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Antenatal genetic testing and the right to remain in ignorance.

As knowledge increases about the human genome, prenatal genetic testing will become cheaper, safer and more comprehensive. It is likely that there will be a great deal of support for making prenatal testing for a wide range of genetic disorders a routine part of antenatal care. Such routine testing is necessarily coercive in nature and does not involve the same standard of consent as is required in other health care settings. This paper asks whether this level of coercion is ethically justifiable in this case, or whether pregnant women have a right to remain in ignorance of the genetic make-up of the fetus they are carrying. While information gained by genetic testing may be useful for pregnant women when making decisions about their pregnancy, it does not prevent harm to future children. It is argued that as this kind of testing provides information in the interests of the pregnant women and not in the interests of any future child, the same standards of consent that are normally required for genetic testing should be required in this instance.

Coercion↗

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.

Bioethics↗

Ethics and genetics: susceptibility testing in the workplace.

Genetic testing in the workplace is a technology both full of promise and fraught with ethical peril. Though not yet common, it is likely to become increasingly so. We survey the key arguments in favour of such testing, along with the most significant ethical worries. We further propose a set of pragmatic criteria, which, if met, would make it permissible for employers to offer (but not require) workplace genetic testing.

Employment↗

Attitudes of health care trainees about genetics and disability: issues of access, health care communication, and decision making.

Prior studies suggest that knowledge and attitudes of health care professionals influence patient communication and medical decision-making. To study this dynamic in the context of genetic disability, we developed a survey on health professionals' attitudes regarding disability and genetic screening and pilot-tested it on a sample of medical students, residents, and genetic counseling students (N=85). Despite minimal experience with disability or genetics, most respondents reported feeling comfortable dealing with genetics (59%) and disability (75%). The majority felt that disability caused significant suffering for both the person (51%) and family (64%), and that research should be directed toward preventing genetic disability (62%). Similar to prior literature, perceived "Quality of Life" was most often based on degrees of physical and cognitive functioning, pain, and social support. However, differences were found between genetic counseling trainees and other medical trainees in their relative emphasis of social versus medical issues in questions of disability and genetic testing, and these response patterns were associated with differences in the groups' priorities for offering information about social resources. Respondents agreed that access to genetic testing and information is personal and that testing should be available upon request for oneself (68%) and to a lesser degree for one's fetus (55%) or child (41%). However, the same individuals frequently stated that society should regulate access to such technologies. Although most felt that the patient and professional should jointly make such decisions on a case-by-case basis, it was also seen as appropriate for the health care professional to occasionally decline genetic testing. It seems appropriate that training and experience influence knowledge and attitudes. Therefore, it is critical to document knowledge and attitudes of various health care providers and trainees, including differences between various specialties, to improve educational interventions geared to this area.

Attitude of Health Personnel↗

The nature and significance of behavioural genetic information.

In light of the human genome project, establishing the genetic aetiology of complex human diseases has become a research priority within Western medicine. However, in addition to the identification of disease genes, numerous research projects are also being undertaken to identify genes contributing to the development of human behavioural characteristics, such as cognitive ability and criminal tendency. The permissibility of this research is obviously controversial: will society benefit from this research, or will it adversely affect our conceptions of ourselves and each other? When assessing the permissibility of this research, it is important to consider the nature and deterministic significance of behavioural genetic information. Whilst to date there has been much discussion and debate about the properties of genetic information per se and genetic determinism, this has not been applied to behavioural genetic research and its ethical implications. Therefore, this paper elucidates how behavioural genetic information can be distinguished from other types of genetic and non-genetic information and also synthesizes the determinative significance of genetic factors for the development of human behavioural traits. Undertaking this analysis enables the ethical issues raised by this research to be debated in an appropriate context and indicates that separate policy considerations are warranted.

Attitude to Health↗

The assent of a nation: genethics and Iceland.

The Icelandic parliament passed legislation authorizing the establishment of a national health sector database which will be sponsored financially by private enterprises through DeCode Genetics Inc. Health related data will be gathered from patients, without their informed consent, from all points of contact with Icelandic public and private health care providers. A centralized data curator will 'non-personalize' the identity of the subjects in a one-way coding system which the government and DeCode Genetics argue overrides the need for informed consent. This legislation is in conflict with the European Data Protection Act, which requires informed consent for the collection of personal data. The law raises many ethical questions regarding the central tenets of informed consent, the power of government, the rights of the human subject, and finally, the responsibility of the clinician balancing commitments of the patient and research.

Bioethics↗

To test or not to test: an ethical conflict with presymptomatic testing of individuals at 25% risk for Huntington's disorder.

The first presymptomatic test for Huntington's disease was developed in the 1980s. With the detection of the gene causing the disorder in 1993, it became possible to do direct mutation tests with almost 100% sensitivity and specificity. The author discusses some of the ethical issues that arise when an adult child at 25% risk for the disease wishes to have the test, but the parent(s) at 50% risk refuses to have one. If the child tests positive, the genetic status of the parent will also be disclosed. No matter what course of action is chosen in this situation, the ethically legitimate interests of either child or parent might be violated. The author examines different alternatives and suggests a solution that might be acceptable to all parties.

Adult↗

We're off to see the genome.

We discuss some societal and legal ramifications of the human genetics revolution. Our reflections were stimulated by discussions among scientists, citizens and legal experts at a large public symposium. We outline key issues regarding oversight of genetic research on human subjects, banking of DNA data by governments and corporations, the potential impact of behavioural genetics and effects upon racial and racist thinking. We contend that, in some cases, well-intentioned but naive efforts to protect the rights of individuals and groups may hurt everyone by blocking the progress of useful research.

Databases, Factual↗