Nancy King

Clinical gene transfer research has both a unique history and a complex and layered system of research oversight, featuring a unique review body, the Recombinant DNA Advisory Committee. This paper briefly describes the process of decision-making about clinical GTR, considers whether the questions, problems, and issues raised in clinical GTR are unique, and concludes by examining whether the RAC's oversight is a useful model that should be reproduced for other similar areas of clinical research.Clinical GTR is governed by the same oversight system as most clinical trials, with a significant addition: the RAC. Like other research with human subjects, GTR, if it is affiliated with a federally funded institution, must be approved by an institutional review board whose activities are governed by the common rule, that is, the federal regulations for protection of human subjects in research. Like other research intended to produce a drug, device, or biologic to be marketed in the United States, GTR is also overseen by the Food and Drug Administration.

“Regenerative medicine” describes a set of innovative approaches to the treatment of illness, injury, and disability, focusing on the growth, replacement, and repair of cells, organs, and tissues specific to the health needs of particular individuals. The extraordinary breadth of application of this approach is clear from an enumeration of just a few areas of regenerative medicine research, such as stem cells, including embryonic stem cells, pluripotent stem cells produced by genetic reprogramming, and multipotent stem cells from non-embryonic tissues; techniques for stimulating endogenous cell growth and repair for the kidney and pancreas in diabetes, or for digits and limbs injured as a result of trauma; and the growth of replacement tissues and organs, for example, blood vessels, hollow organs like the bladder, and even solid organs like the heart. This enormous diversity of applications, all currently in various stages of research and development, stems from a multidisciplinary research orientation incorporating genetics, informatics, basic research into the structure, mechanics, and development of different tissues, and creative production techniques. Despite its enormous promise, however, at this time regenerative medicine’s many applications constitute a very early step along the road to effective treatments. Most of the attention to ethical issues in regenerative medicine has been consumed by debate about the use of human embryonic stem cells in research, specifically, the destruction of embryos in order to create cell lines, disputes over the role of federal funding for research with human embryonic stem cells, and concerns about the safety, scientific purity, and adequacy of consent for the research use of human embryonic stem cell lines. Like other novel biotechnologies, however, regenerative medicine raises a number of additional critical research ethics issues that are not new, but that have not yet been adequately addressed. Instead, as is common in new science, familiar and longstanding questions appear in the fresh context of regenerative medicine research and renew old debates. Advances in regenerative medicine therefore provide a much-needed opportunity to reexamine important issues in human subjects research. Moreover, because regenerative medicine has taken a thoroughgoing translational perspective, seeking to anticipate and plan for the issues (scientific, policy, and practical) that are likely to arise along the full research trajectory from bench to bedside to clinical product, it presents a model system for comprehensively identifying and addressing issues and needs in ethics and policy as they arise in translational research involving this developing science. This article discusses some of the novel technologies within regenerative medicine. The article then examines the range of ethical issues raised by each novel regenerative medicine technology, including but not limited to: the ethics of research design; issues to consider in first-in-humans regenerative medicine research; and informed consent and the therapeutic misconception. The article further considers whether regenerative medicine helps to blur any distinction that may exist between medical treatment and enhancement, possibly creating more ethical issues to address in the long term. The article concludes by advising scholars and policymakers in bioethics to take the opportunity offered by regenerative medicine to move research ethics and policy forward by examining these issues anew through the lens of this groundbreaking medical science.

At the time of this writing, a widely publicized, waived-consent trial is underway. Sponsored by Northfield Laboratories, Inc. (Evanston, IL) the trial is intended to evaluate the emergency use of PolyHeme®, an oxygen-carrying resuscitative fluid that might prevent deaths from uncontrolled bleeding. The protocol allows patients in hemorrhagic shock to be randomized between PolyHeme® and saline in the field and, still without consent, randomized between PolyHeme® and blood after arrival at an emergency department. The Federal regulations that govern the waiver of consent restrict its applicability to circumstances where proven, satisfactory treatments are unavailable. Blood—the standard treatment for hemorrhagic shock—is not available in ambulances but is available in hospitals. The authors argue that the in-hospital stage of the study fails to meet ethical and regulatory standards.

First-in-human research has several characteristics that require special attention with respect to ethics and human subjects protections. At least some nanomedical technologies may also have characteristics that merit special attention in clinical research, as other papers in this symposium show. This paper considers how to address these characteristics in the consent form and process for FIH nanomedicine research, focusing principally on experimental nanotherapeutic interventions but also considering nanodiagnostic interventions.It is essential, as a starting point, to recognize that the consent form and process are by no means the primary protectors of human subjects. Instead, consideration of the form and content of informed consent becomes relevant only after a clinical trial has been reviewed and deemed scientifically and ethically acceptable.Two convergent types of challenges to informed consent are posed by nanomedicine FIH research. First, some issues appear generally applicable to FIH research, but have specific nanomedicine implications.

_Bioethics, Public Moral Argument, and Social Responsibility_ explores the role of democratically oriented argument in promoting public understanding and discussion of the benefits and burdens of biotechnological progress. The contributors examine moral and policy controversies surrounding biomedical technologies and their place in American society, beginning with an examination of discourse and moral authority in democracy, and addressing a set of issues that include: dignity in health care; the social responsibilities of scientists, journalists, and scholars; and the language of genetics and moral responsibility.

In much the same way that genomic technologies are changing the complexion of biomedical research, the issues they generate are changing the agenda of IRBs and research ethics. Many of the biggest challenges facing traditional research ethics today — privacy and confidentiality of research subjects; ownership, control, and sharing of research data; return of results and incidental findings; the relevance of group interests and harms; the scope of informed consent; and the relative importance of the therapeutic misconception — have become important policy issues over the last 20 years because of the ways they have been magnified by genomic research efforts. Research that examines the ethical, legal, and social implications of human genomics research has become a burgeoning international field of scholarship over the last 20 years, thanks in part to its support first by the genome research funding bodies in the U.S. and then by national science agencies in other countries.

In Shaping Our Selves, Erik Parens offers both a personal history of bioethics and a cleverly clarifying lens to train on disputes in bioethics about emerging technologies. The question for readers is whether this lens, as useful as it is, leaves too much outside our field of vision. Parens, born in 1957, comes from the first wave of bioethics scholars—those of us who still mostly happened into bioethics as a field, before it was sufficiently well-established to be identified as a career pathway. Bioethics enjoys a fascinating diversity of origin stories, and Parens’s is no exception. He began his studies at the University of Chicago’s pan-disciplinary Committee on Social Thought, one of a handful..

Gene therapy is still a very crude way of treating very complicated problems. It's hard to get new genes to go where they're needed, and hard to keep them from going where they're not wanted. The worst‐case scenario is that they find their way into a patient's germ cells—eggs or sperm—and end up harming the patient's offspring. Yet this possibility is hard to study in human trials, and would be hard to deal with in the clinic. It should, instead, simply be avoided. Doing so requires fundamentally changing our approach to gene therapy.