Opinion

Understanding CRISPR

Cancer survivors strive to rebuild their lives despite the many obstacles they face in obtaining bank loans, resuming their careers or finding reasonably priced insurance policies. Many wish to have children but are concerned about passing on their genetic predispositions to their offspring. Why not directly edit cancer survivors’ DNA in order to rid them of these mutations and eradicate the possibility of passing it on to the next generation? With recent developments in genome editing — including technologies such as clustered regularly interspaced short palindromic repeats — genetically modifying cancer predispositions is closer to practical science than science fiction.

Cancer survivors can carry mutations that will be transmitted to their children. Today, many of these mutations have been identified and can be tracked. With the recent development of genome editing technologies and CRISPR the possibility of genetically modifying the human germline (gametes and embryos) has never been closer. This perspective has sparked a controversy within the scientific community with reactions ranging from calls for a ban on modification, to cautious approval of further research.

The debate over CRISPR-based engineering is generally framed from an ethical and scientific perspective. The economic dimension is often overlooked. CRISPR will both create and meet demands on the individual and collective levels. Economic stakeholders — biotech and medtech firms, public payers, health insurers, fertility clinics, parents-to-be, cancer survivors, their relatives and offspring – may share converging interests in preventing the spread of cancer predispositions in the human population.

The use of CRISPR on non-viable human embryos has sparked a sense of urgency in the scientific community. In reaction, an international summit was hosted in December 2015 by the U.S. National Academy of Sciences, the Chinese Academy of Sciences, and the Royal Society of the U.K., in order to issue a warning statement on human germ cell manipulation. The statement calls for a cautiousness on genome editing of human germlines for reproductive purposes. It invokes several arguments such as the risk of technical error; responsibility towards the future generations that will inherit these modifications; the difficulty in reversing the modifications once they have been introduced and disseminated in the population; the possibility that genetic improvements will only concern a subset of the population, thereby exacerbating social inequities; the ethical and moral considerations in purposely altering human evolution.

The technical risk argument is legitimate — but as with all biotechnological breakthroughs, the risk could decrease through scientific advances.

The risk of exacerbating social inequities is an argument commonly put forward regarding the introduction of new technologies that are costly. Yet the low cost of CRISPR could allow health care systems to propose it under universal coverage, thereby ensuring equal access to all in the name of social justice.

Another argument invokes the moral responsibility of purposely altering human evolution. But what do we mean by “human evolution”? This argument appears to assume, on the one hand, that human evolution is simply the evolution of the genome, and on the other hand, that the human genome in its natural state cannot be perfected. If we extrapolate this logic, shouldn’t doctors feel guilty about their everyday attempts to cure natural disorders affecting the human body? Shouldn’t the centuries-long endeavor to extend life expectancy be considered a clear interference in the natural evolution of humanity?

CRISPR illustrates what the economist Joseph Schumpeter coined “creative destruction”: Genome-editing technologies could carry “everlasting storms of innovations” that will disrupt market structures. Eventually, CRISPR could drastically alleviate the economic burden of cancer by revolutionizing two models currently used by healthcare systems: cancer screening programs, and precision medicine.

The prevention strategy used by health policymakers to fight cancer mainly consists of cancer screening programs to detect tumors as early as possible and rapidly begin treatment. But with CRISPR, prevention campaigns would make it possible to intervene even earlier, detecting and correcting genetic mutations before they produce tumors. CRISPR could make it possible to eradicate close to 3,600 rare monogenic disorders caused by identified genes.

CRISPR could turn this century into a huge wave of genome decontamination. Like the carbon footprint, a genomic footprint disseminated in the general population could be taxed as a prejudice to the common good. CRISPR would make it possible to decontaminate a population’s reproductive cells. One could choose not to do so — in the name of individual freedom — but this would spawn a new kind of polluter payer tax, since parents would be taking the risk of disseminating harmful genes in the general population, potentially resulting in costly treatments for the community at large.

Public opinion surveys show that most Americans are in favor of genome editing to prevent their children from inheriting serious disease, though 65 percent consider that modifying the genes of unborn children should not be legalized. Another survey conducted in 2016 found that 49 percent of Americans approve of the use of germline editing to reduce the transmission of hereditary diseases. A caveat to these surveys is that they were conducted in the general population, where cancer survivors statistically represent only a small fraction. In these days of “patient-centricity,” it would have been interesting to compare the survey results of the general population with a sample of cancer patients and their families.

CRISPR could lead to the emergence of what Nietzsche called “the grand politics [which] places physiology above all other questions — it wants to rear humanity as a whole, it measures the range of the races, of peoples, of individuals according to the guarantee of life that they carry within them.” In the CRISPR century, this vision is probably not a prophecy but a possible future.

 

Gregory Katz is a chaired professor of innovation management & healthcare performance at the Paris-Descartes University School of Medicine. Peter Pitts is the president of the Center for Medicine in the Public Interest.

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