As an alternative to the “standard mode” of clinical ethics, with its typical emphasis on formal ethical reasoning (often including ethical principles) and other forms of “top-down” analysis, we suggest that clinical ethics is better understood in terms of socio-institutional processes. It is just such processes that are at work in Stanley Fish’s interpretive communities, that engage students as they begin their professional education, and that frame how trainees and clinicians feel and think about the ethical challenges and problems that they encounter in their work. We also look at how these socio-institutional processes are interconnected with the systemic, human, and social elements of institutional culture in professional schools and hospitals.