Understanding genetic disease in a socio-historical context: a case study of cystic fibrosis

Democratising or disrupting diagnosis? Ethical issues raised by the use of AI tools for rare disease diagnosis

Computational phenotyping (CP) technology uses facial recognition algorithms to classify and potentially diagnose rare genetic disorders on the basis of digitised facial images. This AI technology has a number of research as well as clinical applications, such as supporting diagnostic decision-making. Using the example of CP, we examine stakeholders' views of the benefits and costs of using AI as a diagnostic tool within the clinic. Through a series of in-depth interviews (n ​= ​20) with: clinicians, clinical researchers, data scientists, industry and support group representatives, we report stakeholder views regarding the adoption of this technology in a clinical setting. While most interviewees were supportive of employing CP as a diagnostic tool in some capacity we observed ambivalence around the potential for artificial intelligence to overcome diagnostic uncertainty in a clinical context. Thus, while there was widespread agreement amongst interviewees concerning the public benefits of AI assisted diagnosis, namely, its potential to increase diagnostic yield and enable faster more objective and accurate diagnoses by up skilling non specialists and thereby enabling access to diagnosis that is potentially lacking, interviewees also raised concerns about ensuring algorithmic reliability, expunging algorithmic bias and that the use of AI could result in deskilling the specialist clinical workforce. We conclude that, prior to widespread clinical implementation, on-going reflection is needed regarding the trade-offs required to determine acceptable levels of bias and conclude that diagnostic AI tools should only be employed as an assistive technology within the dysmorphology clinic.

Framing utility: Regulatory reform and genetic tests in the USA, 1989-2000

Before about 1990, insofar as diagnostic and other medical tests were subject to regulatory oversight, it was chiefly to ensure that they met appropriate standards of analytic and clinical validity. Over the course of the 1990s, however, regulatory reformers in the United States began to argue that genetic tests, specifically, should also be assessed to determine whether or not they actually benefit those undergoing testing-whether they possess "clinical utility", as they put it. The present paper asks why this shift in regulatory focus occurred specifically in relation to genetic tests, and why clinical utility became a key object of assessment. It answers these questions by situating concerns about genetic tests in the longer history of medical genetics. Looking back to the 1970s and medical geneticists' efforts to distance themselves from their earlier association with eugenics, it shows that they adopted a particular framing of the dangers of genetic testing which would inform their response to the proliferation of new genetic tests and the growth of commercial testing in the 1990s. In a series of policy committees convened over the course of that decade, medical geneticists called for regulatory measures to be implemented to ensure that genetic tests were only introduced into medical practice if they had been shown to be beneficial to those tested. The paper follows the deliberations of those committees to show in detail how geneticists worked within this framing to accommodate new technical capacities and regulatory opportunities. In the course of these deliberations, they adopted the idea of clinical utility to signify the need for evidence of benefit specifically to those tested. The paper concludes with some observations regarding how this framing of genetic tests relates to current understandings of "genetic exceptionalism" and to more recent articulations of clinical utility.

Presenting life with cystic fibrosis: a Q-methodological approach to developing balanced, experience-based prenatal screening information

BACKGROUND

Cystic fibrosis (CF) is one of the most common life-threatening genetically inherited conditions and prenatal screening for CF is available in many countries. Genetic counsellors and other health professionals are expected to provide information about the condition in a way that facilitates personal decision making. Knowing what information to deliver about complex genetic conditions to support informed screening decisions can be challenging for health professionals.

OBJECTIVE

To solicit views from those with personal experience with CF on which aspects of the condition they consider most important to include in prenatal screening materials.

METHODS

Q-methodology; an approach to systematically explore variations in viewpoint that combines factor analytic techniques with qualitative approaches to pattern interpretation.

SETTING AND PARTICIPANTS

Twelve adults with CF and 18 parents of affected children were recruited from a regional centre in the UK.

RESULTS

Five distinct viewpoints on the items most and least important to include in screening information were identified: Factor 1 the normality of life with CF and increasing life expectancy; Factor 2 the hardships and reduced lifespan. Factor 3 medical interventions and the importance of societal support. Factor 4 longer-term consequences of CF. Factor 5 the ability to adjust to the condition.

DISCUSSION

The identification of five different views on what represented the most and least important information to include about CF highlights the challenge of portraying a complex genetic condition in a balanced and accurate manner. Novel ways in which Q-methodology findings can be used to meet this challenge are presented.

Expanded newborn screening: articulating the ontology of diseases with bridging work in the clinic

Population screening follows the logic of secondary prevention: a population is screened to detect disease early and to initiate treatment before symptoms emerge. However, not all population screening is justifiable under all circumstances. In this article, we unpack Wilson and Jungner's requirement that knowledge about the natural history of a disease must be 'adequate' for screening to proceed. We argue that any prior understanding of disease is inevitably found to be insufficient once population screening is instituted. Drawing upon ethnographic observations of clinical consultations and staff meetings conducted in a California regional clinical centre for metabolic-genetic disorders, we introduce the notion of bridging work to draw attention to the collective activities of the genetics team to revise the ontological nature of conditions unsettled by population-based newborn screening. Bridging work refers to the many activities required to reconcile the promise of technologies with the realities of their implementation. We illustrate how clinicians bridge the gap between what was known about a disease prior to screening and anomalous screening results, leading to an ontological transformation of disease categories.

The tenacity of the coronary candidate: how people with familial hypercholesterolaemia construct raised cholesterol and coronary heart disease

This article considers how people with familial hypercholesterolaemia (FH), an inherited high cholesterol condition, construct FH, high cholesterol and coronary heart disease (CHD). These data are used to explore some of the more prevalent claims about the expansion of genetic explanations for health and illness and its implications. The article draws on 31 interviews with people with FH undertaken at a large lipid clinic, a specialist outpatient clinic, in the north of England. I argue that interviewees tended to distinguish between their own `hereditary' high cholesterol and other people's `lifestyle induced' high cholesterol as a way to establish their own lack of culpability for their condition. At the same time, however, they strongly emphasized the need to take care of themselves, in particular by adhering to appropriate dietary and lifestyle regimes. Interviewees' accounts of CHD were not strongly framed in genetic terms, but tended to conform to established lay notions encapsulated by the idea of the `coronary candidate'. In sum, having FH does not seem to transform these people's understandings of the causes of high cholesterol or CHD. Their experiences were largely accommodated within existing lay frameworks. The analysis contributes to a growing reappraisal of transformative narratives about genetic knowledge.

Geneticization and bioethics: advancing debate and research

In the present paper, we focus on the role that the concept of geneticization has played in the discussion about health care, bioethics and society. The concept is discussed and examples from the evolving discourse about geneticization are critically analyzed. The relationship between geneticization, medicalization and biomedicalization is described, emphasizing how debates about the latter concepts can inspire future research on geneticization. It is shown how recurrent themes from the media coverage of genetics portray typical traits of geneticization and thus contribute to the process. We look at examples of small-scale studies from the literature where geneticization of medical practice has been demonstrated. Methodological disputes about the relevance of empirical evidence for the geneticization thesis and the normative status of the concept are discussed. We consider arguments to the effect that ideas from mainstream bioethics have facilitated geneticization by emphasizing individualistic notions of autonomy and responsibility while ignoring the role of genetics in the wider social context. It is shown how a concept like geneticization, which can be used to draw the attention of philosophers, social scientists and others to challenges that tend to be neglected by mainstream bioethics, also has the potential to move people's attention away from other pertinent issues. This may happen if researchers become preoccupied with the transformative effects of genetics, and we argue that a wider reading of geneticization should inspire critical analysis of the sociocultural preconditions under which genetics is currently evolving.