Do We Really Understand?

Okay, call me a cynic, or maybe even a curmudgeon, but I sometimes wonder just how much we understand about Information –and by extension, it’s relationship to Knowledge.

Information can be construed as the answer to a question or, seen from a different perspective, as that which has the potential to resolve uncertainty. Numbers, for example, are not information unless they pertain to something. And when we think of information in the form of data, it doesn’t necessarily require someone to receive it, but can stand alone, unwatched and unprocessed until summoned. Knowledge on the other hand can be thought of as the reception, collation, and subsequent processing of that data –requested, in other words. Whether that which stands in isolation, unprocessed and unused constitutes Knowledge is an interesting, but tricky issue –likely of the same ilk as ‘If a tree falls in the woods with no one around to hear it, does it still make a noise?’ that we all puzzled over in Philosophy 101 in University. Because data –information- has the potential to answer a question, does that automatically qualify it as knowledge even if there is no question? Even if it might not resolve any uncertainty?

I raise these issues not to transition into a discussion of information theory, but to ask how much we are furthered by information about issues that are incompletely understood –known?- even by experts in the field. I’m referring, of course, to our own DNA.

Scientists are accumulating more and more data about genes and their codes and loci on specific chromosomes. They are beginning to link particular code changes in these genes to specific conditions, and the process is just beginning. Progress seems to increase logarithmically. The promise of this information is enormous in terms of diagnosis and perhaps eventually, treatment. http://www.bbc.com/news/health-35282764

I do wonder, however, whether it is valuable or premature to offer personalized genotypes as a commercial venture to anyone who asks for them. Clearly, there are situations when the information would be helpful when questions are asked of it: risks of a genetically-carried disease, hereditary lineage, or even paternity, as examples. But do we really know more about ourselves because some company has mapped our chromosomes? Without a question being posed to which the genetic sequences are the answer, is what is received useful, or pap? At this stage of our investigation of the genetic code, is an undirected map of base-pairs on a chromosome anything other than simply that: a small scale map of largely unnamed streets of a mysterious city that happens to have the label of the requester on it? A hieroglyph?

Undoubtedly, as the data accumulate, this mapping will progress to the stage where it becomes an essential guide to a city we wish –or need- to explore. And perhaps the store of information acquired will allow retrospective analysis of things whose importance we have yet to understand. Answer questions we don’t yet have –or at least can’t yet formulate in a way that could be solved.

In the meantime, however, I worry about that very personal and private information being made available against our wishes and perhaps to our detriment. Insurance companies, for example, employers –or maybe even an untrammeled government worried about threats of terrorism or contagion may request, or perhaps legislate that the genetic information be provided –especially if it has already been obtained. Unfortunately, at least at the time of this writing, there is no protection in Canada against discrimination based on genetics. There is, however, some legislation under review (Bill S-201) that addresses this. https://openparliament.ca/bills/41-2/S-201/ One hopes that its adoption will be soon, but it is a concern that certainly needs resolution before widespread adoption of personalized DNA should be considered. Once Pandora’s box has been opened, it might be too late, so we must think long and hard about what we decide.

Well considered safeguards are essential in advance -both for governments as well as for industry that may be tempted to oversell the potential. I stand with Hamlet in this: one may smile, and smile, and be a villain.

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Non-Invasive Prenatal Testing

Chromosomally derived anomalies have been with us for millenia –maintaining structural and functional integrity is obviously difficult when you think about it. We humans have 46 chromosomes that must continually divide and reproduce unerring copies of themselves as they issue unique and contextual instructions for cell development or maintenance.

The functional components of chromosomes are called genes and we have around 20,000-30,000 of them, each one built from smaller base pairs like words in a sentence. And depending on the chromosome, each strand of DNA has well over a hundred million base pairs to supervise. It doesn’t take too much imagination to realize that rearranging words in such a sentence, or letters in each word, can alter its meaning. Jumble its information – or even destroy its function…

Throughout recorded history, there has been a recognition that some individuals lacked the same intellectual or emotional attributes as the rest of the community, and yet these people still had a role in the society. They were tolerated and often cherished members of the group and contributed to the weft and warp of the social fabric. Every town had its Village Idiot, to use the ancient (and non-revisionist) term; every village had its special people…

It would seem we live in different times, however, and social values have shifted; there is an expectation of normalcy, if not perfection, in our offspring. The current thrust is early –prenatal– diagnosis of suspected anomalies so that the expectant parents can choose whether the issue lies within their comfort and capability zones.

Prenatal testing has undergone many sea-changes over the years as technology and attitudes have goaded each other. Early tests sought to detect only the most frequent genetic anomaly: Down syndrome –or trisomy 21. As time and ability progressed, more genetic abnormalities have received similar surveillance.

But accuracy of prediction has come under scrutiny of late. It is no longer acceptable merely to arouse suspicion of an abnormality. False positives (thinking the anomaly is present when it is not) and false negatives (not detecting the anomaly) each have their own consequences. Risk of error, in other words, needed to be minimized if decisions were to be reliably dependent on the results.

In Canada, there are currently three (and now four –the subject of this essay) options for prenatal screening of genetic abnormalities –still largely for trisomy 21 because it is by far the largest component of the pool of abnormalities:

  • First trimester screening –done between 11 and 14 weeks gestational age with a detection rate of 87-90% and a false +ve rate of 5%
  • Integrated prenatal screening– consisting of two parts: the first one the same as with first trimester screening and the second between 15 and 20 weeks gestational age. This has a detection rate of 87%-95% and a false +ve rate of 2 to 5%
  • Quad screening– done between 15-20 weeks but with a detection rate of only 81% and a false +ve rate of between 5 and 7%

These results are pretty good and statistically acceptable –unless, that is, a mother has to make an irrevocable decision based on them. There was a need for even more accuracy –less risk- and so technology again rose to the challenge: the Non-Invasive Prenatal Test (NIPT). This is a blood test taken from the mother that measures her baby’s DNA that is floating free in the part of her blood called plasma. It is being continually released into the maternal circulation (with a half-life of around 16 minutes), so it’s an up to date survey of the foetus. There is maternal DNA there though, and the fetal fraction of it is usually about 10% so, to be sure the result is representative, the fetal fraction measured has to be at least 4%… Confused? Well, just remember that it is most reliably measured after 10 weeks gestation and with no upper limit of gestational age; that it has a detection rate of over 98% and a false +ve rate of less than 0.3% (I’ve taken these figures from the June 2014 edition of JOGC).

There are some caveats, of course –there always are- and seemingly a variety of iterations of what can be measured. But by and large it seems close to ideal: high accuracy with minimal if any risk to mother or baby. It is still recommended that a result indicating a chromosomal anomaly be confirmed with an amniocentesis (taking a sample of fluid from around the baby in the uterus) for confirmation, however.

So why don’t we fully embrace NIPT and relegate the other tests to history –tests that were helpful in their time, but indirectly naïve on sober reflection? Well, apart from the current high cost which might preclude its equal availability to all strata of society, there are other ethical considerations. And although these same considerations obtain with any prenatal genetic test, with NIPT these are largely attributable to its accuracy; one could foresee a time when the recommendation for a corroborative amniocentesis to obviate any risk of false positivity might be rescinded, further decreasing the time available for thoughtful and reflective parental decision-making.

Autonomy is the right of an individual to make informed choices for herself. But the key word here is ‘informed’. This implies that the information that informs her is both relevant and appropriate information. And yet, by necessity, it is provided and constructed by others; it is drawn from social and political contexts that she may not share and the options it provides may reflect this. Relational autonomy is an ethical theory that considers the ramifications of those choices that are made available to her. More traditional views have tended to treat the person making decisions as an isolated unit; but in fact, she is embedded in her own -perhaps differing- culture that influences both the context and the situation in which she has to make her decision.

We do not all react the same to identical information, nor is the ability to make an informed choice simply a function of the amount of information available. Women and doctors have different data priorities. Even different message priorities. We all need time to sift through the context; we need time for processing our feelings. Our needs. Our connection to the simmering culture in which we swim.

And then there is the issue of what we want NIPT to detect. Access to fetal DNA offers boundless opportunities in the future for singling out other aspects of the chromosomes we wish to interrogate –whether with serious concerns: hereditary conditions like cystic fibrosis, for example, or with more broad-based anxieties such as concern about random mutations

Other, more frivolous concerns such as sex selection or, in the forseeable future, even searches for –and hence management of- certain genetic traits, present a growing tension between individual autonomy and societal values. For that matter, even detection of the trisomies has engendered much controversy, let alone the prospect of finding and perhaps eliminating other abnormalities not shared by the majority. What is the expectation –perceived or otherwise- after an ‘abnormal’ test? And what is abnormal? What should we accept?

I suppose, ultimately, it is for each of us to decide. Of course Shakespeare offered his opinion long ago: Love looks not with the eyes, but with the mind. But are we still that wise? Or have time and circumstance changed that as well?