Genes and ethics

Genes and ethics always feature prominently in any thinking about the future of health care. The genetic revolution has the potential to transform medicine from an enterprise concerned mostly with end stage disease to one that more often predicts and prevents. The revolution also presents new ethical problems. The topics of genes and ethics will become ever commoner in medical journals, and this issue of the BMJ is a step along that way.

Two Britons and an American have this week won Nobel prizes for their work on genes (p 791). Sydney Brenner from Cambridge used a nematode model to advance understanding of cell division and differentiation and organ development. John Sulston, also from Cambridge, described how programmed cell death is part of the process of normal differentiation, and Robert Horvitz from the Massachusetts Institute of Technology discovered the genes controlling cell death.

The announcement of the Nobel prize comes in the same week as the publication of the genome of both Plasmodium falciparum and the Anopholes mosquito (p 792). This dramatic achievement will allow the development of new candidate molecules for vaccines against malaria, but unfortunately the block to developing a vaccine is not a shortage of candidates but the cost of pushing them through the whole system.

This is all good news, but the story of a French boy being treated with gene therapy and developing leukaemia is bad news (p 791). There are over 600 gene therapy trials underway in the world, and there is so far little evidence that the treatment works well in humans. Britain's gene therapy advisory committee has identified two studies similar to the one that led to the leukaemia. It recommends that the trials continue, not least because the alternative treatment for the children affected has a one year mortality of 20%.

Gene therapy raises ethical difficulties, and so does the buying and selling of organs for transplantation (p 835). Most medical authorities have traditionally found the idea unacceptable, fearing exploitation of the poor and vulnerable and believing that “the integrity of the human body should never be subject to trade.” Others, including the American Medical Association, believe that the worldwide shortage of organs means that the idea should be considered. A BMJ editorial argued that if the NHS was the sole purchaser then exploitation might be avoided (20 July, p 114. Several correspondents disagree, and a report from JAMA shows that Indians who sell kidneys suffer both financially and medically in the long term (p 795).

Little is more difficult in ethics than the question of whether ethical principles can be applied universally. The World Medical Association says that clinical trials should not be conducted in developing countries unless tested against the “best current therapeutic method” and local participants will benefit from the findings. But an African epidemiologist said last week that such strictures will paralyse important research in sub-Saharan Africa (p 796).