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Education, ethics and knowledge deficits in clinical pharmacogenetics.

Whatever one’s view on the likelihood of pharmacogenomics moving into widespread clinical practice, it is hard to deny that this area of research has been subject to some of the most extensive and optimistic expectations seen in modern bioscience. Of course there have been such ‘bubbles of optimism’ in the past around technologies such as monoclonal antibodies, but nothing quite like the exuberance that has developed around pharmacogenetics. However, despite this excitement on the part of scientific, industrial, political and even bioethical authorities [1], the tone of many recent opinion pieces by leaders in the field has been to reduce expectations and to tone down the hype. For example, Klaus Lindpainter has noted that: “Pharmacogenetics and pharmacogenomics... are commonly touted as heralding a ‘revolution’ in medicine, yet as soon as one begins to probe more carefully, little substance is yet to be found to support these enthusiastic claims” [2]. There are various reasons for this increased caution. At the industrial level, the constant reshaping, mergers and buy outs within the sector have created instability and uncertainty, as evidenced by the high ‘attrition rate’ among small firms specializing in pharmacogenetics [101]. Another reason is that moving the results of pharmacogenetic research from research settings into clinical practice has proved to be far more difficult than might have been anticipated [3]. One way of viewing this shortfall of clinical pharmacogenetics is to suggest that the problem lies with clinicians: their lack of knowledge regarding this technology leads to resistance to change and an unwillingness to adopt approaches that might benefit their patients. To be fair, this merely echoes concerns that have been raised regarding the clinical take-up of genetics as a whole [4]. However, the suggestion that this is a generally held view among supporters of pharmacogenetics is supported by the constant call for the ‘education’ of clinicians, policymakers and the public, to prevent irrational rejection of such a useful technology [5,6]. Such thinking, which posits education as the solution to people’s ambivalence towards new technologies, has been labeled the ‘deficit model’ of public understanding of science and is widely discredited among social scientists researching in this area. In this perspective, I wish to suggest that although education is important, and may well impact on the clinical uptake of pharmacogentics, there are a number of other complex nontechnical issues that may play just as important a role in how pharmacogenetics moves into the clinic. The focus of this perspective will be on one such factor, clinicians’ ‘indigenous morality’ [7] and how it can impact on the clinical uptake of pharmacogenetics.