Duke Medical Ethics Journal

From the surface, it seems as though genetic engineering is somewhat of a one-size-fits-all solution to a host of genetic conditions. However, there are numerous flaws with this logic, and it is essential to consider opposing perspectives when deciding the future of the clinic applications of technologies like CRISPR. For one, from a technical perspective, these technologies, like all medicine, can have unintended consequences that are invisible until after decades of research across generations. Already, CRISPR is known to have off-target effects, whereby it can unintentionally alter DNA sequences that are perfectly functional, doing more harm than good [2]. Further, the harmful effects of these changes may not be seen until later on in life or until the next generation is born. Predicting and preventing this risk is extremely difficult, and despite no obvious solution currently existing, it seems as though CRISPR use in humans is already just a few years away. Meanwhile, from an ethical perspective, genetic engineering remains the hottest topic in medicine.

As described earlier, CRISPR and other technologies have the potential to treat genetic diseases like hemophilia or cancer, significantly improving patient outcomes and extending lifespan. Although this is certainly beneficial, it also raises questions over how society views diseases in general. Many question whether they should be regarded as mere imperfections that should be corrected or as naturally occurring differences that exist between humans. For those who accept gene editing technologies, they will likely live a much higher quality of life and have more freedom to pursue their passions; for those that do not, they may be treated as outcasts or unfortunate sufferers, and stigmas around having genetic conditions will undoubtedly become much more extreme and hurtful. Society has developed accommodations for people with such conditions, but the quality and availability of these accommodations may decline with the rise of genetic engineering. Beyond just diseases, genetic engineering can also change other, more neutral traits, such as eye color, height, and even muscle mass [3]. This raises a host of other questions: should parents be allowed to pick and choose what traits their children have, essentially designing unborn babies to appear a specific way? Is it morally justified to choose an unborn child’s gender, appearance, and other genetic predispositions without their consent? Drawing the line between what traits and genes CRISPR can and cannot be used to edit, including whether the benefit of doing so would be from a survival or purely aesthetic/behavioral perspective, is essential; determining whether genetic engineering should only be allowed in informed adults of a certain age of consent (somatic editing) or also in future, unborn generations of children within families (germline editing) is also crucial [4]. Yet, reaching a consensus on these two debates, both among the scientific community and the general public, is likely impossible. Religious, political, and moral beliefs are unique to every individual, and all of these factors play into whether or not a person supports genetic engineering. Why? Humans are products of evolution. Hundreds of millions of years of mutations and reproduction have produced a population in which no two individuals are the same. However, if ‘desirable’ traits are heavily favored, genetic engineering has the capacity to reduce diversity among the population; in other words, although it may save lives, it may also make each one of us less unique [5]. Taken to the extreme, several decades of genetic manipulation may lead to the creation of an ideal body type, worsening the cycles of body shaming, racism, and discrimination that already plague our schools, hospitals, and workplaces.

Apart from the medical side of genetic engineering, the financial element provides yet another source of concern. CRISPR treatments today are extremely expensive – even years down the line, CRISPR is expected to cost well over $2 million per patient [6]. Many experts argue that this could exacerbate preexisting inequalities based on socioeconomic status in medicine. Namely, it is likely that only the wealthy will be able to afford such treatments, restricting the the disease-treating and trait-modifying capabilities of genetic engineering to an already privileged stratum of the population. On one hand, there is the idea that if such technologies can provide potentially life-saving changes, then anyone who can access and afford them should be able to use them. Conversely, it can easily be argued that until the cost of technologies are reduced significantly, to the point where the majority of the population can afford them, they should not available to anyone, as they may be used by the wealthy as yet another tool to increase socioeconomic gaps in medical care and quality of life [7]. Moreover, designing and verifying a CRISPR design before testing it in a real human is a long and exorbitant process. Even with a person’s specific DNA code, the treatment, which must be designed uniquely and only for them, must be also tested in other clinical models (such as lab mice), tested in real human cells, and modified to eliminate unwanted side effects before being used – a process that can take several years and costs hundreds of thousands of dollars [6]. This financial burden may disincentivize a large number of pharmaceutical companies from entering the genetic engineering market, leaving only a few with heavy pricing control. Meanwhile, these companies may choose to limit the availability of technologies or offer them at unreasonable prices if left unregulated. Uncertainties thus exist around whether CRISPR research should be publicly or privately funded, and whether genetic engineering at large should be regulated as a commodity for the entire public’s general well-being or as a for-profit industry.