AMA Journal of Ethics^®

Abstract

Mission statements communicate health care organizations’ fundamental purposes and can help potential patients choose where to seek care and employees where to seek employment. They offer limited benefit, however, when patients do not have meaningful choices about where to seek care, and they can be misused. Ethical implementation of mission statements requires health care organizations to be truthful and transparent about how their mission influences patient care, to create environments that help clinicians execute their professional obligations to patients, and to amplify their obligations to communities.

Ethics, Mission, Standard of Care

Mission statements have long been used to communicate an organization’s values, priorities, and goals;¹ serve as a moral compass for an organization; guide institutional decision making; and align efforts of employees.² They can also be seen as advertising to prospective patients and employees. Although health care organizations’ mission statements serve these beneficial purposes, ethical questions (especially about business practices seen as motivating profit by rewarding underutilization^2,3,4) arise when mission implementation conflicts with acting in the best interests of patients. Ethical questions also arise when religiously affiliated organizations deny clinically indicated care in order to uphold their religiously based mission. For example, a Catholic organization’s mission statement might include phrases such as “faithful,” “honoring our sponsor’s spirit,” or “promoting reverence for life” and likely accords the Ethical and Religious Directives for Catholic Health Care Services, which Catholic organizations’ clinicians are required to follow as a condition of employment or privileges.⁵

When strictly followed, these directives restrict health care service delivery, such that patients—particularly those seeking contraception, pregnancy termination, miscarriage management, end-of-life care, or other services perceived as conflicting with Catholic teaching—are not given the standard of care. Federal and state laws protect conscience rights of organizations, allowing them to refuse to provide services that conflict with the deeply held beliefs and values that drive their mission.⁶ Recognizing the potential for conflict between mission statements and patients’ autonomy or best interests, we maintain that health care organizations have fundamental ethical and professional obligations to patients that should not be superseded by a mission statement.

Using mission statements of religiously affiliated hospitals as a useful test case, we perform an evidence-based analysis to address the question of what ethical obligations health care organizations have to patients and to determine which criteria should be used to judge whether a mission statement is deployed in an ethical manner. We argue that an organization must be honest and transparent about its mission and the ways it might affect patients; must allow all physicians who wish to act on their conscience to provide safe, high-quality care that fulfills professional standards; and may deny care only when it is actually feasible for patients to access reasonable alternative care.

Transparency

Given that mission statements serve as tools to communicate with prospective patients, it is essential that these statements truthfully and clearly portray the priorities of the health care organization. Furthermore, in implementing its mission, a health care organization should be transparent about the ways in which its mission might alter or restrict patient care. Studies of reproductive care restrictions at Catholic hospitals have demonstrated the importance of this type of transparency. A recent survey demonstrated that most women desire information about restrictions on care at religious institutions in order to decide where to seek reproductive care.⁷ In practice, however, women often lack the information needed to make informed decisions regarding whether to seek reproductive care at a religiously affiliated hospital because some hospitals lack transparency about their religious affiliation or its implications for patient care. A recent study found that though 79% of Catholic hospitals report their Catholic affiliation on their website, only 28% describe how this affiliation affects the care they can provide patients.⁸ The need for improved transparency was demonstrated by a recent national survey’s finding that 37% of women whose primary hospital was Catholic were unaware of its religious affiliation.⁹ In addition, many women do not anticipate the restrictions that can be in place at religious hospitals. When surveyed about their expectations for reproductive care at a Catholic hospital, 69% of women expected that they could receive birth control from an obstetrician/gynecologist (OBGYN), 63% that sterilization would be available, 44% that in vitro fertilization would be available, and 27% that abortion would be an option if the fetus had a serious health condition.¹⁰ The directives that doctors in Catholic facilities must follow prohibit provision of all of these services, but many women did not anticipate denials of care.

When operationalizing the moral tenets of a mission statement, an organization is ethically obligated to prevent patient harm.

Chervenak and McCullough, who have written extensively about ethics in obstetrics, argue that lack of transparency in hospitals’ reproductive health policies places the principle of respect for patient autonomy “at risk of systematic … compromise.”¹¹ The recent trend in hospital mergers and acquisitions adds confusion, as policies can change rapidly.^12,13 Formerly secular institutions purchased by religious health care systems may retain their secular name and mission statement while following the Catholic Directives.¹⁴ Based on values of truth telling and respect for patient autonomy, health care organizations have a duty to inform potential and current patients about ways in which their missions might limit or change the services they provide.

Conscience

When physicians are faced with a conflict of interest—between organizational priorities and patient well-being, for example—commonly accepted ethical standards dictate that physicians give primacy to the needs of their patients.¹⁵ Physicians can be caught in these conflicts because of their dual identities as clinicians and representatives of their institution.¹⁶ In a 2011 nationally representative survey of practicing obstetrician-gynecologists (OB-GYNs), 37% of those who worked in religiously affiliated hospitals reported conflicts with their institution over religious policies for patient care; that number rose to 52% among OB-GYNs who worked at a Catholic institution.¹⁷ These physicians reported instances in which their hospitals, on moral grounds, prevented them from providing what they considered to be the standard of care for obstetric complications and emergencies.^18,19 Harm in various forms—from inconvenience to serious morbidity and mortality—can befall patients when physicians are not allowed to practice according to the professional and ethical standards of medicine.

Although obligated to act in the best interest of their patients, physicians, like institutions, have a legal right to refuse to provide care that conflicts with their conscience.^20,21 While the federal government recently strengthened legal protections for clinicians who refrain from providing a service based on conscience,²² the right to provide a service according to one’s conscience has been less vigorously defended. For instance, when physicians are compelled by conscience to provide abortion, some hospitals have prohibited them from doing so even in their free time.²³ In this way, our current legal system values the conscience of those refusing to provide care above the conscience of those willing to provide care to a willing patient.²⁴ A developing legal case in Colorado, in which a physician was fired by a religiously affiliated institution over the provision of aid-in-dying medication, will test the legality of valuing the conscience of a corporation over the conscience of a physician who feels compelled to provide care.²⁵

It is in this legal setting that health care organizations must navigate the ethical implementation of their mission statements. When operationalizing the moral tenets of a mission statement, an organization is ethically obligated to prevent patient harm by creating an environment in which the conscience of individual clinicians is respected and in which they are able to faithfully fulfill the professional and ethical standards they have sworn an oath to uphold.

Referrals

In cases in which an organizational mission prevents a patient from receiving needed care, referral to a willing institution is often pointed to as a solution. However, whether clinicians and institutions are morally obligated to make referrals for services they refuse to provide is debated. The American Medical Association (AMA) Code of Medical Ethics makes it clear that referral should be the default action when a clinician or institution refuses to deliver needed care but doesn’t outright require referral.²⁶ The American College of Obstetricians and Gynecologists Committee on Ethics makes a stronger appeal, arguing that clinicians who refuse care have a “duty to refer patients.”²⁷ A national survey of physicians demonstrated that the majority (71%) believe they have a moral obligation to refer in such circumstances.²⁸

In reality, referral is only a morally acceptable option if patients have access to reasonable alternatives for care. The growth of Catholic health systems has made it increasingly difficult for patients to find institutions that don’t restrict the options available for reproductive or end-of-life care, as 1 of 6 acute care hospital beds in the United States is at a Catholic institution.^13,29,30 This lack of access is amplified by geography and financial insecurity. For instance, research in Cook County, Illinois, found that most women receiving public insurance are enrolled in plans that have an overrepresentation of Catholic hospitals.³¹ In addition, the federal government has designated many Catholic hospitals “sole community hospitals” in recognition that alternative secular facilities are often prohibitively far away for patients.¹² Physicians have noted financial barriers as a leading reason why referrals for services prohibited in Catholic hospitals were inadequate to meet patients’ needs.³²

The AMA Code recognizes lack of access as an important consideration in physicians’ exercise of conscientious objection, noting that physicians have “stronger obligations” to act against their conscience and in the best interest of the patient when a patient cannot reasonably receive the care from another physician or institution.²⁶ Ethicist George Annas calls the transfer of patients to willing facilities “ethical dumping,” arguing that it should not be considered a morally superior option because it inflicts harm on patients.³³ Ultimately, referrals are only an ethical alternative to providing the requested service if patients are able to act on the referral without facing significant burdens in travel, cost, or time. Given the barriers to accessing reproductive health care discussed above, in many areas of the country and for many patients with limited resources, these burdens are prohibitive.

Conclusion

Fundamental ethical principles of medical care are not altered by organizations codifying and communicating their priorities in the form of mission statements. Thus, in deciding whether an organization has ethically formulated and implemented its mission statement, we recommend asking the following questions: First, is the organization truthful and transparent about its mission and the ways it might affect patient care? Second, does it create an environment that respects and supports the ethical and professional obligations of its physicians, allowing them to put the needs of the patient first? If these 2 questions are answered in the affirmative, then the mission statement is ethical. In addition, relying on referrals or transfers-of-care for needed services that conflict with an organization’s mission is only ethically acceptable if patients truly have access to reasonable alternatives for their care. Health care organizations have obligations to patients that cannot be superseded by ideas laid out in their mission statements. Indeed, they must avoid causing harm to patients that compromises the ethical underpinnings of the medical field and instead must support clinicians in their dedication to serving patients.