How prenatal genetic testing protects patients—and you
Misinterpreted or incomplete genetic testing does not serve the patient—and is likely to spark a lawsuit
IN THIS ARTICLE
The author reports no financial relationships relevant to this article.
CASE 1 ObGyn fails to scrutinize test results
A woman consulted board-certified ObGyns during the first trimester of her pregnancy and informed one of them that she had recently been given a diagnosis of measles, but was unsure whether the illness was German (rubella virus) measles. The physician examined her and ordered a rubella titer. The results, he noted, “were indicative of past infection.” Instead of performing further testing, he told the patient she “had nothing to worry about because she had become immune to German measles as a child.”1
Soon after birth, her child was diagnosed as suffering from congenital rubella syndrome, including eye lesions, heart disease, and auditory defects.1
Apparently, the physician had failed to consider whether the positive test result was indicative of current, rather than past, infection—and failed to perform further testing to determine whether the titer was falling, stable, or rising.
Is he legally liable for this omission?
The physician in this case violated a simple tenet: If a test is ordered, the clinician must be able to interpret the results or order further testing to ensure that the patient is given valid advice. This physician’s error was compounded by the fact that the patient had notified him of the potential for fetal injury.
Would he be held accountable in a court of law?
The answer to that question depends on:
- the state in which the case arose, and the laws in effect at the time of the incident
- the action initiated by the plaintiff and her attorneys, which may involve “wrongful birth,” “wrongful life,” or other allegation
- the time that transpires between the genetic test (or diagnostic test, such as a rubella titer) and the legal case—in other words, the statute of limitations. In some cases, this period encompasses the time elapsed between omission of a test (or birth of a child) and the filing of a legal claim.
In this article, I highlight three pertinent legal cases and the lessons to be learned. Because national legal case reporters generally publish opinions from appellate courts, they usually focus on determinations of law, with factual determinations and decisions on liability remanded back to the trial court.
For the purposes of this article, I assume that the facts in the judicial opinion are correct, but focus on legal principle.
Don’t overlook the patient when planning prenatal tests
Patient testing: ethical issues in selection and counseling. ACOG Committee Opinion No. 363. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2007;109:1021–1023.
Knowledge can be a dangerous thing. At the very least, a bid for genetic data requires careful consideration and preparation, particularly when the information may determine whether a woman continues or terminates her pregnancy.
In April, the American College of Obstetricians and Gynecologists published a Committee Opinion on ethical considerations in the selection and counseling of patients in regard to testing. Although the opinion concerns testing in general—rather than prenatal genetic testing specifically—a number of recommendations are applicable to both:
- Perform testing for the benefit of the patient, not simply because a third party—e.g., her partner, extended family, employer, insurer, or health-care provider—deems it to be necessary. Ensure that she gives consent before proceeding.
- Do not base testing decisions on assumptions about how the patient will respond. “Prejudgments about a patient’s wishes regarding fetal abnormalities, for example, should not preclude her being offered prenatal testing,” the opinion states.
- Tell the patient how the results will be communicated, and to whom.
- Provide or refer the patient for specific counseling whenever planned testing may have multiple medical or psychological implications.
- Respect the patient’s autonomy and involve her in decision-making. If she elects to forego a recommended test, document her refusal in the medical record—and include the reason.
Detectable genetic disorders have increased exponentially
Almost any health-care provider encounters patients who have inheritable disease. Cases have arisen against an oncologist for failure to convey to the patient the potential for genetic transmission of colonic polyposis and against a surgeon for failing to warn a young breast cancer patient that she may carry genes that predispose her offspring to ovarian cancer. But the highest-risk category is reserved for the obstetrician, who must, on a daily basis, consider the need for appropriate screening and proper counseling about the availability of genetic testing that may enable the patient to avoid passing catastrophic disease to her children.
This responsibility is complicated by a dramatic increase in the number of genetic tests. Few areas of medical practice have expanded as rapidly as prenatal genetic testing and counseling. Forty years ago, an obstetrician—or even a nurse—might have discussed the risks of pregnancy at an advanced age, as well as a few possible genetic abnormalities. Today, certified genetic counselors are employed by many clinics and even private practices, and more than 1,000 disorders—as many as 1,300, by some reports—can be detected by the proper test.
Although most of these disorders are uncommon, several dozen or so are more prevalent and, therefore, regularly tested for. They include cystic fibrosis, Down syndrome, and neural tube defects, as well as diseases associated with certain religious, racial, or ethnic groups, such as thalassemia (Mediterranean, Asian, or African heritage), Tay-Sachs (Eastern European or Ashkenazi Jewish descent), and sickle cell disease (African-American ancestry).
Ethical complexity makes resolution difficult
Legal actions are bound to increase as technology evolves, particularly when a child is born with a genetically transmissible disorder that could have been identified with proper counseling and testing. These legal actions are particularly difficult to resolve because they involve complex ethical issues. For example, in “wrongful birth” actions, the parents often allege that they would not have conceived a child if they had known that it might be afflicted with a certain trait or illness, or that they would have terminated the pregnancy if they had learned of the disorder in a timely fashion.
In most of these cases, the plaintiffs are the parents. In a few states, however, successful actions have been brought by the child (“wrongful life”), who, some contend, essentially claims that nonexistence would be better than life with a serious congenital condition. They usually seek the extraordinary expense associated with the condition, as well as other damages.
Similar actions have been brought by children, and parents of children, with acquired conditions such as congenital rubella syndrome, as in the opening case. In that scenario, the parents’ case was declined by attorneys because their state of residence did not allow actions for wrongful birth or wrongful life. The state courts subsequently changed the law to allow wrongful birth actions, but by the time the parents learned of the change in the law, the statute of limitations had expired. They therefore added the attorneys as defendants, alleging that they failed to recall the parents when the law changed, in time to file their lawsuit. By the time the case finally reached the state’s supreme court, the law had changed again, and the child was allowed to proceed with a wrongful life action.
CASE 2 Physician mistakes patient’s tissue for fetus’s
Before becoming pregnant, a woman experienced several medical problems that prompted her and her husband to seek genetic testing and counseling. Testing revealed that she had a balanced translocation of chromosomes 11 and 22.2
After conceiving, the woman underwent chorionic villus sampling, which indicated that the fetus was probably a female with the same chromosomal condition as the mother—therefore, she would develop normally. The mother also underwent several ultrasonographic tests to rule out fetal abnormalities and was told that imaging showed a normally developing fetus.
The woman went on to deliver a boy, and genetic testing revealed that he had trisomy 22, with severe, permanent disabilities.2 The parents sued.
Were the woman’s health-care providers liable?
This case prompts a number of questions:
- Did the physicians seek confirmation that the tissue studied was fetal?
- Did they counsel the parents about the possibility that maternal genetic material might be recovered during sampling? If so, did they consider that possibility when the specimen was identical to the mother’s?
- How is it possible that, on subsequent ultrasonographic evaluations, the male sex of the fetus was not noted? If it was noted, did it register with the providers that the result was inconsistent with the genetic studies?
These questions were not addressed in the court opinion, but they could have had a significant impact on the final outcome of the case. Although the court allowed some aspects of this case to go forward, damages were limited to the costs of the pregnancy and—for reasons not disclosed—that claim was dismissed. If the delivery had been complicated, however, those costs could have been substantial.
Despite the dismissal, which was a favorable turn of events for the physicians, they almost certainly lost substantial work time and experienced the emotional roller-coaster ride that accompanies being sued—not to mention the revelation that they may have harmed a patient.
CASE 3 Physician fails to complete testing
The mother of a developmentally delayed daughter delivered another child. Before she conceived, however, she and her husband consulted a physician (a pediatrician) to find out whether there was a genetic reason for the daughter’s developmental delay and the mental retardation of another child, the girl’s half-brother.3 The physician wrote in her notes: “? Chromosomes + fragile X” to indicate testing planned for the daughter.
The testing was performed at a medical center and reported to be normal. The physician relayed this finding to the parents, but failed to mention that fragile X testing had not been conducted. Because they had discussed fragile X testing during the initial consultation, the mother assumed it had been performed and was included in the normal results.3
The latest child was also developmentally delayed, and subsequent testing revealed that all three children were positive for fragile X syndrome. The parents sued, alleging that the physician was negligent for failing to perform the genetic test, and claiming that they would not have conceived another child if they had known of the daughter’s fragile X status.
Are their claims reasonable?
Despite a state statute that prohibited wrongful birth and wrongful life actions that allege that the pregnancy would have been terminated if the parents had known of the genetic impairment, the state supreme court allowed this case to proceed because the issue was whether the mother would have avoided conception. The plaintiffs also argued that the claim did not exceed the statute of limitations. Their reasoning: Although the medical care had been provided more than 4 years earlier (the limitation period), the injury did not occur (i.e., action did not “accrue”) until conception of the child.
Perhaps most telling was the court’s statement that, “[O]ur decision today is informed by the practical reality of the field of genetic testing and counseling; genetic testing and diagnosis [do] not affect only the patient. Both the patient and her family can benefit from accurate testing and diagnosis. And, conversely, both the patient and her family can be harmed by negligent testing and diagnosis.”3
Establishing degree of harm is especially difficult
As you might imagine, allegations involving potential pregnancy termination arouse intense emotions on both sides of the abortion debate. The determination of damages is equally contentious. Among the issues that may arise at the time of trial:
- How much is a parent harmed by the birth of a child with hereditary disease?
- Should damages be offset by the benefit of having any child, even if the child is not “normal”?
- How do you measure the value of a life with Down syndrome, for example, compared with no life at all?
- Should damages include the cost of raising the child, including additional medical expenses, which can be substantial?
These and many other serious questions have faced judges and legislators for more than 30 years, and are expected to remain controversial for the foreseeable future.
Assigning blame for genetic disease is difficult
The arguments in cases involving genetic testing often differ from those made when a fetus sustains injury. In the latter, the injury may be caused by the provider—e.g., after administration of a cytotoxic drug during pregnancy or because of induction of labor at a seriously miscalculated gestational age. Legal actions associated with such injury are widely accepted.