Opinion ID: 1993394
Heading Depth: 1
Heading Rank: 7

Heading: The Establishment of Religion Clause

Text: In Murray, supra, 241 Md. at 398, the Court set forth the guide lines which we found in the decisions of the Supreme Court in respect of the establishment clause of the First Amendment, now beyond question made applicable to the States through the Fourteenth. In Horace Mann, supra, those general principles were repeated; the dissent went only to their application on the particular facts. They are as follows: We are a religious people and recognize the effect religious institutions have on human activity. The First Amendment was designed to erect `a wall of separation between church and State.' Mutual independence, under our Constitution, is deemed best for the State and best for religion. The State cannot forbid nor can it perform or aid in performing the religious function. Like other broad constitutional concepts, the meaning of `separation' is to be ascertained in the application of the principle to specific cases. A state cannot pass a law to aid one religion or all religions, but state action to promote the general welfare of society, apart from any religious considerations, is valid, even though religious interests may be indirectly benefited. If the primary purpose of the state action is to promote religion, that action is in violation of the Amendment, but if a statute furthers both secular and religious ends, an examination of the means used is necessary to determine whether the state could reasonably have attained the secular end by means which do not further the promotion of religion. In this case, we find that while under the Act religious interests may be indirectly benefited, the State action is taken to promote the general welfare of society, apart from any religious considerations; that the promotion of religion is not a primary purpose or effect; and that the State could not reasonably have attained the secular end by means which would not indirectly aid religious interests. The proposed loans to the three hospitals under the Act will be for long terms at comparatively low rates of interest, and admittedly will make the cost of the new facilities substantially less than if a comparable portion of the cost were financed through private lending institutions, if such financing in the proposed amounts were feasible. St. Joseph's is owned and operated by an Order of the Roman Catholic Church. That Order has made available to the hospital $1,000,000 or more for its proposed enlargement, in addition to the funds requested for a loan under the Act. If the loan were not granted, the presumption seems irrebuttable that the Order would be called upon for more of its funds. The loan will release the resources of the Order for use in its religious purposes. Whether Church Home and Greater Baltimore are church-oriented is disputed, but the degree, if any, in which either of these hospitals is church-affiliated is less than in the case of St. Joseph's. We do not reach the questions involved in a consideration of the structure and antecedents of Church Home and Greater Baltimore for, in our opinion, the indirect aid to the Mother Order in the case of the loan to St. Joseph's is evident, and we consider the constitutionality of the Act under the establishment clause on the basis of that finding. The appellants do not dispute that, insofar as the State's interest under the Act is to aid the public health and welfare, that intent is a legitimate secular purpose. In the words of Mr. Chief Justice Warren, in McGowan v. Maryland, 366 U.S. 420, 444 (1961); Throughout this century and longer, both the federal and state governments have oriented their activities very largely toward improvement of the health, safety, recreation and general well-being of our citizens. The purpose of the General Assembly to aid the health and general well-being of Maryland citizens through the operation of the Act is shown in the discussion of the Act's history in Part II of this opinion. The provisions of the Act, in the light of that history, show the legislative intent to provide a general plan for the extension and improvement of hospital facilities; in that plan, qualified sectarian hospitals are eligible for loans, not because they are sectarian, but because they are, or will be, parts of the State's hospital resources. Paradoxically, the 1966 amendment, in its temporary separation, until this case is decided, of the $50,000,000 fund into two equal parts  one for secular and one for church-affiliated hospitals  emphasizes the legislative intent that, as soon as possible, the loans shall be made only on the basis of what is best for the health and welfare of Maryland's citizens. The appellants contend, however, that the Act violates the establishment clause because one effect of the loans here involved is to promote religion and because the State's purpose could reasonably be attained without State loans to sectarian hospitals. The questions of whether the Act had as one of its purposes or primary effects the aid to or promotion of religion and whether the public health of Maryland citizens could reasonably have been attained without provision for loans such as are here involved are to be approached in the perspective of the development of the sectarian hospitals and their present role. From the earliest recorded times, the care of the sick was undertaken by the religious organizations. The temples of Saturn, some 4000 years B.C., were medical schools in their earliest form; in Egypt and Greece the custom of laying the sick in the precincts of the temples was a national practice. Harun al-Rashid, Caliph of Baghdad, (763-809 A.D.) attached a hospital to every mosque. Christian religious orders founded and maintained hospitals from the time of Constantine. The crusaders, in their route, established church and hospital foundations. 13 Encyc. Britannica, 791-92 (11th ed. 1910, article by Sir Henry Burdett). The earliest hospitals in the colonization of the United States were founded under church auspices. Commission on Hospital Care, Hospital Care in the United States (1947), 43-44. In 1956, church-affiliated hospitals in the United States accounted for more than one out of every six hospitals and admitted over one-fourth of all hospital patients. Hamilton, Patterns of Hospital Ownership and Control, 90 (1961). These figures include Roman Catholic and Protestant hospitals, but exclude Jewish hospitals. [7] In that year, approximately one-half of the nation's hospitals, including the church-affiliated ones, were nongovernmental, nonprofit institutions; although they contained only about one-fourth of the total hospital beds, they admitted more than two-thirds of all hospital patients. Hamilton, supra, 89. The report of the Committee on Medical Care of the Maryland State Planning Commission states that in 1961 three-quarters of the hospital beds in the general and certain special-purpose hospitals in Maryland were operated by voluntary nonprofit hospitals (the report does not distinguish between secular and church-affiliated hospitals) and that, of the patient days served by all the general and the certain special-purpose hospitals in the State in that year, three-quarters were served by the voluntary nonprofit institutions. State aid to such institutions has been the policy and practice from the beginning of the State's government. See Finan, supra, at 567. The constitutional propriety of the State's using secular qualified nonprofit hospitals to effectuate its policy of aiding the public health cannot be questioned. The appellants, however, contend that the church-connected hospitals should have been excluded as beneficiaries of loans. In the consideration of that question, we deem it of vital significance that admittedly each of the three hospitals here involved for some time has had a completely nonsectarian policy as to the admission and treatment of patients and the hiring of personnel, and that the remaining vestige of recording the religious affiliation or preference of patients on admission is for the convenience of the patients and their families, and is without significance to the hospitals. It is also agreed, as the record makes clear, that no attempt is made in any of the hospitals to promote a particular religious belief or religious belief in general among patients or to influence their religious beliefs in any manner. The secular nature of the aid given to the patients in the hospitals is as apparent to us as was the secular purpose of the Sunday closing laws to the Supreme Court in McGowan. There the laws were clearly religious in origin, but, the Court held, had become secular in purpose, to provide a uniform day of rest for all citizens. Mr. Chief Justice Warren, for the Court, said that the fact that this day is Sunday, a day of particular significance for the dominant Christian sects, does not bar the State from achieving its secular goals. 366 U.S. at 445. The treatment given patients by church-affiliated hospitals may not always have been as disconnected with the promotion of religion as it is today, but, on the facts before us, the use of the hospitals as a conduit for the treatment of Maryland patients is devoid of religious connotation. In Horace Mann, this Court held, three judges dissenting, that as to three of the four church-related colleges there involved, their purposes and activities were predominantly sectarian in nature, and that, consequently, the State grants to those colleges for construction of buildings had the operative effect of aiding religion and therefore were unconstitutional under the establishment clause. Here, the purposes and activities of the three hospitals are secular in nature. The appellants contend that the operative effect of the loans is to aid religion because each of the hospitals maintains on its premises a chapel for religious worship. The chapels of St. Joseph's and Greater Baltimore were built as part of their new hospitals. Church Home's chapel was built in 1958, before it applied for a loan, and is not included in the cost of its contemplated improvements. The Greater Baltimore chapel cost about $25,000, or about .2% of the total cost of construction. The cost of the St. Joseph's chapel was about $300,000 or 2.36% of the total cost. All three chapels have the usual church appearance and furnishings, and religious services of varying frequency are conducted by regular chaplains for such of the patients and employees who care to attend. The appellants argue that the existence and maintenance of these chapels shows that the State loans will support religious activities and institutions. We disagree, for the evidence, in our opinion, conclusively shows that the chapels are maintained, to a large extent, because of their therapeutic value in the treatment of some of the patients. David Everhart, called by the appellees, is Administrator and Vice-President Administrator of the Johns Hopkins Hospital, a non-sectarian institution. Before coming to Hopkins, he was Associate Director of the Henry Ford Hospital in Detroit, and has been engaged in hospital administration in various capacities since 1950. He testified that: [A]s an administrator I would consider the provisions for facilities to support religious needs of patients in hospitals as essential as the provisions of other basic patient care services such as nursing or pharmacy or central supply or other basic services. Recognition of this need has been made by the American Hospital Association, which body in about 1960 published a suggested framework of organization of chaplaincy services in hospitals and I think it has been ultimately recognized by the medical profession and by the AMA that there is a direct relationship between spiritual health and physical health. He testified, further, that the Johns Hopkins Hospital maintains a full-time chaplain, as do the Baltimore City Hospitals. In view of this uncontradicted testimony, we find nothing in the Act which makes its purpose or effect to support religion. It may be that, without the State loan, the chapels of the hospitals would have been erected by donations from religious groups or individuals who are members of such groups and that therefore these monies, by reason of the State loans, are freed for other religious purposes, but this possible effect of an indirect aid to religion, in view of the primary therapeutic effect of the chapels, is even more remote than the indirect aid to the Mother Order of St. Joseph's. In Murray, we held that the exemption from taxation of structures used exclusively for public worship did not contravene the prohibition of the establishment clause, because the exemption was part of a general plan for the public welfare primarily secular in nature, and because the secular purposes could not be reasonably achieved without an incidental benefit to religious organizations. In Horace Mann, the Court held, unanimously, that as to Hood College the primary purpose of the State grant was not to aid or support religion, even though there may have been some requirements for student attendance at chapel, because we found, on the totality of the evidence, that Hood was not religiously oriented. In Everson v. Board of Education, 330 U.S. 1, 17 (1947), the Supreme Court held, in a 5 to 4 decision, that state action in reimbursing parents for the cost of the bus transportation of their children to and from parochial schools did not violate the First Amendment, because the purpose of the legislation was only to provide for the safe transportation of school children irrespective of their religious faith. Mr. Justice Black, in the majority opinion, said: It is undoubtedly true that children are helped to get to church schools. In this case, the end to be served by the hospitals, the treatment of patients, is secular, and the availability of chapels, as one of the means to that end, is secular in its effect. Here, in our opinion, far more clearly than in Everson, the purpose and primary effect of the legislation are for the public welfare and not to promote or aid religion. In reaching this decision, we do not rely on Bradfield v. Roberts, 175 U.S. 291 (1899) or Speer v. Colbert, 200 U.S. 130 (1906) which followed it. It is true that Bradfield involved the validity of an agreement by the Commissioners of the District of Columbia with an incorporated hospital owned and operated by a Roman Catholic order, under which the Commissioners agreed to erect a building for the treatment of minor contagious diseases on the hospital's land, and that Congress appropriated money for the purpose. The action attacked was that of the federal Government, and the First Amendment was invoked by the taxpayer who disputed the constitutionality of the payment. The case was decided on the demurrer to the bill; the Court held that the allegations of the bill did not render the corporation a religious or sectarian body and affirmed the decree dismissing the action. In Horace Mann, Chief Judge Prescott, for the Court, agreed with Mr. Justice Brennan's concurring opinion in School Dist. of Abington Township v. Schempp, 374 U.S. 203, 246 (1963), that Bradfield did not decide any constitutional issues under the First Amendment. It is of interest, however, that the charter of the hospital, referred to in the opinion, stated that its powers were to open and maintain a hospital in the city of Washington for the care of such sick and invalid persons as may place themselves under [its] treatment and care, and that Mr. Justice Peckham, in delivering the Court's opinion, stated that there was no allegation that the work of the hospital was confined to members of the Roman Catholic Church, or that the hospital had been conducted so as to violate its charter in the smallest degree. There are many State decisions on the question of validity of State grants to sectarian hospitals but almost all of these decisions deal with particular constitutional and statutory provisions which vary from state to state and which are not here relevant (see Part VI of this opinion) or do not consider the constitutionality of the grants under the First Amendment after Everson. For a collection of many of these cases see Antieau, Carroll, & Burke, Religion Under the State Constitutions, 10-14 (1965). There are, however, two decisions of other state courts, cited by Judge Harris in his opinion below, which we deem particularly relevant to the issue here discussed. In Lien v. City of Ketchikan, Alaska, 383 P.2d 721, 724 (1963), the city had leased a hospital constructed with state, federal and local funds to a religious order for a term of 10 years at $1 a year. The Alaska Constitution, in the words of the federal First Amendment, provides that: No law shall be made respecting an establishment of religion, or prohibiting the free exercise thereof. The Supreme Court of Alaska sustained the validity of the lease against an attack based, inter alia, on the contention that the effect of the lease was a violation of the freedom of religion clause of the State Constitution. The Court said: The hospital was constructed and the lease made in order to provide for the care of the sick, without regard to race, color or creed, and thus accomplish a valid public purpose. There is nothing in this arrangement from which it can be inferred that a tax-established, public institution is to be utilized to aid a religious group to spread its faith or to interfere with the religious beliefs of others. The city's action was not designed, nor does it have the effect by its nature, of promoting or giving a preferred position to whatever religious beliefs the individual members of the corporation might have. The fact that specific sectarian beliefs may be entertained by those persons does not bar the city from achieving its valid secular goal of caring for the sick. In Abernathy v. City of Irving, Kentucky, 355 S.W.2d 159 (1962), the factual situation was the same as in Lien. As in Lien, one of the grounds of attack was that the $1 a year lease of the hospital gave public property to a religious organization in violation of the First and Fourteenth Amendments to the federal Constitution. The Kentucky Court of Appeals denied the contention on the basis of its decision in Kentucky Bldg. Comm'n v. Effron, 310 Ky. 355, 359, 220 S.W.2d 836 (1949). In Effron, the Court had held that use of state funds for construction of certain non-profit hospitals, including a hospital owned and operated by a religious organization, did not violate the freedom of religion clause of the State Constitution, which the court said closely followed, and had been drafted with the same purpose as the First Amendment to the federal Constitution. The Court said in Effron : Manifestly, the drafters of our Constitution did not intend to go so far as to prevent a public benefit, like a hospital in which the followers of all faiths and creeds are admitted, from receiving State aid merely because it was originally founded by a certain denomination whose members now serve on its board of trustees. The Supreme Court denied certiorari in Abernathy, 371 U.S. 831 (1962). The appellants contend that the concededly legitimate purpose of the State of aiding public health and the general welfare can reasonably be attained without State loans to sectarian hospitals, so that any indirect aid to religious interests can be avoided. They rely upon testimony of John B. Rich, Chairman of the Commission, that there is no legal requirement that all hospital proposals for construction be submitted to the Commission under the Act, and that, if the Commission knew what those plans were, it could develop a plan which would not include church-affiliated hospitals. Chairman Rich testified there are 18 hospitals in the Baltimore area; he said that 10 are not church-affiliated and that these 10 contain almost half of the beds available in the area. The appellants point to the fact that prior to December 31, 1964, 11 of the 18 applicants for loans under the Act definitely were not church-affiliated as showing that loans to the affiliated hospitals are unnecessary, and stress the enactment of the 1966 amendment as evidencing the legislative realization of this conclusion. There are several answers to the appellants' contention. While Commissioner Rich testified that it would be possible to develop a plan for loans to non-affiliated hospitals only, the record as a whole shows that such a plan would be uncoordinated and duplicative, and would delay critically needed facilities, in addition to entailing greater over-all expense. We agree with the appellants that the protection of constitutional rights by the State cannot be made to depend upon the cost of maintaining them, but, entirely apart from fiscal considerations, the evidence convinces us that the State could not reasonably have attained its secular end of aiding the health of its citizens if the Act had confined the contemplated loans to secular institutions. The inherent inefficiency of such an alternate plan is shown by the important place which church-affiliated hospitals play, geographically and proportionately, in the State hospital structure; it is the total hospital facilities of the State which determines need. The need for expansion of the over-all facilities is evident and immediate. The 1966 amendment, to our minds, instead of evincing the feasibility of eliminating church-affiliated hospitals from the general plan, emphasized the legislative realization of the urgency of putting so much of the plan as was not contested into effect immediately. The amendment was enacted as an emergency measure, necessary for the public health and safety, and the comprehensive, non-discriminatory aspect of the plan is to be restored if and when the Court upholds the constitutionality of the Act. There is another reason, in our opinion, why the State could not reasonably have attained its secular end if it had eliminated loans to church-affiliated hospitals. Many persons, in times of illness, instinctively wish to go to institutions in some way connected with their church or religious community. If neither the primary purpose nor effect of the State action is to aid a constitutionally prohibited result, the State, in forming a general plan for the assistance of hospitals, has the right to take into account the mores of our pluralistic society. That Amendment [the First] requires the state to be a neutral in its relations with groups of religious believers and non-believers; it does not require the state to be their adversary. Everson, 330 U.S. at 18. Finally, if the Act prohibited loans to church-affiliated hospitals, serious constitutional questions would arise. These questions would involve both unconstitutional discrimination, Murray, 241 Md. at 401-02 and cases therein cited, and infringement upon the free exercise of religion. See Follett v. Town of McCormick, 321 U.S. 573 (1944); Murdock v. Pennsylvania, 319 U.S. 105 (1943) and Sherbert v. Verner, 374 U.S. 398 (1963). The Act, we have found, is designed to make loans available to qualified hospitals serving the general public under a Statewide plan, assuring, in the words of the 1962 Joint Resolution, equal concern for all communities and not by special consideration. The plan, under the Act, makes available $50,000,000 of State money for loans to qualified voluntary nonprofit hospitals on a non-discriminatory basis, geared to the health needs of the State. We have held that the primary effect of the Act and its application in this case are secular in nature. We do not reach the constitutional questions which would have to be decided if the Act forbad loans to church-affiliated hospitals; we hold only that the Legislature, in endeavoring to attain its secular end, acted reasonably in not creating the constitutional problems to which the exclusion of loans to church-affiliated hospitals would have given rise. Decree affirmed; costs to be paid by appellants. BARNES, J., filed the following opinion, concurring in the result. I concur most heartily in the result in this case and, indeed, with most of the reasoning in the Court's opinion. Where I differ with the opinion of the Court is (1) in regard to the applicability to the States of the provisions of the First Amendment to the Constitution of the United States in regard to the establishment of religion through the Fourteenth Amendment, and (2) the assumption that the recent decision of the Court in The Horace Mann League v. Board of Public Works, 242 Md. 645, 220 A.2d 51 (1966) was a proper one.