relationship based research in social work understanding practice research

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Relationship-Based Research in Social Work: Understanding Practice Research Paperback – March 21, 2016

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Relationship-based research is founded on the idea that human relationships are of paramount importance and should be central to social work research and practice.

Drawing on psychodynamic and systemic understandings of research and practice, this book offers practitioners and academics an insight into what constitutes relationship-based approaches to research. These ideas are brought to life by illustrative case studies of research projects carried out in England and Finland, where the concept originated. The authors clearly demonstrate how this approach can be applied across the social work sector and provide a model for practice.

This will be a key reference for social work students, practitioners on post-qualifying courses, research students, and consultant and senior practitioner social workers promoting research-informed practice.

• Print length 240 pages
• Language English
• Publisher Jessica Kingsley Publishers
• Publication date March 21, 2016
• Dimensions 5.98 x 0.55 x 9.02 inches
• ISBN-10 1849054576
• ISBN-13 978-1849054577
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• Publisher ‏ : ‎ Jessica Kingsley Publishers (March 21, 2016)
• Language ‏ : ‎ English
• Paperback ‏ : ‎ 240 pages
• ISBN-10 ‏ : ‎ 1849054576
• ISBN-13 ‏ : ‎ 978-1849054577
• Item Weight ‏ : ‎ 12.5 ounces
• Dimensions ‏ : ‎ 5.98 x 0.55 x 9.02 inches
• #13,322 in Social Services & Welfare (Books)
• #14,746 in Social Work (Books)
• #22,078 in European Politics Books

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Relationship-based research in social work : understanding practice research

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• 1. Introducing the Book. Gillian Ruch, Professor of Social Work, University of Sussex, UK and Ilse Julkunen, Professor of Practice Research in Social Work, Helsinki University, Finland.
• 2. Developing Relevant and Respectful Research Relationships. Gillian Ruch, Professor of Social Work, University of Sussex, UK. 3 Doing Practice Research that Matters: Building Relevant and Sustainable Research Relationships. Ilse Julkunen, Professor of Practice Research in Social Work, Helsinki University, Finland.
• 4. Ethnography On The 'Front Line': Why Some Teams Struggle and Others Thrive. Judy Foster, Visiting Lecturer in Social Work, Tavistock and Portman NHS Trust, UK. 5 Collaborative Knowledge Production in Research Practice: The Development Of The 'Mirror Method' in Team Settings. Laura Yliruka with Jonna Vanhanen, Outi Jaakkola and Erja Saurama, Finland.
• 6. Exploring Relationships Through Ethnography: A Research Study of Boys in School. Harry Lunabba, Doctor of Social Science, Senior Lecturer, Helsinki University, Finland.
• 7. Using Observation to Research the Experiences of Teenagers with Severe Learning Disabilities: Observing the 'Ordinary'. Helen Hingley Jones, Associate Professor Social Work (Research and Teaching), Middlesex University, UK.
• 8. Undertaking a Co-operative Inquiry in a Children's Social Care Service: Prerequisites, Opportunities, Complexities and Challenges in Achieving Relationship-Based Research. Gavin Swann, Qualified Social Worker and Senior Manager in Children Social Care, UK.
• 9. Critical Reflection on Fiction - Increasing Practitioner Reflexivity, Making Knowledge and Enhancing Practice. Katarina Fagerstroem, Doctoral Student, Helsinki University, Finland.
• 10. Exploring Relationships and Emotions Through Reflexive Secondary Data Analysis: Peer Supporters', Professionals' and Clients' Experiences of a Finnish Street-Level Substance Misuse Clinic. Elina Virokannas, University of Jyvaskyla, Finland.
• 11. Designing a Qualitative Research Study: Giving Fathers with Cancer a Voice. Kathleen Sheridan Russell, Visiting Lecturer, The Tavistock Centre, UK.
• 12. Getting to the Heart of Relationships in Social Work Research in Practice. Gillian Ruch, Professor of Social Work, University of Sussex, UK and Ilse Julkunen, Professor of Practice Research in Social Work, Helsinki University, Finland. Contributor biographies.
• (source: Nielsen Book Data)

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Article Contents

Introduction, what is practice research and why (and for whom) does it matter, practice research as an organisationally rooted participatory research methodology, practice research frameworks, how can service users benefit from participating in practice research, integrating practice research processes into social service organisational analysis, applications of practice research for social service organisations, methodological and ethical considerations for practice research-based organisational analysis, implications and an agenda for social work researchers, acknowledgements.

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Practice research methods in social work: Processes, applications and implications for social service organisations

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Bowen McBeath, Michael J Austin, Sarah Carnochan, Emmeline Chuang, Practice research methods in social work: Processes, applications and implications for social service organisations, The British Journal of Social Work , Volume 52, Issue 6, September 2022, Pages 3328–3346, https://doi.org/10.1093/bjsw/bcab246

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Although social work research is commonly rooted within social service settings, it can be difficult for social work researchers and practitioners to develop and sustain participatory studies that specifically promote knowledge sharing and service improvement involving organisational practice. One participatory approach is practice research (PR), which involves social work researchers and practitioners collaborating to define, understand and try to improve the delivery of health and social care services and organisational structures and processes. The two goals of this commentary are to introduce essential methods and approaches to PR and to identify points of connection involving PR and social service organisational studies. Our specific focus on PR in statutory, voluntary and private social service organisations reflects efforts to connect practice, theory and qualitative and quantitative research methods to develop and share organisationally-situated knowledge.

This paper offers an overview of practice research (PR) that focuses on the delivery of social work services in social service organisations. PR is a participatory method used by researchers to address the needs of vulnerable populations, notably poor communities of colour, who receive health and social care services in formal organisational settings. PR is ‘a knowledge development process that focuses primarily on the roles of the service provider, service user, and the service researcher who all participate in defining the research questions and interpreting the findings’ ( Fisher et al. , 2016 ). PR therefore seeks to improve social work and other social services and promote the well-being of service users; and functions as a collaborative process that minimises power differentials between participants ( Austin, 2020 ).

The macro-organisational context of PR studies includes concerns of managerialism amidst neoliberalism, involving increased professionalisation, the use of evidence-based practices and the structuring of service programmes around carefully defined performance measures in response to administrative and policy requirements ( Hasenfeld and Garrow, 2012 ; Harlow et al. , 2013 ; Yan et al. , 2017 ). The meso-organisational context of PR studies involves the development and sustainment of organisational spaces for reflection and sharing that support practitioner engagement in evidence-informed practice ( Carnochan et al. , 2017 ; Brandt et al. , 2020 ). The immediate context for PR is the bureaucratic encounters that involve staff and service users as well as practitioner use of research to promote organisational learning ( Austin and Carnochan, 2020 ). With its specific focus on statutory, voluntary and private social service organisations, PR aims to strengthen the collaborative capacity of practitioners and researchers to support service improvement and responsiveness to the perspectives of service users (capturing the expertise of experience).

In order to describe PR within organisations providing health and social care services, our paper is divided into four sections. First, we provide a brief introduction to PR to characterise its core elements. We also provide a brief review of the major approaches to PR, distinguishing between PR frameworks at different levels of practice and in different geographic contexts. We then identify how service users can benefit from PR. Secondly, we identify how PR processes can be integrated within social service organisational analysis, focusing in particular on how practice researchers and their agency partners (notably front line staff and managers) collaboratively seek to improve social service delivery, support organisational learning and promote interorganisational knowledge sharing. We also summarise PR processes that are based on the core concepts embedded in the science of the concrete (SOC) ( Flyvbjerg, 2001 ). Thirdly, we illustrate the applications of PR for local authorities/counties and voluntary social service organisations with the use of three brief examples featuring methodological and ethical considerations for researchers using PR approaches. Finally, we conclude by identifying implications for social work organisational researchers participating in PR studies and proposing a future research agenda.

At its core, PR is a negotiated process involving multiple stakeholders ( Uggerhøj, 2011 ). These stakeholders include statutory, voluntary and private social service organisations; managers, staff and service users within the organisation; researchers; and policymakers and community leaders. They all function within the context of intergroup communications, negotiation and shared learning needed to address the gap between research and practice and support learning across role-based social, cultural and organisational distances ( Austin and Carnochan, 2020 ).

In order to address this gap, PR involves elements of both practice and research. The elements of practice include: (1) engaging and including diverse types of stakeholders; (2) an effort to rebalance power relationships across organisational contexts, by validating the experiences and expertise of participants at different levels of the organisation; (3) open and frequent conversations to promote dialogue and sustain norms of trust and reciprocity; and (4) an appreciation for the critical role of organisational supports (notably managers) for exploring service innovation ( Uggerhøj, 2011 ).

Essential research elements of PR include the use of quantitative and qualitative data, as well as the reliance on evidence collected within the agency setting. The use of different types of evidence can generate two major research tensions; namely, balancing the breadth (as seen in large organisational surveys and administrative service databases) and depth (e.g. analysis of client case records, in-depth interviews) of research while navigating the tension between research rigour and practice wisdom displayed by practitioners and service users ( Julkunen, 2011 ).

These practice and research elements are integrated into PR studies that evolve in response to ongoing and changing agency needs and priorities. Facilitated group dialogue is used to collaboratively identify practice concerns, conduct research in response to the concerns, and share findings with a focus on assessing current social work practices and identifying opportunities for improvement ( Austin, 2020 ). PR involves power sharing and role shifting through reciprocal learning, as traditionally less-engaged stakeholders explore new roles (e.g. from service user to PR partner); and as managers and researchers reframe their traditional roles (e.g. exploring the emergence of practice-informed management research and research-informed management practice) ( Fisher et al. , 2016 ).

As one of several participatory social science research methods, PR reflects the emphasis of researchers on practice-in-context. In particular, PR shares a number of characteristics with participatory action research (PAR) and empowerment evaluation. In each method, collaboration with service users and other stakeholder groups is central to identifying basic research questions that relate to practices, programmes and/or policies as expressions of larger institutional forces. Furthermore, these approaches draw on diverse sources of literature, including practice and policy reports as well as academic research studies, to inform research questions. Lastly, collaborative collection and analysis of qualitative and/or quantitative data is carried out by research and practice partners across the three research traditions ( Healy, 2001 ; Fetterman et al. , 2017 ).

However, while PR shares many similarities with PAR and programme evaluation principles, it also differs in several important ways related to goals, data sources, data interpretation and the nature of knowledge development and dissemination (see Table 1 ). For example, a main goal of programme evaluation includes the central role of specifying programme objectives to inform funder or organisational decision making in a narrowly defined area (e.g. continue, modify or eliminate a programme). In contrast, PR goals may be much broader, and intended to inform participants’ conceptual thinking about current practice or service delivery and create dialogical opportunities without the same emphasis on direct implications for organisational decision making. Differences also appear in the area of research dissemination. Specifically, programme evaluation results are often used to support organisational planning in response to formal funding and policy requirements, and PAR is often used to support socio-political action or community change. In comparison, PR focuses more on service and practice improvement as well as the relationship between theory and practice, with the goal of encouraging more research-minded practitioners and more practice-minded researchers ( Saurama and Julkunen, 2012 ).

Comparing PR with other research frameworks a

Adapted from Austin and Carnochan (2020 , p. 199).

Another critical factor that distinguishes PR from other participatory research methods is the connection between social work practice and social service managers. Compared to action research and empowerment evaluation methodologies, PR is more explicitly organisational in understanding how managers, front line staff and service users make sense of their diverse roles and often competing statuses. PR is also more attentive to the collaborative interrelationships of service users, front line agency staff and managers in their interorganisational and institutional context. Finally, PR demonstrates an awareness of how questions of service delivery reflect the professionalisation of social work and social services vis-à-vis questions of organisational learning ( Fisher et al. , 2016 ).

Finally, another key difference between PR and its related methodologies can be found in the relationship of organisationally situated theories vis-à-vis practice. For practice researchers, considerations of theory-informed practice and practice-informed theory are important ( Fisher, 2011 ). The exploration and development of diverse theories (e.g. cultural–historical activity theory; Foot, 2014 ) helps practice researchers and participants identify shared practice challenges and explore possible solutions. For example, practice researchers can share lessons learned and practice implications of different theories of group-based learning and relational work, so that managers, workers and service users can determine how each theory enhances shared understanding of service problems and possible solutions ( Austin, 2020 ; Muurinen and Kaarianen, 2021 ).

In sum, PR is explicitly rooted within social service organisations, with a basic goal of collaborating to improve the delivery of health and social care services and organisational capacity within and between organisations ( Austin and Carnochan, 2020 ). Practice researchers pay close attention to the delivery of front line services as well as multilevel practice issues relating to managers, staff and service users.

The evolution of PR has reflected theoretical and practical developments. Practice researchers have used person-in-organisation theories of practice in an effort to explain the ‘everyday actions’ ( Feldman and Orlikowski, 2011 , p. 1241) and ‘concrete activities’ ( Barley and Kunda, 2001 , p. 76) that capture the relationship between agency-based service providers and service users. Researchers have also proposed ways of enhancing the practical relevance of research that involves social work researchers and practitioners promoting shared learning, with a goal of resolving fundamental service delivery dilemmas ( Austin et al. , 2014 ).

In response to these developments, the interrelated streams of PR have been explored in the form of collaboration and negotiation. For example, the foundational perspective of PR invites practitioners and service users to collaboratively identify opportunities to improve social work practices and organisational processes—particularly in response to administrative requirements and statutory mandates ( Fook and Gardner, 2007 ; Epstein, 2009 ). Similarly, there are opportunities to negotiate across differing approaches and perspectives that practitioners, service users and researchers bring to the knowledge production process ( Uggerhøj, 2011 ).

Based on the original formulation of PR, Julkunen (2011) developed a typology of PR studies, distinguishing between practitioner-oriented, generative, method-oriented and democratic models. In the practitioner-oriented model, the practitioner reflectively dialogues with others in order to address pressing practice issues. The generative model involves cycles of agency practice and research designed to connect practical knowledge to action by testing and evaluating potential practice innovations. The method-oriented model involves the service user, practitioner and researcher collaboratively developing practice-based knowledge as well as knowledge that can inform theory development and application. Finally, the democratic model focuses specifically on service users, practitioners, researchers and organisational and system leaders using PR to advocate for practice reforms, thereby connecting PR to policy change (also see Fisher, 2013 ).

Although scholarship on PR has historically reflected the perspectives of Nordic and US academic institutions and social welfare states, a globally diverse body of PR literature is emerging ( Chan and Sim, 2020 ). This literature demonstrates that different PR studies may reflect different: political, policy and organisational contexts of social service delivery; research methods; understandings of service user and practitioner involvement and collaboration and understandings of practice ( Sim et al. , 2018 ).

Empirical research on benefits accrued by service users when engaging in PR is currently limited. However, preliminary evidence suggests that benefits can be organised in terms of empowerment processes and measurable outcomes built on the service user premise of ‘nothing about us, without us’ ( Beresford and McLaughlin, 2020 ). Such processes invite PR participants to learn how to participate in non-hierarchical relationships that ensure diversity, equity and inclusion among service users and providers. This partnership relationship often involves joint problem-solving as well as developing a critical consciousness leading to an alliance through the articulation of shared and different needs and challenges ( Fook and Gardner, 2007 ). Engaging in this process can help service users gain a greater understanding of the contextualised nature of social problems they face.

Another key benefit of participating in PR involves expanding the capacities of service users to amplify their own voices and assume the position of representing the perspectives of peer-colleagues ( Austin and Carnochan, 2020 ). Service users may advocate internally (in response to management directives) and externally (in response to policy dicta and fiscal requirements). As they engage in advocacy efforts, service users can also increase their skills in identifying and accessing community resources (e.g. job training programmes that enhance employability). The process of engaging in humanising power-sharing relationships using dialogical communications between service users, staff and managers can thus involve a shared search for community resources and organisational funding needed to maintain service delivery at needed levels ( Ramon et al. , 2019 ).

The benefits of service user involvement do not necessarily lead to major organisational changes when the focus is on modifying or improving direct service or managerial practice. However, service user involvement can lead to both changes in practice as well as changes in organisational policies and structures ( Julkunen, 2011 ; Fisher, 2013 ). Through involvement in PR, service users can also participate in training and other learning-oriented events as co-equals with staff and other community stakeholders. These opportunities can involve service users playing critical roles of knowledge navigation and translation within social service organisational contexts, particularly where service user perspectives are needed to translate deep knowledge of programme and policy gaps to staff, managers and policymakers ( Muurinen and Kaarianen, 2021 ). Such PR efforts can help spur organisational change and the development of new approaches to system transformation. For service users, skills acquired through participation in PR can also be leveraged in future advocacy efforts or employment opportunities (e.g. serving as a consultant or staff member based on their expertise of experience with a particular social issue) ( Voronka and Grant, 2021 ).

In summary, some of the major benefits derived from service user involvement have been documented ( Natland and Celik, 2015 ) by noting the transition of service user from functioning with a sense of shame or trauma to one of pride and empowerment, in addition to learning how services can be evaluated and improved based on timely and strategic input from service users. A major limitation related to service user involvement could be that their involvement in which their service user experiences are contextualised or revisited could result in being retraumatised (e.g. reliving the experiences of being homeless, incarcerated, unemployed, physically disabled or mentally disabled), especially when acquiring the ‘big picture understanding’ of the pervasiveness of social problems in the larger society ( Müller and Pihl-Thingvad, 2020 ).

The next section identifies common approaches for practice researchers to collaborate with agency-based practitioners and managers in support of service user preferences.

PR processes reflect the evolving interests of social service organisational researchers and practitioners, as seen in their concerns with the formal delivery of contract-based public services, with specific focus on service access and equity considerations ( Jindra et al. , 2020 ). In a similar way, PR processes capture the concerns of managerialism as a response to neoliberalism and austerity, especially in European, Australian and Asian social welfare contexts ( Yan et al. , 2017 ; Alexander and Fernandez, 2021 ). Underlying these interests is an abiding focus on studies that validate and feature the perspectives of service users and service providers ( Hasenfeld and Garrow, 2012 ; Harlow et al. , 2013 ). These studies reflect decades of organisational research, as seen in Table 2 (for a review, see Austin and Carnochan, 2020 ). The overarching effort is to democratise knowledge sharing within social service organisational settings by identifying complementary ways for service users, practitioners, researchers and advocates to contribute to social service delivery.

Complementary types of practice research with social service organisations

For social service organisational scholars, PR processes support exploratory, explanatory and interventive research aims. In exploratory research, PR is used to identify the diverse organisational experiences of service users and service providers ( Austin, 2020 ). These exploratory studies are analogous to participatory needs assessments. In contrast, explanatory PR examines connections between service, programme or policy logics, and identifies broken or missing logics reflecting needed resources (notably, time, funding and training). For example, the identification of gaps between needs and services often reflects historically and/or currently unaddressed service needs (as seen by service users), programme needs (as perceived by front line staff) and organisational learning and policy implementation needs (as viewed by agency leaders) ( Hasenfeld and Garrow, 2012 ; Spitzmueller, 2018 ). Finally, PR can support intervention studies that involve the co-design, co-development, refinement and sharing of new practices within programmes (e.g. practical innovations that benefit service users and front line workers) ( Schalock et al. , 2014 ).

PR-based social service studies can be viewed from the perspectives of the SOC ( Flyvbjerg, 2001 ) that invites researchers to propose person-oriented research questions related to those individuals and groups most impacted by the issues at hand. The SOC also asks researchers to focus on small practices that support big events or processes by exploring everyday activities and their contexts that connect people and their organisational milieu. Finally, the SOC involves engaging multiple stakeholders while reducing power differentials. In PR, managers are viewed as essential linchpins who facilitate shared learning, by validating the multiple organisational identities of participants.

Although social service organisational research based on the SOC can take many forms, it ordinarily begins with question formulation around one or more practical problems or concerns. As elucidated by Austin and Carnochan (2020) , PR questions can take a variety of forms but generally involve three fundamental questions: How can we improve social services and, more broadly, enhance opportunities for health and social care? How can we amplify the voices of service users? and How can we sustain small innovations and promising practices in social work, particularly in different organisational and policy settings? Jointly defining PR questions involves validating the perspectives of each type of participant. Questions derived from the perspectives of service users and staff require considerable outreach in order to engage and amplify service user and practitioner voices (e.g. via service user- and staff-led meetings) ( Uggerhøj, 2011 ).

In comparison, organisational and policy-focused research questions are often formulated by senior management in regards to intra-organisational issues (e.g. cross-departmental coordination and collaboration) and inter-organisational issues (e.g. contracting and implementation challenges involving statutory, voluntary and private social service organisations) ( Fisher, 2013 ). Negotiating among the diverse types of research questions involves explaining why the questions are relevant for different groups, how each envisioned research study can support mutually beneficial goals, and what benefits and challenges might arise as a result.

Other key concepts of the SOC that support PR studies include collaboration and engagement with partners based on persistent communication, representation of diverse memberships, fostering inclusiveness, engaging in difficult conversations and consensus building. Other needed skills involve managing critical tensions, often relating to the responsibilities and expectations of different PR stakeholders. Additional tensions reflect the evolving demands of the organisation vis-à-vis its institutional environment. These tensions need to be addressed through shared dialogue in PR teams ( Julkunen, 2011 ).

As the PR team coalesces, it informs research design, data collection, data interpretation and research dissemination and utilisation in unique ways ( Austin, 2020 ). For example, the more traditional use of literature reviews is to ensure that the research questions and study design are informed by the latest peer-reviewed research studies, by reflecting their findings, key concepts, research methods and implications for future research. In comparison, building on existing knowledge in PR may also involve review of organisational documents, grey literature and the practice wisdom of practitioners and service users ( Austin and Carnochan, 2020 ).

In PR, literature reviews can also become ends in themselves. For example, PR-informed literature reviews can assist in reframing service processes (i.e. identifying how service users and practitioners understand the theories of action underlying service logic models); help staff to become more evidence-informed by reflecting on diverse practice literature and inform managerial decision-making processes. Similarly, in contrast to the traditional scholarly approach of disseminating research findings via peer-reviewed publications in academic journals, practice researchers also share findings directly with service providers and service users in the form of reports and presentations so that practice partners can identify novel applications and more effective approaches to practice.

This section provides three brief examples of PR-based organisational studies. The institutional context of the examples reflects a longstanding PR centre located in a US public research university, a regional consortium of county organisations that administer statutorily required social services and a regional consortium of non-profit organisations that provide voluntary social services. Regionalisation of PR efforts is not uncommon, particularly when organised through academic–practice partnerships involving research, education and training and service functions (often in metropolitan areas).

PR centres serve as network hubs for developing service, workforce and programme studies in response to institutional and local demands (e.g. new policy implementation requirements impacting service delivery). They share PR-based knowledge in order to advocate with local and regional policy and practice bodies, and work to promote mutual support and shared leadership among social service organisations. From the social service organisational perspective, consortium membership and affiliation with the PR centre can advance knowledge development and utilisation that might not otherwise be possible due to considerations of cost, research capacity or timing ( Schalock et al. , 2014 ). Whilst some PR centres are university-based ( Austin et al. , 1999 ), others are located in public settings (e.g. ministries of health and social services) ( Muurinen and Kaarianen, 2021 ). However, the general purpose of PR centres is similar to centres providing applied evaluation and technical assistance.

For over twenty-five years, the PR centre from which the following examples are drawn has supported collaborative, usable knowledge related to the management and improvement of social work services across the public and non-profit social service sectors ( Austin, 2018 ). Its studies have involved research at the front line, organisational and inter-organisational levels, ranging from qualitative agency-based case studies to large quantitative surveys that span public and non-profit organisations across the region. The studies have supported the collection and sharing of three types of research evidence as noted by Nutley et al. (2007) . The first type relates to conceptual evidence that is often drawn from exploratory PR studies that are designed to support future applications. The second type includes persuasive research evidence that often involves explanatory PR, and is used to advocate (within organisations) and externally (notably, with policymakers, funders and civic leaders). And the third type involves instrumental evidence that often relates to explanatory or interventive PR that is designed to support practice improvements (notably in response to identified service and training needs).

To illustrate some of these PR-informed studies of service delivery, we note the purpose of each study, and then summarise its use by study partners and the consortia of local authorities/counties and non-profit social service organisations. As each study evolved, practice researchers attended to the perspectives of organisational partners through persistent communications, relational work centred in interpersonal and small group meetings, managing tensions in response to ongoing and new challenges and celebrating successes.

The first example involved an exploration of the attributes and sustainability of pioneering non-profit social service organisations through in-depth case histories ( Austin, 2013 ) and focused on the organisational developmental needs of long-serving nonprofits. The study partners and regional consortium of non-profit social service organisations expressed significant interest in findings, leading to requests for self-assessment-based organisational and management support tools designed to promote front line service improvement.

The second example was a survey-based study of how front line and management practitioners across eleven county-based public social service organisations engaged in evidence-informed practice. The quantitative aspect of the study noted the importance of organisational roles and resources, and individual practitioner attitudes towards practice and innovation, in supporting different levels of evidence use ( McBeath et al. , 2015 ). The qualitative component of the study identified the specific cognitive, interactive, action and compliance dimensions of evidence-informed practice that are embedded within agency-based social and organisational practices and priorities ( Carnochan et al. , 2017 ). This explanatory study resulted in the provision of recommendations to the eleven county social service organisations, focused on identifying needed resources and opportunities for peer sharing and social support.

The third example involved a mixed methods study examining the collaborative nature of non-profit contracting amidst technical challenges that reflect the underlying complexity of social service delivery. Qualitative, comparative case study analysis was used to explore the multiple dimensions of relational contracting between non-profit and county social service organisations in three counties ( McBeath et al. , 2017 ). The quantitative component of the study entailed surveying non-profit and county social service organisations across different counties to assess the importance of cross-sector communications, trust-building and shared client accountability for collaborative contracting and social service outcome achievement ( Carnochan et al. , 2019 ; Chuang et al. , 2020 ). Study findings identified the need for public-non-profit social service contracting support structures and processes, including: regularly scheduled cross-sector meetings to identify emergent needs and promising service approaches; and cross-sector training and technical assistance to promote collaborative contracting and improved service outcomes.

Each example involved engagement with agency directors, division heads, senior managers and line staff. In each study, the research design and reporting process was iterative between levels, in support of facilitating communication on broadly relevant topics involving diverse staff groups. Overall, these and other studies from the specific PR centre have regularly featured critical information exchange sessions, involving agency staff presentations of local practices as well as research staff presentations of research syntheses, and in which the audience is cross-division and multi-level.

PR methods complement social service organisational research methodologies in at least two ways. First, PR offers an alternative to traditional organisational research that relies on quantitative analysis of elite surveys (notably agency directors). In comparison, PR studies incorporate diverse types of data (e.g. use of agency documents, interviews, focus groups, surveys) and the perspectives of individuals at different levels of analysis (including administrators and managers, front line staff and service users). These qualitative and quantitative data collection methods are intended to address common source bias and validity concerns. Mixed methods PR studies therefore need to anticipate concerns about the perceived trustworthiness, credibility, confirmability and dependability of the data (e.g. by pilot testing survey instruments and interview guides). (For a summative review concerning how to promote the rigour and relevance of PR studies, see Austin and Carnochan (2020 , pp. 183–189)).

Secondly, PR provides a balanced response to the understanding of researchers as either directing and managing the research process, or serving in subsidiary roles. In comparison, PR is a participatory process in which the research interests and perspectives of the researchers and practitioners are actively negotiated, and often reflect multiple objectives ( Fisher et al. , 2016 ). As noted previously, these include instrumental objectives (e.g. to use PR to enhance understanding of services and programmes, and/or to support organisational learning) along with process and interactional objectives (e.g. to support PR-based participation and collaboration). Among the most challenging aspects embedded in negotiations are values-based objectives that are designed to enhance equity and empowerment through PR projects.

Practice researchers therefore need to be prepared to take on co-facilitative roles on issues ranging from research question formulation to the interpretation, use and wider sharing of PR findings in organisations and broader contexts. These co-roles are essential for addressing group dynamics and cross-sector challenges, celebrating shared wins and fostering inclusiveness and active dialogue. Working through these critical tensions depends on power sharing—particularly for practice researchers and senior agency staff vis-à-vis front line staff and service users—and reflects key elements of intergroup dialogue amidst difference ( Austin, 2020 ).

Whilst there is a wide range of ethical issues associated with PR that draws heavily from social science research, some of the more prominent issues include service user and case record confidentiality, final report contributor equity, teamwork accountability derived from participatory decision making in search of consensus and adherence to data source protocols. The theme of confidentiality is wide ranging. It includes respecting the confidential nature of service user information collected as part of a PR project. It also involves the confidential discussions among research team members, who can include service users and staff. A final concern relates to the ethics of the timely reporting of the research to service users, other agency stakeholders and the larger community (e.g. elected officials, other organisations and researchers). In essence, PR involves the various ethical views of three different communities; namely, the research community, the service provider community and the service user community. The convergence of these three perspectives can be challenging for the various participants to both understand and accept.

These methodological and ethical considerations lead to four suggestions for social service organisational researchers when co-facilitating PR studies to enhance their ability to anticipate common PR challenges. First, PR presents communication-based coordination challenges (involving questions of trust, ethical dilemmas and available expertise), as practice and research partners may need to dialogue regularly amidst already-demanding work schedules. Secondly, partners may face changing and/or limited capacity for and engagement with PR, particularly as practice and research roles and priorities evolve. Thirdly, navigating PR projects requires attending to differing perspectives on the time frame to generate research results, viewed as fast by university standards and slow by agency standards. Fourthly, practice researchers need to demonstrate the capacity to convert research implications into practical recommendations for organisational change given the limited experience with the unique aspects of organisational cultures that differ across participating agencies and research institutions. Underscoring these suggestions is the importance of practice researchers and agency partners remaining flexible with respect to different role-based expectations and university versus agency-based priorities.

We conclude with two major recommendations for social work researchers and practitioners in the social service organisational milieu. First, developing, maintaining and supporting collaborative, trust-based relationships is essential for PR studies. Relationship-building involves recognising mutually beneficial capabilities and shared objectives across different organisational roles (e.g. service users, staff and managers within the agency, and practice-informed researchers inside and outside the agency) to advance collaborative planning. Supporting relationships can involve power-sharing to promote mutual respect and trust as well as social support, particularly amidst the complex dynamics of PR teams. Sustaining relationships calls for transparent information-sharing, consistent communication to address evolving practice and research dilemmas and reciprocal risk-taking that respects the negotiated boundaries of various partners. Finally, sustained relationships often require continuous boundary spanning within the organisation and between agency and university partners.

For productive PR relationships to evolve, an ongoing assessment of practice and research relationships includes monitoring evolving organisational and community contexts, revisiting shared goals in light of changes, and managing PR project expectations in response to evolving stakeholder needs and ethical challenges. Relational work is perhaps the most essential dimension of collaborative, participatory research with social service organisational partners.

Secondly, for practice researchers and agency-based practitioners, the balancing of diverse relational commitments requires sustained self-reflection . Self-reflection involves considering the tensions between the breadth and depth possible in empirical research as well as between the commitment to peer-reviewed empirical research and the investment in practice-based research (e.g. grey literature, agency statistics, practice wisdom). Self-reflection also relates to addressing the different expectations and emphases of service users, staff, managers and other agency stakeholders as well as the different collaborative roles that researchers are required to play when they are invited to step up as co-leaders or step back (e.g. comfortably serving as a research consultant), depending on the specific needs of the research team in its organisational context. These reflexive considerations are centred in an ethos of collaboratively improving service delivery to enhance service user well-being.

While reflecting on identified tensions is a critical aspect of the efforts of practice researchers in relationship with agency-based partners, it is also essential for researchers located in university-based settings. Self-reflection on these tensions can involve deeper questions of how to: (1) reconcile the often-competing expectations of one’s academic home, one’s social service organisational partners and one’s role as a scholar–researcher and (2) reframe these competing expectations into complementary aims. Regular dialogue involving practice and research partners concerning these two issues can involve iterative processes of shared debriefing, deconstructing and redefining key needs. The overall goal is to find win–wins that benefit the university, agency and oneself in carrying out research and disseminating practical knowledge in community-based organisational settings.

In order to identify mutually beneficial PR opportunities for social service organisational researchers, we propose a research agenda in the form of ten questions designed to promote speculation and dialogue as illustrated in Table 3 . The array of questions captures the tensions related to the different ways that practice researchers: engage and consider collaborating with possible agency partners; transition from the development of participatory research studies to their dissemination in complex agency contexts and sustain participatory studies in larger institutional settings. The questions seek to capture a lifecycle of participatory research projects at different stages of organisational development and across different contexts.

New directions for practice research-informed social service organisational analysis.

In summary, PR is a participatory, organisationally focused approach that combines the search for practice-relevant knowledge with qualitative and quantitative research methods in order to enhance services and promote organisational improvement in diverse contexts. PR therefore complements participatory methodologies as well as other applied social science methods used in social service organisational analysis. The future challenges include promoting more participatory studies of social service organisations as well as articulating additional perspectives on PR processes, applications and implications.

The authors would like to express their appreciation to the anonymous peer reviewers and Editors for their very helpful suggestions regarding the manuscript.

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Relationship-Based Research in Social Work: Understanding Practice Research Paperback – 21 Mar. 2016

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Relationship-based research is founded on the idea that human relationships are of paramount importance and should be central to social work research and practice. Drawing on psychodynamic and systemic understandings of research and practice, this book offers practitioners and academics an insight into what constitutes relationship-based approaches to research. These ideas are brought to life by illustrative case studies of research projects carried out in England and Finland, where the concept originated. The authors clearly demonstrate how this approach can be applied across the social work sector and provide a model for practice. This will be a key reference for social work students, practitioners on post-qualifying courses, research students, and consultant and senior practitioner social workers promoting research-informed practice.

• ISBN-10 1849054576
• ISBN-13 978-1849054577
• Publisher Jessica Kingsley Publishers
• Publication date 21 Mar. 2016
• Language English
• Dimensions 15.19 x 1.4 x 22.91 cm
• Print length 240 pages
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• Publisher ‏ : ‎ Jessica Kingsley Publishers (21 Mar. 2016)
• Language ‏ : ‎ English
• Paperback ‏ : ‎ 240 pages
• ISBN-10 ‏ : ‎ 1849054576
• ISBN-13 ‏ : ‎ 978-1849054577
• Dimensions ‏ : ‎ 15.19 x 1.4 x 22.91 cm
• Best Sellers Rank: 2,065,899 in Books ( See Top 100 in Books )

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Understanding Social Work Research

• Hugh McLaughlin - Manchester Metropolitan University, UK
• Description

In the second edition of this highly regarded book, Hugh McLaughlin shows how a research-minded perspective and an appreciation of evidence-based practice can lead students to achieve the highest level of individual and collective social work practice.

Topics covered include:

- How to assess, appraise and apply research

- The philosophy of research

- Improving the use of research in practice

- Interdisciplinary contributions to social work and social work research

Providing reflexive questions, practice examples and suggested reading throughout, this book is essential reading for all undergraduate students of social work. It will also be valuable reading for postgraduates and qualified social workers wishing to consolidate their understanding of social work research.

Essential reading for both students and practitioners of social work. The previous edition of this book was highly successful, and in this edition McLaughlin builds on that success to make the book a must have buy.-Professor Richard Barker, Northumbria University

This book is refreshingly easy to understand for a research book, introducing social work students to key issues in a non-threatening way. I will definitely recommend this book to students undertaking dissertations and research projects.

A useful introduction into social work research. I would use this as an introductory textbook at undergraduate and Masters level. The book focuses heavily on the ethical aspects of social work research and is aimed at making social work practitioners more research minded. I would like to have seen a greater focus on research methods alongside the focus on values. The book is clearly written throughout.

This book addresses the important topic of social workers using rather than doing research. The book includes debate on wide-ranging philosophical and ethical issues in relation to understanding research. It engages with key domains such as social work values and the voice of the service user. However the book is 'about' rather than 'how to'. It will appeal more to those wishing to address their own mental barriers and connect with a wider conceptual world than those looking for guidance on practicalities of bringing evidence into practice.

This is a helpful text for showing how to produce good quality research which is relevant to social work. It contains some useful chapters on the philosophy of research and ethical considerations. This text will be recommended on the MA social work degree programme at the University of Wolverhampton.

Excellent, especially for students who are new to research

Excellent resource and students will find the content very accessible whilst undertaking their research proposal assignment and dissertation, and will assist them to develop a research minded approach to their continuing studies and well into their qualified practice.

A really useful book for both undergraduates and postqualifying student.

Clear style that is easily understood and a very good addition to my reading list.

This text provides social workers with specific, detailed help in choosing and undertaking research in their chosen specialism.

Hugh McLaughlin has managed to write a book that will appeal to the beginner as well as the experienced researcher...well done!

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Relationship-Based Research in Social Work: Understanding Practice Research

• Sosiaalityö

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T2 - Understanding Practice Research

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Cultural Relativity and Acceptance of Embryonic Stem Cell Research

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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.

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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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