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The overarching rationale of research ethics guidance is that human participants should not be exploited when contributing to the good of science and society. Two essential requisites for this are that human participants consent voluntarily after being informed about a research trial and that benefits and risks are distributed fairly. With the increasingly global practice of biomedical research, fulfilling these requisites creates challenges in some contexts. I examine the challenges of applying these ethical requirements when patients are enrolled into research trials in Pakistan, with reference to the moral reasoning employed by researchers to negotiate these challenges. Using insights obtained from interviewing physicians conducting research and patients in tertiary-care hospitals, and from observing the interactions between these physician-researchers and patients in the context of research trial enrolment, I demonstrate how the socio-cultural environment in which research is carried out shapes the practice of ethics in important ways. I present the issue of informed consent as the core challenge. 1 also examine the implications for research of the researchers' view that their primary duty is that of a physician. The researchers determine the amount of information patients receive about research, guided in this by their sense of duty and influenced by their communication skills, time constraints and patients' education status. The process of decision-making is affected by such factors as the patients' gender, education level, financial independence and the role of other actors such as the spouse, relatives and the researcher. Commonly, a joint decision is reached after mutual consultation within the family. but sometimes patients may delegate or accept decisions made by the family, and occasionally the family's interest is inconsistent with the best health interest of the patient. This raises ethical challenges. When recording consent, a written consent is obtained because sponsors and guidelines require it and researchers prefer it. This emphasis on a written consent raises ethical challenges with regard to the ethical principle of respect for persons. I also argue that following the ethical principles of justice and equity are essential to avoiding exploitation when conducting research. Complex issues arise when guidance and local norms are at variance, or there is disagreement between local norms and fundamental rights. Their resolution requires sensitivity to, and awareness of, the context. Importantly, it is the commitment of those conducting research and at the interface with patients that determines the ethics of research. I conclude that upholding the spirit of the guidelines is more important than procedural intransigence.

A growing area of academic research is the study of the social and ethical implications of assisted conception techniques. Approximately one third of all infertile couples undergoing assisted conception techniques have embryos that remain unused during their treatment. Some decide to donate their surplus embryos to other infertile couples or to scientific research, such as stem cell research, which forms part of the process known as embryo donation.

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Freedom is a key element in contemporary Western thinking and one which is central to all bioethical discussions, including the stem cell debate. However, the adequacy of the current understanding of the concept has not been subject to sufficient analysis. In order to address this deficiency, using the stem cell debate as a case study, I engage with the current understanding of freedom in a particular area of social activity. Examining the stem cell debate, I consider that freedom is defined in three ways; as the freedom of research, as the consent of gamete and embryo donors to create stem cells and as the freedom to transcend physical limitations. I argue that Isaiah Berlin’s categorization of freedom as negative and positive is useful in examining the understandings of freedom in the stem cell debate. I conclude that all of the currently accepted understandings of freedom in the stem cell debate tend to be focused on the individual and I argue that they are consequently problematic, resulting in individualism, conflict, subjectivism and inappropriate attitudes toward natural resources. In response to the problems identified, in the second part of the thesis I draw on the theology of Hans Urs von Balthasar in order to offer an alternative conception of freedom. Von Balthasar argues that although freedom entails individual willing and choosing, it also is relational, involving interaction with other people and God, both in the realisation of the possession of freedom and in the fulfilment of that freedom. Thus I argue that von Balthasar’s theology provides an effective counter to the neglect of relationships in the contemporary understanding of freedom. However von Balthasar, in his analysis, focuses on interpersonal relationships and he can be criticised for underplaying the role of society. I therefore expand upon his work employing the concept of the common good. This provides a means of examining freedom in the context of wider society. The conception of freedom thus arrived at is then considered in relation to the original case study of the stem cell debate. In doing this I provide a more nuanced rendering of the issues involved; one that is better able to accommodate the social and personal aspects.