Prospects and Ethics of Stem Cell Research: An Islamic

JIMA: Volume 39, 2007 - Page 73

Islamic Perspectives

PPrroossppeeccttss aanndd EEtthhiiccss ooff SStteemm CCeellll RReesseeaarrcchh:: AAnn IIssllaammiicc PPeerrssppeeccttiivvee

Hossam E. Fadel, MD, PhD, FACOG Director of Maternal Fetal Medicine, University Hospital

Clinical Professor, Department of Obstetrics and Gynecology, Medical College of GeorgiaAugusta, Georgia

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cceellll ttyyppeess.. TThhiiss cchhaarraacctteerriissttiicc mmaakkeess tthheemm aappppeeaalliinngg ffoorr uussee iinn rreesseeaarrcchh wwiitthhvviieeww ooff tthheerraappeeuuttiicc uussee,, eessppeecciiaallllyy iinn ““rreeggeenneerraattiivvee mmeeddiicciinnee..”” SStteemm cceellll ssoouurrcceessiinncclluuddee tthhee ffoolllloowwiinngg::11.. EEmmbbrryyoonniicc sstteemm cceellllss ((EESSCCss)):: TThheessee aarree ddeerriivveedd ffrroomm tthhee iinnnneerr cceellll mmaassss ooffddeevveellooppiinngg eemmbbrryyooss..22.. AAdduulltt sstteemm cceellllss ((AASSCCss)):: TThhee bbeesstt kknnoowwnn ssoouurrccee ooff AASSCCss iiss tthhee hheemmaattooppooiieettiicccceellllss ooff tthhee bboonnee mmaarrrrooww.. TThheessee hhaavvee bbeeeenn uusseedd cclliinniiccaallllyy wwiitthh ggoooodd rreessuullttss iinntthhee ttrreeaattmmeenntt ooff lleeuukkeemmiiaass.. VVeerryy ffeeww AASSCCss mmaayy bbee pprreesseenntt iinn ootthheerr oorrggaannss,, ee..gg..tthhee bbrraaiinn..33.. CCoorrdd bblloooodd:: CCoorrdd bblloooodd iiss aannootthheerr ssoouurrccee ooff ““aadduulltt”” hheemmaattooppooiieettiicc sstteemm cceellllss..44.. TThheerraappeeuuttiicc cclloonniinngg:: TThheerraappeeuuttiicc cclloonniinngg uuttiilliizzeess nnuucclleeaarr ttrraannssffeerr tteecchhnniiqquueessttoo pprroodduuccee pplluurriippootteenntt SSCCss wwiitthh tthhee ggeennoommee ooff tthhee nnuucclleeuuss ooff oorriiggiinn.. TThheessee cceellllssccaann bbee iinndduucceedd ttoo ddiiffffeerreennttiiaattee iinnttoo rreeppllaacceemmeenntt cceellllss ffoorr ttrraannssppllaannttaattiioonn iinnttootthhee iinnddiivviidduuaall ffrroomm wwhhoomm tthhee oorriiggiinnaall cceellll wwaass oobbttaaiinneedd,, tthhuuss eelliimmiinnaattiinngg tthheerreeqquuiirreemmeenntt ooff iimmmmuunnee ssuupppprreessssiioonn..

IInn tthhiiss ppaappeerr II wwiillll ddiissccuussss tthhee ppootteennttiiaall aanndd rreeaalliizzeedd ggaaiinnss ooff sstteemm cceellll tthheerr--aappiieess aass wweellll aass tthhee ppootteennttiiaall pprroobblleemmss aassssoocciiaatteedd wwiitthh tthheeiirr uussee.. II tthheenn wwiillll ddiiss--ccuussss tthhee eetthhiiccaall ddiilleemmmmaa tthhaatt tthhiiss rreesseeaarrcchh eennttaaiillss aass iitt ddeeaallss wwiitthh tthhee hhuummaanneemmbbrryyoo.. II wwiillll ddiissccuussss tthhee mmoorraall ssttaattuuss ooff tthhee eemmbbrryyoo aanndd tthhee vvaarryyiinngg vviieewwss ooffeetthhiicciissttss iinn tthhiiss rreeggaarrdd aanndd tthheenn II wwiillll ddiissccuussss tthhee ooppiinniioonn ooff rreelliiggiioouuss ccoommmmuunnii--ttiieess aanndd,, ssppeecciiffiiccaallllyy,, tthhee IIssllaammiicc ppeerrssppeeccttiivvee.. IIssllaammiiccaallllyy,, sstteemm cceellll rreesseeaarrcchh iisspprroobbaabbllyy ppeerrmmiissssiibbllee,, eexxcceepptt ffoorr tthhee ccrreeaattiioonn ooff eemmbbrryyooss ffoorr tthhee ssppeecciiffiicc ppuurrppoosseeooff uussiinngg tthheemm oonnllyy iinn rreesseeaarrcchh.. TThheerraappeeuuttiicc cclloonniinngg wwiillll bbee IIssllaammiiccaallllyy aacccceepptt--aabbllee wwhheenn tthhee iinntteenntt iiss ttoo ccrreeaattee ttiissssuuee//oorrggaann ffrroomm tthhee iinnddiivviidduuaall wwhhoo nneeeeddss iitt,,tthhee pprroocceedduurree iiss ffeeaassiibbllee,, aanndd tthhee rreessuulltt iiss eexxppeecctteedd ttoo bbee ggoooodd..

FFiinnaallllyy,, II wwiillll ddiissccuussss tthhee pprreesseenntt ssttaattuuss ooff sstteemm cceellll rreesseeaarrcchh iinn tthhee UUnniitteeddSSttaatteess aanndd tthhee ppoolliittiiccss tthhaatt iimmppaacctt iitt..

KKeeyy wwoorrddss:: HHuummaann eemmbbrryyoonniicc sstteemm cceellllss,, aadduulltt sstteemm cceellllss,, uummbbiilliiccaall ccoorrdd bbllooooddsstteemm cceellllss,, sstteemm cceellll rreesseeaarrcchh,, ssoommaattiicc cceellll nnuucclleeaarr ttrraannssffeerr,, rreeggeenneerraattiivvee mmeeddii--cciinnee,, eetthhiiccaall ccoonnssiiddeerraattiioonnss,, CChhrriissttiiaanniittyy,, JJuuddaaiissmm,, IIssllaamm,, IIssllaammiicc sshhaarriiaahh,, ppoolliittiiccssaanndd sscciieennccee..

Presented at the July 2006 conference of the Islamic MedicalAssociation of North America in Beijing, China.

May 2007:38486-IMANA.qxd 12/16/2008 10:13 AM Page 73

Stem cell research is a relatively new field ofmedicine that has great promise but has led toconfrontation with established religious and

moral values. It already has generated heated debateregarding the boundaries of scientific research thatit should not cross.1,2

In this paper I will explain, in the most basicterms, what stem cell research is, what its goals are,and when it may conflict with religious and moralvalues. I then will discuss the ethical principles thatmay guide us in establishing a balance and the posi-tions of various religions, specifically Islam.

WWhhaatt aarree SStteemm CCeellllss??Stems cells are simply the “original” cells from

which all 210 different kinds of cells that make thehuman body develop.3 They can be classified into:

1. Totipotent cells: These are the cells that cangenerate a complex organism, be it animal orhuman, but they cannot self regenerate.These are the embryonic cells beginning withthe zygote until the 8-cell morula stage.

2. Pluripotent cells: These cells retain the capac-ity to transform into all three primary germlayers i.e., the endoderm, mesoderm, andectoderm and, therefore, can still form acomplex organism. They can — in contrast tothe totipotent cells — self renew, for examplein tissues culture. These are the cells of theinner cell mass of the blastocyst and consti-tute what are usually called embryonic stemcells (ESCs).

3. Mulitpotent and progenitor cells: These cellsin the developing embryo are the descen-dants of the inner cell mass. They are alreadydifferentiated and develop in specific types ofcells e.g. blood cells, liver cell, cardiomy-ocytes, neurons, etc., and eventually makethe different body organs (Figure 1).

Stem cells are also present in adult tissues andorgans in small numbers with a limited potential ofself-renewal. They may be able to replace lost ordamaged cells. It is unknown to what extent theymay (or be made to) transdifferentiate into cells ofother lineage. They have been found in the brain,eye, bone marrow, peripheral blood, skin, liver, etc.They are also in the umbilical cord blood.4

EEmmbbrryyoonniicc SStteemm CCeellllssMost ongoing research has been utilizing embry-

onic stem cells (ESCs), which are derived from theembryonic inner cell mass and kept growing in tis-sue culture (Figure 2). Most studies were made onmurine ESCs, but there also has been great demandfor human ESCs (hESCs) because they are believed tobe much more promising in the search for cures of


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human disease. Human embryos have been createdby in vitro fertilization (IVF) specifically for stem cellresearch, but more commonly human embryos usedfor stem cell research were supernumerary embryosleft over from IVF done for reproductive purposesand donated by the couples concerned. Attemptsalso have been made to use spontaneously abortedfetuses but mostly these cells fail to grow in culture.Also, cloned embryos have been developed throughthe procedure of somatic cell nuclear transfer(SCNT), which is sometimes called therapeuticcloning, a procedure that will be discussed later.1

RReeaalliizzeedd aanndd PPootteennttiiaall BBeenneeffiittss ooff SStteemm CCeellll RReesseeaarrcchhThere have been realized benefits of stem cell

research, the best known of which is the successfultreatment of leukemia and many other hematologicdisorders by bone marrow transplants and, morerecently, by using umbilical cord blood stem cells.However, the real promise of stem cell research isthe potential development of a new field of “regen-erative medicine,”5 which aims at growing tailor-made human tissues or organs to be used to colonizeor to replace damaged tissues/organs to recovertheir lost function. Progenitor cells have been devel-oped that can be made to differentiate into myocar-dial cells, neurons, and pancreatic as well as othertypes of cells (Figure 3). These cells can potentiallybe used to treat Parkinson’s disease, Alzheimer’s dis-ease, and patients with spinal cord injuries. It is spec-ulated that they will also be used in the treatment oftype 1 diabetes, myocardial infarction as well asother conditions. I will mention just a few examplesof such studies. Dopaminergic cells generated fromprimate embryonic stem cells were transplantedinto monkeys with MPTP-induced Parkinson’s-likedisease. These transplanted cells attenuated the neu-rological symptoms.6 Laminectomized mice receivedcontusion spinal cord injury. Human CNS stem cellswere transplanted to an adjacent region. These CNSSC transplants promoted locomotor receovery.7

Wistar rats were randomized into control myocar-dial infarction (MI), MI plus transplanted cord bloodstem cells, and sham groups. Cord blood transplantsincreased mRNA expression of vascular endothelialgrowth factor and promoted a higher level of angio-genesis in the infarct zones. Echocardiographydemonstrated improved left ventricular function inthe treatment group compared to MI controls.8

There is a growing number of clinical trials investi-gating the use of stem cells to treat heart conditions.There were 57 such trials from 2000-2005 and 87 in2006 alone.9

It is to be emphasized, however, that thesepotential benefits and the prospect of stem cell ther-apy are still a long way from being a part of clinicalpractice.

Another important potential benefit is in thefield of pharmacology.3 ESCs can be used to identifynew molecular targets for drug therapy and thusfacilitate the development of novel drugs. Also,research can be directed to test the safety of drugsand to predict their potential toxicity in vitro (cul-ture) and reduce the need for animal testing in phar-macotoxicology. Of special importance is its use inthe field of embryotoxicology.3 It can be used toidentify the primary molecular mechanisms respon-sible for the teratogenic effect of drugs. For example,thalidomide was found to inhibit angiogenesis by thegeneration of hydroxyl radicals. When testing med-


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ications in growing cultures of ESCs becomes practi-cal, it will eliminate the need for the use of experi-mental animals, which has been plagued by the prob-lem of interspecies variation.

PPootteennttiiaall PPrroobblleemmss wwiitthh SStteemm CCeellll--BBaasseedd TThheerraappiieessApproximately one genetic mutation occurs with

each cell division.3 The multitude of cell divisions thatwill have to be part of the process of stem cell-basedtherapies may add up to significant genetic mutationsthat may cause serious health problems. In addition,epigenetic modifications such as DNA mutation mayalso occur. Another serious consideration is that thestem cells are programmed to divide, and, if this divi-sion continues uncontrolled, it may lead to tumorige-nesis. Also, implanted ESCs are going to be immuno-genic, and graft rejection is possible.

Scientists are cognizant of these complicationsand realize that, along with the pursuit of stem cellresearch applications for therapy, strategies to pro-duce techniques that enhance the possibility ofreversibility should be developed as well before stemcell research enters into the clinical realm.3 So at thisstage it behooves scientists, while emphasizingpotential benefits of stem cell therapy, not to exag-gerate these benefits.10

SSoommaattiicc CCeellll NNuucclleeaarr TTrraannssffeerr ((SSCCNNTT))In this procedure,3 a somatic cell is obtained (by

biopsy) from an individual. A human oocyte isobtained from an egg donor. The oocyte is enucleatedand then fused with the biopsied cell, transferring itsnucleus to the new cell, which is then induced todevelop into an embryo in a process akin to that usedin cloning, and hence the name therapeutic cloning.As the blastocyst forms, the inner cell mass is isolatedand cultivated to produce ESCs, which are theninduced to differentiate into various cell types, even-tually producing a tissue to be used as an autologoustissue graft to the original person from whom thesomatic cell was obtained (Figure 4). If the procedureis successful, it can be used to clinically derive thesomatic cell from a diabetic patient, for example, andgenerate pancreatic cells to be transplanted in thatperson. If they function properly, the person will becured of diabetes. The new transplanted pancreatictissue will have the sick person’s DNA and antigens.There will be no need for immunosuppression. Therewill be no danger of organ/tissue rejection.

Additional potential benefits of this technologyare the ability to study the pathogenesis of geneticdisease. The procedure allows the production ofhESCs from predefined individuals with the specificgenetic diseases to be studied. It has the potential toallow for the study of methods to correct the geneticdefect in the pluripotent stem cells. These cells canthen be transplanted into experimental animals totest whether such gene correction precluded diseasedevelopment. This can ultimately lead to the possibil-


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ity of correction of abnormal genes in vivo or theproduction of drugs that act on the proteins encod-ed by the pathogenic genes.5

UUmmbbiilliiccaall CCoorrdd BBlloooodd aass aa SSoouurrccee ooff SStteemm CCeellllssUmbilical cord blood (UCB) is a valuable source of

hematopoetic stem cells.11 It was first used in 1988 totreat Fanconi’s anemia in a sibling. Its major advan-tage is that it is less immunogenic. Only 4 out of 6HLA antigen matches are used in contrast to bonemarrow transplant where 9 out of 10 or even 10 outof 10 matches is required, yet it yields comparableclinical outcomes. For the same reason, UCB trans-plants are associated with a lower incidence of acutegraft versus host reactions. However, the cell dose isapproximately 10% of an adult bone marrow donorunit, so it can be used only in children or smalladults.

Another major advantage is that it does not raisethe ethical objection that is intrinsic to the use ofhESCs.

At least 60 mls of UCB are collected at delivery.Stem cells are separated and cryopreserved.Cryopreserved stem cells can survive for at least 15years. Autologous use is possible, except for inbornerrors of metabolism and many types of leukemia.However, it can be used even for these conditions forsiblings and or parents. Cord blood transplanting hasbeen successful in the treatment of many hemato-logic, immunologic, metabolic, and oncologic dis-eases.11 Its use is rapidly expanding into new areasincluding regenerative medicine e.g. the treatmentof diabetes.12 For more details and information aboutnewer clinical applications, see Young (2006).13

UUssee ooff AAdduulltt SStteemm CCeellllss iinn TThheerraappyyAs mentioned earlier, few stem cells are found in

many adult tissues. Hematopoeitic stem cells frombone marrow were coaxed to differentiate into neu-ral, myogenic, and hepatic cell types.13 Neural andskeletal muscle cells were coaxed to develop intohematopoeitic cells. Stromal stem cells were coaxedto develop into cardiac myocytes. Mensencymalstem cells were made to develop into adipocytic,chondrocytic, or osteocytic lineages. The mainadvantage of ASCs is that they will not provokeimmune system rejection and that they should notbecome cancerous, in addition to the fact that theiruse does not raise serious ethical or moral objec-

tions. On the other hand, the transdifferentiationpotential for most ASCs is probably limited com-pared to the unlimited transdifferentiation potentialof the pluripotent hESCs. Further, ASCs1,2 are rarecompared to the abundant hESCs that can beobtained, and ASCs are hard to grow in vitro.4

EEtthhiiccaall CCoonnssiiddeerraattiioonnssFrom what has been discussed so far, the use of

hESCs holds the greatest promise. At the same time,it is the one that has created the greatest controver-


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sy. Because of the use of human embryos and theobjection of many in the religious/ethical communi-ties, politics has been introduced into the realm ofthis scientific endeavor to an unprecedented extentin the form of legislation, presidential executiveorders, and the single presidential veto so far.Embryonic stem cell research brings into conflicttwo moral principles:

1. The duty to respect human life.2. The duty to reduce human suffering.

The dilemma is whether we as a society can agreeon which of these two principles ought to be givenprecedence or if we agree that there is a time in thedevelopment of the embryo that it cannot be consid-ered “human” and worthy of the “full” protectionaccorded a fetus or a live born infant.

The question then revolves on determining themoral status of the human embryo.1,14 There arethree positions:

1. The fertilized egg (zygote) has a full moralstatus.15

2. While the fertilized egg has a moral status, itbecomes deserving of protection only at alater stage. The moral status increases as thefertilized egg becomes more human-like.16

3. The embryo has no moral status at all; it is anorganic material with a status no differentfrom any other body part.14,17

Those who believe that the fertilized egg has afull moral status argue that there is no nonarbitrarypoint or morally significant dividing line in the con-tinuum of physical growth between an embryo and adeveloped human. Therefore, the human embryo is apotential person from the time of fertilization. Theirpoint is that while it is true that an embryo does notexhibit the properties of personhood, it will ifallowed to develop and fulfill its potential.18,19

The proponents of the second opinion agree thatthe fertilized egg is potentially a person but theyargue that there are degrees of value of a lifedepending on the stage of this life. Consequently,there are degrees of respect that ought to be shownto that life. They define these following stages: a) fer-tilization to implantation at the 6th day, b) from the6th day (implantation) to the appearance of the

primitive streak at the end of the second week, andc) viability, which has traditionally been set at 24weeks. They argue that the rights of the humanembryo/fetus increase as it goes from one of thesestages to the next.

The last group states that the embryo has nomoral status. It argues that fertilized humaneggs/embryos are merely parts of other peoples’bodies. They claim that for a “being” to be destroyedthat being should have an interest that is defeated.They further argue that for a being to have an “inter-est” this being must have beliefs, desires, expecta-tions, aims, and purposes and that the embryo hasnone of these.20 I believe that this position is extremeand can not be accepted on a moral/ethical ground.It denies that this being is a new creation of God.

Many ethicists have taken a reasonable middleground view. They point out that before implanta-tion (6-7 days after fertilization), the blastocysts cannot grow independently. They thus argue that astage in the development of the embryo ending atthe second week (after fertilization), at which timethe primitive streak appears, can be defined. Theprimitive streak defines the head-tail and right-leftorientation of the embryo and along which themajor tissues and organs begin to develop. This stagehas been called the pre-embryo. The pre-embryo hasno nervous system and cannot be considered sen-sate.21 Also, at the end of the second week there is nomore possibility of twinning.19 At that time, the pre-embryo becomes an embryo and acquires a uniquepersonhood. In this view, the early human embryohas an “intermediate” moral status. Thus, the pre-embryo and, particularly before implantation, theblastocyst can be used for experimentation i.e. stemcell research. However, special respect needs to begiven by limiting their use to important human pur-poses, establishing guidelines for the research, anddeveloping procedures to ensure that these guide-lines are followed.

Proponents of this view support their argumentwith the observation that in natural reproduction,many fertilized eggs either stop developing or fail toimplant and are “lost”. We as a society do not grievethe natural loss of these fertilized eggs the same waywe grieve the death of an infant. Therefore, weshould not be too concerned about the loss of someembryos in the process of stem cell research.18

Further, IVF procedures generate many embryos



which are found to be “nonviable” and will be dis-carded. These instead could be used for research.13

UUssee ooff HHuummaann EEmmbbrryyooss ffoorr SStteemm CCeellll RReesseeaarrcchhThe most widely available source is the supernu-

merary fertilized eggs produced during the course ofIVF procedures. These are commonly cryopreservedfor possible future use by the couples who producedthem, but often they are never used and can be anadequate source for stem cell research. However,obtaining stem cell lines from fresh human embryosis more efficient than from cryopreserved embryos.It is estimated that only 10% of frozen embryos can beinduced to develop into blastocysts.22 Thus, the use offresh zygotes/embryos is more attractive. Fresh non-viable fertilized eggs produced during IVF proceduresor fertilized eggs produced during IVF proceduresperformed for preimplantation genetic diagnosiscould be another source. Some have advocated askingthe couples undergoing IVF for fertility to donatesome of the fresh viable fertilized eggs for researchinstead of having them cryopreserved for possiblefuture use. Clearly this may reduce the chance of asuccessful pregnancy and increase the risk of goingthrough additional cycles of IVF to achieve a pregnan-cy instead of using already cryopreserved fertilizedeggs from a previous IVF cycle. However, ethicistsagree that it will be permissible to approach thesecouples with the idea of donating some of the excessfertilized eggs so they are not deprived of the chanceto contribute to science if they choose to do so.Detailed and comprehensive counseling should beprovided in these cases, and a consent form signed bythe couple should be thorough. On the other hand, insome institutions, physicians do not mention the pos-sibility of donating embryos for that purpose until acouple indicates a wish to discard their remainingembryos. As a precaution it is suggested that deci-sions to donate embryos in infertility clinics shouldnot be influenced by stem cell scientists.22

EEtthhiiccaall CCoonnssiiddeerraattiioonnss wwiitthh SSoommaattiicc CCeellll NNuucclleeaarrTTrraannssffeerr ((SSCCNNTT))

The misconception that SCNT is reproductivecloning is the result of it being called “therapeuticcloning” in the popular nomenclature. SCNT is notreproductive cloning. Its opponents argue that this isa first step along a slippery slope that would concludewith reproductive cloning. Realistically, SCNT success

will not make reproductive cloning more likely.Embryos produced by SCNT have little if any potentialof developing to the point of being born alive.1 It istrue that the cloned embryos are produced forresearch, but the eventual aim is to use them for ther-apy.

Another ethical concern is the source of thedonated human eggs (ova) used for SCNT. These needto be donated by healthy women. The concern is thatfor this research to continue there will be a surge inthe need for donor women, and this will substantiallyincrease if SCNT is developed — as it is hoped — into atherapeutic modality with the concern that there willbe the potential for exploitation of women in order tosatisfy the increasing demand for human eggs.1,22 Eggdonation involves the use of hormones to stimulateegg production and an invasive procedure to retrievethe eggs. Donors are usually compensated.Compensation is generally permissible to substitutefor lost wages, expenses for the procedure, and theinconvenience caused by possible side effects fromthe use of hormones to cause superovulation with themajor risk, though rare, of ovarian hyperstimulationin addition to the inconvenience of the invasive pro-cedures.1,22 The question is how much these are worthand would money be the reason for volunteering orwould it be pure altruism. The average compensationnow is $6,000 per cycle but probably this amount willincrease as the demand increases. In any case, a thor-ough informed consent must be obtained.22

To summarize the previous discussion “EthicalConsiderations”, one can say that while there is nodispute that the ability to treat serious disease is agreat good, it must also be recognized that not allmeans of achieving a desired good are morally andethically justifiable.

RReelliiggiioonn aanndd SStteemm CCeellll RReesseeaarrcchhThe United States of America is a secular state, yet

religion and religious values play an important role inhow individuals view the different issues particularlymoral and ethical issues and their views becomereflected in the politicians’ attitudes and opinions andthis is further reflected in governmental policies.Therefore, a discussion of stem cell research and itsethical implications cannot be complete without dis-cussing the religious viewpoints. I will limit this dis-cussion to Christianity, Judaism, and Islam, although Ibelieve other religions and sects have views as well.14



CChhrriissttiiaanniittyyBroadly speaking, Catholic, Orthodox

(Greek/Coptic), and conservative Protestant church-es have similar views on this topic. They believe thatthe human embryo is an individual from the momentof fertilization and that it has the right to its own life.They further believe that every intervention not infavor of the embryo is a violation of its right and thatno good end justifies the destruction of anembryo.23,24 On the other hand, for a lack of a betterterm, less conservative Protestant churches teachthat the embryo has a potential human status, butthe life of the embryo has to be weighed against thepossible benefit that may result from scientificresearch. They believe that while the life of anembryo is sacred from the time of fertilization,embryo research may be permitted prior to theprimitive streak stage.14

JJuuddaaiissmmJudaism is also nonmonolithic. The main groups

of Judaism are Orthodox, conservative, and reform.Broadly speaking, there are some principles inJudaism that pertain to this discussion.

1. Healing is a required obligation.25

2. Any activity that contributes to advancementin the world cannot be considered contra-dicting God’s orders.26

3. God is the one who gave us the power to cre-ate new technology, and then we can use it.16

4. Each activity that has no reason to be prohib-ited is permitted without having to find a rea-son for its permissibility.26

5. The human fetus < 40 days of age and certain-ly the preimplantation embryo do not havefull human status.27

IIssllaammIslam is usually defined as submission to Allah’s

(God) will جل جلاله. Mus lims believe that Is lam controlstheir actions in material as well as s piritual mat-ters. Is lam is commonly des cribed as a way oflife . S o, a Mus lim in performing any act s houldas k hims elf whether this act is permis s ible. O nehas to find if there is a Q uranic injunction on thatmatter and if not, one has to find out if there is aḥadῑth (saying) of Prophet Muhammad صلى الله عليه وسلم and ifnot, one has to res ort to the opinion of fuqahā’

(Islamic legal scholars) who use ijtihād (independentjudgment) and have made a concerted effort tocome up with a new ruling.28

The most important consideration in the topicunder discussion is when life starts. There is no spe-cific definition of the beginning of life either in theQuran or the ḥadῑth collections. It is generally agreedthat ensoulment, the breathing of Allah’s rūḥ (spirit)into the fetus, differentiates biological life, whichstarts at the time of fertilization, from human life.29

There is a difference of opinion between scholars asto whether ensoulment occurs at 40 or 120 days,29-31

depending on different interpretations of a ḥadῑthnarrated on the authority of Ibn Mas`ūd.32 All schol-ars agree that embryonic life is entitled to respecteven before ensoulment but becomes more so after itoccurs.33

Four Islamic principles may apply to stem cellresearch:

1. Islam has always encouraged men to contem-plate and explore new horizons.34-6

2. Prophet Muhammad صلى الله عليه وسلم ordered us tos eek cure for dis eas e. He s aid “Allah جل جلالهdid not create a disease without creating acure for it except senility, so sons of Adamseek cures but do not use ḥarām (forbiddenthings)”.37

3. All actions are in principle permissible as longas they are not categorically prohibited.

4. In matters in which other invocations aresilent the concept of maṣlaḥa (public interest)applies: “Where the welfare of people resides,there resides the statute of God.”33

The Muslim World League’s IslamicJurisprudence Council conference in December 2003held in Mecca, Saudi Arabia, issued a fatwā (religiousopinion) regarding this topic, excerpts of which aretranslated below:

It is permissible to acquire, grow and usestem cells for therapy or scientific researchas long as the cells’ sources are permissible.Examples of permissible sources are adultswho consent as long as it does not inflictharm on them, children whose guardiansconsent for a legal benefit without inflictingharm on the children, placenta or umbilical



cord blood with the permission of the par-ents, spontaneously aborted embryos orthose aborted for a legally acceptable causeand with the permission of the parents, andexcess fertilized eggs produced during thecourse of IVF and donated by the parentswith assurance that they are not to be used toproduce an illegal pregnancy. It is forbiddento obtain or use stem cells if its source is for-bidden. Examples of this include fetusesintentionally aborted without a legal medicalreason, intentional fertilization between adonated ovum and sperm, and therapeuticcloning.38

This last point is unclear. Although it seems toprohibit therapeutic cloning completely, it may bethat the prohibition is meant to be if it is just used tocreate an embryo to be a stem cell donor or in thecontext of “reproductive” cloning. This probablydoes not apply to the actual SCNT to generate a tis-sue that will be transplanted in the donor of thesomatic cell or to diagnose and study treatment of agenetic disease in that donor.

Abdulaziz Sachedina, a Muslim professor of reli-gious studies at the University of Virginia, stated“Research on stem cells made possible by biotechni-cal intervention is regarded as an act of faith in theultimate will of God as the Giver of all life as long assuch an intervention is undertaken with the purposeof improving human health.”39

There has been several published reports on theIslamic perspective of stem cell research by bothnon-Muslims14,16 and Muslims.40-2 These authors con-clude that Islam permits stem cell research in princi-ple. The latter authors report that the IslamicRepublic of Iran is one of the first countries that hasproduced hESCs.41

The Islamic position on stem cell research can beoutlined as follows:

1. In principle stem cell research is acceptabledue to its therapeutic potential.

2. Fertilized eggs before implantation are notconsidered fully human because withoutimplantation they cannot survive and devel-op into a human being.

3. The supernumerary embryos produced dur-

ing IVF can not be donated to other couples,and if they will not be used by the same cou-ple, they will have to be destroyed or left todie. Using them for stem cell research is then— at a minimum — acceptable and may evenbe preferable to their destruction.

4. Islamic scholars agree that creating humanembryos for the sole purpose of research isprohibited.

SSttaattuuss ooff HHuummaann EEmmbbrryyoonniicc SStteemm CCeellll RReesseeaarrcchh iinntthhee UUnniitteedd SSttaatteess

President Bush, by an executive order, allowedhuman embryonic stem cell research to continue oncell lines created before August 9, 2001.5 The orderprevented any funding for subsequent hESC produc-tion or SCNT stem cell production. At that time,there were probably 60-70 such lines and only 22 ofthem could be propagated in culture. However, thesecell lines were not found to be useful for therapiesbecause they were potentially contaminated withpathogens from mouse cells.43 There are currentlyapproximately 400,000 cryopreserved human pre-embryos in storage that are not to be used for repro-duction but can be used for research.44 However, theFederal prohibition significantly limits their use. TheU.S. Congress passed a bill that would allow federalgrant support for stem cell research, but PresidentBush vetoed that bill in July 2006, and the U.S. Houseof Representatives failed to override the veto.45

Several states have bills under consideration orhave passed bills regarding stem cell research. For amore detailed discussion of the status of hESCresearch in the different states, see Weissman (2005)5

and Okie (2005).22

Klimanskaya et al46 were able to develop hESClines by using only one blastomere, allowing theembryo to continue developing. They used a proce-dure akin to that used in preimplantation geneticdiagnosis (PGD). Numerous reports show that thesurvival rate of embryos with one blastomereremoved is unaffected and that the subsequentdevelopment and chances of implantation are thesame for both normal embryos and those biopsiedfor PGD. By avoiding the death of the embryo, thetechnique might obviate the principle concern ofopponents to stem cell research. So far, this tech-nique has had no effect on the ongoing debate.46



RReeffeerreenncceess1. Brock DW. Is a consensus possible on stem cellresearch? Moral and political obstacles. J Med Ethics.2006;32:36-42.2. NIH Stem Cell Information Home Page. In StemCell Information [World Wide Web site]. Bethesda,MD: National Institutes of Health, U.S. Department ofHealth and Human Services, 2007 [cited Wednesday,March 28, 2007] Available at<http://stemcells.nih.gov/index>.3. Wobus AM, Boheler KR. Embryonic stem cells:prospects for developmental biology and cell thera-py. Physiol Rev 2005;85:635-78.4. Sanai N, Alvarez-Buylla A, Berger, MS. Neural stemcells and the origin of gliomas. N Engl J Med.2005;353:811-22.5. Weissman I. Stem cell research: paths to cancertherapies and regenerative medicine. JAMA.2005;294:1359-66.6. Takagi Y, Takahashi J, Saiki H, et al. Dopaminergicneurons generated from monkey embryonic stemcells function in a Parkinson primate model. J ClinInvest. 2005;115:102-9.7. Cummings BJ, Uchida N, Tamaki SJ, et al. Humanneural stem cells differentiate and promote locomo-tor recovery in spinal cord–injured mice. Proc NatlAcad Sci USA. 2005;102:14069-74.8. Hu CH, Wu GF, Wang XQ, et al. Transplantedhuman umbilical cord blood mononuclear cellsimprove left ventricular function through angiogen-esis in myocardial infarction. Chinese Med J.2006;119:1499-506.9. ClinicalTrials.gov [World Wide Web site].Bethesda, MD: National Institutes of Health, U.S.Department of Health and Human Services, 2007.Available at <http://www.clinicaltrials.gov>.Accessed 25 Oct 2006.10. The European Group on Ethics in Sciences andNew Technologies. Adoption of an opinion on ethicalaspects of human stem cell research and use.Available athttp://ec.europa.eu/european_group_ethics/docs/dp15_en.pdf. [Revised Jan 2001; viewed 28 Mar 2007].11. Moise KJ. Contemporaryobgyn.net [World WideWeb site]. What to tell patients about banking cordblood stem cells. Available athttp://www.contemporaryobgyn.net/obgyn/article/articleDetail.jsp?id=320177. [Revised 15 Apr 2006;viewed 28 Mar 2007].

12. Juvenile Diabetes Research Foundation.University of Florida. ClinicalTrials.gov [World WideWeb site]. Umbilical cord blood infusion to treat typeI diabetes. Bethesda, MD: National Institutes ofHealth, U.S. Department of Health and HumanServices, 2007. Available atwww.clinicaltrials.gov/ct/show/NCT00305344.[Updated 12 Sep 2006; viewed 28 Mar 2007]. 13. Young B, editor. Emerging stem cell therapies.The role of cord blood banks. A supplement to ObGManagement. 2006 Oct. Available athttp://www.obgmanagement.com/MedEdLibr/PDFs/OBGSupp_HUCB.pdf.14. Hug K. Therapeutic perspectives of humanembryonic stem cell research versus the moral sta-tus of a human embryo–does one have to be compro-mised for the other? Medicina (Kaunas). 2006;42:107-14.15. Mahoney J. Bioethics and belief: religion andmedicine in dialogue. London: Sheed and Ward; 1984.16. Lampman J. Different faiths, different views onstem cells. Christian Science Monitor. 23 Jul 2001.Available fromhttp://www.csmonitor.com/2001/0723/p1s2.html.17. Harris J. Should we experiment on embryos? InLee R, Morgan D (editors). Birthrights: law and ethicsat the beginnings of life. London: Rutledge; 1989:85-95.18. Sandel MJ. Embryo ethics–the moral logic ofstem-cell research. N Engl J Med. 2004;351:207-9.19. Knoepffler N. Stem cell research: an ethical eval-uation of policy options. Kennedy Inst Ethics J.2004;14:55-74.20. Rickard M. Current issues brief no 5 2002-03: Keyethical issues in embryonic stem cell research.Parliamentary Library. Parliament of Australia[World Wide Web site].http://www.aph.gov.au/library/pubs/cib/2002-03/03cib05.htm. [Revised 21 Nov 2002; viewed 28Mar 2007].21. Fischbach GD, Fischbach RL. Stem cell: science,policy and ethics. J Clin Invest. 2004;114:1364-70.22. Okie S. Stem-cell research–signposts and road-blocks. N Engl J Med. 2005;353:1-5.23. Landry DW, Zucker HA. Embryonic death and thecreation of human embryonic stem cells. J ClinInvest. 2004;114:1184-6.24. Welin S. Ethical issues in human embryonic stemcell research. Acta Obstet Gynecol Scand.




2002;81:377-82. 25. Walters L. Human embryonic stem cell research:an intercultural perspective. Kennedy Inst Ethics J.2004;14:3-38.26. Guigui A. Ethics in medicine and Judaism. In TheEuropean Group on Ethics in Sciences and NewTechnologies (editor). Adoption of an opinion on eth-ical aspects of human stem cell research and use.Available athttp://ec.europa.eu/european_group_ethics/docs/dp15_en.pdf. [Revised Jan 2001; viewed 28 Mar2007]:145-9.27. Sullivan B. Religions reveal little consensus oncloning. MSNBC News [World Wide Web site]. c2004.Viewed Jan 11, 2005. Available fromhttp://msnbc.msn.com/id/3076930.28. Kamali MH. Principles of Islamic jurisprudence.3rd ed. Cambridge, UK: Islamic Texts Society;2005.29. Yassin MN. The inception of human life in thelight of statements of the Holy Quran and Sunnah andthe opinions of Muslim scholars. J Islam Med Assn.1990;22:159-67. 30. Athar S, Fadel HE, Ahmad WD, et al. IslamicMedical Ethics. The IMANA Perspective. J Islam MedAssn. 2005;37:33-42.31. Albar MA. Human development as revealed in theHoly Quran and Hadith. Jeddah, Saudi Arabia: SaudiPublishing House;1992.32. Ibn Ḥajar al-Àsqalānῑ. Fatḥ al-Bārῑ bi sharḥ ṣaḥῑḥal-Bukhārῑ. Kitāb al-qadar. Bāb fī al-qadar. Availableon-line at http://www.muhadith.org. 33. Saḥῑḥ Muslim. Kitāb al-qadar. Bāb kayfiyya al-khalq al-ādamī fī baṭn ‘ummihi wa kitāba rizqihi waajalihi wa àmalihi wa shaqāwatihi wa sa`ādatihi.Hadith no. 2643. Available on-line athttp://www.muhadith.org.33. Abū Ḥāmid Muḥammad al-Ghazālī. Iḥyā’ ùlūm al-dīn. Àbd al-Àzīz Ìzz al-dīn al-Sairawān (editor). 3rded. Beirut, Lebanon: Dār al-qalam.34. Glorious Quran, Chapter 29, Verse 20.35. Glorious Quran, Chapter 35, Verses 29-30.36. Glorious Quran, Chapter 7, Verse 185.37. Sunan Abῑ Dāwūd. Kitāb al-ṭibb. Bāb fῑ al-adwiyyaal-makrūha. Hadith no. 3874. Available from

http://www.muhaddith.org.38. Muslim Word League. Islamic JurisprudenceCouncil Conference, Dec 13-17, 2003, Makka, SaudiArabia. Fatwa number 3. Regarding stem cells.Available fromhttp://www.themwl.org/Fatwa/default.aspx?d=1&cidi=152&l=AR&cid=12. [Accessed 27 Mar 2007].39. Sachedina AA. Islamic Perspectives on Researchwith Human Embryonic Stem Cells. In Ethical issuesin human stem cell research. Religious perspectives(Vol 3). Rockville, MD: Governmental Printing Office;2000. Available from:http://bioethicsprint.bioethics.gov/reports/past_commissions/nbac_stemcell3.pdf.40. Beloucif S. The Muslim’s perspective related tostem cell research. In The European Group on Ethicsin Science and New Technologies to the EuropeanCommission (editor). Adoption of an opinion on ethi-cal aspects of human stem cell research and use.Available athttp://ec.europa.eu/european_group_ethics/docs/dp15_en.pdf. [Revised Jan 2001; viewed 28 Mar2007]:134-8.41. Larijani B, Zahedi F. Islamic perspective on humancloning and stem cell research. Transplant Proc.2004;36:3188-9.42. Aksoy S. Making regulations and drawing up legis-lation in Islamic counties under conditions of uncer-tainty with special reference to embryonic stem cellresearch. J Med Ethics. 2005;31:399-403.43. Martin MJ, Muotri A, Gage F, et al. Human embry-onic stem cells express an immunogenic nonhumansialic acid. Nat Med. 2005;11;228-32.44. Weiss R. 400,000 human embryos frozen in U.S.Number at fertility clinics is far greater than previousestimates, survey finds. Washington Post. 2003 May8;A10.45. MSNBC News Services. House can’t override stemcell veto. [updated 2006 Jul 19; cited 2007 Feb 10].Available fromhttp://www.msnbc.msn.com/id/13934199.46. Klimanskaya I, Chung Y, Becker S, et al. Humanembryonic stem cell lines derived from single blas-tomeres. Nature. 2006;444(7118):481-5.


Documents

Prospects and Ethics of Stem Cell Research: An Islamic