research on child protection policy

Child Protection: A Child Rights Approach for Schools

• First Online: 19 May 2020

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• Christina M. Fiorvanti 4 , 5 &
• Marla R. Brassard 5  

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This chapter describes how child protection – protecting children from abuse and neglect and promoting their well-being – is conceptualized in a child-rights informed school psychology practice framework. The goal of such practice is to prevent violence and neglect before it occurs by valuing all children and creating school environments and communities that promote their full development. This approach focuses on promotion and prevention by raising consciousness about human and child rights, creating open dialogue, teaching skills (including how to protect oneself from abuse and speak up if it occurs), building stronger relationships, implementing and evaluating effective policy, increasing child participation, and embracing advocacy – all of which improve school climates. When maltreatment does occur, the goal is to respond in a way that both protects and supports the child and the family. The chapter describes effective child protection practice from an international perspective, recommends country and local goal setting for monitoring progress relevant to child protection, lists resources organized by student age and tier in a multitier framework from universal prevention (i.e., tier 1) to targeted intensive intervention (i.e., tier 3), presents a case study to illustrate aspects of the framework, and calls for school psychologists to participate in integrated developmental and intervention science and advocacy as part of global efforts focused on child rights and children’s well-being.

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The training manual is available as an online accompanying resource to this volume. See also Tulane University Child Rights Team (TURC, 2013 ) and Table 2 for information about the self-study version.

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Fiorvanti, C.M., Brassard, M.R. (2020). Child Protection: A Child Rights Approach for Schools. In: Nastasi, B.K., Hart, S.N., Naser, S.C. (eds) International Handbook on Child Rights and School Psychology. Springer, Cham. https://doi.org/10.1007/978-3-030-37119-7_15

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Children’s Participation in Child Welfare: A Systematic Review of Systematic Reviews

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Paul McCafferty, Esther Mercado Garcia, Children’s Participation in Child Welfare: A Systematic Review of Systematic Reviews, The British Journal of Social Work , Volume 54, Issue 3, April 2024, Pages 1092–1108, https://doi.org/10.1093/bjsw/bcad167

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The objective of this research was to conduct a systematic review of systematic reviews related to Article 12 of the UN Convention on the Rights of the Child (UNCRC) as it relates to children and young people involved with child welfare agencies. This systematic review sought to comply with the guidance from the JBI Manual for Evidence Synthesis on umbrella reviews. Fourteen databases were searched using predefined terms. Six hundred seventy-four original hits were retrieved for title and abstract searching after independent searching by the authors. Of those, fourteen were included for full independent reads and all fourteen were selected after discussion. Each systematic review was appraised using an eleven-point quality checklist from JBI. A thematic review was conducted to ascertain the themes across all systematic reviews. Three themes emerged (i) children’s voice is not taken seriously; (ii) relationships are an important determining factor in (un)successful participation; and (iii) the context of participation is important. Our conclusion is that despite mandated UNCRC requirements to involve children and young people within the child protection system, the possibilities for children and young people to express their views remain restricted.

Article 12 of the UN Convention on the Rights of the Child (UNCRC) stipulates that children have the right to express their views and to participate in decisions that directly affect them. Uncomplicated enough one would have supposed, intuitive in fact, for who could possibly argue against children and young people (C&YP) having a voice in decisions that affect them—the most basic of human rights. After all, adults enjoy this right. And for the authors of the Convention, this inalienable right must have seemed obvious too, fundamental almost in its inherent assumption that it is just the right thing to do.

But the reality of successfully applying Article 12 has bedevilled legislators, policymakers and practitioners alike since the inception on the Convention on the Rights of the Child (the Convention) as they struggle to decipher and apply their Article 12 obligations to practice ( McCafferty, 2021 ). Consequently, the practice reality regarding enacting Article 12 obligations has created something of a legislative, policy and practice duality; one in which States and state actors are mandated to listen, involve and respond to C&YP’s voice but find doing so exceptionally taxing. What we call the practice reality/legislative mandate duality has arguably led to unintended obfuscation in the participatory landscape with a parallel diminution of the voice of C&YP. This duality is nowhere more apparent than in child welfare, the result of which has generated a disappointing stasis where the voice of arguably society’s most vulnerable C&YP is lost ( McCafferty, 2021 ).

Whilst research in the social work field may have been to some extent sluggish to explore children’s participation, it has increased more recently in both quality and quantity with a growing number of scholars paying greater attention to this field of study. Both empirical and theoretical studies are beginning to enrich our understanding of the opportunities and challenges Article 12 presents for C&YPs participation in child welfare. This increased interest is fuelled by a feeling that we in social work are somehow just not getting it right and we stand accused of persistent failures to involve children fully in decisions affecting them (e.g. Department for Education (DfE), 2020 ).

General themes emerging from research broadly suggest two things. First, that challenges exist at practitioner, managerial, organisational, systems and societal level that frustrate the full actualisation of C&YP’s right to be heard. For example, Toros (2021a,b ) in two systematic reviews suggests that children are not able to participate in decision-making processes often enough and their voices are either not being heard or not taken seriously. Faced with the unenviable task of protecting children in an ever increasingly complex world, child welfare professionals are entrusted both ethically and legally with acting in children’s best interests and deciding where and how those best interests are met. However, these best interest decisions are recognised as being amongst the most testing decisions a child welfare worker is likely to make due to their challenging and contested nature (McCafferty, 2020). In this environment, research by McCafferty et al. (2021) suggests that child welfare practitioners are making increasingly more protectionist and interventionist decisions and that this process instinctively reduces C&YP’s agentic status as individuals capable of forming a view and for that view to be heard. ‘As a result of this deficit archetype based on difference, children tend to be granted protection in social work which excludes them from decisions, deprives them of their autonomy, assumes incompetence and emphasises dependence on adults’ ( McCafferty, 2017 , p. 333).

Secondly, when done well, involving C&YP in decisions that affect their life trajectory has beneficial outcomes for them and evidence of this exists across a range of disciplines such as in health, education and policy making ( van Bijleveld et al. , 2015 ; Kennan et al. , 2018 ). Furthermore, participation in decision-making results in beneficial developmental effects ( Falch‐Eriksen et al ., 2021 ) as well as potentially improving decision-making processes and outcomes by ensuring that decisions are more inclusive, responsive and tailored to specific needs. C&YP’s participation increases the likelihood of assessments being more accurate and outcomes more in line with what C&YP need, contributing to more accurate assessment outcomes, as it increases the accuracy of the understanding of the child’s emotional state, thoughts, feelings and hopes for the future.

So, we know that since 1989 when the UNCRC was first enacted, social work has studied C&YPs participation in child welfare, and several systematic reviews have already been conducted. Collectively they provide a large body of relevant evidence, one so large, however, that it is not easy to summarise the patterns in their findings. This makes it challenging for decision makers, researchers, academics and practitioners to utilise the best available evidence to inform their decisions. The time is right therefore to draw thirty-three years’ worth of data into one study so that we can take stock of where we are at in terms of our knowledge, drawing all the disparate systematic reviews into one place.

The purpose of this systematic review is to condense data from all the existing systematic reviews into one overarching review and deliver a meticulous summary of all the available research from systematic reviews of C&YPs participation in child welfare. Called an umbrella review by Aromataris and Munn (2020) , this umbrella review will appraise and collate all relevant empirical evidence gathered from existing systematic reviews into one place to provide a complete interpretation of research results. Doing so will identify questions for which the available evidence provides clear answers and thus for which further research is not necessary. The review will also identify research gaps in our current understanding of the field and help set the short- to medium-term research priorities for scholars going forward.

Search strategy

The characteristics of a systematic review are well-defined and internationally accepted and they generally agree that the defining characteristics of a systematic review are that it must have (i) clearly articulated objectives and questions to be addressed; (ii) an inclusion and exclusion criteria stipulated a priori that determine the eligibility of studies; (iii) a comprehensive search to identify all relevant studies, both published and unpublished; (iv) an appraisal of the quality of included studies, assessment of the validity of their results, and reporting of any exclusions based on quality; (v) analysis of data extracted from the included research; (vi) a presentation and synthesis of the findings extracted and (vii) a transparent reporting of the methodology and methods used to conduct the review ( Higgins et al., 2022 ). This review sought to comply with the guidance from JBI Manual for Evidence Synthesis (Aromataris and Munn, 2020), specifically Chapter 10, Umbrella Reviews, and Evidence-Based Practice ( Aromataris et al. , 2020 ).

In the process of creating a search formula, the topic addressed by this review was converted into four key concept groups as agreed by both authors: <participation> AND <social work> AND <child welfare> AND <children and young people>. For each concept, search terms reflecting its main characteristics were identified and combined into a search formula by both authors in consultation with the subject specialist librarian from Queen’s University Belfast over three meetings. This generic formula was reviewed and later adjusted by both authors along with the subject librarian to fit the databases’ particular facilities. The selection of electronic bibliographic databases was informed by both pragmatic and methodological considerations relating to databases’ quality appraisal, relevance and accessibility. The searches took place over a two-week period between 15 and 29 August 2022.

Overall, fourteen electronic bibliographic databases were selected:

Child Development.

Directory of Open Access Journals (DOJA).

International Bibliography of the Social Sciences (IBSS).

Social Care Online.

Social Policy and Practice.

Social Science Citation Index.

Social Services Abstracts.

Sociological Abstracts.

Campbell Collaboration.

CINAHL Plus.

Cochrane Central Register of Controlled Trials (CENTRAL).

Google Scholar.

Inclusion and exclusion criteria

Beginning with quality criteria, this umbrella review was restricted to articles published in peer-reviewed journals. Doing so ensures that there was an independent standard of quality applied that goes beyond the knowledge base of the authors and incorporates the expertise of journal reviewers ( Alfandari and Taylor, 2022 ). Regarding relevance criteria, to be included in our umbrella review, studies needed to be (i) a systematic review of relevant papers pertaining to the topic, (ii) the topic needed to relate to C&YP’s participation in child welfare social work, (iii) to qualify as a systematic review, reviews needed to (a) employ a systematic, recognised, explicit and replicable processes for searching the literature to retrieve research related to the topic, and (b) report on empirical research that is based on either quantitative, qualitative or mixed methods research designs—action research or single case study methods that impose greater challenges for determining quality ( Taylor et al. , 2015 ) theoretical material, editorials, government papers and policy documents were all excluded from this review. In addition, the time frame of the search was from 1989 when the UNCRC was enacted to ensure we gained a full representation of every review published since that time. Finally, for practical reasons, the search was restricted to publications in the English language.

Search outcome and screening

There were two rounds of searches, both done independently by each author. Bibliographic data about the studies derived was imported into an Excel spreadsheet with separate pages for each database and when combined there was a total of 889 searches retrieved. Through discussion, 215 duplicates were agreed upon and removed leaving 674 original hits. When agreement was reached about the removal, initial titles and abstract screening against the inclusion criteria took place, again independently. Based on a structured colour coding scheme developed by the authors, each study was tagged with one of four possible colours: (i) blue for inclusion; (ii) red for exclusion; (iii) green in cases of uncertainties that required more discussion; and (iv) grey, in cases of uncertainties that required additional information when bibliographic data were incomplete. Studies coloured red were also recorded by the reasons for their exclusion, which were chosen from our inclusion criteria. The authors then came together and agreed on ninety-eight studies for full-text assessment for inclusion with eligibility carried out independently by the authors. When disagreements arose, they were thoroughly discussed between the authors until a consensus was reached. Of these ninety-eight studies, eighty-four were removed leaving fourteen studies included for the umbrella review.

Once this first round was complete, each author completed an independent review of each study’s reference list by hand. One further study was identified through this search for a full read but was discounted by agreement having not met the inclusion criteria.

The review’s selection process is outlined in Figure 1 using the PRISMA diagram ( Page et al. , 2021 ).

Flowchart of the search and screening process.

Data analysis

Data analysis summarised the included reviews focusing on number of reviews published, type of review (e.g. systematic review, systematic scoping, literature review), aim, period, number of articles, place of publication, analysis and findings. When articles specified the PRISMA flow diagram was used, it was specified. For data analysis, the authors reviewed all the articles and developed three themes—(i) children’s voice is not taken seriously, (ii) relationships are an important determining factor in (un)successful participation and (iii) the context of participation is important.

Included studies

Data analysis is based on fourteen studies published from 1989 to 2022. The characteristics of included studies provided an overview of the existing literature on the subject (see Table 1 ).

Summary of studies analysed.

Quality appraisal

Studies identified as meeting the inclusion criteria were appraised for quality against the JBI Checklist for Systematic Reviews and Research Synthesis by Aromataris et al. (2015) using an eleven-point quality assessment tool to determine the quality of each of the systematic reviews selected for inclusion. The authors independently scored each of the items before jointly discussing them and coming to a consensus about quality. Discussions focused on what was considered acceptable to the aims of the review in terms of the specific study characteristics and what represented an adequate search strategy or appropriate methods of synthesis. Discussions took place prior to this appraisal so we agreed on what constituted acceptable levels of information to allocate a positive appraisal compared with a negative, or response of ‘unclear’. All fourteen studies were included.

Umbrella review

Data analysis revealed three main themes.

Theme 1: Children’s voice is not taken seriously

Studies show children’s participation in the child protection system is significantly diminished in practice ( Skauge et al ., 2021 ; Toros, 2021a ). Children have the right to be heard and to make decisions about their own lives, but their voices have been weakened and they find that being authentically heard and to exercise their right to participation is challenging ( Brummelaar et al ., 2018 ; Collins et al. , 2021 ; McPherson et al ., 2021 ). This is particularly evident in residential settings ( McPherson et al. , 2021 ; van Bijleveld et al ., 2015 ), child maltreatment ( Bartelink et al. , 2015 ) and within mental health services ( Davies and Wright, 2008 ).

This research indicates that despite the recognised importance of children’s rights and participation ( Falch-Eriksen et al. , 2021 ), children are often unable to participate in decision-making processes and that their voices are not taken seriously or heard ( Toros, 2021b ). Kennan et al. (2018) , however, showed how the use of advocates could encourage participation in such contexts, especially with younger children who feel more dissatisfied ( Brummelaar et al ., 2018 ).

Theme 2: Relationships are an important determining factor in (un)successful participation

The relationship between social workers and children is essential to the promotion of participation. McPherson et al. (2021) address the central role of the relationship and relational practice in the process of facilitating participation. Findings across studies suggest several factors influence this relationship and the process and success of participation. First, the age of the child ( Brummelaar et al. , 2018 ; Toros, 2021a ); secondly, protectionist approaches adopted by professionals and welfare agencies ( Toros, 2021a ; van Bijleveld et al. , 2015 ); thirdly, the quality of the professional relationship ( van Bijleveld et al. , 2015 ; Brummelaar et al. , 2018 ; Kennan et al. , 2018 ; Strømland et al. , 2022 ); fourthly, professionals’ attitude towards participation—positive or negative ( Brummelaar et al., 2018 ); fifthly, stigmatising and impairment-focused practices ( Toros et al., 2018 ) and, finally, professional qualities ( Davies and Wright, 2008 ; van Bijleveld et al ., 2015 ). From the perspective of C&YP themselves within the child protection system itself, the study by Wilson et al. (2020) emphasises that C&YP’s early experiences of child welfare relationships are felt as frightening due to the pressure of the investigation process, the invasiveness of professionals and that this decreases participatory activity.

In this sense, professionals may have conflicting attitudes towards children’s views and perceptions ( Brummelaar et al ., 2018 ), differences in the interpretation of participation and the weight given to C&YP opinions in the decision-making process exist ( van Bijleveld et al ., 2015 ; Skauge et al ., 2021 ), ambivalence towards professional participatory intervention also exists ( Davies and Wright, 2008 ), whilst children’s perspectives differ from that of professionals ( Toros et al., 2018 ).

Theme 3: The context of participation is important

The concept of participation is confusing ( Collins et al ., 2021 ). The lack of full recognition and operationalisation of children’s right to be sufficiently heard is one of the main challenges in the context of participation ( Strømland et al ., 2022 ). This may be because child protection systems are very heterogeneous in terms of legislation, approaches and working methods ( Skauge et al. , 2021 ). Ideas about participation are underpinned by policies in which different cultural and organisational contexts underlie and limit participation itself ( Brummelaar et al ., 2018 ; Jensen et al ., 2020 ; Skauge et al ., 2021 ). Despite attempts to follow processes such as the use of advocates, a child’s attendance at an assessment, planning or review meeting, Family Welfare Conferences and recording a child’s views in writing, spaces are neither inclusive nor conducive to fostering such participation ( Kennan et al ., 2018 ). In the study of Toros et al. (2018) , studies suggest that protection concerns and bureaucratised and authority-based systems limit such a participatory context.

These organisational challenges are related to government perceptions and media representations of public awareness ( Davies and Wright, 2008 ; van Bijleveld et al ., 2015 ) and risk assessment of children ( Davies and Wright, 2008 ; Bartelink et al ., 2015 ). The lack of quality time to work directly with C&YP has also been cited as one of the main problems social workers encounter when trying to involve C&YP ( van Bijleveld et al., 2015 ).

Participation has become firmly rooted in child rights discourse, public policy and research around the world ( Skauge et al ., 2021 ). Within the child protection system, it has been considered an important issue, but despite the CRC guidelines, possibilities to express their views and needs are restricted ( Toros, 2021a ).

Cultural conceptions, the adult-centric worldview of social work professionals, age discrimination, denial of opportunities and unhelpful participatory efforts remain a major challenge ( Collins, 2017 ; Strømland et al ., 2022 ). How this power is exercised is influenced by ideology, attitudes and beliefs ( Wilson et al ., 2020 ; McPherson et al ., 2021 ). As such, conceptualisations of protection continue to reflect traditional approaches to participation in child welfare that indicate a reductionist paternalistic attitude that privileges protection over empowerment ( Collins, 2017 ; Collins et al ., 2021 ). The findings found in this article evidence that the fragmented view of children through polarised thinking via dichotomous positions rather than a holistic view may be due to the complexity of child protection work ( Jensen, 2020 ). The poor relationship between professionals and children may be influenced by bureaucratisation, lack of resources and lack of knowledge ( van Bijleveld et al ., 2015 ; Falch-Eriksen et al ., 2021 ; Skauge et al ., 2021 ).

Based on the three main themes of this article, several implications can be drawn. First, care and professional systems can break down the division between everyday life decisions and important decisions in children’s lives ( McPherson et al ., 2021 ). Structured and shared methods of assessment and decision making are therefore needed ( Bartelink et al ., 2015 ). Secondly, the role of social workers and their relationship with the child is crucial in fostering the right to participation ( Brummelaar et al., 2018 ). To improve the quality of relationships between workers and children, therefore, a paradigm shift and methods are needed to help professionals increase their competence and confidence to engage children effectively ( Toros et al ., 2018 ). Thirdly, ensuring the best interests of children means that their voices are not silenced and that access to information and helping them to express their views must be one of the tasks of both professionals and child protection systems ( Davies and Wright, 2008 ; Strømland et al ., 2022 ). Therefore, the process of participation involves understanding the importance of the child’s experience in the context of everyday life ( Skauge et al ., 2021 ).

Limitations

In terms of the methodology of the review search, we used the largest number of electronic bibliographic databases that it was feasible to use in the circumstances (i.e. all the databases available in the first author’s library at Queen’s University Belfast), but a funded review might retrieve additional papers. Quality appraisal was affected by restricting inclusion to publications in peer-reviewed journals, but we cannot exclude the possibility of the review having some publication bias. Grey literature was not searched for example, which may have uncovered theses in this area and there is a plethora of evaluations of participatory practice in child welfare agencies that are neither published nor easily accessed. Already recognised by van Bijleveld et al. (2015) , there are still problems with the search terms that challenged us given the variety of terms used across agencies, cultures and countries to describe participation, so greater homogeneity in language would be helpful going forward to reduce the chance of missing valuable research. To reduce this risk, we consulted with the specialist librarian at Queen’s University Belfast and conducted our own initial scoping exercise to identify core terms, which we subsequently used in this research.

To avoid homogenising C&YP as one group, it is important to disaggregate them across age, culture, class, gender, ethnic background, etc., to understand them, not as one amorphous mass but as individuals with different identities, needs and ways of being seen and heard. It is also important to move away from small-scale micro studies that ignore the macro-political, sociocultural, economic, philosophical and geographic influences that are brought to bear on the micro participatory landscape, for these influences (not always benign) undoubtedly impact the opportunities for authentic participation. Finally, we see the importance of large-scale efficacy studies to determine the effectiveness of participatory interventions to develop a more informed evidence base of what works, in what circumstances, why and for who. This of course will necessitate more funding being made available and in a competitive funding landscape this will require funders to realise the importance of this area of study—we remain hopeful.

We would like to thank Norma Menabney for the specialist librarian support provided.

This study has been funded by José Castillejo Programme for mobility abroad youth doctor and carried out by Prof. Dr Mercado at Queen’s University of Belfast (reference number CAS21/0254).

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A qualitative analysis of child protection professionals' challenges during the COVID-19 pandemic

Sidnei r. priolo filho.

a Laboratório de Pesquisa, Prevenção e Intervenção em Psicologia Forense, Universidade Tuiuti do Paraná, Curitiba, Brazil

b Florida International University, Miami, FL, United States of America

Ayesha Bhakta

Bárbara renata moura, bianca borges correia, jackeline da silva santos, thaisy luana sieben, deborah goldfarb, associated data.

Data will be made available on request.

Child Protection Professionals (CPPs) play a key role in providing insights into the child protection system and how it can best support children's right to personal security, particularly during trying times like the COVID-19 pandemic. Qualitative research provides one potential tool to tap into this knowledge and awareness. This research thus expanded earlier qualitative work on CPPs' perceptions of the impact of COVID-19 on their work, including potential struggles and barriers, into the context of a developing country.

A total of 309 CPPs from all five regions in Brazil answered demographics, pandemic-related resilient behaviors, and open-ended questions regarding their profession during the pandemic.

Data went through a three-step process of analysis: (1) pre-analysis; (2) category creation; and (3) coding of responses. Five categories emerged from the analysis: the Pandemic's Impact on CPPs' Work; the Impact of the Pandemic on CPP-Involved Families; Occupational Concerns during the Pandemic; Politics and the Pandemic; and Vulnerability due to the Pandemic.

Conclusions

Our qualitative analyses showed the pandemic resulted in increased challenges for CPPs across several fronts within their workplace. Although each of these categories is discussed separately, they all influenced one another. This highlights the need to continue efforts to support CPPs.

1. Introduction

The COVID-19 pandemic placed an incredible strain on both Child Protective Services (CPS) and Child Protection Professionals (CPPs). A study by Katz, Katz et al. (2021) found deleterious impacts of the pandemic on child protection systems in different countries worldwide, indicating a global phenomenon caused by COVID-19. When considering how CPPs face adversities and challenges under contexts such as the COVID-19 pandemic, qualitative research provides unique insights into CPPs' perspectives and opinions about the challenging task of protecting children. Hearing CPPs' voices and perspectives in prior research created opportunities for change within the child protection system, enabling it to better serve the children and families it seeks to support ( Katz, Katz, et al., 2021 ; Katz, Priolo Filho, et al., 2021 ; see Fig. 1 ). For example, Whitt-Woosley et al. (2022) investigated how foster care parents and professionals in the United States described the impact of COVID-19 on their lives and professional practice in 2020. The authors reported 15 different themes, showing both increased pressure and challenges faced by the system and its professionals during the pandemic. What is unclear from the current research, however, is whether such themes would replicate within the context of a developing nation, such as Brazil.

Model by Katz, Priolo Filho et al. (2021) adapted with participants' quotes.

CPPs have become an increasingly vital part of Brazilian society since the democratization of Brazil in 1990, which led to greater legal recognition of children's right to personal safety ( Lopes & Ferreira, 2010 ). Brazil currently has an integrated child protection system with professionals from different fields, such as child protection, healthcare, education, and law, responsible for assessing, responding to, and maintaining children's safety in their homes. CPPs have mandatory reporting regarding suspicious cases of child abuse ( Ministry of Health, 2002 ; Rates et al., 2015 ). As mandatory reporters, these CPPs must be trained on and able to provide the child and family with access to care across different professionals realms and areas (i.e., social work, healthcare), including the specialized Conselho Tutelar (Child Protective Services). Legislation created since democratization in the 1980s was an attempt to build a coordinated protection network in which health, education, social work, and the legal system prevent, intervene, and improve the condition of child maltreatment ( Prinz, 2016 ). Despite its centralized structure, child protection varies across Brazil. Funding, number of services, and number of professionals vary according to local city council decisions.

Brazil's child protection system has a federal governing body that oversees state and local CPS ( Gonçalves & Garcia, 2007 ). Suspicious cases of child abuse must be reported by professionals to their local CPS or police corps, with the possibility of providing an anonymous report ( Ministry of Health, 2002 ; Rates et al., 2015 ). CPS must investigate the case, sometimes with the support of the police, and ultimately report whether the report was founded or unfounded. During this period of investigation, CPS may provide referrals for the family, including medical support and social welfare support. CPS also works with schools to obtain information to guide their investigation and future interventions.

The novel coronavirus (COVID-19) pandemic placed a strain on this nascent but promising Brazilian system. Due to concerns about viral spread and to protect public health, new measures and actions in the child protection system were necessary. For example, home visits in a time of social distancing were not possible, even though assessments of the ‘home condition’ are considered vital in child neglect and maltreatment investigations ( Ferguson, 2009 ). In Brazil, the lack of proper funding for CPS before and during the pandemic, and the absence of a national policy during the pandemic for those professionals, compounded the CPPs' struggles to provide services. Priolo Filho et al. (2020) and Goldfarb et al. (2022) surveyed Brazilian CPPs about their working conditions during 2020 and 2021 COVID-19 pandemic. They found that CPPs reported an increase in work hours, a lack of information regarding the number of child abuse cases during the pandemic, and that resilience predicted lower mental distress during those enduring times. No work yet, however, has qualitatively analyzed CPPs' beliefs about the impact of the COVID-19 pandemic in their activities on a developing nation and compared those to results found in a developed nation, such as the United States ( Whitt-Woosley et al., 2022 ).

1.1. Present study

Here, we sought to address that gap. Specifically, we conducted a qualitative analysis of CPPs' perceptions of the protection of children and their working conditions during the COVID-19 pandemic. The ongoing pandemic provides a unique context within which to study CPPs' perceptions of the struggles and barriers they face during a time of acute crisis. Additionally, given that Brazil's government has undergone many political and structural changes in recent years, there is no historical precedence on how CPPs manage their work in a challenging time like the COVID-19 pandemic. Such data can help improve CPPs' working environment during the pandemic, as well as provide guidance to CPPs in the event of a future catastrophic event (e.g., natural disaster). This will enable professionals to better secure children's right to safety.

Surveys are a useful method for gathering qualitative data, especially when a larger sample is necessary, as was the case here, to investigate social norms and social experiences that were differentially experienced depending on participants' occupation, education, and geographic location ( Braun et al., 2021 ). Given that this data was gathered during times of social isolation and were on topics that had previously not been studied, an online survey permitted longer responses without requiring the increased bandwidth necessary for online video interviews ( Burton et al., 2012 ; Torrentira, 2020 ). Surveys also allowed us to reach a large number of participants, while still maintaining privacy in smaller communities with fewer CPS workers. Privacy was particularly important here as we were exploring a sensitive theme during the pandemic ( Braun et al., 2021 ; Burton et al., 2012 ; Sousa & Santos, 2020 ). Online qualitative data collection balanced the needs arising from pandemic data collection with the weaknesses of such an approach ( Braun et al., 2021 ; Burton et al., 2012 ; Sousa & Santos, 2020 ; Torrentira, 2020 ).

2.1. Participants

Three hundred and nine professionals, all of whom worked in child protection-related fields (e.g., psychologists, social workers, teachers, pediatricians, nurses, and legal professionals), participated in this study (89.05 % female). Participants were recruited from five different regions in Brazil (i.e., North, Northeast, Central, Southeast, and South). The average age of participants was 40.26 years ( SD age  = 10.27), with a mean of 14.17 ( SD age  = 10.19) years of experience. A majority of the participants worked as educators (38.5 %), followed by psychologists (27.5 %), healthcare professionals (17.5 %), legal professionals (9.4 %), social workers (5.2 %), and other professionals (2.5 %). Further details about the sample can be found in Priolo Filho et al. (2020) .

2.2. Measures

2.2.1. demographic measure.

Participants answered demographic questions about their age, gender, profession, the number of years that they had worked in the child protection-related field, and weekly workload during the COVID-19 pandemic.

2.2.2. State of CPP practice in the pandemic

The survey was created by the authors and contained a qualitative and a quantitative section. The quantitative area contained the CPPs' Perceptions of Work Conditions during the Pandemic and Professional Resilient Behaviors Measure. Quantitative analyses are available in Priolo Filho et al. (2020) After the quantitative questions, the participants answered the two open-ended questions that asked CPPs about their current practice during the COVID-19 pandemic. Specifically, participants were asked: “In your opinion, what are the biggest challenges for Brazilian child protection professionals during the pandemic?” and “Would you like to tell us more about protecting children, your work, or the pandemic, or anything else that we have not addressed?”. All questions and instructions to participants were in Brazilian Portuguese.

2.3. Procedure

Participants were invited to participate in the study through social media and professional networks. Participants were asked to send the study invitation to their colleagues or coworkers through a snowball sampling that is thought to be particularly beneficial for reaching participants with unique characteristics, such as CPPs ( Baltar & Brunet, 2012 ). The study invitation included a link to the consent form. Once consent was obtained, participants were redirected to the demographic questionnaire, a measure of pandemic-related resilient behaviors (see Priolo Filho et al., 2020 for further details), and the two open-ended questions regarding their professional experiences during the pandemic. At the end of the survey, participants received links to resources on resilience such as relaxation videos, crossword puzzles, and a research paper about resilience importance and engagement ( Priolo Filho & Rodrigues, 2018 ).

2.4. Data analysis

A qualitative content analysis was used here ( Bardin, 2011 ; Sousa & Santos, 2020 ). The methodology has been used in previous studies of professionals' perceptions of child maltreatment (see Dahlbo et al., 2017 ); The specific qualitative content analysis here has three phases (pre-analysis, category creation, and coding, and interpretation) and involves frequent team discussions regarding the coding process (i.e., consensus workshops). During the pre-analysis phase, the coders reviewed the participants' responses to gain familiarity with the content within and across responses. Second, in the category creation and coding phase, the five coders (authors on this paper) each independently reported the categories they thought emerged from the responses and then met to develop a consensus as to the categories the team saw in the data. In the end, the coders reported five categories (see Table 1 for the five categories). The coders then divided participants' responses into registry units (e.g., a sentence, a fragment of a sentence, a whole paragraph). Coders identified 232 units in the participants' responses to the first question (i.e., the biggest challenges for CPPs in the pandemic) and 89 units in response to the second question (i.e., tell us more about protecting children, your work, or the pandemic).

Five categories and definitions obtained after data analysis procedure.

Next, the five coders categorized each unit into the five identified categories, with every unit only being able to be classified into one category. The coders then met again to determine whether all 5 coders agreed on the categorization of the units. Raters revealed a high rate of agreement in categorization, with 98 % agreement across all five coders across all the codes.

The third and final phase of the analysis, the interpretation of the results, includes the interpretation of the coding. The same five judges as in the second phase analyzed all of the responses, codes, categories, and stages of categorization and discussed their interpretation of the results. The responses, the categories, and the interpretation are all discussed below.

The average length of each response was 21.24 words. Table 2 shows the percentage of the CPPs' responses that addressed each of the five categories. Responses are further divided into the five different CPP fields represented in our sample. This division permitted insight into which of the categories was most frequently addressed depending on the participants' professional field. For instance, overall, professionals most frequently discussed the Pandemic's Impact on CPPs' Work , except for social workers who focused on Vulnerability due to the Pandemic. Each of the categories is addressed below. The original responses were provided by the participants in Portuguese and translated into English. We attempted to maintain the participants' original words and phrasing. Due to this fact, minor grammatical issues may persist in the quotations below.

Participants' responses in each category by profession.

Note: the numbers outside the parentheses are raw frequencies.

3.1. Pandemic's impact on CPPs' work

The Pandemic category refers to responses concerning the impact of COVID-19 on CPPs' work and/or CPP-involved families. For example, CPPs mentioned that they had not been able to assess children's safety in the children's homes because of social distancing guidelines . One participant stated, “Being able to see if something is wrong with the families due to social distancing, as the children are not attending school, it becomes more difficult to perceive something” (ID13, Female, 33-year-old, Teacher, Paraná, Human Development Index (HDI) 0.655). Similarly, CPPs expressed their frustration with not being able to have face-to-face monitoring of children's safety: “The biggest challenge is the distance and the impossibility of visiting them” (ID249, Male, 22-year-old, Teacher, Santa Catarina, HDI 0.755); “Not having access to the children and monitoring their development, not knowing if they are in a toxic environment or not” (ID52, Female, 62-year-old, Pre-school teacher, Paraná, HDI 0.672). This same concern was expressed by two legal professionals: “In my work, we are avoiding home visits and face-to-face contacts, but it is very difficult to observe a family from whom there are reports of ill-treatment without any direct contact” (ID299, Female, 23-year-old, Lawyer, São Paulo, HDI 0.700); “Professional structure and equipment for monitoring, monitoring and assistance for these children, as well as for the families” (ID175, Female, 39-year-old, Lawyer, Paraná, HDI 0.699). The professionals stated that the lack of active monitoring due to the pandemic could have devastating consequences on children's safety.

Another concern expressed in the responses that fell under the Pandemic category was the loss of the school system as an avenue for reporting maltreatment and an agent of prevention of maltreatment . “There is, then, a reduction in access to public and institutional support systems, such as schools, daycare centers, churches, which makes it difficult to seek help and protection” (ID82, Male, 46-year-old, Prosecutor, Paraná, HDI 0.782). Another participant, a teacher, similarly expressed concerns that they were unable to physically assess children in the neutral school environment: “When you see the child at school, for example, it is sometimes possible to notice a bruise or behavioral change” (ID56, Female, 33-year-old, Pre-school Teacher, Paraná, HDI 0.823). CPPs were thus concerned about how the pandemic has negatively affected safety measures that are used to protect children.

Lastly, CPPs mentioned that they have been increasingly focusing on children's mental health during the pandemic . “The social isolation itself. Many children staying at home can get anxiety and thus demanding more from their parents” (ID159, Female, 23-year-old, Psychologist, Paraná, HDI 0.823); “I would include how to deal with the stress of these children inside the house without leaving for anything” (ID36, Male, 36-year-old, Juvenile Correction Officer, São Paulo, HDI 0.823). Medical professionals also noted increasing concerns about mental health: “I am a pediatrician and I realize that both parents and children are much more stressed/nervous/insecure about the pandemic, which makes children more irritable/insecure/disobedient/anxious” (ID53, Male, 53-year-old, Pediatrician, Paraná, HDI 0.782). CPPs reported teaching children the value of having a daily routine to prevent or decrease acute anxiety and stress during uncertain times, including setting a wake-up time, scheduling mealtimes, doing daily activities, then going to bed.

3.2. Impact of the pandemic on CPP-involved families

The Impact of the Pandemic on CPP-Involved Families category captured CPPs' difficulty in assessing families during the pandemic and the challenges families faced during this particular time. Some professionals noted that the pandemic was increasing stressors that were, in turn, hampering families' abilities to meet their children's needs . For instance, one professional mentioned struggling with helping families adjust to their new environment and was focusing on teaching parents how to interact with their children in isolation, “Playing with children, understanding their fun and how parents can interact” (ID276, Male, 26-year-old, Lawyer, Rio de Janeiro, HDI 0.716).

CPPs also expressed concerns about families' current living situations, particularly where children were now living full-time with their alleged aggressor . Indeed, CPPs often used phrases like “increased time with the ‘abuser’ at home” (ID197, Female, 30-year-old, Nurse, São Paulo, HDI 0.778). They were also concerned that children being restricted to their homes decreased children's ability to access resources (“Absence from school and the time the child spends at school/daycare helps to stimulate development and social relationships, in addition to providing access to meals. Often, the domestic environment does not provide adequate conditions for development and the school partially compensates for this” (ID245, Female, 32-year-old, Nurse, São Paulo, HDI 0.785), while also damaging family dynamics and increasing risk (“…increase in anxiety and stress experienced by adults is also dangerous for the children, which can decrease patience and increase physical and psychological violence” (ID48, Female, 40-year-old, Psychologist, Paraná, HDI 0.823)). Indeed, many CPPs reported that “parents and children are way more stressed during the pandemic than before” (ID116, Female, 56-year-old, Pediatrician, São Paulo, HDI 0.750), and that “parents are too stressed because of all the problems of the pandemic, and that stress carries to us, professionals” (ID194, Female, 44-year-old, Nurse, Santa Catarina, HDI 0.827).

3.3. Occupational concerns during the pandemic

The Occupational Concerns during the Pandemic category captured professionals' workplace challenges in general, as well as those attributable to the pandemic. Many CPPs reported the need for additional training to respond to the challenges arising from the pandemic . A significant number of CPPs expressed the need for more training on identifying and intervening in violent situations. For example, a professional stated, “Unfortunately, some professionals fail to notice the small warning signs that a child gives in their actions and even in their parents' complaints” (ID30, Male, 52-year-old, Nurse, Paraná, HDI 0.823). Another professional responded, “Knowing how to identify warning signs that a child experiences during contact with them” (ID298, Female, 55-year-old, Educational Psychologist, Minas Gerais, HDI 0.789). As a result of a lack of training, CPPs are concerned that cases of child maltreatment end up not being identified and reported.

Participants also described the lack of teamwork, collaboration, and support between child-protection-focused agencies . For example, a professional stated, “Work in an intersectional way, create and maintain solid dialogues between health policy, social work and especially education policies. Make these dialogues reach the top workers in the form of more effective actions, in the reduction of bureaucracies, etc.” (ID47, Female, 27-year-old, Child Protective Services Agent, São Paulo, HDI 0.840). Another professional mentioned, “The biggest challenge is not being able to count on some agencies of the safety net, as some of them do not even attend the meetings to discuss the referrals to be taken in situations of social vulnerability” (ID83, Female, 46-year-old, Prosecutor, Paraná, 0,763). One key aspect noted by the CPPs was the need to grow such support from leaders in their organization: “support from the managers, in the sense of seeking to understand the role of each tool/service and professional, so that they validate the necessary actions” (ID54, Female, 31-year-old, Lawyer, Santa Catarina, HDI 0.681).

Professionals also expressed concerns as to their workplaces adequately responding to and preparing them for the COVID-19 pandemic . One professional detailed the lack of Personal Protective Equipment (PPE) in her workplace– “there is protection, but it is not enough, because they often spend many hours with the same PPE” (ID272, Female, 47-year-old, Teacher, Paraná, HDI 0.742). Others were concerned about the lack of support for remote working. In addition, disparities in access to new technology among professionals interfered with CPPs' responsibilities. Professionals mentioned the “lack of skill in the use of online platforms” (ID207, Female, 57-year-old, CPS agent, Rio de Janeiro, HDI 0.716) and “lack of habit of a large part of the population in online communication, even though the technology is present in most homes, including smartphones” (ID217, Male, 48-year-old, Lawyer, São Paulo, HDI 0.781).

3.4. Politics and the pandemic

The responses in the Politics and the Pandemic category reflect criticisms of public policies . For instance, a professional reported, “There is no technical guidance in this regard [to the challenges during the pandemic]” (ID32, Female, 52-year-old, Teacher, Paraná, HDI 0.823). Another professional stated, “I would like there to be greater national mobilization and a look at this demand” (ID256, Female, 42-year-old, Lawyer, São Paulo, HDI 0.800). CPPs also pointed out that public policies for child protection need more attention. For instance, a professional responded, “May the safety services network actually work, even when we report the child protective services network act slowly or do not even take notice of cases when we contact them to discuss it” (ID215, Female, 34-year-old, Nurse, São Paulo, HDI 0.805). One CPP noted the explicit connection between public policies and potential harm for families and children: “The lack of public policies increases the vulnerabilities of families, and children” (ID220, Female, 56-year-old, Teacher, Paraná, HDI 0.823).

3.5. Vulnerability due to the pandemic

The Vulnerability Due to the Pandemic category included responses indicating potential risks of increased violence and vulnerability to children . One participant mentioned, “Many children do not have access to the internet and do not even know this reality, so they do not even know that they can ask for help” (ID48, Female, 48-year-old, Nurse, São Paulo, HDI 0.805). Another participant reported, “Many do not have access to technology and those who do, do not always have quality internet access” (ID258, Male, 37-year-old, Psychologist, Rio Grande do Sul, HDI 0.805). CPPs also were concerned that delays and failures in resolving cases resulted in sending victimized children back home making the children more vulnerable to violence: “The mismatch of information leads to delays in resolving situations presented in the CPS” (ID153, Female, 45-year-old, CPS Agent, São Paulo, HDI 0.798). For instance, one participant mentioned, “The biggest challenge is the mismatch of information. It takes a long time to resolve the situations presented in the Protection Network. Complicated when the victim returns to the aggressor's house” (ID29, Female, 42-year-old, Pediatrician, Paraná, HDI 0.700).

4. Discussion

Here, we qualitatively analyzed over 300 CPPs' reflections on the struggles and barriers faced by their profession during the COVID-19 pandemic. Our analyses revealed five key categories across the statements, many of them centered on concerns about protecting children's right to safety. Below, we review the key findings from these analyses, discuss how the research aligns with prior work, and note the interrelated nature of these five categories. Finally, we discuss the application of this research to professional and research settings.

Across all five categories (P andemic's Impact on CPPs' work; Impact of the Pandemic on CPP-Involved Families, Occupation Concerns During the Pandemic; Politics and the Pandemic; and Vulnerability Due to the Pandemic ), CPPs reported a concern that the pandemic was hampering their ability to adequately do their job, potentially decreasing their ability to protect children from an increasingly alarming situation. These findings align with prior quantitative analyses within the same sample ( Priolo Filho et al., 2020 ) and theoretical and empirical research with CPPs internationally ( Katz, Katz, et al., 2021 ; Renov et al., 2021 ; Teo & Griffiths, 2020 ; Whitt-Woosley et al., 2022 ). Indeed, despite cultural and organizational differences between CPS in Brazil and the United States, similar categories were identified here and in Whitt-Woosley et al.'s (2022) qualitative analysis of American CPPs. CPPs in both countries noted that it was more difficult to conduct assessments, the pandemic negatively impacted cases, and that it was a challenge to balance work and home life. Politics did not appear to be mentioned as frequently by the CPPs working in the United States, with Brazilian CPPs presenting complaints regarding the lack of guidelines from the government during the pandemic. This might be due to a centralized child protection system and a more centralized response to the COVID-19 pandemic, which may have led to more of a uniformity in experience in the connection between the two for CPPs in Brazil.

Our sample has a wide range of types of professionals who were interviewed as CPPs. However, this study shows that despite working in different fields, such as education, law, or medicine CPPs in Brazil still share similar concerns and challenges during the pandemic. We believe this is because all CPPs are part of the centralized child protection system in Brazil ( Ministry of Health, 2002 ), therefore, their responsibilities as CPPs shares areas of overlap even though they would be dealing with children in different circumstances. Thus, this study highlights the impact of a unified response while investigating different professional categories during the pandemic.

Brazil has one of the highest numbers of cases and deaths due to COVID-19 ( Johns Hopkins, 2022 ) and concerns have been raised regarding whether the government sufficiently responded to the pandemic ( The Lancet, 2020 ). Although finding commonalities in struggles across CPPs throughout the world can be disheartening, it is also a reminder of the value and strength of international research. Hearing the voices of CPPs from one country can also be informative and a source of insight for professionals in other countries.

Fig. 1 presents the model by Katz, Priolo Filho, et al. (2021) with quotes from our participants placed within the relevant category of the ecological model. Katz and colleagues' proposed ecological framework encourages researchers to consider the interrelated and interdependent nature of individual and interpersonal interactions (e.g., school closings, parent' behavior), neighborhood and communities (e.g., family-services communication), and societal and cultural context (e.g., policy) on CPPs' and the families that they serve. Although each of our five categories were discussed separately above, many of the CPPs' responses reflect the interrelated nature encouraged by this framework. For instance, one CPP noted that the lack of policies had a direct impact on failures to protect children. Others, however, noted that the decrease in community-level services had impacted parent's behavior, which in turn could have resulted in decreased safety for children. These results highlight that a single-component response to the pandemic's effects on CPPs cannot capture the full impact of such a crisis on both the professionals themselves but also on the families that they support.

Across both our qualitative and quantitative analyses ( Goldfarb et al., 2022 ; Priolo Filho et al., 2020 ), CPPs noted the central importance of the workplace in bolstering their resiliency to this pandemic. CPPs here provided further insight into how they thought that such change might be necessary on a policy level to help increase coordination of agencies and professionals who protect children. Such policy change within Brazil may be particularly powerful given the federal nature of child protection and the geographic size of the country.

Although the data here was gathered during the pandemic, which provided a unique lens through which to study CPPs' work environment, it is vital to note that resolving this international health crisis is not a panacea for these issues. CPPs deal with families during crises and must support and guide children through one of those most difficult times in their life; such work has consistently been found to be stressful and to potentially lead to burnout ( Bride et al., 2007 ; Drake & Yadama, 1996 ; Griffiths et al., 2018 ; Tavormina & Clossey, 2017 ). The pandemic may have exacerbated many of these issues, but these problems existed prior to the outbreak of COVID-19. Policies thus must bolster support for CPPs. One potential pathway for support may be a continued focus on providing CPPs with space to practice resilient behaviors and analyzing the unmet needs of CPPs both during and after the pandemic concludes ( Goldfarb et al., 2022 ; Liu et al., 2017 , Liu et al., 2020 ; Priolo Filho et al., 2020 ).

5. Conclusion

As evidenced by the responses gathered from CPPs, the COVID-19 pandemic highlighted and exacerbated the vulnerabilities of the child protection system in Brazil. The five categories compiled in this study aim to bring attention and awareness to the struggles faced by the CPPs during a time when vulnerable populations were placed even more at risk. The qualitative analysis here, however, has the additional benefit of allowing professionals to state their concerns in their own words and allows the identification of themes that may not be apparent in quantitative research. Providing CPPs with a voice to talk about their work may bolster CPPs' mental health and decrease burnout ( Griffiths & Royse, 2017 ; Tavormina & Clossey, 2017 ). As one professional stated, “Everything I have answered in this research is important to me. We have to take care of our minds before, during, and after the pandemic. Thank you for this” (ID139, Female, 39-year-old, Teacher, São Paulo, HDI 0.805). This work, hopefully, provides a powerful window into the incredible value of the work conducted by these professionals and allows us to hear the reforms that can further enable them to protect children's safety.

Declaration of competing interest

The Author(s) declare(s) that there is no conflict of interest or funding provided for this research.

Acknowledgments

We want to thank the participants for their continuous effort during COVID-19 to protect children and families.

Data availability

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• Published: 14 June 2016

Child protection: a universal concern and a permanent challenge in the field of child and adolescent mental health

• Joerg M. Fegert 1 &
• Manuela Stötzel 2  

Child and Adolescent Psychiatry and Mental Health volume  10 , Article number:  18 ( 2016 ) Cite this article

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For much of history, cruelty to children was viewed as a private rather than a societal concern. An early sign of change occurred in the 1870s, when the pivotal case of Mary Ellen Wilson, a severely abused child in New York City, attracted intensive coverage in influential newspapers such as the New York Times and led to the founding of the first child protection agency. Sociologist Michael King has described the media response to cases of extreme child abuse in terms of a moral agenda, saying, “In this category of agenda it is not individuals, but social systems which are being unjust to children” [ 1 ].

It would take many more years before child protection would come to be seen as the responsibility of society overall. In 1889, the British Parliament issued the first law to protect children from abuse; however, for a long time, child protection services remained the domain of private philanthropic societies rather than of the state. Awareness of the problem increased following the publication in 1962 of a revolutionary article by Kempe et al. titled “The battered child syndrome”[ 2 ], which described clinical evidence of child abuse and emphasized the importance of medical diagnostics in the field of child protection. The effect of this publication was to launch an organized movement within the medical profession to intervene in cases of child abuse and neglect.

More recently, fatal cases of abuse such as those of eight-year-old Victoria Climbié in the UK in 2000 and a two-year-old boy identified only as “Kevin” in Germany in 2006 motivated many countries to launch serious investigations into dysfunctions in the child welfare system, and inspired new legislation and changes in child protection practices. Revelations about the sexual abuse scandals of the Roman Catholic Church and various educational institutions further contributed to a change in the public’s perception of child sexual abuse, physical abuse, and neglect. Media coverage of the scandals and the ensuing political reactions helped drive advances in research, and the last 20 years has seen a vast increase in scientific publications in this area.

While individual tragedies have served to attract attention to child maltreatment, focusing on single cases can be a hindrance with respect to acknowledging the magnitude and ubiquity of the problem. What is needed are ongoing efforts, supported by adequate funding, to conduct fundamental research into the prevention and the consequences of traumatization in childhood. These efforts need to include the implementation of monitoring systems and epidemiology studies, so that data can be monitored and assessed in a comparable way across different countries. Prevention and intervention strategies need to be developed, and approaches that are found to be successful need to be implemented on a larger scale. Some efforts that have been made in recent years to address the problem at the international level and within Germany are described below.

Back in 2000, the United Nations set out its “Millennium Development Goals”, which over the following years helped to contribute to a worldwide reduction of child mortality, better maternal health, and other medical improvements. Building on this example, in 2015 the U.N. released a report titled “The Road to Dignity by 2030: Ending Poverty, Transforming All Lives and Protecting the Planet”, which laid out an agenda for formulating sustainable development goals through the promotion of peaceful and inclusive societies. One of the important goals in this agenda is “to end abuse, exploitation, trafficking and all forms of violence and torture against children” [ 3 ]. This report was followed by one put out by UNICEF titled “A Post-2015 World Fit for Children” [ 4 ]. The first agenda item in the UNICEF report reads as follows:

“ End violence against children: In a world where almost one billion children under 15 suffer regular physical punishment, and nearly a quarter of all girls between the ages of 15 and 19 report experiencing physical violence, violence against children affects every country and every community. While violence against children is often invisible, its impact on individual children and their societies is profound and far - reaching, undermining developmental gains made in other areas. Because violence against children is a universal problem, investing in protecting children from violence, exploitation and abuse must be a global priority. More must be done to raise awareness of violence and encourage people to speak out when they see or suspect violence against children and to strengthen social welfare systems and services that protect children from harm and provide support to those who are already victims of violence.”

The World Health Organization (WHO) has also taken steps to address violence against children, issuing regional reports on the prevention of child maltreatment. In the report issued for Europe in 2013 [ 5 ], it proposed that all European countries develop national policies based on multi-disciplinary efforts, and that they define priorities for research. It also urged improvements in data collection for purposes of monitoring and evaluation, since such knowledge is of utmost importance in strengthening the ability of health systems to implement strategies for prevention and treatment. In addition, the WHO has produced a Toolkit for mapping the responses by legal, healthcare, and social services to child maltreatment [ 6 ].

The European Union sponsored a project titled CAN–MDS ( C oordinated Response to Child A buse and N eglect via a M inimum D ata S et) aimed at coordinating the monitoring of routine data in child protection systems in Europe. However, comparison of national data sets in Europe remains difficult because many studies use different definitions. In 2014, the WHO released a publication titled “Investing in children: The European child maltreatment prevention action plan 2015–2020” [ 7 ]. This report estimated that the global prevalence rates for child maltreatment are 16.3 % for physical neglect and 18.4 % for emotional neglect, from which it concluded: “Applying these figures to the population of children in Europe suggests that 18 million children suffer from sexual abuse, 44 million from physical abuse and 55 million from mental abuse.” It further stated, “Child maltreatment is a cause of social and health inequality within and between countries. There is strong evidence for the development of mental and physical disorders. Therefore capacity building in child and adolescent psychiatry and in mental health services for children and adolescents is crucial.”

These high estimates of prevalence rates, which were derived mainly from self-report studies, came as a shock to many clinicians as well as to the public. Their accuracy is not certain, given that data from different sources may not be comparable. However, given the likely magnitude of the problem, all societies should make the strengthening of child protection systems a national priority. Considering the low investment that has been made in research and development up to now, the WHO identifies this problem as a “best buy”, meaning that a great deal of value and advancement can be gained for a relatively small investment compared to that needed to address other health issues.

The societal costs of the consequences of child maltreatment are very high. In Germany, a study sponsored by the Ministry of Family Affairs on the annual costs to society arising from all forms of traumatization in childhood (i.e., neglect, physical abuse, and sexual abuse) found that the estimation based on a moderate model was 11 billion euros [ 8 – 10 ]. Similar costs have been found elsewhere. A US study done in 2008 estimated the societal costs related to child abuse and neglect to be USD 103.8 billion per year, not including intangible costs [ 9 ]. In Australia, a 2007 study calculated these costs at approximately AUD 4.0 billion on the basis of a population survey, and at AUD 10.7 billion on the basis of prevalence information from literature [ 10 ]. In Canada, a study done in 2003 calculated the “minimum cost to society” to be around CAD 15.7 billion [ 11 ]. As these findings were published several years ago, it seems likely that costs have gone up since then.

In Germany, following the child sexual abuse scandal that came to light in 2010, the government appointed an Independent Commissioner to gather data on the problem and provide recommendations [ 12 – 14 ]. In December 2014, in collaboration with the editor of CAPMH and supported by the Dreiländer Institute, a center for research and teaching that serves the three German-speaking countries, the Independent Commissioner invited leading international experts in the field of child abuse and neglect to a meeting in Berlin to discuss ways to implement better monitoring systems [ 15 , 16 ].

The first article in this series, by Jud et al., is based on a report edited by the Independent Commissioner [ 17 , 18 ]. That report provides an overview of international research as well as recommendations for the future development of research and monitoring in the field of child protection in Germany. The article by Trocmé et al. analyzes trends in the rate of child maltreatment and of foster care placements in Canada, and describes how there has been an increase in both the number of investigations of child abuse and in the number of children removed from their homes. Glaesmer et al. report on prevalence rates Germany that were derived using the Childhood Trauma Questionnaire [ 19 ].

While there is increased knowledge today about the prevalence of abuse, sexual abuse, and neglect of children in different settings, more research is needed on prevention and intervention. Professionals in the fields of child and adolescent psychiatry as well as in other mental health areas can play an important role in establishing a continuous monitoring system within the healthcare system, in cooperation with other professions. The scaling-up of successfully evaluated approaches is one of the greatest challenges. In addition, basic research into genetic and epigenetic effects related to early neglect and traumatization is needed. For example, while the hormonal stress reaction is quite well studied, little is understood yet about the immunological consequences of trauma.

Since 2010, the German government has invested about 50 million euros to assist abused and neglected children, with about 20 million euros going to efforts supporting research and the dissemination of research findings, such as the establishment of e-learning programs aimed at professionals. In 2013, the Editor-in-Chief of CAPMH founded a competence center in the state of Baden-Württemberg for research into child abuse and neglect; and an interdisciplinary trauma research center has been established at the University of Ulm. However, at present there is no agenda at either the national or the EU level for improved coordination of research work and clinical approaches in child protection.

When a working group created by the Independent Commissioner sent out a questionnaire on funding activities and programs to research funding bodies in 2015, the EU was among those that did not respond. It may be that a political agenda such as the “Road to Dignity” report produced by the United Nations is needed in order to underscore the importance of child protection to professionals in healthcare fields. Knowledge about adverse childhood experiences has grown [ 20 ], and much is now understood about the lifelong consequences of abuse. Experts in child and adolescent psychiatry and other areas of child mental health are the frontline workers in the diagnosis and treatment of early traumatization.

In recognition of the significance of child abuse, both standard sets of diagnostic criteria have added information specific to this problem. The recently updated version of the Diagnostic and Statistical Manual of Mental Disorders, DSM-5, attempts to integrate more age-specific diagnostic criteria in the definition of PTSD, while the upcoming version of the International Classification of Diseases, ICD-11, due out in 2018, will outline the importance of complex and sequential traumatization to which children who are institutionalized or in foster care are sometimes subjected.

The editorial board of CAPMH invites researchers and clinicians from around the world to publish their findings on child protection in our open access journal. Child protection is an interdisciplinary issue, and open access publishing is the most appropriate way to ensure that data and information are made accessible to everybody.

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Acknowledgements

This thematic series and the international meeting of experts in child abuse were made possible by funding provided by the Independent Commissioner for Questions Related to Child Sexual Abuse of the German government and by the “Dreiländer Institut”.

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Fegert, J.M., Stötzel, M. Child protection: a universal concern and a permanent challenge in the field of child and adolescent mental health. Child Adolesc Psychiatry Ment Health 10 , 18 (2016). https://doi.org/10.1186/s13034-016-0106-7

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What Happens When Abusive Parents Keep Their Children

By Naomi Schaefer Riley

Ms. Riley is a senior fellow at the American Enterprise Institute and the author of “No Way to Treat a Child.”

In February 2023, Phoenix Castro was born in San Jose, Calif., suffering from neonatal opioid withdrawal after being exposed to fentanyl and methamphetamine in her mother’s womb.

Her mother was sent to jail and then ended up at a drug treatment facility. But her father, who had multiple drug arrests, was allowed to take the newborn to his San Jose apartment, even though a social worker had warned that the baby would be at “very high” risk if she was sent home. The county’s child protection agency had already removed the couple’s two older children because of neglect.

Three months later, Phoenix was dead from an overdose of fentanyl and methamphetamine.

The ensuing uproar, chronicled in detail by The Mercury News, focused on new efforts by the county to keep at-risk families together. In the past, children often would be removed from unsafe homes and placed in foster care, and newborns like Phoenix in all likelihood would not have been sent home.

Those policy changes led to a “ significant ” drop in removals of children from troubled homes in the San Jose area, according to the state’s social services agency. They reflected a larger shift in child welfare thinking nationwide that has upended the foster care system. Reducing the number of children placed in foster care has been hailed as an achievement. But leaving children in families with histories of abuse and neglect to avoid the trauma of removing them has had tragic results.

We need to ask whether avoiding foster care, seemingly at all costs — especially for children in families mired in violence, addiction or mental illness — is too often compromising their safety and welfare.

The use of foster care has been in decline even as more children are dying from abuse and neglect in their homes. In recent years, the number of children in foster care fell by nearly 16 percent while the fatality rate from abuse and neglect rose by almost 18 percent. Many factors were and are at work, among them caseworker inexperience, a lack of resources and the high bars for removing children from their homes that have been erected by child welfare agencies, policymakers and judges.

What is clear from a sampling of states that release fatality reports in a timely fashion is that we are seeing deaths of children in cases in which they had been allowed to remain in homes with records of violence, drug use and neglect.

In Minnesota, a children’s advocacy group’s study of 88 child fatalities in the state from 2014 to 2022 found that “many of these deaths were preventable” and were the result of a “child welfare philosophy which gave such high priority to the interests of parents and other adults in households, as well as to the goals of family preservation and reunification, that child safety and well-being were regularly compromised.”

The prioritization of family preservation has been advanced by states and the federal government and by the nation’s largest foundation focused on reducing the need for foster care, Casey Family Programs.

Three ideas seem to have guided the effort: the child welfare system is plagued by systemic racial bias, adults should not be punished for drug addiction, and a majority of children in the system are simply in need of financial support and social services.

This effort was bolstered in 2018 with the passage by Congress of the Family First Prevention Services Act , which enables states to use federal funds “to provide enhanced support to children and families and prevent foster care placements through the provision of mental health and substance abuse prevention and treatment services” and other programs.

The push certainly has been well-intentioned. There was a sense that child welfare authorities had overreacted to concerns about a crack baby epidemic in the 1980s. Mothers were arrested and babies and children taken away. The number of children in foster care more than doubled between 1985 and 2000. There was also deep concern — concern that persists — that Black children in particular were bearing the brunt of being removed from their homes and sent to foster care, which can cause its own upheaval for children.

In some states, the reductions in the number of children in foster care were drastic. But there are limits to how much those numbers can be reduced without putting children in grave danger.

In Santa Clara County, Calif., where Phoenix Castro died, an inquiry the previous year by the California Department of Social Services into the county’s child protection agency found “multiple” instances of “children placed into protective custody by law enforcement,” only to have the county agency “immediately” place “the children back in the care of the unsafe parent.” (In what appears to be an about-face by the county, The Mercury News reported that in the last two months of 2023, the number of children removed from their homes was triple the two-month average for the previous months of that year.)

In an email to Santa Clara County’s Department of Family and Children’s Services staff in 2021, explaining the new emphasis on keeping families together, the director at the time described the move as part of the county’s strong commitment “to racial justice and to healing the historical wounds underlying disproportionate representation of children of color in the child welfare system.”

As much as racial disparities in foster care are deeply troubling — Black children are twice as likely as white children to spend time in foster care — Black children also suffer fatalities from abuse and neglect at three times the rate of white children. Which means that policies intended to reduce disproportionality by reducing foster care may actually be resulting in more deaths of Black children.

Foster care is not a panacea. The trauma children suffer from suddenly being removed from their home and their siblings, to be placed in a strange home with a caregiver they don’t know, is well documented. But the alternative, allowing a child to remain in a dangerous home, should never be an alternative.

Naomi Schaefer Riley is a senior fellow at the American Enterprise Institute and the author of “No Way to Treat a Child.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Mifrah Hayath

SM Candidate Harvard Medical School, MS Biotechnology Johns Hopkins University

Olivia Bowers

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

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