Ethics and Counseling Theory, Pharma

Question 1

Institutional ethics committee vs Professional ethics committee – differences?

Answer 1

institutional can be a hospital, they take providers’ AND patients’ views into account

professional ethics committee only takes provider’s view

Question 2

Ethical arguments against testing minors

Answer 2

Nonmaleficence
     Poor body image; feelings of unworthiness, shame & fear
     Change in family relationships
Autonomy
      Future decision-making capacity
      Confidentiality
Beneficence
      Tenet of do no harm – is the primary point
       No immediate medical benefit

Question 3

The primary concern of genetic counselors is the interests of

Answer 3

their clients

Question 4

The relationships of genetic counselors with society include interest and participation in activities that have the purpose of promoting

Answer 4

the well-being of society and access to health care

Oppose the use of genetic information as the basis for discrimination.

Participate in activities necessary to bring about socially responsible change. – vague!

Adhere to laws and regulations of society. However, when such laws are in conflict with the principles of the profession, genetic counselors work toward change that will benefit the public interest. “yes, I committed medical fraud, and if you tell anyone, I WILL de-ny it!”

Question 5

American Society of Human Genetics (ASHG) - what are their ethical principles?

Answer 5

advancement of science
integrity
privacy
transparency

Question 6

ACMG practice guidelines

Answer 6

https://www.acmg.net/ACMG/Publications/Practice_Guidelines/ACMG/Publications/Practice_Guidelines.aspx?hkey=b5e361a3-65b1-40ae-bb3e-4254fce9453a

Question 7

When making decisions under uncertainty, patients use heuristic principles like

REPRESENTATIVENESS = ?

Answer 7

Representativeness = relying on idealized or prototype version of what might happen. “If I have a boy child, then I should have a girl child next.”

Question 8

When making decisions under uncertainty, patients use heuristic principles like

AVAILABILITY = ?

Answer 8

Availability = an individual’s understanding about the likelihood of an event is influenced by actual or dramatic instances

the availability of striking examples

Question 9

When making decisions under uncertainty, patients use heuristic principles like

ANCHORING = ?

Answer 9

Anchoring = an initial value is adjusted to yield a final estimate

if someone comes in with a preconceived value, then they will adjust their expectations after the session based on info given, and it will STILL be strongly influenced by the “anchor” value.

Question 10

Transference

Answer 10

Transference

One brings old patterns of expectations to new events in order to create familiar structure

Based on unconscious templates

(inappropriate) reaction to events or relationships in the past

Question 11

Countertransference

Answer 11

Countertransference

Reaction or response to counselee’s story, defenses, emotions, or transference

Question 12

Countertransferance: Associative

Answer 12

Associative – counselee’s experience or story causes the counselor to become introspective, remember emotions, review mental images, recall conversations

• -> Distraction
• –> Does not allow the counselor to better understand the patient

–> introspective/self-absorbed

Question 13

Countertransferance: Projective

Answer 13

Projective – counselor makes assumptions about the patient based on his/her own past experience

• –> Counselor often assumes that the emotions belong to the patient
• –> Complex example – counselee is having a challenging experience and is unable to respond appropriately – the counselee “projects” the emotion onto the counselor, who actually experiences the emotion

–> outward-facing, labeling/judging

Question 14

Mimic of denial: deferral

Answer 14

Deferral:

• – May manifest as avoidance, failure to keep appointments
• –Findings or information are accepted but implications are ignored
• —Reflects limits in what people think they have the resources to deal with, solution is to put things off
• —Counselor may help to identify resources, reduce barriers to care, break down tasks into smaller steps (less overwhelming)

Question 15

Mimic of denial: disbelief

Answer 15

Disbelief:

• —May manifest as confusion
• —-Failure to accept information because it does not make sense
• —-Absent or unnoticed signs and symptoms
• —–Dissonance between what the patient is hearing and what they perceive

Question 16

Denial

Answer 16

Denial:

• —-Inability to acknowledge certain information, buys time to deal with the information
• —–Usually short term, but true denial may require a referral for additional support

Question 17

Mimics of denial:

dismissal

Answer 17

Dismissal

• —-May manifest as anger, questioning the legitimacy of the messenger or the health profession
• —Allows the patient to change their focus from the information to the information-giver
• —–May be helpful to seek a “middle ground”, identify what aspects the patient sees as legitimate and explore what they do not

Question 18

Grief: anger - what should you do?

Answer 18

1. let patient express it

2. discuss it - usually masking sadness, fear, anxiety, shame etc.

Question 19

grief usually lasts

Answer 19

1-2 years –> within the range of “normal”

Question 20

coping style:

escape-avoidance

Answer 20

wishful thinking, hoping for a miracle

1. avoid the situation
2. hope to escape situation thinking it won’t actually happen

Question 21

differences between coping styles and psychological defenses

Answer 21

coping stlye = conscious, e.g., denial

psychological defenses = unconscious, e.g., repression

Question 22

psychological defense: reaction formation

Answer 22

forming the opposite reaction from the initial, socially unacceptable one

Question 23

psychological defense: projective identification

Answer 23

causing an unacceptable emotion in others

e.g., making someone mad when you are feeling anger

Question 24

psychological defense: identification

Answer 24

Assuming the attitude or behavior of another person

e.g., my sister/neighbor says ___, so I will do ___.

Question 25

psychological defenses: undoing

Answer 25

Attempting to “cancel-out” a distressing experience or feeling by doing something that signifies an opposite feeling

• -> e.g., acting out of anger toward a person, then giving them a gift
• -> for the person to feel better about themselves, not necessarily with the aim of making “victim” feel better

Question 26

Better ways to instruct adults (rather than delivering1 information and expecting that the student will learn)

Answer 26

Treat the student as a partner in the learning process
Build upon valuable life experiences and previous learning
Promote personal direction and control of learning

Question 27

pharmacogenomics:

Phase I of drug metabolism primarily does ___

Answer 27

Phase I =

transformation of substance into something less toxis

Question 28

pharmacogenomics:

Phase II of drug metabolism primarily does ___

Answer 28

Phase II =

combination of subtance with small molecules to aid in excretion

Question 29

CYP protein responsible for metabolism of largest proportion of common drugs (25%)

Answer 29

CYP2D6

• —-Over 100 polymorphisms in CYP2D6 have been identified
• —-Frequency of poor metabolizing polymorophisms varies by ethnicity

Question 30

EGAPP - what is it

Answer 30

Evaluation of Genomic Applications in Practice and Prevention

(provides evidence reports and recommendations, e.g., for CYP450 polymorphism testing).

Question 31

Warfarin

Answer 31

• • anti-coagulant
• –up to 10-fold variation between people
• –over/under-dose is #1 drug-related ER indication
• –40% of response is due to genetics (other 60% is age, sex, wt, smoking, diet, etc.)

Question 32

VKORC1

Answer 32

• gene that contributes to variability in (primarily) AA metabolism of Warfarin
• involved in Vit K cycle

Question 33

VKORC1 + CYP2C9 explain ___ % of variation in Warfarin (Coumadin) metabolism

Answer 33

30-40%

Question 34

Meta Analysis shows that genotyping for Warfarin does/does not reduce major adverse events ?

Answer 34

does NOT (2014, Stergiopoulos)

but does reduce hospitalizations?

Question 35

Abacavir / pharmacogenomics

Answer 35

genotyping HLA gene led to ~100% reduction in adverse hypersensitivity reactions due to Abacavir (HIV drug).

thus, genotyping prior to drug use is universal now.

Question 36

PharmGKB

Answer 36

like GeneReviews for pharma genes

Question 37

Coefficient of inbreeding (F)

Answer 37

F=
Average proportion of the autosomal genome that is IBD in the offspring of related parents

For example, on average, 6.25% or 1/16th of the genome of offspring of first cousins (F = 1/16) is IBD.

Question 38

pedigree: vertical transmission, all males affected, yes male-to-male transmission, some female “carriers” are skipped – inheritance?

Answer 38

autosomal dominant, sex-limited

Question 39

pedigree: verital transmission, all females affected, many SABs - all SABs male

Answer 39

X-linked dominant, with lethality in males

Question 40

pedigree: most males affected, no male-to-male transmission, ~2X females than males but only mildly affected

Answer 40

X-linked dominant –> less severe in females

(could be X-linked recessive with manifesting carriers?)

expect 2x females because they have two X chroms

Question 41

pedigree: don’t forget they aren’t static, there could be age-dependent penetrance

Answer 41

e.g., Huntington

Question 42

pedigree: can there ever be male-to-male transmission in x-linked recessive conditions?

Answer 42

yes, if there is consanguinity between affected dad, and carrier mom, yielding affected son.