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Incidental Enhancements: A Neglected Governance Challenge for Human Genome Editing Research

June 25, 2020

The increasing pace and international diffusion of developments in human genome editing research have prompted ongoing efforts to develop responsible governance for such research. One point of broad agreement across these efforts is that human genome editing research should prioritize medical applications over attempts to enhance human traits because of the moral concerns the latter would raise. What qualifies as human enhancement and how to address issues that may arise in this arena remain uncertain. Moreover, several influential reports expand their interpretation of medical applications beyond disease treatment to endorse disease prevention as a goal for genome editing research. Basic human genome research and animal studies aspiring to this goal are already underway. But preventing disease through human genome editing would incidentally facilitate human enhancement applications in a variety of ways. If these translational research efforts are penalized by policy concerns about those applications, then their preventive health benefits could be lost. Conversely, society could be caught off guard by the emergence of genome editing applications that evoke the very moral concerns that the policy line against enhancement is meant to forestall. To responsibly anticipate these challenges, science policymakers will need to know more about the salience of enhancement concerns in the context of preventive genome editing (PGE) research and how best to develop research governance to address them.

This project addresses these needs through the following research questions:

  1. How do the goals, incentives, and values driving cases of preclinical PGE research affect the ways that its incidental enhancement implications are interpreted and addressed for governance purposes?
  2. How well might different forms of research governance be expected to anticipate and address these different concerns?
  3. Given the potential human health benefits of preventive genome editing research, what ethical weight should science policy give to the various enhancement concerns? Answering these questions requires both empirical research and ethical analysis.

Specific Aims

  • Enlists scientists to examine the professional and social factors that shape the trajectory of basic research relevant to preventive genome editing. Their perspectives will inform a taxonomy of different ways of interpreting incidental enhancements for policy purposes, and a preview of the governance challenges they will raise.
  • Follow national and global genome editing policy groups to capture the lessons of their experiences, in order to assess the relative merits of different approaches to governance in dealing with incidental enhancement concerns.
  • To inform an empirically grounded ethical analysis of the policy choices facing those engaged in genome editing research governance in different cases. The product of this project will be a set of case studies designed to help science policy makers, the research community, and the public anticipates the incidental enhancement concerns that preventive genome editing research will pose.

Principal Investigators


  • Jean Cadigan, Ph.D., Associate Professor, Department of Social Medicine, University of North Carolina at Chapel Hill
  • Gail E. Henderson, Ph.D., Director, UNC Center for Genomics and Society, University of North Carolina at Chapel Hill
  • Douglas P. MacKay, Ph.D., Assistant Professor, Department of Public Policy, University of North Carolina at Chapel Hill
  • Rebecca L. Walker, Ph.D., Professor, Department of Social Medicine, University of North Carolina at Chapel Hill
  • Arlene M. Davis, J.D., Associate Professor, Department of Social Medicine, University of North Carolina at Chapel Hill
  • John M. Conley, Ph.D., Professor, School of Law, University of North Carolina at Chapel Hill


NIH – National Human Genome Research (1R01HG010661-01A1, 4/1/2020 – 3/31/2024)

Healthy Volunteers as Model Organisms

September 5, 2017

Comparative Research Ethics and Policy for Phase I Trials

Principal Investigators: Jill A. Fisher and Rebecca L. Walker

This project addresses the need for a novel evidence-based approach to the protection of Phase I healthy volunteers. Phase I clinical trials test the safety of investigational drugs that eventually may be used in affected patients. These trials have distinctive features that may undermine the validity of data gathered and lead to ethics and policy gaps in protecting healthy volunteers. One such feature is that healthy volunteers must stay in the clinic during the trial where they are given a prescribed diet and experience other restrictions. Another feature of Phase I trials is they rely on repeat volunteers who do not mirror the health or sociodemographic characteristics of typical patient populations. Given these unique features of Phase I trials, we contend that valuable insights may be gained through a comparison with non-human animal “model organism” research. We will investigate this comparison and generate new ethics and policy guidance that addresses the problems of risk, subject selection, validity, and translation that are particular to healthy volunteer trials.

To do so, this project has 3 primary aims:

  1. Describe and normatively evaluate the limitations of current research oversight in Phase I trials by analyzing data on healthy volunteers’ perceptions of clinical trials, including through a non-human animal research “model organism” lens;
  2. Compare the ways in which Phase I researchers, non-human animal researchers, bioethicists and policymakers, regulatory and research oversight staff, and healthy volunteers conceptualize: a.) similarities and differences between healthy volunteer and non-human animal research and b.) ethical, policy, and translational science problems particular to each arena; and
  3. Develop ethics and policy guidance for Phase I healthy volunteer research that a.) extrapolates from the model organism framework in Specific Aims 1 and 2, b.) is attentive to the structural features of Phase I research, and c.) is vetted by expert stakeholders.

This 4-year project is a renewal of our current longitudinal R01 study of 180 healthy volunteers (the HealthyVOICES Project). To address the new aims, we will analyze the current grant’s dataset to identify ethics and policy gaps and generate empirically-grounded points of comparison between Phase I trials and animal research (Aim 1). We will also conduct 60 interviews and 300 surveys with expert informants from Phase I healthy volunteer research, animal studies, and bioethics and regulatory perspectives about the key ethical, policy, and translational issues at stake (Aim 2). Finally, we will develop ethics and policy guidance to protect Phase I subjects and improve the translational science pipeline. Four stakeholder forums across the US will provide a vetting process for our draft guidance and initiate dissemination for our final recommendations (Aim 3). We expect the contribution of the proposed project to be significant because it will generate ethics and policy guidance that can provide advances in healthy volunteer welfare and the translational efficacy of Phase I trials.

Ethics of HIV-Related Research Involving Adolescents in Kenya

August 7, 2017

Despite the high social value of adolescent HIV prevention research in sub-Saharan Africa, investigators are reluctant to involve adolescents in studies with HIV testing and disclosure of results because of ethical concerns about the risks of their participation. This study examines four inter-related ethical issues essential to adolescent HIV research: the effects of disclosure of HIV test results on adolescent psychosocial well-being, health-seeking, or risk behavior; minimizing harms in the recruitment of adolescents; comprehension of informed consent among parents, children, and adolescents 18 years and older; and the appropriate use of compensatory payments for youth and parent participation. The study setting is Siaya County in western Kenya.

Specific Aims

  1. To examine the effects of HIV testing and disclosure on adolescent behavior and psychosocial well-being in the context of a research study.  About 4,200 adolescents aged 15-19 will participate in an empirical study of HIV testing and disclosure per the standard of care to inform ethical guidelines.
  2. To examine stakeholder perceptions about adolescent HIV research methods for recruitment, informed consent, HIV testing and disclosure of results, and compensation/inducements for study participation.
  3. To develop guidelines for the ethical conduct of adolescent HIV research and to refine them in consultation with key stakeholders. Findings from Aims 1 and 2 will be used to develop preliminary guidelines for conducting ethical adolescent HIV research. Perceptions about the guidelines from the Kenya advisory boards, and from comparable focus group participants and local ethicists from two additional sub-Saharan countries will be analyzed and used to refine the guidelines and assess their generalizability.

Principal Investigator

  • Winfred Luseno, PhD, Pacific Institute for Research and Evaluation (PIRE)


  • Stuart Rennie, PhD, University of North Carolina at Chapel Hill
  • Denise Hallfors, PhD, PIRE
  • Hyunsan Cho, PhD, PIRE
  • Daniel Kwaro, MBChB, MPH, Kenya Medical Research Institute (KEMRI)
  • Amek Nyaguara, PhD, KEMRI
  • David Ayuku, PhD, Moi University
  • Muhammed Afolabi, PhD, Gambia, Medical Research Council
  • Arthur Caplan, PhD, New York University


  • NIH-National Institute of Mental Health (R01 MH102125, 9/1/2014 – 8/31/2019)


Exploring Moral Distress Within the Context of Our Health Care System

July 27, 2017

This study employs survey, focus group and interview data to examine moral distress among clinicians. Moral distress was first described within the context of nursing in the 1980s as a situation in which “one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action” (Jameton 1984). Moral distress is increasingly recognized within a wide variety of contexts. Studies suggest that moral distress is experienced by various health care professionals including nurses, respiratory therapists, physicians, and trainees. Left unaddressed, moral distress in health care can erode inter- and intra- personal relationships and lead to provider burnout, thereby compromising patient care.

The goal of this project is to develop more effective metrics to define and characterize moral distress amongst the diverse health care professionals within the UNC Health Care System. Our collaborative will utilize data obtained with these tools to develop targeted interventions for responding to moral distress at the institutional level.

Team Members

Using Simulation to Assess Ethical Skills in the Context of ACGME Residency Milestones

July 27, 2017

This project is funded through an AHEC Campus Innovation Grant and is a collaborative project by members of the Center for Bioethics, the Hospital Ethics Committee, and the School of Medicine’s Clinical Skills and Patient Simulation Center. It uses simulation to assess ethical skills as framed in the ACGME professionalism milestones for pediatric residencies. While the use of an objective structured clinical exam (OSCE), via simulation, is a well-developed tool in other parts of medical education, there is limited data on the use of OSCEs at the resident level for assessing ethical skills and professionalism. Simulation allows for a more objective and informed milestone determination in these challenging areas. We will create OSCEs sensitive to the ethical skills captured in professionalism milestones in pediatrics. Our model of simulation will permit pediatric residents to demonstrate, and preceptors to evaluate, competencies in ethical practice as prescribed by the professionalism milestones. Our ultimate product will be an ethics simulation module containing cases, assessment forms, and an instruction guide. This ethics module will be translatable to other residency groups beyond pediatrics. We will also promote the module and make it easily available to AHEC faculty throughout North Carolina.

Team Members

  • PI: Arlene Davis, JD, Center for Bioethics, Department of Social Medicine
  • Jean Cadigan, PhD; Center for Bioethics, Dept. of Social Medicine
  • Benny L. Joyner, Jr., MD, MPH; Dept. of Pediatrics and Clinical Co-director of the Clinical Skills and Patient Simulation Center
  • Margaret Waltz, PhD; Department of Social Medicine
  • Kimberly Blasius, MD; Dept. of Anesthesiology
  • Melissa Smith, MD; Dept. of Pediatrics
  • Gene Hobbs, BA; Dept. of Pediatrics and Simulation Lab Director
  •  Research Assistance from Warren Whipple, Dept of Social Medicine, Elizabeth Brassfield, UNC MD/PhD program, and Rohit Jaswaney, MS2, NY Medical College

Acute Infection: Lived Experiences and Ethical Challenges in HIV Research

February 6, 2017

A better understanding of acute HIV infection is essential to public health, impacting both HIV transmission and potential advances in HIV cure clinical research. Acute HIV infection refers to the earliest stages of HIV infection, the short window of time right after a person becomes infected when they are most infectious. Individuals diagnosed and treated during acute infection are an important population for HIV cure research.

Early phase HIV cure research protocols are both novel (and potentially riskier) to participants. Research done with this population presents a unique set of challenges as an acute diagnosis in itself may contribute to strong emotional and behavioral responses. Faced with new HIV-positive identities and increased transmission risk to their sex partners, acutely diagnosed patients may face greater stress and confusion as they navigate decisions related to medical care and research participation. This intersection of public health interest, HIV cure scientific value, and patients’ personal challenges indicates a compelling need to consider whether acute HIV experiences merit special ethical guidance for research.

The aims of this project are three-fold:

  1. Examine the experiences of acutely infected research participants involved in HIV treatment and cure-related studies using anthropological methods.
  2. Compare perceptions of risks and benefits of clinical HIV trial participation between acute and chronic HIV diagnosed research subjects.
  3. Develop a set of ethical recommendations that address specific challenges related to identifying, recruiting, and retaining AHI diagnosed individuals in HIV clinical (especially cure) research.

This project is conducted at three sites: the University of North Carolina at Chapel Hill, Duke University Medical Center, and Guy’s and St Thomas’ Hospital, London, UK.

Research team members:

  • Stuart Rennie (Principal Investigator), Assistant Professor, UNC Center for Bioethics, Department of Social Medicine, UNC-Chapel Hill
  • Adam Gilbertson (Co-Principal Investigator) Postdoctoral Research Fellow, UNC Center for Bioethics, Department of Social Medicine, UNC-Chapel Hill
  • Joe Tucker (Co-investigator) Assistant Professor of Medicine and Director of UNC Project-China, Department of Medicine, UNC-Chapel Hill
  • Julie Fox (Co-Investigator) HIV Consultant, King’s College London and Guy’s and St Thomas’ Hospital, London, United Kingdom
  • Audrey Pettifor (Co-investigator) Associate Professor, Dept. of Epidemiology, UNC-Chapel Hill
  • JoAnn Kuruc (Co-investigator) Clinical Program Director, UNC HIV Cure Center at the UNC-Chapel Hill
  • Kate MacQueen (Consultant) Senior Social Scientist, Global Health Research, FHI 360
  • Kara McGee (Consultant) Physician Assistant, Duke University Medical Center
  • Alice Sharp (Research Manager) Guy’s and St Thomas’s Hospital London, UK
  • Liz Kelly (Graduate Research Assistant) UNC-Chapel Hill

Funded by NIAID, the National Institute of Allergy and Infectious Diseases.
Grant number 1R21AI120549-01A1.


Re-Engaging Ethics: Ethical Issues in Engaged Research

January 30, 2017
Clockwise starting at top-left: Giselle Corbie-Smith, Al Richmond, Mysha Wynn, and Stuart Rennie

Project Description

Re-Engaging Ethics is a project that is funded by the Greenwall Foundation. The purpose of this project is to create and disseminate recommendations for the review and conduct of community-engaged research, by engaging a diverse set of stakeholders in dialogue about the unique ethical concerns that arise in this emerging scientific approach to public health and biomedical research. While there has been some conceptual work in the peer-reviewed literature on the ethical issues that arise in engaged scholarship, the field is so new that there hasn’t been a comprehensive examination of these issues, nor have there been clear recommendations for review. In addition, much of what has been written has been from the perspective of the investigator or ethicist; few include the perspectives of community members as authors, and even fewer bring all of these perspectives to bear in one set of recommendations. Our project seeks to remedy these issues by soliciting the varied perspectives of community, academic and ethics scholars through in depth interviews, questionnaires, workshops, and literature reviews, and developing a set of recommendations that address ethical issues in engaged scholarship.

Research Team

Real World Narratives Wanted!

The Re-Engaging Ethics team seeks narratives in the following topic areas: equitable and just research, relationship dynamics, community informed risk/benefit assessment, and accountability. Visit this page to learn more about submitting a narrative.

Strengthening Bioethics Capacity and Justice in Health

January 27, 2017
Kinshasa School of Public Health
Kinshasa School of Public Health

Francophone African countries are among the most resource-constrained in the world. Citizens in these regions commonly struggle with a wide variety of health problems related to poverty, political conflict and social upheaval. Those involved in local efforts to improve health, in clinical medicine, biomedical research or public health initiatives, often find themselves in difficult situations of moral conflict. Managing these conflicts is challenging, partly because local health professionals may come to them unprepared due to bioethics typically not forming an explicit part of the medical curriculum and having little presence in common culture.

This training project, entitled Strengthening Bioethics Capacity and Justice in Health, seeks to increase awareness of ethical issues in biomedicine in Francophone Africa, and contribute to locally relevant bioethics education and practice in this region. Our project conducts workshops, organizes conferences, provides training in bioethics for local collaborators and interested scholars, publishes peer-reviewed articles on bioethical issues in Francophone Africa, and integrates bioethics content into existing curricula in key educational institutions. The target countries for our initiatives are the Democratic Republic of Congo (DRC) and Madagascar. Strengthening Bioethics Capacity and Justice in Health is a collaborative project among leading health institutions in the United States, Belgium, Madagascar and the DRC.

Site leaders

Key investigators


Vermont Study on Aid in Dying

January 11, 2017

Vermont SAID

Lee Farm, Woodstock, Vermont

The Vermont Study of Aid-in-Dying (Vermont SAID) investigates the implementation and cultural impact of Vermont’s “Patient Choice and Control at End of Life” Act (Act 39), enacted in May 2013. Due to the recent enactment of Act 39, and Vermont’s small size and the geographic proximity of key institutions, Vermont offers an unparalleled setting for documenting emergent responses to the law across multiple sites and actors (e.g. patients, caregivers, medical providers and administrators, activists, legislators). The study will yield descriptive information about how the legalization of assisted dying affects death, dying, and end-of-life care. It will also describe ethical challenges that assisted dying raises for clinical communication about end-of-life care and the patient-provider relationship. Ultimately, the goal of the study is to 1) provide information that can be used to enhance end-of-life communication and policymaking, and 2) contribute to anthropological understandings of the biomedical management of death.

Research Team

mara-buchbinder-tileDr. Mara Buchbinder is the Principal Investigator on the project and a medical anthropologist specializing in the culture of medicine in the United States. Her recent work has explored how patients, families, and healthcare providers navigate social and ethical challenges raised by new developments in medical technology, public health policy, and law. She is especially interested in the role of language in medicine and in the relationships among patients, families, and clinicians in managing illness and healthcare. Dr. Buchbinder is an Associate Professor in the UNC Department of Social Medicine and core faculty in the UNC Center for Bioethics.

dragana-lassiterDragana Lassiter is the study research assistant and a PhD candidate in the UNC Department of Anthropology.

Study Participation

Over the past two years, Dr. Buchbinder has interviewed 78 clinicians, advocates and legislators, and family members/caregivers. In addition to these groups, we would also like to understand the perspectives of people who have been diagnosed with a serious or life-threatening medical condition. We hope to capture a variety of perspectives on the issue, including the voices of patients on either side of the debate, as well as those who don’t have a strong stance or don’t feel affected by the law. Interviews are typically an hour long and include questions about: your background, perspectives on the law, and ideas about what constitutes a good death. The study will run through the end of 2017. If you would like to participate, we would love to hear from you! (

Frequently Asked Questions

  • Who is funding the study?
    The study has been funded by the National Science Foundation and the Greenwall Foundation.
  • Should I expect any benefits from participating in the study?
    There is no financial compensation for participating in the study. However, sharing your perspectives and experiences might help advance the conversation about aid-in-dying in Vermont.
  • What does participation entail?
    Participation entails an hour long recorded interview at an agreed-upon location.
  • How will my privacy be protected?
    Once we transcribe the interviews, all personal information is removed. This generally includes all personal names, institution names, and names of towns and other geographical landmarks. We also work hard to remove any contextual information that could be identifying, such as one’s unique professional role or position within an institution.
  • What is your stance on physician aid-in-dying?
    We do not advocate for or against aid-in-dying. Instead, we are interested in the way legislating AID shapes end-of-life care and cultural perceptions of death and dying.


Mara Buchbinder, PhD
Associate Professor
Department of Social Medicine
University of North Carolina at Chapel Hill
333 S. Columbia Street
341A MacNider Hall
Chapel Hill, NC 27599-7240

phone: 216.402.0498


Project Website