Dr. Kadish: How do you feel about the ethics of gene editing or even cloning?

Dr. Caplan: We’ve heard a lot about gene editing and cloning.  I think we can get cloning human beings off the table fast. It’s actually rather boring.  It’s prone to produce errors and malformations in the animals we’ve tried it in, and I don’t think cloning full-born humans has much of a future. It probably has applications in animals and domestic animals, farm animals, pet animals. Having copies of the same animal for lamb chops or fur or something makes sense. But I think in gene editing, the future is safeguarding from diseases or to enhance or improve traits, not just copying the same thing. There may be a few narcissists amongst us who think that’s a great idea, but I think there’s not too many and there’s probably not a big financial business there in the same way that there would be for having the same cattle that produce the same meat, and so on. That’s the potential area for cloning—animals.

For gene editing, you can do it by altering body cells, or you can do it by altering hereditary material. Somatic therapies change body cells and we’re starting to see them come to fruition with diseases like hemophilia and sickle cell, potentially cystic fibrosis and Leber’s disease. There are many things where by altering say even a single gene you can really fix a pretty nasty disease in the person. There are obviously ethical issues around risk, so we have to be sure that if we’re using safe models when possible.  For example in trying to repair something in the eyes, that we do one eye at a time and make sure things work in one eye first.  We have to follow people for years with registries, which we’re not always doing, to make sure the long-term effects stick and that there aren’t late onset safety issues. But, probably the biggest issue for somatic gene therapy in the future is cost and access. They’re often hugely expensive. It’s not clear why the prices are the way they are, not clear who’s going to be able to use them both in the U.S. and in other nations where they certainly could benefit but have even less resources. So, I think we’re going to have a big battle coming over access and cost with somatic gene therapy.

Genetic therapy should I think sometimes be used to try to make us better, stronger, faster, smarter. I’m not against enhancement. I know there are people who say we should never go down that road, because they have fears of eugenics—they know what happened in Nazi Germany in the name of eugenics, the Nazi attempt to eliminate racial and ethnic groups through sterilization and mass murder… But I think that if you look at enhancement say caused by vaccines, if there’s a way to enhance our immune system against diseases by germline engineering we would all accept that. Practicing tennis lessons at camp is a way to improve our performance. In other words, we’re not always against performance improvement. What we want to do is make sure that we’re not taking risks to get to silly goals, like trying to make someone’s freckles disappear or remove some trait that is trivial but that some people don’t like.

The future, I think, is to perfect the techniques so that we know how to use them to eliminate diseases. Once we’ve mastered that, we can then move on to a fight about enhancement. At that point I think we are going to have to take it case by case. If I can find a way to boost memory or boost the immune system or find some part of the body that could perhaps make bone marrow cells that don’t mutate as much over time bringing cancer and so on, I’d be for those enhancements. Whether we’re going to worry about hair color, freckles and other more trivial matters in terms of what we can afford and what it might be right to impose on our children I am less positive about. I’d be willing to debate it and I think we could draw some lines. When people worry about a slippery slope, my response is ‘build some stairs’.

Dr. Kadish: One last question. You talked a little bit about the costs of correcting genetic defects. But in terms of enhancement, don’t you think that has the potential to further exacerbate class distinctions in our society—particularly since it’s likely to be very expensive and not available to everyone?

Dr. Caplan: There’s no doubt that if we don’t insist on availability as a condition of moving forward into enhancement areas, we’re going to get more exacerbations of class differences, economic differences. That said, we have to keep in mind that we tolerate those differences in amazing ways today. It’s not like they’re not huge, because it’s not like they don’t give the rich huge advantages, such as the college scandals with people bribing their kids’ way into universities behind the scenes. Look at the amount of money people spend on tutoring and special training and Kaplan courses and on and on to get their kids into the right school or a fabulous kindergarten and nursery school so they can set their kids up for success. The reason I point this out is huge advantages go to the rich wherever they are. It hasn’t stopped us from allowing them to take advantage of those things unless they do it under the table. In the open though, that is tolerated, even praised. Interestingly enough, if rich people just give gifts to universities, they can probably get their kids into those universities without bribing people. They can do it upfront.

I don’t know that inequity is going to be an efficient counter argument to stop us from using genetic enhancement. It hasn’t done it with social enhancement. I’m not sure it would stop us from doing it with genes. So we’re going to have to build in policies in advance—if we’re going to be fair—then it’s got to be open to everybody. Will we do that? I am not so optimistic.