Ethics and Counseling Theory, Pharma Flashcards
Institutional ethics committee vs Professional ethics committee – differences?
institutional can be a hospital, they take providers’ AND patients’ views into account
professional ethics committee only takes provider’s view
Ethical arguments against testing minors
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 benefitThe primary concern of genetic counselors is the interests of
their clients
The relationships of genetic counselors with society include interest and participation in activities that have the purpose of promoting
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!”
American Society of Human Genetics (ASHG) - what are their ethical principles?
advancement of science
integrity
privacy
transparency
ACMG practice guidelines
https://www.acmg.net/ACMG/Publications/Practice_Guidelines/ACMG/Publications/Practice_Guidelines.aspx?hkey=b5e361a3-65b1-40ae-bb3e-4254fce9453a
When making decisions under uncertainty, patients use heuristic principles like
REPRESENTATIVENESS = ?
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.”
When making decisions under uncertainty, patients use heuristic principles like
AVAILABILITY = ?
Availability = an individual’s understanding about the likelihood of an event is influenced by actual or dramatic instances
the availability of striking examples
When making decisions under uncertainty, patients use heuristic principles like
ANCHORING = ?
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.
Transference
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
Countertransference
Countertransference
Reaction or response to counselee’s story, defenses, emotions, or transference
Countertransferance: Associative
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
Countertransferance: Projective
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
Mimic of denial: deferral
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)
Mimic of denial: disbelief
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
Denial
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
Mimics of denial:
dismissal
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
Grief: anger - what should you do?
- let patient express it
2. discuss it - usually masking sadness, fear, anxiety, shame etc.
grief usually lasts
1-2 years –> within the range of “normal”
coping style:
escape-avoidance
wishful thinking, hoping for a miracle
- avoid the situation
- hope to escape situation thinking it won’t actually happen
differences between coping styles and psychological defenses
coping stlye = conscious, e.g., denial
psychological defenses = unconscious, e.g., repression
psychological defense: reaction formation
forming the opposite reaction from the initial, socially unacceptable one
psychological defense: projective identification
causing an unacceptable emotion in others
e.g., making someone mad when you are feeling anger
psychological defense: identification
Assuming the attitude or behavior of another person
e.g., my sister/neighbor says ___, so I will do ___.
psychological defenses: undoing
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
Better ways to instruct adults (rather than delivering1 information and expecting that the student will learn)
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
pharmacogenomics:
Phase I of drug metabolism primarily does ___
Phase I =
transformation of substance into something less toxis
pharmacogenomics:
Phase II of drug metabolism primarily does ___
Phase II =
combination of subtance with small molecules to aid in excretion
CYP protein responsible for metabolism of largest proportion of common drugs (25%)
CYP2D6
- —-Over 100 polymorphisms in CYP2D6 have been identified
- —-Frequency of poor metabolizing polymorophisms varies by ethnicity
EGAPP - what is it
Evaluation of Genomic Applications in Practice and Prevention
(provides evidence reports and recommendations, e.g., for CYP450 polymorphism testing).
Warfarin
- 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.)
VKORC1
- gene that contributes to variability in (primarily) AA metabolism of Warfarin
- involved in Vit K cycle
VKORC1 + CYP2C9 explain ___ % of variation in Warfarin (Coumadin) metabolism
30-40%
Meta Analysis shows that genotyping for Warfarin does/does not reduce major adverse events ?
does NOT (2014, Stergiopoulos)
but does reduce hospitalizations?
Abacavir / pharmacogenomics
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.
PharmGKB
like GeneReviews for pharma genes
Coefficient of inbreeding (F)
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.
pedigree: vertical transmission, all males affected, yes male-to-male transmission, some female “carriers” are skipped – inheritance?
autosomal dominant, sex-limited
pedigree: verital transmission, all females affected, many SABs - all SABs male
X-linked dominant, with lethality in males
pedigree: most males affected, no male-to-male transmission, ~2X females than males but only mildly affected
X-linked dominant –> less severe in females
(could be X-linked recessive with manifesting carriers?)
expect 2x females because they have two X chroms
pedigree: don’t forget they aren’t static, there could be age-dependent penetrance
e.g., Huntington
pedigree: can there ever be male-to-male transmission in x-linked recessive conditions?
yes, if there is consanguinity between affected dad, and carrier mom, yielding affected son.
