Towards ethical drug pricing: the European Orphan Genomic Therapies Fund.

An increasing number of novel genomic therapies are expected to become available for patients with rare or ultra-rare diseases. However, the primary obstacle to equal patient access to these orphan genomic therapies are currently very high prices charged by manufacturers in the context of limited healthcare budgets. Taking into account ethical pricing theories, the paper proposes the implementation of a pricing infrastructure covering all European member states, which has the potential to promote distributive justice while maintaining the attractiveness of genomic therapy development.

Heritable human genome editing: correction, selection and treatment.

Heritable human genome editing (HHGE) to correct a nuclear gene sequence that would result in a serious genetic condition in a future child is presented as 'treatment' in various ethics and policy materials, and as morally preferable to the 'selection' practice of preimplantation genetic testing (PGT), which is subject to the disability critique. However, whether HHGE is 'treatment' for a future child, or another form of 'selection', or whether HHGE instead 'treats' prospective parents, are now central questions in the debate regarding its possible legalisation. This article argues that the idea of 'treatment' for a future child is largely a proxy for 'seriousness of purpose', intended to distinguish HHGE to avoid serious genetic conditions from less obviously justifiable uses; that HHGE is best understood, and morally justified, as a form of 'treatment' for prospective parents who strongly desire an unaffected genetically related child and who have no, or poor, options to achieve this; that HHGE would be morally permissible if consistent with that child's welfare; that legalisation is supportable with reference to the right to respect for private and family life under Article 8 of the European Convention on Human Rights; and that HHGE is morally distinguishable from PGT.

Ethical challenges for a new generation of early-phase pediatric gene therapy trials.

After decades of setbacks, gene therapy (GT) is experiencing major breakthroughs. Five GTs have received US regulatory approval since 2017, and over 900 others are currently in development. Many of these GTs target rare pediatric diseases that are severely life-limiting, given a lack of effective treatments. As these GTs enter early-phase clinical trials, specific ethical challenges remain unresolved in three domains: evaluating risks and potential benefits, selecting participants fairly, and engaging with patient communities. Drawing on our experience as clinical investigators, basic scientists, and bioethicists involved in a first-in-human GT trial for an ultrarare pediatric disease, we analyze these ethical challenges and offer points to consider for future GT trials.

Setting ethical limits on human gene editing after the fall of the somatic/germline barrier.

The ethical debate about what is now called human gene editing (HGE) has gone on for more than 50 y. For nearly that entire time, there has been consensus that a moral divide exists between somatic and germline HGE. Conceptualizing this divide as a barrier on a slippery slope, in this paper, I first describe the slope, what makes it slippery, and describe strong barriers that arrest the slippage down to the dystopian bottom of pervasive eugenic enhancement. I then show how the somatic/germline barrier in the debate has been weakened to the level of ineffectiveness, with no replacement below. I examine a number of possible barriers on the slope below the somatic/germline barrier, most of which lack sufficient strength. With the exception of the minority of people in the HGE debate who see the eugenic society as utopia, the majority will need a barrier on the slope to stop the slide to dystopia.

La terapia génica en México y España, una aproximación bioética desde la investigación científica / Gene therapy in Mexico and Spain, a bioethical approach from scientific research

La terapia génica es una línea de investigación que, por medio de la transferencia genética, busca nuevos tratamientos a enfermedades que son difíciles de tratar mediante métodos tradicionales. Esta línea de investigación tiene características específicas para realizarse, como los métodos de transferencia genética y las enfermedades a tratar. No obstante, las características de la terapia génica pueden estar influenciadas por el entorno social, económico y/o político del país donde se realiza, para que la investigación tenga un objetivo y/o aplicación específica. México y España son países que tienen proyectos de terapia génica en sus instituciones educativas y de salud. Sin embargo, se desconocen las características que dicha línea tiene en los países mencionados y la influencia que el contexto de cada país ejerce en la terapia génica. En el presente estudio se realizó un esfuerzo por identificar las características que la investigación de terapia génica tiene en México y España por medio de la aplicación de cuestionarios dirigidos a investigadores de ambos países. Se utilizaron tablas de frecuencias para identificar las características generales de la terapia génica de ambos países. Así como, un análisis correlacional para identificar, entre todas las respuestas obtenidas, las características distintivas de cada país. Los resultados sugieren que la influencia del contexto español presenta las características necesarias para llevar a la terapia génica a una etapa clínica, mientras que el contexto mexicano se limita la promoción de la investigación básica de esta línea de investigación (AU)

Gene therapy is a research line that; seeks new treatments for diseases that are difficult to treat by traditional methods. This line of research has specific characteristics to be carried out, such as genetic transfer methods and diseases to treat. However, the characteristics of gene therapy may be influenced by social, economic and/or political environment of the country where it is performed, therefore the research might have a specific objective and/or application. Mexico and Spain are countries that have gene therapy projects in their educational and health institutions. However, the characteristics of this line in the above-mentioned countries and the influence that the context of each country has on gene therapy are unknown. This article aims to identify the characteristics that gene therapy research has in Mexico and Spain, through the application of questionnaires addressed to researchers from both countries. Frequency tables were used to identify the general characteristics of gene therapy in Mexico and Spain, as well as a correlational analysis to identify, among all the responses obtained, the distinctive characteristics of each country. The results suggest that the influence of the Spanish context allows the necessary characteristics to bring gene therapy to a clinical stage, while the Mexican context is restricted to promoting the basic research of this line of research (AU)

La teràpia gènica és una línia de recerca que, per mitjà de la transferència genètica, cerca nous tractaments a malalties que són difícils de tractar mitjançant mètodes tradicionals. Aquesta línia de recerca té característiques específiques per a realitzar-se, com els mètodes de transferència genètica i les malalties a tractar. No obstant això, les característiques de la teràpia gènica poden estar influenciades per l'entorn social, econòmic i/o polític del país on es realitza, perquè la recerca tingui un objectiu i/o aplicació específica. Mèxic i Espanya són països que tenen projectes de teràpia gènica en les seves institucions educatives i de salut. No obstant això, es desconeixen les característiques que aquesta línia té als països esmentats i la influència que el context de cada país exerceix en la teràpia gènica. En el present estudi es va realitzar un esforç per identificar les característiques que la recerca de teràpia gènica té a Mèxic i Espanya, per mitjà de l'aplicació de qüestionaris dirigits a investigadors de tots dos països. Es van utilitzar taules de freqüències per a identificar les característiques generals de la teràpia gènica de tots dos països, així com una anàlisi correlacional per a identificar, entre totes les respostes obtingudes, les característiques distintives de cada país. Els resultats suggereixen que la influència del context espanyol presenta les característiques necessàries per a portar a la teràpia gènica a una etapa clínica, mentre que el context mexicà es limita la promoció de la recerca bàsica d'aquesta línia de recerca (AU)

Patient and public perspectives on cell and gene therapies: a systematic review.

Cell and gene therapies offer opportunities for treating disease with potential to restore function, and cure disease. However, they are not without risk and pose complex logistical, economic, ethical and social challenges for health systems. Here we report our systematic review of the current evidence on patient and public knowledge and perspectives of cell and gene therapies, to inform future research, education and awareness raising activities. We screened 10,735 titles and abstracts, and evaluated the full texts of 151 publications. The final selection was 35 publications. Four themes were generated from the narrative synthesis of the study findings namely: (1) Knowledge and understanding of cell and gene therapies, (2) Acceptance of cell and gene therapies (3) Understanding of risk and benefits of therapy, and (4) Information needs and current sources of information. As potential funders or future recipients, it is important that the public and patients are aware of these therapies, understand the issues involved, and can contribute to the debate. This review highlights the need for appropriate patient and public education on the various aspects of cell and gene therapies. High quality studies exploring patient and public opinions and experiences of cell and gene therapy are required. Patient and public perceptions of these therapies, alongside evidence of clinical and cost-effectiveness, will be central to their uptake and use.

Various Aspects of a Gene Editing System-CRISPR-Cas9.

The discovery of clustered, regularly interspaced short palindromic repeats (CRISPR) and their cooperation with CRISPR-associated (Cas) genes is one of the greatest advances of the century and has marked their application as a powerful genome engineering tool. The CRISPR-Cas system was discovered as a part of the adaptive immune system in bacteria and archaea to defend from plasmids and phages. CRISPR has been found to be an advanced alternative to zinc-finger nucleases (ZFN) and transcription activator-like effector nucleases (TALEN) for gene editing and regulation, as the CRISPR-Cas9 protein remains the same for various gene targets and just a short guide RNA sequence needs to be altered to redirect the site-specific cleavage. Due to its high efficiency and precision, the Cas9 protein derived from the type II CRISPR system has been found to have applications in many fields of science. Although CRISPR-Cas9 allows easy genome editing and has a number of benefits, we should not ignore the important ethical and biosafety issues. Moreover, any tool that has great potential and offers significant capabilities carries a level of risk of being used for non-legal purposes. In this review, we present a brief history and mechanism of the CRISPR-Cas9 system. We also describe on the applications of this technology in gene regulation and genome editing; the treatment of cancer and other diseases; and limitations and concerns of the use of CRISPR-Cas9.

Beginning of life ethics at the dawn of a new era of genome editing: are bioethical precepts and fast-evolving biotechnologies irreconcilable?

The amazing and almost unimaginable advances that have unfolded over the past decades in biotechnologies (heritable germline editing in particular) have brought bioethical issues to the forefront, sparking public debate and increasing attention worldwide. Such mind-blowing progress has already resulted in major improvement and enhancements for humans, and holds the potential for even more. Technology and bioengineering have begun to take over in the life sciences industry. Man's capacity to genetically engineer the biological world is nothing short of mind-boggling in its current magnitude, and may even evolve, in a not too distant future, into attempts to fuse man and machine into a cohesive bioengineered entity; a "super human being", endowed with enhanced cognitive and physical capabilities and impervious to disease, may be not too far down the road. That will not come without caveats, however. In fact, scientific advancements at such an accelerated pace have already negatively affected our cultural, ethical, and legal values and our ability to harness the opportunities and face the dangers posed by such developments. As a matter of fact, science seems to consistently outpace public morals, ethics and policymaking, which calls for a high degree of caution and common answers.

Revising, Correcting, and Transferring Genes.

The distinction between germline and somatic gene editing is fundamental to the ethics of human gene editing. Multiple conferences of scientists, ethicists, and policymakers, and multiple professional bodies, have called for moratoria on germline gene editing, and editing of human germline cells is considered to be an ethical "red line" that either never should be crossed, or should only be crossed with great caution and care. However, as research on germline gene editing has progressed, it has become clear that not all germline interventions are alike, and that these differences make a significant moral difference, when it comes to ethical questions about research, regulation, clinical application, and medical justification. In this paper, I argue that, rather than lumping all germline interventions together, we should distinguish between revising, correcting, and transferring genes, and I assess the consequences of this move for the ethics of gene editing.

[Gene therapy for retinitis pigmentosa]. / La thérapie génique des rétinites pigmentaires héréditaires.

Retinitis pigmentosa is the most common blinding inherited retinal dystrophy. Gene therapy is a burgeoning revolutionary approach that paves the way to treatment of previously incurable diseases. At the end of 2017 and 2018, a gene therapy, Luxturna®, obtained a marketing authorization by respectively the FDA (Food and Drug Administration) and the EMA (European Medicines Agency). This treatment, with proven efficacy, is available to patients with Leber congenital amaurosis and retinitis pigmentosa associated with bi-allelic mutations of the RPE 65 gene. In this paper, we present the current advances in gene therapy for retinitis pigmentosa and discuss the technological, economic and ethical challenges to overcome for gene therapy to improve medical practices.

TITLE: La thérapie génique des rétinites pigmentaires héréditaires. ABSTRACT: Les rétinites pigmentaires, ou dystrophies rétiniennes héréditaires, sont des maladies dégénératives cécitantes d'origine génétique. La thérapie génique est une approche révolutionnaire en plein essor qui ouvre la voie au traitement de maladies jusqu'ici incurables. Une thérapie génique, le Luxturna®, a obtenu une autorisation de mise sur le marché par la FDA (Food and Drug Administration) fin 2017 et l'EMA (European Medicines Agency) fin 2018. Ce traitement, à l'efficacité démontrée, destiné aux patients porteurs d'une amaurose congénitale de Leber ou d'une rétinopathie pigmentaire en lien avec une mutation bi-allélique du gène RPE65, apporte beaucoup plus de questions que de réponses. Nous présentons, dans cette revue, les avancées actuelles, puis les défis technologiques, économiques et éthiques à surmonter pour que la thérapie génique améliore nos pratiques médicales.

[Gene-based therapies of spinal muscular atrophy: a piece of history of medicine]. / Thérapies géniques de l'amyotrophie spinale infantile - Un morceau d'histoire de la médecine.

It is worth stating that a generation is needed to bring about a new family of drugs. After the deciphering of the genetic cause in 1995, two innovative classes of therapeutics are now available for spinal muscular atrophy (SMA): the repeated administration of antisens oligonucleotides and the one-shot administration of a scAAV9-SMN as a gene therapy. By addressing the genetic mechanisms of the disease, these drugs fundamentally change its course. These major advances in an extremely severe disease, often fatal before the age of 18 months in the type 1 form (50% of patients), pave the way for the treatment of other serious pathologies of the nervous or neuromuscular system, and provide unambiguous evidence of the effectiveness of these new classes of drugs called to address a number of genetic or acquired diseases. These breakthroughs raise also new scientific and technological questions (limited production yields of gene therapy drugs) but also ethical issues (access of patients to these innovative therapies) that resonate beyond this disease alone.

TITLE: Thérapies géniques de l'amyotrophie spinale infantile - Un morceau d'histoire de la médecine. ABSTRACT: On convient de dire qu'une génération est nécessaire pour faire émerger une nouvelle famille de médicaments. L'amyotrophie spinale infantile (SMA), après l'élucidation du gène causal en 1995, dispose depuis peu de deux classes innovantes de thérapeutiques : l'administration répétée d'oligonucléotides antisens et l'administration unique d'une thérapie génique par scAAV9-SMN. En s'adressant aux mécanismes génétiques de la maladie, elles en modifient fondamentalement le cours. Ces avancées majeures dans une maladie extrêmement sévère, mortelle souvent avant l'âge de 18 mois dans les formes de type 1 (50 % des malades), ouvrent la voie pour d'autres pathologies graves du système nerveux ou neuromusculaire, et apportent une preuve déterminante de l'efficacité de ces classes nouvelles de produits appelés à s'adresser à de nombreuses maladies génétiques ou acquises. Elles génèrent aussi de nouvelles questions d'ordre scientifique et technologique (capacités limitées de production des quantités nécessaires en thérapie génique) mais également d'ordre éthique (conditions d'accès des malades à ces thérapies innovantes), qui résonnent au-delà de cette seule maladie.

Human artificial chromosomes for pluripotent stem cell-based tissue replacement therapy.

The gene therapy approach aiming at curing various human diseases began to develop as a technology from early eighties of the last century. To date the delivery of therapeutic genes are mainly mediated by virus-based, predominantly, non-integrated virus vectors. These gene delivery approaches have several fundamental limitations on the way of efficient deployment in clinical gene therapy. A totally different approach was suggested about 20 years ago when episomal non-integrative artificial chromosome-based vectors featuring large size inserts (even native gene loci) advanced to the stage. Since then numerous human artificial chromosome (HAC) vectors were developed by both de novo synthesis and top-down engineering technology. This approach so far is limited to ex vivo gene transfer and correction within highly proliferative or reversibly immortalized precursor stem cells or pluripotent stem cells. Recent breakthrough in generation of induced pluripotent stem cells and embryonic stem cell manipulation give the additional pivotal stimuli to integrate it with the HAC technology and to develop thereby novel approaches to replacement therapies of human genetic diseases. The HAC technology is complex and time consuming while nowadays it has significantly advanced and become notably closer to medical applications. In this review we discuss current advancements in the HAC technology, in particular, in terms of improvement of chromosome transfer method and achievements in developing mouse-based gene therapy tissue replacement models for several monogenic human diseases. The main progress has been done in elaboration of top-down type HAC technology in modeling and preclinical studies of gene therapy treatment for Duchenne muscular dystrophy (DMD) disease.

The Future of In Utero Gene Therapy.

Significant advances in the safety and efficacy of gene therapy have sparked a new frontier in therapeutics for genetic diseases as evidenced by the greater than 700 active gene therapy investigational new drug applications reported by the NIH and the US Food and Drug Association. Although postnatal gene therapy trials are encouraging, limitations to effective therapy including an immune barrier and initiation of treatment after disease onset can exist. Advances in prenatal diagnostics provide hope that many genetic abnormalities will be able to be diagnosed before birth. Prenatal gene therapy has the potential to take advantage of normal developmental properties of the fetus and overcome some of the current limitations to efficient postnatal gene therapy. The rationale for prenatal gene therapy includes the small fetal size, the tolerogenic fetal immune system, the presence of highly proliferative and accessible stem/progenitor cells of multiple organs, and, ultimately, the ability to treat diseases in which irreversible pathology begins prior to birth. This rationale is based on and supported by a number of published animal studies. Unique ethical considerations exist in the context of prenatal gene therapy, including the importance of rigorous evaluation of the effect of the therapy on fetal germ cells and developing organs as well as the mother. To date, animal studies have not demonstrated any significant germline or maternal effect of prenatal gene therapy. Finally, practical considerations of future clinical prenatal gene therapy will include, but not be limited to, determining the initial target disease characteristics and the importance of non-directive prenatal counseling of families carrying a fetus with a genetic diagnosis.