Pharmacogenetics, race, and ethnicity: social identities and individualized medical care

Racial biases in healthcare: Examining the contributions of Point of Care tools and unintended practitioner bias to patient treatment and diagnosis

Sophisticated algorithms are used daily to search through hundreds of medical journals in order to package updated medical insights into commercial databases. Healthcare practitioners can access these searchable databases-called Point of Care (PoC) tools-as downloadable apps on their smartphones or tablets to comprehensively and efficiently inform patient diagnosis and treatment. Because racist biases are unintentionally incorporated into the search reports that the companies generate and that practitioners regularly access, the aim of this article is to examine how healthcare practitioners' "pre-existing" racial stereotypes interact with pithy conclusions about race and ethnicity in PoC tools. I use qualitative research methods (content analysis, discourse analysis, open-ended semi-structured interviews, and role play) to frame the analysis within the Public Health Critical Race Praxis (PHCRP). This approach facilitates an understanding of how biological racism-the use of scientific evidence to support inherent differences between races-that is embedded in PoC algorithms informs a practitioner's assessment of a patient, and converges with persistent racial bias in medical training, medical research and healthcare. I contextualize the study with one semi-structured interview with an Editor of a leading PoC tool, MedScope (pseudonomized), and 10 semi-structured interviews with healthcare practitioners in S.E. Ontario, Canada. The article concludes that PoC tools and practitioners' personal biases contribute to racial prejudices in healthcare provision. This warrants further research on racial bias in medical literature and curriculum design in medical school.

The frequency of major ABCG2, SLCO1B1 and CYP2C9 variants in Asian, Native Hawaiian and Pacific Islander women subgroups: implications for personalized statins dosing

Aim: The frequencies of SLCO1B1*5 and CYP2C9*2 and *3 in specific Asian, Native Hawaiian and Pacific Islander (NHPI) subgroups are unknown. Patients & methods: Repository DNA samples from 1064 women self-identifying as Filipino, Korean, Japanese, Native Hawaiian, Marshallese or Samoan and aged 18 years or older were used for targeted sequencing of three genetic variants (rs4149056, rs1799853 and rs1057910). Results: SLCO1B1*5 was significantly less frequent in NHPI women (0.5-6%) than in Europeans (16%). Except for Koreans, CYP2C9*2 (0-1.4%) and *3 (0.5-3%) were significantly less frequent in all subgroups than in Europeans (8 and 12.7%, respectively). Prior reports showed that Asian and NHPI individuals have significantly higher ABCG2 Q141K allele frequency (13-46%) than Europeans (9.4%). Combined phenotype rates for rosuvastatin and fluvastatin revealed that Filipinos and Koreans had the highest frequencies of statin-associated myopathy symptoms risk alleles. Conclusion: Differences in ABCG2, SLCO1B1 and CYP2C9 allele frequencies among different racial and ethnic subgroups highlight the need for increased diversity in pharmacogenetic research. Risk alleles for statin-associated myopathy symptoms are more prevalent in Filipinos, underscoring the importance of genotype-based statin dosing.

Standardized Biogeographic Grouping System for Annotating Populations in Pharmacogenetic Research

The varying frequencies of pharmacogenetic alleles among populations have important implications for the impact of these alleles in different populations. Current population grouping methods to communicate these patterns are insufficient as they are inconsistent and fail to reflect the global distribution of genetic variability. To facilitate and standardize the reporting of variability in pharmacogenetic allele frequencies, we present seven geographically defined groups: American, Central/South Asian, East Asian, European, Near Eastern, Oceanian, and Sub-Saharan African, and two admixed groups: African American/Afro-Caribbean and Latino. These nine groups are defined by global autosomal genetic structure and based on data from large-scale sequencing initiatives. We recognize that broadly grouping global populations is an oversimplification of human diversity and does not capture complex social and cultural identity. However, these groups meet a key need in pharmacogenetics research by enabling consistent communication of the scale of variability in global allele frequencies and are now used by Pharmacogenomics Knowledgebase (PharmGKB).

A consumer adoption model for personalized medicine: an exploratory study

Purpose

– The purpose of this research is to identify factors linked to the potential acceptance of personalized medicine (PM) by consumers. Roger’s diffusion of innovation model (1995) and the work of Duguay et al. (2003) on transgenic biopharmaceuticals contributed to the development of the proposed conceptual model.

Design/methodology/approach

– The study design was an exploratory cross-sectional survey that used a Canadian national online panel of 307 respondents.

Findings

– The results suggest that the most important factors leading to consumer adoption of PM are knowledge, relative advantage and compatibility with existing values. The level of homophilus traits was negatively related to the acceptance of PM.

Originality/value

– Marketers will need to provide documented evidence of PM’s benefits over existing therapy based on improved efficacy and reduced side effects. Further, concerns about higher price, product distribution and drug reimbursement policies may limit its acceptance. This is the first study to examine the potential adoption and acceptance of PM by consumers.

The logic of identity and resemblance in culturally appropriate health care

Greater diversity in the health care workforce is frequently proposed as a means of addressing health disparities between minority and majority populations in the USA by improving health care access and quality for minority groups. ‘Culturally appropriate’ health care programs that include ethnic resemblance between physician and patient are emerging as new technologies of knowledge and power in a wide range of health care settings. Based on participant-observation research and interviews with patients and health care providers at a federally funded New England clinic, this article uses theories of cultural identity supported by ethnographic examples to examine arguments in favor of patient—provider resemblance. While ethnic identity is often assumed to incorporate cultural expertise or competence, in practice, developing and maintaining such expertise is the result of repeated performances developed in part through didactic trainings described herein. Claims for the efficacy of patient—provider resemblance in addressing disparities in quality of care mobilize notions of specificity, difference and recognition that both depend on and construct racialized ethnic identities. Proposed as a means to expand access to health care, resemblance programs nonetheless perpetuate segregation in health care by relying on minority health care providers to care for the minority poor. Both patients and health care providers I interviewed perceived benefits associated with ethnic resemblance, yet also articulated critiques of the essentialized notions of identity that render ethnicity automatically efficacious. Following Laclau, I argue that an exclusive focus on physician—patient resemblance constructs ethnicity as ‘mere particularity’ and in so doing helps to obscure the relations of power and inequality that produce the very health disparities that resemblance is meant to solve.

Genotyping the future: scientists' expectations about race/ ethnicity after BiDil

The ongoing debate about the FDA approval of BiDil in 2005 demonstrates how the first racially/ethnically licensed drug is entangled in both Utopian and dystopian future visions about the continued saliency of race/ethnicity in science and medicine. Drawing on the sociology of expectations, this paper analyzes how scientists in the field of pharmacogenetics are constructing certain visions of the future with respect to the use of social categories of race/ethnicity and the impact of high-throughput genotyping technologies that promise to transform scientific practices.

Racially classified social group tobacco-related health disparities: what is the role of genetics?

Certain racially classified social groups suffer disproportionately from tobacco-caused morbidity and mortality. Recent advances in genetics are leading researchers to examine variables that may account for this. However, it is critical that investigators proceed with caution and utilize transdisciplinary approaches. A number of fundamental questions might be used to stimulate consensus building in this area of science. What is race and how should its complexity be operationalized? Is it possible/likely that pharmacogenetics will allow us to match smokers with cessation strategies based on a gene-psychological profile? What are the most important conceptual and methodological issues for a research agenda in this area?

The Diffusion of Innovation: Factors Influencing the Uptake of Pharmacogenetics

BACKGROUND

Inspired by diffusion research, this paper examines how perceived need, health status, experiences with medicine and testing, consumption of mass media and sociodemography influence the public's familiarity, knowledge, attitudes and intentions regarding pharmacogenetics. The objective is to identify factors affecting the adoption pattern of pharmacogenetics in the public.

METHOD

The paper is based on an Internet-based questionnaire survey conducted in March 2005. A total of 3,000 representative Danes aged 18-70 years were included in the survey, representing a response rate of 58.9%.

RESULTS/CONCLUSION

Knowledge of pharmacogenetics, and thus the diffusion of the technology, is influenced by medicine consumption, experienced lack of effect and side effects, use of medical testing and perception of societal need. Increased knowledge is seen in all cases. The general perception of and attitude to pharmacogenetics is related to prior use of medical tests and perception of societal need for pharmacogenetics, which in both cases indicates an increased positive approach.

Pharmacogenetics and uncertainty: implications for policy makers

Uncertainty for policy makers is not new but the pressure to make decisions under conditions of uncertainty is perhaps greater than ever. The arrival of new scientific developments such as pharmacogenetics offers potentially great benefits (as well as significant risks). They have passionate supporters as well as doubters. The evidence is often extensive but unclear and policy makers may find themselves under pressure to make decisions before they feel that the evidence is compelling. The UK is particularly well placed to play a leading role in the development of pharmacogenetics and is equally well placed to derive the benefits to both health and wealth that could flow from this. However, the uncertainties threaten to overwhelm the capacity of policy makers to act effectively. The uncertainties are both about the context within which the science and delivery of pharmacogenetics is being developed and about the interests that could be served. This paper maps these uncertainties and concludes with some suggestions, drawing on deliberative democracy and futures thinking, as to how policy makers might manage the tensions and dilemmas they face by moving from an unstable, emergent policy arena to a more stable one.

Genes, environment, and race: quantitative genetic approaches

Understanding the origins of racial health disparities is currently a central focus of health-oriented funding agencies and the health policy community. In particular, the role of genetics in the origin of racial health disparities is receiving growing attention and has been susceptible to considerable misinterpretation. In this article, the authors provide a basic discussion about the concept of genes and race, an introduction to quantitative genetics, and some examples of quantitative genetic analyses of health conditions in an underserved population. The intent is to outline the conceptual limitations of exclusivist views of either environmental or genetic determination and to emphasize the coaction and interaction of genes and environments in health.

Exploration of the impact of messages about genes and race on lay attitudes

The effect of messages about genetics on lay audiences was assessed through an experimental study that exposed participants (n = 96) to a Public Service Announcement about race, genes, and heart disease. Participants who received a message that specified either 'Whites' or 'Blacks' as the subject of the message demonstrated elevated levels of racism, genetic basis for racism, and one dimension of genetic discrimination as compared to those receiving a version of the message with no race specification or in a no-message control condition. The presentation of such messages to the public is not recommended until additional research clarifies this finding and perhaps describes mitigating vocabularies or approaches.

Tailored medicine: whom will it fit? The ethics of patient and disease stratification

A key selling point of pharmacogenetics is the genetic stratification of either patients or diseases in order to target the prescribing of medicine. The hope is that genetically 'tailored' medicines will replace the current 'one-size-fits-all' paradigm of drug development and usage. This paper is concerned with the relationship between difference and justice in the use of pharmacogenetics. This new technology, which facilitates the identification and use of difference, has, we shall argue, the potential to lead to injustice either by the inappropriate use of difference or through the inappropriate failure to use difference. We build on empirical data from a detailed study of the range of options for the development of pharmacogenetics to present a consideration of the ethical issues that surround patient and disease stratification. In it we explore the ways in which the use of pharmacogenetics may lead to the creation of new, genetically stratified, forms of difference and new forms of injustice based on these divisions. We also examine the ways in which existing forms of difference and social stratification may interact with the use of pharmacogenetics. In conclusion, we suggest how an understanding of these ethical issues could usefully inform future policy discussions.

Protecting communities in pharmacogenetic and pharmacogenomic research

The existing EELS literature has usefully identified the scope of ethical issues posed by pharmacogenetic and pharmacogenomic research. The time has come for in-depth examination of particular ethical issues. The involvement of racial and ethnic communities in pharmacogenetic and pharmacogenomic research is contentious precisely because it touches upon the science and politics of studying racial and ethnic difference. To date, the ethics literature has not seriously taken account of the fact that such research impinges upon the interests of communities, and that taking such interests seriously requires that we both protect and empower communities in research. We propose a framework that rests upon the recognition that communities are heterogeneous human associations and differing policies are appropriate for differing communities. Community consent and consultation and community consultation alone are neither appropriate nor required for all pharmacogenetic and pharmacogenomic research. Rather, application of these policy protections must take into account particulars of both planned research and the communities involved.

Using pharmacogenetics and pharmacogenomics in the treatment of psychiatric disorders: some ethical and economic considerations

Current pharmacotherapies for psychiatric disorders are generally incompletely effective. Many patients do not respond well or suffer adverse reactions to these drugs, which can result in poor patient compliance and poor treatment outcome. Adverse drug reactions and non-response are likely to be influenced by genetic polymorphisms. Pharmacogenetics holds some promise for improving the treatment of mood disorders by utilising information about genetic polymorphisms to match patients to the drug therapy that is the most effective with the fewest side effects. Pharmacogenomics promises to facilitate the development of new drugs for treatment. However, these technologies raise many ethical, economic and regulatory issues that need to be addressed before they can be integrated into psychiatry, and medicine more generally. We discuss ethical and policy issues arising from pharmacogenetic testing and pharmacogenomics research, such as informed consent, privacy and confidentiality, research on vulnerable persons and discrimination; and economic viability of pharmacogenetics and pharmacogenomics. We conclude with recommendations for the regulation and distribution of pharmacogenetic testing services and pharmacogenomic drugs.

Ethical, social and legal implications of pharmacogenomics: a critical review

OBJECTIVE

My aim was to examine the ethical, social and legal implications of pharmacogenomics.

METHODS

I performed a critical review of the literature. The primary focal point is the bioethical principle discussed. The second outcome measure is the perspective of the discussion.

RESULTS

This review documents that the pharmacogenomics issues of concern are comparable to issues concerning other genetic developments in general. However, two main issues are particular to the case of pharmacogenomics. Firstly, this review reveals that society, industry, groups and individuals appreciate the prospect of pharmacogenomics very differently. Secondly, there is a lack of research into the post-marketing implications of pharmacogenomics.

CONCLUSION

An extensive focus on the ethical, social and legal implications of pharmacogenomics, in terms of both pre- as well as post-marketing issues, is essential. Also, a multidisciplinary approach which includes individual and group opinions in an upfront manner in the research and development process is essential. Otherwise, there is a substantial risk that the positive prospects of pharmacogenomics will not survive due to fear and a lack of acceptance and understanding on the part of the general public.

The drugs don't work: expectations and the shaping of pharmacogenetics

This article examines one particular set of technologies arising from developments in human genetics, those aimed at improving the targeting, design and use of conventional small molecule drugs-pharmacogenetics. Much of the debate about the applications and consequences of pharmacogenetics has been highly speculative, since little or no working technology is yet on the market. This article provides a novel analysis of the development of pharmacogenetics, and the social and ethical issues it raises, based on the sociology of technological expectations. In particular, it outlines how two alternative visions for the development of the technology are being articulated and embedded in a range of heterogeneous discourses, artefacts, actor strategies and practices, including: competing scientific research agendas, experimental technologies, emerging industrial structures and new ethical discourses. Expectations of how pharmacogenetics might emerge in each of these arenas are actively shaping the trajectory of this nascent technology and its potential socio-economic consequences.

Policy Before Practice

The value of genetics in medicine has been steadily developing with our increasing knowledge of the human genome. Genetic testing to determine disease risk or potential drug effects is set to become more commonplace. With this comes increasing concern about access to genetic information, and the potential for discriminatory usage of such information. At present, the scope and predictability of genetic testing and the conclusions that may be drawn fairly from genetic information are limited. Nonetheless, public concerns about discrimination based on the possession of a genetic trait or condition are well documented. The prospect that such information might be used in decisions regarding employment or insurability has caused anxiety and prompted legislation largely dedicated to the use of information about one's genotype rather than medical information in general. These laws emphasize genetic information as distinct from other medical information and attempt to prioritize interests in genetic information. As the distinction between genetic and medical information becomes untenable, those who would regulate the use of genotypic information will find this approach to policy problematic.In considering the limits of legislation as an effective tool of regulating genetic discrimination, several conclusions can be drawn: firstly, despite the promise of genomic medicine, current knowledge is insufficient to justify the use or application of certain genetic information in nonmedical contexts; secondly, public resistance to genomic medicine that is based on fear of genetic discrimination poses a danger that justifies a policy response; and thirdly, such a response may be purely symbolic and not entirely effective, provided that the policy establishes a consensus regarding the applicability of genetic information in nonmedical contexts.