# introduction

In this text, I would like to comment on an essay written by Vardit Ravitsky (1), President of the Hastings Center, where she expresses her views on the repositioning of bioethics in order to face current and future challenges, as well as her wish that the Hastings Center include many different fields and partners. More than simply a promotional text, Ravitsky places the Hastings Center in the same position as bioethics: it doesn’t have all the answers, it needs to continue its reflection, and it is open to a variety of opinions and perspectives. She cites a few examples of these challenges, such as poverty, racism and difficulties of access. Reflecting, moving forward and making progress are, in my view, three very important aspects for ensuring that bioethics, a relatively young interdisciplinary field (2,3), does not stagnate or even die out. In this text, I first address the main strength of Ravitsky’s essay, that is, it’s inclusive vision of the field, and then its shortcoming, namely the absence of attention to organizational ethics, and conclude with its contribution to the bioethics literature.
# A strength: inclusion

Ravitsky’s essay has several strengths, not least of which is the unifying vision that the bioethics must take, or “building bridges” as Ravitsky would say, how the Hastings Center embodies this desire for collective responsibility, and the micro-meso-macro approach to current and future challenges, which together should lead to a repositioning of bioethics (1). Nevertheless, I choose to focus here on what I believe to be the main strength of the essay, that is, inclusion. Firstly, it should be noted that Ravitsky does not forget the major current strands linked to bioethics (and the expertise generally associated with these), i.e., healthcare, biomedical research and public health. Indeed, Ravitsky names these three areas as important strands of bioethics for which there have been (and continue to be) many important and ongoing developments. Among these, Ravitsky names advances in understanding and promoting individual autonomy, and the rise of empirical bioethics and neuroethics. She discusses the advances made by these three domains (principles, frames of reference, policies, etc.) and argues that these must continue. Nevertheless, given the presence of various problems such as racism and poverty, which Ravitsky considers to be systemic in nature, she argues that bioethics must also become more systemic in focus, whether to reflect on these problematic situations and develop ethics frameworks or guidelines to respond to these challenges (1).

For Ravitsky, this work is important and must be continued so that bioethics becomes more global. This would give greater added value to all the work being done in the field. She proposes a variety of solutions, involving not only the expertise already present in bioethics (in philosophy, theology, clinical practice and research, etc.), but also other areas of expertise, such as environmental sciences and the humanities. Thus, for Ravitsky, increasing the overall capacity of bioethics can make a significant difference, as perspectives would be broadened to recognize what’s important to people and to respond to different challenges. Ravitsky explains that bioethics will continue to be what it is — a field that asks different questions (e.g., about principles, such as autonomy), explores various aspects (e.g., quality of life) and constructs ethics frameworks — but this will be more comprehensive if it broadens its horizons (1). Overall, the fact that Ravitsky mentions the word “systemic” several times in the essay is, in my opinion, a sign of inclusion, even innovation. She talks not only of the importance for bioethics of moving towards a more systemic level of analysis, something bioethics is largely not accustomed to doing, but also the contribution that several areas of expertise (current and new) can make to bioethics, both in terms of reflection and the creation of new frameworks. These reflections and frameworks can be integrated into various organizations, including health and social services organizations, especially via areas of bioethics that are already well-established, such as clinical ethics, research ethics and public health ethics.
# A shortcoming: the absence of organizational
        ethics

Even though Ravitsky is very inclusive in her essay, and she clearly wishes to integrate various areas of expertise into the field of bioethics, while not forgetting the expertise already present, she has, in my opinion, omitted one important aspect: organizational ethics, which is increasingly present in health and social service organizations. Indeed, she doesn’t mention this type of expertise at all in her essay, even though she mentions several others.

Before going any further, a few words about organizational ethics are in order, as they will help illustrate my point. Organizational ethics, which is well established in several industrial sectors, with its own literature, and which is beginning to take root in the health and social services field, involves reflection on the choice of values to guide management decisions that may influence care and services, as well as their evolution in a changing environment and at the level of clinical practice (4,5). Above all, it refers to administration, management, compliance, governance and shared values within an organization (6,7). It is there to influence organizational decisions by adding a form of ethicality (8,9). These decisions have repercussions for patients, users of health and social services, staff and the community to which the organization belongs. Organizational ethics involves the articulation, application and evaluation of the implementation of an organization’s values and moral positions (11,12), which are referred to in organizational documents such as the mission statement, code of ethics or list of organizational values and their definition. It leads managers to assume their decision-making responsibilities while respecting the principles of distributive justice and equity in access to services (11,12). The principle of distributive justice in health and social services have to do with ensuring that care and services are provided based on individual needs and available resources (11,12), without discrimination and with constant and consistent application of the rules (9). Organizational ethics also encourages decision-making based on analysis of the facts, identification of the values at stake and knowledge of obligations (ethical and legal) in order to make organizations (more) ethical. The human rights inherent in decision-making must be included; these rights are embodied in the law, but also in an organization’s values (12).

These few words on organizational ethics demonstrate, in my view, the place that it should have had in Ravitsky’s essay. Why? First, because of certain challenges mentioned and described by Ravitsky, such as the difficulties of accessing and allocating resources. The centrality of the principle of distributive justice within organizational ethics explained above illustrates the pertinence of organizational ethics and the important contributions it can bring to thinking about and establishing frameworks designed to ensure equitable and timely access to resources. Secondly, Ravitsky mentions that many of the challenges she describes stem from structural difficulties, with issues of access being one example. Organizational ethics provides just such a structure, since it refers to the administration and governance of organizations, among other things. In addition, Ravitsky mentions the importance of going beyond individual and healthcare-centric approaches (without, however, setting them aside). Traditional biomedical ethics (not to be reduced to bioethics) are more concerned with individual issues (6). This is not the case with organizational ethics, which, as described above, focuses on multi-stakeholder issues and challenges. As a result, it is more systemic since it involves the analysis of the workings of organizations in order to propose and implement structural changes and thus solutions (including prevention) to ongoing problems. As Ravitsky points out with reference to other examples, this broader systemic perspective would enable us to go further in our bioethics reflection. Finally, Ravitsky mentions the importance of contributing to the development of policies and the implementation of recommendations to reflect on and resolve different challenges. Organizational ethics enables this through the implementation of important documents, such as ethics frameworks and mission statements, that are designed to, as closely as possible, match the values and meet the needs of the various stakeholders.

Overall, the introduction of organizational ethics into bioethics would make the field even more systematic in its analyses and applications, which Ravitsky clearly articulates in her essay, and would allow for even greater inclusivity, as other stakeholders could join in thinking through the various challenges as well as creating new or adapting existing ethics frameworks.
# Conclusion: The essay’s contribution to bioethics
        literature

It is important that that bioethics community reflect on the scope of our research and practice in order to move forward and make progress that ensures that bioethics remains pertinent and relevant. Inclusiveness is the main strength of Ravitsky’s essay, and she clearly wishes to make bioethics more systemic and include different types of expertise, whether those already present in bioethics or to bring new expertise from other fields or disciplines. However, she has omitted an important component, namely organizational ethics. In my opinion, the inclusion of this component can make bioethics even more systematic and allow us to include expertise to fuel more nuanced and pertinent reflection for our health organizations.

Ravitsky’s essay provides food for thought for bioethics. First, she points to the importance of bioethics becoming more systemic and inclusive, naming various problems that bioethics can reflect on and help, such as poverty and racism. Even if Ravitsky names only a few examples in her essay, I take from her words that she is inviting readers to themselves explore possible new areas of expertise or combinations of these. Second, the solutions she proposes, that is, the micro-meso-macro vision, highlight the bridges that must be built between different partners and between different fields, and the frameworks that can provide guidance in certain areas. These solutions are clear, but Ravitsky notes that there are many ways of achieving them, and that it’s up to readers to think through their potential application. In short, the doors are open for everyone to take bioethics to the next level.

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