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Incurious about Ethics?

Posted by Marcy Darnovsky on April 9th, 2015

An Institute of Medicine committee is in the midst of a 19-month study, undertaken at the FDA’s request, of the “ethical and social policy considerations” of germline-modifying techniques that cobble together gametes or embryos produced with eggs from two women. The committee held its first public meeting on March 31 and April 1, in the wake of statements of concern about human germline gene editing by several groups of prominent scientists.

Presumably because of the Center for Genetics and Society’s longstanding interest in the techniques and their serious implications, I was invited to speak on a panel about human germline modification. The materials I received in preparation for the meeting included questions about the social and ethical implications of modifying genes that are inherited by future generations, and about the historical context of the prohibitions against human germline modification that have been put in place by several international human rights treaties and dozens of countries (though not the US).

Another question was whether it would be “advisable” to draw policy lines between therapeutic and enhancement applications of genetic modification techniques, the implication being that this might be preferable to the current widespread agreement  that encourages gene transfer to treat sick people, but puts off limits changes that would be passed on to children and subsequent generations. Several invited speakers addressed these questions from a cautionary perspective; see, for examples, here and here.

Unfortunately, most of the IOM committee members seemed remarkably incurious about these points. Few follow-up questions were asked about the societal implications of human germline modification, or about the social values and concerns that have prompted more than 40 countries to adopt laws against it. Committee members didn’t inquire, let alone probe, about the effects of violating this prevailing policy agreement, or about the commercial and social dynamics that might come into play if human germline modification were to be introduced into fertility clinics.

There was, however, a framework of value-laden assumptions that seemed to guide many committee members. In this framework, ethical considerations center on relationships between physicians and their patients, and between researchers and their human subjects (in this case, with parents acting as proxies for their future children). Thus the overwhelming majority of committee members’ comments and questions about ethics involved matters of informed consent, acceptable risk, and whether it was permissible for parents to be required or encouraged to permit medical follow-up of any children produced as a result of germline mitochondrial manipulation.

In short, “ethical considerations” were largely equated with “research ethics,” a critically important but ultimately narrow set of guidelines that is indifferent – and sometimes hostile – to broader social concerns. Within this research ethics framework, the plans and prerogatives of scientists are subject to limits only when there is clear evidence that they are likely to directly harm individuals.

Also central to many committee members’ thinking are those parental desires for genetically related children. For some, such desires trump even the fact that trying to fulfill them would put any resulting children at significant risk. From this perspective, the risks to a child born as a result of mitochondrial manipulation should be weighed against the burden of mitochondrial disease. Of course, this logic assumes both that people at risk of passing on mitochondrial disease have no alternatives, and that the desire for a child who is not just healthy but full genetically related is paramount.

In fact, there is a much less risky way for the overwhelming majority of women with mutated mitochondria to have healthy and genetically related children. But this was also curiously under-explored. Some speakers simply ignored the availability of pre-implantation genetic diagnosis (PGD), an embryo-screening technique that can identify “healthy” embryos for almost all affected women. Another speaker, a proponent of moving ahead with mitochondrial manipulations, went into some detail about the successful use of PGD in Europe for preventing the transmission of mitochondrial disease. But his remarks failed to prompt any reconsideration of the need for germline mitochondrial techniques.

One of the final invited speakers, University of Texas bioethicist John Robertson, is known for his theory of “procreative liberty,” which elevates the desire of some parents for a genetically related child to a right that should be constitutionally protected. Although risks to women and offspring can be taken into account, Robertson argued, any other concerns are “airy” and “moralistic.”

The FDA commissioned the IOM study because its own focus is supposed to be safety and efficacy, and because it recognized the salience and critical importance of broader concerns about mitochondrial manipulation techniques after they came up repeatedly at its February 2014 Advisory Committee meeting. Taken as a whole, the day-and-a-half conversation at the recent IOM meeting leaves a lot of room for a more thorough exploration of the “ethical and social policy considerations” of these germline-modifying techniques. The IOM committee plans another three meetings before it develops its report to the FDA. So there’s still time, if there’s interest and willingness.

Previously on Biopolitical Times:

Hype, Money and Stem Cells

Posted by Pete Shanks on April 9th, 2015

Michael Hiltzik of the Los Angeles Times used newly published research by Kalina Kamenova and Timothy Caulfield [abstract] to write a scathing article largely focused on the California Institute for Regenerative Medicine (CIRM):

New study: Stem cell field is infected with hype

This conclusion is scarcely novel, but both the academic analysis and the polemical journalistic commentary are welcome. The researchers examined "the portrayal of translational stem cell research in major daily newspapers in Canada, the United States, and the United Kingdom between 2010 and 2013" and found that optimistic perspectives outnumbered pessimistic ones by more than five to one, with less than a third of the reports being neutral.

Kamenova and Caulfield conclude by essentially pinning the responsibility on scientists for "authoritative statements … regarding unrealistic timelines." Hiltzik, on the other hand, "wouldn't give journalists this much of a pass," noting their complicity in exaggerating promises of breakthroughs and cures.

In fact, there is plenty of criticism to spread around.

There are also long-term effects of stem-cell hype. Many people are still predisposed to believe hucksters — and why wouldn't they be? Weren't we promised cures a decade ago?

Blog comments reveal that some people now think that the pharmaceutical multinationals are in cahoots with the FDA to prevent treatments from becoming available. (The discussion at this post, in which Paul Knoepfler explains the need for regulation, is one of the better threads.) It is therefore hardly surprising that desperate patients are willing to travel to Mexico, or the Philippines, or the Bahamas, or elsewhere, and to spend thousands of dollars on what are almost certainly placebos at best.

The stem cell hucksters and frauds have become so blatant and widespread that a number of prominent figures and organizations in the field have begun working hard to counter them. This is a welcome development. But the researchers, biotech entrepreneurs, patient advocates and others who puffed the possibilities of stem cells, perhaps most egregiously in the Prop. 71 campaign that led to CIRM, never seem to admit responsibility for the fantasies they did so much to promote.

What may draw their attention is that increased funding for CIRM, as David Jensen notes, is looking unlikely:

The agency has undoubtedly made a major contribution to stem cell science. But the unfulfilled promises of the campaign hype gave its foes the kind of tools they need to battle any efforts to provide more state funding for the agency.

Meanwhile, governments around the world are also beginning to wrestle with the details of regulating stem cell clinics. It's about time.

Previously on Biopolitical Times:

A Tipping Point on Human Germline Modification?

Posted by Jessica Cussins on March 19th, 2015

Untitled Document

In a March 5 expose in MIT Technology Review titled "Engineering the Perfect Baby," Antonio Regalado reported on just how close some scientists are to using the precision gene editing technique CRISPR to modify nuclear DNA within human gametes or embryos. A week later, an article in Nature alluded to rumors that this has already been done, and that papers reporting on it will be published shortly.

This startling news has prompted statements about human germline modification from three different groups of scientists so far: one published in Nature, one in Science, and one released by the International Society for Stem Cell Research. All discourage clinical applications and call for public dialogue and debate to acknowledge the profound societal, policy, ethical and safety implications raised by efforts to control the genes we pass on to future generations – a welcome sign from within the scientific community. But the statements offer a range of different paths forward.

A Center for Genetics and Society press statement released this morning supports the call for a moratorium on human germline gene editing. CGS opposes efforts to create genetically altered human beings, and has long advocated that the United States join the 40+ other countries that already prohibit this.

The proposal for the strongest moratorium came from scientists writing in Nature under the clear headline "Don’t edit the human germ line." Their commentary, posted on March 12, calls for "a voluntary moratorium in the scientific community" to discourage human germline modification and to raise public awareness of the critical difference between gene editing in somatic cells and in germ cells. The authors include scientists and executives associated with the gene-editing company Sangamo BioSciences and with the Alliance for Regenerative Medicine, an advocacy organization of stem cell companies and institutes, whose executive committee approved the statement.

The authors emphasize a key distinction between altering somatic (non-reproductive) and germline cells. While somatic gene therapies hold real medical promise for treating a range of diseases, the medical rationale for using germline alterations on gametes or embryos is unconvincing. As the authors of the Nature commentary put it, “Heritable human genetic modifications pose serious risks, and the therapeutic benefits are tenuous.”

(Unfortunately, the authors seem less concerned about “mitochondrial DNA transfer,” which is an example of a distinct, but nonetheless profound, form of germline alteration that poses an accompanying array of inherent challenges. Is there a justifiable reason to condemn every form of germline alteration but this one? Does this really qualify as a “truly compelling case” when safer alternatives exist?)

The second commentary, published today by Science, is authored by a group of prominent bioethicists and scientific figures. As suggested by its title, “A prudent path forward for genomic engineering and germline gene modification,” its tone is more permissive than that of the Nature statement, and in fact it encourages moving ahead with germline gene editing research. It does, however, “strongly discourage…any attempts at germline genome modification for clinical applications in humans, while societal, environmental, and ethical implications of such activity are discussed among scientific and governmental organizations.”

A statement from the International Society for Stem Cell Research, also released today, takes a similar line, calling for “a moratorium on attempts to apply nuclear genome editing of the human germ line in clinical practice.” It notes that

consensus is lacking on what, if any, therapeutic applications of germ line genome modification might be permissible. For example, some argue that the ability to eradicate disease justifies attempts at therapeutic editing of the human germ line, while others emphasize the difficulty of drawing clear distinctions between applications in human disease and attempts at human enhancement.

News articles about these developments have appeared in Nature (1, 2), Science, The New York Times, MIT Technology Review and The Independent. Stem cell biologist Paul Knoepfler has been tracking them on his blog. According to a poll he conducted over the past week, readers across the globe support a moratorium on gene editing of human germ cells.

Science’s Gretchen Vogel sums up the broad calls for restraint here, noting that while these technical possibilities were mostly hypothetical at the infamous 1975 Asilomar conference, we now have to face their reality. Vogel quotes George Church asking: “What is the scenario that we’re actually worried about? That it won’t work well enough? Or that it will work too well?” The fact that both scenarios are deeply troubling marks human germline modification as one of the world’s most dangerous and consequential technologies.

Previously on Biopolitical Times:

“High IQ Eggs Wanted” – ads appeal to ego and altruism, offer $10,000

Posted by Lisa C. Ikemoto, Biopolitical Times guest contributor on March 19th, 2015

This ad appeared as a “suggested post” on a law student’s Facebook News Feed page. Sponsored by A Perfect Match, a southern California company that “specializes in the recruitment of intelligent, college-aged egg donors,” it includes appealing taglines: “Gift of life,” “$10,000 or more,” “Change lives . . . earn money!”

The law student said the ad made her feel “like a hen.”

The fertility industry asserts that women gift their eggs for others’ use and receive payment for the time and effort of doing so. Thus, we call them “egg donors.” In fact, the egg donation process carefully calibrates the ratio of altruism and financial need that motivates women to provide eggs for other’s use.

Medical sociologist Jennifer Haylett’s work in fertility centers reveals that staff screen out applicants who place too much emphasis on financial motive. Rene Almeling’s research shows that fertility clinics nudge egg providers to construct altruistic explanations. And yet, what intended parents and agencies pay for are ascribed traits.

The ABCs of egg donation are SAT, IQ, and college ranking. High scores and enrollment at prestigious universities are central to the egg market. Certainly, other traits matter, as well. Youth, good health, race, ethnicity, religion, good looks, height, and athleticism are among the characteristics used to solicit, profile, and select women. Women not enrolled in college are sometimes chosen as third-party egg providers. But what agencies prize are college students.

Third-party eggs form the basis of a luxury market governed by the rules of supply and demand. For example, demand for eggs from Asian women exceeds supply. Thus, prices offered to Asian women for their eggs sometimes exceed the prices offered to women of other races. However, it is the elitist criteria – near-perfect SAT scores and a place at a top-ten university – that consistently command the higher prices.

Paying women to provide high IQ eggs resembles a mix of awarding scholarships and executing futures contracts. Universities, egg agencies, and intended parents offer “$10,000 or more” to applicants who meet the elite criteria. Like commodities traders, they are speculating. Agency ads invite speculation in high scores as predictors of future success. It is probably true that if and when conception with third-party eggs results in birth, parents care more about the happiness and well-being than the IQs of their children. But at the outset, so-called traits like test scores matter. They matter most because of the ways in which SAT, IQ and college ranking are used to sort and price women who want “to change lives and earn money.”

The “High IQ Eggs Wanted” ad omits any notice of health risks arising from ovarian stimulation and egg retrieval. California law requires that ads include specific notice language that includes the statement, “There may be risks associated with human egg donation.” The law exempts members of the American Society for Reproductive Medicine (ASRM) who certify compliance with ASRM guidelines. By its own admission, A Perfect Match, Inc. exceeds the ASRM guidelines that restrict payment to women to $5,000 to $10,000, and is therefore subject to the notice requirement.

The California law also requires disclosure to women, before any contract is signed, of “specific information on the known risks of egg donation.” Disclosure does not address risks arising from the conflict of interest that pervades egg retrieval from egg donors – most physicians who perform the procedure are paid to maximize the fertility chances of another.

However, disclosure is important. Known risks focus on short-term, physical risks. They range from mild to severe effects of the drugs used to suppress ovulation, stimulate production of multiple eggs, and then release the eggs simultaneously. Severe ovarian hyperstimulation syndrome (OHSS) may be the scariest risk. Researchers have identified risk factors for OHSS,and ironically, agencies select for two of these factors – youth and low body mass index. It is suspected that conflict of interest prompts use of a third factor – high doses of ovarian stimulation drugs to maximize egg production.

There are unknowns, as well, including long-term effects of the drug most often used for ovarian suppression. Apparently, that’s the acceptable cost of making the gift of life.

Lisa Ikemoto, J.D., LL.M., is Professor at the University of California, Davis School of Law, where she teaches bioethics, health care law, public health law, reproductive rights, law & policy, and marital property, and a Fellow at the Center for Genetics and Society.

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