by Nicole Martinez-Martin
Kong and colleagues raise substantive areas of ethical concern regarding the translation of psychiatric genetic research into clinical and public health contexts. They recognize that psychiatric genomic research itself does not support essentialist claims, but point out that, nonetheless, the translation of genetic research to these new contexts may reinforce essentialist views of mental illness. Underlying Kong and colleagues’ analysis is recognition of the ways in which certain epistemological orientations, embedded within culture and institutional practices, may shape the translation of genetic research. For example, they discuss the ways that the cultural paradigm of the “responsible self” could influence individuals who have a mental illness to feel a responsibility to manage their own genetic risk, thus increasing the experience of stigma and burden. The translation of psychiatric genetics is shaped by societal trends towards biological reductionism in understanding mental illness, and towards valuing biological over social and environmental approaches to mental health. However, in proposing an ethics agenda for psychiatric genetics, Kong and colleagues did not sufficiently examine how psychiatric genetics fits into the broader cultural context of how risk is assessed, perceived and managed by social institutions and individuals. While they address the role of psychiatric genetics in identifying risk, there also needs to be engagement with how cultural attitudes regarding risk will influence translation of psychiatric genetics, as well as how genetics interacts with other tools for risk assessment. Kong and colleagues also ignore one of the main societal institutions for dealing with “risky” behavior and individuals who have mental illness: the criminal justice system.
Because the need to identify and manage risk presents itself as a straightforward and desirable activity, it may be easy to overlook the centrality of prediction and prevention of harms to many cultural practices and institutions. In modern states, “the expert management of risk has become an essential task of government that reaches into practically every domain”. The prioritization of risk management practices, and the inherent obligations for institutions and individuals to act early to prevent future harms from materializing, will necessarily shape the ways in which psychiatric genetic research is interpreted and utilized in clinical and institutional contexts. The selection of which risks to emphasize and respond to, as well as selection of how to respond to that risk, is influenced by cultural norms and moral values. It is therefore important to study the ways in which attitudes and practices for risk management influence the utilization of psychiatric genetics. As de Vries and colleagues note, the attitudes regarding biological essentialism and health resource allocation discussed by Kong and colleagues are different in low and middle-income countries. Similarly, the ways in which psychiatric genetics are utilized for risk management strategies will need to be studied in a range of countries and contexts.
Information identifying genetic risk certainly can and will be used for the benefit of individuals and society, such as through contributions to improved preventive health measures. However, the calculation and management of risk has social implications for individuals that need to be recognized and studied. When a person is labeled as being “at risk” for a psychiatric illness, it impacts how they are treated by government and health institutions, as well as how they perceive themselves. For example, Char cautions that further study is needed regarding how psychiatric-genetic testing will influence the rationing of resources in pediatric cases. Well before an individual is symptomatic, the identification of the risk will impact them – and of course in some cases they may never develop symptoms, yet will live with that risk assessment. It will therefore also be necessary to study how individuals are affected by the identification of psychiatric risk factors over the life course. Children and adolescents are often a focus for programs that identify risk of psychiatric disorders, and Sabatello accordingly outlines the significant need to study how psychiatric-genomic knowledge impacts adolescents, noting that economic and racial factors can influence the type of treatment an “at risk” youth is subject to.
Mozersky and colleagues raise a key point that there is a need to “expand our lens beyond genomics” to consider other forms of technologies used to “identify and stratify individuals by risk.” Psychiatric genetics research is being used in ways that interact with both older and new technologies for risk assessment, such as neuroimaging, facial recognition software cognitive testing, biological markers and examination of health records. Therefore, understanding how identification of risk for mental illness affects the experience of individuals and provision of treatment will entail examination of how these technologies work together. The criminal justice system is an example of an institution which has shown enthusiasm for utilizing neuroimaging and psychiatric genetics, as well as more traditional tools, in order to identify and manage individuals who have a risk of mental disorder.
The criminal justice system is the primary institution for addressing antisocial behavior and, in the U.S., it has become a primary institution for addressing mental illness. In many American states, jails and prisons are de facto asylums, treating a larger number of mentally ill than the mental health institutions. It is estimated that 16-20 percent of incarcerated individuals have a severe mental illness, a rate that is three to six times that of general population. The criminal justice system relies upon assessments of the risk of antisocial and dangerous behavior for many aspects of its work. Therefore, it is crucial that the criminal justice system is also addressed in Kong and colleagues’ proposed program of ethics research. Many of the current tools used for risk assessment in criminal justice are ineffective and genetics may prove useful in improving assessment. Furthermore, psychiatric genetics research could lead to more effective allocation of resources or provision of treatment in the criminal justice system. At the same time, the concerns that Kong and colleagues identify regarding the potential impact of genetics on essentialist views of behavior and responsibility, and the associated impact on distribution of treatment resources only intensify within criminal justice settings. Criminology has long been influenced by theories linking biology with criminality. The use of psychiatric genetics within criminal justice will likely be shaped by and reinforce this orientation towards biological reductionism. Even though the treatment and management of large numbers individuals with mental illness by the criminal justice is financially inefficient and strains institutional resources, the political reality is that this situation nonetheless continues. In part, this situation likely reflects the perception that the inmates are both “mad” and “bad” and therefore morally undeserving of better treatment. There is the possibility that psychiatric genetics research could reinforce the idea that such people are permanently bad because of their biology.
Furthermore, there is a need to study how new technologies are applied for criminal justice purposes to predict and prevent antisocial and aggressive behavior. Such efforts often involve the use of psychiatric genetics and neuroimaging to identify individuals who have a ‘susceptibility’ for aggressive or antisocial behavior, and then intervene to prevent that behavior. While these practices would have a seemingly desirable goal to prevent criminal behavior, it remains important to study the short and long-term impact of being identified as a “risky” individual. Moreover, other societal institutions, such as public schools, may ultimately engage in these types of practices to predict and control antisocial behavior. Within criminal justice, environmental and psychosocial approaches to mental health treatment have rarely been a priority. One only need look at the history of how mental disorder is treated within the criminal justice system to recognize the danger that the treatment of individuals at risk of antisocial behavior would prioritize preventive detention or a problematic emphasis on biological interventions.
Kong and colleagues recognize the ways in which psychiatric genetics presents both promise and challenges for alleviating the burden of mental illness. They have outlined a welcome and necessary program for multi-faceted interdisciplinary research to assess the impact of genomics on mental health treatment and policy. Their proposed ethics research program would be improved by expanding to recognize institutions beyond the clinical and public health context that utilize psychiatric genetics as part of risk management strategies.