Psychological issues in genetic counselling

Summary In the case of prenatal diagnosis and its possible consequences, there is discussion on the limits of freedom of decision. Nevertheless, there is considerable agreement that the individual family should be helped to make its own decisions and to live with these decisions. To attain these goals psychological issues are necessarily of importance. This paper presents concepts on these psychological issues and how they have to be taken into account in counselling. The character of mutuality in providing information is emphasized as well as cognitive and affective processes determining the understanding and outcome of genetic counselling. The role of prior knowledge, expectations, experience, and meaning attached to the disease and its consequences are discussed. Tasks for the counselling staff ranging from preparation for genetic counselling to follow-ups, counselling skills, and methods facilitating the counselling process are specified.     

Beyond consent: ethical and social issues in genetic testing

Informed consent is a vital ethical doctrine in clinical medicine and, through genetic counselling, is being applied to genetic testing. But genetic testing raises issues that transcend the traditional concept of informed consent. Genetic tests are adopted without demonstrable clinical benefit, and the consequences of testing can reach beyond the individual to their families and communities. Understanding the social and cultural context of genetic testing will lead to more informed discussion and debate on these issues.     

Trinucleotide (CAG) repeat expansion in chromosomes of Spanish patients with Huntington's disease

Huntington's disease (HD) is a neurodegenerative and hereditary disease characterized by progressive movement disorders and mental and behavioral abnormalities. The HD gene is an expanding and unstable trinucleotide repeat (CAG repeat sequences). We studied 77 individuals from 38 families with HD in an attempt to obtain information for genetic counselling and differential diagnosis. Our results indicate that individuals with more than 40 repeats will be affected by the disease, whereas those with fewer than 30 will be healthy. There can be some overlap between 30 and 40 repeats, and one should be careful when interpreting these results.     

Prospective study of genetic counselling.

A prospective study was carried out on 200 consecutive subjects seen for counselling (consultands) for serious genetic disorders. Educational and social background of consultands and their knowledge and understanding of their particular problem were assessed before counselling, and their response was determined immediately afterwards and three months and two years later by an independent observer not concerned in the genetic counselling. The husband''s educational background was particularly important in influencing a couple''s comprehension of counselling. X-linked recessive and chromosomal disorders presented the most difficulties in comprehension. The counsellors'' assessment of comprehension was a good guide to the consultands'' comprehension as assessed at subsequent follow-up. The proportion deterred from having children increased with time and over a third had been sterilised within two years of counselling. It is suggested that follow-up after counselling should be routine, especially when the counsellor suspects that comprehension has not been good, in X-linked recessive and chromosomal disorders, and when the risks of having an affected child are considered to be high.     

Science and society: genetic counselling and customary consanguineous marriage

Consanguineous marriage is customary in many societies, but leads to an increased birth prevalence of infants with severe recessive disorders. It is therefore often proposed that consanguineous marriage should be discouraged on medical grounds. However, several expert groups have pointed out that this proposal is inconsistent with the ethical principles of genetic counselling, overlooks the social importance of consanguineous marriage and is ineffective. Instead, they suggest that the custom increases the possibilities for effective genetic counselling, and recommend a concerted effort to identify families at increased risk, and to provide them with risk information and carrier testing when feasible.     

Systematic neonatal detection of Duchenne's muscular dystrophy. Results after 10 years' of experience in Lyons (France)

Neonatal screening of Duchenne Muscular Dystrophy using serum CK level measurement has been performed for 10 years in a part of the Rh?ne-Alpes area (40,000 newborns per year). This test avoids consecutive cases in an affected family by mean of an early genetic counselling. So, 10 potential DMD boys have been avoided (i.e. one out of five of the D.M.D., as a whole which would be born during this same ten year study). Details on familial structures and efficiency of genetic counselling are given, and this efficiency will be increased by the DNA study of the concerned families.     

Small marker chromosomes in a series of 1,000 prenatal diagnoses by amniocentesis

We diagnosed two small marker chromosomes in a series of 1,000 prenatal cytogenetic studies of amniotic fluid cells. Each of these chromosomes was analyzed with various staining techniques in order to determine its structure and the possible mechanism of its formation. On the basis of the results thus obtained and the familial nature of these abnormalities, we predicted phenotypically normal fetuses in both cases. Postnatal follow-up confirmed this. Notwithstanding the correct diagnoses made in these two cases, we feel that a more substantial body of literature on this type of anomaly must become available before it will be possible to give firm genetic counselling in such cases.     

Bioethics for clinicians: 14. Ethics and genetics in medicine

Information about a patient''s inherited risk of disease has important ethical and legal implications in clinical practice. Because genetic information is by nature highly personal yet familial, issues of confidentiality arise. Counselling and informed consent before testing are important in view of the social and psychological risks that accompany testing, the complexity of information surrounding testing, and the fact that effective interventions are often not available. Follow-up counselling is also important to help patients integrate test results into their lives and the lives of their relatives. Genetic counselling should be provided by practitioners who have up-to-date knowledge of the genetics of and the tests available for specific diseases, are aware of the social and psychological risks associated with testing, and are able to provide appropriate clinical follow-up. Some physicians may elect to refer patients for genetic counselling and testing. However, it is inevitable that all physicians will be involved in long-term follow-up both by monitoring for disease and by supporting the integration of genetic information into patients'' lives.     

Ethics and practice: two worlds? The example of genetic counselling

The aim of this paper is to work out the relationship between ethics and practice with reference to genetic counselling. First, the most important principles with respect to genetic counselling and to counsellor-client-interaction, are explained briefly. Then, we discuss what these principles might mean, when applied to the practice of counselling. To do so, we also look at some empirical data. Finally, we draw some conclusions.     

Ascertainment and Prevention of Genetic Disease

A genetic register system has been developed for the ascertainment and prevention of genetic disease. Its potential value is illustrated with data collected from 478 families with serious genetic disorders which had been seen during the past five years. Of these 249 were referred specifically for genetic counselling, autosomal dominant disorders accounting for the largest group of families with individuals at high risk of becoming affected. Of 717 individuals at high risk of having affected children (or carrier daughters in the case of X-linked recessive disorders), only 101 were referred specifically for counselling. Many were referred only after the birth of an affected child which might otherwise have been prevented. A genetic register system linked to practitioner, hospital, and health department records could be a valuable means of preventing genetic disease.     

Genetic linkage relationships of seven DNA probes with Duchenne and Becker muscular dystrophy

Summary The inheritance of seven restriction fragment length polymorphisms detected by DNA probes has been studied in families with Duchenne and Becker muscular dystrophies (DMD and BMD). The probes used have all been mapped to the short arm of the X-chromosome, four being distal and three proximal to the disease loci located within the Xp21 region. Linkage analysis of the DNA polymorphisms in relation to the two disorders showed similar genetic distances. Data obtained from DMD and BMD families have been combined to give more precise values for the different recombination fractions. Combined use of these polymorphic DNA markers will be of practical value in the genetic counselling of women at risk for Duchenne and Becker muscular dystrophy.     

Women's need for information before attending genetic counselling for familial breast or ovarian cancer: a questionnaire,interview, and observational study.

OBJECTIVES: To describe women''s information needs prior to genetic counselling for familial breast or ovarian cancer. DESIGN: Prospective study including semistructured telephone interviews before genetic counselling, observations of consultations, completion of postal questionnaires, and face-to face interviews within two months of counselling. SUBJECTS: 46 women attending genetic counselling for familial breast or ovarian cancer. MAIN OUTCOME MEASURES: Subjects'' understanding of process and content of genetic counselling before attending and attitudes about their preparation for the counselling session. RESULTS: Although all women interviewed before the clinic expected to discuss their risk of developing cancer and risk management options, there was evidence of a lack of knowledge about the process and content of genetic counselling, 17 (37%) women said they did not know what else would happen. Most women interviewed after counselling viewed it positively, but 26 (65%) felt they had been inadequately prepared and 11 (28%) felt that their lack of preparation meant that they could not be given an accurate estimation of their risk of cancer. CONCLUSIONS: Some women felt that they did not obtain optimum benefit from genetic counselling because they were inadequately prepared for it. We suggest that cancer family history clinics should provide women with written information about the process and content of genetic counselling before their clinic attendance.     

Experiences of Genetic Risk: Disclosure and the Gendering of Responsibility

The question of ‘who owns genetic information‘ is increasingly a focus of ethical inquiry. Applied to predictive testing, several recent critiques suggest that persons with a genetic disorder have a moral duty to disclose that information to other family members. The justification for this obligation is that genetic information belongs to and may benefit not only a single individual, but also members of a biological kinship. This paper considers this issue from a different vantage point: How does gender intersect with the moral duty to disclose genetic information? Scholars have argued that gender is partly comprised of distinct assignments and assumptions of responsibility. Thus, there is a danger that gendered patterns of socialization will make women feel that they should take primary responsibility for disclosing genetic information to others. This article explores issues of responsibility and disclosure of risk information by drawing on an empirical study of women and men who have undergone genetic testing for hereditary breast/ovarian cancer. The research study suggests that disclosure of genetic information is a gendered activity, with both the benefits and burdens of this task falling primarily on women. It also illustrates that when disclosure is understood contextually, it is a far more complicated matter than when viewed through a theoretical lens. The article considers the relevance of these findings on ethical debate and genetic counselling practices.     

Linkage studies in Emery-Dreifuss muscular dystrophy

We report linkage studies between Emery-Dreifuss muscular dystrophy (EDMD) and polymorphic probes from the long arm of chromosome X in two pedigrees. The results don't show significant linkage but are consistent with previous localisation of EDMD in Xq28. Further studies will be necessary to apply molecular biology to genetic counselling and prenatal diagnosis of this disease.     

Cerebellar ataxia and mental retardation in a child with an inherited satellited chromosome 4q

We identified a case of familial satellited chromosome 4q through a child with cerebellar ataxia and mental retardation. No loss of genetic material could be demonstrated at the molecular level but other possible mechanisms of this association are discussed. We conclude that in these cases genetic counselling should be reassuring.     

Genetic counselling. I. Definition and present status (author's transl)]

Genetic counselling is a medical action which must be carried out by a M.D. specialized in genetics. Genetic counselling is peculiar in that couples rather than individuals are involved. Furthermore it is not concerned with the health of the consultants but with that of their expected children. Genetic counselling is not restricted to the statistical estimation of a risk; it raises important problems of psychology and behaviour. Finally, eugenic considerations about the diffusion of deleterious genes should not be taken into account in genetic counselling, which is given in the interest of individuals, not of the society. The increasing demand for genetic counselling is due to the change of the reproductive pattern. People do not want only to fix the size of their family, but also to avoid any accident of procreation.     

Ethical considerations in the presymptomatic diagnosis of Alzheimer's disease

Research into the human genome has undoubtedly opened up a new perspective in medicine. The ability to identify the cause of specific diseases, especially neurodegenerative diseases, will definitively change the concepts of disease and treatment, while advances such as antibiotic therapy and anesthesia will be relegated to history. However, the arrival of genome medicine poses major bioethical challenges, many of which remain to be resolved. We review the applicability, results and consequences of predictions based on genetic tests for presymptomatic Alzheimer's disease, as well as the dilemmas and contradictions that are already arising as a result of the commercialization of predictive tests for public use with little or no medical supervision. Given that there is currently no effective treatment of Alzheimer?s disease, the greatest challenge and contradiction lies in managing the results of predictive tests. There are no indications for the performance of predictive genetic tests in late or sporadic Alzheimer's disease or for counselling of persons requesting these tests. The PICOGEN program provides a safe, effective, reliable and satisfactory option for persons requesting these tests who meet the inclusion criteria. Currently, caution should be the norm when considering the performance of predictive tests in presymptomatic dementia.     

Malformation uropathies and multiple malformation syndromes

The authors, from their experience emphasize the associated malformations' frequency in major congenital urinary tract malformations (26,9%). It is essential to recognize in these multiple defects some certified syndromes - inherited or not. The most associations are still unknown, nevertheless the genetic counselling require an accurate diagnosis.     

Aspectos éticos del diagnóstico presintomático de la enfermedad de Alzheimer

Research into the human genome has undoubtedly opened up a new perspective in medicine. The ability to identify the cause of specific diseases, especially neurodegenerative diseases, will definitively change the concepts of disease and treatment, while advances such as antibiotic therapy and anesthesia will be relegated to history. However, the arrival of genome medicine poses major bioethical challenges, many of which remain to be resolved. We review the applicability, results and consequences of predictions based on genetic tests for presymptomatic Alzheimer's disease, as well as the dilemmas and contradictions that are already arising as a result of the commercialization of predictive tests for public use with little or no medical supervision. Given that there is currently no effective treatment of Alzheime?s disease, the greatest challenge and contradiction lies in managing the results of predictive tests. There are no indications for the performance of predictive genetic tests in late or sporadic Alzheimer's disease or for counselling of persons requesting these tests. The PICOGEN program provides a safe, effective, reliable and satisfactory option for persons requesting these tests who meet the inclusion criteria. Currently, caution should be the norm when considering the performance of predictive tests in presymptomatic dementia.     

Variability in the effect of alcohol on alcohol metabolizing enzymes may determine relative sensitivity to alcohols: a new hypothesis

Individual and racial differences in response to alcohol and with respect to alcoholism have strong genetic predispositions. Most studies on the actual genetic determinants have concentrated on the isozymes of alcohol dehydrogenase (ADH) and acetaldehyde dehydrogenase (ALDH), the two enzymes of the primary pathway of alcohol metabolism. Although few "activity" variants (associated with mutations in the structural genes) of the two enzymes are known to exist in susceptible groups, these observations do not offer an adequate explanation for the observed variability in response to alcohols in the population. Some recent studies have reported alterations in the specific activity of the two enzymes following exposure to alcohol for different lengths of time in man, rat, and mice. The induction-repression so observed is hypothesized to be regulated by one or more inducibility genetic elements (IGE) associated with the structural loci of the two enzymes. Variability in IGE will permit a genotype (individual) specific response in ADH and ALDH specific activity when challenged with a given level of alcohol. Considering the relative toxicity of acetaldehyde, the primary metabolite of this pathway, the resistant individuals would be expected to show ALDH induction. Conversely, the susceptible individuals should respond to alcohol by ALDH repression. The ability of an individual to show induction or repression following alcohol ingestion will depend on his or her IGE genotype(s) associated with specific enzyme loci. Also, the degree of polymorphism at these loci would be expected to be extensive and yet population and race specific. Once experimentally established, this approach could have important implications in screening, counselling, prevention, and in novel approaches to treatment.