The tension between mission—spiritually rich and charitably-oriented care—and market demands dates to the establishment of the first modern hospitals in the late nineteenth and early twentieth centuries.

Then, as now, hospitals needed resources to pursue both their mission and their medical and social goals. Today's marketplace philosophy simply intensifies and transforms the specific features of this old tension. But adaptation to change has always been necessary.

The very names of those older institutions—Presbyterian, St. Vincent's, St. Mary's, Mt. Sinai, Adventist, Deaconess—conjure visions of clergymen, clubwomen, business leaders, and other leaders coming together to establish community institutions that expressed both spiritual and religious commitments and the noblesse oblige that class status warranted. This commitment is evidenced by the numbers—in 1904 all but 220 hospitals of approximately 1500 in the United States were under ecclesiastical or nonsectarian/benevolent sponsorship.

In these early years, when hospitals offered little that could not be done at home, trustees translated religious and civic conviction and spiritual impulses into charitable care for poor but "worthy" members of their own ethnic, cultural, or religious group. This meant that the "unworthy" poor, including the old, incurable, or chronically ill, had to rely on almshouses and public hospitals. In making such a distinction, hospital trustees simply reflected the uninhibitedly paternalistic approach to social welfare that marked the late nineteenth and early twentieth centuries. But even this distinction did not eliminate, in historian Rosemary Steven's words, "the grudging, if not punitive, attitude toward the indigent." Though it did serve as a rough sorting mechanism for distributing limited resources without abandoning the original charitable impulse, hospitals were never easy with the concept of free care.

Enacting one's spirituality through practical acts of charity encountered even more powerful obstacles once medical science developed treatments that would attract middle class, paying patients to hospitals. Small, free-standing institutions, often located in poor neighborhoods that provided both social and medical services disappeared as the modern hospital emerged. Enthusiastic belief in the possibilities of scientific medicine, perhaps a little premature, nonetheless began the unending reconfiguration of American hospitals, faith-based or otherwise. Taking care of poor people—in historian David Rosner's expression, "the once charitable enterprise"—became a residual service as hospitals sought to stay alive, respond to financial exigencies, and redesign services around the needs of wealthier clients. New trustees reflected the economic and demographic shifts in medicine. Yet, their rationalized approach to hospital financing and management did not go unnoticed. In 1914, the president of a Lutheran Hospital exclaimed, "Our hospital work is a work of mercy. It is not a business."

The remaking of hospitals was essentially complete by 1920. By the '30s the pace accelerated; hospitals were becoming centers of medical care with little time, money, or tolerance for the earlier community-orientation of medical practice. This rapid shift in the practice of medicine led one physician at Montefiore Hospital in Bronx, New York to comment, "Everyone is treating the electrolytes, but who is treating the Israelites?"

Around this time, echoes of the current refrain—that careful business practices need not interfere with the caring mission—reverberated; good care requires financial stability. Yet, resistance to a business-oriented approach persisted. A well-known surgeon, an advocate for scientific medicine, nonetheless protested: "Our charitable hospitals have become businesses…and are wolves in sheep's clothing." Historian David Rosner sums up the losses:

Today, virtually every faith-based institution must struggle to maintain consonance with founding narratives that translated Jewish and Christian commitments to charity, justice, and spiritual well-being into a broad charitable mission. Simultaneously, as reimbursement controls tighten and scientific medicine becomes even more costly, faith-based institutions must struggle mightily to develop identifiable expressions that express their spirituality and reveal their faith commitments. This task is hard. Hospitals are no longer homogeneous, community-based institutions where patients, trustees, physicians, nurses, aides, and others share a neighborhood, church, or synagogue. How does one create a moral community that reflects commonly held commitments in which diversity is the reality? How does any one hospital honor its founding faith tradition in the diverse, multihospital systems that now dominate American medicine?

Certainly a commitment to charity care still motivates trustees committed to religious values and spiritual concerns, but the bottom line is a constant reminder of its limits. This tension between market and mission has led to different responses. Some hospitals have been sold or merged in part because changing neighborhoods eroded the once strong ethnic base they relied on for income. Others have addressed competition through mergers. And most work to preserve what they can of their religious or ethnic identity in ways that won't offend their diverse patients, physicians, and other personnel. Rooted in traditions but not in the old neighborhoods and experiencing the effects of the cost control juggernaut, faith-based institutions must seek new ways to express their mission in the daily life of the hospital. Yet, translating mission into representative actions is no easy task. Indicative of the problems, think about the faith-based message one would deliver for Beth Israel Deaconess Medical Center (Boston). Not an easy task.