The aim of the study was to illuminate the meanings of being in ethically difficult situations that led to the burden of having a troubled conscience, as narrated by physicians working in dialysis care. The findings show that the physicians felt trapped in irresolution when obliged to decide about withdrawing or withholding dialysis in the face of dissonant opinions. They experienced being torn by conflicting demands when ideals and reality clashed. The situations related in their narratives represented true ethical dilemmas in which physicians wanted to do good by avoiding doing wrong. In ethical dilemmas, however, there is no one truly good solution . The physicians' choice was, therefore, not between doing good or bad but rather which would be the lesser of two evils . When telling their stories physicians realized that by avoiding one evil they unintentionally opened the door to the worse evil by not being sensitive enough to the patient's wishes, failing the relatives by not bringing up the crucial problem for discussion and ultimately failing themselves by not being true to their own values. Ricoeur  says that in the concrete situation when conflicts between different demands clash and we not only have to choose between good or bad but rather between an evil and a lesser evil to protect life, it is important to validate one's standpoint. Silfverberg  believes that an ethical dilemma makes us feel confused and uncertain because we do not know what to do, but we still feel bound to act with no rules to follow . To find a clue as to what is best for the other in an ethical dilemma, it is essential to be sensitive to one's own attitude and clarify one's inner motives [29, 30].
The physicians in this study tried to follow what they believed was a good way of handling the ethical dilemma caused by conflicting opinions. They tried to do good by avoiding conflict between patients and relatives and wanted to open the way for consensus while not influencing the relatives' opinions. In hesitating to make a final decision about withdrawal of treatment they hoped the patient and relative would arrive at the right decision. Instead of following their own conscience in giving the patient and relative guidance, the physicians said they kept out of the way. They felt they were hemmed in and, in avoiding taking action, assumed a defensive attitude. Lögstrup  claims that by continuously considering instead of acting in difficult situations we may escape uncomfortable moral obligations to take the initiative for change. It is easier to continue considering but to do it continuously robs us of the power to act. Nykänen  argues that if one's conscience knows what is right but one still does what one believes others expect, one is directed by a false conscience and ultimately turns against oneself. Disregarding one's conscience means escaping from the true self and is often followed by feelings of guilt.
According to Fromm  when you are not sensitive enough to follow the voice of conscience, conscious feelings of guilt about the person being failed will be induced. Later on a whole complex of unconscious guilt feelings for failing oneself arises. In the midst of unconscious feelings of guilt the experience of being trapped is generated . The presence of such feelings of unconscious guilt was traced in the interview situation when the physicians' expressed a desire for another way in which to meet an ethical dilemma. The physicians wished they had been more sensitive to their own conscience and had been brave enough to influence the relatives in order to avoid the patients' suffering. Ricoeur  claims that conscience comes both from outside and inside. Its function is to examine our actions with suspicion, the judgmental function of conscience, but also to give us attestation that we are a sufficiently ethical being, in other words our-power-to-be.
According to the authors' interpretation the physicians in this study wanted to be confirmed, by their conscience but also by their colleagues and RNs, when making decisions in ethical dilemmas. Lacking support from colleagues and understanding and respect from RNs, the physicians felt devalued. Sörlie  found that in ethical dilemmas in pediatric care physicians felt lonely and burdened by uncertainty and responsibility. As mentioned above facing an ethical dilemma means facing conflicting moral demands where no decision is totally good . It means that we often need to consult not only our conscience but also others to ascertain that the decision is as good as it can be, given the circumstances. We need to feel assured that we have not overlooked better ways to act . Analysing situations involving ethical dilemmas together with others opens the way for sensitivity to others' perspectives and promotes moral development . Interviewing psychiatric care providers about having troubled a conscience Dahlqvist et al  found that being sensitive but having a realistic approach towards one's conscience enhanced reconciliation and an ability to feel "good enough".
In this study, physicians spoke about feelings of being burdened by having sole responsibility in situations involving decisions about life or death. When investigating the ways physicians dealt with challenges in their work Andrae  found that they are educated to master all situations, are generally expected to have answers to all questions  and to make medical decisions on their own . Hansson  describes the medical profession as not having developed a collaborative culture with support and shared responsibility for patients. The physicians in this study did not only have difficulties in reaching a consensus with colleagues, they also described feelings of being questioned and blamed by RNs. Sörlie  showed that support, encouragement and shared feelings of uncertainty helped physicians to develop an insight and acceptance that in an ethical dilemma one has to deal with insoluble problems. A prerequisite for being able to endure sole responsibility was being able to share the agony of being morally responsible when things go wrong. Silfverberg  emphasizes that an ethical mind with a feeling for concerns and judgements can be developed not only through being sensitive to the voice of conscience but also by observing and being corrected, in a sense of togetherness, by other people. In such an ethical climate personal character and virtues may develop.
In this study some of the physicians discussed ethical dilemmas with colleagues whom they knew from earlier experience had similar opinions and with whom they would probably be able to reach a consensus. The physicians and RNs had various experiences and perspectives concerning the patient's situation which they seemed to have difficulties communicating about. That these professional perspectives were not shared became an obstacle to reaching a common understanding. Lindseth, et al  showed that physicians and RNs in Norway had differing ethical perspectives in relation to the patient but deeper reflection revealed that they had similar core values. When different perspectives can be seen as complementing each other, in-depth dialogue between and among various professionals allowed mutual understanding and ultimately consensus concerning acceptable actions . Studying ethically difficult situations in intensive care, Söderberg  showed that an ethical dilemma can only have a good outcome in an atmosphere of consensus. Physicians who succeeded in implementing very difficult decisions shared the following characteristics; they dared to remain in difficult situations, acted respectfully towards their opponents, were open to criticism, created a feeling of solidarity and succeeded in discussing the situation in such a way that they could achieve consensus.
The number of participants in this study is small, only five physicians were asked for interviews. The reason for this is that seven RNs were also interviewed for the study. The extent and richness of the resulting interview text and findings, however, led us to divide the reporting of the study into two manuscripts. The results of the RNs' interviews and the comparison between the groups will, therefore, be reported elsewhere. Despite the small sample the findings make an important contribution to developing a way of encountering ethical dilemmas.
Ricoeur  claims that the methodological steps help to create a distance between the researcher and her/his pre-understanding. Such a distance cannot be realized completely [27, 41] but becoming more aware of the situation through reflection helps to limit the bias . The authors are all RNs working in the following fields: clinical ethical support for all groups of professionals in a County Council (AS); researching matters of conscience in healthcare (VD); and working in anaesthetic care for many years (CFG). All three authors were involved in the analytical process and focused attention on awareness of their own values in order to increase the credibility of the analysis .
Interviewing another professional may constitute a methodological limitation. However, there may also be a positive effect in that physicians might be more open and willing to explain more explicitly what they mean to another professional. Another professional may also be sensitive to aspects of the phenomenon that are taken for granted within one's own profession.
A further limitation is that the interviewees were preselected by the chief physician according to the criteria for inclusion. However, the chief physician asked the clinical ethics committee for help and he knew which of the physicians on the ward would meet the inclusion criteria and could provide rich narratives. The interviews were carried out at one of the few hospitals in northern Sweden where dialysis is performed, making it possible to identify the participants. In order to preserve their confidentiality, age and gender are excluded from the text. During the analysis process five sub-themes emerged which are linked. The sub-theme "Feeling squeezed between time restraints, professional and personal demands" covers conflicts concerning prioritization of time in everyday situations. It does not concern crucial decisions about life or death but crucial decisions about how to do good or be good.
The findings from this study cannot be generalised, but can probably be re-contextualized to other contexts where similar ethical dilemmas occur concerning the withdrawing or withholding of treatment, e.g. in intensive, oncology and emergency care. The findings can also be re-contextualized/transferred to other contexts where professionals have to live and deal with conflicting demands.