harvard referencing online research paper

Citation guides

All you need to know about citations

How to cite an online report in Harvard

To cite an online report in a reference entry in Harvard style include the following elements:

• Author or organization: Give the last name and initials (e. g. Watson, J.) of up to three authors with the last name preceded by 'and'. For four authors or more include the first name followed by et al., unless your institution requires referencing of all named authors.
• Year of publication: Give the year in round brackets.
• Title of the online report: Give the title as presented in the source. Only the first letter of the first word and proper nouns are capitalized.
• Place of publication: List the city and the US state using the two-letter abbreviation. Spell out country names if outside of the UK or the USA.
• Publisher: Give the name of the publisher.
• URL: Give the full URL of the web page including the protocol (http:// or https://).
• Date of access: Give the day month and year.

Here is the basic format for a reference list entry of an online report in Harvard style:

Author or organization . ( Year of publication ) Title of the online report . Place of publication : Publisher . Available at: URL (Accessed: Date of access ).

Take a look at our reference list examples that demonstrate the Harvard style guidelines in action:

A report retrieved online

Department of Making Pregnancy Safer . ( 2006 ) Annual report, 2005 . Available at: https://apps.who.int/ iris/bitstream/handle/10665/69505/WHO_MPS_07.01_eng.pdf (Accessed: 6 September 2010 ).

Bureau of Fiscal Service, Department of Treasury . ( 2018 ) Financial Report of the United States Government . Available at: https://fiscal.treasury.gov/files/reports-statements/financial-report/2018/03282019-FR(Final).pdf"> (Accessed: 2 September 2019 ).

This citation style guide is based on the Cite Them Right (10 th edition) Harvard referencing guide.

More useful guides

• UQ Harvard referencing style: Report
• Citing & Referencing: Harvard Style
• Harvard referencing tutorial

More great BibGuru guides

• AMA: how to cite an online journal article
• AMA: how to cite an online newspaper article
• Harvard: how to cite a film

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Free Harvard Referencing Generator

Generate accurate Harvard reference lists quickly and for FREE, with MyBib!

🤔 What is a Harvard Referencing Generator?

A Harvard Referencing Generator is a tool that automatically generates formatted academic references in the Harvard style.

It takes in relevant details about a source -- usually critical information like author names, article titles, publish dates, and URLs -- and adds the correct punctuation and formatting required by the Harvard referencing style.

The generated references can be copied into a reference list or bibliography, and then collectively appended to the end of an academic assignment. This is the standard way to give credit to sources used in the main body of an assignment.

👩‍🎓 Who uses a Harvard Referencing Generator?

Harvard is the main referencing style at colleges and universities in the United Kingdom and Australia. It is also very popular in other English-speaking countries such as South Africa, Hong Kong, and New Zealand. University-level students in these countries are most likely to use a Harvard generator to aid them with their undergraduate assignments (and often post-graduate too).

🙌 Why should I use a Harvard Referencing Generator?

A Harvard Referencing Generator solves two problems:

• It provides a way to organise and keep track of the sources referenced in the content of an academic paper.
• It ensures that references are formatted correctly -- inline with the Harvard referencing style -- and it does so considerably faster than writing them out manually.

A well-formatted and broad bibliography can account for up to 20% of the total grade for an undergraduate-level project, and using a generator tool can contribute significantly towards earning them.

⚙️ How do I use MyBib's Harvard Referencing Generator?

Here's how to use our reference generator:

• If citing a book, website, journal, or video: enter the URL or title into the search bar at the top of the page and press the search button.
• Choose the most relevant results from the list of search results.
• Our generator will automatically locate the source details and format them in the correct Harvard format. You can make further changes if required.
• Then either copy the formatted reference directly into your reference list by clicking the 'copy' button, or save it to your MyBib account for later.

MyBib supports the following for Harvard style:

🍏 What other versions of Harvard referencing exist?

There isn't "one true way" to do Harvard referencing, and many universities have their own slightly different guidelines for the style. Our generator can adapt to handle the following list of different Harvard styles:

• Cite Them Right
• Manchester Metropolitan University (MMU)
• University of the West of England (UWE)

Daniel is a qualified librarian, former teacher, and citation expert. He has been contributing to MyBib since 2018.

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Format Your Paper & Cite Your Sources

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• Citing Sources
• Avoid Plagiarism
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• APA Style, 7th Edition
• Chicago Style

What is Harvard Style?

What you need to know, harvard style tutorial.

• Other Styles
• Annotated Bibliographies
• How to Create an Attribution

Harvard Style

The Harvard referencing system is known as the Author-Date style . It emphasizes the name of the creator of a piece of information and the date of publication, with the list of references in alphabetical order at the end of your paper.

Unlike other citation styles, there is no single, definitive version of Harvard Style. Therefore, you may see a variation in features such as punctuation, capitalization, abbreviations, and the use of italics. 

Always check with your instructor and follow the rules he or she gives you.

• Harvard Style Guidelines Your class handout
• Harvard Referencing Quick Guide From Staffordshire University

Harvard Style will affect your paper in two places:

• In-text citations in the body of your paper, and
• The reference list at the end of your paper
• All in-text citations should be listed in the reference list at the end of your paper.
• Reference list entries need to contain all the information that someone reading your paper would need in order to find your source.
• Reference lists in Harvard Style are arranged alphabetically by first author.
• Begin your Reference list on a new page after your text and number it consecutively.

Sample References List:

Click on the Links Below to See Additional Examples:

• Sample Paper Paper provided by Kurt Olson
• Harvard Citation Examples Document created by The University of Western Australia

Click on the image below to launch this tutorial that was created by the University of Leeds. The section on Citing in Text is especially useful.

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• Last Updated: May 1, 2024 2:04 PM
• URL: https://libguides.mjc.edu/citeyoursources

Except where otherwise noted, this work is licensed under CC BY-SA 4.0 and CC BY-NC 4.0 Licenses .

Harvard Citation Guide: Getting Started

• Getting Started
• How do I Cite?
• In-Text Citations
• Reference List
• Additional Resources

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What is Harvard Style?

Harvard style is a set of rules for research papers and publications. It is one of the most widely used styles in the world.

In Harvard, you must cite sources that you have paraphrased, quoted, or consulted to write your research paper. Cite your sources in two places:

• In the body of your paper (in-text citation).
• In the Reference list at the end of your paper (full bibliographic reference).

Digital Object Identifiers (DOI)

Also known as a permalink, a DOI, or  digital object identifier , is an article's permanent online location. DOIs are used for a variety of academic and non-academic sources that are located online. 

Include a DOI for all works that have a DOI. If an online work has both a DOI and a URL, include only the DOI; if the source only has a URL, include the URL.

Cite Them Right 11th edition

Many of the disciplines and institutions that favor Harvard style use  Cite Them Right 11th edition  as their primary manual.

Cite Them Right   This is the official website for Cite Them Right.

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Quick guide to Harvard referencing (Cite Them Right)

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There are different versions of the Harvard referencing style. This guide is a quick introduction to the commonly-used Cite Them Right version. You will find further guidance available through the OU Library on the Cite Them Right Database .

For help and support with referencing and the full Cite Them Right guide, have a look at the Library’s page on referencing and plagiarism . If you need guidance referencing OU module material you can check out which sections of Cite Them Right are recommended when referencing physical and online module material .

This guide does not apply to OU Law undergraduate students . If you are studying a module beginning with W1xx, W2xx or W3xx, you should refer to the Quick guide to Cite Them Right referencing for Law modules .

Table of contents

In-text citations and full references.

• Secondary referencing
• Page numbers
• Citing multiple sources published in the same year by the same author

Full reference examples

Referencing consists of two elements:

• in-text citations, which are inserted in the body of your text and are included in the word count. An in-text citation gives the author(s) and publication date of a source you are referring to. If the publication date is not given, the phrase 'no date' is used instead of a date. If using direct quotations or you refer to a specific section in the source you also need the page number/s if available, or paragraph number for web pages.
• full references, which are given in alphabetical order in reference list at the end of your work and are not included in the word count. Full references give full bibliographical information for all the sources you have referred to in the body of your text.

To see a reference list and intext citations check out this example assignment on Cite Them Right .

Difference between reference list and bibliography

a reference list only includes sources you have referred to in the body of your text

a bibliography includes sources you have referred to in the body of your text AND sources that were part of your background reading that you did not use in your assignment

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Examples of in-text citations

You need to include an in-text citation wherever you quote or paraphrase from a source. An in-text citation consists of the last name of the author(s), the year of publication, and a page number if relevant. There are a number of ways of incorporating in-text citations into your work - some examples are provided below. Alternatively you can see examples of setting out in-text citations in Cite Them Right .

Note: When referencing a chapter of an edited book, your in-text citation should give the author(s) of the chapter.

Online module materials

(Includes written online module activities, audio-visual material such as online tutorials, recordings or videos).

When referencing material from module websites, the date of publication is the year you started studying the module.

Surname, Initial. (Year of publication/presentation) 'Title of item'. Module code: Module title . Available at: URL of VLE (Accessed: date).

OR, if there is no named author:

The Open University (Year of publication/presentation) 'Title of item'. Module code: Module title . Available at: URL of VLE (Accessed: date).

Rietdorf, K. and Bootman, M. (2022) 'Topic 3: Rare diseases'. S290: Investigating human health and disease . Available at: https://learn2.open.ac.uk/mod/oucontent/view.php?id=1967195 (Accessed: 24 January 2023).

The Open University (2022) ‘3.1 The purposes of childhood and youth research’. EK313: Issues in research with children and young people . Available at: https://learn2.open.ac.uk/mod/oucontent/view.php?id=1949633&section=1.3 (Accessed: 24 January 2023).

You can also use this template to reference videos and audio that are hosted on your module website:

The Open University (2022) ‘Video 2.7 An example of a Frith-Happé animation’. SK298: Brain, mind and mental health . Available at: https://learn2.open.ac.uk/mod/oucontent/view.php?id=2013014&section=4.9.6 (Accessed: 22 November 2022).

The Open University (2022) ‘Audio 2 Interview with Richard Sorabji (Part 2)’. A113: Revolutions . Available at: https://learn2.open.ac.uk/mod/oucontent/view.php?id=1960941&section=5.6 (Accessed: 22 November 2022).

Note: if a complete journal article has been uploaded to a module website, or if you have seen an article referred to on the website and then accessed the original version, reference the original journal article, and do not mention the module materials. If only an extract from an article is included in your module materials that you want to reference, you should use secondary referencing, with the module materials as the 'cited in' source, as described above.

Surname, Initial. (Year of publication) 'Title of message', Title of discussion board , in Module code: Module title . Available at: URL of VLE (Accessed: date).

Fitzpatrick, M. (2022) ‘A215 - presentation of TMAs', Tutor group discussion & Workbook activities , in A215: Creative writing . Available at: https://learn2.open.ac.uk/mod/forumng/discuss.php?d=4209566 (Accessed: 24 January 2022).

Note: When an ebook looks like a printed book, with publication details and pagination, reference as a printed book.

Surname, Initial. (Year of publication) Title . Edition if later than first. Place of publication: publisher. Series and volume number if relevant.

For ebooks that do not contain print publication details

Surname, Initial. (Year of publication) Title of book . Available at: DOI or URL (Accessed: date).

Example with one author:

Bell, J. (2014) Doing your research project . Maidenhead: Open University Press.

Adams, D. (1979) The hitchhiker's guide to the galaxy . Available at: http://www.amazon.co.uk/kindle-ebooks (Accessed: 23 June 2021).

Example with two or three authors:

Goddard, J. and Barrett, S. (2015) The health needs of young people leaving care . Norwich: University of East Anglia, School of Social Work and Psychosocial Studies.

Example with four or more authors:

Young, H.D. et al. (2015) Sears and Zemansky's university physics . San Francisco, CA: Addison-Wesley.

Note: You can choose one or other method to reference four or more authors (unless your School requires you to name all authors in your reference list) and your approach should be consistent.

Note: Books that have an editor, or editors, where each chapter is written by a different author or authors.

Surname of chapter author, Initial. (Year of publication) 'Title of chapter or section', in Initial. Surname of book editor (ed.) Title of book . Place of publication: publisher, Page reference.

Franklin, A.W. (2012) 'Management of the problem', in S.M. Smith (ed.) The maltreatment of children . Lancaster: MTP, pp. 83–95.

Surname, Initial. (Year of publication) 'Title of article', Title of Journal , volume number (issue number), page reference.

If accessed online:

Surname, Initial. (Year of publication) 'Title of article', Title of Journal , volume number (issue number), page reference. Available at: DOI or URL (if required) (Accessed: date).

Shirazi, T. (2010) 'Successful teaching placements in secondary schools: achieving QTS practical handbooks', European Journal of Teacher Education , 33(3), pp. 323–326.

Shirazi, T. (2010) 'Successful teaching placements in secondary schools: achieving QTS practical handbooks', European Journal of Teacher Education , 33(3), pp. 323–326. Available at: https://libezproxy.open.ac.uk/login?url=https://search.ebscohost.com/log... (Accessed: 27 January 2023).

Barke, M. and Mowl, G. (2016) 'Málaga – a failed resort of the early twentieth century?', Journal of Tourism History , 2(3), pp. 187–212. Available at: https://doi.org/10.1080/1755182X.2010.523145

Surname, Initial. (Year of publication) 'Title of article', Title of Newspaper , Day and month, Page reference.

Surname, Initial. (Year of publication) 'Title of article', Title of Newspaper , Day and month, Page reference if available. Available at: URL (Accessed: date).

Mansell, W. and Bloom, A. (2012) ‘£10,000 carrot to tempt physics experts’, The Guardian , 20 June, p. 5.

Roberts, D. and Ackerman, S. (2013) 'US draft resolution allows Obama 90 days for military action against Syria', The Guardian , 4 September. Available at: http://www.theguardian.com/world/2013/sep/04/syria-strikes-draft-resolut... (Accessed: 9 September 2015).

Surname, Initial. (Year that the site was published/last updated) Title of web page . Available at: URL (Accessed: date).

Organisation (Year that the page was last updated) Title of web page . Available at: URL (Accessed: date).

Robinson, J. (2007) Social variation across the UK . Available at: https://www.bl.uk/british-accents-and-dialects/articles/social-variation... (Accessed: 21 November 2021).

The British Psychological Society (2018) Code of Ethics and Conduct . Available at: https://www.bps.org.uk/news-and-policy/bps-code-ethics-and-conduct (Accessed: 22 March 2019).

Note: Cite Them Right Online offers guidance for referencing webpages that do not include authors' names and dates. However, be extra vigilant about the suitability of such webpages.

Surname, Initial. (Year) Title of photograph . Available at: URL (Accessed: date).

Kitton, J. (2013) Golden sunset . Available at: https://www.jameskittophotography.co.uk/photo_8692150.html (Accessed: 21 November 2021).

stanitsa_dance (2021) Cossack dance ensemble . Available at: https://www.instagram.com/p/COI_slphWJ_/ (Accessed: 13 June 2023).

Note: If no title can be found then replace it with a short description.

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To be made up of:

• Author or organisation.
• Year of publication (in round brackets).
• Title of report (in italics).
• Working paper series and/or number (if available).
• Place of publication: publisher (if available).

If accessed on the internet, add:

• Available at: URL/DOI.
• (Accessed: date).

In-text citation:

(Malter, 2014).

Reference list:

Malter, D. (2014). Eclipsed and confounded identities: when high-status affiliations impede organizational growth . Harvard Business School Strategy Unit Working Paper No. 15-019. Available at https://www.hbs.edu/faculty/Pages/item.aspx?num=48092  (Accessed: 10 February 2015).

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Citing isn’t something you usually think about, but it’s important nonetheless. You already do it in your everyday life without realising it. Have you ever said, “I heard on XYZ News that . . . “, or “I read in XYZ that those two celebrities are dating”, or even “Mom said that you can’t do that”. By saying where you got your information, you are casually citing a source. We do this because it gives credibility to what we say, but also because it credits the originator of the information. It also allows others to follow up if they need more information. Formal citing done for papers and projects takes this a step further. In addition to the reasons mentioned above, citing sources in academia provides evidence of your research process and helps you avoid plagiarism. Plagiarism is a word you never want to hear describing your work. You’ve probably seen headlines in the news and heard stories in school about the negative consequences of plagiarism. It’s not good but it is preventable. By creating references and citations with Cite This For Me™ tools you’re taking steps to help avoid this.

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Harvard Style Guide: Journal article ePublication (ahead of print)

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Journal article epublication (ahead of print)

Reference : Author(s) Last name, Initials. (Year) ‘Article title’, Journal Title (published online ahead of print Day Month). Available at: DOI/URL (Accessed Day Month Year).

Example : Hawke, J., Wadsworth, S., & DeFries, J. (2006) ‘Genetic influences on reading difficulties in boys and girls: the Colorado twin study’, Dyslexia (published online ahead of print 24 September). Available at: http://www3.interscience.wiley.com/cgi-bin/fulltext/112098736/PDFSTART  (Accessed 10 October 2006).

In-Text-Citation :

• Author(s) Last name (Year)
• (Author(s) Last name, Year)
• Hawke, Wadsworth and DeFries (2006) argue ….
• Others have shown (Hawke, Wadsworth and DeFries, 2006).... 

Note: In the absence of clear guidelines from the title "Cite Them Right", this is how UCD Library have interpreted online advice on referencing ahead of print journal publications.

Still unsure what in-text citation and referencing mean? Check  here .

Still unsure why you need to reference all this information? Check  here .

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Home / Guides / Citation Guides / Harvard Referencing / Harvard Referencing Style Examples / How to reference an image in Harvard style

How to reference an image in Harvard style

Referencing images can be confusing. Do you reference the photographer or the subject of the image itself? Do you include where you saw or found the image? What if you took the photograph yourself? This guide will help clear up the confusion!  

Below, the guide will cover how to cite images in different scenarios, both as an in-text citation and a reference. For each scenario, you will be given a citation structure, along with examples to illustrate each case.

Online images/photographs  

Today, finding and citing a digital or online image is simple. You’ll need the following information:

• Photographer’s name
• (Year published)  
• Title of the photograph, italizised
• Available at: URL (Accessed: the date you sourced the image)  

In-text citation structure and example:

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Models were stratified by age, cohort (sex), and calendar time, and adjusted for Southern European/Mediterranean ancestry (yes/no), married (yes/no), living alone (yes/no), smoking status (never, former, current smoker 1-14 cigarettes/d, 15-24 cigarettes/d, or ≥25 cigarettes/d), physical activity (<3.0, 3.0-8.9, 9.0-17.9, 18.0-26.9, ≥27.0 metabolic equivalent of task–h/wk), multivitamin use (yes/no), history of hypertension (yes/no), history of hypercholesterolemia (yes/no), history of diabetes (yes/no), in women postmenopausal status and menopausal hormone use (premenopausal, postmenopausal [no, past, or current hormone use]), total energy intake (kcal/d), family history of dementia (yes/no), history of depression (yes/no), census socioeconomic status (9-variable score, in quintiles), and body mass index calculated as weight in kilograms divided by height in meters squared (<23, 23-25, 25-30, 30-35, ≥35). Pooled results were obtained by pooling the datasets of the cohorts. AMED score is without monounsaturated:saturated fats intake ratio component. AHEI score is without polyunsaturated fats intake component. HR indicates hazard ratio.

a Reference value.

b P  < .05.

Substitution analysis of 5 g/d intake of olive oil for the equivalent amount of butter, other vegetable oils, mayonnaise, and margarine. All Cox proportional hazards models were stratified by age and calendar time. Models were adjusted for Southern European/Mediterranean ancestry (yes/no), married (yes/no), living alone (yes/no), smoking status (never, former, current smoker 1-14 cigarettes/d, 15-24 cigarettes/d, or ≥25 cigarettes/d), alcohol intake (0, 0.1-4.9, 5.0-9.9, 10.0-14.9, and ≥15.0 g/d), physical activity (<3.0, 3.0-8.9, 9.0-17.9, 18.0-26.9, ≥27.0 metabolic equivalent of task–h/wk), multivitamin use (yes/no), history of hypertension (yes/no), history of hypercholesterolemia (yes/no), in women postmenopausal status and menopausal hormone use (premenopausal, postmenopausal [no, past, or current hormone use]), total energy intake (kcal/d), family history of dementia (yes/no), history of depression (yes/no), census socioeconomic status (9-variable score, in quintiles), body mass index calculated as weight in kilograms divided by height in meters squared (<23, 23-25, 25-30, 30-35, ≥35), red meat, fruits and vegetables, nuts, soda, whole grains intake (in quintiles), and trans-fat. Pooled results were obtained by pooling the data sets of the cohorts and Cox proportional hazards model 3 was further stratified by cohort (sex). HR indicates hazard ratio.

eTable 1. Odds Ratios for Dementia-Related Mortality by APOE4 Allelic Dosage

eTable 2. Risk of Death With Dementia (Composite Outcome) According to Categories of Total Olive Oil

eTable 3. Joint Associations of Olive Oil Intake and AMED (A), and AHEI (B) With Dementia-Related Mortality Risk

eTable 4. Risk of Dementia-Related Mortality According to Categories of Total Olive Oil in the Genomic DNA Subsample

eFigure. Subgroup Analyses for 5g/d Increase in Olive Oil Intake With Dementia-Related Mortality Risk

eTable 5. Risk of Dementia-Related Mortality According to Categories of Total Olive Oil Without Stopping Diet Update Upon Report of Intermediate Non-Fatal Events

eTable 6. Risk of Dementia Mortality According to Categories of Total Olive Oil Applying a 4-Year Lag Period Between Dietary Intake and Dementia Mortality

eTable 7. Risk of Dementia-Related Mortality According to Categories of Total Olive Oil Adjusting for Other Covariates

eTable 8. Risk of Mortality From Dementia and Other Causes of Death According to Categories of Total Olive Oil Applying a Competing Risk Model

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Tessier A , Cortese M , Yuan C, et al. Consumption of Olive Oil and Diet Quality and Risk of Dementia-Related Death. JAMA Netw Open. 2024;7(5):e2410021. doi:10.1001/jamanetworkopen.2024.10021

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Consumption of Olive Oil and Diet Quality and Risk of Dementia-Related Death

• 1 Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
• 2 School of Public Health, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
• 3 Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
• 4 Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
• 5 Department of Public Health and Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark

Question   Is the long-term consumption of olive oil associated with dementia-related death risk?

Findings   In a prospective cohort study of 92 383 adults observed over 28 years, the consumption of more than 7 g/d of olive oil was associated with a 28% lower risk of dementia-related death compared with never or rarely consuming olive oil, irrespective of diet quality.

Meaning   These results suggest that olive oil intake represents a potential strategy to reduce dementia mortality risk.

Importance   Age-standardized dementia mortality rates are on the rise. Whether long-term consumption of olive oil and diet quality are associated with dementia-related death is unknown.

Objective   To examine the association of olive oil intake with the subsequent risk of dementia-related death and assess the joint association with diet quality and substitution for other fats.

Design, Setting, and Participants   This prospective cohort study examined data from the Nurses’ Health Study (NHS; 1990-2018) and Health Professionals Follow-Up Study (HPFS; 1990-2018). The population included women from the NHS and men from the HPFS who were free of cardiovascular disease and cancer at baseline. Data were analyzed from May 2022 to July 2023.

Exposures   Olive oil intake was assessed every 4 years using a food frequency questionnaire and categorized as (1) never or less than once per month, (2) greater than 0 to less than or equal to 4.5 g/d, (3) greater than 4.5 g/d to less than or equal to 7 g/d, and (4) greater than 7 g/d. Diet quality was based on the Alternative Healthy Eating Index and Mediterranean Diet score.

Main Outcome and Measure   Dementia death was ascertained from death records. Multivariable Cox proportional hazards regressions were used to estimate hazard ratios (HRs) and 95% CIs adjusted for confounders including genetic, sociodemographic, and lifestyle factors.

Results   Of 92 383 participants, 60 582 (65.6%) were women and the mean (SD) age was 56.4 (8.0) years. During 28 years of follow-up (2 183 095 person-years), 4751 dementia-related deaths occurred. Individuals who were homozygous for the apolipoprotein ε4 ( APOE ε4 ) allele were 5 to 9 times more likely to die with dementia. Consuming at least 7 g/d of olive oil was associated with a 28% lower risk of dementia-related death (adjusted pooled HR, 0.72 [95% CI, 0.64-0.81]) compared with never or rarely consuming olive oil ( P for trend < .001); results were consistent after further adjustment for APOE ε4 . No interaction by diet quality scores was found. In modeled substitution analyses, replacing 5 g/d of margarine and mayonnaise with the equivalent amount of olive oil was associated with an 8% (95% CI, 4%-12%) to 14% (95% CI, 7%-20%) lower risk of dementia mortality. Substitutions for other vegetable oils or butter were not significant.

Conclusions and Relevance   In US adults, higher olive oil intake was associated with a lower risk of dementia-related mortality, irrespective of diet quality. Beyond heart health, the findings extend the current dietary recommendations of choosing olive oil and other vegetable oils for cognitive-related health.

One-third of older adults die with Alzheimer disease or another dementia. 1 While deaths from diseases such as stroke and heart disease have been decreasing over the past 20 years, age-standardized dementia mortality rates have been on the rise. 2 The Mediterranean diet has gained in popularity owing to its recognized, multifaceted health benefits, particularly on cardiovascular outcomes. 3 Accruing evidence suggests this dietary pattern also has a beneficial effect on cognitive health. 4 As part of the Mediterranean diet, olive oil may exert anti-inflammatory and neuroprotective effects due to its high content of monounsaturated fatty acids and other compounds with antioxidant properties such as vitamin E and polyphenols. 5 A substudy conducted as part of the Prevencion con Dieta Mediterranea (PREDIMED) randomized trial provided evidence that higher intake of olive oil for 6.5 years combined with adherence to a Mediterranean diet was protective of cognitive decline when compared with a low-fat control diet. 6 - 8

Given that most previous studies on olive oil consumption and cognition were conducted in Mediterranean countries, 7 - 10 studying the US population, where olive oil consumption is generally lower, could offer unique insights. Recently, we showed that olive oil consumption was associated with a lower risk of total and cause-specific mortality in large US prospective cohort studies, including a 29% (95% CI, 22%-36%) lower risk for neurodegenerative disease mortality in participants who consumed more than 7 g/d of olive oil compared with little or none. 11 However, this previous analysis was not designed to examine the association of olive oil and diet quality with dementia-related mortality, and therefore the latter remains unclear.

In this study, we examined the association between total olive oil consumption and the subsequent risk of dementia-related mortality in 2 large prospective studies of US women and men. Additionally, we evaluated the joint associations of diet quality (adherence to the Mediterranean diet and Alternative Healthy Eating Index [AHEI] score) and olive oil consumption with the risk of dementia-related mortality. We also estimated the difference in the risk of dementia-related mortality when other dietary fats were substituted with an equivalent amount of olive oil.

Analyses were performed in 2 large US prospective cohorts: the Nurses’ Health Study I (NHS) and the Health Professionals Follow-Up Study (HPFS). The NHS was initiated in 1976 and recruited 121 700 US female registered nurses aged 30 to 55 years. 12 The HPFS was established in 1986 and included 51 525 male health professionals aged 40 to 75 years. 13 The cohorts have been described elsewhere. 12 , 13 Lifestyle factors and medical history were assessed biennially through mailed questionnaires, with a follow-up rate greater than 90%. Baseline for this analysis was 1990, which is when the food frequency questionnaires (FFQs) first included information on olive oil consumption.

Participants with a history of cardiovascular disease (CVD) or cancer at baseline, with missing data on olive oil consumption, or who reported implausible total energy intakes (<500 or >3500 kcal/d for women and <800 or >4200 kcal/d for men) were excluded. The completion of the questionnaire self-selected cognitively highly functioning women and men. In total, 60 582 women and 31 801 men were included. The study protocol was approved by the institutional review boards of the Brigham and Women’s Hospital and Harvard T.H. Chan School of Public Health, which deemed the participants’ completion of the questionnaire to be considered as implied consent. This report followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

Dietary intake was measured using a validated greater than 130-item FFQ administered in 1990 and every 4 years thereafter. The validity and reliability of the FFQ have been described previously. 14 Participants were asked how frequently they consumed specific foods, including types of fats and oils used for cooking or added to meals in the past 12 months. Total olive oil intake was determined by summing up answers to 3 questions related to olive oil consumption (ie, olive oil used for salad dressings, olive oil added to food or bread, and olive oil used for baking and frying at home). The equivalent of 1 tablespoon of olive oil was considered to be 13.5 g. Intakes of other fats and nutrients were calculated using the United States Department of Agriculture and Harvard University Food Composition Database, 15 and biochemical analyses. The nutritional composition of olive oil and other types of fat, as well as trends of types of fat intake in the NHS and HPFS, have been reported previously. 11

Adherence to the Mediterranean diet was assessed using a modified version of the 9-point Alternative Mediterranean index (AMED) score. 16 Adherence to the AHEI (0-110), previously associated with lower risk of chronic disease, was also computed. 17 Higher scores indicated better overall diet quality.

The apolipoprotein E ε4 ( APOE ε4 ) allele is known to interfere with lipid and glucose metabolism such that it increases the risk of dementia. 18  APOE genotyping was conducted in a subset of 27 296 participants. Blood samples were collected between 1989 and 1990 in the NHS and between 1993 and 1995 in the HPFS. NHS participants who had not provided blood samples were invited to contribute buccal samples from 2002 to 2004. DNA was extracted with the ReturPureGene DNA Isolation Kit (Gentra Systems). The APOE genotype was determined using a Taqman Assay (Applied Biosystems) 19 in 5069 participants, and through imputation from multiple genome-wide association studies, 20 which has shown high accuracy, 20 in the remaining subset.

Deaths were ascertained from state vital statistics records and the National Death Index or by reports from next of kin or the postal authorities. The follow-up for mortality exceeded 98% in these cohorts. Dementia deaths were determined by physician review of medical records, autopsy reports, or death certificates. Dementia deaths were those in which dementia was listed as the underlying cause of death, or as a contributing cause of death, or as reported by the family, in the absence of a more likely cause. The International Classification of Diseases, Eighth Revision (ICD-8) was used in the NHS and ICD-9 in the HPFS, which were the revisions used at the inception of those cohorts. Dementia deaths included codes 290.0 (senile dementia, simple type), 290.1 (presenile dementia), and 331.0 (Alzheimer disease). To test the validity of the dementia mortality outcome, we examined the likelihood of dementia mortality by APOE ε4 allelic dosage (eTable 1 in Supplement 1 ). 18 A composite outcome was also created including both participants who reported having dementia during follow-up and later died, with those who had dementia reported on their death certificate.

Participants completed biennial questionnaires reporting updates on body weight, smoking, physical activity, multivitamin use, menopausal status, and postmenopausal hormone use in women, family history of dementia, self-report of chronic diseases, and ancestry. History of depression was identified based on antidepressive medication use and self-report of depression. Socioeconomic status (SES) was established through a composite score derived from home address details and various factors such as income, education, and housing; the composite score methods are described in a previous report. 21 Body mass index (BMI) was obtained by dividing the weight in kilograms by the height in meters squared.

In each cohort, age-stratified Cox proportional hazard models were used to evaluate the association of olive oil intake with dementia-related mortality. Participant person-time was calculated from baseline until end of follow-up (June 30, 2018, in NHS; January 31, 2018, in HPFS), loss to follow-up, or death, whichever came first. The cumulative average (mean) of olive oil intake from all available FFQs, from baseline until 2014 (or loss to follow-up or death), was used as the exposure. Because potential diet modifications following cancer or CVD diagnosis may not represent long-term diet, we ceased updating dietary variables upon report of these conditions. For missing covariates, we carried forward nonmissing values from previous questionnaires and assigned median values for continuous variables.

Participants were categorized by olive oil intake frequency: never or less than once per month (reference group), greater than 0 to less than or equal to 4.5 g/d, greater than 4.5 g/d to less than or equal to 7 g/d, and greater than 7 g/d. P values for linear trends were obtained using the Wald test on a continuous variable represented by the median intake of each category. Multivariable Cox proportional hazard models were used to estimate the hazard ratios (HRs) and 95% CIs for dementia mortality according to categories of olive oil intake, separately in each cohort. Participants were censored at death from causes other than dementia. Model 1 was stratified for age and calendar time. Multivariable model 2 was adjusted for Southern European/Mediterranean ancestry, married, living alone, smoking, alcohol intake, physical activity, multivitamin use, history of hypertension and hypercholesterolemia, in women postmenopausal status and menopausal hormone use, total energy intake, family history of dementia, history of depression, census SES, and BMI. Multivariable model 3 was further adjusted for intake of red meat, fruits and vegetables, nuts, soda, whole grains, and trans-fat, all indicative of diet quality.

In a secondary analysis we used the composite outcome for dementia-related deaths. We also repeated the main analysis in the genotyping subsample. We carried out mediation analyses to calculate the percentage of the association between olive oil intake and dementia-related mortality that is attributable to CVD, hypercholesterolemia, hypertension, and diabetes. We also performed stratified analyses by prespecified subgroups (eMethods in Supplement 1 ).

A joint analysis was performed to test whether olive oil intake (never or <1/mo, >0 to ≤7g/d, and >7g/d) and the AMED or the AHEI score (tertiles) combined as the exposure was associated with dementia mortality. In substitution analyses, we assessed the risk of dementia-related mortality by replacing 5 g/d of different fat sources, including margarine, mayonnaise, butter, and a combination of other vegetable oils (corn, safflower, soybean, and canola), with olive oil. Both continuous variables as 5-g/d increments were included in a multivariable model 3, mutually adjusted for other types of fat. The difference in the coefficients obtained for olive oil and the substituted fat provided the estimated HR and 95% CI for substituting 5 g/d of olive oil for an equivalent amount of the other fats.

Several exploratory sensitivity analyses were performed including a 4-year lagged analysis, analyses adjusting for other covariates, a cause-specific competing risk model and analyses excluding participants who self-reported having dementia at baseline (n = 12) (eMethods in Supplement 1 ). Analyses were performed from May 2022 to July 2023 using SAS version 9.4 (SAS Institute). All statistical tests were 2-sided with an α = .05.

Over 2 183 095 person-years of follow-up, this study documented a total of 4751 dementia deaths (3473 in NHS and 1278 in HPFS; 37 649 total deaths). Among 92 383 participants included at baseline in 1990, 60 582 (65.6%) were women, and the mean (SD) age was 56.4 (8.0) years. Mean (SD) olive oil intake was 1.3 (2.5) g/d in both NHS and HPFS; the mean (SD) adherence score for the Mediterranean diet was 4.5 (1.9) points in the NHS and 4.2 (1.9) points in the HPFS; and the mean (SD) AHEI diet quality score was 52.5 (11.1) points in the NHS and 53.4 (11.6) points in the HPFS.

Table 1 shows baseline characteristics of participants categorized by total olive oil intake. Participants with a higher olive oil intake (>7 g/d) at baseline had an overall higher caloric intake, but not a higher BMI, had better diet quality, had higher alcohol intake, were more physically active, and were less likely to smoke compared with those never consuming olive oil or less than once per month ( Table1 ). Individuals who were homozygous for the APOE ε4 allele were 5.5 to 9.4 times more likely to die with dementia compared with noncarriers for the APOE e4 allele (χ 2  P  < .001) (eTable 1 in Supplement 1 ).

Olive oil intake was inversely associated with dementia-related mortality in age-stratified and multivariable-adjusted models ( Table 2 ). Compared with participants with the lowest olive oil intake, the pooled HR for dementia-related death among participants with the highest olive oil intake (>7 g/d) was 0.72 (95% CI, 0.64-0.81), after adjusting for sociodemographic and lifestyle factors. The association between each 5-g increment in olive oil consumption with dementia-related death was also inverse and significant in the pooled analysis. The multivariable-adjusted HR for dementia-related death for the highest compared with the lowest olive oil intake (>7 g/d) was 0.67 (95% CI, 0.59-0.77) for women and 0.87 (95% CI, 0.69-1.09) for men ( Table 2 ). Olive oil intake in 5-g increments was inversely associated with dementia-related mortality in women (HR, 0.88 [95% CI, 0.84-0.93]), but not in men (HR, 0.96 [95% CI, 0.88-1.04]). Analyses remained consistent when using the composite outcome for death with dementia (eTable 2 in Supplement 2 ). In the genotyping subsample, the results remained unchanged after further adjusting for the APOE ε4 allelic genotype (multivariable-adjusted pooled HR comparing high vs low olive oil intake, 0.66 [95% CI, 0.54-0.81]; P for trend < .001) (eTable 4 in Supplement 1 ). Pooled mediation analyses found that CVD, hypercholesterolemia, hypertension, and diabetes did not significantly attenuate the association (unchanged HRs with and without adjusting for the intermediate; data not shown).

In joint analyses, participants with the highest olive oil intake had a lower risk for dementia-related mortality, irrespective of their AMED score (28% to 34% lower risk compared with participants in the combined low olive oil and high AMED) ( Figure 1 A; eTable 3 in Supplement 1 ) and of their AHEI (27% to 38% lower risk compared with participants with low olive oil and high AHEI) ( Figure 1 B; eTable 3 in Supplement 1 ).

Replacing 5 g/d of mayonnaise with 5 g/d of olive oil was associated with a 14% (95% CI, 7%-20%) lower risk of dementia-related mortality in pooled multivariable-adjusted models ( Figure 2 ). As for the substitution of 5 g/d of margarine with the equivalent amount of olive oil, we estimated an 8% (95% CI, 4%-12%) lower risk. Substitutions of other vegetable oils or butter with olive oil were not statistically significant.

Exploratory subgroup analyses (eFigure in Supplement 1 ) showed associations between higher olive oil intake and lower risk of dementia-related mortality across most subgroups. No statistically significant associations were found in participants with a family history of dementia, living alone, using a multivitamin, and in non– APOE ε4 carriers. Results from exploratory sensitivity analyses (eTables 5-8 in Supplement 1 ) were comparable with the findings from the main analysis (eResults in Supplement 1 ).

In 2 large US prospective cohorts of men and women, we found that participants who consumed more than 7 g/d of olive oil had 28% lower risk of dying from dementia compared with participants who never or rarely consumed olive oil. This association remained significant after adjustment for diet quality scores including adherence to the Mediterranean diet. We estimated that substituting 5 g/d of margarine and mayonnaise with olive oil was associated with significantly lower dementia-related death risk, but not when substituting butter and other vegetable oils. These findings provide evidence to support dietary recommendations advocating for the use of olive oil and other vegetable oils as a potential strategy to maintain overall health and prevent dementia.

In the NHS and HPFS, a lower risk of neurodegenerative disease mortality, including dementia mortality, was observed with higher olive oil consumption (HR, 0.81 [95% CI, 0.78-0.84]). 11 Evidence that pertains to cognitive decline or incident dementia is more widely available than it is for dementia mortality. 6 , 22 In the French Three-City Study (n = 6947), participants with the highest olive oil intake were 17% (95% CI, 1%-29%) less likely to experience a 4-year cognitive decline related to visual memory, but no association was found for verbal fluency (odds ratio [OR], 0.85 [95% CI, 0.70-1.03]). 22 Furthermore, participants with a higher intake of olive oil (moderate or intensive vs never) had a lower risk of verbal fluency and visual memory cognitive impairment. Potential sex differences were not investigated. In the PREDIMED trial, which supplemented a Mediterranean-style diet with extra-virgin olive oil (1 L/wk/household) or nuts (30 g/d), 23 the authors investigated cognitive effects and status in 285 and 522 cognitively healthy participants using global and in-depth neuropsychological battery testing. Although the study was not originally designed for cognitive outcomes and the effect of olive oil cannot be isolated, after 6.5 years, the olive oil group exhibited improved cognitive performance in verbal fluency and memory tests compared with a low-fat diet (control), and they were less prone to develop mild cognitive impairment (OR, 0.34 [95% CI, 0.12-0.97]; n = 285). 6 Global cognitive performance was higher in both the olive oil and the nut groups compared with the control post trial (n = 522). 8 These studies were conducted in Europe, in populations with typically higher olive oil intake compared with US populations.

Observational studies and some trials have consistently found associations between following diets such as the Mediterranean, DASH, MIND, and AHEI, and prudent patterns to healthier brain structure, 24 reduced cognitive impairment and Alzheimer risk, and improved cognitive function. 4 In our study, those with the highest olive oil intake (>7 g/d) had the lowest dementia-related death risk compared with those with minimal intake (never or less than once per month), regardless of diet quality. This highlights a potentially specific role for olive oil. Still, the group with both high AHEI scores and high olive oil intake exhibited the lowest dementia mortality risk (HR, 0.68 [95% CI, 0.58-0.79]; reference: low AHEI score and low olive oil intake), suggesting that combining higher diet quality with higher olive oil intake may confer enhanced benefit.

Olive oil consumption may lower dementia mortality by improving vascular health. 18 Several clinical trials support the effect of olive oil in reducing CVD via improved endothelial function, coagulation, lipid metabolism, oxidative stress, platelet aggregation and decreased inflammation. 25 Nonetheless, the results of our study remained independent of hypertension and hypercholesterolemia. Mild cognitive impairment, Alzheimer disease, and related dementias were associated with abnormal blood brain barrier permeability, possibly allowing the crossing of neurotoxic molecules into the brain. 26 Mechanistical evidence from animal 27 - 29 and human studies 9 , 30 have shown that phenolic compounds in olive oil, particularly extra-virgin olive oil, may attenuate inflammation, oxidative stress and restore blood brain barrier function, thereby reducing brain amyloid-β and tau-related pathologies and improving cognitive function. However, incident CVD, hypercholesterolemia, hypertension, and diabetes were not significant mediators of the association between olive oil intake and dementia-related death in our study.

The association was significant in both sexes but did not remain in men after full adjustment of the model. Some previous research has reported cognitive-related sex differences. Evidence from trials also showed sex- and/or gender-specific responses to lifestyle interventions for preventing cognitive decline, possibly due to differences in brain structure, hormones (sex) and social factors (gender). 31 Olive oil intake may be protective of dementia and related mortality, particularly in women. Nonetheless, we did not observe significant heterogeneity or interaction of cohort by olive oil intake on the risk of fatal dementia. Sex and gender differences should be carefully considered in future studies examining the association or effect of olive oil on cognitive-related outcomes to improve our understanding.

We found that using olive oil instead of margarine and mayonnaise, but not butter and other vegetable oils, was associated with a lower risk of dementia-related death. At the time of the study, margarine and mayonnaise contained considerable levels of hydrogenated trans-fats. The latter were strongly associated with all-cause mortality, CVD, type 2 diabetes, and dementia, 32 , 33 which may explain the lower dementia-related death risk observed when replacing it with olive oil. The US Food and Drug Administration banned manufacturers from adding partially hydrogenated oils to foods in 2020. 34 Future studies examining intake of trans-fat–free margarine will be informative. Although the substitution of butter with olive oil was found to be associated with a lower risk of type 2 diabetes, CVD, and total mortality, 11 we did not find an association with the risk of dementia mortality. Although these previous studies did not examine the associations for butter per se, intake of regular fat dairy products, including cheese, yogurt, and milk, was reported to be either not associated or inversely associated with lower cognitive function, cognitive decline, and dementia. 35 - 37

Our cohort analyses include several strengths, namely the long follow-up period and large sample size with a high number of dementia death cases. Also, we included genotyping of the APOE ε4 allele in a large subsample of participants to reduce potential confounding attributed to this well-known risk factor for Alzheimer disease. Additionally, our repeated diet measurements, weight, and lifestyle variables permitted us to account for long-term olive oil intake and confounding factors. Furthermore, the use of dietary cumulative average updates reduced random measurement error by considering within-person variations in intake.

This study has limitations. The possibility of reverse causation cannot be excluded due to the observational nature of our study. However, the 4-year lagged analysis results, consistent with the primary analysis, suggest that olive oil intake is predictive of dementia mortality rather than a consequence of premorbid dementia. While it is plausible that higher olive oil intake could be indicative of a healthier diet and higher SES, our results remained consistent after accounting for the latter. Despite adjusting for key covariates, residual confounding may remain due to unmeasured factors. Also, our study was conducted among health professionals. While this minimizes the potential confounding effects of socioeconomic factors and likely increases reporting due to a high level of education, this may also limit generalizability. Our population was predominantly of non-Hispanic White participants, limiting generalizability to more diverse populations. Additionally, we could not differentiate among various types of olive oil that differ in their polyphenols and other nonlipid bioactive compounds content.

This study found that in US adults, particularly women, consuming more olive oil was associated with lower risk of dementia-related mortality, regardless of diet quality. Substituting olive oil intake for margarine and mayonnaise was associated with lower risk of dementia mortality and may be a potential strategy to improve longevity free of dementia. These findings extend the current dietary recommendations of choosing olive oil and other vegetable oils to the context of cognitive health and related mortality.

Accepted for Publication: March 6, 2024.

Published: May 6, 2024. doi:10.1001/jamanetworkopen.2024.10021

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Tessier AJ et al. JAMA Network Open .

Corresponding Authors: Anne-Julie Tessier, RD, PhD ( [email protected] ), and Marta Guasch-Ferré, PhD ( [email protected] ), Department of Nutrition, Harvard T.H. Chan School of Public Health, 655 Huntington Ave, Bldg 2, Boston, MA 02115.

Author Contributions: Drs Tessier and Guasch-Ferré had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Tessier, Chavarro, Hu, Willett, Guasch-Ferré.

Acquisition, analysis, or interpretation of data: Tessier, Cortese, Yuan, Bjornevik, Ascherio, Wang, Chavarro, Stampfer, Willett, Guasch-Ferré.

Drafting of the manuscript: Tessier.

Critical review of the manuscript for important intellectual content: Tessier, Cortese, Yuan, Bjornevik, Ascherio, Wang, Chavarro, Stampfer, Hu, Willett, Guasch-Ferré.

Statistical analysis: Tessier, Cortese, Wang, Willett, Guasch-Ferré.

Obtained funding: Chavarro, Stampfer, Hu, Guasch-Ferré.

Administrative, technical, or material support: Cortese, Yuan, Stampfer, Hu.

Supervision: Chavarro, Hu, Guasch-Ferré.

Conflict of Interest Disclosures: Dr Cortese reported a speaker honorarium from Roche outside the submitted work. Dr Ascherio reported receiving speaker honoraria from WebMD, Prada Foundation, Biogen, Moderna, Merck, Roche, and Glaxo-Smith-Kline. No other disclosures were reported.

Funding/Support: This study is supported by the research grant R21 AG070375 from the National Institutes of Health to Dr Guasch-Ferré. The NHS, NHSII and HPFS are supported by grants from the National Institutes of Health (UM1 CA186107, P01 CA87969, U01 CA167552, P30 DK046200, HL034594, HL088521, HL35464, HL60712). Dr Tessier is supported by the Canadian Institutes of Health Research (CIHR) Postdoctoral Fellowship Award. Dr Guasch-Ferré is supported the Novo Nordisk Foundation grant NNF23SA0084103.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2 .

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Online short-term ship response prediction with dynamic buffer window using transient free switching filter

• Majidian, Hamed
• Enshaei, Hossein
• Howe, Damon

Considering the broad applications in autonomous marine vehicle control, ship response prediction has emerged as a significant area of interest in seakeeping. In particular, the short-term prediction and online updates of the ship response have been in the practical attention span. Although numerous studies have explored various predictors, the asymptotic properties of estimators employing different window lengths of time series have been neglected. Existing analyses focus on fixed observation windows without considering intrinsic statistical traits within the time series. The current research has investigated the performance of two nonlinear and linear based regressors: support vector regression (SVR) and the adaptive Seasonal Auto-Regressive and Integrated Moving Average (SARIMA) models on the data obtained from a simulated semisubmersible platform in different sea states. Results show prediction accuracy's strong dependence on observation window length relative to response statistical properties under wave conditions. Therefore, an innovative nonlinear filter has been introduced to dynamically adjust the buffer window size based on the signal statistical characteristics. The promising results showed that the filter not only could contribute to promoting any predictors used in autonomous onboard decision-making and stabilization systems for intelligent onboard control but the proposed mechanism can be employed in dynamic systems in other disciplines.

• Dynamic systems;
• Autonomous ships;
• Short-term prediction;
• Ship response;
• Time series analysis;

Cultural Relativity and Acceptance of Embryonic Stem Cell Research

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Main Article Content

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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[2] Poliwoda, S., Noor, N., Downs, E., Schaaf, A., Cantwell, A., Ganti, L., Kaye, A. D., Mosel, L. I., Carroll, C. B., Viswanath, O., & Urits, I. (2022). Stem cells: a comprehensive review of origins and emerging clinical roles in medical practice.  Orthopedic reviews ,  14 (3), 37498. https://doi.org/10.52965/001c.37498

[3] International Society for Stem Cell Research. (2023). Laboratory-based human embryonic stem cell research, embryo research, and related research activities . International Society for Stem Cell Research. https://www.isscr.org/guidelines/blog-post-title-one-ed2td-6fcdk ; Kimmelman, J., Hyun, I., Benvenisty, N.  et al.  Policy: Global standards for stem-cell research.  Nature   533 , 311–313 (2016). https://doi.org/10.1038/533311a

[4] International Society for Stem Cell Research. (2023). Laboratory-based human embryonic stem cell research, embryo research, and related research activities . International Society for Stem Cell Research. https://www.isscr.org/guidelines/blog-post-title-one-ed2td-6fcdk

[5] Concerning the moral philosophies of stem cell research, our paper does not posit a personal moral stance nor delve into the “when” of human life begins. To read further about the philosophical debate, consider the following sources:

Sandel M. J. (2004). Embryo ethics--the moral logic of stem-cell research.  The New England journal of medicine ,  351 (3), 207–209. https://doi.org/10.1056/NEJMp048145 ; George, R. P., & Lee, P. (2020, September 26). Acorns and Embryos . The New Atlantis. https://www.thenewatlantis.com/publications/acorns-and-embryos ; Sagan, A., & Singer, P. (2007). The moral status of stem cells. Metaphilosophy , 38 (2/3), 264–284. http://www.jstor.org/stable/24439776 ; McHugh P. R. (2004). Zygote and "clonote"--the ethical use of embryonic stem cells.  The New England journal of medicine ,  351 (3), 209–211. https://doi.org/10.1056/NEJMp048147 ; Kurjak, A., & Tripalo, A. (2004). The facts and doubts about beginning of the human life and personality.  Bosnian journal of basic medical sciences ,  4 (1), 5–14. https://doi.org/10.17305/bjbms.2004.3453

[6] Vazin, T., & Freed, W. J. (2010). Human embryonic stem cells: derivation, culture, and differentiation: a review.  Restorative neurology and neuroscience ,  28 (4), 589–603. https://doi.org/10.3233/RNN-2010-0543

[7] Socially, at its core, the Western approach to ethics is widely principle-based, autonomy being one of the key factors to ensure a fundamental respect for persons within research. For information regarding autonomy in research, see: Department of Health, Education, and Welfare, & National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1978). The Belmont Report. Ethical principles and guidelines for the protection of human subjects of research.; For a more in-depth review of autonomy within the US, see: Beauchamp, T. L., & Childress, J. F. (1994). Principles of Biomedical Ethics . Oxford University Press.

[8] Sherley v. Sebelius , 644 F.3d 388 (D.C. Cir. 2011), citing 45 C.F.R. 46.204(b) and [42 U.S.C. § 289g(b)]. https://www.cadc.uscourts.gov/internet/opinions.nsf/6c690438a9b43dd685257a64004ebf99/$file/11-5241-1391178.pdf

[9] Stem Cell Research Enhancement Act of 2005, H. R. 810, 109 th Cong. (2001). https://www.govtrack.us/congress/bills/109/hr810/text ; Bush, G. W. (2006, July 19). Message to the House of Representatives . National Archives and Records Administration. https://georgewbush-whitehouse.archives.gov/news/releases/2006/07/20060719-5.html

[10] National Archives and Records Administration. (2009, March 9). Executive order 13505 -- removing barriers to responsible scientific research involving human stem cells . National Archives and Records Administration. https://obamawhitehouse.archives.gov/the-press-office/removing-barriers-responsible-scientific-research-involving-human-stem-cells

[11] Hurlbut, W. B. (2006). Science, Religion, and the Politics of Stem Cells.  Social Research ,  73 (3), 819–834. http://www.jstor.org/stable/40971854

[12] Akpa-Inyang, Francis & Chima, Sylvester. (2021). South African traditional values and beliefs regarding informed consent and limitations of the principle of respect for autonomy in African communities: a cross-cultural qualitative study. BMC Medical Ethics . 22. 10.1186/s12910-021-00678-4.

[13] Source for further reading: Tangwa G. B. (2007). Moral status of embryonic stem cells: perspective of an African villager. Bioethics , 21(8), 449–457. https://doi.org/10.1111/j.1467-8519.2007.00582.x , see also Mnisi, F. M. (2020). An African analysis based on ethics of Ubuntu - are human embryonic stem cell patents morally justifiable? African Insight , 49 (4).

[14] Jecker, N. S., & Atuire, C. (2021). Bioethics in Africa: A contextually enlightened analysis of three cases. Developing World Bioethics , 22 (2), 112–122. https://doi.org/10.1111/dewb.12324

[15] Jecker, N. S., & Atuire, C. (2021). Bioethics in Africa: A contextually enlightened analysis of three cases. Developing World Bioethics, 22(2), 112–122. https://doi.org/10.1111/dewb.12324

[16] Jackson, C.S., Pepper, M.S. Opportunities and barriers to establishing a cell therapy programme in South Africa.  Stem Cell Res Ther   4 , 54 (2013). https://doi.org/10.1186/scrt204 ; Pew Research Center. (2014, May 1). Public health a major priority in African nations . Pew Research Center’s Global Attitudes Project. https://www.pewresearch.org/global/2014/05/01/public-health-a-major-priority-in-african-nations/

[17] Department of Health Republic of South Africa. (2021). Health Research Priorities (revised) for South Africa 2021-2024 . National Health Research Strategy. https://www.health.gov.za/wp-content/uploads/2022/05/National-Health-Research-Priorities-2021-2024.pdf

[18] Oosthuizen, H. (2013). Legal and Ethical Issues in Stem Cell Research in South Africa. In: Beran, R. (eds) Legal and Forensic Medicine. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-32338-6_80 , see also: Gaobotse G (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[19] United States Bureau of Citizenship and Immigration Services. (1998). Tunisia: Information on the status of Christian conversions in Tunisia . UNHCR Web Archive. https://webarchive.archive.unhcr.org/20230522142618/https://www.refworld.org/docid/3df0be9a2.html

[20] Gaobotse, G. (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[21] Kooli, C. Review of assisted reproduction techniques, laws, and regulations in Muslim countries.  Middle East Fertil Soc J   24 , 8 (2020). https://doi.org/10.1186/s43043-019-0011-0 ; Gaobotse, G. (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[22] Pang M. C. (1999). Protective truthfulness: the Chinese way of safeguarding patients in informed treatment decisions. Journal of medical ethics , 25(3), 247–253. https://doi.org/10.1136/jme.25.3.247

[23] Wang, L., Wang, F., & Zhang, W. (2021). Bioethics in China’s biosecurity law: Forms, effects, and unsettled issues. Journal of law and the biosciences , 8(1).  https://doi.org/10.1093/jlb/lsab019 https://academic.oup.com/jlb/article/8/1/lsab019/6299199

[24] Wang, Y., Xue, Y., & Guo, H. D. (2022). Intervention effects of traditional Chinese medicine on stem cell therapy of myocardial infarction.  Frontiers in pharmacology ,  13 , 1013740. https://doi.org/10.3389/fphar.2022.1013740

[25] Li, X.-T., & Zhao, J. (2012). Chapter 4: An Approach to the Nature of Qi in TCM- Qi and Bioenergy. In Recent Advances in Theories and Practice of Chinese Medicine (p. 79). InTech.

[26] Luo, D., Xu, Z., Wang, Z., & Ran, W. (2021). China's Stem Cell Research and Knowledge Levels of Medical Practitioners and Students.  Stem cells international ,  2021 , 6667743. https://doi.org/10.1155/2021/6667743

[27] Luo, D., Xu, Z., Wang, Z., & Ran, W. (2021). China's Stem Cell Research and Knowledge Levels of Medical Practitioners and Students.  Stem cells international ,  2021 , 6667743. https://doi.org/10.1155/2021/6667743

[28] Zhang, J. Y. (2017). Lost in translation? accountability and governance of Clinical Stem Cell Research in China. Regenerative Medicine , 12 (6), 647–656. https://doi.org/10.2217/rme-2017-0035

[29] Wang, L., Wang, F., & Zhang, W. (2021). Bioethics in China’s biosecurity law: Forms, effects, and unsettled issues. Journal of law and the biosciences , 8(1).  https://doi.org/10.1093/jlb/lsab019 https://academic.oup.com/jlb/article/8/1/lsab019/6299199

[30] Chen, H., Wei, T., Wang, H.  et al.  Association of China’s two-child policy with changes in number of births and birth defects rate, 2008–2017.  BMC Public Health   22 , 434 (2022). https://doi.org/10.1186/s12889-022-12839-0

[31] Azuma, K. Regulatory Landscape of Regenerative Medicine in Japan.  Curr Stem Cell Rep   1 , 118–128 (2015). https://doi.org/10.1007/s40778-015-0012-6

[32] Harris, R. (2005, May 19). Researchers Report Advance in Stem Cell Production . NPR. https://www.npr.org/2005/05/19/4658967/researchers-report-advance-in-stem-cell-production

[33] Park, S. (2012). South Korea steps up stem-cell work.  Nature . https://doi.org/10.1038/nature.2012.10565

[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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Harvard In-Text Citation | A Complete Guide & Examples

Published on 30 April 2020 by Jack Caulfield . Revised on 5 May 2022.

An in-text citation should appear wherever you quote or paraphrase a source in your writing, pointing your reader to the full reference .

In Harvard style , citations appear in brackets in the text. An in-text citation consists of the last name of the author,  the year of publication, and a page number if relevant.

Up to three authors are included in Harvard in-text citations. If there are four or more authors, the citation is shortened with et al .

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Table of contents

Including page numbers in citations, where to place harvard in-text citations, citing sources with missing information, frequently asked questions about harvard in-text citations.

When you quote directly from a source or paraphrase a specific passage, your in-text citation must include a page number to specify where the relevant passage is located.

Use ‘p.’ for a single page and ‘pp.’ for a page range:

• Meanwhile, another commentator asserts that the economy is ‘on the downturn’ (Singh, 2015, p. 13 ).
• Wilson (2015, pp. 12–14 ) makes an argument for the efficacy of the technique.

If you are summarising the general argument of a source or paraphrasing ideas that recur throughout the text, no page number is needed.

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When incorporating citations into your text, you can either name the author directly in the text or only include the author’s name in brackets.

Naming the author in the text

When you name the author in the sentence itself, the year and (if relevant) page number are typically given in brackets straight after the name:

Naming the author directly in your sentence is the best approach when you want to critique or comment on the source.

Naming the author in brackets

When you  you haven’t mentioned the author’s name in your sentence, include it inside the brackets. The citation is generally placed after the relevant quote or paraphrase, or at the end of the sentence, before the full stop:

Multiple citations can be included in one place, listed in order of publication year and separated by semicolons:

This type of citation is useful when you want to support a claim or summarise the overall findings of sources.

Common mistakes with in-text citations

In-text citations in brackets should not appear as the subject of your sentences. Anything that’s essential to the meaning of a sentence should be written outside the brackets:

• (Smith, 2019) argues that…
• Smith (2019) argues that…

Similarly, don’t repeat the author’s name in the bracketed citation and in the sentence itself:

• As Caulfield (Caulfield, 2020) writes…
• As Caulfield (2020) writes…

Sometimes you won’t have access to all the source information you need for an in-text citation. Here’s what to do if you’re missing the publication date, author’s name, or page numbers for a source.

If a source doesn’t list a clear publication date, as is sometimes the case with online sources or historical documents, replace the date with the words ‘no date’:

When it’s not clear who the author of a source is, you’ll sometimes be able to substitute a corporate author – the group or organisation responsible for the publication:

When there’s no corporate author to cite, you can use the title of the source in place of the author’s name:

No page numbers

If you quote from a source without page numbers, such as a website, you can just omit this information if it’s a short text – it should be easy enough to find the quote without it.

If you quote from a longer source without page numbers, it’s best to find an alternate location marker, such as a paragraph number or subheading, and include that:

A Harvard in-text citation should appear in brackets every time you quote, paraphrase, or refer to information from a source.

The citation can appear immediately after the quotation or paraphrase, or at the end of the sentence. If you’re quoting, place the citation outside of the quotation marks but before any other punctuation like a comma or full stop.

In Harvard referencing, up to three author names are included in an in-text citation or reference list entry. When there are four or more authors, include only the first, followed by ‘ et al. ’

In Harvard style , when you quote directly from a source that includes page numbers, your in-text citation must include a page number. For example: (Smith, 2014, p. 33).

You can also include page numbers to point the reader towards a passage that you paraphrased . If you refer to the general ideas or findings of the source as a whole, you don’t need to include a page number.

When you want to use a quote but can’t access the original source, you can cite it indirectly. In the in-text citation , first mention the source you want to refer to, and then the source in which you found it. For example:

It’s advisable to avoid indirect citations wherever possible, because they suggest you don’t have full knowledge of the sources you’re citing. Only use an indirect citation if you can’t reasonably gain access to the original source.

In Harvard style referencing , to distinguish between two sources by the same author that were published in the same year, you add a different letter after the year for each source:

• (Smith, 2019a)
• (Smith, 2019b)

Add ‘a’ to the first one you cite, ‘b’ to the second, and so on. Do the same in your bibliography or reference list .

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Caulfield, J. (2022, May 05). Harvard In-Text Citation | A Complete Guide & Examples. Scribbr. Retrieved 14 May 2024, from https://www.scribbr.co.uk/referencing/harvard-in-text-citation/

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