Abstract This article reviews central developments on the intersections of genetics research, genetic counselling and bioethics that, in the 1970s and 1980s came together in the construction of the genetic decision maker through an “enhancement imaginary”. It argues that this image of genetic decision making, along with emerging socio-economic developmental traits in the West, will come under increasing pressure. This will generate the need for an up-scaled decision making complex, incorporating digital means and cognitive science in contexts increasingly outside of health care institutions. The handling of information, identity and decision making under changing and complex circumstances becomes central. Such developments raise concerns about, simultaneously, increasing surveillance, social inequality and exclusion, and emerging expert/lay relations. New attitudes, institutions and forms of knowledge are needed to meet emerging genomic futures in constructive ways.