Ethical issues and public communication in the development of cell-based treatments for COVID-19: Lessons from the pandemic.

The significant morbidity and mortality of coronavirus disease 19 (COVID-19) prompted a global race to develop new therapies. These include interventions using cell- or cell-derived products, several of which are being tested in well-designed, properly controlled clinical trials. Yet, the search for cell-based COVID-19 treatments has also been fraught with hyperbolic claims; flouting of crucial regulatory, scientific, and ethical norms; and distorted communication of research findings. In this paper, we critically examine ethical issues and public communication challenges related to the development of cell-based therapeutics for COVID-19. Drawing on the lessons learned from this ongoing process, we argue against the rushed development of cell-based interventions. We conclude by outlining ways to improve the ethical conduct of cell-based clinical investigations and public communication of therapeutic claims.

Unproven stem cell interventions: A global public health problem requiring global deliberation.

The unproven stem cell intervention (SCI) industry is a global health problem. Despite efforts of some nations, the industry continues to flourish. In this paper, we call for a global approach and the establishment of a World Health Organization (WHO) Expert Advisory Committee on Regenerative Medicine to tackle this issue and provide guidance. The WHO committee can harmonize national regulations; promote regulatory approaches responsive to unmet patient needs; and formulate an education campaign against misinformation. Fostering an international dialog and developing recommendations that can be adopted by member states would effectively address the global market of unproven SCIs.

Reflection on the enactment and impact of safety laws for regenerative medicine in Japan.

Japan's Act on the Safety of Regenerative Medicine (ASRM) created an innovative regulatory framework intended to safely promote the clinical development of stem cell-based interventions (SCBIs) while subjecting commercialized unproven SCBIs to greater scrutiny and accountability. This article reviews ASRM's origins, explains its unprecedented scope, and assesses how it envisions the regulation of SCBIs. This analysis is used to highlight three key insights that are pertinent to the current revision of the ASRM: clarifying how the concept of safety should be defined and assessed in research and clinical care settings; revisiting risk criteria for review of SCBIs; and taking stronger measures to support the transition from unproven interventions to evidence-based therapies. Finally, the article reflects on lessons drawn from Japanese experiences in dealing with unproven SCBIs for international endeavors to regulate SCBIs.

ISSCR guidelines for the transfer of human pluripotent stem cells and their direct derivatives into animal hosts.

The newly revised 2021 ISSCR Guidelines for Stem Cell Research and Clinical Translation includes scientific and ethical guidance for the transfer of human pluripotent stem cells and their direct derivatives into animal models. In this white paper, the ISSCR subcommittee that drafted these guidelines for research involving the use of nonhuman embryos and postnatal animals explains and summarizes their recommendations.

Stem Cell Treatments in India: An Ethnography of Regular Practice.

In this article I explore how experimental stem cell treatments have become a therapeutic choice in India. Drawing on ethnographic fieldwork, I illustrate six sociotechnical pathways by which clinically unproven treatment is rendered regular health care practice for consumers and providers across the country. Through each pathway, based on the themes of bioconsumption, integration, consumer contacts, treatment experience and rituals, and political culture, I demonstrate how the experimental status of stem cell treatment is undermined and thereby experienced by key stakeholders as just another medical option. In analyzing the pathways, I argue that unproven stem cell treatment practices are promoted and sustained by multiple social, political and technical forces. The discussion on pathways is therefore situated within a conceptual framework of "normalization," derived from studies that investigate the multidimensional aspects to controversial and/or new medical technologies becoming routine.

Human artificial chromosomes for pluripotent stem cell-based tissue replacement therapy.

The gene therapy approach aiming at curing various human diseases began to develop as a technology from early eighties of the last century. To date the delivery of therapeutic genes are mainly mediated by virus-based, predominantly, non-integrated virus vectors. These gene delivery approaches have several fundamental limitations on the way of efficient deployment in clinical gene therapy. A totally different approach was suggested about 20 years ago when episomal non-integrative artificial chromosome-based vectors featuring large size inserts (even native gene loci) advanced to the stage. Since then numerous human artificial chromosome (HAC) vectors were developed by both de novo synthesis and top-down engineering technology. This approach so far is limited to ex vivo gene transfer and correction within highly proliferative or reversibly immortalized precursor stem cells or pluripotent stem cells. Recent breakthrough in generation of induced pluripotent stem cells and embryonic stem cell manipulation give the additional pivotal stimuli to integrate it with the HAC technology and to develop thereby novel approaches to replacement therapies of human genetic diseases. The HAC technology is complex and time consuming while nowadays it has significantly advanced and become notably closer to medical applications. In this review we discuss current advancements in the HAC technology, in particular, in terms of improvement of chromosome transfer method and achievements in developing mouse-based gene therapy tissue replacement models for several monogenic human diseases. The main progress has been done in elaboration of top-down type HAC technology in modeling and preclinical studies of gene therapy treatment for Duchenne muscular dystrophy (DMD) disease.

Adhering to Ethical Benchmarks in Neurology Clinical Trials Using iPSCs.

We examine the ethics of using induced pluripotent stem cells (iPSCs) in cell transplantation treatment of neurologic diseases and the essential types of ethical benchmarks required in clinical trials in neurology using iPSCs, including embryonic pluripotent stem cells. We focus on two issues: (1) comparison and (2) criticism of the two types of neuro-hype (neuro-purism and neuro-essentialism). In order to ensure that the dialog on ethical benchmarks continues to develop in a manner that promotes trust with society and research subjects, concerns about the clinical use of pluripotent stem cells (particularly iPSCs) in neurology must be at the forefront of any ethics discussion.

[Ethics of stem cell therapy for heart failure]. / Terapia con células madre e insuficiencia cardiaca: aspectos éticos.

Heart failure is one of the first diseases in which stem cells were used for regenerative medicine. Since 2001, many publications have shown that stem cell therapy has the potential to mitigate heart diseases, but there is no solid scientific evidence to fully support its clinical application at present. The future of regenerative medicine requires validated clinical trials with standardized platforms and transdisciplinary efforts to enable the development of safe and effective regenerative therapies to protect patients and to promote the ethical application of this new and highly promising therapy. Doctors and scientists have a responsibility to discuss with patients the current reality of regenerative therapies. They also have a responsibility to discourage the indiscriminate and commercial use of these therapies, which are sometimes based on false hopes, since their inappropriate use can harm vulnerable patients as well as research efforts. Although regenerative medicine may be the medicine of the future and might bring the hope of cure for chronic diseases, it is not yet ready for its wide clinical application.

Regulatory and policy tools to address unproven stem cell interventions in Canada: the need for action.

BACKGROUND: The marketing of unproven direct-to-consumer stem cell interventions is becoming widespread in Canada. There is little evidence supporting their use and they have been associated with a range of harms. Canada has been slower to act against clinics offering these interventions than other jurisdictions, including the United States. Here, we outline the regulatory and policy tools available in Canada to address this growing problem. MAIN BODY: Health Canada's regulations governing cell therapies are complex, but recent statements make it clear that Health Canada believes it has jurisdiction over many of the currently marketed stem cell interventions. Still, further regulatory clarity is needed from Health Canada, as are increased directed enforcement efforts on interventions that fall within their scope. The Competition Bureau, via the Competition Act, prohibits advertisers from making materially false or misleading promotional representations. The Competition Bureau could collaborate with the scientific community to analyze the claims of existing clinics in Canada, and impose sanctions upon those who breach the established standard. Professional regulators, including provincial colleges of physicians and surgeons, have considerable power over what products and services their members can offer. Every college of physicians in Canada requires, via policy and codes of ethics, that doctors maintain evidence-based practices. This requirement is incompatible with offering many unproven stem cell interventions. Litigation may be another tool, including the use of fraud, misrepresentation and/or negligence claims for failing to meet the required standard of care. Finally, political pressure on federal and provincial lawmakers could encourage changes to marketing, cell therapy and professional regulations that would allow a more comprehensive response. CONCLUSIONS: In sum, there are many existing tools that can be used to protect the public from unproven stem cell interventions. Increased bureaucratic will and grassroots efforts are needed in order to effect a positive policy response.

Unproven stem cell therapies: is it my right to try?

BACKGROUND: Nowadays one of the most critical aspects of innovative cell-based therapies is the unregulated industry, as it is becoming a competitor of the regulated system. Many private clinics, worldwide, advertise and offer cell-based interventions treatments directly to the consumer and this poses a risk to both vulnerable patients and health systems. Several countries have implemented Compassionate Use Programmes (CUP) that provide patients with medicines that have not yet completed the approval pathway, in the event that no reasonable alternative exists. Recently, in the public discourse, compassionate use has been increasingly associated with a patient's right to try. Thus, the aim of this study was to assess public knowledge of the clinical trials process with specific reference to innovative stem cell treatments, and trust in the institutions responsible for regulatory activities. We also asked people about their "right" to use unregulated therapies. METHODS: We developed an ad hoc questionnaire on three main areas of concern and administered it to 300 people in the patient waiting room at an Italian university hospital. RESULTS: Our findings suggest that people have a good knowledge of the clinical trials process and trust in healthcare institutions. Nonetheless, one person in two believes it is a right to use unregulated therapies. CONCLUSIONS: We stress the need, in the age of cellular therapies, for a commitment to support vulnerable patients and to strengthen awareness among the public about the substantial boundary that differentiates experimental therapies from unproven therapies. There should not be a "right to try" something that is unsafe but rather approved treatments and in line with good clinical practice. The trend, which emerged on this issue from our study, is quite different, confirming the urgent need to improve health information so that it is as complete as possible.

Ethical development of stem-cell-based interventions.

The process of developing new and complex stem-cell-based therapeutics is incremental and requires decades of sustained collaboration among different stakeholders. In this Perspective, we address key ethical and policy challenges confronting the clinical translation of stem-cell-based interventions (SCBIs), including premature diffusion of SCBIs to clinical practice, assessment of risk in trials, obtaining valid informed consent for research participants, balanced and complete scientific reporting and public communications, regulation, and equitable access to treatment. We propose a way forward for translating these therapies with the above challenges in mind.

Stem cells in aesthetic dermatology: bioethical and professional obligations.

Recently, stem cells in aesthetics have attracted increased attention, especially as they have become a popular trend that is being mass-marketed to consumers on the Internet and social media. Unfortunately, studies have shown this marketing to be misleading as it portrays many purported benefits of stem cells that have yet to be proven in the limited studies that are available. It is important for clinicians to understand the evidence and marketing behind any new trends, especially in the fast-paced world of aesthetics, where treatments often outpace current medical understanding. As clinicians, we have bioethical and professional obligations to educate ourselves on current trends, ensure adequate patient safety, and advocate for continued consumer education.

Human-Monkey Chimeras for Modeling Human Disease: Opportunities and Challenges.

The search for a better animal model to simulate human disease has been a "holy grail" of biomedical research for decades. Recent identification of different types of pluripotent stem cells (PS cells) and advances in chimera research might soon permit the generation of interspecies chimeras from closely related species, such as those between humans and other primates. Here, we suggest that the creation of human-primate chimeras-specifically, the transfer of human stem cells into (non-ape) primate hosts-could surpass the limitations of current monkey models of neurological and psychiatric disease, but would also raise important ethical considerations concerning the use of monkeys in invasive research. Questions regarding the scientific value and ethical concerns raised by the prospect of human-monkey chimeras are more urgent in light of recent advances in PS cell research and attempts to generate interspecies chimeras between humans and animals. While some jurisdictions prohibit the introduction of human PS cells into monkey preimplantation embryos, other jurisdictions may permit and even encourage such experiments. Therefore, it is useful to consider blastocyst complementation experiments more closely in light of advances that could make these chimeras possible and to consider the ethical and political issues that are raised.

Terapia con células madre e insuficiencia cardiaca: aspectos éticos / Ethics of stem cell therapy for heart failure

Heart failure is one of the first diseases in which stem cells were used for regenerative medicine. Since 2001, many publications have shown that stem cell therapy has the potential to mitigate heart diseases, but there is no solid scientific evidence to fully support its clinical application at present. The future of regenerative medicine requires validated clinical trials with standardized platforms and transdisciplinary efforts to enable the development of safe and effective regenerative therapies to protect patients and to promote the ethical application of this new and highly promising therapy. Doctors and scientists have a responsibility to discuss with patients the current reality of regenerative therapies. They also have a responsibility to discourage the indiscriminate and commercial use of these therapies, which are sometimes based on false hopes, since their inappropriate use can harm vulnerable patients as well as research efforts. Although regenerative medicine may be the medicine of the future and might bring the hope of cure for chronic diseases, it is not yet ready for its wide clinical application.

Ethical issues in living-related corneal tissue transplantation.

The cornea was the first human solid tissue to be transplanted successfully, and is now a common procedure in ophthalmic surgery. The grafts come from deceased donors. Corneal therapies are now being developed that rely on tissue from living-related donors. This presents new ethical challenges for ophthalmic surgeons, who have hitherto been somewhat insulated from debates in transplantation and donation ethics. This paper provides the first overview of the ethical considerations generated by ocular tissue donation from living donors and suggests how these might be addressed in practice. These are discussed in the context of a novel treatment for corneal limbal stem cell deficiency. This involves limbal cell grafts which are transplanted, either directly or after ex vivo expansion, onto recipient stem cell-deficient eyes. Where only one eye is diseased, the unaffected eye can be used as a source of graft tissue. Bilateral disease requires an allogenic donation, preferably from a genetically related living donor. While numerous papers have dealt with the theory, surgical approaches and clinical outcomes of limbal stem cell therapies, none has addressed the ethical dimensions of this form of tissue donation.

Ethics in musculoskeletal regenerative medicine; guidance in choosing the appropriate comparator in clinical trials.

BACKGROUND: Regenerative Medicine (RM) techniques aimed at the musculoskeletal system are increasingly translated to clinical trials and patient care. This revolutionary era in science raises novel ethical challenges. One of these challenges concerns the appropriate choice of the comparator in (randomized controlled) trials, including the ethically contentious use of sham procedures. To date, only general guidelines regarding the choice of the comparator exist. OBJECTIVE: To provide specific guidelines for clinical trial comparator choice in musculoskeletal RM. METHODS: In this manuscript, we discuss the ethics of comparator selection in RM trials. First, we make a classification of RM interventions according to different health states from disease prevention, return to normal health, postponing RM treatment, supplementing RM treatment, substituting RM treatment, improving RM outcome, and slowing progression. Subsequently, per objective, the accompanying ethical points to consider are evaluated with support from the available literature. RESULTS: a sham procedure is demonstrated to be an ethically acceptable comparator in RM trials with certain objectives, but less appropriate for musculoskeletal RM interventions that aim at preventing disease or substituting a surgical treatment. The latter may be compared to 'standard of care'. CONCLUSION: From a scientific perspective, choosing the correct comparator based on ethical guidelines is a step forward in the success of musculoskeletal RM.

Examining the therapeutic potential of various stem cell sources for differentiation into insulin-producing cells to treat diabetes.

Novel strategies are being developed to generate stem-cell-derived insulin-producing cells (IPCs), which could reverse the growing incidence of diabetes worldwide. We reviewed studies of stem-cell-based therapies for pancreatic ß-cell regeneration published between 1997 and 2017. Differentiation into IPCs can be achieved using various stem-cell sources: embryonic stem cells (ESCs), induced pluripotent stem cells (iPSCs), and several types of adult stem cells such as pancreatic, hepatic and mesenchymal stem cells. However, reliable cell replacement therapy for diabetes is still in its early stages, and safety and ethical concerns are pressing issues. It will be necessary to find means of identifying optimal stem-cell sources and of inducing ß-cell differentiation without using genetic mutations. The present article examines the potential of various stem-cell candidates for IPC generation, and the current obstacles preventing emergence of a candidate source.