Does a healthcare institution's religious affiliation make a difference in the nature of the ethical issues it confronts? Or in the way its committee and consultants work? Consider three cases, two clinical and one organizational.

Case One
A clinical team working in a Lutheran hospital has requested an ethics consultation. The team is treating an adult Jehovah's Witness woman with decision making capacity. The patient is a mother of three young children and is in danger of dying without a transfusion. One of the team's physicians does not want to respect the patient's right to refuse needed blood products on religious grounds.

Only one member of the ethics consultation team, a chaplain, is Lutheran, but all members of the team know that there is no moral prohibition on receiving needed blood products in a Lutheran hospital. However, they also know that respect for persons, both as individuals and as they are situated and formed in their communities, is a basic principle of the Lutheran ethical tradition and of contemporary secular ethics. On the basis of this principle, the ethics consultation team—albeit somewhat reluctantly—recommends that the physician transfer his patient to another physician who can, in good conscience, respect the woman's right to refuse the needed blood products.

Case Two
A Roman Catholic woman delivered three children in the past six years at the local Catholic hospital. She likes having a Catholic hospital in the town where she lives and, as a Catholic, feels a certain pride in knowing her church is doing good work with the town's poor through that hospital. The woman is now in the hospital and in labor with her fourth child. She tells her obstetrician: "When this is over, I want my tubes tied. I don't think I can deal with any more children." Her physician hesitates, for even though he is not Roman Catholic himself, he knows the hospital does not permit direct sterilization. The woman is disappointed and a little angry when her obstetrician explains that she will have to get the sterilization later and in some other hospital. Nevertheless, after more conversation, the obstetrician is persuaded to ask the hospital's ethics committee to recommend an exception for this woman to the hospital's administrators.

Case Three
A small, nonprofit community hospital has been struggling for years to keep its doors open. Recently its board members determined they needed to affiliate with a larger hospital chain to continue to serve their community. The hospital has two possible partners: an aggressive, investor-owned, for-profit national healthcare system or a smaller but prosperous, nonprofit Catholic health system.

The community hospital's board and leaders have discovered, however, that this is not a straightforward choice. Their hospital's culture and mission are much more closely aligned with the Catholic system. This community hospital, for example, does not provide abortions or permit its physicians or staff to participate in assisted suicides. But a local woman's organization has threatened to take the hospital to court if it ceases to provide sterilization services. The hospital's board and leaders decide to seek the counsel of an ethics consultant who has extensive knowledge of the Catholic moral tradition to help them identify and weigh the options open to them.

Differences?
The first case is not uncommon, and it could as easily occur in a secular hospital as in a religiously affiliated hospital. The ethics consultation team wants to respect the patient's religious beliefs, not because they share them, but because they respect her moral and legal right to refuse any treatment, even if that treatment could delay death. Their recognition of this moral right could be motivated by the Christian faith as practiced and understood in the Lutheran tradition; by any number of other religious traditions, Christian and non-Christian; or by the humanism behind many moral commitments in our secular society. Thus, while the issue is clearly related to the patient's religious beliefs, the religious affiliation of the hospital probably does not affect how the ethics committee views the issue, and it is not likely to make a difference in the consultation team's way of deliberating or in its recommendation. Its religious affiliation may or may not lead its employees and physicians to be more sensitive to such concerns.

The second case is also not uncommon, but it is a bit more complicated. A practicing Catholic woman, who undoubtedly knows her church's official teaching on sterilization, is nonetheless disappointed when she is told that she cannot have the procedure done in the local Catholic hospital. The administrators of the Catholic hospital will almost surely refuse to make an exception for her, even though members of the ethics consultation team and the hospital administrators may not personally believe that sterilization is "intrinsically evil"—that is, always morally wrong regardless of circumstances. They are obligated by their positions or roles in the Catholic hospital to follow church teaching on such matters. Thus, sterilization could be an issue in this case only because the hospital is affiliated with the Catholic Church. However, while the ethics consultation team and administrators will be guided by church teaching on sterilization in a substantive sense, they are not likely to deliberate about the issue procedurally in a manner that differs from a committee working in a hospital that is not religiously affiliated. In this case, Catholic Church teaching functions like other regulatory constraints: compliance is expected, but a personal belief that the regulation is justified, though perhaps some would prefer it, is not required.

In the third case, even though the hospital is not religiously affiliated, and individual board members and hospital leaders may not share the religious beliefs of the Catholic Church, they sense great affinity with the mission and values of the Catholic health system. The community hospital leaders reflect the various religious and humanitarian traditions of the community, whereas the Catholic system reflects the explicitly religious beliefs of the Catholic Church. These different beliefs, however, motivate very similar actions in health care, with the exception in this case of sterilization. If requested, the ethics consultant will struggle to structure the relationship in a way that both meets the perceived needs of the community for sterilization services and protects the Catholic system from violating its commitments to follow church teaching. This may or may not be possible, but the entire process is complicated by the legal threats of the woman's group. Not only will their suit add considerable cost to pursuing the partnership, it will greatly increase the risk of adverse publicity for both organizations. The board may decide not to pursue the partnership for these reasons alone.

In any case, sterilization is an issue for the ethics consultant because of the Catholic system's religious affiliation. Moreover, as the consultant struggles to structure the relationship, he or she will most likely use a complicated set of Catholic ethical principles that are typically discussed under the heading of "material cooperation." Here, deliberations about the issue are decidedly influenced by the religious affiliation of the Catholic partner; indeed, the Catholic partner is obligated by the Ethical and Religious Directives for Catholic Health Care Services to use material cooperation—as opposed to other possible ethical frameworks—in approaching the relationship.

In light of these cases, then, does a healthcare organization's religious affiliation make a difference in the nature of the ethical issues it confronts or in the way its ethics committee and consultants work? In case one, the refusal of blood products was a religous concern, but not from a Lutheran perspective. Thus the religious affiliation of the Lutheran hospital made no discernible difference in the nature of the issue under consideration or in the way it was considered and resolved procedurally. In case two, the religious affiliation of the Catholic hospital did make a difference in the nature of the issue under consideration, but not in the way the ethics committee and administrators deliberated about it. In case three, the religious affiliation of the potential Catholic partner both shaped the issue for the secular community hospital and determined how the ethics consultant would deliberate about it.

These cases suggest that the answer to our question seems to be case specific. If this is true, it suggests that ethics committees and consultants need to be flexible enough to respond in a variety of ways to specific issues, depending on what the issues are and how they are viewed by the religious tradition with which their hospital is affiliated.