胚胎干细胞研究的伦理和心理学问题

背景：胚胎干细胞研究具有重要的医学价值,在基因治疗、组织工程学、药学等许多领域都具有广泛的应用,使人们看到了治疗疾病的新希望,而其相关研究成果也引发了许多伦理和心理学问题。 目的：综述目前胚胎干细胞研究中的伦理和心理学问题。 方法：应用计算机检索2001-01/2010-12 PubMed数据库、维普数据库及万方数据库有关干细胞研究产生的伦理和心理学问题相关文献,英文检索词“embryonic stem cells,morality,psychological”,中文检索词“胚胎干细胞,伦理学,心理学”。检索文献量总计122篇,最终纳入符合标准的文献33篇。 结果与结论：胚胎干细胞究中伦理学问题的焦点主要包括：干细胞来源的伦理学问题,干细胞“克隆”的伦理学问题,干细胞与生命的伦理学问题,干细胞研究存在和需要解决的问题及干细胞研究中伦理学规范问题。干细胞研究中的心理学问题主要是人们对干细胞研究特别是“克隆”技术的认识。相关研究多涉及造血干细胞移植患者的心理变化。胚胎干细胞的研究目前已取得了突破性成果,给医疗、卫生健康等方面带来了革命性影响。     

Ethics and subsequent use of electronic health record data

The digital health landscape in the United States is evolving and electronic health record data hold great promise for improving health and health equity. Like many scientific and technological advances in health and medicine, there exists an exciting narrative about what we can do with the new technology, as well as reflection about what we should do with it based on what we value. Ethical reflections about the use of EHR data for research and quality improvement have considered the important issues of privacy and informed consent for subsequent use of data. Additional ethical aspects are important in the conversation, including data validity, patient obligation to participate in the learning health system, and ethics integration into training for all personnel who interact with personal health data. Attention to these ethical issues is paramount to our realizing the benefits of electronic health data.     

Diversity in Public Views Toward Stem Cell Sources and Policies

Studies of public views on stem cell research have traditionally focused on human embryonic stem cells. With more recent scientific research on developing other stem cell sources, a series of focus group studies was undertaken with Canadian adults to examine their views on different stem cell sources (adult, umbilical cord blood, human embryonic stem cells, somatic cell nuclear transfer or SCNT, and interspecies nuclear transfer, or iSCNT). Views on three different policy models—a permissive, middle-of-the-road and restrictive policy approach—were also explored. Participants were recruited from several different social groups including patients, young adults, seniors, members of two ethnic communities, and a mixed group of adults. Participants were generally supportive of the use of adult stem cell sources. While there was also majority support for the use of hESC and SCNT, this was conditional on strict regulatory oversight. There was also majority support for a permissive policy which allows research on hESC and SCNT. General themes that cut across different groups included the potential cost of new technologies to the health care system, issues around who would gain access to these technologies, and trust in the scientific establishment and regulatory systems. A diversity of viewpoints was found as participants justified their positions on stem cell sources and policy approaches, showing more complexity and nuance than has been generally portrayed. The authors acknowledge support for this study from the project “Towards the clinic: ethical, legal, and social issues relevant to emerging stem cell therapies” funded by the Stem Cell Network of Canada.     

Stem cells from residual IVF-embryos - Continuation of life justifies isolation

Embryonic stem cells are undifferentiated pluripotent cells that can indefinitely grow in vitro. They are derived from the inner mass of early embryos. Because of their ability to differentiate into all three embryonic germ layers, and finally into specialized somatic cell types, human embryonic stem cells represent important material for studying developmental biology and cell replacement therapy. They are usually isolated from excess human IVF-embryos. Since many people regard isolation of human stem cells as intentional killing of the embryo, it is a very difficult ethical problem. Similar feelings concern medical or scientific use of these stem cells. Is this feeling correct, or does it arise from a sentimental view? The problem encloses two aspects: (i) use of stem cells for medical therapy and scientific research and (ii) isolation of stem cells from human IVF-embryos. Worldwide human tissues are cultured, transplanted and used for medical and scientific research. Therefore, it may be concluded that factual use of human embryonic stem cells cannot be a real ethical problem. The main key of the problem seems to be hidden in the exact definition of 'death'; in other words: is there nothing between 'death' and 'life'? Bacterial spores, lyophilised bacteria and other micro-organisms, micro-organisms stored in glycerol mixtures at -80 degrees C and tissue cultures and sperm cells stored in liquid nitrogen, they are all neither dead nor alive, but still viable. From this point it is clear that there is more than the antithesis 'dead' versus 'alive'. In addition, we think that there is still another alternative: partial death. The present view concerning isolation of stem cells implies that residual embryos and thus new human lives are killed, and that therefore these embryos must be (passively) destroyed. However, it is especially the very well planned IVF-procedure that makes that passive destruction of not-implanted embryos means intentional killing. By isolation of stem cells embryos are not fully killed: at least one embryonic cell, i.e., a stem cell, remains alive. The life of stem cells cannot be qualified as independent. Nevertheless, the embryo's life is not completely stopped and continues in a primitive way of life and consequently it is not completely dead. Against this background we feel that isolation of human embryonic stem cells is preferred instead of passive destruction.     

Exploring common ground in the stem cell ethical debate—A perspective for scientists

The purpose of this special issue of Stem Cell Reviews is to address some of the most difficult ethical debates surrounding the derivation of pluripotent stem cell lines. The possible benefits of stem cells are widely discussed, but the scientific community is particularly aware that research in this area is still at an early, but essential, stage of development. With this research at such an early stage, it is noteworthy that the media, the public, religious leaders, politicians, policy makers, and regulators have had as much interest in stem cell research as for any other area of scientific inquiry. The central issue that has made this area so controversial has been the use of the human embryo for deriving stem cell lines.     

To Screen or Not To Screen for Methicillin-Resistant Staphylococcus aureus

There are few more compelling questions in clinical microbiology today than the issue of whether or not to screen for the presence of methicillin-resistant Staphylococcus aureus (MRSA), with the results being used to institute infection control interventions aimed at preventing transmission of MRSA in health care environments. Numerous different matters must be addressed when considering a screening program. Who is to be screened, what method is to be employed to detect MRSA, and what sites should be sampled? When and how often should the screening be performed? Who is going to pay for the screening, and, finally and perhaps most importantly, how are screening results to be communicated to health care providers and what kind of interventions are best undertaken based on the results? Numerous governmental agencies have mandated MRSA screening programs, and yet several authorities in infection control organizations have questioned the appropriateness of mandated screening.In this Point-Counterpoint feature, Dr. Lance Peterson of Evanston Hospital (Evanston, IL) offers his perspective on why screening for MRSA is to be encouraged. Dr. Daniel Diekema of the University of Iowa Carver College of Medicine (Iowa City, IA) offers an opposing view.     

'New embryos' - new challenges for the ethics of stem cell research

Among the many ethical issues raised by human embryonic stem cell research (in the following all references to 'stem cells' should be read as references to human embryonic stem cells), two have gained specific prominence: (1) whether stem cell research is ethically problematic because it entails the destruction of human embryos and (2) what kind of control embryo donors should have over the stem cell lines derived from their embryos. In the present paper, I will analyse how these two issues are engaged by various attempts to derive stem cells from anomalous embryos (e.g. embryos in cleavage arrest, embryos not implanted following pre-implantation genetic diagnosis or embryos created by altered nuclear transfer) or in ways that are claimed to be non-destructive for the embryo (e.g. blastocyst or blastomere biopsy).     

Ethical and Policy Issues Surrounding the Donation of Cryopreserved and Fresh Embryos for Human Embryonic Stem Cell Research

The use of human embryos in human embryonic stem cell (hESC) research raises significant ethical and policy issues associated with their donation. Recent research conducted in several countries assesses the percent of persons with cryopreserved and fresh supernumerary embryos willing to donate them for research, their reasons for considering this option, and the concerns they raise about its personal import. Such research provides new insights into rising ethical and policy questions associated with embryo donation for hESC research that should be addressed. In response to such questions, it is argued here that consent to the donation of supernumerary embryos for hESC research should be sought in two or three stages, depending on whether fresh or frozen embryos are at issue, in order to provide patients and their partners with sufficient time and information before they make a final decision. In addition, steps should be taken to support the voluntariness of their decisions by having personnel other than the treating reproductive specialist or stem cell investigators solicit their consent. Prospective embryo donors should also be given a choice about the uses to which hESCs derived from their donated embryos will be put in order to honor their ethical convictions and ensure that there are sufficient embryos for this research. The well-being and rights of those who donate embryos for this research require the sort of support and protection that can be provided by an ethical and policy framework that allows hESC investigations to move forward according to standards that are transparent and that resound with public values.     

Mired in the quagmire of uncertainty: The "catch-22" of embryonic stem cell research

Pluripotent human embryonic stem (ES) cells hold remarkable therapeutic potential, but their use is fraught with moral, ethical, scientific, and political concerns. In this essay, I discuss how an odd combination of patent issues, presidential policy, market uncertainties, and evolving Food and Drug Administration regulations have together hindered the progress of ES cell research in the United States of America. This coalescence of issues is unique. I suggest that these factors explain why the United States has not been a dominant player in advancing ES research. I predict that small, noncontroversial changes would go far in ameliorating many of the roadblocks that now exist. Most of these changes would not require a change in policy or even action by the U.S. government; a simple clarification and definition would suffice.The reason these changes have met solid resistance is suggested to derive from financial rather than moral, ethical, or scientific issues.     

Consensus and the search for pluripotent stem cells

Good science and good ethics are not mutually exclusive. Good science is conducted in an ethical manner, but it also pursues goals that are ethically well-grounded. And good ethical reflection on science must be rooted firmly in a sophisticated understanding of both the available data and the scientific frameworks offered to explain that data. In short, good science depends on ethical conduct and good ethics are rooted in good facts. Although we might dispute whether either of these principles is always true, it is reasonable to view both as desirable ideals. If so, then who has the responsibility to achieve these goals? Is this solely the responsibility of scientists working at the frontiers of what we already know? Is it the responsibility of the general public or policymakers, most of whom have minimal understanding of the process of science, much less the implications of current areas of inquiry? And in an increasingly polarized society, how can competing views be reconciled even within the scientific community? These challenges are as clear for research involving human embryonic stem cells as for any other current inquiry.     

Shifting sands: the complexities and uncertainties of the evolving US regulatory,policy, and scientific landscape for biospecimen research

Human tissue biorepositories and the biospecimens they provide play a critical role in advancing research and medical care, especially in supporting research to develop precision medicine. However, advancements in genomics, informatics, and other sophisticated technologies and extensive biospecimen and data sharing have raised questions about how best to protect research participants. Complex ethical issues remain unresolved, such as the identifiability of biospecimens and associated data, the best consent models for future research, ownership and commercial use of biospecimens, and return of individual research results.This review summarizes the relevant US regulations and recent changes to them, as well as current and future ethical and policy issues related to biospecimen research. Because many issues remain unresolved, additional policy development will be needed. We discuss approaches for how researchers and other stakeholders can provide input to ensure that these policies will protect research participants while facilitating research important for scientific and medical advancements.     

The legal risks of returning results of genomics research

Published guidelines suggest that research results and incidental findings should be offered to study participants under some circumstances. Although some have argued against the return of results in research, many cite an emerging consensus that there is an ethical obligation to return at least some results; the debate quickly turns to issues of mechanics (e.g., which results? who discloses? for how long does the obligation exist?). Although commentators are careful to distinguish this as an ethical rather than legal obligation, we worry that return of results may unjustifiably become standard of care based on this growing “consensus,” which could quickly lead to a legal (negligence-based) duty to offer and return individualized genetic research results. We caution against this and argue in this essay that the debate to date has failed to give adequate weight to a number of fundamental ethical and policy issues that should undergird policy on return of research results in the first instance, many of which go to the fundamental differences between research and clinical care. We confine our comments to research using data from large biobanks, the topic of the guidelines proposed in this symposium issue.Genet Med 2012:14(4):473–477     

A new era in the ethics of human embryonic stem cell research

Scientific progress in human embryonic stem cell (hESC) research and increased funding make it imperative to look ahead to the ethical issues generated by the expected use of hESCs for transplantation. Several issues should be addressed now, even though phase I clinical trials of hESC transplantation are still in the future. To minimize the risk of hESC transplantation, donors of materials used to derive hESC lines will need to be recontacted to update their medical history and screening. Because of privacy concerns, such recontact needs to be discussed and agreed to at the time of donation, before new hESC lines are derived. Informed consent for phase I clinical trials of hESC transplantation also raises ethical concerns. In previous phase I trials of highly innovative interventions, allegations that trial participants had not really understood the risk and benefits caused delays in subsequent trials. Thus, researchers should consider what information needs to be discussed during the consent process for hESC clinical trials and how to verify that participants have a realistic understanding of the study. Lack of attention to the special ethical concerns raised by clinical trials of hESC transplantation and their implications for the derivation of new hESC lines may undermine or delay progress toward stem cell therapies.     

Ethical aspects of tissue engineering: a review

Tissue engineering (TE) is a promising new field of medical technology. However, like other new technologies, it is not free of ethical challenges. Identifying these ethical questions at an early stage is not only part of science's responsibility toward society, but also in the interest of the field itself. In this review, we map which ethical issues related to TE have already been documented in the scientific literature. The issues that turn out to dominate the debate are the use of human embryonic stem cells and therapeutic cloning. Nevertheless, a variety of other ethical aspects are mentioned, which relate to different phases in the development of the field. In addition, we discuss a number of ethical issues that have not yet been raised in the literature.     

Communicating Risks and Benefits About Ethically Controversial Topics: the Case of Induced Pluripotent Stem (iPS) Cells

Many are supportive of approaches that incorporate lay citizens into policy making and risk management decisions. However, a great deal of learning must first take place about how citizen engagement for controversial topics is best accomplished. Online risk communication efforts are increasing in popularity but there is little empirical evidence accrued to demonstrate the effectiveness of such methods. The intention of our overall study is to create a powerful method for in-depth two-way communication with the public and expert communities about complex and sensitive issues at the heart of stem cell (SC) research. The fundamental objective is to raise awareness of SC science with lay citizens by fostering more holistic or “all things considered” ethical judgments. Our risk communication study demonstrates that lay citizens are both interested in, and capable of learning about, complex scientific issues provided the right tools are used to convey information and assess understanding. Our results show that it is worth the time and effort for SC researchers to continue posting podcasts and FAQ’s about their work for non-expert communities to view. In addition, despite having increased our participants’ risk perceptions about induced pluripotent stem (iPS) cell research, almost all were very supportive of this type of research in Canada by the end of the survey. In other words, participants understood that this research did in fact pose some risks and learned a great deal about both the risks and benefits of iPS cell research, and still thought this research was worthwhile to pursue.     

Unproven stem cell-based interventions & physicians’ professional obligations; a qualitative study with medical regulatory authorities in Canada

Background

The pursuit of unproven stem cell-based interventions (“stem cell tourism”) is an emerging issue that raises various concerns. Physicians play different roles in this market, many of which engage their legal, ethical and professional obligations. In Canada, physicians are members of a self-regulated profession and their professional regulatory bodies are responsible for regulating the practice of medicine and protecting the public interest. They also provide policy guidance to their members and discipline members for unprofessional conduct.

Methods

We conducted semi-structured telephone interviews with representatives from six different provincial Colleges of Physicians and Surgeons in Canada to discuss their experiences and perspectives regarding stem cell tourism. Our focus was on exploring how different types of physician involvement in this market would be viewed by physicians’ professional regulatory bodies in Canada.

Results

When considering physicians’ professional obligations, participants drew analogies between stem cell tourism and other areas of medical tourism as well as with some aspects of complementary alternative medicine where existing policies, codes of ethics and regulations provide some guidance. Canadian physicians are required to act in the best interests of their patients, respect patient autonomy, avoid conflicts of interest and pursue evidence-based practice in accordance with accepted standards of care. Physicians who provide unproven treatments falling outside the standard of care, not in the context of an approved research protocol, could be subject to professional discipline. Other types of problematic conduct include referrals involving financial conflict of interest and failure to provide urgent medically necessary care. Areas of ambiguity include physicians’ obligations when asked for information and advice about seeking unproven medical treatments, in terms of providing non-urgent follow-up care, and when asked to support efforts to go abroad by providing tests or procedures in advance that would not otherwise be medically indicated.

Conclusions

Specific policy guidance regarding the identified areas of tension or ambiguity may prove helpful for physicians struggling with these issues. Further consideration of the complex interplay of factors at issue in how physicians may (should) respond to patient demands related to unproven medical interventions while meeting their professional, legal and ethical obligations, is warranted.

     

Ethical aspects of human biobanks: a systematic review

Aim

To systematically assess the existing literature on ethical aspects of human biobanks.

Method

We searched the Web of Science and PubMed databases to find studies addressing ethical problems in biobanks with no limits set (study design, study population, time period, or language of publication). All identified articles published until November 2010 were included. We analyzed the type of published articles, journals publishing them, involvement of countries/institutions, year of publication, and citations received, and qualitatively assessed every article in order to identify ethical issues addressed by the majority of published research on human biobanking.

Results

Hundred and fifty four studies satisfied our review criteria. The studies mainly came from highly developed countries and were all published in the last two decades, with over half of them published in 2009 or 2010. They most commonly discussed the informed consent, privacy and identifiability, return of results to participants, importance of public trust, involvement of children, commercialization, the role of ethics boards, international data exchange, ownership of samples, and benefit sharing.

Conclusions

The focus on ethical aspects is strongly present through the whole biobanking research field. Although there is a consensus on the old and most typical ethical issues, with further development of the field and increasingly complex structure of human biobanks, these issues will likely continue to arise and accumulate, hence requiring constant re-appraisal and continuing discussion.Biobanks comprise organized collections of human biological samples, usually associated personal health information, which are used together for biomedical research. Research results are generally very important for the society and biobanks have been heavily supported by many governments. Thus, in the recent few years biobanks have undergone rapid proliferation and have become increasingly complex. Their complexity has arisen from an increasingly diverse set of research purposes, and of types and sources of the samples. For instance, biobanks could comprise the collections of human bodily substances of all kinds, such as cells, tissues, blood, or DNA. They range in capacity from small collections of samples to large-scale national repositories. The collected samples could be population-based or disease-specific, originating from diverse profile of individuals, eg, minors or adult persons. Biobanks may contain anonymous human samples or samples linked to the specific personal information. Also, there are various purposes of biobanks, such as diagnostic, therapeutic, or research. Biobanks could be an ownership of public or private subjects, the latter being non-profit or profit based. As a consequence, such a diversity of biobanking is associated with a broad spectrum of ethical and legal issues (1-5).Ethical issues are commonly present in many aspects of biobanking. The fact that biobanks deal with human samples, invading an individual autonomy or limiting self-control, provokes a number of ethical issues. Who is actually competent to give informed consent and donate a sample? When individuals donate part of their body to a biobank, how is that human sample processed? Who is the owner of the sample? Who should decide how it should be used? Who has the right to know individual results of research? These and many more ethical dilemmas exist in the ethical framework of biobanks. With the recent rapid developments in biobanking, all of these issues are magnified with plenty of further new questions continuously arising. Ethical framework has been the most controversial issue in the domain of biobanking. Thus, it is not surprising that there is a substantial literature focusing on ethical dilemas in biobanking, such as informed consent, privacy, protection, and returning of results to participants (6-9).Due to these reasons, it is very important that researchers are provided with a current review of the literature on the ethics of biobanking in a systematic way, to document the latest consensus on ethical issues in biobanking and to highlight emerging issues. For that purpose, we reviewed the existing literature on ethical aspects of human biobanks. We aimed to develop a systematic framework for categorizing ethical concerns relevant to human biobanks and to monitor the impact of research into ethical issues. This could help the ethical boards in decision making when dealing with issues within the framework of biobanking. Moreover, we believe that such kind of work could stimulate policymakers and lawmakers to create an adequate legal framework for biobanking, an important, but still largely unregulated issue.     

干细胞及组织移植治疗甲状腺功能减退症

背景：干细胞及甲状腺组织移植治疗甲状腺功能减退症已经取得了一定的成果。 目的：回顾分析干细胞与组织移植治疗甲状腺功能减退症的基础和临床研究进展。 方法：由作者检索1980/2010 PubMed 数据库及万方数据库有关干细胞与甲状腺移植治疗甲状腺功能减退症的基础和临床研究。 结果与结论：自体甲状腺组织移植治疗不可逆性甲状腺功能减退症的作用是肯定的,但存在不足之处,比如需要移植多少甲状腺组织才能使甲状腺功能保持在正常状态,移植后的长期效果还需要更多样本、更长期的跟踪随访来评价。胚胎干细胞在体外环境下可诱导分化为甲状腺细胞,但受伦理学和细胞移植排斥反应等原因困扰。脐血间充质干细胞具有来源丰富、易于采集、保存和运输、无异体排斥、避免伦理争议等诸多优点,在不同诱导条件下能够向不同谱系分化,已被广泛用于治疗各种疾病,但能否通过多种途径诱导其分化为甲状腺细胞,并通过移植方法来治疗甲状腺功能减退症仍需深入研究。