Themes
We identified three key themes: (1) the future autonomy principle, (2) balancing no medical benefit and other factors in the assessment of best interests, and (3) reframing the request as when, not whether, to test.
Participants supported the key principle in guidelines (see, for example, BSHG
2010) that the protection of a child’s future autonomy was an important argument against testing (young) children for later-onset conditions. However, they varied in how strongly they held to the principle in their decision making in practice. There was general consensus that it should be applied when there was
clearly no medical benefit at the time of the request for testing; for example testing a baby for Huntington disease or inherited breast cancer (e.g. BRCA1/2). Despite this general support, some HCPs thought that most young people/adults would not mind having had a predictive genetic test as a child without their input into the decision and, as such, the impact of a test result on a future adult’s autonomy could be overstated. However, as one HCP noted, for a few it would be an issue:
The reason for not testing them is so they can make their own decision in the future. I would imagine that for 95% of them it’s not going to be a big issue as to whether or not they’re tested now as opposed to in the future and it’s us being more protective of them. But, of course, it’s that 5%, how big an issue is it going to be for them and I don’t think we know” (Consultant, P21).
Given that we do not know who would mind at the time of the request for testing, adopting a general principle can be an appropriate and ethical approach.
HCPs differed in their application of the principle for (autosomal recessive) carrier testing. Some thought that a positive carrier test result was not the same as burdening a child with the knowledge of developing, or being at risk of, a medical condition in adulthood. Others argued that the principle should apply, on the basis that knowledge about carrier status is appropriate only at an age when potential carriers are making reproductive decisions or when they can understand the reproductive implications of the result. Predicting disease in a child’s future offspring was viewed as equally inappropriate and as lacking in medical benefit in childhood as predicting later-onset disease in the child:
I don’t see that it’s any different from any other genetic test where it’s not going to have any [immediate benefit]. You can’t predict how somebody’s going to react to a result that somebody is a carrier or how they’ll understand it (Counselor, P32).
The way HCPs interpreted guidelines played a key role in how they balanced harms and benefits of testing. Some HCPs were flexible in their interpretation, viewing guidelines as helpful
guidance. Others adopted a very strict rule-based interpretation: unless there was clear identifiable medical benefit, the future autonomy principle was the default position. For example, one HCP argued that they had a firm policy of not testing
any child under sixteen:
We’ve had quite a number of requests for prediction work from minors, under 16, and it’s just a categorical no” (Counselor, P26).
All participants referred to an assessment of the child’s ‘best interest’ in decisions about testing but they also commented on how, in practice, they found it difficult to make such an assessment. They placed strong emphasis on medical criteria, taking into account the severity of the condition; how predictive the test was for the child’s future physical health; the difference between the child’s current age and the likely age of onset; and the availability of future treatment or interventions. In fact, many thought that medical criteria were the only criteria they themselves could reasonably apply to make a best interest judgement, identifying the non-medical factors that might contribute to the assessment of a child’s best interest to be largely outside their scope of knowledge:
[The] reasons for testing other than for pure medical reasons are the ones that are very hard in practice, because they’re the reasons the medical profession has least insight into and the parent has most insight into… they’re the hardest to describe. So, if we’re saying in our guidelines that it is sometimes acceptable to do testing other than for medical benefit, if the parents can put forward a compelling argument for that testing to take place, then it’s quite hard for us to assess how compelling the argument is (Consultant, P13).
HCPs therefore felt that parents’ role in any best interest assessment was an important one. For some this meant that test requests might be met because they believed that parents were acting in their child’s best interest:
I think that parents on the whole do the best for their child that they can and if they feel that this is the way forward then that’s what I would support” (Counselor, P17).
That is not to say that they felt that their role was simply to accede to parents’ wishes-- doing so might not ultimately be in the child’s best interest.
However, despite this perceived difficulty of identifying non-medical harms and benefits, in practice, most HCPs indicated that they did draw on factors beyond medical utility when considering best interests. HCPs found these factors compelling enough to over-ride the future autonomy principle and agree to test. These included the likely psychological and social impact of testing for the child; the parents’ experience of the genetic condition; whether parents seemed to understand that testing would reveal future (not current) risks; and the need to maintain a positive relationship with the child and family; for example:
I think to have [a] blanket approach is quite damaging … we have to be more flexible with families and see that it’s not just about medical risk but actually it’s about the emotional side of things … in families and relationships together (Counselor, P05).
In some cases, HCPs tested in childhood because they considered benefit to parents and the family would in turn benefit the child; for example the impact of parental anxiety on a child’s welfare in a best interest assessment. They were sympathetic to families with an extensive history of the condition for which they wanted their child tested; one HCP agreed to test the child of a parent whose deceased spouse and extended family had a history of heart disease:
[I] just felt that she just had to know which of her children might be at the same risk as her husband with that … her anxiety levels were so high… so I ended up testing” (Consultant, P13).
Similarly the anxiety of not knowing a child’s status could affect the parents’ relationship with them, so testing was considered to be the best interest of a child if it could improve this relationship for this HCP:
…not knowing can affect bonding with young children and there’s been lots of parents that have reported that actually the anxiety makes it very difficult for them … Their parenting skills are affected this couple [who] … seriously needed to know and they weren’t sleeping…Testing someone to relieve an anxiety is not an unreasonable request (Counselor, P19).
The potential to avoid parents treating a child differently, if they assumed that the child had a condition, was another example given by our participants: one tested a 9-year old child at 50 % risk of a faulty
P53 gene because:
The family …couldn’t treat the child normally. Every time they had a headache, they took her to casualty. They were medicalising the child (Counselor, P09).
Keeping the family engaged with the health service was deemed better for the child than the parents seeking private or commercial testing without medical support. This was also seen as a strong benefit to childhood testing:
If we upset them [by saying ‘no’], we’re not helping the children in the long run either. That was another thing that persuaded me to test. An important thing was that the family were still engaged with us and would come back to talk about things (Consultant, P34).
Finally, benefit to the family played out in different type of case where another child had previously been tested and the result was positive (e.g., carrier status). One participant articulated this in terms of testing on the grounds of equity:
…when it comes to sharing information, the child who hasn’t been tested could feel left out…People all want to be offered the same and have the same opportunities (Counselor, P19).
Interestingly, they did not weigh this ‘equity’ with the child having lost their ability to make decisions for themselves at a later date.
As illustrated above, for many HCPs the decision-making process focussed on what they considered to be in the child’s best interest, taking into account medical and wider reasons. Another approach to requests for testing was to involve parents in discussion and negotiation about
when genetic testing would be appropriate for their particular child or--to put it another way--when testing would be in their best interests. For example, in response to a question about how they would deal with requests to test children for conditions such as Huntington disease, one HCP stated:
[the request would] be taken as an invitation to, let’s think about this disease and how you and your family are going to handle it…..so it’s just an opportunity to talk (Consultant, P22).
HCPs expressed a number of connected reasons for re-framing the request as finding the best time for the test. First, it was seen as less adversarial: if parents came to clinic with a request, it would not help the patient-professional relationship for HCPs to immediately argue that testing was not permitted or possible. In such cases, HCPs reported that parents would often become more insistent and would not be willing to engage in further discussion or to consider the potential adverse consequences of testing:
I would never say, ‘no’ that’s it, we’re not going to do it, because immediately you get their backs up and you’ve damaged the relationship before it starts (Counselor, P05).
Another reason was that it created space for discussion about the pros and cons of testing which could include deferring testing to an age when the child would be old enough to be involved in the decision-making process:
I usually try to establish quite early on that my job is not to sit here and refuse testing, it’s to look at all the aspects and arrive at a good decision that everybody is comfortable with, in the best interests (Consultant, P16).
This helped to ensure the child’s ‘voice’ was not lost. Furthermore, it opened up discussion about the range of factors that could contribute to the best interest decision. Indeed, some HCPs saw their role as helping parents to make an informed decision about what was in the child’s best interest and understand why testing at that point might not be:
They come along and say, “gene test, must-have…” But, once you make them aware that there are consequences… then they’re more aware of it. And I think we’ve had parents who have been very grateful for the extra conversation (Consultant, P03).
Thus there was a recognition that when parents request testing they have not necessarily had the opportunity to talk through the pros and cons and the different options available to them. HCPs who engaged in discussions rather than agreeing or disagreeing with initial requests had often adopted this approach over time, commenting that when they had less experience they were more persuaded by parental rights or by the apparent rules that guidelines provided them. One argued that the greater the clinical experience a HCP had, the more comfortable and able they would be to engage in a meaningful discussion with parents and come to a mutual agreement:
It’s very much people’s individual experience and how competent they feel in that situation. Some people enjoy exploring it with the family. Whereas others would much rather not. But that can work both ways, either completely withdraw and let the family do exactly what they want to do, or be paternalistic and say ‘no, you can’t have it because we’ve got guidelines’. You could avoid either way, having that discussion (Counselor, P12).
Lack of experience might also make HCPs think they were legally required to provide the test if requested:
Sometimes tests are done, I think, that may have more to do with the fear of being sued than [the test] being necessary (Consultant, P32).
Ultimately, although HCPs reported that parents’ desire to test often changed after discussion, some parents remained insistent. When such wishes were sustained even after detailed discussions, most HCPs said they would grant the parents’ request, arguing that as long as such a request was informed, it was something the HCP should try to meet:
At some point you feel that it’s their right to make that decision and you’re just there to help them make a decision, not to make the decision for them (Consultant, P22).
In effect, sustained requests meant that HCPs might be more likely to give more weight to parents’ rights.