The current context of healthcare, which perpetuates the subordinate position of the patient and the violation of patients’ rights, demands the construction of a bioethical theory based on the ethical commitment to change this reality. Consequently, Principialism, the hegemonic line of Clinical Bioethics, needs to be overcome, and another framework needs to be formulated, such as what is now proposed based on clinical empathy and empathic care. This new framework for Clinical Bioethics conforms to an innovative aspect called “Healthcare Bioethics,” which has been the subject of a series of studies. These studies aimed at the theoretical structure of Healthcare Bioethics but did not focus on empathic care as an ethical structuring of this new theoretical-normative proposition. This article proposes theoretical contributions to Healthcare Bioethics based on clinical empathy and, specifically, by formulating the empathic care concept as a constituent and structuring command of this new aspect of Clinical Bioethics. Empathic care is a central ethical command of the further reference of clinical practice, Healthcare Bioethics. However, as seen, empathy is a motivational phenomenon conditioned to subjective factors that concern the individuals themselves and the context in which they find themselves. Although empathy is essential to our well-being, self-esteem, sense of belonging, and positive emotions, often, the choice is not to be empathic, given the costs of being so. This is also true in healthcare. Thus, health institutions and systems must adopt training, continuing education of health professionals, and other motivational interventions to drive empathic choice. It is an illusion to expect this choice to be made predominantly without creating factors that motivate empathic care, which must be an ethical substrate for constructing these motivational interventions. Therefore, empathic care should be incorporated into the health area as a new paradigm that founds institutions and health systems centered on the patient and the quality of care.

Keywords: empathy, clinical empathy, bioethics

In the seventies, Bioethics presented two dimensions when formulated as a new field of knowledge: the Potterian, focused on building a bridge between science and values¹ and Hellegers’s, of a clinical nature, focused on emerging healthcare issues. Over time, Bioethics has gained new contours, emphasizing its environmental and social perspectives, expressed in UNESCO’s Universal Declaration on Bioethics and Human Rights.² Although the scope expansion of Bioethics is commendable, surpassing the micro perspective of clinical issues, it is noted that the main ethical issues concerning healthcare have not yet been overcome. In addition, it is noteworthy that Clinical Bioethics, notably through Principalism,³ contributed little to changing the framework of abusive practices in the context of healthcare to face the asymmetry of power in the professional-patient relationship and to give centrality to the patient, notably by respecting their rights as such. Indeed, healthcare institutions are rife with abusive and discriminatory practices toward patients.⁴ The conduct of professionals who do not respect patients’ rights leads to unsatisfactory results in healthcare and patient dissatisfaction. Furthermore, when patients experience situations that violate their rights, they start to fear seeking health services, negatively impacting the health of the patient and the general population. Thus, a study showed that patients are commonly ignored, discriminated against, intimidated, and labeled because of their social status. These practices affect the quality of care. In the same sense, research on the theme indicates that when care is patient-centered, and dignity is preserved, the patient feels safer to tell important aspects of their health condition, which leads to fewer diagnostic errors, reduced hospital stays, and patient’s greater engagement in their care.

Thus, the current context of healthcare, which perpetuates the subordinate position of the patient and the violation of patients’ rights, demands the construction of a bioethical theory based on the ethical commitment to change this reality. Consequently, Principialism, the hegemonic line of Clinical Bioethics, needs to be overcome, and another framework needs to be formulated, such as what is now proposed based on clinical empathy and empathic care.⁵ This new framework for Clinical Bioethics conforms to an innovative aspect called “Healthcare Bioethics,” which has been the subject of a series of studies.^6–8 These studies aimed at the theoretical structure of Healthcare Bioethics but did not focus on empathic care as an ethical structuring of this new theoretical-normative proposition. Clinical Bioethics, which consists of the analysis and prescription of behavior in clinical practice aimed at guiding healthcare, encompasses knowledge not only of a theoretical nature but also a normative one, given that Bioethics is an applied ethics and can offer tools for conducting prescription and conflict resolution.

Clinical empathy, which consists of health professionals being able to be empathic towards patients, is a predictor of pro-patient behaviors insofar as it implies the professional’s attitude in recognizing themselves as a moral agent endowed with their perspectives, emotions, needs, and preferences. In this sense, healthcare based on clinical empathy, called “empathic care” in this study, also presents a conformation that situates it as the ethical command of Clinical Bioethics since it presupposes that health professionals perceive the patient in a certain way and conducts themselves according to such perception, as it will be demonstrated in this article. Thus, this article proposes theoretical contributions to Healthcare Bioethics based on clinical empathy and, specifically, by formulating the empathic care concept as a constituent and structuring command of this new aspect of Clinical Bioethics. Thus, the scope is ultimate to offer bioethicists and members of Hospital Bioethics Committees the reason for the need to rethink Principialism based on Clinical Bioethics grounded on new substantive ethics capable of conferring arguments, criteria, and justifications for the analysis of cases and proposing conduct specifications. Considering the previous studies, this theoretical article is based on the research of Albuquerque, et al.⁸ and Churchill, et al.⁹ on proposing a new aspect of Clinical Bioethics. It should be noted that this is an investigation of a theoretical nature based on chosen milestones and their application in each object for the original formulation of academic contributions.

As for clinical empathy, the proposed framework is anchored in the studies of Howick and his collaborators.^10,11 The reference adopted for the concept of care was that of Herring, et al.^12–14 about their analysis and empathic care is a novelty of this study, which originates from previous research developed by the author, based on the formulations of Cameron and collaborators on empathic choice. This article is structured in four parts: the first outlines the new aspect of Clinical Bioethics – Healthcare Bioethics; the second presents the concept of clinical empathy used in this study; next, the scope is empathic care in clinical practice; and finally, the study of empathic care as an ethical command of Healthcare Bioethics and its interfaces with empathic choice.¹⁵

Healthcare Bioethics consists of an aspect of Clinical Bioethics that supports the biopsychosocial model, patient centrality, and the importance of the professional-patient relationship. In addition, this aspect advocates a transition from the predominance of the professional’s voice and biomedical evidence in the clinical encounter to seriously consider the patient’s experiential knowledge, as well as a clinical practice “oriented by the disease or task to be fulfilled” to one “oriented by the patient.¹⁶ Howick and Rees point out that there is a new paradigm in healthcare: the central axis of clinical practice is the human relationship. According to this new paradigm, some fundamental elements directly interest Healthcare Bioethics: (a) empathic communication is understood as an effective intervention in its own right; (b) patients’ views and experiences are valued as part of the decision-making process; (c) the ability of patients and caregivers to access, understand and use health information is supported.¹⁷ Considering the formulation above, an aspect of Clinical Bioethics is expected to promote relationships between professionals and patients that recognize their individuality and address their concerns.¹⁸

The formulation of Healthcare Bioethics’ theoretical contributions stems from the patient’s experience, without neglecting the role of the professional, since the relationship between both is one of the contributions that support Healthcare Bioethics. However, unlike other bioethical aspects, it is not the clinical experience of the professional that will dictate the basis on which the central themes and their contributions are built. Thus, Healthcare Bioethics is based on clinical empathy and its developments in the various components of care quality, such as communication, professional-patient partnership, and patient centrality. These theoretical contributions are combined with the respect and promotion of patients’ human rights applied to healthcare¹⁹ which must be observed prima facie by everyone, including health professionals. Moreover, it should be noted that there is currently no ethical approach that should not take human rights into account, especially when it comes to the context in which one of its actors presents a condition of increased vulnerability, such as the patient. Thus, Healthcare Bioethics consists of theoretical contributions and normative prescriptions. These theoretical contributions are divided along three axes: (a) empathic communication between health professionals and patients; (b) partnership relationship between health professionals and patients; (c) patient centrality and empowerment, whose voice must be amplified in healthcare. The theoretical-normative framework of the Human Rights of the Patient establishes its normative prescriptions. The theoretical and referential axes of the Human Rights of Patients will not be developed in this article, whose scope is to create the concept of empathic care, which is the foundation of the axes above designed in previous research.

Empathy is a multidimensional, complex, and essential capacity for social life and is linked to the survival of the human species, thus presenting an evolutionary trait.²⁰ In this study, we start from the understanding of empathy as the cognitive and emotional human capacity that allows the resonance of the emotions of the other, the understanding of their mental states, and being attentive to their perspective. Moreover, empathy presupposes the differentiation of oneself from others, so it does not mean putting oneself in the other’s shoes. Empathy is the ability to connect with another person’s world by tuning into their emotions and understanding their thoughts and situation. Thus, empathy is complex and implies an openness to the other. Therefore, it is not automatic as emotional contagion, nor does it demand emotional similarity, but rather an emotional attunement or resonance. Similarly, it requires a certain level of imagination to have perspective, which can be nuanced depending on the situation. In short, empathy provides a precise knowledge of the inner world of the other.²¹

Considering the confusion between empathy and compassion in healthcare, a brief distinction will be made between both concepts. Compassion is an emotion caused by the awareness that another person experiences a situation of suffering without deserving it, and it has three elements: the severe suffering of others; the condition causing the suffering was not caused by the fault of those who suffer; the person who suffers is worthy of concern. In short, compassion involves awareness of another’s suffering and the intention to alleviate it. On the other hand, empathy is a complex multidimensional capacity that encompasses complex cognitive functions, such as perspective-taking and is not necessarily linked to a situation of the other person's suffering. It can resonate positive emotions, such as joy. Moreover, empathy does not encompass an action in search of relief from suffering, although it is a predictor of prosocial behaviors.

In the sphere of healthcare, the empathic capacity of the health professional concerning the patient is called clinical empathy. Howick and Rees structure the concept of clinical empathy based on three components: (a) understanding the patient’s situation, feelings, and perspectives; recognizing the difficulties of putting oneself in the patient’s shoes; (b) communicating this understanding, checking its accuracy; (c) acting according to this understanding to help the patient. To this end, studies on the subject indicate that health professionals must have the following behaviors as guides of empathic care: (a) adopt sufficient time to understand the patient’s history; (b) talk about general issues; (c) offer encouragement; (d) give verbal signs that the patient is being understood (hmm, ahh, etc.); (e) be physically engaged (by adopting specific postures, gestures, eye contact, appropriate touch, and others); (f) be welcoming during the consultation, from the beginning until the end. Thus, there is a consensus in the specialized literature that clinical empathy consists of three components. Therefore, it can be stated that clinical empathy involves the professional’s ability to understand the patient’s point of view and health situation, to express this understanding, and to participate in decision-making based on this shared understanding.²²

Care from the perspective of the ethics of care

The concept of care is imprecise and presents non-unisonous propositions. Given the difficulty of demarcating it, the focus will be on its four constituent components, in the terms supported by Herring. Before addressing such elements, it is essential to emphasize the relational aspect of care. Contrary to the liberal political perspective, in which human beings are seen atomized and separated from their relations and community, the relational perspective brings as a central element of ethics the fact that human beings are relational and live in an interrelated, interdependent, and interconnected way. This relational perspective is a constitutive substrate of care ethics formulated by Herring, et al.²³ The ethics of care is an essential aspect of Clinical Bioethics, founded on feminist studies,²⁴ and which supports, in general terms, non-universal and inductive formulations based on the recognition that the bases for ethical decisions are extracted from concrete human relations. Thus, Gilligan opposed the “ethics of justice,” based on principles and deductive analysis, to the “ethics of care,” which is contextual and focused on preserving relationships. Tronto, unlike Gilligan, understands care as an activity and incorporates universal principles, such as the duty of care of all people concerning their neighbors, which involves the perception that there is a need that demands an assessment and a suitable response to it.²⁵ Noddings, in turn, addresses a fundamental characteristic of care, that is, attention concerning others, insofar as listening to and connecting with another allows a motivational shift, which implies putting the other at the center to meet their needs, which consists of the primary chain of care.²⁶ It is important to note that Noddings exposes an interface between care and empathy without formulating the concept of empathic care. Returning to the conforming components of care, according to Herring, these are (a) meeting needs: (b) respect; (c) responsibility; (d) relational. When meeting needs, all human beings need to be cared for; that is why we care for others and are cared for, a need equivalent to breathing clean air. Respect means that care imposes attention to the needs of the other and the appropriate response to those needs without objectifying these people. Likewise, respect encompasses other aspects: the recognition of humanity in the other; listening to the other and to their consent to care; treatment according to their inherent dignity; and awareness of how the other experiences the experience of being cared for. Responsibility concerns the caregiver, specifically their responsibility to take care not only when they want to or when it is at their convenience but showing a willingness to take care regardless of their preferences. Finally, care must be understood in the context of reciprocal relationships. Therefore, according to Herring’s ethics of care, care aims to meet human needs so that the interaction between the caregiver and the patient is seen as reciprocal and mutually significant, based on respect for the other and being aware of the social responsibility of the care provision.²⁷

According to Herring, the role of emotions in the ethics of care is to offer moral insights. Suppose it is up to the law to promote care relationships. In that case, emotions should be taken seriously in legislation, as these laws are ineffective for fostering care in societies if they do not consider emotions in human interactions. Endorsing Herring’s perspective, Maio points out that the ethics of care proclaims the value of emotions in the constitution of morality. To this point, Albuquerque demonstrated that there is currently no way to sustain the dissociation between judgment and moral decisions without considering emotions.

Maio examines Ricoeur’s care formulation, for whom care is being with someone and for someone; it is bidirectional, as the person cared for also causes changes in the caregiver. Interactions with others shape our view of ourselves, as shown in the care relationship. And in this relationship, the caregiver, once aware and open to this relational characteristic of the human being, can assume a less asymmetrical position since the asymmetry of power is present in the relationship of care. For Ricoeur, care consists of self-awareness, intentionality (orientation towards the other), goodwill, and spontaneity. In this study, the objective is not to deepen the reflection on the ethics of care but only to employ the concept of care formulated by Herring and to highlight the convergence between the ethics of care and Healthcare Bioethics, especially regarding the importance given to human relations and the emotional dimension of the human being. On the other hand, Healthcare Bioethics distances itself from its refusal to accept universal principles and normativity in the clinical field. Therefore, the understanding of empathic care’s essence is extracted from constructs of the ethics of care. Thus, Healthcare Bioethics is closely related to the ethics of care in highlighting relationships, needs, and emotions. It is also close to principled ethics, anchored in normative prescriptions that guide care, such as human rights.

Healthcare is a set of practices carried out by the health professional relationally and interactively with the patient, aiming to respond to their needs. The notion of care as a practice is extracted from Tronto, for whom care relates to attitudes and actions, and Herring, who considers caring an activity designed to meet needs. Care in the clinical context occurs in an interaction between the patient and the professional, in which there is the presence of dialogue through which they develop a shared understanding of the patient’s situation, as well as identify and discover ways to improve it, according to the preferences of each patient.²⁸ Therefore, healthcare consists of more than actions developed by professionals; it is a relational, communicational, and dialogical process. For this care to be classified as empathic, clinical empathy must be present both in its constitutive dimension, as a capacity of the health professional, and in its relational dimension, when this capacity is expressed in the interaction with the patient. Thus, empathic healthcare is provided by an empathic health professional who recruits empathy when interacting with the patient. For the care to be empathic, the professional needs to choose to be empathic, and the environment in which they find themselves needs to provide this choice. Thus, the empathic choice is a component of empathic care because, without this choice, the health professional will not be empathic – empathy in its cognitive and emotional dimensions. Consequently, it is essential to discuss the empathic choice by health professionals.

Although empathy is a human capacity, it is also the product of a dynamic decision-making process about whether to be empathic in each context. This process is based on a decision that happens quickly and unconsciously, weighing and prioritizing goals, such as avoiding material costs and maintaining social relationships. Choosing to be empathic or not means valuing and selecting some goals over others. For example, empathizing with another person may satisfy our moral goal but hinders the goal of minimizing effort.²⁹ Thus, although empathy's social and individual benefits are widely recognized, it also involves costs and is conditioned to the context and environment in which the person is. In other words, empathy drives us to help those with whom we share our genes, but reciprocal cooperation with mutual benefits brings emotional, cognitive, and material costs. Moreover, empathy depends on externalities of the context and the environment. Considering the costs of empathy, one may question empathic choice; that is, human beings choose whether to be empathic given its benefits and costs. According to Cameron and collaborators, people generally choose not to be empathic; their preference is driven by judging the costs of empathy inherent to empathizing.

Empathy is a motivational phenomenon. Thus, people can recruit and increase their empathic capacity by changing their motivation to exercise it. This motivation stems from the expected subjective value, which encompasses the weight each one gives to the costs and rewards present in exercising empathic capacity. Therefore, empathy can be avoided when there are material costs – being empathic costs time and money – or emotional costs when being empathic are associated with distress. As for cognitive costs, these include effort, aversion, and ineffectiveness. In this study, the costs of effort and ineffectiveness stand out, as they are applied in the context of clinical practice by Cameron et al. Effort is the subjective intensification of physical and mental activity to achieve a specific goal. Ineffectiveness is the lack of accuracy in emotional resonance and understanding of the other’s situation and mental state. It is essential to point out that even when there are rewards in being empathic – such as positive emotions – there are costs, creating a strong desire to avoid empathy. Thus, when people are about to face a situation that triggers the recruitment of their empathy, they tend to weigh the expected value of their mental costs – such as effort, negative emotions, and ineffectiveness – and the material costs and rewards. These rewards commonly relate to their desire to do the right thing and adjust to social norms.

Particularly in the case of physicians, studies have shown that they report increased satisfaction when they help others, indicating an increase in empathy and an ability to regulate their empathic capacity to avoid psychological costs. Cameron and Inzlicht’s research points out that physicians show less empathy when compared to the control group, although other research does not endorse this distinction; on the contrary, some show that physicians demonstrate a greater likelihood of empathic choice. To the authors, significant motivational factors are observed in the empathic choice in the work environment associated with positive experiences in helping others, leading to the conclusion that, in the case of physicians, empathy is more relevant for the adoption of enabling behaviors, which is positively associated with empathic choice. The fact that physicians perform emotional self-regulation to avoid empathic fatigue, according to the authors, does not lead to the assertion that this regulation generates an empathic deficit. Moreover, the empathic choice by physicians is motivated by the belief that empathy is helpful in clinical practice and that being empathic brings satisfaction.³⁰ Another factor that impacts physicians’ empathy is the sense of ineffectiveness, that is, their perception of effectiveness in inferring the patient’s mental state and situation. Their ineffectiveness can be improved with training in communication and continuing education in this theme.

People choose to be empathic in different ways, depending on their goals, so modulating these goals can change how they regulate their empathy and, in the case of physicians, how they care for patients. For example, if physicians are led to reflect on empathy’s essential role in healthcare, this can increase their empathic choice. This also happens if they are permanently reminded that empathy leads to positive and satisfactory results in their interaction with patients.

The choice to be empathic is not always made, although being empathic provokes in human beings the sense that they are doing something good, which causes positive impacts on their self-esteem and makes them feel proud of themselves. It also facilitates rapprochement and positive relationships and motivates prosocial behaviors.

As mentioned before, being empathic is costly, and there is a certain tendency not to choose to be empathic; however, when it comes to health professionals, this choice should be perceived differently, as clinical empathy is a proven factor in increasing healthcare quality. It brings benefits to patients and the professionals themselves. Therefore, it can be said that health professionals don’t have an empathic choice; that is, they cannot choose to stop being empathic towards patients, mainly because of the choice of engaging or not in situations that may require us to be empathic or not does exist in the case of healthcare, given that the interaction with the patient always requires a certain level of empathic capacity from the professional. Therefore, although it starts from the premise that being empathic is a constituent of the health profession, this does not mean that professionals, in practice, will stop weighing the costs and rewards of being empathic. Consequently, in addition to maintaining clinical empathy as a professional skill, providing the environment/space and motivation for empathic choices to be made in healthcare is necessary. Thus, health systems based on empathic care are required so there is an environment conducive to empathic choice, which imposes the recognition that empathic care is a central ethical command of clinical practice.

Healthcare Bioethics is an ethical framework for clinical practice that is based on theoretical contributions and normative prescriptions, namely: (a) empathic communication between health professionals and patients; (b) partnership relationship between health professionals and patients; (c) patient centrality and empowerment; and its normative prescriptions are established by the theoretical-normative framework of Human Rights of the Patient. In addition to this framework, the care recommended by Healthcare Bioethics is empathic, the care consisting of the relational response of the professional based on the understanding of the patient’s situation and their needs, carried out through the empathy expressed in the interaction between both. Healthcare aims to respond to the needs of the patient – not those assumed by the professional, but those extracted from the empathic interaction between them. Therefore, empathic care is an ethical structuring command of Healthcare Bioethics. Healthcare Bioethics, in line with the ethics of care, stems from the interdependence of human beings and does not consider the patient in a situation of increased inferior vulnerability, incapable or unskillful. Similarly, the power asymmetry in the professional-patient relationship cannot lead to benevolent paternalism. On the contrary, recognizing that the relationship is unequal leads to postulating the same level of respect, which is associated with clinical empathy, insofar as it allows one to apprehend the needs and preferences of patients, which guides decision-making. Therefore, empathic care is a necessary command to respect the patient, as it is a tool to mitigate power asymmetry. In addition, Healthcare Bioethics incorporates the responsiveness of ethics of care since it primarily focuses on the response of those who need care and is “response-focused” ethics. Moreover, only empathic care allows for the practical realization of this responsiveness because without accessing the patient’s mental state and situation, there is no way for the professional to respond appropriately to their needs.

To carry out this ethical command of Healthcare Bioethics, health professionals need in their training and continuing education to be aware that their empathic capacity is beneficial for patients and themselves, as well as for the provision of quality care, impacting the entire health system. In addition, empathic care must be understood as an ethical command, that is, as the right choice. This perception by health professionals that they are doing something morally and socially valued and useful has the power to promote their empathic choice. Resonating with the patient’s emotions by understanding their perspective, needs, and preferences is an ethical command that integrates Patient-Centered Care, Shared Decision-Making, patient participation in their care, and the realization of patients’ rights, constitutive approaches of Healthcare Bioethics. This is because empathizing with the patient provides information about their mental state and situation, facilitating interaction and improving communication. Thus, the health professional can be motivated to value empathic care not only as an objective but also as a means to other objectives, such as providing quality care for the patient. The cognitive and emotional costs of empathic care should not be denied or mitigated for health professionals; on the contrary, they must be addressed in these professionals’ training, and continuing education process so that they are aware that their profession has its issues to deal with. Concealing the complexity of human relations and emphasizing only the positive aspects is inadequate for preparing health professionals to face the emotions that emerge from encountering patients daily. In this sense, communication must also be integrated into the list of professional skills, particularly empathic communication related to the patient, as one of the cognitive costs of empathic choice is the fear of failing to infer the patient’s mental state and situation, which is closely linked to the communicational component of clinical empathy.

Similarly, it is necessary to elucidate the rewards of being empathic and to remember that when health professionals choose to work in the health field, empathy is one of the required skills. Moreover, it is crucial to show that the rewards outweigh the costs. The rewards are a sense of closeness, affiliation, self-efficacy, and relational competence, as well as altruistic motivation and prosocial behavior, which increases the ability to regulate social interactions and cooperate toward shared goals. In addition, when the health professional’s helpful behavior is rewarded by the patient’s gratitude, for example, and this professional perceives their empathic competence, positive feelings are incorporated into their repertoire, contributing to their well-being and resilience. Thus, when empathic care is valued in undergraduate courses in the health area, in institutions and health systems, professionals who seek to be empathic are also socially recognized as examples to be followed, reputed as role models and good professionals. This is critical to empathic choice because having a good reputation and being recognized for being empathic is rewarding, mitigating the costs of empathy. Consequently, empathic care should be introduced as the model healthcare of the entire health system and be the foundation of Medicine, Nursing, and other courses in the field of health.

Notably, in the context of health systems, the structure and organization contribute to incorporating certain beliefs by health professionals. Thus, health institutions and systems must facilitate the building and maintenance of the moral justification of these beliefs. One-way institutions can influence moral beliefs and individual actions is by creating conditions that promote certain practices and reinforce the conservation of specific points of view. Regarding empathy, health systems and institutions must reward and strengthen beliefs that empathic capacity and empathic care are non-negotiable values.³¹ Health professionals unconsciously choose objectives underlying their decision to be empathic or not. To be motivated to make decisions based on empathic choice, it is necessary to adopt the following motivational interventions: (a) recognize the costs of empathy and deal with the issue openly with students and professionals in the field of health; (b) create a context in which the rewards of being empathic are increased, such as having empathic care valued by the institution and the health system, cultivate the importance of adopting pro-patient behaviors, adopt work processes that provide empathy in the clinical encounter and recognize empathic health professionals; (c) include empathic care as a professional objective in training health students and in the continuing education of professionals, and include empathy and communication as professional skills, increasing their sense of self-efficacy; (d) adopt as values of the institution and the health system the objectives related to empathic care, such as providing quality care, responding appropriately to the needs of patients and being an ethical professional. Being empathic implies prioritizing the objectives linked to empathic care at the expense of their costs. Therefore, these objectives must be cultivated since the beginning of the health professional training and be continuously recalled, as such objectives must make subjective sense to professionals and not be imposed. Research shows that individuals who give intrinsic value to empathy value these goals, prioritizing them when faced with the costs of being empathic.

Finally, it should be noted that in addition to the cognitive and emotional costs of being empathic, there are several barriers to clinical empathy being recruited by the health professional. These barriers are not the object of this study, focusing on empathic care as an ethical command of clinical practice.

None.

The authors declares that there are no conflict of interests.

1. Ten Have, Henk AMJ. Potter's notion of bioethics. Kenney Inst Ethics J. 2012;22(1):59–82.
2. UNESCO. Declaração sobre Bioética e Direitos Humanos. 2005.
3. Beauchamp Tom L, Childress James F. Principles of Biomedical Ethics. Nova Iorque. Oxford. 2019.
4. Kwame Abukari, Petrucka Pammla M. Universal healthcare coverage, patients’ rights, and nurse-patient communication: a critical review of the evidence. BMC Nurs. 2022;21(1):54.
5. Albuquerque Aline. Criticisms of Principialism from the perspective of the new ethical paradigm in healthcare: the protagonism of the patient. Revista Redbioética/UNESCO. 2022;1(25).
6. Albuquerque Aline, Tanure Cintia. The necessity of new bioethics to clinical practice. NCOAJ. 2023;9(2):38–39.
7. Albuquerque Aline, Howick Jeremy. The moral function of clinical empathy. IJFCM. 2023;7(1):11–14.
8. Albuquerque Aline. Empathy in healthcare: communication and ethics in clinical practice. Rio de Janeiro: Manole; 2023.
9. Churchill Larry R, Fanning Joseph B, Schenck David. What Patients Teach. Nova Iorque: Oxford. 2014.
10. Howick Jeremy, Rees, S. Overthrowing barriers to empathy in healthcare: empathy in the age of the Internet. J R Soc Med. 2017;110(9):352–357.
11. Howick J, Mittooo S, Abel L, et al. A price tag on clinical empathy? Factors influencing its cost-effectiveness. J R Soc Med. 2020;113(10):389–393.
12. Herring J. Compassion, ethics of care and legal rights. International Journal of Law in Context. 2017;13(2).
13. Herring J. Ethics of care and the public good of abortion. 2021.
14. Cameron Daryl. Empathy is hard work: People choose to avoid empathy because of its cognitive costs. J Exp Psychol Gen. 2019;148(6):962–976.
15. Cameron C. Motivating empathy: three methodological recommendations for mapping empathy. Social and Personality Psychological Compass. 2018;12(11):12418.
16. Naldemirci Ö, Nickey B, Helen L, et al. Epistemic injustices in clinical communication: the example of narrative elicitation in person-centered care. Sociol Health Illn. 2021;43(1):186–200.
17. Bikker, Annemieke P, Stewart W, et al. Embracing empathy in healthcare. Nurse Older People. 2014;26(8):10.
18. Jeffrey David. Empathy-Based Ethics: A Way to Practice Humane Medicine. Springer. 2020.
19. Albuquerque A. Human rights of patients. Curitiba: Juruá, 2016.
20. Ferguson M, cameron C, Daryl C, et al. Motivational effects on empathic choices. Journal of Experimental Social Psychology. 2020;90(1):104010.
21. Gatyas M. Emotion sharing as empathic. Philosophical Psychology. 2022.36(1):85–108.
22. Howick J, Steinkopf L, Ulyte A et al. How empathic is your healthcare practitioner? a systematic review and meta-analysis of patient surveys. BMC Med Educ. 2017;17(1):136.
23. Edwards Steven. Three versions of an ethics of care. Nurs Philos. 2009;10(4):231–240.
24. Zoboli Elma. The rediscovery of Ethics of Care: focus in the relationships. Rev Esc Enferm USP. 2004;38(1):21–27.
25. Maio Giovanni. Fundamentals of an ethics of care. 2018.
26. Noddings N. Complexity in caring and empathy. Abstracta. 2010;5:6–12.
27. Herring Jonathan. Caring and the Law, Oxford. Hart Publishing. 2013.
28. Victori M, Merel M, Hargraves G, et al. Shared decision-making as a method of care. BMJ Evid Based Med. 2022.
29. Cameron C, William A, Blair S, et al. The ends of empathy: constructing empathy from valued-based choice. 2018.
30. C Daryl, Michael I. Empathy choice in physicians and non-physicians. Br J Soc Psychol. 2020;59(2):715–732.
31. Kerasidou A, Kristine B, Zackary B, et al. The need for empathetic healthcare systems. J Med Ethics. 2021;47(12):e27.