Designing and implementing a research integrity promotion plan: Recommendations for research funders.

Various stakeholders in science have put research integrity high on their agenda. Among them, research funders are prominently placed to foster research integrity by requiring that the organizations and individual researchers they support make an explicit commitment to research integrity. Moreover, funders need to adopt appropriate research integrity practices themselves. To facilitate this, we recommend that funders develop and implement a Research Integrity Promotion Plan (RIPP). This Consensus View offers a range of examples of how funders are already promoting research integrity, distills 6 core topics that funders should cover in a RIPP, and provides guidelines on how to develop and implement a RIPP. We believe that the 6 core topics we put forward will guide funders towards strengthening research integrity policy in their organization and guide the researchers and research organizations they fund.

Taking the risk. A systematic review of ethical reasons and moral arguments in the clinical use of polygenic risk scores.

Debates about the prospective clinical use of polygenic risk scores (PRS) have grown considerably in the last years. The potential benefits of PRS to improve patient care at individual and population levels have been extensively underlined. Nonetheless, the use of PRS in clinical contexts presents a number of unresolved ethical challenges and consequent normative gaps that hinder their optimal implementation. Here, we conducted a systematic review of reasons of the normative literature discussing ethical issues and moral arguments related to the use of PRS for the prevention and treatment of common complex diseases. In total, we have included and analyzed 34 records, spanning from 2013 to 2023. The findings have been organized in three major themes: in the first theme, we consider the potential harms of PRS to individuals and their kin. In the theme "Threats to health equity," we consider ethical concerns of social relevance, with a focus on justice issues. Finally, the theme "Towards best practices" collects a series of research priorities and provisional recommendations to be considered for an optimal clinical translation of PRS. We conclude that the use of PRS in clinical care reinvigorates old debates in matters of health justice; however, open questions, regarding best practices in clinical counseling, suggest that the ethical considerations applicable in monogenic settings will not be sufficient to face PRS emerging challenges.

Ethics without borders: an analysis of national and international guidelines on ethics in basic medical education.

BACKGROUND: It has been widely recognized that ethics is central to the practice of medicine. Since physicians' identities are heavily influenced by their basic medical training, education in ethics during this period would facilitate their professional development. To enable this, some global and national organizations have published guidelines detailing the aspects of ethics that need to be taught to medical student. However, it is not known how many such guidelines exist and to what extent they concur or differ. AIM: This study aims to identify and examine the content of existing national or international guidelines on the inclusion of ethics in basic medical education, in the English language. By doing so, it hopes to explore and highlight the similarities and differences regarding their pedagogical goals and their prescribed content, thereby contributing to a more holistic understanding on the state of medical ethics education. METHODS: Data collection was performed through systematic searches on Google and on scientific databases. The guidelines that fulfilled the inclusion criteria were thematically analyzed using the method proposed by Braun and Clarke (2006). The resulting themes and sub-themes were grouped and characterized. RESULTS: Thirteen guidelines (ten national and three international) fulfilled the inclusion criteria. Among these, two major approaches can be discerned: value-based and norm-based. Value-based guidelines tend to be more globally applicable, because they endorse more abstract and universal principles. Norm-based guidelines, on the other hand, are more context-specific and have a practical focus. Understanding this distinction could facilitate discussions on different perspectives in ethics education.

Moving beyond the moral status of organoid-entities.

Ethical deliberations are unfolding for potentially controversial organoid-entities such as brain organoids and embryoids. Much of the ethical deliberation centers on the questionable moral status of such organoid-entities. However, while such work is important and appropriate, ethical deliberations may become too exclusively rooted in moral status and potentially overshadow other relevant moral dilemmas. The ethical discussion on organoid models can benefit from insights brought forth by both Judith Jarvis Thomson and Don Marquis in how they attempted to advance the abortion debate. To discuss other abortion ethical issues more fully, both Thomson and Marquis assumed differing moral status positions of the conceptus and followed lines of reasoning based on these moral status assumptions. We suggest a similar approach with controversial organoid-entities like brain organoids and embryoids. To avoid overshadowing or overlooking other relevant ethical issues, ethicists ought to first assume an organoid-entity moral status position (such as a high moral status or no moral status) and explore any possible arguments that may result from such a position. While we ought not to copy the content of Thomson and Marquis' arguments exactly for organoid-entities, it is worthwhile to translate their arguments' overarching structures. This paper explores the relevant insights of Thomson and Marquis, how they can be translated into the organoid ethics debate, and what possible lines of inquiry may be worth exploring based on particular moral status assumptions.

The Mentor's Role in Fostering Research Integrity Standards Among New Generations of Researchers: A Review of Empirical Studies.

Promoting research integrity practices among doctoral candidates and early career researchers is important for creating a stable and healthy research environment. In addition to teaching specific technical skills and knowledge, research supervisors and mentors inevitably convey research practices, both directly and indirectly. We conducted a scoping review to summarise the role of mentors in fostering research integrity practices, mentors' responsibilities and the role that institutions have in supporting good mentorship. We searched five different databases and included studies that used an empirical methodology. After searching, a total of 1199 articles were retrieved, of which 24 were eligible for analysis. After snowballing, a total of 35 empirical articles were selected. The review discusses various themes such as the importance of good mentorship, poor mentorship practices, virtues and qualities of mentors, responsibilities and activities of mentors, group mentoring and responsibilities of the institution in supporting good mentorship. This review demonstrates the importance of mentors instilling responsible research practices and attitudes, and promoting research integrity among their mentees. Mentors are responsible for providing explicit guidance and for acting as good role models. The review highlights how poor mentorship can have a bad impact on the research climate. In addition, the review highlights the important influence that institutions can have in supporting mentorship.

The Value-Free Ideal of Science: A Useful Fiction? A Review of Non-epistemic Reasons for the Research Integrity Community.

Even if the "value-free ideal of science" (VFI) were an unattainable goal, one could ask: can it be a useful fiction, one that is beneficial for the research community and society? This question is particularly crucial for scholars and institutions concerned with research integrity (RI), as one cannot offer normative guidance to researchers without making some assumptions about what ideal scientific research looks like. Despite the insofar little interaction between scholars studying RI and those working on values in science, the overlap of topics and interests make collaboration between the two fields promising for understanding research and its ethics. Here, we identify-for the use of RI scholars-the non-epistemic reasons (societal, political, professional) for and against the VFI considered in the literature. All of these are concerned with the beneficial or detrimental consequences that endorsing the VFI would have on society, policy-making, or the scientific community, with some authors appealing to the same principles to argue for opposite positions. Though most of the reviewed articles do not endorse the VFI, it is generally agreed that some constraints have to be put on the use of non-epistemic values. Disagreement on the utility of the VFI lies both on the different epistemic-descriptive positions taken by different authors, and on the scarcity of relevant empirical studies. Engaging critically with the reasons here identified and more in general with the values in science debate will help the RI community decide whether the VFI should be included in future codes of conduct.

Co-creating Research Integrity Education Guidelines for Research Institutions.

To foster research integrity (RI), research institutions should develop a continuous RI education approach, addressing various target groups. To support institutions to achieve this, we developed RI education guidelines together with RI experts and research administrators, exploring similarities and differences in recommendations across target groups, as well as recommendations about RI education using approaches other than formal RI training. We used an iterative co-creative process. We conducted four half-day online co-creation workshops with 16 participants in total, which were informed by the RI education evidence-base. In the first two workshops, participants generated ideas for guidelines' content, focusing on different target groups and various approaches to RI education. Based on this content we developed first drafts of the guidelines. Participants in the third and fourth workshop refined those drafts. We next organized a working group which further prioritized, reorganized, and optimized the content of the guidelines. We developed four guidelines on RI education focusing on (a) bachelor, master and PhD students; (b) post-doctorate and senior researchers; (c) other RI stakeholders; as well as (d) continuous RI education. Across guidelines, we recommend mandatory RI training; follow-up refresher training; informal discussions about RI; appropriate rewards and incentives for active participation in RI education; and evaluation of RI educational events. Our work provides experience-based co-created guidance to research institutions on what to consider when developing a successful RI education strategy. Each guideline is offered as a distinct, publicly available tool in our toolbox ( www.sops4ri.eu/toolbox ) which institutions can access, adapt and implement to meet their institution-specific RI education needs.Trial registration https://osf.io/zej5b .

A Tale of Two Chimeras: Applying the Six Principles to Human Brain Organoid Xenotransplantation.

Cerebral organoid models in-of-themselves are considered as an alternative to research animal models. But their developmental and biological limitations currently inhibit the probability that organoids can fully replace animal models. Furthermore, these organoid limitations have, somewhat ironically, brought researchers back to the animal model via xenotransplantation, thus creating hybrids and chimeras. In addition to attempting to study and overcome cerebral organoid limitations, transplanting cerebral organoids into animal models brings an opportunity to observe behavioral changes in the animal itself. Traditional animal ethics frameworks, such as the well-known three Rs (reduce, refine, and replace), have previously addressed chimeras and xenotransplantation of tissue. But these frameworks have yet to completely assess the neural-chimeric possibilities. And while the three Rs framework was a historical landmark in animal ethics, there are identifiable gaps in the framework that require attention. The authors propose to utilize an expanded three Rs framework initially developed by David DeGrazia and Tom L. Beauchamp, known as the Six Principles (6Ps). This framework aims to expand upon the three Rs, fill in the gaps, and be a practical means for assessing animal ethical issues like that of neural-chimeras and cerebral organoid xenotransplantation. The scope of this 6Ps application will focus on two separate but recent studies, which were published in 2019 and 2020. First, they consider a study wherein cerebral organoids were grown from donors with Down syndrome and from neurotypical donors. After these organoids were grown and studied, they were then surgically implanted into mouse models to observe the physiological effects and any behavioral change in the chimera. Second, they consider a separate study wherein neurotypical human embryonic stem cell-derived cerebral organoids were grown and transplanted into mouse and macaque models. The aim was to observe if such a transplantation method would contribute to therapies for brain injury or stroke. The authors place both studies under the lens of the 6Ps framework, assess the relevant contexts of each case, and provide relevant normative conclusions. In this way, they demonstrate how the 6Ps could be applied in future cases of neural-chimeras and cerebral organoid xenotransplantation.

Do biomedical researchers differ in their perceptions of plagiarism across Europe? Findings from an online survey among leading universities.

BACKGROUND: Existing research on perceptions of plagiarism and cultural influences mainly focuses on comparisons between the Western World and the Eastern World. However, possible differences within the Western World have hardly been assessed, especially among biomedical academics. The authors compared perceptions of plagiarism among European biomedical researchers who participated in an online survey. METHODS: The present work is based on the data collected in a previous online survey done in 2018 among biomedical researchers working in leading European and Chinese universities. Respondents based in Europe were grouped into three geographical regions (northern Europe, southern Europe and northwestern Europe) and their responses were analyzed using logistic regression analysis with adjustments for demographic factors. RESULTS: Data were available from 810 respondents (265 northern Europe, 101 southern Europe, 444 northwestern Europe). In addition to their generally similar responses, different perceptions of plagiarism were observed among respondents in the three European regions. In summary, among the three European regions, Nordic respondents identified the most types of practices as plagiarism. Compared to the southern respondents, Nordic and northwestern respondents were more likely to consider less evident practices as plagiarism, such as Rephrasing another person's work without crediting the source [aORN|S 1.99 (95%CI 1.08;3.67), aORS|NW 0.50 (95%CI 0.28;0.91)] and With permission from the original author, using another's text without crediting the source [aORN|S 3.16 (95%CI 1.90;5.25), aORS|NW 0.26 (95%CI 0.16;0.42)]. In contrast, the southern respondents were the most inclined to recognize recycling of one's previously rejected research proposal as plagiarism. CONCLUSIONS: In spite of a generally similar response pattern, the present study indicates different perceptions of plagiarism among European biomedical researchers. These intra-European differences should be considered when addressing plagiarism.

The Many Moral Matters of Organoid Models: A systematic review of reasons.

OBJECTIVE: To present the ethical issues, moral arguments, and reasons found in the ethical literature on organoid models. DESIGN: In this systematic review of reasons in ethical literature, we selected sources based on predefined criteria: (1) The publication mentions moral reasons or arguments directly relating to the creation and/or use of organoid models in biomedical research; (2) These moral reasons and arguments are significantly addressed, not as mere passing mentions, or comprise a large portion of the body of work; (3) The publication is peer-reviewed and published in an academic article, book, national-level report, working paper, or Ph.D. thesis; (4) The publications collected are in English. ANALYSIS: Each article was read in-depth for identifiable moral reasons, arguments, and concerns. These were then inductively classified and synthesized to create broader categories of reasons, and eventually an overarching conceptual scheme was created. RESULTS: A total of twenty-three sources were included and analyzed out of an initial 266 collected sources. Five themes of ethical issues and arguments were found: Animal Experimentation; Clinical Applications and Experiments; Commercialization and Consent; Organoid Ontology and Moral Status; and Research Ethics and Research Integrity. These themes are then further broken down into sub-themes and topics. Given the extensive nature of the topics found, we will focus on describing the topics that comprised of more in-depth reasons and arguments rather than few, passing mentions or concerns. CONCLUSIONS: The ethics of organoids requires further deliberation in multiple areas, as much of the discussions are not presented as in-depth arguments. Such sentiments are also echoed throughout the organoid ethics literature.

Research Integrity Supervision Practices and Institutional Support: A Qualitative Study.

Scientific malpractice is not just due to researchers having bad intentions, but also due to a lack of education concerning research integrity practices. Besides the importance of institutionalised trainings on research integrity, research supervisors play an important role in translating what doctoral students learn during research integrity formal sessions. Supervision practices and role modelling influence directly and indirectly supervisees' attitudes and behaviour toward responsible research. Research supervisors can not be left alone in this effort. Research institutions are responsible for supporting supervisors in being more aware of their RI function, and in supporting responsible supervision practices to have a positive cascading effect on supervisees' research practices. We interviewed 22 European research supervisors to investigate how they perceive their role as research integrity trainers and their real-life supervision practices. Moreover, we investigated their points of view concerning the role of research institutions in supporting supervision practices. Although there are different commonalities in supervisors' perception of their research integrity-related role, differences are emphasised depending on the supervisors' characteristics such as academic domain, seniority, working country and gender. In addition, supervisors' way of mentoring depend also on supervisees' learning curve. Overall, all supervisors agreed on institutions playing an important role in support their supervision effort and practices. This study aims to be a starting point for better understanding research integrity supervision practices and the role of institutions in supporting them. Moreover, it puts the basis to further investigate differences in supervision practices depending on supervisors' characteristics. Supplementary Information: The online version contains supplementary material available at 10.1007/s10805-022-09468-y.

The TOTAL trial dilemma: A survey among professionals on equipoise regarding fetal therapy for severe congenital diaphragmatic hernia.

OBJECTIVE: Running randomized clinical trials (RCT) in fetal therapy is challenging. This is no different for fetoscopic endoluminal tracheal occlusion (FETO) for severe left-sided Congenital Diaphragmatic Hernia (CDH). We assessed the knowledge, attitude and practice (KAP) of maternal-fetal medicine specialists toward the antenatal management of CDH, and the randomized controlled clinical (RCT) "Tracheal Occlusion To Accelerate Lung growth-trial." METHODS: A cross-sectional KAP-survey was conducted among 311 registrants of the 18th World Congress in Fetal Medicine. RESULTS: The overall knowledge of CDH and FETO was high. Remarkably only 45% considers prenatal prediction of neonatal outcome reliable. Despite, in their clinical practice they perform severity assessment (80%) and refer families for FETO either within the context of an RCT (43%) or on patient request (32%). Seventy percent perceives not offering FETO on patient demand seems as if no treatment is provided to a fetus with predicted poor outcome. Only 20% of respondents considers denying access to FETO on patient demand not as a psychological burden. CONCLUSION: Often the views of individual respondents contradicted with their clinical practice. It seems that, for severe CDH, clinicians face personal and practical dilemmas that undermine equipoise. To us, this indicates the tension between the clinical and scientific obligations physicians experience.

Research integrity codes of conduct in Europe: Understanding the divergences.

In the past decade, policy-makers in science have been concerned with harmonizing research integrity standards across Europe. These standards are encapsulated in the European Code of Conduct for Research Integrity. Yet, almost every European country today has its own national-level code of conduct for research integrity. In this study we document in detail how national-level codes diverge on almost all aspects concerning research integrity-except for what constitutes egregious misconduct. Besides allowing for potentially unfair responses to joint misconduct by international collaborations, we argue that the divergences raise questions about the envisaged self-regulatory function of the codes of conduct.

Trust and professionalism in science: medical codes as a model for scientific negligence?

BACKGROUND: Professional communities such as the medical community are acutely concerned with negligence: the category of misconduct where a professional does not live up to the standards expected of a professional of similar qualifications. Since science is currently strengthening its structures of self-regulation in parallel to the professions, this raises the question to what extent the scientific community is concerned with negligence, and if not, whether it should be. By means of comparative analysis of medical and scientific codes of conduct, we aim to highlight the role (or lack thereof) of negligence provisions in codes of conduct for scientists, and to discuss the normative consequences for future codes of conduct. METHODS: We collected scientific and medical codes of conduct in a selection of OECD countries, and submitted each code of conduct to comparative textual analysis. RESULTS: Negligence is invariably listed as an infraction of the norms of integrity in medical codes of conduct, but only rarely so in the scientific codes. When the latter list negligence, they typically do not provide any detail on the meaning of 'negligence'. DISCUSSION: Unlike codes of conduct for professionals, current codes of conduct for scientists are largely silent on the issue of negligence, or explicitly exclude negligence as a type of misconduct. In the few cases where negligence is stipulated to constitute misconduct, no responsibilities are identified that would help prevent negligence. While we caution against unreasonable negligence provisions as well as disproportionate sanctioning systems, we do argue that negligence provisions are crucial for justified trust in the scientific community, and hence that there is a very strong rationale for including negligence provisions in codes of conduct.

Stakeholders' perspectives on research integrity training practices: a qualitative study.

BACKGROUND: Even though research integrity (RI) training programs have been developed in the last decades, it is argued that current training practices are not always able to increase RI-related awareness within the scientific community. Defining and understanding the capacities and lacunas of existing RI training are becoming extremely important for developing up-to-date educational practices to tackle present-day challenges. Recommendations on how to implement RI education have been primarily made by selected people with specific RI-related expertise. Those recommendations were developed mainly without consulting a broader audience with no specific RI expertise. Moreover, the academic literature lacks qualitative studies on RI training practices. For these reasons, performing in-depth focus groups with non-RI expert stakeholders are of a primary necessity to understand and outline how RI education should be implemented. METHODS: In this qualitative analysis, different focus groups were conducted to examine stakeholders' perspectives on RI training practices. Five stakeholders' groups, namely publishers and peer reviewers, researchers on RI, RI trainers, PhDs and postdoctoral researchers, and research administrators working within academia, have been identified to have a broader overview of state of the art. RESULTS: A total of 39 participants participated in five focus group sessions. Eight training-related themes were highlighted during the focus group discussions. The training goals, timing and frequency, customisation, format and teaching approach, mentoring, compulsoriness, certification and evaluation, and RI-related responsibilities were discussed. Although confirming what was already proposed by research integrity experts in terms of timing, frequency, duration, and target audience in organising RI education, participants proposed other possible implementations strategies concerning the teaching approach, researchers' obligations, and development an evaluation-certification system. CONCLUSIONS: This research aims to be a starting point for a better understanding of necessary, definitive, and consistent ways of structuring RI education. The research gives an overview of what has to be considered needed in planning RI training sessions regarding objectives, organisation, and teaching approach.

Cultures and cures: neurodiversity and brain organoids.

BACKGROUND: Research with cerebral organoids is beginning to make significant progress in understanding the etiology of autism spectrum disorder (ASD). Brain organoid models can be grown from the cells of donors with ASD. Researchers can explore the genetic, developmental, and other factors that may give rise to the varieties of autism. Researchers could study all of these factors together with brain organoids grown from cells originating from ASD individuals. This makes brain organoids unique from other forms of ASD research. They are like a multi-tool, one with significant versatility for the scope of ASD research and clinical applications. There is hope that brain organoids could one day be used for precision medicine, like developing tailored ASD drug treatments. MAIN BODY: Brain organoid researchers often incorporate the medical model of disability when researching the origins of ASD, especially when the research has the specific aim of potentially finding tailored clinical treatments for ASD individuals. The neurodiversity movement-a developmental disability movement and paradigm that understands autism as a form of natural human diversity-will potentially disagree with approaches or aims of cerebral organoid research on ASD. Neurodiversity advocates incorporate a social model of disability into their movement, which focuses more on the social, attitudinal, and environmental barriers rather than biophysical or psychological deficits. Therefore, a potential conflict may arise between these perspectives on how to proceed with cerebral organoid research regarding neurodevelopmental conditions, especially ASD. CONCLUSIONS: Here, we present these perspectives and give at least three initial recommendations to achieve a more holistic and inclusive approach to cerebral organoid research on ASD. These three initial starting points can build bridges between researchers and the neurodiversity movement. First, neurodiverse individuals should be included as co-creators in both the scientific process and research communication. Second, clinicians and neurodiverse communities should have open and respectful communication. Finally, we suggest a continual reconceptualization of illness, impairment, disability, behavior, and person.

Educating PhD Students in Research Integrity in Europe.

No university or research institution is immune to research misconduct or the more widespread problem of questionable research practices. To strengthen integrity in research, universities worldwide have developed education in research integrity. However, little is known about education in research integrity for PhD students in European research-intensive universities. We conducted a content analysis of didactic materials of 11 of the 23 members of the League of European Research Universities (LERU) to map out the content, format, frequency, duration, timing, and compulsory status of their training programmes and the characteristics of instructors of the onsite courses. Quantitative results revealed substantial variation in educational materials among the studied institutions. This variation might be because European research universities are free to design curricula without any requirements from the European, national, or institutional public funding channels. Given the challenges inherent to modern science and preventing misconduct, research institutions should empower future generations of researchers to engage in responsible research practices. To promote integrity in research among PhD students, we provide a set of recommendations for university-wide education in research integrity for doctoral trainees based on our investigation of educational resources.

Parents' multi-layered expectations when requesting an Autism Spectrum Disorder assessment of their young child: an in-depth interview study.

BACKGROUND: Parents are valued stakeholders in research, clinical practice and policy development concerning autism spectrum disorder (ASD). However, little is known about what drives and moves parents besides their obvious worries and help request when they ask for a diagnostic ASD assessment of their child. METHODS: Seventeen Flemish parents of 11 young children participated in a longitudinal study consisting of three in-depth interviews before and after their child's diagnostic ASD assessment. Data were analysed in Nvivo 11 according to the procedures of Interpretative Phenomenological Analysis. RESULTS: In this paper we report the results of the first series of interviews which were conducted after parents had asked for an ASD assessment of their young child, and before this assessment started. The pre-assessment experiences of the parents were dominated by the anticipation of various implications of an ASD diagnosis, comprising both positive and negative expectations. The theme of positive expectations consisted of two equally prominent subthemes: treatment-related implications but also expectations pertaining to their psychological and relational experiences. CONCLUSIONS: This study suggests important issues for clinicians to bear in mind during a consultation with parents who request an ASD assessment of their young child. We argue that attending to and communicating about parents' expectations prior to their child's ASD assessment may help clinicians to better understand parents' requests for help, and to address their needs more effectively.

Perceptions of plagiarism by biomedical researchers: an online survey in Europe and China.

BACKGROUND: Plagiarism is considered as serious research misconduct, together with data fabrication and falsification. However, little is known about biomedical researchers' views on plagiarism. Moreover, it has been argued - based on limited empirical evidence - that perceptions of plagiarism depend on cultural and other determinants. The authors explored, by means of an online survey among 46 reputable universities in Europe and China, how plagiarism is perceived by biomedical researchers in both regions. METHODS: We collected work e-mail addresses of biomedical researchers identified through the websites of 13 reputable universities in Europe and 33 reputable universities in China and invited them to participate in an online anonymous survey. Our questionnaire was designed to assess respondents' views about plagiarism by asking whether they considered specific practices as plagiarism. We analyzed if respondents in China and Europe responded differently, using logistic regression analysis with adjustments for demographic and other relevant factors. RESULTS: The authors obtained valid responses from 204 researchers based in China (response rate 2.1%) and 826 researchers based in Europe (response rate 5.6%). Copying text from someone else's publication without crediting the source, using idea(s) from someone else's publication without crediting the source and republishing one's own work in another language without crediting the source were considered as plagiarism by 98, 67 and 64%, respectively. About one-third of the respondents reported to have been unsure whether they had been plagiarizing. Overall, the pattern of responses was similar among respondents based in Europe and China. Nevertheless, for some items significant differences did occur in disadvantage of Chinese respondents. CONCLUSIONS: Findings indicate that nearly all biomedical researchers understand (and disapprove of) the most obvious forms of plagiarism, but uncertainties and doubts were apparent for many aspects. And the minority of researchers who did not recognize some types of plagiarism as plagiarism was larger among China-based respondents than among Europe-based respondents. The authors conclude that biomedical researchers need clearer working definitions of plagiarism in order to deal with grey zones.