We applaud the authors’ efforts to provide a theoretical basis for and more clearly link clinical ethics support services (CESS) to organisational-level quality improvement (QI). We agree that additional theorising and testing of the resultant theoretical frameworks is of benefit to the field of clinical ethics and that the outcome of a CESS is more valuable than the sum of the individual cases that it handles. We would suggest that the authors have emphasised the output of the CESS without fully considering the process by which it happens. While moral case deliberation does provide an example pathway for QI, such improvements do not necessarily need to occur through the mechanism of moral case deliberation. Further engagement with QI literature could provide valuable insights to quality within the field of clinical ethics. For example, combining the QI concepts of organisational culture and high reliability organisations (HROs) with the clinical ethics concept of moral spaces may illuminate additional pathways by which CESS contribute to QI.1–3

Organisational culture is composed of the values, beliefs and norms shared by healthcare practitioners and other staff throughout the organisation that influence their actions and behaviours, and of which behaviours are rewarded, supported, expected and accepted in an organisation.1 Organisational culture exists at multiple levels: unit, department, institution and system. To build an organisational culture of safety, quality and efficiency, HROs employ several …