PANELISTS
Dr. Devan Stahl, PhD - Assistant Professor of religion and bioethics at Baylor University and former hospital chaplain and clinical ethicist
Dr. Renee Fennell, RN, DMD - President of Dental First Corp. and Adjunct Professor at Temple University’s Kornberg School of Dentistry
Dr. Bijan Etemad, MD - Clinical Associate Professor of Psychiatry at the University of Pennsylvania and practicing Psychiatrist with over 60 years of experience
EVENT DESCRIPTION
To many, it would seem that religion has no place in medicine. Yet, since before the time of Hippocrates in the fifth century, the popular belief was that the gods caused as well as cured human diseases. Hippocrates is considered the Father of Modern Medicine and since his time Western societies began to believe that natural forces like the cosmos and an imbalance of the four humours caused disease. Although, western medical practices today are shaped more by science, religious views still have a strong influence for many people and what they expect from caregivers. As a result, religious literacy and the skills of dialogue are essential for medical caregivers. Join us for a dialogue centered on the relationship between religion and medicine and hear our panelist’s personal experiences of navigating diverse religious orientations among their patients.
Event Transcript from November 15, 2021
David Krueger: Good afternoon, everyone. On behalf of the Dialogue Institute at Temple University in Philadelphia, the United States, I'd like to welcome you to this zoom panel discussion titled Religion and Medicine, a Dialogue with Health Care Providers on Navigating Religious Diversity. This afternoon we have experts from around the region and around the U.S. that will be contributing to what will no doubt be a fascinating discussion about the role that dialogue and religious literacy plays in providing health care in communities. So if you don't mind I'd like to share just a little bit of an introduction to the Dialogue Institute in case this is an organization that is new to you.
The mission of the Dialogue Institute is to engage religious, civic, and academic leaders in practicing the skills of respectful dialogue and critical thinking, building and sustaining transformative relationships across lines of religion and culture. It provides resources and creates networks for intra- and inter- religious scholarship and action that value difference and foster human dignity.
Established in 1964, the peer reviewed Journal of Ecumenical Studies advances critical awareness of the latest directions and ecumenical and interreligious research and, of course, our Journal of Ecumenical Studies is open for submissions and also open for book reviewers if you are so inclined. Be sure to visit our website to learn a bit more about our programming.
Some of the key programs we run include our Study of the US institutes on religious pluralism. This is a program that runs in collaboration, and with the support, of the US State Department, where we host international groups from around the world, both young adults and older adults, in programs that teach literacy and understanding of religious difference, discuss the origins of democracy in the United States, and teach the skills of dialogue and leadership to be applied in home settings. We also have a new program over the past year, in partnership with Citizen Diplomacy International where we train young innovators in social innovation and stem innovation, and training them and equipping them with the skills of dialogue and cross cultural understanding and communication. We are also running a tours program, highlighting religious diversity and pluralism in the city of Philadelphia and beyond. You can sign up if you want to take a virtual or in person tour on the streets of Philadelphia and beyond. Lastly, we also have a new program that facilitates dialogue and understanding between African Americans and Jews in Philadelphia, we have a partnership with a documentary film, and we're looking to expand our programming in these areas as well. So we're excited today, because this is a program that really gets to the core of the work that we do; advancing understanding across religious differences, helping people to be equipped to understand and to work across differences, and number two, to also to be focusing on the skills of dialogue- how can we apply dialogue to everyday life. So without further ado I'm going to turn it to a recent Temple University Department of Religion graduate, Heidi Isaac who will assist us with some conceptual framing and set a foundation for our conversation today. Heidi?
Heidi Isaac: Thank you, Dave. I would like to just say a few words before our panelists get started sharing their experiences. So, personally, I know that medicine was developed through the study of religion, yet I have encountered numerous individuals who do not know the connection, and importance, of having a religious studies background in the medical field. So I'd like to say a few words about that.
In the fifth century BC Hippocrates, often remembered as the father of modern medicine, recognized the body's natural ability to heal itself. He even instructed physicians to find blockage within patients and between them and the cosmos when attempting to heal them. Hippocrates’ formal name was Hippocrates Asclepiades, which meant “descendant of (the doctor-god) Asclepios.” Before Hippocrates, people believed that the gods caused human diseases. Through Hippocrates practices and teachings, which are recorded in the oldest medical books, more than 60 books collectively known as the Hippocratic Corpus, the belief that natural forces caused diseases became the new popular belief. The Hippocratic Corpus was completed 100 years after Hippocrates’ death by many different physicians during his time that are believed to share the same basic assumptions Hippocrates had about the human body, how it works, and the nature of disease. The medical practices found in the Corpus lead to the creation of the Hippocratic Oath.
The Hippocratic Oath, as many know it today, is a document on medical practices, ethics, and morals. However, the oath that medical graduates take today at the start of their career is not the original one of the 5thcentury BCE. The original oath starts off by mentioning 4 Greek gods, yet today, it may seem that religion is removed from medicine altogether. In fact, physicians are told not to let their own religious views affect how they practice medicine. Physicians are supposed to not let their religious views control their decisions, yet it is not uncommon for a patient to choose the medical practices that best agree with their religion. Therefore, we here at the Dialogue Institute strongly believe that having knowledge of religious pluralism would be highly beneficial in the medical field- that it would lead to better care for the patients and their family, insure all the needs of a patient are met, avoid any unnecessary, added stress to the patient and their family, and reduce the number of lawsuits against physicians and hospitals.
Two years ago, our editor-in-chief of the Journal of Ecumenical Studies, Dr. Terry Rey, and his late wife, Maria Rey, a former medical interpreter at CHOP, wrote an editorial for our 54:3 issue. In it, they each provide a personal case study where religious illiteracy had detrimental outcomes for the patients and hospitals. They make the case that training in religious literacy should be provided to all health care providers, especially in a large, ethnically, and religiously diverse country like the United States. The United States attracts patients and families from every other continent, each coming with their own set of religious beliefs and practices. Rey and Rey discuss the consequences that arise from misunderstanding such beliefs and practices and call for hospital professionals to “be conversant with the religious-based values of the traditions that they are most likely to encounter on any given day.” You can read their article in full in our summer 2019 issue, but now we will turn things over to our honored panelists who will be sharing their experiences regarding the following questions:
We know that in the past, religious and moral narratives informed our understandings of illness and disease. Does this still hold true today? What are some of the challenges that health care providers face in practicing medicine in a multi-religious, multicultural environment? And, have there been instances where your patient's religious views have restricted or influenced how you have provided care to them?
First we will hear from Dr. Devan Stahl, an Assistant Professor of Religion and Bioethics at Baylor University. Dr. Stahl has taught bioethics to undergraduates, medical students, nursing students, veterinary students, and residents. She also worked as a hospital chaplain and as a clinical ethicist in hospitals. Her interests include medicine, theological bioethics, disability studies, and end of life issues.
Next, we have Dr. Renee Hamdiyah Fennell, the president of Dental First Corp. and is involved with Temple University Kornberg School of Dentistry’s Diversity Office. Dr. Fennell was a registered nurse before she started practicing dental medicine and uses both trainings to educate the community about the connection between oral and systemic health. She is working on a book titled “Oral Health, The Gateway to a Healthy Heart!”
Our third panelist for today is Dr. Bijan Etemad, a Clinical Associate Professor of Psychiatry at the University of Pennsylvania, as well as a practicing Psychiatrist. When it comes to patient care, Dr. Etemad has the most experience among our guests this afternoon, over 60 years of it. Dr. Stahl, would you like to start us off?
Devan Stahl: Hello everyone. Thanks for having me. I'll keep these remarks brief, so we can get into lots of good questions and answers. So when we think about the landscape of religion and medicine it's easy to think now that there's an easy separation between the two, the medical sciences rely on fact and religion relies on belief. But of course it's not that simple. A lot of my research is on how theological ideas influenced medical practice in earlier centuries, as Heidi was just saying, particularly in the West. There's no question that for most of recorded history there was a strong alliance between medicine and religion. Natural philosophers, who today we call scientists, were concerned with discovering who God was through learning more about the human body and the natural world. These physician philosophers were considered secular theologians, meaning they thought about theology not as ministers of the Church, but as people who taught and thought about the natural world.
In fact, against the myth that religion and science have always been opposing discourses, it was religious belief in God, that God could be known through studying the natural world, that fueled the scientific revolution of the modern era.
Now, since that time medicine has really pulled away from its reliance on theology and any particular understanding of God, so the scientific method itself doesn't necessarily rely on theological premises. However, in many parts of the world, including in this country, we still have a significant number of people who consider themselves religious. Their understanding of illness is shaped by their religion and their engagement with medicine is also influenced by their religious beliefs. Study after study shows that people make medical decisions based upon their religious beliefs. Now sometimes this is obvious, like when a Jehovah's witness refuses a blood transfusion, or when a Christian scientist believes that prayer alone will cure their disease.
When I was a chaplain it wasn't uncommon for patients to ask me to pray that they would receive a miraculous cure, or that God would guide their physicians to affect a cure, but beliefs can act more subtly too; influencing people's trust in medicine or their physicians, the spiritual distress they may experience as a result of illness, or the coping mechanisms they use to get them through illness. Religion remains pervasive in the patient imagination, as well as for some of our medical professionals. The diversity of religious belief in our country presents particular challenges for clinicians, however. I fear that many of our clinicians are not trained to have religious conversations.
Even if a clinician is themselves religious, this doesn't necessarily mean they have a basic understanding of the various religious beliefs of their patients, and of course we wouldn't expect them to. I have a graduate degree in religion and I don't understand everything about every religion. In fact, I fear that we're equipping many of our clinicians with just enough knowledge to be dangerous. In other words, we teach them a little bit about different religious worldviews and then they assume they know much more than they do. Or, they forget that belonging to a religion doesn't necessarily mean that a patient adheres to every aspect of their tradition’s beliefs.
Instead, I think we should be teaching our clinicians how to ask the right kinds of questions of patients and to not be afraid when patients present them with very particular religious answers and explanations to their beliefs. We don't want to debate theology with our patients, but we also don't want religious belief to be a conversation stopper, and this can be a delicate balance. So as a clinical ethicist, I've seen it happen many times, where a physician became quite frustrated with a patient when their religious beliefs seem to be driving them to reject medical care, or to request aggressive medical care.
I remember a time when a young mother refused a blood transfusion knowing that she would likely die without it. This created incredible distress on the medical team, who worried that her religious beliefs were coerced, and had a hard time accepting that anyone in their right mind would refuse something as simple as a blood transfusion. Once it was established that the woman did have decision making capacity, and that her decision wasn't coerced, she was allowed to refuse that transfusion and she did die. After that, there was a lot of debriefing that needed to happen with the medical team, so they could better understand her decisions and express their feelings about it.
I've also witnessed and done research on requests for non-beneficial treatment at the end of life in the hopes that a person would receive a miracle. This can be an incredibly frustrating experience for many clinicians because they aren't sure how to talk about religion with these patients, and they feel as though they're going against their professional obligations of beneficence and nonmaleficence to provide treatment that's non-beneficial. This is where I think training on how to talk with patients about their religious beliefs can be incredibly beneficial.
Many patients want to talk about their beliefs with their physicians, but many physicians don't feel equipped to have these conversations. This is where chaplains and ethicists can be tremendously helpful. In many instances I'll bring in religious leaders into family meetings to help guide these conversations, which is not something we would normally do. Now, of course, not every patient will want that, but if religion, and religious authority, is important to a patient, and is helping to direct their medical choices, then this is something the medical care team should take seriously. I don't think that we need to provide any and all medical treatment that a patient requests, simply because they say the request is based on their religious belief, but attending to those beliefs can establish trust and respect with patients, and maybe necessary if we want to find mutually agreeable treatment plans with our patients.
Now all that to say, I think we have a long way to go in training our medical professionals to understand, respect, and converse with patients who hold religious beliefs that they themselves don't hold. So, given the diversity of religious traditions in this country that's no small task. So I hope we can chip away at that a little bit this afternoon. Thank you.
Heidi Isaac: Thank you, Dr. Stahl. Dr. Fennell?
Renee Fennell: Greetings everybody. I'm going to echo Dr. Stahl, and I'm going to come from a position of unconscious bias. From that position of unconscious bias, I'm echoing her to say that it starts in the medical schools, the dental schools, the nursing schools, the pharmacy schools, and everyone, we all have unconscious bias. We actually don't know that we actually have it, but it does rear its head many times. So the real question is, are you aware, or are you not aware. Are you aware that this might be a bias that you might have against religion or any cultural difference that you might have as a practitioner?
The way of teaching cultural competency or religious literacy, you can't learn all the religions, you can't learn every aspect of every religion or every culture. So I think that the key is communication and the key is coming from a humanistic point of view and, like Dr. Stahl said, communication and compassion. If we do communication, passion, and humanistic conversation with our patients and we teach that in the dental schools, medical schools, and all of the schools, we will actually be able to be better practitioners, better instructors, philosophers and everything.
What we find a lot, especially in the western world, is we find ethnocentrism and what ethnocentrism is, is that it's the feeling that your culture, or your religion, or your point of view trump's everybody else's. And so when we're in a space of scientific evidence and our culture, here in the United States, appoints us to scientific evidence, when people come with a religious background or philosophical background, many people will tend to just not honor it, not even hear it, become confused with it, and discredit what the patient is actually saying. The opposite of the ethnocentrism is xenocentrism, and especially with a lot of disenfranchised communities who suffer xenocentrism, where they feel like other people's culture trump's theirs, and so they don't speak up, they don't ask questions. They they just go with what the doctors might be telling them and all of these things, they breed mistrust, they breed misinformation. As practitioners, the more that we can get into with our own bias and the more that we can keep compassion and communication to the forefront, the better that we’ll be able to serve our patients. And one of the ways we can do that is cultural relativism. Cultural relativism will point us in the direction where we understand we have a bias and, just like the example that Dr. Stahl gave, would be Jehovah’s witnesses and the lack of taking transfusions. We don’t understand it, but we're able to accept it because we now know that people think a little bit differently than we do.
And so I'm going to close by just talking about a few of my own patients. I have patients from all walks of life and so many times I think to myself why are they coming to me when they could go to their Buddhists, Jewish, or holy leader. Why do they come to me? And I think that they do because we don't judge ,we don't judge, and we also actually just listen. And so the communication of listening and asking the right questions so that patients can tell us things like, “We don't like to take the blood transfusion,” or for me, it will be I hear things like, a big one, which we're going to discuss later, is the vaccine. Why people don't want to take the vaccine. Why Muslim women only want to be seen by Muslim women doctors, for the most part.
As we go about this whole conversation today, I would like to ask each of us to just think about our own unconscious biases that we may have. I have to think about them all the time. I have patients that have tattoos from the top of their heads, to the bottom of their toes and they're afraid of a needle, and I just sit there and think to myself you've been pricked, and pricked, and pricked, but you're definitely afraid of this anesthesia that you're going to get today. So without judgment, we just take a deep breath, with no bias, with no judgment and listen to their conversation, because maybe at one point in life, they had a horrible experience and that's where it's coming from and not really the needle itself.
So today I will be coming from , as we further our conversation, self awareness, and being taught in medical schools, and all of the schools, talk about unconscious bias, talk about compassion, and talk about communication skills. Thank you, Heidi.
Heidi Isaac: Thank you, Dr. Fennell. Dr. Etemad?
Bijan Etemad: It has been delightful and educational and I learned an awful lot so far, but I come from a different background. I was raised in a Baha’i family and learned early on to respect all faiths and was actually taught about different faiths. So growing up, I had a good understanding of Judaism, Christianity, Islam and the Baha’i faith. And was basically raised with the understanding that we are all the same, there’s only one God, and during my medical school training, and based on my faith, that when it comes to science and religion, there should be some element of harmony between the two. We cannot separate the science from religion, and the religion from science.
I hardly had any difficulty in my practice as a trained child psychiatrist, a board certified geriatric psychiatrist, and as the head of general psychiatry at UPenn, or during my research for about 20 years. So during my wide spectrum of practices and encounters, I never really encountered any difficulty regarding bias, or had any misunderstanding about a patience’s point of view.
You see, spirituality and religion are two separate things. Spirituality is very individualized and has a wider spectrum of understanding. Religion is more like an institutional thing. So in my practice, when someone comes to see me, religion really never comes up, but there have been examples when a patient comes in, a Muslim woman who is covered and I won't be able to see their face, and I respectfully ask that, “unless I see your face, in my profession as a psychiatrist, I really cannot make any assessment whether or not you're depressed, whether or not you're anxious and I usually ask the husband to come in. If the patient is still uncomfortable, I respectfully ask the patient maybe she should see a woman psychiatrist, where the patient would be comfortable to unveil and can be treated more judiciously and property.
But outside of those very rare examples religion never really comes into my practice, and I don't think it really comes to other physicians’ practices. I think what you are raising here is also a fascinating thing, and that is, we need to raise our children early on, in terms of understanding other humans and in terms of differences, and the differences of faith, and somehow not to be prejudice against those who happened to have a different faith, color, shape, background, or nationality. That is really what is missing, not only in this country, I think, but also all over the world.
So, in so many ways, I was blessed to have been raised in that kind of a family and I have enjoyed the work that I have done and I'll be more than happy to entertain any question. You know, one of the principles of the Baha’i faith is, that if you're sick you seek the best physician, that is part of the Baha’i text, that you seek the best there is in the illness that you are encountering and you're struggling with. And in so many ways it kind of helped me to do the best I can in the kind of things that I have limited experience in. To do the best that I can for my patients. So I think I'm done, unless you have questions.
Heidi Isaac: Thank you, Dr. Etemad an thank you again to all three panelists. That was wonderful. So we're going to start off the question section with a few prepared questions that the staff at the Dialogue Institute had come up with, and we also have a few SUSI alumni in attendance here and one will also ask a few questions he himself had prepared for us. So first question we have, and this is for all three panelists, “What role do you think dialogue plays in health, and how healthcare providers engage with their patients? Are the skills necessary for the patient-provider relationship?”
Bijan Etemad: I think dialogue is essential in understanding, this is speaking from my own practice, understanding the patient and doing the best you can for your patient because I don't ever claim that I know anything, unless I listen and unless there's a dialogue established between me and the person that I care for, and through the dialogue process, I gain better insight and better understanding of the kind of thing that I'm going to be dealing with.
Renee Fennell: I think dialogue is critical, but I think it also must be taught with communication skills. Just having dialogue without communication skills and religious and cultural literacy can often be actually offensive to patients and colleagues. I just think that it, I agree that it needs to be taught, I do think that we also need to actually include those communication skills, with the literacy of cultural competence and religious literacy, along with it.
Devan Stahl: Yeah I'll just sort of ECHO that. I think medical schools are fairly good at teaching students about shared decision making, or at least the concept of shared decision making, as being sort of this two way street, where patients know a lot about themselves and their goals and their values, although not always, and sometimes you even need to guide them through those kinds of conversations, on how do I connect my values with this particular medical option that I have. So that is being done, but I think sometimes, at least in my experience, the religious element, or the cultural element, can be a conversation stopper in that. So we're very comfortable talking about all sorts of values; I enjoy spending time with my grandchildren, I enjoy, you know these sorts of things, but as soon as somebody brings up, sort of a very particular religious belief, that can kind of shut things down because it's hard to identify with that, perhaps.
I think that there is more work to be done in dialoguing in those more uncomfortable terrains, those terrains can be more uncomfortable for some physicians, either because of unconscious bias, or just because they're not as informed about that religion as they feel like they might need to be, so that could kind of shut things down. Say there's the dialogue and it’s so so important and there’s a kind of humility about asking the right kinds of questions. I think cultural competency gets us close to this and, or maybe you want to call it cultural humility, but I’m always trying to prompt physicians to, “well, they said they want this miracle. Did you ask them what they meant by that? Did you probe a little bit further, just into that belief itself because maybe they really wanted to explain it to you and you didn't sort of ask the follow up questions that were necessary to understand.” So I think that's where we can sort of push the dialogue forward.
David Krueger: If you don't mind, if I could just jump in just to tease that out just a little bit. I'm curious, for each of you, if there are some specific prompts or questions that you have found to be helpful at kind of opening up a conversation and creating that space for dialogue. Can any of you offer any kind of practical suggestions that have worked?
Renee Fennell: I think I’ll start. When we take our [patients] medical histories, we could do a better job by adding some of these kinds of questions to our medical histories, so that we could actually get a sense of not just what medicines they take or allergies, or past conditions they have, but if you notice that most medical histories have very limited emotional, spiritual questions. When you see spiritual it'll say “what religion,” and it just kind of stops at the head. And so if, just like you probed us right now, we look deeper into the question, I think that our medical histories is a good place to start the conversation with our patients and if we are actually in an environment that we wish to make humanistic and have compassion, you can just like Dr. Etemad said, “I need to look at your face.” You can look at people's facial expressions and their body movements and kind of get a feel to see if you're in tune with what else they may want to tell you. But I think the medical history form can be expanded and used as an initial tool to have this kind of conversation.
Bijan Etemad: You know it's interesting. Every so often I convey to my wife, I say,
“Really, I think there was a miracle,” and that refers to someone that I had been trying to attend to, and the complexity of that individual psyche is so complex. It's interesting. Sometimes I kind of pray to be guided, to be put in a state of some tranquility, or maybe a defective process to see whether or not I’m on the right track, or be directed to the right track. Now, whether or not that prayer, and no other entity, is assisting me, but it's certainly assisting me as an individual to kind of pause for a minute and to reflect. I consider myself relatively a good psychiatrist after so many years and so, to be conscious of your own spirituality and your own faith and understand how delicate and sensitive, and how important it is for you to have a faith, and everybody else has a faith, I think it brings humility into your care of individual patients.
So in that I mean I have seen miracles, but not that they are better over medicine. I just figured that, you know, this combination or that combination probably based on science is the proper combination and is many times a reflective process.
Devan Stahl: I'll just add quickly that I think there's some sort of blanket questions that are always helpful. I'll caveat this with, I don't think that every patient wants to talk about their religion with their physician, or any other medical professional. Sometimes that could just be like awkward and actually really uncomfortable, but if your choices are being directed by that religious belief, and that's really obvious, or you're in an existential crisis because your illness has prompted you to re examine your religion, “I don't know why God would be doing this to me.” I hear that sort of thing you know, why is God testing me like this, what did I do wrong to deserve this illness. That really should prompt some questions. And I think questions like,
”Can you tell me about your belief and why you're struggling so much. It sounds like religion is very important to you. Can you tell me more about that? Do you have a religious authority that you'd like to bring in that would be comforting to you in this moment? Might we send a chaplain your way?”
I mean, I think just sort of probing into that a little bit more, and then learning from our patients when to stop, but actually it seems to be that many more want to have those conversations that are being afforded the opportunity to have those. So when it seems appropriate when the medical decision is being prompted by a religious belief, or when the patient is in a crisis, a spiritual crisis because of that religious belief, I think that's the appropriate time to start prodding them to examine what's really going on and to figure out who is the most appropriate person to address those concerns.
Bijan Etemad: I think it's an excellent point, but at the same time I will never forget a family who lost their son. They became so angry at their own faith and they basically said, you know, “I don't no longer believe in God and so forth, and so on. And I happen to be involved with the family and I try to basically help them to understand that the mishap, and unfortunate events, happening to our loved ones, has nothing to do with God. It was just a bad accident. I tried to help them refer back to their own faith, talk to their, you know, counselors, speak to their ministers, or to their Imam, and so forth. Trying to understand that really, that God has no place in these things.
See, one of the challenges in medicine is the patient coming to you, on one hand, they believe that God really has the ultimate decision in terms of your life or not living, and at the same time, they come to you, as a physician, expecting that you with your knowledge have the tools to rescue them from that illness. So the patient has struggled with this. To begin with, 60-70% of patients, according to statistics, really believe in God, that God ultimately decides their life. And then how do you plug in, as a scientist, into that scenario, to assist your patient so they can still remain faithful, but at the same time to be compliant with scientific thinking.
Heidi Isaac: Thank you. I see that we have already some great questions in the chat, we'll get to them shortly. We would like to invite now SUSI alumni Manuel to ask one of his prepared questions.
Manuel Maroun: Hello! I am Manuel Maroun, a third year medical student from Lebanon and I'm glad to be here with you tonight. I just wanted to ask if any of the panelists ever witnessed any sort of miracles, sometimes, and if so, how can they explain them. The results are quite surprising when it comes to the CT scans, or the MRIs, or something that we can really evaluate. So what do you think about this and how can you evaluate them?
Bijan Etemad: Is that question directed at me?
Heidi Isaac: it's directed at all three.
Bijan Etemad: What was the question again? I missed the first part.
Manuel Maroun: If you can evaluate, maybe not in your domain, for example, not in psychiatry, but, for example, if a miracle happens in neurosurgery, or in any other medical domain. How can you explain this, especially when it comes to results that you can really see, like in the MRI/CT scans, everything, sometimes an x-ray? How can you explain miracles, if you are a physician, if you are a nurse, if you're in the medical field?
Bijan Etemad: Well, I can speak on the fact that. Although we know an awful lot, there is also an awful lot which is unknown to medicine and to science. Things change and we don't understand it. A patient comes and says, you know, '' I'm fine. I got better,” and in many ways it is truly a miracle, but at the same time, we know that there is so much unknown in terms of science, that can happen without you knowing it. It's my take on it.
Renee Fennell: I agree. The way I explain miracles, is the same way. That there's so much we don't know. We really know so little about the human body and much of what we know are theories that we have all kind of accepted. And then as we move on, and on, and on and on, through evolution, for my say, things that will kind of rebuild themselves later on down in history and will say that, “oh, so interesting. They thought that was a miracle years ago.” And so, once our country separated state and religion, or at least thought that, you know, they became to have a disconnect, and saying, non-judgmental, about whatever the patient believes has happened, is probably a good way of just honoring their beliefs and also honoring our scientific, evidence based knowledge.
Devan Stahl: Yeah, I know that those things have to be in contradiction right? I think that's what Dr Fennell is saying. I mean, the more I do research on miracles, and how patients believe in miracles, the more you realize that we all actually are saying something really different. And so I never presume that we all have the same definition of miracle, even in the Christian faith, that I belong to, people can think miracle means either some completely unexplainable event, something that doesn't really happen anymore, or it can be the mundane things that are extraordinary, “every child is a miracle.” So the ways that we use those terms are just so, so varied, and so it's good to probe into what the patient really means by that. But I mean, I think a lot of physicians, even if they don't necessarily adhere to a religious faith, would admit that there are things they can't explain and they're perfectly happy to let the patient sort of say that it felt like a miracle.I think, where it gets tricky is when patients are sort of then make driving medical decisions based on that hope, for a miracle to occur. And so that can create some sticky situations where the physicians feel uncomfortable providing certain treatments.
But you know, I think it's the last Pew study I looked at, in 2015, said something like 80% of Americans believe in miracles and the majority of them believe that a miracle can happen and save a patient's life, even if the physician says that they’re certain to die. It's something like 60% of people believe that statement to be true. That's an incredible number of people who will not trust physicians like sort of prognosis that death is certain, and so, when we sort of take that into account, I think we really need to be careful, then, how we're talking about what the miracle is, and what we should expect from that, given how many people continue to believe in the presence of miracles and medicine.
Heidi Isaac: The next question we have for our panelists kind of is regarding medical schools, when you attended medical schools and medical schools today. We were wondering if religious literacy is taught in medical schools and, if so, in what capacity and if not, do you believe that it should be? Do you feel that the education that you received when you were in school prepared you to properly treat patients with diverse religious backgrounds?
Renee Fennell: I think I will go first with that. I think it really has grown. It's not like it was when I went to dental school 25 years ago. You'll see a lot of our major institutions, for instance, in dentistry, we have a quota, the Commission on Dental Accreditation for dental schools, they have actually put cultural competency of which religious literacy falls under that topic, as a prerequisite to accreditation. So dental schools have to prove that they are teaching these things in an experiential way, as well as a didactic way to their students. And because of that, and also because of the diversity that we see in the dental schools around the country- some places are not diverse at all and some places are really very diverse, but because of the diversity, and all of the social media, and communication methods that have made us global, even though we often times feel comfortable in our own microcosm of where, we've had to expand our thinking. Since we have become global like this, we have thoughts, and philosophies, and education from all over the world now coming together in our schools, and that has provided a wonderful dialogue within the dental schools. So the medical schools I will let the other doctors speak on those.
Bijan Etemad: I know some medical schools in this country have as part of the curriculum for the medical students some insight into religious diversity and faith. How much you need? That is a good question. Did I have it when I went to medical school? Yes, and I think what really helped me a great deal was my upbringing. And I think that is what is missing, really, and again, I don't mean to be critical, but you know, having my children born here, raised here, they went to school here, associated with so many other families and so forth, and faith always has been kind of on the back burner in some extent, you know. Insensitivity to diversity has been always on the back burner and so I think these are the kind of things that we can do when we contemplate our family, and children, and educating our teachers, and helping parents and so forth, to really raise a community with sensitivity about this diversity and understanding about differences. But I think we're on the right track. I think we're going to get better as we dialogue more and more. I think the future's bright.
Devan Stahl: So I've only ever worked in one Medical School and the entirety of that medical literacy, to the religious literacy training, was a lecture that was mandatory and all the students really resented having to go to hahaha. Because of where it was placed in the curriculum. I think it's true, as Dr. Fennell described with dental school, that there is a cultural competency element that is needed and religious literacy would fall under that.
The tricky part is, kind of like with ethics as well, you just have to show that you taught it somewhere, but there's no requirements for what you have to teach, or how it's being taught, or how many hours if it's required. So you can get incredible diversity in what students are being taught across medical schools. I know some medical schools have really robust religious literacy programs, and some have almost none. And so I think that some consistency across the accrediting board, so the ACGME would be nice.
I also think it's really tricky, like who's competent to teach that and how is it being taught needs to be standardized because I'm afraid that what a lot of students are getting is just not good enough, or actually might be detrimental to them. I’m sure everyone's seen these medical textbooks that are like, “Muslims believe this and Christians believe this,” and that's just not a very good way to be taught about religious literacy.
David Krueger: If I can just jump in for a moment. I think it was Dr. Stahl who made the comment that having some religious literacy knowledge can be dangerous, like you could have enough just enough to be dangerous and to perhaps maybe bring more obscurity to the conversation with the patient, rather than clarity. It reminds me of what Dr. Etemad said about this distinction that you made between religion and spirituality, of saying that, yes, we're rooted, you know, in a religious or non-religious tradition, but that sense of spirituality is something that's very much the driving force to the person that is in that room with you. And they may be Muslim, Hindu, Atheist, whatever might be, but what are their spiritual needs, perhaps in that space, in that encounter.
I think what you've all been saying is, you know, us thinking through what are the right questions to ask for that moment? Does this factor need to be brought into this room? Is the patient bringing this forward as something that needs to be addressed? Dialogue blended in with religious literacy, and really focusing on the person there, rather than the representative of some larger imagined group is probably a good approach. So Heidi? Could you maybe turn us to one of the questions in the chat.
Heidi Isaac: Sure! So the first question we had posted in the chat was from Dr. Effiong Udo, and this was directed to Dr. Fennell. He stated, he was wondering whether virtues, such as compassion, patience, kindness, etc. and striving to promote the dignity of individuals, can as well be cultivated by medicine? This was very early on, when you were speaking about dialogue and medicine.
Renee Fennell: Yes, I think it can be cultivated in medicine and, yes, I think it should be cultivated in medicine and the reason why I think so is because those attributes are what connect us as humans. When we talk about religious literacy, there's a humanness underneath all of that, and if we can just tune into the humanity aspect of it, then the religious literacy becomes helpful, but it's not the all-in-all, because when you're looking at a person you're seeing human. And we all say that all the time, you know, “We're all human. We're all human,” but a lot of times we don't really treat each other with that golden rule- do unto others as you would have them do unto you.
Patients ask me all the time, “Would you prescribe this to your mother?” Hahaha. When they asked me that, it always just jolts me because yes. Yes, I would. This is why I'm giving you this recommendation because I’m treating you as a human being, just like I would treat my own mother.
And so, in our society where healthcare has become so monetized, or economically based, or all of those financial words, we have students who come out of medical school with increasing and increasing debt. The ethics and the integrity comes into place, where they’re trying to pay their school loans, they’re still trying to drive that car, they want to get married, the big wedding, the da da da da da da da. For surgeons, for internists, it doesn’t really matter.
If we don’t teach these things early on, like compassion, other things can lead us down a path where we're not actually honoring our patients and we're honoring financial gain, I'll just use those kinds of words. So yes. Yes, I do believe that compassion, kindness, respect, like Dr. Etemad said, this disrespect will go a long way in the, I was gonna say dental education, but in the medical education as a whole.
Bijan Etemad: You know, I’m so delighted to hear what you said. These are the attributes that we need to teach, not just in medical school or dental school, we need to teach them; at home, in primary school, in high school, in churches, in the mosque, in synagogues, and on the streets. Everywhere. We need to create a culture of understanding, sensitivity, compassion, decency and honesty.
You cannot cramp humanity into the complicated, packed curriculum of medical school, or dental school, or nursing school. As it was stated, you give a course, nobody wants to hear it, they hated it, one hour, two hours, get over it, and out. Haha, you see, it's not going to have any impact unless we learn to begin early so we create a society where sensitivity, and understanding, and decency become part of the makeup. Of course, that's my point on this.
Heidi Isaac: Thank you. We had one more question from Manuel. He wanted to know, “When the cons outweigh the pros in any given treatment, like in palliative care or during final stages of cancer, do doctors still have a moral obligation to continue treatment or can they place the patient in hospice care and make them as comfortable as possible until they pass?
Devan Stahl: I can start on this one. This is really tricky so the first thing I'll say is, as a clinical ethicist, I'm always trying to prompt physicians that they absolutely shouldn't be providing treatments that they don't believe will work and you might be surprised how often I have to reiterate that, because a lot of physicians are under the impression that, if a patient insists or asks for something, then we're obligated to provide it, because that's what they want and it's all about patient autonomy. But of course, if it's not going to benefit them, it's probably going to hurt them, and so we ought not to be hurting our patients. We can't, in this country, automatically enroll them in hospice; you have to actually agree to be in hospice.
We do want to make sure that people are consenting to things like hospice care, even though I think it's an incredibly wonderful program. If you don't want to be in it, then we can't force you. You have a right to reject any and all medical treatment that you don't want, but you do not have a right to request treatment that physicians don't believe will benefit you. So that's sort of the big difference. We don't have to provide things that won't work, but we're not going to then force you into hospice. We can just sort of guide you into comfort care, but these are things that you need to also agree to. So we need to be careful in that balance.
Renee Fennell: Can I just piggyback on what Sr. Stahl said, and I'm going to just go back to what I just talked about a little bit later, I mean earlier, and what Dr. Etemad said also. It’s a wider picture. It's not just medical and dental school. It's pharmaceuticals, it's insurance companies. Many times, these doctors get caught up in standards of care where they don't want to be sued, you know, so they’re trying to do things that, you know, their integrity tells them to go one way, but the insurance company tells them to go another way. So this whole concept, like Dr. Etemad said, has to be overarching. It's the overarching concept of bringing integrity, and I don’t even want to say integrity, but holistic care, I’ll call it holistic care, where we are caring for a patient's mind, spirit and their soul.
In our country, we tend to be, because we're so scientifically evidence-based, we care for the body, and that is what we do, and we leave the emotions to the psychiatric people, and we leave the soul to the spiritual people, or the religious people whatever you would like to say. When we can find a way to blend all of those back together and treat our patients holistically, (mind, body and spirit) then I think that, and i'm going to make it even broader to say we treat them environmentally too. Some of our environments are really not healthy for patients and when patients ask me, “What's the best treatment?” What is the best treatment for you may not be the best treatment for somebody else. It's all so quite individualized. We’ve all seen where people are on drugs, for instance, go back to the same environment and it is very hard for them to make a way. And so, when we can incorporate these three modalities together, I think we're going to see a real change in how we approach medicine. Hahaha I hope that wasn't too wordy.
Heidi Isaac: We would now like to open it up to the rest of the participants, if anyone has any questions for our panelists.
David Krueger: If you already asked a question in the chat don't be shy, you can go ahead and I think Heidi? It's okay if they unmute themselves? Would that be alright?
Heidi Isaac: Of course.
Jekonia Tarigan: Thank you. May I?
Heidi Isaac: Go ahead.
Jekonia Tarigan: Thank you for all the speakers. I'm Jekonia Tarigan, from Indonesia, Jakarta Indonesia. I'm doing my PhD now in Indonesian consortium for religious studies, Gadjah Mada University graduate school. I'm really excited to discuss, because I am doing my dissertation research now about the interreligious encounter within religiously affiliated hospitals. So maybe I need to tell the context first. In Jakarta, in my city, there are three religiously affiliated hospital. From Christian, Catholic, and Islam. All of them already served the society for like, hundreds of years, and people go to these three hospitals, no matter what their religious background is. But, uniquely, interestingly, the majority of the people in the city are Muslim and most of them go to the Christian and Catholic hospitals.
I found it interesting that in Jakarta the problem of religious identity is quite strong. I mean, some people from the Muslim side are actually quite sensitive about Christian mission. So even though they go to the Christian or Catholic hospital, there is an acquisition, whether they will be asked to convert to another religion, to Christianity, for example.
They still enjoyed the medical services, because most of my informants, for example, they said that Christian hospitals provide better service than the Islamic hospitals, but still those accusations exist. They can go to a Christian or a Catholic hospital, but for another issue, related to some doctrine, for example, they are forbidden to wish Christians a Merry Christmas. So it is different cases, related to certain religious doctrine. They cannot accept it, they cannot do dialogue with Christians, but in the healthcare context, they go to Christian hospitals because they need it. Like Dr. Etemad said, that when people get sick, they search for the best service.
So how, actually my question goes specifically Dr. Stahl, how do we see dialogue in this kind of context, because in hospitals, mostly people accept the issue of religion in a universal way, I think. If the healthcare service, or the counselor from the hospital come, they may accept a universal message to keep spirit and be disciplined, to use your medicine, or something like that. But if you go to the specific issue of religion, they cannot accept it because it is rather sensitive.
In Jakarta, some people also come from a Japanese ethnic group, and they usually accept interfaith marriage. They experience interfaith in their own family which influence them to accept the dialogue within religiously affiliated hospitals. Maybe my question and the context is rather confusing, but I'm really excited to hear from you Dr. Stahl. Thank you.
Devan Stahl: Sure, yeah. So, it's a very different context than what I'm used to so the first thing I want to say is knowing your community s so important to resolving these issues so I'd hate to sort of like tell your community how they should be thinking about this because it's not my community. I’ll risk some humility here, but I do think there are some tactics of being open and trying not to be so judgmental, that hopefully can prompt conversation.
I would never push somebody to start talking about their religion, if that made them uncomfortable. At the same time, when I was trained as a chaplain, here in the US, it was very important to be an interreligious chaplain so, even though I come from a specific tradition, it's never my goal to impose that on anybody, or even to sort of try to manipulate everything into like a Christian conversation, which required me asking a lot of questions of people, and assuring them that my goal was not to convert, was not to force a religious conversation, but really my goal as the chaplain was to just comfort them, and be there for them, and talk about whatever it is that they wanted to talk about.
At first, some people would be very sensitive about religion and not want to talk about it, but, the more they saw that you were just there to have a conversation, to talk about whatever it is that they needed to talk about, the more open they would become. And, as a young female Chaplin, you know, some people were very suspicious of me, that I didn't have the kind of religious authority that they thought was important.
They rejected me, sometimes, but sometimes once they saw that I was open, they were more open to me. So I think just being gentle and guiding in those ways, being non-judgmental as our other panelists have said, and sort of exploring with them what interfaith means, making sure that you come across as a person who's not trying to convert them. I think those can be strategies for opening up conversation, but I think also knowing the context of your situation is so important.
So, for me, getting to know the religious authorities in my community is really important for the work that I do. Getting to know how they talk to their parishioners? Very important. And so the more I can do that, the more I can loop them into conversations and the more I can sort of understand my own community.
Jekonia Tarigan: Thank you Dr. Stahl.
Heidi Isaac: Thank you. In the chat we had a question from Sergio. Sergio, would you like to ask your question now?
Sergio Mazza: Sure, let me go back and read it again. So, in hospitals, in the experience of the three speakers, is there a systematic approach to involving hospital chaplains in difficult situations that require cultural and religious competency?
Bijan Etemad: I can speak for the University of Pennsylvania that the answer is yes. And they're always involved and very helpful.
David Krueger: And that determination is made by the health care provider to say that there would be a sense of like, there needs to be some more insight brought in, or how are those decisions made?
Bijan Etemad: Well, there is a healthcare provider, primarily, and then a consultation with other healthcare providers in this setting, and the staff, and then collectively, it’s an understanding that we need other services and other experts into the mix, especially the chaplain, to really give us a different insight, different point of view, to deal with this complex issue regarding that individual health issue, or a family issue. That kind of scenario. Pretty often, and I have been involved in a number of them.
Renee Fennell: I would like to also chime in and piggyback on Dr. Etemad. In my years of nursing, as a registered nurse, when we have team meetings, the recommendations can come from any point on the patient's care team. So, the recommendation can come from the nurse, it can come from the doctor, it can come from the social worker. Whoever had a interaction with the patient and said, to the team, “Okay, we need to bring in a chaplain,” or “We need to refer the patient to a psychiatrist.” Anyone on the team, and I want to say that the hospitals I worked at had a way to put that information in the system so that they got them.
Devan Stahl: So that's my experience, too. Any member of the healthcare team can make a referral, which will go straight to the chaplain, either through a consult request, or through the medical record. patients themselves can typically request a chaplain, although most patients don't know that chaplains exist, which I think is so strange, in part because most hospitals that I've ever worked in have like a one to 100 ratio of chaplains to patient beds.
In a hospital with about 400 beds, my hospital has three, sometimes four, chaplains. So there's definitely not enough chaplains in hospitals and when healthcare jobs are getting cut, it's typically the chaplains that get cut first. We have this sort of huge problem, I think, of a lack of chaplaincy but the mechanism is typically there. How many patients chaplains are able to see in a day, just might depend on the capacity of that particular hospital and how many chaplains staff they have. And if they can cover nights and weekends, because not all hospitals have chaplains that cover nights and weekends either.
Renee Fennell: I think a lot of that has to do with the diagnosis of the patient. Would you agree Dr. Stahl, Dr. Etemad? Patients who have a more severe diagnosis tend to get into that system a little quicker than patients who have less severe diagnosis.
Bijan Etemad: Yes, it is, and even the patient has the right to ask for their own chaplain, or rabbi, or imam, or a religious leader or individual that they can trust to be part of the team and consult with, or comfort the patient, and so forth. There is a pretty open-door process to assist the family and patients to go through that difficult time.
Devan Stahl: Sorry, the palliative care team at our hospital itself has its own chaplain, so those patients that are sort of, are chronically ill, and tend to be a little bit sort of getting a little bit more serious, there is a chaplain that works just with them. That's not true of every hospital, but I do think you're right Dr. Fennell that the more serious your condition, the more likely it is that the healthcare team is going to recommend that you speak with a chaplain. But I think anyone at any point can request that, in the hospital.
Atsede Elegba: Can I just chime in? I'm a healthcare chaplain and I actually have some patients I have to go to see, but you're right. Thank you, Dr. Stahl for speaking for chaplains. I put that in the chat. And to Jekonia’s question, which I thought was great, I think that even though we don't often work in that environment, the people that he was talking about, it sounds like it's the health care facility that projects a specific religious ideology that the patients are concerned are going to be projected onto them, or you know, forcing them to convert.
That does happen in small bits here, because very often there are staff sometimes that, or people that come from outside, who have not been trained, as you were Dr. Stahl, or that I was as a board certified chaplain. And so they feel it is their duty to convert and we try to avoid that. Even here, we have people who don't want to see a chaplain because they're afraid that they're going to be, that they're going to proselytize. So that does happen, in certain instances.
So, but again I think that's a whole nother question and the other thing, in terms of what you were just speaking about, I'm glad I put that question in the chat that, you know how often do medical professionals use the chaplain. So, I'm glad to hear that, it sounds like you all do, in certain instances, and again to your point, yes, more of my time as a chaplain has been in hospice and palliative care. When a person gets to that point, where their diagnosis, or prognosis, is more severe than people feel that will, this is the time, but that's when medical staff is backing off, and so the end of life care goes to the spiritual care providers, but most of us who do this work, think that it should come in a lot earlier.
A lot of what we do is listen. If we listen based on the person's spiritual trajectory, based on the person's spiritual background, not on what we believe. But a lot of people do feel, even here, that the reason why you're a chaplain is coming into the room, sometimes I have to say I'm not here because I think you're dying, so yeah, there's this perception and part of what we can all do is to clarify that for people. To have them feel more comfortable visiting with a spiritual care provider, as we're often called that as supposed to chaplains, you know, to kind of break that barrier, again, between religion and spirituality etc. So thank you very much for a great conversation.
Heidi Isaac: Before we end for today, Gity had something to share as well.
Gity Etemad: Yeah. I just want to make two short comments about what we talked about before. The Yale University School of Medicine, in the department of family medicine, in the questionnaire that they asked a patient on arrival, they ask, “Do you believe in God?” If they say no, they just let it go. If they say yes, then they go a little bit further, and they say, “Do you go to any church,” and if they say no, then they say okay. Then they go further down.
The reason they do this is they want to find out if the physician can get any, in the case of need, they can have some head from a family from the Church from the Community, that would help the family. So I think this is something that Yale university Medical School has started.
The other point I want to make it came about the chat about the chaplain is that I work at St Christopher's Hospital for Children and because, in the Baha'i faith we don't have a clergy, there was a very sick child and they were wondering if there is no one around what they can do. And I said I leave you a Baha’i prayer, whoever wants to read it to calm the child or calm the family, that would be good. So there are folks from different faiths, at least it was when I was there, I don't know if they are still there, so that's another way to give some spiritual support to the patient of the child who was very sick.
Heidi Isaac: Thank you Gity, and thank you everyone for joining us today for this very important dialogue. Obviously there's so much more we could say on the topic, but we are getting close to the end. Just wanted to remind everyone that this video will be posted on our YouTube channel and Sayge put the link in the chat so you could go back and rewatch it or send it to anyone who couldn't join us today. Sayge also said that she was going to save the wonderful conversation we had in the chat for you as well.
Mo’men: So are we finishing, but can I add one last question?
David Krueger: Last word haha.
Mo’men: Yeah, I'm sorry but I just need to ask this. Okay, so now we've touched on the level of respecting religions and having dialogue and all that, but if the people, in categories. just for the sake of this question, so we have people who are being treated and they don't care so much about religion and that's not a problem for us. And then you have this group of people who are religious, but you as a healthcare provider have to accommodate their beliefs. Let's not let's not say religious beliefs, but there, but their beliefs that can be solved. And then you have this group that their beliefs can affect their health, but only affect their health, like Renee said, the woman who doesn't accept to have a blood transfusion and that's Okay, because at the end it's her decision.
I want to ask, what if his decision, or his beliefs, could affect someone else's health?
For example, here in Egypt, I graduated from Medical School last year and I am working now in general surgery, and in Egypt here we have a problem with FGM, or female genital mutilation, or what they call female circumcision. This is a huge problem here in Egypt and people say that this is their beliefs, but actually it's affecting their children, or you know, young girls who don't have authority over themselves at this age. So don’t you think that me, as a healthcare provider, should have some authority when it comes to such things?
So now we have surpassed the problem of, “It is my beliefs affecting me so it's my life.” So what do you think about this problem? How can this be addressed, because believe it or not, it's still happening, and some people say it's religious, but I don't know, let's not say it's religious. Let’s just say it's just beliefs, cultural beliefs, whatever it is, but it's still a problem and it still has to be addressed, because it is affecting so many lives around the world, and I have seen it myself. It's pretty devastating and breaks hearts. So how can you think we can address this problem? Thank you very much and I’m sorry for taking up so much of your time.
Bijan Etemad: I think we as physicians have learned not to do harm to patients. And that is our moral, ethical, legal, spiritual obligation. To do whatever we can to fight this awful, almost like a genocide. I mean, have been involved in, you know, some legal cases, people from different countries, mostly European, and so forth, and I think we as physicians have that obligation to really rally around the issue and to stop it. you know. Say something, do something. That is my statement.
Devan Stahl: I’ll just quickly add to that. In this country, we don't let parents make decisions for their children that are potentially life-threatening, or mutilating. So it's not as much of an issue in our country, because the Supreme Court decided a long time ago that we can't make martyrs of our children. That's sort of the famous line in the case. There's lots of instances in which physicians are able to override parents who are making life-limiting decisions for their children, based on any number of beliefs. But also that all clinicians have a right of conscience themselves, and so, if a patient is requesting something for themselves, or on behalf of their children, that the physician thinks is immoral, or wrong, they're allowed to say, “No. I don't want to participate in that. It's my right of conscience to say no,” and we respect that, for the most part in this country, especially with these kinds of cases where there is considerable dispute about whether this is part of the medical profession or not.
Renee Fennell: Can I just answer real quickly, piggybacking off of my co-panelists? Never underestimate your power of education. You might not use your power of education within the actual hospital setting, but outside the setting, you and other physicians can go around and just teach people. We were really effective. I worked with a group that went to and taught in Africa, in Ghana. And in Ghana, there was a real problem of this cultural taboo that they would be cured from AIDS if they had sex with a virgin. The men in the community were running around, you know, attacking the virgins, to try to get cured with AIDS.
What we did, I didn't do it personally, hahaha but I just contributed money to the cause, but what they did was they actually wrote up a whole curriculum of education to teach, not only the men in the community, but the women in the community, the mothers in the community, and also the boys and the young women. They had the statistics that it really didn't make a difference. So, you do have that power of education. That you can get with your colleagues and make a difference in your community.
David Krueger: Thank you so much for that, and thank you Mo’men for taking the risk of asking one of the most difficult questions of the conversation today, right at the very, very end, but I'm so grateful that you all stayed around for that, because that was really a powerful call. There are so many issues and topics that emerged out of our conversation today. We could have a series of these conversations, or perhaps a conference someday.
But thank you all again, much appreciated and let's stay in dialogue. This video will be posted soon. So thank you all for joining us from around the world.
Bijan Etemad: Thank you, it was a pleasure.
Devan Stahl: Thanks everyone.
David Walline: Thank you.
Heidi Isaac: Have a good day. Thanks for joining.
