The Separation of Church and State: Medicine and Healthcare Practices

Author: Jasmyn J. Tang, MPH

November 19, 2025

The separation of church and state is a common phrase utilized in governmental policy and discussion. Not directly appearing in the United States Constitution, the concept is embodied by the First Amendment: "Congress shall make no law respecting an establishment of religion.”^1,2 

Within the First Amendment, two clauses guarantee religious freedom: the Establishment Clause and the Free Exercise Clause. The Establishment Clause prevents the government from advancing or hindering religion, preferring one religion over others, or favoring religion over nonreligion, while the Free Exercise Clause protects the right to practice religion openly and freely without government interference.^3,4

Graphic created by Jasmyn J. Tang

“Separation,” where the line is drawn, is still consistently debated. One popular discussion is religious practices within schools. The Supreme Court case, Engel v. Vitale, in 1962, was the first to challenge state-sponsored school prayers. The court ruled in favor of the parents, stating that state-written prayers in public schools were unconstitutional government promotion of religion.⁴ In 1963, Pennsylvania v. Schempp decided that school-sponsored Bible reading and the recitation of the Lord’s Prayer in public schools were unconstitutional as the practice violated the neutrality toward religion required of public schools by the establishment clause.⁴ 

The “Lemon test” set forth by Lemon v. Kurtzman in 1971 dictates that the government can assist religion only if (1) the primary purpose of the assistance is secular, (2) the assistance must neither promote nor inhibit religion, and (3) there is no excessive entanglement between church and state.^3,4 As long as one does not directly influence the other, freedom of religion still applies to all levels of education. Yet, what does this have to do with medical practice?

Religious beliefs and practices can influence both physician and patient decision-making. Though still a complex relationship, multiple peer-reviewed studies have examined how religion is associated with healthcare practices and planning. In a survey analysis of 2,196 residents of a low-income, African-American neighborhood, church attendance increased the likelihood of medical visits and practices, including dental check ups and blood pressure measurements.⁵ Prior studies have even shown that frequent religious attendance lowered overall mortality rates, and increased religious struggle with illness increased the risk of death even after controlling for demographic, physical health, and mental health measures.^6,7 Addressing religion in a medical setting is debatable within physician communities.

Though there has been a long history intertwining medicine and religion, Koenig discusses the many concerns addressing the appropriateness of religion in patient care.⁸ First, religion is a very sensitive and personal issue that may be too private for physicians to inquire about. Second, involving physicians can be coercive, as physicians may impose their religious beliefs on a vulnerable patient. Third, many physicians do not have the requisite training or expertise to address religion. 

Interestingly, though the provider may feel uncomfortable bridging the topic, most patients welcome the conversation. Based on a self-administered questionnaire completed by ambulatory adult patients visiting the pulmonary outpatient practice at the Hospital of the University of Pennsylvania, 94% agreed that physicians should inquire about their religious beliefs when gravely ill.⁹ Furthermore, 45% of participants who denied religious or spiritual beliefs also supported physicians asking about their beliefs. Only 16% reported that they would not welcome religious inquiries. Additionally, among parents of children in pediatric intensive care units, 49% of all respondents stated that their beliefs influenced decisions made about their child's medical care, with 48% desiring religious conversations if their child were severely ill.¹⁰

Observing a seemingly positive response from patients, medical policies have had great implications for the patient-provider relationship and future healthcare services especially with women. A popular example is Burwell v. Hobby Lobby in June 2014, which allowed “certain for-profit employers a religious exemption from a federal requirement that private health plans cover the full range of contraceptive methods, services, and counseling.”^11,12 This case related to contraceptive coverage in Obamacare, which required private health plans to cover many preventative care services like contraceptives without out-of-pocket costs. Due to oppositions, accommodations were established for health plans sponsored by houses of worship, religious employers, and religiously affiliated nonprofit organizations where “the organization itself does not have to ‘contract, arrange, pay or refer’ for any contraceptive coverage to which it objects on religious grounds.”¹¹ Even so, over 100 lawsuits have been filed alleging infringement of religious rights, with almost half from nonprofits requesting exemptions where employees and dependents would be denied contraceptive coverage.^11,13

Another sizable topic that some may see as controversial is abortion. Most major religious doctrines disapprove of or condemn abortion.¹⁴ In a study of 78 semi-structured interviews conducted at 9 abortion clinics across the United States in 2008 and 2015, women were questioned regarding their experience and decision-making, along with any influence relating to religious or moral beliefs.¹⁵ Of the respondents, 74% spoke of their religion and God in the decision-making process, with 26% indicating no religious affiliations. Based on the interviews, there were common themes that women discussed. First was internalized abortion stigma with explicit reference to religious beliefs from religious women. Second were feelings of religiously based condemnation and judgment from family and community members. Third were strategies embodied to manage abortion stigma, including invoking personal exceptionalism, revising previously held prejudices, concealing their abortions, and rationalizing that God is the only judge of their behavior, whether their religious doctrine states otherwise. But, why is this important and how does it affect the separation of church and state?

What the separation of church and state implies is neutrality. Favoritism of religion or nonreligion is prohibited. This also includes direct interference, which may bias another’s viewpoint. Though, as seen in prior evidence, this is harder said than done. The concept is logical and straightforward, but the effects it has on medical planning and care for physicians and patients when implemented are vast. The embodiment of religion in medicine is a given fact. One’s beliefs can greatly influence decision-making when faced with illness. However, there are limitations to these studies that may affect the results, including prior illness, personal emotions and perceptions, sociodemographics of health, and economic status, among others. That being said, is there any way to improve the relationship between medicine and religion? 

For providers, cultural competence, or “…the ability of health providers and organizations to deliver health care services that meet the cultural, social, and religious needs of patients and their families” is very important.¹⁶ Providers can train or develop strategies to improve responses to a patient’s religious and spiritual needs, which in turn can increase the quality of patient-provider interaction and decrease barriers to care influenced by demographic and religious factors.¹⁶ This type of competence can also offer support within hospitals, clinics, and other health systems. Both the Veterans Affairs (VA) and Centers for Medicare & Medicaid Services (CMS) have established chaplaincy and spiritual counseling for patients while also keeping medical application independent.^17-19 Finally, acknowledging that religion and spirituality can either be a facilitator or barrier to clinical practice can encourage policymakers to take into consideration their influence in order to create respectable policy and engagement that will improve the quality of treatment and outcomes of care. It is impossible to completely separate church and state, but positive steps forward can only come from the respect and consideration of others’ opinions, religion, concerns, and attitudes. 

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Glossary

• CMS: Centers for Medicare & Medicaid Services

• Chaplaincy: the practice of providing spiritual and emotional care to people in various settings, such as hospitals, prisons, universities, and the military.

• Infringement: a violation, a breach, or an unauthorized act

• Neutrality: not supporting or helping either side in a conflict and/or disagreement; impartiality.

• VA: Veterans Affairs

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References

1. Callaway D. What Is Separation of Church and State? Freedom Forum. Accessed October 14, 2025. https://www.freedomforum.org/separation-of-church-and-state/. 

2. The Bill of Rights: A Transcription. U.S. National Archives and Records Administration. August 7, 2025. Accessed October 14, 2025. https://www.archives.gov/founding-docs/bill-of-rights-transcript. 

3. First Amendment and Religion. United States Courts. Accessed October 14, 2025. https://www.uscourts.gov/about-federal-courts/educational-resources/about-educational-outreach/activity-resources/first-amendment-and-religion.  

4. Haynes C. The Establishment Clause: Everything To Know. Freedom Forum. Accessed October 14, 2025. https://www.freedomforum.org/the-establishment-clause/.

5. Felix Aaron K, Levine D, Burstin HR. African American church participation and health care practices. J Gen Intern Med. 2003;18(11):908-913. doi:10.1046/j.1525-1497.2003.20936.x

6. Pargament KI, Koenig HG, Tarakeshwar N, Hahn J. Religious struggle as a predictor of mortality among medically ill elderly patients: a 2-year longitudinal study. Arch Intern Med. 2001;161(15):1881-1885. doi:10.1001/archinte.161.15.1881

7. Strawbridge WJ, Cohen RD, Shema SJ, Kaplan GA. Frequent attendance at religious services and mortality over 28 years. Am J Public Health. 1997;87(6):957-961. doi:10.2105/ajph.87.6.957

8. Koenig HG. Religion, spirituality, and medicine: how are they related and what does it mean?. Mayo Clin Proc. 2001;76(12):1189-1191. doi:10.4065/76.12.1189

9. Ehman JW, Ott BB, Short TH, Ciampa RC, Hansen-Flaschen J. Do patients want physicians to inquire about their spiritual or religious beliefs if they become gravely ill?. Arch Intern Med. 1999;159(15):1803-1806. doi:10.1001/archinte.159.15.1803

10. Arutyunyan T, Odetola F, Swieringa R, Niedner M. Religion and Spiritual Care in Pediatric Intensive Care Unit: Parental Attitudes Regarding Physician Spiritual and Religious Inquiry. Am J Hosp Palliat Care. 2018;35(1):28-33. doi:10.1177/1049909116682016

11. Sonfield, Adam. Religious Exemptions in Insurance Coverage and the Patient-Clinician Relationship. AMA Journal of Ethics. 2014;16(11):864-869. Doi: 10.1001/virtualmentor.2014.16.11.spec1-1411.

12. Fallon CL. United States Reports: Burwell v. Hobby Lobby Stores, Inc. Vol 573. U. S. Government Publishing Office; 2020:682. Accessed October 14, 2025. https://www.supremecourt.gov/opinions/boundvolumes/573BV.pdf. 

13. Challenges to the Federal Contraceptive Coverage Rule. American Civil Liberties Union. May 28, 2015. Accessed October 15, 2025. https://www.aclu.org/documents/challenges-federal-contraceptive-coverage-rule. 

14. Religious Groups’ Official Positions on Abortion. Pew Research Center. January 16, 2013. Accessed October 15, 2025. https://www.pewresearch.org/religion/2013/01/16/religious-groups-official-positions-on-abortion/. 

15. Frohwirth L, Coleman M, Moore AM. Managing Religion and Morality Within the Abortion Experience: Qualitative Interviews With Women Obtaining Abortions in the U.S. World Med Health Policy. 2018;10(4):381-400. doi:10.1002/wmh3.289

16. Swihart DL, Yarrarapu SNS, Martin RL. Cultural Religious Competence in Clinical Practice. In: StatPearls. Treasure Island (FL): StatPearls Publishing; July 24, 2023.

17. Long KNG, Symons X, VanderWeele TJ, et al. Spirituality As A Determinant Of Health: Emerging Policies, Practices, And Systems. Health Aff (Millwood). 2024;43(6):783-790. doi:10.1377/hlthaff.2023.01643 

18. Hospice. Centers for Medicare & Medicaid Services. November 6, 2024. Accessed October 15, 2025. https://www.cms.gov/medicare/payment/fee-for-service-providers/hospice. 

19. Skaggs M. VA Health Care First to have Centers for Medicare & Medicaid Services Codes for Chaplain Care. Chaplaincy Innovation Lab. July 27, 2020. Accessed October 15, 2025. https://chaplaincyinnovation.org/2020/07/vha-new-clinical-codes.