Systematic Reviews of Ethical Literature
(Supplementary Figures are available in Additional File 1).
General characteristics
Table 3 presents an extensive overview of the characteristics of each selected SREL. Selected SREL were published between 2010 and 2015, with a peak in 2014 (n=10). SREL first authors came from Europe (n=19), the US (n=5), Australia (n=3), Iran (n=2), Turkey (n=1) and Mexico (n=1).
Table 3: General characteristics of the selected 31 Systematic Reviews of Ethical Literature.
Year
|
Author(s)
|
Country
|
Title
|
Publishing journal (JAF)
|
Review topic
|
Object of review
|
Inclusion of recommendations
|
2015
|
Kalkman et al (24)
|
NL
|
Pragmatic randomized trials in drug development pose new ethical questions: a systematic review
|
Drug Discovery Today (Pharmacology & Pharmacy)
|
Research Ethics: Clinical trial
|
Ethical issues
|
No
|
McCarthy et al (25)
|
IE
|
Moral distress: a review of the argument-based nursing ethics literature
|
Nursing Ethics (Nursing)
|
Clinical Ethics: Nursing
|
Ethical arguments
|
No
|
Niemansburg et al (26)
|
NL
|
Reconsidering the ethics of sham interventions in an era of emerging technologies
|
Surgery (Surgery)
|
Research Ethics: Clinical trial
|
Ethical arguments
|
Recommendations for research
|
Preshaw et al (27)
|
UK
|
Ethical issues experienced by healthcare workers in nursing homes: literature review
|
Nursing Ethics (Nursing)
|
Clinical Ethics: Geriatrics
|
Ethical issues and principles
|
No
|
2014
|
Calvert et al (28)
|
UK
|
Patient-reported outcome (PRO) assessment in clinical trials: a systematic review of guidance for trial protocol writers
|
PloS One (Multidisciplinary sciences)
|
Research Ethics: Clinical trial
|
Ethical recommendations
|
Recommendations for research
|
Huang et al (29)
|
AU
|
Ethical and methodological issues in qualitative health research involving children: A systematic review
|
Nursing Ethics (Nursing)
|
Research Ethics: Paediatric research
|
Ethical issues and arguments
|
Recommendations for practice
|
Jamshidi et al (30)
|
IR
|
Ethical Considerations of Community-based Participatory Research: Contextual Underpinnings for Developing Countries
|
International Journal of Preventive Medicine (Medicine, General and internal)
|
Research Ethics: Community-based participatory research
|
Ethical issues and guidelines
|
No
|
McDougall and Notini (31)
|
AU
|
Overriding parents’ medical decisions for their children: a systematic review of normative literature
|
Journal of Medical Ethics (Medical Ethics)
|
Clinical Ethics: Pediatric care
|
Ethical recommendations
|
No
|
Pratt et al (32)
|
US
|
Perspectives from South and East Asia on clinical and research ethics: a literature review
|
Journal of Empirical Research on Human Research Ethics (Medical Ethics)
|
Clinical and Research Ethics
|
Ethical values
|
No
|
Valdez-Martinez et al (33)
|
MX
|
When to stop? Decision-making when children's cancer treatment is no longer curative: a mixed-method systematic review
|
BMC Pediatrics (Pediatrics)
|
Clinical Ethics: Pediatric care
|
Ethical recommendations and issues
|
Recommendations for research
|
Van der Dam et al (34)
|
NL
|
Ethics support in institutional elderly care: a review of the literature
|
Journal of Medical Ethics (Medical Ethics)
|
Clinical Ethics: Geriatrics
|
Ethical recommendations
|
No
|
Schildmann and Schildmann (35)
|
DE
|
Palliative sedation therapy: a systematic literature review and critical appraisal of available guidance on indication and decision making
|
Journal of Palliative Medicine (Health care sciences and services)
|
Clinical Ethics: End of Life
|
Ethical recommendations
|
No
|
Whicher et al (36)
|
US
|
Ethical Issues in Patient Safety Research: A Systematic Review of the Literature
|
Journal of Patient Safety (Healthcare science and service)
|
Research Ethics: Safety
|
Ethical issues and arguments
|
No
|
2013
|
Ayuso et al (37)
|
SP
|
Informed consent for whole-genome sequencing studies in the clinical setting. Proposed recommendations on essential content and process
|
European Journal of Human Genetics (Genetics and Heredity)
|
Research Ethics: Informed consent
|
Ethical issues and recommendations
|
Recommendations for practice
|
Christenhusz et al (38)
|
BE
|
To tell or not to tell? A systematic review of ethical reflections on incidental findings arising in genetics contexts
|
European Journal of Human Genetics (Genetics and Heredity)
|
Research Ethics: Genetics
|
Ethical reasons
|
Recommendations for practice
|
Mikesell et al (39)
|
US
|
Ethical community-engaged research: a literature review
|
American Journal of Public Health (Public, Environmental and Occupational Health)
|
Research Ethics: Community-based participatory research
|
Ethical principles and issues
|
No
|
Strech et al (40)
|
DE
|
The full spectrum of ethical issues in dementia care: systematic qualitative review
|
British Journal of Psychiatry (Psychiatry)
|
Clinical ethics: other
|
Ethical issues
|
Recommendations for methods
|
Thys et al (41)
|
BE
|
Could minors be living kidney donors? A systematic review of guidelines, position papers and reports
|
Transplant International (Transplantation surgery)
|
Clinical Ethics: Transplantation
|
Ethical recommendations
|
No
|
2012
|
Choo et al (42)
|
UK
|
Ethical issues and challenges in pressure ulcer research - the research nurses' perspective
|
Journal of Tissue Viability (Dermatology)
|
Research Ethics: Nursing
|
Ethical principles and issues
|
No
|
Dinç et al (10)
|
TR
|
Trust and trustworthiness in nursing: an argument-based literature review
|
Nursing Inquiry (Nursing)
|
Clinical Ethics: Nursing
|
Ethical arguments
|
No
|
Kanekar and Bitto (43)
|
US
|
Public health ethics related training for public health workforce: an emerging need in the United States
|
Iranian Journal fo Public Health (Public, Environmental and Occupational Health)
|
Public Health Ethics
|
Ethical considerations
|
Recommendations for training
|
Mahieu and Gastmans (44)
|
BE
|
Sexuality in institutionalized elderly persons: A systematic review of argument-based ethics literature
|
International Psychogeriatrics (Psychology, psychiatry, geriatrics)
|
Clinical Ethics: Geriatrics
|
Ethical arguments
|
No
|
Mobasher et al (45)
|
IR
|
Key ethical issues in pediatric research: islamic perspective, Iranian experience
|
Iranian Journal of Pediatrics (Pedriatrics)
|
Research Ethics: Paediatric research
|
Ethical recommendations and arguments
|
Recommendations for practice
|
2011
|
Droste et al (46)
|
DE
|
Ethical issues in autologous stem cell transplantation (ASCT) in advanced breast cancer: a systematic literature review
|
BMC Medical Ethics (Medical Ethics)
|
Clinical ethics: other
|
Ethical issues
|
No
|
Dulhunty et al (47)
|
AU
|
Determining authorship in multicenter trials: a systematic review
|
Acta Anaesthesiological Scandinavica (Anesthesiology)
|
Research Ethics: Clinical trial
|
Ethical considerations in authorship
|
Recommendations for authorship
|
Sofaer and Strech (48)
|
UK
|
Reasons why post-trial access to trial drugs should, or need not be ensured to research participants: a systematic review
|
Public Health Ethics (Public, Environmental and Occupational Health)
|
Research Ethics: Clinical trial
|
Ethical arguments
|
Recommendations for practice
|
Strech and Schildmann (49)
|
DE
|
Quality of ethical guidelines and ethical content in clinical guidelines: the example of end-of-life decision-making
|
Journal of Medical Ethics (Medical Ethics)
|
Clinical Ethics: End of Life
|
Ethical recommendations
|
Recommendations for practice
|
Zwijsen et al (50)
|
NL
|
Ethics of using assistive technology in the care for community-dwelling elderly people: an overview of the literature
|
Aging & Mental Health (Psychology, psychiatry, geriatrics)
|
Clinical Ethics: Geriatrics
|
Ethical issues
|
No
|
2010
|
Kangasniemi (51)
|
FN
|
Equality as a central concept of nursing ethics: a systematic literature review
|
Scandinavian Journal of Caring Sciences (Nursing)
|
Clinical Ethics: Nursing
|
Ethical concepts
|
No
|
Koelch et al (52)
|
DE
|
Safeguarding children's rights in psychopharmacological research: ethical and legal issues
|
Current Pharmaceutical Design (Pharmacology and pharmacy)
|
Research Ethics: Paediatric research
|
Ethical issues
|
No
|
Wernow and Gastmans (53)
|
US
|
A Review and Taxonomy of Argument-Based Ethics Literature regarding Conscientious Objections to End-of-Life Procedures
|
Christian Bioethics (Religion, philosophy)
|
Clinical Ethics: End of Life
|
Ethical arguments
|
Recommendations for practice
|
JAF (Journal Academic Field), review topics, objects of review and recommendation statuses are the result of our own analysis and subsequent classification. Countries abbreviations : AU: Australia / BE: Belgium / DE: Germany / FI: Finland / IE: Ireland / IR: Iran / MX: Mexico / NL: Netherlands / SP: Spain / TR: Turkey / UK: United Kingdom / US: United States of America.
Review topics
As shown in Table 3, our sample of SREL shows a relative balance between reviews dealing with research ethics (n=14) and clinical ethics (n=15). One SREL dealt with both clinical and research ethics and another one with Public Health Ethics. Among the reviews within research ethics, clinical trials (n=5) and pediatric research (n=3) are the most common topics. Among the reviews addressing issues belonging to clinical ethics, geriatrics (n=4), nursing (n=3), and end of life (n=3) are the most frequent subjects.
Review objects
As displayed in Table 3, most selected SREL (n=14) review ethical issues, topics, or dilemmas specific to a given situation, e.g. ethical issues in dementia care or in the use of assistive technologies for elderly patients. A third of the SREL (n=10) review literature providing arguments for deciding on an ethically sensitive topic, e.g. disclosure of incidental findings arising in genetic studies. Ethical guidelines or recommendations are the objects of review of another third of the selected SREL (n=10), e.g. living organ donation among minors. Some SREL (n=5) focus on literature discussing ethical principles, values or norms, e.g. concept of equality or moral distress in nursing. A few SREL review other objects that include: existing ethics support mechanisms; ethical tools such as institutional bodies, frameworks, educational programs, policies; ethics-related instruction in schools and programs of public health. Since selected SREL could have more than 1 object of review, the total does not correspond to the number of SREL (n=31).
Journal academic fields (JAF)
Table 3 also reveals that most selected SREL were published in journals belonging to the fields of Medical Ethics (n=5) and Nursing (n=5). 20 SREL were published in different journals across various medical fields: Public Health (n=3); Psychology, Psychiatry & Geriatrics (n=3); Health Care Sciences & Services (n=2); Biochemistry and Genetics (n=2); Pharmacology & Pharmacy (n=2) and Pediatrics (n=2); Multidisciplinary Sciences (n=1); Surgery (n=1); Transplantation (n=1); Dermatology (n=1); Anaesthesiology (n=1); General and Internal Medicine (n=1). One SREL was published in a journal belonging to the philosophical/ religious field.
Recommendation status
13 of the 31 selected SREL issued ethical recommendations: 7 recommended changes in practice and 6 recommended other changes, for instance changes in methodology or in research focus (see Table 3).
Citations
General characteristics
The number of citing publications retrieved on Google Scholar in the given timeframe was 1685 (range from 3 to 224; mean: 52,6; median: 40,5). At the end of our 2-step selection process, a total of 593 documents were excluded, leaving 1092 documents ready for analysis. A detailed overview on the number of excluded documents and the stage of exclusion is provided in Figure 1.
[INSERT FIGURE 1]
Since some publications cite more than once the SREL under consideration, we eventually reached a total of 1812 citations to analyse (range from 1 to 303 citations per SREL; mean: 58,4; median: 27). Only 3% of all citations (n=62) are direct quotations from the original SREL. 90% af all citations are of a thematic nature (n=1623), the remaining 10% are methodological (n=189).
As shown in Figure 2, citations taken as a whole sample are mostly used to support a particular statement, without further discussion or transformation (“support”, 47%, n=846). The second most common function of citation, indistinctive of their nature, is the mention of the SREL without further specification (“mention”, 35%, n=628). Within thematic citations, nearly 50% (n=795) are supporting a statement while 25% of methodological citations (n=51) are used for the same purpose. Proportionally methodological citations are more often used as mere mentions (38%, n=72) and sometimes indicate a positive (10%, n=19) or negative appropriation of methods (4%, n=7).
[INSERT FIGURE 2]
As shown in Figure 3, most citations are retrieved from the selected SREL that were published in journals belonging to the academic fields of Psychology, Psychiatry, Geriatrics and Gerontology as well as Nursing.
[INSERT FIGURE 3]
Citations according to the nature of the citing publications
Nearly all retrieved citations (96%, n=1753) are located in scientific publications: empirical investigations (39%, n=704), theoretical articles (25%, n=461), systematic reviews (14%, n=252), reviews (e.g. narrative or scoping) (9%, n=161), methodological investigations (7%, n=124), letters (1%, n=23), editorials (1%, n=17) and scientific reports (1%, n=11). The remaining citations (4%, n=59) are found in conference proceedings (1.6%, n=30), newspaper articles (<1%, n=11), patient information (<1%, n=6), guidelines or recommendations (<1%, n=3), teaching material (<1%, n=3), blogs (<1%, n=2) and others (<1%, n=4).
As shown in Figure 4, within scientific publications, most thematic citations are found in empirical (43%, n=680) and theoretical publications (28%, n=441). Most methodological citations are found in methodological publications (35%, n=65) and in systematic reviews (34%, n=63).
[INSERT FIGURE 4]
In our sample, thematic citations are mostly used to support statements across the different publication types (22%, n=346 in empirical publications; 13%, n=213 in theoretical publications). Thematic citations are also often used as mere mentions (16%, n=262 in empirical publications; 8%, n=131 in theoretical publications). Thematic citations indicating some form of analysis or transformation of content are predominantly found in theoretical (4%, n=66) and empirical scientific publications (3,5%, n=55). For more details on thematic citations, see Figure S1 in Additional File 1.
Methodological citations often appear to be mentions across the different publication types (e.g. 16%, n=30 in methodological publications; 12,5%, n=23 in systematic reviews). They are also used as support (e.g. 8,6%, n=16 in methodological publications; 8,1%, n=15 in systematic reviews). In systematic reviews, and to a minor extent in reviews, methodological citations also indicate an appropriation or an adaptation of the method (7,6%, n=14) as well as the use of the SREL as a research object (2,7%, n=5 in systematic reviews; 2,1%, n=4 in methodological publications). For more details on methodological citations, see Figure S2 in Additional File 1.
The observed high proportions of methodological citations in methodological and systematic reviews publications as well as the high proportions of thematic citations indicating an analysis or transformation of content in conceptual publications were confirmed as statistically significant in this sample through Pearson’s chi-square tests (for thematic citations: c2=601,8; df=112; Asymp. Sig.=0,000; for methodological citations: c2=507,3; df=126; Asymp. Sig.=0,000; a=0,05).
Citations according to their localisation within the IMRaD structure
About half of the identified citations (n=833) were retrieved in publications using the IMRaD structure. As illustrated in Figure 5, most of these citations were found in the Introduction / Background (42%) and the Discussion / Conclusion (35%) of these publications. Accordingly, 45% of all thematic citations are found in the Introduction and 37% in the Discussion. Methodological citations are mostly present in the Methods section (42%).
[INSERT FIGURE 5]
When looking at the specific nature of the citations, we see that, across the different IMRaD sections, most thematic and methodological citations are used to support a statement, indicating that their content is not discussed or further analysed. Furthermore, some methodological citations found in the methods section (n=11, 10%) indicate either an appropriation or an adaptation of the method described in the SREL.
Among thematic citations, mentions (n=144, 20%) or support (n=156, 22%) were mainly found in the Introduction/Background section, followed by the Discussion/Conclusions section (mentions: n=84, 11%; support: n=135, 19%); considerably fewer occurred in the Methods (mention: n=11, 1,5%; support: n=23, 3%) and Results (mention: n=14, 2%; support: n=33, 4,5%) sections. Thematic citations indicating analysis or transformation were mainly found in the Discussion/Conclusion sections (n=34, 5%). For more details on thematic citations according to publication section, see Figure S3 in Additional File 1.
Among methodological citations, mentions (n=14, 12,5%), support (n=13, 12%) and citations indicating a positive appropriation (n=11, 10%) were mainly found in the Methods section. The latter were also found, to some extent, in the discussion section (n=5, 4,5%). An overview of these findings can be found in the Figure S4 in Additional File 1.
Most of these observations are statistically significant following Pearson chi-square tests i.e., methodological citations indicating mention, support and object of research are more present in Methods; thematic citations indicating that SREL were taken as objects of research are found in Methods; and thematic citations indicating analysis/transformation are dominant in Discussion / Conclusion (for thematic citations: c2=431,5; df=56; Asymp. Sig.=0,000; for methodological citations: c2=408,6; df=63; Asymp. Sig.=0,000; a=0,05).
Citations according to review object of the Systematic Review of Ethical Literature
As illustrated in Figure 6, most citations come from SREL that had reviewed ethical issues, topics or dilemmas (39%, n=702) followed by SREL on ethical arguments or reasons (32%, 578). The remaining citations are evenly distributed between SREL that reviewed ethical principles, values or concepts (14%, n=249) and ethical guidelines and recommendations (14%, n=252). Thematic citations follow this general distribution while methodological citations frequently come from SREL that reviewed ethical issues, topics and dilemmas (46%, n=87) as well as ethical arguments or reasons (41%, n=77).
[INSERT FIGURE 6]
As shown in Figure 7, thematic citations indicating analysis or transformation mostly come from SREL reviewing ethical arguments (n=69, 4%) and ethical issues, topics and dilemmas (n=63, 3,8%). Otherwise, support citations dominate among all types of SREL, but also mention citations, while the remaining citation types do not differ significantly.
[INSERT FIGURE 7]
As shown in Figure 8, methodological citations tend to be mere mentions or to be used as support, especially when they are citations from SREL on ethical issues and ethical arguments (n=28, 15%). Methodological citations indicating a form of appropriation are more common when they cite SREL that focused on ethical issues, topics and dilemmas (n=13, 7%). Methodological citations indicating an analysis or a transformation were citing SREL that reviewed ethical arguments or reasons (n=12, 6%).
[INSERT FIGURE 8]
Citations according to the recommendation status of the Systematic Review of the Ethical Literature
Most citations (64%, n=1164) were retrieved from SREL that did not issue recommendations. Among the citations of SREL that issued recommendations (36%, n=648), the majority came from reviews that issued ethical recommendations (24%, n=434) and the rest from reviews that issued recommendations of another nature (12%, n=214). As methodological citations are evenly distributed across the different categories, they are also proportionally more commonly made from SREL that issued ethical recommendations (34%, n=65) than thematical citations (23%, n=369). An overview of these findings can be found in the Figure S5 in Additional File 1.
Among the citations of those SREL that issued recommendations (36%, n=648), 6 citing publications issued themselves some recommendations. A limited qualitative analysis revealed that, in most cases (n=4), the recommendations entailed in the citation were covered by the SREL referenced in the text. In 2 occurrences we could see that the recommendation entailed in the citation was only partially covered by the SREL.