Institutional arrangements can impede or facilitate ethically excellent medical care. As clinical ethics matures, increasing attention is being paid to the institutional contexts in which health care is provided, and the ethical impact of recent changes in methods of care delivery. The growth of this new area of bioethical focus is adumbrated in the third of the articles in this section. Thinking about ethics in organizations, as well as in the interactions between individuals, can take various forms. Clinical ethics problems can be caused or exacerbated by structural arrangements within institutions. Recurrence of similar clinical ethics problems can sometimes be prevented by institutional changes in staffing, accountability, or interventions. Further, many clinical ethics issues, such as confidentiality, informed consent, or disclosure and truth telling, have institutional analogues which must be addressed by different strategies than their individual-level counterparts. Institutional structures or routines can cause ethical problems in particular cases, and sources of ethical distress which are out of the control of individual caregivers can sometimes be ameliorated by scrupulous attention to institutional processes. Heightened sensitivity to ethical issues in clinical practice opens the door to considering ways in which the organizations within which clinicians practice can improve their ethical climate.

The three cases in this part call attention, in different ways, to structural sources of ethical perplexities. In one case, the structure of medical practice causes difficulties that thoughtful structural interventions can ameliorate; in another an institutional component, the ethics committee, carries out its function in a way that impedes, rather than facilitates, the ethical climate of an institutional unit.