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Life-and-death dilemmas. New medical technologies. Controversial treatments. In playing god? we hear from the patients whose lives were transformed—and sometimes saved—by medical innovations and the bioethicists who help guide complex decisions.
Ventilators can keep critically ill people alive, but when is it acceptable to turn the machines off? Organ transplants save lives, but when demand outpaces supply, how do we decide who gets them? Novel reproductive technologies can help people have babies in ways that are far beyond what nature allows. So, when should these “Brave New World” technologies be introduced, and who should control them?
playing god? is a production of the Berman Institute of Bioethics at Johns Hopkins University, with generous support from The Greenwall Foundation. New episodes drop every Tuesday.
The Berman Institute has created a guide for each episode where you can learn more about the guests, the history, and the ethics issues at: bioethics.jhu.edu/playing-god
00:00:04
Speaker 1: On today's show, as we wrap up this season, we're doing something a little different. We're going into the future to learn about a technology that's in the works but not yet available, a technology that even in its development stage, has people asking all kinds of questions.
00:00:22
Speaker 2: Imagine it became possible so that you could go to a hotel where Brad Pitt had been, you could take the dead skin, and you could use that genetic material to produce children. Would that be something that was problematic.
00:00:34
Speaker 1: We're talking about a type of reproductive technology called in vitro gametogenesis or IVG, that has the potential to open up a whole world of options for how humans procreate. IVG is essentially a process where cells, including human skin cells, could be used to make babies. Glen Cohen knows all about IVG. He's a professor of bioethics and law at Harvard Law School.
00:01:02
Speaker 2: You could both produce sperm an egg yourself and have a child that is your direct genetic descendant, but completely taking your genetic material rather than someone else. Now, I think for most people this strikes them as extremely strange as a desire. Why would you possibly ever want this? But just as there are people who want a single pair. In terms of rearing a child, there might be people who want to not have anybody else's genetic material involved.
00:01:28
Speaker 1: This may sound like science fiction, but scientists and biotech startups are already working or making it a reality. I'm Laurena Rora Hutchinson. I'm the director of the Ideas Lab at the Johns Hopkins Berman Institute of Bioethics. On today's episode, there are a lot of ways IVG could be used. People who for any reason aren't able to juice eggs or sperm could still have biological children, like people who've gone through menopause and people whose fertility has been impacted by cancer treatment. And people in same sex relationships could both be the genetic parent of the same child. But given that we could be shaping the future of humanity with this new technology, there are a lot of ethical questions to unravel. Are there good or bad reasons to do IVG? How much should regulators play a role? And how long do we have before all this becomes a reality. Some researchers predict that it may take decades, while commercial startups promise proof of concept trials within one to two years. From pushkin Industries and the Johns Hopkins Berman Institute of Bioethics. This is playing God. We'll hear more from Glen Cohen later on in this episode, but first I wanted to understand more about this technology, like how it actually works and where the research stands today. So I called up Amanda Clark. She's a professor of molecular, cell and Developmental biology at the University of California, Los Angeles, and she's an internationally renowned researcher and expert on in vitro gamito genesis. She's been working on developing it for decades.
00:03:35
Speaker 3: I am a basic scientist, and I'm interested in questions that are related to fertility and infertility and reproductive health. And what I saw as I looked at the scientific landscape for what's available to couples who are struggling with infertility, is that there seems to be a limit to what can currently be achieved with assisted reproductive technologies and medical technologies. So for those individuals who, for example, they're ovary or testis was destroyed as part of occupational health injury or due to chemotherapy or radiation therapy following a cancer diagnosis, and now they're cancer survivors. All of these types of injuries destroy the cells in the overy in testice that enable a person to have a biologically related child. And so as a stem cell scientist, I became really interested in what could we do as in a scientific community to be able to help those individuals and couples who want to have a family that don't have the cell types necessary for it anymore. So could we regenerate these cell types from stem cells? And that's the basis of in vitrogemetogenesis.
00:04:55
Speaker 1: Could you give me the broad strokes of what's going on with IVG and how it works, So if you're just explaining this to someone who had no idea what it.
00:05:03
Speaker 3: Was, So let's begin with the G in IVG. So IVG stands for in vitro gametagenesis. So most people understand what in vitro is because in vitro fertilization is used currently as a medical technology to help an individual or a couple to have a baby. The G gametogenesis means game meats eggs and sperm. So if we add it together, in vitro gamita genesis means making eggs and sperm in the lab for the purposes of reproduction. For those people that their testes and their ovaries aren't working properly, they may not make a functional egg cell or a sperm cell. And so if your egg cell or sperm cell's not functional or you don't make them in your body, that means you can't have a biologically related child.
00:05:58
Speaker 1: And so with IVG eggs or sperm cells made.
00:06:01
Speaker 3: So in future, agamtagenesis means instead of these egg and sperm cells being made inside of the body, they are made in the lab by researchers, starting with a different cell type in the body, for example a skin cell. So scientists now know how to take a biopsy of the skin or perhaps a biopsy of the blood, and to grow those cells in the lab and to use molecular biology to convert those cells to a stem cell. And this stem cell has the potential to become an egg and sperm cell in the lab that could then be used for fertilization through in vitro fertilization.
00:06:45
Speaker 1: So, just to be clear on this, it means someone would be able to create an egg or sperm which was genetically matched to them because they'd be using their own skin cells.
00:06:57
Speaker 3: Yes, that's right. So in future, agametera genesis provides the opportunity for having a genetically related child because the skin cell, for example, comes from the person who's the intended parent. Wow.
00:07:13
Speaker 1: So where exactly is this technology currently?
00:07:15
Speaker 3: In future, gemtagenesis is being used for research because scientists still can't make an egg or sperm cell in the lab from human cells. So what scientists are able to do is to make very immature egg or sperm cells in the lab from human cells. And so this is actually very helpful because we don't understand much about how egg and sperm cells are made inside the body because they're inside an organ and they're relatively rare cell type, and so in future, cometagenesis is providing really important molecular and genetic information about how gameat forms and that can help us to understand the disease of infertility. But it's not yet at the point of making a GA meat that can be used for reproductive purposes. We are looking at decades away from being able to make an egg or sperm cell in the lab that could be used for reproductive purposes, and that's where the field would like to go.
00:08:16
Speaker 1: When we do get to that point, what applications do you think would be the best to try first for clinical research?
00:08:25
Speaker 3: Well, one of the options is to study in vitrogametogenesis in a species that is closely related to humans, for example, using non human primates as an alternate model to make game meats in the lab, and to use those lab made gameats the egg or the sperm cell in order to cure a disease model of infertility. And once those scientific models have shown that the game meat can successfully lead to a healthy pregnancy and a healthy baby, and that the resulting animal itself is fertile, only then will this technology move into clinical trials inhuman.
00:09:13
Speaker 1: And so, if it is shown to be safe and effective, as you've just explained, and it becomes approved as a reproductive technology, who do you think would be interested in using it?
00:09:28
Speaker 3: And why? I certainly get emails on a regular basis from couples that have been going through in viture fertilization for five years or more and successive rounds, and none of them have been successful, and so this is the sort of group who would be very interested in signing up for in future commutagenesis. Of course, we had the really important breakthrough study that was published using a mouse model, which is a model that scientists use in the lab where the sex of a gameat can be switched so that an egg cell can be made from cells that are taken from a man. And so this opens up the possibility of same sex reproduction for those that are socially infertile. And I think that this is a really important aspect of the technology as well.
00:10:31
Speaker 1: And what would it take to make sure that it would be a safe process?
00:10:37
Speaker 3: Yeah, in vitrogametogenesis would need to be proven safe. That game meat would need to be proven to have the equivalent quality competency of a gameat an eggorosperm that would have been made inside of the body. And so what this means is testing the quality of the gameat, the competency of the gamat and developing scientific tools that don't exist yet. And so a lot of that technology now needs to be developed too.
00:11:09
Speaker 1: Do you think that could be potential safety risks two children born via IVG.
00:11:15
Speaker 3: Well, human reproduction itself is actually not very successful and that is why the use of in future fertilization is increasing year over year of a year around the world. And one thing we have learned about studying embryos in the IVF lab is there's a lot of genetic abnormalities during early embryo development in humans, much more so than in any other species. And actually we understand very little about why there is so much genetic instability in the early human embryo. And of course, genetic instability in the early human embryo leads to early pregnancy loss. And so when we turn now to in vitrogamy genesis, the expectation is that the game meat made a research in the lab and used in fertilization studies is also going to have these same issues that a game meat made in the body has. And so the question is how do we measure the quality of an embryo made from an in vitrogametogenesis gameat eggosperm versus an eggosperm cell that's made inside the body. And so that's the beginning of understanding how these ga meats would be safe. But in the end not even natural conception has always successful, and so we know that there are children that are born who do suffer from genetic abnormalities, and so it's safeguarding against all of those potential eventualities with a game meat made inside the lab.
00:12:52
Speaker 1: And are there concerns in the academic research community about this technology being used in a way that's risky or problematic.
00:13:00
Speaker 3: So I think it's really important that the academic community talks about the promise but also the realistic challenges of in viuturogemeta genesis. What makes me very nervous is that it's potentially possible to get ahead of the science and talk about in viuture gemeta genesis as being a technology that's right around the corner for use in reproduction. But what we're talking about is a reproductive technology that has the potential to be transformative. But there's a lot of scientific hurdles that need to be overcome in order for this technology to become a reality, and it's really important that as scientists we communicate that effectively so that we're not giving false hope to people who think this technology is going to be right around the corner and could help them within the next five to ten years, when the technology is just not there yet, and the most important thing will be ensuring the safety of the technology, and that in the end comes down to the quality of the erg or sperm cell made in the lab and ensuring that that quality is equivalent to the quality of an erg or sperm cell that would have been made in the body.
00:14:21
Speaker 1: Thank you, Amando. It's been amazing to hear about this new technology and all the important work that you're doing.
00:14:27
Speaker 3: So happy for the opportunity to talk about the science.
00:14:31
Speaker 1: After the break, we'll go back to Glen Cohen. The ethicis we heard from earlier. We'll find out how he thinks as a society we should approach IBG. Let's go back to Glen Cohen. Glenn is a professor and deputy dean at Harvard Law School. There, he's also the director of the Peak Flom Center for Health Law, Policy, Biotechnology, and Bioethics. Glenn thinks reproductive technologies like IVG have the potential to really change our society and spark new ethical challenges. So, Glenn, could you tell us about some of the ethical issues surrounding IVG.
00:15:20
Speaker 2: So when talking about IVG, I think it's really important to distinguish different use cases, because different use cases raise different ethical questions. Start with the easiest use case, I think, ethically speaking, which is the use of IVG to help individuals who cannot produce scam meat, So, for example, people who cannot produce eggs during their regular, normal, healthy fertility period. For that group, some of the issues are, what do we have to do to perfect this technology? Does it involve a lot of embryo destruction along the way and is that a problem? How do we know when this is safe and effective and ready for human use? And when do we move to first in human How will we know what the inter generational effects might be and how do we track that? And can we actually demand to have data from successive generations people who never consented, for example, to this because they were born this way. And then I think we have some kind of interesting questions about policing inappropriate use, So whether, for example, we're worried that people might derive eggs from adult cells from someone who didn't consent, so taking leftover skin cells for example. And then maybe finally is just a broader question about whether this is a worthwhile goal for humanity, especially when we have so many people with other kinds of medical needs. Is this really where we should be spending our time, spending our money, and spending our research effort.
00:16:42
Speaker 1: Yeah, a lot of different ethical issues there. So you've begun with talking about keeping it within a person's period of life where they would, in theory be able to produce eggs. Could you talk about some of the ethical issues around using IVG for a person who's gone through menopause, for example.
00:17:04
Speaker 2: So I often like to distinguish what I call mimicking uses versus extending uses of new reproductive technologies. Mimicking is attempting to give people who by virtue of medical issues would ordinarily be able to do the kind of reproduction that everybody else does, enabling them to do that. So a way of thinking about this is there's a person with a disability and we're trying to correct for that disability. Extension uses are attempts to extend and give people fertility options that would not be available to other people similarly situated. And the post meant apausal example is a good example of an extension use. Women have as a species a set reproductive period where they are producing eggs that comes to an end, and the question is should we extend beyond that end. So, in terms of the ethical issues that are raised here, one set of issues has to do with whether enabling reproduction later in life is a worthwhile goal. There are some individuals who are worried that when you produce children whose parents are quite old, that's an unfortunate circumstance for the child. And that's a relevant thing to think about. So that's one issue. Another is that there are some individuals who just think the human species is a particular kind of thing and living a uniquely good human life is to be a particular kind of entity. And that's an entity that has a period for everything, right, a time for all things in life, and it's just wrong to go beyond that.
00:18:29
Speaker 3: Yeah.
00:18:29
Speaker 1: So it's really interesting hearing your distinction of extension versus mimicking. And I'm just really curious when people are in the same sex relationship and they want to reproduce genetically, would you also put them in the extension category.
00:18:43
Speaker 2: Yeah, so I think this is a really interesting question, especially if we're talking, for example, about two women. Right, you may have two women who are actually completely healthy in terms of their reproductive life. Right, if we were to provide sperm, each of them would be able to reproduce. And yet they're making an ask to say that's it's not what we want. We want to both be genetic parents, And they're saying It's not that I want to kind of have parody with somebody who's healthy when I'm unhealthy. Instead, they're saying, I want to have parity with everybody else who's heterosexual, infertile, who's able to basically use sperm and egg from both parts of their couple. I do think that this is an extension use. Now calling it an extension use does not itself determine whether it's right or wrong, good or bad, But I think it does acknowledge that the ask here is a little bit different, and that the political theory and the questions we're going to ask about whether this is the kind of ask that's appropriate or one society should support, are a little bit different than the case of somebody who's facing medical infertility. Some of my colleagues, they prefer the term disfertility for this situation. Single individuals, same sex individuals. So it's not that they are, in terms of their healthcare or their medical state, infertile. It's that there's a social reason why they can't reproduce, and they are making an ask of society to help them overcome this social reason.
00:20:03
Speaker 1: Yeah, so interesting the different ways that things become framed, even in the development of the science has big impacts on how it's then perceived by wider society.
00:20:12
Speaker 2: And that's exactly right. And it's worth emphasizing that one of the leading IVG commercial players, there's not that many on the scene, but have been public about it in the press about them and the New Yorker story that was done about them, there's a lot of emphasis that the leading kind of scientists and the leading kind of business person in it are gay men, right, and this idea of kind of personalizing it. So a big part of their story and their pitch is that as gay men, we wanted to have children with our partners that are also genetically both of ours. All of this puts pressure on the question about whether genetic parentage is the end all and be all right, because you might say, there's a way in which all of this discussion of IVG might strike adoptive parents, for example, as quite untoward. Is to say, it's so important that I know adopt that actually that I want to invent this entire new technology and do this. So there's a way in which how you frame this is also how you frame questions about the value of genetic connection versus other kinds of connections, and I think it's worthwhile for us to have that conversation. That conversation requires us to take a hard look at ourselves and say, why is genetic parentage so important for us? Why is it so important that both of us be genetic parents? And it's true, fertile heterosexual individuals are able to do this, no problem. But you know, is this the kind of thing that we think it's a really strong moral imperative to have technology to solve, or instead should our goal be to try to de emphasize genetic parentage. And there's a certain irony here because chosen family and I'm gay, so I can say this chosen family is a big adage within the gay community. And yet it seems to be there's a way in which this is a chosen family, but also a way in which this is a very genetically related family that in some ways reproduces very typical, very heterosexual conceptions of what family is.
00:22:03
Speaker 1: I think that some of the questions that are raising here, we really have to think about this as we are moving into this new unknown territory and the directions we're going in, the implications that can have so would IVG resolve any of the ethical concerns around existing alternatives to biological procreation, so for example, using an egg donor surrogacy or adoption.
00:22:28
Speaker 2: So one thing that's nice about IVG that helps kind of resolve some of the ethical considerations about other technologies is for egg retrieval. There's many people who say egg retrieval imposes risks on women, and in particular, if you think about egg freezing, where we're talking about young women who are kind of proactively trying to retrieve eggs and freeze them for a potential future use, there's a way in which they are imposing hardship on themselves, costs upon themselves, and also the potential low risk levels but potential for things like ovarian hyperstimulation syndrome for a potential future use. And if you could tell people, if you ever find yourself in that situation, we'll have a solution then and there you don't have to proactively do that, that might be quite attractive. So that's one thing that might be ethically good about this or solve another ethical problem. The other is the question of markets for eggs more generally and sperm to a lesser extent. But there are some people who find it objectionable that we have widespread markets in the United States where people buy and sell eggs. If you think those kinds of markets are problematic, there's a way in which IVG solves the problem because you now are able to do it to yourself. So it ends a certain market that at least some people find problematic. Those are two kind of advantageous parts about IVG. One disadvantage is, at least in the case of gay men or single men or women who have a medical issue that stops them from carrying to term, it might increase the use of surrogacy. And for people who think markets and surrogacy or surrogacy as a whole is problematic, it may be that by stimulating surrogacy use in the United States or across the world is a problem.
00:24:06
Speaker 1: So how will we know when it's ready to do a trial with human participants?
00:24:11
Speaker 2: So this is a very very complicated process. You know, we have an agency FDA, which is very good at looking at drugs, for example, to say we're ready to do a clinical trial in human beings. It does not have particular experience with reproductive technologies. And in the US at least that's partially a political reality that it doesn't. But I think that essentially what you're going to do is you're going to get increasingly close to human kinds of processes in animals and animals whose biology and reproduction is closer and closer to humans. You're going to get more and more evidence, and then at some point we're going to have to just make a decision, and it's probably going to be a regulator who's going to make the decision that we are close enough and we have enough evidence that with people who are fully informed of the risk, who are well selected for a clinical trial to minimize the risk, that it's time to begin a clinical trial in human beings.
00:25:00
Speaker 1: And some of the groups that are furthest along in getting IVG technology ready for human reproduction are for profit companies. Where are they coming from?
00:25:12
Speaker 2: These our companies that I think have a lot in common with some of the tech companies we've seen in Silicon Valley. And this is not uncommon when people are pushing an envelope that there is kind of a philosophy in Silicon Valley that there's a great idea, there's an unmet need and we should solve it with technology, and there's a way in which that's exactly what's being done here. But in the biospace as opposed to the technological.
00:25:34
Speaker 1: Space, it seems like IVG could end up being pretty expensive. So how do f this think about the problem of unequal access to these new reproductive technologies.
00:25:47
Speaker 2: You know the writer William Gibson, I think he said this on NPR once. It was quoted as saying, the future is already here, it's just not very evenly distributed. And I think that's like an interesting perspective on this or ethicists like me. It is a concern when we have something that's good, that we think is going to make people's lives go better, that it only be available to a small subset of the population. So I do think that this is something to keep one's eye on. But that said, if we look at in vitro fertilization as kind of a predecessor of technology, it's still extremely expensive. It's still not available to most people, and although I think it's somewhere between fifteen or nineteen US states have some requirement that insures cover IVF, it's a relatively weak form of coverage. So in some ways, I would say, if you ask me the cynical hat on. My guess is if IVG ever becomes available, it'll take a while to have any requirement of insurance coverage, and I doubt that the insurance coverage requirement will be more robust than the one we have for IVF at the moment, which is not all that robust. So with IVF and all reproductive technologies, it's become a game of the haves and have not.
00:26:55
Speaker 1: And what is the best case scenario in your mind regarding the laws and regulations surrounding IVG.
00:27:03
Speaker 2: For me, the best possible story of regulation, We'll start with a particular use case, and I would say start with one of the less objectionable, easier to get behind use cases, So, for example, the use of IVG to allow individuals who are still within their typical reproductive years to reproduce because they are not able to produce eggs or sperms. Supply them the thing that they are missing, And basically we would start there. We'd have significant public engagement, maybe we'd have citizen juries, deliberative democracy experiments, we'd have widespread discussion as a country, we'd have debates in Congress or in parliament, and we would settle on what I would hope would be a heavily regulated system where we have a government agency supervising learning, licensing, getting data, and then evaluating after a set period of time whether to expand to one of the other use cases, and again providing an opportunity to engage on those questions.
00:27:58
Speaker 1: And so that's the best case. Could you tell us the worst case?
00:28:02
Speaker 2: Well, I think there are two worst cases. One worst case is straight out prohibition. That we have people who could benefit from this technology, and we decide without any real deep reflection it's just too weird, it's too icky, We're just going to prohibit it. And for me, that's a bad case scenario because if there's value to this for some people, I'd like to at least us have an adult conversation about it. The other worst case scenario, I think would be a totally unregulated system where anybody could do this tomorrow, just at you find it too a physician or a lab that's willing to do and the technology is available and nobody's monitoring it, nobody is concerned, nobody's considering the ethical objections.
00:28:38
Speaker 1: So I guess it's with developments like these, the science needs to happen but also the infrastructure around the regulations also needs to happen too.
00:28:48
Speaker 2: I think that's right. And also I'll just say the human face of what we're talking about, right, Yeah. One of the reasons why we're seeing enforce in the United States a raft of personhood bills and restrictions on abortion. Any of the same arguments might apply to embryo destruction, but we don't see huge attempts to politically restrict in vitro fertilization in the United States. And if you ask why, one of the answers is even very conservative legislatures they know or they themselves have used in viuture fertilization. There's somebody who they picture when they picture the technology, and they picture the happy family that is the result. The more those kinds of stories can be, the stories of things like in vitro commutagenesis, the more likely it is that you will find a political majority in favor of permitting it. The less you are able to tell that kind of story, the harder it will be.
00:29:33
Speaker 1: It was so fascinating for me to talk with Amanda and Glenn and hear about where we are at with this new technology. I can see how something like IVG would bring so much to so many people who long for having a genetically related baby. But I can also see the importance of thinking really intentionally about this how if IVG becomes widely available, we'll need to be careful about how it's used for what purpose. Even though it remains to be seen how this technology develops and how we can use it responsibly, I think it's important that we all start having these conversations now. Throughout the series, we've been talking about the decisions we make about technology, and specifically what the ethical implications are of how new medical technologies are used. I'm thinking about the strong in Goldberg's losing their son, Sally Settel's search for a kidney, Andrew Cameron fighting for his patients, and so many other moving stories of patients, families, scientists, and caregivers. I'm also thinking about all the people whose stories we haven't heard because they weren't able to access the care they needed. Sometimes these medical dilemmas involve difficult decisions, often with no perfect answer. Whatever we choose, we must live or die with the consequences. We hope you've enjoyed playing God and we have something extra lined up for you. Next week. It's a prequel episode about a troubling chapter in medical history that helped give birth to the field of bioethics. In the nineteen sixties in Seattle, a committee of everyday people sort of like a jury of peers, was tasked with deciding which critically ill patients in their community deserved to live and who should be left to die. So watch out for that in your podcast feed next week. Thanks to our guests in this episode, Amanda Clark and Glen Cohen. Playing God is a co production of Pushkin Industries and the Johns Hopkins Berman Institute of Bioethics. Emily Vaughn is our lead producer. Production support from Sophie Crane and Lucy Sullivan. Our editors are Karen Shakergie and Kate Parkinson Morgan. Mixing by Samir Sengupta, the music by Echo Mountain, Engineering support from Sarah Bruguerre and Amanda Kaiwang. Show art by Sean Karney, fact checking by David jar and Arthur Gompertz. Our executive producer is Justine Lang at the Johns Hopkins Berman Institute of Bioethics. Our executive producers are Jeffrey Kahan and Anna Mastriani, working with Amelia Hood and with support from Susan Snead, Aaron Henkin, Abigail Brickler, Kim bikermer Anna Oakes, and Jamie Smith. Special thanks to Ari Cohen. Funding provided by the green Wall Foundation. Special thanks to voice coach Vicky Merrick. This is our last episode, so we'd like to thank some of the many people at Pushkin who've supported this show throughout the season, including Jacob Weisberg, Heather Fane, John Snarz, Letal Malad Greta Cohne, Carl Mcliori, Jasmine Perez, Eric Sandler, Jordan mcmill, Isabella Navarez, Nicole op Den Bosch, Maya Kanig, Jake Flanagan, Owen Miller, David Glover, Nina Lawrence, Mia LaBelle, and Ian Petzer. To learn more about bioethics and the issues presented in this series, please visit Bioethics dot jhu dot Edu Forward slash Playing God. I'm Lauren Aroora Hutchinson. Thanks for listening to Playing God. As you've heard through the series. I'm the director of the Ideas Lab at the Johns Hopkins Berman Institute of Bioethics at the Ideas Lab. We are exploring new innovative ways of telling stories about the intersection of ethics, science, medicine, and public health. As well as podcasts, we do screenwriting, films, and immersive experiences. To get involved, visit Bioethics dot Jhu dot edu, Forward Slash Ideas Lab