Ethical Dilemma Structure (IPSOJ)
When to use it
MMI ethics stations and 'what would you do?' scenarios — especially practical ones where you, as a student or junior doctor, must act (a colleague smelling of alcohol, a patient still driving against advice). Pairs naturally with the Four Pillars in the Principles step.
The steps
- 1
Identify
State the core conflict in one sentence and clarify facts you would want to know. 'The dilemma is between respecting this patient's confidentiality and protecting other road users.' Asking a clarifying question here is a strength, not a weakness.
- 2
Principles
Apply the relevant pillars plus law and professional guidance (GMC, Mental Capacity Act, safeguarding duties). Name the tension explicitly.
- 3
Stakeholders
Who is affected? The patient, family, colleagues, other patients, the public, the wider trust in the profession. Consider each person's perspective, including the one you disagree with.
- 4
Options
Lay out a range from least to most interventionist. Usually the first step is to talk to the person, explore their reasons and seek senior advice — escalation is rarely the opening move, but it must be on the list.
- 5
Justify
Choose a course of action, explain why it best balances the principles, say what you would do if the first step failed, and note that you would document and seek senior support.
Worked example
A patient with newly diagnosed epilepsy tells you he is still driving to work. Identify: confidentiality versus the safety of the public. Principles: autonomy and confidentiality matter, but confidentiality is not absolute — GMC guidance allows disclosure in the public interest where there is a risk of death or serious harm. Stakeholders: the patient (his job, independence), other road users, his family, trust in doctors. Options: explain the risk and his legal duty to inform the DVLA; explore why he is still driving and help with alternatives; involve family if he agrees; if he continues, tell him you intend to inform the DVLA, then do so, and document. Justify: persuasion first respects his autonomy and preserves trust; disclosure is a proportionate last resort because the potential harm to others is serious.
Common mistakes
- Jumping straight to the most drastic option ('I'd report them') without first talking to the person.
- Staying on the fence — you must reach a decision, even if provisional.
- Forgetting to mention escalation to a senior and documentation.
- Presenting options without saying which one you would choose and why.
Questions that use this framework
- A fellow medical student posts a photo on Instagram from their hospital placement. A patient's name is visible on a whiteboard in the background. What would you do?Main frameworkStandard
- A patient recently diagnosed with epilepsy tells his GP that he is still driving to work every day because he can't afford to lose his job. What should the GP do?Main frameworkChallenging
- You are a medical student on placement. You notice that a junior doctor you are working with smells strongly of alcohol at the start of a morning shift. What would you do?Main framework