Getting from "Just Us" to Justice: individual initiatives need organizational support.

As health-care systems increase in complexity, how do they ensure ethical practices, with a specific focus on addressing persistent health disparities and advancing justice? This essay contemplates the role of a system-level ethics committee in supporting organizational efforts toward justice, drawing on the author's experiences leading ethics efforts at Beth Israel Medical Deaconess Medical Center and now developing a system-level ethics committee for the broader Beth Israel Lahey Health system. Although the author's experiences largely demonstrate the rich potential for a grassroots, bottom-up approach centered around individual employee initiative to create a justice-oriented organizational ethic, there is also a benefit to top-down support from the organization's leadership to formalize and articulate the mission and values that should drive the actions of the organization and its individual employees. Arguing that neither a bottom-up nor top-down approach is independently sufficient, the essay suggests a combined approach to further the organization's mission and, in particular, health-care justice. Insights from this analysis are translated into five recommendations for the role and contributions of a system-level ethics committee to ethics- and justice-oriented practice within a complex health system.