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. While some chapters focus on the more classic issues arising in individual care, others explore the trade offs between collective goods and individual good.
Chapter 32 outlines the challenges of organizational ethics. This represents a new field of ethical reflection that explores issues arising in healthcare organizations as corporate citizens. Priority setting is a ubiquitous challenge in healthcare, occurs at all levels of health service provision, and raises difficult ethical issues requiring systematic deliberation. In Ch. 33, a framework is provided for analyzing these difficult issues. Error has similarly been shown to be a universal issue in healthcare provision and Hébert et al. in Ch. 34 survey recent initiatives in what can broadly be termed a revolution in the way in which error is conceived and managed. Rather than focusing on faulting individual agents, the emphasis is on seeing error as a system issue and error reduction as part of a transparent and collaborative effort.
Conflicts of interest are also a ubiquitous component of medical care. The extent to which they pervade every day practice is largely underestimated. Chapter. 35 provides a succinct overview of the multiple ways in which conflicts of interest arise and provides guidance on their management. Ethical issues at the intersection of clinical care and public health are discussed in Ch. 36. The mission of public health is the protection and promotion of the health of communities. As such, the focus of practice is on populations, and the interests of communities may be at variance with the rights of individuals. How these conflicts are managed and the obligations of clinicians to public health are discussed in Ch. 36. In the aftermath of the tsunami, Hurricane Katrina, 9/11 and several notable terrorist acts against civilians, it has become evident that healthcare providers may find themselves drawn into disaster responses. The set of obligations for physicians in these contexts pose novel ethical challenges that are summarized in Ch. 37. The unique challenges faced by rural practitioners are described in Ch. 38 while Ch. 39 focuses on the provision of community healthcare – both drawing awareness to the lack of attention that these topics have received in the literature.
The chapters in this section summarize the current issues and controversies in the various fields. It is evident from each chapter that they are characterized by diverse and complex ethical challenges where some consensus exists but where further research and scholarship, both empirical and conceptual, are required.