Genetic screening: ethical issues - Nuffield Council on Bioethics

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20 pregnancies. DNA techniques, which identify carriers as well as affected children, have been used for confirmation of the diagnosis in the newborn period. 3.20 Pilot neonatal <strong>screening</strong> programmes for early identification of Duchenne muscular dystrophy have been set up in the UK (in Wales) and several other countries. 6 All of these programmes have been based on an indirect method; the detection of the level of the enzyme, creatine kinase, in the blood. These programmes vary somewhat in detail, and in the manner of obtaining consent : the Pittsburgh study, for example, employs informed dissent (see paragraph 3.16). The X-linked nature of this disease raises particular <strong>ethical</strong> <strong>issues</strong> in terms of implications for the extended family (see paragraph 5.13). 3.21 Because neonatal <strong>screening</strong> for Duchenne muscular dystrophy is essentially still in the pilot stage, evaluation of all the <strong>ethical</strong> <strong>issues</strong> is not possible. Most of those involved consider that extensive, well-monitored pilot phases should precede a decision on more general implementation. 6 3.22 All newborn babies have a physical examination which may detect congenital disorders, some of which may have a genetic component. Examinations are often carried out in the presence of the mother and the parents are informed about any abnormalities and their implications. Later childhood <strong>screening</strong> 3.23 As part of routine child health surveillance, all children have a physical examination for a variety of diseases which may in part have a genetic basis; for example, hearing defects may be detected. Programmes of <strong>screening</strong> for specific genetic disorders are at present in the pilot stage. 3.24 In Montreal, genetic <strong>screening</strong> programmes directed at high school students have been conducted for Tay-Sachs disease, beta thalassaemia and cystic fibrosis. 7,8,9 All three projects appear to have been well accepted. The vast majority (over 90%) in all programmes approved of <strong>screening</strong> in high school and understood the significance of the findings. Clearly the community was well informed as genetic <strong>screening</strong> in the local high schools is regarded as a ‘normal activity’. Most carriers for Tay-Sachs or beta thalassaemia claimed they would want to know the carrier status of an intended spouse; a small minority of the Tay-Sachs carriers would ‘reconsider’ if the prospective partner proved to be a carrier. A follow-up survey of attitudes towards <strong>screening</strong> for
21 Tay-Sachs concluded that “students have a very positive attitude toward genetic <strong>screening</strong> in general. These findings are associated with an effort to expand the human genetics content in the biology curriculum....The <strong>screening</strong> clinic in the schools, and literature provided by the <strong>screening</strong> authority, was an effective source of knowledge about the significance of Tay-Sachs heterozygosity [ie of being a Tay-Sachs carrier].” 7 Adult <strong>screening</strong> 3.25 Screening of adults may be carried out to detect existing disease or predisposition to a disease, or may identify carriers with a reproductive genetic risk. Most presymptomatic testing for late onset genetic diseases (for example, Huntington’s disease) is currently offered to family members at risk. General <strong>screening</strong> for such late-onset genetic diseases is increasingly becoming technically feasible, though not necessarily desirable. 3.26 Screening programmes for various forms of cancer which may have a genetic basis are currently the main form of genetic <strong>screening</strong> in the adult population. Testing of the gene itself is now possible for familial adenomatous polyposis, an inherited form of colorectal cancer. It may shortly become possible to screen a sub-group of women at high risk of familial breast cancer, though at present such <strong>screening</strong> is aimed at early detection of the cancer itself. These testing programmes in families already known to be at risk may be the forerunners of future <strong>screening</strong> programmes. 3.27 The general <strong>screening</strong> of individuals who may be carriers for inherited disease genes is currently used only as a service to those in an ethnic group known to have a high incidence of an inherited disease, for example the haemoglobin disorders and Tay-Sachs disease. 3.28 Pilot projects have been undertaken in several centres to detect carriers for cystic fibrosis in adults aged between 16 and 45 years through <strong>screening</strong> in general practice. 10,11 Preliminary results suggest a high uptake when individuals are offered testing and counselling through personal contact. These projects are discussed more fully in Chapter 4.
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Page 6 and 7: ii The broad framework provided as
Page 8 and 9: Terms of reference iv The terms of
Page 10 and 11: vi Page Chapter 7 : INSURANCE 65 Li
Page 12 and 13: 2 the ways in which groups have bee
Page 14 and 15: 4 Both programmes identify potentia
Page 16 and 17: 6 the size of that risk depends on
Page 18 and 19: 8 In addition to the genetic contri
Page 20 and 21: 10 Chromosomal disorders 2.6 Chromo
Page 22 and 23: 12 2.13 Major scientific advances h
Page 25 and 26: 15 Chapter 3 Genetic</stron
Page 27 and 28: 17 if it develops. It is therefore
Page 29: any major ethical
Page 33 and 34: an X-linked disorder or if either p
Page 35 and 36: 25 children born to younger women (
Page 37: 27 CURRENT GENETIC SCREENING PROGRA
Page 40 and 41: 30 relatively small numbers of peop
Page 42 and 43: 32 4.10 A number of pilot s
Page 44 and 45: 34 4.12 Two of the cystic fibrosis
Page 46 and 47: 36 Counselling and consent 4.17 In
Page 48 and 49: 38 4.22 Although the training and s
Page 50 and 51: 40 Conclusions and recommendations
Page 52 and 53: 42 future decisions about having ch
Page 54 and 55: 44 The importance of confidentialit
Page 56 and 57: 46 interest may be outweighed by so
Page 58 and 59: 48 5.22 Do additional measures need
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Page 62 and 63: 52 (i) (ii) (iii) a genetic registe
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Page 73 and 74: 63 legal regulation does not appear
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7.25 According to the ABI’s posit
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7.34 If insurance companies are to
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75 Chapter 8 Genetic</stron
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77 What are the dangers of stigmati
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79 easier to accept and deal with o
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8.22 As it becomes feasible to test
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84 9.3 We emphasise that there shou
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87 Chapter 10 Conclusions 10.1 We s
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counsellors) in particular among th
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91 (iii) the condition is one for w
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10.20 We recommend that the Departm
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96 References CHAPTER 1 1. Mennie M
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98 CHAPTER 6 1. Haldane J Heredity
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100 Official legislative and profes
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102 France: Comité Consultatif Nat
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104 Scientific terms Only those ter
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106 Recessive The form of inheritan
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108 Congenital hypothyroidism Mode
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110 but to a lesser degree : about
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112 Hypertrophic cardiomyopathy Mod
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114 Tay-Sachs disease Mode of inher
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Nuffield C
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Genetic screening: ethical issues - Nuffield Council on Bioethics

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