how to write a medical ethics research paper

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• Volume 44, Issue 12
• How to read an ethics paper
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• http://orcid.org/0000-0002-4609-9179 Melanie Jansen 1 , 2 ,
• Peter Ellerton 3
• 1 Paediatric Intensive Care Unit & Centre for Children’s Health Ethics and Law , Children’s Health Queensland Hospital and Health Service , South Brisbane , Queensland , Australia
• 2 Faculty of Medicine , University of Queensland , Herston , Queensland , Australia
• 3 Faculty of Humanities and Social Sciences , University of Queensland , Brisbane , Queensland , Australia
• Correspondence to Dr Melanie Jansen, Paediatric Intensive Care Unit & Centre for Children’s Health Ethics and Law, Children’s Health Queensland Hospital and Health Service, Brisbane, QLD 4101, Australia; doctormjansen{at}gmail.com

In recent decades, evidence-based medicine has become one of the foundations of clinical practice, making it necessary that healthcare practitioners develop keen critical appraisal skills for scientific papers. Worksheets to guide clinicians through this critical appraisal are often used in journal clubs, a key part of continuing medical education. A similar need is arising for health professionals to develop skills in the critical appraisal of medical ethics papers. Medicine is increasingly ethically complex, and there is a growing medical ethics literature that modern practitioners need to be able to use in their practice. In addition, clinical ethics services are commonplace in healthcare institutions, and the lion’s share of the work done by these services is done by clinicians in addition to their usual roles. Education to support this work is important. In this paper, we present a worksheet designed to help busy healthcare practitioners critically appraise ethics papers relevant to clinical practice. In the first section, we explain what is different about ethics papers. We then describe how to work through the steps in our critical appraisal worksheet: identifying the point at issue; scrutinising definitions; dissecting the arguments presented; considering counterarguments; and finally deciding on relevance. Working through this reflective worksheet will help healthcare practitioners to use the ethics literature effectively in clinical practice. We also intend it to be a shared evaluative tool that can form the basis of professional discussion such as at ethics journal clubs. Practising these critical reasoning skills will also increase practitioners’ capacity to think through difficult ethical decisions in daily clinical practice.

• clinical ethics
• education for health care professionals

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/medethics-2018-104997

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Evidence-based medicine is a foundation of clinical practice, necessitating that healthcare practitioners develop keen critical appraisal skills for scientific papers. Many excellent resources exist, including the paper by Sackett  et al 1 and a reference book by Greenhalgh. 2 In 1992, the Medical Journal of Australia published a paper titled ‘How to read a journal article’ . 3 The authors’ goal was to give a step-by-step guide to critically appraising scientific papers. Journal clubs using this worksheet, or similar, are now commonplace in teaching hospitals and are a key part of medical education. A similar need is arising for health professionals to develop skills in the critical appraisal of ethics papers. The reasons for this are twofold. First, healthcare grows increasingly ethically complex. Just as clinicians must keep abreast of the scientific literature, they should also keep up to date with the ethics literature relevant to their practice. Second, clinical ethics services (CES) have become commonplace in hospitals in developed nations. The lion’s share of the work of these services is done by healthcare professionals in addition to their clinical roles 4–6 and who have highly variable levels of training. 4–8 There is an urgent need to equip these and other clinical staff with skills to appraise papers relevant to these aspects of practice.

In this paper, we present the critical appraisal worksheet developed at the Centre for Children’s Health Ethics and Law (CCHEL), Children’s Health Queensland, Brisbane, Australia ( table 1 ). The worksheet was developed for our ethics journal club and has proved useful both for the critical appraisal of ethics papers and for the development of critical thinking skills that can be applied in clinical practice and in clinical ethics consultation work. The goal of this paper is to provide a tool for clinicians without extensive philosophical training to critically appraise ethics papers relevant to clinical practice. We also intend it to be a shared evaluative tool that can form the basis of professional discussion such as at ethics journal clubs. In the first section, we explain what is different about ethics papers. We then describe the steps in our critical appraisal worksheet.

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Ethics critical appraisal worksheet

What is different about ethics papers? A discussion of arguments, facts and values

It is important to recognise that ethics is a philosophical, not a scientific, discipline. Healthcare professionals are accustomed to critically appraising scientific data, and to constructing an argument based on that data for why a particular clinical decision is justified. Note that we use the word argument in the philosophical sense, meaning a set of reasons that justify a position. For example, if a patient presents with clinical signs consistent with bacterial pneumonia, the doctor will prescribe an antibiotic regimen based on their knowledge of the likely pathogens and the efficacy of particular antibiotics against these. That oral amoxicillin is an effective treatment for mild community-acquired pneumonia is a factual claim supported by scientific evidence. In contrast, ethical claims are claims of value and must be justified with an ethical argument. For example, the claim that life-sustaining therapy (LST) should be withdrawn from a patient with end-stage cancer is a value claim. Prescriptive words such as ‘should’ and ‘ought’ are useful signposts for value claims. An argument that may justify the claim that LST should be withdrawn is that the patient had previously stated that they did not want to be maintained on LST, and therefore to respect their autonomy the treatment should be withdrawn.

Note that matters of fact and matters of value coexist in clinical medicine (as they do in life) and that rationales for ethical and medical decisions are usually made up of both fact and value claims. Take the example just given of the argument that therapy should be stopped to respect the patient’s autonomy. That the patient had previously expressed wishes not to be maintained on life support is a factual claim. The claim that we should respect autonomy is a value claim. Likewise, when deciding on antibiotics for the patient with pneumonia, the claim that amoxicillin is effective is a factual claim. That we should treat the patient with amoxicillin is a value claim—the implicit argument for which is that the right thing to do is to treat patients with the most effective therapy for their disease. This seems so plainly reasonable that it does not need to be stated; however, it is important to recognise implicit value judgements in clinical decisions, as these are often at issue when there is conflict. The important skill is to be able to differentiate fact and value claims and to understand how the two can interact to form a set of reasons that support a particular conclusion. To do this, it is important to understand how arguments are constructed.

Understanding arguments is important for clinical practice, because ethical decision making threads through everything healthcare practitioners do. High-level skills in this area are especially important for those providing clinical ethics consultation. The UK Clinical Ethics Network and the American Society for Bioethics and Humanities have each published core competencies for clinical ethics consultation. 9 10 Both specify the need for consultants to understand ethical theory and reasoning, to analyse ethical conflicts, and to be able to elicit values and assumptions. Understanding argumentation is fundamental to these skills. The ethics critical appraisal worksheet provides a framework through which to appraise arguments and, by guiding practitioners to read ethics papers actively, aims to deepen understanding of ethical argumentation. We acknowledge that there is a growing literature in empirical ethics—this critical appraisal worksheet is not intended for these papers, as they are scientific papers and can be appraised as such. This worksheet is intended for papers that discuss ethical issues, not those that present scientific data relevant to an ethical issue.

The ethics critical appraisal worksheet

We have structured the worksheet in a similar way to the one by Darzins et al , 3 as a matrix of questions arranged in three columns ( table 1 ). In the first column are questions that prompt the reader to look for important types of information in the article. The second column contains questions that help the reader to decide whether there are problems with these. The third column poses questions to help the reader decide if any problems identified threaten the quality of the paper. Using this worksheet should assist clinicians to more rapidly identify problems with the paper, making the reading of ethics papers more time-efficient.

Critical appraisal questions

What is the point at issue.

The point at issue is the ethical question that the paper is addressing. Well-written ethics papers will explicitly state the point, or points, at issue in the introduction and will go on to address them. Poorly written ethics papers will shift between points at issue, which clouds reasoning and precludes systematic appraisal of all the relevant arguments. Shifting the point at issue happens often in ethical discussions. For example, we may be discussing the issue of whether we should continue providing LST to a child with a very poor prognosis. One person believes that the LST is causing suffering to the child, another person questions the truth of this. A third person points out that we cannot over-ride the parents’ autonomy. This third person is shifting the point at issue. The ethicality of over-riding parental autonomy is important, but concerns a different point at issue. Whether the LST is causing suffering or not is a point that needs to be explored and clarified before moving onto the question of whether it is of a magnitude that makes it reasonable to interfere with parental autonomy.

Has the author defined all of the terms they use?

Defining key terms is critical to avoid confusion. For example, in a paper discussing the rights of adolescents to autonomy in medical decision making, the author needs to define what persons they are referring to with the word ‘adolescent’; exactly what range of decisions they are referring to within the phrase ‘medical decision making’; and exactly how autonomy is conceived in this context. Failing to define key terms used in an argument sacrifices clarity, and defining key terms in an unusual or unreasonable way may have implications for the generalisability of the argument.

Dissect the argument: What are the premises of the author’s argument? What is/are the author’s conclusion/s?

This section of the worksheet requires explanation of the anatomy of an argument and clarification of the difference between truth and validity.

Arguments consist of premises and a conclusion, for example:

Premise 1: Human suffering is undesirable.

Premise 2: Medically extending life in case X prolongs human suffering.

Conclusion: Medically extending life in case X is undesirable.

This is a valid argument because the conclusion follows logically from the premises; that is, it is impossible for the premises to be true and the conclusion false. Whether the conclusion (or a premise) is true or not is a separate issue. Refuting this argument requires proving one or both of the premises to be false—finding evidence that suffering is not always undesirable, or making a case that this particular medical intervention does not prolong suffering. There are no errors of reasoning in this argument, but there may be factual errors which will prove the argument to be a bad one. Consider another argument:

Premise 1: Lucy has a chronic cough.

Premise 2: Lung cancer can present with a chronic cough.

Conclusion: Lucy has lung cancer.

In this case, the argument is invalid. The premises are true but the reasoning is flawed. It is true that Lucy has a chronic cough, and that lung cancer can present with a chronic cough, but it does not follow that Lucy necessarily has lung cancer. Her chronic cough may be from asthma or chronic bronchitis. Lucy may even have lung cancer, although it could be of a type that would not usually cause coughing. So, even if all the information given is true, the conclusion that she must have lung cancer does not necessarily follow.

Another important phenomenon to be aware of is the ‘hidden assumption’. A hidden assumption is a premise that is not explicitly stated. For example, a person may claim that homosexuality is morally wrong because it is unnatural. The hidden premise here is that things that are unnatural are morally wrong, as follows:

Premise 1: (Hidden) Things that are unnatural are morally wrong.

Premise 2: Homosexuality is unnatural.

Conclusion: Homosexuality is morally wrong.

To refute this argument one needs to either show the premises are false or that the reasoning is invalid. The reasoning is valid because it is impossible for the premises to be true and the conclusion false. However, even if one were to accept premise 2—in ignorance of the natural occurrence of homosexuality in many animals—the hidden premise 1 ignores that many things that are unnatural are considered morally good (or at least morally neutral), such as medicines, clothing or the telephone. Identifying the hidden premise is necessary to fully represent the argument, and hence to properly evaluate it.

In ethics papers, deciding whether premises are true will often require recourse to the scientific literature. Good ethics papers have well-researched references for factual premises. Appraising the validity of reasoning can be more difficult and requires practice. A full and rich account of logical fallacies is outside the scope of this paper; however, there are excellent, accessible resources available to hone these skills. 11 It is also worth noting that the overall position of an ethics paper is likely to be made up of a complex argument, with the conclusions of initial arguments making up the premises of further arguments. For example, some may claim that premise 1 (above) is a claim about the existence of ethical laws of nature. To support this claim, the person must develop an argument for the existence of ethical laws of nature and the definition of ‘unnatural’, ending with premise 1—things that are unnatural are morally wrong—as the conclusion. The analytical framework we present here is applicable to each constituent argument of a complex argument.

Does the author address all relevant counterarguments?

When making a case for an ethical position, it is imperative that authors address counterarguments to their position. If an author has not addressed relevant counterarguments, or has done so unconvincingly, this significantly decreases the strength of their case, or at least suggests a shallow investigation of the issue.

Is the argument or exploration of the issue relevant to your practice?

Some ethics papers will address a specific ethical question arising in the reader’s own practice and assist them in navigating this scenario. Other papers will change the way practitioners think, affecting practice in myriad but subtle ways. There will be papers that, while of good internal quality, are not relevant to the reader’s practice. Explicitly deciding on the relevance of a paper prompts practitioners to contextualise new ethical information within their own practice.

Working through this reflective worksheet will aid healthcare practitioners in actively reading and critically appraising ethics papers, enabling them to use the ethics literature more effectively. Developing these critical reasoning skills will also increase capacity to think through difficult ethical decisions in day-to-day practice. It is of particular importance that clinicians working within CES develop these skills to a high level. In the future, we hope to empirically evaluate the ethics critical appraisal worksheet.

Key messages

Healthcare is increasingly ethically complex, and so there is a growing need for clinicians to keep up to date with the ethics literature relevant to clinical practice.

Clinical ethics services have become commonplace, and the majority of the work of these services is done by clinicians in addition to their clinical roles.

Ethics papers differ in important ways from scientific papers, requiring a different set of critical appraisal skills.

We have developed a worksheet to assist clinicians in the critical appraisal of ethics papers, which can also be used as a shared evaluative tool, such as at ethics journal clubs.

Acknowledgments

The authors would like to acknowledge all CCHEL Clinical Ethics Response Pool members who have participated in the ethics journal club, and in so doing have helped to refine this critical appraisal worksheet.

• Sackett DL ,
• Rosenberg WM ,
• Gray JA , et al
• Greenhalgh T
• Darzins PJ ,
• Pearlman RA
• Slowther AM ,
• McClimans L ,
• Irving H , et al
• Godkin MD ,
• Upshur RE , et al
• Kesselheim JC ,
• Johnson J ,
• Larcher V ,
• Richardson J ,
• Meaden S , et al

Contributors MJ conceived the idea of the critical appraisal worksheet for clinicians. PE assisted in developing the idea and refining the worksheet. MJ wrote the initial draft of the manuscript. PE and MJ were both involved in draft review and development of the final version of the manuscript. MJ is the guarantor of this article.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Disclaimer The views expressed in this paper are the authors’ own and do not necessarily reflect the views of their institutions.

Competing interests None declared.

Patient consent Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement No additional data are available.

Author note MJ is a medical doctor in intensive care medicine and has additional qualifications and experience in clinical ethics. She co-led the working group to establish the Centre for Children’s Health Ethics and Law at Children’s Health Queensland, and was the centre’s inaugural Clinical Ethics Fellow. MJ recently completed a Churchill Fellowship in clinical ethics. She has published both empirical research and analysis pieces on healthcare ethics issues. PE is a science educator and philosopher, and is the Curriculum Director of the University of Queensland Critical Thinking Project. He is an expert in critical thinking and argumentation and has published on these topics in a number of contexts.

Correction notice This article has been made Open Access since it was published Online First.

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How to Write Better Medical Papers

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• Assists clinicians and researchers in writing papers for publication in peer-reviewed scientific journals in medicine, health, and life sciences
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Table of contents (60 chapters)

Front matter, introduction.

Michael Hanna

The Ethical Foundations of Medical Scientific Writing

Ethics of conducting research, searching the literature, the elevator speech, the outline, envision your readers, ethics of data analysis, data preparation, statistics: general principles, statistics: common mistakes, presentation: figures versus tables versus text, figures: general guidance.

• medical writing
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This book guides medical researchers through all stages of transforming their scientific data and ideas into a published paper.  Many researchers in medicine, including the life sciences and health sciences, struggle to get their research written and published.  Manuscripts are typically rejected and/or sent back for revisions several times before ever being published.  One reason for this is that researchers have not received much instruction in the specific subjects and skills needed to write and publish scientific medical papers:  research methodology, ethics, statistics, data visualization, writing, revising, and the practicalities of publishing. 

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Mercury medical research & writing, new york, usa, about the author.

Michael Hanna, PhD, is an independent Medical Writer and Research Consultant from New York City.  He has over a decade of experience consulting on study design, conducting literature reviews, performing statistical analysis, and writing and editing scientific papers across the spectrum of medical specialties.  He has lectured widely in Europe and North America on medical writing and has mentored many researchers and medical residents on scientific writing.

            Michael Hanna earned a doctoral degree in Clinical Psychology from the University of Cologne, Germany,  and completed a post-doctoral fellowship at Cornell University’s medical school in New York City.  Previously, he earned a Master’s degree in Psychology from the University of Paris VIII and a Bachelor’s degree in Neuroscience and in French Studies from Wesleyan University in Middletown, CT, USA.

            Prior to becoming a professional Medical Writer and Research Consultant, Michael Hanna taught at the University Hospital of Aachen, Germany.  He also acquired clinical and scientific experience at the University of Cologne, Germany; the Raymond Poincaré Hospital in Paris, France; and other specialized clinics in America and Europe.  He is fluent in German, French, and Spanish.   

Bibliographic Information

Book Title : How to Write Better Medical Papers

Authors : Michael Hanna

DOI : https://doi.org/10.1007/978-3-030-02955-5

Publisher : Springer Cham

eBook Packages : Medicine , Medicine (R0)

Copyright Information : Springer Nature Switzerland AG 2019

Softcover ISBN : 978-3-030-02954-8 Published: 29 March 2019

eBook ISBN : 978-3-030-02955-5 Published: 20 March 2019

Edition Number : 1

Number of Pages : XI, 335

Number of Illustrations : 8 illustrations in colour

Topics : Internal Medicine , Primary Care Medicine

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Example reference style:

Article within a journal

Smith JJ. The world of science. Am J Sci. 1999;36:234-5.

Article within a journal (no page numbers)

Rohrmann S, Overvad K, Bueno-de-Mesquita HB, Jakobsen MU, Egeberg R, Tjønneland A, et al. Meat consumption and mortality - results from the European Prospective Investigation into Cancer and Nutrition. BMC Medicine. 2013;11:63.

Article within a journal by DOI

Slifka MK, Whitton JL. Clinical implications of dysregulated cytokine production. Dig J Mol Med. 2000; doi:10.1007/s801090000086.

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Frumin AM, Nussbaum J, Esposito M. Functional asplenia: demonstration of splenic activity by bone marrow scan. Blood 1979;59 Suppl 1:26-32.

Book chapter, or an article within a book

Wyllie AH, Kerr JFR, Currie AR. Cell death: the significance of apoptosis. In: Bourne GH, Danielli JF, Jeon KW, editors. International review of cytology. London: Academic; 1980. p. 251-306.

OnlineFirst chapter in a series (without a volume designation but with a DOI)

Saito Y, Hyuga H. Rate equation approaches to amplification of enantiomeric excess and chiral symmetry breaking. Top Curr Chem. 2007. doi:10.1007/128_2006_108.

Complete book, authored

Blenkinsopp A, Paxton P. Symptoms in the pharmacy: a guide to the management of common illness. 3rd ed. Oxford: Blackwell Science; 1998.

Online document

Doe J. Title of subordinate document. In: The dictionary of substances and their effects. Royal Society of Chemistry. 1999. http://www.rsc.org/dose/title of subordinate document. Accessed 15 Jan 1999.

Online database

Healthwise Knowledgebase. US Pharmacopeia, Rockville. 1998. http://www.healthwise.org. Accessed 21 Sept 1998.

Supplementary material/private homepage

Doe J. Title of supplementary material. 2000. http://www.privatehomepage.com. Accessed 22 Feb 2000.

University site

Doe, J: Title of preprint. http://www.uni-heidelberg.de/mydata.html (1999). Accessed 25 Dec 1999.

Doe, J: Trivial HTTP, RFC2169. ftp://ftp.isi.edu/in-notes/rfc2169.txt (1999). Accessed 12 Nov 1999.

Organization site

ISSN International Centre: The ISSN register. http://www.issn.org (2006). Accessed 20 Feb 2007.

Dataset with persistent identifier

Zheng L-Y, Guo X-S, He B, Sun L-J, Peng Y, Dong S-S, et al. Genome data from sweet and grain sorghum (Sorghum bicolor). GigaScience Database. 2011. http://dx.doi.org/10.5524/100012 .

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How to Write a Medical Research Paper

Last Updated: February 5, 2024 Approved

This article was co-authored by Chris M. Matsko, MD . Dr. Chris M. Matsko is a retired physician based in Pittsburgh, Pennsylvania. With over 25 years of medical research experience, Dr. Matsko was awarded the Pittsburgh Cornell University Leadership Award for Excellence. He holds a BS in Nutritional Science from Cornell University and an MD from the Temple University School of Medicine in 2007. Dr. Matsko earned a Research Writing Certification from the American Medical Writers Association (AMWA) in 2016 and a Medical Writing & Editing Certification from the University of Chicago in 2017. wikiHow marks an article as reader-approved once it receives enough positive feedback. In this case, 89% of readers who voted found the article helpful, earning it our reader-approved status. This article has been viewed 202,674 times.

Writing a medical research paper is similar to writing other research papers in that you want to use reliable sources, write in a clear and organized style, and offer a strong argument for all conclusions you present. In some cases the research you discuss will be data you have actually collected to answer your research questions. Understanding proper formatting, citations, and style will help you write and informative and respected paper.

Researching Your Paper

• Pick something that really interests you to make the research more fun.
• Choose a topic that has unanswered questions and propose solutions.

• Quantitative studies consist of original research performed by the writer. These research papers will need to include sections like Hypothesis (or Research Question), Previous Findings, Method, Limitations, Results, Discussion, and Application.
• Synthesis papers review the research already published and analyze it. They find weaknesses and strengths in the research, apply it to a specific situation, and then indicate a direction for future research.

• Keep track of your sources. Write down all publication information necessary for citation: author, title of article, title of book or journal, publisher, edition, date published, volume number, issue number, page number, and anything else pertaining to your source. A program like Endnote can help you keep track of your sources.
• Take detailed notes as you read. Paraphrase information in your own words or if you copy directly from the article or book, indicate that these are direct quotes by using quotation marks to prevent plagiarism.
• Be sure to keep all of your notes with the correct source.
• Your professor and librarians can also help you find good resources.

• Keep all of your notes in a physical folder or in a digitized form on the computer.
• Start to form the basic outline of your paper using the notes you have collected.

Writing Your Paper

• Start with bullet points and then add in notes you've taken from references that support your ideas. [1] X Trustworthy Source PubMed Central Journal archive from the U.S. National Institutes of Health Go to source
• A common way to format research papers is to follow the IMRAD format. This dictates the structure of your paper in the following order: I ntroduction, M ethods, R esults, a nd D iscussion. [2] X Research source
• The outline is just the basic structure of your paper. Don't worry if you have to rearrange a few times to get it right.
• Ask others to look over your outline and get feedback on the organization.
• Know the audience you are writing for and adjust your style accordingly. [3] X Research source

• Use a standard font type and size, such as Times New Roman 12 point font.
• Double-space your paper.
• If necessary, create a cover page. Most schools require a cover page of some sort. Include your main title, running title (often a shortened version of your main title), author's name, course name, and semester.

• Break up information into sections and subsections and address one main point per section.
• Include any figures or data tables that support your main ideas.
• For a quantitative study, state the methods used to obtain results.

• Clearly state and summarize the main points of your research paper.
• Discuss how this research contributes to the field and why it is important. [4] X Research source
• Highlight potential applications of the theory if appropriate.
• Propose future directions that build upon the research you have presented. [5] X Research source
• Keep the introduction and discussion short, and spend more time explaining the methods and results.

• State why the problem is important to address.
• Discuss what is currently known and what is lacking in the field.
• State the objective of your paper.
• Keep the introduction short.

• Highlight the purpose of the paper and the main conclusions.
• State why your conclusions are important.
• Be concise in your summary of the paper.
• Show that you have a solid study design and a high-quality data set.
• Abstracts are usually one paragraph and between 250 – 500 words.

• Unless otherwise directed, use the American Medical Association (AMA) style guide to properly format citations.
• Add citations at end of a sentence to indicate that you are using someone else's idea. Use these throughout your research paper as needed. They include the author's last name, year of publication, and page number.
• Compile your reference list and add it to the end of your paper.
• Use a citation program if you have access to one to simplify the process.

• Continually revise your paper to make sure it is structured in a logical way.
• Proofread your paper for spelling and grammatical errors.
• Make sure you are following the proper formatting guidelines provided for the paper.
• Have others read your paper to proofread and check for clarity. Revise as needed.

Expert Q&A

• Ask your professor for help if you are stuck or confused about any part of your research paper. They are familiar with the style and structure of papers and can provide you with more resources. Thanks Helpful 0 Not Helpful 0
• Refer to your professor's specific guidelines. Some instructors modify parts of a research paper to better fit their assignment. Others may request supplementary details, such as a synopsis for your research project . Thanks Helpful 0 Not Helpful 0
• Set aside blocks of time specifically for writing each day. Thanks Helpful 0 Not Helpful 0

• Do not plagiarize. Plagiarism is using someone else's work, words, or ideas and presenting them as your own. It is important to cite all sources in your research paper, both through internal citations and on your reference page. Thanks Helpful 4 Not Helpful 2

You Might Also Like

• ↑ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3178846/
• ↑ http://owl.excelsior.edu/research-and-citations/outlining/outlining-imrad/
• ↑ http://china.elsevier.com/ElsevierDNN/Portals/7/How%20to%20write%20a%20world-class%20paper.pdf
• ↑ http://intqhc.oxfordjournals.org/content/16/3/191
• ↑ http://www.ruf.rice.edu/~bioslabs/tools/report/reportform.html#form

About This Article

To write a medical research paper, research your topic thoroughly and compile your data. Next, organize your notes and create a strong outline that breaks up the information into sections and subsections, addressing one main point per section. Write the results and discussion sections first to go over your findings, then write the introduction to state your objective and provide background information. Finally, write the abstract, which concisely summarizes the article by highlighting the main points. For tips on formatting and using citations, read on! Did this summary help you? Yes No

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Medical Ethics - Free Essay Samples And Topic Ideas

Medical Ethics is a form of applied ethics that examines ethical principles and moral or ethical problems that arise in a medical environment. Essays on medical ethics could delve into various ethical dilemmas faced by healthcare professionals, the principles guiding medical ethics like autonomy, beneficence, and justice, and how these principles apply in real-world clinical settings. Discussions might also cover controversial medical practices, the impact of legislation and policy on medical ethics, and the changing ethical landscape in light of technological advancements in medicine. We have collected a large number of free essay examples about Medical Ethics you can find at Papersowl. You can use our samples for inspiration to write your own essay, research paper, or just to explore a new topic for yourself.

Biomedical Ethics

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Why is Medical Ethics Important? a Critical Analysis of End-of-Life Policies

Ethics have been long talked about in health care in the United States. Ethics suggests that every decision made has a right or wrong action. This sense of right or wrong, however, could be subjective to different experiences in one’s life. Ethics are influenced by many different factors like culture, climate, and morals (Kreitner & Kinicki, 2016). This creates grey areas in ethical policy regarding end-of-life issues. Ethics are defined as beliefs, ideas, or values that are foundations of why […]

Euthanasia: is it Ethical

While doing research on the topic of Euthanasia and Physician Assisted Suicide, I have come to see that people have a hard time believing that this should be an option for people who have terminal illnesses. Euthanasia is the painless killing of a patient suffering from an incurable and painful disease or in an irreversible coma and Physician Assisted Suicide (PAS) is The voluntary termination of one's own life by administration of a lethal substance with the direct or indirect […]

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Birth Control for Minors

Introduction According to the CDC, even though United States is one of the top industrial nations in the world, our nation has the most teenage pregnancies, in the latest statistics ""in 2017 a total of 194,377 babies were born to teenage mothers age 15 to 19 years old. (CDC, 2019). Unfortunately, about 50% of these teen Moms will drop out of high school and many will live in poverty. Despite these high rates of births, the question and dilemma is […]

Euthanasia Debate

The intention to deliberately help someone accelerate the death of an incurable patient, even to stop his or her suffering has never been an easy task. The ethics of euthanasia is one that has been debated over since the fourth century B.C. Euthanasia is translated from Greek as "good death" or "easy death. At first, the term referred to painless and peaceful natural deaths in old age that occurred in comfortable and familiar surroundings. Today the word is currently understood […]

Abortion Issue: Saving a Life

Abortion is a topic that is a controversial issues in the United States today. Abortion is the removal of an embryo from the female's uterus resulting to the end of pregnancy (dictionary.com). Weather abortion is legal or not women around the world have tried to end their pregnancies. Women having an abortion are jeporadizing their safety and health by self inducing or seeking illegal product. This procedure is done by a licensed healthcare professional. The procedure is done by a […]

End of Life Ethical Issues

Medical advances that are quite recent, have overshadowed it’s long held ethical belief of compassion and care. The main issue has been the appropriate use of technological advances at the end of life. Should these advances be used on every patient despite the chance of an undesired outcome? If not, what guidelines should be put into effect for the use and non-use of medical interventions during this time? This paper will address the ethical issues that guide medical practice and […]

Nursing Care for End of Life Patient

Introduction Nurses have a responsibility of talking care to end of life patents. This ranges from providing medical need to having a sensitive conversation with the patient and family members. This is because days of the dying person, more especially during the last weeks are demanding and stressful. For this reason, nurses are required to exercise a broad range of ethical values. Besides, it is this last aspect that underpins the whole nursing care towards these patients. In this way, […]

Abortion and Adoption

Abortion is not as simple as walking into a medical office and having the procedure performed. Although Roe v. Wade made abortion legal in the United States in 1973 women often have to deal with judgment from others including not only protestors but significant others and family members, choosing between abortion and adoption, emotional stress possibly from the reason they are needing an abortion, physical complications, as well as state governments trying to take away their right to have an […]

Physician Assisted Suicide: the Growing Issue of Dying with Dignity and Euthanasia

Is someone wanting to die with dignity more important than the conscience of a doctor who provides care for others? The issue of physician-assisted death can be summed up by simply saying it has a snowball effect. What starts as physician-assisted death turns into euthanizing and from there it could end up in the killing of patients without their full comprehension as to what they agreed to. The solution to this issue is accepting there is a problem and figuring […]

“The Desire for Parents”

“The desire for parents to be involved in important decisions in their children’s ` lives are understandable, however parental protectiveness could trump a person’s right to her own body and her own future.” (Valenti, 2016). According to Merriam-Webster, abortions are the termination of a pregnancy after accompanied by, resulting in, or closely followed by the death of the embryo or fetus. In most scenarios, women undergo this procedure because they were not financially stable, or experienced sexual harassment in their […]

Learner Record

The suitable plan from the learning was that health officials should form a clinical ethics that has unique parameters and a district focus. For unstable it is noted that the ethics concepts have respect for authority and should express in the individual law. Each of this observation. However, it is also noted that the law can be resolved at a clinical level. The second part learned was on the clinical ethics. Clinical ethics is defined as the methodology for considering […]

Euthanasia and Physician Assisted Suicide

Sometimes people criticize euthanasia and physician-assisted suicide from what is called "pro-life" perspectives and other times from "pro-death" perspectives; each perspective has a different argument about their position and the side they are on in this debate. This paper will review some of these arguments that have been made to date, as well as some of the more recent developments in this issue (Dieterle 129). To begin with, many people argue that euthanasia and physician-assisted suicide are morally acceptable because […]

Reasons for and against Telling Patients the Truth Concerning their Medical Condition

One of the reasons why it is important to tell patients the truth is the fact that lying acts as a barrier to the patient from making an informed independent decision concerning their health condition. The decisions made in this case ends up not being personally meaningful to the patient. In addition to this, it also breaks the trust that the patient has put on the doctor in the event that they find out they have been deceived about their […]

Religious Perspectives on Assisted Suicide and Euthanasia

""Humans are finite. This reality does not intimidate the mature Christian. The believer recognizes the opportunity to serve others is limited but nonetheless significant. The faithful follower seeks to live a temporary life for an eternal purpose. Even dying itself can serve this end."" If only we were all mature Christians, then the approach to life and indeed to death would not be so varied and emotive. The reality is mature Christians are in the minority and death is either […]

Addiction Specialist Calls out Alcoholics Anonymous – is he being Fair?

When Dr. Smith and Bill Wilson started Alcoholics Anonymous (AA) back in 1935, no one anticipated it would turn into the juggernaut it eventually became. AA threw struggling alcoholics a lifeline, and over the past 80 years tens of millions have grabbed it and held on for dear life. But are 12-Step programs like AA really effective against alcoholism? Dr. Lance Dodes, a psychiatrist who specializes in treatment for substance abuse, claims most emphatically that they are not. His critique […]

Drinking United States

Almost 90 percent of adults in the United States report that they drink alcohol at some point in their life. Over half have been reported that they have been drinking in this past month. Many people use alcohol to relax, socialize, celebrate, and sometimes to enjoy a meal. Alcohol is one of the biggest parts of our society. But people do not know or understand the consequences that come with drinking it. The most commonly used addictive substance in the […]

Legalizing Assisted Suicide and Euthanasia for a Dignified End

Every day in the United States, Americans are exposed to society's arguments concerning issues about our right to make our own choices in life-changing decisions. We often hear about gay marriage rights and abortion rights but rarely does physician-assisted suicide get a voice. Not because it isn't happening but because death is often viewed as a taboo subject and becomes even more so if it is a matter of death by suicide. Understanding Physician-Assisted Suicide As stated on the website, […]

The Importance of Code of Ethics in Nursing: Virtue Ethics and Beneficenc

The Importance of Virtue Ethics and Beneficence in Nursing It is often said that it takes a certain kind of person to become a nurse. They must be well-rounded, flexible, and ready for anything. A day in the life of a nurse is filled with critical thinking, tough conversations, moral dilemmas, and the selfless act of caring for others. Virtue ethics is a way of living that focuses on developing good character traits and always doing what the person believes […]

Personal Values and Beliefs in the Nursing Profession

There is more to nursing than just treating an illness; it is driven to bring optimal patient care that focuses on the needs of each patient as an individual. Patient values should be honored by providing compassionate and holistic care, which will be done to the best of my ability when I am a nurse. My Philosophy Towards Nursing This philosophy is derived from the values and beliefs of being respectful, empathetic, compassionate, and a longing desire to care for […]

Should Euthanasia be Legalized in Canada: Compassion Versus Moral Quandaries

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Importance of Ethics in Healthcare: Safeguarding Trust and Humanity at the Heart of Healing

Healthcare is not merely about treating diseases or alleviating pain, it is intrinsically tied to our shared humanity, touching upon the core of what it means to be human. At the heart of this profession lies a set of moral principles and values that ensure the well-being of patients and promote trust. This set of principles is broadly referred to as healthcare ethics. Defining Healthcare Ethics Ethics in healthcare can be distilled into several core tenets, each of which plays […]

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The Ethical Fabric of Nursing: Guiding Principles

In the dynamic world of healthcare, nursing stands out as a profession uniquely woven with compassion, duty, and moral responsibility. At the heart of this intricate tapestry are the ethical principles that guide nurses in their daily practices, ensuring that the care they provide is both effective and humane. These principles not only underscore the importance of patient welfare but also highlight the delicate balance nurses must maintain in navigating complex healthcare scenarios. One of the cornerstones of nursing ethics […]

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Writing Ethical Papers: Top Tips to Ace Your Assignment

17 August, 2021

13 minutes read

Author:  Kate Smith

Writing a complex essay paper can be a tough task for any student, especially for those who do not have their skills developed well or do not have enough time for lengthy assignments. At the same time, the majority of college students need to keep their grades high to maintain their right to receive merit-based scholarships and continue their studies the next year. To help you with your ethical papers writing, we created this guide. Below, you will find out what an ethical paper is, how to structure it and write it efficiently. 

What is an Ethical Paper?

An ethics paper is a type of an argumentative assignment that deals with a certain ethical problem that a student has to describe and solve. Also, it can be an essay where a certain controversial event or concept is elaborated through an ethical lens (e.g. moral rules and principles), or a certain ethical dilemma is explained. Since ethics is connected to moral concepts and choices, a student needs to have a fair knowledge of philosophy and get ready to answer questions related to relationships, justice, professional and social duties, the origin of good and evil, etc., to write a quality paper. Also, writing an ethics paper implies that a student should process a great amount of information regarding their topic and analyze it according to paper terms.

General Aspects of Writing an Ethics Paper

Understanding the ethical papers’ features.

Every essay has differences and features that make it unique. Writing ethical papers implies that a student will use their knowledge of morality and philosophy to resolve a certain ethical dilemma or solve a situation. It can also be a paper in which a student needs to provide their reasoning on ethical or legal circumstances that follow a social issue. Finally, it can be an assignment in which an ethical concept and its application are described. On the contrary, a history essay deals with events that took place somewhen earlier, while a narrative essay is a paper where students demonstrate their storytelling skills, etc.

Defining What Type of Essay Should Be Written

Most of the time, ethical paper topics imply that a student will write an argumentative essay; however, ethics essays can also be descriptive and expository. Each of these essay types has different guidelines for writing, so be sure you know them before you start writing your papers on ethics. In case you missed this step in your ethical paper preparation stage, you would end up writing a paper that misses many important points.

Studying the Ethical Paper Guidelines

Once you get your ethical paper assignment, look through the guidelines that your instructor provided to you. If you receive them during the class, don’t hesitate to pose any questions immediately to remove any misunderstanding before writing an ethics paper outline, or ask for references that you need to use. When you are about to write your first draft, don’t rush: read the paper instructions once again to make sure you understand what is needed from you.

Paying Attention to the Paper Topic

The next thing you need to pay attention to is the ethical paper topic: once you are given one, make sure it falls into the scope of your educational course. After that, consider what additional knowledge may be needed to elaborate on your topic and think about what courses of your program could be helpful for it. Once you are done, read through your topic again to recheck whether you understand your assignment right.

Understanding the Notions of Ethical Arguments, Ethical and Legal Implications, and Ethical Dilemma

Last but not least, another important factor is that a student has to understand the basic terms of the assignment to write a high-quality paper. Ethical arguments are a set of moral rules that are used to defend your position on an ethical issue stated in your essay topic. We refer to ethical versus legal implications when we think about the compensation for certain ethical dilemma outcomes and whether it should be a moral punishment or legal judgment. An ethical dilemma itself refers to a problem or situation which makes an individual doubt what position to take: e.g, abortion, bribery, corruption, etc.

Writing Outline and Structure of an Ethics Paper

Every essay has a structure that makes it a solid piece of writing with straight reasoning and argumentation, and an ethics paper is not an exclusion. This paper has an introduction, body paragraphs, and conclusion. Below, we will describe how each part of ethical papers should be organized and what information they should contain.

First comes the introduction. It is the opening part of your paper which helps a reader to get familiar with your topic and understand what your paper will be about. Therefore, it should contain some information on your ethics paper topics and a thesis statement, which is a central statement of your paper.

The essay body is the most substantive part of your essay where all the reasoning and arguments should be presented. Each paragraph should contain an argument that supports or contradicts your thesis statement and pieces of evidence to support your position. Pick at least three arguments to make your position clear in your essay, and then your paper will be considered well-structured.

The third part of an ethics paper outline is a conclusion, which is a finishing essay part. Its goal is to wrap up the whole essay and make the author’s position clear for the last time. The thoughtful formulation in this essay part should be especially clear and concise to demonstrate the writer’s ability to make conclusions and persuade readers.

Also, don’t forget to include the works cited page after your writing. It should mention all the reference materials that you used in your paper in the order of appearance or in the alphabetical one. This page should be formatted according to the assigned formatting style. Most often, the most frequently used format for ethical papers is APA.

20 Examples of Ethical Paper Topics

• Are there any issues in the 21st century that we can consider immoral and why?
• What is corporate ethics?
• Why is being selfish no longer an issue in 2023?
• Euthanasia: pros and cons
• Marijuana legalization: should it be allowed all over the world?
• Is abortion an ethical issue nowadays?
• Can we invent a universal religion appropriate for all?
• Is the church necessary to pray to God?
• Can we forgive infidelity and should we do it?
• How to react if you are witnessing high school bullying?
• What are the ways to respond to a family abusing individual?
• How to demand your privacy protection in a digital world?
• The history of the American ethical thought
• Can war be ethical and what should the conflicting sides do to make it possible?
• Ethical issues of keeping a zoo in 2023
• Who is in charge of controlling the world’s population?
• How to achieve equality in the world’s rich and poor gap?
• Is science ethical?
• How ethical is genetic engineering?
• Why many countries refuse to go back to carrying out the death penalty?

Ethical Papers Examples

If you still have no idea about how to write an ethics paper, looking through other students’ successful examples is always a good idea. Below, you can find a relevant ethics paper example that you can skim through and see how to build your reasoning and argumentation in your own paper.

https://www.currentschoolnews.com/education-news/ethics-essay-examples/

https://sites.psu.edu/academy/2014/11/18/essay-2-personal-ethics-and-decision-making/

Ethical Papers Writing Tips

Choose a topic that falls into the ethics course program.

In case you were not given the ethics paper topic, consider choosing it yourself. To do that, brainstorm the ethical issues that fascinate you enough to do research. List all these issues on a paper sheet and then cross out those that are too broad or require expertise that you don’t have. The next step you need to take is to choose three or four ethical topics for papers from the list and try to do a quick search online to find out whether these topics are elaborated enough to find sources and reference materials on them. Last, choose one topic that you like the most and find the most relevant one in terms of available data for reference.

Do your research

Once the topic is chosen and organized, dive deeper into it to find the most credible, reliable, and trusted service. Use your university library, online scientific journals, documentaries, and other sources to get the information from. Remember to take notes while working with every new piece of reference material to not forget the ideas that you will base your argumentation on.

Follow the guidelines for a paper outline

During the preparation for your ethical paper and the process of writing it, remember to follow your professor’s instructions (e.g. font, size, spacing, citation style, etc.). If you neglect them, your grade for the paper will decrease significantly.

Write the essay body first

Do not rush to start writing your ethics papers from the very beginning; to write a good essay, you need to have your outline and thesis statement first. Then, go to writing body paragraphs to demonstrate your expertise on the issue you are writing about. Remember that one supporting idea should be covered in one paragraph and should be followed by the piece of evidence that confirms it.

Make sure your introduction and conclusion translate the same message

After your essay body is done, write a conclusion and an introduction for your paper. The main tip regarding these ethics paper parts is that you should make them interrelated: your conclusion has to restate your introduction but not repeat it. Also, a conclusion should wrap up your writing and make it credible for the audience.

Add citations

Every top-quality paper has the works cited page and citations to demonstrate that the research on the topic has been carried out. Therefore, do not omit this point when formatting your paper: add all the sources to the works cited page and pay attention to citing throughout the text. The latter should be done according to the formatting style indicated in your instructions.

Edit your paper

Last but not least is the editing and proofreading stage that you need to carry out before you submit your paper to your instructor. Consider keeping your first draft away from sight for a day or two to have a rest, and then go back to check it for errors and redundant phrases. Don’t rush to change anything immediately after finishing your writing since you are already tired and less focused, so some mistakes may be missed.

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Cultural Relativity and Acceptance of Embryonic Stem Cell Research

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Main Article Content

There is a debate about the ethical implications of using human embryos in stem cell research, which can be influenced by cultural, moral, and social values. This paper argues for an adaptable framework to accommodate diverse cultural and religious perspectives. By using an adaptive ethics model, research protections can reflect various populations and foster growth in stem cell research possibilities.

INTRODUCTION

Stem cell research combines biology, medicine, and technology, promising to alter health care and the understanding of human development. Yet, ethical contention exists because of individuals’ perceptions of using human embryos based on their various cultural, moral, and social values. While these disagreements concerning policy, use, and general acceptance have prompted the development of an international ethics policy, such a uniform approach can overlook the nuanced ethical landscapes between cultures. With diverse viewpoints in public health, a single global policy, especially one reflecting Western ethics or the ethics prevalent in high-income countries, is impractical. This paper argues for a culturally sensitive, adaptable framework for the use of embryonic stem cells. Stem cell policy should accommodate varying ethical viewpoints and promote an effective global dialogue. With an extension of an ethics model that can adapt to various cultures, we recommend localized guidelines that reflect the moral views of the people those guidelines serve.

Stem cells, characterized by their unique ability to differentiate into various cell types, enable the repair or replacement of damaged tissues. Two primary types of stem cells are somatic stem cells (adult stem cells) and embryonic stem cells. Adult stem cells exist in developed tissues and maintain the body’s repair processes. [1] Embryonic stem cells (ESC) are remarkably pluripotent or versatile, making them valuable in research. [2] However, the use of ESCs has sparked ethics debates. Considering the potential of embryonic stem cells, research guidelines are essential. The International Society for Stem Cell Research (ISSCR) provides international stem cell research guidelines. They call for “public conversations touching on the scientific significance as well as the societal and ethical issues raised by ESC research.” [3] The ISSCR also publishes updates about culturing human embryos 14 days post fertilization, suggesting local policies and regulations should continue to evolve as ESC research develops. [4]  Like the ISSCR, which calls for local law and policy to adapt to developing stem cell research given cultural acceptance, this paper highlights the importance of local social factors such as religion and culture.

I.     Global Cultural Perspective of Embryonic Stem Cells

Views on ESCs vary throughout the world. Some countries readily embrace stem cell research and therapies, while others have stricter regulations due to ethical concerns surrounding embryonic stem cells and when an embryo becomes entitled to moral consideration. The philosophical issue of when the “someone” begins to be a human after fertilization, in the morally relevant sense, [5] impacts when an embryo becomes not just worthy of protection but morally entitled to it. The process of creating embryonic stem cell lines involves the destruction of the embryos for research. [6] Consequently, global engagement in ESC research depends on social-cultural acceptability.

a.     US and Rights-Based Cultures

In the United States, attitudes toward stem cell therapies are diverse. The ethics and social approaches, which value individualism, [7] trigger debates regarding the destruction of human embryos, creating a complex regulatory environment. For example, the 1996 Dickey-Wicker Amendment prohibited federal funding for the creation of embryos for research and the destruction of embryos for “more than allowed for research on fetuses in utero.” [8] Following suit, in 2001, the Bush Administration heavily restricted stem cell lines for research. However, the Stem Cell Research Enhancement Act of 2005 was proposed to help develop ESC research but was ultimately vetoed. [9] Under the Obama administration, in 2009, an executive order lifted restrictions allowing for more development in this field. [10] The flux of research capacity and funding parallels the different cultural perceptions of human dignity of the embryo and how it is socially presented within the country’s research culture. [11]

b.     Ubuntu and Collective Cultures

African bioethics differs from Western individualism because of the different traditions and values. African traditions, as described by individuals from South Africa and supported by some studies in other African countries, including Ghana and Kenya, follow the African moral philosophies of Ubuntu or Botho and Ukama , which “advocates for a form of wholeness that comes through one’s relationship and connectedness with other people in the society,” [12] making autonomy a socially collective concept. In this context, for the community to act autonomously, individuals would come together to decide what is best for the collective. Thus, stem cell research would require examining the value of the research to society as a whole and the use of the embryos as a collective societal resource. If society views the source as part of the collective whole, and opposes using stem cells, compromising the cultural values to pursue research may cause social detachment and stunt research growth. [13] Based on local culture and moral philosophy, the permissibility of stem cell research depends on how embryo, stem cell, and cell line therapies relate to the community as a whole. Ubuntu is the expression of humanness, with the person’s identity drawn from the “’I am because we are’” value. [14] The decision in a collectivistic culture becomes one born of cultural context, and individual decisions give deference to others in the society.

Consent differs in cultures where thought and moral philosophy are based on a collective paradigm. So, applying Western bioethical concepts is unrealistic. For one, Africa is a diverse continent with many countries with different belief systems, access to health care, and reliance on traditional or Western medicines. Where traditional medicine is the primary treatment, the “’restrictive focus on biomedically-related bioethics’” [is] problematic in African contexts because it neglects bioethical issues raised by traditional systems.” [15] No single approach applies in all areas or contexts. Rather than evaluating the permissibility of ESC research according to Western concepts such as the four principles approach, different ethics approaches should prevail.

Another consideration is the socio-economic standing of countries. In parts of South Africa, researchers have not focused heavily on contributing to the stem cell discourse, either because it is not considered health care or a health science priority or because resources are unavailable. [16] Each country’s priorities differ given different social, political, and economic factors. In South Africa, for instance, areas such as maternal mortality, non-communicable diseases, telemedicine, and the strength of health systems need improvement and require more focus. [17] Stem cell research could benefit the population, but it also could divert resources from basic medical care. Researchers in South Africa adhere to the National Health Act and Medicines Control Act in South Africa and international guidelines; however, the Act is not strictly enforced, and there is no clear legislation for research conduct or ethical guidelines. [18]

Some parts of Africa condemn stem cell research. For example, 98.2 percent of the Tunisian population is Muslim. [19] Tunisia does not permit stem cell research because of moral conflict with a Fatwa. Religion heavily saturates the regulation and direction of research. [20] Stem cell use became permissible for reproductive purposes only recently, with tight restrictions preventing cells from being used in any research other than procedures concerning ART/IVF.  Their use is conditioned on consent, and available only to married couples. [21] The community's receptiveness to stem cell research depends on including communitarian African ethics.

c.     Asia

Some Asian countries also have a collective model of ethics and decision making. [22] In China, the ethics model promotes a sincere respect for life or human dignity, [23] based on protective medicine. This model, influenced by Traditional Chinese Medicine (TCM), [24] recognizes Qi as the vital energy delivered via the meridians of the body; it connects illness to body systems, the body’s entire constitution, and the universe for a holistic bond of nature, health, and quality of life. [25] Following a protective ethics model, and traditional customs of wholeness, investment in stem cell research is heavily desired for its applications in regenerative therapies, disease modeling, and protective medicines. In a survey of medical students and healthcare practitioners, 30.8 percent considered stem cell research morally unacceptable while 63.5 percent accepted medical research using human embryonic stem cells. Of these individuals, 89.9 percent supported increased funding for stem cell research. [26] The scientific community might not reflect the overall population. From 1997 to 2019, China spent a total of $576 million (USD) on stem cell research at 8,050 stem cell programs, increased published presence from 0.6 percent to 14.01 percent of total global stem cell publications as of 2014, and made significant strides in cell-based therapies for various medical conditions. [27] However, while China has made substantial investments in stem cell research and achieved notable progress in clinical applications, concerns linger regarding ethical oversight and transparency. [28] For example, the China Biosecurity Law, promoted by the National Health Commission and China Hospital Association, attempted to mitigate risks by introducing an institutional review board (IRB) in the regulatory bodies. 5800 IRBs registered with the Chinese Clinical Trial Registry since 2021. [29] However, issues still need to be addressed in implementing effective IRB review and approval procedures.

The substantial government funding and focus on scientific advancement have sometimes overshadowed considerations of regional cultures, ethnic minorities, and individual perspectives, particularly evident during the one-child policy era. As government policy adapts to promote public stability, such as the change from the one-child to the two-child policy, [30] research ethics should also adapt to ensure respect for the values of its represented peoples.

Japan is also relatively supportive of stem cell research and therapies. Japan has a more transparent regulatory framework, allowing for faster approval of regenerative medicine products, which has led to several advanced clinical trials and therapies. [31] South Korea is also actively engaged in stem cell research and has a history of breakthroughs in cloning and embryonic stem cells. [32] However, the field is controversial, and there are issues of scientific integrity. For example, the Korean FDA fast-tracked products for approval, [33] and in another instance, the oocyte source was unclear and possibly violated ethical standards. [34] Trust is important in research, as it builds collaborative foundations between colleagues, trial participant comfort, open-mindedness for complicated and sensitive discussions, and supports regulatory procedures for stakeholders. There is a need to respect the culture’s interest, engagement, and for research and clinical trials to be transparent and have ethical oversight to promote global research discourse and trust.

d.     Middle East

Countries in the Middle East have varying degrees of acceptance of or restrictions to policies related to using embryonic stem cells due to cultural and religious influences. Saudi Arabia has made significant contributions to stem cell research, and conducts research based on international guidelines for ethical conduct and under strict adherence to guidelines in accordance with Islamic principles. Specifically, the Saudi government and people require ESC research to adhere to Sharia law. In addition to umbilical and placental stem cells, [35] Saudi Arabia permits the use of embryonic stem cells as long as they come from miscarriages, therapeutic abortions permissible by Sharia law, or are left over from in vitro fertilization and donated to research. [36] Laws and ethical guidelines for stem cell research allow the development of research institutions such as the King Abdullah International Medical Research Center, which has a cord blood bank and a stem cell registry with nearly 10,000 donors. [37] Such volume and acceptance are due to the ethical ‘permissibility’ of the donor sources, which do not conflict with religious pillars. However, some researchers err on the side of caution, choosing not to use embryos or fetal tissue as they feel it is unethical to do so. [38]

Jordan has a positive research ethics culture. [39] However, there is a significant issue of lack of trust in researchers, with 45.23 percent (38.66 percent agreeing and 6.57 percent strongly agreeing) of Jordanians holding a low level of trust in researchers, compared to 81.34 percent of Jordanians agreeing that they feel safe to participate in a research trial. [40] Safety testifies to the feeling of confidence that adequate measures are in place to protect participants from harm, whereas trust in researchers could represent the confidence in researchers to act in the participants’ best interests, adhere to ethical guidelines, provide accurate information, and respect participants’ rights and dignity. One method to improve trust would be to address communication issues relevant to ESC. Legislation surrounding stem cell research has adopted specific language, especially concerning clarification “between ‘stem cells’ and ‘embryonic stem cells’” in translation. [41] Furthermore, legislation “mandates the creation of a national committee… laying out specific regulations for stem-cell banking in accordance with international standards.” [42] This broad regulation opens the door for future global engagement and maintains transparency. However, these regulations may also constrain the influence of research direction, pace, and accessibility of research outcomes.

e.     Europe

In the European Union (EU), ethics is also principle-based, but the principles of autonomy, dignity, integrity, and vulnerability are interconnected. [43] As such, the opportunity for cohesion and concessions between individuals’ thoughts and ideals allows for a more adaptable ethics model due to the flexible principles that relate to the human experience The EU has put forth a framework in its Convention for the Protection of Human Rights and Dignity of the Human Being allowing member states to take different approaches. Each European state applies these principles to its specific conventions, leading to or reflecting different acceptance levels of stem cell research. [44]

For example, in Germany, Lebenzusammenhang , or the coherence of life, references integrity in the unity of human culture. Namely, the personal sphere “should not be subject to external intervention.” [45]  Stem cell interventions could affect this concept of bodily completeness, leading to heavy restrictions. Under the Grundgesetz, human dignity and the right to life with physical integrity are paramount. [46] The Embryo Protection Act of 1991 made producing cell lines illegal. Cell lines can be imported if approved by the Central Ethics Commission for Stem Cell Research only if they were derived before May 2007. [47] Stem cell research respects the integrity of life for the embryo with heavy specifications and intense oversight. This is vastly different in Finland, where the regulatory bodies find research more permissible in IVF excess, but only up to 14 days after fertilization. [48] Spain’s approach differs still, with a comprehensive regulatory framework. [49] Thus, research regulation can be culture-specific due to variations in applied principles. Diverse cultures call for various approaches to ethical permissibility. [50] Only an adaptive-deliberative model can address the cultural constructions of self and achieve positive, culturally sensitive stem cell research practices. [51]

II.     Religious Perspectives on ESC

Embryonic stem cell sources are the main consideration within religious contexts. While individuals may not regard their own religious texts as authoritative or factual, religion can shape their foundations or perspectives.

The Qur'an states:

“And indeed We created man from a quintessence of clay. Then We placed within him a small quantity of nutfa (sperm to fertilize) in a safe place. Then We have fashioned the nutfa into an ‘alaqa (clinging clot or cell cluster), then We developed the ‘alaqa into mudgha (a lump of flesh), and We made mudgha into bones, and clothed the bones with flesh, then We brought it into being as a new creation. So Blessed is Allah, the Best of Creators.” [52]

Many scholars of Islam estimate the time of soul installment, marked by the angel breathing in the soul to bring the individual into creation, as 120 days from conception. [53] Personhood begins at this point, and the value of life would prohibit research or experimentation that could harm the individual. If the fetus is more than 120 days old, the time ensoulment is interpreted to occur according to Islamic law, abortion is no longer permissible. [54] There are a few opposing opinions about early embryos in Islamic traditions. According to some Islamic theologians, there is no ensoulment of the early embryo, which is the source of stem cells for ESC research. [55]

In Buddhism, the stance on stem cell research is not settled. The main tenets, the prohibition against harming or destroying others (ahimsa) and the pursuit of knowledge (prajña) and compassion (karuna), leave Buddhist scholars and communities divided. [56] Some scholars argue stem cell research is in accordance with the Buddhist tenet of seeking knowledge and ending human suffering. Others feel it violates the principle of not harming others. Finding the balance between these two points relies on the karmic burden of Buddhist morality. In trying to prevent ahimsa towards the embryo, Buddhist scholars suggest that to comply with Buddhist tenets, research cannot be done as the embryo has personhood at the moment of conception and would reincarnate immediately, harming the individual's ability to build their karmic burden. [57] On the other hand, the Bodhisattvas, those considered to be on the path to enlightenment or Nirvana, have given organs and flesh to others to help alleviate grieving and to benefit all. [58] Acceptance varies on applied beliefs and interpretations.

Catholicism does not support embryonic stem cell research, as it entails creation or destruction of human embryos. This destruction conflicts with the belief in the sanctity of life. For example, in the Old Testament, Genesis describes humanity as being created in God’s image and multiplying on the Earth, referencing the sacred rights to human conception and the purpose of development and life. In the Ten Commandments, the tenet that one should not kill has numerous interpretations where killing could mean murder or shedding of the sanctity of life, demonstrating the high value of human personhood. In other books, the theological conception of when life begins is interpreted as in utero, [59] highlighting the inviolability of life and its formation in vivo to make a religious point for accepting such research as relatively limited, if at all. [60] The Vatican has released ethical directives to help apply a theological basis to modern-day conflicts. The Magisterium of the Church states that “unless there is a moral certainty of not causing harm,” experimentation on fetuses, fertilized cells, stem cells, or embryos constitutes a crime. [61] Such procedures would not respect the human person who exists at these stages, according to Catholicism. Damages to the embryo are considered gravely immoral and illicit. [62] Although the Catholic Church officially opposes abortion, surveys demonstrate that many Catholic people hold pro-choice views, whether due to the context of conception, stage of pregnancy, threat to the mother’s life, or for other reasons, demonstrating that practicing members can also accept some but not all tenets. [63]

Some major Jewish denominations, such as the Reform, Conservative, and Reconstructionist movements, are open to supporting ESC use or research as long as it is for saving a life. [64] Within Judaism, the Talmud, or study, gives personhood to the child at birth and emphasizes that life does not begin at conception: [65]

“If she is found pregnant, until the fortieth day it is mere fluid,” [66]

Whereas most religions prioritize the status of human embryos, the Halakah (Jewish religious law) states that to save one life, most other religious laws can be ignored because it is in pursuit of preservation. [67] Stem cell research is accepted due to application of these religious laws.

We recognize that all religions contain subsets and sects. The variety of environmental and cultural differences within religious groups requires further analysis to respect the flexibility of religious thoughts and practices. We make no presumptions that all cultures require notions of autonomy or morality as under the common morality theory , which asserts a set of universal moral norms that all individuals share provides moral reasoning and guides ethical decisions. [68] We only wish to show that the interaction with morality varies between cultures and countries.

III.     A Flexible Ethical Approach

The plurality of different moral approaches described above demonstrates that there can be no universally acceptable uniform law for ESC on a global scale. Instead of developing one standard, flexible ethical applications must be continued. We recommend local guidelines that incorporate important cultural and ethical priorities.

While the Declaration of Helsinki is more relevant to people in clinical trials receiving ESC products, in keeping with the tradition of protections for research subjects, consent of the donor is an ethical requirement for ESC donation in many jurisdictions including the US, Canada, and Europe. [69] The Declaration of Helsinki provides a reference point for regulatory standards and could potentially be used as a universal baseline for obtaining consent prior to gamete or embryo donation.

For instance, in Columbia University’s egg donor program for stem cell research, donors followed standard screening protocols and “underwent counseling sessions that included information as to the purpose of oocyte donation for research, what the oocytes would be used for, the risks and benefits of donation, and process of oocyte stimulation” to ensure transparency for consent. [70] The program helped advance stem cell research and provided clear and safe research methods with paid participants. Though paid participation or covering costs of incidental expenses may not be socially acceptable in every culture or context, [71] and creating embryos for ESC research is illegal in many jurisdictions, Columbia’s program was effective because of the clear and honest communications with donors, IRBs, and related stakeholders.  This example demonstrates that cultural acceptance of scientific research and of the idea that an egg or embryo does not have personhood is likely behind societal acceptance of donating eggs for ESC research. As noted, many countries do not permit the creation of embryos for research.

Proper communication and education regarding the process and purpose of stem cell research may bolster comprehension and garner more acceptance. “Given the sensitive subject material, a complete consent process can support voluntary participation through trust, understanding, and ethical norms from the cultures and morals participants value. This can be hard for researchers entering countries of different socioeconomic stability, with different languages and different societal values. [72]

An adequate moral foundation in medical ethics is derived from the cultural and religious basis that informs knowledge and actions. [73] Understanding local cultural and religious values and their impact on research could help researchers develop humility and promote inclusion.

IV.     Concerns

Some may argue that if researchers all adhere to one ethics standard, protection will be satisfied across all borders, and the global public will trust researchers. However, defining what needs to be protected and how to define such research standards is very specific to the people to which standards are applied. We suggest that applying one uniform guide cannot accurately protect each individual because we all possess our own perceptions and interpretations of social values. [74] Therefore, the issue of not adjusting to the moral pluralism between peoples in applying one standard of ethics can be resolved by building out ethics models that can be adapted to different cultures and religions.

Other concerns include medical tourism, which may promote health inequities. [75] Some countries may develop and approve products derived from ESC research before others, compromising research ethics or drug approval processes. There are also concerns about the sale of unauthorized stem cell treatments, for example, those without FDA approval in the United States. Countries with robust research infrastructures may be tempted to attract medical tourists, and some customers will have false hopes based on aggressive publicity of unproven treatments. [76]

For example, in China, stem cell clinics can market to foreign clients who are not protected under the regulatory regimes. Companies employ a marketing strategy of “ethically friendly” therapies. Specifically, in the case of Beike, China’s leading stem cell tourism company and sprouting network, ethical oversight of administrators or health bureaus at one site has “the unintended consequence of shifting questionable activities to another node in Beike's diffuse network.” [77] In contrast, Jordan is aware of stem cell research’s potential abuse and its own status as a “health-care hub.” Jordan’s expanded regulations include preserving the interests of individuals in clinical trials and banning private companies from ESC research to preserve transparency and the integrity of research practices. [78]

The social priorities of the community are also a concern. The ISSCR explicitly states that guidelines “should be periodically revised to accommodate scientific advances, new challenges, and evolving social priorities.” [79] The adaptable ethics model extends this consideration further by addressing whether research is warranted given the varying degrees of socioeconomic conditions, political stability, and healthcare accessibilities and limitations. An ethical approach would require discussion about resource allocation and appropriate distribution of funds. [80]

While some religions emphasize the sanctity of life from conception, which may lead to public opposition to ESC research, others encourage ESC research due to its potential for healing and alleviating human pain. Many countries have special regulations that balance local views on embryonic personhood, the benefits of research as individual or societal goods, and the protection of human research subjects. To foster understanding and constructive dialogue, global policy frameworks should prioritize the protection of universal human rights, transparency, and informed consent. In addition to these foundational global policies, we recommend tailoring local guidelines to reflect the diverse cultural and religious perspectives of the populations they govern. Ethics models should be adapted to local populations to effectively establish research protections, growth, and possibilities of stem cell research.

For example, in countries with strong beliefs in the moral sanctity of embryos or heavy religious restrictions, an adaptive model can allow for discussion instead of immediate rejection. In countries with limited individual rights and voice in science policy, an adaptive model ensures cultural, moral, and religious views are taken into consideration, thereby building social inclusion. While this ethical consideration by the government may not give a complete voice to every individual, it will help balance policies and maintain the diverse perspectives of those it affects. Embracing an adaptive ethics model of ESC research promotes open-minded dialogue and respect for the importance of human belief and tradition. By actively engaging with cultural and religious values, researchers can better handle disagreements and promote ethical research practices that benefit each society.

This brief exploration of the religious and cultural differences that impact ESC research reveals the nuances of relative ethics and highlights a need for local policymakers to apply a more intense adaptive model.

[1] Poliwoda, S., Noor, N., Downs, E., Schaaf, A., Cantwell, A., Ganti, L., Kaye, A. D., Mosel, L. I., Carroll, C. B., Viswanath, O., & Urits, I. (2022). Stem cells: a comprehensive review of origins and emerging clinical roles in medical practice.  Orthopedic reviews ,  14 (3), 37498. https://doi.org/10.52965/001c.37498

[2] Poliwoda, S., Noor, N., Downs, E., Schaaf, A., Cantwell, A., Ganti, L., Kaye, A. D., Mosel, L. I., Carroll, C. B., Viswanath, O., & Urits, I. (2022). Stem cells: a comprehensive review of origins and emerging clinical roles in medical practice.  Orthopedic reviews ,  14 (3), 37498. https://doi.org/10.52965/001c.37498

[3] International Society for Stem Cell Research. (2023). Laboratory-based human embryonic stem cell research, embryo research, and related research activities . International Society for Stem Cell Research. https://www.isscr.org/guidelines/blog-post-title-one-ed2td-6fcdk ; Kimmelman, J., Hyun, I., Benvenisty, N.  et al.  Policy: Global standards for stem-cell research.  Nature   533 , 311–313 (2016). https://doi.org/10.1038/533311a

[4] International Society for Stem Cell Research. (2023). Laboratory-based human embryonic stem cell research, embryo research, and related research activities . International Society for Stem Cell Research. https://www.isscr.org/guidelines/blog-post-title-one-ed2td-6fcdk

[5] Concerning the moral philosophies of stem cell research, our paper does not posit a personal moral stance nor delve into the “when” of human life begins. To read further about the philosophical debate, consider the following sources:

Sandel M. J. (2004). Embryo ethics--the moral logic of stem-cell research.  The New England journal of medicine ,  351 (3), 207–209. https://doi.org/10.1056/NEJMp048145 ; George, R. P., & Lee, P. (2020, September 26). Acorns and Embryos . The New Atlantis. https://www.thenewatlantis.com/publications/acorns-and-embryos ; Sagan, A., & Singer, P. (2007). The moral status of stem cells. Metaphilosophy , 38 (2/3), 264–284. http://www.jstor.org/stable/24439776 ; McHugh P. R. (2004). Zygote and "clonote"--the ethical use of embryonic stem cells.  The New England journal of medicine ,  351 (3), 209–211. https://doi.org/10.1056/NEJMp048147 ; Kurjak, A., & Tripalo, A. (2004). The facts and doubts about beginning of the human life and personality.  Bosnian journal of basic medical sciences ,  4 (1), 5–14. https://doi.org/10.17305/bjbms.2004.3453

[6] Vazin, T., & Freed, W. J. (2010). Human embryonic stem cells: derivation, culture, and differentiation: a review.  Restorative neurology and neuroscience ,  28 (4), 589–603. https://doi.org/10.3233/RNN-2010-0543

[7] Socially, at its core, the Western approach to ethics is widely principle-based, autonomy being one of the key factors to ensure a fundamental respect for persons within research. For information regarding autonomy in research, see: Department of Health, Education, and Welfare, & National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1978). The Belmont Report. Ethical principles and guidelines for the protection of human subjects of research.; For a more in-depth review of autonomy within the US, see: Beauchamp, T. L., & Childress, J. F. (1994). Principles of Biomedical Ethics . Oxford University Press.

[8] Sherley v. Sebelius , 644 F.3d 388 (D.C. Cir. 2011), citing 45 C.F.R. 46.204(b) and [42 U.S.C. § 289g(b)]. https://www.cadc.uscourts.gov/internet/opinions.nsf/6c690438a9b43dd685257a64004ebf99/$file/11-5241-1391178.pdf

[9] Stem Cell Research Enhancement Act of 2005, H. R. 810, 109 th Cong. (2001). https://www.govtrack.us/congress/bills/109/hr810/text ; Bush, G. W. (2006, July 19). Message to the House of Representatives . National Archives and Records Administration. https://georgewbush-whitehouse.archives.gov/news/releases/2006/07/20060719-5.html

[10] National Archives and Records Administration. (2009, March 9). Executive order 13505 -- removing barriers to responsible scientific research involving human stem cells . National Archives and Records Administration. https://obamawhitehouse.archives.gov/the-press-office/removing-barriers-responsible-scientific-research-involving-human-stem-cells

[11] Hurlbut, W. B. (2006). Science, Religion, and the Politics of Stem Cells.  Social Research ,  73 (3), 819–834. http://www.jstor.org/stable/40971854

[12] Akpa-Inyang, Francis & Chima, Sylvester. (2021). South African traditional values and beliefs regarding informed consent and limitations of the principle of respect for autonomy in African communities: a cross-cultural qualitative study. BMC Medical Ethics . 22. 10.1186/s12910-021-00678-4.

[13] Source for further reading: Tangwa G. B. (2007). Moral status of embryonic stem cells: perspective of an African villager. Bioethics , 21(8), 449–457. https://doi.org/10.1111/j.1467-8519.2007.00582.x , see also Mnisi, F. M. (2020). An African analysis based on ethics of Ubuntu - are human embryonic stem cell patents morally justifiable? African Insight , 49 (4).

[14] Jecker, N. S., & Atuire, C. (2021). Bioethics in Africa: A contextually enlightened analysis of three cases. Developing World Bioethics , 22 (2), 112–122. https://doi.org/10.1111/dewb.12324

[15] Jecker, N. S., & Atuire, C. (2021). Bioethics in Africa: A contextually enlightened analysis of three cases. Developing World Bioethics, 22(2), 112–122. https://doi.org/10.1111/dewb.12324

[16] Jackson, C.S., Pepper, M.S. Opportunities and barriers to establishing a cell therapy programme in South Africa.  Stem Cell Res Ther   4 , 54 (2013). https://doi.org/10.1186/scrt204 ; Pew Research Center. (2014, May 1). Public health a major priority in African nations . Pew Research Center’s Global Attitudes Project. https://www.pewresearch.org/global/2014/05/01/public-health-a-major-priority-in-african-nations/

[17] Department of Health Republic of South Africa. (2021). Health Research Priorities (revised) for South Africa 2021-2024 . National Health Research Strategy. https://www.health.gov.za/wp-content/uploads/2022/05/National-Health-Research-Priorities-2021-2024.pdf

[18] Oosthuizen, H. (2013). Legal and Ethical Issues in Stem Cell Research in South Africa. In: Beran, R. (eds) Legal and Forensic Medicine. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-32338-6_80 , see also: Gaobotse G (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[19] United States Bureau of Citizenship and Immigration Services. (1998). Tunisia: Information on the status of Christian conversions in Tunisia . UNHCR Web Archive. https://webarchive.archive.unhcr.org/20230522142618/https://www.refworld.org/docid/3df0be9a2.html

[20] Gaobotse, G. (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[21] Kooli, C. Review of assisted reproduction techniques, laws, and regulations in Muslim countries.  Middle East Fertil Soc J   24 , 8 (2020). https://doi.org/10.1186/s43043-019-0011-0 ; Gaobotse, G. (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[22] Pang M. C. (1999). Protective truthfulness: the Chinese way of safeguarding patients in informed treatment decisions. Journal of medical ethics , 25(3), 247–253. https://doi.org/10.1136/jme.25.3.247

[23] Wang, L., Wang, F., & Zhang, W. (2021). Bioethics in China’s biosecurity law: Forms, effects, and unsettled issues. Journal of law and the biosciences , 8(1).  https://doi.org/10.1093/jlb/lsab019 https://academic.oup.com/jlb/article/8/1/lsab019/6299199

[24] Wang, Y., Xue, Y., & Guo, H. D. (2022). Intervention effects of traditional Chinese medicine on stem cell therapy of myocardial infarction.  Frontiers in pharmacology ,  13 , 1013740. https://doi.org/10.3389/fphar.2022.1013740

[25] Li, X.-T., & Zhao, J. (2012). Chapter 4: An Approach to the Nature of Qi in TCM- Qi and Bioenergy. In Recent Advances in Theories and Practice of Chinese Medicine (p. 79). InTech.

[26] Luo, D., Xu, Z., Wang, Z., & Ran, W. (2021). China's Stem Cell Research and Knowledge Levels of Medical Practitioners and Students.  Stem cells international ,  2021 , 6667743. https://doi.org/10.1155/2021/6667743

[27] Luo, D., Xu, Z., Wang, Z., & Ran, W. (2021). China's Stem Cell Research and Knowledge Levels of Medical Practitioners and Students.  Stem cells international ,  2021 , 6667743. https://doi.org/10.1155/2021/6667743

[28] Zhang, J. Y. (2017). Lost in translation? accountability and governance of Clinical Stem Cell Research in China. Regenerative Medicine , 12 (6), 647–656. https://doi.org/10.2217/rme-2017-0035

[29] Wang, L., Wang, F., & Zhang, W. (2021). Bioethics in China’s biosecurity law: Forms, effects, and unsettled issues. Journal of law and the biosciences , 8(1).  https://doi.org/10.1093/jlb/lsab019 https://academic.oup.com/jlb/article/8/1/lsab019/6299199

[30] Chen, H., Wei, T., Wang, H.  et al.  Association of China’s two-child policy with changes in number of births and birth defects rate, 2008–2017.  BMC Public Health   22 , 434 (2022). https://doi.org/10.1186/s12889-022-12839-0

[31] Azuma, K. Regulatory Landscape of Regenerative Medicine in Japan.  Curr Stem Cell Rep   1 , 118–128 (2015). https://doi.org/10.1007/s40778-015-0012-6

[32] Harris, R. (2005, May 19). Researchers Report Advance in Stem Cell Production . NPR. https://www.npr.org/2005/05/19/4658967/researchers-report-advance-in-stem-cell-production

[33] Park, S. (2012). South Korea steps up stem-cell work.  Nature . https://doi.org/10.1038/nature.2012.10565

[34] Resnik, D. B., Shamoo, A. E., & Krimsky, S. (2006). Fraudulent human embryonic stem cell research in South Korea: lessons learned.  Accountability in research ,  13 (1), 101–109. https://doi.org/10.1080/08989620600634193 .

[35] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6

[36] Association for the Advancement of Blood and Biotherapies.  https://www.aabb.org/regulatory-and-advocacy/regulatory-affairs/regulatory-for-cellular-therapies/international-competent-authorities/saudi-arabia

[37] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: Interviews with researchers from Saudi Arabia.  BMC medical ethics ,  21 (1), 35. https://doi.org/10.1186/s12910-020-00482-6

[38] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: Interviews with researchers from Saudi Arabia. BMC medical ethics , 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6

Culturally, autonomy practices follow a relational autonomy approach based on a paternalistic deontological health care model. The adherence to strict international research policies and religious pillars within the regulatory environment is a great foundation for research ethics. However, there is a need to develop locally targeted ethics approaches for research (as called for in Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6), this decision-making approach may help advise a research decision model. For more on the clinical cultural autonomy approaches, see: Alabdullah, Y. Y., Alzaid, E., Alsaad, S., Alamri, T., Alolayan, S. W., Bah, S., & Aljoudi, A. S. (2022). Autonomy and paternalism in Shared decision‐making in a Saudi Arabian tertiary hospital: A cross‐sectional study. Developing World Bioethics , 23 (3), 260–268. https://doi.org/10.1111/dewb.12355 ; Bukhari, A. A. (2017). Universal Principles of Bioethics and Patient Rights in Saudi Arabia (Doctoral dissertation, Duquesne University). https://dsc.duq.edu/etd/124; Ladha, S., Nakshawani, S. A., Alzaidy, A., & Tarab, B. (2023, October 26). Islam and Bioethics: What We All Need to Know . Columbia University School of Professional Studies. https://sps.columbia.edu/events/islam-and-bioethics-what-we-all-need-know

[39] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics.  Research Ethics ,  17 (2), 228-241.  https://doi.org/10.1177/1747016120966779

[40] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics.  Research Ethics ,  17 (2), 228-241.  https://doi.org/10.1177/1747016120966779

[41] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East.  Nature  510, 189. https://doi.org/10.1038/510189a

[42] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East.  Nature  510, 189. https://doi.org/10.1038/510189a

[43] The EU’s definition of autonomy relates to the capacity for creating ideas, moral insight, decisions, and actions without constraint, personal responsibility, and informed consent. However, the EU views autonomy as not completely able to protect individuals and depends on other principles, such as dignity, which “expresses the intrinsic worth and fundamental equality of all human beings.” Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3

[44] Council of Europe. Convention for the protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine (ETS No. 164) https://www.coe.int/en/web/conventions/full-list?module=treaty-detail&treatynum=164 (forbidding the creation of embryos for research purposes only, and suggests embryos in vitro have protections.); Also see Drabiak-Syed B. K. (2013). New President, New Human Embryonic Stem Cell Research Policy: Comparative International Perspectives and Embryonic Stem Cell Research Laws in France.  Biotechnology Law Report ,  32 (6), 349–356. https://doi.org/10.1089/blr.2013.9865

[45] Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3

[46] Tomuschat, C., Currie, D. P., Kommers, D. P., & Kerr, R. (Trans.). (1949, May 23). Basic law for the Federal Republic of Germany. https://www.btg-bestellservice.de/pdf/80201000.pdf

[47] Regulation of Stem Cell Research in Germany . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-germany

[48] Regulation of Stem Cell Research in Finland . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-finland

[49] Regulation of Stem Cell Research in Spain . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-spain

[50] Some sources to consider regarding ethics models or regulatory oversights of other cultures not covered:

Kara MA. Applicability of the principle of respect for autonomy: the perspective of Turkey. J Med Ethics. 2007 Nov;33(11):627-30. doi: 10.1136/jme.2006.017400. PMID: 17971462; PMCID: PMC2598110.

Ugarte, O. N., & Acioly, M. A. (2014). The principle of autonomy in Brazil: one needs to discuss it ...  Revista do Colegio Brasileiro de Cirurgioes ,  41 (5), 374–377. https://doi.org/10.1590/0100-69912014005013

Bharadwaj, A., & Glasner, P. E. (2012). Local cells, global science: The rise of embryonic stem cell research in India . Routledge.

For further research on specific European countries regarding ethical and regulatory framework, we recommend this database: Regulation of Stem Cell Research in Europe . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-europe   

[51] Klitzman, R. (2006). Complications of culture in obtaining informed consent. The American Journal of Bioethics, 6(1), 20–21. https://doi.org/10.1080/15265160500394671 see also: Ekmekci, P. E., & Arda, B. (2017). Interculturalism and Informed Consent: Respecting Cultural Differences without Breaching Human Rights.  Cultura (Iasi, Romania) ,  14 (2), 159–172.; For why trust is important in research, see also: Gray, B., Hilder, J., Macdonald, L., Tester, R., Dowell, A., & Stubbe, M. (2017). Are research ethics guidelines culturally competent?  Research Ethics ,  13 (1), 23-41.  https://doi.org/10.1177/1747016116650235

[52] The Qur'an  (M. Khattab, Trans.). (1965). Al-Mu’minun, 23: 12-14. https://quran.com/23

[53] Lenfest, Y. (2017, December 8). Islam and the beginning of human life . Bill of Health. https://blog.petrieflom.law.harvard.edu/2017/12/08/islam-and-the-beginning-of-human-life/

[54] Aksoy, S. (2005). Making regulations and drawing up legislation in Islamic countries under conditions of uncertainty, with special reference to embryonic stem cell research. Journal of Medical Ethics , 31: 399-403.; see also: Mahmoud, Azza. "Islamic Bioethics: National Regulations and Guidelines of Human Stem Cell Research in the Muslim World." Master's thesis, Chapman University, 2022. https://doi.org/10.36837/ chapman.000386

[55] Rashid, R. (2022). When does Ensoulment occur in the Human Foetus. Journal of the British Islamic Medical Association , 12 (4). ISSN 2634 8071. https://www.jbima.com/wp-content/uploads/2023/01/2-Ethics-3_-Ensoulment_Rafaqat.pdf.

[56] Sivaraman, M. & Noor, S. (2017). Ethics of embryonic stem cell research according to Buddhist, Hindu, Catholic, and Islamic religions: perspective from Malaysia. Asian Biomedicine,8(1) 43-52.  https://doi.org/10.5372/1905-7415.0801.260

[57] Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.),  Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues  (pp. 79-94). Berkeley: University of California Press.  https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[58] Lecso, P. A. (1991). The Bodhisattva Ideal and Organ Transplantation.  Journal of Religion and Health ,  30 (1), 35–41. http://www.jstor.org/stable/27510629 ; Bodhisattva, S. (n.d.). The Key of Becoming a Bodhisattva . A Guide to the Bodhisattva Way of Life. http://www.buddhism.org/Sutras/2/BodhisattvaWay.htm

[59] There is no explicit religious reference to when life begins or how to conduct research that interacts with the concept of life. However, these are relevant verses pertaining to how the fetus is viewed. (( King James Bible . (1999). Oxford University Press. (original work published 1769))

Jerimiah 1: 5 “Before I formed thee in the belly I knew thee; and before thou camest forth out of the womb I sanctified thee…”

In prophet Jerimiah’s insight, God set him apart as a person known before childbirth, a theme carried within the Psalm of David.

Psalm 139: 13-14 “…Thou hast covered me in my mother's womb. I will praise thee; for I am fearfully and wonderfully made…”

These verses demonstrate David’s respect for God as an entity that would know of all man’s thoughts and doings even before birth.

[60] It should be noted that abortion is not supported as well.

[61] The Vatican. (1987, February 22). Instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation Replies to Certain Questions of the Day . Congregation For the Doctrine of the Faith. https://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19870222_respect-for-human-life_en.html

[62] The Vatican. (2000, August 25). Declaration On the Production and the Scientific and Therapeutic Use of Human Embryonic Stem Cells . Pontifical Academy for Life. https://www.vatican.va/roman_curia/pontifical_academies/acdlife/documents/rc_pa_acdlife_doc_20000824_cellule-staminali_en.html ; Ohara, N. (2003). Ethical Consideration of Experimentation Using Living Human Embryos: The Catholic Church’s Position on Human Embryonic Stem Cell Research and Human Cloning. Department of Obstetrics and Gynecology . Retrieved from https://article.imrpress.com/journal/CEOG/30/2-3/pii/2003018/77-81.pdf.

[63] Smith, G. A. (2022, May 23). Like Americans overall, Catholics vary in their abortion views, with regular mass attenders most opposed . Pew Research Center. https://www.pewresearch.org/short-reads/2022/05/23/like-americans-overall-catholics-vary-in-their-abortion-views-with-regular-mass-attenders-most-opposed/

[64] Rosner, F., & Reichman, E. (2002). Embryonic stem cell research in Jewish law. Journal of halacha and contemporary society , (43), 49–68.; Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.),  Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues  (pp. 79-94). Berkeley: University of California Press.  https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[65] Schenker J. G. (2008). The beginning of human life: status of embryo. Perspectives in Halakha (Jewish Religious Law).  Journal of assisted reproduction and genetics ,  25 (6), 271–276. https://doi.org/10.1007/s10815-008-9221-6

[66] Ruttenberg, D. (2020, May 5). The Torah of Abortion Justice (annotated source sheet) . Sefaria. https://www.sefaria.org/sheets/234926.7?lang=bi&with=all&lang2=en

[67] Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.),  Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues  (pp. 79-94). Berkeley: University of California Press.  https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[68] Gert, B. (2007). Common morality: Deciding what to do . Oxford Univ. Press.

[69] World Medical Association (2013). World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA , 310(20), 2191–2194. https://doi.org/10.1001/jama.2013.281053 Declaration of Helsinki – WMA – The World Medical Association .; see also: National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. (1979).  The Belmont report: Ethical principles and guidelines for the protection of human subjects of research . U.S. Department of Health and Human Services.  https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/read-the-belmont-report/index.html

[70] Zakarin Safier, L., Gumer, A., Kline, M., Egli, D., & Sauer, M. V. (2018). Compensating human subjects providing oocytes for stem cell research: 9-year experience and outcomes.  Journal of assisted reproduction and genetics ,  35 (7), 1219–1225. https://doi.org/10.1007/s10815-018-1171-z https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6063839/ see also: Riordan, N. H., & Paz Rodríguez, J. (2021). Addressing concerns regarding associated costs, transparency, and integrity of research in recent stem cell trial. Stem Cells Translational Medicine , 10 (12), 1715–1716. https://doi.org/10.1002/sctm.21-0234

[71] Klitzman, R., & Sauer, M. V. (2009). Payment of egg donors in stem cell research in the USA.  Reproductive biomedicine online ,  18 (5), 603–608. https://doi.org/10.1016/s1472-6483(10)60002-8

[72] Krosin, M. T., Klitzman, R., Levin, B., Cheng, J., & Ranney, M. L. (2006). Problems in comprehension of informed consent in rural and peri-urban Mali, West Africa.  Clinical trials (London, England) ,  3 (3), 306–313. https://doi.org/10.1191/1740774506cn150oa

[73] Veatch, Robert M.  Hippocratic, Religious, and Secular Medical Ethics: The Points of Conflict . Georgetown University Press, 2012.

[74] Msoroka, M. S., & Amundsen, D. (2018). One size fits not quite all: Universal research ethics with diversity.  Research Ethics ,  14 (3), 1-17.  https://doi.org/10.1177/1747016117739939

[75] Pirzada, N. (2022). The Expansion of Turkey’s Medical Tourism Industry.  Voices in Bioethics ,  8 . https://doi.org/10.52214/vib.v8i.9894

[76] Stem Cell Tourism: False Hope for Real Money . Harvard Stem Cell Institute (HSCI). (2023). https://hsci.harvard.edu/stem-cell-tourism , See also: Bissassar, M. (2017). Transnational Stem Cell Tourism: An ethical analysis.  Voices in Bioethics ,  3 . https://doi.org/10.7916/vib.v3i.6027

[77] Song, P. (2011) The proliferation of stem cell therapies in post-Mao China: problematizing ethical regulation,  New Genetics and Society , 30:2, 141-153, DOI:  10.1080/14636778.2011.574375

[78] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East.  Nature  510, 189. https://doi.org/10.1038/510189a

[79] International Society for Stem Cell Research. (2024). Standards in stem cell research . International Society for Stem Cell Research. https://www.isscr.org/guidelines/5-standards-in-stem-cell-research

[80] Benjamin, R. (2013). People’s science bodies and rights on the Stem Cell Frontier . Stanford University Press.

Mifrah Hayath

SM Candidate Harvard Medical School, MS Biotechnology Johns Hopkins University

Olivia Bowers

MS Bioethics Columbia University (Disclosure: affiliated with Voices in Bioethics)

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Ethical Lapses in the Medical Profession

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To the Editor:

Re “ Moral Dilemmas in Medical Care ” (Opinion guest essay, May 8):

It is unsettling, and dismaying, to read Dr. Carl Elliott’s account of moral lapses continuing to exist, if not thrive, in medical education. As a neurology resident in the early 1970s, I was assigned a patient who was scheduled to have psychosurgery.

He was a prisoner who had murdered a nurse in a hospital basement, and the surgery to remove part of his brain was considered by the department to be a therapeutic and even forward-looking procedure. This was despite its being widely discredited, and involving a prisoner who could not provide truly informed consent.

A fellow resident and I knew that refusing would almost certainly result in suspension or dismissal from the residency, so we anonymously contacted our local newspapers, whose reporting resulted in an overflow protest meeting, cancellation of the psychosurgery and legislative action placing conditions on the acceptance of informed consent by prisoners.

It is lamentable that even though bioethics programs are widely incorporated into medical education, moral and ethical transgressions remain a stubborn problem as part of medical structures’ groupthink.

As Richard Feynman has emphasized , doubt, uncertainty and continued questioning are the hallmarks of scientific endeavor. They need to be an integral element of medical education to better prepare young doctors for the inevitable moral challenges that lie ahead.

Robert Hausner Mill Valley, Calif.

I would like to thank Carl Elliott for exposing the “Moral Dilemmas in Medical Care.” There is a medical school culture that favors doctors as privileged persons over patients.

I can remember multiple patient interactions in medical school in which I thanked a patient for allowing me to examine them and apologized for hurting them during my exam of their painful conditions.

I was then criticized by attending physicians for apologizing to the patients. I was told, on multiple occasions, that the patient should be thanking me for the privilege of assisting in my education.

Medical training, in a medical school culture that favors the privilege of the medical staff over the rights and feelings of patients, needs to be exposed and changed.

Doug Pasto-Crosby Nashville The writer is a retired emergency room physician.

As a psychiatrist and medical ethicist, I commend Dr. Carl Elliott for calling attention to several egregious violations of medical ethics, including failure to obtain the patient’s informed consent. Dr. Elliott could have included a discussion of physician-assisted suicide and the slippery slope of eligibility for this procedure, as my colleagues and I recently discussed in Psychiatric Times .

For example, as reported in The Journal of Eating Disorders , three patients with the eating disorder anorexia nervosa were prescribed lethal medication under Colorado’s End-of-Life Options Act. Because of the near-delusional cognitive distortions present in severe anorexia nervosa, it is extremely doubtful that afflicted patients can give truly informed consent to physician-assisted suicide. Worse still, under Colorado law, such patients are not required to avail themselves of accepted treatments for anorexia nervosa before prescription of the lethal drugs.

Tragically, what Dr. Elliott calls “the culture of medicine” has become increasingly desensitized to physician-assisted suicide, nowadays touted as just another form of medical care. In the anorexia cases cited, informed consent may have been one casualty of this cultural shift.

Ronald W. Pies Lexington, Mass. The writer is on the faculty of SUNY Upstate Medical University and Tufts University School of Medicine, but the views expressed are his own.

Carl Elliot’s article on medical ethics was excellent. But it is not just in the medical profession that there exists the “subtle danger” that assimilation into an organization will teach you to no longer recognize what is horrible.

Businesses too have a culture that can “transform your sensibility.” In many industries executives check their consciences at the office door each morning. For example, they promote cigarettes; they forget they too breathe the air as they lobby against clean-air policies; they forget they too have children or grandchildren as they fight climate-friendly policies or resist gun-control measures. The list could go on.

In every organization, we need individuals to say no to policies and actions that may benefit the organization but are harmful, even destructive, to broader society.

Colin Day Ann Arbor, Mich.

Re “ Columbia’s Protests Also Bring Pressure From a Private Donor ” (front page, May 11):

Universities are meant to be institutions of higher learning, research and service to the community. They are not items on an auction block to be sold to the highest bidder.

Universities that sell off their policy platform to spoiled one-issue donors who threaten to throw a tantrum no longer deserve our respect. Grant-making foundations should not be grandstanding online. Give money, or don’t, but don’t call a news conference about it.

If Columbia caves, why should prospective students trust it as a place where they can go to become freethinkers and explore their own political conscience as they begin to contemplate the wider world and issues of social justice?

This is a real test of Columbia and its leadership. I do not envy its president, Nemat Shafik, who has few good choices and no way to make everyone happy. What she should not sell is her integrity, or the university’s. She should stand up to these selfish donors. Learn to say, “Thanks, but no thanks.”

Carl Henn Marathon, Texas

Re “ Book Bans? So Open a Bookstore ” (Arts, May 13):

Deep respect for the American novelist Lauren Groff and her husband, Clay Kallman, for opening the Lynx, their new bookstore in Gainesville, Fla. The store focuses on offering titles among the more than 5,100 books that were banned in Florida schools from July 2021 through December 2023.

To all the book clubbers and haters of bans: Order straight from the Lynx.

Fight evil. Read books.

Ted Gallagher New York

Re “ Keep a Firm Grip on Those Mickey Mouse Balloons. It’s the Law ” (front page, May 9):

Balloons are some of the deadliest ocean trash for wildlife, as mentioned in your article about Florida’s expected balloon release ban.

Plastic balloon debris poses a significant threat to marine life, often mistaken for food or becoming entangled in marine habitats, leading to devastating consequences for our fragile ocean ecosystems.

As the founder of Clean Miami Beach, an environmental conservation organization, I’m concerned about the impact of plastic pollution on Florida’s wildlife and coastal areas. Florida’s stunning beaches and diverse marine life are not only treasures to us locals but also draw millions of tourists each year.

Because of the dangers, intentional balloon releases have been banned in many cities and counties across the state. A poll released by Oceana showed that 87 percent of Florida voters support local, state and national policies that reduce single-use plastic. Gov. Ron DeSantis must waste no time in signing this important piece of legislation into law.

Our elected officials should continue to work together to address environmental issues so Floridians and tourists can enjoy our beautiful state without its being marred by plastic pollution.

Sophie Ringel Miami Beach

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How to read an ethics paper

Melanie jansen.

1 Paediatric Intensive Care Unit & Centre for Children’s Health Ethics and Law, Children’s Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia

2 Faculty of Medicine, University of Queensland, Herston, Queensland, Australia

Peter Ellerton

3 Faculty of Humanities and Social Sciences, University of Queensland, Brisbane, Queensland, Australia

In recent decades, evidence-based medicine has become one of the foundations of clinical practice, making it necessary that healthcare practitioners develop keen critical appraisal skills for scientific papers. Worksheets to guide clinicians through this critical appraisal are often used in journal clubs, a key part of continuing medical education. A similar need is arising for health professionals to develop skills in the critical appraisal of medical ethics papers. Medicine is increasingly ethically complex, and there is a growing medical ethics literature that modern practitioners need to be able to use in their practice. In addition, clinical ethics services are commonplace in healthcare institutions, and the lion’s share of the work done by these services is done by clinicians in addition to their usual roles. Education to support this work is important. In this paper, we present a worksheet designed to help busy healthcare practitioners critically appraise ethics papers relevant to clinical practice. In the first section, we explain what is different about ethics papers. We then describe how to work through the steps in our critical appraisal worksheet: identifying the point at issue; scrutinising definitions; dissecting the arguments presented; considering counterarguments; and finally deciding on relevance. Working through this reflective worksheet will help healthcare practitioners to use the ethics literature effectively in clinical practice. We also intend it to be a shared evaluative tool that can form the basis of professional discussion such as at ethics journal clubs. Practising these critical reasoning skills will also increase practitioners’ capacity to think through difficult ethical decisions in daily clinical practice.

Evidence-based medicine is a foundation of clinical practice, necessitating that healthcare practitioners develop keen critical appraisal skills for scientific papers. Many excellent resources exist, including the paper by Sackett  et al 1 and a reference book by Greenhalgh. 2 In 1992, the Medical Journal of Australia published a paper titled ‘How to read a journal article’ . 3 The authors’ goal was to give a step-by-step guide to critically appraising scientific papers. Journal clubs using this worksheet, or similar, are now commonplace in teaching hospitals and are a key part of medical education. A similar need is arising for health professionals to develop skills in the critical appraisal of ethics papers. The reasons for this are twofold. First, healthcare grows increasingly ethically complex. Just as clinicians must keep abreast of the scientific literature, they should also keep up to date with the ethics literature relevant to their practice. Second, clinical ethics services (CES) have become commonplace in hospitals in developed nations. The lion’s share of the work of these services is done by healthcare professionals in addition to their clinical roles 4–6 and who have highly variable levels of training. 4–8 There is an urgent need to equip these and other clinical staff with skills to appraise papers relevant to these aspects of practice.

In this paper, we present the critical appraisal worksheet developed at the Centre for Children’s Health Ethics and Law (CCHEL), Children’s Health Queensland, Brisbane, Australia ( table 1 ). The worksheet was developed for our ethics journal club and has proved useful both for the critical appraisal of ethics papers and for the development of critical thinking skills that can be applied in clinical practice and in clinical ethics consultation work. The goal of this paper is to provide a tool for clinicians without extensive philosophical training to critically appraise ethics papers relevant to clinical practice. We also intend it to be a shared evaluative tool that can form the basis of professional discussion such as at ethics journal clubs. In the first section, we explain what is different about ethics papers. We then describe the steps in our critical appraisal worksheet.

Ethics critical appraisal worksheet

What is different about ethics papers? A discussion of arguments, facts and values

It is important to recognise that ethics is a philosophical, not a scientific, discipline. Healthcare professionals are accustomed to critically appraising scientific data, and to constructing an argument based on that data for why a particular clinical decision is justified. Note that we use the word argument in the philosophical sense, meaning a set of reasons that justify a position. For example, if a patient presents with clinical signs consistent with bacterial pneumonia, the doctor will prescribe an antibiotic regimen based on their knowledge of the likely pathogens and the efficacy of particular antibiotics against these. That oral amoxicillin is an effective treatment for mild community-acquired pneumonia is a factual claim supported by scientific evidence. In contrast, ethical claims are claims of value and must be justified with an ethical argument. For example, the claim that life-sustaining therapy (LST) should be withdrawn from a patient with end-stage cancer is a value claim. Prescriptive words such as ‘should’ and ‘ought’ are useful signposts for value claims. An argument that may justify the claim that LST should be withdrawn is that the patient had previously stated that they did not want to be maintained on LST, and therefore to respect their autonomy the treatment should be withdrawn.

Note that matters of fact and matters of value coexist in clinical medicine (as they do in life) and that rationales for ethical and medical decisions are usually made up of both fact and value claims. Take the example just given of the argument that therapy should be stopped to respect the patient’s autonomy. That the patient had previously expressed wishes not to be maintained on life support is a factual claim. The claim that we should respect autonomy is a value claim. Likewise, when deciding on antibiotics for the patient with pneumonia, the claim that amoxicillin is effective is a factual claim. That we should treat the patient with amoxicillin is a value claim—the implicit argument for which is that the right thing to do is to treat patients with the most effective therapy for their disease. This seems so plainly reasonable that it does not need to be stated; however, it is important to recognise implicit value judgements in clinical decisions, as these are often at issue when there is conflict. The important skill is to be able to differentiate fact and value claims and to understand how the two can interact to form a set of reasons that support a particular conclusion. To do this, it is important to understand how arguments are constructed.

Understanding arguments is important for clinical practice, because ethical decision making threads through everything healthcare practitioners do. High-level skills in this area are especially important for those providing clinical ethics consultation. The UK Clinical Ethics Network and the American Society for Bioethics and Humanities have each published core competencies for clinical ethics consultation. 9 10 Both specify the need for consultants to understand ethical theory and reasoning, to analyse ethical conflicts, and to be able to elicit values and assumptions. Understanding argumentation is fundamental to these skills. The ethics critical appraisal worksheet provides a framework through which to appraise arguments and, by guiding practitioners to read ethics papers actively, aims to deepen understanding of ethical argumentation. We acknowledge that there is a growing literature in empirical ethics—this critical appraisal worksheet is not intended for these papers, as they are scientific papers and can be appraised as such. This worksheet is intended for papers that discuss ethical issues, not those that present scientific data relevant to an ethical issue.

The ethics critical appraisal worksheet

We have structured the worksheet in a similar way to the one by Darzins et al , 3 as a matrix of questions arranged in three columns ( table 1 ). In the first column are questions that prompt the reader to look for important types of information in the article. The second column contains questions that help the reader to decide whether there are problems with these. The third column poses questions to help the reader decide if any problems identified threaten the quality of the paper. Using this worksheet should assist clinicians to more rapidly identify problems with the paper, making the reading of ethics papers more time-efficient.

Critical appraisal questions

What is the point at issue.

The point at issue is the ethical question that the paper is addressing. Well-written ethics papers will explicitly state the point, or points, at issue in the introduction and will go on to address them. Poorly written ethics papers will shift between points at issue, which clouds reasoning and precludes systematic appraisal of all the relevant arguments. Shifting the point at issue happens often in ethical discussions. For example, we may be discussing the issue of whether we should continue providing LST to a child with a very poor prognosis. One person believes that the LST is causing suffering to the child, another person questions the truth of this. A third person points out that we cannot over-ride the parents’ autonomy. This third person is shifting the point at issue. The ethicality of over-riding parental autonomy is important, but concerns a different point at issue. Whether the LST is causing suffering or not is a point that needs to be explored and clarified before moving onto the question of whether it is of a magnitude that makes it reasonable to interfere with parental autonomy.

Has the author defined all of the terms they use?

Defining key terms is critical to avoid confusion. For example, in a paper discussing the rights of adolescents to autonomy in medical decision making, the author needs to define what persons they are referring to with the word ‘adolescent’; exactly what range of decisions they are referring to within the phrase ‘medical decision making’; and exactly how autonomy is conceived in this context. Failing to define key terms used in an argument sacrifices clarity, and defining key terms in an unusual or unreasonable way may have implications for the generalisability of the argument.

Dissect the argument: What are the premises of the author’s argument? What is/are the author’s conclusion/s?

This section of the worksheet requires explanation of the anatomy of an argument and clarification of the difference between truth and validity.

Arguments consist of premises and a conclusion, for example:

Premise 1: Human suffering is undesirable.

Premise 2: Medically extending life in case X prolongs human suffering.

Conclusion: Medically extending life in case X is undesirable.

This is a valid argument because the conclusion follows logically from the premises; that is, it is impossible for the premises to be true and the conclusion false. Whether the conclusion (or a premise) is true or not is a separate issue. Refuting this argument requires proving one or both of the premises to be false—finding evidence that suffering is not always undesirable, or making a case that this particular medical intervention does not prolong suffering. There are no errors of reasoning in this argument, but there may be factual errors which will prove the argument to be a bad one. Consider another argument:

Premise 1: Lucy has a chronic cough.

Premise 2: Lung cancer can present with a chronic cough.

Conclusion: Lucy has lung cancer.

In this case, the argument is invalid. The premises are true but the reasoning is flawed. It is true that Lucy has a chronic cough, and that lung cancer can present with a chronic cough, but it does not follow that Lucy necessarily has lung cancer. Her chronic cough may be from asthma or chronic bronchitis. Lucy may even have lung cancer, although it could be of a type that would not usually cause coughing. So, even if all the information given is true, the conclusion that she must have lung cancer does not necessarily follow.

Another important phenomenon to be aware of is the ‘hidden assumption’. A hidden assumption is a premise that is not explicitly stated. For example, a person may claim that homosexuality is morally wrong because it is unnatural. The hidden premise here is that things that are unnatural are morally wrong, as follows:

Premise 1: (Hidden) Things that are unnatural are morally wrong.

Premise 2: Homosexuality is unnatural.

Conclusion: Homosexuality is morally wrong.

To refute this argument one needs to either show the premises are false or that the reasoning is invalid. The reasoning is valid because it is impossible for the premises to be true and the conclusion false. However, even if one were to accept premise 2—in ignorance of the natural occurrence of homosexuality in many animals—the hidden premise 1 ignores that many things that are unnatural are considered morally good (or at least morally neutral), such as medicines, clothing or the telephone. Identifying the hidden premise is necessary to fully represent the argument, and hence to properly evaluate it.

In ethics papers, deciding whether premises are true will often require recourse to the scientific literature. Good ethics papers have well-researched references for factual premises. Appraising the validity of reasoning can be more difficult and requires practice. A full and rich account of logical fallacies is outside the scope of this paper; however, there are excellent, accessible resources available to hone these skills. 11 It is also worth noting that the overall position of an ethics paper is likely to be made up of a complex argument, with the conclusions of initial arguments making up the premises of further arguments. For example, some may claim that premise 1 (above) is a claim about the existence of ethical laws of nature. To support this claim, the person must develop an argument for the existence of ethical laws of nature and the definition of ‘unnatural’, ending with premise 1—things that are unnatural are morally wrong—as the conclusion. The analytical framework we present here is applicable to each constituent argument of a complex argument.

Does the author address all relevant counterarguments?

When making a case for an ethical position, it is imperative that authors address counterarguments to their position. If an author has not addressed relevant counterarguments, or has done so unconvincingly, this significantly decreases the strength of their case, or at least suggests a shallow investigation of the issue.

Is the argument or exploration of the issue relevant to your practice?

Some ethics papers will address a specific ethical question arising in the reader’s own practice and assist them in navigating this scenario. Other papers will change the way practitioners think, affecting practice in myriad but subtle ways. There will be papers that, while of good internal quality, are not relevant to the reader’s practice. Explicitly deciding on the relevance of a paper prompts practitioners to contextualise new ethical information within their own practice.

Working through this reflective worksheet will aid healthcare practitioners in actively reading and critically appraising ethics papers, enabling them to use the ethics literature more effectively. Developing these critical reasoning skills will also increase capacity to think through difficult ethical decisions in day-to-day practice. It is of particular importance that clinicians working within CES develop these skills to a high level. In the future, we hope to empirically evaluate the ethics critical appraisal worksheet.

Key messages

• Healthcare is increasingly ethically complex, and so there is a growing need for clinicians to keep up to date with the ethics literature relevant to clinical practice.
• Clinical ethics services have become commonplace, and the majority of the work of these services is done by clinicians in addition to their clinical roles.
• Ethics papers differ in important ways from scientific papers, requiring a different set of critical appraisal skills.
• We have developed a worksheet to assist clinicians in the critical appraisal of ethics papers, which can also be used as a shared evaluative tool, such as at ethics journal clubs.

Acknowledgments

The authors would like to acknowledge all CCHEL Clinical Ethics Response Pool members who have participated in the ethics journal club, and in so doing have helped to refine this critical appraisal worksheet.

Contributors: MJ conceived the idea of the critical appraisal worksheet for clinicians. PE assisted in developing the idea and refining the worksheet. MJ wrote the initial draft of the manuscript. PE and MJ were both involved in draft review and development of the final version of the manuscript. MJ is the guarantor of this article.

Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Disclaimer: The views expressed in this paper are the authors’ own and do not necessarily reflect the views of their institutions.

Competing interests: None declared.

Patient consent: Not required.

Provenance and peer review: Not commissioned; externally peer reviewed.

Data sharing statement: No additional data are available.

Author note: MJ is a medical doctor in intensive care medicine and has additional qualifications and experience in clinical ethics. She co-led the working group to establish the Centre for Children’s Health Ethics and Law at Children’s Health Queensland, and was the centre’s inaugural Clinical Ethics Fellow. MJ recently completed a Churchill Fellowship in clinical ethics. She has published both empirical research and analysis pieces on healthcare ethics issues. PE is a science educator and philosopher, and is the Curriculum Director of the University of Queensland Critical Thinking Project. He is an expert in critical thinking and argumentation and has published on these topics in a number of contexts.

Correction notice: This article has been made Open Access since it was published Online First.

This paper is in the following e-collection/theme issue:

Published on 17.5.2024 in Vol 26 (2024)

Reporting of Ethical Considerations in Qualitative Research Utilizing Social Media Data on Public Health Care: Scoping Review

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AI-assisted writing is quietly booming in academic journals—here's why that's OK

by Julian Koplin, The Conversation

If you search Google Scholar for the phrase " as an AI language model ," you'll find plenty of AI research literature and also some rather suspicious results. For example, one paper on agricultural technology says,

"As an AI language model, I don't have direct access to current research articles or studies. However, I can provide you with an overview of some recent trends and advancements …"

Obvious gaffes like this aren't the only signs that researchers are increasingly turning to generative AI tools when writing up their research. A recent study examined the frequency of certain words in academic writing (such as "commendable," "meticulously" and "intricate"), and found they became far more common after the launch of ChatGPT—so much so that 1% of all journal articles published in 2023 may have contained AI-generated text.

(Why do AI models overuse these words? There is speculation it's because they are more common in English as spoken in Nigeria, where key elements of model training often occur.)

The aforementioned study also looks at preliminary data from 2024, which indicates that AI writing assistance is only becoming more common. Is this a crisis for modern scholarship, or a boon for academic productivity?

Who should take credit for AI writing?

Many people are worried by the use of AI in academic papers. Indeed, the practice has been described as " contaminating " scholarly literature.

Some argue that using AI output amounts to plagiarism. If your ideas are copy-pasted from ChatGPT, it is questionable whether you really deserve credit for them.

But there are important differences between "plagiarizing" text authored by humans and text authored by AI. Those who plagiarize humans' work receive credit for ideas that ought to have gone to the original author.

By contrast, it is debatable whether AI systems like ChatGPT can have ideas, let alone deserve credit for them. An AI tool is more like your phone's autocomplete function than a human researcher.

The question of bias

Another worry is that AI outputs might be biased in ways that could seep into the scholarly record. Infamously, older language models tended to portray people who are female, black and/or gay in distinctly unflattering ways, compared with people who are male, white and/or straight.

This kind of bias is less pronounced in the current version of ChatGPT.

However, other studies have found a different kind of bias in ChatGPT and other large language models : a tendency to reflect a left-liberal political ideology.

Any such bias could subtly distort scholarly writing produced using these tools.

The hallucination problem

The most serious worry relates to a well-known limitation of generative AI systems: that they often make serious mistakes.

For example, when I asked ChatGPT-4 to generate an ASCII image of a mushroom, it provided me with the following output.

It then confidently told me I could use this image of a "mushroom" for my own purposes.

These kinds of overconfident mistakes have been referred to as "AI hallucinations" and " AI bullshit ." While it is easy to spot that the above ASCII image looks nothing like a mushroom (and quite a bit like a snail), it may be much harder to identify any mistakes ChatGPT makes when surveying scientific literature or describing the state of a philosophical debate.

Unlike (most) humans, AI systems are fundamentally unconcerned with the truth of what they say. If used carelessly, their hallucinations could corrupt the scholarly record.

Should AI-produced text be banned?

One response to the rise of text generators has been to ban them outright. For example, Science—one of the world's most influential academic journals—disallows any use of AI-generated text .

I see two problems with this approach.

The first problem is a practical one: current tools for detecting AI-generated text are highly unreliable. This includes the detector created by ChatGPT's own developers, which was taken offline after it was found to have only a 26% accuracy rate (and a 9% false positive rate ). Humans also make mistakes when assessing whether something was written by AI.

It is also possible to circumvent AI text detectors. Online communities are actively exploring how to prompt ChatGPT in ways that allow the user to evade detection. Human users can also superficially rewrite AI outputs, effectively scrubbing away the traces of AI (like its overuse of the words "commendable," "meticulously" and "intricate").

The second problem is that banning generative AI outright prevents us from realizing these technologies' benefits. Used well, generative AI can boost academic productivity by streamlining the writing process. In this way, it could help further human knowledge. Ideally, we should try to reap these benefits while avoiding the problems.

The problem is poor quality control, not AI

The most serious problem with AI is the risk of introducing unnoticed errors, leading to sloppy scholarship. Instead of banning AI, we should try to ensure that mistaken, implausible or biased claims cannot make it onto the academic record.

After all, humans can also produce writing with serious errors, and mechanisms such as peer review often fail to prevent its publication.

We need to get better at ensuring academic papers are free from serious mistakes, regardless of whether these mistakes are caused by careless use of AI or sloppy human scholarship. Not only is this more achievable than policing AI usage, it will improve the standards of academic research as a whole.

This would be (as ChatGPT might say) a commendable and meticulously intricate solution.

Provided by The Conversation

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