internet addiction research paper pdf

The relationship between internet addiction and adolescent learning engagement: the role of future orientation and cognitive reappraisal

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• Published: 08 May 2024

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• Xidan Xiao   ORCID: orcid.org/0000-0002-1309-7089 1 ,
• Jiahan Cai 1 &
• Qiuyu Yang 2  

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The primary objective of this study was to investigate the relationship between internet addiction and adolescents’ learning engagement, with a specific focus on the mediating sequential roles of future orientation and cognitive reappraisal. A survey encompassing 1200 high school students was conducted, utilizing instruments such as the Internet Addiction Scale, Learning Engagement Scale, Future Orientation Scale, and Cognitive Reappraisal Scale. The findings of this investigation yielded the following outcomes: (1) Internet addiction exhibited a pronounced negative correlation with high school students’ learning engagement, future orientation, and cognitive reappraisal. Furthermore, future orientation and cognitive reappraisal demonstrated mutually positive associations with learning engagement. (2) Future orientation and cognitive reappraisal jointly mediated the relationship between internet addiction and learning engagement among adolescents, forming a sequential mediation process. These findings suggest that enhancing adolescents’ future orientation and cognitive reappraisal abilities can contribute to mitigating the deleterious impact of internet addiction on academic performance.

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The datasets generated during or analysed during the current study are available from the corresponding author on reasonable request.

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Xiao, X., Cai, J. & Yang, Q. The relationship between internet addiction and adolescent learning engagement: the role of future orientation and cognitive reappraisal. Curr Psychol (2024). https://doi.org/10.1007/s12144-024-05982-x

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Current Research and Viewpoints on Internet Addiction in Adolescents

David s. bickham.

Digital Wellness Lab, Division of Adolescent and Young Adult Medicine, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115 USA

Purpose of Review

This review describes recent research findings and contemporary viewpoints regarding internet addiction in adolescents including its nomenclature, prevalence, potential determinants, comorbid disorders, and treatment.

Recent Findings

Prevalence studies show findings that are disparate by location and vary widely by definitions being used. Impulsivity, aggression, and neuroticism potentially predispose youth to internet addiction. Cognitive behavioral therapy and medications that treat commonly co-occurring mental health problems including depression and ADHD hold considerable clinical promise for internet addiction.

The inclusion of internet gaming disorder in the DSM-5 and the ICD-11 has prompted considerable work demonstrating the validity of these diagnostic approaches. However, there is also a movement for a conceptualization of the disorder that captures a broader range of media-use behaviors beyond only gaming. Efforts to resolve these approaches are necessary in order to standardize definitions and clinical approaches. Future work should focus on clinical investigations of treatments, especially in the USA, and longitudinal studies of the disorder’s etiology.

Introduction

Every day we carry with us a tool that provides unlimited social, creative, and entertainment possibilities. Activities facilitated by our smartphones have always been central to the developmental goals of adolescents—as young people move toward their peers as their primary social support system, their phones provide constant connection to their friends as well as access to the popular media that often defines and shapes youth culture. Considering young people’s continued use of more venerable forms of entertainment screen media (e.g., television, video games, computers), it is not surprising that adolescents spend more time using media than they do sleeping or in school—an average of 7 h 22 min a day [ 1 ]. While the majority of young media users adequately integrate it into their otherwise rich lives, an undeniable subset suffers from what has been termed by some as internet addiction [ 2 ] but, as discussed below, has been referred to by many different names. While overuse of technology and its impact has been of concern since the days of television, the constantly changing media landscape as well as advances in our understanding of the issue requires regular updates of what is known. The purpose of this review is to provide an understanding of this issue grounded in the established evidence of the field but primarily informed by work published between 2015 and 2020 and, in doing so, address the following questions: What is internet addiction and is this the best term for the problem? What is its prevalence among adolescents around the world? What individual characteristics predispose young people to internet addiction and what are the common comorbidities? And, finally, what treatment strategies are being use and which have been found to be effective?

Defining the Issue

To answer any of these questions, first we must define the problem at hand. Unfortunately, this is a difficult task as recent publications use a wide variety of terms to reference this problem. Video game addiction, problematic internet use, problematic internet gaming, internet addiction, problematic video gaming, and numerous other terms have been used to identify this problem in the last 5 years. Such terms all have limitations. Focusing on a specific behavior, such as internet gaming, does not capture the variety of media use problems experienced by young people. Even the term “internet” may not be especially precise or consistent in meaning as online functionality is now seamless and permeates all activities on a phone, computer, tablet, game system, or television. In order to focus the nomenclature on the variety of behaviors that cross devices and avoid the term addiction which may unnecessarily stigmatize game players and impede their seeking help, my colleagues and I have suggested the use of the term problematic interactive media use (PIMU) [ 3 – 6 ]. The term PIMU attempts to capture the broad spectrum of potential media use behaviors seen in clinical settings including gaming, information seeking, pornography use, and social media use without naming a specific behavior or type of media which could position the term for obsolescence [ 3 •].

A Focus on Gaming

Another approach to defining this issue has been to focus on internet games as they are seen as having unique features and elevated harm through excessive use [ 7 ]. In 2013 the American Psychiatric Association described internet gaming disorder (IGD) in its updated Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a condition needing further research in order to classify as a unique mental disorder [ 8 ]. The proposed clinical diagnosis of IGD includes persistent use of the internet to play games with associated distress or life impairment as well as endorsement of at least 5 of 9 symptoms including preoccupation with games, increased need to spend more time gaming, inability to reduce game time, lying to others about the amount of gaming, and using gaming to reduce negative mood [ 8 ]. Following suit, the World Health Organization included gaming disorder (GD) in its 11th revision of the International Classification of Diseases (ICD-11) [ 9 ]. These two diagnostic approaches both characterize problematic gaming as repetitive, persistent, lasting at least a year, and resulting in significant impairments of daily life [ 10 ]. While there is considerable overlap in the identified clinical symptoms (e.g., loss of control over gaming and continued use of gaming even when after negative consequences), the GD diagnosis does seem to focus on more severe levels of problematic use and worse functional impairment [ 10 ]. The inclusion of IGD and GD in these major diagnostic manuals have been seen as an opportunity for unification in the field around the conceptualization, and measurement of problematic gaming and resulting discussions have, to some extent, indicated increasing agreement [ 7 ].

However, in the years following the definition of IGD, numerous authors took umbrage with these diagnostic criteria pointing out limitations of the defined symptoms and calling into question the idea that there is consensus in the field around this diagnosis [ 11 ••]. For example, preoccupation with gaming, they argue, could represent a form of engagement similar to other types of engrossing activities rather than something pathological [ 11 ••]. Similarly, using gaming to avoid adverse moods is unlikely to differentiate problematic from casual gamers. The use of the term “internet” in the name of the condition was also met with resistance considering that it assumes that video games accessed through the internet are different from other video games in terms of their addictive qualities [ 11 ••]. Some argue that the field is lacking the unified definitions and extensive, foundational research necessary that must precede a diagnosis [ 12 ]. Finally, by focusing on gaming, IGD does not account for other potentially addictive online behaviors. There appears, however, not to be an easy solution to this concern. A broader conceptualization of the disorder has been seen as too general by some, but it seems untenable to create new diagnostic criteria for each specific online behavior. This complexity is evident even within the APA’s description of IGD when the manual states that “Internet gaming disorder” is “also commonly referred to as Internet use disorder, Internet addiction, or gaming addiction [ 8 ].”

Scales and Assessment

Building effective igd scales.

As evidence that much of the field is accepting IGD as a unifying conceptualization of problematic media use, numerous clinicians and scientist have investigated the DSM-5 criteria by designing and testing new scales or applying existing scales to this new framework. Some early testing utilized an interview procedure to confirm a 5-symptom cutoff for IGD, although a cutoff of 4 was adequate for differentiating between those suffering from IGD and healthy controls [ 13 ]. Scales such as the Internet Gaming Disorder Scale and its short form as well as the Internet Gaming Disorder Test (IGDT-10) have been designed and tested demonstrating that fairly short (e.g., 9 or 10 items) assessments can demonstrate strong psychometric properties, support the defined cutoff of 5 symptoms, and successfully measure a single construct [ 14 – 17 ]. Testing has been done on other assessment tools that are aligned with the IGD criteria including the Clinical Video Game Addiction Test which provided further support for the 5-item cutoff diagnosis [ 18 ] and the Chen Internet Addiction Scale—Gaming Version which identified its own cutoff [ 19 ]. This abundance of screeners and other instruments demonstrates how, as a result of the inclusion of IGD in the DSM-5, researchers and clinicians have access to numerous well-designed and tested assessments for problematic game play. On the other hand, the profusion of scales may also indicate that the field is still far from one regularly stated goal: a universal and standardized measurement tool.

Internet Addiction Scales

To further expand the assessment landscape, researchers and clinicians who prefer a broader conceptualization of this disorder, one more aligned with internet addiction rather than gaming disorder, have also created scales for research and clinical settings. The Chen Internet Addiction Scale is one of the earliest and most utilized scales [ 20 ]. Developed by applying established concepts from substance abuse and impulse control, it and its revised form have established internal reliability and criterion validity [ 21 ]. The designers of the 20-item Internet Addiction Test (IAT) used the criteria for pathological gambling as the basis of the test and designed it specifically to differentiate between casual and compulsive internet users [ 2 ]. The IAT has high internal reliability [ 22 ], a consistent factor structure across age categories [ 23 ], and is associated with expected comorbidities including depression [ 22 ] and attention-deficit disorders [ 24 ]. The 18-item Problematic and Risky Internet Use Screening Scale (PRIUSS) has three subscales—social consequences, emotional consequences, and risky/impulsive internet use—and a 3-item version was created that used one question from each subscale [ 25 , 26 ]. The strong psychometric properties of both versions of this scale are indicative of their value as tools for identifying adolescents and young adults struggling with their technology use.

Much like the measures of IGD, these internet addiction scales are more similar than dissimilar. They all assess a diverse array of experiences and consequences related to PIMU including its impact on social relationships, sleep, and aspects of mental health. In fact, some items from the different scales are almost identical. For example, the IAT asks, “Do you choose to spend more time online over going out with others?” the PRIUSS asks, “Do you choose to socialize online instead of in person?” and the CIAS asks how much this statement matches your experiences: “I find myself going online instead of spending time with friends.” The scales share an overall approach of asking about internet use in general rather than about specific online activities. While this allows the instruments to focus on the impulsive and risky aspects of internet use in general, it requires young people to differentiate between online and offline activities, a distinction that may no longer be relevant. Scales using this approach should continually be tested and revised as technology develops.

Considering the similarities of the scales, a researcher or clinician would likely be well served by any of them. However, even though the IAT and the CIAS both have identified diagnostic cutoffs, the availability of a 3-item pre-screener for the PRIUSS makes this instrument especially useful for inclusion in a battery of in-office measures. The PRIUSS does, however, require the adolescent or young adult patient to endorse behaviors that are worded in such a way that might activate feelings of judgment or reactance. For example, the question “Do you neglect your responsibilities because of the internet?” puts the onus directly on the user with little room for rationalizing an external cause. That said, the consistently high performance of this scale indicates the set of questions as a whole are successful at classifying problematic internet users.

Because the field lacks standardized language, reporting on the current prevalence of this issue requires the use of work that employs different definitions. However, the similarities across measures likely result in reasonably comparable prevalence rates. In a systematic review focusing on problematic gaming, reported rates varied from 0.6 (in Norway) to 50% (in Korea) with a median prevalence rate of 5.5% across all included studies and 2.0% for population-based studies [ 27 ]. A meta-analyses using data across multiple decades found a pooled prevalence of 4.6% with a range of .6 to 19.9% with higher frequencies in studies performed in the 1990s (12.1%), those with samples under 1000 (8.6%), those that utilized concepts based of psychological gambling (9.5%), and those performed in Asia (9.9%) and North America (9.4%) [ 28 ••].

Recent studies reinforce the variability of prevalence in different regions of the world. In a study of 7 European countries with a representative sample of 12,938, the prevalence of IGD was 1.6% with 5.1% being considered “at-risk” for IGD with little variation among countries [ 29 ]. In studies of individual countries, prevalence of IGD in Germany ranged from 1.16 [ 30 ] to 3.5% [ 31 ]. In Italy, 12.1% were classified as having problematic use and .4% as having internet addiction [ 32 ].

Countries in Asia showed similar disparities. In a review of 38 studies from countries defined by the authors as Southeast Asia (with most being from India), prevalence of internet addiction ranged from 0 to 47.4% [ 33 ]. Among middle and high school students in Japan, prevalence was 7.9% for problematic internet use and 15.9% for adaptive internet use, a lower cutoff of the diagnostic questionnaire [ 34 ]. In rural Thailand, 5.4% reached the cutoff for IGD [ 35 ], and in Taiwan 3.1% met that threshold [ 17 ]. Among 2666 urban middle school children in China, prevalence of IGD was 13.0% [ 36 ]. Finally, in rural South Korea, the prevalence of PIU was 21.6% among a sample of 1168 13- to 18-year-olds [ 37 ].

With such disparate findings from around the world, it seems that PIMU prevalence varies considerably from county to country and region to region. While this may be the case, summary findings from two large reviews do have similar final estimates—5.5% [ 27 ] and 4.6% [ 28 •• ]. This rate is also similar to the prevalence of youth “at-risk” for IGD across Europe (5.1%) [ 29 ] and for full IGD in rural Thailand (5.4%) [ 35 ]. While far from definitive, 5% might be our strongest general prevalence estimate given the evidence. There are some sample and study characteristics that seem to result in a higher prevalence. Unsurprisingly, rates are higher when less restrictive definitions of the disorder are used. There is also some evidence that rates are lower in Europe and higher in North America and Asia, but these results were not universal. If we accept a prevalence of approximately 5% in the USA, that would translate to approximately 1.5 million adolescents experiencing significant life consequences as a result of their struggles with digital technology. Understanding who is most at risk and how best to treat this problem is essential for comprehensive, contemporary adolescent medicine.

Potential Determinants of PIMU

Individual characteristics, demographic features, and psychosocial traits have all been identified as possible determinants of PIMU. Perhaps the most widely documented risk factor is being male. Prevalence among boys and young men has been found to be 2 [ 38 ], 3 [ 28 ••], or even 5 [ 27 ] times higher than among girls and young women. Throughout early adolescence PIMU increases with age, but peaks around 15–16 [ 39 ]. Indicators of lower socioeconomic status including less maternal education and a single parent household have been shown to increase the risk for PIMU [ 36 ].

Family Functioning

Young people’s family functioning also seems to play a role in their development of PIMU. Risk factors seem to include lower levels of family cohesion, more family conflict, and poorer family relationships [ 40 ]. The most frequent finding in a recent systematic review was that a worse parent-child relationship was associated with more problematic gaming [ 41 ]. Less time with parents, less affection from parents, more hostility from parents, and lower quality parenting were all family characteristics potentially indicated in the development of gaming problems [ 41 ]. Game play and other online social activities may serve as solace from difficult family lives as adolescents seeking treatment for gaming addiction report that they are motived to play in part by escapism and the draw of virtual friendships [ 42 ]. At the other end of the spectrum, positive parent-child relationships may be protective against the development of problematic gaming [ 41 ]. Additionally, parental monitoring of adolescents’ internet use can also reduce PIMU which, in turn, improves parent-child relationships [ 43 ]. Parents, it seems, have some prevention tools available to them which could improve their family functioning overall. Fathers appear to have a particularly influential role as their relationships with adolescents has been shown to be especially protective [ 41 , 43 ].

Personality Traits

Certain individual personality traits appear to be common among adolescents with media use issues potentially indicating that young people with these traits are predisposed to develop PIMU. PIMU sufferers regularly demonstrate limitations in areas related to self-control including higher levels of impulsivity. In two studies examining problematic smartphone use, one identified dysfunctional impulsivity and low self-control as two key risk factors [ 44 ] and the other found impulsivity to predict this behavior in their female participants [ 45 ]. Patients diagnosed with IGD also demonstrated higher levels of impulsivity than healthy controls [ 46 ]. A systematic review of research examining the personality traits predictive of IGD concludes that impulsivity plays a role in IGD and that certain aspects of this trait, such as high levels of urgency, are especially potent risk factors. [ 47 •].

In addition to impulsivity, behavior traits related to aggression and hostility are common among adolescents with media use problems. Aggressive tendencies were identified as a predictor of IGD by multiple studies in a recent review of the research [ 47 •]. In a large European survey study, adolescents who reported IGD had higher scores on rule-breaking and aggressive behaviors scales [ 29 ]. While it may seem that aggression findings are simply indicative of the observed gender differences, models that include gender as well as other traits that predict PIMU found that hostility was independently associated with problematic smartphone use [ 48 ] and conduct problems were predictive of problematic internet use [ 49 ].

Neuroticism, the tendency to feel nervous and to worry, has been identified as a potential predisposing factor for PIMU. Using the Big Five model of personality to investigate commonalities among young people with IGD, the authors of a recent review highlighted multiple studies linking neuroticism with PIMU and concluded that this work demonstrates a clear and consistent link [ 47 •]. Some of the strongest evidence comes from clinical samples in which young people seeking care for IGD showed higher levels of neuroticism than healthy controls [ 50 ]. Additionally, neuroticism may be an important trait that differentiates game players who have problematic use versus those who are simply heavily engaged with the games [ 51 ] perhaps in part because the control provided by video games is especially appealing to those with neurotic tendencies [ 50 ]. Neuroticism is a common element of internalizing mood disorders including anxiety and depression [ 52 ], which, as described below, are frequently comorbid with PIMU.

While it is clear that some traits are common among PIMU sufferers (and there are others not covered above), we must stop short of claiming a defining personality profile. Young people experiencing PIMU are likely to have as much diversity as they do similarity in their psychological and personality characteristics. Some of the most conclusive findings originate from clinical samples, but, because of limited specialized care opportunities, this work has been almost entirely conducted outside of the USA. Seeing as culture plays an important role in the development of personality, investigations are necessary to determine if our current knowledge is generalizable to the USA.

Neurobiology and Brain Function

Apart from individual characteristics and family functioning, there appear to be some neurobiological dysfunction that may characterize PIMU sufferers. Working from models based on the brain functioning in gambling and substance use addicts, researchers have looked for similarities with these disorders. Sussman and colleagues call attention to the viewpoint that people are not actually addicted to a substance or a behavior itself but rather to the brain’s response to the drug or activity [ 53 ••]. This perspective opens the door for digital entertainment obsession to be compared to substance use and gambling disorder. Video games and certain types of internet use have been shown to release dopamine at a rapid rate leading to immediate gratification and the potential for a repetitive response that can include compulsive behaviors and increased tolerance [ 53 ••]. In a simultaneous test of reward processing and inhibitory control, both behavioral and electroencephalography findings indicate adolescents with IGD demonstrate irregularities in both systems [ 54 • ]. Additionally, fMRI studies have documented neurobiological explanations for dysregulated reward processing, diminished impulse control, and other behavioral and cognitive patterns in IGD sufferers that are similar to those from people with gambling disorders [ 55 ]. Imaging studies have demonstrated that the brains of adolescents with internet addiction share at least one structural abnormality with brains of those with substance use disorder, namely, reduced thickness in the orbitofrontal cortex [ 56 ]. The evidence at hand seems to indicate that PIMU shares similarities in neural functioning and potentially some brain structures with other compulsive behaviors as well as substance use. However, there are still many fewer neuroimaging studies of PIMU sufferers than of substance users, and many of the existing studies are hindered by small, heterogeneous samples and lack of attention to comorbid conditions [ 55 ].

The observed similarities between PIMU and substance use disorder do not necessarily signify that compulsive technology use should be characterized as a behavioral addiction. In fact, there are strong reasons to consider other conceptualizations for this set of behaviors. Excessive use may be indicative of maladaptive coping [ 57 ] or the manifestation of existing self-regulatory problems [ 58 •]. Rather than being a novel disorder, PIMU behaviors may be symptoms of existing psychiatric problems being expressed within the digital environment [ 3 •]. If these underlying disorders are appropriate explanations for these behaviors, then, some argue, we should not classify the set of symptoms as a behavioral addiction [ 59 ]. Furthermore, there is limited evidence that stopping use results in serious withdrawal symptoms which is a key factor in some diagnostic tools [ 60 ].The term addiction may also convey a sense of stigma and potentially interfere with one’s likelihood for seeking help or leading to incorrect treatment [ 3 , 61 ]. A consistent set of observed, troublesome, comorbid disorders may support the possibility that existing problems drive problematic media use rather than the behavior indicating a uniquely diagnosable behavioral addiction.

Comorbidities

A core set of mental health problems comorbid with PIMU have been identified and include depression, attention deficit hyperactivity disorder (ADHD), anxiety, and autism [ 62 •]. As most of the research in this area is cross-sectional, the exact explanation for the association between PIMU and these other disorders is unknown and could include a one directional relationship (in either direction), a bi-directional relationship, or a common factor causing both issues [ 62 •]. Bearing in mind the complex etiology of these severe mental health issues, PIMU may very well arise from pre-existing mental health problems. The behaviors and environment afforded by excessive game play and internet use may also exacerbate certain symptoms of these disorders. The associations likely differ by unique co-occurring disorder as well as by the specific behaviors evident in an individual’s experience of PIMU. Longitudinal representative research along with additional clinical investigations examining different presentations of PIMU (especially using samples from the USA) is needed to fully understand this relationship.

Depression and Anxiety

Regardless of the specifics of the relationships, identifying the most common mental health issues that are comorbid with PIMU can help illuminate the disorder. Depression is consistently found to be predictive of problematic video game, internet, and smartphone use [ 63 – 65 ]. In a study comparing multiple predictors of the Internet Addiction Scale, level of depression had the strongest association even when considering demographics, personality traits, and future time perspective (i.e., the ability to envision and pursue future goals) [ 22 ]. Considering anxiety is closely related to depression, it is not surprising that it too has been shown to be linked to PIMU. Young people’s use of technology to cope with depression and anxiety likely explains at least some of these observed relationships, but a reciprocal relationship between PIMU and depression or anxiety is likely most realistic [ 64 , 66 ].

Seeing as impulsivity is a common trait of adolescents suffering from PIMU, it follows that ADHD is one of its most common comorbidities. In a recent review, 87% of the included studies found significant relationships between ADHD symptoms and PIMU [ 62 •]. Findings from a meta-analysis align with these results with studies consistently showing that PIMU is present at higher rates among those with ADHD from those without [ 67 ]. Furthermore, adolescents with ADHD show more severe symptoms of PIMU and are less likely to respond to treatment [ 67 , 68 ]. Ease of boredom, poor self-control, and other typical symptoms of ADHD are likely driving this association [ 67 ].

PIMU was shown to be prevalence in 45.5% of a small clinical sample of youth with Autism Spectrum Disorder (ASD) [ 69 ]. Youth with ASD have higher levels of compulsive internet use and video game play compared to healthy peers [ 70 ]. Online communication platforms especially those that occur within the well-defined ruleset of multiplayer games may be seen as less threatening and thereby particularly attractive to youth with ASD who desire connection but tend to lack well-developed social skills [ 4 ]. The coexistence of ADHD and ASD is an especially predictive combination with PIMU observed in 12.5% of patients with ADHD, 10.8% of those with ASD, and 20.0% of those with both disorders [ 71 ].

For clinicians hoping to better discriminate between adolescents who are heavily engaged with screen media and those who are experiencing problematic use, it is likely effective to attend carefully to young people with mental health issues commonly comorbid to PIMU. To inform on this effort, my colleagues and I have proposed the acronym A-SAD (ADHD, social anxiety, ASD,depression) to remember these key disorders [ 5 •]. While this suggestion is consistent with current evidence, research testing this approach is still necessary in order to understand its overall effectiveness in clinical settings.

Even though there is continued debate about the nomenclature around this issue and the appropriateness of labeling the problem an addiction or its own mental health diagnosis, adolescents around the world are seeking treatment to overcome their disordered media use and its consequences. As of yet, there is not an agreed upon approach for treating PIMU resulting in resourceful and skilled clinicians applying and adapting multiple approaches known to be effective to similar issues to this newer problem. For many years, there were few systematic investigations of these treatments, but recently the number of clinical trials has increased.

Cognitive Behavioral Therapy

With rigorous research in this field becoming more common, a recent review was able to rely more heavily on randomized clinical trials in reaching its conclusions [ 72 •]. This work identified 3 treatment possibilities as most heavily researched—cognitive behavioral therapy (CBT), pharmacological, and group/family therapies—however, approaches in all three were only classified as experimental [ 72 •]. CBT seeks to change problematic thought patterns and their resulting behaviors especially in terms of coping with psychological problems in healthy, direct ways. The approach of using CBT to address the cognitions of problematic users was proposed almost two decades ago and has been applied and adjusted to numerous populations and settings [ 73 ]. In a prototypical study, patients identified as having internet addiction and a comorbid disorder received CBT for 10 sessions and showed improvement in both internet use and anxiety [ 74 •]. Pooled effect sizes from studies of this treatment have demonstrated that overall, CBT is successful at reducing symptoms of depression and of IGD and slightly less so for anxiety [ 75 ••]. Although there is less evidence for CBT’s effectiveness at reducing game play, such a goal is less central as gaming is not inherently problematic [ 75 ••]. Dialectical behavior therapy, which is based on CBT but addresses emotions along with thoughts and behaviors, has also been applied to PIMU and seems to offer promise for future treatment [ 6 ].

Pharmacological Treatment

Other treatments including pharmacological and group and family therapies have not been the subject of as many research investigations as CBT, but findings from these areas do show encouraging effects. The general approach of pharmacological treatment has been to use medications to treat comorbid conditions or underlying pathologies of PIMU including depression [ 76 ], ADHD [ 77 ], obsessive-compulsive disorder (OCD) [ 78 ], and others. In an exemplar RCT of 114 adolescents and adults with IGD, the effectiveness of two antidepressants (escitalopram and bupropion) were investigated [ 79 ••]. Both were effective at reducing IGD, but bupropion also improved impulsivity, inattention, and mood problems which is consistent with its reported use as a treatment for ADHD [ 79 ••]. Following a similar protocol, researchers compared the effectiveness of two ADHD medications, a stimulant (methylphenidate) and non-stimulant (atomoxetine), on symptoms of both ADHD and IGD [ 80 ]. Both medications successfully reduced symptoms of IGD seemingly through their ability to regulate impulsivity [ 80 ]. Other studies reveal similar effects resulting in an overall conclusion that a pharmacological approach can be successful in reducing symptoms of both PIMU and comorbid disorders [ 81 ].

Group and Family Therapies

Group and family therapies are also being used to address PIMU. While group-based interventions that are 8-weeks or longer and include 9–12 people appear most effective [ 82 ], these approaches vary greatly making it difficult to determine which other aspects of the approach contribute to any observed successes. A systematic review describes four studies using single-family groups, multi-family groups, and school-based groups and implementing CBT-based approaches, novel psychotherapy approaches designed specifically for PIMU sufferers, and traditional family therapy approaches [ 81 ]. Group interventions have also been designed to prevent PIMU among adolescents although the effectiveness of this approach is still unknown [ 83 ]. Investigations of these treatments do show some promise. For example, a study of using multi-family group therapy found 20 out of 21 adolescent participants were no longer considered addicted to the internet following the six, 2-h sessions [ 84 ]. While the approach as a whole is based on strategies known to be effective in substance use and other adolescent problems, the heterogeneity of the therapies makes it difficult to draw any final conclusions.

There has been much advancement in identifying and treating PIMU over the last 5 years. The inclusion of IGD in the DSM-5 and of GD in the WHO’s ICD-11 has been the impetus for a growing consensus around terminology and approach. Considerable research has demonstrated that IGD can be assessed reliably and that the defined cutoffs effectively differentiate between those with and without the disorder. However, a large debate continues about whether the terminology and subsequent conceptual and clinical approaches should be based on a specific activity or broader set of behaviors. A framework that describes and addresses a multitude of behaviors that share certain determinants, comorbidities, and expressions can avoid the unsustainable situation of developing a new term and tactic for every problematic media behavior.

Additional research is necessary to more fully develop our clinical understanding and treatment approach to PIMU. Foundational, longitudinal work would help disentangle the direction of association between mental health problems and PIMU, and clinical investigations could continue to determine how therapy and medication can most effectively treat the condition. Clinical work investigating patient samples from the USA are very rare and are necessary to build awareness and increase resources available to treat the problem. Additionally, new research should explore the impact of the COVID-19 pandemic on PIMU. As screens have been relied upon for essential purposes including education, communication, and social connectedness, use has inevitably risen, and youth previously balancing media use and other activities may find themselves struggling. While our knowledge has grown substantially in this area, there are still questions that need to be answered before we can effectively treat this modern facet of adolescent health.

Acknowledgments

The author would like to thank Jill Kavanaugh, MLIS for her assistance with the literature searches for this review.

Compliance with Ethical Standards

The author declares that he has no conflicts of interest.

This article does not contain any studies with human or animal subjects performed by any of the authors.

This article is part of the Topical Collection on Adolescent Medicine

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Research Paper: Internet Addiction in High School Students and Its Relationship With the Symptoms of Mental Disorders

Objectives: One of the problems that the Internet has created is a virtual addiction or addiction to the global web world causing adverse psychological behavioral effects on the users. One of the groups at higher risk for Internet addiction is teenagers, and since Internet addiction will lead to academic failure in students, evaluating it among them and its relationship with signs of mental disorders seems necessary. Therefore, the aim of this research was to study Internet addiction and its relationship with the symptoms of mental disorders. Methods: This study was descriptive and correlational design. The sample population for the present study consisted of all male and female high school students of the academic year 2013-2014 in district 5 of Tehran. Among these individuals, a sample of 400 participants was randomly selected for analysis using cluster sampling method. To collect data, Internet addiction test and Brief Symptom Inventory were used, and data were analyzed using T-Test, Pearson correlation coefficient and multiple regression analysis. Results: The results showed that there is no significant difference between prevalence of Internet addiction in male and female high school students in district 5 of Tehran. However, there is a significant positive relationship between Internet addiction variables and symptoms of mental disorders and particularly, independent variables of psychosis and anxiety from the signs of mental disorders had a profound effect on Internet addiction. Discussion: Internet addiction causes negative effects on individuals. As prevention is better than treatment and according to this study, it is necessary to take this phenomenon into consideration as a psychological problem that often involves the younger generation who are responsible for future society construction and through education in families, schools and universities, the culture of proper use of computers, in particular the Internet and its facilities should be replaced with the false methods.

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The present piece of research work is to study influence of Internet Addiction on the Mental health of Adolescents students. 100 college students comprised the sample for the study. Tools used to measure the above mentioned variables were Internet Addiction Test by Dr. Kimberly Young (1998) to measure Internet Addiction. It consists of 20 items that measures mild, moderate and severe level of internet addiction. Mental Health was measured by Mental Health Inventory by Dr. Jagdish and Dr. A.K. Srivastava. The major findings of the present study are a negative correlation of-0.456 has been found between these two variables. A significance difference has been found between the mental health of low and high internet user college students. A significance difference between the mental health of high internet user girls and boys college students at the 0.05 level of significance. A significance significant difference between the mental health of low internet user boys and girls college students at the 0.05 level of significance. furthermore it was found that no significant difference has been found between the mental health of high internet user college students in rural and urban areas and no significant difference has been found between the mental health of low internet user college students in rural and urban areas

Betül Aktaş

Objective: In this present study, the aim was to investigate the level of internet addiction and the effects of the level of internet addiction on health, based on fam ilies’ and children’s viewpoints. Methods: The population of the descriptive of study include d 1410 students. The study data were collected from the participating students and their families separately. The study data were collected from the participating students and their families separatel y. Data collected from students: Personal Informat ion Form, Internet Addiction Test (IAT) was used. Data collec ted from families: Family Personal Information Form and Family-Child Internet Addiction Test (PCIAT) were u sed. Results: In conclusion, according to their IAT scores, of t he students, 91.2% were not internet addicted, 7.9% were likely to be internet addicted, and 0.9% were int rnet addicted. According to their PCIAT scores, of the students, 96.5% had no symptoms and 3.5% had a limi ted number of symptoms. The studen...

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The aim of the research is to examine the internet addiction of adolescents according to their genders, the type of their high-schools and class level, the time interval that they use internet most widely, their internet usage duration and usage purpose. For that, it is studied with 335 high-school students in Elazig city of Turkey in 2015. The internet addiction scale that Young (1998) developed was used to determine internet addiction of adolescents. In the analysis of data, t-test and unilateral variance analysis were used. At the result of analysis, the mean score of that adolescents got by internet addiction scale was determined as 69 , 2 = X. In analysis between variables it was seen that the internet addiction level of Science-High School students was lower compared to Anatolian and Vocational High-School students. It was observed that the more the usage duration increases the more the internet addiction increases. It was determined the students who use internet mostly for games or social media are more addicted. Besides; as statistical, a significant difference wasn't determined between genders, classes and the variables that internet is mostly used.

Asean Journal of Psychiatry

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Objective: Internet addiction is defined as mismanagement of internet use that causes mental, social and occupational problems. Thus, the assessment of prevalence of this disorder can lead to preventive measures and appropriate treatment to prevent its spread. Methods: In this cross-sectional study, prevalence of internet addiction disorder was assessed in Rafsanjan University of Medical Sciences, Rafsanjan, Iran in 2012. Stratified random sample was used to select 224 students. Demographic data were recorded and Internet Addiction test Test (IAT) questionnaire was administrated. Results: Out off 224 students participating in the study, 86 (38.4%) were males and 138 (61.6%) were female with a mean age of 21.05± 0.1 years. Most of the students (42.4%) were using the internet "under one hour" and the lowest (4%) "More than six hours". Mean test score of IAT was 24.81 ± 1.08 (mild addiction). In terms of internet addiction, 95 (42.4%) cases were normal users, 115 (...

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Cultural Relativity and Acceptance of Embryonic Stem Cell Research

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

INTRODUCTION

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

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

I.     Global Cultural Perspective of Embryonic Stem Cells

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

a.     US and Rights-Based Cultures

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

b.     Ubuntu and Collective Cultures

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

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

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

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

c.     Asia

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

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

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

d.     Middle East

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

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

e.     Europe

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

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

II.     Religious Perspectives on ESC

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

The Qur'an states:

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

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

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

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

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

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

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

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

III.     A Flexible Ethical Approach

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

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

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

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

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

IV.     Concerns

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Mifrah Hayath

SM Candidate Harvard Medical School, MS Biotechnology Johns Hopkins University

Olivia Bowers

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

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