The elusive ideal of inclusiveness: lessons from a worldwide survey of neurologists on the ethical issues raised by whole-genome sequencing

Exploring neurologists' perspectives on the return of next generation sequencing results to their patients: a needed step in the development of guidelines

Background

The use of Next Generation Sequencing such as Whole Genome Sequencing (WGS) is a promising step towards a better understanding and treatment of neurological diseases. WGS can result into unexpected information (incidental findings, IFs), and information with uncertain clinical significance. In the context of a Genome Canada project on ‘Personalized Medicine in the Treatment of Epilepsy’, we intended to address these challenges surveying neurologists’ opinions about the type of results that should be returned, and their professional responsibility toward recontacting patients regarding new discovered mutations.

Methods

Potential participants were contacted through professional organizations or direct invitations.

Results

A total of 204 neurologists were recruited. Fifty nine percent indicated that to be conveyed, WGS results should have a demonstrated clinical utility for diagnosis, prognosis or treatment. Yet, 41% deemed appropriate to return results without clinical utility, when they could impact patients’ reproductive decisions, or on patients’ request. Current use of targeted genetic testing and age of patients influenced respondents’ answers. Respondents stated that analysis of genomics data resulting from WGS should be limited to the genes likely to be relevant for the patient’s specific medical condition (69%), so as to limit IFs. Respondents felt responsible to recontact patients and inform them about newly discovered mutations related to the medical condition that triggered the test (75%) for as long as they are following up on the patient (55%). Finally, 53.5% of the respondents felt responsible to recontact and inform patients of clinically significant, newly discovered IFs.

Conclusion

Our results show the importance of formulating professional guidelines sensitive to the various – and sometimes opposite – viewpoints that may prevail within a same community of practice, as well as flexible so as to be attuned to the characteristics of the neurological conditions that triggered a WGS.

Asymétrie de pouvoir dans les partenariats de recherche en santé mondiale : étude qualitative auprès de chercheurs en Côte d’Ivoire

Résumé :

Contexte :

L’asymétrie de pouvoir dans les partenariats de recherche en santé mondiale constitue un enjeu de justice et d’équité pour les institutions de recherche, les chercheurs et les communautés, en particulier dans les pays en développement. Pour les chercheurs, l’asymétrie de pouvoir peut constituer un obstacle pour une recherche efficiente et équitable et ils sont à risque d’être en situation de vulnérabilité.

Objectifs :

Ces enjeux sont largement discutés dans la littérature mais ce phénomène reste encore étudié au plan théorique et peu de données empiriques sont disponibles, particulièrement dans les pays en développement. Cette étude a donc pour objectifs d’identifier les facteurs et les mécanismes de l’asymétrie de pouvoir en recherche en santé mondiale dans la perspective de chercheurs dans un pays du sud.

Méthodologie :

Une étude qualitative a été menée auprès de 19 chercheurs dans le domaine de la santé en Côte d’Ivoire. Tous les participants poursuivaient une carrière universitaire d’enseignement et recherche, dont 17 cliniciens en Centre Hospitalier Universitaire et 2 chercheurs non cliniciens. Des entrevues semi-dirigées ont été réalisées pour évaluer leur perception sur les facteurs qui influencent l’asymétrie de pouvoir et les mécanismes par lesquels ils opèrent.

Résultats :

Deux thèmes principaux émergent de l’analyse des données : les défis du financement et la complexité des relations interpersonnelles dans les partenariats.

Discussion :

Cette étude montre que la pression sur l’accès aux ressources contribue à détériorer les conditions dans lesquelles les partenariats sont mis en œuvre. Par ailleurs, l’environnement institutionnel de la recherche montre des liens de subordination qui font peser des risques sur l’autonomie des jeunes chercheurs et l’intégrité de leurs travaux. À cet égard nous recommandons une analyse approfondie de l’environnement dans lequel ces partenariats sont mis en œuvre notamment sur les dimensions de reddition de comptes, d’imputabilité et d’intégrité professionnelle.

Practices and views of neurologists regarding the use of whole-genome sequencing in clinical settings: a web-based survey

The use of Whole-Genome Sequencing (WGS) in clinical settings has brought up a number of controversial scientific and ethical issues. The application of WGS is of particular relevance in neurology, as many conditions are difficult to diagnose. We conducted a worldwide, web-based survey to explore neurologists' views on the benefits of, and concerns regarding, the clinical use of WGS, as well as the resources necessary to implement it. Almost half of the 204 neurologists in the study treated mostly adult patients (48%), while the rest mainly children (37.3%), or both (14.7%). Epilepsy (73%) and headaches (57.8%) were the predominant conditions treated. Factor analysis brought out two profiles: neurologists who would offer WGS to their patients, and those who would not, or were not sure in which circumstances it should be offered. Neurologists considering the use of WGS as bringing more benefits than drawbacks currently used targeted genetic testing (P<0.05) or treated mainly children (P<0.05). WGS' benefits were directed towards the patients, while its risks were of a financial and legal nature. Furthermore, there was a correlation between respondents' current use of genetic tests and an anticipation of increased use in the future (P<0.001). However, over half of respondents did not feel sufficiently informed to use WGS in their practice (53.5%). Our results highlight gaps in education, organization, and funding to support the use of WGS in neurology, and draw attention to the need for resources that could strongly contribute to more straightforward diagnoses and possibly better treatment of neurological conditions.