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Enzo A. The expressivist argument for recent policy changes regarding the provision of prenatal testing in Japan. Glob Bioeth 2024; 35:2398299. [PMID: 39228857 PMCID: PMC11370675 DOI: 10.1080/11287462.2024.2398299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 08/26/2024] [Indexed: 09/05/2024] Open
Abstract
The Japanese government and medical professionals have negative attitudes toward the provision of prenatal testing and related information due to social concern regarding discrimination against persons with disabilities. However, with the rapid increase in the number of non-invasive prenatal tests, particularly at non-certificated medical facilities, in response to the growing demand from pregnant women, the Japanese government and medical professional associations have enacted radical changes marking an active commitment to the provision of information on these services. While a major justification for these policy changes is to ensure respect for reproductive autonomy and women's self-determination, they may reinforce the concern regarding discrimination. This article investigated the argument that these new policies may reinforce discrimination and examined three objections to this argument. The results revealed that the recent policy changes, particularly for specific fetal traits, may imply a negative belief about people living with the same traits. Consequently, fundamental institutional changes are necessary.
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Affiliation(s)
- Aya Enzo
- Department of Medical Ethics, Tohoku University Graduate School of Medicine, Sendai, Japan
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2
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Luo X, Liu W, Hu L, Cong X, Liu X, Niu H, Zhou F, Li G, Wen L, Guo Y. Prenatal diagnosis, pregnancy determination and follow up of sex chromosome aneuploidy screened by non-invasive prenatal testing from 122 453 unselected singleton pregnancies: A retrospective analysis of 7-year experience. Congenit Anom (Kyoto) 2024; 64:99-106. [PMID: 38454888 DOI: 10.1111/cga.12558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 01/11/2024] [Accepted: 02/16/2024] [Indexed: 03/09/2024]
Abstract
The phenotype of SCA patients are diversities, make prenatal counseling and parental decision-making following the prenatal diagnosis of SCA more complicated and challenging. NIPT has higher sensitivity and specificity in screening trisomy 21 syndrome, but the effectiveness of NIPT in detecting SCA is still controversial. This study is a large-scale retrospective cohort of positive SCA screened from unselected singleton pregnancies by non-invasive prenatal testing (NIPT) from a single prenatal center of a tertiary hospital. Clinical information, indications, diagnostic results, ultrasound findings, pregnancy determinations, and follow-up were reviewed and analyzed. 596 cases of SCA positive were screened out of 122 453, giving a positive detection rate of 0.49%. 510 cases (85.6%) conducted with amniocentesis to detect fetal chromosome, of which 236 were confirmed as true positive of SCA with PPV of 46.3% (236/510). Of the 236 cases confirmed as true positive SCA, 114 cases (48.3%)chose to terminate the pregnancy (93.0%, 65.3%, 15.4% and 10.9% for 45,X, 47,XXY, 47,XXX and 47,XYY, respectively), 122 cases (51.7%) elected to continue the pregnancy. In conclusions, NIPT as a first-tier routine method for screening autosomal aneuploidies, also could play an important role in screening SCA. Low-risk pregnant women are the main indication for the detection of SCA as NIPT test provides to non-selective population. For 47,XXX and 47,XYY with mild phenotype, couples would like to continue the pregnancy. But for 45,X and 47,XXY, parents apt to terminate pregnancy no matter ultrasound abnormalities were found or not.
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Affiliation(s)
- Xiaojin Luo
- The Genetics Laboratory, Longgang District Maternity &Child Heathcare Hospital of Shenzhen City (Longgang Maternity and Child Institute of Shantou University Medical College), Shenzhen, Guangdong Province, China
| | - Weiqiang Liu
- The Genetics Laboratory, Longgang District Maternity &Child Heathcare Hospital of Shenzhen City (Longgang Maternity and Child Institute of Shantou University Medical College), Shenzhen, Guangdong Province, China
| | - Liang Hu
- The Genetics Laboratory, Longgang District Maternity &Child Heathcare Hospital of Shenzhen City (Longgang Maternity and Child Institute of Shantou University Medical College), Shenzhen, Guangdong Province, China
| | - Xiaoyi Cong
- The Genetics Laboratory, Longgang District Maternity &Child Heathcare Hospital of Shenzhen City (Longgang Maternity and Child Institute of Shantou University Medical College), Shenzhen, Guangdong Province, China
| | - Xiaoyi Liu
- The Genetics Laboratory, Longgang District Maternity &Child Heathcare Hospital of Shenzhen City (Longgang Maternity and Child Institute of Shantou University Medical College), Shenzhen, Guangdong Province, China
| | - Hongyan Niu
- The Genetics Laboratory, Longgang District Maternity &Child Heathcare Hospital of Shenzhen City (Longgang Maternity and Child Institute of Shantou University Medical College), Shenzhen, Guangdong Province, China
| | - Fei Zhou
- The Genetics Laboratory, Longgang District Maternity &Child Heathcare Hospital of Shenzhen City (Longgang Maternity and Child Institute of Shantou University Medical College), Shenzhen, Guangdong Province, China
| | - Gaochi Li
- The Genetics Laboratory, Longgang District Maternity &Child Heathcare Hospital of Shenzhen City (Longgang Maternity and Child Institute of Shantou University Medical College), Shenzhen, Guangdong Province, China
| | - Lijuan Wen
- The Genetics Laboratory, Longgang District Maternity &Child Heathcare Hospital of Shenzhen City (Longgang Maternity and Child Institute of Shantou University Medical College), Shenzhen, Guangdong Province, China
| | - Yanyun Guo
- Department of Community Center, Longgang District People's Hospital (The Second Affiliated Hospital of The Chinese University of Hong Kong, Shenzhen), Shenzhen, Guangdong Province, China
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3
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Nakou P, Bennett R. The risk of normative bias in reporting empirical research: lessons learned from prenatal screening studies about the prominence of acknowledged limitations. THEORETICAL MEDICINE AND BIOETHICS 2023; 44:589-606. [PMID: 37930620 PMCID: PMC10643326 DOI: 10.1007/s11017-023-09639-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/02/2023] [Indexed: 11/07/2023]
Abstract
Empirical data can be an extremely powerful and influential tool in bioethical research. However, when researchers or policy makers look for answers to ethical questions by engaging with empirical research, there can be a tendency (conscious or unconscious) to shape, report, and use empirical research in a way that confirms their own preferred ethical conclusions. This skewing effect - what we call 'normative bias' - is often so subtle it falls short of clear misconduct and thus can be difficult to call out. However, we argue that this subtle influence of bias has the potential to significantly influence debate and policy around highly sensitive ethical issues and must be guarded against. In this paper we share the lessons we have learned through a journey of self-reflection around the effect that normative bias can have when reporting on and referring to empirical data relating to ethical issues. We use a variety of papers from our area of the ethics of routine prenatal screening to illustrate these subtle but often powerfully distorting effects of bias. Our aim in doing so is not to criticise the work of others, as we recognise our own normative bias, but to improve awareness of this issue, remind the need for reflexivity to guard against our own biases, and introduce a new criterion - the idea of a 'limitation prominence assessment' - that can work as a practical way to evaluate the seriousness of the limitations of an empirical study and thus, the risks of the study being misread or misinterpreted through superficial reading.
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Affiliation(s)
- Panagiota Nakou
- Department of Law, Centre for Social Ethics and Policy, The University of Manchester, Manchester, M13 9PL, UK.
| | - Rebecca Bennett
- Department of Law, Centre for Social Ethics and Policy, The University of Manchester, Manchester, M13 9PL, UK
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4
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Cai M, Lin N, Chen X, Li Y, Lin M, Fu X, Huang H, He S, Xu L. Non-invasive prenatal testing for the diagnosis of congenital abnormalities: Insights from a large multicenter study in southern China. Braz J Med Biol Res 2023; 56:e12506. [PMID: 37377305 DOI: 10.1590/1414-431x2023e12506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/04/2023] [Indexed: 06/29/2023] Open
Abstract
Although non-invasive prenatal testing (NIPT) is widely used to detect fetal abnormalities, the results of NIPT vary by population, and data for the screening efficiency of NIPT positive predictive value (PPV) from different populations is limited. Herein, we retrospectively analyzed the NIPT results in a large multicenter study involving 52,855 pregnant women. Depending on gestational age, amniotic fluid or umbilical cord blood was extracted for karyotype and/or chromosome microarray analysis (CMA) in NIPT-positive patients, and the PPV and follow-up data were evaluated to determine its clinical value. Among the 52,855 cases, 754 were NIPT-positive, with a positivity rate of 1.4%. Karyotype analysis and/or CMA confirmed 323 chromosomal abnormalities, with a PPV of 45.1%. PPV for trisomy 21 (T21), trisomy 18 (T18), trisomy 13 (T13), sex chromosomal aneuploidies (SCAs), and copy number variations (CNVs) were 78.9, 35.3, 22.2, 36.9, and 32.9%, respectively. The PPVs for T21, T18, and T13 increased with age, whereas the PPVs for SCAs and CNVs had little correlation with age. The PPV was significantly higher in patients with advanced age and abnormal ultrasound. The NIPT results are affected by population characteristics. NIPT had a high PPV for T21 and a low PPV for T13 and T18, and screening for SCAs and CNVs showed clinical significance in southern China.
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Affiliation(s)
- Meiying Cai
- Medical Genetic Diagnosis and Therapy Center, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fujian Key Laboratory for Prenatal Diagnosis and Birth Defect, Fuzhou, China
| | - Na Lin
- Medical Genetic Diagnosis and Therapy Center, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fujian Key Laboratory for Prenatal Diagnosis and Birth Defect, Fuzhou, China
| | - Xuemei Chen
- Medical Genetic Diagnosis and Therapy Center, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fujian Key Laboratory for Prenatal Diagnosis and Birth Defect, Fuzhou, China
| | - Ying Li
- Medical Genetic Diagnosis and Therapy Center, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fujian Key Laboratory for Prenatal Diagnosis and Birth Defect, Fuzhou, China
| | - Min Lin
- Medical Genetic Diagnosis and Therapy Center, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fujian Key Laboratory for Prenatal Diagnosis and Birth Defect, Fuzhou, China
| | - Xianguo Fu
- Department of Prenatal Diagnosis, Ningde Municipal Hospital, Ningde Normal University, Ningde, China
| | - Hailong Huang
- Medical Genetic Diagnosis and Therapy Center, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fujian Key Laboratory for Prenatal Diagnosis and Birth Defect, Fuzhou, China
| | - Shuqiong He
- Medical Genetic Diagnosis and Therapy Center, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fujian Key Laboratory for Prenatal Diagnosis and Birth Defect, Fuzhou, China
| | - Liangpu Xu
- Medical Genetic Diagnosis and Therapy Center, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fujian Key Laboratory for Prenatal Diagnosis and Birth Defect, Fuzhou, China
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5
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Johnston M, Warton C, Pertile MD, Taylor-Sands M, Delatycki MB, Hui L, Savulescu J, Mills C. Ethical issues associated with prenatal screening using non-invasive prenatal testing for sex chromosome aneuploidy. Prenat Diagn 2023; 43:226-234. [PMID: 35929376 DOI: 10.1002/pd.6217] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/24/2022] [Accepted: 07/22/2022] [Indexed: 11/11/2022]
Abstract
Prenatal screening for sex chromosome aneuploidies (SCAs) is increasingly available through expanded non-invasive prenatal testing (NIPT). NIPT for SCAs raises complex ethical issues for clinical providers, prospective parents and future children. This paper discusses the ethical issues that arise around NIPT for SCAs and current guidelines and protocols for management. The first section outlines current practice and the limitations of NIPT for SCAs. It then outlines key guidelines before discussing the ethical issues raised by this use of NIPT. We conclude that while screening for SCAs should be made available for people seeking to use NIPT, its implementation requires careful consideration of what, when and how information is provided to users.
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Affiliation(s)
| | | | - Mark D Pertile
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | | | - Martin B Delatycki
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Lisa Hui
- University of Melbourne, Melbourne, Victoria, Australia
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Lewit-Mendes MF, Robson H, Kelley J, Elliott J, Brown E, Menezes M, Archibald AD. Experiences of receiving an increased chance of sex chromosome aneuploidy result from non-invasive prenatal testing in Australia: "A more complicated scenario than what I had ever realized". J Genet Couns 2023; 32:213-223. [PMID: 36114608 DOI: 10.1002/jgc4.1635] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 08/23/2022] [Accepted: 08/24/2022] [Indexed: 11/11/2022]
Abstract
Many non-invasive prenatal testing (NIPT) platforms screen for sex chromosome aneuploidy (SCA) and SCA analysis is generally included in Australia where NIPT is available as a self-funded test. Little is known about the experience of receiving an NIPT result indicating an increased chance of SCA. This study aimed to explore the experiences of people who received this result and their perspectives on the information, care, and support they received from healthcare practitioners (HCPs). Semi-structured interviews were conducted with people who received an NIPT result indicating an increased chance of SCA and continued their pregnancy. Most participants only had contact with a genetic counselor after receiving their result. Transcribed data were analyzed using rigorous thematic analysis to identify important patterns and themes. Participants (18 women, 2 male partners) described embarking on NIPT, primarily based on advice from their HCP and without much consideration. Consequently, participants expressed feeling unprepared for the unanticipated complexity of their NIPT result and were faced with making a time-sensitive decision about a condition they had not previously considered. While more pre-test information was desired, timely access to genetic counseling post-test assisted with adjustment to the result. These findings suggest that routinization of NIPT may be compromising informed decision-making, resulting in unpreparedness for an increased chance result. Given the increasing uptake and expanding scope of NIPT, resources should be dedicated to educating HCPs offering NIPT and ensuring timely access to genetic counseling post-result. With appropriate funding, genetics services may be able to play a central role in offering information and support to both people who undertake NIPT and their HCPs ordering the testing. Implementing a publicly funded screening program in Australia could assist with standardizing prenatal screening care pathways and consequently better access to appropriate resources.
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Affiliation(s)
- Miranda F Lewit-Mendes
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Monash Genetics, Monash Health, Melbourne, Victoria, Australia
| | - Hazel Robson
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Genetics Department, Number 1 Fertility, Melbourne, Victoria, Australia
| | - Joanne Kelley
- Mercy Perinatal, Mercy Hospital for Women, Melbourne, Victoria, Australia
| | - Justine Elliott
- Victorian Clinical Genetics Services, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Erica Brown
- Genetics Clinic, The Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Melody Menezes
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Monash Ultrasound for Women, Monash IVF, Melbourne, Victoria, Australia
| | - Alison D Archibald
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Victorian Clinical Genetics Services, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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7
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Stanić Ž, Hrgović Z, Fureš R, Vusić I, Lagančić M. Ethical Aspects of Prenatal DNA Testing. Z Geburtshilfe Neonatol 2022; 226:300-303. [DOI: 10.1055/a-1904-8406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
AbstractCell-free DNA (cfDNA) first-trimester screening for fetal aneuploidies, as a
non-invasive, safe, and rather accurate method, has changed prenatal screening
policies all over the world. Owing to aggressive marketing, cfDNA screening
tests exhibit global popularity and a rapid spread in routine prenatal care.
However, wide availability of the tests, together with observed difficulties in
the test’s interpretation, bring to light several serious ethical
concerns. To date it is vital to identify and address the most important
ethical, legal, and social issues regarding prenatal screening tests.
Furthermore, guidelines and restrictions in certain cfDNA screening advancements
that may provide information regarding fetal genetic traits of unknown clinical
significance, conditions with variable penetrance, or late-onset conditions,
should be considered.
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Affiliation(s)
- Žana Stanić
- Department for Integrative Gynecology, Obstetrics and Minimally
Invasive Gynecologic Surgery, Zabok General Hospital and Croatian Veterans
Hospital, Zabok, Croatia
- Faculty of Dental Medicine and Health, Josip Juraj Strossmayer
University of Osijek, Osijek, Croatia
| | - Zlatko Hrgović
- Women's Health Clinic, J. W. Goethe University
Frankfurt, Frankfurt am Main, Germany
| | - Rajko Fureš
- Department for Integrative Gynecology, Obstetrics and Minimally
Invasive Gynecologic Surgery, Zabok General Hospital and Croatian Veterans
Hospital, Zabok, Croatia
- Faculty of Dental Medicine and Health, Josip Juraj Strossmayer
University of Osijek, Osijek, Croatia
| | - Iva Vusić
- Health Center of Bjelovar-Bilogora County, Bjelovar,
Croatia
| | - Marko Lagančić
- Emergency Department, University Hospital Dubrava, Zagreb,
Croatia
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8
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Morel-Laforce T, Ravitsky V, Laberge AM. La recherche translationnelle et la science de l’implantation : des outils pour les bioéthiciens pour étudier les enjeux éthiques de nouvelles technologies. CANADIAN JOURNAL OF BIOETHICS 2022. [DOI: 10.7202/1089788ar] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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9
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Huang TX, Ma GC, Chen M, Li WF, Shaw SW. Difficulties of Prenatal Genetic Counseling for a Subsequent Child in a Family With Multiple Genetic Variations. Front Genet 2022; 12:612100. [PMID: 34970295 PMCID: PMC8712678 DOI: 10.3389/fgene.2021.612100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 11/15/2021] [Indexed: 11/13/2022] Open
Abstract
Many parents with a disabled child caused by a genetic condition appreciate the option of prenatal genetic diagnosis to understand the chance of recurrence in a future pregnancy. Genome-wide tests, such as chromosomal microarray analysis and whole-exome sequencing, have been increasingly used for prenatal diagnosis, but prenatal counseling can be challenging due to the complexity of genomic data. This situation is further complicated by incidental findings of additional genetic variations in subsequent pregnancies. Here, we report the prenatal identification of a baby with a MECP2 missense variant and 15q11.2 microduplication in a family that has had a child with developmental and epileptic encephalopathy caused by a de novo KCNQ2 variant. An extended segregation analysis including extended relatives, in addition to the parents, was carried out to provide further information for genetic counseling. This case illustrates the challenges of prenatal counseling and highlights the need to understand the clinical and ethical implications of genome-wide tests.
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Affiliation(s)
- Ting-Xuan Huang
- Department of Obstetrics and Gynecology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Gwo-Chin Ma
- Department of Genomic Medicine and Center for Medical Genetics, Changhua Christian Hospital, Changhua, Taiwan
| | - Ming Chen
- Department of Genomic Medicine and Center for Medical Genetics, Changhua Christian Hospital, Changhua, Taiwan.,Department of Obstetrics and Gynecology, Changhua Christian Hospital, Changhua, Taiwan.,Department of Molecular Biotechnology, Da-Yeh University, Changhua, Taiwan.,Department of Obstetrics and Gynecology, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Medical Genetics, National Taiwan University Hospital, Taipei, Taiwan.,Department of Medical Science, National Tsing Hua University, Hsinchu, Taiwan
| | - Wen-Fang Li
- Department of Obstetrics and Gynecology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Steven W Shaw
- Department of Obstetrics and Gynecology, Taipei Chang Gung Memorial Hospital, Taipei, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Prenatal Cell and Gene Therapy Group, Institute for Women's Health University College London, London, United Kingdom
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10
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Yamamoto K, Chang H, Fukushima A. Pregnant women's experiences of non-invasive prenatal testing (NIPT) in Japan: A qualitative study. J Genet Couns 2021; 31:338-355. [PMID: 34432354 DOI: 10.1002/jgc4.1494] [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: 08/14/2020] [Revised: 07/27/2021] [Accepted: 07/28/2021] [Indexed: 11/09/2022]
Abstract
In Japan, prenatal testing does not include a publicly insured routine health check-up for pregnant women. Hence, taking advantage of such prenatal testing procedures is still not an option for a majority of Japanese women. However, social support systems for children and adults with disabilities have been developed with the assumption that people with disabilities will continue receiving support from their family members, especially their mothers. In this study, we described pregnant women's experiences regarding noninvasive prenatal testing (NIPT) within the context of their physical experiences during the NIPT process, Japanese society, and their medical circumstances. Women with no family history of genetic diseases or fetal disabilities and who had also received negative results after the NIPT explanation were recruited. Altogether, 15 women participated in the biographical narrative interview. The data were subjected to reflexive thematic analysis and signified advanced age for pregnancy as a trigger for both the women's consideration regarding receiving NIPT and interventions from their families and social group members. Participants considered themselves as the main caretaker for the older adults and individuals with disabilities and thus were afraid of the multiple responsibilities inherent in this reality. They were also concerned about the impact on any other siblings if the baby had disabilities. In addition, participants encounter physical and mental changes during the timeframe of the NIPT processes. Hence, as their fetuses mature, the psychological bonds the women develop with them are constantly evolving, and participants with histories of miscarriages or possible miscarriages expressed concerned not only about the results of NIPT but also about the specific possibility of losing their child in any way. In conclusion, the continuous support of these women throughout the NIPT process and social efforts for the improvement of the welfare system for people with disabilities are required to utilize NIPT effectively.
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Affiliation(s)
- Kayono Yamamoto
- Department of Clinical Genetics, School of Medicine, Iwate Medical University, Iwate, Japan
| | - Hyangri Chang
- Department of Genomic Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Akimune Fukushima
- Department of Clinical Genetics, School of Medicine, Iwate Medical University, Iwate, Japan
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11
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Garcia E, Henneman L, Gitsels-van der Wal JT, Martin L, Koopmanschap I, Bekker MN, Timmermans DRM. Non-invasive prenatal testing (NIPT) and pregnant women's views on good motherhood: a qualitative study. Eur J Hum Genet 2021; 30:669-675. [PMID: 34400811 DOI: 10.1038/s41431-021-00945-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 05/09/2021] [Accepted: 08/03/2021] [Indexed: 11/09/2022] Open
Abstract
Women's views on responsible motherhood influence decision-making regarding participation in prenatal screening. Previous studies showed that the probabilistic nature of the first-trimester combined test and the potential requirement for subsequent invasive diagnostics serve as legitimate reasons for women to exclude prenatal screening from their moral responsibilities. These moral barriers might now be less relevant with the introduction of the non-invasive prenatal test (NIPT) resulting in women feeling a moral duty to use NIPT screening as part of responsible motherhood. This qualitative study explores the impact of NIPT on women's moral beliefs about the meaning of prenatal screening in relation to responsible motherhood. We performed semi-structured interviews with 29 pregnant women who were offered NIPT as a first-tier screening test within a Dutch nationwide study (TRIDENT-2). Results show that the inherent uncertainty about the fetus's health despite improved accuracy and the lack of treatment for a detected disorder, combined with the possibility to obtain information about actionable anomalies through the fetal anomaly scan, support women's perspectives that NIPT is not an obligation of responsible motherhood. Acceptance of NIPT is considered to be a free decision related to the information each woman needs to be a good mother for her child and her family. Women's views may change when NIPT has expanded to include treatable or preventable conditions.
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Affiliation(s)
- Elisa Garcia
- Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands. .,Department of Clinical Genetics, Section Community Genetics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands.
| | - Lidewij Henneman
- Department of Clinical Genetics, Section Community Genetics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - Janneke T Gitsels-van der Wal
- Department of Midwifery Science, Amsterdam UMC, Vrije Universiteit Amsterdam, AVAG, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Linda Martin
- Department of Midwifery Science, Amsterdam UMC, Vrije Universiteit Amsterdam, AVAG, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Isabel Koopmanschap
- Department of Clinical Genetics, Section Community Genetics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - Mireille N Bekker
- Department of Obstetrics and Gynecology, Utrecht University Medical Center, Utrecht, The Netherlands
| | - Danielle R M Timmermans
- Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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12
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Vander Plaetsen AS, Weymaere J, Tytgat O, Buyle M, Deforce D, Van Nieuwerburgh F. Enrichment of circulating trophoblasts from maternal blood using laminar microscale vortices. Prenat Diagn 2021; 41:1171-1178. [PMID: 33434320 PMCID: PMC8451878 DOI: 10.1002/pd.5901] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 12/11/2020] [Accepted: 01/05/2021] [Indexed: 01/20/2023]
Abstract
Objective Enrichment of circulating trophoblasts (CTs) from maternal blood at week 11–13 of gestation, using laminar microscale vortices, and evaluation of the performance of the VTX‐1 Liquid Biopsy System in terms of CT recovery and purity. Method Eight mililiter of blood was collected from 15 pregnant women and processed with the VTX‐1 Liquid Biopsy System. Y‐chromosome specific quantitative PCR was performed to estimate the number of enriched male CTs. To evaluate the VTX‐1 performance, the target cell recovery was characterized by spiking experiments with a trophoblast cell line. Furthermore, the total quantity of DNA after enrichment was used to calculate the number of retained maternal cells. Results Successful recovery of male CTs was established in 7 out of 10 first trimester samples from pregnant women carrying a male fetus. The number of CTs, recovered from 8 ml of blood, was estimated between two and six. Spiking experiments resulted in a CT recovery of ±35 % with ±1524 retained maternal blood cells. Conclusion CTs can be enriched from maternal blood with high purity, using laminar microscale vortices, starting from 8 ml of blood.
What's already known about this topic?
Cell‐free noninvasive prenatal testing (cfNIPT) is an established, clinically validated method for the prenatal screening of large chromosomal aberrations. The isolation of circulating trophoblasts (CTs), allowing cell‐based NIPT, has been accomplished by means of marker‐based enrichment, although approximately 30‐40 ml of maternal blood is required. Size‐based enrichment of CTs was published in 2012, but was never repeated nor confirmed.
What does this study add?
Laminar microscale vortices allow size‐based enrichment of circulating trophoblasts, starting from only 8 ml of maternal blood. CT recovery and purity after enrichment using the VTX‐1 Liquid Biopsy System are reported.
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Affiliation(s)
| | - Jana Weymaere
- Laboratory of Pharmaceutical Biotechnology, Ghent University, Gent, Belgium
| | - Olivier Tytgat
- Laboratory of Pharmaceutical Biotechnology, Ghent University, Gent, Belgium.,Department of Life Science Technologies, IMEC, Leuven, Belgium
| | - Magaly Buyle
- Department of Obstetrics and Gynecology, Ghent University Hospital, Gent, Belgium
| | - Dieter Deforce
- Laboratory of Pharmaceutical Biotechnology, Ghent University, Gent, Belgium
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13
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Marcon AR, Ravitsky V, Caulfield T. Discussing non-invasive prenatal testing on Reddit: The benefits, the concerns, and the comradery. Prenat Diagn 2020; 41:100-110. [PMID: 33058217 DOI: 10.1002/pd.5841] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 10/09/2020] [Accepted: 10/11/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVE As the use of non-invasive prenatal testing (NIPT) increases, its benefits and concerns are being examined through surveys, qualitative studies, and bioethical analysis. However, only scant research has examined public discourse on the topic. This research examined NIPT discussions on the social media platform Reddit. METHOD Content and qualitative description analysis was performed on 98 NIPT discussions (2682 comments), obtained by inputting "NIPT" into Reddit's search engine. RESULTS Detailing of benefits and concerns was found in collaborative and supportive discussions. Overall, NIPT is seen as valuable and desirable. Some concerns focused on cost-related barriers to access, anxiety related to testing, and interpretation of results. NIPT is often portrayed as offering peace of mind and is sometimes described as a means of preparing for possible outcomes. CONCLUSION In the discussions analyzed, NIPT is seen, overall, as valuable and greater access to it is desired. Some questions and concerns about NIPT were evident. Reddit stands as a valuable and appreciated tool for individuals wishing to discuss NIPT and to solicit and share information, opinions, and experiences. Health care providers should consider the ways social platforms such as Reddit can be engaged to better inform and educate the public.
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Affiliation(s)
- Alessandro R Marcon
- Health Law Institute, Faculty of Law, University of Alberta, Edmonton, Alberta, Canada
| | - Vardit Ravitsky
- Department of Social and Preventative Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Timothy Caulfield
- Health Law Institute, Faculty of Law, University of Alberta, Edmonton, Alberta, Canada
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14
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Chen A, Tenhunen H, Torkki P, Heinonen S, Lillrank P, Stefanovic V. Women's decisional conflict in the pathway of prenatal screening and testing: an explorative study within Finnish public maternity care. J Perinat Med 2020; 48:527-537. [PMID: 32304311 DOI: 10.1515/jpm-2019-0450] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 03/23/2020] [Indexed: 02/06/2023]
Abstract
Objectives To explore women's decisional conflict in the pathway of prenatal screening and testing (PreST) in Finland and to evaluate a counseling service. Methods Self-completion surveys were conducted at two medical settings (screening and further testing) of PreST. Decisional Conflict Scale (DCS) was the main measure. Different types of statistical tests were used to compare women's decisional conflict at different medical settings of PreST, and before-after pre-test counseling. Multivariable linear regressions analyzed the influences of the medical settings and other factors on women's decisional conflict. Results Compared to women in population-based screening, women in further testing (before pre-test counseling) were more likely to feel well informed (P < 0.001), had increased values clarity (P < 0.001), but more likely experienced uncertainty (P = 0.040). Besides medical settings, maternal age, gravidity and previous experience of fetal aneuploidy significantly influenced decisional conflict. After counseling, screen-positive women felt better informed (P < 0.001), had increased values clarity (P < 0.001), perceived more support (P < 0.001), and had better decision certainty (P < 0.001) than before counseling. Conclusions Medical settings influence women's decisional conflict during PreST. Individual counseling is effective in improving screen-positive women's decisional conflict. This research adds knowledge and experience on developing decision-making supports across the pathway of PreST.
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Affiliation(s)
- An Chen
- Institute of Healthcare Engineering, Management and Architecture (HEMA Institute), Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
| | - Henni Tenhunen
- Institute of Healthcare Engineering, Management and Architecture (HEMA Institute), Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
| | - Paulus Torkki
- Institute of Healthcare Engineering, Management and Architecture (HEMA Institute), Department of Industrial Engineering and Management, Aalto University, Espoo, Finland.,Department of Public Health, Faculty of Medicine, Helsinki University, Helsinki, Finland
| | - Seppo Heinonen
- Professor of Obstetrics and Gynecology, Department of Obstetrics and Gynaecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Paul Lillrank
- Institute of Healthcare Engineering, Management and Architecture (HEMA Institute), Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
| | - Vedran Stefanovic
- Professor of Obstetrics, Gynecology and Fetal Medicine, Senior Consultant, Senior Lecturer, Department of Obstetrics and Gynaecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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15
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Governing the futures of non-invasive prenatal testing: An exploration of social acceptability using the Delphi method. Soc Sci Med 2020; 304:112930. [PMID: 32216981 DOI: 10.1016/j.socscimed.2020.112930] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 03/03/2020] [Accepted: 03/12/2020] [Indexed: 01/16/2023]
Abstract
Non-invasive prenatal testing (NIPT) using cell-free DNA (cfDNA) offers numerous benefits to pregnant women and their families. It also raises ethical, legal and social concerns regarding, for instance, the possible effects of a routinization of prenatal genetic testing on free and informed decision-making by prospective parents, and the role of the state in governing its use. Technological advances are allowing cfDNA analyses to detect an increasing number of genetic risks and conditions in the fetus, potentially further exacerbating such concerns. From May 2015 to December 2016, we conducted a three-round Policy Delphi study (NR1 = 61, NR2 = 58, NR3 = 47; overall retention rate = 77.0%) to explore the social acceptability (SA) of current and potential future uses of NIPT in Canada according to participants with relevant professional, research or advocacy expertise. Participants came from four groups: healthcare professionals (NR3 = 14), social sciences and humanities researchers (NR3 = 13), patients/disability rights advocates (NR3 = 14), and cultural/religious communities advocates (NR3 = 6). This paper presents SA criteria and contextual contingencies relevant to the assessment of NIPT's SA according to the group. It also reports what uses (conditions or motives) participants thought should be banned, permitted, publicly funded, or promoted as a public health strategy. According to them, conditions resulting in severe pain or early death, as well as trisomies (13, 18, 21) and sex chromosome abnormalities, should be covered by Canadian public health insurance. However, there was wide agreement that direct-to-consumer NIPT should be legally banned, and that testing for fetal sex for non-medical reasons using NIPT should be either proscribed or discouraged. In addition to identifying areas of consensus, our results point to disagreement regarding, for instance, the required level of governance of whole-genome sequencing and testing for late onset conditions with low penetrance. This study also provides a model for exploring the SA of emerging technologies using the Policy Delphi method.
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16
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Bakkeren IM, Kater-Kuipers A, Bunnik EM, Go ATJI, Tibben A, de Beaufort ID, Galjaard RJH, Riedijk SR. Implementing non-invasive prenatal testing (NIPT) in the Netherlands: An interview study exploring opinions about and experiences with societal pressure, reimbursement, and an expanding scope. J Genet Couns 2019; 29:112-121. [PMID: 31710169 PMCID: PMC7041621 DOI: 10.1002/jgc4.1188] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 10/22/2019] [Accepted: 10/22/2019] [Indexed: 01/13/2023]
Abstract
The noninvasive prenatal test (NIPT) as the first trimester prenatal screening (FTS) for trisomies 21, 18, and 13 is offered to all pregnant women in the Netherlands. NIPT using genome sequencing allows for an expansion of the scope of FTS and the introduction of NIPT gives rise to ethical and societal concerns about deliberated decision‐making, pressure to engage in screening, and possible lack of equal access due to the financial contribution (€175) to NIPT. We explored the opinions and experiences of pregnant women, who were offered FTS, about these concerns, and the possibility of a broadened scope. Nineteen pregnant women representing a diversity of backgrounds were interviewed using a semi‐structured interview guide. Eight women did not opt for prenatal screening while 11 did (NIPT = 4, combined test = 7). Women experienced a free choice to accept or decline prenatal screening, despite sometimes receiving advice from others. Prior to pretest counseling, some women had already deliberated about what an abnormal test result would mean to them. Others accepted or declined FTS without deliberation. The current Dutch policy of requiring a co‐payment was acceptable to some, who believed that it functioned as a threshold to think carefully about FTS. Others were concerned that a financial threshold would lead to unequal access to screening. Finally, pregnant women found it difficult to formulate opinions on the scope of FTS, because of lack of knowledge. Life expectancy, severity, and treatability were considered important criteria for the inclusion of a condition in NIPT.
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Affiliation(s)
- Iris M Bakkeren
- Department of Clinical Genetics, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Adriana Kater-Kuipers
- Department of Medical Ethics, Philosophy of Medicine and Medical History, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Eline M Bunnik
- Department of Medical Ethics, Philosophy of Medicine and Medical History, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Attie T J I Go
- Department of Obstetrics and Gynecology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Aad Tibben
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Inez D de Beaufort
- Department of Medical Ethics, Philosophy of Medicine and Medical History, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Robert-Jan H Galjaard
- Department of Clinical Genetics, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Sam R Riedijk
- Department of Clinical Genetics, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
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17
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Di Gioacchino V, Langlois S, Elliott AM. Canadian genetic healthcare professionals' attitudes towards discussing private pay options with patients. Mol Genet Genomic Med 2019; 7:e00572. [PMID: 30712332 PMCID: PMC6465662 DOI: 10.1002/mgg3.572] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 11/12/2018] [Accepted: 12/02/2018] [Indexed: 12/31/2022] Open
Abstract
Background Just as there is inconsistency with respect to coverage of genomic testing with insurance carriers, there is interprovincial discrepancy in Canada. Consequently, the option of private pay (e.g., self pay) arises, which can lead to inequities in access, particularly when patients may not be aware of this option. There are currently no published data regarding how the Canadian genetics community handles discussions of private pay options with patients. The purpose of this study was to assess the attitudes of genetic healthcare professionals (GHPs: medical geneticists, genetic counselors, and genetic nurses) practicing in Canada toward these discussions. Methods An online survey was distributed to members of the Canadian College of Medical Geneticists and the Canadian Association of Genetic Counsellors to assess frequencies, rationale, and ethical considerations regarding these conversations. Quantitative data were analyzed using descriptive statistics. Results Of 144 respondents, 95% reported discussing private pay and 65% reported working in a clinic without a policy on this issue. There were geographic and practice‐specific differences. The most common circumstance for these discussions was when a test was clinically indicated (e.g., but funding was denied) followed by when the patient initiated the conversation. The most frequently discussed tests included: multi‐gene panels (73% of respondents), noninvasive prenatal testing (62%), and pre‐implantation genetic diagnosis (58%). Although 65% felt it was ethical to discuss private pay, 35% indicated it was “sometimes” ethical. Conclusion With the increasing availability of genomic technologies, these findings inform how we practice and demonstrate the need for policy in this area.
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Affiliation(s)
- Vanessa Di Gioacchino
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sylvie Langlois
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada.,BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada.,Women's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Alison M Elliott
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada.,BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada.,Women's Hospital Research Institute, Vancouver, British Columbia, Canada
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18
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Rezaei M, Winter M, Zander-Fox D, Whitehead C, Liebelt J, Warkiani ME, Hardy T, Thierry B. A Reappraisal of Circulating Fetal Cell Noninvasive Prenatal Testing. Trends Biotechnol 2018; 37:632-644. [PMID: 30501925 DOI: 10.1016/j.tibtech.2018.11.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/04/2018] [Accepted: 11/05/2018] [Indexed: 01/09/2023]
Abstract
New tools for higher-resolution fetal genome analysis including microarray and next-generation sequencing have revolutionized prenatal screening. This article provides commentary on this rapidly advancing field and a future perspective emphasizing circulating fetal cell (CFC) utility. Despite the tremendous technological challenges associated with their reliable and cost-effective isolation from maternal blood, CFCs have a strong potential to bridge the gap between the diagnostic sensitivity of invasive procedures and the desirable noninvasive nature of cell-free fetal DNA (cffDNA). Considering the rapid advances in both rare cell isolation and low-input DNA analysis, we argue here that CFC-based noninvasive prenatal testing is poised to be implemented clinically in the near future.
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Affiliation(s)
- Meysam Rezaei
- Future Industries Institute and ARC Centre of Excellence in Convergent Bio and Nano Science and Technology, University of South Australia, Mawson Lakes Campus, Mawson Lakes, South Australia, Australia; Joint first authors. https://twitter.com/@CBNSSA
| | - Marnie Winter
- Future Industries Institute and ARC Centre of Excellence in Convergent Bio and Nano Science and Technology, University of South Australia, Mawson Lakes Campus, Mawson Lakes, South Australia, Australia; Joint first authors. https://twitter.com/@CBNSSA
| | | | - Clare Whitehead
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON, Canada
| | - Jan Liebelt
- South Australian Clinical Genetics Service, Women's and Children's Hospital, Adelaide, Australia
| | - Majid Ebrahimi Warkiani
- School of Biomedical Engineering, University of Technology Sydney, Sydney, Ultimo NSW 2007, Australia; Institute of Molecular Medicine, Sechenov First Moscow State University, Moscow 119991, Russia
| | - Tristan Hardy
- SA Pathology, Adelaide, Australia; Repromed, Dulwich, South Australia, Australia.
| | - Benjamin Thierry
- Future Industries Institute and ARC Centre of Excellence in Convergent Bio and Nano Science and Technology, University of South Australia, Mawson Lakes Campus, Mawson Lakes, South Australia, Australia; http://bionanoengineering.com/. https://twitter.com/@CBNSSA
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19
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Kater-Kuipers A, Bunnik EM, de Beaufort ID, Galjaard RJH. Limits to the scope of non-invasive prenatal testing (NIPT): an analysis of the international ethical framework for prenatal screening and an interview study with Dutch professionals. BMC Pregnancy Childbirth 2018; 18:409. [PMID: 30340550 PMCID: PMC6194707 DOI: 10.1186/s12884-018-2050-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 10/10/2018] [Indexed: 12/21/2022] Open
Abstract
Background The introduction of non-invasive prenatal testing (NIPT) for foetal aneuploidies is currently changing the field of prenatal screening in many countries. As it is non-invasive, safe and accurate, this technique allows for a broad implementation of first-trimester prenatal screening, which raises ethical issues, related, for instance, to informed choice and adverse societal consequences. This article offers an account of a leading international ethical framework for prenatal screening, examines how this framework is used by professionals working in the field of NIPT, and presents ethical guidance for the expansion of the scope of prenatal screening in practice. Methods A comparative analysis of authoritative documents is combined with 15 semi-structured interviews with professionals in the field of prenatal screening in the Netherlands. Data were recorded, transcribed verbatim and analysed using thematic analysis. Results The current ethical framework consists of four pillars: the aim of screening, the proportionality of the test, justice, and societal aspects. Respondents recognised and supported this framework in practice, but expressed some concerns. Professionals felt that pregnant women do not always make informed choices, while this is seen as central to reproductive autonomy (the aim of screening), and that pre-test counselling practices stand in need of improvement. Respondents believed that the benefits of NIPT, and of an expansion of its scope, outweigh the harms (proportionality), which are thought to be acceptable. They felt that the out-of-pocket financial contribution currently required by pregnant women constitutes a barrier to access to NIPT, which disproportionally affects those of a lower socioeconomic status (justice). Finally, professionals recognised but did not share concerns about a rising pressure to test or discrimination of disabled persons (societal aspects). Conclusions Four types of limits to the scope of NIPT are proposed: NIPT should generate only test outcomes that are relevant to reproductive decision-making, informed choice should be (made) possible through adequate pre-test counselling, the rights of future children should be respected, and equal access should be guaranteed. Although the focus of the interview study is on the Dutch healthcare setting, insights and conclusions can be applied internationally and to other healthcare systems.
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Affiliation(s)
- A Kater-Kuipers
- Department of Medical Ethics and Philosophy of Medicine, Erasmus MC, University Medical Centre Rotterdam, Room 24.17, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
| | - E M Bunnik
- Department of Medical Ethics and Philosophy of Medicine, Erasmus MC, University Medical Centre Rotterdam, Room 24.17, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands.
| | - I D de Beaufort
- Department of Medical Ethics and Philosophy of Medicine, Erasmus MC, University Medical Centre Rotterdam, Room 24.17, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
| | - R J H Galjaard
- Department of Clinical Genetics, Erasmus MC, University Medical Centre Rotterdam, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
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20
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Dupras C, Birko S, Affdal A, Haidar H, Lemoine ME, Ravitsky V. Benefits, challenges and ethical principles associated with implementing noninvasive prenatal testing: a Delphi study. CMAJ Open 2018; 6:E513-E519. [PMID: 30381324 PMCID: PMC6208091 DOI: 10.9778/cmajo.20180083] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Noninvasive prenatal testing is a recent technology that provides some genetic information about the fetus through the analysis of cell-free fetal DNA circulating in maternal blood. We aimed to identify the benefits, challenges and guiding ethical principles most relevant to the clinical integration of noninvasive prenatal testing in Canada, according to experts throughout the country. METHODS We conducted a 3-round Delphi study involving Canadian experts of contemporary discussions about the ethical and societal implications of prenatal testing and genomic technologies. In round 1, we asked participants to identify clinical benefits and challenges related to the implementation of noninvasive prenatal testing in Canada, and the ethical principles they think should guide it. In round 2, we asked participants to select the most important elements stated by their peers. In round 3, participants were informed of the aggregated results from round 2, and invited to revise or confirm their selection. RESULTS Round 1 had a participation rate of 20.2%, and involved 61 participants. Subsequent rounds 2 and 3 had retention rates of 95.1% (n = 58) and 84.5% (n = 49), respectively. Through these discussions, we identified 3 lists of benefits (n = 10), challenges (n = 27), and ethical principles (n = 16) prioritized by Canadian experts as being most relevant to the implementation of noninvasive prenatal testing in Canada. INTERPRETATION Although multiple and diverse potential issues were identified, Canadian experts agreed on 2 sets of requirements for the responsible implementation of noninvasive prenatal testing in Canada. Interdisciplinary appraisals may be instrumental to responsible policy-making related to the implementation of noninvasive prenatal testing in Canada.
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Affiliation(s)
- Charles Dupras
- Center of Genomics and Policy (Dupras) and Institute for Health and Social Policy (Haidar) McGill University; École de santé publique, Université de Montréal (Birko, Affdal, Haidar, Lemoine, Ravitsky), Montréal, Que.
| | - Stanislav Birko
- Center of Genomics and Policy (Dupras) and Institute for Health and Social Policy (Haidar) McGill University; École de santé publique, Université de Montréal (Birko, Affdal, Haidar, Lemoine, Ravitsky), Montréal, Que
| | - Aliya Affdal
- Center of Genomics and Policy (Dupras) and Institute for Health and Social Policy (Haidar) McGill University; École de santé publique, Université de Montréal (Birko, Affdal, Haidar, Lemoine, Ravitsky), Montréal, Que
| | - Hazar Haidar
- Center of Genomics and Policy (Dupras) and Institute for Health and Social Policy (Haidar) McGill University; École de santé publique, Université de Montréal (Birko, Affdal, Haidar, Lemoine, Ravitsky), Montréal, Que
| | - Marie-Eve Lemoine
- Center of Genomics and Policy (Dupras) and Institute for Health and Social Policy (Haidar) McGill University; École de santé publique, Université de Montréal (Birko, Affdal, Haidar, Lemoine, Ravitsky), Montréal, Que
| | - Vardit Ravitsky
- Center of Genomics and Policy (Dupras) and Institute for Health and Social Policy (Haidar) McGill University; École de santé publique, Université de Montréal (Birko, Affdal, Haidar, Lemoine, Ravitsky), Montréal, Que
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21
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Kater-Kuipers A, de Beaufort ID, Galjaard RJH, Bunnik EM. Ethics of routine: a critical analysis of the concept of 'routinisation' in prenatal screening. JOURNAL OF MEDICAL ETHICS 2018; 44:626-631. [PMID: 29695408 DOI: 10.1136/medethics-2017-104729] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 03/13/2018] [Accepted: 03/26/2018] [Indexed: 06/08/2023]
Abstract
In the debate surrounding the introduction of non-invasive prenatal testing (NIPT) in prenatal screening programmes, the concept of routinisation is often used to refer to concerns and potential negative consequences of the test. A literature analysis shows that routinisation has many different meanings, which can be distinguished in three major versions of the concept. Each of these versions comprises several inter-related fears and concerns regarding prenatal screening and particularly regarding NIPT in three areas: (1) informed choice, (2) freedom to choose and (3) consequences for people with a disability. Three of the strongest arguments raised under the flag of routinisation are assessed for their validity: the threat that NIPT poses to informed choice, the potential increase in uptake of first-trimester prenatal screening and its consequences for social pressure to participate in screening or terminate affected pregnancies, and the negative consequences for disabled people. These routinisation arguments lack empirical or normative ground. However, the results of this analysis do not imply that no attention should be paid to possible problems surrounding the introduction of NIPT. At least two problems remain and should be addressed: there should be an ongoing debate about the requirements of informed choice, particularly related to an expanded scope of prenatal screening. Also, reproductive autonomy can only be achieved when expecting parents' options are variegated, real and valuable, so that they can continue to choose whether or not to screen or to terminate a pregnancy.
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Affiliation(s)
- Adriana Kater-Kuipers
- Department of Medical Ethics and Philosophy of Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Inez D de Beaufort
- Department of Medical Ethics and Philosophy of Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Robert-Jan H Galjaard
- Department of Clinical Genetics, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Eline M Bunnik
- Department of Medical Ethics and Philosophy of Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
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22
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Abstract
The landscape of genetic testing and screening has changed tremendously since the initial description of the molecular structure of DNA. Given this, it is critical that providers reflect on the goals of prenatal screening and diagnostic testing, and how these tests impact perinatal outcomes. The participants of this workshop were in agreement that the goal of prenatal genetic testing should be focused on improving outcomes for women and families. While prenatal testing has historically focused on the option for pregnancy termination, increasing numbers of prenatal and perinatal treatments are available. As more in utero therapies are developed, the detection of disorders that are amenable to, and would benefit from, prenatal or immediate neonatal targeted therapy will increasingly be a focus of prenatal testing. Prenatal genetic testing must also balance the ethical principles of autonomy and distributive justice. The workshop participants agreed that stakeholders such as medical professionals, professional societies, insurers, commercial laboratories, and the public should consider and come to agreement regarding the appropriate objectives for and use of these tests.
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Affiliation(s)
- Stephanie Dukhovny
- Department of OBGYN, Maternal Fetal Medicine, Oregon Health & Sciences University, 3181 SW Sam Jackson Park Road, Portland OR 97239, United States.
| | - Mary E Norton
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, 550 16th St, 7th floor, San Francisco CA 94143, United States.
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Vanstone M, Cernat A, Nisker J, Schwartz L. Women's perspectives on the ethical implications of non-invasive prenatal testing: a qualitative analysis to inform health policy decisions. BMC Med Ethics 2018; 19:27. [PMID: 29661182 PMCID: PMC5902938 DOI: 10.1186/s12910-018-0267-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 04/08/2018] [Indexed: 12/13/2022] Open
Abstract
Background Non-Invasive Prenatal Testing (NIPT) is a technology which provides information about fetal genetic characteristics (including sex) very early in pregnancy by examining fetal DNA obtained from a sample of maternal blood. NIPT is a morally complex technology that has advanced quickly to market with a strong push from industry developers, leaving many areas of uncertainty still to be resolved, and creating a strong need for health policy that reflects women’s social and ethical values. We approach the need for ethical policy-making by studying the use of NIPT and emerging policy in the province of Ontario, Canada. Methods Using an adapted version of constructivist grounded theory, we conducted interviews with 38 women who have had personal experiences with NIPT. We used an iterative process of data collection and analysis and a staged coding strategy to conduct a descriptive analysis of ethics issues identified implicitly and explicitly by women who have been affected by this technology. Results The findings of this paper focus on current ethical issues for women seeking NIPT, including place in the prenatal pathway, health care provider counselling about the test, industry influence on the diffusion of NIPT, consequences of availability of test results. Other issues gain relevance in the context of future policy decisions regarding NIPT, including funding of NIPT and principles that may govern the expansion of the scope of NIPT. These findings are not an exhaustive list of all the potential ethical issues related to NIPT, but rather a representation of the issues which concern women who have personal experience with this test. Conclusions Women who have had personal experience with NIPT have concerns and priorities which sometimes contrast dramatically with the theoretical ethics literature. These findings suggest the importance of engaging patients in ethical deliberation about morally complex technologies, and point to the need for more deliberative patient engagement work in this area. Electronic supplementary material The online version of this article (10.1186/s12910-018-0267-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Meredith Vanstone
- Department of Family Medicine, McMaster University, DBHSC 5003E, 100 Main St W, Hamilton, ON, L8P 1H6, Canada. .,Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada.
| | - Alexandra Cernat
- Life Sciences Program, McMaster University, Hamilton, ON, Canada
| | - Jeff Nisker
- Department of Obstetrics and Gynecology, Western University, London, ON, Canada.,Children's Health Research Institute, London, ON, Canada
| | - Lisa Schwartz
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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24
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Ravitsky V. The Shifting Landscape of Prenatal Testing:Between Reproductive Autonomy and Public Health. Hastings Cent Rep 2017; 47 Suppl 3:S34-S40. [DOI: 10.1002/hast.793] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Liehr T, Lauten A, Schneider U, Schleussner E, Weise A. Noninvasive Prenatal Testing - When Is It Advantageous to Apply. Biomed Hub 2017; 2:1-11. [PMID: 31988902 PMCID: PMC6945944 DOI: 10.1159/000458432] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 01/27/2017] [Indexed: 12/23/2022] Open
Abstract
Nowadays it is common sense in obstetrics that an increased risk for pregnancy loss due to invasive testing does not exist. Nonetheless, noninvasive prenatal testing (NIPT) is a hot topic, even though this approach does not provide a reduction of unintentionally induced abortions. NIPT has a number of shortcuts which are highlighted in this review, including: (1) in NIPT placental rather than fetal DNA is studied, (2) NIPT fails in 2–6% of cases, and (3) trisomy 21 accounts for only ∼50% of existing chromosomal aberrations. Thus, we agree with the literature that NIPT is a fascinating possibility to gain information on unborn life from minimal amounts of DNA. However, it remains a pure risk estimation test directed towards the detection of specific chromosomal abnormalities from peripheral blood of the pregnant woman. It is important to highlight that families buying this test, and getting a normal result, may be provided with a false sense of security. Thus, careful and comprehensive genetic counselling should be performed before the test is offered, and should include a clear explanation of the advantages and disadvantages, as well as limitations, compared to other methods.
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Affiliation(s)
- Thomas Liehr
- Institute of Human Genetics, Friedrich Schiller University, Jena, Germany
| | - Angela Lauten
- Institute of Clinic for Obstetrics and Gynecology, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Uwe Schneider
- Institute of Clinic for Obstetrics and Gynecology, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Ekkehard Schleussner
- Institute of Clinic for Obstetrics and Gynecology, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Anja Weise
- Institute of Human Genetics, Friedrich Schiller University, Jena, Germany
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Murdoch B, Ravitsky V, Ogbogu U, Ali-Khan S, Bertier G, Birko S, Bubela T, De Beer J, Dupras C, Ellis M, Granados Moreno P, Joly Y, Kamenova K, Master Z, Marcon A, Paulden M, Rousseau F, Caulfield T. Non-invasive Prenatal Testing and the Unveiling of an Impaired Translation Process. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 39:10-17. [DOI: 10.1016/j.jogc.2016.09.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 08/29/2016] [Indexed: 12/15/2022]
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Ravitsky V, Rousseau F, Laberge AM. Providing Unrestricted Access to Prenatal Testing Does Not Translate to Enhanced Autonomy. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2017; 17:39-41. [PMID: 27996925 DOI: 10.1080/15265161.2016.1251651] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
| | - Francois Rousseau
- b Centre de recherche du CHU de Québec, CHU de Québec-Université Laval
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