: 12/15/2022]
Abstract
Due to a number of recent achievements, the field of prenatal medicine is now on the verge of a profound transformation into prenatal genomic medicine. This transformation is expected to not only substantially expand the spectrum of prenatal diagnostic and screening possibilities, but finally also to advance fetal care and the prenatal management of certain fetal diseases and malformations. It will come along with new and profound challenges for the normative framework and clinical care pathways in prenatal (and reproductive) medicine. To adequately address the potential ethically challenging aspects without discarding the obvious benefits, several agents are required to engage in different debates. The permissibility of the sequencing of the whole fetal exome or genome will have to be examined from a philosophical and legal point of view, in particular with regard to conflicts with potential rights of future children. A second requirement is a societal debate on the question of priority setting and justice in relation to prenatal genomic testing. Third, a professional-ethical debate and positioning on the goal of prenatal genomic testing and a consequential re-structuring of clinical care pathways seems to be important. In all these efforts, it might be helpful to envisage the unborn rather not as a fetus, not as a separate moral subject and a second "patient", but in its unique physical connection with the pregnant woman, and to accept the moral quandaries implicitly given in this situation.
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Affiliation(s)
- Dagmar Schmitz
- Institute for History, Theory and Ethics in Medicine, RWTH Aachen University, Wendlingweg 2, 52074, Aachen, Germany.
| | - Wolfram Henn
- Institute of Human Genetics, Saarland University, Homburg/Saar, Germany
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20
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Ralefala D, Kasule M, Wonkam A, Matshaba M, de Vries J. Should Feedback of Individual Results be Integrated into the Consent Process in African Genomics? Participants' Views from an HIV-TB Genomics Research Project in Botswana. AJOB Empir Bioeth 2021; 13:48-56. [PMID: 34197280 DOI: 10.1080/23294515.2021.1941414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Whilst informed consent is a key component of considering whether individual genomic research results could or should be fed back to research participants, little is known about the views of African research participants on its role. METHODS We carried out a qualitative study to explore views of adolescents and parents or caregivers regarding informed consent for feedback of individual results from a genomics research project in Botswana. We conducted 24 deliberative focus group discussions with 93 participants (44 adolescents and 49 parents or caregivers) and 12 in-depth interviews (6 adolescents and 6 parents). RESULTS Our findings revealed that most participants would like to be informed about the possibility of discovering individual genetic results during the consent process and that consent be obtained for feedback during the enrollment process. They further expressed that in cases where prior consent to feedback was not obtained, then participants should be re-contacted where life-saving genetic information is discovered. Participants emphasized the need for researchers to ensure that participants' decisions regarding feedback of results are well-informed. Autonomy, transparency, and communication were identified as key values to uphold during the consent process. CONCLUSION In conclusion, obtaining participants' consent for feedback of results is important to ensure that their rights and wellbeing are protected in research. This is critical in building trust relationships between participants and researchers.
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Affiliation(s)
- Dimpho Ralefala
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Office of Research and Development, University of Botswana, Gaborone, Botswana
| | - Mary Kasule
- Botswana-Baylor Children's Clinical Centre of Excellence, Gaborone, Botswana
| | - Ambroise Wonkam
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Deputy Dean's Office, Faculty of Health Sciences and Groote Schuur Hospital, Cape Town, South Africa
| | - Mogomotsi Matshaba
- Botswana-Baylor Children's Clinical Centre of Excellence, Gaborone, Botswana.,Baylor College of Medicine, Houston, Texas, USA
| | - Jantina de Vries
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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21
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Speechly C, Stenhouse R, Berman Y, Barlow-Stewart K, Fleming J, Petrie D, Culling B. Genetic counselors, patients', and carers' views on an Australian clinical genetics service information system. J Genet Couns 2021; 30:1440-1451. [PMID: 33866647 DOI: 10.1002/jgc4.1412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 02/14/2021] [Accepted: 02/15/2021] [Indexed: 11/07/2022]
Abstract
The Genetic Information System (GIS) is an Australian database of family genetic information. This health information technology system has been used by all 31 publicly operated clinical genetics services across New South Wales (NSW) and the Australian Capital Territory (ACT) for over a decade. As these services are separated geographically, the linkage engendered by the GIS facilitates the services to operate as a virtual state-wide service. This study aimed to explore the views of genetic counselors, patients, and carers on the use and storage of family genetic information in the GIS. Data were collected using audio-recorded semi-structured telephone interviews with genetic counselors experienced with using the GIS and focus groups with past patients/carers of the services. Using thematic analysis, four themes were identified from genetic counselor participant interviews (n = 12): (a) Shared information is valuable; (b) inconsistent data entry provides a challenge; (c) perceived need for the GIS to be current and integrated with other health systems; and (d) future challenges and strategies for the GIS. Three themes were identified following three focus groups with consumer participants (n = 14): (a) access to family genetic information provides a 'clearer picture'; (b) support, but caution, concerning use of information for relatives' health care; and (c) stewardship of family information. Genetic counselors and consumers identified similar advantages and privacy concerns regarding the sharing of family genetic information and all participants wanted patients/carers to be better informed about the GIS early in the genetic counseling process. Consumers were reassured by genetics health professionals' stewardship of their information, but surprised the GIS was not available nationally or for private geneticists or certain non-genetic specialists. These findings may inform further development of the GIS and other clinical genetic databases and lead to increased patient/carer knowledge through education and resource development.
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Affiliation(s)
- Catherine Speechly
- Faculty of Medicine and Health, Northern Clinical School, University of Sydney, St Leonards, NSW, Australia
| | - Rachael Stenhouse
- Faculty of Medicine and Health, Northern Clinical School, University of Sydney, St Leonards, NSW, Australia
| | - Yemima Berman
- Faculty of Medicine and Health, Northern Clinical School, University of Sydney, St Leonards, NSW, Australia.,Department of Clinical Genetics, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Kristine Barlow-Stewart
- Faculty of Medicine and Health, Northern Clinical School, University of Sydney, St Leonards, NSW, Australia
| | - Jane Fleming
- Faculty of Medicine and Health, Northern Clinical School, University of Sydney, St Leonards, NSW, Australia
| | | | - Bronwyn Culling
- Clinical Applications Support, Service Delivery, eHealth NSW, Chatswood, NSW, Australia
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22
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Filoche S, Stone P, Cram F, Bacharach S, Dowell A, Sika-Paotonu D, Beard A, Ormandy J, Buchanan C, Thunders M, Dew K. Uncovering social structures and informational prejudices to reduce inequity in delivery and uptake of new molecular technologies. JOURNAL OF MEDICAL ETHICS 2020; 46:763-767. [PMID: 31911498 PMCID: PMC7656149 DOI: 10.1136/medethics-2019-105734] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 11/16/2019] [Accepted: 11/19/2019] [Indexed: 05/08/2023]
Abstract
Advances in molecular technologies have the potential to help remedy health inequities through earlier detection and prevention; if, however, their delivery and uptake (and therefore any benefits associated with such testing) are not more carefully considered, there is a very real risk that existing inequities in access and use will be further exacerbated. We argue this risk relates to the way that information and knowledge about the technology is both acquired and shared, or not, between health practitioners and their patients.A healthcare system can be viewed as a complex social network comprising individuals with different worldviews, hierarchies, professional cultures and subcultures and personal beliefs, both for those giving and receiving care. When healthcare practitioners are not perceived as knowledge equals, they would experience informational prejudices, and the result is that knowledge dissemination across and between them would be impeded. The uptake and delivery of a new technology may be inequitable as a result. Patients would also experience informational prejudice when they are viewed as not being able to understand the information that is presented to them, and information may be withheld.Informational prejudices driven by social relations and structures have thus far been underexplored in considering (in)equitable implementation and uptake of new molecular technologies. Every healthcare interaction represents an opportunity for experiencing informational prejudice, and with it the risk of being inappropriately informed for undertaking (or offering) such screening or testing. Making knowledge acquisition and information dissemination, and experiences of informational prejudice, explicit through sociologically framed investigations would extend our understandings of (in)equity, and offer ways to affect network relationships and structures that support equity in delivery and uptake.
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Affiliation(s)
- Sara Filoche
- Department of Obstetrics, Gynaecology and Women's Health and Department of Pathology and Molecular Medicine, University of Otago, Wellington, New Zealand
| | - Peter Stone
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | | | - Sondra Bacharach
- School of History, Philosophy, Political Science and International Relations, Victoria University, Wellington, New Zealand
| | - Anthony Dowell
- Department of Primary Health Care and General Practice, University of Otago Wellington, Wellington, New Zealand
| | - Dianne Sika-Paotonu
- Department of Pathology and Molecular Medicine, University of Otago, Wellington, New Zealand
| | - Angela Beard
- Christchurch Obstetric Associates, Christchurch, New Zealand
| | - Judy Ormandy
- Department of Obstetrics and Gynaecology, University of Otago, Christchurch, New Zealand
| | - Christina Buchanan
- Faculty of Medical and Health Sciences, The University of Auckland, New Zealand
| | - Michelle Thunders
- Department of Pathology and Molecular Medicine, University of Otago, Wellington, New Zealand
| | - Kevin Dew
- School of Social and Cultural Studies, Victoria University, Wellington, New Zealand
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23
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O'Sullivan L, Crowley R, McAuliffe É, Doran P. Contributory factors to the evolution of the concept and practice of informed consent in clinical research: A narrative review. Contemp Clin Trials Commun 2020; 19:100634. [PMID: 33024880 PMCID: PMC7528065 DOI: 10.1016/j.conctc.2020.100634] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/31/2020] [Accepted: 08/09/2020] [Indexed: 12/02/2022] Open
Abstract
Informed consent can be defined as a freely-given decision or agreement following disclosure of relevant information. This review explores how legislation surrounding informed consent has impacted upon clinical research practices, with a focus on clinical trials involving individuals with the capacity to give consent in the non-emergency setting. We also highlight the challenges which remain with the informed consent process, including those which exist in the era of data protection legislation and genetic research. Modern ethicists agree that informed consent encompasses three principal factors: disclosure of information, capacity for decision making, and voluntariness. In the context of clinical research, informed consent is now required by regulatory and ethical frameworks as well as by law, and various guidelines govern the practice of informed consent, including the Declaration of Helsinki and the Good Clinical Practice Guidelines. Historically, however, researchers acted paternalistically and included participants in research without their knowledge or consent. Following societal and political revolution, an autonomy model of consent became prevalent, and individuals became free to make individual choices about whether to participate. Despite this, it is also recognized that an individual's community has a role in supporting their decision making, and this may be a strong influence, particularly within some societies. Research scandals and controversies and whistle-blowers which exposed unethical practices in the area of informed consent also contributed to changes in societal attitudes and legislation changed as a result. Medical journals also have an established, although indirect, role in strengthening good practices surrounding informed consent.
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Affiliation(s)
- Lydia O'Sullivan
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland
- Health Research Board-Trials Methodology Research Network, National University of Ireland, Galway, Ireland
- School of Nursing, Midwifery and Health Systems, University College Dublin, Belfield, Dublin 4, Ireland
| | - Rachel Crowley
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland
- Department of Endocrinology, Saint Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Éilish McAuliffe
- School of Nursing, Midwifery and Health Systems, University College Dublin, Belfield, Dublin 4, Ireland
| | - Peter Doran
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland
- Health Research Board-Trials Methodology Research Network, National University of Ireland, Galway, Ireland
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24
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McDermott JH. Genetic testing in the acute setting: a round table discussion. JOURNAL OF MEDICAL ETHICS 2020; 46:531-532. [PMID: 32651253 PMCID: PMC7418589 DOI: 10.1136/medethics-2019-106043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 02/02/2020] [Indexed: 05/06/2023]
Abstract
Genetic testing has historically been performed in the context of chronic disease and cancer diagnostics. The timelines for these tests are typically measured in days or weeks, rather than in minutes. As such, the concept that genetic information might be generated and then used to alter management in the acute setting has, thus far, not been feasible. However, recent advances in genetic technologies have the potential to allow genetic information to be generated significantly quicker. The m.1555A>G genetic variant is present in one in 500 individuals and predisposes to profound hearing loss following the administration of aminoglycoside antibiotics. These antibiotics are used frequently in cases of neonatal sepsis and it is estimated that approximately 180 neonates in the UK are at risk of antibiotic induced hearing loss each year because of this genetic change. Knowledge of this variant in the acute setting would allow clinicians to prescribe alternative antibiotics. The Pharmacogenetics to Avoid Loss of Hearing study will implement a genetic point of care test (POCT) for the m.1555A>G variant within two major UK based neonatal intensive care units. This represents the first trial of a genetic POCT aimed at altering management in the acute setting. This round table discussion outlines the novel ethical issues faced in the development of this trial and the legal barriers to implementation. We ask five stakeholders to provide their opinions on this trial and their perspectives on the concept of genetic testing in the acute setting.Trial registration numberISRCTN-13704894.
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Affiliation(s)
- John Henry McDermott
- Manchester Centre for Genomic, Manchester University NHS Foundation Trust, Manchester, UK
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Davies G, Butow P, Napier CE, Bartley N, Juraskova I, Meiser B, Ballinger ML, Thomas DM, Schlub TE, Best MC. Advanced Cancer Patient Knowledge of and Attitudes towards Tumor Molecular Profiling. Transl Oncol 2020; 13:100799. [PMID: 32450551 PMCID: PMC7256320 DOI: 10.1016/j.tranon.2020.100799] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/01/2020] [Accepted: 05/04/2020] [Indexed: 01/24/2023] Open
Abstract
Limited research has indicated that despite their overwhelming interest in tumor molecular profiling (MP),1 cancer patients have poor knowledge about MP. The current study aimed to investigate demographic and psychological predictors of knowledge and perceived importance of MP in an advanced cancer patient cohort. Eligible participants had advanced solid cancers of any histological type with sufficient accessible tissue for MP and were enrolled in the Molecular Screening and Therapeutics (MoST) Program. A questionnaire was completed by 1074 participants (91% response rate) after consent, prior to undergoing MP. Overall, participants had poor to moderate knowledge of MP, yet perceived MP to have high importance. Higher education, speaking English at home, and greater satisfaction with the decision to undergo MP were associated with higher knowledge scores. More negative attitudes towards uncertainty, greater self-efficacy to cope with results, and lower perceived likelihood of cancer progression were associated with greater perceived importance of MP. Less educated participants and those who do not speak English at home will need clear explanations, visual aids and ample opportunity to ask questions about MP at the time of their decision-making. Clinicians also need to consider psychological factors relevant to patients' decision to pursue MP. Given the increased awareness of and demand for cancer genomic information and the rapidly changing nature of the actionability of MP, these findings will help inform an important ongoing debate on how to facilitate ethical and informed consent and manage patient expectations about personalized treatments.
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Affiliation(s)
- Grace Davies
- The University of Sydney, Faculty of Science, School of Psychology, Psycho-Oncology Co-operative Research Group, Sydney, NSW 2006, Australia.
| | - Phyllis Butow
- The University of Sydney, Faculty of Science, School of Psychology, Psycho-Oncology Co-operative Research Group, Sydney, NSW 2006, Australia.
| | - Christine E Napier
- Cancer Division, Garvan Institute of Medical Research, Sydney, NSW 2010, Australia.
| | - Nicci Bartley
- The University of Sydney, Faculty of Science, School of Psychology, Psycho-Oncology Co-operative Research Group, Sydney, NSW 2006, Australia.
| | - Ilona Juraskova
- The University of Sydney, Faculty of Science, School of Psychology, Psycho-Oncology Co-operative Research Group, Sydney, NSW 2006, Australia.
| | - Bettina Meiser
- Psychosocial Research Group, Prince of Wales Clinical School, University of NSW, Sydney, NSW 2032, Australia.
| | - Mandy L Ballinger
- Cancer Division, Garvan Institute of Medical Research, Sydney, NSW 2010, Australia; St Vincent's Clinical School, University of NSW, Sydney, NSW 2010, Australia.
| | - David M Thomas
- Cancer Division, Garvan Institute of Medical Research, Sydney, NSW 2010, Australia; St Vincent's Clinical School, University of NSW, Sydney, NSW 2010, Australia.
| | - Timothy E Schlub
- The University of Sydney, Faculty of Medicine and Health, Sydney School of Public Health, Sydney, NSW 2006, Australia.
| | - Megan C Best
- The University of Sydney, Faculty of Science, School of Psychology, Psycho-Oncology Co-operative Research Group, Sydney, NSW 2006, Australia.
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Exploring broad consent in the context of the 100,000 Genomes Project: a mixed methods study. Eur J Hum Genet 2020; 28:732-741. [PMID: 31919452 DOI: 10.1038/s41431-019-0570-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 12/06/2019] [Accepted: 12/17/2019] [Indexed: 11/09/2022] Open
Abstract
The 100,000 Genomes Project (100kGP)-a hybrid clinical-research initiative-was set up to analyse whole-genome sequences (WGS) from patients living with a rare disease or cancer. The project positioned participant consent as being of central importance, but consent in the context of genomic testing raises challenging issues. In this mixed method study, we surveyed 1337 100kGP participants regarding their experiences of taking part in the project and conducted in-depth interviews with 24 survey respondents to explore these findings further. Survey responses were analysed using descriptive statistics and interview data were analysed thematically. The consent approach of the 100kGP resulted in a proportion of our study's participants not understanding the complexities of the project and what types of results they might receive; for example, 20% of participants who we surveyed from the cancer arm did not recall what decisions they had made regarding additional findings. It is not surprising that a project such as this, with such diverse aims and participant groups, would throw up at least some challenges. However, participants reported being satisfied with their experience of the project to date. Our study highlights that in the context of consent for more complex endeavours, such as the 100kGP, it is important to assess (and document) an agreement to take part, but complicated decisions about what and when to communicate may need revisiting over time in response to changing contexts. We discuss the implications of our findings with reference to participants of the 100kGP and the newly formed NHS Genomic Medicine Service.
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Horton R, Lucassen A. Genomic testing in healthcare: a hybrid space where clinical practice and research need to co-exist. Expert Rev Mol Diagn 2019; 19:963-967. [PMID: 31603004 PMCID: PMC6817952 DOI: 10.1080/14737159.2019.1672540] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 09/23/2019] [Indexed: 01/05/2023]
Abstract
Introduction: Clinical practice and research are traditionally seen as distinct activities that are governed by different principles and processes. Innovative technologies such as genomic testing challenge this model, involving many activities that cannot be easily categorized as purely research, or purely clinical care. Areas covered: We discuss the interdependence of research and clinical practice in the context of genomics, for example, when determining the significance of rare genetic variants, or diagnosing newly described rare diseases. We highlight the potential of the symbiotic relationship between clinical practice and research. Expert opinion: In the context of genomics, it is not appropriate to treat clinical practice and research as entirely separable. Forcing binary categorization of activities as one or the other risks losing the many benefits that derive from their integration. We need to explore the hybrid area where clinical practice and research coincide, developing governance that allows us to maximize its potential, rather than insisting that hybrid clinical-research activities conform to processes built for 'pure clinical practice' or 'pure research'. We argue the need for a renegotiation of the contract around genomic testing, recognizing, valuing and facilitating the hybrid space where clinical practice and research co-exist.
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Affiliation(s)
- Rachel Horton
- Clinical Ethics and Law at Southampton (CELS), Faculty of Medicine, University of Southampton, UK
- Wessex Clinical Genetics Service, Princess Anne Hospital, Southampton, UK
| | - Anneke Lucassen
- Clinical Ethics and Law at Southampton (CELS), Faculty of Medicine, University of Southampton, UK
- Wessex Clinical Genetics Service, Princess Anne Hospital, Southampton, UK
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