Motivation

To ensure our experience is not subjective and unique, we first started off by collecting and analyzing the different views of Singaporeans about gene editing technologies on different media platforms. We believe the different stands and the different arguments being raised would inform us about the main issues in the discussion.

 Summary of Arguments

In Singapore, proponents of gene editing argue that it is a great tool for us to cure genetic diseases. With the CRISPR/Cas system, target efficiency and specificity have been greatly improved. It promises an affordable solution for curing rare genetically linked diseases, the cost of which is unimaginable for many families. Lastly, many believe that it is important for many parents with genetic diseases to have an equal opportunity to have their children.  

However, opponents against gene editing argue that no one is born to be perfect, so we should not deliberately change our genetic makeup to eliminate disease causing-genes. Many also think that germline gene editing objectifies humans and violates bodily integrity. More importantly, many question the safety of such treatment, fearing for the variation in the results and the consequences that come after.

In general, the discussions in Singapore are capable of reaching the consensus that at the very least, we should treat it just like traditional medical methods, where the technology itself is morally neutral, but its morality depends on how people use it. Majority of the voices agree that only applications in disease treatment should be allowed but not for enhancement purposes, to prevent the unregulated use of gene editing and they call for all stakeholders, including scientists, politicians, and the public to bear the responsibility of regulating gene editing together. 

For example,  Singapore has Bioethics Advisory Committee made up of a group of specialists, professors, and doctors in the medical field to review relevant laws and rules associated with gene editing. Where necessary, it engages public and reviews all the ethical, legal and social implications arising from gene editing and suggests to the government bodies what are the best actions to be taken. This exemplifies how different stakeholders shall cooperate and the recent call for legalizing mitochondrial replacement therapy is a realistic example. A summary of all arguments can be found here.

 Our Takeaway

There is a myriad of views towards gene editing, especially for germline editing, with some arguing that it is a social leveler while some others arguing the opposite.  The most discussed issues regarding gene editing are the social ones. People are worried about the social change that will be caused by gene editing technology.

Most Singaporeans hold an attitude of cautious acceptance towards gene editing. They look forward to its power, meanwhile take caution on its potential negative effect. Their assurance is partly for the fact that Singapore has relevant authorities to keep research and application in gene editing under careful observation.

 Our Actions

The overall attitude towards gene editing in Singapore is a receptive one, so we are assured that our research will be supported by the public and will hold a good opportunity to be applied in Singapore’s society. However, we still see many issues being raised, like affordability and safety. We should measure and rank their relative importance. Hence, from the pilot testing of our survey in National Junior College, we decided to expand this survey further.

 Motivation

After our survey, with the public concerns that we collected, we want to interview the last stakeholder in our conversation, the  professional doctors, as they are the ones utilizing gene therapy in the future, therefore it is important to know what their attitude towards gene therapy is. They also know the needs of the patients from a professional standpoint rather than an emotional one, so they are able to provide us with valuable suggestions to address issues with the patients.

 Professor Denise Goh

Professor Denise Goh is a Senior Consultant and heads the Division of Pediatric Genetics and Metabolism at the Khoo Teck Puat-National University Children's Medical Institute, National University Hospital.

She holds an optimistic view on gene editing, especially using AAV and CRISPR-Cas to treat genetic disorders. She hopes that gene editing can be made available in five years’ time, and to replace traditional methods of treatments, which are comparatively ineffective or cumbersome. For example, the enzyme replacement treatment for Hemophilia, she pointed out, requires the patient to receive the treatment continually and also posed to the possibility of a severe immune response.

When asked about DNA editing and RNA editing for disease treatment, she thinks that DNA editing has a major advantage over RNA editing, which is a relatively lower cost. As RNA editing needs to be tailored to the individual patient, and the effect is not as durable as DNA, the cost for customization and continual treatment would make it more expensive. On the issue of safety, she is not worried too much on that of DNA editing, as she believes that RNA editing, whose effect being transient, is also able to cause a severe immune response and result in organ failure in a short time. While the negative effect of DNA editing is long-lasting, its advantage of fixing the gene permanently, in her view, outweighs the potentially disastrous effect. 

In spite of that, she also finds value in RNA editing — for cancer treatment, some are analyzing transcriptome to identify the disease-causing transcripts, one layer above protein profiling, because the same gene can produce multiple transcripts due to alternative splicing, therefore, when the genome is not erroneous, and when defective proteins are too many to be corrected, it is important to identify the transcripts and correct or knock down them. The major problem now, she asserts, is that RNA is very unstable as compared to DNA or protein, and the transcriptome changes from time to time, from cell to cell, making it especially hard to analyze.

 Training Doctors from Duke-NUS Medical School 

We also interviewed training doctors Dr. Tracy Koh and her fellow colleagues from Duke-NUS medical school to see how future doctors view such an issue. 

Figure 7. Photo of our interviewer with training doctors

We raised the issue of safety to the interviewees, and they agreed that safety is indeed a big issue as the patients would be worried about the risks of receiving the treatment, especially when it is not so well-tested at this stage. From a technical point of view, apart from efficiency issues related with CRISPR-Cas, delivery system would also be a problem where target cells may not be reached. Only by having enough clinical trials can we ensure the safety level, which takes a long period to accomplish. From the public’s aspect, they may not have sufficient basic information about the risks related to gene editing. There are public concerns even about GMOs, not to mention having their own genes altered, as one of the interviewees mentioned. Therefore, public education is needed to establish a more objective view towards gene editing instead of a subjective one fueled with fear for change.

When we asked about the issue of cost, they affirmed that cost is going to be inevitably high at first, due to the fact that the technology is still at its early stage — even sequencing was very expensive at the start, one of the training doctors added. The general view towards cost is optimistic as they believe that as the research progresses, gene therapy will eventually become more affordable.

On the issue of DNA and RNA editing, they hold the view that both are important and it will depend on the particular disease. For a life-threatening disease such as cancer, DNA would be a better option while for a less severe disease with short-term effects, RNA editing might be a better option. Since most patients would have no idea of what DNA editing or RNA editing is, it would be important that the doctors have professional knowledge and advice the patients the best method according to the need of the patient. It is the patient who makes the ultimate decision, so it is equally important that the patients have some basic understanding of different forms of treatment.

 Our Takeaways

Both DNA and RNA editing have their own values, as each has a unique advantage under different situations. Since gene therapy is still a rather unexplored field, we cannot be sure that one will definitely work better than the other. Therefore, we should research in both areas, especially gene editing on the RNA level, which is less developed and researched as compared to DNA editing.

Currently, DNA editing is likely to be preferred due to the possibly larger cost incurred from multiple treatments of RNA editing. In order to not limit ourselves to DNA editing only, we seek to reduce the cost of treatment at the very early stage — disease analysis. We could develop an easier sequencing technique and make it more affordable to identify the genetic mutations since current transcriptome analysis is too time-consuming and complicated.