A multi-systemic ethical dilemma model in hemodialysis patients: a qualitative study

In hemodialysis, patients navigate ethical tensions arising from the intersection of clinical demands, personal values, and systemic constraints. While existing research has focused largely on clinician perspectives, limited attention has been paid to how patients themselves experience and interpret these ethical dilemmas. This study aims to identify and analyze the ethical dilemmas experienced by hemodialysis patients, and to construct a multi-level conceptual model that articulates how these ethical issues manifest across different systemic dimensions. This study employed a qualitative descriptive design. 35 hemodialysis patients were purposely selected from four traditional Chinese medicine hospitals in Shandong Province, China. Data were collected through semi-structured interviews between September and December 2025 and analyzed using inductive thematic analysis. The framework of Ecological Systems Theory was applied to determine how multilevel systemic interactions give rise to ethical dilemmas, leading to the construction of a multidimensional conceptual model. Ethical dilemmas experienced by hemodialysis patients were grouped into three themes with 12 subthemes and 19 subcategories. A multi-systemic ethical dilemma model was developed, encompassing macro-level dilemmas involving policy, organization, culture, and community dimensions; mezzo-level interactions among healthcare providers, family members, and other patients; and micro-level individual struggles. Furthermore, we illustrate how dilemmas at one level can directly generate, or indirectly exacerbate dilemmas at other levels through dynamic interplay. This study introduces a multi-systemic ethical dilemma model grounded in patients’ experiences, revealing how ethical challenges in hemodialysis operate across macro, mezzo, and micro levels of the care ecosystem. By reframing dilemmas as embedded rather than isolated, the model underscores the need for systemic solutions that address structural and policy-level factors alongside individual support. These findings call for holistic approaches in research, practice, and policy to foster ethically sustainable environments for patients.