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such as Sheehan et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">2</span></a> have reported that increased moral reasoning is associated with higher quality care&#59; moreover&#44; difficulties in managing the patient&#39;s values and concerns can result in a deficient clinical practice&#46; The greater the empathy&#44; the better the clinical practice and quality and the less the burnout&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">A recent article indicated that physicians&#8217; ethical development and communication skills play an essential role in high-quality care&#44; safety and patient&#39;s quality of life but questions whether the current medical curriculum is truly effective in ensuring appropriate training in ethics and communication&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">4</span></a> The acquisition of ethical and communication skills should be a key factor in medical education&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">However&#44; numerous studies have suggested that medical students undergo very few changes in their expected moral development&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">6&#8211;12</span></a> A number of studies have even shown regression in moral development during medical training&#44; the so-called &#8220;ethical erosion&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">13</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">According to Kohlberg&#39;s theory of moral reasoning&#44;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">14&#44;15</span></a> there is significant improvement in the moral reasoning stages of young adults&#44; with rapid progression toward conventional thinking and the start of postconventionalism&#46; However&#44; various studies have shown that medical students&#44; who correspond to this young adult era&#44; do not show the expected moral progression for their age and even regress&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">6&#8211;13</span></a> In the Spanish setting&#44; one of the pioneering studies conducted at the University of Zaragoza&#44; Spain&#44; compared students from Zaragoza and Qatar&#44; progressively and before and after their training in bioethics without finding moral growth&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">16</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Studies have also assessed the ethical competency of medical students in a more applied manner through &#8220;case studies&#8221;&#44; which sought to assess &#8220;ethical sensitivity&#8221;&#44; defined as &#8220;the ability or capacity to recognize the presence of an ethical or moral problem in a clinical case&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">5</span></a> Various authors have used vignettes to measure the development of ethical sensitivity and have achieved a good degree of validity and reliability&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">17&#8211;20</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">As with ethical competency&#44; numerous studies have shown a significant reduction in the empathy of medical students during their academic career&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">21&#8211;25</span></a> The reduction is more pronounced in men&#44; in students with greater initial empathy&#44; greater empathic stress or with a greater preference for their particular specialty&#46; A number of studies&#44; however&#44; have shown an increase in empathy during medical training<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">26</span></a> or with appropriate training strategies&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">27</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In general&#44; there appears to be a confluence between ethical development and empathy&#44; such that the socialization of healthcare professionals combines the acquisition of appropriate values&#44; attitudes and behaviors&#44;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">28</span></a> suggesting a relationship between ethical medicine and empathic medicine&#46; Hoffman described theoretically how the development of empathy and prosocial behavior&#44; in the setting of children and adolescents&#44; is related to ethical and moral development&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">29&#44;30</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">We have found no studies that have jointly analyzed these variables in the setting of medical students&#46; A study with Japanese medical students measured the relationship between moral development and ethical sensitivity but found no relationship between the two&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">31</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Based on our literature review&#44; we propose the hypothesis that there is a relationship in medical students between moral&#44; ethical and empathic development and that variables such as academic year&#44; age and sex influence this development&#46; The aim of this study was to describe the relationship between ethics &#40;moral reasoning and ethical sensitivity&#41; and empathy and their relationship with other variables such as sex&#44; age and academic year&#46; This relationship could help in developing more extensive and inclusive training curricula that jointly incorporate ethical and empathic development and prevent burnout&#44; whose prevalence is high among health professionals<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">3</span></a> and is inversely correlated with empathy&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Materials and methods</span><p id="par0055" class="elsevierStylePara elsevierViewall">A cross-sectional observational study was conducted with 193 medical students of the University of Lleida&#44; Spain&#46; We included all first&#44; third&#44; fourth and fifth-year students who attended class on the day the questionnaires were administered&#46; Given that bioethics training in Spain is taught at the start of the sixth academic year&#44; these students did not participate in the study because we wanted the selected students to not yet have any training in this subject&#46; The fourth and fifth-year students were recruited from one subject they performed jointly and were analyzed jointly&#46; Participation was anonymous and voluntary and was authorized by the center&#46; We administered a sociodemographic questionnaire &#40;age&#44; sex&#44; course&#44; origin &#91;rural or urban&#93;&#44; presence of family members who were in the medical profession&#44; desired specialty&#41;&#44; Rest&#39;s Defining Issues Test &#40;DIT&#41;&#44; clinical vignettes and a cognitive and emotional empathy test &#40;<span class="elsevierStyleItalic">Test de Empat&#237;a Cognitiva y Afectiva</span>&#44; TECA&#41; as the measure of empathy&#46; The team of authors trained in psychology scored the tests&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">To assess the stage of moral reasoning&#44; we employed DIT&#44; which measures the moral development stage&#44; and an overall moral maturity score according to the Kohlberg stages&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">14&#44;15</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">To measure ethical sensitivity&#44; we employed Hebert&#39;s clinical vignettes&#44;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">19&#44;20</span></a> corresponding to 4 case studies&#44; with standardized semiqualitative correction and validated based on the judgment of experts&#46; In brief&#44; the case studies consisted of &#40;1&#41; a 58-year-old patient who experienced a massive cerebral hemorrhage&#44; with advance directives to not resuscitate&#59; however&#44; the family requests resuscitation&#59; &#40;2&#41; an 80-year-old woman with progressive impairment&#44; living alone&#44; refuses to be admitted for an examination&#59; &#40;3&#41; patient with serology indicating positive for human immunodeficiency virus who does not wish to report this to their partner&#59; and &#40;4&#41; a patient with cancer for whom their family requests hiding the diagnosis and information&#46; The vignettes were translated to Spanish&#46; All arguments considered appropriate were scored&#44; obtaining a score for each case and an overall score&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">As a measure of empathy&#44; we employed TECA&#44;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">32</span></a> which is a 33-item instrument to assess empathy in adults&#44; with high psychometric validity&#46; We chose TECA because it provides information on the cognitive and affective components of empathy using 4 sub-scales&#58; adoption of perspectives&#44; emotional comprehension&#44; empathic stress and empathic happiness&#46; TECA also offers a total score for empathy&#46; The measure is expressed as a percentage from 0&#37; to 100&#37;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">We performed a descriptive analysis of the study variables&#46; To assess the association of variables among different tests&#44; we performed a linear correlation analysis with Pearson&#39;s correlation coefficient&#44; as well as an analysis of variance with the Bonferroni test&#46; A <span class="elsevierStyleItalic">p</span>-value &#60;&#46;05 was considered statistically significant&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">We included 193 students from the Faculty of Medicine of the University of Lleida&#46; We excluded 11 students for not entirely completing the questionnaires&#44; which hampered the scoring&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The final sample consisted of 137 women and 45 men&#44; with a mean age of 20&#46;1 years &#40;standard deviation &#91;SD&#93;&#44; 2&#46;2&#59; range&#44; 17&#8211;35 years&#41;&#46; Of the surveyed students&#44; 64 were first-year students&#44; 74 were third-year&#44; and 53 were graduate level &#40;fourth and fifth-year&#41;&#59; corresponding respectively to 58&#37; of the first-year students&#44; 70&#37; of third-year students and 33&#37; to fourth and fifth-year students&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">One hundred eighty students completed the DIT moral reasoning test&#44; showing a predominant Kohlberg moral stage of 4 &#40;47&#46;8&#37;&#41;&#44; followed by stage 5 &#40;35&#37;&#41; and stage 3 &#40;17&#46;2&#37;&#41;&#46; The mean score measuring overall maturity was 38&#46;2 &#40;SD&#44; 11&#46;6&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">One hundred eighty-two students completed the clinical vignettes&#44; with a mean of 6&#46;4 correct arguments among the 4 cases &#40;SD&#44; 2&#46;4&#41;&#46; The mean overall empathy score on the TECA was 58&#46;9 &#40;SD&#44; 26&#46;7&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">We found a significant relationship between moral development and greater empathy &#40;Pearson&#39;s <span class="elsevierStyleItalic">r</span>&#44; 0&#46;219&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;004&#41; and between moral development and ethical sensitivity &#40;<span class="elsevierStyleItalic">r</span>&#44; 0&#46;164&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;03&#41;&#46; Likewise&#44; the relationship between empathy and ethical sensitivity was also significant &#40;<span class="elsevierStyleItalic">r</span>&#44; 0&#46;199&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;009&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In terms of the empathy subscales&#44; there was a significant difference between moral development and ethical sensitivity using the &#8220;adopting perspectives&#8221; scale&#46; The students with higher scores on this scale had a higher moral stage &#40;<span class="elsevierStyleItalic">r</span>&#44; 0&#46;203&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;008&#41; and greater ethical sensitivity &#40;<span class="elsevierStyleItalic">r</span>&#44; 0&#46;237&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;003&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">We found no significant differences between sex and moral maturity stage or ethical sensitivity&#46; In terms of the measure of empathy&#44; we found a significant difference in terms of sex &#40;Student&#39;s <span class="elsevierStyleItalic">t</span>-test&#44; 3&#46;2&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;002&#41;&#44; with the women showing higher scores &#40;mean score&#44; 60&#46;2&#59; SD&#44; 25&#46;6&#41; than the men &#40;mean score&#44; 42&#46;3&#59; SD&#44; 30&#46;6&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the results according to academic year&#46; We can see an increase in moral development between the first year and the rest &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The Bonferroni analysis showed only progression between the first and third year &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;002&#41;&#44; with no improvement from the third year on&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">We found an increase in ethical sensitivity over the academic years &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#58; the PIT score increased between the academic years &#40;analysis of variance&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; but only between the first and third year &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;004&#41;&#44; with no increase from the third year on&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">We found no relationship between moral development and empathy on one hand and the rest of the variables on the other &#40;e&#46;g&#46;&#44; origin&#44; medical relatives and desired specialty&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Discussion</span><p id="par0130" class="elsevierStylePara elsevierViewall">The present study is an approach to the joint measurement of moral development&#44; ethical sensitivity and empathy in medical students of our setting&#46; In this study&#44; the overall P score&#44; relative to the degree of moral reasoning&#44; was similar to that of other studies&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">7</span></a> In terms of moral development&#44; we found stagnation from the third year on&#44; similar to that found in previous studies in other contexts&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">7&#8211;10</span></a> A study that compared students from Zaragoza and Qatar<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">16</span></a> had similar results&#46; The authors found a lack of progression in moral development in the third year&#44; both in the Spanish and Qatari students&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">In the present sample&#44; we found no progression in the degree of ethical sensitivity from the third year on&#44; similar to previous studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">19&#44;20</span></a> The mean overall score for the first-year students was low&#44; because the students initially provided only one valid argument per vignette&#46; However&#44; a moderate score was achieved when the third-year students were assessed&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">We found a relationship between moral reasoning and ethical sensitivity&#46; The only previous study in the literature&#44; which included Japanese medical students&#44; did not find a relationship between these variables&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">31</span></a> We believe that this difference lies in the fact that the objective of the study by Akabayashi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">31</span></a> was to design a brief and objective measure to assess students and that they only used a part of the DIT&#44; to assess moral reasoning&#44; and a Japanese adaptation of the Hebert vignettes to measure ethical sensitivity&#44; with different clinical scenarios than those used initially&#46; The results of the Japanese study are therefore not entirely comparable to our study&#39;s results&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The scarce progression in moral reasoning and ethical sensitivity in our study sample confirms the &#8220;lack of ethical progression&#8221; among medical students as described by Culver et al&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">33</span></a> This phenomenon was not reproduced in other university studies&#44; which observed a marked increase in moral reasoning&#44; the so-called &#8220;college effect&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">34</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Numerous reasons have been provided for the lack of progression in the moral and ethical evolution of medical students&#46; Hafferty et al&#46; emphasized the importance of the &#8220;hidden curriculum&#8221; as opposed to the explicit training in medical ethics and communication&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">35</span></a> For these authors&#44; the values&#44; attitudes and behaviors in medical education are basically learned by socializing and &#8220;In fact&#44; what is &#8216;taught&#8217; in this hidden curriculum often can be antithetical to the goals and content of those courses that are formally offered&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">35</span></a> Similarly&#44; Hren et al&#46; observed that the hidden curriculum sometimes offers opposite values to the explicit curriculum&#44; as well as inconsistencies and mixed messages&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">8</span></a> These contradictions can affect the development of moral reasoning and empathy and lead to &#8220;ethical erosion&#8221;&#46; Less empathy has been associated with greater burnout&#46;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">36&#44;37</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Offri described medical socialization as an intensely disorienting experience&#44; in which students need to learn medicine and how to be physicians&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">38</span></a> Medical students need to acquire an enormous quantity of new skills &#40;learning hospital language and jargon&#44; interacting with patients and their families&#44; dealing with errors&#44; clinical rotations and emergencies&#44; etc&#46;&#41;&#46; A large part of what we have learned about ethics and patient-doctor communication is very difficult to apply to the reality of patient care&#46; Students observe how medical mentors behave and how they interact with patients&#44; interactions that sometimes do not correspond to what they have studied&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Other authors have identified various factors in medical education that can inhibit the moral and empathic development in clinical practice&#44; such as academic pressure&#44; the need to adhere to unwritten standards and rules to survive and the lack of support for ethical problems or for making them explicit&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">5&#44;6&#44;13</span></a> In the experience of Feudtner et al&#46;&#44; &#8220;ethical erosion&#8221; can be related to increased cynicism&#44; at times implicit&#44; in clinical practice&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">13</span></a> Hafferty argues that any attempt to develop an exhaustive medical curriculum should recognize the importance of the hidden curriculum and extensive social-cultural medium&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">35</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">In our sample&#44; a more mature moral sense&#44; greater empathy and greater ethical sensitivity were highly inter-related&#46; According to Hoffman&#44;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">29&#44;30</span></a> there is a parallel between feelings and emotions on one hand and thoughts and moral principles on the other&#46; This parallelism determines the behavioral trends&#46; According to this theory&#44; empathy and moral development are intimately linked&#44; such that&#44; in the individual&#39;s development&#44; empathic feelings trigger moral principles and guide both behavior and decision making&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Based on our study&#39;s results&#44; we believe it is important to consider both settings&#44; ethical-moral and empathy&#44; when designing and assessing the training curriculum in bioethics&#44; so as to ensure not only ethical competency but also the development of empathy and emotional competency&#46; The more comprehensive approach to training in ethics and communication&#44; including the factors related to medical socialization&#44; the development of values and attitudes<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">36&#44;39</span></a> regarding communication aspects and the hidden curriculum&#44; all contribute to developing more ethical and empathic physicians&#46;</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study limitations and proposals</span><p id="par0175" class="elsevierStylePara elsevierViewall">One of the study limitations was its cross-sectional and nonlongitudinal nature&#46; Although we cannot ensure that there were no other factors that influenced the results&#44; we found no cultural or academic differences between the different academic years&#46; Another of the study limitations was that we did not measure the impact of bioethical training&#44; because the main objective was to assess the relationship between variables&#46; Lastly&#44; the submitted results correspond to a single faculty of medicine&#46; As a proposal for future studies&#44; it would be important to assess the influence of teaching in bioethics on the analyzed variables&#44; widen the sample and include various medical schools&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusions</span><p id="par0180" class="elsevierStylePara elsevierViewall">The results of this study have helped us understand the characteristics of a group of medical students regarding their moral development&#44; ethical sensitivity and empathy&#46; We found a correlation between the 3 variables&#44; such that students who were more mature morally presented greater ethical sensitivity and empathy&#46; In this respect&#44; we believe a more global and complete approach is needed for training in communication and ethics&#44; which facilitates the acquisition of appropriate attitudes&#44; values and behaviors&#44; preventing ethical erosion and promoting higher quality care&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of interest</span><p id="par0185" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">High-quality clinical practice includes not only improving clinicians&#8217; expertise in scientific and technical aspects but also managing values&#44; ethical sensitivity and skills for assessing and dealing with ethical conflicts&#46; The reviewed literature suggests the presence of an &#8220;ethical erosion&#8221;&#44; according to which ethical competence and empathy decrease or do not progress during medical training&#46; The aim of this study was to determine the relationship between ethics &#40;moral reasoning and ethical sensitivity&#41; and empathy in a group of medical students and to determine the relationship with other variables such as academic year and sex&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Material and method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A cross-sectional observational study was conducted with 193 medical students from different academic years&#44; who were administered a sociodemographic questionnaire&#44; the Rest sociomoral dilemma test&#44; clinical vignettes to measure ethical sensitivity &#40;Problem Identification Test &#91;PIT&#93;&#41; and a cognitive and emotional empathy test &#40;<span class="elsevierStyleItalic">test de empat&#237;a cognitiva y afectiva</span>&#44; TECA&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We found a direct and significant relationship between moral development&#44; ethical sensitivity and greater empathy&#46; We detected an increase in moral reasoning and ethical sensitivity among first and third-year students&#44; with no increase between the third year and later academic years&#46; There were no significant differences between these variables and sex&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">This study found a correlation between moral reasoning&#44; ethical sensitivity and empathy and a lack of progression of the first 2 variables in the last years of the medical degree&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:1 [
            "identificador" => "abst0005"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and method"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La pr&#225;ctica cl&#237;nica de calidad no incluye tan solo la mejora de conocimientos en aspectos cient&#237;ficos y t&#233;cnicos&#44; sino tambi&#233;n en la gesti&#243;n de valores&#44; la sensibilidad &#233;tica y las habilidades en la valoraci&#243;n y manejo de los conflictos &#233;ticos&#46; La literatura revisada sugiere la existencia de la llamada &#171;erosi&#243;n &#233;tica&#187;&#44; seg&#250;n la cual la competencia &#233;tica y la empat&#237;a disminuyen&#44; o no progresan&#44; durante la formaci&#243;n m&#233;dica&#46; La finalidad del presente estudio es determinar la relaci&#243;n entre estas variables&#58; &#233;tica &#40;razonamiento moral y sensibilidad &#233;tica&#41; y empat&#237;a en un grupo de estudiantes de medicina&#44; as&#237; como determinar la relaci&#243;n con otras variables como el curso acad&#233;mico y el g&#233;nero&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Material y m&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional transversal realizado a 193 estudiantes de medicina de diferentes cursos&#46; Se les administr&#243; un cuestionario sociodemogr&#225;fico&#44; escala de dilemas sociomorales de Rest&#44; vi&#241;etas cl&#237;nicas de medida de sensibilidad &#233;tica <span class="elsevierStyleItalic">&#40;Problem Identification Test&#41;</span> y el Test de empat&#237;a cognitiva y afectiva&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se hall&#243; una relaci&#243;n directa y significativa entre desarrollo moral&#44; la sensibilidad &#233;tica y la mayor empat&#237;a&#46; Se detect&#243; un incremento de razonamiento moral y sensibilidad &#233;tica entre los alumnos de 1&#46;&#176; y 3&#46;&#176;&#44; sin incremento entre 3&#46;&#176; y cursos superiores&#46; No se encontraron diferencias significativas entre estas variables y el g&#233;nero&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En este estudio se ha hallado una correlaci&#243;n entre razonamiento moral&#44; sensibilidad &#233;tica y empat&#237;a&#44; as&#237; como una falta de progresi&#243;n de las 2 primeras variables en los &#250;ltimos cursos del grado de medicina&#46;</p></span>"
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            "identificador" => "abst0035"
            "titulo" => "Resultados"
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          3 => array:2 [
            "identificador" => "abst0040"
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    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Yuguero O&#44; Esquerda M&#44; Vi&#241;as J&#44; Soler-Gonzalez J&#44; Pifarr&#233; J&#46; &#201;tica y empat&#237;a&#58; relaci&#243;n entre razonamiento moral&#44; sensibilidad &#233;tica y empat&#237;a en estudiantes de medicina&#46; Rev Clin Esp&#46; 2019&#59;219&#58;73&#8211;78&#46;</p>"
      ]
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Relationship between the Kohlberg P score &#40;overall maturity&#41; and academic year&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Relationship between the Problem Identification Test score on ethical sensitivity and academic year&#46;</p>"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; PIT&#44; Problem Identification Test &#40;measure of ethical sensitivity&#41;&#59; SD&#44; standard deviation&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">First year &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>64&#41;</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Third year &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>74&#41;</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Graduate level &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>53&#41;</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Total &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>191&#41;</th><th class="td" title="table-head  " align="left" valign="top" scope="col">ANOVA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="10" align="left" valign="top"><span class="elsevierStyleItalic">Moral development</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Moral stage P score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41&#46;6 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">191&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&#46;2 &#40;11&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;1<br>&#60;&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="10" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="10" align="left" valign="top"><span class="elsevierStyleItalic">Ethical sensitivity</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Total PIT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;5 &#40;2&#46;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;9 &#40;2&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;2&#46;23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">181&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;5 &#40;2&#46;44&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#46;8<br>&#60;&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="10" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="10" align="left" valign="top"><span class="elsevierStyleItalic">Empathy</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Total score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">54&#46;3 &#40;26&#46;82&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58&#46;5 &#40;27&#46;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">65&#46;3 &#40;26&#46;04&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">172&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">59 &#40;26&#46;92&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;9<br>&#46;119&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Moral&#44; empathic and ethical sensitivity development depending on the academic year&#46;</p>"
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    "bibliografia" => array:2 [
      "titulo" => "References"
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                  "host" => array:1 [
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                            1 => "E&#46;M&#46; Meslin"
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                          ]
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                      ]
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Original article
Ethics and empathy: The relationship between moral reasoning, ethical sensitivity and empathy in medical students
Ética y empatía: relación entre razonamiento moral, sensibilidad ética y empatía en estudiantes de medicina
O. Yugueroa,b, M. Esquerdaa,c,d,
Corresponding author
mesquerda@ibb.url.edu

Corresponding author.
, J. Viñasa,b,c, J. Soler-Gonzaleza, J. Pifarréa,d,e
a Facultad de Medicina, Universitat de Lleida, Lleida, Spain
b Hospital Universitari Arnau de Vilanova de Lleida, Lleida, Spain
c Institut Borja Bioètica, Universitat Ramon Llull, Barcelona, Spain
d Sant Joan de Déu Terres de Lleida, Lleida, Spain
e GSS-Hospital Universitari Santa Maria, Lleida, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Bioethics is an established discipline in academic settings&#44; with a deep&#44; implemented theoretical body&#44; professional specialists and specific debate settings&#46; The pending bioethical challenges of the 21st century include the full integration of bioethics in all professional settings and its consolidation in clinical practice&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">High-quality clinical practice includes not only improving expertise in scientific and technical aspects but also communication&#44; managing values&#44; ethical sensitivity and skills for assessing and managing ethical conflicts&#46; A number of authors&#44; such as Sheehan et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">2</span></a> have reported that increased moral reasoning is associated with higher quality care&#59; moreover&#44; difficulties in managing the patient&#39;s values and concerns can result in a deficient clinical practice&#46; The greater the empathy&#44; the better the clinical practice and quality and the less the burnout&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">A recent article indicated that physicians&#8217; ethical development and communication skills play an essential role in high-quality care&#44; safety and patient&#39;s quality of life but questions whether the current medical curriculum is truly effective in ensuring appropriate training in ethics and communication&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">4</span></a> The acquisition of ethical and communication skills should be a key factor in medical education&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">However&#44; numerous studies have suggested that medical students undergo very few changes in their expected moral development&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">6&#8211;12</span></a> A number of studies have even shown regression in moral development during medical training&#44; the so-called &#8220;ethical erosion&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">13</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">According to Kohlberg&#39;s theory of moral reasoning&#44;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">14&#44;15</span></a> there is significant improvement in the moral reasoning stages of young adults&#44; with rapid progression toward conventional thinking and the start of postconventionalism&#46; However&#44; various studies have shown that medical students&#44; who correspond to this young adult era&#44; do not show the expected moral progression for their age and even regress&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">6&#8211;13</span></a> In the Spanish setting&#44; one of the pioneering studies conducted at the University of Zaragoza&#44; Spain&#44; compared students from Zaragoza and Qatar&#44; progressively and before and after their training in bioethics without finding moral growth&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">16</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Studies have also assessed the ethical competency of medical students in a more applied manner through &#8220;case studies&#8221;&#44; which sought to assess &#8220;ethical sensitivity&#8221;&#44; defined as &#8220;the ability or capacity to recognize the presence of an ethical or moral problem in a clinical case&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">5</span></a> Various authors have used vignettes to measure the development of ethical sensitivity and have achieved a good degree of validity and reliability&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">17&#8211;20</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">As with ethical competency&#44; numerous studies have shown a significant reduction in the empathy of medical students during their academic career&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">21&#8211;25</span></a> The reduction is more pronounced in men&#44; in students with greater initial empathy&#44; greater empathic stress or with a greater preference for their particular specialty&#46; A number of studies&#44; however&#44; have shown an increase in empathy during medical training<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">26</span></a> or with appropriate training strategies&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">27</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In general&#44; there appears to be a confluence between ethical development and empathy&#44; such that the socialization of healthcare professionals combines the acquisition of appropriate values&#44; attitudes and behaviors&#44;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">28</span></a> suggesting a relationship between ethical medicine and empathic medicine&#46; Hoffman described theoretically how the development of empathy and prosocial behavior&#44; in the setting of children and adolescents&#44; is related to ethical and moral development&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">29&#44;30</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">We have found no studies that have jointly analyzed these variables in the setting of medical students&#46; A study with Japanese medical students measured the relationship between moral development and ethical sensitivity but found no relationship between the two&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">31</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Based on our literature review&#44; we propose the hypothesis that there is a relationship in medical students between moral&#44; ethical and empathic development and that variables such as academic year&#44; age and sex influence this development&#46; The aim of this study was to describe the relationship between ethics &#40;moral reasoning and ethical sensitivity&#41; and empathy and their relationship with other variables such as sex&#44; age and academic year&#46; This relationship could help in developing more extensive and inclusive training curricula that jointly incorporate ethical and empathic development and prevent burnout&#44; whose prevalence is high among health professionals<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">3</span></a> and is inversely correlated with empathy&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Materials and methods</span><p id="par0055" class="elsevierStylePara elsevierViewall">A cross-sectional observational study was conducted with 193 medical students of the University of Lleida&#44; Spain&#46; We included all first&#44; third&#44; fourth and fifth-year students who attended class on the day the questionnaires were administered&#46; Given that bioethics training in Spain is taught at the start of the sixth academic year&#44; these students did not participate in the study because we wanted the selected students to not yet have any training in this subject&#46; The fourth and fifth-year students were recruited from one subject they performed jointly and were analyzed jointly&#46; Participation was anonymous and voluntary and was authorized by the center&#46; We administered a sociodemographic questionnaire &#40;age&#44; sex&#44; course&#44; origin &#91;rural or urban&#93;&#44; presence of family members who were in the medical profession&#44; desired specialty&#41;&#44; Rest&#39;s Defining Issues Test &#40;DIT&#41;&#44; clinical vignettes and a cognitive and emotional empathy test &#40;<span class="elsevierStyleItalic">Test de Empat&#237;a Cognitiva y Afectiva</span>&#44; TECA&#41; as the measure of empathy&#46; The team of authors trained in psychology scored the tests&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">To assess the stage of moral reasoning&#44; we employed DIT&#44; which measures the moral development stage&#44; and an overall moral maturity score according to the Kohlberg stages&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">14&#44;15</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">To measure ethical sensitivity&#44; we employed Hebert&#39;s clinical vignettes&#44;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">19&#44;20</span></a> corresponding to 4 case studies&#44; with standardized semiqualitative correction and validated based on the judgment of experts&#46; In brief&#44; the case studies consisted of &#40;1&#41; a 58-year-old patient who experienced a massive cerebral hemorrhage&#44; with advance directives to not resuscitate&#59; however&#44; the family requests resuscitation&#59; &#40;2&#41; an 80-year-old woman with progressive impairment&#44; living alone&#44; refuses to be admitted for an examination&#59; &#40;3&#41; patient with serology indicating positive for human immunodeficiency virus who does not wish to report this to their partner&#59; and &#40;4&#41; a patient with cancer for whom their family requests hiding the diagnosis and information&#46; The vignettes were translated to Spanish&#46; All arguments considered appropriate were scored&#44; obtaining a score for each case and an overall score&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">As a measure of empathy&#44; we employed TECA&#44;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">32</span></a> which is a 33-item instrument to assess empathy in adults&#44; with high psychometric validity&#46; We chose TECA because it provides information on the cognitive and affective components of empathy using 4 sub-scales&#58; adoption of perspectives&#44; emotional comprehension&#44; empathic stress and empathic happiness&#46; TECA also offers a total score for empathy&#46; The measure is expressed as a percentage from 0&#37; to 100&#37;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">We performed a descriptive analysis of the study variables&#46; To assess the association of variables among different tests&#44; we performed a linear correlation analysis with Pearson&#39;s correlation coefficient&#44; as well as an analysis of variance with the Bonferroni test&#46; A <span class="elsevierStyleItalic">p</span>-value &#60;&#46;05 was considered statistically significant&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">We included 193 students from the Faculty of Medicine of the University of Lleida&#46; We excluded 11 students for not entirely completing the questionnaires&#44; which hampered the scoring&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The final sample consisted of 137 women and 45 men&#44; with a mean age of 20&#46;1 years &#40;standard deviation &#91;SD&#93;&#44; 2&#46;2&#59; range&#44; 17&#8211;35 years&#41;&#46; Of the surveyed students&#44; 64 were first-year students&#44; 74 were third-year&#44; and 53 were graduate level &#40;fourth and fifth-year&#41;&#59; corresponding respectively to 58&#37; of the first-year students&#44; 70&#37; of third-year students and 33&#37; to fourth and fifth-year students&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">One hundred eighty students completed the DIT moral reasoning test&#44; showing a predominant Kohlberg moral stage of 4 &#40;47&#46;8&#37;&#41;&#44; followed by stage 5 &#40;35&#37;&#41; and stage 3 &#40;17&#46;2&#37;&#41;&#46; The mean score measuring overall maturity was 38&#46;2 &#40;SD&#44; 11&#46;6&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">One hundred eighty-two students completed the clinical vignettes&#44; with a mean of 6&#46;4 correct arguments among the 4 cases &#40;SD&#44; 2&#46;4&#41;&#46; The mean overall empathy score on the TECA was 58&#46;9 &#40;SD&#44; 26&#46;7&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">We found a significant relationship between moral development and greater empathy &#40;Pearson&#39;s <span class="elsevierStyleItalic">r</span>&#44; 0&#46;219&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;004&#41; and between moral development and ethical sensitivity &#40;<span class="elsevierStyleItalic">r</span>&#44; 0&#46;164&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;03&#41;&#46; Likewise&#44; the relationship between empathy and ethical sensitivity was also significant &#40;<span class="elsevierStyleItalic">r</span>&#44; 0&#46;199&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;009&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In terms of the empathy subscales&#44; there was a significant difference between moral development and ethical sensitivity using the &#8220;adopting perspectives&#8221; scale&#46; The students with higher scores on this scale had a higher moral stage &#40;<span class="elsevierStyleItalic">r</span>&#44; 0&#46;203&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;008&#41; and greater ethical sensitivity &#40;<span class="elsevierStyleItalic">r</span>&#44; 0&#46;237&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;003&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">We found no significant differences between sex and moral maturity stage or ethical sensitivity&#46; In terms of the measure of empathy&#44; we found a significant difference in terms of sex &#40;Student&#39;s <span class="elsevierStyleItalic">t</span>-test&#44; 3&#46;2&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;002&#41;&#44; with the women showing higher scores &#40;mean score&#44; 60&#46;2&#59; SD&#44; 25&#46;6&#41; than the men &#40;mean score&#44; 42&#46;3&#59; SD&#44; 30&#46;6&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the results according to academic year&#46; We can see an increase in moral development between the first year and the rest &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The Bonferroni analysis showed only progression between the first and third year &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;002&#41;&#44; with no improvement from the third year on&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">We found an increase in ethical sensitivity over the academic years &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#58; the PIT score increased between the academic years &#40;analysis of variance&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; but only between the first and third year &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;004&#41;&#44; with no increase from the third year on&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">We found no relationship between moral development and empathy on one hand and the rest of the variables on the other &#40;e&#46;g&#46;&#44; origin&#44; medical relatives and desired specialty&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Discussion</span><p id="par0130" class="elsevierStylePara elsevierViewall">The present study is an approach to the joint measurement of moral development&#44; ethical sensitivity and empathy in medical students of our setting&#46; In this study&#44; the overall P score&#44; relative to the degree of moral reasoning&#44; was similar to that of other studies&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">7</span></a> In terms of moral development&#44; we found stagnation from the third year on&#44; similar to that found in previous studies in other contexts&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">7&#8211;10</span></a> A study that compared students from Zaragoza and Qatar<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">16</span></a> had similar results&#46; The authors found a lack of progression in moral development in the third year&#44; both in the Spanish and Qatari students&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">In the present sample&#44; we found no progression in the degree of ethical sensitivity from the third year on&#44; similar to previous studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">19&#44;20</span></a> The mean overall score for the first-year students was low&#44; because the students initially provided only one valid argument per vignette&#46; However&#44; a moderate score was achieved when the third-year students were assessed&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">We found a relationship between moral reasoning and ethical sensitivity&#46; The only previous study in the literature&#44; which included Japanese medical students&#44; did not find a relationship between these variables&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">31</span></a> We believe that this difference lies in the fact that the objective of the study by Akabayashi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">31</span></a> was to design a brief and objective measure to assess students and that they only used a part of the DIT&#44; to assess moral reasoning&#44; and a Japanese adaptation of the Hebert vignettes to measure ethical sensitivity&#44; with different clinical scenarios than those used initially&#46; The results of the Japanese study are therefore not entirely comparable to our study&#39;s results&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The scarce progression in moral reasoning and ethical sensitivity in our study sample confirms the &#8220;lack of ethical progression&#8221; among medical students as described by Culver et al&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">33</span></a> This phenomenon was not reproduced in other university studies&#44; which observed a marked increase in moral reasoning&#44; the so-called &#8220;college effect&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">34</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Numerous reasons have been provided for the lack of progression in the moral and ethical evolution of medical students&#46; Hafferty et al&#46; emphasized the importance of the &#8220;hidden curriculum&#8221; as opposed to the explicit training in medical ethics and communication&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">35</span></a> For these authors&#44; the values&#44; attitudes and behaviors in medical education are basically learned by socializing and &#8220;In fact&#44; what is &#8216;taught&#8217; in this hidden curriculum often can be antithetical to the goals and content of those courses that are formally offered&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">35</span></a> Similarly&#44; Hren et al&#46; observed that the hidden curriculum sometimes offers opposite values to the explicit curriculum&#44; as well as inconsistencies and mixed messages&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">8</span></a> These contradictions can affect the development of moral reasoning and empathy and lead to &#8220;ethical erosion&#8221;&#46; Less empathy has been associated with greater burnout&#46;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">36&#44;37</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Offri described medical socialization as an intensely disorienting experience&#44; in which students need to learn medicine and how to be physicians&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">38</span></a> Medical students need to acquire an enormous quantity of new skills &#40;learning hospital language and jargon&#44; interacting with patients and their families&#44; dealing with errors&#44; clinical rotations and emergencies&#44; etc&#46;&#41;&#46; A large part of what we have learned about ethics and patient-doctor communication is very difficult to apply to the reality of patient care&#46; Students observe how medical mentors behave and how they interact with patients&#44; interactions that sometimes do not correspond to what they have studied&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Other authors have identified various factors in medical education that can inhibit the moral and empathic development in clinical practice&#44; such as academic pressure&#44; the need to adhere to unwritten standards and rules to survive and the lack of support for ethical problems or for making them explicit&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">5&#44;6&#44;13</span></a> In the experience of Feudtner et al&#46;&#44; &#8220;ethical erosion&#8221; can be related to increased cynicism&#44; at times implicit&#44; in clinical practice&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">13</span></a> Hafferty argues that any attempt to develop an exhaustive medical curriculum should recognize the importance of the hidden curriculum and extensive social-cultural medium&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">35</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">In our sample&#44; a more mature moral sense&#44; greater empathy and greater ethical sensitivity were highly inter-related&#46; According to Hoffman&#44;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">29&#44;30</span></a> there is a parallel between feelings and emotions on one hand and thoughts and moral principles on the other&#46; This parallelism determines the behavioral trends&#46; According to this theory&#44; empathy and moral development are intimately linked&#44; such that&#44; in the individual&#39;s development&#44; empathic feelings trigger moral principles and guide both behavior and decision making&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Based on our study&#39;s results&#44; we believe it is important to consider both settings&#44; ethical-moral and empathy&#44; when designing and assessing the training curriculum in bioethics&#44; so as to ensure not only ethical competency but also the development of empathy and emotional competency&#46; The more comprehensive approach to training in ethics and communication&#44; including the factors related to medical socialization&#44; the development of values and attitudes<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">36&#44;39</span></a> regarding communication aspects and the hidden curriculum&#44; all contribute to developing more ethical and empathic physicians&#46;</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study limitations and proposals</span><p id="par0175" class="elsevierStylePara elsevierViewall">One of the study limitations was its cross-sectional and nonlongitudinal nature&#46; Although we cannot ensure that there were no other factors that influenced the results&#44; we found no cultural or academic differences between the different academic years&#46; Another of the study limitations was that we did not measure the impact of bioethical training&#44; because the main objective was to assess the relationship between variables&#46; Lastly&#44; the submitted results correspond to a single faculty of medicine&#46; As a proposal for future studies&#44; it would be important to assess the influence of teaching in bioethics on the analyzed variables&#44; widen the sample and include various medical schools&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusions</span><p id="par0180" class="elsevierStylePara elsevierViewall">The results of this study have helped us understand the characteristics of a group of medical students regarding their moral development&#44; ethical sensitivity and empathy&#46; We found a correlation between the 3 variables&#44; such that students who were more mature morally presented greater ethical sensitivity and empathy&#46; In this respect&#44; we believe a more global and complete approach is needed for training in communication and ethics&#44; which facilitates the acquisition of appropriate attitudes&#44; values and behaviors&#44; preventing ethical erosion and promoting higher quality care&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of interest</span><p id="par0185" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">High-quality clinical practice includes not only improving clinicians&#8217; expertise in scientific and technical aspects but also managing values&#44; ethical sensitivity and skills for assessing and dealing with ethical conflicts&#46; The reviewed literature suggests the presence of an &#8220;ethical erosion&#8221;&#44; according to which ethical competence and empathy decrease or do not progress during medical training&#46; The aim of this study was to determine the relationship between ethics &#40;moral reasoning and ethical sensitivity&#41; and empathy in a group of medical students and to determine the relationship with other variables such as academic year and sex&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Material and method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A cross-sectional observational study was conducted with 193 medical students from different academic years&#44; who were administered a sociodemographic questionnaire&#44; the Rest sociomoral dilemma test&#44; clinical vignettes to measure ethical sensitivity &#40;Problem Identification Test &#91;PIT&#93;&#41; and a cognitive and emotional empathy test &#40;<span class="elsevierStyleItalic">test de empat&#237;a cognitiva y afectiva</span>&#44; TECA&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We found a direct and significant relationship between moral development&#44; ethical sensitivity and greater empathy&#46; We detected an increase in moral reasoning and ethical sensitivity among first and third-year students&#44; with no increase between the third year and later academic years&#46; There were no significant differences between these variables and sex&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">This study found a correlation between moral reasoning&#44; ethical sensitivity and empathy and a lack of progression of the first 2 variables in the last years of the medical degree&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La pr&#225;ctica cl&#237;nica de calidad no incluye tan solo la mejora de conocimientos en aspectos cient&#237;ficos y t&#233;cnicos&#44; sino tambi&#233;n en la gesti&#243;n de valores&#44; la sensibilidad &#233;tica y las habilidades en la valoraci&#243;n y manejo de los conflictos &#233;ticos&#46; La literatura revisada sugiere la existencia de la llamada &#171;erosi&#243;n &#233;tica&#187;&#44; seg&#250;n la cual la competencia &#233;tica y la empat&#237;a disminuyen&#44; o no progresan&#44; durante la formaci&#243;n m&#233;dica&#46; La finalidad del presente estudio es determinar la relaci&#243;n entre estas variables&#58; &#233;tica &#40;razonamiento moral y sensibilidad &#233;tica&#41; y empat&#237;a en un grupo de estudiantes de medicina&#44; as&#237; como determinar la relaci&#243;n con otras variables como el curso acad&#233;mico y el g&#233;nero&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Material y m&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional transversal realizado a 193 estudiantes de medicina de diferentes cursos&#46; Se les administr&#243; un cuestionario sociodemogr&#225;fico&#44; escala de dilemas sociomorales de Rest&#44; vi&#241;etas cl&#237;nicas de medida de sensibilidad &#233;tica <span class="elsevierStyleItalic">&#40;Problem Identification Test&#41;</span> y el Test de empat&#237;a cognitiva y afectiva&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se hall&#243; una relaci&#243;n directa y significativa entre desarrollo moral&#44; la sensibilidad &#233;tica y la mayor empat&#237;a&#46; Se detect&#243; un incremento de razonamiento moral y sensibilidad &#233;tica entre los alumnos de 1&#46;&#176; y 3&#46;&#176;&#44; sin incremento entre 3&#46;&#176; y cursos superiores&#46; No se encontraron diferencias significativas entre estas variables y el g&#233;nero&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En este estudio se ha hallado una correlaci&#243;n entre razonamiento moral&#44; sensibilidad &#233;tica y empat&#237;a&#44; as&#237; como una falta de progresi&#243;n de las 2 primeras variables en los &#250;ltimos cursos del grado de medicina&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Yuguero O&#44; Esquerda M&#44; Vi&#241;as J&#44; Soler-Gonzalez J&#44; Pifarr&#233; J&#46; &#201;tica y empat&#237;a&#58; relaci&#243;n entre razonamiento moral&#44; sensibilidad &#233;tica y empat&#237;a en estudiantes de medicina&#46; Rev Clin Esp&#46; 2019&#59;219&#58;73&#8211;78&#46;</p>"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; PIT&#44; Problem Identification Test &#40;measure of ethical sensitivity&#41;&#59; SD&#44; standard deviation&#46;</p>"
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="10" align="left" valign="top"><span class="elsevierStyleItalic">Moral development</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Moral stage P score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41&#46;6 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">191&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&#46;2 &#40;11&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;1<br>&#60;&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="10" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="10" align="left" valign="top"><span class="elsevierStyleItalic">Ethical sensitivity</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Total PIT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;5 &#40;2&#46;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;9 &#40;2&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;2&#46;23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">181&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;5 &#40;2&#46;44&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#46;8<br>&#60;&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="10" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="10" align="left" valign="top"><span class="elsevierStyleItalic">Empathy</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Total score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">54&#46;3 &#40;26&#46;82&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58&#46;5 &#40;27&#46;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">65&#46;3 &#40;26&#46;04&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">172&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">59 &#40;26&#46;92&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;9<br>&#46;119&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Moral&#44; empathic and ethical sensitivity development depending on the academic year&#46;</p>"
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Original language: English
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