HOLY AND GREAT COUNCIL DOCUMENT

Draft Synodical Document

Δευτέρα 11 Ιουνίου 2018

ΤIJANA PETKOVIC: MORAL AND ETHICAL ISSUES IN GENETICS


Moral and Ethical Issues in Genetics
Tijana Petković[1]

Draft paper


What are people ready to do to make their life perfect?

 Imagine that you are planning of starting a family and doctor tells you that you have the option to genetically enhance your child’s intelligence without risking the life of the embryo. Whould you do it? 

Or on the other case, genetic test reveals your child has Down syndrome and they are offering the option to undo the genetic manipulation. Would you do it? Are we talking about science fiction or reality?



Genetic research has advanced radically in the last few decades, to the point where it has now become possible for us to attempt therapeutic genetic modification. That possibility offers CRISPR/Cas-9 and other related technologies. Scientists demonstrated that CRISPR/Cas-9 can edit the genes of living human cells at a fraction of the time and cost required by previous methods.

Think of editing the genome like a “find-and-replace” function: a tool finds, removes, and replaces a specific sequence of genetic material. In older methods of gene editing, imprecise protein structures, which are laborious to construct, search for the specific sequence. Instead, CRISPR uses RNA. The development of the CRISPR/Cas9 nucleases has meant that the pace of progress has increased exponentially. It is predicted that in the next decade many genome editing-based clinical trials will be developed by academics, biotechnology start-ups and pharmaceutical companies.



Everyone thinks that curing monogenic diseases is simple, but it’s not the case. As an illustration of the complexity of what is being proposed in human gene editing, there are approximately 3 billion (3,000,000,000) base pairs in the human genome. There are approximately 3 million (3,000,000) letters in the text of the Bible- so it would take almost 1,000 copies of the Bible to contain the same number of letters as there are base pairs in the human genome. To achieve the successful editing of a single base pair in the human genome would therefore be equivalent to changing a single letter in one of 1,000 copies of the Bible, and to do so at the sub- microscopic scale of DNA.[2]



Genome editing is indeed very powerful when we consider that is is not only a method which potentionaly provides a mechanism  to modify single nucleotides, but these technique is able to make more sophisticated genomic changes, which could be used to cure more common diseases  or to modify their course. Moreover, these changes could be transmitted to all future generations. As such, genome editing is potentially very powerful indeed.

We know that every human being is created “in the image and likeness of God.” However the term “image” is to be defined, it implies what theologians today call “being-in-communion.” The human person is not an isolated entity but a member of a community. And the primary and primordial community is that of the Church, the Body of the risen and glorified Lord, Jesus Christ.

In order for us to reflect the perfection of the Trinity, we cannot avoid engaging in an ongoing struggle against the tendencies of our darker side, what the ascetic tradition calls the “passions.” Accordingly, many of the Church Fathers will make a distinction between “image” and “likeness,” defining “likeness” as the goal of that ascetic struggle, the “unseen warfare” of the soul. Just as every human being is created in the divine “image,” so every one is called to assume the divine “likeness.” The image, in other words, refers to our nature, the “givenness” of human life that we all share. The likeness, on the other hand, constitutes the goal toward which each “person” or particular human being is called to strive. That goal is described as “theosis.”[3]

Genetics is the study of heredity, where a parent passes certain genes onto their children or offspring. Every child inherits genes from both of their biological parents and these genes in turn express specific traits. Some of these traits may be physical, for example hair and eye color, skin color etc. On the other hand, some genes may also carry the predisposition for certain diseases and disorders that may be passed on from parents to their offspring. In addition, it is not only about the human being, but also about variations in similar or related animals and plants.

If we are speaking about genetics, we need to mention some basic elements for easier understanding.

Chromosome is a structure that is thread-shaped, made up of DNA that occurs within the cell nucleus as a microscopic unit. Chromosomes are usually in pairs and the number is different from species to species. “For human beings it is normal to have twenty-three pairs. One in each pair comes from each parent. Twenty-two pairs are essentially alike in both males and females and are called “autosomes”. The twenty-third pair determines sex and hence is distinguished in the male (XY) and female (XX).“[4]

Gene is a segment of DNA that we can find as a structural part of chromosomes and codes for the production of the inherited traits and characteristics. Genes can determine many things that are transmitted from parent to child, like the skeleton, organs or mental chararacteristics. Genes are also in the pairs, and on single chromosomes, we can find many genes. “It is estimated that as many as 30 000 genes exist in each human cell nucleus. If chromosomes are imagined as strings of bread, then the genes would be the bread.”[5]

“An allele is one of two or more alternative forms of a gene that occupy the same position on homologous chromosomes.”[6]



Genetic material has the possibility to change. This is called mutation. A mutation can be the result of a number of different causes, it can be inherited or maybe the product of environment (radiation). Some anomalies are not only the result of a mutation of genes, but a chromosomal defect. There are problems with extra chromosome, that are responsible for the Down syndrome, or lack of autosome, where individuals do not survive birth. There are also problems when a sex chromosome is missing (Turner’s syndrome-XO), or an extra sex chromosome is present (Klinefelter’s syndrome-XXY).

Homo Sapiens − whom Scripture identifies with Adam, person created in the image of God, with possibilities to attain the divine likeness today is almost replaced with Homo scientificus.[7] This is the product of the new age. The things that humans could only dream about and that we saw in science-fiction movies, today is a reality.






Genetic screening can be done on the fetus, or on the parent(s) with different objectives in mind. If the screening is done on the adults, the aim is to be sure regarding reproductive decisions or to test on the late onset disease like Huntington’s disease. In the care of fetus, parents are asking for it, because they can be uncertain about continuing the pregnancy because of the risk of some genetic anomaly. Genetic screening is not possible and not desirable for all. There must be some suspicion.

There are four classes of individuals that are usually identified as most at risk, prime candidates for genetic testing are the following:

1.      “When a family history shows examples of a genetic defect in successive generations, the present generation will surely need to be concerned about its genetic inheritance.”[9]

2.      Second situation will be in a family where a previous pregnancy produced a child with genetic disability.

3.      Third situation will be racial and ethnic groups among whom particular genetic defects occur with some frequency.

4.      Fetal testing is recommended for chromosomal abnormalities when a pregnant woman is over thirty-five.

Questions of ethical implication in the context of genetics have also evolved around equality. This kind of genetic screening is very expensive and it is not possible for everyone. The health care gap is obvious in this case. People are also questioning the matter of invasion of their privacy, as well as insurance companies will want to limit the risk. The question regarding the suspected intention of “perfect” children has increased. It is not only about prevention through abortion when genetic deviation are known in, but also through personal wishes of parents who want children with specific characteristics. It is not only a question about screening, but also about engineering.

We are questioning what will happen in future. What will happen to those children who “slip through whatever genetic safety nets we construct”?[10] For many people abortion is under consideration, when they find out that a genetic deviation is known.  According to statistics, 95% of parents decide for abortion after they find out that the child will have the Down's syndrome. We need to reconsider, how people with disabilities are looking on this. They may understand themselves as a mistake,rather than as a surplus, in the context of such decisions, which are necessarily  complex and subjective discernment processes. However, one can show with these examples how genetic testing and screening interviews both personal and societal ethical dimensions. Therefore, a careful public discourse needs to be led, in which the individual decisions are respected and protected.



PGD - Preimplantation Genetic Diagnosis[11]

Preimplantation genetic diagnosis is understood as testing of embryos because of doubt on some genetic disease. Also, PGD is used in the cases where they need compatible tissue for the family in the case of sickness.[12]  The process of PGD is very simple: one cell is taken away from the embryo when embryo is in the eight-cell phase (that is usually the third day of growth). DNK is analyzed from allocated cell in order to determine the level of the risk of a genetic disease or extra genetic material. In practice, the biggest number of embryos tested is conceived with IVF. Then the couple can make a decision. They can choose which embryo they will put into womb. This process is called PGD with embryonic selection.




The advantage of PGD is that it allows couples with a high probability of serious genetic disease to have a child who will be genetically theirs, but will not inherit the disease. Also, in the UK PGD is most frequently used in order to select a particular gender, in order to avoid diseases that are transmitted on the X chromosome and to check chromosomal disorders. Cystic fibrosis is the most common disease that is tested by PGD.

PGD is inefficient with regard to the characteristics that vary according to two or more genes, however, more serious disorders with a single gene could be easily discovered, and thus present the parents with the possibility of nonimplantation. PGD does not involve modification of the human genetic material. The disadvantage of PGD is that people are not paying attention to the treatment of the embryo, although there is diagnosis, but only on their removal. It is alleged that the implantation of such embryos into a woman increases the risk of miscarriage, and thus after the diagnosis of steam requires to make judgments about life or death of the embryo.[13]


When we talk about choosing gender during PGD, it should be exclusively for medical purposes. This attitude of the ethical committee of the American Society for Reproductive Medicine was presented in 1994. However, since then, more and more people are interested in IVF with no medical indication, but because of the possibility to choose gender. The report from 1994 stated that we should discourage the selection of embryos for a particular sex, because the launch of IVF with PGD for the only reason ofchild sex selection has a higher risk of unjustified gender issues and causes social harm and using medical terms for the wrong purposes. [15]

In May 2001, a new report was published which says that, if it is determined that the cell sorting is safe and effective; doctors should offer sex selection for couples. Couples should be the ones who are fully informed about the risks and failures, and to confirm that it will completely accept a child of the opposite sex, who were advised about unrealistic expectations about the behavior of children of opposite chosen sex and offered them to participate in research on conservation, efficiency and demographics selection of the chosen gender.

       Certainly, we must set boundaries, in which cases the sex selection is allowed and where it is not. Scientist Ewing argues that it is essential that medical ethics should be based on the consistent ethic of the Church, which is staunchly committed to protecting human life, claiming that regardless whether the child is healthy or not, he/she has personality.[16] PGD is quite an expensive process. Of course, the costs are not the only problem, but it is a problem, because this way the diagnosis is only available to certain couples. In the United States, about 9% of clinics allow choosing sex during PGD calling it "family balancing". In these families, if a couple has more children who are of the same sex, they would choose to have another pregnancy only if they will be sure of the child's sex.


Manipulations of genetic material of human beings had biological and social consequences that affect virtually everyone. Genetic engineering involves manipulations of genetic material (DNA) in the gametes or embryo for either therapeutic or eugenic purposes.[18]

Many questions have been raised in the first years when genetic engineering appeared. People were curious what kind of new life is possible to create in the laboratories and what consequences will that have on the future generations? Is it legal to patent living organisms? First experiments were on the animals, and then animal rights advocacy tried to protect them. We have almost the same picture today. Especially in the non-developing countries where there are no legal provisions to protect them.


Scientists after testing for genetic anomalies seek for possibilities to cure, and since the cause of the defect is in the genetic material itself, the only solution is to replace or rebuilt it. Today, we have possibilities for two ways of therapeutic genetic engineering. Those ways are different because of the use of different types of cells. The human organism has two kinds of cells: germ cells (reproductive cells) or somatic (non-reproductive cells). Each normal somatic cell in the nucleus contains 46 chromosomes (23 pairs). Germ cells contain 23 chromosomes, so that the union of sperm and ovum produces a combination of 46 chromosomes. Segments of DNA that determine the genetic code of inherited characteristic we can find in every chromosome that comprises some 100 000 genes. If we want to alter the genetic material of an organism, we need “recombinant DNA” (rDNA) or directly through “transformation” or through “transduction” which is viral transmission. [19]

In 1990 Dr Anderson started gene therapy on a four-year-old child suffered from severe combined immunodeficiency (SCID) by introducing into her blood stream other cells that contain a copy of foreign (foren) gene. Dr Anderson first extracted T-cells from the child’s own blood and exposed to a mouse-leukemia retrovirus. Retrovirus then acting as a vector, invaded the T-cells and incorporated its genetic material, including the missing gene. After that, followed the process of  infusing reengineered T-cells back to the child’s bloodstream, where the new gene began to produce the missing enzyme, so that the immune system started to recover. Dr Anderson reported after few years that the child now has a healthy normal life. This therapy lasted for years, and the child needed to receive weekly injections of PEG-ADA, a drug that provides missing enzymes. After two years of gene therapy, the doctors said that the child does not need to receive therapy anymore, because reengineered cells are now producing ADA enzyme.

Dr Anderson said that gene therapy had not produced a cure, but claimed, “if you put a correct gene into enough cells patient, you will correct the disease”.[20] Today, any activity that involves therapeutic genetic engineering is experimental.

The Orthodox Church in America in 2001 recognized the document entitled "Studies of embryonic stem cells in the perspective of Orthodox Christianity," in which it explicitly exposed the opinion of the Church. The document begins by explaining that the Orthodox believes that human life begins at fertilization and that it is holy from the beginning. [21] Embryonic stem cells can be used for different purposes. On the one hand they can help in the research of infertility or early pregnancy loss. They can also be used in toxicological studies, regarding the effect of new drugs. The most important potential of these cells is their use in transplantation medicine, which can be used as a replacement cell therapy. In this way, it could help people who suffer from diseases that until now could not be cured. Such as diabetes, Parkinson's disease, multiple sclerosis, arthritis, stroke. [22] The American government has allowed research on embryonic stem cells, but this refers to the destroyed embryos that have no possibility of implantation. It further encourages researchers to use adult stem cells to achieve the therapeutic objectives set for embryonic stem cells. What is criticized in relation with such research is mainly the exploitation of the situation by the pharmaceutical industry and the doctors. The point is that these drugs, which are also questionable, will not be able to be accessible to everyone, but only to certain people who have the financial possibilities.

Due to the intrinsic uncertainty about downstream effects, it is necessary to consider the precautionary principle, which demands a justification before permitting any risk-creating activity, with risk being defined both in terms of known hazards and unknown possibilities. The latter is, by definition, incapable of measurement, leading to the criticism that the precautionary principle can be stretched into a generalized prohibition. In cases of known risks- such as devastating genetic diseases- some might argue that any risks associated with gene editing procedures are acceptable. To NOT use a God- given ability would, by this argument, be wrong. At the same time, it must be admitted that it is impossible to confidently predict ALL of the consequences of gene editing- whether of introducing deleterious traits, or by losing unanticipated benefits to retaining particular alleles (7).

Many see the act of choosing to intervene to edit the genome as a usurpation of God’s role in mankind’s existence. While some see choosing as ‘playing God’, others see it as ‘playing human’- exercising an ability given to us by God, as God's agents, part of the stewardship


imputed to us. In this view, being such a partner means taking an active role, and ‘artificiality’, far from being wrong or evil, is rather a sign of humanity's constructive contribution, a sign of doing the duty God has given. Furthermore, it is argued, humans can actively engage in furthering the overall state of humanity by intervening in the works of nature, when the goal is to achieve a natural good, such as health or fertility.

Eugenic Genetic engineering

 When scientists are correcting genetic anomalies, they are doing only one possible way of recombinant DNA technology. There is also the opposite way, when scientists decide to modify the faulty genetic material at concept. Alternatively, even further if there is no defect at all. When this is happening, this can be called eugenic genetic engineering. Here  we can make a connection with PDG for choosing sex.  This is also a method without medical indication, there is nothing to cure, but the couple wants to know what sex will be their future child. They segregate X chromosome from Y. An egg can be artificially fertilized to produce the desired sex. Also, when the intervention has the aim to increase some desirable traits or characteristics it is named as “enhancement genetic engineering”, where the creation of an “improved” individual in a species or a new life form is termed “eugenic genetic engineering”. [23] Cloning involved in genetic manipulation and it’s development created dramatically new dimensions to the discussion of the clinical applications of genetic science and of artificial reproduction. The idea of cloning evolved in history for some time, but it was hard to be implemented. The first famous case that shook the whole planet was the case of sheep Dolly in 1997. There were different theories on the best way for cloning, but DrWilmut who cloned Dolly had a radically new idea. He called it procedure- somatic-cell nuclear transfer technology. Scientist took the nucleus from the six-year-old sheep’s mammary cell and inserted it into an egg from another adult sheep that he had previously enucleated.[24] Then they applied electrical charge that caused the pores of the egg and cell to open, fusing the contents of two and they got an embryo. What may sound an easy procedure was the result of more than 250 attempts before they made it. There were many similar attempts, but what scared people was the idea of cloning people. The same doctor that succeeded in the cloning of Dolly at the end of the 20th century announced that he has the idea of cloning human beings. For the start maybe not the whole human beings, but to clone human embryos in order to withdraw them stem cells.
Stem cells attract big attention of scientists, biologists and theologians. There are a number of reasons. These cells have great potential for healing tissue, so that is the reason why many researchers perceive stem cells as a cell of the future. Also, they can replace defective cells. What is problematic and about what they are debating is that the human embryonic stem cell hES cells derived from human embryos before implantation. The UK is the first country that enacted a law regulating the use of human embryos for stem cell research. [25] Exploitation of stem cells to create chimeras-animals with tissues and organs produced from human stem cells is not ethical. If this would constitute the trend, it will come to a tragic devaluation of human life. Also, Holocaust is universally accepted principle that human experimentation can not be conducted without the permission of the subject. If we consider embryonic stem cells as the beginning of life, how we can get approval?
The main finding of the document that the Orthodox Church in America released is the information that has been proven to be found in adult stem cells, and bearing such great potential, can be said very similar potential with regard to embryonic stem cells, and therefore it is absurd to use the embryonic stem cells. It appeals to the believers not to do evil, citing the Apostle Paul: "Why not say-as some slanderously claim that we say-"Let us do evil that good may result"? Their condemnation is just!" (Rom. 3:8)


Conclusion
      
The separation of therapeutic and non-therapeutic intervention on the human body is very hard and demanding, especially if the body is seen as a psycho-physical corpus. The body of Christ, which is the Church, should be seen as a hermeneutical key of interpretation of the body and because the characteristics of the Church can provide criteria for differentiation allowing unauthorized forms of genetic intervention.
Huxley explored in his novel “Brave New World”, the idea of applying genetic engineering beyond the area of corrective or preventative medicine into changing human characteristics, such as engineering a “master race” and a “slave race”.
If we want that genome editing become a clinical reality, the implications for human enhancement would need to be fully explored alongside the potentional for furthering social disparity. The biggest problem and difficult task is to know where to draw a line from treatment of illness to performance enhancement. If we can do something, does that mean that we should do it? God given ability to reason and explore should be used, as a talent. But, as a Christians, we also need to look wider and to safe those who canot safe themselves, because they are too weak to speak for themselves. Genome editing is seen by many as representing a next step in our ability to analyse and alter the genetics of plants and animals, including ourselves. The notion that knowledge and the choices it offers might be our downfall is as old as the biblical tale of the Garden of Eden. But, in equal measure, history demonstrates the enormous benefits in health and happiness that come with responsible exercise of our intellect and powers of invention. The newest developments in genome editing will demand that we think again about how to balance hope and fear.[26]




[1] Faculty of Orthodox Theology, University of Belgrade. tijana_klek@yahoo.com
[2] Discussion paper by Dr. Murdo Macdonald, Church of Scotland and member of the Thematic Reference Group on Bioethics, Moral and ethical issues in human gene editing.

[3] John Breck, God with us: Critical Issues in Christian Life and Faith, St. Vladimir’s Seminary Press, 2003, 29.

[4]Richard J. Devine, Good care, painful choices: Medical Ethics For Ordinary People, 3rd ed. (Paulist Press, 2004), 125.
[5] Devine, Good care, painful choices, 126.
[6]Ibid.
[7]John Breck, Lyn Breck, Stages on Life’s Way: Orthodox Thinking on Bioethics (Crestwood,NY: St.Vladimir’s Seminary Press,2005), 34.
[8] Tijana Petkovic, A Christian Perspective on Genetic Manipulations,Astra Salvensis, Review of History and Culture, IV, No. 7, 2016.
[9] Devine, Good care, painful choices, 129.
[10]Ibid, 151.
[11] Petkovic, A Christian Perspective.
[12] Australian Government, National Health and Medical Research Council , “Ethical guidelines for the clinical practice of ART in Clinical Practise and Research”, (June 2007), 55.
[13] Ivan Kešina,” Preimplantacijska dijagnostika- u  službi selektivnog pobačaja prije trudnoće”, in: Crkva u svetu 36 (2, 2001), 153-173.
[14] Ethics Committee of the American Society for Reproductive Medicine, “Use of preimplantation genetic diagnosis for serious adult onset conditions: a committee opinion”, in :Fertility and Sterility , (March 13 2013), vol.100, 54-57.
[15] Selena Ewing, “Sex selection 'approved' by the American Society for Reproductive Medicine”, in: Bioethics Research Notes, 13 (December 2001).
[16] Ibid.
[17] Petkovic, A Christian Perspective.
[18]Cf. John Breck, The Sacred Gift Of Life: Orthodox Christianity and Bioethics, (Crestwood,NY: St.Vladimir’s Seminary Press,July 2010), 190.
[19]Breck, The sacred gift of life, 191.
[20] Devine, Good care, painful choises,133.
[21] Orthodox Church in America, “Embryonic Stem Cell Research in the Perspective of Orthodox Christianity”, OCA Chancery NY, (October 17, 2001).
[22] Guido de Wert, Christine Mummery, “Human embryonic stem cells: research, ethics and policy”,in:  Oxford Journals, (Vol. 18, Issue 4), 672-682. 
[23] Devine, Good care, painful choises, 134.
[24] Ibid.
[25]Cf. Guido de Wert, Christine Mummery.
[26] Discussion paper by Dr. Murdo Macdonald, Church of Scotland and member of the Thematic Reference Group on Bioethics, Moral and ethical issues in human gene editing.