The respondents who answered the survey were generally very positive about using ES cells for treatment, especially when it comes to treatment of PD. They were a bit less positive concerning the treatment of other diseases. However, if iPS cells are available with equal efficacy, the respondents were less positive about using ES cells. This corresponds to the findings reported in our previous interview study with individuals from the Swedish population [18]. It is possible that individuals with a special interest in PD were more likely to respond to the survey, thus resulting in a bias in the sample. That could explain them being more positive toward accepting treatment for PD in particular. Another explanation is that the attitudes were biased by the information about PD at the beginning of the survey, making the respondents feel more strongly about PD. However, finding an effective treatment for diseases that lack an available treatment was ranked the most important aspect to consider when utilizing ES cells for treatment purposes, dominating all other factors considered. This can explain why treatment for PD was ranked higher than treatment for other diseases, since current PD therapies only address symptoms. The results were not surprising as it corresponds to a previous qualitative study, where the respondents did not distinguish between PD and other serious chronic diseases lacking a curable treatment [18]. However, the respondents had a low ranking for the importance of using iPS cells instead of ES cells to produce medical products for moral reasons, indicating that, although it was considered important, other aspects are more important. However, there were 25 respondents (5.7%) who ranked this as the most important aspect; these respondents were probably more religious and perceived the moral status of the early embryo as a human or close to a human.
In this study, we found an association between attitude toward using ES cells for medical treatment purposes and religious views and the perceived moral status of the early embryo among the Swedish general population. A Swiss study found that IVF couples’ perception of the moral status of an embryo and their stated religious views were independently predictive of their attitudes toward donation of surplus embryos for various purposes [20]. The number of people in our study who stated that religion was important or very important in their life, and the number of respondents who viewed the moral status of the embryo as a human or close to a human, were relatively few (11.4% and 12.6%, respectively). According to the Culture Map, provided by the World Value Survey, Sweden is a country with the most secular values in the world [21]. The culture map also shows that the values of migrants from e.g., Afghanistan, Iraq, Somalia, living in Sweden differ substantially compared with native Swedes [21]. Sharma et al. found that Asian immigrants in the United States were less likely to donate surplus embryos for research use [22]. In our study, about 14% of the respondents were born outside of Sweden, but we do not know from which countries.
The assessment of religious concerns in this study may be seen as a limitation, and, indeed more nuanced views may have been revealed if we had used an instrument and questions from life view research that captured religious beliefs, morally salient values, as well as fundamental attitudes as a basic component of a religious worldview [23, 24]. However, the aim was to see if the respondents self-reported as seeing religion as something important in their lives, whether their views were influenced by beliefs about the world and human beings, their morally salient values, or basic attitudes related to if they had a more positive or a more negative view of life. The instrument used did, in fact, reflect both on beliefs and values, e.g., the biological and moral status of a human embryo. Furthermore, previous studies have assessed religious views in similar ways, also finding that individuals with moderate to strong religious beliefs were less likely to donate to research [25]. Further empirical explorations in life- and worldview research may provide a richer understanding of how both comprehensive and fragmented religious views may direct moral positions. It may also be noted that from other religious contexts, the views are both aligned with and different from the majority view in this study. For instance, Sivaraman and Noor have studied ethical views about using ES cell among religious leaders from different religions in Malaysia. They found that the Islamic and Hindu leaders allowed the use of surplus embryos, to which they attached less moral weight, while they prohibited the use of “research embryos.” Furthermore, Islamic leaders have concluded that the use of ES cells is allowed for the purpose of maintaining health, and mandatory if it can relieve people’s suffering. The Buddhist leaders in their study did not see any ethical difference between the use of either source of embryos, approving the use of ES cells as long as it is done with caution and care. The Catholic leaders, however, opposed the use of embryos, whether surplus or research embryos. The different standpoints reflected different views on the moral value of the embryo, and whether the benefit is more important than the harm. They also found different reflections from leaders from the same religion, expect the Catholic leaders, who repeated the same message as formulated by the Vatican [17].
Besides religious views and the moral status of the early embryo, other studies have found that men, in general, are positive about allowing embryo donation for research [14, 26]. Likewise, the univariate analyses in this study showed that men held a more positive attitude. However, this association was not found in the adjusted analyses. Furthermore, health professionals have been more positive than the public in previous studies on donating embryos for research [26]. Being scientifically oriented and having trust in experts and the medical system are also factors related to a more positive attitude [13, 18]. A limitation of the study is that we have not assessed the respondents’ trust in the healthcare systems or whether the respondents worked within the healthcare systems themselves. Neither does the questionnaire assess the importance of considering genetic privacy issues for donors or issues regarding commercialization. Another limitation is the low response rate (17%), restricting the generalization of the results to the Swedish population at large. Our study sample consisted of more individuals with a university degree compared with the Swedish general population. However, a random sample of the general population was invited to participate, and the final sample included an equal number of men and women of various ages and educational- and occupational backgrounds, which is a strength of the study. Therefore, although migrant groups may be missing, it is possible to make a statement about the attitudes and values of native Swedes of various ages.
The literature on the ethics of using stem cells give witness to moral concerns and sometimes to intense discussions [27, 28]. Some areas where this is evident are gene therapy, pre-implantation genetic diagnosis, whole genome sequencing, or gene editing. They have all, like stem cell-based research, stirred intense ethical discussions when they first were presented in scholarly journals and reported in public media. Some early research applications with these technologies were indeed premature and should have awaited better evidence but, after some progress and more scientific evidence about benefits and risks, most of them will belong to mainstream medical science. Gene therapy is an example of a promising new technology developed 40 years ago. It met quite some resistance, not the least from religious representatives. Some warned against Gene therapy as a way of “Playing God” [29]. Forty years later, there are approved treatments and several clinical trials with gene therapy ongoing. The technology is now moving into the mainstream medical science governed by ordinary regulatory frameworks for clinical trials, despite the fact that in the beginning it was viewed by many as being morally unacceptable. It is against this background that the results of this study are of particular interest, showing that the majority of the general public care foremost about issues relating to medical needs and being able to improve medical treatment. Furthermore, the history of stem cell research have shown us that strong moral values och opinions from some voices in society, e.g., activists or religious leaders, can influence legislation and stop development of valuable treatments for patients. For democratic reasons, it is crucial to make an effort to listen to the voice of the general public as direct stakeholders, and not only those with openly voiced opinions. It is not apparent that policy should always do as the majority thinks, but policy makers should always listen to their perspective, as part of a transparent dialogue to maintain trust for researchers, the health care system and the pharmaceutical industry. It is our hope that policy makers use the findings from this study for deliberation and communication.