An ethical framework for human embryology with embryo models

A human embryo's legal definition and its entitlement to protection vary greatly worldwide. Recently, human pluripotent stem cells have been used to form in vitro models of early embryos that have challenged legal definitions and raised questions regarding their usage. In this light, we propose a refined legal definition of an embryo, suggest "tipping points" for when human embryo models could eventually be afforded similar protection to that of embryos, and then revisit basic ethical principles that might help to draft a roadmap for the gradual, justified usage of embryo models in a manner that aims to maximize benefits to society.

Shadowed by past, gene-editing summit looks to future

London meeting touts sickle cell success, but questions about embryo editing linger.

Autonomy in the Development of Stem Cell-Derived Embryoids: Sprouting Blastocyst-Like Cysts, and Ethical Implications

The experimental production of complex structures resembling mammalian embryos (e.g., blastoids, gastruloids) from pluripotent stem cells in vitro has become a booming research field. Since some of these embryoid models appear to reach a degree of complexity that may come close to viability, a broad discussion has set in with the aim to arrive at a consensus on the ethical implications with regard to acceptability of the use of this technology with human cells. The present text focuses on aspects of the gain of organismic wholeness of such stem cell-derived constructs, and of autonomy of self-organization, raised by recent reports on blastocyst-like cysts spontaneously budding in mouse stem cell cultures, and by previous reports on likewise spontaneous formation of gastrulating embryonic disc-like structures in primate models. Mechanisms of pattern (axis) formation in early embryogenesis are discussed in the context of self-organization of stem cell clusters. It is concluded that ethical aspects of development of organismic wholeness in the formation of embryoids need to receive more attention in the present discussions about new legal regulations in this field.

Human embryo research, stem cell-derived embryo models and in vitro gametogenesis: Considerations leading to the revised ISSCR guidelines

The ISSCR Guidelines for Stem Cell Research and Clinical Translation were last revised in 2016. Since then, rapid progress has been made in research areas related to in vitro culture of human embryos, creation of stem cell-based embryo models, and in vitro gametogenesis. Therefore, a working group of international experts was convened to review the oversight process and provide an update to the guidelines. This report captures the discussion and summarizes the major recommendations made by this working group, with a specific emphasis on updating the categories of review and engagement with the specialized scientific and ethical oversight process.

The ethics of human-embryoids model: a call for consistency

In this article, we discuss the ethics of human embryoids, i.e., embryo-like structures made from pluripotent stem cells for modeling natural embryos. We argue that defining our social priorities is critical to design a consistent ethical guideline for research on those new entities. The absence of clear regulations on these emerging technologies stems from an unresolved debate surrounding natural human embryo research and one common opinion that one needs to solve the question of the moral status of the human embryo before regulating their surrogate. The recent NIH funding restrictions for research on human embryoids have made scientists even more unlikely to raise their voices. As a result, the scientific community has maintained a low profile while longing for a more favorable socio-political climate for their research. This article is a call for consistency among biomedical research on human materials, trying to position human embryoids within a spectrum of existing practice from stem cell research or IVF to research involving human subjects. We specifically note that the current practices in infertility clinics of freezing human embryos or disposing of them without any consideration for their potential benefits contradicts the assumption of special consideration for human material. Conversely, creating human embryoids for research purposes could ensure that no human material be used in vain, always serving humankind. We argue here that it is time to reconsider the full ban on embryo research (human embryos and embryoids) beyond the 14-day rule and that research on those entities should obey a sliding scale combining the completeness of the model (e.g., complete vs. partial) and the developmental stage: with more advanced completeness and developmental stage of the considered entity, being associated with more rigorous evaluation of societal benefits, statements of intention, and necessity of such research.

The Nuffield Council's green light for genome editing human embryos defies fundamental human rights law

In July 2018, the Nuffield Council on Bioethics released the report Genome editing and human reproduction: Social and ethical issues, concluding that human germline modification of human embryos for implantation is not 'morally unacceptable in itself' and could be ethically permissible in certain circumstances once the risks of adverse outcomes have been assessed and the procedure appears 'reasonably safe'. The Nuffield Council set forth two main principles governing anticipated uses and envisions applications that may include health enhancements as a public health measure. This essay provides a critique of three aspects in the Nuffield Council's Report: its presumption of therapeutic efficacy, its inflation of parental rights to create a certain type of child, and its reliance on a specially commissioned report that appears to distort key definitions in international law.

Germline genome editing versus preimplantation genetic diagnosis: Is there a case in favour of germline interventions?

CRISPR is widely considered to be a disruptive technology. However, when it comes to the most controversial topic, germline genome editing (GGE), there is no consensus on whether this technology has any substantial advantages over existing procedures such as embryo selection after in vitro fertilization (IVF) and preimplantation genetic diagnosis (PGD). Answering this question, however, is crucial for evaluating whether the pursuit of further research and development on GGE is justified. This paper explores the question from both a clinical and a moral viewpoint, namely whether GGE has any advantages over existing technologies of selective reproduction and whether GGE could complement or even replace them. In a first step, I review an argument of extended applicability. The paper confirms that there are some scenarios in which only germline intervention allows couples to have (biologically related) healthy offspring, because selection will not avoid disease. In a second step, I examine possible moral arguments in favour of genetic modification, namely that GGE could save some embryos and that GGE would provide certain benefits for a future person that PGD does not. Both arguments for GGE have limitations. With regard to the extended applicability of GGE, however, a weak case in favour of GGE should still be made.

Time to start intervening in the human germline? A utilitarian perspective

Focusing on present-day possibilities raised by existing technology, I consider the normative aspects of genetically modifying the human germline from a utilitarian standpoint. With reference to a hypothetical case, I examine the probable consequences of permitting a well-conceived attempt to correct a disease-associated gene in the human germline using current CRISPR gene-editing technology. I consider inter alia the likely effects on utility of creating healthy new lives, of discouraging adoption, and of kickstarting a revolution in human germline genetic modification (HGGM). I reject various objections to HGGM, including claims that the risks of genetic harm outweigh the likely benefits. From this utilitarian analysis, I conclude that strong grounds exist to support intervening in the human germline using current technology. Delay in commencing such work will impose a utility cost, because the longer we wait until commencing the HGGM revolution and moving towards a world of increased utility, the greater will be the quantity of suffering accrued meantime through genetically influenced disease. Nevertheless, considering residual safety concerns and the negative publicity engendered by an ethically problematic recent (2018) first attempt at HGGM, it seems prudent-and ultimately generative of the greatest amount of utility-to delay implementing HGGM for a modest period of time, in the order of 1-2 years.

Regulating germline editing in assisted reproductive technology: An EU cross-disciplinary perspective

Potential applications of genome editing in assisted reproductive technology (ART) raise a vast array of strong opinions, emotional reactions and divergent perceptions. Acknowledging the need for caution and respecting such reactions, we observe that at least some are based on either a misunderstanding of the science or misconceptions about the content and flexibility of the existing legal frameworks. Combining medical, legal and ethical expertise, we present and discuss regulatory responses at the national, European and international levels. The discussion has an EU starting point and is meant as a contribution to the general international regulatory debate. Overall, this paper concludes that gene editing technologies should not be regulated autonomously. Rather, potential uses should be regulated under general, existing frameworks and where applicable by reference to sufficiently equivalent technologies and techniques already subject to specific regulation. To be clear, we do not argue for the hasty introduction of gene editing as a reproductive treatment option in the immediate future. We call for caution with regard to overreaching moratoria and prohibitions that will also affect basic research. We recommend flexible regulations that allow for further responsible research into the potential development of the technology. We call for an open and inclusive debate and argue that scientific communication should claim a more prominent role to counter the danger of widespread misinformation. A high level of transparency and accuracy should guide scientific communication while simultaneously global-scale responsibility and governance should be fostered by promoting cross-disciplinary thinking and multi-level stakeholder involvement in legal and regulatory processes.

Designing Preclinical Studies in Germline Gene Editing: Scientific and Ethical Aspects

Human germline gene editing is often debated in hypothetical terms: if it were safe and efficient, on what further conditions would it then be ethically acceptable? This paper takes another course. The key question is: how can scientists reduce uncertainty about safety and efficiency to a level that may justify initiation of first-time clinical trials? The only way to proceed is by well-designed preclinical studies. However, what kinds of investigation should preclinical studies include and what specific conditions should they satisfy in order to be considered well-designed? It is argued that multispecies and multigenerational animal studies are needed as well as human embryo editing without implantation. In order to be possible to translate to first-time clinical trials, animal studies need to satisfy strict conditions of validity. Moreover, embryo studies intended for translation to first-time clinical trials need to correspond to the animal studies in experimental design (with exception of implantation). Only in this way can uncertainty about risk for harm (safety) and prospect of benefit (efficiency) in first-time clinical trials be reduced to a modest level. If uncertainty is not reduced to such a level, first-time clinical trials in germline gene editing should not be initiated.

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 Wisdom of Germline Editing: An Ethical Analysis of the Use of CRISPR-Cas9 to Edit Human Embryos

With recent reports that a Chinese scientist used CRISPR-Cas9 to heritably edit the genomes of human embryos (i.e., germline editing) brought to term, discussions regarding the ethics of the technology are urgently needed. Although certain applications of germline editing have been endorsed by both the National Academy of Sciences (US) and the Nuffield Council (UK), this paper explores the ethical concerns related even to such therapeutic uses of the technology. Additionally, this paper questions whether the technology could ever feasibly be contained to the therapeutic realm. Consequently, this paper necessarily considers the ethical concerns related to enhancement uses of the technology even if only therapeutic applications are initially considered. In light of the concomitant risks, this paper assesses the technology's countervailing benefits to conclude they do not prevail given that similar outcomes can largely be achieved with existing technologies. Consequently, this paper recommends an international ban on germline editing.

The Boundaries of Embryo Research: Extending the Fourteen-Day Rule : Australasian Association of Bioethics and Health Law John McPhee (Law) Student Essay Prize 2018

The disciplines of ethics, science, and the law often conflict when it comes to determining the limits and boundaries of embryo research. Under current Australian law and regulations, and in various other jurisdictions, research conducted on the embryo in vitro is permitted up until day fourteen, after which, the embryo must be destroyed. Reproductive technology and associated research is rapidly advancing at a rate that contests current societal and ethical limits surrounding the treatment of the embryo. This has brought about the question of the adequacy of the fourteen-day rule and whether it is necessary for it be reconsidered and reformed. This paper will highlight some of the tensions that exist in ethics, science, and the law in relation to the extension of the rule. It will be concluded that any move to extend the rule must be accompanied by close consultation with the public as the ultimate stakeholders in how the future of reproductive technology is created, constructed, and contested.

Ethics and cloning

BACKGROUND

Scientists have cloned animals since the late 19th century, but the crucial step for ethics was the cloning of the first mammal by somatic cell nuclear transfer in 1997. This suggested that scientists could also clone, and possibly enhance, human beings.

SOURCES OF DATA

This survey examines ethical literature on cloning since the 1960s.

AREAS OF AGREEMENT

The one ethical area of agreement in this issue is that we should not try to create new human beings by somatic cell nuclear transfer now.

AREAS OF CONTROVERSY

Ethicists disagree, however, on what justifies this norm. Some appeal to preference satisfaction and freedom from external constraints, others question this approach by more profound religious and moral considerations.

GROWING POINTS

The discussion is currently not progressing, as the same arguments have been in use since the 1970s.

AREAS TIMELY FOR DEVELOPING RESEARCH

Philosophers should prepare deeper analyses of the presuppositions of the ethical arguments used in the discussion before the issue surfaces again.

How to Rethink the Fourteen-Day Rule

Recently, attention has been drawn to the basic principles governing the use of human embryos in research: specifically, the so-called fourteen-day rule. This rule stipulates that human embryos should not be allowed to grow in vitro past fourteen days of development. For years, the fourteen-day limit was largely theoretical, since culture techniques were not sufficient to maintain embryos up to this point. Yet in the past year, research has suggested that growing embryos beyond fourteen days might be feasible and scientifically valuable. At the same time, work with pluripotent stem cells, including human PSCs, has shown that under certain conditions, they can form structures that recapitulate developmental features of the postimplantation embryo. This raises the possibility that PSCs could generate embryo-like structures in vitro, even "synthetic embryos," that might provoke moral concern but would not fall under most current embryo research policies. In countries that permit embryo research, the fourteen-day rule has long been the linchpin of an effective policy compromise between what remain deeply divided moral positions on the human embryo's status. It has also, particularly in the United Kingdom, been influential in establishing a bioethics public-policy process. Any moves to change the rule must consider not just the implications for the use of embryos but also the potential impact of this model of bioethical governance of science.

A Crispr Future for Gene-Editing Regulation: a Proposal for an Updated Biotechnology Regulatory System in an Era of Human Genomic Editing

Recent developments in gene-editing technology have enabled scientists to manipulate the human genome in unprecedented ways. One technology in particular, Clustered Regularly Interspaced Short Pallindromic Repeat (CRISPR), has made gene editing more precise and cost-effective than ever before. Indeed, scientists have already shown that CRISPR can eliminate genes linked to life-threatening diseases from an individual's genetic makeup and, when used on human embryos, CRISPR has the potential to permanently eliminate hereditary diseases from the human genome in its entirety. These developments have brought great hope to individuals and their families, who suffer from genetically linked diseases. But there is a dark side: in the wrong hands, CRISPR could negatively impact the course of human evolution or be used to create biological weaponry. Despite these possible consequences, CRISPR remains largely unregulated due to the United States's outdated regulatory scheme for biotechnology. Moreover, human embryo research, which is likely critical to maximizing the therapeutic applications of CRISPR, is not easily undertaken by scientists due to a number of federal and state restrictions aimed at preventing such research. This Note examines the possible benefits and consequences of CRISPR and discusses the current regulations in both the fields of biotechnology and human embryo research that hamper the government's ability to effectively regulate this technology. Ultimately, this Note proposes a new regulatory scheme for biotechnology that focuses on the processes used to create products using CRISPR, rather than the products themselves, with a focus on enabling ethical research using human embryos to maximize the potential benefits of CRISPR.

Attitudes Towards the Donation of Human Embryos for Stem Cell Research Among Chinese IVF Patients and Students

Bioethical debates on the use of human embryos and oocytes for stem cell research have often been criticized for the lack of empirical insights into the perceptions and experiences of the women and couples who are asked to donate these tissues in the IVF clinic. Empirical studies that have investigated the attitudes of IVF patients and citizens on the (potential) donation of their embryos and oocytes have been scarce and have focused predominantly on the situation in Europe and Australia. This article examines the viewpoints on the donation of embryos for stem cell research among IVF patients and students in China. Research into the perceptions of patients is based on in-depth interviews with IVF patients and IVF clinicians. Research into the attitudes of students is based on a quantitative survey study (n=427). The empirical findings in this paper indicate that perceptions of the donation of human embryos for stem cell research in China are far more diverse and complex than has commonly been suggested. Claims that ethical concerns regarding the donation and use of embryos and oocytes for stem cell research are typical for Western societies but absent in China cannot be upheld. The article shows that research into the situated perceptions and cultural specificities of human tissue donation can play a crucial role in the deconstruction of politicized bioethical argumentation and the (often ill-informed) assumptions about "others" that underlie socio-ethical debates on the moral dilemmas of technology developments in the life sciences.

Defending eugenics : From cryptic choice to conscious selection

For most of human history children have been a byproduct of sex rather than a conscious choice by parents to create people with traits that they care about. As our understanding of genetics advances along with our ability to control reproduction and manipulate genes, prospective parents have stronger moral reasons to consider how their choices are likely to affect their children, and how their children are likely to affect other people. With the advent of cheap and effective contraception, and the emergence of new technologies for in vitro fertilization, embryo selection, and genetic engineering, it is becoming increasingly difficult to justify rolling the genetic dice by having children without thinking about the traits they will have. It is time to face up to the awesome responsibilities that accompany our reproductive choices.

The futility of fertility research? Barriers to embryo research in New Zealand

AIMS

Successive New Zealand Health Ministers have failed to approve guidelines for research using viable human embryos, which effectively places a blanket ban on all research that "uses" viable human embryos in this country. This includes research that aims to improve currently available reproductive technologies, illustrated by a failed application to ministerial ethics committees for a clinical research project investigating the efficacy of in vitro fertilisation procedures. However, no data currently exists describing the degree to which these restrictions are inhibiting reproductive research in this country.

METHODS

We have conducted a qualitative survey of New Zealand researchers from 20 major academic, clinical and governmental institutes to qualify the impact these restrictions are having on New Zealand's research outputs.

RESULTS

The results suggest dissatisfaction with the current guidelines, and the lack of guidance from the Ministry of Health and associated ethics committees regarding what constitutes embryo research and therefore what research can be performed.

CONCLUSIONS

The lack of current guidelines regarding the use of embryos for research is restricting improvements to established reproductive technologies, and any future research. We suggest that the Minister of Health instructs ministerial advisory and ethics committees to review the current guidelines and to define the term "use of embryos".

[Chapter 3. Governing the research on embryos]

The bioethics laws since their first adoption in 1994 until the latest proposals, have been widely commented and analyzed, regarding the provisions related to the legal qualification and the legal status of the embryo and of the embryonic stem cells. The legal issues raised by these hesitations imply instability for both researchers and health professionals about what they can and cannot do when it comes to the embryo and its cells. Thus, while the protection of the embryo was the subject of a consensus until the end of the 2000s, it now appears as the object of a political will, from researchers and state agencies, to support this research. The legal frameworks have been modified step by step leading to an administrative police that reconciles freedom of research and ethical issues whose legal enforcement remains weak and uncertain. It will therefore be important to highlight the legal and institutional milestones that led to the acceptance of embryo research and to the liberalization of the legal framework. Some doubts will then be expressed about the benefits of this liberalization notably because cases law on the patentability of inventions resulting from this research are a bit of a threat to encourage development perspectives and because embryonic stem cells could remain marginal because of the economic and scientific contexts.

[Chapter 2. The embryo in abortion legislation]

For a long time, the legal condition of the child conceived, the embryo or the human fœtus, to use the language of biomedicine, was dominated by two main principles : one, having its roots in Roman law, made it possible to count it, by anticipation, among beings with a legal existence, so as to grant it its rights, as if it was already born (the infans conceptus maxim) : the other, protecting its life in utero, and so its chances of being born, by the penal incrimination of abortion. The legalisation of abortion by the ?Veil? law of 17 January 1975 upset this traditional approach of the law. The subsequent evolution of the legislation has accentuated the phenomenon. The promotion of the freedom of women to obtain an abortion has been accompanied by a correlated decline in the protection of the embryo. At the same time, abortion resting on medical techniques has become a means, precious for research, to obtain embryo or foetal cells or tissues. Eliminated on the one hand, the embryo has finally become on the other hand the object of medical and scientific stakes.

[CRISPR-Cas9, germinal cells and human embryo]

The performance of the molecular tool using CRISPR-Cas9, which makes it possible to induce targeted modifications of the DNA, has found numerous applications in research and open promising prospects in human clinic. CRISPR-Cas9 has been widely used to generate transgenic animals after targeted modification of the genome at the zygotic stage. It was also tested on human embryos on an experimental basis. Although there are potential medical indications that may justify a targeted modification of the embryo or germ cell genome, the uncertainties regarding the efficacy and safety of the method do not allow us to consider implementing such germline gene therapy in the short-term. However, it is necessary to weigh the scientific and ethical issues involved in this approach.

Using Surplus Embryos and Research Embryos in Stem Cell Research: Ethical Viewpoints of Buddhist, Hindu and Catholic Leaders in Malaysia on the Permissibility of Research

The sources of embryos for Embryonic Stem Cell Research (ESCR) include surplus embryos from infertility treatments, and research embryos which are created solely for an ESCR purpose. The latter raises more ethical concerns. In a multi-religious country like Malaysia, ethical discussions on the permissibility of ESCR with regard to the use surplus and research embryos are diversified. Malaysia has formulated guidelines influenced by the national fatwa ruling which allows the use of surplus embryos in ESCR. Input from other main religions is yet to be documented. In light of this, this study addresses (i) the ethical viewpoints of Buddhist, Hindu and Catholic leaders on the permissibility of using surplus and research embryos; and (ii) the moral standpoints of religious leaders towards attaining a consensus on the practice of ESCR in Malaysia. Responses from the religious leaders were obtained via semi-structured, face-to-face interviews. The findings show that generally the Buddhist and Hindu leaders approve the use of surplus embryos. Their responses on the creation of research embryos for ESCR are varied. Meanwhile, the Catholic leaders distinctively objected to ESCR regardless of the embryo sources, referring to it as the destruction of life. Taking into account the diverse views, this study explores the response of the religious leaders for a general consensus wherever possible. The ethical discourse surrounding ESCR in a multi-religious setting offers new perspective, which needs to be explored in a broader global community.

200 Years After Frankenstein

Mary Shelley's Frankenstein is 200 years old and remains relevant to 21st-century scientific experimentation. Molecular biologists today have become especially bold in their attempts to cure diseases while remaining mindful of the real dangers of their research. Scientists presumably share an abiding concern about producing uncontrollable mutations in people, animals, and the wider environment, yet a sense of urgency appears to inform the current scientific willingness to take risks, especially in the realm of embryology and germ-line modification. This willingness to go more boldly than before could be influenced by the unprecedented ability of such gene-cutting technologies as CRISPR to make immediate and lasting improvements to persons suffering from certain diseases and other physical malignancies, but also by an acculturated sense that such persons deserve to participate more fully in broader society.

The ethics of creating genetically modified children using genome editing

PURPOSE OF REVIEW

To review the recent ethical, legal, and social issues surrounding human reproduction involving germline genome editing.

RECENT FINDINGS

Genome editing techniques, such as CRISPR/Cas9, have facilitated genetic modification in human embryos. The most likely purpose of germline genome editing is the prevention of serious genetic disease in offspring. However, complex issues still remain, including irremediable risks to fetuses and future generations, the role of women, the availability of alternatives, long-term follow-up, health insurance coverage, misuse for human enhancement, and the potential effects on adoption. Further discussions, a broad consensus, and appropriate regulations are required before human germline genome editing is introduced into the global society.

SUMMARY

Before germline genome editing is used for disease prevention, a broad consensus must be formed by carefully discussing its ethical, legal, and social issues.

A 14-day limit for bioethics: the debate over human embryo research

BACKGROUND

This article explores the reasons in favour of revising and extending the current 14-day statutory limit to maintaining human embryos in culture. This limit is enshrined in law in over a dozen countries, including the United Kingdom. In two recently published studies (2016), scientists have shown that embryos can be sustained in vitro for about 13 days after fertilisation. Positive reactions to these results have gone hand in hand with calls for revising the 14-day rule, which only allows embryo research until the 14th day after fertilisation.

MAIN TEXT

The article explores the most prominent arguments in favour of and against the extension of the 14-day limit for conducting research on human embryos. It situates these arguments within the history of the 14-day limit. I start by discussing the history of the 14-day limit in the United Kingdom and the reasons behind the decision to opt for a compromise between competing moral views. I then analyse the arguments that those who are generally in favour of embryo research put forward in support of extending the 14-day rule, namely (a) the argument of the beneficence of research and (b) the argument of technical feasibility (further explained in the article). I then show how these two arguments played a role in the recent approval of two novel techniques for the replacement of faulty mitochondrial DNA in the United Kingdom. Despite the popularity and widespread use of these arguments, I argue that they are ultimately problematic and should not be straightforwardly accepted (i.e. accepted without further scrutiny). I end by making a case for respecting value pluralism in the context of embryo research, and I present two reasons in favour of respecting value pluralism: the argument of public trust and the argument of democracy.

CONCLUSION

I argue that 14-day limit for embryo research is not a valuable tool despite being a solution of compromise, but rather because of it. The importance of respecting value pluralism (and of respecting different views on embryo research) needs to be considered in any evaluation concerning a potential change to the 14-day rule.

A patient-centred approach to embryo donation for research

Most couples enrolled in Assisted Reproductive Technologies' (ART) treatments need to make decisions regarding embryo disposition, as they are asked to sign a consent form about embryo donation for research. Beyond the current assessment of patients' individual experiences and levels of satisfaction with care delivery, we argue that it is crucial to provide stakeholders in health systems with feedback on patients' views about legal and regulatory frameworks. Such knowledge will lend credence and robustness to the consent that the couples give, and will contribute to the implementation of informed relational ethics in clinical practice and to improved patient-centredness in the field of ART.

What's Wrong with Human/Nonhuman Chimera Research?

The National Institutes of Health (NIH) is poised to lift its funding moratorium on research involving chimeric human/nonhuman embryos, pending further consideration by an NIH steering committee. The kinds of ethical concerns that seem to underlie this research and chimera research more generally can be adequately addressed.

This Perspective argues that the ethical concerns behind the NIH funding moratorium on chimeric embryo research can be adequately and reasonably addressed.

Stem Cell and Related Therapies: Nurses and midwives representing all parties

Nurses and midwives are part of health care in all the stages of our lives from preconception to death. Recent scientific advances have introduced new techniques of screening and diagnosis linked to stem cell isolation and therapies. These could affect us at any age and therefore nurses will be involved as carers and patients advocates for these techniques. In this article stem cell techniques and therapies are outlined, as well as some of the ethical challenges faced by various nursing groups, whether in adult, learning difficulties, mental health, paediatric, primary care, public health or health visiting areas. Nurses have to understand the ethical issues and the rights of all parties (donor, recipient and families), which may conflict with each other, to be able to weigh up the benefits and costs to each group involved. Answers have to be found on a case-by-case basis within local moral frameworks and law. Nurses represent all parties in these therapies and act as advocates for every patient group. They need to act in an interprofessional environment to promote the best interests of all their clients, both clinically and ethically.