As ethical reflection in healthcare evolves, the scope and range of issues of concern continues to grow. Early scholarship in ethics focused primarily on ethical issues arising from the care of individual patients in hospitals, such as end of life care, broad policy issues such as euthanasia and abortion, or the domain of research ethics. For the most part, the issues concerned analyzing ethical dilemmas arising from the extensive and well-described value conflicts that can arise between healthcare providers, patients, and families.

There is a transition occurring, with a new emphasis on issues emerging from intersection of the actions of healthcare providers, healthcare institutions, and broader social and community concerns. As well, there are new and emerging ethical issues arising at organizational levels. In terms of the level of reflection, the concerns are less with interactions between individuals as between individuals and collectives, and between collectives and collectives. Current efforts explicating the ethical challenges in planning for an influenza pandemic illustrate the interactions of ethical reflection at several levels of application and the complex set of values required for a coherent framework for analysis of these issues (Joint Centre for Bioethics Pandemic Influenza Working Group, 2005). For the most part, this level of ethical reflection has been neglected or underdeveloped in standard accounts of clinical ethics.

These issues fall, somewhat neatly, under the heading of health systems and institutions. The chapters in this section illustrate this transition.