Appeal from decree of Court of Common Pleas, Civil Division, of Allegheny County, July T., 1970, No. 1501, in case of Lawrence N. Adler v. The Montefiore Hospital Association of Western Pennsylvania.
Paul H. Titus, with him Kaufman & Kaufman, for appellant.
Robert Engel, with him Marcus Aaron, II, Alan A. Garfinkel, and Berkman, Ruslander, Pohl, Lieber & Engel, for appellee.
Jones, C. J., Eagen, O'Brien, Roberts, Pomeroy, Nix and Manderino, JJ. Opinion by Mr. Justice Pomeroy. Mr. Justice Nix concurs in the result. Dissenting Opinion by Mr. Justice Roberts. Mr. Justice Manderino joins in this dissenting opinion.
This appeal requires us to decide whether a private physician associated with a public teaching hospital is entitled to render what he considers comprehensive medical treatment to his patients by use of certain hospital facilities and equipment, or whether his claimed right to do so must yield to rules and regulations established by the hospital for its own effective administration, and which forbids such use. We resolve the conflict in favor of the hospital.
Appellant, a physician specializing in cardiology, and a member of the medical staff of appellee, The Montefiore Hospital Association of Western Pennsylvania (herein "Montefiore" or "Hospital"), brought this suit in equity to enjoin the Hospital from denying him the right to perform certain procedures in the Cardiac Catheterization Laboratory (Laboratory) of the Hospital. After trial, the chancellor entered an adjudication denying the requested relief. Exceptions to the findings of fact and conclusions of law were dismissed by a court en banc, and a final decree was entered. This appeal followed.
We have reiterated time and again the scope of our review in an appeal from a decree in equity following a hearing or trial. As we put it recently in Cowen v. Krasas, 438 Pa. 171, 173, 264 A.2d 628 (1970): "The scope of our review is clear: A chancellor's findings of fact, when approved by the court en banc, have the force and effect of a jury verdict and will not be disturbed on appeal if supported by adequate evidence. Stewart v. Watkins, 427 Pa. 557, 235 A.2d 604 (1967); Girard Trust Bank v. Sweeney, 426 Pa. 324, 231 A.2d 407 (1967); and Kalyvas v. Kalyvas, 371 Pa. 371, 89 A.2d 819 (1952). However, the chancellor's inferences and the conclusions from the facts as found to exist are always subject to review (Kemp v. Majestic Amusement Co., 427 Pa. 429, 234 A.2d 846 (1967)), as well as his application of the law." The factual posture of this case has been set out extensively in the findings of fact of the chancellor, which incorporated a lengthy stipulation of facts by the parties. Although appellant filed numerous exceptions to the adjudication, he did not specifically allege that any finding was unsupported by competent evidence; neither does he do so in his brief to this court. Like the court en banc, however, we have undertaken an independent review of the record and conclude that the findings of the chancellor, summarized below, are supported by competent evidence.
Appellant is a practicing cardiologist on the active medical staff of Montefiore and of three other Pittsburgh hospitals. In addition, he maintains two private offices in separate sections of the City.*fn1 Appellee is a
non-profit hospital corporation organized under the laws of this Commonwealth. Its corporate purpose, as expressed in the articles of incorporation, is the "conducting and operating [of] a hospital and dispensary; and in connection therewith carrying on such educational, philanthropic and scientific activities as are incidental to hospital work. . . ." Pursuant to these goals, the Hospital since 1957 has sought increasingly to integrate its operations into the activities of the University of Pittsburgh School of Medicine, of which it became an affiliate in 1969. The Hospital is also a formal corporate member of the University Health Center.
Under its by-laws, the Hospital is divided into five departments: Medicine, Surgery, Radiology, Anesthesiology, and Pathology, each with its own full-time chief physician who has authority over all departmental activities within the Hospital. The Division of Cardiology and its Laboratory are within the Department of Medicine.
From July 16, 1963 until July 1, 1969 appellant was employed by the Hospital as the part-time, salaried director of its Laboratory. During this same period, he was also on the Active Staff of the Department of Medicine, possessing the same rights and privileges as all other staff physicians, specifically all other staff cardiologists. As director of the Laboratory, appellant was the only cardiologist on the Hospital staff authorized to perform cardiac catheterizations and related procedures, except cardioversions and the installation
of pacemakers.*fn2 Although four other qualified cardiologists were on the staff, all their patients who required catheterizations were referred to appellant.*fn3
On July 1, 1969, appellant's employment as part-time director of the Laboratory was terminated, and Dr. Edward Curtiss was hired as his full-time replacement. The establishment of the Laboratory in 1963, its subsequent expansion, and finally its restructuring on a full-time basis in 1969 were part of the evolution of Montefiore from a community hospital to a major teaching institution responsible for the training of medical students, interns and residents.*fn4 Contemporaneously with these changes, many of the physicians employed on a part-time basis to direct the specialty units and laboratories were replaced with full-time physicians.*fn5 After the part-time employees were replaced, they were
no longer permitted to perform the specialized procedures pertaining to their units, even though they continued to be fully qualified to do so. This was true also with respect to the Laboratory, with the result that appellant was not allowed access to it to perform procedures therein even though such procedures were with respect to his own patients. The prior policy and practice established under Dr. Adler's regime as director was thus continued under Dr. Curtiss' directorship. It is this policy of exclusivity, not his discharge as an employee of the Hospital, which appellant challenges as unlawful.
At the same time that appellant's employment with the Laboratory was terminated, he was hired as the salaried, part-time chief of Montefiore's Coronary Care Unit. On March 1, 1970, he was relieved of these duties for alleged failure to follow hospital rules, attempts to subvert the system, failure to fulfill teaching commitments, and removal of expensive equipment from the premises without authorization. Again, this discharge is not here challenged. Eight months after his replacement as Director of the Laboratory, and during a period when his position with the Coronary Care Unit was in jeopardy, appellant requested a hearing before the Joint Conference Committee of the Hospital, as permitted by the Hospital by-laws, on the ground that his exclusion from the Laboratory amounted to a reduction of privileges.*fn6 The request was denied.
The chancellor's findings of fact included a finding that "[c]ardiac catheterizations and related procedures are essentially team functions which are complicated
procedures and require other personnel, usually technicians or nurses, besides the physician actually performing the procedure." Though generally diagnostic in nature, these procedures involve definite risks. Potential complications include, among others, death, serious infections, cardiac complications, and serious bleeding. Because these and less serious side-effects can arise without warning and after the probe has been completed, there is a need for monitoring and close observation for several hours after completion of the procedures.
The chancellor further found that the challenged policy, i.e., permitting only the full-time director of the Laboratory to the exclusion of other qualified cardiologists on the active staff to perform the procedures involved, was an accepted practice in major university-affiliated teaching hospitals. Based upon voluminous expert testimony, he concluded that this practice improves patient care, the teaching program and efficient administration in the following ways: (1) as the procedures are essentially team functions, the members are able to develop a routine as well as a familiarity with the equipment and its utilization by a particular physician; (2) full-time presence at the Hospital by the operator permits optimal patient care because complications can be treated by the physician who performed the procedure; (3) physician competence can be maintained only by the performance of at least three cardiac catheterizations per week, and in a low volume laboratory such as Montefiore's this can be assured only by restricting performance to the full-time director; (4) a full-time physician-director has the extra time necessary to teach effectively the many medical students, interns and residents who utilize the Laboratory as a basic learning tool; (5) scheduling problems are reduced when it is not necessary to attempt to accommodate practitioners on the staff who have outside commitments;
(6) procedures should be scheduled when possible in the morning so that the performing physician can be available in the afternoon should complications arise; (7) a full-time director insures that the non-professional but essential administrative details of operating a laboratory will be performed by a physician; were the director's volume of procedures reduced by allowing others to perform them, it would be extremely difficult to obtain a qualified cardiologist willing to assume the administrative functions; (8) equipment breakdowns and lack of reliability are minimized by limiting equipment utilization to a single physician; and (9) appellee has a substantial and legitimate interest in insuring the optimal performance of its employees and use of equipment because it is liable for negligently caused injuries.
From the foregoing findings, the chancellor concluded that the challenged policy was related to the purposes and objectives of the Hospital, was reasonable, and therefore did not violate either the due process or equal protection clauses of the Fourteenth Amendment; that appellant was accorded the same rights and privileges as all other staff cardiologists not employed by the Hospital and therefore was not entitled to a hearing either by his contract with the Hospital or under the procedural due process requirements of the Fourteenth Amendment; that the Hospital's policy has not interfered with the patient's right to choose his own physician; and that appellant has not been deprived of any privilege necessary to treat his patients effectively. As indicated at the outset, we agree with the conclusions of the lower court and affirm its decree.
We recognize at the outset that the Fourteenth Amendment of the Constitution of the United States
applies only to "state action" and not to private conduct. Burton v. Wilmington Parking Authority, 365 U.S. 715, 6 L. Ed. 2d 45 (1961); Shelley v. Kraemer, 334 U.S. 1, 92 L. Ed. 1161 (1948); Civil Rights Cases, 109 U.S. 3 (1883). In Burton, supra, the United States Supreme Court held that essentially private conduct does not do violence to the Fourteenth Amendment (in that case the Equal Protection Clause) unless the state has become involved to some significant extent. The amount of involvement must be measured by the facts of each particular case. The parties in the case at bar stipulated, and the chancellor accepted without question, that "[b]y reason of the affiliation with a state-related university [the University of Pittsburgh] and the financial support from the Commonwealth of Pennsylvania and the Federal Government, Montefiore Hospital is a public institution and the conduct and actions of Montefiore Hospital are 'state actions' within the scope of the Fourteenth Amendment to the Constitution of the United States." Although we do not consider that this legal conclusion to which the parties agreed is necessarily binding on the courts having responsibility to render a decision in this action, we do not ...