What if, in the course of studying a specific disease, a researcher finds a genetic mutation associated with that disease in a tissue sample provided by a study participant? Or what if the researcher finds some other genetic variant completely incidental to what he or she set out to look for? Should the researcher disclose the finding to the study participant?
As it turns out, this seemingly simple question has no simple answer. How researchers proceed depends on a number of considerations, which include the clinical accuracy and validity of the test results – itself a contested question– as well as the nature of the disease in question, whether or not it can be treated, and the participant’s right to know or not know. Does the information provide clear direction for action or carry with it some uncertainty?
“For the last five years or so, we’ve seen a growing body of literature that supports sharing more individual-level information with study participants,” comments Béatrice Godard, a bioethicist with the Université de Montreal. “Typically what happens now is participants might be offered access to general research results – sometimes they’re given a contact number in case they want to find out more about published scientific data – but not individual results.”
Along with her team, Godard is analyzing the ethical implications of sharing genetic research results with study participants, as part of a GE3LS project integrated with “Identification and Characterization of Genes Involved in Common Developmental Brain Diseases”, co-led by Guy Rouleau and Pierre Drapeau in Québec.
Godard and colleagues surveyed families who had given blood samples as part of an earlier research project on autism led by Rouleau. The anonymous survey asked participants if they would have wished to receive individual genetic results as part of the study and, if so, why they wanted the information and what they would have done with it. (The questionnaire made it clear that these were theoretical questions since no individual results from the study will be shared.)
An overwhelming majority – 98 percent – indicated they would have wanted access to their family’s individual research results.
“I was really surprised by that number,” says Godard. “In the literature, typically only about 30 percent want to know their individual results. But you do have to look at what’s being studied. If it’s related to Huntington’s disease for instance, the potential for individual results to cause psychological distress to people is higher than for autism because the consequences could be more dramatic. With Huntington’s, for instance, we know that carrying the gene will inevitably cause the individual to suffer from the debilitating effects of this untreatable disease. So fewer people might want to know their individual results for this disease.”
“The other salient factor is that parents typically want information that could concern their children; they feel a sense of responsibility toward them, and having [their family’s genetic test results for autism] gives them hope that they could do something about this condition in the future.” This is particularly so in cases where the parents can seek a confirmed clinical diagnosis and access support services that can help their child in a timely manner.
Godard was equally surprised by the finding that study participants would have wanted to receive individual genetic test results even if they were negative, and that the preferred method of receiving such information was by letter, rather than in person or over the phone.
“Sometimes we assume people want to find out results face-to-face, or that they want counselling, but in this survey, people clearly told us they didn’t.”
According to Godard, the desire to know more about one’s individual genetic information is “part of the general movement against paternalism in medicine and research, and a sign of reciprocity between researchers and study participants.”
Godard found that some study participants feel research is too one-sided and that they don’t get enough back. “Many survey respondents expressed a feeling of being ‘used’. They said, ‘many times they ask us to give a blood sample, but when it comes time to give information to us, nobody is there, or they don’t want to give us certain information in order to protect us’.”
“More and more, we are recognizing the autonomy of the person. If someone is able to understand why you’re doing research on the genetics of autism, for example, they’ll probably be able to understand the information you provide at the end of the research.” Godard, who sits on numerous research ethics boards and committees, hopes her study will help inform researchers’ decisions about whether or not individual genetic results should be shared with participants in future genetic studies.
Two other integrated GE3LS projects, both based in Ontario, are exploring similar questions – so similar, in fact, that the two GE3LS researchers decided to combine efforts.
Although no funding dollars are being pooled or shared, Fiona Miller and Robin Hayeems, both from the University of Toronto, examined participant attitudes on the return of individual genetic research results in the context of a large-scale study on autism led by Stephen Scherer and another on cystic fibrosis (CF) co-led by Peter Durie and Julian Zielenski.
The pair then decided to collaborate and examine the same question, but from the researcher’s perspective. “Instead of just pursuing how study participants feel about sharing results,” says Hayeems, “we decided to explore researchers’ attitudes and decision-making processes on this issue since we felt that the obligation of disclosure should not only be a function of what participants desired.”
“The collaboration gives us an ability to do a comparative case study on two different conditions, autism and CF,” explains Hayeems. “It has created a nice synergy and an ability to more robustly explore the influence of context on research findings. It seemed like an opportunity to achieve greater statistical power and impact.”
Initially, Hayeems conducted a pilot survey with families involved in the CF study, to get a “pulse” of how they felt about receiving results.
“I wanted to use a real live example. The CF research study had recently published a new finding in a scientific journal, which had also been announced through a press release. I used that example to get a sense of the families’ expectations of what information was owed to them by the researchers and gauge how families were interpreting what had been disclosed.”
In the pilot survey, Hayeems found that most families held a “high expectation of what information they should receive from researchers”.
But according to Hayeems, it’s not only families who expect researchers to share individual information; there’s also a “heightened interest among some researchers themselves to give participants more information as a way of reciprocating for time spent participating in a study”.
“One phenomenon we observed in Fiona’s preceding work in the autism context is that, in some cases, research mimics clinical care. The instinct – particularly of clinician-researchers – is to provide information to their patients. This begins to blur the boundaries between their role as researcher and as clinician. Add the fact that clinical services are lacking in certain areas, particularly in the case of autism, and you find researchers increasingly wanting to help the families they’re studying. But that may not be a responsibility researchers can adequately assume.”
To understand more about which factors seem to be driving researchers’ decisions to disclose, or not disclose, individual information, Hayeems and Miller designed a survey aimed at international researchers. The pair has finished collecting survey data, and, according to Hayeems, are “right in the thick of data analysis”, which they expect to complete in the coming months.
“We’re interested in exploring the nature of this emerging sense of obligation to share results with study participants. The argument that all research findings should systematically be reported to study participants may perhaps be ignoring the context. Numerous factors could influence a researcher’s decision-making, including the clinical significance of findings, the nature of services in their jurisdiction, the nature of their relationship with the participant, how robust the findings are, and if they’ve been replicated.”
Hayeems suggests that when research data are uncertain, researchers could still fulfill their responsibility to communicate with study participants via general newsletters highlighting research progress and providing updates of recent developments in the field.
“If scientific research results are provisional, or in an infancy stage of understanding, it may be inappropriate to share them. The wish to respect a person’s autonomy may not be enough to warrant systematic disclosure of all individual research results.”
Returning individual genetic results to study participants is a highly complex question that depends on many different considerations, including:
- What is the clinical accuracy, validity and utility of the genetic test conducted for research purposes? Is it as technologically and scientifically robust as that which would be carried out in the clinical context for diagnostic purposes?
- What is the degree of certainty or predictability that the identified genetic mutation will cause a known condition or disease?
- Is the researcher, or member of the research team, qualified to make such diagnostic determinations? Is the mutation related to the very aim of the study in which the researcher likely has some degree of specialization or is it a completely incidental finding for which the researcher has no interpretative expertise whatsoever?
- What is the nature of the condition or disease? How significant are its health or reproductive implications for the individual and/or their family?
- Is it something that the individual, if told, could still do something about in a timely manner to their benefit? Or is it information about a late-onset or fatal disease for which there is no known cure or treatment? Even if there is no possible intervention, is it something the individual would want to know about in order to prepare themselves for, or is it information which, without any likelihood of benefit, is likely to cause only undue suffering or distress?
- What is the participant’s expectation of what they would be told after the research test? Have the implications of receiving or not receiving individual results been explained to them? Have they expressed a desire to know or not to know?
- What about the researcher? Is he or she also the treating clinician with a duty to disclose? Or if the researcher is a non MD, do they nonetheless have some “lesser” legal or moral duty to disclose?
- If the researcher non-MD decides to disclose, should they do so directly to the participant or should they communicate through a health professional who could help verify and interpret the results, answer the individual’s questions and offer support? In the latter case, will the genetic test result thereby become part of the individual’s clinical record, jeopardizing his or her chances of securing insurance or employment? Does the individual know about the potential risk of discrimination, and is he or she willing to assume it?