Background

The purpose of biomedical ethics is to study, build, and judge the criteria necessary to philosophically assess medical quandaries that demand otherwise morally gray or seemingly immoral solutions [1, 2]. Beauchamp and Childress (1979) proposed developing moral judgment in bioethics in terms of four principles (prima facie) that are a part of common morality (unphilosophical commonsense and tradition) and are neither overarching nor overly specific: autonomy, beneficence, non-maleficence, and justice [2]. These principles are also a part of the Islamic bioethics present in Saudi Arabia [2, 4]. Thus, Islamic bioethics or Islamic medical ethics is a system of moral assessment made to identify, analyze, and solve ethical problems arising in medical practice and research based on Islamic moral and legislative sources (primarily Quran and Sunna and secondarily by ijma/ consensus of Muslim scholars, qiyas/ analogies from Quran or legal precedents) [2, 4].

There is extensive literature on theoretical discussions and fundamental issues to understand the current debates on bioethics within the Islamic moral and legislative sources as well as within Saudi healthcare system [2,3,4] Hence a preliminary search of databases was conducted to look into most studied areas of bioethics in Saudi Arabia. The search showed that there are a few fundamental domains of importance to understanding the current state of bioethics in Saudi Arabia that have shaped the perspective of most research [3,4,5].

The first concern is physician–patient relations, which sets clear boundaries on what doctors are allowed and not allowed to do. According to Saudi Commission for Health Specialties (2015), the core of every successful physician–patient interaction is trust, integrity, and honesty. Healthcare professionals must be upfront with patients regarding their rights and responsibilities, and how those rights are supported through informed consent [4,5,6]. However, the physician–patient relationship in Saudi Arabia is different as Saudi patients cannot be isolated from their families. The family plays an essential role in decision-making in Saudi Arabia, and doctors recognize the importance of this domain in bioethics and its relation to the patient’s family members [6,7,8,9]. Similar to decision-making, Saudi doctors recognize the importance of informed consent and its relation to the patient’s family members. In this context, informed consent aims to inform not only the patient but the family of the expected consequences of the treatment course [8,9,10].

Illness in Islam is considered a trial through which the patient must persevere, and the doctor has no right to terminate a patient's life. When death becomes inevitable, as determined by the doctors assigned to terminally ill patients, the FatwaFootnote 1 No. 12086 dated 30/6/1409 (1989) of the High Council of Scholars and Ifta'aFootnote 2 of Saudi Arabia, Riyadh, allowed the "Do Not Resuscitate Policy" if three competent doctors deemed the available medical interventions to be futile (Permanent Committee for Scholarly Research and Ifta’a, 1989). The decisions and integrity of these specialists and competent doctors are to be respected [10]. The family must be informed of the decision, but they cannot interfere, as they are not considered qualified under the Fatwa. The Fatwa must be explained to the family. If the family still insists against the DNR policies, they should be offered to transfer the patient to a different hospital willing to accept the patient. Despite existing regulations and legislation, the debate about DNR practice continues to vary widely [6, 10].

The fourth most debated bioethical domain is organ transplantation, a common practice since the 1960s. Organ donation in Saudi Arabia has been rising, as awareness of this global phenomenon, which aims to save lives through altruism, has increased [6]. In 1985, the Saudi Center of Organ Transplantation (SCOT) was founded as the government agency. At present, SCOT oversees all national organ donation and transplantation activities in Saudi Arabia [11, 12]. Nevertheless, organ transplantation raises several ethical issues among healthcare providers and general public, including the definition of death, the decision to donate organs, organ procurement, and organ allocation [6, 13, 14].

In general, the development of medical ethics and its domains have been accompanied by numerous social, legal, and ethical debates [1,2,3,4]. Public opinion tends to be skeptical about such developments in science and is prone to showing significant ambivalence in their attitude. Moreover, the variance in ethical education in Saudi Arabia and other Middle Eastern countries reflects knowledge gaps among both undergraduate and postgraduate medical students and, in some cases, doctors [1, 2]. Bioethics curriculum development was seen as part of general steps forward in developing moral attitudes, the complexity of the healthcare system, ethical and legal issues that need to be addressed systematically and consistently through the integration into medical education [2,3,4,5]. This shift has resulted in the increasing involvement of scientists and clinicians in teaching medical ethics based on the ideas of the philosophers who pioneered the teaching of the subject [2,3,4,5].

While modern research in bioethics covers issues such as stem cell research, genetic and biobanking, cloning, and fertility treatment, the search for evidence showed that despite well-establsihed fatwas, bioethics in Saudi Arabia is still on the rise, exploring the very foundations of medical ethics. Hence, this research cannot claim to have treated all domains of bioethics within the Saudi healthcare system. Rather, the aim is to present fundamental domains of bioethics that will shed light on essential ethical questions and applied ethics.These fundamental bioethical domains often challenge researchers and general public, as they contradict moral traditions and sometimes perceive matters in an unconventional light, which must take the entire spectrum of ethical theories into account [1, 2]. For this reason, this systematic review aimed to systematically identify, compile, describe and discuss ethical arguments and concepts in the most-argued domains of bioethics in Saudi Arabia and present cultural, social, educational, and humane perspectives.

Methods

Systematic reviews are best known as a consolidation of sources that help researchers to identify what is known with certainty, what is tentatively known, and where the gaps in knowledge are. The goal of systematic review is to reach broad conclusions that represent the findings of individual studies as a body of work, which is often referred to as synthesis [15,16,17]. In order to meet the goals of contemporary systematic reviews, a straightforward, transparent, and reproducible approach has been adapted, recommended, and used by previous researchers. This approach is essential for generating reliable data for future research and prospective policy development [18,19,20].

This systematic review has been carried in accordance with the following stages: (1) creating clear and explicit objectives, (2) definition of inclusion and exclusion criteria based on the objectives of the study and the selected the domains, (3) performing an effective and wide-ranging literature search based on the objectives and eligibility criteria, (4) exercising a methodological quality of studies, (5) extracting data from included studies, and (6) presenting findings of the review in the form of a descriptive summary in a table supplemented with text commentary [18,19,20].

Research aims and questions

To the authors’ knowledge, there are no previous studies aimed to systematically identify, compile, describe and discuss ethical arguments and concepts in the best-studied domains of bioethics in Saudi Arabia and to present cultural, social, educational, and humane perspectives. Based on the aim of the study, the following questions were developed:

  1. 1.

    What do Saudi health professionals and the general public know about fatwas regulating the medical ethics curriculum, doctor-patient relationship, informed consent, DNR, and organ transplantation?

  2. 2.

    What is the attitude of Saudi health professionals and the general public about medical ethics curriculum, doctor-patient relationship, informed consent, DNR, and organ transplantation?

What are the concerns of Saudi health professionals and students about medical ethics curriculum, doctor-patient relationship, informed consent, DNR, and organ transplantation?

Eligibility criteria

It is essential to specify the eligibility criteria (i.e., inclusion/exclusion) for studies that need to be met before being included in a systematic review. Failure to identify eligibility criteria can result in bias. The eligibility criteria should derive from the aims and research questions [12, 17, 21].

The inclusion and exclusion criteria of the current systematic review are as follows:

Inclusion criteria

  • Publication Type: Published journal articles

  • Language: Title/abstract level: only articles with at least an abstract in English

  • Be explicitly concerned with normative ethical considerations of medical topics in Saudi Arabia

    1. i.

      Pose an ethical question

    2. ii.

      Determine ethical problems/challenges

    3. iii.

      Address ethical decision making or the use of ethical frameworks for decision making

    4. iv.

      Explore ethical views or reasons for/against a decision

    5. v.

      Look for/produce experimental data for ethical decision making or ethical evaluation

    6. vi.

      Examine ethical regulations or recommendations

    7. vii.

      Studies highlighting or emphasizing upon physician–patient relationship (specifically informed consent), beneficence (DNR, organ donation and transplantation), non-malificence (physician competency, standard of care) and justice (provision of care) were selected.

Exclusion criteria

  • Articles published before 2010

  • Randomized controlled trials (RCTs)

  • Cohort studies

  • Case–control studies

  • Reviews and editorials

  • Meta-analyses

The publication is written in a language other than English, e.g., Arabic.

Literature search

Six electronic literature databases were searched, covering the fields of healthcare sciences, ethics, and religion: PubMed, Embase, Web of Science, Scopus, CINAHL, Google Scholar. All databases were searched using Boolean operators (AND, OR, NOT) expressed in English through a combination of words in a single search. For instance, Ethical issues truth AND Saudi Arabia Ethical issues AND euthanasia OR do not resuscitate AND Saudi Arabia Islam ethics and organ donation OR transplantation and Saudi Arabia Medical ethics AND privacy confidentiality AND Saudi Arabia DNR OR DNT AND Saudi Arabia Do not resuscitate OR do not treat AND Saudi Arabia Medical issues OR bioethics AND Saudi Arabia. In addition to applying Boolean operators, National Center for Biotechnology Information (NCBI) filters were applied. This allowed to search for articles by type, year(s) of interest, species (i.e., humans), age, language, and other filters. The two search strings used for the PubMed database are presented in Table 1. An independent librarian at Prince Sultan Military College of Health Sciences (PSMCHS) reviewed and validated the final search strategies.

Table 1 PubMed search strings stratified according to organizing concepts—explorative and refined
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Selection process

The database was searched between December 2020 and June 2021. The first author originally made the selection. The second author then checked all selection results for inclusion and exclusion criteria. To reach a consensus, discrepancies were discussed and successfully resolved through discussion with the third author. The search and report process followed the statement and flowchart of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (Fig. 1). The full texts of potentially eligible records were retrieved and independently assessed for eligibility by the first and second authors.

Fig. 1
figure 1

Study identification, screening, and inclusion, guided by PRISMA

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Results

The database search resulted in 1,637 studies. Fourteen articles were included, sourced from the reference lists identified through the original database search. After removing duplicates (973), the relevant articles and publications were selected in two stages. During the first stage, the titles and abstracts of the articles were screened, and non-relevant articles were excluded (296). In the second stage, the full text of included studies was explored. Articles published before 2010, randomized controlled trials, cohort studies, case–control studies, reviews and editorials, meta-analyses, and publication language was other than English were excluded (208). As a result, 82 studies were selected for a final review and assessment (Fig. 1).

Data extraction

The following data items were extracted from the included studies and reported in Table 2: (1) author and year of publication of the study; (2) study setting, sample size, and characteristics of participants; (3) main findings of the research. An additional column has been added to show the definition and rules of the given bioethics domain in the Saudi setting (Table 2).

Table 2 Synthesis of included studies following domains
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Overall research trends analysis

The total number of publications and citations of the medical ethics literature, based on study objectives, from 2010 to 2021 are shown in Fig. 2. The first five years (2010–2015) have observed little progress, and in 2011 there was no publication as such. However, the highest number of citations falls on articles published from 2010 to 2013. Although since 2017, the growth of publications has been gradually increasing, the number of citations has decreased from 2017 to 2021, with most of the publications having 0 citations. The publications peaked in 2020 (TP = 15), and the number of citations peaked in 2012 (TC = 138).

Fig. 2
figure 2

Publishing and citations patterns of medical ethics articles 2010–2021

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Thematic analysis of published articles

The thematic evaluation of five domains included in this research showed that the most publications were produced focusing on ‘Organ Donation & Transplantation’ with 33 articles, followed by ‘Doctor-Patient Relations’ with 18 publications (Fig. 3). The lowest publications were associated with ‘Medical Ethics Curriculum’ with ten articles. Furthermore, Fig. 3 shows the shift of ‘Do-Not-Resuscitate’ research streams with the highest number of publications released in 2019 and 2020.

Fig. 3
figure 3

Thematic analysis medical ethics articles 2010–2021

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Most productive provinces on medical ethics research

Figure 4 presents data on the publication of articles on medical ethics in Saudi Arabia and its provinces. The number of articles targeting Saudis from all provinces of the Kingdom was 17. The Central Province emerged the first in the number of publications (33), followed by the Western province with 16 publications. The Eastern and Southern provinces issued eight articles each, half the number of Western and Central Provinces. Although residents of the Northern province have been included in the articles targeting Saudis from all provinces, no research has been identified where the target population would be residents of the Northern Borders Province only.

Fig. 4
figure 4

Medical ethics articles publishing patterns for Saudi Arabia and Provinces 2010–2021

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Authorship pattern

Figure 5 shows a sample of authorship of medical ethics articles included in this study. The authorship pattern ranges from a minimum of one author to a maximum of 11 authors. Overall, these data indicate that medical ethics research has followed a collaborative approach in most cases involving two authors (15) and six authors (17). In addition, there are four publications with ten or more authors.

Fig. 5
figure 5

Authorship pattern of medical ethics literature 2010–2021

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Highly cited articles on medical ethics research

Figure 6 presents the bibliographic information of the top 15 highly cited medical ethics articles included in this research. The top 15 highly cited articles’ citations and years ranged a maximum of 16 to 84 citations from 2010 to 2016. One article obtained 84 citations by Alghanim, S.A., 2010, entitled “Knowledge and attitudes toward organ donation: a community-based study is comparing rural and urban populations.” This article was followed by an article written by Al-Yousefi, N.A., 2012, entitled “Observations of Muslim doctors regarding the influence of religion on health and their clinical approach.” The article obtained 50 citations. A thematic evaluation of the five domains included in this study found four articles in each of the following areas were among the most cited: ‘Organ Donation & Transplantation,’ ‘Doctor-Patient Relations,’ and ‘Medical Ethics Curriculum.’ However, despite publication growth in ‘Do-Not-Resuscitate’ research, only one article in this area has appeared on the most-cited list. This article was cited 24 times and was written by Amoudi, A.S., Albar, M.H., Bokhari, A.M., Yahya, S.H. and Merdad, A.A., 2016, entitled "Perspectives of interns and residents toward do-not-resuscitate policies in Saudi Arabia." Remarkably, 24 of the 82 included articles received zero citations, with 11 published in 2020 and 7 in 2021.

Fig. 6
figure 6

Top 15 most cited articles on medical ethics in Saudi Arabia 2016–2021

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Keyword analysis of medical ethics research in Saudi Arabia

The next cluster of keywords (Fig. 7) demonstrates that the issue was constantly discussed in the studied articles under consideration between 2010 and 2021. Each color represents a separate cluster, and clusters are arranged based on link strength and occurrence. Co-occurrence network of author keywords was a minimum number of occurrences: three (i.e., consent, DNR implementation, medical ethics, patient’s rights).

Fig. 7
figure 7

Co-occurrence network of keywords used by the authors (2010–2021)

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There are five clusters (indicating various colors) having a relationship. Cluster one is the strongest network relationship, followed by 2–5 clusters, respectively. Hence, the size of the bubble indicates the nature of the relationship with link strength and occurrence. The five keywords with the highest total link strength are ‘Saudi Arabia’ (link strength: 61), ‘attitude PHC’ (39), ‘organ donation’ (32), ‘knowledge and education’ (30), and ‘donation’ (21). The results confirm the importance of knowledge and education among health care providers and the general public to improve the attitudes towards medical ethics issues and concerns.

Discussion

This systematic review is the first organized synthesis of the five most debated bioethical domains that have been studied in the Kingdom of Saudi Arabia. Eighty-two studies were identified across five main domains for a final review and assessment: 'Medical Ethics Curriculum in Saudi Arabia,' 'Doctor-Patient Relations,' 'Informed Consent,' 'Do-Not-Resuscitate,' 'Organ Donation & Transplantation.' To the authors' knowledge, there are no similar systematic reviews in bioethical research in the Kingdom of Saudi Arabia, and therefore the direct comparison is not possible.

Medical ethics curriculum

In the past two decades, the discussion of bioethical issues in Saudi society has become increasingly important. However, it would be fair to note that there is still limited guidance on teaching and learning bioethics, which will inevitably have a tangible impact on society in the future [1, 2]. Despite the researchers’ growing interest in medical ethics, this systematic review has shown that from 2010 to 2021, only ten articles were published studying the ‘Medical Ethics Curriculum’ in KSA [22,23,24,25,26,27,28,29,30,31]. Of these ten articles, the research by El-Sobkey et al. (2014) is in the list of the most cited articles with 21 citations.

Overall synthesis of this domain showed that regardless of the region, target population, most participants in all included studies agreed on the importance of studying the principles of medical ethics as a discipline with its methods, literature, vocabulary, and content [22,23,24,25,26,27,28,29,30,31]. Although some participants completed theoretical ethics classes while attending medical school, the theory does not address the practical ethical dilemma faced in daily practice after graduation [25, 27,28,29, 31].

Thus, there was a lack of knowledge about organ donation regulations, withholding or stopping mechanical ventilation, conflict with family, and advice from the ethics committee, religious aspects, brain death, DNR policies, the existence of the Saudi PBR [23, 24, 26, 27].

The conclusions and recommendations of all included articles were consistent, stating that teaching bioethics is a complex and long-term process that helps graduate and undergraduate students embrace the roots of their culture, knowledge, and principles [22,23,24,25,26,27,28,29,30,31]. While there is no single best model for teaching medical ethics, teaching bioethics is essential to educating medical students by developing a comprehensive bioethics curriculum. Students are encouraged to participate in all processes actively [22,23,24,25,26,27,28,29,30,31]. The learning outcomes for each activity should be used as a guide for assessing the adequacy of the bioethics curriculum, together with an assessment of effectiveness.

Doctor-patient relations

The thematic evaluation found that 'Doctor-Patient Relations' with 18 publications was the second most studied domain. The synthesis of the included studies on medical ethics knowledge showed that most participants, mainly healthcare representatives had little knowledge about doctor-patient relations [32, 33, 36, 41, 42, 44, 45, 48]. However, there was a strong consensus that every patient should be treated with honesty and dignity. Patients of a high socioeconomic class should not be treated with extra care, and confidentiality should be maintained in all circumstances [32, 33, 36, 41, 42, 44, 45, 48].

Lack of training, knowledge of cultural norms, patient participation in decision-making, gender differences between patients and doctors, and a lack of time were major barriers to effective communication skills with patients and their families [32, 34, 37,38,39,40, 43, 46]. Patients recommended doctors and nurses to improve their interpersonal skills and take a more holistic, patient-centered approach. This can improve information delivery and resolve disagreements between patients/family members and healthcare providers about treatment decisions [32, 34, 37,38,39,40, 43, 46].

The doctor’s specialty influenced communication patterns and patient satisfaction. Family doctors were more closely associated with building rapport, psychosocial exchange, and patient orientation than other specialties. Senior medical specialists were more confident in their communication skills [34, 35, 38,39,40,41, 46,47,48,49]. Doctors working in public hospitals were more likely to have higher patient trust than private hospitals. Despite the general synthesis of results confirming patient satisfaction with explaining treatment procedures and the prompt response to their questions, some patients perceived the nurses as insufficiently responsive and compassionate [34, 35, 38,39,40,41, 46,47,48,49].

As shown, the doctor-patient relationship is a complex area made up of several factors, including doctor-patient communication, patient participation in decision-making, and patient satisfaction. Hence, in most cases, treatment is based on this relationship [2, 4, 7, 8]. The doctor and patient are expected and recommended to work together to improve psychopathological conditions, with particular attention to therapeutic relationships that affect the patient's thoughts, emotions, and behavior [32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49].

Informed consent

The third most studied domain of medical ethics research in Saudi Arabia was 'Informed Consent’ with 12 publications. Health care providers supported informed consent. The majority agreed that consent should be given for each new procedure and should be perceived as an ongoing process, not a one-off decision, with parental consent being considered mandatory for children's treatment. However, there was low quality of informed consent in terms of experience with informed consent processes and transparency of risks [33, 37, 50, 51, 55,56,57, 59].

Although patients’ opinions on the purpose of informed consent varied, the informed consent process and being aware of treatment was important for all [50, 52, 53, 55,56,57, 59]. In terms of the trust, some patients trusted the doctor to make decisions on their behalf, while others required more independent decision-making and preferably more effective disclosure of information. In addition, there was an overall poor quality of informed consent process and administration, knowledge of the risks of intervention and alternative treatment, and insufficient information included in informed consent [50, 52, 53, 58].

Remarkably, a study by Alsaihati et al. (2017) among n = 140 surgeons in Saudi Arabia found that while there was sufficient knowledge about informed consent to surgery and how to obtain it, most surgeons did not fully inform patients about the procedure before obtaining consent. Some saw consent as just a preoperative routine or simply signing a document because the consent process is strange to Saudi psychology. The majority were against the use of consent for all surgical procedures [54].

Informed consent is a standard procedure for human studies involving individually identifiable data. The principle of informed consent is based on patient autonomy, which is explained as the legal embodiment of the idea that everyone has the right to make decisions that affect their well-being [6, 37, 52]. The Saudi Council for Health Specialties has developed guidelines on informed consent as part of the ethics of the medical profession. However, doctors' and patients' levels of awareness and adherence to these guidelines in Saudi Arabia remain unclear and controversial. Thus, these findings create a basis for introducing formal informed consent training to make written information more accessible to doctors and patients [6, 54].

Do-not-resuscitate

The synthesis of results showed that most healthcare representatives could define the order of DNR. Still, it required deeper knowledge to learn whether there is a clear local or national DNR policy. Those who knew about the policy did not read in detail [60,61,62,63, 67, 68, 70]. The most common limitation of essential discussions about DNR was a lack of patient understanding, educational level, cultural background of patients, and a lack of DNR policy knowledge by medical staff [60,61,62,63,64]. Most health care representatives wanted to learn more about patients' rights regarding end-of-life care and the use of the DNR order, as this would support the treatment plan for terminally ill patients [60, 62, 67, 68, 71].

Studies in which patients were included as a target population reported a lack of knowledge of the medical conditions for DNR practice [62, 65, 66, 68, 69]. Patients expressed a will to participate in discussions with doctors on planning end-of-life care and making their own decisions. Patients with higher levels of education, medical background, and knowledge of DNR were more likely to agree with DNR practice [62, 65, 66, 68, 69].

Non-Saudi doctors making decisions about life-sustaining treatment or DNR orders consulted with ethics committees in their hospitals more often than Saudi doctors [46]. Saudi doctors who received their education and postgraduate studies abroad were confident in their knowledge of ethics in medical practice but were less confident in making decisions about life-sustaining treatment or DNR orders [46].

Saudi Arabia's DNR Policy is a binding legal document formulated following the provisions of Islamic law, with a focus on Saudi patients, cultural background, and social needs [6, 10]. However, it has been shown that more efforts are required to improve and optimize end-of-life care and DNR policies by educating and training healthcare personnel and the general public.

Organ donation and transplantation

The most studied domain of five included domains was ‘Organ Donation and Transplantation,’ 33 articles, with the most papers being published in 2020. Alghanim (2010) wrote the most cited article on knowledge and attitudes toward organ donation [72].

The synthesis of organ donation and transplantation data has led to several general conclusions reported by different authors. Thus, the overall knowledge about organ donation and transplantation varied based on the research objective (i.e., blood, skin, kidney donation). In general, the participants reported insufficient information about organ donation and transplantation [72, 75, 78, 90, 91, 95, 96, 102]. The main source of information about organ donation was TV, social media [72, 75, 77, 79, 81,82,83,84, 89].

Participants from rural areas were less likely to have information about organ donation than their counterparts in urban areas [72]. Organ donation awareness was higher in educated individuals with higher socioeconomic status and married participants [86, 87, 94, 99, 100, 102, 103]. The degree of awareness was found to impact the willingness to donate positively. Reasons for refusal to donate were the fear of premature termination of medical treatment to facilitate organ retrieval and transplantation, worries about receiving inadequate health care after donation, lack of family support, lack of incentives, not enough information about organ donation, fear of complications after organ donation, religion [72, 75, 79,80,81,82,83, 86, 95, 97, 99, 100].

In contrast to the stated barriers to organ donation, among those participants who expressed their will or were positive about organ donation and transplantation, gender, age of the recipient, religion and incentives did not appear to play a role. Moreover, organ donation was motivated by helping others and compassion, a good deed, the importance of donation, belief that organs are not beneficial after death, and an altruistic act [30, 73,74,75,76, 81, 85, 87,88,89, 93, 98, 101, 103].

Despite the Saudi Center for Organ Transplantation (SCOT) activities since 1985, there was a lack of knowledge on where to go for organ donation [83, 92, 97]. Thus, in the study by Alnasyan et al. [92], the level of knowledge about SCOT was only 12.6%. This is consistent with Thirunavukkarasu et al. [97], where about two-thirds of the study participants were unaware of SCOT and its organ donation activities. Furthermore, in an earlier study by Agrawal et al. (2017), less than 3% knew the correct place to go for organ donation [83].

Organ transplantation is a life-prolonging and life-saving medical procedure in which an entire or partial organ of a deceased or living person is transplanted to another person. Islamic guidelines and Islamic law describe certain rules and regulations that allow organ transplants to be performed [6, 11, 12]. Organ donation is an act of mercy, benevolence, altruism, and love for humanity. Nonetheless, as can be seen from the literature cited, organ donation remains a very personal yet complex decision involving medical, legal, religious, cultural, and ethical concerns [6].

This bibliometric analysis was limited to five domains of bioethics within Saudi society. However, a literature search identified a number of articles addressing ethical issues related to the COVID-19 outbreak, such as the distribution of intensive care unit (IC) beds, digital tracking applications, vaccine distribution, the ethics of the general risks of COVID-19, risks in vaccine supply chain infrastructures, ethical issues in patient care, among others [104,105,106,107]. Hence, this study could start a series of systematic reviews that will explore all areas of bioethics in the Saudi health care system. Particular attention should be paid to study bioethical issues during COVID-19 pandemic [104,105,106,107].

Strengths and limitations

The strengths of the study design include its systematic approach, an explicit, transparent, and reproducible approach that has been adapted, recommended, and used by previous researchers. However, research design comes with potential limitations. Although researchers thoroughly searched databases to include all relevant articles, there is a chance that several important studies may have been overlooked. Thus, most literature on included domains have been written in Arabic, whil this study was limited to English literature, causing a significant deficiency in including more studies, which ultimately affected the results and conclusion.

As mentioned, many fatwas govern bioethical research in different domains. However, including all domains in one systematic review would be incomprehensible and a source of bias. Therefore, based on this study, a new systematic review could be initiated to address areas such as stem cell research, genetic and biobanking ethics, cloning, and infertility treatment, among others.

This study of medical ethics in Saudi Arabia offers new avenues for future research even with limitations. Researchers and policymakers can formulate strategies based on these data. Furthermore, authors identified evolving themes that have received little attention in previous research, including assisted reproductive technologies; medical, surgical, and ethical dilemmas of Siamese twins; hermaphroditism; genetic diseases. It is recommended that future research directions based on this bibliometric analysis of literature include comparative studies from developed and developing countries using more comprehensive demographic variables.

Conclusion

The overall aim of this study was to systematically identify, compile, describe and discuss ethical arguments and concepts in the five most-studied domains of bioethics in Saudi Arabia and present cultural, social, educational, and humane perspectives. From 2010 to 2021, 82 articles were found to be eligible. Most of the publications with the highest citations were from the Central Province. The articles were mainly published in the ‘Organ Donation and Transplantation’ domain. This systematic quantitative synthesis is expected to guide researchers, funders, and policymakers about the strengths and gaps in knowledge and attitudes regarding medical ethics in Saudi Arabia, both among the general public and health professionals.