The role of case manager is fraught with challenges in a healthcare environment characterized by rapid aging of the population, a move against institutionalization of seniors, and the need to contain healthcare costs. This study examined experiences of 89 case managers through focus groups in five urban and five rural regions of Canada to identify ethical dilemmas and issues encountered in their role. Overall, the case managers expressed frustration for the lack of support for their work as evidenced by inadequate resources and few agency policies. The analysis of the focus group data revealed four main themes in relation to ethical concerns and dilemmas: (1) issues related to equity, (2) beneficence, (3) non-maleficence, and (4) autonomy and power imbalances. The situation facing these workers is grave and steps must be taken to provide them with ongoing training, support, and resources to continue in this vital role. System changes that would reduce some of the ethical conflicts experienced by case managers include funding for long-term care to keep pace with growing demands, better management of client waitlists to ensure that the most needy are given the highest priority, more supportive housing options that provide for some on-site coordination of services, better opportunities for health promotion, and better interdisciplinary teamwork so that case managers are not left making decisions in the absence of other key service providers.