The Ne w E n g l a nd Jo u r n a l o f Me d ic i ne

Sounding Board S TEM C ELLS S CIENTIFIC , M EDICAL , AND P OLITICAL I SSUES

T is rare that a scientific subject causes controversy not only among scientists but also among politicians and the public. Stem-cell biology is such a subject. The media reports new claims as soon as (or before) they appear in the scientific literature or are presented at scientific meetings. Talk-show hosts present their views, and both Congress and the executive branch follow with policy initiatives. But in its present state, there is little certitude in the science of stem cells, and the hard facts are emerging slowly. It is important for the public and policy makers to understand the fundamentals of stem-cell biology and for physicians to recognize that this knowledge will alter the way we think about the origin and regeneration of tissues and organs and the development of disease. It has already influenced medical practice and will eventually affect medicine in important ways. Much will be gained by developing medical interventions that are based on these cells and the processes that regulate them.
WHAT ARE STEM CELLS?

cells, such as hematopoietic stem cells, are still unclear. Pluripotent stem cells generate germ-line stem cells plus tissue-specific stem cells, perhaps by way of an intermediate class of multisomatic stem cells, which would differ from pluripotent cells by contributing to all somatic lineages, but not the germ line.7 Multipotent tissue-specific stem cells can be found from the fetal stage onward.3 In adults, they can participate in the renewal and regeneration of tissue, and during fetal life they may be units of tissue generation. It is likely that there are specific stem cells for most, if not all, tissues, but there is confusion about when the results of an experiment or a therapeutic intervention can be attributed to stem cells. Verification of the presence of the critical properties of stem cells self-renewal and differentiation should be the gold standard for all such studies. For example, autologous transplants of mobilized peripheral blood from patients with cancer may contain hematopoietic stem cells, cancer cells, and all types of blood cells, yet nearly every group calls these stem-cell transplants. This practice is incorrect and misleading. The term hematopoietic stem-cell transplantation should be used only when stem cells are the sole cell population in the transplant.
CAN TISSUE-SPECIFIC STEM CELLS CHANGE THEIR FATES IN ADULTS?

Stem cells have the unique capacity not only to give rise to more stem cells (self-renewal) but also to generate differentiated progeny.1-3 They are present at all stages of development and probably exist in all multicellular organisms. In the blastocyst stage of the embryo before implantation, the inner cell mass contains cells that will become the fetus. Some of these cells are pluripotent stem cells that give rise to all types of somatic and germ-line cells. When these pluripotent cells are grown in vitro, they become embryonic stemcell lines.4,5 When mouse embryonic stem cells are transplanted into mouse blastocysts, the offspring of such blastocysts are often somatic and germ-line chimeras that carry genes from both the embryonic stem cells and the original blastocysts. These chimeras are powerful tools for research. One can, for example, repair or mutate a gene in a transplantable embryonic stem cell and study the way this action alters the development or function of the stem cells daughter cells in the mouse recipient. Moreover, the insertion of human disease genes into mouse embryonic stem cells has yielded useful animal models of human diseases. Human embryonic stem cells are now available and are at an early stage of validation.6 The developmental stages between pluripotent embryonic cells and multipotent tissue-specific stem

Almost every week, the scientific literature and the public media announce an experiment showing that stem cells from one tissue can circulate to another tissue and adopt the developmental fate of the second tissue (a process called transdifferentiation). In fact, in only a few studies of transdifferentiation have authentic stem cells been prospectively isolated or marked to ensure the accurate identification of the original cells. In true transdifferentiation, the differentiated cells in the second tissue or organ must arise solely from single cells of the first tissue, and the transdifferentiated cells must have not only the appearance but also the function of the second tissue.8-11 Moreover, it is important to determine whether the original stem cell is a multipotent tissue-restricted stem cell that transdifferentiates or an itinerant stem cell that has traveled through the blood from, say, the heart to the bone marrow and then back to the heart. (This is a common problem; in mice, more than 10,000 hematopoietic stem cells pass through the bloodstream and tissues every day.)12 It is still unclear whether true multisomatic stem cells exist in adults, and very few published studies meet the rigorous criteria essential for the identification of such cells.8-10 A clear resolution of this question is essential for the formulation of a rational public policy concerning stem-cell research and medical applications of stem-cell transplantation.

1576 N Engl J Med, Vol. 346, No. 20 May 16, 2002 www.nejm.org

SOUND ING BOA RD

HUMAN EMBRYONIC STEM CELLS IN SCIENCE AND MEDICINE

Several human embryonic stem-cell lines have the capacity to differentiate into a variety of types of tissue.6 The diversity of these lines is limited both by their number and by the fact that they were derived from patients in fertility clinics. That is, they do not represent the full ethnic and genetic diversity of the U.S. population. Nevertheless, much valuable knowledge will come from the research use of these cells, which may make it possible to investigate the geneexpression patterns of all intermediates between pluripotent embryonic stem cells and various multipotent tissue-specific stem cells, as well as between these stages and mature tissue cells. Even more might be learned by following the differentiation of single human embryonic stem cells after they have been transplanted into mouse blastocysts, but in my view, before embarking on such experiments, we must be able to guarantee that no human gametes could form. I believe that using the currently available embryonic stem-cell lines to delineate developmental lineages of human cells will be extremely valuable. Knowledge gained from such studies should spawn a search for molecules or factors that cause particular cells to follow particular pathways and inhibit them from following others. We can expect such research to affect not only classic pharmaceutical research but also the development of cell-based therapies. However, I believe that new lines of human embryonic stem cells will be needed. We know that the presence of a genetic predilection to a disease does not necessarily mean that the disease will develop. Germline alterations at several loci and somatic mutations may also be necessary. For these reasons, it is almost certain that no line of embryonic stem cells derived from blastocysts produced in fertility clinics will have the right combination of genes to be useful in studies of a particular disease. They will not, for example, serve for studies of the many kinds of cancer that result from a succession of somatic mutations. It is selfevident that no available embryonic stem-cell line or, for that matter, any random somatic cell from an affected person carries the entire set of genes with relevance to the disease under investigation. Only the diseased cells have these genes. By contrast, embryonic stem-cell lines with the appropriate sets of inherited and acquired genes should prove invaluable for studying the cellular basis of many diseases. How could such stem-cell lines be generated? One way is by transferring somatic-cell nuclei into enucleated eggs (nuclear transplantation). When stimulated to divide, the cell can form blastocysts of predefined nuclear genotype (with the mitochondrial DNA coming from the egg). Cells from the inner cell mass of these blastocysts can be isolated, cultured, and used

to generate embryonic stem-cell lines of predefined genotype.13-16 Many groups of investigators plan to derive such stem-cell lines from and for persons who need transplants of multipotent stem cells a process called therapeutic cloning. The risk of immune rejection is minimal (there is some risk, however, since proteins encoded by mitochondrial genes can stimulate the immune system).
POLITICAL AND ETHICAL ISSUES

During this congressional session, it is likely that legislation will be passed governing research involving human embryonic stem cells, including the practice of deriving embryonic stem-cell lines from embryos created in clinics for in vitro fertilization and the use of nuclear transplantation to produce human pluripotent cell lines. It is possible that religious and ethical considerations will lead to a ban on such research. Nearly 25 years ago, similar considerations led to calls for a ban on research involving recombinant DNA, but it is now unquestioned that hundreds of thousands of people are alive or healthier because of the use of recombinant DNA to produce insulin, erythropoietin, granulocyte colony-stimulating factor, interferons, and other important therapeutic recombinant molecules. The new question of whether to permit nuclear transplantation for the production of human embryonic stem-cell lines of defined genotype now faces Congress, state legislatures, and the executive branch, which is advised by the recently appointed Presidents Council on Bioethics. The debate has been complicated by the fear that nuclear transplantation into enucleated eggs might be used to clone a human being. This past year, two panels appointed by the National Academies published reports on these questions. One of these reports, Stem Cells and the Future of Regenerative Medicine, includes the deliberations and testimony of scientists, physicians, ethicists, and those who, for religious reasons, moral reasons, or both, oppose research involving human embryonic stem cells.17 The main recommendations in that report are to allow the continuation of research on both adult and embryonic human stem cells; to permit the expansion of the number of embryonic stem-cell lines for research purposes; and to encourage research into ways of preventing the immune rejection of stem cells and tissues derived from them, including those obtained through therapeutic cloning.17 The second panel considered the scientific, medical, and ethical aspects of reproductive cloning and nuclear transplantation for the production of pluripotent human stem-cell lines.18 It did not focus on moral issues. The intention of the report, Scientific and Medical Aspects of Human Reproductive Cloning, was to provide information to broad segments

N Engl J Med, Vol. 346, No. 20 May 16, 2002 www.nejm.org 1577

The Ne w E n g l a nd Jo u r n a l o f Me d ic i ne

of society, including government and private agencies. The panel recommended the prohibition of human reproductive cloning and suggested enacting a legally enforceable ban on the procedure and scheduling a review of this recommendation within five years. It concluded that the scientific and medical considerations that justify a ban on human reproductive cloning were not applicable to nuclear transplantation for the production of stem cells. The legally enforceable ban would protect against rogue groups that sought to implant intermediary blastocysts for reproductive cloning. The panel also encouraged a broad national dialogue on the societal, religious, and ethical questions raised by the new technology.18 There may be no middle ground in the debate. For some segments of society, blastocysts produced by nuclear transplantation are embryos to be accorded full human rights, and their destruction or biopsy to produce embryonic stem-cell lines constitutes the taking of lives. But preventing the use of such blastocysts would halt all research on embryonic stem-cell lines derived from nuclear transplantation, thereby blocking important medical research. I believe such research will be as valuable to medicine as recombinant DNA research has proved to be. It is important that the ethical and legislative debates proceed with the understanding that the decision makers are responsible for the lives that would be affected by preventing or delaying research involving embryonic stem cells. The legislative and executive branches of federal and local government that will make decisions about research on stem cells should be ready to accept this responsibility. Last summer, the House of Representatives briefly considered and then passed a bill that banned both human reproductive cloning and nuclear transplantation for the production of stem cells. The House passed the bill without the benefit of any comprehensive scientific or medical testimony. Since then, reports from the National Academies17,18 and from a California commission19 have provided extensive and well-documented scientific, veterinary, and medical data, as well as addressing the ethical considerations surrounding the use of human embryonic stem cells. The issues are now before the Senate. If the Senate permits nuclear transplantation for the production of human stem cells, it would be prudent for the House to use the opportunity of reconsideration to inform themselves by studying these reports, at the very least. President George W. Bush has appointed a Council on Bioethics to consider these issues; a minority of its members are scientists and physicians. Unlike the panels of the National Academies, whose members were pledged to maintain objectivity and did not draft their reports until all the relevant data and information had been received and discussed, the

Council on Bioethics contains several members who have continued to speak and write publicly in opposition to nuclear transplantation for the production of human pluripotent embryonic stem-cell lines. In my view, an objective recommendation cannot be obtained from that body unless its members lay aside their preconceived notions, review the data, and forswear any attempts to sway the public debate before they hear all the arguments. What if nuclear transplantation for the production of stem cells is banned in the United States but allowed in other countries (for example, China, Sweden, and the United Kingdom)? Biomedical researchers in the United States will have to learn of new advances by reading about them, rather than participating in them, or they will have to leave the United States in order to participate in research. New biomedical companies that translate these discoveries into therapies will be created in other countries, not here. And what if these companies succeed? Their products could not be imported to treat our patients (according to provisions of the Weldon bill [H.R.2505] and the Brownback bill [S.790, the Human Cloning Prohibition Act of 2001]), and only the wealthy would gain access to such treatments abroad. Even if these therapies could be imported, it is possible that physicians might withhold them from their patients for religious reasons. Unfortunately, there are few in Congress or the Presidents council who can evaluate the scientific and medical issues in order to make an appropriately informed decision. Too often in recent Senate hearings, the views expressed by senators have been based on articles in newspapers and popular magazines rather than reports of the National Academies or articles in peer-reviewed journals. Some journalists are failing the public trust by publicizing findings that have not been published in the scientific literature or independently replicated. In summary, experiments in animals have shown that nuclear transplantation for the production of embryonic stem-cell lines can be accomplished with mature cell nuclei, including nuclei containing medically important genetic defects and mutations. There is already evidence that these embryonic stem-cell lines can help unlock secrets of developmental and pathogenic events that might not be revealed otherwise. The technology is ready for the production of human embryonic stem-cell lines from diverse members of our society, from somatic cells of patients with heritable diseases, and from diseased cells (for example, all cancers) whose nuclei are a repository of the history of inherited and somatic mutations that caused these diseases. The method has the potential for producing cells for the treatment of a variety of diseases. Congress, the President, and the

1578 N Engl J Med, Vol. 346, No. 20 May 16, 2002 www.nejm.org

SOUND ING BOA RD

medical community now face a difficult decision: to prevent the production of blastocysts by nuclear transplantation, or to pursue paths of medical research and therapies that, in my view, will affect hundreds of thousands of lives.
IRVING L. WEISSMAN, M.D.
Stanford University School of Medicine Stanford, CA 94305-5323
Dr. Weissman was cofounder of two companies that perform research with adult stem cells, SyStemix, Inc., and StemCells, Inc., and has held or holds significant equity in these companies. He was also the chairman of the National Academies panel cited in reference 17. The opinions expressed in this article are those of the author and not necessarily those of that panel or the National Academies.

E UROPEAN P ERSPECTIVES ON T HERAPEUTIC C LONING

LTHOUGH recent advances in stem-cell research hold promise for therapeutic use, this promise has been accompanied by social, political, economic, legal, religious, and ethical questions. These questions have touched a raw nerve, and numerous laws and regulations have been implemented or are being considered in order to control the use and spread of this new technology. The legal situation is particularly complex in Europe, where each country is governed through both national legislation and the international European legislation passed by the European Union. Since there are deep social and political disparities among countries within the union that stem in part from cultural and religious differences, it is not surprising that a patchwork of legislation and regulation is emerging. These legislative and regulatory initiatives address two main ethical questions. First, does the production or use of human embryos in research threaten human dignity? And second, might therapeutic cloning lead to a commercialization of human eggs or embryos? In this article, I will discuss the ways in which these questions are being addressed in Europe.
PRODUCTION AND USE OF EMBRYOS IN RESEARCH AND THERAPY

REFERENCES
1. Becker AJ, McCulloch EA, Till JE. Cytological demonstration of the clonal nature of spleen colonies derived from transplanted mouse marrow cells. Nature 1963;197:452-4. 2. Siminovitch L, McCulloch EA, Till JE. The distribution of colonyforming cells among spleen colonies. J Cell Comp Physiol 1963;62:32736. 3. Weissman IL. Translating stem and progenitor cell biology to the clinic: barriers and opportunities. Science 2000;287:1442-6. 4. Evans MJ, Kaufman MH. Establishment in culture of pluripotent cells from mouse embryos. Nature 1981;292:154-6. 5. Martin GR. Isolation of a pluripotent cell line from early mouse embryos cultured in medium conditioned by teratocarcinoma stem cells. Proc Natl Acad Sci U S A 1981;78:7634-8. 6. Thomson JA, Itskovitz-Eldor J, Shapiro SS, et al. Embryonic stem cell lines derived from human blastocysts. Science 1998;282:1145-7. [Erratum, Science 1998;282:1827.] 7. Weissman IL. Stem cells: units of development, units of recognition, and units in evolution. Cell 2000;100:157-68. 8. Anderson DJ, Gage FH, Weissman IL. Can stem cells cross lineage boundaries? Nat Med 2001;7:393-5. 9. Weissman IL, Anderson DJ, Gage F. Stem and progenitor cells: origins, phenotypes, lineage commitments, and transdifferentiation. Annu Rev Cell Dev Biol 2001;17:387-403. 10. Morrison SJ. Stem cell potential: can anything make anything? Curr Biol 2001;11:R7-R9. 11. Blau HM, Brazelton TR, Weimann JM. The evolving concept of a stem cell: entity or function? Cell 2001;105:829-41. 12. Wright DE, Wagers AJ, Gulati AP, Johnson FL, Weissman IL. Physiological migration of hematopoietic stem and progenitor cells. Science 2001;294:1933-6. 13. Wakayama T, Tabar V, Rodriguez I, Perry AC, Studer L, Mombaerts P. Differentiation of embryonic stem cell lines generated from adult somatic cells by nuclear transfer. Science 2001;292:740-3. 14. Munsie MJ, Michalska AE, OBrien CM, Trounson AO, Pera MF, Mountford PS. Isolation of pluripotent embryonic stem cells from reprogrammed adult mouse somatic cell nuclei. Curr Biol 2000;10:989-92. 15. Hochedlinger K, Jaenisch R. Monoclonal mice generated by nuclear transfer from mature B and T donor cells. Nature 2002;415:1035-8. 16. Kawase E, Yamazaki Y, Yagi T, Yanagimachi R, Pedersen RA. Mouse embryonic stem (ES) cell lines established from neuronal cell-derived cloned blastocysts. Genesis 2000;28:156-63. 17. Committee on the Biological and Biomedical Applications of Stem Cell Research. Stem cells and the future of regenerative medicine. Washington, D.C.: National Academy Press, 2002. 18. Panel on Scientific and Medical Aspects of Human Reproductive Cloning. Scientific and medical aspects of human reproductive cloning. Washington, D.C.: National Academy Press, 2002. 19. California Advisory Committee on Human Cloning. Final report of the California Advisory Committee on Human Cloning. Sacramento: California Department of Health Services, 2002. (Accessed April 23, 2002, at http://www.law.stanford.edu/features/greely/.)

Copyright 2002 Massachusetts Medical Society.

The debate over the production or use of embryos in research can be reframed to highlight the ethical issues if it is posed in the following form: to what extent do human embryos and fetuses in their early stages have the right to protection? It is a fundamental tenet in many European cultures that humans shall not be treated merely as the means to an end but also as ends in themselves. If the rights accorded to humans after birth are also valid for unborn humans, from what stage of development are these rights accorded? The vigor with which this problem is debated varies from country to country. In countries in which religion has a strong influence on political decision making, such as Italy, Germany, Norway, Argentina, and the United States, the moral status of the human sperm, egg, or fetus is at the center of the debate. If a fertilized egg is conceded moral status, conducting experiments on this egg becomes more morally problematic than if it were not conceded any such status in its own right. A focus on human dignity reveals a basic conflict: the mothers dignity (especially her right to ultimate authority over her own body) stands opposed to that of the fertilized egg (in terms of its right to develop into a person). The dignity of the adult human (male or female) also conflicts with what is alleged in some countries to be the right of the

N Engl J Med, Vol. 346, No. 20 May 16, 2002 www.nejm.org 1579