Germ-line gene therapy: a new stage of debate

Modular Ontologies for Genetically Modified People and their Bioethical Implications

Participants in the long-running bioethical debate over human germline genetic modification (HGGM) tend to imagine future people abstractly and on the basis of conventionalized characteristics familiar from science fiction, such as intelligence, disease resistance and height. In order to distinguish these from scientifically meaningful terms like "phenotype" and "trait," this article proposes the term "persemes" to describe the units of difference for hypothetical people. In the HGGM debate, persemes are frequently conceptualized as similar, modular entities, like building blocks to be assembled into genetically modified people. They are discussed as though they each would be chosen individually without affecting other persemes and as though they existed as components within future people rather than being imposed through social context. This modular conceptual framework appears to influence bioethical approaches to HGGM by reinforcing the idea of human capacities as natural primary goods subject to distributive justice and supporting the use of objective list theories of well-being. As a result, assumptions of modularity may limit the ability of stakeholders with other perspectives to present them in the HGGM debate. This article examines the historical trends behind the modular framework for genetically modified people, its likely psychological basis, and its philosophical ramifications.

Novel Gene Therapy Approaches for Targeting Neurodegenerative Disorders: Focusing on Delivering Neurotrophic Genes

Neurodegenerative illnesses (NDDs) like Alzheimer's, Parkinson's, amyotrophic lateral sclerosis, spinal muscular atrophy, and Huntington's disease have demonstrated considerable potential for gene therapy as a viable therapeutic intervention. NDDs are marked by the decline of neurons, resulting in changes in both behavior and pathology within the body. Strikingly, only symptomatic management is available without a cure for the NDDs. There is an unmet need for a permanent therapeutic approach. Many studies have been going on to target the newer therapeutic molecular targets for NDDs including gene-based therapy. Gene therapy has the potential to provide therapeutic benefits to a large number of patients with NDDs by offering mechanisms including neuroprotection, neuro-restoration, and rectification of pathogenic pathways. Gene therapy is a medical approach that aims to modify the biological characteristics of living cells by controlling the expression of specific genes in certain neurological disorders. Despite being the most complex and well-protected organ in the human body, there is clinical evidence to show that it is possible to specifically target the central nervous system (CNS). This provides hope for the prospective application of gene therapy in treating NDDs in the future. There are several advanced techniques available for using viral or non-viral vectors to deliver the therapeutic gene to the afflicted region. Neurotrophic factors (NTF) in the brain are crucial for the development, differentiation, and survival of neurons in the CNS, making them important in the context of various neurological illnesses. Gene delivery of NTF has the potential to be used as a therapeutic approach for the treatment of neurological problems in the brain. This review primarily focuses on the methodologies employed for delivering the genes of different NTFs to treat neurological disorders. These techniques are currently being explored as a viable therapeutic approach for neurodegenerative diseases. The article exclusively addresses gene delivery approaches and does not cover additional therapy strategies for NDDs. Gene therapy offers a promising alternative treatment for NDDs by stimulating neuronal growth instead of solely relying on symptom relief from drugs and their associated adverse effects. It can serve as a long-lasting and advantageous treatment choice for the management of NDDs. The likelihood of developing NDDs increases with age as a result of neuronal degradation in the brain. Gene therapy is an optimal approach for promoting neuronal growth through the introduction of nerve growth factor genes.

Addressing Conflicts of Interest and Conflicts of Commitment in Public Advocacy and Policy Making on CRISPR/Cas-Based Human Genome Editing

Leading experts on CRISPR/Cas-based genome editing-such as 2020 Nobel laureates Jennifer Doudna and Emmanuelle Charpentier-are not only renowned specialists in their fields, but also public advocates for upcoming regulatory frameworks on CRISPR/Cas. These frameworks will affect large portions of biomedical research on human genome editing. In advocating for particular ways of handling the risks and prospects of this technology, high-profile scientists not only serve as scientific experts, but also as moral advisers. The majority of them currently intend to bring about a "responsible pathway" toward human genome interventions in clinical therapy. Engaging in advocacy for such a pathway, they issue moral judgments on the risks and benefits of this new technology. They declare that there actually is a responsible pathway, they draft resolutions on temporary moratoria, they make judgments on which groups and individuals are credible and should participate in public and semi-public debates, so they also set the standards for deciding who counts as well-informed, as well as the standards of evidence for adopting or rejecting research policies. This degree of influence on public debates and policy making is, at the very least, noteworthy. This contribution sounds a note of caution with regard to the endeavor of a responsible pathway to human genome editing and in particular scrutinizes the legitimacy of expert-driven research policies given commercial conflicts of interest and conflicts of commitment among first-rank scholars.

Setting ethical limits on human gene editing after the fall of the somatic/germline barrier

The ethical debate about what is now called human gene editing (HGE) has gone on for more than 50 y. For nearly that entire time, there has been consensus that a moral divide exists between somatic and germline HGE. Conceptualizing this divide as a barrier on a slippery slope, in this paper, I first describe the slope, what makes it slippery, and describe strong barriers that arrest the slippage down to the dystopian bottom of pervasive eugenic enhancement. I then show how the somatic/germline barrier in the debate has been weakened to the level of ineffectiveness, with no replacement below. I examine a number of possible barriers on the slope below the somatic/germline barrier, most of which lack sufficient strength. With the exception of the minority of people in the HGE debate who see the eugenic society as utopia, the majority will need a barrier on the slope to stop the slide to dystopia.

No end to caring?

In a recent issue of Politics and the Life Sciences Mark Walker presented a compelling proposition for reducing evil in the world via an interdisciplinary program he calls the "Genetic Virtue Project" (GVP). As Walker explains, the purpose of the GVP is "to discover and enhance human ethics using biotechnology genetic correlates of virtuous behavior." PLS subsequently published several critiques of this proposal. While most of these critiques focused on conventional doubts about the technical feasibility or the ethics of such interventions, the more fundamental concern revealed by both Walker's proposal and its critiques is in the largely unquestioned assumption that more morality is necessarily better. Human history is marked by a gradual if uneven extension of moral concern to increasingly distant others, which many take as evidence of the rationality of morality. There is substantial evidence, though, that this expansion is fundamentally biological in origin and therefore not ultimately limited by rationality. Because these expanding moral feelings feel so good to us, we are incapable of perceiving the danger from their ever-expanding focus, in particular from the sincere but increasingly maladaptive collective policies they will engender. Utilizing the philosophy of Friedrich Nietzsche as a platform, the feasibility of different natural and cultural responses to this impending crisis of caring are examined, none of which are found capable of counteracting this expanding morality. Instead, the best hope for a successful response to this dangerous expansion of caring is actually a sort of reverse GVP, in which the biological mechanisms for this unchecked moral expansion are manipulated via genetic engineering to dial back this expansion. However, the likelihood of actually implementing such an admittedly counterintuitive and controversial program within an increasingly democratized world is doubtful. Ultimately, if we are unable to overcome this betrayal by our best intentions, where does that leave us as a species?

The ethics of germ line gene manipulation--a five dimensional debate

Contributors to the debate surrounding the ethics of germ line gene manipulation have by and large concentrated their efforts on discussions of the potential risks that are associated with the use of this technology. Many international advisory committees have ruled out the acceptability of germ line gene manipulation at least for the time being. The purpose of this work is to generate much needed discussion on the many other ethical issues concerning the implementation of not only germ line gene manipulation but also other related biotechnologies. In this paper I systematically investigate and analyse the most salient issues put forward by proponents and opponents alike. I argue that if germ line manipulation proves to be a safe and effective procedure, then the principle of beneficence imposes on the medical profession a moral duty to pursue the technology.

Human germline gene therapy reconsidered

This paper reevaluates the notion of human germline gene therapy (HGLGT) in light of developments in biomedicine, biotechnology, and ethical and policy analysis. The essay makes the following key points. First, because the distinction among "therapy," "prevention," and "enhancement" is not clear in human genetics, "gene therapy" is an inadequate descriptor of the process and goals of germline genetic alterations. The alternate use of the phrase "human germline genome modification" (HGLGM) could avoid a misleading label. Second, procedures that could be construed as genetic "enhancement" may not be as morally problematic as some have supposed, once one understands that the boundaries between therapy, prevention, and enhancement are not obvious in genetic medicine. Third, HGLGM might be the medically and morally most appropriate way of avoiding the birth of a child with a genetic disease in only a small range of cases. Fourth, there are still many ethical and scientific problems relating to the safety and efficacy of HGLGM.

The application of genetic knowledge: ethical and policy implications

This article explores societal ethical concerns about the application of the rapidly developing knowledge in the field of genetics. The article calls for nurses to reflect on these ethical concerns not only in the care of patients but also in professional and societal discussion, so that sound ethical and societally acceptable public policy can be adopted. A brief summary introduces the concepts of ethics and policy. The text than offers discussion of genetic testing for adults and children, testing in relation to behavioral attributes, and genetics and reproduction. Hypothetical cases using fictional names are used to illustrate each section. Recommendations for nurse action are cited. Finally, the article poses questions that require public awareness and discussion.

Genetic engineering: moral aspects and control of practice

Present-day scientific advances have made it possible to use somatic cell gene therapy for the treatment of serious human genetic disease. Gene therapy is enormously important for curing some diseases, otherwise untreatable. The technical ability to perform germline gene alteration is also under way. Society must determine its attitude toward germline alteration and toward intervention for the purpose of genetic enhancement. Eugenic genetics is purely theoretical at present and is likely to remain so for a long time. Articles in the press, sometimes influenced by specific pressure groups, generate public fear that is in most cases unfounded, due to the lack of feasibility of performing the claims voiced in them. Still, society must be concerned about the possibility that gene therapy will be misused in the future. Gene therapy should only be used in ways that maintain human dignity. The best insurance against misuse is a public well informed and not unnecessarily frightened. With proper safeguards imposed by society, gene therapy can be ethically used.

Human fetal gene therapy: moral and ethical questions

This two-part paper discusses moral and ethical questions raised by future trials of human fetal gene therapy. The first part examines broad moral issues to explore whether fetal gene therapy is a morally praiseworthy goal. Ought it be done at all? These issues include (i) how the concept of fetal gene therapy originally arose as a goal envisioned at the beginning of prenatal diagnosis, (ii) preimplantation genetic diagnosis as a better preconceptual alternative for parents at higher genetic risk, (iii) alternatives to genetic abortions, (iv) the social and economic priority of fetal gene therapy, and (v) whether fetal gene therapy is a "slippery slope" that will end in germ-line gene therapy. This part concludes that far more reasons exist to commend fetal gene therapy than to reject it, given its limits and modest social and economic priority. The second part responds to specific ethical questions that must be raised about any protocol for human gene therapy. These questions and issues are adapted to the prenatal situation: (i) how the previable fetus becomes a "patient," (ii) concern for clinical benefit and minimizing risks to the fetus and pregnant woman, (iii) concern for the voluntary and informed participation of the pregnant woman, the father, and for protection of their privacy, (iv) concern for fair selection of subjects, (v) considerations of harm to germ line cells, and (vi) the role of public oversight of fetal gene therapy. The article concludes by recommending a continuation of the consolidated Recombinant Advisory Committee (RAC) for the near future.

"Prevention" and the goals of genetic medicine

Authors participating in the renewed discussion of germ-line gene therapy have begun conflating two senses of the term "prevention," which I distinguish as "phenotypic prevention" and "genotypic prevention." Phenotypic prevention describes medical efforts to forestall the clinical manifestation of a genetic disease in an at-risk patient, like newborn screening and dietary prophylaxis for phenylketonuria. Genotypic prevention, by contrast, describes efforts to avoid the transmission of particular genotypes to the next generation, like selective termination following intrauterine diagnosis. Genotypic prevention is either performed on behalf of a prospective parent (or two) as a reproductive risk reduction strategy, or as a public health intervention to reduce the incidence of a disease in the larger population. Conflating phenotypic and genotypic prevention in discussions of germ-line gene therapy is dangerous, because it blurs the line (well-established in clinical genetics) between medical interventions appropriate to prescribe to individuals and families, and reproductive choices that should be theirs alone to make. As the new genetic medicine emerges, its pioneers should be careful to articulate their professional goals in ways that respect that important moral boundary, by explicitly excluding genotypic prevention from among them.

International perceptions and approval of gene therapy

Gene therapy is in clinical trials in a number of countries, raising the question of whether different ethical standards can be justified in different countries. One key issue is how divergent are the perceptions and bioethical reasoning of peoples around the world. An International Bioethics Survey with 150 questions, including 35 open ones, was developed to look at how people think about diseases, life, nature, and selected issues of science and technology, biotechnology, genetic engineering, genetic screening, and gene therapy. The mail response survey was conducted in 1993 among the public in Australia, India, Israel, Japan, New Zealand, Russia, and Thailand, and the same written survey was conducted among university students in Australia, Hong Kong, India, Japan, New Zealand, The Philippines, Russia, Singapore, and Thailand. Similar questions were included in an international high school education bioethics survey among high school teachers in Australia, Japan, and New Zealand. Further international comparisons to the United States and Europe are made. About three-quarters of all samples supported personal use of gene therapy, with higher support for children's use of gene therapy. The diversity of views was generally similar within each country. The major reasons given were to save life and increase the quality of life. About 5-7% rejected gene therapy, considering it to be playing God, or unnatural. There was very little concern about eugenics (0.5-2%), and more respondents gave supportive reasons like "improving genes," especially in Thailand and India. Support for specific applications was significantly less for "improving physical characters," "improving intelligence," or "making people more ethical" than for curing diseases like cancer or diabetes, but there was little difference between inheritable or noninheritable gene therapy.

Gene-modified cells for the treatment of cancer

Gene therapy involves the insertion of a gene into an organism to treat a disease. Since its early development in the 1970s, gene therapy has expanded rapidly both in terms of the methods available and the number of candidate diseases for treatment. This report reviews gene therapy for cancer, including methodology, pre-clinical studies and experimental clinical trials.

Should we hold the (germ) line?

In 1982, the President's Commission produced its report on human gene therapy. One of that report's recommendations was to expand the Recombinant DNA Advisory Committee (RAC) to the National Institutes of Health to include a subcommittee on human gene therapy. In 1984, the Human Gene Therapy Subcommittee was established, and in 1989 it produced a document—“Points to Consider for Protocols for the Transfer of Recombinant DNA into Human Subjects”—that stated the RAC's position on what sorts of protocols it would approve.

In assessing the impact of the President's Commission report, Alexander Capron wrote,

Preimplantation genetics: a case for prospective action

Preimplantation genetics describes a newly-emerging field in medical genetics, the consequence of the implementation of clinical preimplantation diagnosis and the likely future development of germ-line gene therapy. Given the existing clinical and laboratory difficulties already demonstrated in preimplantation diagnosis and the sensitive ethical issues surrounding genetic manipulation of human embryos, there is a need for 1) critical and objective evaluation of developments in this field by human and medical geneticists and 2) development of guidelines for research and clinical practice in the years ahead. We propose a course of prospective action for preimplantation genetics implemented through the newly-formed American College of Medical Genetics in order to address the ethics, safety, accuracy, cost, and overall merit of preimplantation genetics.

National and international approaches to human germ-line gene therapy

Germ-line gene therapy, in which genetic flaws are corrected in the DNA of externally fertilized human embryos, lies in the distant yet foreseeable future. Worries about germ-line therapy have prompted international bodies to craft guidelines that are unusual for their anticipatory nature. Motivating these guidelines is the idea that a “transnational harmonization” of principles should be reached before national policies are developed. This article reviews selected national policies and international recommendations, and it concludes that national policies should be precedents for, rather than descendants of, international normative codes. The inclination to develop morally-based codes, which is implicit in transnational harmonization, will be more useful if grounded in empirically-based medical technologies and politically-tested policies rather than on abstract principles developed well in advance of technological feasibility.

Germ-line gene modification and disease prevention: some medical and ethical perspectives

There has been considerable debate about the ethics of human germ-line gene modification. As a result of recent advances in the micromanipulation of embryos and the laboratory development of transgenic mice, a lively discussion has begun concerning both the technical feasibility and the ethical acceptability of human germ-line modification for the prevention of serious disease. This article summarizes some of the recent research on germ-line gene modification in animal models. Certain monogenic deficiency diseases that ultimately might be candidates for correction by germ-line intervention are identified. Several of the most frequently considered ethical issues relative to human germ-line gene modification are considered in the context of professional ethics, parental responsibility, and public policy. Finally, it is suggested that there is merit in continuing the discussion about human germ-line intervention, so that this technique can be carefully compared with alternative strategies for preventing genetic disease.

Human gene therapy: a biopolitical overview and analysis

The benefits, risks, and social consequences arising from human gene therapy have received substantial citation in the literatures of medical, biological, ethical, and legal commentary. I argue that the question of what "public policy garb" best fits the parameters of human gene therapy in the United States and around the world is a quintessential political question, best understood under the microscope of political science analytic inquiry. I describe the nature of that inquiry, apply its insights to the various ends and means of human gene therapy, and posit empirical models of "political success" for the salient purposes of the craft. I focus particularly on the tract record of the National Institutes of Health's Recombinant DNA Advisory Committee (RAC) in orchestrating the process by which human gene therapy protocols achieve official sanction.