A New Era in the Ethics of Human Embryonic Stem Cell Research

Therapeutic abortion and ectopic pregnancy: alternative sources for fetal stem cell research and therapy in Iran as an Islamic country

Regenerative medicine as a background of stem cell research and therapy has a long history. A wide variety of diseases including Parkinson's disease, heart diseases, multiple sclerosis, spinal cord injury, diabetes mellitus and etc. are candidate to be treated using different types of stem cells. There are several sources of stem cells such as bone marrow, umbilical cord, peripheral blood, germ cells and the embryo/fetus tissues. Fetal stem cells (FSCs) and embryonic stem cells (ESCs) have been described as the most potent stem cell source. Although their pluri- or multipotent properties leads to promising reports for their clinical applications, owning to some ethical and legal obstacles in different communities such as Muslim countries, care should be taken for therapeutic applications of FSCs and ESCs. Derivation of these cell types needs termination of pregnancy and embryo or fetus life that is prohibited according to almost all rules and teaches in Muslim communities. Abortion and termination of pregnancy under a normal condition for the procurement of stem cell materials is forbidden by nearly all the major world religions such as Islam. Legislated laws in the most of Muslim countries permit termination of pregnancy and abortion only when the life of the mother is severely threatened or when continuing pregnancy may lead to the birth of a mentally retarded, genetically or anatomically malformed child. Based on the rules and conditions in Islamic countries, finding an alternative and biologically normal source for embryonic or fetal stem cell isolation will be too difficult. On the one hand, Muslim scientists have the feasibility for finding of genetically and anatomically normal embryonic or fetal stem cell sources for research or therapy, but on the other hand they should adhere to the law and related regional and local rules in all parts of their investigation. The authors suggest that the utilization of ectopic pregnancy (EP) conceptus, extra-embryonic tissues, and therapeutic abortion materials as a valuable source of stem cells for research and medical purposes can overcome limitations associated with finding the appropriate stem cell source. Pregnancy termination because of the mentioned subjects is accepted by almost all Islamic laws because of maternal lifesaving. Also, there are no ethical or legal obstacles in the use of extra-embryonic or EP derived tissues which lead to candidate FSCs as a valuable source for stem cell researches and therapeutic applications.

Use of human stem cells in Huntington disease modeling and translational research

Huntington disease (HD) is a devastating neurological disorder caused by an extended CAG repeat in exon 1 of the gene that encodes the huntingtin (HTT) protein. HD pathology involves a loss of striatal medium spiny neurons (MSNs) and progressive neurodegeneration affects the striatum and other brain regions. Because HTT is involved in multiple cellular processes, the molecular mechanisms of HD pathogenesis should be investigated on multiple levels. On the cellular level, in vitro stem cell models, such as induced pluripotent stem cells (iPSCs) derived from HD patients and HD embryonic stem cells (ESCs), have yielded progress. Approaches to differentiate functional MSNs from ESCs, iPSCs, and neural stem/progenitor cells (NSCs/NPCs) have been established, enabling MSN differentiation to be studied and disease phenotypes to be recapitulated. Isolation of target stem cells and precursor cells may also provide a resource for grafting. In animal models, transplantation of striatal precursors differentiated in vitro to the striatum has been reported to improve disease phenotype. Initial clinical trials examining intrastriatal transplantation of fetal neural tissue suggest a more favorable clinical course in a subset of HD patients, though shortcomings persist. Here, we review recent advances in the development of cellular HD models and approaches aimed at cell regeneration with human stem cells. We also describe how genome editing tools could be used to correct the HTT mutation in patient-specific stem cells. Finally, we discuss the potential and the remaining challenges of stem cell-based approaches in HD research and therapy development.

Scientific Productivity on Research in Ethical Issues over the Past Half Century: A JoinPoint Regression Analysis

BACKGROUND

Ethics is one of the main pillars in the development of science. We performed a JoinPoint regression analysis to analyze the trends of ethical issue research over the past half century. The question is whether ethical issues are neglected despite their importance in modern research.

METHOD

PubMed electronic library was used to retrieve publications of all fields and ethical issues. JoinPoint regression analysis was used to identify the significant time trends of publications of all fields and ethical issues, as well as the proportion of publications on ethical issues to all fields over the past half century. Annual percent changes (APC) were computed with their 95% confidence intervals, and a p-value < 0.05 was considered statistically significant.

RESULTS

We found that publications of ethical issues increased during the period of 1965-1996 but slightly fell in recent years (from 1996 to 2013). When comparing the absolute number of ethics related articles (APEI) to all publications of all fields (APAF) on PubMed, the results showed that the proportion of APEI to APAF statistically increased during the periods of 1965-1974, 1974-1986, and 1986-1993, with APCs of 11.0, 2.1, and 8.8, respectively. However, the trend has gradually dropped since 1993 and shown a marked decrease from 2002 to 2013 with an annual percent change of -7.4%.

CONCLUSIONS

Scientific productivity in ethical issues research on over the past half century rapidly increased during the first 30-year period but has recently been in decline. Since ethics is an important aspect of scientific research, we suggest that greater attention is needed in order to emphasize the role of ethics in modern research.

Stem cell therapy for stress urinary incontinence: a systematic review in human subjects

PURPOSE

To systematically evaluate the current evidence on the safety and efficacy of stem cell therapy (SCT) in stress urinary incontinence (SUI) to allow objective comparison with existing surgical techniques.

METHODS

Systematic literature search of Medline from years 1946-2012 using terms: "stem", "cell", "stress", "urinary", and "incontinence". Included studies presented empirical data on the treatment of SUI using SCT.

OUTCOMES

adverse events, incontinence, quality of life, urodynamic, transurethral ultrasound and urethral EMG findings.

RESULTS

Eight studies met inclusion criteria (seven observational and one randomized). Quality score: median 10.75 of 20 (range 2-12.5). Adverse events: one patient had bladder perforation and two procedures could not be completed due to pain. Temporary urinary retention and cystitis were also reported. Incontinence score: Four studies describe significant improvement. Quality of life: significant improvement in four studies. Urodynamic outcomes: four studies show significant improvement in contractility of urethral sphincter; three studies demonstrate no change in bladder capacity and significant reduction in residual volume; significant improvement in urinary flow three studies, although two found no difference; increase in leak point pressure and detrusor pressure in three studies. Urethral ultrasound: three studies found significant increases in rhabdosphincter thickness and contractility. Urethral EMG: two studies found significant increases in the EMG at rest and at contraction.

CONCLUSION

Data suggest that SC treatment for SUI is safe and effective in the short term. However, the quality and maturity of the data are limited. Robust data from better quality studies comparing this to current surgical techniques are needed.

Quo Vadis medycyno regeneracyjna?: Quo Vadis Regenerative Medicine?

There are presented the most important sources of pluripotent stem cells for potential application in the regenerative medicine. This review summarizes also advantages and disadvantages for potential application of these cells in clinical medicine.

Derivation of novel genetically diverse human embryonic stem cell lines

Human embryonic stem cells (hESCs) have the potential to revolutionize many biomedical fields ranging from basic research to disease modeling, regenerative medicine, drug discovery, and toxicity testing. A multitude of hESC lines have been derived worldwide since the first 5 lines by Thomson et al. 13 years ago, but many of these are poorly characterized, unavailable, or do not represent desired traits, thus making them unsuitable for application purposes. In order to provide the scientific community with better options, we have derived 12 new hESC lines at New York University from discarded genetically normal and abnormal embryos using the latest techniques. We examined the genetic status of the NYUES lines in detail as well as their molecular and cellular features and DNA fingerprinting profile. Furthermore, we differentiated our hESCs into the tissues most affected by a specific condition or into clinically desired cell types. To our knowledge, a number of characteristics of our hESCs have not been previously reported, for example, mutation for alpha thalassemia X-linked mental retardation syndrome, linkage to conditions with a genetic component such as asthma or poor sperm morphology, and novel combinations of ethnic backgrounds. Importantly, all of our undifferentiated euploid female lines tested to date did not show X chromosome inactivation, believed to result in superior potency. We continue to derive new hESC lines and add them to the NIH registry and other registries. This should facilitate the use of our hESCs and lead to advancements for patient-benefitting applications.

Target populations for first-in-human embryonic stem cell research in spinal cord injury

Geron recently announced that it had begun enrolling patients in the world's first-in-human clinical trial involving cells derived from human embryonic stem cells (hESCs). This trial raises important questions regarding the future of hESC-based therapies, especially in spinal cord injury (SCI) patients. We address some safety and efficacy concerns with this research, as well as the ethics of fair subject selection. We consider other populations that might be better for this research: chronic complete SCI patients for a safety trial, subacute incomplete SCI patients for an efficacy trial, and perhaps primary progressive multiple sclerosis (MS) patients for a combined safety and efficacy trial.

Development of cellular therapy for the treatment of stress urinary incontinence

Stress urinary incontinence (SUI) is highly prevalent and associated with a reduced quality of life. An intact rhabdosphincter at the mid-urethra is mandatory to maintain urinary continence. Adult stem cell injection therapy for the regenerative repair of an impaired sphincter is currently at the forefront of incontinence research. The implanted cells will fuse with muscle and release trophic factors promoting nerve and muscle integration. Hereby, we review the use of mesenchymal stem cell therapy for SUI and the experience with the development of muscle-derived stem cells.

Research ethics. Beyond access vs. protection in trials of innovative therapies

Review of first-in-human trials should aim to safeguard the integrity of the scientific enterprise through a focus on pre-clinical and clinical study quality.

Toward a better bioethics: commentary on "Forbidding science: some beginning reflections"

It has been argued that bioethicists too often tend to represent the interests of scientists and not of the broader polity. Indeed, bioethicists seem predisposed to discard the voices and viewpoints of all but the cognoscenti. Focusing particularly on human pluripotent stem cell research, this commentary explores a variety of characterizations of bioethics and bioethicists in relation to forbidding science. Rather than proselytizing or prohibiting, bioethicists should work in partnership with scientists and publics to craft scientifically well-informed and morally sophisticated debates about forbidding science.

Ethical issues in stem cell research

Stem cell research offers great promise for understanding basic mechanisms of human development and differentiation, as well as the hope for new treatments for diseases such as diabetes, spinal cord injury, Parkinson's disease, and myocardial infarction. However, human stem cell (hSC) research also raises sharp ethical and political controversies. The derivation of pluripotent stem cell lines from oocytes and embryos is fraught with disputes about the onset of human personhood. The reprogramming of somatic cells to produce induced pluripotent stem cells avoids the ethical problems specific to embryonic stem cell research. In any hSC research, however, difficult dilemmas arise regarding sensitive downstream research, consent to donate materials for hSC research, early clinical trials of hSC therapies, and oversight of hSC research. These ethical and policy issues need to be discussed along with scientific challenges to ensure that stem cell research is carried out in an ethically appropriate manner. This article provides a critical analysis of these issues and how they are addressed in current policies.

Clinical trials in stem cell transplantation: guidelines for scientific and ethical review

BACKGROUND

Transplantation of cells derived through the manipulation of pluripotent stem cells may involve great uncertainty and the possibility of serious risks.

PURPOSE

To develop guidelines for the ethical conduct of clinical trials using such stem cells.

METHODS

Review of literature on clinical trials ethics and clinical applications of stem cells; critical deliberation on potential guidelines.

RESULTS

Such transplantation should be allowed in clinical practice only after clinical trials demonstrate efficacy and safety. These clinical trials should follow ethical principles that guide all clinical research. Additional requirements to strengthen trial design, coordinate scientific and ethics review, verify that participants understand key features of the trial, and ensure publication of findings are also warranted because of the highly innovative nature of the intervention, limited experience in humans, and the high hopes of patients who have no alternative effective treatments.

LIMITATIONS

These recommendations will need to be modified in light of actual experience with stem cell clinical trials.

CONCLUSIONS

These recommendations will help guarantee that the efficacy and safety of innovative stem cell interventions will be rigorously established, while also protecting study participants.

[Yes to research, no to utilization? Medical, pharmacological and toxicological utilization of human embryonic stem cells from an ethical point of view]

In exceptional cases, the German Stem Cell Act allows research on human embryonic stem cells. However, it does not allow the implementation of the research results if this in turn requires the use of further embryonic stem cell lines. It has, in the meantime, transpired that such research results could be of concrete use. Thus, in the distant future, it could be used in the clinical treatment of patients. Already in the nearer future the use of human embryonic stem cell lines can be envisaged for both the development and testing of medicines as well as in the field of toxicology. To this end, research concerning embryo toxicity and neurotoxicity is ground-breaking. The toxicological and pharmacological use of human embryonic stem cell lines should serve the protection of human health as well as the safe and reliable use of medicines. In addition, animal experiments could be reduced, which is desirable from a point of view of animal protection ethics. Since research on human embryonic stem cell lines is actually permitted in Germany, the use of the respective research results should be allowed all the more. This follows from the basic human right to health protection and health care. Legal ambiguities, which still exist in this respect, should be removed.

Stem cells: new frontiers of ethics, law, and policy

✓ After the successful isolation of human embryonic stem cells in 1998, ethics and policy debates centered on the moral status of the embryo—whether the 2- to 4-day-old blastocyst is a person, and whether we should protect it at all costs. As the research has moved quickly forward, however, new questions have emerged for the study of stem cell ethics, law, and policy. Powerful new lines made without eggs or embryos have recently been reported, the intellectual property and regulatory environment is uncertain, and clinical trials using adult stem cells and cells derived from embryonic stem cells are about to commence. The new landscape of ethics, law, and policy is discussed in the context of these developments, with an emphasis on the evaluation of risks and benefits for first-in-human clinical studies.

Banking on it: public policy and the ethics of stem cell research and development

If the therapeutic potential of stem cell-based therapies is ever realized, demand for stem cells and derivative tissues will be tremendous and will create new challenges for health care systems, especially publicly funded health care systems. We propose a framework for the ethical analysis of stem cell research and development that considers the welfare of communities, tissue recipients, and cell sources in relation to a range of stem cell production and distribution options. Ethical desiderata include: equitable access, maximized potential therapeutic benefit across demographic and disease groups, and reasonable cost. Other ethical priorities include the minimization of stem cell line and tissue wastage, risk of immune rejection, risk of transmitting diseases, the use of human embryos, and risk to those contributing source cells. We array plausible sources of stem cells and distribution strategies to characterize 12 potential models for producing and distributing cells and tissues in the future. We describe "personalized", "matched", and "universalized" models, and compare the ethical acceptability of these models. Popular and scientific discourses about stem cells typically emphasize personalized or matched stem cell distribution models. We show that universalized models may ultimately best serve the interest of taxpayers, communities and patients who hold high stakes in the therapeutic success of stem cell science. They are therefore highly worthy of scientific pursuit. This conclusion is provisional and the framework must be reapplied as scientific knowledge, technological capacity and ethical mores evolve.

Human embryonic stem cells: A journey beyond cell replacement therapies

Success in the derivation of human embryonic stem cell (hESC) lines has opened up a new area of research in biomedicine. Human ESC not only raise hope for cell replacement therapies but also provide a potential novel system to better understand early human normal development, model human abnormal development and disease, and perform drug-screening and toxicity studies. The realization of these potentials, however, depends on expanding our knowledge about the cellular and molecular mechanisms that regulate self-renewal and lineage specification. Here, we briefly highlight the potential applications of hESC and review how flow cytometry has contributed to the initial characterization of both undifferentiated hESC cultures and hematopoietic development arising from hESC. We envision that a combination of state-of-the-art technologies, including cytomics, proteomics and genomics, will be instrumental in moving the field forward, ultimately lending invaluable knowledge to research areas such as human embryology, oncology and immunology.

Establishing procedures for institutional oversight of stem cell research

Academic health centers (AHCs), which are at the forefront of stem cell research, need to establish institutional stem cell research oversight committees (SCROs) to comply with 2005 National Academy of Sciences (NAS) recommendations and to establish public trust in this sensitive research. Institutional review boards (IRBs) typically lack the expertise and time to adequately review the specific ethical issues raised by stem cell research. To assure careful, timely, and coordinated review of the science and ethics of stem cell protocols, AHCs need to address many practical procedural issues, such as SCRO membership, quorum, conflicts of interest, and procedures for protocol review. The SCRO committee at the University of California San Francisco (UCSF), established in 2003, has developed detailed policies and procedures on these issues. The UCSF SCRO has broad scientific expertise and uses ad hoc reviewers to strengthen the review process. Studies receiving full SCRO review have three lead reviewers: a scientist, a reviewer with ethics expertise, and a public representative. Studies introducing human stem cells into nonhuman blastocysts receive full review, even if the stem cells are anonymized. Some protocols are eligible for expedited review. The SCRO neither replaces nor duplicates review by the IRB and institutional animal care and use committees. Other AHCs can draw on the UCSF experience when developing their own policies and procedures for stem cell research oversight.

Governing stem cell research in California and the USA: towards a social infrastructure

Owing to the restrictive human embryonic stem cell (hESC) policies of the US government, the question of whether to pursue human embryonic stem cell experiments has dominated the ethical and political discourse concerning such research. Explicit attention must now turn to problems of implementing the research on a large scale: in the 2004 US elections, California voters approved a state initiative for stem cell research, earmarking $3 billion in direct spending over 10 years. This article explores three ethical and political problem areas emerging out of the California program, the resolution of which will help set the trajectory of hESC research in the US and abroad, and then proposes an institutional approach to help address them: a network of public stem cell banks in the US that feature transparent and shared governance.

Moving human embryonic stem cells from legislature to lab: remaining legal and ethical questions

Greely discusses unanswered ethical and legal issues, such as those surrounding the creation of embryos, derivation of cell lines, uses of cell lines, and questions of intellectual property.

Nanomedicine: techniques, potentials, and ethical implications

Nanotechnology is concerned with materials and systems whose structures and components exhibit novel physical, chemical, and biological properties due to their nanoscale size. This paper focuses on what is known as nanomedicine, referring to the application of nanotechnology to medicine. We consider the use and potentials of emerging nanoscience techniques in medicine such as nanosurgery, tissue engineering, and targeted drug delivery, and we discuss the ethical questions that these techniques raise. The ethical considerations involved in nanomedicine are related to risk assessment in general, somatic-cell versus germline-cell therapy, the enhancement of human capabilities, research into human embryonic stem cells and the toxicity, uncontrolled function and self-assembly of nanoparticles. The ethical considerations associated with the application of nanotechnology to medicine have not been greatly discussed. This paper aims to balance clear ethical discussion and sound science and so provide nanotechnologists and biotechnologists with tools to assess ethical problems in nanomedicine.