Ethical dilemmas are part of medicine, but the type of challenges, the frequency of their occurrence and the nuances in the difficulties have not been systematically studied in low-income settings. The objective of this paper was to map out the ethical dilemmas from the perspective of Ethiopian physicians working in public hospitals. A national survey of physicians from 49 public hospitals using stratified, multi-stage sampling was conducted in six of the 11 regions in Ethiopia. Descriptive statistics were used and the responses to the open-ended question “If you have experienced any ethical dilemma, can you please describe a dilemma you have encountered in your own words?” were analyzed using a template analysis process. A total of 587 physicians responded (response rate 91,7%), and 565 met the inclusion criteria. Twelve of 24 specified ethically challenging situations were reported to be experienced often or sometimes by more than 50% of the physicians. The most frequently reported challenge concerned resource distribution: 93% agreed that they often or sometimes had to make difficult choices due to resource limitation, and 83% often or sometimes encountered difficulties because patients were unable to pay for the preferred course of treatment. Other frequently reported difficulties were doubts about doing good or harming the patient, relating to conflicting views, concern for family welfare, disclosure issues and caring for patients not able to consent. Few reported dilemmas related to end-of-life issues. The 200 responses to the open-ended question mirrored the quantitative results. Ethiopian physicians report ethical challenges related more to bedside rationing and fairness concerns than futility discussions and conflicts about autonomy as described in studies from high-income countries. In addition to the high report of experienced challenges, gravity of the dilemmas that are present in their narratives are striking. Recognition of the everyday experiences of physicians in low-income settings should prompt the development of ethics teaching and support mechanisms, discussion of ethical guidelines as well as increase our focus on how to improve the grave resource scarcity they describe.

中文翻译：

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低收入环境下的临床伦理困境-埃塞俄比亚医师的全国调查

道德困境是医学的一部分，但是在低收入环境中，尚未系统地研究挑战的类型，发生的频率和困难的细微差别。本文的目的是从在公立医院工作的埃塞俄比亚医生的角度来绘制伦理困境。在埃塞俄比亚的11个地区中的六个地区，采用分层，多阶段抽样的方法，对来自49家公立医院的医生进行了一次全国性调查。使用了描述性统计数据，并回答了开放式问题“如果您遇到任何道德困境，请您以自己的语言描述遇到的困境吗？” 使用模板分析过程进行了分析。共有587位医生做出了回应（回应率91.7％），其中565位符合纳入标准。据报道，超过50％的医生经常或有时经历24种特定的具有伦理挑战性的情况中的12种。报道最多的挑战涉及资源分配：93％的人同意由于资源有限，他们经常或有时不得不做出艰难的选择，而83％的人经常或有时遇到困难，因为患者无法支付首选治疗的费用。其他经常报告的困难包括对意见的好坏或对患者的伤害，与观点冲突，对家庭福利的关注，披露问题以及对无法同意的患者的照顾。关于报废问题的两难困境报道很少。对开放式问题的200个回答反映了定量结果。埃塞俄比亚的医生报告，与高收入国家的研究相比，道德挑战更多地与床边配给和公平问题有关，而不是徒劳的讨论和关于自治的冲突。除了对经历的挑战的大量报道外，在其叙述中出现的困境的严重性也令人震惊。认识到低收入环境中医生的日常经验，应促进伦理学教学和支持机制的发展，对伦理学准则的讨论，并增加我们对如何改善他们所描述的严重资源短缺的关注。叙述中出现的困境的严重性令人震惊。认识到低收入环境中医生的日常经验，应促进伦理学教学和支持机制的发展，对伦理学准则的讨论，并增加我们对如何改善他们所描述的严重资源短缺的关注。叙述中出现的困境的严重性令人震惊。认识到低收入环境中医生的日常经验，应促进伦理学教学和支持机制的发展，对伦理学准则的讨论，并增加我们对如何改善他们所描述的严重资源短缺的关注。