The HDMs in this study, revealed both ethical dilemmas and their
experiences of being in ethically difficult situations related to elder
care. They were directly or indirectly involved with the dilemmas. The
ethical dilemmas revealed were associated with a lack of good elder
care and a lack of agreement concerning care. These issues addressed
for example vulnerable patients in inappropriate care settings,
weaknesses in medical support, dissimilar focuses between the caring
systems as well as justness in the distribution of care and deficient
information. The HDMs' experiences of being in ethically difficult
situations were associated with their exposed situations, feelings of
having to be strategic and having to live with divided feelings. These
issues addressed aspects such as aloneness and loneliness, uncertainty,
lack of confirmation, risk of being threatened or of becoming a
scapegoat. Avoidance of difficult decisions and loyalty vs. own
conviction was also highlighted.
Lack of good care such as inappropriate care settings for patients
with dementia disease were seen as ethically problematic. Chronically
ill individuals are to be met with dignity and should have priority in
the health care system [20,21].
Future conflicts related to the extensive care needs of a growing older
population together with decreased resources are well known . Ensuring good residences for the most vulnerable patients will inevitably be one of the dilemmas on the HDMs agenda.
Weaknesses in medical support due to a continuous shortage of
physicians in elder care were expressed as ethically troublesome.
Unnecessary transfers of older adults to the hospital were mentioned as
a result of this situation. High transfer rates among older adults
living in sheltered housing facilities to the emergency departments
have been reported, but more analysis was recommended .
The shortage of physicians in elder care and current recruiting
difficulties can originate from several causes but are still problems
the HDMs are obligated to resolve. Physicians have ranked caring for
older patients last in the area of prestige .
This ranking indicates the degree of esteem the physicians, health care
services and society in general seem to have towards older adults .
Dissimilar focuses and lack of structure and agreement between the
municipalities' and the county councils' organisations responsible for
elder care in Sweden were reported in our study as being a cause of
ethical dilemmas. This is comparable to what Thompsen 
called "the problem of many hands", which means that when many
officials contribute to decisions and policies of government it is
difficult to identify who is morally responsible for the political
outcomes. A society can be referred to as being unethical if it has
vague policies. An example mentioned is a health care system that lacks
structure and policy .
In our study it was empathized that lack of structure is a factor
contributing to ethical difficulties. It is reasonable to assume that
the HDMs are to a large extent responsible for handling the problems
related to the organisational structure deficiencies especially since a
system can interfere with the understanding of what is right and fair
and can thereby be a source of ethical dilemmas or can prevent them . In a system lacking policy and structure, it can be difficult to act ethically even if people have the intention to do so .
Lack of agreement concerning care was related by the HDMs as the
incongruence between health care needs and the budget. This situation
has caused relatives to assume a greater amount of responsibility,
which is something they question to some extent the appropriateness of.
Relatives are already assuming much responsibility in elder care and
many of those doing so are the spouses .
Additionally, the reduction of sheltered housing facilities in several
municipalities has been rapid and there are few studies that
investigate the consequences of these changes .
Dealing with the justness in the distribution of care between
different groups was referred to in our study as a source of ethical
dilemmas. This justness was associated with the difficulties of
prioritising and fairly providing for the care needs of the different
groups while still remaining within the budget. When preconditions
associated with priority setting among decision-makers, physicians,
private citizens and patients were studied ,
it was shown that private citizens and patients in general had high
expectations regarding what should be offered by the public health care
system. These expectations did not correspond with the decision-makers'
and physicians' view . In a study, by Hammarström 
involving politicians, civil servants and health care professionals it
was found that the medical ethical principals established by Swedish
health care legislation were not much reflected in the decision making
process when priorities or budget cuts were being decided upon. Instead
of seeing these actors as being insensitive, these results were
interpreted as being due to the vague ethical guidelines and the
difficult nature of the issues being faced .
The justness in the distribution of care mentioned in our study was
associated with the fact that the voices of some groups are stronger
Deficient information due to the poor reporting systems were
experienced by the HDMs as problematic as it could lead them to make
incorrect decisions. One of the purposes of the "Swedish National Study
on Aging and Care"  was to develop useful descriptions of the older patients needs in the health care system. A study by Mamhidir et al. 
was conducted in which one of the previously developed systems was
applied. Reporting systems can help reduce the problems that lead to
ethical difficulties or as mentioned by HDMs, increase them. When
referring to the idea of Heidegger, Sartre and Buber regarding the
authentic existence, Nerheim 
wrote about the blindness related to our own inauthentic understanding
that focuses on the theories and the moral systems. It is necessary to
set our inauthentic understanding within parentheses since theories and
moral principles can be misleading. The inauthentic understanding will
tell us what the "fact" is, and that might be risky, as it does not
include our "life" and could therefore become a hindrance to what can
be sensed and understood. In our study it was noticed that the HDMs
seemed to externalize the poor reporting systems and refer to them as
something out of their control. Sorlie et al. [18,8]
have reported on externalization of ethical dilemmas among enrolled
nurses and registered nurses working in acute care settings. The
enrolled nurses in contrast placed the responsibility for their failure
to achieve a good caring standard on the authorities, administrators
and health care system and cited in particular a lack of resources .
Registered nurses tended to externalise less and seemed to focus more
on the responsibility at hand instead of faulting someone else for the
With these results in mind, a necessary dialogue between the different
levels might reduce the "finger pointing" and improve the elder care
system. External placing of responsibility is known to protect against
experiences of stress, which could be caused by qualms of conscience .
The HDMs' experiences of being in ethically difficult situations
were associated with aspects such as their high and exposed position.
They felt that the higher up in the hierarchy they were, the more alone
they became, especially when situations got difficult. They also
expressed feelings of uncertainty. Loneliness and uncertainty are
fundamental conditions of life ,
and as such are therefore unavoidable, and it is these states of
existence that make a person vulnerable. Henriksen & Vetlesen 
empathize that when a person assumes heavy responsibility the
unpleasant feelings associated with it can be their conscience striving
to influence their ethical integrity. The HDMs in our study realized
that these feelings were something they had to learn to live with or
quit their jobs since they are required to make final decisions and
stand by them. They saw their salary as somewhat of a compensation for
the unpleasantness. Professionals in the different health care fields
of surgery  paediatrics  and geriatrics  are reported to have accepted the inevitability of uncertainty.
It is obvious that the HDMs were experiencing a lack of
confirmation, which is in contrast to what some others working in the
health care system have experienced [14,37].
Lack of confirmation can negatively affect a person's identity. Social
confirmation and recognition from others is needed for the construction
of ones identity .
Our self image is formed by social confirmation and the lack of it
could lead to a breakdown of ones self image and contribute to mistrust
which can negatively affect how well we act with others. The risk of
becoming scapegoats or being threatened was mentioned in our study as
contributing to emotional strain. The occurrences of threats and
violence against elected officials have been reported to be 16% at the
municipal level and 20% at the county council level .
Included in these threats considered to be serious not only against the
individual but against the democracy as well were: assault and battery,
unlawful threat, slander and insult . Facing these risks expressed the sense of vulnerability.
Living with divided feelings proved ethically challenging when the
HDMs' loyalty to their jobs came into conflict with their convictions.
Decisions they thought could be detrimental to the older adults gave
them a felling of failure. Guilt can be felt if a person does not meet
what they feel is required of them in a situation or deny something
valuable in their own life .
In our study it seems that the HDMs remembered their fallibility in
their dealings with other difficult situations. This indicates what
calls the memory of ethics, which means that people never can or will
forget situations in which they failed to do right or something good.
The HDMs felt a loyalty to their job because of the responsibility they
had assumed, even when uncomfortable decisions had to be made. This is
in line with the reasoning that Lundqvist 
presented where in some situations an ethical demand confronting an
administration can be made less important if a legitimate authority had
given directives concerning it. Individuals that are attended to in a
system can feel a strong commitment to it and the authority represented
in it causes a willingness to obey . However, it is important to not blindly obey others but base actions on ones own ethical judgements .
Possible motives behind the HDMs loyalty to their positions could be
the desire to bring about good elder care or to benefit their own
In our study, different ethical dilemmas and the meaning of being in
ethically difficult situations related to elder care have been revealed
by the HDMs. This confirms the idea of Lindseth 
that both an action and relational ethics perspective persists
simultaneously and are closely related. This is so even though the HDMs
are not directly involved with the patients or the professionals. As
leaders it disturbs them when they receive reports or hear of not only
bad incidents occurring in elder care but also of bad relationships.
When this occurs these issues are up close and personal, they are
touched by them, their feelings are moved and they become directly
involved. They also expressed feeling uncertain as to whether their
decisions would lead to good care. It is therefore understandable that
the HDMs deal with questions that reflect both perspectives such as
"What should I do" as well as "How do I fulfil my role . This ethical theory 
is useful for illustrating the complexity of the ethical challenges and
that ethics concerns everyone, caregivers as well as HDMs.
Health administrators and politicians have been viewed as having
little understanding for the demands expressed by staff in acute care  and have been reported as probably cold and cynical .
In our study, it is reasonable to believe that the HDMs' experiences of
being ethically challenged concerns their feelings that important
issues and needs are at stake in elder care as well as for themselves.
The crux of the ethical challenges seems to be related to the HDMs
having a covenant with older patients and society to provide good care
and that this care is governed by the limited budgets of the different
health care organisations. Bakken et al. 
stressed that the rhetoric regarding the welfare state at the national
level, including the health care sector can be experienced as being
almost unlimited. The welfare state ambitions are executed at the local
political level and the disparity between the ambitions and available
recourses systematically creates ethical dilemmas .
The HDMs, in our study requested a public debate addressing what can be
expected from and offered by the national public health care systems.
This underlines their uncertainty about how to deal with troublesome
situations including reports of problems in elder care. A wish for some
support for making decisions or maybe some relief by sharing these
difficult issues with others might be sought. It might also reflect
what Thompson 
calls restoring responsibility in health care. The fundamental key
issue of trust between individuals must be transferable into the
character of the health care system or organisations. Studies have
addressed the concept called "organisational ethics" in which, for
example, the issues related to ethical conflicts at different levels
and by different professionals in the organisation are revealed. The
management is required to make sure that the necessary prerequisites
are provided to ensure that the structures and processes enable
dialogues concerning ethical issues and behaviours within a health care
Our paper provides further insight into the ethical dilemmas and
ethical challenges met at the HDM level, which is important since their
decisions affect many stakeholders in elder care. According to our
results it seems that ethical discussions do not have a high priority
on the HDMs agenda. The distance between the patients, professionals
and HDMs may affect that situation. Our results can be used to
stimulate discussions between HDMs and health care professionals
concerning ways of dealing with ethical issues and the necessity of
structures that facilitate dealing with them. Ethical reflections will
probably have an impact on the trust in the caring system. Future
research is suggested that studies how situations affect people when
loyalties to a position come into conflict with personal convictions.
Since ethical dilemmas that confront all levels of health care
organisation will persist, the concept of organisational ethics also
needs further research. Our paper provides further insight into the
ethical dilemmas and ethical challenges met by high level
decision-makers', which is important since the overall responsibility
for elder care that is also ethically defensible rests with them. They
have power and their decisions affect many stakeholders in elder care.
Our results can lead to stimulating discussions between high level
decision-makers and health care professionals concerning ways of
dealing with ethical issues and the necessity of structures that
facilitate it. Even if the high level decision-makers have learned to
live with the ethical challenges that confronted them, it was obvious
that they were not free from feelings of uncertainty, frustration and
loneliness. Vulnerability was revealed regarding themselves and others.
Their feelings of failure indicated that they felt something was at
stake for the older adults in elder care and for themselves as well, in
that there was the risk that important needs would go unmet.