Geneforum Interview with Dr. Eric T. Juengst - Enhancement Genetics: Let the Games Begin

A Geneforum Interview with Dr. Eric T. Juengst
Professor of Medical Ethics, Oncology, and Philosophy of Science
Center for Biomedical Ethics
Case Western Reserve University

by Mark Compton

When the US National Institutes of Health first set up the National Center for Human Genome Research, concerns about the ethical dimensions of the research were so great that 5 percent of all the funds allocated to the Human Genome Project were set aside to study just those very issues. The NIH's Ethical, Legal and Social Implications Branch (ELSI, for short) was created as a result. And the first chief of that operation, from 1990 until 1994, was Dr. Eric Juengst.

Eric T. JuengstNow teaching medical ethics, oncology and the philosophy of science at the Case Western Reserve University School of Medicine, Juengst remains actively involved in efforts to set public policy. Besides serving on a steering committee that develops new initiatives for ELSI, he's also a member of the US Recombinant DNA Advisory Committee and the Federal Bureau of Investigation's DNA Advisory Board.

All of which serves to give Juengst a front-row seat to the competition to develop winning genetic interventions. But, as he freely concedes, it remains to be seen whether efforts to improve on natural genetics will ultimately prove to be a triumph of intrepid scientific endeavor or just another human comedy.

[The views and opinions expressed by the participants in this interview are not necessarily those of Geneforum, and the publication of this interview should in no way be construed as an endorsement of those views.]

[Mark Compton]: Johann Olav Koss, the Norwegian speed skating champion who won an Olympic gold medal in 1994, has since become a physician. So it was interesting to read recently that he'd been quoted as saying he believed athletes may already be employing gene engineering to achieve enhanced performance. But don't we have a way to go before we have safe and effective interventions for increasing fast-twitch muscle fibers, strength and oxygen-carrying capacity?

[Eric Juengst]: Yes, we certainly do have a way to go. But I don't think Koss could have been thinking about gene transfer experiments. He must have been talking about biosynthetic hormones and other biologicals produced through genetic engineering.

Something that's injected or taken orally as opposed to something that's inserted directly into a cell?

Right. Like EPO blood doping to increase the oxygen-carrying capacity of your blood. Well, that's a product of genetic engineering in the sense that the compound is produced by bacteria in some biotech lab. But it's not genetic engineering in the sense of actually altering the athlete's genes.

I take it, then, that you don't believe anyone is foolish enough to attempt any of the primitive gene replacement interventions that might be available at this point.

I make no representations as to degrees of foolishness. It's true that in elite sports the competition is fierce enough to drive people to do all kinds of foolish things. And it's conceivable to me that athletes and their physicians somewhere along the line might embark on just the sort of course you're suggesting. I just don't believe it would work.

But as it stands—given the obvious risks—wouldn't such treatments be in clear violation of traditional medical ethics?

Yes—as is the abuse of performance-enhancing drugs, but that's already very much in evidence today.

So an athlete bent on achieving an advantage through gene replacement is likely to have no difficulty in locating an obliging physician?

Right. Obliging physicians are not in short supply. As to whether those physicians will have the requisite technical know-how, that may be another matter.

The New York Times recently reported that as part of a 1995 survey, nearly 200 aspiring American Olympians were asked if they would take a banned substance that would guarantee victory in every competition for five years but then would cause death. More than half said they would. Despite the American tradition of giving individuals a huge amount of autonomy over their bodies, can researchers and health providers ethically permit themselves to be swayed by values that are so obviously skewed?

No, they shouldn't. But that striking survey just points out how coercive sports competition can be. And in a sense, that's the leg physicians and scientists have to stand on when they say their duty requires them to draw a line on this issue. Rather than focusing on whether we're interfering with the athletes' freedoms—their autonomy to do as they wish with their bodies—what I think we should bear in mind is that what these individuals do with their bodies ends up having a direct impact on what other athletes do with their bodies.

So people end up being persuaded to follow this path simply because they feel that not to do so would put them at a significant competitive disadvantage?

Right. The presumption is that they're all in this game together and that the pressure to win forces them to keep up with all the latest advantages, whether that's clapped skates, fiberglass vaulting poles or shark swimsuits. If anyone has one, then everyone needs to have one in order to compete. And the same goes for modifications of their own bodies. In the medical provider community, we've traditionally said, "You're free to do what you like, up to the point where your actions start affecting the interests of other people."

But even apart from considerations of social pressure, wouldn't a physician be morally obliged to at least explore the implications—that is, to encourage the patient to step back and weigh all the risks against the potential benefits?

Right. That age-old axiom in medical ethics, "first do no harm," would come into play and should give any physician pause. The risks of this are so very high that you, Mr. Athlete, need to think about the benefit:risk ratio. The question is: What considerations do you allow as part of that calculation? On strictly medical grounds, it's pretty clear that the risks outweigh the benefits. But if we're going to let the athlete factor in his own life plans, his own values, his own interests as part of the calculus, then maybe the equation balances or even comes out in favor of the interventions.

Now, of course, for all the risks and uncertainties that seem so clear today, isn't it possible that gene replacement interventions might someday prove to be quite safe and effective?

Yes. I don't think the wind is totally out of the sails for gene therapy. Obviously, in the 10 years of experience we've had, it's proven more difficult and complicated than the pioneers first thought. But that probably shouldn't come as a surprise. Biology is always more complicated than we think.

And really, is 10 years all that much time?

Exactly. I think we will, with time, develop techniques that get around a lot of the problems we're facing today. For example, one of the promising things on the horizon is the advent of new capabilities for getting DNA into human cells, which should allow us to abandon the use of viruses altogether.

And the significance of that is due to the difficulties with targeting viruses?

Yes. Difficulties with targeting and also with the kinds of immune reactions that can lead to dramatic complications, even death. And that's precisely what can happen when the body recognizes a virus as something it's seen and tried to fight off before. A better alternative would be to go with an artificial chromosome, a completely constructed package for the modified DNA that could be insinuated into the cell, where it would then behave just like the rest of our chromosomes.

With the artificial chromosomes, would it also be possible to incorporate "on" and "off" switches?

Right. That's another advantage—in theory, at least. The idea is that they could be controlled by the patient or his doctors by way of medication. You'd take a particular drug that would help to regulate the artificial chromosomes.

I can see that in certain situations—the stimulation of growth hormone, for example—you'd clearly want to be able to find the off switch at some point.

That's right. And maybe even some other capabilities beyond what the regular cellular regulatory systems would be able to provide.

Is it feasible that the day will come when technical issues are no longer even a consideration?

No, I think technical considerations will always be an issue because as we resolve certain problems, new ones will arise. We'll always be trying to do more difficult things. So that's always going to be a part of the equation, but in the foreseeable future I expect we'll be able to do some significant set of gene transfer interventions with relative safety.

Just for the sake of exploring some of the ethical dimensions, then, let's make the optimistic assumption that refined techniques capable of the success rates we tend to associate with proven medical procedures will someday be achieved. I really wonder how much angst all this will cause a few years from now. I mean, for example, a Newsweek report appearing shortly after a 1998 UCLA gene engineering conference suggested that while the genetic engineers at the conference were ethically reconciled with somatic gene therapies (which treat patients but leave their genetic legacies unaltered), they were far more dubious about germline gene replacements (which affect not only the patient but also all of the patient's descendents). In fact, it was reported in that same article that "the overwhelming majority of scientists and ethicists oppose gene therapy that changes the germline." But now, barely three years later, it would seem that—within the genetic research community, at least—most qualms having to do with germline therapies for serious human diseases have been laid to rest. Instead, most of the questions and criticisms now seem to be reserved for gene manipulations aimed at achieving enhancements beyond good health. I'm reminded of the furor and moral outrage surrounding the introduction of in-vitro fertilization techniques just over a decade ago. Now, in-vitro procedures have become quite commonplace. Does this all suggest, ultimately, that we can get used to just about anything?

Yes. I think we can get used to just about anything. The question is: Should we? Because there are a lot of things—social, environmental and interpersonal—that we live with but probably shouldn't. Does that represent a kind of complacent acceptance of a fait accompli? Or is it the result of some real change in people's thinking? I think it's a little too early to say the tide has shifted where gene therapy is concerned. If you polled the scientific community, I think you'd still find that the majority of scientists express concerns over germline interventions.

That is, if you expanded the survey to more than just the ideologically pure types that tend to appear at conferences?

Right. It's actually quite interesting to note that the main proponents for germline gene therapy in the literature over the past few years—with the exception of some prominent scientists like Lee Silver and Jim Watson—have been non-scientists. The people who've really taken up the cause, by and large, are ethicists and even some theologians.

Really?

Yes. Ted Peters at the Graduate Theological Union in Berkeley is a good example. In contrast, scientists—according to my observations, at least—remain quite cautious. For example, the report from the AAAS (the American Association for the Advancement of Science) on this topic of germline interventions takes quite a cautionary approach in its conclusions. It says that if we were ever to contemplate developing therapies aimed at the germline, the studies done to ensure their safety and efficacy would essentially have to be performed over multiple generations in order to see the effects in the offspring and their offspring. So, according to that view, we should settle back for the next 100 years before we even begin to think about launching into this.

I somehow doubt everyone is going to be quite that patient.

Right. So clearly, the sociology of the debate is still very unsettled. It's an open question, with arguments to be made on both sides. But that's different from a few years ago when everybody—critics and proponents alike—could happily agree to bracket off the whole topic for later consideration. The scientific possibilities just didn't seem quite so imminent back then. What's changed is that the science is getting much closer. I think we always believed we'd be able to work out the kinks in somatic cell gene therapy before we'd even have to think about tangling with all the ethical issues surrounding germline interventions.

So, basically, germline has appeared on the radar screen much earlier than anticipated.

That's right. And that's partly because we've discovered that it's very hard to make somatic cell interventions work the way we want them to. One way to achieve greater efficiency—to raise the levels of gene expression—is to make the changes earlier in development, pre-natally.

That certainly would eliminate the targeting problem as well.

Right. So, rather than waiting for somatic cell therapy to be perfected, we find ourselves looking at doing interventions that are functionally equivalent to germline interventions in order to achieve the goals originally set out for somatic cell therapy.

So we're more or less stumbling into germline intervention instead of addressing it directly. Isn't there some danger in that?

Sure. And that's exactly what we're seeing with the mitochondrial transplants. We've definitely stumbled into intervening in the human germline by injecting cytoplasm from one set of eggs, including mitochondria which contain their own DNA, into the eggs of another woman in order to improve her chance of fertility. That's already happened, so we've already crossed the germline barrier in that respect. And that's something that happened completely off the radar screen of public policy debate because it wasn't initially perceived as a form of germline engineering. We just weren't looking in that particular direction when it came to pass.

So the gendarmes were unaware? But was that step across the germline entirely inadvertent?

Well, it wasn't an accident because, in the paper the researchers [J. A. Barritt, et. al.] published in Human Reproduction, they were quite proud to announce that these births represented the first successful germline modification of human beings.

Always better to ask forgiveness than permission, I say.

Actually, I've used that phrase myself.

Okay, so germline interventions are with us. That's reality. But there's still the question as to where they're appropriate and where they aren't. For the most part, scientists seem to distinguish between interventions that fight serious disease and those aimed at attaining certain improvements. Assuming there is, in fact, an important moral distinction to be made between combating human disease and enhancing human traits, how do you go about drawing the line? And where do you draw that line?

That's a good question. But it's hard to answer because every trait spans an entire spectrum of considerations.

Okay, but what would be some of your chief criteria? Let's approach it that way.

The way I've seen this debate evolve is that we have three basic classes of interventions. One includes those interventions aimed at treating classic diseases—diseases that follow the medical paradigm of being diagnosable and causing suffering and having specific causes. That's one end of the spectrum. At the other end of the spectrum are those interventions that don't seem to treat a disease at all but are instead specifically aimed at enhancing normal human traits. And then in the middle—the interesting place where we're going to have to draw this line—are interventions aimed at enhancing normal traits in order to prevent classic diseases. For example, what if we want to upgrade someone's immune system so as it will be better at seeking out and destroying cancer cells? Well, in fact, there's a big class of gene therapy protocols, called Cancer Vaccination Protocols. And no one has raised the red flag and tagged these as "enhancements" because they're so clearly aimed at preventing serious disease.

Presumably, there would also be some family history or some other indicator that would merit that sort of prophylactic therapy in the first place. So we're not exactly talking about handing out sugar cubes in the school gym, are we?

No. But as time goes on and we're able to do more of this kind of preventive gene therapy, you can probably see the rationale for interventions on that scale should we, for example, develop an effective gene therapy protocol aimed at treating hypercholesterolemia. That's a fairly common genetic disease, and the people it affects have high rates of heart disease because they have way too much cholesterol built up in their bloodstream. So, let's say a gene therapy approach has been developed that gives their blood cells an enhanced ability to clean cholesterol out of the bloodstream. Well, if it works for these patients to compensate for their high cholesterol, then what about in me? Why wouldn't I want to prevent the accumulation of cholesterol in my bloodstream? That way, I'd be able to enjoy all the fatty foods I wanted.

Moreover, from a public policy perspective, wouldn't society want you to have that therapy if it meant reducing the potential for you occupying a hospital bed for much of the rest of your life?

Sure. The thrust of public policy in recent years has been in the direction of preventive care, so this would fit right in with that. But if we go very far down that path, we begin to make significant changes in the human form and function that look an awful lot like the sort of improvements and enhancements we've been worrying about. Because along with that comes all the problematic public policy choices of who gets access to these prophylactic enhancements and who doesn't.

Going back to the vaccination notion, let's say we find some way to treat HIV effectively. Given what's happening in South Africa today, would it not be better to administer that treatment via widespread germline therapy instead of being faced with the need to vaccinate every generation from here to eternity?

That's right That's the argument for attempting to develop germline interventions. It's much better to do it once and fix the problem for the whole family line.

But, you know, I'm not sure we've quite nailed this issue yet of how to distinguish medically necessary germline therapies from purely optional enhancement interventions. That still seems rather murky to me.

Well, clearly the distinction lies somewhere in this preventative zone we're discussing. I mean, let's say we've come up with an intervention that enhances cognition and memory and so can serve as a prophylactic against Alzheimer's disease. How could we stand in the way of the widespread use of something like that? Even if we knew it was being used "off label," as it were, by students to increase their performance in the classroom? And that's the route by which virtually all enhancement interventions will come into society. They'll first be introduced as interventions designed to treat disease. The RAC [the National Institutes of Health's Recombinant DNA Advisory Committee] is in no danger of having to face the enhancement issue head-on because it will never review a protocol labeled as an enhancement intervention per se. Those applications will always be couched as treatments for some serious disease. So if we're going to police enhancements—if we're really going to try to hold that line—it simply can't be done at the level of basic research, because there'll always be legitimate justifications for just about any sort of treatment. No, if we're going to police this, it's going to have to be at the level of the user or the physician.

I'm not sure which of the two would be trickier.

Both are going to be difficult. But chances are the medical community will be easier to police because you can at least appeal to their sense of professional autonomy and integrity.

You can also threaten to take away their license to practice.

Right. But with parents and individuals, we're in much the same boat as we are with athletes. That is, you don't want to end up inadvertently caving in to dubious social pressures. For example, let's just say society is prejudiced against very short people, and that my wish is that I could do something to erase that prejudice. But, of course, I can't. And, meanwhile, I certainly want to give my kids every advantage I can, so if there's something I can do that promises to make my children taller, I'm likely to be interested—even though that would only end up feeding into the very problem I find so offensive.

It's this problem of complicity that's so incredibly hard to police because, on the face of it, parents' motivations are often perfectly understandable. Their first obligations are clearly to their own offspring, and if that ends up adding a brick to the wall of some social injustice...well, that's beyond the scope of their responsibility. So this is all somewhat akin to the discussion that used to go on in the African-American community about the ethics of passing for white—using skin lighteners or hair straighteners or anything of that sort in an attempt to look more white. One point of view is that measures such as that simply feed racism and should be discouraged as a consequence.

But, by and large, most people aren't looking to martyr themselves for social justice. They just want a nicer house, a bigger car, a better job.

Exactly. And who can blame them? So that will become society's challenge—to police users by influencing them through consciousness raising, education and other soft measures. Basically, that means solving the problem at the social level rather than at the individual one. And what that probably means is that, ultimately, in much the same way that we currently protect people with disabilities from discrimination, it may someday be important to develop comparable protections for people who either choose not to jump on the enhancement bandwagon or simply can't afford to.

So, in effect, we can pretty much plan on the playing field getting tilted. But if that happens, will we still even by playing the same game anymore?

Right. And we already see examples of exactly what you're talking about in sports where, in addition to the American Power Lifting Association, we now also have the American Drugfree Power Lifting Association. But whereas in sport, you can arbitrarily change the rules of the game, it's much more difficult to accomplish that in the world of social practices, where people compete for jobs, spouses and pretty much everything else.

Even within the athletic realm, to the degree that sports becomes essentially a test of "who's got the better biotech sponsor?", does athletic competition really have any meaning any longer?

Precisely. And I think that's the very philosophical problem that Koss and other athletes are beginning to point out. Just what human excellences are we supposed to be celebrating here?

Stealth perhaps?

Yes. Very good. And drug tolerance.

But if the short fellow who's deeply pained by his lack of stature truly and desperately wants an added jolt of human growth hormone—all risks aside—what business is it of anybody else? Where's the ethical quandary in that?

There hardly is one for the individual.

Even if he's playing into a social stereotype?

Right. That's why if we're going to try to address that problem, we're going to have to do it at a societal level instead of trying to police the end users.

So it's really the Prohibition issue all over again, isn't it?

That's right. It would just be a different form of Prohibition, and we'd probably be just about as effective in policing it.

And yet, as with drugs and alcohol, there also are real dangers associated with gene therapy. I mean, even assuming a virtually unlimited list of relatively safe enhancements, do we have the wisdom to make intelligent choices? That is, are we old enough yet to start playing with the power tools?

I think that's a very good question. There's plenty of evidence that suggests we're not old enough yet. One of my major concerns has to do with how genetic engineering might be used to either reinforce or destabilize the various racial and social categories already used to discriminate between people.

Are you alluding to the use of eugenics?

Yes, in a way—but also to scientific racism in a much broader sense. The attempt to use DNA and genetic markers to widen the social cracks we've driven between ourselves pains me deeply. On the one hand, the population geneticists say, "Don't worry, all the genomic evidence suggests that what we see as races and ethnicities and peoples are much harder to distinguish at the genetic level and that evidence will actually serve to undermine those social constructs." But that's not what's happening because so much of the research is itself structured in terms of those very constructs.

And, you know, I just don't hear racists making much reference to the Human Genome Project. The fact that all races look pretty much the same at the microbiological level is just one of those realities that doesn't seem to be an operative part of the debate.

Exactly. It's so nice that the population geneticists are impressed, but what about those other folks we really need to worry about?

And, in any event, racists have staunchly refused to be confused by the facts right along.

On the other hand, there are subtler forms of racism or social labeling that could be undone by genetics. I'm thinking here of the ways in which genetic research might serve to either confirm or debunk people's origin stories. So one test of our social maturity might be: Are we mature enough yet to really be able to handle knowledge of where we came from? We might find out we all have much more in common than we really want to admit.

That would be wonderful. But, even putting all those racial prejudices aside, is there any reason to believe people are wise or sophisticated enough to make intelligent genetic choices?

Or will those choices just end up being swayed by advertising as usual—with generations of parents going through genetic fads and fashions in much the same way we go through kids' names from generation to generation? Now that's a sobering thought. We could end up with a whole slew of little Brittany Spears types.

Sadly, that seems less a possibility than a probability, doesn't it?

Yes, I think so. Proponents for genetic engineering make the argument that it will encourage human diversity because we'll be able to let a thousand flowers bloom and people will go off in all kinds of interesting directions, each according to his or her own values. But I think we're about as likely to do that with genetics as with any of our other resources.

The law of unintended consequences certainly has to be considered here as well. For example, it's easy to imagine that a man who wishes to enhance his artistic side may instead find himself getting more in touch with his inner schizophrenic. And who should be held to account for that? To what degree should medical professionals be responsible for saving people from their own ill-advised impulses?

Well, they have a lot of responsibility. I think that has to be part of the process of producing safe and effective interventions. Just as we worry about the side effects of any therapeutic drug, we also need to worry about the possible downside of any genetic intervention. It might be, as you suggest, that we find the genes we've tampered with are involved in many more biological processes than just the one we were interested in. Or it might mean that a positive change in one place creates problems in other places. So unforeseen consequences will always be a major consideration. And that means part of the challenge of research in this area must always be to come up with clever ways to anticipate the unanticipated.

As to the germline enhancements at the heart of the so-called "designer baby" controversy, might parents be deceiving themselves when they go looking for genetic silver bullets? After all, it's said that in the horse racing game —where bloodlines have always mattered—Secretariat looked to be muscle-bound and Seabiscuit (the legendary racehorse of the '30s) looked more like a cow pony. They were hardly the paragons of textbook perfection that horse breeders typically look for, and yet both horses achieved a level of greatness that may never be equaled again.

I think the first generation of designer babies will take a lot of wind out of the sails because people will see just how unpredictable the process is.

Are we talking Franken-babies here?

No—probably just normal kids that don't end up developing the special traits in just the way that mom and dad had hoped. In some ways, I can't wait for the first clone of an adult because I'm sure that will be a kid who goes out of his way to be as different as possible from his adult source.

I assume that first wave is likely to include some celebrity genetic material.

No doubt. We already have experience with the Nobel Laureate Sperm Bank, which got a lot of attention a couple of decades ago when it was first set up. You'd think we'd be hearing now about a whole new generation of geniuses, but somehow there's not much talk about the Nobel Laureate Sperm Bank anymore.

As a rule, do most people even have the ability to distinguish good traits from bad? That is, assuming that I can plausibly make the argument that Stephen Hawking brings at least as much value to the world as Michael Jordan does, how good are the chances that parents would choose for their children the sort of physical challenges Dr. Hawking has had to face? I ask that because Stephen Hawking himself has said his disease is not only a big part of who he is, but that it has also contributed significantly to his achievement and his success. By editing out impediments, might we in fact be doing our progeny a disservice?

Possibly. That's one of the things people with disabilities have often pointed out—that their disabilities bring them other gifts that allow them to contribute to the larger society in different ways. From the prospective parents' point of view, are they likely to opt to avoid the known disadvantages that come with a congenital disability, or will they be content to hope for an unpredictable positive turn? I think it's likely most people will make the safe decision, which probably suggests we're at risk of losing some of these special contributions.

By infringing on the natural diversity of humanity, aren't we in danger of reviving eugenics, the ideal of breeding a master race made up of perfect individuals?

It would take an amazingly successful advertising firm to sell the entire species on one particular model. If that was the case, we'd have eugenics by advertiser. For the foreseeable future, though, I think that human genetic diversity is not in great danger. Also, don't forget that there will still be plenty of people going about reproduction in the old-fashioned way. In the distant future, it might be a different story but then there'll probably be other considerations to weigh as well. Maybe we'll be flung amongst the planets by that time.

Still, if we end up sliding down the slippery path of eugenics, don't we lose some of what makes us human in the process?

No, I think our humanity is capable of accommodating all manner of atrocities. Our humanity actually isn't all that special is what I guess I'm trying to say. It would be perfectly human of us to grind ourselves into extinction. In fact, there's a special issue of a journal I subscribe to called Politics in the Life Sciences which had a symposium issue on "Is Humanity Destined to Self-Destruct?" It was a bit gloomy but that's why some of these theologians are somewhat enthusiastic about germline gene therapy. In effect, they see man's place in the universe not just as God's subjects but also as God's hands—sort of elevating us to co-creator status. So they're quite happy to talk about our trans-human future—consciously engineering ourselves out of our humanity and into whatever our next state of being is supposed to be.

Go forth and propagate new species.

Yes! Exactly.

In that same vein, Princeton molecular biologist Lee Silver, in his book "Remaking Eden: How Cloning and Beyond Will Change the Human Family," foresees a future society segregated between the "GenRich" and the "Naturals." The GenRich, blessed with certain synthetic genes, would control society and most of its wealth. The Naturals, meanwhile, would supply the labor. Is this all pure SciFi, or is Silver really onto something here?

I think it's mostly science fiction. The history of social stratification has shown that an aristocracy has a hard time maintaining a permanent sort of control—the kind you'd need in order to get a biological subspecies developed. Inevitably, the revolution comes. And as the have-nots become the haves, they gain access to the same genetic advantages. Ultimately, the playing field—if not entirely evened—at least gets very muddied. The book I always think of when I'm talking about this is the Dr. Seuss book about the creatures that have stars on their bellies: "The Star-Bellied Sneetches." The sneetches that don't have any stars on theirs make up the underclass. But a man comes along with a star machine, and soon all the unstarred sneetches manage to buy stars for their bellies, which understandably makes all the starred ones who'd been part of the aristocracy quite concerned. So they go to the man and he tells them that, yes, he does happen to have a star-removing system as well. Pretty soon, there's a constant flow of sneetches through both machines.

Well, there you have it then. It's also been said that the best antidote to the bias and injustice of eugenics would be a good, powerful dose of democracy. Is that how you see it?

That's right. If we're talking about democracy in the sense of public awareness and discussion of the techniques that are coming along, I wholeheartedly agree. That's the very way in which we'll be able to develop reasonable policies. And that's the whole philosophy behind having something like the Recombinant DNA Advisory Committee, whose job it is to review newly developed gene transfer protocols. Of course, that's the reason we're so concerned about inadvertent ventures into germline experimentation. Whether or not the incident in question [at St. Barnabas in New Jersey] was a serious form of germline gene therapy, the fact is that it was never discussed in public. And we need to have those public dialogues if we want this whole business of genetic science to progress in a fair way.

Why would there be any resistance to that? Because it's bothersome, it gets underfoot, it slows things down?

Sure, it slows things down. And from the researchers' point of view, the problem with that is that it's not necessarily in the best interests of the people they're trying to help. In this case, the researchers were helping clients at an infertility clinic who saw this technique as a way of improving their chances of having a child.

So the scientists weren't just angling to write a paper, to gain notoriety, to strut their stuff in front of their peers?

Let's be charitable.

What is it about public discussion that's so powerful? That is, what value do we as a society gain from subjecting reprogenetic technologies and policies to public scrutiny?

We gain a couple of things, actually. The most obvious is simply a form of societal informed consent. People will learn what's coming and we can use the policy-making process to decide whether we want to go down that road or not. Another benefit is that the scientific community, by engaging the public, can learn about what lies ahead for them should they manage to bring the technology in question to fruition. That's to say that in the course of a public discussion, issues come up—risks and wrinkles you never would have thought of otherwise. Also, researchers can learn about some additional applications of the technologies that may end up informing the way they do their work. So, for example, a relatively innocent proposal to study human genetic variation by sampling the world's isolated indigenous populations and comparing their DNA markers was kind of blown wide open by a public discussion that brought to light many of the issues such a research program could raise for those indigenous populations. And many of those issues took the scientists completely by surprise. One of the objections raised, for example, was that this was just the sort of information the oppressors were looking for—a good genetic marker that would serve to set the indigenous people apart, allowing eradication programs to proceed.

This would be the star they'd have to wear?

Exactly.

Even without obtaining valuable feedback like that, though, aren't we still justified in insisting upon dialogue, if only because these capabilities are ones that could easily have profound implications for all of us?

That's right. Science doesn't happen in a vacuum anymore. So in a way, we're all part of the scientific process.

As a practical matter, assuming proven enhancement interventions actually become available, is there any public policy that could possibly be effective in precluding their use?

We've been looking at that and it's awfully hard to imagine a policy that wouldn't be so draconian as to be unpalatable, at least here in America. Because basically what you'd have to do is treat these manipulations in the same way we treat other illegal substances and illegal interventions—which is to say by criminalizing them. And it's hard to imagine doing that for interventions that are ostensibly aimed at simple improvements since, on the whole, we tend to favor people trying to better themselves.

It's questionable even in the most authoritarian society whether access can be effectively precluded to something people really want. Because we can assume that people of means will always have access to enhancement interventions—whether somatic or germline—no matter what the laws say. Can we also assume, then, that restrictions on gene therapy can thus only serve to further stack the deck against the already disadvantaged?

Oh, that's an interesting point. That would be a consideration. I'd say there are three possible approaches to the problem. One would be to say: further restrictions are just going to exacerbate the differences, so let's just make some minimal level of enhancements available to all. That would be the Egalitarian Approach. Do away with the difference that wealth makes by making this a public good. Another approach would be to take a classically liberal model and say: "Well, it's okay that the rich will have access to these interventions because we can expect there to be some trickle-down benefits." If we can help to ensure that trickle-down effect by, for example, packaging a musical ability gene or a financial acuity gene with an altruism gene, then perhaps we should do so. So the idea would be to regulate the product, limiting customers only to certain packages. They would get some socially useful attribute bundled along with whichever one they find personally interesting. I tend to think of that as Genetic Liberalism. Then another possibility would be what I call Genetic Maoism—which would be to bundle desirable traits that confer some sort of advantage with some kind of compensating disadvantage. So yes, you'd be able to get the intelligence gene, but it would come along with a high propensity for depression. So take your pick and make your choice. None of the three policy approaches I've just outlined have any serious proponents that I know of. They might provide the basis for a good science fiction novel, however.

About the Interviewer

Mark Compton monitors trends in information technology and biotechnology from a comfortable perch midway between the Silicon Valley and Oregon's Silicon Forest.

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