ETHICS Dynamic consent in the digital age of biology Richman Wee LLM he concept of ‘dynamic consent’, formulat- prietary genetic banking system was proposed by Faculty of Law—Law ed more than a decade ago and increasingly First Genetic Trust (FGT).3 The concern people Foundation–sponsored Centre for Law and Policy Tused in a number of health information and might have over the security of their personal in Emerging Technologies, communications technology (ICT) initiatives, has genetic data was identified by FGT as a potential University of Otago, Dunedin, been attracting strong interest from innovators barrier in the development of pharmacogenetics New Zealand and commentators. Dynamic consent has been ex- and personalised medicine. To provide greater plored and discussed in the literature on research assurance for individuals that their privacy will ethics, biobanking and genomic medicine. Early be strongly protected, FGT proposed a dynamic references to dynamic consent can be traced back informed consent mechanism that would protect to 2001, when stronger safeguards for protect- ‘the confidentiality of individual medical and ing the confidentiality of individual medical and genetic information, allowing access to select genetic information were being investigated, in information and the use or application of an order to support advances in the field of pharmaco- individual’s DNA only when the patient has genetics and personalised medicine. At that time, given specific consent [emphasis added].’4 FGT a rough draft of the human genome had been pub- would have the role of a third-party broker of lished by both the publicly funded international genetic information—as an intermediary between consortium, known as the Human Genome Pro- patients or research participants on one hand, ject, and the private commercial company called and those conducting genetic research, such as Celera Genomics, headed by J Craig Venter. Last medical researchers, health care providers and year, Venter heralded the arrival of the ‘digital age pharmaceutical companies on the other hand.5 of biology’.1,2 He spoke on the interchangeability of the digital and biological worlds, and envisioned As a trusted third party, FGT would create the a time when our personal biology would be trans- confidential database to the standard of ‘a struc- mitted across the internet at the speed of light. ture with Swiss bank–grade security’.6,7 Individu- als would consent to their genetic information This is the first article in a two-part series being stored in FGT’s database for clinical re- examining a selected number of overseas projects search use and they would control access to their that have developed the idea of dynamic consent own data. Such a protected environment would for use in the management of information and safeguard their privacy and maintain the confi- samples in the health context. dentiality of their genetic and medical informa- tion while they participate in genetic research.8,9 Projects and collaborations exploring The internet would be used by FGT to maintain dynamic consent mechanisms ongoing communication with them, for instance, to provide updates on research findings, seek con- sent for follow-up medical treatment or research First Genetic Trust studies, supply further detailed information J PRIM HEALTH CARE Early references to the dynamic consent approach about the risks and benefits of research projects, 2013;5(3):259–261. can be traced back to 2001 when an online pro- obtain specific consent for new uses of the data, CORRESPONDENCE TO: The ETHICS column explores issues around practising ethically in primary health care and aims to Richman Wee encourage thoughtfulness about ethical dilemmas that we may face. Faculty of Law, University of Otago, THIS ISSUE: This article is the first in a two-part series looking at international projects involved in the PO Box 56, Dunedin development of dynamic consent processes for accessing patient health information and samples. 9054, New Zealand [email protected] VOLUME 5 • NUMBER 3 • SEPTEMBER 2013 JOURNAL OF PRIMARY HEALTH CARE 259 ETHICS and to re-contact them with new requests.10 For decide whether their genetic, mental health, researchers, FGT’s internet-based systems would or any other information they deem sensi- assist them in efficiently collecting, storing, man- tive, should be shared and, if so, with whom. aging and analysing the genetic and medical data In addition, the Private Access online system for use in clinical trials.11 For drug companies, the enables the information of individuals to be FGT database could establish the link between searchable by selected researchers. their company and physician networks, to en- able direct access to many thousands of clinical EnCoRe—Ensuring Consent trial patients or samples for pharmacogenetics and Revocation programmes.9 EnCoRe is a recent information and communi- cations technology (ICT) research project that Private Access examines the design and development of dynamic Private Access Inc., founded in 2006 and head- consent mechanisms.16,17 EnCoRe officially began quartered in California, has been a widely publi- in June 2008 with £3.6 million funding. The cised example of technology being employed for EnCoRe project, undertaken by a group of UK connecting a wide range of stakeholders online multidisciplinary academic researchers and to generate greater awareness and participation industry partners, envisions giving individuals for clinical trials, as well as to bolster recruit- more control over their personal information. ment, increase enrolment, and enable consent With technological ‘know-how’, EnCoRe aims to be sought and obtained on an ongoing and to enable individuals to exercise the choice of interactive basis. All this is achieved with the granting and revoking consent over the use of development of an online clinical trial commu- their information in a way that—in the words of nity that involves patients, physicians and re- the researchers—would be as easy, intuitive and searchers, and is used industry-wide and includes reliable as turning a tap on or off. The EnCoRe a wide range of partners, such as clinical trial system has been described as a ‘patient-centric IT sponsors, patient advocacy groups, technology system which uses a “dynamic consent” approach providers, and other key public and private stake- [emphasis added].’18 holders.12 In addition, Private Access provides opportunities for engaging in social networking Biobanking is one of EnCoRe’s areas of focus on the clinical trial experience. Private Access for designing a system that manages consent extends the current capabilities of internet-based and revocation. ‘Biobanking patients’, as the search engines, to create the ability for properly EnCoRe documents describe them, would authenticated persons (for example, doctors, fam- achieve levels of control over how informa- ily members, researchers and others) to search tion and data relating to them are used by for highly confidential or sensitive personal researchers and clinicians in two ways. The information, based on the ‘private access’ rights first involves methods that inform biobank- that each individual can create to control who ing patients as to the uses of their personal can (or cannot) see all or any particular parts of information; that is, these are predominantly, the individual’s information.13,14,15 if not exclusively, informational in nature. The second involves methods that permit them The patented technology employed by Private to make meaningful decisions that can affect Access offers individuals the ability to exercise future uses of their information; that is, these dynamic, granular data control over their facilitate a two-way exchange of information information. The controls are dynamic in the and allow decisional functions to be exercised. sense that individuals can, at any time, change previously selected preferences as their circum- The key features of EnCoRe, as summarised by stances change, different needs arise, or deeper the researchers working on the project, can be levels of trust are established. The controls categorised in the following four ways. First, provide the ability to be granular down to the individuals can, through the IT interface, specify desired data element, enabling individuals to their preferences about the choices they are 260 VOLUME 5 • NUMBER 3 • SEPTEMBER 2013 JOURNAL OF PRIMARY HEALTH CARE ETHICS given about the use of their data and samples for 7. Cambridge Healthtech Institute. The art of translating research. Second, the EnCoRe system allows indi- genomic data into clinical practice: an interview with David Wang of First Genetic Trust. Molecular Med Monthly. 2004; viduals to change their mind and preferences over 41; [cited 2012 Oct 17]. Available from: http://www.chidb. time, and to have their choices revoked where com/newsarticles/issue41_1.asp appropriate. Third, individuals have the ability to 8. iBIO News. Congratulations to First Genetic Trust for receiving banking system patent. 3 Feb 2004; [cited 2012 Oct 14]. Avail- track and audit any changes they make. Fourth, able from: http://www.ibio.org/NEWS_EVENTS/nws-detail. they can choose when and how they are con- lasso?nws_id=1232 tacted. With the EnCoRe model, consent is ‘not a 9. Lewis G. Tissue collection and the pharmaceutical industry. In: Genetic databases: socio-ethical issues in the collection mere communication exercise but a bidirectional, and use of DNA. Tutton R & Corrigan O, editors. Routledge: ongoing, interactive process between patients and London; 2004. p 189. researchers.’18 10. Weir RF, Olick RS. The stored tissue issue: biomedical re- search, ethics and law in the era of genomic medicine. Oxford University Press; 2004. p 65. Dynamic consent has the potential to build 11. GenomeWeb LLC. Hewlett-Packard Secures IT Infrastructure on key elements of informed consent and help Partnership with First Genetic Trust, 2001; [cited 2012 Sept 14]. Available from: Bioinform. http://h20426.www2.hp.com/ foster deep respect for the rights and interests of products/workstation/kr/ko/fyi_newsletter/0305/file/BioIn- patients and participants.