Q methodology helped participants to parse their thoughts about a complex—and to some participants new—topic before deliberations with other participants. Ranking the statements was experienced as fun and useful by the participants. The five resulting factors are presented below. The factor narratives are presented in order of their eigenvalue, variance, and the number of participants with positive factor loadings. The narratives of the two factors on which most participants loaded and that explained most of the variance are presented in full. The factors that explained less of the variance (factors 3, 4, and 5) are presented in a more condensed way. In all narratives, emphasis is placed on the (clusters of) statements that contribute most to understanding the unique perspective of the factors. An overview of the rationales of the factors is given in Table 1. An overview of all statements and factor loadings can be found in the Appendix.
There were two consensus statements, which did not differ significantly among the factors: (1) ‘CRISPR-Cas9 raises too many questions to use the technology,’ and (2) ‘Further development of CRISPR-Cas9 justifies using embryos’. Both statements did not correspond to unique aspects of any of the factors.
With only one exception, no correlations were identified between the factors and participants’ background characteristics. The two participants in factor 4 (the most liberal view on CRISPR-Cas9) described themselves as non-religious and politically liberal.
Factor 1: Pragmatic Optimists
This factor had an eigenvalue of 7.8 and explained 26% of the variance. Fourteen participants were significantly associated with this factor. Six participants were scientists, four were retirees, two worked in the for-profit sector, one worked for the government, and one was a student. They described themselves as hardly or not religious. Most participants were moderately interested in politics (some not at all). They kept up to date on technological developments by following media (mostly the news, documentaries or other tv programmes, newspapers, or the internet). Participants in this factor focused on medical benefits of CRISPR-Cas9. Non-medical uses were not supported. Moral, societal, and governance considerations were less important.
In this factor, trust in the medical usage of CRISPR-Cas9 was central: Statements on preventing and curing hereditary diseases were ranked either highest or second highest (11 at 3; 13 and 26 at 2). The statement that it is good that CRISPR-Cas9 improves the lives of people with hereditary diseases was also ranked high (32 at 3). This indicates that the contribution of CRISPR-Cas9 to the health and quality of life of people with hereditary diseases was an important sorting rationale in this perspective.
More on the long term, a better understanding of our DNA as a result of CRISPR-Cas9 was also ranked high (28 at 2). Nevertheless, participants’ enthusiasm for the technology (7 and 5 at 1) did not entail that all uses of CRISPR-Cas9 were supported. The technology should not be used to modify DNA at will (15 at -2). It should always be used voluntarily; as it would be undesirable if DNA modification became the norm in society (31 at -2). Two participants explained their reasoning:
I would only use it for purely medical purposes, and not for anything else. . . . The technology is developed with the best intentions in mind, but at a certain point it will be applied to non-medical conditions that will allow you, well, if you can afford it, to increase your quality of life a lot, have smarter children, live longer, and you’ll see that others cannot afford it. And that seems very undesirable to me. [P04]
I think, I see good things in CRISPR-Cas9, as long as it is regulated strictly and is used for certain, for example hereditary, diseases. Not for when you want blue eyes, blond hair, or whatever, that kind of things, those are unacceptable to me. And I would not want them in the future either. That is why I think that, if we regulate it strictly now, you may be able to prevent that it will develop like that. [P02]
Moral and societal considerations were not very prominent in this factor, which points to a pragmatic perspective valuing benefits over moral concerns or societal implications. Moral statements expressing that the CRISPR-Cas9 is ‘wrong’, ‘should never be used’, and is ‘unnatural and therefore unwanted’ were ranked low (3 and 9 at -3; 27 at -2). Most statements on societal implications of CRISPR-Cas9 were ranked at either 1 or -1, suggesting that there were concerns about but other considerations were more pressing. There was some fear of increasingly extreme uses (18 at 1). There was also some fear that CRISPR-Cas9 will eventually overburden the healthcare system (16 at 1) and that it will only be available for the rich (14 at 1). One participant explained in the focus group that there had been differences in healthcare insurances in the past: People with private insurance received faster and better care than people with mutual insurance. She feared a return to this situation with the introduction of new technologies like CRISPR-Cas9:
In the past, there was a class divide in healthcare, and it is a good thing that this no longer exists. This situation should never come back, in my opinion. . . . When I was a child, we had premium healthcare insurance, which meant that you could sit in a special waiting room at the doctor's office and were helped faster. . . . It really was not nice, even though we had premium healthcare insurance ourselves. You do not want to divide people into two groups and treat one group better. [P19]
Regarding governance of CRISPR-Cas9, this factor showed mixed results. In the factor array, governance was not prominent. Strict regulation (10 at 1) is less important than independent monitoring of the technology (12 at 2). In the focus group, however, governance was emphasised more. One participant said: ‘Regulation is a safeguard to me’. Furthermore, the need for global governance was brought up by the participants in several discussions. One participant feared that medical tourism will otherwise arise:
I am afraid it will be a slippery slope that will end in creating designer babies. That is why I think independent oversight and strict regulations of the conditions when it can be used [are important]. And I prefer them to be global, because otherwise people will just travel to Malaysia for it. [P15]
The parties involved in the governance of CRISPR-Cas9 were less important in this factor. Scientists and citizens can play a role (4 and 8 at 0); politicians (6 at -1) and especially (pharmaceutical) companies (2 at -2) receive less support.
Statements about fears and future developments received moderate rankings in this factor. Participants did not see CRISPR-Cas9 as a scary technology (1 at -1), were neutral about the statements that that there are still too many unanswered questions (17 at 0) and that CRISPR-Cas9 may be abused (19 at 0), and had moderate rankings of risks (21 at -1) and the tolerability of using embryos (22 at -1) and animal experiments (24 at 0) to develop the technology further.
Factor 2: Concerned Sceptics
This factor had an eigenvalue of 4.8 and explained 16% of the variance. Five Q sorts loaded significantly on this factor: Three from scientists, two from non-scientists. Three were male, two female. Three described themselves as non-religious, one was moderately religious and one believed in reincarnation. They considered themselves to be low to moderately interested in politics. They kept up to date on technological development by following the news and online media. In this perspective, CRISPR-Cas9 has merit as a scientific development, but its applications on humans should be limited. Many moral and societal/ethical considerations surround the development and use of CRISPR-Cas9.
Governance of CRISPR-Cas9 was very important in this perspective, which manifested itself in high rankings of statements related to participation and regulation. The statements that strict regulation of CRISPR-Cas9 is important and the statement that there is a need for independent oversight (10 and 12 at 3) both were ranked highest. One participant stressed the importance of governance and clear regulations as follows:
That there is at the very least consensus about where it can be used, what is allowed, what is not allowed. I think, if you say something is not allowed, that is always strict for scientists and for companies who can do it. But well, it is not allowed, and it can be done, well, what is strict in a situation like that? You cannot only allow half. You also do not ride a bike half. [P01]
This perspective also involved specific preferences for who should participate in determining the future of CRISPR-Cas9. Participants had considerably more trust in scientists (4 at 2) than in politicians (6 at -2) and, particularly, citizens and companies (8 and 2 at -3).
Some, but not all, of the moral considerations were important to this perspective. Apparently, some moral considerations were more salient than others. Although it was seen as positive that CRISPR-Cas9 contributes to a better understanding of our DNA (28 at 2) and improves the lives of people with hereditary diseases (32 at 1), participants in this factor stressed that people should not play God (25 at 2), that our DNA becoming modifiable is not a good development (2 at -2), that CRISPR-Cas9 is unnatural and therefore unwanted (27 at 1), and that modification of DNA must certainly not be obligatory (31 at -2). Still, participants in this factor would not qualify CRISPR-Cas9 as wrong (3 at -1) and were moderately positive about the possibility to make organs of animals suited for transplantation into humans (30 at 1). Together, these rankings suggest that participants in this factor see CRISPR-Cas9 as a valuable research approach, but one that should largely be confined to petri dishes in the laboratory. Unconditional use on human beings was not supported.
The interpretation that participants in this factor valued CRISPR-Cas9 mostly as a research tool was supported by the rankings of the statements related to its use. Treatment and prevention of hereditary diseases were both ranked neutrally (11 and 13 at 0). In the discussion, some participants expressed some support of treatments with CRISPR-Cas9, indicating that the neutral ranking can suggest tentative support rather than neutrality.
If you ask me, it should never be used. It will become more and more extreme if you go down that road, if we go down that road. Then it will never stop. [P17]
I found it difficult, because I do believe the technology should be used for hereditary things, to correct them. So, when you have people who have hereditary, like, something, but then can have children who have better chances, I would approve of that. But on the other hand, you have the point about embryos and that is… You are moving in the direction of human enhancement and then you’ll have healthy embryos that you are going to give certain characteristics that they want to, or don’t want to, give to their offspring. That goes too far. [P01]
I disagree that people should be able to modify their DNA as they like, because I think, well, life is also to a certain extent a given. [P06]
Several types of considerations appeared to be less important in this perspective. Statements related to the development of CRISPR-Cas9 were ranked low to neutral: In this perspective it would not be an acceptable risk to alter wrong sections of DNA (21 at -1). The use of laboratory animals or embryos to further develop the technology was also not supported (24 and 22 at -1).
Potential societal implications of CRISPR-Cas9 were also not important in this factor. The implication ranked highest was that people can become genetically more identical (23 at 1). The statement about CRISPR-Cas9 becoming a luxury for the rich was ranked neutrally (14 at 0), as were the statements about the potential burden on the healthcare system and increasing inequalities in society (16 and 20 at 0). This does not imply that such considerations were not important, but rather that other types of considerations outweighed them in the ranking of statements. In the focus groups, one participant, for example, brought up a concern about increasing corrosion of solidarity principle in the healthcare system:
It is going in the direction like when you have lung cancer and you are a smoker, then it is your own fault and you’re on your own. It is developing in that direction. So when you do not intervene in your own DNA, then is will be your fault if you’re sick, and you’ll be on your own. [P17]
Finally, affect only played a small role in this perspective. While CRISPR-Cas9 was believed to offer great possibilities (7 at 1), it was not seen as exiting (5 at -1) or scary (1 at 0). This small role can be explained by the emphasis on governance and the focus on CRISPR-Cas9 as a research approach, about which still too much is unknown to consider using it (17 at 2).
Factor 3: Normative Optimists
This factor had an eigenvalue of 2.7 and explained 9% of the variance. All three Q sorts that loaded significantly on this factor were from retirees, and two of them were female. Two participants lived in a city, one in a village. Their educational level were (prolonged) primary school, high school, and higher vocational education. They described themselves as non-religious, moderately religious, or only raised religiously. Two were moderately interested in politics; one not interested. They informed themselves on technological developments by the traditional media and literature. In this perspective, CRISPR-Cas9 may offer medical benefits, but only if moral boundaries are safeguarded and societal side-effects are mitigated.
In this factor, moral and societal considerations regarding CRISPR-Cas9 were very important. The statement that humans should not play God was the moral consideration with the highest rank (25 at 3). Furthermore, people should not be obliged to modify their DNA, nor should non-medical modifications be possible (31 and 15 at -3). These rankings indicated strong moral boundaries regarding the possible uses of CRISPR-Cas9. The most highly ranked reason was curing people with hereditary diseases (11 at 2), which implies that the moral considerations did not result in a categorical rejection of use on humans.
The governance of CRISPR-Cas9 was very important in this perspective. Independent monitoring of the technology was ranked highest (12 at 3), suggesting that monitoring was more important than strict regulation (10 at 1). The desire to have independent oversight indicates a need for checks and balances on a technology that evokes strong moral objections. Regarding the parties participating in deciding about the future of CRISPR-Cas9, participants in this factor felt more comfortable with scientists (4 at 0) and politicians (6 at -1) than with companies and citizens (2 and 8 at -2). Companies are ruled by financial incentives rather than by what is right, which participants feared would lead to wrong usage of the technology. However, the rankings suggest that it is more important that there are rules and monitoring than who should have a say on its future.
Societal considerations were also important in this perspective. CRISPR-Cas9 should be available to everybody and not be a luxury only the rich can afford (14 at 2). Yet, it should not become too great a financial burden for the healthcare system (16 at 2). A third concern was that CRISPR-Cas9 could lead to people becoming more genetically identical (23 at 2). The statement about the risks of increasing inequality in society, however, was ranked neutrally (20 at 0). Together, these rankings indicate that the introduction of CRISPR-Cas9 within society may have undesirable effects. This is in line with the participants’ attention for governance of the technology.
Despite emphasising the moral, societal, and governance aspects of CRISPR-Cas9 , participants in this factor did not reject the use of the technology. They somewhat agreed that it is good that CRISPR-Cas9 can improve the lives of people with hereditary diseases (32 at 1), as well as with other statements about uses. Curing people with hereditary conditions was the most important use of the technology (11 at 2). Prevention of hereditary diseases and modifying embryos to prevent passing down hereditary conditions to future generations were also supported (13 and 26 at 1). Xenotransplantation was ranked low in this perspective (30 at -2) as was the use of CRISPR-Cas9 to alter DNA as desired (15 at -3), indicating that the participants in this factor clearly differentiated between good (medical) and bad (non-medical) uses of CRISPR-Cas9.
The feelings CRISPR-Cas9 evokes were less important in this perspective. The technology was not scary (1 at -2) and somewhat exciting (5 at 1). Yet, CRISPR-Cas9 is not seen to offer great possibilities (7 at -1). In the light of the emphasis on moral considerations and the clear distinction between good and bad uses of CRISPR-Cas9, these rankings make sense. Some moral statements also were not important in this perspective, such as ‘CRISPR-Cas9 is wrong’ or the statement that the technology is unnatural and therefore unwanted (3 and 27 at 0). In the words of one participant:
Of course it is unnatural, but on the other hand… I believe, sometimes you have to do something that is unnatural. [P28]
What is acceptable for the further development of CRISPR-Cas9 was unclear in this perspective, although the risk of modifying wrong pieces of DNA and testing the technology on animals including primates were not supported (21 and 24 at -1).
Factor 4: Enthusiastic Supporters
This factor had an eigenvalue of 1.8 and explained 6% of the variance. Two Q sorts loaded significantly on this factor: one from a scientist and one from a retiree. Both participants were male and described themselves as non-religious. Their political orientation was liberal, although only one o considered himself to be interested in politics. The participants in this factor were outright positive about the health improvements CRISPR-Cas9 promises and did not see many fundamental concerns.
The participants embraced the possibilities CRISPR-Cas9 offers. The technology was absolutely not seen as scary (1 at -3). It can have positive effects, such as improving the lives of people with hereditary diseases is (32 at 2) and gaining a better understanding of our DNA (28 at 2). The participants strongly disagreed that the technology should never be used (9 at -2) and playing God was not a concern (25 at -2). This perspective was in fact so positive about CRISPR-Cas9 that the participants saw using CRISPR-Cas9 to improve DNA as an obligation or ‘moral duty’ (31 at 3). These statements suggest optimism towards CRISPR-Cas9. One participant stated:
If it really is a promising technology and people can benefit from it, then I do not understand why it should never be used. [P08]
Participants in this factor strongly believed that further development and use of CRISPR-Cas9 is a good thing. They found it an acceptable to risk that wrong pieces of DNA may be modified in the further development of the technology (21 at 2). This also reflects in the neutral ranking of the statement that there are too many unanswered questions to proceed using the technology (17 at 0). Experiments were seen as a way to learn about DNA and the use of CRISPR-Cas9 itself. In this perspective, using animals including primates to develop CRISPR-Cas9 received a lot of support (24 at 3), but the use of embryos in tests was much less supported (22 at 0). Discussions did not clarify why the use of animals received much more support than embryos.
Regarding governance and participation in determining the future of CRISPR-Cas9, participants in this factor found independent oversight slightly more important than strict regulations (12 at 1 vs. 10 at 0). Scientists were trusted most for having responsibility to determine the future of the technology (4 at 1). The participants had less confidence in companies, citizens ( 2 and 8 at -1), and especially politicians (6 at -3). Their trust in scientists may be attributed to their understanding of the technology and their lack of financial or political interests in its future.
The participants were less outspoken about uses of CRISPR-Cas9. Modifying embryos to prevent passing down hereditary conditions was ranked higher than curing or preventing hereditary conditions in individuals (26 at 2; 11 and 13 at 1). Xenotransplantation was ranked relatively high (30 at 1). The ranking pattern suggests that the specific applications were not so important, and that the overall goal of improving lives prevailed. Altering DNA as desired received a neutral ranking (15 at 0) here.
The impact CRISPR-Cas9 may have on society was not very important in this perspective. This can be inferred from the moderate rankings of statements about the technology being a luxury only the rich can afford (14 at -1), the financial impact on the healthcare system (16 at 0), and people becoming genetically more identical (23 at 0). Only the statement that further development of CRISPR-Cas9 would lead to increasing inequality in society received a more outspoken ranking, indicating that the participants did not consider it to be important (20 at -2).
Ratio rather than emotion appears to inform the participants in this factor. Statements expressing that CRISPR-Cas9 is scary or exiting or that it has great possibilities received low rankings (1 at -3, 5 and 7 at 0). This does not mean that the sorting pattern was free from emotion, but rather that it was less important for the participants in expressing themselves.
Factor 5: Benevolent Generalists
This factor also had an eigenvalue of 1.8 and explained 6% of the variance. Two Q sorts loaded significantly on this factor: one from a PhD student and one from a retiree. Both were male. One was religious, the other not. One was involved in politics, the other was not interested in politics. Apart from their Q sort, they did not appear to have many similarities. In this perspective, CRISPR-Cas9 is seen as a fascinating, yet complex scientific development. It is too early to know anything for sure, except that governance and public participation are important.
The participants saw CRISPR-Cas9 as an exciting technology (5 at 3) that can lead to great things (7 at 2). But it is also a little scary (1 at 1). Despite considering the technology the scariest of all five perspectives, the participants in this factor did not believe CRISPR-Cas9 should never be used (9 at -3). Fear should thus not stand in the way of excitement or using the possibilities the technology offers. CRISPR-Cas9 thus evoked mixed emotions in this perspective, which could also be seen in the ranking of the other statements.
Independent monitoring of CRISPR-Cas9 was very important to the participants (12 at 3). The technology should be regulated strictly (10 at 2) and it mattered to the participants who are involved in determining the future of CRISPR-Cas9: Citizens were seen as the most suited to determine this future (8 at 2); the other groups—companies and politicians (2 and 6 at -1) and scientists (4 at -2)—were ranked much lower. These rankings indicate that it was important to them that normal citizens have a say in determining the future of the technology. This interpretation is corroborated by the claim of one of the participants that he is always involved in political and societal issues.
With regard to moral considerations, this perspective does not believe that CRISPR-Cas9 is wrong (3 at -2), nor that the technology should never be used (9 at -3). In this perspective, people are not obliged to improve their DNA using CRISPR-Cas9 (31 at -2), nor can the technology be used at will.
I think that on the whole medical technologies cannot be used at liberty, so CRISPR-Cas9 should be treated likewise. [P09]
With the exception of ensuring that CRISPR-Cas9 will not become a luxury only available to the rich (14 at 2), most statements related to the development of CRISPR-Cas9, its applications, its possible societal impact, and the remaining moral considerations were all ranked around the centre. This indicates that the rationale of this perspective focuses on realising the ‘great possibilities’ of CRISPR-Cas9 (7 at 2), with governance and citizens participation as important safeguards. Questions or issues related to development, use, or societal consequences can then be dealt with when they arise.