This appeal presents the question whether the action of a private hospital in revoking staff privileges of a physician is subject to judicial review. The plaintiff appellee is a physician who has been a member of the radiology staff at the Pon-ca City Hospital (Hospital) for nearly twenty years. In November of 1974, plaintiff was notified by letter from the chairman of the Board of Trustees of the Hospital Corporation that his medical staff privileges would be revoked except for those patients presently under his active care. This was done following several hearings before the Board and before the Judicial Committee of the Hospital, and was reached by a unanimous vote of the Board. This disciplinary action was taken because of alleged disruptive activities of the plaintiff and the difficulty the radiology personnel had in working with him.
On being notified of the Board’s decision, plaintiff filed the instant action in the district court asking for a temporary injunction requiring the Hospital to reinstate him to active staff membership and for the further relief of a permanent injunction to the same effect. A temporary restraining order was issued аnd the subsequent temporary injunction was granted as prayed for. In a pretrial order the trial court overruled Hospital’s demurrer and accepted jurisdiction. On hearing and final disposition the trial court issued the permanent injunction enjoining Hospital from taking or enforcing any action affecting the plaintiff’s active staff member *739 ship which was based on acts of the plaintiff prior to the time of the contested dismissal. It is from this permanent injunction that the Hospital appeals.
The Hospital itself is an asset of Ponca City Hospital Incorporated, a private not-fоr-profit corporation existing under the laws of the State of Oklahoma in accordance, with 18 O.S.1971 § 851 et seq. In the late 1950’s, Hospital found it necessary to expand its facilities. The construction was partially financed by receipt of funds under the Hill-Burton Act of 1965, 42 U.S.C. § 291 et seq. Further construction is under way at the present time financed through the Ponca City Hospital Authority, a trust expressly created to raise money for construction by issuance of tax exempt bonds secured by a first mortgage on the hospital. The trust, which will be dissolved upon retirement of the bonds, names the City of Ponca City as beneficiary. Management and control of the Hospital continues at all times to be vested in the Hospital Corporation.
Plaintiff claims that the receipt of Hill-Burton funds and the use of the trust to finance current construction make any action taken by the Hospital, through the Board, state аction as contemplated by the fourteenth amendment to the Constitution of the United States. He alleges that the staff by-laws are a contract between the staff and the hospital and the revocation of his privileges was a breach of said contract. He further claims that he has been deprived of due process by the action of the Board in that his dismissal was unreasonable, arbitrary, capricious and done without sufficient cause.
If, however, as Hospital claims, the mere receipt of funds from governmental or public sources does not change the сharacter of a private hospital into one of a public hospital then the court has no jurisdiction to hear these grievances and the case should have been dismissed.
The trial court, while recognizing the majority of jurisdictions hold there is no judicial review available for a private hospital corporation, found that due to the trust authority and to the fact that there was no other hospital in the community, it did have review authority. It further found the order of dismissal by the Board failed both as to dub process under the bylaws and as to lack of substantial evidence presеnted in the hearing before the Judicial Review Committee. The trial court did not meet the contract issue.
The Hospital submits on appeal that the primary error of the district court was in accepting jurisdiction of a controversy arising from the exercise of discretion and judgment by the Hosрital’s governing body. It claims that the management of the internal affairs of a private hospital is not subject to judicial review and the court is without authority to substitute its judgment for the hospital’s.
Edson v. Griffin Hospital,
There is not much question the Ponca City Hospital was established and incorporate by a private orgаnization within the criteria set down by Shulman v. Washington Hospital Center, supra, p. 61. That Court defined a public hospital as “. . . one owned, maintained and operated by a governmental unit, such as a municipality, or county, and supported by governmental funds.” A private hospital was defined as “. . . one that is owned, maintained and operated by a corporation or an individual without any participation on the part of any governmental agency in its control.”
Management of the Hospital in this case is not in the hands of government officials, nor is it owned by State. What the amount of governmental involvement must be before а hospital may be classified as public or quasi-public has been the subject of much controversy in other jurisdictions, but the question has never been reached by this Court.
*740
One of the first cases to face this distinction was
Levin v. Sinai Hospital of Baltimore City, Inc.,
Khoury v. Community Memorial Hospital, Inc.,
In
Slavcoff v. Harrisburg Polyclinic Hospital,
In
Akopiantz v. Board of County Commissioners of Oters County,
In
Barrett v. United Hospital,
The New York Court then revealed a three pronged test for determining the existence of “state action.” This test provides, in order for a private hospital to be subject to the procedural requirements of the fourteenth as well as the other amendments, it must be shown (1) that the state’s involvement with the private institution is significant, (2) that the state must be involved with the activity that caused the injury in other words a “nexus” must exist, and (3) that the state’s involvement must aid, encourage or connote approval of the complained of activity.
The primary thеme running through this and other recent federal decisions emphasizes requirement number (2) above, that there must be causal connection between the state conduct or involvement and the injury ■ complained of. State action and thus jurisdiction does not arise merely because private hospitals or other institutions receive governmental aid.
Ascherman v. Presbyterian Hospital of Pacific Medical Center, Inc.,
As was the case in Ward and Barrett, plaintiff failed to show that the State was involved in his dismissal frоm the hospital staff.
This situation should not be equated with litigation arising from complaints of racial discrimination. In the cases reviewed by the Court in Barrett a “less onerous test” was used to find state action if the litigation involved racial discrimination. This could be applied equally if age or sex discrimination was involved. There is no such claim here.
The trial court was strongly influenced by plaintiff’s argument that Hospital is the only hospital serving the area and as such serves a public function thus becoming quasi-public. But “(e) ven if it may be successfully argued that a private hospital is performing a public function it is clear that the function involved is the admission and treatment of patients, not the hiring and firing of doctors, nurses and other staff personnel.” Barrett v. United Hospital, supra, p. 799. As did the Barrett Court, we find no compelling reason for finding state action, in the absence of a nexus between the purported governmental function and the violative activity alleged, merely because of the lack of other available facilities.
Plaintiff contends the question is more complex than categorizing a hospital as private or public. Although agreeing that the majority of decisions follow Hospital’s reasoning, plaintiff relies primаrily on
Silver v. Castle Memorial Hospital,
Other cases cited by plaintiff, although allowing judicial review of actions of a quasi-public hospital, would narrowly limit the scope of review to a consideration of whether exclusion from staff privileges was done in accordance with the rules of the hospital.
Bricker v. Sceva Speare Memorial Hospital,
The bill of rights and the fourteеnth amendment to the Constitution of the United States were created to protect citizens from governmental manipulation of their individual freedoms by the State or government officials. Our judicial system is available to all in order to insure this protection. By no stretch of the imagination *742 can wе conceive of any manner in which Dr. Murphree has been denied these protected rights merely because the corporate hospital has acquired money from government appropriations and financial investment by the public. We are not unmindful that occasional injustices may remain uncorrected due to such judicial abstention from review of the internal workings of any corporation serving the public or otherwise. But the reasoning of Barrett is persuasive and we hereby adopt it in holding there is no judicial review of Hospital’s termination of plaintiff’s staff privileges, absent either a showing of a causal relationship between the state’s activity and the activity causing the injury, or a claim of discrimination because of race, sex or age.
Even if it could be successfully argued that the acceptance of the staff by-laws by the Hospital crеated a relationship based on contract, plaintiff’s suit would then be for breach of' contract at law or specific performance, not injunctive relief. The staff by-laws do not purport to be a contract and do not appear to be such on their face. The petition does not sound in contract, although a breach is alleged; plaintiff does not pray for damages or specific performance. The suit was in equity for an injunction and the trial court properly, did not consider the contract issue.
If we were to hold that Hospital’s actions were subject to judicial review, then the presence or absence of a contractual relationship might be significant. But having found no justiciable issue in that Hospital’s status as a private hospital has not been changed by the receipt of Hill-Burton funds or by the trust created for financiаl purposes, we do not reach the question of whether Hospital failed to follow the requirements of the staff by-laws and thus was in breach of contract.
In
State ex rel Wolf v. La Crosse Lutheran Hospital Association,
Reversed and remanded with instructions to sustain Hospital’s demurrer to plaintiff’s petition.
Notes
. Silver, p. 570.