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So, why take the new, riskier—and, to many people, disconcerting—path of gene editing rather than just selecting embryos? There are at least three plausible answers, although they do not apply to many people. First, some people believe that embryos have a high moral status and should, if possible, be saved rather than discarded. From that perspective, a couple would make one or a few embryos, test them all, edit all those with genetic problems, and, over time, transfer all of them for possible implantation and birth.

All of these steps are against Catholic doctrine. I suspect not many. Second, some couples may be limited in their ability to make sufficient IVF embryos for selection through PGT to be effective. If a couple make only one or two embryos, the chances are higher that one or both will carry a deleterious gene.

It is not only that the low odds sometimes happen use IVF in 1 million women and will have a once in a outcome , but additional risk factors come into play; for instance, embryos with the wrong number of chromosomes. This may well affect some couples—at least for a few years—though we do not know how many. There is evidence that PGT, when used to avoid genetic disease, fails to produce live births in most cycles.

Genome editing and human reproduction: social and ethical issues

In the longer term, we should be able to make eggs and, if necessary, sperm from skin cells using induced pluripotent stem cells iPSCs. This has already been done successfully in mice, with both eggs and sperm. I have argued that it is likely to be in widespread clinical use in humans between and If this timing holds, creating gametes through iPSCs may be available by the time, or not much later than, we have good evidence for the safety of GGE. That would eliminate a shortage of embryos as a problem with PGT.

It depends on the proven safety of GGE, on the long-term success of PGT for couples, on the proven ability to provide safe stem cell-derived eggs, and on many other issues. It is possible that GGE will, for some time, be a proven better alternative for some people. My own guess is that this will not prove to be the case, at least not for many or for long, but we will have to wait and see. Consider a couple wherein each has the autosomal recessive disease, cystic fibrosis.

Any genetic child of theirs will get one bad copy from the father and one bad copy from the mother—because that is all they have to give.

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Similarly, a person with two copies of an allele for an autosomal dominant disease can only produce genetic children who have at least one bad copy of the gene because the child must get a copy from him or her. These couples recessive or individuals dominant cannot make any healthy embryos or have any healthy genetic children without genome editing. The stories with X- and Y-linked diseases are similar, although a little more complicated.

Embryo editing might be able to help in these four cases. Knoepfler has put this forward as an argument against this use for GGE. It is possible that GGE may be so wonderful that it will avoid the decades-long uncertainty about safety and efficacy that has characterized so many biomedical advances, from monoclonal antibodies to gene therapy.

It is not impossible, but I would not bet on it.

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These examples require that the people with the disease live long enough and be healthy enough to be willing and able to have children. People born with many rare genetic diseases never live to puberty and will never find themselves in this position. Similarly, a very few people have two copies of a powerfully autosomal dominant disease allele.

How many such couples will there be in the world? That is impossible to know, but it seems highly unlikely it will be more than a few thousands out of the world's 7.

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Are the speculative or metaphysical concerns about GGE good reasons to stop eager people, even if only a handful, from having a plausible way to produce healthy children from their own, otherwise unhealthy genomes—especially in societies that jump through hoops such as IVF or PGT to allow other people to have healthy genetic children? I think not. But PGT is not the only technical possibility for avoiding disease in a child. This kind of somatic cell gene therapy 11 has been under development for nearly 40 years. The FDA approved the first somatic gene therapy treatment for an inherited disease in , 29 but by it expects to approve 10 to 20 gene or cell therapies each year.

Somatic cell therapy does not change the germline, and it is a technology much closer to being shown safe and effective than GGE. Arguably, the fact that the change is only being made in one or a few of the many tissues of the body would improve its safety over a change that exists in every cell, including cells wherein a particular off-target change has harmful effects. In contrast, genome editing of an egg, a sperm, or a zygote only needs to change a single cell. This might prove safer and more effective than changing, say, million blood-forming stem cells or several billion lung cells. Furthermore, somatic cell editing would not necessarily work for all conditions.

ASAN Comments on the Clinical Use of Human Germline Genome Editing | Autistic Self Advocacy Network

For some, it may be the case that the damage begins before birth, or even before the stage of fetal development where in utero somatic editing becomes plausible. For diseases with very early consequential effects, somatic cell therapy may be inferior to embryo editing or embryo selection.

Even when somatic editing is possible, GGE retains one advantage: the process would not have to be repeated in the next generation. If somatic editing is used, that person would still have eggs or sperm that could pass on the disease. If she or he wanted to avoid a sick child, PGT or somatic cell gene therapy might be necessary. But is this a bug or a feature?

It adds a choice—not a choice for the embryo that is, or is not, edited but for the parents of that embryo. Somatic cell editing continues the possibility of a disease in the next generation—but allows that generation's parents to make the decision. One might—or might not—see that as a benefit.

Note that these are prices , not costs—we do not know how much gene therapies cost companies to make and provide, let alone on what accounting basis. Perhaps GGE would be cheaper—depending on vagaries of patent protection and potential regulatory exclusivities. If the GGE therapies are produced by the existing biotechnology and pharmaceutical industries, I think lower prices than for gene therapies, though devoutly to be hoped, are unlikely.

In non-Mendelian multigenic diseases, no one allele plays a powerful role in causing the disease. Variations in dozens or hundreds of genes may influence the condition. The biggest problem with GGE for non-Mendelian conditions is that we do not know nearly enough about the conditions. Many conditions are non-Mendelian, but how many genes are involved? Which alleles add or subtract risk?

How do the effects of alleles from different genes combine to create risks? But there is no inherent reason nature has to work that way; the combined effects may be greater or less than their sum. It is even conceivable that having two alleles that each, individually, raise a person's risk might somehow lower the overall risk. And we know almost nothing about the structure of these multigenic risks.

Human Genome Editing: Science, Ethics, and Governance

The chances of finding an embryo with the right combination of alleles at five spots across the genome will be much smaller than of finding an embryo with just one desirable allele. If multiplex gene editing could safely and effectively edit five places in an embryo's genome or in two gametes' genomes , it could deliver the preferred outcome. In contrast, if we can use genome editing to do that in an embryo or gamete, we may well be able to do the same in a fetus, baby, a child, or an adult through somatic cell gene therapy—unless the condition begins to cause harm early in development, or broadly enough in the body that it needs to be delivered to all the body's cells.

Right now, there is no non-Mendelian condition for which we know the exact set of genes that are involved or the negative and positive effects of various allele combinations. Until these uncertainties are adequately resolved, GGE, though in theory better than PGT, will not be safe or effective enough for use. Once they are resolved, in many situations it will be no better or worse than somatic cell genome editing, except for the absence of a need to repeat the editing for the next generation.

Somewhere in the no man's land between treating disease and enhancing traits lies editing disease-prevention alleles into a person's genome. Instead of editing out an unusual pathogenic variation in favor of a common allele, the procedure could be used to edit out a common normal-risk allele and turning it into an uncommon or even rare allele that lowers the risk below the population average.

Two examples may be illuminating. One is what He Jiankui tried to do: introducing into the normal sequence of CCR5 a base-pair deletion that does not make a functioning protein. The other example changes the normal version of PCSK9 to a nonfunctional version.

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In , researchers discovered that a few people who carried mutant versions of PCSK9 had extremely low LDL levels and very low coronary artery disease risks. He's group had reportedly explored the idea of editing an embryo to inactivate the normal version of PCSK9. PGT would seldom be helpful in choosing embryos with these protective alleles. It can only select embryos with variations their parents have. For these traits, inherited as recessive conditions because of their loss of function nature, each parent would need to have at least one copy of the allele.

Genome editing should—eventually—have little to no trouble with these kinds of changes when they are Mendelian and involve only one gene. This is what He Jiankui tried poorly, recklessly, and unsuccessfully to do. Could somatic gene therapy work equally as well as germline genome editing? Presumably it could. If this could work in embryos, it will work with living people. Again, embryo editing would work better than somatic editing if the problematic conditions started early enough so that even fetal cell therapy would be too late, or if the resulting change needs to be in a large percentage of the body's cells.

In contrast, as already noted, somatic gene therapy can try to target particular tissues, avoiding risks that might arise in other tissues, either from planned or unplanned changes.

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  • Either type of change could have particularly damaging consequences during embryonic or fetal development; somatic therapy would minimize those.