Today's healthcare ethics committees are hybrids, with religion as part of their DNA. The ancestral family tree of ethics committees includes Institutional Review Boards in the research arena, the Dialysis Selection Committees in Seattle in the early 1960s, and medical-moral committees in Catholic hospitals, according to conventional histories.

Committees' membership is also hybrid. Because their core interest is to promote patient care that reflects an interest in ethical values of patients, organizations, and healthcare professions, their expertise is the sort that calls more for breadth than depth of specialized knowledge. They must attend to nonmedical as well as medical facts and factors. Hence, they are inherently multidisciplinary and multilocal: they include social workers, chaplains, and community representatives as well as healthcare providers.

Religion also figures regularly into the agendas of virtually all ethics committees in their education, policy development, and case review functions. How should physicians and hospitals respond to Jehovah's Witnesses who refuse blood transfusions? To Christian Science parents who refuse life-saving therapies for their child? To Orthodox Jewish families in New Jersey and New York whose religiously based rights to disregard diagnoses of brain death are protected by legal statute? How flexible—read "accommodating"—should healthcare professionals and organizations be in respecting religious diversity when patients' practices and rituals raise safety concerns or stretch the membranes of institutional patience and efficiency?

Do ethics committees in religious and nonreligious healthcare organizations (HCOs) serve their patients, staff, organizations, and communities differently, given their shared heritage and the commonalities in their agendas? My experience suggests that there are differences that I will first describe and then illustrate using two committees' approaches to therapeutic abortion.

Three Differences
First, metaphorically, committees in religiously based HCOs have wider "radar screens" than their nonreligious counterparts. The faith-based mission and core values of religious organizations cause some issues to materialize as "ethical," presenting conundrums and calling for resolution. These issues would be otherwise absent from the radar screens of ethics committees in nonreligious HCOs. One example is contraceptive sterilization. Catholic hospitals must abide, or attempt to abide, by the norms of the U.S. Conference of Catholic Bishops' Ethical and Religious Directives for Catholic Health Care Services. These directives do not permit direct sterilizations for contraceptive purposes. When patients and physicians request permission to perform tubal ligations, therefore, it is not sufficient in Catholic hospitals that the proposed procedure be in accordance with state law and professional medical-ethical standards. The procedure must find justification in Catholic moral teaching as the Catholic Bishops apply that teaching to healthcare concerns. The protocol for assessing such requests and justifications in many Catholic hospitals involves the institutional ethics committee, usually in the form of an ad hoc subcommittee. The ethics committee in the nonreligiously based hospital across town never confronts this issue unless other than religious concerns are raised—informed consent, for example.

A second difference is an increased number of ethical norms for committees in religious organizations. Ethics committees in nonreligious HCOs take their bearings primarily in relationship to legal, professional, and secular bioethical guidelines and parameters. These norms are "floating," so to speak: they change over time. An example is futile treatment. Many hospitals have developed policies and procedures to address the conflicts arising when physicians disagree with a family's demands to provide life-extending medical treatments to patients because those treatments cannot achieve medical goals or provide any benefit that the patient can appreciate.

Laws in Texas and California now permit physicians and hospitals to withhold or discontinue treatments not in accord with accepted community standards of medical practice in specific circumstances, when appropriate protocols are followed. In Illinois, new application protocols and forms permit physicians to give "futile treatment" as a reason for requesting permission from state-appointed guardians to withhold or withdraw medical treatments from incapacitated patients meeting one of three descriptions of "end-stage." While the topic is still controversial among professional bioethicists, American Medical Association ethical standards now clearly support a physician's right to withhold noneffective medical treatment, even when a family demands it. So the ethical-legal matrix upon which nonreligiously based HCOs draw has changed noticeably in ten years.

In contrast, ethics committees in religiously based HCOs must consider, in addition to the ethical-legal matrix, whether institutional policies or clinical responses to patient care conundrums are aligned with the organization's religious mission and core values. Committees in religiously based HCOs, in other words, must consult a compass that includes a fixed point of reference, one that does not change as societal laws and professional customs do. The committee must ask itself: "How does what we propose to do conform to the foundational values and beliefs of the church or fellowship?" When the answer is not obvious, the committee has further research and reflection to do.

Third, the two types of ethics committees approach the goal of integration differently—both in how they define the goal and in how they use organizational resources to achieve it. In nonreligiously based HCOs, integration often refers to organizational ethics, the emerging subdiscipline of bioethics. That is, under pressures both evolutionary and environmental—for example, the Joint Commission on Accreditation of Healthcare Organizations' standards—ethics committees are devising ways to help their organizations address business ethics as well as clinical ethics through standards and mechanisms. Some are adding this function to the committee's mission and obtaining additional training or expert guidance to implement it. Others are devising ways to collaborate with corporate compliance programs that have sprung up in other corridors of the institution.

In religiously based HCOs, integration is often a more comprehensive term and challenge. "Mission-values integration," often the responsibility of a vice president, means more than business ethics. It refers to the organization's responsibility to ensure that the foundational mission and core values of the organization influence decision making from the bedside to the boardroom. Values-centered training programs in such organizations seek to equip managers with the skills and tools to integrate religiously based core values into all aspects of their responsibilities, from strategic planning to job evaluation.

Two Cases
Nurses at two hospitals, one religiously based and the other nonreligiously based, asked their ethics committees for assistance concerning requests for therapeutic abortion.

At the nonreligious hospital the committee was informed that a physician had called the night shift nurses in Labor and Delivery to prepare and directed them to assist with a therapeutic abortion. Tests had confirmed several fetal anomalies, and his patient had decided to terminate her pregnancy. The nurses on duty were members of the same local conservative church. They informed the physician that they would not assist with the procedure for religious reasons. The nursing supervisor on duty asked the physician to arrange to perform the procedure at a different hospital. In her written report, she documented "staff rights to conscientious objection" as her reason.

The ethics committee reviewed the case. The committee identified "staff rights to conscientious objection" as the ethical issue, and supported the nurses' rights to refuse to participate in abortions in the future. The committee further recommended that nursing administration develop an efficient system to provide replacement staff in such scenarios. The nurses who originally brought their concern to the ethics committee expressed disappointment with what they viewed as a "political" outcome, one that avoided the central moral issue in the case: abortion itself.

At the religious hospital, a nurse from Obstetrics contacted the ethics committee with a concern about a request from a patient and physician to perform a therapeutic abortion because of a diagnosis of fetal anomalies. She was troubled, she said, because the hospital's Christian mission statement, core beliefs, and ethical guidelines affirmed the sanctity of all fetal life. She had joined the nursing staff at this hospital a year before, she stated, largely because she felt "at home" in this religiously grounded healthcare organization.

The ethics committee held a formal review of the case. After discovering the facts from physicians and nurses involved, the committee formally reviewed the organization's mission, values, and ethical guidelines. One of those guidelines stated that abortions would not be permitted except in the tragic circumstances of rape, incest, or serious threat to the mother's life. The committee determined that careful and sensitive informed consent discussions had been conducted with the parents, and that the physician's request had been carefully reviewed by a medical staff committee, whose chair was a well-known member of the denomination that owned the hospital.

The ethics committee arranged for two educational forums, open to all staff, to ensure that everyone understood the hospital's policy and procedures for cases in which requests were made for therapeutic abortions. During these sessions, there was a review of the three cases during the past fifteen years in which the procedure had been approved, carefully illuminating the circumstances while providing absolute protection of the privacy and confidentiality of participants.

The committee then recommended that the hospital establish a task force to review current policies in light of the mission and core values and recent medical developments in pregnancy termination. The task force was to prepare recommendations, if appropriate, to be presented to the hospital's board of directors.

The nurse who had originally brought the concern to the ethics committee expressed appreciation for the sensitivity, scope, and quality of the organization's response.

I believe that the nurse in the second case experienced a level of institutional support for her personal values, along with a fruitful challenge to her own thinking, that the nurses in the first case did not.