Traditionally, ethics consultations are conducted one case at a time. This typical approach addresses immediate needs pertinent to the case, but seldom looks toward preventing recurrences. The underlying problem is that clinical ethics and organizational ethics are still often regarded as separate areas with separate concerns. When it comes to ethics in health care, nothing helps clarify ideas like a case study. The autopsy case mentioned in this article demonstrates that clinical cases coming before an ethics committee are impeded in and influenced by a larger organizational context. The authors say that a "systems-oriented" perspective toward ethics consultation would help committee members view cases through the widest possible lens. This would enable committees to look at the larger system and thereby propose strategies for anticipated repeat problems.