Ethical Guiding Principles of “Do No Harm” and the “Intention to Save Lives” in relation to Human Embryonic Stem Cell Research: Finding Common Ground between Religious Views and Principles of Medical Ethics

Abstract

One of the goals of medicine is to improve well-being, in line with the principle of beneficence (do no harm). Likewise, scientists claim that the goal of human embryonic stem cell (hESC) research is to find treatments for diseases. In hESC research, stem cells are harvested from a 5-day-old embryo. Surplus embryos from infertility treatments or embryos created for the sole purpose of harvesting stem cells are used in the research, and in the process the embryos get destroyed. The use of human embryos for research purpose raises ethical concern. In this context, the religious leaders play the role to be the moral compass and “reality check” to engage with the public. In Malaysia, the Ministry of Health has outlined the Guidelines for Stem Cell Research and Therapy, reflecting on Islamic principles. Since there has not been much focus on the viewpoints of other faiths in Malaysia, this study attempts to (i) explore the ethical guiding principles deliberated by religious leaders from the Buddhist, Hindu and Catholic traditions and (ii) identify if there is a common ground between the mainstream religious views and principles of medical ethics, in relation to hESC research. Eleven religious leaders representing the Buddhist, Hindu and Catholic traditions were interviewed. Interestingly, though reasoning of religious leaders came from different angles, their underlying concerns revolve around the values of “do no harm” and “intention to save lives”. These values are also the key principles in medical ethics. The findings are applied to answer the question as to whether religious and medical guiding principles can co-exist and complement in ethical decision-making, without compromising the values.

Introduction

Background of Stem Cell Research

One of the goals of medicine is to improve well-being, in line with the principle of beneficence (do no harm). Likewise, scientists claim that the goal of human embryonic stem cell (hESC) research is to find treatments and reduce the burden of diseases. There are many ethical dilemmas in medical research, and hESC research is an example. Before we go into the value of stem cell research (SCR), we need to know what are stem cells. Stem cells have the ability to continuously divide and differentiate into various kinds of cells and tissues. Stem cells are different from other cell types because of their characteristics. They are unspecialized cells capable of renewing themselves through cell division, and they can be induced to give rise to specialized tissue or organs with special functions (National Institutes of Health 2016). Thus, scientists conduct research to investigate how stem cells can be used in the treatment of diseases.

Sources of stem cells include adult stem cells (somatic stem cells) and embryonic stem cells. Adult stem cells are undifferentiated cells derived from the body. For example, haematopoietic stem cells, found in the bone marrow, are used in various clinical treatments (Wilson and Trumpp 2006). Stem cell therapy using adult stem cells, in general, is said to provide therapeutic treatment for a range of health conditions. Meanwhile, embryonic stem cells are harvested from the inner cell mass of pre-implantation embryo and cultured under laboratory conditions (Thomson 2001). The ability of human embryonic stem cells to multiply rapidly under laboratory conditions make them a good source of stem cells for research (Dravid et al. 2005). Scientists conduct hESC research with the aim of seeking to address various health conditions, including spinal cord injury (Shroff and Gupta 2015), restoring visual function (Lamba et al. 2009), treating diabetes (Rezania et al. 2012) and understanding motoneurons (Li et al. 2005). However, the hESC research is an evolving area in regenerative medicine (branch of medicine that deals with regenerating or restoring the structure and function of human cells, tissues and organs). Most clinical trials are still ongoing. New studies are emerging to establish the safety of hESC therapy in patients (Shroff and Barthakur 2015; Izrael et al. 2018). However, we need to understand that most hESC research have not advanced beyond clinical trials, and the efficacy of hESC is still uncertain. Hence, the safety and effectiveness of stem cell therapy need to be understood to ensure only therapies based on scientific evidence are available (Marks et al. 2017; Langrzyk et al. 2018)

Controversy of hESC Research

As the term suggests, unlike adult stem cells derived from the body, the human embryonic stem cells are derived from the embryos. That gives rise to ethical dilemma. The sources of human embryonic stem cells include embryos created via in vitro fertilization (IVF) for infertility treatments which are no longer needed, and they are referred to as surplus embryos (Dickens and Cook 2007). On the other hand, embryos created via IVF solely for research purpose are referred to as research embryos (Lanzendorf et al. 2001). The process of extracting stem cells from a blastocyst (which is a 4- to 5-day-old embryo from the time of fertilization) eventually leads to the destruction of the blastocyst (de Wert and Mummery 2003). As such, hESC research is controversial because embryos are created and/or used for the purpose of harvesting stem cells, only for the embryos to be destroyed in the process. The question is whether to pursue research on those human embryonic stem cells (harvested from 5-day-old embryos), knowing that the process leads to the destruction of the embryos. To date, the benefits of hESC are still uncertain. There is a lot of hype and hope that hESC will be able to alleviate a number of health conditions. With advances in medicine and technology, people are living longer and less accepting that medicine has its limits. This is where religious voices (religious leaders) have an important role—to be that moral compass when medical research is questionable/unethical and to be that “reality check” by engaging with public to think through (philosophical) questions such as: When does life begin? Does a 5-day old embryo constitute life? Is a 5-day-old embryo, a sentient being, worthy of protection? Is it ethical to conduct research using human embryos? These are some of the intrinsic questions that we will ponder along in this paper.

Stem Cell Research in Malaysia

The Ministry of Health (MOH) of Malaysia has acknowledged the role of local scientists and clinicians in advancing stem cell research (SCR). In 2009, the Ministry devised the Malaysian Guidelines for Stem Cell Research and Therapy to guide researchers on what is expected of them (Ministry of Health 2009). In the “Acknowledgements” section, the committee extended its gratitude to the Department of Islamic Advancement Malaysia (JAKIM), Islamic Medical Society of Malaysia, and Malaysia Consultative Council of Buddhism, Christianity, Hinduism, Sikhism and Taoism (MCCBCHST), and non-governmental organizations for their constructive comments in drafting the guidelines. However, the guidelines do not specifically offer any insight to the views and input gathered from the religious representatives and has only made reference to the national fatwa ruling (Ministry of Health 2009, 70). Issues like the use of surplus embryos from IVF were referred to the decision of the Malaysian Fatwa Council (Department of Islamic Development Malaysia 2005) Fatwa is a ruling or an interpretation on a point of Islamic law. Fatwas are formulated by religious scholars and authorities in Islamic jurisprudence after a process of ethical reasoning. Accordingly, frozen surplus embryos from the IVF trials may be allowed to be used for SCR with the couples’ consent. However, the creation of human embryos solely for research by any means including assisted reproductive technology (ART) or through somatic cell nuclear transfer (SCNT) is prohibited. The possible underlying reason for prohibiting creation of embryos solely for research is because embryos are used as a means to an end. The “instrumental use of embryos” compromises the respect for human life (Devolder 2005).

The guidelines were also adopted by the Malaysian Medical Council (MMC) when preparing the Guidelines on Stem Cell Research & Stem Cell Therapy 002/2009, which is to be adhered by the medical practitioners, physicians and healthcare providers (Malaysian Medical Council 2009). Similar to the ministerial guidelines and fatwa ruling, the medical council stated that research on human adult stem cell, the use of embryonic stem cell (ESC) lines for research purpose, and research on ESCs derived from surplus embryos is allowed; but the creation of human embryos via ART or SCNT for the sole purpose of research is prohibited. This guideline highlights the importance and influence of religious voices when a regulatory body formulates its guidelines. It also raises the question as to whether there is a common ground in terms of ethical values between mainstream religious views and principles of medical ethics.

In a multi-religious and multi-cultural country like Malaysia, ethical discussions pertaining to the morality of hESC research has taken a different outlook given the diverse views within and among the religious traditions. The Malaysian population is made up of 61.3% Muslims, 19.8% Buddhists, 9.2% Christians and 6.3% Hindus (Department of Statistics Malaysia 2010). Islam is the official religion as enshrined in Article 3 of the Federal Constitution of Malaysia, but other religions are allowed to be practised in harmony. Input from religious leaders of other major faiths (Buddhism, Hinduism, Catholicism) on hESC research in Malaysia is yet to be documented in as a national guideline. Given that Malaysia is pluralistic, engaging with leaders of different faiths on a controversial subject such as hESC research is necessary. This is because religious leaders who engage in conversation (inter-faith dialogue) are modelling to their devotees what it means to work together and to respect each other, which is important in a multi-cultural society like Malaysia.

Significance of the Study

Harvesting stem cells from human embryos for research purposes is controversial. Which is why this subject has drawn positions from religious scholars. For example, Muslim scholars have elicited their ethical positions, reflections and evaluations from the Islamic perspective (Bouzenita 2017; Fadel 2012; Ilkilic and Ertin 2010). At the global level, there are limited published resources documenting the viewpoints in Buddhism and Hinduism on the matter (Keown 2004; Promta 2004; Dalai Lama 2003; Tyagananda 2002). Meanwhile, the Vatican, the official teaching authority for Catholics, released resources like “Declaration on the Production and the Scientific and Therapeutic Use of Human Embryonic Stem Cells” (Pontifical Academy for Life 2000) and the “Congregation for the Doctrine of the Faith: Instruction Dignitas Personae on Certain Bioethical Questions” by the former pope Benedict XVI (2008), objecting hESC research.

In this context, does culture (values, social norms, traditional beliefs and practices) determine what is acceptable? In a country like Malaysia, culture and religion are essential elements, which often shape the thoughts and attitudes of the community. Hence, this study explores the deliberations by the Buddhist, Hindu and Catholic leaders in relation to hESC research in Malaysia. Since the Malaysian Muslims have already adopted a consensus on hESC research through the formulation of a national fatwa, only a brief review of Islamic literature is presented in this paper. Previous religious perception studies on bioethical issues included the religious perspectives on embryo donation for research (Kerridge et al. 2010), multi-faith perspectives of hESC research (Foong 2011), religious perception on advanced care planning (Pereira-Salgado et al. 2017) and significant work documenting inclusion of opinion of various religious groups on organ donation (Robson et al. 2010).

This study is an extension of my previous studies on the ethical issues pertaining to hESC research (Sivaraman 2018; Sivaraman and Noor 2016). This study attempts to (i) explore the ethical guiding principles deliberated by religious leaders and (ii) to identify if there is a common ground between the mainstream religious views and principles of medical ethics. The ethical viewpoints from the religious leaders are contrasted with the literature in medical ethics. Overall, this study attempts to answer the question as to whether both religious and medical guiding principles can co-exist in a contemporary world and complement each other in ethical decision-making.

Different Views on hESC Research

Numerous research have been conducted on the attitudes and socio-cultural aspects of embryo donation in Asian countries like India (Gupta 2011), Japan (Kato and Sleeboom-Faulkner 2011) and China (Rosemann and Luo 2018). Noting the diversity of views in a pluralistic society, Elliott et al. (2010) stated that something that is deemed ethical in one place may not be deemed ethical in a different cultural and religious context. The Singapore Bioethics Advisory Committee (BAC) took careful considerations of the diverse views not only from the religious community but also from the medical, legal, and scientific community and members from the international panel of experts, when deriving the report “Ethical, Legal and Social Issues in Human Stem Cell Research, Reproductive and Therapeutic Cloning” in 2002. The Singapore BAC adopted the intermediate position that the human embryo has a special status, acknowledging its potentiality to be a human being, but it does not have the same status as a living child or adult. From the Singapore BAC’s perspective, there are wide-ranging benefits from stem cell research, so the BAC permits deriving stem cells from surplus embryos, rather than allowing those embryos to perish (Bioethics Advisory Committee 2002).

In contrast, authors like Turner (2004) consider the existence of varying interpretations of what constitutes ethical practice in a pluralistic society. Religions have become an integral part of ethical debates, giving rise to distinctive deliberations pertaining to medical advancements such as hESC research. In parallel fashion, UNESCO’s report issued by the International Bioethics Committee (IBC) in 2001 on “The Use of Embryonic Stem Cells in Therapeutic Research” recognizes the diverse opinions reflecting pluralism on matters concerning hESC research and the various solutions adopted by different nations (McCall Smith and Revel 2001). In view of the ethical discussions on when human life begins and whether a 5-day-old embryo can be regarded as having life, it is pertinent that those concerns are addressed and reflected from the religious context. This is where religious leaders could shed light into the matter based on their reflections of religious texts or scriptural teachings. Reflecting on the pluralistic views, the UNESCO IBC (McCall Smith and Revel 2001) cautioned that major religious position on the use of embryos in hESC research reveals stark differences in the status of the embryo. Therefore, only if it is defined in a broader perspective will there be room for agreement. The hESC research is deemed controversial in certain societies as the extraction of stem cells involves the destruction of human embryos (Foong 2017). The contentious matter of hESC research has generated discussions in forums on religious standpoints (Knowles 2009; Frazzetto 2004; Pew Research Centre 2008) and a survey on public attitudes on embryonic SCR (Hudson et al. 2005). Public discourse surrounding SCR in recent years tend to focus on medical benefit, utility of research itself and the opposing views. This limits the opportunity to identify shared values (Lysaght et al. 2006). As such, it is timely to address the common values shared by religious leaders on hESC research.

Methodology

A qualitative study, comprising face-to-face, semi-structured and in-depth interviews with the religious leaders from the Buddhist, Hindu and Catholic groups was carried out. The purpose of these interviews was to gather the ethical viewpoints of the religious leaders on hESC research in Malaysia. However, it needs to be noted that the respondents may have presented their views through a Malaysian cultural lens. For example, the Buddhist respondents are from the Theravada school of thought. Theravada regarded as the oldest form of Buddhism and the closest to the Buddha’s teachings, originated from Sri Lanka and subsequently spread to South East Asian countries like Malaysia.

For the purpose of this study, Buddhism and Hinduism are recognized as religions though some may view them as a way of life. For the record, Malaysia recognizes Buddhism and Hinduism as individual religions according to Article 3 of the Constitution of Malaysia. This study was based on my doctoral thesis, whereby I intentionally chose to focus on the two Dharmic religions, which are Buddhism and Hinduism. Hence, I did not seek the perspectives of the religious leaders from other beliefs such as Sikhism and Taoism. Interviews were not conducted with the Muslim authorities as there is already a fatwa on hESC research in Malaysia. However, the available literature on Islamic ethics of hESC research was reviewed. While acknowledging the various denominations within the Christian faith in Malaysia such as the Roman Catholic, Methodist, Anglican, Lutheran, and Presbyterian and independent charismatic churches, I have chosen to explore the Catholic perspectives only. The Catholic churches in Malaysia are part of the global Catholic under the official teaching authority and leadership of the Pope. In 2010, the number of Catholics surpassed one million, covering 3% of the total population and they form 40% of the 2.2 million Christians in Malaysia (Herald Malaysia 2012). Future studies may want to include the perspectives of leaders from the Sikhism, Taoism and Protestant Christianity.

The respondents were identified through purposive (purposeful) sampling. Purposeful sampling allows selecting “information-rich” participants from whom the researcher can learn important issues related to the objective of research (Patton 1990). The respondents were briefed about the background of the study. Prior to the interviews, I had made it clear to the respondents that human embryos are inevitably destroyed in hESC research in order to harvest stem cells. In other words, a brief explanation on the scientific background of hESC research was given to respondents so as to prevent respondents from being misguided or misinformed. The respondents understood the scientific concept of hESC research and clarified all their doubts before interviews were conducted.

The religious leaders identified as valuable resources were selected in view of their vast experience, knowledge, significant contributions within ethics committees and inter-faith council dialogues and their authoritative roles in religious institutions or religious organizations. As such, the views of the leaders reflected and represented their faiths. Within the Theravada Buddhist tradition, I approached the committee of the Buddhist temples and Buddhist associations, where I was directed to meet the relevant leaders. Similarly, I approached the Malaysian Hindu Sangam central committee, who then forwarded me the contacts of leaders who have been playing an active role in inter-faith meetings. Likewise, I approached the Catholic Archdiocese, who then directed me to prominent clergy members and priests who are active in bioethical teachings. The respondents expressed their views and understanding of various sacred texts and holy books with regard to hESC research. The interviews were conducted one-to-one with every leader and not in groups to prevent one leader from influencing the other. At present, there is no official institutional response or any indoctrination of values on hESC research within the Buddhist and Hindu communities. As such, the institutions are largely shaped by the views of the religious leaders. These leaders are the authorities representing their respective religious communities, whose views are often sought in public review meetings and inter-faith dialogues. In this study, the views of the religious leaders represent the views of their respective faiths, and this has to be taken as a limitation of the study.

The sample size depends on various factors, such as the purpose of the inquiry, what the researcher wants to know and what can be gathered with the available resources (Patton 1990). A total of 11 respondents representing their respective religious institutions were interviewed: four Buddhist monks and leaders, four Hindu leaders and three Catholic priests. It is worth noting that the sample size was the maximum achievable number obtained from and referred by the authorities of the religious institutions and religious bodies, and the sample size was not restricted for any other reasons. The number of Catholic leaders was not limited due to any preconception, but only because the researcher observed a consistent viewpoint and a widespread acceptance during the interviews with the Catholic leaders. As such, three Catholic priests from the highest authority were interviewed, compared to four respondents each from the Buddhist and Hindu institutions. The three Catholic priests were not ordinary priests as they respectively hold prominent roles in the Pastoral Institute, Bible Ministry and Jesuit community. Within this modest sample size, this study effectively focused on the high-level leaders from the Buddhist, Hindu and Catholic institutions, whose views are presented in verbatim quotes in their choice of words and hence generating original empirical data. It is hoped that despite the limits, this study could strike new grounds on the ethical discourse.

Prior to the face-to-face interviews, informed consent was obtained from the respondents who agreed to their participation in the study and subsequent publications. While the strengths of a qualitative study are in gaining in-depth knowledge through the respondents, I acknowledge the drawback is that the researcher is the one who decides the way the research will be conducted. As a researcher, I acknowledge that I may have my own views and perspectives, but I did not in any way influence the religious leaders on the possible benefits of hESC research may bring to mankind. There is no better way of presenting a delicate matter on religious leaders’ viewpoints of hESC research other than through interviews. Which is why ethical viewpoints are reported as precisely as how they have been voiced by the respondents. The respondents are aware that hESC research is ongoing at the clinical trial phase, and the benefits of research are yet to be realized. The Catholic respondents, in particular, were well-versed on issues concerning hESC research, as they have been keeping themselves updated about the matter, in line with the standpoint and declaration made by the Vatican. As this study was part of my doctoral research, I played the role of researcher and interviewer. It is to be noted that my thesis had already been approved by the board of examiners and Senate appointed by the university.

Measures were taken to ensure the reliability of the data, such as ensuring the interview questions were open-ended to prevent pre-determined perception. The flow of the conversation with the respondents was not restricted, allowing me to seek clarification as the respondents deliberated on the ethical guiding principles related to hESC research. The interviews were conducted in English, audio-recorded with the consent from the participants and transcribed verbatim. Audio recordings were cross-checked with interview notes to gain full insight. The recorded interviews were immediately transcribed allowing an immediate reflection of the data, and the observations noted during the interviews. The transcripts were forwarded to the leaders (upon request), and at times, the respondents were contacted for clarification. The lines of the transcripts were numbered, and segments of the conversations were highlighted in search for common ideas, which were then clustered into themes, giving rise to two emerging themes: (i) “do no harm” and the (ii) intention to save lives. The themes evolved and emerged from the study and were not pre-determined.

For the purpose of analysis, the Buddhist leaders are labelled BL, Hindu leaders as HL and Catholic leaders as CL. The names of the respondents are kept anonymous. The profiles of the respondents in brief as follows:

• BL1: President and consultant of Buddhist associations

• BL2: Buddhist nun at Maha Vihara Buddhist Temple in Kuala Lumpur

• BL3: Chairman and President of Buddhist associations

• BL4: Chief monk of the Sri Lanka Buddhist Temple in Kuala Lumpur.

• HL1: Former Deputy President and current central council member of the Malaysia Hindu Sangam (MHS)—the official Hindu body

• HL2: Former General Secretary of MHS

• HL3: Active member of the Religious Advisory Board of MHS and serves as a Temple Board Vice President

• HL4: Former President of MHS and its current advisor and Vice President of the World Hindu Congress. Has served as a member of the ethics committee for a medical centre

• CL1: Former Assistant Parish Priest, former Parish Priest and observed “Tertianship” of high order in Jesuit community

• CL2: Director of Archdiocesan Pastoral Institute, spiritual advisor in Catholic medical ethics, appointed by Holy See as “consultor” to the Pontifical Council for inter-religious dialogue

• CL3: Priest at Malacca-Johor Diocese (MAJODI) and Head of Diocesan Bible Ministry

Findings

Theme 1: “Do No Harm”

In the deliberation of the religious leaders, the concept of non-maleficence that is, “first, do no harm”, is extended to human embryos. The Buddhist and Hindu leaders guided by the principle of ahimsa were against inflicting suffering to the embryos. The Hindus and Catholics, who believe in ensoulment, also shared their concerns about not harming a soul and avoiding hurting living entities.

Ensoulment is the moment when a soul is infused into a human being. In other words, it is the moment when a soul enters the forming human body. Islam holds the belief that ensoulment occurs at a later point of foetal development between 40 to 120 days from point of conception. On the other hand, while the Catholic teaching acknowledge that we do not know when an embryo (human being) becomes a human person (“ensouled”), the Roman Catholic Church has always taken the stand that the soul is present from the moment of conception. Recently, the Catechism of the Catholic Church (2017) also declares that a human being is recognized as a human person from the moment of conception and must be given “absolute” protection. Hence, the concept of ensoulment has a moral bearing on the permissibility of hESC research, as the research involves destruction of human embryos. Meanwhile, Hinduism, which believes in cycle of rebirth, holds the view that the soul is already there and is added to a human body during a particular stage of development. Similarly, Buddhism, which believes in “consciousness” (non-material matter), is of the view that the “consciousness” enters a human body during a particular stage of development. More on this will be explored in the “Discussion” section.

The Buddhist and Hindu leaders I interviewed were supportive of hESC research including the use of surplus embryos, while also generally maintaining the principle of “do no harm”. As opposed to the Buddhist and Hindu leaders, the Catholic leaders held the view that hESC research does inflict harm on the embryo’s soul and thus cannot be justified in the name of public good. They opposed all forms of hESC research.

Buddhist Leaders

The viewpoints of the Buddhist leaders focused on the notion “do no harm”. BL1 emphasized that harvesting stem cells from a 5-day-old embryo does inflict harm to the embryo. However, respondents BL2, BL3 and BL4 explained why utilizing a 5-day-old embryo does not violate the precept of “do no harm”, as they viewed that life only begins when there is a consciousness or when there is a reaction to stimuli. As such, they argued that utilizing 5-day-old embryos for hESC research does not violate the first precept in Buddhism, which discourages acts that involves harm. Here, basically, they referred to “harm” as injury, inflicting pain and ending a life. Three Buddhist leaders acknowledged the precept of “do no harm”, but they also maintained that using 5-day-old embryos in hESC research does not violate the precept. The other respondent, BL1, asserted that hESC research does harm embryos and violates the precept of “do no harm” and therefore the research cannot be justified for public good.

Since a 5-day-old embryo is not regarded as a sentient being, BL2 stressed that “as long as this [research] is based on non-violence and not hurting another being” it is allowed. BL2 further stressed that “There’s no damage or harm being done here [hESC research] by using these [embryonic stem] cells.”

Similarly, BL3 did not view that a life is formed in a 5-day-old embryo. He agreed that the first precept in Buddhism, which is directly related to ethics of hESC research is—“do no harm”. However, he asserted the precept is not violated in hESC research. BL3 stressed that generally there are no concerns about harming embryonic life since a life “has not formed” yet in a 5-day-old blastocyst.

BL4 also concurred with the argument about not inflicting harm. However, he pointed out that a 5-day-old embryo has no senses, and thus, there is no pain inflicted on the embryo if it is utilized for research. In his words:

There’s a life period, there’s karmic energy to remain in this world. Same thing here, the embryos destroyed or [not], there’s energy brought over birth. We can say [for] a 5-day [embryo], there are no senses… Pain definitely won’t be there.

Unlike the rest of the Buddhist leaders, BL1 held that a 5-day-old embryo has life. Hence, BL1 argued that research should be done in a way that does not inflict suffering on others and went on to propose that it would be better to find alternatives to using embryos for research. In his words:

They can find many other ways to solve the problems. They should try do their research in such a way as not to incur suffering to other lives.

Hindu Leaders

Meanwhile, the Hindu leader, HL1 pointed out that Hindus are guided by the principle of ahimsa, which means you cannot harm any living being or soul. HL1 particularly asserted that harming a soul is bad karma. However, HL1 said that a 5-day old embryo does not have a soul:

As a 5-day embryo, [it] still has no soul in it, no conscience in it…there is only a vegetation process of a cellular activity, and a soul cannot dwell, because for a soul to dwell, a comprehensive body structure hasn’t developed yet.

According to HL1, a 5-day-old embryo comprising cells has not developed a structured body in which the soul may dwell. As such, harvesting stem cells from a 5-day-old embryo does not harm a soul.

Meanwhile, HL2 stated that research on a 5-day-old embryo is encouraged though he emphasized the argument of not harming a soul on the grounds that:

The soul has not gone through process of happiness and bitterness. It has not gone through the process of karma, process of pain, and all the experiences of a soul yet. The soul is purposeless when the body is not there.

HL2 added that this is the underlying reason as to why a 5-day-old embryo does not experience pain because the body is not fully formed for the soul to dwell in. In other words, according to Hinduism, it is the soul that experiences pain and pleasures. Since a 5-day-old embryo does not have a soul, using it for hESC research is acceptable, says HL2.

Contrary to the rest of the HL respondents, HL3 stated her views promoting the argument that life begins from the point of fertilization. Hence, HL3 was protective of human embryonic life. She recalled the South Indian Hindu tradition which regards the egg as being non-vegetative for the reason that it has the potential to develop into a living being. The fertilized ovum or embryo should, therefore, be recognized as a more advanced stage in human life and hence worthy of protection. According to her, human life begins when the sperm fertilizes the egg. Though HL3 did not favour hESC research, taking into consideration the wastage of surplus embryos, HL3 agreed to the use of surplus embryos in research. HL3 firmly established her views from the context of fertilization. Giving due reverence to the male (sperm) and female (ovum) gametes, HL3 said that each contain the potential to create a new life, “when they meet each other” at point of fertilization. In that context, the notion of not harming an embryonic life was emphasized by HL3.

Meanwhile, HL4 said that the main emphasis is ahimsa, which is to avoid harming others. In his view, a 5-day-old embryo is on the verge of becoming a life. HL4 refers to Siva Puranam on “evolution of consciousness”, describing plants as being at the lowest level, followed by animals and human beings at the highest due to their possession of an intellect. In that context, referring to hESC research, he said “You cannot be completely harmless, but avoid [inflicting] harm intentionally.” HL4 requested that the research be conducted, in the spirit of upholding ahimsa.

On the whole, three Hindu leaders argued that research on 5-day-old embryos does not inflict harm due to the embryo has not fully developed for the soul to dwell in. On the other hand, one Hindu leader, HL3, argued that we should protect the embryo as human life and should not inflict harm.

Catholic Leaders

All three Catholic leaders agreed that hESC research harmed embryos and their souls because these embryos are ultimately destroyed. They emphasized that they are not against SCR but only against hESC research per se. This is because hESC research involves the destruction of human embryos, which they regard as living being right from the point of conception. So, hESC research is not justified.

Respondents CL1 and CL2 did not agree to the argument that hESC research promotes medical advancement and better quality of life, advocating the principle that the “end does not justify the means”.

CL1 said, “the argument that greater good overweighs the evil means cannot be tolerated”.

Besides that, CL1 said that the embryo should be protected from any harm, to allow it to fulfil its potential as a human being. On the notion of harming a soul, CL2 argued that a soul is present from the moment of conception, according to Catholic belief. Thus, he argued that the destruction of an embryo only harms a soul.

The third respondent, CL3, alluded to a verse in the Bible, i.e., Mark 8:36 and Matthew 16:26, that states “What does it profit a Man if he wins the whole world but suffer the loss of his own soul?”, to make the point that the Church does not advocate the “greatest good for the greatest number”. This means that however hESC research may benefit society, and that benefit should not be prioritized above destroying human embryos. Here, I take note that respondent CL3 has drawn parallelism of this biblical verse to the current context of hESC research.

Theme 2: Intention to Save Lives

The underlying argument here is to find balance in carrying out the “moral duty to save lives of people” suffering from diseases while also according the respect to 5-day-old embryos, which some regard as living entities. The phrase “moral duty to save the lives of people” is to be viewed simplistically; that is more of a case of alleviating suffering rather than just averting death. As mentioned earlier, hESC research is seeking to address various health conditions, among others, spinal cord injury, restoring visual function, treating diabetes and studying motoneurons. Proper safety and effectiveness of stem cell therapy need to be adhered, and only therapies based on scientific evidence should be made available (Marks et al. 2017; Langrzyk et al. 2018). Unfortunately, it is not that simple because stem cell clinics are mushrooming and the clinics’ claims are so convincing that the public fall prey to treatments that have no therapeutic benefit. The hESC research is still ongoing at the clinical trial phase, and the benefits of research are yet to be realized. Studies are ongoing to learn how hESC research could enable a better understanding of human biology. For instance, a study has shown that genetic manipulation of human embryonic stem cells will lead to a better understanding of cellular processes of early human development (Menendez et al. 2005). Only time will tell if the ongoing hESC research can be translated to good health outcomes. Hence, the religious leaders I interviewed have given their reasoning based on a hypothetical situation that hESC research may result in saving lives.

Buddhist Leaders

In general, the Buddhist leaders agreed that hESC research should be promoted based on the intention of the research, which seeks to help mankind and to save lives. Though BL1 argued that one cannot justify the research in the name of public good, he agreed that it is better to use the surplus embryos for a good cause to save lives rather than discard them, on the grounds of not wasting the resources and justifying that “the embryo is going to die anyway”.

On the other hand, respondents BL2, BL3 and BL4 agreed to the use of both surplus embryos in hESC research provided the intention is to help mankind to save lives. BL2 argued that since the purpose of the research is to help mankind to attain a better quality of life, by utilizing the embryonic stem cells, then it should be allowed for the good cause. In her words:

…here you are trying to actually help a life by using some cells, to live a better life, to have a better quality of life.

The aim of every Buddhist, that is to be free from suffering, was also highlighted by BL2. “For us our main aim is to bring suffering to an end, to be free from suffering”. This means that if the aim of hESC research is to alleviate the suffering of people, it is encouraged. In addition, respondent BL2 stressed that the aim of the research is not to destroy life but to help mankind and save lives. Hence, the motive or intention of the research is what determines good karma, said BL2.

Similarly, BL3 noted the point that Buddhism allows hESC research but with conditions and that the conditions are based upon the intention of the research itself and the end result. As such, if hESC research is based on good intentions, then it is to be encouraged. In addition, BL3 said that moral interpretation is very important. Even though the destruction of embryos in ECSR is inevitable, the intention behind the research is deemed to be fundamental. BL3 added, “The intention to help the public suffering from diseases is [regarded as] a higher purpose.”

BL4 was driven by the motivation and intention to do good, through the concept of donation. BL4 said the hESC research is in line with the notion of Dana (donation) and empathy:

Buddhism totally supports scientific development [in] doing some sort of research as well as helping people, where we call it Dana or donation.

Thus, donating surplus embryos for research to save human lives represents a good intention and symbolizes empathy towards society. The overall objective of the research which benefits people was considered noble by BL4.

Hindu Leaders

The Hindus are also motivated by the intention to do good to save lives. All the Hindu leaders approved hESC research but limited it to the use of surplus embryos only. HL1 stressed the objective of doing research. HL1 cited verses Inbame sullege ellorum vaalga and Ellorum inbutrirukka ninaipadhuve-allamal veronrariyom Paraparame which basically means let everybody live in harmony, promoting a benefit for all. He also referred to the scriptures which call for the ending of the suffering of people from various diseases.

Meanwhile, HL2 referred to Hindu religious texts like Vedas, Manudharmashastra, Thirumanthiram and Periya Puranam and presented his argument through the Hindu concept of donating (Dana). Donating surplus embryos for research is in line with spiritual teachings which state that excess materials ought to be donated for a good cause. The three respondents, HL2, HL3 and HL4, recounted a story in Periya Puranam about a hunter who donated both his eyes upon seeing the bleeding eyes of the deity of Lord Shiva. When there is an excess of material goods, all the scriptures encourage the act of donation and sharing. Hence, the respondents said that the use of surplus embryos in research for the sake of saving humanity could be viewed in the same way.

HL2 added that it is crucial to look at the end result. According to him, if the intention of hESC research is geared towards helping mankind, then it is regarded as good karma (leading to good consequences), although it may involve the destruction of surplus embryos. On another critical aspect, HL3 said that Hindu teachings related to Dhayai or parivu, which means compassion and caring, can be applied in this context. Accordingly, Hindu scriptures allow aborting embryo/foetus if the mother’s life is in danger. In the same vein, HL3 pointed out that this analogy could be applied to endorse the use of surplus embryos for hESC research to find cures for people suffering from illness.

Given its intention to save lives, HL4 did not object to hESC research but called for “minimum destruction”. He cautioned that “random killing” should be avoided, citing example from nature—carnivores are given teeth to kill their prey, but it is rather for the purpose of fulfilling their need for survival and not essentially for the purpose of killing. Likewise, using surplus embryos for research to improve the health of people can be viewed in the same manner, as long as wastage is minimized and the research is carried out with good intentions to save lives, said HL4.

Catholic Leaders

As opposed to the Buddhist and Hindu leaders, all three Catholic priests were well-versed about the ethical issues regarding hESC research and unanimously held to the argument life begins from the point of fertilization, thus objecting to any form of hESC research. All of them unambiguously adhered to the official position declared by the Vatican and did not hold a different standpoint on the matter. To the Catholic leaders, whether it is discarding surplus embryos or destroying embryos for research, the end product is terminating lives, and hence, both are to be treated as being equally evil. In other words, the Catholic leaders were consistent in holding on to the principle of respect for life at all stages. They focused on the inviolability of embryonic life and gave their utmost priority to respect life and accord protection to the human embryos regarded as a living being.

While the Buddhist and Hindu leaders based the ethics of hESC research with the intention of saving lives of people suffering from diseases, the Catholic leaders, on the other hand, opposed hESC research on the basis of protecting the lives of human embryos. The theme for deliberation revolves around the matters of life. However, ethical decision-making varies according to the moral interpretation and angle of the viewpoints of the religious leaders.

Discussion

In this section, the two themes arising from the interviews with regard to the ethical guiding principles of “do no harm” and the “intention to save lives” are further explored in relation to Buddhist, Hindu and Catholic traditions. In Malaysia, the official religion, Islam, is represented through the mention of the national fatwa. The fatwa outlines when and under what circumstances hESC research is allowed, which is taken as a consensus among the local Islamic community. However, relevant Islamic literature is also presented in this section, in view of the two ethical guiding principles “do no harm” and the “intention to save lives”. This is followed by a discussion on religious views, principles of medical ethics and finding a common ground between the two.

The Ethical Guiding Principle of “Do No Harm”

The basis of religious guidance on when human life begins essentially revolves around the notion of ensoulment in Islam, Catholicism and Hinduism. From the religious perspective, ensoulment refers to the moment when a human being acquires a soul, marking its individual existence and personhood. Human beings are the product of the non-material (consciousness) and material matter. Buddhists do not call it reincarnation because there is no permanent soul that moves from one life to another (Dhammananda 2002, 134). To counter the concept of the soul, Buddha came up with Annata doctrine, which means no-soul, no-self and no-ego (Dhammananda 2002, 155). However, to a large extent, this appears similar to the concept of ensoulment.

Muslim scholars generally agree that ensoulment, which is the “breathing of spirit” into an embryo, is what differentiates biological life from human life (Fadel 2012). Reflecting on the ancient text, Fadel (2012) claims that it is only after ensoulment that the embryo acquires personhood. The process of ensoulment is referred to as: “and breathe into him of His spirit” (Quran 32:9) and supported with a Hadith:

…for forty days in his mother's womb in the form of blood, after which it becomes a clot of blood in another period of forty days. Then it becomes a lump of flesh and forty days later…Then the soul is breathed into him. (Cited in Aksoy 2005, 401)

Based on the Quran, each stage of human development takes 40 days, totalling 120 days, after which ensoulment occurs. In Malaysia, the above teachings have been decisive on the ruling on abortion, which is prohibited after the “third fortieth” (120th) day. Some scholars imply that ensoulment occurs after 120 days. Based on that, scholars point out that abortion is allowed in Islam until the end of the fourth month after fertilization (Larijani and Zahedi 2004). If we apply the same concept, then the argument is that hESC research involving the destruction of 4- to 5-day-old embryos is permissible because ensoulment has not occurred for the embryos to acquire personhood. Comparatively, in the medical context, a human embryo is worthy of protection only after day 14 of fertilization. This is because the formation of the nervous system around day 14 marks the possibility of the first sensation, which is a landmark in the definition of life (Fischbach and Fischbach 2004). Embryonic development takes place from the moment of conception till the eighth week, and after which, foetal development begins. Hence, from the medical perspective, a human embryo, which is only 4- to 5-day-old has not reached the stage where it is worthy of protection.

The principle of “do no harm” remains a major concern for all the religious groups. The notion “do no harm” embodies the medical ethics principle of “non-maleficence”, that is to refrain from doing any harm first, before doing any good. The question is whether the research on a 5-day-old embryo inflicts harm on the embryo. The respondents of this study deliberated on the principle of “do no harm” on two key points, that is emphasizing ahimsa and not to inflict harm on a living entity and not to harm the soul in an embryo. The Buddhists and Hindus applied the religious principle of ahimsa when deliberating on the permissibility of hESC research. Ahimsa can be loosely translated as non-violence and non-hurting which is similar to the clause “do no harm” (Jafari et al. 2008). The argument is that one should abstain from doing research that induces harm on human life, before doing any good. As to whether the research on a 5-day-old embryo inflicts harm on the embryo requires further moral evaluation from the religious leaders through inter-faith dialogues.

The Hindu respondents deliberated from the aspect of ensoulment. The Hindu respondents, particularly, HL1 and HL2, in reference to religious texts, generally argued that for a 5-day-old embryo, the soul is not present and not functional. Thus, there is no necessity to object to using surplus embryos for hESC research. On the other hand, the Buddhists believe in non-self-material, which is the karmic energy (consciousness) that travels from one life to another. The Buddhists respondents BL2, BL3 and BL4, except for respondent BL1, presented their argument from the Buddhist aspect of consciousness (non-material). Since the 5-day-old embryo has not developed consciousness yet, the Buddhists, in general, argue that research on embryo does not inflict any harm and thus allays the restrictions on hESC research. They based this on their understanding of the prospects of hESC research and awareness that the clinical trials are ongoing and have not yielded results.

On the other hand, the Catholics believe that an embryo is a living soul from the moment of fertilization. According to the Catholic respondents, research on embryos inflicts harm both to embryos and the souls in them. Thus, hESC research is viewed as violating the principle of “do no harm’, and thus, the research is rejected.

The Ethical Guiding Principle of the “Intention to Save Lives”

The importance of saving lives in Islam is cited in most deliberations on the ethics of SCR (Al-Hayani 2008), and the following verse in the Quran is often quoted:

Whosoever saves the life of one [human], it shall be as if he saved the life of all humankind (Quran 5:32).

This statement implies that saving lives of people who suffer from pain is given great importance. This can be viewed as a supporting point for hESC research.

Further, hESC research is viewed as an act of faith as long as such “intervention in the early stages of life” is carried out with the purpose of improving human health (Sachedina 2000, G6). Another argument is if the surplus embryos, in any case, are destroyed, then there is no reason why these embryos should not be used in hESC research for the public good (maslaha) aimed at providing treatment for debilitating conditions (Saniei 2012).

Meanwhile, Siddiqi (2002) argued that if hESC research can relieve the suffering of people, then it is denoted as “obligatory” under Fardu Kifayah [societally requisite knowledge]. Siddiqi stated that it becomes a duty for the scientists (the people of knowledge) to assist the society who can benefit from that knowledge as delivering public goods is in accordance with the principle of maslaha. However, we need to take note that the argument about scientific research delivering public good comes from the assumption that benefits of research directly reaches the society. But, in reality, that may not be the case always, with the direct involvement of Big Pharma turning it into a business.

Another viewpoint is that the development of new treatment methods is recommended and “commanded” as long as it is not “categorically prohibited” in accordance to Islamic laws, and it is aimed at improving human health (Aksoy et al. 2007). As such, the argument is that hESC research, which aims to improve the health of people suffering from diseases, is allowed. Although hESC research does not immediately result in a cure for diseases, the research itself may contribute towards a better understanding of physiological and physiopathological processes at a cellular level. This is valued as knowledge seeking from the perspectives of Islamic ethics. Hence, the issue is no longer about finding cures for diseases but about the “increase of knowledge” (Ilkilic and Ertin 2010).

On the other hand, the intention is an intrinsic aspect in Buddhism and Hinduism. Intention, referred to as sankalpa, is beyond mere goals because it places importance on the doer’s willingness to look at the philosophical aspect of a goal. An action is deemed as good karma because of its intentions. The Buddhists and Hindus give priority to the intention of the research to save lives. The Hindu perspectives on biomedical reasoning are clearly presented by Crawford in his book “Hindu bioethics for the twenty-first century”. According to Crawford (2003, 6), the Hindu bioethics is based on three basic principles:

• (i)The transcendent character of human life expressed through the principles of the sanctity of life and quality of life
• (ii)The duty to preserve the health of individuals and community
• (iii)The duty to rectify imbalances in the processes of nature and to repair states that threaten life and well-being of humans

Principle (i) outlined by Crawford seems in line with the findings of this study, which reflect the viewpoints of the Hindu leaders not to harm life. More importantly, the Hindu leaders emphasized on intention—in line with principles (ii) and (iii)—the potential of the research aimed at saving lives, improving health and maintaining the well-being of the community and placing importance on spiritual element, in accordance and in harmony with the law of karma and Dharma.

Both Hinduism and Buddhism are guided by the law of karma, which stresses that every act can be deemed good or bad depending on its consequences. Thus, the focus of the Hindu and Buddhist leaders is on the intention of the research itself. If the “intention of the research” is to help humankind, then it is considered ethical by the Buddhists and Hindus (Hug 2006).

It is worth highlighting that none of the Catholic leaders expressed their views from the point of view of the intention of hESC research in saving lives as the Catholic churches oppose the destruction of embryos in hESC research itself.

Voices of Religions

The Hindu and Buddhist leaders take up a more nuanced position (subtle but not assertive) and are more inclined to accept hESC research in the reflection of the good intention to save lives and alleviate suffering of people. A diversity of views is seen to exist within Buddhism and also Hinduism. The Buddhists and Hindus in Malaysia have not pronounced any formal positions regarding the ethics of hESC research, and the leaders embrace the advantage of an absence of a central authority, which encourages individuals to seek personal understanding from the scriptures (Sivaraman and Noor 2014). Buddhism and Hinduism do not indoctrinate or impose values on their followers. Unlike the Buddhist and Hindu leaders who gave cautious considerations to the potential of hESC research, the Catholic respondents stood firm on the official Church teachings on the sacredness of human embryonic life.

Religious beliefs (Abrahamic religions) emphasizing the sanctity of life appear to clash with the human desire to alleviate suffering and find a cure for diseases through hESC research (Reichhardt et al. 2004). Furthermore, Walters (2004) has observed that the presence of “centralized authority” in Catholicism may be responsible for adjudicating ethical disagreements, unlike Hinduism and Buddhism where there is no central authority, resulting in a diversity of views. In Catholicism, the Magisterium is the teaching authority, under the Pope, and the Bishops who are in communion with the teachings. As such, reasonings pertaining to moral issues are delegated in the Vatican, before Declarations and Encyclicals are released, and abided by the national Bishop Congregations of every country and the Catholic churches worldwide.

The central focus of religious convictions and apprehensions are on the identity, dignity and modification of the embryos (Cole-Turner 2003, 13). Accordingly, the complexity of arguments gives rise to “indecisive” and “inconsistencies” of standpoints. For instance, there is “inconsistency” in the way society reacts to embryo research for therapeutic use but allows the infertile couple to generate embryos through infertility treatment and to discard the surplus embryos (Cole-Turner 2003, 16). Meanwhile, Steinbock (2006) argues that as much as creation and destruction of surplus embryos which is part of IVF is justified for reproduction purposes, so is the creation and destruction of research embryos aimed to improve people’s health. Again, the argument on “inconsistency” is subject to criticism, as the endpoint of fertility treatment is to help infertile couples have a child, whereas the outcome of hESC is less clear-cut in terms of yielding results. However, the fact remains that infertile treatment through IVF generates embryos in surplus which are discarded to trash if they are not donated for research.

In Islam, along with the Shariah (Islamic laws), the procurement of judgments is dependent on reasons used in moral deliberation (Sachedina 2005). Sachedina pointed out that the underlying principles and rules of practical ethical guidance should be referred to when faced with an ethical dilemma. Rispler-Chaim (1989) stressed that when it comes to medical treatment, Muslims usually refer to the Shariah to decide if a treatment is acceptable within Islamic law.

Buddhism places importance on ahimsa, the non-harming principle. Buddhism has reservations on the destruction of life (Keown 2004), as it can be viewed as generating bad karma. On the other hand, in a conference with scientists discussing on “When does a stem cell become a human being?”, Dalai Lama (2003) stated that we do not know at which point “consciousness” enters the embryo. Dalai Lama said that “something more is needed than simply a fertilized egg” for an entity to form a human life. Here, a question worth asking is whether we consider harvesting stem cells from embryo as a destruction of life that generates bad karma. Buddhism also places emphasis on knowledge (prajna) and compassion (karuna) and its tradition of practicing medicine aimed at developing cures to alleviate the suffering of a human being is illustrative of this (Keown 2004). Despite the absence of a central authority, the fundamental values such as compassion and respect for life underpin the Buddhist approach to medical ethics, as argued by Keown (2005). Meanwhile, The Malaysian Ti-Ratana Buddhist Missionary Society reflects upon Buddha’s teachings based on the Four Noble Truths, acknowledges the need to study the cause of diseases in search of cures, thereby demonstrating compassion through the alleviation of the suffering that diseases always bring (Dhammananda 2002).

Hindu deliberations on hESC research are rather limited. One may look into Swami Tyagananda’s lecture, where the destruction of life is held as bad karma unless the act is unavoidable and carried out for the “greater good” of humanity (Tyagananda 2002). Meanwhile, the Vatican outlining the Catholic view, released the “Declaration on the Production and the Scientific and Therapeutic Use of Human Embryonic Stem Cells” (Pontifical Academy for Life 2000). As to whether it is moral to produce living human embryos to obtain stem cells, the Declaration states that the “human embryo from the moment of union of sperm and egg is a well-defined identity…and thus cannot be considered as a simple mass of cells”. It is to be noted that there is still an ongoing debate on the personhood or ensoulment of the embryo in the official documents of the Catholic church. There is no definite position on when the embryo has a soul or if the embryo is a person from the moment of conception. Although there is no scientific evidence on the moment of ensoulment, the argument is to refrain from harming the conceptus and thus the need to accord it protection, right from the beginning. The Vatican takes a “creationist position” that God breathes in the individual soul to each person (Peters et al. 2008, 122). This has led to the view that personhood is tied to conception (Peters et al. 2008, 124).

The voices of religions are influential in shaping healthcare policies, and hESC research is no exception. The diverse views recorded in this study indicate a lack of consensus on matters concerning hESC research. Meanwhile, Ertin and Ilkilic (2017) argued that cultural values and religious convictions of all stakeholders play a decisive role in formulating ethical positions, and therefore, ethical debates are inexorably linked to cultures and traditions. This study, however, attempts to highlight the common ethical values and principles in the religious and medical communities.

Principles of Medical Ethics and Goals of Medicine

At this juncture, it is worthwhile to run through the four medical principles—autonomy, beneficence, non-maleficence and justice (Beauchamp and Childress 2001). In healthcare practice, the principle of autonomy requires the consent of the patients. Individuals have the right and autonomy to accept or reject any form of medical intervention. But we know that in the context of hESC research, the human embryos in the petri dish have no decision-making capacity. Next, beneficence promotes the well-being and welfare of the patients. In line with that, the argument is that hESC research promotes medical advancement. However, the counter-argument is that hESC research impinges on embryonic life. Hence, the end does not justify the means. Then, the principle of justice requires the fair distribution of resources. The question is whether the benefits of hESC research will reach the needy and the poor and, lastly, the concept of non-maleficence, that is to abstain from inflicting harm. The principle of non-maleficence consists of rules such as “do not kill” and “do not cause pain”. This principle is evident in the deliberation of religious leaders in this study, which is not to do harm to a living entity. The moral interpretation between the Buddhist and Hindu leaders differ from the Catholic leaders as the latter view 5-day-old embryos as living entities.

The Declaration of Helsinki, adopted by the 64th General Assembly in 2013, states that the health, well-being and rights of patients, including those who are involved in medical research, must be safeguarded (World Medical Association (2013). Further, the World Medical Association (2013) emphasized that the primary purpose of medical research to generate new knowledge can never take precedence over the rights of individual research subjects. The question is whether the ethical principles outlined for medical research involving human subjects can be extended to 5-day old human embryos in the petri dish.

Although hESC research is a well-discussed topic within the medical ethics community, there have not been any prevailing views applying to the questions of ethics of hESC research. In a similar context, Pawlikowski (2018) wrote that religiously engaged healthcare workers might shape their attitude towards prenatal testing based on religious teachings, and it can especially be found in the teachings of the Catholic church. Pawlikowski also argued that though conscientious objection of healthcare workers to pre-implantation genetic diagnosis may be reinforced by religious reasons, objection results mainly from situations that violate the principle of respect for life and the principle of non-maleficence. As such, one can argue that the conscientious objection of healthcare professionals may emanate from various reasoning and not necessarily religious reasons.

At this juncture, we need to look into the four goals of medicine, in order to help medicine maintain its integrity in the face of societal pressure, which are as follows (The Hastings Center 1996):

• The prevention of disease and injury and promotion and maintenance of health.

• The relief of pain and suffering caused by maladies.

• The care and cure of those with a malady and the care of those who cannot be cured.

• The avoidance of premature death and the pursuit of a peaceful death.

In fact, there is a concern about the growing number of stem cell treatment centres turning them into lucrative business, especially across Asia and in countries that have lax laws dealing with such practices (Editorial Asian Biomedicine 2014). Hence, it is important for us to revisit and highlight these goals of medicine, in order to recognize our needs and to set our priorities in medicine without having the ethics of medical research be reduced to minimalist ethics of business. The goals of medicine must always be for the common good without compromising on the pluralistic values in our society.

Finding Common Ground Between Religious Guiding Principles and Medical Ethics

This study does not intend to propose any harmonization of values or advocate uniformity of views. Instead, this study attempts to identify common ground between the religious guiding principles and medical ethics, with specific reference to hESC research. Although there is no clear characterization of values between religious principles and medical ethics, we cannot ignore the fact that the ethical guiding principles such as “do no harm” and “intention to save lives” are universally accepted by both the religious and medical communities. Although moral evaluation may differ, both religious views and principles of medical ethics are consistent when it comes to matters concerning lives.

Religious tenets, doctrines and sacred texts offer insights on matters concerning life and death. However, the advancement of technology, particularly in the biomedical field, has compelled us to re-examine the religious texts. This is because the religious texts were written during the ancient era, at a time, when the current technological advancement was unknown. As such, one cannot find specific guidelines or direct answers for the ethical conundrum surrounding new medical discoveries. With new developments such as hESC research, there is a need to re-examine the religious texts. This is where the religious scholars and leaders offer their expertise in making moral interpretations of the sacred texts in light of today’s modern medical discovery. For example, religious voices provide meaning to life—in understanding the concept of dignity in Roman Catholic tradition, the unity of all creatures in Buddhism and Dharma in Hinduism (Stempsey 2011). The role of religious voices in public discourse cannot be overlooked. Religion and religious communities have much to offer, including enabling people to make important medical decision-making, providing moral discourse, developing ethical language and discovering our moral commitments (Wind 1990). Furthermore, Wind (1990) described that religious traditions enable us to approach questions concerning suffering, death and procreation, besides helping us to discover our moral commitments

Religious beliefs are important determining factor for people’s worldview and their social existence, so much so that these beliefs support their decisions about medical and scientific issues that have moral implications (Kerridge et al. 2010). Accordingly, it is important for the healthcare professionals and policy makers to understand the religious approaches to medicine, health policy and bioethics. Kerridge et al. (2010) presented commentaries representing six major religious traditions concerning embryo donation for research. They highlighted that religious traditions share a number of concerns and considerations in the way decisions about embryo donation are evaluated. On a similar note, I argue that what is important now is to get the religious and medical communities to work closely together and deliberate on recent medical advancements such as hESC research, which impinges on matters of life and death. The dialogues and engagements would initiate ethical frameworks, which would serve as guidelines to the public and nation.

The world-renowned Hindu monk, Swami Vivekananda (1863–1902) has said that “the voice of Asia is the voice of religion”. Asia, which comprises the largest number of countries, cultures and religious traditions, is the birthplace of most of the world’s religious traditions (Akabayashi et al. 2010). Tsai (1999) compared the ancient Chinese medical ethics (ACME) and the four principles of biomedical ethics and examined cross-cultural plausibility when applied in a cultural context. The findings by Tsai (1999) showed that the concepts of respect for autonomy, non-maleficence, beneficence and justice are identifiable in ACME, but due to the influence of socio-cultural factors, the Chinese society may tend to adopt a “beneficence-oriented” approach. Beneficence and non-maleficence are the keynotes of ACME, since humaneness (jen) is the central theme of Confucianism on which ACME was founded, besides highlighting the deontological feature and personal responsibility for the common good. Meanwhile, Nie and Campbell (2007) argued that multi-cultural dialogue comes with enormous challenge as it requires creative ethical enquiries and bold educational initiatives. They emphasized that given the rapid developments in biomedicine and biotechnology in Asia, there is a pressing need to study the cultural richness and diversity in Asia (Nie and Campbell 2007). Scholars have argued that Western bioethics may not be suitable in multi-cultural Asian countries where compassion, religious virtues and family values are given importance. For example, Chattopadhyay and De Vries (2013) challenged the application of universal principles and Western bioethics in guiding ethical decision-making, as there is a need to acknowledge cultural diversity where the decisions take place. On that note, I argue that the interplay between cultural and religious beliefs need to be explored and their impact on the practice of medical research. This study attempts to highlight the need to find a common ground between religious views and principles of medical ethics in relation to hESC research in a multi-religious country like Malaysia, while acknowledging the cultural differences. The way forward is to train the healthcare professionals of different faiths in medical ethics since they are the ones who understand the realities and challenges of providing good healthcare to patients.

Concluding Remarks and Future Directions

This study attempts to answer the question as to whether both religious and medical guiding principles can co-exist in a contemporary world, where it is hoped that one complements the other in the process of ethical decision-making without compromising the values. Interestingly, in the context of hESC research, though the Buddhist, Hindu and Catholic leaders deliberated their reasonings from various angles in favour or against hESC research, their underlying moral concerns revolve around the themes of “do no harm” and “intention to save lives”. These principles are also acknowledged as the fundamentals in principles of medical ethics. As to whether the two principles can be extended to 5-day-old embryos as deliberated by the religious leaders, it requires further moral evaluation by the religious authorities and healthcare professionals.

It is recommended that efforts must be taken to promote more dialogue between the religious leaders and medical practitioners to identify the gaps and the ethical guiding principles, besides seeking the common ground. Although this comes as a challenge, one should not quell or compress the voice of the other. In a world that is increasingly diverse, studies gathering multi-faith insights on bioethical issues such as hESC research in multi-cultural settings are required, to further expound the guiding principles of both religious and medical communities. Multi-religious views are not there to impede the progress of science and medicine, but they are essential in public discourse as they provide check and balance and foster collaboration between various stakeholders. What is more important is that this study has shown that voices of religious communities, if conveyed in a clear manner, can be an integral part of public discourse related to healthcare.

Abbreviations

ART

Assisted reproductive technology

BAC

Bioethics Advisory Council

ESC

Embryonic stem cell

hESC

Human embryonic stem cell

IBC

International Bioethics Committee

IVF

In vitro fertilization

JAKIM

Department of Islamic Advancement Malaysia

MCCBCHST

Malaysia Consultative Council of Buddhism, Christianity, Hinduism, Sikhism and Taoism

MOH

Ministry of Health (Malaysia)

SCNT

Somatic cell nuclear transfer

SCR

Stem cell research

Glossary

Dana

In Sanskrit, it means giving, in the context of donating

Dharma

In Buddhism, Dharma is the doctrine on universal truth. In Hinduism, Dharma is the moral law concerning individual conduct

Karma

Universal causal law by which good or bad actions determine an individual’s existence

Karuna

The virtue of compassion in Buddhism

Maslaha

A concept in Islamic law prohibiting or permitting something on the basis whether it serves “public interest”

Prajna

In Buddhism, three types of learning to seek enlightenment, which are, in progressive order, sila (moral conduct), samadhi (meditation) and prajna (wisdom and intuitive experience of reality)

Compliance with Ethical Standards

Conflict of Interest

The author declares that she has no conflict of interest.

Human and Animal Rights

This study does not involve clinical intervention using human or animal subjects.

Informed Consent

Informed consent was obtained in writing prior to interviews from all the religious leaders who participated in this study.