Introduction As a specialized field of philosophy, ethics has demanded that more institutions self-assess their actions so as to implement and maintain ethical practice (see the Additional file for definitions of 'ethical practice' and 'ethics'). In healthcare, technological and bureaucratic complexities have created dilemmas never before encountered, at least on the scale in which they now occur. Nowhere are these two issues, a push to self-analyze critically and an increase in novel dilemmas, more present than in the intensive care unit (ICU). The ICU is a place both where patients are exposed to modern advances in health technology and where some of the most challenging questions for bioethicists occur. Because of the pervasiveness of ethical considerations, it is logical to assume that the ethics knowledge base would be well documented in the ICU. In fact, a cursory search of the phrase 'critical care ethics' in PubMed between 1966 and 2004 cited an impressive 1090 articles. Because a more focused search on 'end of life ethics' returned 986 articles, it seems that much of the published literature has a particular focus. 1 Critical Care Medicine ICU directors and nurse managers are required to make difficult decisions with respect to protocols, staffing, and administration of the ICU. Arguably, these have equal, maybe even greater, ethical importance than decisions made at the bedside, because management decisions can affect multiple patients, in a less direct, and transparent, manner. Perhaps the bedside can be described as a simpler ethical environment in that it involves fewer external factors and agents to consider, and the consequences of actions are immediately apparent to all. If the dual roles that ICU physician directors and nurse managers occupy create unique ethical challenges that cannot be adequately captured by either the traditional principalism of medical bioethics because bioethics does not take into account the fundamentals of business, or the existing models of business ethics because these fail to account for the values of medicine, it is possible they should be addressed as a separate entity. The aim of this paper is to review briefly what ethical issues faced by ICU 'clinician–managers' have been described, and to understand the context in which they are addressed. Method To identify publications that focused on ethical issues faced by professionals who occupy both clinical and administrative roles in ICUs, abstract and title searches were performed in Medline/PubMed and CINAHL databases using combinations of the following keywords: Ethics, Clinician-Manager, Critical Care, Intensive Care Unit (ICU), Management, Leadership, Decision-making, Roles, Administration, Medical Directors, and Policy. Our search included primary literature, review, and opinion articles and the inclusion criteria were: 1966 to July 2004, English language, mention of critical or intensive care, direct mention of ethics OR discussed an ethical issue. An article was considered to have discussed an ethical issue if there was recognition of uncertainty about the correct choice of action in a given situation. Thus, any article that asserted one practice to be superior to another, whether anecdotally or as demonstrated by some research, was not considered to recognize an ethical concern. Articles were excluded if managed care was the source of the ethical dilemma and/or the ethical issue was strictly clinical in nature, not including the use of treatment policies because clinician–managers were considered to have a special interest in policy; that is, any ICU physician dealing with the issue was qualified to decide on the appropriate course of action. Bioethics  Critical Care Critical Care Clinics Critical Care Medicine  American Journal of Respiratory and Critical Care Medicine  Intensive Care Medicine  Results 1 1 2 3 4 5 6 7 Discussion Ethical issues are usually expressed as a conflict of ideas, values, and/or norms that are often role dependent. It should therefore be expected that ICU physician directors and nurse managers, who have both clinical and non-clinical duties, should face some of the more difficult moral conflicts in the ICU. In one respect, these professionals follow a patient-centered code of conduct, either the Hippocratic oath or the Nursing Professional Code, which in part defines them. At the same time, they are also agents of the hospital as 'a business', and implicitly society as a whole. Although some clinicians completely relinquish their clinical duties on transition to management, most do not; the professional nature of medicine therefore gives the clinician a patient-centered outlook that is not as easily set aside: once a doctor or nurse, always a doctor or nurse. In summary, the physician director and nurse manager will always be in the unique position of having two separate professional standpoints from which to assess situations, which can therefore lead to unique ethical challenges. 8 1 In this initial survey of the ethical issues experienced by those in dual management–clinician roles in the ICU, important to our conclusion was the development of a categorization scheme. In the absence of any unique approach, we were arbitrary in our definition of categories. Although some of the articles we identified could have been placed in more than one category, or in categories not used, we believe our approach to be valid for the modest purposes of this survey. Additionally, some articles that discussed issues of clinical ethics in the ICU might have contained less prominent opinions or notes relevant to clinician–managers and therefore might have been missed by our search. In spite of these potential issues, the articles selected were distributed to give both a clear and defined picture of what currently exists with regard to ICU ethics for those in both clinical and directing roles at the same time. We also believe it is likely that there were many articles that discussed ethical issues relevant to our review, yet failed to recognize the issues as being 'ethical' in nature. For example, many articles described the nuances of resource allocation in the ICU (see the Introduction), yet neither mentioned ethics or recognized any uncertainty with regard to the 'right' thing to do. The fact that many articles fail to address their ethical components might indicate a lack of awareness of what constitutes an ethical dilemma, but even if this is not so, the goal of better recognition and acknowledgement of the ethical issues that suffuse the operational management of the ICU is desirable. Resource allocation is a well-defined topic of ethical interest that has stimulated much discussion. However, it is important not to perceive resource allocation as the beginning and end of the ethics discussion for clinician–managers in critical care. Perhaps it is also time to move beyond the commentary on resource allocation and devote more research initiatives toward this topic (for example by studying the different approaches to resource allocation). The term 'organizational ethics' is used to denote how a business or institution ought to be organized in any number of ways, including management functions, working environments, and its infrastructure. It should not come as a surprise that organizational ethics should constitute a concern for either an ICU director or a nurse manager, yet over the past 20 years only a handful of articles have been written about the organizational ethics of intensive care and have recognized them as such. Although policies and protocols for an ICU could also fall under the heading of 'organizational ethics', we believe that determining and implementing policies might require ethical concerns that merit special attention. The use of any policy that deals with either patients or staff is to apply one rule to many different people, and necessarily ignores factors that make individual cases unique. Because policies tend to generalize in this way, they create unique ethical challenges. Little reflection is required to determine that both of these issues, organizational ethics and the ethics of policy, constitute ethical concerns for directors in the ICU in which further study is merited. 9 Conclusion 10 11 13 For all critical care leaders, there is now an opportunity to promote a better understanding of the complexity of the ICU environment and to prompt further learning. Abbreviations ICU, intensive care unit. Competing interests The author(s) declare that they have no competing interests. Supplementary Material Additional File 1 A complete list of categorized references for all articles captured in this review can be found here. click here for file