Wake me up when there's a crisis: progress on state pandemic influenza ethics preparedness.

We assessed the progress since 2005 of state plans for pandemic influenza and found that 7 states had recommended steps to further clarify ethical processes or decisions; 6 states had made some progress but almost exclusively in hospital preparedness. Having a high-level public health leader, such as a health department director, committed to ethics was the key determinant of progress. Some state health departments may be destined to gain an appreciation for ethics through ethical mishaps.