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Ethical, Legal and Social Issues (ELSI) Associated with Non-Invasive Prenatal Testing: Reflections on the Evolution of Prenatal Diagnosis and Procreative Choices

Simona Zaami 1 , Alfredo Orrico 2,3,*, Fabrizio Signore 4, Anna Franca Cavaliere 5, Marta Mazzi 6 and Enrico Marinelli 1

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Citation: Zaami, S.; Orrico, A.;

Signore, F.; Cavaliere, A.F.; Mazzi, M.;

Marinelli, E. Ethical, Legal and Social

Issues (ELSI) Associated with

Non-Invasive Prenatal Testing:

Reflections on the Evolution of

Prenatal Diagnosis and Procreative

Choices. Genes 2021, 12, 204.

https://doi.org10.3390/genes12020204

Received: 9 December 2020

Accepted: 29 January 2021

Published: 30 January 2021

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4.0/).

1 Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, 00161 Rome, Italy; [email protected] (S.Z.); [email protected] (E.M.)

2 Molecular Diagnosis and Characterization of Pathogenic Mechanisms of Rare Genetic Diseases, Azienda Ospedaliera Universitaria Senese, 53100 Siena, Italy

3 Clinical Genetics, ASL Toscana SudEst, Ospedale della Misericordia, 58100 Grosseto, Italy 4 Department of Obstetrics and Gynaecology, S. Eugenio Hospital, 00144 Rome, Italy;

[email protected] 5 Department of Obstetrics and Gynecology, Santo Stefano Hospital, Prato USL Toscana Centro,

59100 Prato, Italy; [email protected] 6 Physiopathology of Reproduction Unit, USL Toscana SudEst, Ospedale della Misericordia,

58100 Grosseto, Italy; [email protected] * Correspondence: [email protected]

Abstract: New technologies such as non-invasive prenatal testing (NIPT), capable of analyzing cell-free fetal DNA in the maternal bloodstream, have become increasingly widespread and available, which has in turn led to ethical and policy challenges that need addressing. NIPT is not yet a diagnostic tool, but can still provide information about fetal genetic characteristics (including sex) very early in pregnancy, and there is no denying that it offers valuable opportunities for pregnant women, particularly those at high risk of having a child with severe genetic disorders or seeking an alternative to invasive prenatal testing. Nonetheless, the ethical, legal and social implications (ELSI) include multiple aspects of informed decision-making, which can entail risks for the individual right to procreative autonomy, in addition to the potential threats posed by sex-selective termination of pregnancy (in light of the information about fetal sex within the first trimester), and the stigmatization and discrimination of disabled individuals. After taking such daunting challenges into account and addressing NIPT-related medicolegal complexities, the review’s authors highlight the need for an ethically and legally sustainable framework for the implementation of NIPT, which seems poised to become a diagnostic tool, as its scope is likely to broaden in the near future.

Keywords: non-invasive prenatal testing; cell-free fetal DNA; screening; aneuploidies; ethical, legal and social implications

1. Introduction

Non-invasive prenatal testing (NIPT), also referred to as cell-free DNA (cfDNA) testing and non-invasive prenatal screening (NIPS), is a highly sensitive and specific screening technique, increasingly clinically adopted to assess the risk that the fetus may carry chromosome aneuploidies and, possibly, submicroscopic copy number variations (CNVs) and other genetic conditions [1]. NIPT takes into account fetal DNA fragments resulted from placental trophoblast apoptosis, i.e., programmed cell death [2], flowing through the maternal blood and detectable from the fifth week of gestation.

As the cf-DNA in a pregnant woman is a mixture of genomic DNA fragments of maternal and placental origin (cff-DNA), the fetal fraction represents a critical and limiting factor that seems to be reliably measurable from the tenth week for clinical purposes, when it reaches a proportion of about 10% progressively increasing in the following weeks.

Genes 2021, 12, 204. https://doi.org/10.3390/genes12020204 https://www.mdpi.com/journal/genes

Genes 2021, 12, 204 2 of 9

Given its high sensitivity and specificity, the cost-effectiveness of and the absence of risk of pregnancy loss associated with amniocentesis or chorionic villus sampling, NIPT has turned out to be a widespread screening tool for the most common fetal aneuploidy. NIPT, in fact, results in being especially effective in detecting trisomy 21 (Down’s syndrome; 99% and 99.92%, respectively), trisomy 18 (Edwards syndrome; 96.8% and 99.85%, respectively), trisomy 13 (Patau syndrome 92.1% and 99.8%, respectively) and sex chromosome aneuploi- dies (with a lower sensitivity than the previously reported autosomal aneuploidies), with a combined false-positive rate (FPR) of 0.13% [3]. However, NIPT cannot be considered as a “prenatal diagnostic test” but, up to now, a screening tool, albeit a highly valuable one. In fact, the incidence of false-positive results, generally attributable to mosaicisms confined to placental (CPM) or, less frequently, to other conditions such as vanished twin, maternal CNVs, apoptosis of maternal cancer cells and fetal mosaicism, requires an in- vasive test (preferably, through an amniocentesis) to confirm a positive NIPT result [4]. Such circumstances may occur and, to date, represent the origin of possible discordant test results, failures and contraindications. However, it is expected that technological advances and the involvement of fetal medicine specialists and genetic counsellors, especially in the most complex cases, should allow current limitations to be overcome in the near future.

In the current state of our knowledge and available technical tools, the fact that the cff- DNA concentration is directly proportional to gestational age and inversely proportional to maternal body mass index (BMI) [4] represents a limitation to be kept in mind, and a reason to proceed with caution when proposing this screening method at too early a gestational age (i.e., in the first trimester) or to overweight women, potential causes for a low cff-DNA fraction and, consequently, no-call results or false negative. In that regard, studies accounting for more than 16,000 pregnancies found a low fetal fraction in maternal bloodstream to be linked to a higher risk of fetal aneuploidies [5,6].

The possibility of not having results or to obtain ambiguous results to be confirmed by other methods should be adequately clarified before applying the test, possibly in a prenatal genetic counseling setting to enable informed choices.

In the current practice, the clinical application of NIPT is limited to the screening of the most common fetal aneuploidy and the associated risk assessment. However, in light of the considerable technological advancements in the field and progressively greater affordability of such techniques, NIPT has also begun to be used to test for single-gene disorders [7], as well as for additional and more rare chromosomal disorders [8] and sub- microscopic CNVs [9]. Although further research and validation are needed in order to determine the accuracy in detection rates and false positive and negative rates for these technical and clinical implementations, it is reasonable to predict that in the next few years NIPT will gradually become more applicable and widely adopted to the screening of several more genetic anomalies, including CNVs and single-gene disorders [10].

The suitability of advanced technical tools will involve further changes in clinical practice and, at the same time, will require an equally rapid ability to reflect on the ethical and legal aspects they open up.

2. Non-Invasive Prenatal Testing (NIPT) Ethical, Legal and Social Implications: Maybe Advancing Reproductive Autonomy, But at What Cost?

First introduced in 2011, NIPT was at first offered by private health care providers, and has in recent years been integrated among public healthcare services. In Italy, the NIPT test was introduced in Tuscany in 2019 as a public healthcare tool in the birth path [11].

The increased use of NIPT has significantly reduced the number of invasive tests carried out in many of the nations where it is commonly used. As of today, NIPT is used in less than 25% of pregnancies in most European countries, and as low as 5% in some countries. The highest levels of NIPT use in European Countries have been recorded in Belgium (>75% of pregnancies) and the Netherlands, Italy, Spain and Austria (generally ranging between 25% and 50% of pregnancies) [12]. In the USA, NIPT for high-risk patients (i.e., >35 years, positive cFTS, etc.) is covered by most healthcare insurance companies and most state-sponsored Medicaid programs (in all but nine states). Overall, at the national

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level, 25–50% of all pregnant women undergo NIPT, which mostly screens for chromosome 13, 18, 21 and sex chromosome aneuploidies. On the other hand, the ever lower costs of new molecular technologies and the non-invasiveness of the diagnostic method could allow for greater diffusion and availability, particularly in low-income developing countries.

Screening for other triploidies, rare aneuploidies and some microdeletions is also available, albeit rather rarely used, and not recommended.

Nonetheless, in terms of ethical, legal and social implications, NIPT has a broad range of complexities that need exploring. Prenatal screening for fetal abnormalities is a morally sensitive practice, since it could lead, or at least contribute, to a decision to terminate one’s pregnancy in case of positive results.

Although population screening programs are mostly directed towards the purpose of reducing morbidity and mortality rates, linked to diseases or disorders, in the population at large, two major ethical issues arise as a result of that objective, as far as prenatal screening is concerned. First and foremost, if the success of the program is deemed to rest upon the termination rate of fetuses with detected abnormalities, confirmed by follow-up testing, that interpretation might well generate a certain degree of pressure on women to seek to terminate their pregnancies if fetal genetic conditions are detected. Some fear the risk of turning the personal choice to voluntarily terminate one’s pregnancy into a “public health instrument” [13]. Secondly, the main objective of prenatal screening techniques makes the practice disputable according to the “disability rights” or “expressivist” critique. Such a philosophical stance denounces that a discriminatory message may be sent by the mainstream use of prenatal screening about the inherent worth of human life, and particu- larly the lives of those suffering from severe disabling conditions [14]. The considerable discrepancies that are still unsolved between the various assessments of NIPT’s potential benefits and risks, in addition to the ethical values to which they relate, are bound to engender challenges and conflicts that public policy-makers need to address.

Three core principles have been laid out in a recent, wide-ranging analysis by the Nuffield Council on Bioethics [15], which may be summarized as follows:

• The societal context and environment in which NIPT screening is developed and provided ought to be taken into account when devising and undertaking NIPT policy- making initiatives.

• Access to NIPT should be guaranteed to women and couples under conditions and in an environment that prioritizes autonomous, informed choices.

• Potential, significant risks posed by the growing use and development of NIPT ought to be dealt with and minimized through concerted, multilayered efforts, involving all stakeholders and elected officials.

Such major ethical concerns have also been addressed and countered in policy po- sitions issued by various societies in several countries (such as France [16], the United Kingdom [17], Denmark [18], and the Netherlands [19]). In their analyses, said institutions stressed that the fundamental purpose of prenatal screening is not to prevent children with specific abnormalities from being born, but rather to foster reproductive awareness and uphold reproductive rights by enabling pregnant women and their partners to exercise their full autonomy through informed decisions.

3. More Information Fosters Procreative Autonomy? Not So Fast…

Not surprisingly, one of the most pressing ethical concerns related to NIPT is the opportunity to rely on informed decision making. Professional guidelines currently rec- ommend that patients who opted for prenatal screening should receive pre- and post-test genetic counseling [20,21], as it is already the case at most academic medical centers world- wide and mandatory in the Italian national health system. In the case of NIPT, moreover, the risk of “routinization” or “trivialization” appears even greater than in other prenatal diagnostic approaches. That is likely due to the lack of risk for pregnancy by a non-invasive approach and the great simplicity of the clinical approach. Just by virtue of the higher degree of safety of this approach when compared to other prenatal tests, the risk is that all

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the important implications that NIPT entails may not be fully understood and weighed, if not thoroughly discussed in an informed decision-making process prior to the procedure.

If women are not offered clear information to help them make up their minds about NIPT or other prenatal screening techniques, about the risks and benefits of different approaches and the implications of all possible outcomes, they may not be able to think adequately and determine whether they really want the test results or how they would react to them. Data from experiences with a “standard” blood draw such as serum screening seem to point to poor levels of informed consent before the screening, with many patients remarking that they did not really want to be tested or that, on the contrary, they refused to without being fully aware of its function [22].

Furthermore, wide-ranging emotional and social implications could arise from un- expected test results, even to the point of negatively affecting reproductive autonomy. If the current Italian and, in particular, in Tuscany, two-step prenatal screening approach (a “combined test” followed by invasive test in case of high risk of aneuploidy) were entirely supplanted by NIPT, such a development would arguably detract from the twofold opportunity to foster informed decision-making. It may be argued that NIPT would likely lower health care costs, if it were to become a primary screen; nonetheless, it would also reduce the consultations and dialogue to only one point of contact between a pregnant woman and her physician to discuss the implications of undergoing prenatal testing [23].

Moreover, a large and growing availability of information (as the techniques and the scope of NIPT are further developed) could predict not only late onset diseases (such as cancers or degenerative diseases), but also predispositions to severe and common condi- tions (cancer, diabetes etc…). In addition to that, new methods based on non-coding RNA have been substantially developed [24]: research has focused on RNA-based non-invasive biomarkers, including cell-free nucleic acids such as miRNA, lncRNA and circRNAs [25,26], so as to detect some of the most common conditions related to gestation, such as congenital heart diseases, gestational diabetes and preeclampsia, among others.

Moreover, associations have been widely researched between circulating small and long non-coding RNAs (ncRNAs) and cancer [27,28]. In this way, the so called incidental findings (i.e., off-target results with potential medical implications) can arise with more probability both for the fetus (minor anomalies or irrelevant information from a medical standpoint, such as paternity) and the mother (unsuspected maternal malignancy in asymptomatic women).

Certainly, such a wide-ranging enhancement of testing capabilities might be welcomed as beneficial in terms of upholding the reproductive autonomy of parents. However, there are significant concerns stemming from such unprecedented access to information about a human being yet to be born. Let us consider the confusion likely to be generated by such a deluge of genetic information, often hard to fully interpret and explain for physicians and for parents to fully understand [29]. Secondly, it is worth bearing in mind that even when NIPT does not lead to voluntary termination of pregnancy, there are serious privacy concerns for the future child as well as the mother, stemming from such a broad range of extensive genetic information. Some analysts have contended that testing purely for information on a range of conditions (e.g., adult-onset diseases) is morally objectionable, in that it could harm the child’s and parents’ ability to make future choices in an unconditioned fashion (the “right to an open future”, albeit not deemed an absolute right [30]). That could, to some extent at least, do damage, by exposing the child to higher levels of anxiety as a result of his or her awareness of a future with a particular condition [31].

4. Could NIPT Mainstreaming Go in the Direction of Making Selective Abortion Ethically Acceptable? The “Slippery Slope” Risk

Many have argued that larger and larger amounts of genetic information might ultimately lead to higher voluntary abortion rates [32] (although there seems to be no conclusive evidence to support that assumption [33,34]), as well as its discounting or ‘trivialization’, which could result in the choice to terminate a pregnancy on relatively