Ethical challenges of precision medicine in China_Chinese Journal of Evidence-Based Medicine

Authors：

PANG Cong ^1,2 , CHEN Hongyi ^1,3 , WANG Yifeng ⁴ ,  YIN Jie ^1,2

1. Center for Biomedical Ethics, Fudan University, Shanghai 200433, P.R.China;
2. School of Philosophy, Fudan University, Shanghai 200433, P.R.China;
3. Human Phenome Institute, Fudan University, Shanghai 201203, P.R.China;
4. School of Clinical Medicine, Shanghai Medical College, Fudan University, Shanghai 200032, P.R.China;

Corresponding author：

YIN Jie, Email: jieyin@fudan.edu.cn

Keywords：

Precision medicine; Ethics; Informed consent; Privacy; China

DOI：

10.7507/1672-2531.202009019

Video：

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In order to promote the responsible development of precision medicine in China, the current situation of precision medicine in three major fields (clinical, research and commercial) was briefly introduced, and key ethical issues or disputes in each field (including informed consent, return of incidental findings, and allocation of medical resources in the clinical field; informed consent, return of research results, and data use and sharing in the research field; genetic counseling, clinical utility of genetic testing, and use of data in the field of direct-to-consumer genetic testing) were discussed. It is necessary to actively meet these ethical challenges for the development of precision medicine in China.

Citation： PANG Cong, CHEN Hongyi, WANG Yifeng, YIN Jie. Ethical challenges of precision medicine in China. Chinese Journal of Evidence-Based Medicine, 2020, 20(12): 1367-1372. doi: 10.7507/1672-2531.202009019 Copy

1.	U. S. national library of medicine. What is precision medicine? Available from: https://ghr.nlm.nih.gov//primer/precisionmedicine/definition.
2.	The white house. The precision medicine initiative. Available from: https://obamawhitehouse.archives.gov/precision-medicine.
3.	吴思竹, 钱庆, 杨林. 中国, 美国, 英国精准医学计划比较研究. 中国医院管理, 2017, 37(9): 77-80.
4.	唐金陵, 李立明. 关于循证医学, 精准医学和大数据研究的几点看法. 中华流行病学杂志, 2018, 39(1): 1-7.
5.	阎小妍, 董冲亚, 姚晨. 大数据时代的循证医学研究. 中国循证医学杂志, 2017, 17(3): 249-254.
6.	李佳圆. 中国乳腺癌危险因素研究现况及其风险预测模型研究展望. 中国循证医学杂志, 2020, 20(7): 745-748.
7.	曾春燕, 邱仁宗. 个性化医学/精准医学的伦理考虑. 医学与哲学(A), 2018, 39(7): 92-95.
8.	李磊, 王国豫. 精准的医学与不精准的后果. 中国医学伦理学, 2018, 31(9): 8-13.
9.	陶应时, 王国豫. 精准医学伦理: 当代生命伦理研究的新领域. 自然辩证法通讯, 2019, 41(7): 93-99.
10.	中华人民共和国卫生计生委办公厅. 孕妇外周血胎儿游离DNA产前筛查与诊断技术规范. Available from: http://www.nhc.gov.cn/fys/s3581/201611/0e6fe5bac1664ebda8bc28ad0ed68389.shtml.
11.	中华人民共和国医政医管局. 肿瘤个体化治疗检测技术指南(试行). Available from: http://www.nhc.gov.cn/yzygj/s3593/201507/fca7d0216fed429cac797cdafa2ba466.shtml.
12.	中华人民共和国医政医管局. 药物代谢酶和药物作用靶点基因检测技术指南(试行). Available from: http://www.nhc.gov.cn/yzygj/s3593/201507/fca7d0216fed429cac797cdafa2ba466.shtml.
13.	基因谷. 又一城市实行免费无创产前基因检测. Available from: https://www.sohu.com/a/341140816_733985.
14.	U. S. food and drug administration. Table of pharmacogenomic biomarkers in drug Labeling. Available from: https://www.fda.gov/drugs/science-research-drugs/table-pharmacogenomic-biomarkers-drug-labeling.
15.	Ashley EA. Towards precision medicine. Nat Rev Genet, 2016, 17(9): 507-522.
16.	Ormond KE, Cho MK. Translating personalized medicine using new genetic technologies in clinical practice: the ethical issues. Per Med, 2014, 11(2): 211-222.
17.	McGowan ML, Settersten RA, Juengst ET, et al. Integrating genomics into clinical oncology: ethical and social challenges from proponents of personalized medicine. Urol Oncol, 2014, 32(2): 187-192.
18.	Buchanan A, Sachs A, Toler T, et al. NIPT: current utilization and implications for the future of prenatal genetic counseling. Prenat Diagn, 2014, 34(9): 850-857.
19.	中国遗传学会遗传咨询分会. 分会简介. Available from: http://cbgc.org.cn/profile/introduce/.
20.	Regier DA, Peacock SJ, Pataky R, et al. Societal preferences for the return of incidental findings from clinical genomic sequencing: a discrete-choice experiment. CMAJ, 2015, 187(6): E190-E197.
21.	Shahmirzadi L, Chao EC, Palmaer E, et al. Patient decisions for disclosure of secondary findings among the first 200 individuals undergoing clinical diagnostic exome sequencing. Genet Med, 2014, 16(5): 395-399.
22.	Schuol S, Schickhardt C, Wiemann S, et al. So rare we need to hunt for them: reframing the ethical debate on incidental findings. Genome Med, 2015, 7(1): 83.
23.	Kohane IS, Masys DR, Altman RB. The incidentalome: a threat to genomic medicine. JAMA, 2006, 296(2): 212-215.
24.	Green RC, Berg JS, Grody WW, et al. ACMG recommendations for reporting of incidental findings in clinical exome and genome sequencing. Genet Med, 2013, 15(7): 565-574.
25.	Holtzman NA. ACMG recommendations on incidental findings are flawed scientifically and ethically. Genet Med, 2013, 15(9): 750-751.
26.	Burke W, Antommaria AH, Bennett R, et al. Recommendations for returning genomic incidental findings? We need to talk! Genet Med, 2013, 15(11): 854-859.
27.	ACMG Board of Directors. ACMG policy statement: updated recommendations regarding analysis and reporting of secondary findings in clinical genome-scale sequencing. Genet Med, 2015, 17(1): 68-69.
28.	Chan SL, Samaranayake N, Ross CJ, et al. Genetic diversity of variants involved in drug response and metabolism in Sri Lankan populations: implications for clinical implementation of pharmacogenomics. Pharmacogenet Genomics, 2016, 26(1): 28-39.
29.	Peng Q, Huang S, Chen X, et al. Validation of warfarin pharmacogenetic algorithms in 586 Han Chinese patients. Pharmacogenomics, 2015, 16(13): 1465-1474.
30.	Johnson JA, Cavallari LH. Warfarin pharmacogenetics. Trends Cardiovasc Med, 2015, 25(1): 33-41.
31.	Need AC, Goldstein DB. Next generation disparities in human genomics: concerns and remedies. Trends Genet, 2009, 25(11): 489-494.
32.	Korngiebel DM, Thummel KE, Burke W. Implementing precision medicine: the ethical challenges. Trends Pharmacol Sci, 2017, 38(1): 8-14.
33.	Aronson SJ, Rehm HL. Building the foundation for genomics in precision medicine. Nature, 2015, 526(7573): 336-342.
34.	中华人民共和国科学技术部. 科技部关于发布国家重点研发计划精准医学研究等重点专项2016年度项目申报指南的通知. Available from: http://www.most.gov.cn/tztg/201603/t20160308_124542.htm.
35.	王博, 刘芳, 张二春, 等. 国家基因库: 共有, 共为, 共享. 遗传, 2019, 41(8): 761-772.
36.	薛江莉. 泰州队列生物样本库资源共享管理优化研究. 桂林: 广西师范大学, 2019.
37.	Callier SL, Abudu R, Mehlman MJ, et al. Ethical, legal, and social implications of personalized genomic medicine research: current literature and suggestions for the future. Bioethics, 2016, 30(9): 698-705.
38.	Helgesson G. In defense of broad consent. Camb Q Healthc Ethics, 2012, 21(1): 40-50.
39.	Caulfield T. Biobanks and blanket consent: the proper place of the public good and public perception rationales. Kings Law J, 2007, 18(2): 209-226.
40.	Grady C, Eckstein L, Berkman B, et al. Broad consent for research with biological samples: workshop conclusions. Am J Bioeth, 2015, 15(9): 34-42.
41.	UK biobank. Consent form: UK biobank (version 20061124). Available from: https:/www.ukbiobank.ac.uk/wp-content/uploads/2011/06/Consent_form.pdf?phpMyAdmin=trmKQlYdjjnQIgJ%2CfAzikMhEnx6.
42.	Elger B, Biller-Andorno N, Mauron A, et al. Ethical issues in governing biobanks: global perspectives. Farnham: Routledge, 2008.
43.	Kaye J, Whitley EA, Lund D, et al. Dynamic consent: a patient interface for twenty-first century research networks. Eur J Hum Genet, 2015, 23(2): 141-146.
44.	Ploug T, Holm S. Meta consent: a flexible and autonomous way of obtaining informed consent for secondary research. BMJ, 2015, 350: h2146.
45.	Appelbaum PS, Parens E, Waldman CR, et al. Models of consent to return of incidental findings in genomic research. Hastings Cent Rep, 2014, 44(4): 22-32.
46.	Weiner C. Anticipate and communicate: ethical management of incidental and secondary findings in the clinical, research, and direct-to-consumer contexts (December 2013 report of the Presidential Commission for the Study of Bioethical Issues). Am J Epidemiol, 2014, 180(6): 562-564.
47.	Henderson GE, Juengst ET, King NM, et al. What research ethics should learn from genomics and society research: lessons from the ELSI Congress of 2011. J Law Med Ethics, 2012, 40(4): 1008-1024.
48.	World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA, 2013, 310(20): 2191-2194.
49.	Largent EA, Joffe S, Miller FG. Can research and care be ethically integrated? Hastings Cent Rep, 2011, 41(4): 37-46.
50.	Bledsoe MJ, Clayton EW, McGuire AL, et al. Return of research results from genomic biobanks: cost matters. Genet Med, 2013, 15(2): 103-105.
51.	Bledsoe MJ, Grizzle WE, Clark BJ, et al. Practical implementation issues and challenges for biobanks in the return of individual research results. Genet Med, 2012, 14(4): 478-483.
52.	Kirschen MP, Jaworska A, Illes J. Subjects' expectations in neuroimaging research. J Magn Reson Imaging, 2006, 23(2): 205-209.
53.	Miller FG, Joffe S. Evaluating the therapeutic misconception. Kennedy Inst Ethics J, 2006, 16(4): 353-366.
54.	Homer N, Szelinger S, Redman M, et al. Resolving individuals contributing trace amounts of DNA to highly complex mixtures using high-density SNP genotyping microarrays. PLoS Genet, 2008, 4(8): e1000167.
55.	McGuire AL, Hamilton JA, Lunstroth R, et al. DNA data sharing: research participants' perspectives. Genet Med, 2008, 10(1): 46-53.
56.	Williams S, Scott J, Murphy J, et al. The genetic town hall: public opinion about research on genes, environment, and health. Available from: https://www.pewtrusts.org/en/research-and-analysis/reports/2009/01/30/the-genetic-town-hall-public-opinion-about-research-on-genes-environment-and-health.
57.	Karlsen JR, Solbakk JH, Holm S. Ethical endgames: broad consent for narrow interests; open consent for closed minds. Camb Q Healthc Ethics, 2011, 20(4): 572-583.
58.	Prainsack B, Buyx A. A solidarity-based approach to the governance of research biobanks. Med Law Rev, 2013, 21(1): 71-91.
59.	转化医学网. 全面盘点\|国内外消费级基因检测企业及产品. Available from: https://www.sohu.com/a/233602504_183834.
60.	Niemiec E, Kalokairinou L, Howard HC. Current ethical and legal issues in health-related direct-to-consumer genetic testing. Per Med, 2017, 14(5): 433-445.
61.	Almeling R, Gadarian SK. Public opinion on policy issues in genetics and genomics. Genet Med, 2014, 16(6): 491-494.
62.	McGuire AL, Diaz CM, Wang T, et al. Social networkers' attitudes toward direct-to-consumer personal genome testing. Am J Bioeth, 2009, 9(6-7): 3-10.
63.	Schaper M, Wöhlke S, Schicktanz S. "I would rather have it done by a doctor"-laypeople's perceptions of direct-to-consumer genetic testing (DTC GT) and its ethical implications. Med Health Care Philos, 2019, 22(1): 31-40.
64.	Howard HC, Borry P. Is there a doctor in the house? The presence of physicians in the direct-to-consumer genetic testing context. J Community Genet, 2012, 3(2): 105-112.
65.	Janssens AC, Gwinn M, Bradley LA, et al. A critical appraisal of the scientific basis of commercial genomic profiles used to assess health risks and personalize health interventions. Am J Hum Genet, 2008, 82(3): 593-599.
66.	McGuire AL, Burke W. Health system implications of direct-to-consumer personal genome testing. Public Health Genomics, 2011, 14(1): 53-58.
67.	Roberts JL, Pereira S, McGuire AL. Should you profit from your genome? Nat Biotechnol, 2017, 35(1): 18-20.

1. U. S. national library of medicine. What is precision medicine? Available from: https://ghr.nlm.nih.gov//primer/precisionmedicine/definition.
2. The white house. The precision medicine initiative. Available from: https://obamawhitehouse.archives.gov/precision-medicine.
3. 吴思竹, 钱庆, 杨林. 中国, 美国, 英国精准医学计划比较研究. 中国医院管理, 2017, 37(9): 77-80.
4. 唐金陵, 李立明. 关于循证医学, 精准医学和大数据研究的几点看法. 中华流行病学杂志, 2018, 39(1): 1-7.
5. 阎小妍, 董冲亚, 姚晨. 大数据时代的循证医学研究. 中国循证医学杂志, 2017, 17(3): 249-254.
6. 李佳圆. 中国乳腺癌危险因素研究现况及其风险预测模型研究展望. 中国循证医学杂志, 2020, 20(7): 745-748.
7. 曾春燕, 邱仁宗. 个性化医学/精准医学的伦理考虑. 医学与哲学(A), 2018, 39(7): 92-95.
8. 李磊, 王国豫. 精准的医学与不精准的后果. 中国医学伦理学, 2018, 31(9): 8-13.
9. 陶应时, 王国豫. 精准医学伦理: 当代生命伦理研究的新领域. 自然辩证法通讯, 2019, 41(7): 93-99.
10. 中华人民共和国卫生计生委办公厅. 孕妇外周血胎儿游离DNA产前筛查与诊断技术规范. Available from: http://www.nhc.gov.cn/fys/s3581/201611/0e6fe5bac1664ebda8bc28ad0ed68389.shtml.
11. 中华人民共和国医政医管局. 肿瘤个体化治疗检测技术指南(试行). Available from: http://www.nhc.gov.cn/yzygj/s3593/201507/fca7d0216fed429cac797cdafa2ba466.shtml.
12. 中华人民共和国医政医管局. 药物代谢酶和药物作用靶点基因检测技术指南(试行). Available from: http://www.nhc.gov.cn/yzygj/s3593/201507/fca7d0216fed429cac797cdafa2ba466.shtml.
13. 基因谷. 又一城市实行免费无创产前基因检测. Available from: https://www.sohu.com/a/341140816_733985.
14. U. S. food and drug administration. Table of pharmacogenomic biomarkers in drug Labeling. Available from: https://www.fda.gov/drugs/science-research-drugs/table-pharmacogenomic-biomarkers-drug-labeling.
15. Ashley EA. Towards precision medicine. Nat Rev Genet, 2016, 17(9): 507-522.
16. Ormond KE, Cho MK. Translating personalized medicine using new genetic technologies in clinical practice: the ethical issues. Per Med, 2014, 11(2): 211-222.
17. McGowan ML, Settersten RA, Juengst ET, et al. Integrating genomics into clinical oncology: ethical and social challenges from proponents of personalized medicine. Urol Oncol, 2014, 32(2): 187-192.
18. Buchanan A, Sachs A, Toler T, et al. NIPT: current utilization and implications for the future of prenatal genetic counseling. Prenat Diagn, 2014, 34(9): 850-857.
19. 中国遗传学会遗传咨询分会. 分会简介. Available from: http://cbgc.org.cn/profile/introduce/.
20. Regier DA, Peacock SJ, Pataky R, et al. Societal preferences for the return of incidental findings from clinical genomic sequencing: a discrete-choice experiment. CMAJ, 2015, 187(6): E190-E197.
21. Shahmirzadi L, Chao EC, Palmaer E, et al. Patient decisions for disclosure of secondary findings among the first 200 individuals undergoing clinical diagnostic exome sequencing. Genet Med, 2014, 16(5): 395-399.
22. Schuol S, Schickhardt C, Wiemann S, et al. So rare we need to hunt for them: reframing the ethical debate on incidental findings. Genome Med, 2015, 7(1): 83.
23. Kohane IS, Masys DR, Altman RB. The incidentalome: a threat to genomic medicine. JAMA, 2006, 296(2): 212-215.
24. Green RC, Berg JS, Grody WW, et al. ACMG recommendations for reporting of incidental findings in clinical exome and genome sequencing. Genet Med, 2013, 15(7): 565-574.
25. Holtzman NA. ACMG recommendations on incidental findings are flawed scientifically and ethically. Genet Med, 2013, 15(9): 750-751.
26. Burke W, Antommaria AH, Bennett R, et al. Recommendations for returning genomic incidental findings? We need to talk! Genet Med, 2013, 15(11): 854-859.
27. ACMG Board of Directors. ACMG policy statement: updated recommendations regarding analysis and reporting of secondary findings in clinical genome-scale sequencing. Genet Med, 2015, 17(1): 68-69.
28. Chan SL, Samaranayake N, Ross CJ, et al. Genetic diversity of variants involved in drug response and metabolism in Sri Lankan populations: implications for clinical implementation of pharmacogenomics. Pharmacogenet Genomics, 2016, 26(1): 28-39.
29. Peng Q, Huang S, Chen X, et al. Validation of warfarin pharmacogenetic algorithms in 586 Han Chinese patients. Pharmacogenomics, 2015, 16(13): 1465-1474.
30. Johnson JA, Cavallari LH. Warfarin pharmacogenetics. Trends Cardiovasc Med, 2015, 25(1): 33-41.
31. Need AC, Goldstein DB. Next generation disparities in human genomics: concerns and remedies. Trends Genet, 2009, 25(11): 489-494.
32. Korngiebel DM, Thummel KE, Burke W. Implementing precision medicine: the ethical challenges. Trends Pharmacol Sci, 2017, 38(1): 8-14.
33. Aronson SJ, Rehm HL. Building the foundation for genomics in precision medicine. Nature, 2015, 526(7573): 336-342.
34. 中华人民共和国科学技术部. 科技部关于发布国家重点研发计划精准医学研究等重点专项2016年度项目申报指南的通知. Available from: http://www.most.gov.cn/tztg/201603/t20160308_124542.htm.
35. 王博, 刘芳, 张二春, 等. 国家基因库: 共有, 共为, 共享. 遗传, 2019, 41(8): 761-772.
36. 薛江莉. 泰州队列生物样本库资源共享管理优化研究. 桂林: 广西师范大学, 2019.
37. Callier SL, Abudu R, Mehlman MJ, et al. Ethical, legal, and social implications of personalized genomic medicine research: current literature and suggestions for the future. Bioethics, 2016, 30(9): 698-705.
38. Helgesson G. In defense of broad consent. Camb Q Healthc Ethics, 2012, 21(1): 40-50.
39. Caulfield T. Biobanks and blanket consent: the proper place of the public good and public perception rationales. Kings Law J, 2007, 18(2): 209-226.
40. Grady C, Eckstein L, Berkman B, et al. Broad consent for research with biological samples: workshop conclusions. Am J Bioeth, 2015, 15(9): 34-42.
41. UK biobank. Consent form: UK biobank (version 20061124). Available from: https:/www.ukbiobank.ac.uk/wp-content/uploads/2011/06/Consent_form.pdf?phpMyAdmin=trmKQlYdjjnQIgJ%2CfAzikMhEnx6.
42. Elger B, Biller-Andorno N, Mauron A, et al. Ethical issues in governing biobanks: global perspectives. Farnham: Routledge, 2008.
43. Kaye J, Whitley EA, Lund D, et al. Dynamic consent: a patient interface for twenty-first century research networks. Eur J Hum Genet, 2015, 23(2): 141-146.
44. Ploug T, Holm S. Meta consent: a flexible and autonomous way of obtaining informed consent for secondary research. BMJ, 2015, 350: h2146.
45. Appelbaum PS, Parens E, Waldman CR, et al. Models of consent to return of incidental findings in genomic research. Hastings Cent Rep, 2014, 44(4): 22-32.
46. Weiner C. Anticipate and communicate: ethical management of incidental and secondary findings in the clinical, research, and direct-to-consumer contexts (December 2013 report of the Presidential Commission for the Study of Bioethical Issues). Am J Epidemiol, 2014, 180(6): 562-564.
47. Henderson GE, Juengst ET, King NM, et al. What research ethics should learn from genomics and society research: lessons from the ELSI Congress of 2011. J Law Med Ethics, 2012, 40(4): 1008-1024.
48. World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA, 2013, 310(20): 2191-2194.
49. Largent EA, Joffe S, Miller FG. Can research and care be ethically integrated? Hastings Cent Rep, 2011, 41(4): 37-46.
50. Bledsoe MJ, Clayton EW, McGuire AL, et al. Return of research results from genomic biobanks: cost matters. Genet Med, 2013, 15(2): 103-105.
51. Bledsoe MJ, Grizzle WE, Clark BJ, et al. Practical implementation issues and challenges for biobanks in the return of individual research results. Genet Med, 2012, 14(4): 478-483.
52. Kirschen MP, Jaworska A, Illes J. Subjects' expectations in neuroimaging research. J Magn Reson Imaging, 2006, 23(2): 205-209.
53. Miller FG, Joffe S. Evaluating the therapeutic misconception. Kennedy Inst Ethics J, 2006, 16(4): 353-366.
54. Homer N, Szelinger S, Redman M, et al. Resolving individuals contributing trace amounts of DNA to highly complex mixtures using high-density SNP genotyping microarrays. PLoS Genet, 2008, 4(8): e1000167.
55. McGuire AL, Hamilton JA, Lunstroth R, et al. DNA data sharing: research participants' perspectives. Genet Med, 2008, 10(1): 46-53.
56. Williams S, Scott J, Murphy J, et al. The genetic town hall: public opinion about research on genes, environment, and health. Available from: https://www.pewtrusts.org/en/research-and-analysis/reports/2009/01/30/the-genetic-town-hall-public-opinion-about-research-on-genes-environment-and-health.
57. Karlsen JR, Solbakk JH, Holm S. Ethical endgames: broad consent for narrow interests; open consent for closed minds. Camb Q Healthc Ethics, 2011, 20(4): 572-583.
58. Prainsack B, Buyx A. A solidarity-based approach to the governance of research biobanks. Med Law Rev, 2013, 21(1): 71-91.
59. 转化医学网. 全面盘点|国内外消费级基因检测企业及产品. Available from: https://www.sohu.com/a/233602504_183834.
60. Niemiec E, Kalokairinou L, Howard HC. Current ethical and legal issues in health-related direct-to-consumer genetic testing. Per Med, 2017, 14(5): 433-445.
61. Almeling R, Gadarian SK. Public opinion on policy issues in genetics and genomics. Genet Med, 2014, 16(6): 491-494.
62. McGuire AL, Diaz CM, Wang T, et al. Social networkers' attitudes toward direct-to-consumer personal genome testing. Am J Bioeth, 2009, 9(6-7): 3-10.
63. Schaper M, Wöhlke S, Schicktanz S. "I would rather have it done by a doctor"-laypeople's perceptions of direct-to-consumer genetic testing (DTC GT) and its ethical implications. Med Health Care Philos, 2019, 22(1): 31-40.
64. Howard HC, Borry P. Is there a doctor in the house? The presence of physicians in the direct-to-consumer genetic testing context. J Community Genet, 2012, 3(2): 105-112.
65. Janssens AC, Gwinn M, Bradley LA, et al. A critical appraisal of the scientific basis of commercial genomic profiles used to assess health risks and personalize health interventions. Am J Hum Genet, 2008, 82(3): 593-599.
66. McGuire AL, Burke W. Health system implications of direct-to-consumer personal genome testing. Public Health Genomics, 2011, 14(1): 53-58.
67. Roberts JL, Pereira S, McGuire AL. Should you profit from your genome? Nat Biotechnol, 2017, 35(1): 18-20.

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Ethical challenges of precision medicine in China

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