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    Over at MedPage Today, Dr. Val presents a very special Inauguration day Grand Rounds, giving our new president some pointers and principles by which he might guide health care reform with wisdom and virtue.  It is very well done, not the least because my post was featured.  Check it out for some great thoughts on the state of medicine today.

      The Gene Genie carnival is out at Genetic Future, with its finger on the pulse of our genes and the future, Encephalon is out at the Mouse Trap for those looking for the neuroscience slant, and a very fine Surgexperiences landed some neurosurgeon named Gupta to guest host/distract from the drama of the OR at Vagus Surgicalis aka Monash Medical Student.  Enjoy.

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First Published April 25, 2008.

 

Becoming the parent of a child with a genetic disease is a harrowing experience. This is likely more true today than it has ever been. We are hardwired to want the best for our children. Discovering they have a life altering condition pulls the rug right out from under parents. Discovering that the very genetic blueprint they passed on to the child is the problem makes this “act of God” personal. Suddenly, it is your fault.

Child birth is an exciting time full of anticipation. What parents often don’t anticipate is the possibility that anything could ever go seriously wrong. I took a first year medical school genetics elective right at the time my wife was expecting our first child. Note to all medical students. DO NOT EVER do this. It is a bad idea. It brought me right down to Earth real quick. It also caused me lost sleep, racing thoughts, and all around needless worry.

I also witnessed firsthand some real parental anguish.  My heart ached for them.  They became very caught up in questions like what the diagnosis actually was, what the chances of having another child with the same problem were, and do they need to have family members tested.  The more understanding we have, the more directed the questions and more uncertain the future.

      This has created or at least accentuated a new phenomenon, gene guilt.  In college I had a cell biology professor who referred to himself as a “genetic cess pool.”  on account of a daughter with spinal muscular atrophy, type I, a fatal recessive genetic disorder.  The irony is that his genes were likely no worse than anyone else’s.  It just happened that he married someone with a matching bad gene.  We likely all walk around with at least a few faulty genes, usually more, among our thousands.  Any one of these could result in disease if we concieve children with someone with the same exact hit.  The odds of that are low, like winning the lottery, only the prize is heartbreaking.

   Some genes are bad enough that disease shows up with just one copy, but for unknown reasons is super mild in some people, who may go undiagnosed until half their children get it.  Other gene mutations, called nucleotide repeats actually worsen through generations until the unlucky one gets disease, and then their children get worse disease.  With X chromosome disorders, the Mother passes a gene to her sons that caused her no problem because she had both a good and a bad copy.  Problem is her son gets the bad gene, and has no second copy because he is male.  Other diseases of the mitochondria are given strictly from the mother.  All of these situations can worsen the guilt and crush the self esteem of the parent. 

     Science compounds the problem with evolution.  We learn that nature’s way is survival of the fittest.  Bad genes are selected out of populations naturally.  With medicine, we have sort of beat evolution over the head by outsmarting nature, at least temporarily.  People with chronic conditions are living longer and better than ever before.   It is a natural step therefore, once we know about a bad gene and see its effect, to wonder if we should not select it out of the population by not having any more children.  This is unnatural selection, if you will.  We reason that we must do something nature has been doing anyway without our input.  Some reason that if they have children they are threatening the gene pool of the race.  I think it is a very flawed mindset.

      Certainly many disagree with me.  During the above mentioned genetic rotation, I met a teenager who was diagnosed with Li-Fraumeni syndrome, a disorder that increases susceptibility to cancer.  Her parents died at a young age, and she was being raised by an aunt.  The conversation between them was profound.  This patient felt emphatically that her life was not a mistake.  To suggest this was perhaps even offensive to her.  Who would want to think their life was a mistake?  For this reason, she insisted that she intended to have kids if the opportunity arose.  The Aunt was mortified. 

      Granted, this patient had not yet experience the ravages of cancer, perhaps her point of view was flawed, but I think she had a point.   This is a tough issue and certainly there are no easy answers.  But I believe we often overestimate the suffering of others.  I can’t help but admire her for realizing she is more than her genes.  Her life was more than her disease.  Individuals have much more contribution to make to society than just their genome. 

    I think this is a point too many people miss, especially us doctors.  We are consumed with patient’s conditions.  The disease too easily become the only reason we relate to them at all.  We start to refer to patient’s who happen to have Cystic Fibrosis as CF’ers, Sickle cell disease as sicklers, with Asthma as wheezers, etc. al etc.  It obscures the fact that we a dealing with living, thinking, feeling human beings.  We physicians wan’t to prevent disease, not enable it.  We grow weary of those who do not take care of themselves and present us with disease.  Too many doctors fall into the snare of exasperation and contempt for the reproductive habits of those we care for.  

   We are too obsessed with perfection in this country.  We airbrush pictures of models, causing young women to starve themselves to meet a nonexistent ideal.  We celebrate beauty, strength, speed, endurance.  We reject difference.  It is a natural social response with ugly consequences.  Just as the sick, albino or deformed chick will be relentlessly assaulted by the rest of the brood, we can have a visceral revulsion witnessing malformation, scarring, or amputation.  For me, this is the human flaw we really need to work on, not the diseases.   As we gain the power to manipulate our genome, how will we decide what is appropriate to treat and what is not.  Short height is now an indication for human growth hormone therapy.  I find that disturbing. 

    We need to learn to see the beauty in our flaws.  Only then will we really see the beauty in humanity.  I believe our imperfections are a centrally important part of our being  here in the first place.  Forty years ago, a French philosopher named Jean Vanier founded a religious community devoted entirely to living and worshipping among developmentally impaired adults.  Speaking of Faith featured L’arche in a podcast with some profound, moving, and amazing descriptions of what we can learn from them.  I encourage everyone to take a listen. 

     The dystopian movie Gattaca takes a look at just where a culture of perfection can lead.  It isn’t pretty.  In the 1930s a madman rose to power with a dream of a blonde haired, blue eyed master race setting off the most massive conflict in world history.  Will we as a people fall prey to the same ideas as we develop the power to actually make it happen?

Every man can, if he so desires, become the sculptor his own brain“.
             Santiago Ramon y Cajal (1852-1934)
                             Spanish Neuroscientist

  Life is distinguished from the inanimate by its ability to recreate itself and hold a pattern.  Throughout our lives, The very material we are made up of is recycled or regenerated.  Every few weeks we completely change out the cells that compose our skin.   The body is constantly in a state of regenerating itself.  Even the bones are borrowing or depositing calcium throughout our lives.  The machinery of our cells are constantly disposing of waste, replacing damaged portions, killing cells that are old or dysfunctional and making new ones.  All this processes are kept in order by our genetic information.  In essence the only thing that holds our form and keeps it from weathering away and degenerating is our DNA.  This is the master set of instructions that our cells use to replace, rebuild, and develop us into the body we now have.  It is the ultimate difference between the collection of elements that is us, and a rock.

     However, there is much more to what we are than just the DNA blueprints.  I remember a moment at the beginning of my very first year of medical school that really brought this home to me.  In anatomy we had to memorize every crater, every bump, every nodule, line and crevice in every bone in the body.  As we learned about these landmarks, we learned that they form not as part of some genetic program, but as a reaction to stress forces from pulling tendons and ligaments, triggering a reaction that caused the cells in that part of the bone to duplicate and reinforce the bone as needed.  In other words, our actions determine the shape of our bones every bit as much as our genes.

Read the rest of this entry »

We hear a lot on-line about everything that is wrong is medicine. Improvement should always be our aim and this is healthy. I think it does us all a little good to take a step back and realize just what we have. There are some things medicine has done for us I don’t think you could put any price tag on. While most are intensely aware of shortcomings, here is a reminder of just what how powerful modern medicine has been. Read the rest of this entry »

Becoming the parent of a child with a genetic disease is a harrowing experience. This is likely more true today than it has ever been. We are hardwired to want the best for our children. Discovering they have a life altering condition pulls the rug right out from under parents. Discovering that the very genetic blueprint they passed on to the child is the problem makes this “act of God” personal. Suddenly, it is your fault.

Read the rest of this entry »

We live in an age where our understanding of life is far beyond what our forefathers could have dreamed. We have cracked the genetic code. We have to capability to splice and dice. We have an entirely new field, bioengineering dedicated to the proposition that we can literally, “engineer life” to suit our needs. The breakthroughs we have made are astonishing. We have sequenced the entire genome of mankind. We have the power to modify species at will.

In a sense we have been at this for a very long time. We have domesticated the dog and the cat. The grains that we rely on to feed mankind are all a product of manipulation of one seed with another, keeping the ones that grow the “best” crop. Rice, wheat, corn are all essentially artificial and manmade in a sense. I find it a little ironic those that will look at genetically altered agricultural produce with fear and disdain when by definition, agricultural products are manmade. Whether we select genetic traits in a lab or in the field, the fact is we alter them. Read the rest of this entry »

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