True dilemmas arise relatively frequently in day-to-day work in mental health, and they are an important aspect of clinical practice. Dilemmas are not simply difficult decisions. They arise when the clinician is confronted with a choice between two or more unsatisfactory courses of action. It is in the nature of dilemmas that there is no right answer, and that there is no readily available template that can be used to resolve them.

There is an ethical dimension to many clinical dilemmas, which makes matters considerably more complicated. Different ethical imperatives can be in conflict with each other. For example, the principle of respect for patient autonomy can guide decision making towards consequences that conflict with the professional duty to preserve life. Because there are no wholly satisfactory solutions available to resolve dilemmas, the clinician is left feeling uneasy about the course that he has followed. This creates a temptation to shy away from dilemmas, to either refuse to deal with them at all, or to resolve the tension of uncertainty by denying the complexities of the situation. Following the line of least resistance in this way is bound to lead either to default non-decisions or to ill-considered decisions. Invariably these are eventually regretted.

Clinical dilemmas are protean phenomena. They come in a multitude of forms, and even after decades of practice you continue to encounter novel problems of this sort. Although there are no formulae to resolve them, there are two principles that are useful in dealing with them.