Estimation of risks becomes much more important in the face of NGS data because multiple pathogenic variants or VUS could be obtained from one individual. To best explain the meaning of each variant to the P/C, the counselors should estimate the risks associated with the observed variants. For example, a VUS can be reclassified into other types of variants using different methods [56].

When the test result is first announced, it is very important to find a way to present the finding in a positive way to the P/C. In addition, since information on the mode of inheritance might create a feeling of guilt in the parents, a careful and prudent approach is needed while discussing this topic.

P/C autonomy refers to the P/C's right to make his/her own medical decision without considering the value judgment of others. However, individuals must first be deemed capable of making autonomous decisions in order to be awarded the rights of decision-making and privacy [7]. Non-autonomous individuals include minors (children), people with mental disability or illness, and prisoners. Persons in a certain age range, e.g., adolescents or younger children, could be considered to have some aspects of autonomy. Although respect for autonomy is an essential quality in genetic counseling, there are nevertheless some limitations [8]. For example, not all P/Cs have equal access to all medical choices owing to economic and social considerations. Indeed, autonomy is an ethical construct particular to Westernized cultures.

Uncritical dependence or overreliance on autonomy can result in a non-favorable outcome for patients and families. Familial autonomy may sometimes be more important than individual autonomy. Thus, although P/C autonomy is a fundamental principle of genetic counseling, this does not imply that autonomy should dominate over all other values in all situations. Rather, the concept of autonomy in genetic counseling should be applied in accordance with the cultural norms of a given society.

Another important concept to consider is non-directiveness that is a genetic counseling strategy, in which the genetic counselor tries to avoid influencing a P/C's decision [8]. “What would you do if you were in my place?” is the most commonly encountered question of a P/C during genetic counseling. The traditional and theoretical response is to avoid answering this question. However, such avoidance could make a P/C feel helpless and abandoned. Counselors can help the patient imagine the full extent of the consequences by explaining and providing examples based on rational and objective facts. By using this technique, the counselors engage in a process that can help promote patient decision-making.

The principle of privacy is also highly dependent on the cultural background, and thus varies from society to society or even from one group to another group in a single society. The Korean society is currently in a transitional phase, in which the value of privacy differs between elderly and young people. Elderly people tend to have no issues with sharing genetic test results among family members, whereas younger people might consider that disclosing one's genetic test result represents an infringement upon one's privacy, even when sharing among family members.

The concept of the “right not to know” in genetic counseling has been heavily debated [9101112]. Hofmann [13] insisted that as long as the information is not accurate and/or actionable, ignorance is bliss. According to several studies performed around the world, approximately 80% of individuals at risk for Huntington's disease did not want to know their carrier status [14]. Even for medically actionable diseases, some individuals feel comfortable not knowing their risk status [15]. Moreover, it is not technically simple to secure the right not to know with WES or WGS data, or even with a multiple gene panel test, as this would require a tremendous amount of time and effort to help the P/C decide what he/she wants to know and what he/she does not want to know among the large amount of data generated.

True coercion involves some type of harm or the threat of harm; however, there are many other types of more subtle pressure tactics possible, including persuasion and manipulation [7]. For example, the P/C might be persuaded by his/her relatives to undergo a genetic test. In this case, the counselor can provide other options such as offering a genetic test to other relatives.

Counselors need to respect client confidentiality by not releasing any client data to a third party, including the P/C's relatives [7]. Ethical dilemmas can occur when the P/C does not want to share genetic test results with relatives or wants to share genetic test results with some but not all relatives. However, some researchers have pointed out that the doctor's duty of confidentiality is not absolute [16]. In some very special circumstances, confidentiality may be overruled for the public interest or to prevent injury or severe health damage to other individuals [16].

In the United States, there is no single overarching legal authority dictating the requirements or limitations of prenatal testing or the clinical practices that surround how healthcare professionals offer screening or explain or treat genetic disorders [17]. By contrast, in Korea, the Bioethics Law and the Mother and Child Health Law permit prenatal test and preimplantation genetic diagnosis (PGD) only for particular sets of diseases, for e.g., testing for Duchenne muscular dystrophy is permitted, while that for Wilson's disease is not. We suggest that different criteria should be applied to prenatal diagnosis and PGD owing to the possibility of eugenics. This is an important consideration in terms of genetic diversity, because it is not known which genomes were present prior to survival in a particular environment. According to Sparrow [18], one could assert that it is not fair to compromise on the welfare of individuals in order to maintain diversity. We believe that society should come together in solidarity to support and protect individuals with diseases.

Gene editing methods such as clustered regularly interspaced short palindromic repeats (CRISPR)/Cas9 are complicated techniques that could be applied toward the creation of so-called “designer babies” toward eliminating disease-causing gene variants from the population; thus, this possibility should be urgently discussed in depth. Other issues related to gene editing should also be discussed based on the concept of social solidarity.

Whenever possible, children and adolescents should provide assent for testing and treatment [19]. There is no precise age at which an adolescent's wishes should be considered to be equally important as those of the parents. This decision will vary on a cultural, familial, legal, and individual basis. Upon reflection, adolescents of varying ages at the time of genetic counseling felt that they had a greater sense of stability when they were 15 to 16 years of age compared to the transition between elementary school and high school at age 13, which was associated with significant social adjustment and fears of not being accepted [20].