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Germline Gene Transfer

Gene transfer represents a relatively new possibility for the treatment of rare genetic disorders
and common multifactorial diseases by changing the expression of a person's genes. Typically
gene transfer involves using a vector such as a virus to deliver a therapeutic gene to the
appropriate target cells. The technique, which is still in its infancy and is not yet available outside
clinical trials, was originally envisaged as a treatment of monogenic disorders, but the majority of
trials now involve the treatment of cancer, infectious diseases and vascular disease. Human
gene transfer raises several important ethical issues, in particular the potential use of genetic
therapies for genetic enhancement and the potential impact of germline gene transfer on future
Scientific Issues
Gene transfer can be targeted to somatic (body) or germ (egg and sperm) cells. In somatic gene
transfer the recipient's genome is changed, but the change is not passed on to the next
generation. In germline gene transfer, the parents' egg and sperm cells are changed with the
goal of passing on the changes to their offspring. Germline gene transfer is not being actively
investigated, at least in larger animals and humans, although a great deal of discussion is being
conducted about its value and desirability.
Many people falsely assume that germline gene transfer is already routine. For example, news
reports of parents selecting a genetically tested egg for implantation or choosing the sex of their
unborn child may lead the public to think that gene transfer is occurring, when actually, in these
cases, genetic information is being used for selection, with no cells being altered or changed. In
addition, in 2001 scientists confirmed the birth of 30 genetically altered children whose mothers
had undergone a procedure called ooplasmic transfer. In this process, doctors injected some of
the contents of a healthy donor egg into an egg from a woman with infertility problems. The
result was an egg with two types of mitochondria, cellular structures that contain a minuscule
amount of DNA and that provide energy for the cell. The children born following this procedure
thus have three genetic parents, since they carry DNA from the donor as well as the mother and
father. Although the researchers announced this as the "first case of human germline genetic
modification," the gene transfer was an inadvertent side effect of the infertility procedure.
Many factors have prevented researchers from developing successful gene transfer techniques in
both somatic and germline attempts (the latter in animals). The first hurdle is the gene delivery
tool. The new gene is inserted into the body through vehicles called vectors (gene carriers),
which deliver therapeutic genes to the patients' cells. Currently, the most common vectors are
viruses, which have evolved a mechanism to encapsulate and deliver their genes to human cells
in a pathogenic manner. Scientists have tried to take advantage of the virus's biology and
manipulate its genome to remove human disease-causing genes and insert therapeutic genes.
However, viruses, while effective, introduce other problems to the body, such as toxicity,
immune and inflammatory responses, and gene control and targeting issues. Complexes of DNA
with lipids and proteins provide an alternative to viruses, and researchers are also experimenting
with introducing a 47th (artificial human) chromosome to the body that would exist
autonomously along side the standard 46 chromosomes, presumably not affecting their
functioning or causing any mutations. An additional chromosome would be a large vector
capable of carrying substantial amounts of genetic code, and it is anticipated that, because of its
construction and autonomy, the body's immune systems would not attack it.

Some of the concerns raised about somatic gene transfer are related to the possibility that it
could inadvertently lead to germline gene transfer. The possibility of germline modification
through these techniques is the result of the hit-or-miss nature of the current technologies. It is
always possible that a vector will introduce the gene into a cell other than that for which it is
supposed to be targeted (e.g., a spermatocytic cell) or that through a secondary mechanism
target cells that have taken up the new gene will through some independent natural process
(such as transfection) transfer the gene to a germline cell. Moreover, if somatic gene transfer
were to be conducted in utero, especially before the second trimester, it would increase the
likelihood that some of the cells into which the gene is taken up will become part of the germline.
It is possible that to effectively treat certain diseases using gene transfer, it might be necessary
to apply somatic techniques early in development so that germline transfer is inevitable.
In contrast to inadvertent germline transfer following somatic gene transfer, intentional germline
gene transfer would involve the deliberate introduction of new genetic material into either germ
cells (sperm or oocytes) or into zygotes in vitro prior to fertilization or implantation. Currently,
this technology has not been applied to humans; however, it has been successfully applied to
some plants and animals. The aim of this process is to produce a developing embryo in which
each cell (including those that will develop into gametes in the future) carries the newly inserted
gene as part of its genetic make-up.
Current efforts in animals have demonstrated the difficulty of this approach. Some cells do not
acquire the gene or acquire multiple or partial copies of the gene. In addition, it is not yet
possible to specify with any accuracy where in the genome the new gene will be introduced, and
some insertion locations may interfere with other important genes. If these kinds of errors are
detected, then theoretically embryos with these defects could be "selected out." However,
should germline gene transfer be attempted in humans, it is likely that not all errors introduced
as a result of the gene transfer will be detected.
Currently, however, animal studies have shown that gene transfer approaches that involve the
early embryo can be far more effective than somatic cell gene therapy methodologies used later
in development, depending on the complexity of the trait that is being improved or eliminated.
Embryo gene transfer affords the opportunity to transform most or all cells of the organism and
thus overcome the inefficient transformation that plagues somatic cell gene transfer protocols.
Gene transfer selects one relevant locus for a trait (when in fact there might be many interactive
loci) and then attempts to improve the trait in isolation. This approach, while potentially more
powerful and efficient than conventional breeding techniques, involves more uncertainty risks.
Ethical Concerns
Thus, both kinds of studies - germline gene transfer at the gamete and zygote stages - have
significant risks. In cases in which the gene has failed to be introduced or fails to be activated,
the resulting child would likely be no worse off than he or she would have been without the
attempted gene transfer. However, those with partial or multiple copies of a gene could be in
significantly worse condition. The problems resulting from errors caused by the gene insertion
could be severe - even lethal - or they might not be evident until well after the child has been
born, perhaps even well into adulthood, when the errors could be passed on to future
generations. For these reasons, given the limits of current technology, germline gene transfer
has been considered ethically impermissible.
Beyond the medical risks to the potential child, a number of long-standing ethical concerns exist
regarding the possible practice of germline gene transfer in both human and nonhuman cases.

Such modifications in human beings raise the possibility that we are changing not merely a
single individual but a host of future individuals as well, with potential for harm to occur to those
individuals and perhaps to humanity as a whole. Concerns involve issues ranging from the
autonomy of future individuals to distributive justice, fairness, and the application of these
technologies to "enhancement" rather than treating disease. In germline gene transfer, the
persons being affected by the procedure - those for whom the procedure is undertaken - do not
yet exist. Thus, the potential beneficiaries are not in a position to consent to or refuse such a
Regulation and Policy
Gene transfer clinical trials have a unique oversight process that is conducted by the National
Institutes of Health (NIH) through the Recombinant DNA Advisory Committee (RAC) and the NIH
Guidelines for Research Involving Recombinant DNA Molecules, and by the Food and Drug
Administration (FDA) through regulation (including scientific review, regulatory research, testing,
and compliance activities, including inspection and education). Of note, FDA regulations apply to
all clinical gene transfer research, while NIH governs gene transfer research that is supported
with NIH funds or that is conducted at or sponsored by institutions that receive funding for
recombinant DNA research. Currently, the majority of somatic cell gene transfer research is
subject to the NIH Guidelines; however RAC will not currently consider protocols using germline
gene transfer.
In addition, NIH has added to its guidelines the following statement:
The RAC continues to explore the issues raised by the potential of in utero gene transfer clinical
research. However, the RAC concludes that, at present, it is premature to undertake any in
utero gene transfer clinical trial. Significant additional preclinical and clinical studies addressing
vector transduction efficacy, biodistribution, and toxicity are required before a human in utero
gene transfer protocol can proceed. In addition, a more thorough understanding of the
development of human organ systems, such as the immune and nervous systems, is needed to
better define the potential efficacy and risks of human in utero gene transfer. Prerequisites for
considering any specific human in utero gene transfer procedure include an understanding of the
pathophysiology of the candidate disease and a demonstrable advantage to the in
utero approach. Once the above criteria are met, the RAC would be willing to consider well
rationalized human in utero gene transfer clinical trials.
Is germline gene therapy ethical?

Germline gene therapy targets the reproductive cells, meaning any changes
made to the DNA will be passed on to the next generation. Consequently, the
practice has dramatically divided opinion.
Germline gene therapy is when DNA is transferred into the cells that produce
reproductive cells, eggs or sperm, in the body. This type of therapy allows for the
correction of disease-causing gene variants that are certain to be passed down from
generation to generation.

However, for many, this is where they feel the benefits of germline gene therapy
stop. Germline gene therapy is currently not legal in the UK because the risks still
appear to outweigh the benefits.
Somatic? gene therapy is when DNA is transferred into body tissues. It specifically
targets cells in the body which are not passed on to the persons children. As a
consequence, it doesnt raise the same ethical issues as germline gene therapy.
So, do the ethical issues associated with germline gene therapy make it
unacceptable? Or, is it just the lesser of two evils when compared with the impact of
some genetic diseases? Read some of the arguments for and against, and see what
you think

Do the potential benefits of germline gene therapy outweigh the

potential risks?
The effects of gene therapy are too unpredictable. Even if the therapy successfully
cures the disease, other mutations can potentially be introduced.
Because germline gene therapy targets the reproductive cells, any additional
mutations that are introduced as a result will be passed on to the next generation.

Does germline gene therapy consider an individual's human rights?

Individuals produced through germline gene therapy cannot give their consent
for their genetic material to be modified.

Is germline gene therapy ethically acceptable?

Theoretically germline gene therapy could be used to select for particular
physical characteristics regardless of whether they are important for the health of
the individual.
On a large scale, germline gene therapy could result in the selection of
characteristics to improve the genetics of a population.
The widespread use of germline gene therapy may make society less accepting of
people who are different or who have a particular disability or genetic condition.

Is germline gene therapy affordable?

In areas of the world without a free health service, only parents who can afford
suitable health insurance will be able to undergo germline gene therapy. Poorer
parents will not have access to this form of therapy.

Is germline gene therapy really needed?

Germline gene therapy would never be effective enough to rule out the need for
post-fertilisation screening ofembryos?.
Germline gene therapy involves more steps and introduces additional risks to the
embryo compared with IVF and screening for healthy embryos before implantation.

It is clear that there will always be people who will exploit new successes. If germ line
gene therapy is proven to cure various diseases in the near future, who knows what new
experiments we can achieve. For instance, scientists will find fresh new ideas for the
supply of desirable traits that individuals would want. It could create chaos. The line
between right and wrong will always be cloudy no matter what the subject is, including
science. On the other hand, there is still a lot of scientific risk and uncertainty. Germ line
gene therapy is still in its youth, so we do not know how much control it has. While it is
ultimately used to cure various diseases, it has not even been trialed on humans yet.
These countless factors needed to be taken into account before testing it on ourselves.
Furthermore, more failures in tests would mean more supplies, money and time wasted.
Paul Diehl, who is the current Director of Business Development in biotech company
Cellecta Inc explains, Gene therapy involving germ line cells--eggs and sperm--is
controversial because the changes are heritable. Genetic changes in these cells affect
untold future generations so the impact of any mistake can be catastrophic.
Germ line gene therapy would lead to an as yet unborn individual having their genes
tampered with, without them being able to agree to it or not. If something goes wrong,
they have to live with it.
Germline gene therapy would involve the genetic modification of germ cells. Such
therapy would change the genetic make up of the egg or sperm of an individual and
would be carried on to future generations. This would offer the possibility of removing an
inherited disorder from a family line forever. This could be achieved by other methods,
such as, at present, diagnosis when there is a known risk before embryo implantation
during IVF. Germ line therapy is a remote prospect and general opinion is strongly
negative; such therapy is currently illegal in most of Europe.
Germ line gene therapy is very controversial, as it modifies what we were made to be.
Changing ourselves to what we want ourselves to become, can be seen as immoral and

dishonest. Furthermore, it conflicts with countless religions, because of the ways we are
trying to make ourselves better. Like the last argument, this could be a stepping stone
to manipulating human traits, characteristics and personalities. It can spark many ideas
that are eugenically terrifying too. It is clear that genetic technology will always affect
humanity no matter what the circumstance is.
1. Germ-line therapy involves too much scientific uncertainty and risk.
2. As germ-line therapy involves research on early embryos, such research essentially creates generations of
unconsenting research subjects.
3. Germ-line therapy would violate the rights of subsequent generations to inherit a genetic endowment that has not been
intentionally modified.

Germline gene therapy and somatic gene therapy are two quite different proposals, and the legitimate
concerns and risks of the former should not be used to stall progress on the latter. The biomedical
research community should act quickly and decisively to divorce the two before pushing ahead with wellconceived postnatal and fetal somatic gene therapy protocols.
That gene therapy continues to attract some of the best minds and major funding despite having few
successes to its name is testament to the great potential of this technique. When challenging but technical
issues surrounding efficient and selective delivery, and continued and appropriate expression of the
therapeutic gene are overcome, gene therapy could revolutionize a large sector of the medical community.
Following French Anderson's well-publicized and welcome move to have the US Recombinant DNA Advisory
Committee (RAC) review two human fetal gene therapy protocols, fetal (or in utero) gene therapy has
become the 'talk of the biomedical town'. And as Holm Schneider and Charles Coutelle explain in their
Commentary (see page 256 of this issue), there are good reasons to extend gene therapy trials to the
fetus: The high level of cell division in the fetus suggests that in utero gene therapy may result in better
cellular uptake of vectors and their therapeutic genes; the still-developing immune system is more likely
than a more mature postnatal immune system to accept this foreign invader; and finally, the early
correction of genetic defects will often avoid irreparable damage to the developing fetus. Paul Billings
presents the counter-argument (see page 255), stressing the difficulty involved in monitoring the safety of
such protocols (and particularly subtle or long term adverse effects); the fact that there are alternatives
to in utero gene therapy; and of course the considerable shortcomings of current gene therapy protocols.
But the mere mention of fetal gene therapy more often than not leads to a quite different discussionthat
of germline alterations. Indeed, the possibility that somatic gene therapeutics may find their way to the
recipient's germline and from there become part of the heritable genetic make up of the subject (also
discussed in the above Commentaries) is often at the center of objections to the procedure. So far, only a
few studies of this potential have been published, and none have shown any risk to the germline. Certainly
the issue should be addressed and in utero animal trials should incorporate an assessment of the risk to
the germline. But this issue should not stand in the way of future research and, when the time comes,
human trials.
Even more troubling is the recent spread of the germline risk argument to include postnatal gene therapy
trials. Philip Noguchi, Director of the Division of Cellular Therapies at the Food and Drug Administration
(FDA), confirms that concern with germline spread is so great that after successful animal studies, some
researchers have found their postnatal human gene therapy clinical trial protocols stalled over the
germline issue. This is relatively new development at the FDAtraditionally, human trials have been
approved without the need to examine the germline risk.
The RAC advises the FDA on such issues, and at a January 1999 meeting to discuss in uterogene therapy,
the question of germline risk was tackled. James Wilson, director of the Institute for Human Gene Therapy
at the University of Pennsylvania Medical Center, explained that because gene therapy vectors spread
beyond the site of distribution, they find their way into the circulation and therefore inevitably into the
gonads. Thus, there is a finite chance that vectors could integrate into the germline genetic material.
Examination of gonadal tissue taken from animals used in post natal somatic gene therapy protocols
confirms that gene therapy vectors injected intramuscularly do occasionally make their way to the gonads.
But is an untoward effect on the germline likely?
Wilson has considered the efficiency of transduction within the gonads, the likelihood that such a
transduction event involves a germ cell (as opposed to the preponderance of non-germ cells found in the
gonads), and the chance that a vector insertion event might lead to a genetic defect. His conservative
estimation of the overall risk of a negative outcome due to inadvertent germline gene transfer is in the
order of a one in a billion chance or less! Of course these calculations are at best an approximation based
on only a broad examination of the issues. But in conjunction with experimental data, they suggest that

the risk that somatic gene therapy trials, postnatal or in utero, have a heritable component is not only
unlikely, but so unlikely as to be an unnecessary distraction from the pursuit of effective in utero and
postnatal gene therapy.
Data on gonadal and germ cell vector transfer is relatively easy to gather, and as it accumulates, these
risks will be refined. While demanding that such analyses be incorporated into all future animal and human
gene therapy trials, the FDA and other regulatory bodies around the world should resist inevitable
pressure from luddites, and perhaps the politicians that listen to them, to delay these important trials
because of a vanishingly small germ cell risk. Meanwhile, the community should start serious and openminded discussions on the pros and cons associated with germline gene therapy itselfa completely
separate issue.