  The 1997 report of the ELSI Working Group's Task Force on Genetic Testing focuses on ensuring the safety and effectiveness of genetic tests (Holtzman and Watson 1997)—an important concern given the social pressures likely to encourage the expansion of genetic testing and screening as more tests become available: commercial interests of the biotech industry; clinicians’ (and their malpractice insurers’) fears of wrongful birth or wrongful life lawsuits; and expectations of governments and other institutions (e.g. private foundations, HMOs) that, by preventing the births of individuals with costly conditions at sufficient rates, carrier and prenatal screening programs will prove cost-effective (Holtzman 1989; Paul 1994a). At the opposite end of the spectrum, the expanding availability of direct-to-consumer genetic tests, which the report recommends against, has led to ethical controversy (Beckman 2004). Like the 1994 report published by the Committee on Assessing Genetic Risks (Andrews et al. 1994), the Task Force report also stresses the need for voluntariness, informed consent, confidentiality, legislative protection against discrimination, improved education of clinicians and the public, nondirectiveness in reproductive decisions, and availability of genetic counseling. Professional codes of ethics for genetic counseling (e.g. the National Society of Genetic Counselors in the U.S.) emphasize the importance of value-neutral, nondirective counseling in all of these situations: the goal is for clients to make their own decisions based on their own values once they are fully informed about their options. Ethical questions are raised about the ideals of value-neutrality and nondirectiveness: choosing which information to present and how to do so inescapably makes evaluative choices—for example, emphasizing medical over social information about disability in prenatal testing (Vehmas 2001); preference for certain outcomes is built into the system—for example, abortion of affected fetuses as society moves to routine prenatal screening (Bennett 2001); and nondirectiveness can be taken to an extreme where counselors are hesitant to challenge clients’ decisions no matter how inconsistent with their expressed values or irrational they appear (Singer 1996). Many difficult ethical questions confront genetic counselors and other clinicians involved in genetic testing in particular cases. Increased knowledge is not an unmitigated good: denial may be a coping mechanism; individuals may feel guilty for passing on harmful mutations to their offspring or stigmatized as having the potential to do so; survivor guilt may arise in a person who finds out she is not at risk for HD after all, or she may become at a loss about how to live her life differently; another person who finds out he is destined to develop HD or early-onset Alzheimer's may become depressed or even suicidal; paternity may not be what it is assumed to be. One person's decision to be tested may also have ramifications for others: for tests that rely on linkage analysis, there may be pressure on relatives to be tested; test results may have implications for the risk status of yet-untested family members; protecting confidentiality may deprive a spouse or child of important information. These issues will be tackled in the next two sections (“Genetic Discrimination” and “Genetic Privacy”).