Should genetic health care providers attempt to influence reproductive outcome using directive counseling techniques? A public health prospective

Many areas of agreement exist among genetic health care (GHC) professionals (i.e., MD and PhD clinical geneticists, master's level genetic counselors, and others) and public health (PH) professionals. However, there are in ou r opinion at least two areas or tenets where a distinct difference of opini on exists. Two tenets widely expressed by prenatal GHC professionals are: ( 1) they should never attempt to influence the outcome of a pregnancy, and ( 2) they should only use non-directive genetic counseling techniques. From a PH perspective, these tenets could be viewed in some instances as counterp roductive and contrary to a major goal of PH (i.e., to improve the health a nd well-being of all residents, including newborns). For example, PH's mess age regarding fetal alcohol syndrome (FAS) prevention is clear: If you are pregnant, don't drink; and if you drink, don't get pregnant. PH's message r egarding neural tube defect (NTD) prevention is equally clear: all women of childbearing age who are capable of becoming pregnant should consume 0.4 m g of folic acid daily to reduce the risk of NTDs. In the past, issues such as eugenics, abortion of affected fetuses, and a l ack of methods for the primary prevention of birth defects and genetic diso rders have caused GHC providers to perform genetic counseling according to the two tenets mentioned above. Clearly, there are no moral or ethical reas ons why children who are at risk for FAS, NTDs, fetal rubella syndrome, or many other conditions should not have the opportunity to be born healthy. A lso, we know of no laws that prohibit providers from telling a woman to do something to improve her baby's chance of being born healthy. In our opinio n, it is time for prenatal GHC professionals to re-examine the two tenets n oted above on a case-by-case basis to determine when it is appropriate to u se directive counseling techniques to improve reproductive outcomes in acco rdance with the goals of PH. a framework is provided here that could serve as: (1) a guide for future discussions dealing with these issues, and (2) a method to ensure that prenatal GHC policy and practice regarding these iss ues conform with one another.