Putting genetics in perspective

Public health genomics and genetic test evaluation: the challenge of conducting behavioural research on the utility of lifestyle-genetic tests

Human genetics research is increasingly concerned with multifactorial conditions such as diabetes and heart disease, which are influenced not only by genetic but also lifestyle factors such as diet and smoking. Although the results of 'lifestyle-genetic' tests using this information could conceivably motivate lifestyle changes in the future, companies are already selling such tests and related lifestyle advice commercially. Some academics and lobby groups have condemned the companies for selling these tests in advance of scientific support. Others are concerned that the tests may not motivate lifestyle improvements, instead causing distress in people receiving adverse test results and complacency in those receiving reassuring results. There is currently no regulatory oversight of genetic test utility, despite consensus in the Public Health Genomics community that clinical utility (including psychological and behavioural impact) of all emerging genetic tests should be evaluated before being introduced for individual use. Clearly, empirical data in this area is much needed, to inform understanding of the potential utility of these tests, and of whether stricter regulation of commercial exploitation is needed. In this article, we review the current situation regarding lifestyle-genetic tests, and discuss the challenges inherent in conducting this kind of behavioural research in the genomics era.

Health visitors' perceived priority needs in relation to their genetics education

There is a growing recognition, nationally and internationally of the need to increase the genetics education of health professionals. Nurses in primary care are expected to be an important link between people undergoing genetic investigation and regional clinical genetic centres. Core competencies in relation to genetics for all nurses, midwives and health visitors have recently been identified within the United Kingdom. This paper reports a study that sought to investigate health visitors' views on the components of these core competencies in genetics and their self reported educational needs in the area of genetics. A questionnaire based survey of 345 health visitors was undertaken in Northern Ireland, as one region of the United Kingdom during late 2003. Completed questionnaires were returned by 194 health visitors (56.2% response). Respondents largely supported the components of the core competencies now endorsed by the Nursing and Midwifery Council and reported their need for further education in relation to genetics. However, they had a limited view on their role in supporting parents of children undergoing genetic investigation. Further action needs to be taken to provide health visitors with the necessary genetic knowledge and skills in order that they are in stronger position to provide 'collateral' support for people undergoing genetic investigation.

Public health genetics and social justice

This article deals with societal challenges of Public Health Genetics and reflects on social justice as its fundamental norm. Accordingly, the first emphasis is put on the difference between the idea of the good and the right. Then the capabilities approach is introduced as the adequate concept of justice in Public Health Genetics. Considering the conflict between respect for autonomy and common welfare in this field of discussion, the author finally presents an ethical grading.

Understanding the new human genetics: A review of scientific editorials

Developments in genetics are expected to have a profound impact on health and health care, yet much remains to be learned about how leaders of the research and clinical communities view and frame these expectations. We conducted a comprehensive review of editorials about developments in genetic medicine published in scientific journals, to understand what this elite group of commentators anticipate. Editorials are an important resource for understanding how the new genetics is understood and portrayed. They allow leaders of the research and clinical communities to communicate to each other and informed publics, and are a forum for the expression of widely shared elite beliefs and opinions. We analyzed selected editorials for content and metaphoric language to explore attitudes and expectations concerning developments in genetic science and technology. Our analysis suggests that a diverse group of leaders of the research and clinical communities are remarkably uniform in their discourse about the future of genetic medicine. Editorialists have great expectations for developments in basic science and in the comprehension and management of disease. They also anticipate important effects on health care, notably the health care professions, and on wider society. Yet editorialists do not discuss these prospects in a consistently positive or optimistic manner, and they utilize metaphoric imagery that emphasizes the inexorable nature of progress, and the sometimes ominous manner in which developments emerge. The dominant discourse of editorialists claims authority for clinicians and researchers and asserts a broad sphere of expertise, but it also positions these leaders as handmaidens of a science they do not control, and insists that their ultimate contribution is to prepare themselves and others for the inexorable march of progress.

Supporting parents who have a child referred for genetic investigation: the contribution of health visitors

AIM

This paper reports a study of the views of health visitors in relation to their role in supporting parents of children referred for genetic investigations.

BACKGROUND

An increasing number of children are likely to be referred for genetic investigations as our understanding of genetic inheritance develops and a wider range of tests becomes available. Internationally, there are growing expectations that nurses will be able to discuss the referral and testing processes with parents, as well as facilitate informed decision-making. However, previous studies have highlighted the limited support received from staff in primary care services by parents of children referred for genetic investigation.

METHODS

A questionnaire survey of 345 health visitors was undertaken in 11 community health and social services trusts in Northern Ireland. Questionnaires were distributed at health visitor team meetings and returned in prepaid envelopes. Data collection occurred in 2003.

FINDINGS

Completed questionnaires were returned by 194 health visitors (56.2% response rate). Many were unsure of the location of their Regional Clinical Genetics Service and reported limited contact with these services. The majority of health visitors were not informed that children on their caseload had a forthcoming appointment, or that they had attended an appointment with a geneticist. Health visitors did not routinely visit parents of children referred for genetic investigation to discuss the appointment, and they reported limited confidence in supporting parents in relation to genetic investigations.

CONCLUSION

Improved communication links are needed with Regional Clinical Genetics Services and to ensure that health visitors are informed when children on their caseload have been referred for genetic investigation. In addition, steps need to be taken to increase the coordination of support to parents provided by health visitors and staff within regional genetic services.

Prevention and genetic testing for breast cancer: variations in medical decisions

The discovery linking the genes BRCA1&2 to familial breast cancer played an important role in the clinical practice of geneticists and physicians. The availability of genetic tests for BRCA gene mutations prompted cancer geneticists to give information about genetic risk and to assess many women with a personal or family history of breast or ovarian cancer to inform them of preventive measures. These consist mainly of breast self-examination, mammography screening, chemoprevention and prophylactic surgery (mastectomy, oophorectomy). This paper examines clinical practices related to hereditary breast cancer testing and introduces a number of results from a survey carried out, between 1996 and 1998, in three clinics located in Montreal (Quebec, Canada), Marseilles (France) and Manchester (Great Britain). Results show substantial differences in the way cancer geneticists deal with environmental risk factors, breast and ovarian cancer testing, and chemoprevention and prophylactic surgery. Differences across cities persist in the multivariate analysis, suggesting that attitudes towards preventive measures may be partially explained by cultural factors. Different dimensions of culture are discussed including the social representation of health and risk, the interpretation of scientific evidence and the role of innovation leadership.

Genetics and genomics in practice: the continuum from genetic disease to genetic information in health and disease

This article reviews how the continuum and gradual shift from genetics (study of genes) to genomics (study of the whole genome) in medicine and public health will require reassessment of the traditional approach to delivery of genetic information, namely genetic services. A more general approach is needed to assess the value-added of genetic information for promoting health and for diagnosing, treating, predicting, and preventing all diseases, not only "genetic diseases." The article also discusses how family history can serve as a bridge from genetics to genomics in practice because it reflects the presence, not only of single-gene disorders, but also of shared genes, shared environments, and complex gene-environment interactions. Because of the expected volume of new genetic information, evidence-based practice should increasingly rely on scientific data on analytic performance of such information, its validity in predicting health outcomes, and its utility in improving health and preventing disease beyond approaches that do not use genetic information.

Genetics and the interpersonal elaboration of ethics

Confidentiality in genetic testing poses important ethical challenges to the current primacy of respect for autonomy and patient choice in health care. It also presents a challenge to approaches to decision-making emphasising the ethical importance of the consequences of health care decisions. In this paper a case is described in which respect for confidentiality calls both for disclosure and non-disclosure, and in which respect for patient autonomy and the demand to avoid causing harm each appear to call both for testing without consent, and testing only with consent. This creates problems not only for clinicians, families and patients, but also for those who propose clinical bioethics as a tool for the resolution of such dilemmas. In this paper I propose some practical ways in which ethical issues in clinical genetics and elsewhere, might be addressed. In particular I call for a closer relationship between ethics and communication in health care decision-making and describe an approach to the ethics consultation that places particular emphasis on the value of interpersonal deliberation in the search for moral understanding. I reach these conclusions through an analysis of the concept of 'moral development' in which I argue that the achievement of moral understanding is a necessarily intersubjective project elaborated by moral persons.