Todas las Voces

INDEX

1.      Abstract

2.      Introduction

3.      Materials and Methods

4.      Results

4.1.   Production of papers with bioethical content in general and by authors from Ibero-American institutions

4.2.   Scientific production by Ibero-American countries

4.3.   Diachronic evolution of scientific production

4.4.   Publications by authors from Ibero-American institutions in collaboration with authors from institutions in other countries

4.5.   Number of papers published in Ibero-American journals

4.6.   Assessment of the quality of the papers as determined by the number of citations received

4.7.   Assessment of the quality of the papers as determined by the number of citations received

4.8.   Number of articles published by Ibero-American authors in peer-reviewed journals in the area of bioethics and the number of citations

4.9.   Number of articles published by Ibero-American authors in peer-reviewed journals in the area of bioethics and the number of citations

5.      Discussion

6.      Limitations

7.      Bibliography and notes

 

1.      Abstract

            The bioethics research conducted in Ibero-American countries has been very much restricted to its own realm. The aim of this study was to perform a bibliometric evaluation of bioethics papers by authors affiliated with Ibero-American institutions, and to determine how their work influences global bioethics literature. We performed a literature search in the Web of Science Core Collection (WoS CC) and Scopus. We identified a total of 5,975 documents, of which 84.3% were articles, 11.6% re- views and 4.1% book chapters. The median number of citations per paper was higher in English-language journals. Only 10 articles published between 2010 and 2019 in peer-reviewed bioethics journals and produced exclusively by authors from Ibero-American institutions garnered more than 15 citations. Our study suggests that if researchers from Ibero-American institutions want to influence global bioethical thinking, they must make the required leap in quality to be able to publish in high-quality bioethics and mainstream journals.

Keywords

Codes of/position statements on professional ethics, position statements (of organizations/ groups), research on special populations, scientific research.-

 

2.      Introduction

            It is widely acknowledged that advances — both in the experimental sciences and in humanistic thought — are generated mainly in English speaking countries, but above all, are disseminated in English-language scientific literature.[i] Accordingly, to assess the extent to which an author, research group, educational institution or country influences current thinking within a given area of knowledge, it may be useful to examine whether the literature produced in these institutions or countries is published in English-language media of accredited scientific quality.

            The bioethics research conducted in Ibero-American countries has been very much confined to its own setting, with the result that their bioethical thinking has had - and indeed has - little impact on the global bioethics field. To get a general idea of this, one need only review the references of some randomly chosen books on bioethics published in English to verify the presence of Ibero-American authors in the bibliography contained therein. In a random selection of five books written by English-speaking authors[ii], we found that, out of a total of 2,490 literature references listed, there were no citations for Ibero-American authors.

            An approach to understanding the impact of authors from Ibero- American institutions on global bioethical thinking can be made by conducting bibliometric studies, since they offer a quantitative perspective that allows assessment of the development and evolution of research on the issues to be analyzed. These studies use easy-to-understand indicators of production, collaboration and impact, identifying trends over time[iii]. The methods employed have been widely used in many scientific disciplines[iv], as well as in bioethics. In 2006, Berg and Furton declared that there was a progressive development of bioethics that culminated in an increase in scientific publications[v]. Since then, bibliometric studies have been conducted that have analyzed international collaboration in articles on bioethics[vi]; scientific production in bioethics in Spain[vii]; research in neuroethics[viii]; the most cited articles in bioethics[ix]; and the value of empirical research for bioethics[x].

            The aim of this study was to analyze the bioethics literature produced by authors affiliated with Ibero-American institutions, to address the following specific objectives: 1) evolution of scientific literature; 2) to determine the Ibero-American countries that publish most; 3) to identify the most cited papers; 4) to examine the relationship between the number of paper citations and the language in which they are published; 5) to determine whether the number of citations varies if authors from Ibero-American institutions collabo- rate with institutions in other countries; 6) to determine to what ex- tent authors from Ibero-American institutions publish in high-quality bioethics and mainstream journals; and 7) to make an approximation to the areas of research through keyword and co-word analysis.

 

3.      Materials and Methods

            Papers analyzed in this study were retrieved from the Web of Science Core Collection (WoS CC) and Scopus databases. These databases were accessed through the Spanish Science and Technology Foundation (FECYT), including the literature referenced in these databases[xi] up to 2019.

            In order to retrieve bioethics-related papers, a specific search equation was designed in each database. In this article, bioethics is considered in a broad sense, where medical ethics is included according to the definition given by the Encyclopedia Britannica: “In one common usage, bioethics is more or less equivalent to medical ethics, or biomedical ethics […]. Bioethics, however, is broader than this, because some of the issues it encompasses concern not so much the practice of health care as the conduct and results of re- search in the life sciences, especially in areas such as cloning and gene therapy [...], stem cell research, xenotransplantation (animal-to- human transplantation), and human longevity”[xii], and what Markose et al.[xiii] say about medical ethics: “The issues in medical ethics often involve [...] rights of patient, informed consent, confidentiality, competence, advance directives, negligence, and many others”.

            The search equation was not limited only to the thematic categories of journals specialized in ethics, as exemplified by the thematic categories "Medical Ethics" from Journal Citation Reports (JCR) or "Issues, Ethics and Legal Aspects" from Scimago Journal Rank (SJR), since articles not relevant to the search could be included. At the same time, scientific publications in journals from other thematic categories could be excluded by this search, like in the case of the New England Journal of Medicine, Science, Nature, Lancet and JAMA, among others. In fact, in August 2016, articles on bioethics such as “Equipoise and the ethics of clinical research” published in 1987 in the New England Journal of Medicine and “What makes clinical research ethical?” published in JAMA in 2000, had been cited 1,726 times and 1,656 times, respectfully, in Google Scholar[xiv]. Accordingly, specific terms such as “bioethics” were included in the search, and generic terms such as “ethics” were combined with medical aspects that are often associated with ethical issues, such as “genetics”, “abortion” and “autism”.

            The search equation was also applied to bioethics journals listed at Georgetown University[xv], Bioethics.com[xvi] at the Center for Bioethics & Human Dignity (CBHD), and journals included in the subject category “Bioethics”, and medical ethics in Free Medical Journals on the Geneva Foundation for Medical Education and Research website.[xvii]

            The search was conducted on February 5, 2020. The bibliographic fields in which the search was made were Source (SO), WoS Category (WC), Paper title (TI), and Topic, the latter of which includes Paper title, Abstract, Keywords, and Keyword plus. Only re- cords with the document type, article, review, proceedings paper, book chapter or book were selected.

            Using our own software, “bibliométricos”, bibliographic records were included in a relational database with exclusion of duplicates in Scopus;[xviii] records from Scopus that were already included in the WoS CC were deleted. All papers in which at least one Ibero- American institution had participated were then selected. An institution was considered to be Ibero-American if it was located in one of the 22 countries participating in the Ibero-American Summit[xix]: Andorra, Argentina, Bolivia, Brazil, Colombia, Costa Rica, Cuba, Chile, Ecuador, El Salvador, Spain, Guatemala, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Portugal, Dominican Republic, Uruguay and Venezuela. We excluded documents that addressed aspects related to ethics but not to bioethics or medical ethics, such as those dealing with aspects related to organization, business, politics, gaming, sport and economics. In order to exclude them, a search was carried out on the documents that included these terms in the title or key words field in the Access database where the records obtained in the search were downloaded for processing and bibliometric and documentary analysis. The authors then reviewed those records to decide whether or not their exclusion was appropriate.

            The authors conducted a random sampling of 100 papers to validate the relevance of the papers retrieved. The percentage of irrelevant papers was 1%, but it was considered that they could be related to broad aspects of bioethics, such as the environment.

            Statistical analysis was performed using the IBM® SPSS® Statistics v.26 statistical program. A descriptive study was carried out with measures of central tendency. Chi-square was used for the comparison between papers produced only by authors from Ibero- American institutions or in collaboration with other institutions and the language of publication, as well as whether the paper was published in peer-reviewed journals in the field of bioethics. We used a non-parametric test for comparison of medians of the number of citations between papers written only in English, in English and another language, or only in languages other than English. We chose this non-parametric test since the number of citations per paper did not have a normal distribution. The level of statistical significance was set at p < 0.05.

            Thematic analysis of the publications analyzing the frequency of the keywords and the co-keywords network were also studied. The Pajek program[xx] was used to create and graphically display the networks of countries and keywords. The size of the vertices is proportional to the number of occurrences. The thickness of the lines connecting two vertices is proportional to the number of times the two terms appear simultaneously in the total number of papers. For inclusion in the graphic representation of countries, the co-occurrence of more than seven papers was considered. For inclusion in the graphic representation of keywords, the co-occurrence of four or more keywords was considered. This analysis was performed with the authors’ keywords in the records. Just over one quarter of records (26.5%) had no keywords. Keywords with more than two occurrences were standardized in terms of abbreviation, singular and plural, and British and American English.

            All information relating to the search equation in Web of Science, tables and figures not included in this article are available as supplementary material in Zenodo repository (https://doi.org/10.5281/ zenodo.4446868).

 

4.      Results

 

4.1.   Production of papers with bioethical content in general and by authors from Ibero-American institutions

            First, the tremendous production of scientific papers with some bioethical content that were included in the study databases up to 31 December 2019 should be highlighted. In that period, 82,387 documents were identified in the WoS CC database and 141,711 in Scopus, although it should be taken into account that some of them may be contained simultaneously in both databases.

            If we select papers out of the total number of papers identified in which a researcher from an Ibero-American institute participated, the number of documents is reduced to 6,260. If we then exclude those containing aspects not related to bioethics or medical ethics (n=285), the total sample is composed of 5,975 documents, 1,272 of which were retrieved in both databases, 1,786 in WoS alone and 2,917 in Scopus alone. Of the 5,975 documents retrieved, 84.3% were articles, 11.6% reviews and 4.1% book chapters, books or proceedings papers.

 

4.2    Scientific production by Ibero-American countries

            If we analyze the scientific production by Ibero-American countries, we find first, that of the 22 countries, all except Andorra produced at least one paper with bioethical content in the time period evaluated, and eight produced more than 100 (Table 1). Spain leads the group of Ibero-American countries, with 1,992 papers (33.3%), followed by Brazil with 1,414 (23.7%), Chile with 574 (9.6%) and Mexico with 503 (8.4%).

 

4.3   Diachronic evolution of scientific production

            In terms of the diachronic evolution of scientific production by decades, from 1970 to 2019, of the Ibero-American countries that published more than 200 papers, the group is headed by Spain. Both Spain and Brazil have experienced exponential growth in the last two decades, while growth in the other Ibero-American countries has been linear (see Supplementary material, Figure 1).

            The two oldest papers retrieved in the databases were from 1973, and were published in Portuguese in two Brazilian journals: “Saude, humanizacao da Medicina e Etica medica”, authored by Kassab and published in Revista da Associacao Medica Brasileira; and “Sobre o estudo da deontología nos Cursos de Formacao profis- sional”, authored by Teixeira and published in Revista da Associacao Medica de Minas Geraisque.

 

4.4   Publications by authors from Ibero-American institutions in collaboration with authors from institutions in other countries

            As regards papers published by researchers from Ibero-American institutions co-authored with researchers from other countries, we found that they collaborated with authors from 108 non- Ibero-American countries. Most of the collaboration was with the United States (US) (n=395; 6.6%) and the United Kingdom (UK) (n=238; 4%), with the strongest collaboration between Spain and the UK (n=119), Spain and the US (n=103) and Spain and Italy (n=85). Among Ibero-American countries, the strongest collaborations were between Brazil and Portugal (n=33), Spain and Portugal (n=30), Spain and Brazil (n=26), and Spain and Chile (n=22). Figure 2 of the supplementary material presents the collaborative network between countries that have co-authored more than seven papers.

 

 4.5   Number of papers published in Ibero-American journals

            We consider Ibero-American journals to be those published in Ibero-American countries, although they may also publish articles in English. Journals that have published more than 40 papers are listed in Table 2. Acta Bioethica was the most productive, followed by Cuadernos de Bioética, Revista Colombiana de Bioética, Revista Médica de Chile, Interface Comunicao Saude Educaçao, Ciencia e Saude Coletiva, and Medicina Clínica.

 

4.6   Assessment of the quality of the papers as determined by the number of citations received

            The mean number of citations for articles in the most productive Ibero-American journals was 7.3 in Cuadernos de Saude Publica, 6.4 in Clinical Medicine, 4.6 in Revista da Associacao Medica Brasileira, 4.3 in Science e Saude Collective, 2.8 in Revista Brasileira de Enfermagem and 2.4 in Revista Médica de Chile (Table 2). None of these journals are in the top quartile of the subject categories included in the JCR and SJR. The most cited articles in Ibero-American journals were “Animal-based medicines: Biological prospection and the sustainable use of zootherapeutic resources”, by Costa-Neto, published in 2005 in Anais da Academia Brasileira de Ciencias, with 94 citations; “Moral deliberation: the method of clinical ethics”, by Gracia, published in Medicina Clínica in 2001; and “How effective is dog culling in controlling zoonotic visceral leishmaniasis? A critical evaluation of the science, politics and ethics behind this public health policy”, by Costa, published in Revista da Sociedade Brasileira de Medicina Tropical in 2011, with 76 citations.

Table 3 shows the 12 papers with more than 125 citations. None of them were written only by authors from Ibero-American institutions; authors from a non-Ibero-American institution - especially English-speaking - co-authored all of them, and they were published in English-language journals. It should also be noted that none of these articles were published in specialist bioethics journals.

            In terms of citations, the effect of the language in which the paper is published is notable, since the 3,276 (54.8%) papers that were published in a language other than English amassed 5,488 citations (1.68 citations per paper); the 264 (4.4%) published in English and other languages amassed 568 citations (2.15 citations per paper); and the 2,435 (40.8%) published in English only amassed 21,509 citations (8.83 citations per paper). The median distribution of citations varies significantly in all three groups (p<0.001), with the median being 2 for papers published in English; 1 for those papers published in English and another language; and 0 for those papers published in a language other than English. Among the Ibero-American countries with more than 100 publications, Portugal, Spain and Brazil have the highest citation rate per paper (Table 1).

 

4.7   Publication language of the papers

 

            We found papers written in 14 languages; 4.5% were written in more than one language. Of those written in only one language, 2,699 (45.2%) were in English, 2,706 (45.3%) in Spanish, 799 (13.4%) in Portuguese and 35 (0.6%) in French.

            Of the papers in which only authors from Ibero-American institutions participated (n=5,039), 32.1% were written in English, 5.1% in English and another language, and 62.8% in another language. However, in papers in which an author from a non-Ibero-American institution collaborated (n=936), 87.2% were written in English, 0.7% in English and another language, and 12.1% in other languages.

 

4.8   Number of articles published by Ibero-American authors in peer-reviewed journals in the area of bioethics and the number of citations

 

            This section includes the major bioethics and medical ethics journals selected according to the following criteria: a) all journals included in the JCR, within the categories “Ethics” and “Medical ethics”; b) journals in the top two quartiles of the subject category “Issues, Ethics and Legal Aspects” of the SJR; c) journals in the subject categories “Obstetrics & Gynecology” and “Public, Environmental & Occupational Health” with an impact factor greater than 5; and d) bioethics, multidisciplinary and mainstream journals, which, in the experience of the Bioethics Observatory at the Catholic University of Valencia, usually include papers related to bioethics and medical ethics. The journals selected are shown in the supplementary material.

            When only authors from Ibero-American institutions participated, the two Ibero-American journals that published most articles were Acta Bioethica (306) and Cuadernos de Bioética (287). When the same was assessed in the group of English-language bioethics journals, those that published most papers were: Nursing Ethics (54), Journal of Medical Ethics (53), Bioethics (27), BMC Medical Ethics (19), Science and Engineering Ethics (19), Cambridge Quarterly of Healthcare Ethics (10), and Journal of Bioethical Enquiry (10). As of December 2019, a total of 215 papers by authors from Ibero-American institutions had been published in this group. When the same was considered for papers in which a non-Ibero-American author participated, the journals in which these papers were published were: Science and Engineering Ethics (15), BMC Medical Ethics (12), Cambridge Quarterly of Healthcare Ethics (12) Journal of Empirical Research on Human Research Ethics (11), Developing World Bioethics (9) and American Journal of Bioethics (8). A total of 66 papers were published in this group as of December 2019.

            It should be noted that there are differences in the number of papers published in these journals if an author from a non-Ibero-American institution collaborates. Thus, of the 5,039 documents written only by authors from Ibero-American institutions, 931 (18.5%) were published in these journals. However, if authors from non-Ibero-American institutions co-authored the papers (n=936), 217 (23.2%) were published in these journals (Χ2=11.27; p<0.002).

            Table 4 shows articles written only by authors from Ibero-American institutions in the decade 2010-2019, and which being published in peer-reviewed bioethics journals have obtained more than 15 citations. Only 10 articles meet this requirement. Notably, of these 10 articles, four were published in Nursing Ethics, two in the Journal of Medical Ethics and one in BMC Medical Ethics. The most cited articles were “Burnout in palliative care: A systemic review,” published in Nursing Ethics[xxi] in 2011; “Role of a research ethics committee in follow-up and publication of results,” published in the Lancet[xxii] in 2003; and “The vulnerable and the susceptible,” published in Bioethics[xxiii] in 2003, with 99, 88, and 65 citations, respectively.

            The median number of citations per paper in the peer-reviewed journals of the documents produced only by authors from Ibero-American institutions is lower than if authors from other countries collaborated (1 compared to 4) (p<0.001). Likewise, this median number of citations in the papers authored only by authors from Ibero-American institutions was higher in the peer-reviewed journals than if the rest of the journals were considered (1 compared to 0) (p<0.001).

            When we determined the percentage of papers published only by authors affiliated with Ibero-American institutions in the decade 2010 to 2019, we found that this was 21.4% compared to 13.4% in the previous four decades (Χ2=49.99; p<0.001).

 

4.9   Content analysis of the papers

            The keywords assigned by the authors of the papers, excluding those related to the subject of the study, were “informed consent” (192), “nursing” (n=130), “autonomy” (n=127), “research” (n=112), “human rights” (n=101) “euthanasia” (n=96), “education” (n=87), “public health” (n=85) and “palliative care” (n=83).

            Figure 1 shows the network made up of keywords with more than three occurrences. As can be seen, the core is established with the terms being examined, “bioethics” and “ethics”. In the over- all graph, “ethics” is related mainly to “research” (n=63), “nursing” (n=55) and “informed consent” (n=33), while “bioethics” is mainly related to “informed consent” (n=86), “autonomy” (n=59) and “human rights” (n=58).

            The network of co-words of papers by authors from Spanish institutions includes 99 terms. From these, three groups are created: a larger group of 95 keywords and two pairs of terms, one formed by the terms “Crispr” with “gene editing” (n=4) and the other by the terms “principlism” and “virtues” (n=4). In the larger network (Supplementary material, Figure 3), we can see that “ethics” is related to “nursing” (n=11), “informed consent” (n=10) and “research” (n=10), while “bioethics” is related to “informed consent” (n=33), “advance directives” (n=22), “decision making” and “living skills” (n=19). In the network of co-words generated by the papers published by authors from Brazilian institutions, a network of 76 keywords arises which is divided into two groups: a larger one with 74 components and another with two components, with the words “melipona” and “stingless bees” (n=4). Figure 4 of the supplementary material shows the group with the highest number of keywords as it is the most important core. In it, we can see that “ethics” is related to “nursing” (n=35), “research” (n=22) and “education” (n=12), while “bioethics” is also related to “nursing” (n=23), “human rights” (n=17) and “personal autonomy” (n=16).

 

 

5.   Discussion

            The first point to highlight among our findings is the vast amount of published papers that include aspects of bioethics or medical ethics, somewhat in excess of 200,000. Without going into further depth, this certainly reflects the interest of the scientific community in these topics. However, this interest appears to be lower when it comes to the Ibero-American community. In fact, if one considers that there are approximately 7.5 billion inhabitants in the world, we can estimate that the number of documents with bioethical or medical ethics content produced per inhabitant is approximately 1 per 34,000 inhabitants. In contrast, considering that there are some 0.6 billion Ibero-Americans in the world, this index for the Ibero-American world is approximately 1 paper per 95,000 inhabitants, reflecting, in a first approximation, the lower capacity for output of scientific papers on bioethics by authors affiliated with Ibero- American institutions. These data corroborate those reported in an article by Borry et al.,[xxiv] who evaluated the number of papers published in nine of the top bioethics journals, per million inhabitants. New Zealand, with 14 articles per million inhabitants, was the most productive country, followed by the UK (9.2) and Finland (8.8), while Switzerland appeared in last place with 1.6 articles per million inhabitants. Interestingly, no Ibero-American country produced more than 1 article per million inhabitants.

            After selecting the papers authored by at least one Ibero- American institution, we found that, of the approximately 200,000 documents retrieved, 5,975 were produced by authors affiliated with Ibero-American institutions exclusively or by these authors in collaboration with institutions in other countries. Notably, 45.2% of papers published were in English, indicating the Ibero-American scientific community’s interest in publishing in this language, clearly because they are aware of the greater diffusion of articles published in English.[xxv] However, if we look at papers published only by authors from Ibero-American institutions, that percentage falls to 37.2%, whereas when they are published in collaboration with other countries, the percentage of those published in English rises to 87.9%. This is probably due to collaboration primarily with English-speaking countries such as the UK, US, Canada and Australia.

            In relation to the amount of scientific literature produced by researchers from Ibero-American institutions, only eight countries were identified that published more than 100 papers in the time period evaluated (approximately 50 years). This clearly indicates the scant bioethical- or medical ethics-related scientific production by Ibero-American institutions. The four countries with the highest scientific production are Spain (33.3%), Brazil (23.7%), Chile (9.6%), and Mexico (8.4%). These results are similar to those of other previous studies that identified the scientific production of Latin American countries and have shown that Spain and Brazil are the most productive countries in other areas such as research on local development[xxvi] and legal medicine.[xxvii] Brazil, Chile, and Mexico are also the most productive Latin American countries in terms of research in child sexual abuse[xxviii] and health inequalities.[xxix] If we look at the diachronic evolution by decades for papers published, Spain and Brazil stand out, with other countries very far behind these two. It is important to note that Portugal, which occupies the 25th position in the scientific production ranking,[xxx] is not among the most productive countries, and that Chile occupies that position. Chile’s position is probably due to the strong Catholic tradition in which discussions about the embryo and abortion arise, or the creation in Chile of a number of specific centres such as the Institute of Bioethics at the University of Chile, with support from the Pan American Health Organization.[xxxi] As mentioned, authors affiliated with Ibero- American institutions collaborate extensively with those from other countries, with such collaboration being more substantial with the US and UK, although as has already been noted, this international collaboration is very extensive, as it has been undertaken with 108 countries.

            Apart from the aforementioned quantitative assessment, in a first approach to the qualitative assessment, we found that the number of citations was higher for papers published in English, since the 3,276 papers (54.8%) published in a language other than English only merited 1.68 citations per paper, increasing to 2.15 when published in English and another language, and to 8.83 citations when published in English only. This trend toward the increased citation of papers published in English has been observed by other authors[xxxii], and may be influencing the fact that, in the area of bioethics, highly cited articles have been produced by the US, UK or Canada,[xxxiii] which are the countries that collaborate most with the Ibero-American institutions in this study. This finding is also corroborated if we estimate the median number of citations garnered: 2 for papers published in English, 1 for those papers published in another language and in English, and 0 for those papers published in a language other than English.

            Spain, Brazil and Portugal are the countries that achieve a higher number of citations per paper, which at the outset means that these are the countries that have the highest quality scientific activity in this area of thinking among the Ibero-American community.

            If we refer to the quality of Ibero-American journals, according to citation of their articles, the more important ones are Cuadernos de Saude Publica, Medicina Clínica, and Revista da Associacao Medica Brasileira, i.e. general medicine or public health journals.

            In our view, however, one of the criteria that can better define the quality of papers published by Ibero-American authors is the number of their articles published in high-quality English-language journals. In the time period evaluated, only 215 articles have been published in these journals by Ibero-American authors. Since this has taken place over approximately fifty years, the average number of articles published in these journals by this group is 4.3 per year. If this same calculation is performed when the articles are co-authored with authors from a non-Ibero-American country, we find that there are 66 articles published in this same time period, i.e. only 1.32 articles per year.

            This is in line with the study by Borry et al., who found that, among the 21 countries that had published 12 or more articles in last place with Switzerland, both countries with 12 publications, ac- counting for 0.3% of articles published.[xxxiv]

            These data confirm the difficulty faced by authors from Ibero- American institutions to publish in quality peer-reviewed bioethics journals.

            After analyzing these data, it is also worth noting that the top four bioethics journals in which authors from Ibero-American institutions have published are: Nursing Ethics, Journal of Medical Ethics, Bioethics, and Developing World Bioethics. This is consistent with other studies indicating that the journals that include the highest percentage of papers published in bioethics are the Journal of Medical Ethics and Nursing Ethics.[xxxv]

            All of the above seems to suggest that the Ibero-American bio- ethical heritage has, at present, little impact on global bioethical thinking. In fact, in the article by Borry and Dierickx[xxxvi], the authors note that between 1990 and 2003, the US was the undisputed leader of bioethical scientific activity, having published 2,390 papers in nine of the leading bioethics journals, accounting for 59.3% of the total; second in that ranking was the UK, but much further behind with 544 articles, accounting for 13.5% of articles published.

            Study of the subject shows that the most frequent topics are “in- formed consent”, “nursing”, “autonomy”, “research”, “human rights”, “euthanasia”, “education”, and “public health”. Research, education, human rights and euthanasia have already been highlighted as main subjects of research in bioethics by Ibero-American countries[xxxvii], with research ethics having increased in recent years, as already stated by Jin et al.[xxxviii] The consolidation of “nursing” may be due, as Tschudin[xxxix] said, to the fact that “nurses are now taking their professional life into their own hands”. Based on what has been said, a final reflection seems necessary.

            When writing a bioethical paper, it is essential to know the objective pursued in advance. If authors want to make their findings available to the Ibero-American world, then publishing their research in journals in that sphere will undoubtedly be justified, especially in Acta Bioethics and Cuadernos de Bioética for Hispanics, and in Cuadernos de Saude Publica, Revista da Associacao Brasileira and Ciencia e Saude Collective for Portuguese speakers. However, if authors want to influence global bioethical thinking, researchers in Ibero-American institutions will have to make the necessary leap in quality to be able to publish in English-language bioethical journals, especially high-quality ones.

 

6.   Limitations

 

            In the present study, the WoS CC and Scopus databases were selected as the main academic databases, where journals must meet that time period, Spain was the only Ibero-American country, sharing a number of requirements to be included therein and from which various indices are obtained based on the number of citations received by the articles included. These indices are published in the JCR in the case of the WoS CC, and in the SJR in the case of Scopus. A limitation of this study is that no other databases such as PubMed or the Philosophy Index were considered. This was mainly because PubMed did not begin to include the countries of the authors' working institutions in their records until 2015, with the corresponding author’s institution appearing in previous years, while in the Philosopher's Index, the countries of the institutions are not listed. Thus, neither is suitable for the purpose of this study and would not reflect the entire perspective of the health sciences.

            Other limitations of the study should be considered: a) the paper studies works in which at least one author has an Ibero-American institutional affiliation, so authors from other countries working at an Ibero-American institution could have been included, or works by Ibero-American authors working at institutions in other non-Ibero- American countries could have been disregarded; b) a random analysis of the records was carried out and an exhaustive search profile was designed and certain records related to other topics were excluded, but it is still possible that non-relevant documents were included or that relevant documents could not be retrieved; c) content analysis was done only on the basis of the papers available in the database of the keywords provided by authors, and relevant subjects may have been left unanalyzed. Nevertheless, we believe that both the sample of papers that do include them and their number are high and can therefore be considered sufficiently representative of the total document collection.