Is Enhancement the Price of Prevention in Human Gene Editing?

Adapting Ourselves, Instead of the Environment: An Inquiry into Human Enhancement for Function and Beyond

Technology enables humans not only to adapt their environment to their needs but also to modify themselves. Means of Human Enhancement - embodied technologies to improve the human body's capabilities or to create a new one - are the designated means of adapting ourselves instead of the environment. The debate about these technologies is typically fought on ethical soil. However, alarmist, utopian, and science fiction scenarios distract from the fact that Human Enhancement is a historical and pervasive phenomenon incorporated into many everyday practices. In the vein of disentangling conceptual difficulties, we claim that means of Human Enhancement are either physiologically or psychologically embodied, rendering the merging with the human user their most defining aspect. To fulfill its purpose, an enhancement must pass the test-in-the-world, i.e., assisting with effective engagement with a dynamic world. Even if failing in this regard: Human Enhancement is the fundamental and semi-targeted process of changing the users relationship with the world through the physical or psychological embodiment of a hitherto external object and/or change of one's body. This can potentially change the notion of being human. Drawing on a rich body of theoretical and empirical literature, we aim to provide a nuanced analysis of the transformative nature of this phenomenon in close proximity to human practice. Stakeholders are invited to apply the theory presented here to interrogate their perspective on technology in general and Human Enhancement in particular.

Seven open questions in the futures of human genome editing

Scholarly discussion around the governance of human genome editing (HGE) recognizes that development and application of HGE techniques could result in unexpected societal outcomes. However, it contains few to no methodological models for how to anticipate, prepare for, or shape such outcomes. This article presents early-stage results from research guided by anticipatory governance, a framework for broad expert and public consideration of innovation processes and purposes. We present and discuss key themes emerging from a set of future-oriented interviews with genome editing practitioners and experts, designed to inform broadly scoped deliberations about plausible futures of HGE. We articulate our results as seven "open questions," the answers to which will be important components of HGE's eventual shape and outcomes. Some themes are perennial in studies of science and society, and others are more novel to HGE. Each helps to reframe HGE beyond a simple comparison of risk and benefit. Such reframing opens up new and important terrain for discussion among policymakers, academics, scientists, and publics. We suggest that discussion framed around broad and reflexive questions like those presented here will help governance efforts to better acknowledge and flexibly respond to the uncertainty and complexities of HGE developments.

Reflections about the Molecular Tool That Could Change the Course of Human History: Genome Editing

Genetic editing has many applications in almost all areas of society, but may also lead to unpredictable consequences. Genome editing to modify the human germline is at the center of global discussion. Owing to the increasing number of unanswered scientific, ethical, and policy questions, the scientific community agrees that it would be inappropriate to genetically modify embryos. A serious and open debate is necessary to decide whether such research should be suspended or encouraged. Here we show some bold arguments in favor of deleting deleterious genes from the human genome and the risks liberal eugenism poses.

The View from the Benches: Scientists' Perspectives on the Uses and Governance of Human Gene-Editing Research

The advent of human gene editing has stimulated international interest in how best to govern this research. However, research on stakeholder views has neglected scientists themselves. We surveyed 212 scientists who use gene editing in their work. Questions captured views on oversight and use of somatic and germline human gene editing for treatment, prevention, and enhancement. More respondents were supportive of somatic than germline editing, and more supported gene editing for treatment compared to prevention. Few supported its use for enhancement. When presented with specific conditions, levels of support for somatic editing differed by type of condition. Almost all respondents said scientists and national government representatives should be involved in oversight, but only 28% said scientists are best positioned to oversee gene-editing research. These results can inform the development of sound approaches to research governance, demonstrating the importance of identifying specific gene-editing uses when considering oversight.

Toward Anticipatory Governance of Human Genome Editing: A Critical Review of Scholarly Governance Discourse

The rapid development of human genome editing (HGE) techniques evokes an urgent need for forward-looking deliberation regarding the aims, processes, and governance of research. The framework of anticipatory governance (AG) may serve this need. This article reviews scholarly discourse about HGE through an AG lens, aiming to identify gaps in discussion and practice and suggest how AG efforts may fill them. Discourse on HGE has insufficiently reckoned with the institutional and systemic contexts, inputs, and implications of HGE work, to the detriment of its ability to prepare for a variety of possible futures and pursue socially desirable ones. More broadly framed and inclusive efforts in foresight and public engagement, focused not only upon the in-principle permissibility of HGE activities but upon the contexts of such work, may permit improved identification of public values relevant to HGE and of actions by which researchers, funders, policymakers, and publics may promote them.

Responsible Translational Pathways for Germline Gene Editing?

Purpose of Review

Continued development of gene editing techniques has raised the real possibility of clinical application of germline gene editing. These results, as well as reports of an unethical experiment which resulted in the birth of at least two children from edited embryos in 2018, have highlighted the urgency and importance of ethical issues about translational pathways for editing of human germline cells. Charting responsible translational pathways for germline gene editing requires tackling some significant and complex ethical issues.

Recent Findings

A literature on development of clinical applications of germline gene editing is emerging, and several key ethical issues are coming into focus as major challenges for responsible translational pathways.

Summary

Potential clinical utility, clinical justification, and human subjects research for germline gene editing raise outstanding ethical questions. Work on these questions will help provide guidance to researchers and clinicians and direct translational projects toward justifiable applications.

'Serious' factor-a relevant starting point for further debate: a response

In this reply, we wish to defend our original position and address several of the points raised by two excellent responses. The first response (De Miguel Beriain) questions the relevance of the notion of 'serious' within the context of human germline genome modification (HGGM). We argue that the 'serious' factor is relevant and that there is a need for medical and social lenses to delineate the limits of acceptability and initial permissible applications of HGGM. In this way, 'serious' acts as a starting point for further discussions and debates on the acceptability of the potential clinical translation of HGGM. Therefore, there is a pressing need to clarify its scope, from a regulatory perspective, so as to prevent individuals from using HGGM for non-therapeutic or enhancement purposes. The second response (Kalsi) criticizes the narrow interpretation of the objectivist approach and the apparent bias towards material innovations when discussing the right to benefit from scientific advancements. As an in-depth discussion of the objectivist and constructivist approaches was beyond the scope of our original paper, we chose to focus on one specific objectivist account, one which focuses on biological and scientific facts. We agree, however, with the critique that material innovations should not be the sole focus of the right to benefit from scientific advancements, which also incorporates freedom of scientific research and access to scientific knowledge scientific freedom and knowledge, including the influence of these on ethical thinking and cultures.

Human germline genome editing is illegal in Canada, but could it be desirable for some members of the rare disease community?

Human germline genome editing may prove to be especially poignant for members of the rare disease community, many of whom are diagnosed with monogenic diseases. This community lacks broad representation in the literature surrounding genome editing, notably in Canada, yet is likely to be directly affected by eventual clinical applications of this technology. Although not generalizable, the literature does offer some commonalities regarding the experiences of rare disease patients. This manuscript seeks to contribute to the search for broader societal dialogue surrounding human germline genome editing by exploring some of those commonalities that comfort the notion that CRISPR may hold promise or be desirable for some members of this community. We first explore the legal and policy context surrounding germline genome editing, focusing closely on Canada, then provide an overview of the common challenges experienced by members of the rare disease community, and finally assess the opportunities of germline genome editing vis-à-vis rare disease as we advocate for the need to more actively engage with the community in our search for public engagement.

The 'serious' factor in germline modification

Current advances in assisted reproductive technologies aim to promote the health and well-being of future children. They offer the possibility to select embryos with the greatest potential of being born healthy (eg, preimplantation genetic testing) and may someday correct faulty genes responsible for heritable diseases in the embryo (eg, human germline genome modification (HGGM)). Most laws and policy statements surrounding HGGM refer to the notion of 'serious' as a core criterion in determining what genetic diseases should be targeted by these technologies. Yet, this notion remains vague and poorly defined, rendering its application challenging and decision making subjective and arbitrary. By way of background, we begin by briefly presenting two conceptual approaches to 'health' and 'disease': objectivism (ie, based on biological facts) and constructivism (ie, based on human values). The basic challenge under both is sorting out whether and to what extent social and environmental factors have a role in helping to define what qualifies as a 'serious' disease beyond the medical criteria. We then focus on how a human rights framework (eg, right to science and right to the highest attainable health) could integrate the concepts of objectivism and constructivism so as to provide guidance for a more actionable consideration of 'serious'. Ultimately, it could be argued that a human rights framework, by way of its legally binding nature and its globally accepted norms and values, provides a more universal foundation for discussions of the ethical, legal and social implications of emerging or disruptive technologies.

The clinical application of gene editing: ethical and social issues

Gene-editing techniques have progressed rapidly in the past 5 years. There are already ongoing human somatic gene-editing clinical trials for multiple diseases. And there has been one purported scenario of human germline gene editing in late 2018. In this paper, we will review the current state of the technology, discuss the ethical and social issues that surround the various forms of gene editing, as well as review emerging stakeholder data from professionals, the ‘general public’ and individuals and families dealing with genetic diseases potentially treatable by gene editing.