Moral sensitivity is the ability to recognize that a situation contains ethical stakes at all—to notice, for example, that a patient’s confused refusal of medication is not just a clinical inconvenience but a question about autonomy and consent. Psychologists typically treat it as the first step in a chain of ethical decision-making: before a clinician can judge or act morally, she must first perceive the moral contours of the situation. The instrument most often used to measure it, the revised Moral Sensitivity Questionnaire, distinguishes two dimensions. The deliberative subscale captures reflective, patient-centered reasoning in which the professional weighs options and respects the patient’s perspective. The paternalistic subscale, by contrast, registers the degree to which a respondent assumes the professional knows best and may override the patient’s wishes for the patient’s own good.

Whether these two dimensions change over the course of professional education, and what psychological traits predict them, has remained surprisingly murky. Most earlier work has been cross-sectional—snapshots of different students at different stages—which cannot separate genuine development within individuals from differences between cohorts. The Croatian team, led by Dora Vukorepa together with Mariano Kaliterna, Ana Marušić and Marija Franka Žuljević, tackled the problem with a hybrid design that combined both approaches: a one-year longitudinal cohort that followed the same students across critical transitions, and a large cross-sectional survey spanning the full range of study years.

The longitudinal arm enrolled 151 Croatian-language medical students and successfully re-assessed 90 of them—a retention rate of 59.6 percent—at two points one year apart, capturing the transitions from the third to the fourth year and from the fifth to the sixth year. The cross-sectional arm surveyed 574 medical students across all six years of the curriculum, plus an exploratory comparison group of 31 psychology students. Each participant completed three validated instruments: the revised Moral Sensitivity Questionnaire with its deliberative and paternalistic subscales, the Moral Foundations Questionnaire, which measures the weight people place on Care, Fairness, Loyalty, Authority and Sanctity as moral concerns, and the Big Five Inventory, the standard five-factor measure of personality covering openness, conscientiousness, extraversion, agreeableness and neuroticism.

Because the questionnaire scores were not normally distributed, the researchers relied on non-parametric statistics—Wilcoxon signed-rank tests for within-student change, Mann–Whitney U tests for between-group comparisons, and Spearman correlations for associations—before moving to adjusted linear regression models that controlled for demographic and academic covariates. The longitudinal results were striking in their asymmetry. Paternalistic attitude scores were essentially unchanged over the year, with a p-value of .968 indicating no detectable within-student movement whatsoever. Deliberative scores, on the other hand, rose significantly overall (p < .001), and the increase was concentrated almost entirely in the transition from the third to the fourth year, where the effect was large (p < .001, r = −.742). In practical terms, students did not drift gradually toward more reflective moral reasoning across their studies; they appeared to make a discrete jump exactly when classroom learning gave way to hands-on patient contact.

The cross-sectional data added a twist that only a combined design could reveal. Clinical-phase students—those in years four through six—scored higher than preclinical students on both the paternalistic subscale (p < .001) and the deliberative subscale (p = .006). Yet for the paternalistic dimension, this between-cohort difference was not mirrored by any within-student change over the year. That discrepancy matters: it suggests the apparent cohort gap in paternalism reflects differences in who enters or persists in clinical training, or in cohort composition, rather than a developmental shift that training itself produces. The deliberative increase, by contrast, was corroborated both within students over time and between cohorts across stages, making it the more robust developmental signal.

The study’s second major contribution lies in mapping which psychological characteristics track each dimension of moral sensitivity. Bivariately, the deliberative subscale showed broader associations with moral foundations and Big Five traits than the paternalistic subscale did, though most of these correlations were small. The pattern sharpened in adjusted regression models. Fairness emerged as the most consistent predictor, positively associated with both the deliberative and paternalistic dimensions. Higher Loyalty and lower Care were each linked to higher paternalistic scores—a combination that fits the construct’s meaning, since paternalism involves prioritizing group norms and professional authority over the individual patient’s immediate welfare. The Big Five personality traits, by contrast, produced less consistent associations once the models were adjusted, and their longitudinal relationships were similarly weak. Character, in other words, appears to matter less for moral sensitivity than the moral values a person actually endorses.

The exploratory comparison between medical and psychology students also yielded a cautionary lesson about statistical adjustment. In raw comparisons, the two groups differed on moral sensitivity measures, but those differences disappeared entirely after adjustment for covariates. What looked like a discipline-specific moral profile was better explained by the demographic and academic characteristics of the students themselves. For a field that has produced many headline-grabbing claims about how different professional cultures shape moral thinking, the result is a reminder that unadjusted group differences can evaporate under proper controls.

Methodologically, the study is candid about its limits. It was conducted at a single Croatian medical school, the longitudinal retention rate of 59.6 percent leaves open the possibility that students who dropped out differed systematically from those who stayed, and the psychology comparison group of 31 students was explicitly exploratory and far too small to support firm conclusions. The self-report instruments measure stated attitudes rather than observed behavior at the bedside, and the one-year follow-up captured only two of the several transitions in a six-year curriculum. Still, the combination of longitudinal and cross-sectional evidence, the use of adjusted models, and the transparent reporting of effect sizes place this work among the more rigorous attempts to chart moral development in health-professions education.

The practical implications are concrete. If the jump in deliberative moral sensitivity occurs precisely at the transition to clinical training, that period becomes an obvious target for ethics education—curricula that address moral values, patient autonomy and professional responsibilities at the moment students first confront real patients with real stakes. The stability of paternalistic attitudes, meanwhile, suggests that simply exposing students to clinical work will not, by itself, erode doctor-knows-best assumptions; if educators want to cultivate respect for patient autonomy, they may need to engage students’ underlying moral foundations, particularly the balance between Care for the individual and Loyalty to professional norms. As the authors conclude, the two dimensions of moral sensitivity behave as genuinely separate constructs—one responsive to educational experience, the other anchored in enduring values—and ethics teaching that treats them as a single skill risks missing the mark.

Subject of Research: Longitudinal and cross-sectional study of moral sensitivity, moral foundations and personality traits among medical and psychology students

Article Title: Moral sensitivity in medical education: a longitudinal and cross-sectional study of personality and moral foundations among medical and psychology students

Article References: Vukorepa, D., Kaliterna, M., Marušić, A., & Žuljević, M. F. (2026). Moral sensitivity in medical education: a longitudinal and cross-sectional study of personality and moral foundations among medical and psychology students. BMC Medical Education. https://doi.org/10.1186/s12909-026-10599-8

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10599-8

Keywords: moral sensitivity, medical education, medical students, moral foundations, Big Five personality traits, paternalism, moral deliberation, ethics education, longitudinal study, cross-sectional study, patient autonomy, moral psychology