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9/1/2004 Vol. 1, No. 15

Professional Practice
 

Dr. Wilson Mertens on the importance of spiritual counseling in the care of cancer patients

A Physician's Support for Incorporating Spirituality Into the Healing Process

Many cancer programs have incorporated “alternative”or “complementary”cancer therapies in their offerings, in an effort to engage patients and caregivers known from survey data to employ unconventional healthcare approaches [1]. However, few programs have robust spiritual or religious approaches to their supportive care components; this omission is the more regrettable given that religion constitutes an important aspect of their lives, and that many patients become more religious after a diagnosis of cancer [2, 3].

Perhaps the most likely explanation for this is the uneasiness felt by clinicians and healthcare program administrators, of offering care that might cause distress to patients who hold religious convictions of differing types and intensity. Yet, experience has demonstrated the remarkable patient receptiveness to chaplaincy in the inpatient hospital setting; indeed, a recent Gallop poll revealed that 95% of respondents believed in a higher power, and 82% felt the need to experience spiritual growth [4].

Cancer programs find themselves in a quandary with regard to delivery of psychosocial services: while early detection has led to dramatic increases in patient volumes, revenue challenges and a shortage of behavioral heath professionals make the goal of providing services to all in need, difficult. Incorporating chaplaincy might help to address both the challenges to spirituality individuals face as well as the desire to provide broader counseling by establishing non-clinical relationships with as many patients and families as possible.

I joined our cancer program as medical director in 2000, and was presented with the unique opportunity to work with a chaplain specifically assigned to our service. While accustomed to the intermittent ministry of hospital inpatient wards, the availability of a chaplain, attached not to the patient’s local church or synagogue but to an ambulatory healthcare setting, providing counsel and support to patients in the context of a relationship developing over time, was utterly new. Adding to the novelty was the discovery, or perhaps my developing awareness, of the widespread receptiveness of patients and their families to spiritual support provided by a cancer program. Finally, the opportunity for reconciliation for patients estranged from their faith has had a profound calming effect for many facing the struggle of their lives.

Chaplaincy and spiritual support in our program provides both comfort and discovery. It is an approach we have used for the implementation of other so-called alternative or complementary therapies: to provide support and relief without questioning or affirming an unproven intervention’s ability to change patient outcomes, while asserting a commitment to determine the true impact on patients through scientific study. Varieties of individual, group, and community chaplaincy programs are offered, planned, or led by our chaplain; many are evaluated for patient satisfaction and need [5, 6]. Others are involved in clinical trials, approved by our institutional review board, designed to determine if an aspect of spiritual support improves the patient state.

But the most striking impact of cancer program-based chaplaincy is the growing openness with which patients proclaim their faith in the clinical setting. Increasingly, patients feel a unity of effort between cancer treatment, chaplaincy, and belief. While I must confess that, being trained as a physician and not in the ministry, I felt initially uncomfortable by these demonstrations and conversations, I never cease to be impressed by the concurrent expressions of hope, relief, and acceptance that bolstered spiritual belief can achieve. Now these conversations are commonplace in our program and in my practice, and represent an important part of the journey to recovery and peace for many of our patients and their families.

The health benefits of spirituality are, fortunately, a growing area of investigative and clinical interest. When a cancer program provides such support for patients a twofold message is conveyed; the religious community supports the patient’s pursuit of physical well-being and physicians support their effort to incorporate spirituality into the healing process. Additional goals, including clinical investigation and outcomes assessment must be pursued to fully document and appreciate the impact of this aspect of caring.

References

[1] VandeCreek L, Rogers E, Lester J. “Use of alternative therapies among breast cancer outpatients compared with the general population.” Alternative Therapies in Health and Medicine 1999;5: 71-76.
[2] Fehring RJ, Miller JF, Shaw C. “Spiritual well-being, religiosity, hope, depression, and other mood states in elderly people coping with cancer.” Oncology Nursing Forum 1997;24:663-671.
[3] Eidinger RN, Schapira D. “Cancer patients’ insight into their treatment, prognosis, and unconventional therapies.” Cancer 1984;53: 2736-2740.
[4] Gallup G Jr, Lindsay DM. Surveying the Religious Landscape. Chicago and London: University of Chicago Press; 1999.
[5] Dann N.J., Mertens W.C. “Taking a ‘leap of faith': acceptance and value of a cancer program-sponsored spiritual event.” Cancer Nursing 2004; 27:134-141.
[6] Dann N.J., Higby D.J., Mertens W.C. “A structured spiritual service for cancer patients and families: analysis of attendee responses.” Annual Meeting, American Society of Clinical Oncology, New Orleans, LA, June 5-8, 2004 (poster). Proceedings of the American Society of Clinical Oncology 2004; 23: 758 (abstr).


Wilson Mertens is the medical director of the Baystate Regional Cancer Program, and of Cancer Services, Baystate Health System, Springfield, Massachusetts, and associate professor of medicine, Tufts University School of Medicine, Boston. He completed his undergraduate and medical training at The University of Western Ontario, London, Canada. A medical oncologist, Dr. Mertens has specialty board certifications from the Royal College of Physicians and Surgeons of Canada and the American Board of Internal Medicine. He also holds a masters of science in business administration from Madonna University, Livonia, Michigan. His previous positions include director of Biometry and Outcome Measurement, London Regional Cancer Center, and director of quality assurance and associate professor of medicine at the Barbara Ann Karmanos Cancer Institute at Wayne State University, Detroit.

 

Advocacy
   

Rev. Russell Myers, Sheilia Withrow, B.S.N. and Craig E. Litz, MD on chaplains and Institutional Review Boards

Patients Place Their Trust in IRB Members to Safeguard Their Rights
Who Can Better Represent Their Interests?

Many chaplains are familiar with the Food and Drug Administration (FDA) regulations regarding research on human subjects. Such research must be reviewed and monitored by an Institutional Review Board, or IRB. For those who are unfamiliar with the IRB process, here are a couple of definitions:

Under FDA regulations, an IRB is an appropriately constituted group that has been formally designated to review and monitor biomedical research involving human subjects. In accordance with FDA regulations, an IRB has the authority to approve, require modifications in (to secure approval), or disapprove research. This group review serves an important role in the protection of the rights and welfare of human research subjects.

The purpose of IRB review is to assure, both in advance and by periodic review, that appropriate steps are taken to protect the rights and welfare of humans participating as subjects in the research. To accomplish this purpose, IRBs use a group process to review research protocols and related materials (e.g., informed consent documents and investigator brochures) to ensure protection of the rights and welfare of human subjects of research.
(http://www.fda.gov/oc/ohrt/irbs/faqs.html#IRBOrg #1)

FDA regulations require at least one member of the IRB to have primary concerns in the scientific area and at least one to have primary concerns in the non-scientific area. Most IRBs include physicians and Ph.D-level physical or biological scientists. Such members satisfy the requirement for at least one scientist... FDA believes the intent of the requirement for diversity of disciplines was to include members who had little or no scientific or medical training or experience. In the past, lawyers, clergy and ethicists have been cited as examples of persons whose primary concerns would be in non-scientific areas. (http://www.fda.gov/oc/ohrt/irbs/faqs.html#IRBOrg #17)

We serve together on the Institutional Review Board of US Oncology, whose mission statement is: To safeguard the rights and welfare of research participants while enhancing the clinical research process. In that endeavor, we find the interdisciplinary makeup of the IRB to be a critical component of the review process. Each board member brings a unique and necessary voice to the table. It is our observation that hospital-based chaplains provide a valuable contribution to the healthcare enterprise by serving on IRBs. The chaplain brings:

1. Familiarity with the healthcare setting: The chaplain knows the culture of the hospital and is comfortable relating to physicians as peers in the interdisciplinary care team.
2. Professional expertise: Chaplains review the Consent Form from a non-medical perspective. They look for language that may confuse or frighten the patient, who may be anxious due to the diagnosis, and/or ready to take unnecessary risks to improve their health condition.
3. Conscious awareness of one’s limits: e.g. "I'm an educated person and if I don't understand the medical terms used in the consent form, maybe the patient won’t either."

Every hospital or healthcare organization that participates in clinical trials of experimental medical devices or experimental study drugs has an Institutional Review Board. If you haven’t been involved already, we encourage you to consider serving a term on an IRB. You will be asked to read a fair amount of material prior to the meetings, and to serve as primary reviewer for some of the studies. You will wade through pages of reports, looking at the Consent Forms for unfamiliar terms or phrases. You may wonder at times if you are making an impact. We can assure you of the following:

1. The process depends on the active participation of non-scientific board members;
2. The patients on the receiving end of the experimental drugs and medical devices are placing their trust in the IRB members to safeguard their rights and welfare; and
3. The medical professionals in your midst will look to you for your expertise as you work together toward that goal.


Rev. Russell Myers, D.Min., BCC has been a staff chaplain at United Hospital, St. Paul, MN since 1993. He is ordained in the Evangelical Lutheran Church in America and is a co-author of "Providing Spiritual Care to Cardiac Patients: Assessment and Implications for Practice" published in Critical Care Nurse, Vol. 20, No. 4, August 2000. Russ serves as the Association of Professional Chaplains State Advocacy chair for Minnesota and has been a member of the USOncology IRB since 1997.

Sheilia J. Withrow, B.S.N. is project coordinator for the US Oncology, Inc. IRB in Dallas, TX. She has worked in research since May of 2000 as a research report coordinator, senior regulatory safety coordinator, and senior coordinator for the IRB.

Craig E. Litz, MD, is currently the co-chair of the US Oncology Internal Review Board (IRB) on which he has sat for seven years. He works as a pathologist at St. Paul University Hospital in Dallas, TX. Prior to this he was an associate professor in hematopathology at the University of Minnesota Medical School in Minneapolis.

Education & Research
   

 

Chaplain Michael Pollitt on spiritual withdrawal in chemical dependency

Intoxication is a Form of Spirituality

Withdrawal is defined as a “positive craving.” In this instance the word positive is understood not as good but rather as seeking after. It is my belief, based on my experience in the chemical dependency field, that one of the major causes of relapse is something I call a “spiritual withdrawal.” What follows is a brief examination of the work of five of the leading figures in the area of addiction and spirituality. The underlying premise of all is that intoxicants answer spiritual needs. For the addict and alcoholic, intoxication is a form of spirituality, misguided and destructive, but spirituality just the same.

William James, MD (The Varieties of the Religious Experience, 1902), found striking similarities between intoxication and the mystical state. He called this “pathological mysticism” and “the anesthetic revelation.” James believed that there were two basic functions in man and woman. He called these the “yes” function and “no” function. There is a proper balance between the two. When the “no” function dominates, the individual is looking for something to bring back a spiritual parity. What he or she discovers is that intoxicants become “the great exciter of the yes function in man.” An historical note: It was James’ book that Ebby Thacher gave to Bill Wilson (the founder of Alcoholics Anonymous) in November 1934 at Towns Hospital, New York City.

Howard Clinebell, Ph.D. (Understanding and Counseling Persons with Alcohol and Drug and Behavioral Addictions, 1984), maintains that “we will never understand intoxication as a problem until we see it as a solution.” He also observes that the existential and spirituality anxiety of the addict and alcoholic is “quieted” by the “pseudo-religious sense of oneness with themselves, others, and the divine spirit.” The addict and alcoholic attempt to satisfy spiritual needs with chemical means.

Gerald May, MD (Addiction and Grace, 1988), a layman, reminded clergy of the major spiritual element in addiction and calls upon them to utilize this fact in their ministry to the addicted. According to May, addicts and alcoholics attach themselves to things that appear to fill their spiritual void. Because intoxicants produce a good feeling they become substitutes for the spiritual.

Stephen Anthrop (Alcohol and Substance Abuse: A Handbook for Clergy and Congregations, 1990), believes that we seek out things with apparent spiritual potential. When the spiritual potential is not activated, the person sees little reason to exist. Intoxicants become resources with apparent spiritual value until eventually they become value itself.

Thomas Baker, D.Min. (Understanding the Spiritual Nature of Addiction, 1995), argues that both spirituality and intoxication involve a search for meaning, value, and purpose in life. All persons desire these, but addicts and alcoholics are uniquely afflicted with a spiritual hunger, and traditional forms of spirituality do not satisfy them. He also observes that addicts and alcoholics suffer greatly from estrangement and intoxicants seem to provide a sense of connectedness.

We treat physical and psychological withdrawal but to a great extent we have neglected the spiritual withdrawal. The Spiritual Assessment at the Coatesville VA Hospital seeks to find out which spiritual and existential needs are being met by the patient’s drug of choice, and without that drug, i.e. sobriety, which spiritual and existential needs are not being met. This approach speaks to the importance of the spiritual and existential side of addiction, and the belief that intoxicants are used, in counterfeit fashion, to answer those needs. The major problem which addicts and alcoholics face in recovery is not addiction but rather relapse. It is my contention that relapse, the return to one’s drug of choice after a period of sobriety, is primarily a spiritual and existential problem. In sobriety the spiritual and existential vacuum that the intoxicant filled is present again. Nature hates a vacuum and will eventually fill it. The addict and alcoholic cannot be spiritually and existentially passive in their recovery.


Chaplain Michael Pollitt, D.Min., BCC, CAC, is chief chaplain at the Coatesville (PA) Veterans Affairs Medical Center. He is author of “The Spiritual and Existential Nature of Relapse in Chemically Dependent Patients” published in Chaplaincy Today, Vol. 19, No. 1, Spring/Summer 2003. He is a certified addictions counselor and an Episcopal priest. Correspondence may be directed to Michael.Pollitt2@med.va.gov.

Spiritual Development
   

The Rev. Cari Jackson on the power of choice

Choices Motivated by Love

Everyday we have the opportunity to make choices — some large, some small. Sometimes the options are so slim or grim, we may feel like we have no choices at all. Often we focus on the quality of the things we have to choose from. But the real issue is what is directing our choice-making. That is, what is the greater influence directing our life choices — love or fear?

When I was in college, I read The Purity of the Heart is to Will One Thing by Søren Kierkegaard in which he raised this question: Why do you serve God, because of a fear of hell or a love of God? This question transformed my world. Because my religious teaching was deeply influenced by a fear of G-d, fear was the basis of my relationship with G-d. Then I realized how much fear was the operating paradigm that dictated all of my life. And because I was afraid to “mess up,” I often did not take the risks and the leaps of faith needed to help me experience myself as a whole and courageous person.

Some argue that if people did not have the fear that G-d would zap them for wrongdoing that they would abuse G-d’s love. Because this theology of fear was instilled in me, at first I could not get it that G-d’s love for me is so great that no matter what “wrong” turns or “bad” choices I made, G-d would always search, find, and bring me to where I needed to be–like the parable of the lost sheep. Over time, because of the challenge presented to me in The Purity of the Heart, I began seeking to make choices in relationship to G-d and all of life with a focus on love. To my surprise, as I focused more on love, I had less desire to engage in any activities that did not honor G-d, myself or others. And the more I focused on love in all of my relationships, career choices, etc., the more joy, power and freedom I discovered in all of my life.

Perhaps you have been making choices directed by fear for so long that you don’t even know when fear is leading you or how to follow love. So here are some things that work for me.

  • Trust that whatever choices you make or path you take, G-d will be with you and will use the journeying of your life for your growth and G-d’s glory. Remember, it’s not about the destination, but the journey.     
  • Check how your body responds to your thoughts about your current choices, especially your head, neck, shoulders, back, chest, stomach, and hands. What is your body telling you? If you feel fear, ask your body what you are afraid of.
  •  
  • Go deeply within your spirit, through meditation and prayer, in order to access information within you beyond the level of judgment and fear about what the “good and right and whole”path is for you now.
  •    
  • Invite someone with whom you feel safe to sit with you and listen to you while you speak about the choices before you. Your partner is not to interrupt you, just listen. Invite your partner to ask you clarifying questions. Then, ask your partner to share what s/he heard and felt is primarily directing you—love or fear.

Choices motivated by love —even though you may make mistakes in the process —enable you to see more clearly and to live more fully, freely, and authentically. Choices about jobs/career, relationships, self-care, finances, and so on become more life-affirming and consistent with your life goals and values when you are directed by love.


The Rev. Cari Jackson is the founder and executive director of The Center of Spiritual Light, a psycho-spiritual healing and wellness center in New York City. She formerly served as associate pastor for congregational life at The Church of St. Paul and St. Andrew, United Methodist, interim pastor and lecturer at Union Theological Seminary, and as assistant worship coordinator at The Riverside Church all in New York City. Cari is the author of The Gift to Listen, The Courage to Hear (Augsburg Books, 2003). She is a Ph.D. student in Christian Social Ethics at Drew University, focusing on psycho-spiritual self-care as an ethical responsibility of clergy.

EthicsWalk

EthicsWalk addresses spiritual care as an ethical enterprise. It explores why relationships between spiritual care providers and those they serve need protection, and examines what that protection entails. PlainViews invites our readers to share their responses to each EthicsWalk column, which will be published in the following issue.

If you’d like to respond to EthicsWalk, please send a comment of no more than 100 words. You can use the e-form below (click on "hearing from you," link) or submit your commentary to the editors in the body of an e-mail (or as a “Word” attachment) sent to Info@PlainViews.org. Please put the phrase “EthicsWalk” in your subject line.

We look forward to hearing from you.


An Ethical Dilemma Affecting Clergy and Other Ministers:
The First Amendment and Title VII

The last EthicsWalk discussed “ethical dilemmas,”those instances where one must choose between good but competing moral values. This EthicsWalk examines an ethical dilemma directly affecting ministers.[1] The potentially conflicting values are religious freedom and justice in employment relationships.

Religious freedom, meaning government non-interference in the religious life of citizens, is guaranteed by the Free Exercise and Establishment clauses of the First Amendment.[ 2] The decisions of religious leaders on “matters of discipline, faith, internal organization, or ecclesiastical rule, custom, or law,”[3] are not open to secular court scrutiny or civil legislation. This includes decisions affecting the paid or volunteer work of ministers.

Justice in employment relationships is promoted by Title VII of the Civil Rights Act of 1967 as amended. It applies to public and private work places with fifteen or more regular, full time employees.

First Amendment constraints exempt religious bodies from Title VII. How they hire, fire or otherwise relate to employees with “ministerial”duties is beyond the reach of civil law.[4] The WalMart clerk is better protected against work place sexual or racial harassment than is the chaplain at a Baptist Hospital,[5] the seminary theology professor [6] or the associate rabbi.[7]

Clergy and lay ministers have no recourse to legal action if their “civil”rights are violated in their work with religious institutions. Only the religious body can enforce rules and remedies. There is an ethical duty to enforce policies prohibiting discriminatory behavior by or towards all employees: those with ministerial duties and those without. (The latter remain covered by Title VII in most instances). Secular policies provide a foundation; the religious body can articulate higher standards in its codes and procedures.

Some idealists mistakenly believe that religious bodies are free from behaviors addressed by Title VII. In a 1993 survey of women rabbis, 70% reported being sexually harassed during their career. Twenty-five percent experienced harassment monthly.[8] Figures are similar for Protestant clergy women with most problems occurring during seminary, field placements, and pulpit searches.

Public and judicial trust in religious institutions “doing what’s right”is eroding. Courts reflect societal changes, and their resistance to claims involving ministers or religious institutions is softening. The child sex abuse scandals exposed religious leaders more intent on protecting their own than the vulnerable.

This July the Ninth Circuit overturned a lower court’s routine dismissal of Title VII sexual harassment claims by an associate minister against her church and senior pastor. While upholding traditional First Amendment protections, the Court distinguished aspects of the claim that could proceed without implicating constitutional prohibitions. The court notes, “These issues concern the Defendants’actions, not their beliefs.”[9] “The First Amendment should not require that churches become sanctuaries for sexual harassment by those who act outside of church doctrine.”[10]

Courts appear ready to find mechanisms to require compliance with minimal standards for treating employees and congregants with respect. Perhaps religious bodies should welcome, rather than resist, secular review when moral failure is alleged.

I encourage you to respond to this column.

The next EthicsWalk notes that harassment policies also protect the people served by ministers and discusses why such protection is an ethical imperative.


[1] Courts apply the term “minister”to all ordained clergy as well as lay persons who have some pastoral duties. For example, EEOC v. Catholic University, 83 F.3d 455 says lay employees fall under clergy exemption if their “primary duties consist of teaching, spreading the faith, church governance, supervision of a religious order, or supervision or participation in religious ritual and worship.”
[2] “Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof.”
[3] Serbian Eastern Orthodox Diocese v. Milivojevich, 426 U.S. 696,713 (1976)
[4] Id.
[5] Sharon v. St. Luke’s Episcopal Presbyterian Hosp., 929 F.2d 360 (8th Cir.1991)
[6] Maguire v. Marguette University,627 F. Supp. At 1506.
[7] Elvig v. Calvin Presbyterian Church, 9th Cir., No. 02-35805, 7/23/04.
[8] Cowan, Jennifer R. Moment: The Magazine of Jewish Culture and Opinion, 18 (5,Oct.):34-37.
[9] Elvig at 9729.
[10] Id. 9731.


Anne Underwood has an undergraduate degree in religious studies, a master’s degree in rural sociology and a mid-life law degree obtained after working over a decade as a college administrator. She has mediated for the Maine family courts since 1983. Currently she serves as an advisor to the ethics commissions of ACPE, APC, the CCAR (Central Conference of American Rabbis), and NAJC, and consults with a variety of Protestant faith communities on issues of power, fair process, and congregational conflict management. Her articles on mediation and restorative justice have appeared in the ACPE News, The APC News and on the ACPE web cite. Articles on clergy accountability and judicatory processes are published by the Alban Institute and The Journal on Religion and Abuse. A chapter, “Clergy Sexual Misconduct: A Justice Issue,” appears in Body and Soul: Rethinking Sexuality as Justice-Love, Marvin Ellison and Sylvia Thorson-Smith, editors, The Pilgrim Press, 2003.

 

Reviews

Macky Alston reviews the film Baraka: A World Beyond Words

Baraka: A World Beyond Words

Baraka: A World Beyond Words, is a religious experience. Many have labeled it prayer on film. It has been used creatively in a range of settings, from hospitals to universities, and we recommend it to chaplains looking for engaging resources for their constituents.

There is no dialogue in this 96-minute film. It is the images shot throughout the world of humankind, often involved in religious rituals, and of nature at its most dramatic, all set against a haunting musical score that make Baraka so spiritual. The film is shot in breathtaking 70 mm in 24 countries on six continents.

“Baraka” is an ancient Sufi word that translates as a blessing, or as the breath or essence of life from which the evolutionary process unfolds. The film captures not only the harmony and interconnectedness of humankind with the earth, but also the disjointed and harmful relationship between the relentless advance of civilization and the sanctity of our planet.

Baraka must be seen to be understood.


Macky Alston is the director of Auburn Media, a division of the Center for Multifaith Education at Auburn Theological Seminary committed to supporting, cultivating and promoting powerful, engaging, balanced and responsible media on religion, spirituality and ethics. He is a graduate of Union Theological Seminary and an award-winning documentary filmmaker.

Completed: 1993
Running Time: 96 Minutes

Directed and filmed by: Rom Fricke
Produced by: Mark Magidson
Edited by: Ron Fricke, Mark Magidson and David Aubrey
Music by: Michael Stearns, Dead Can Dance, Daivd Hykes/The Harmonic Choir, Somet Satoh, Anugama & Sebastiano, Kohachiro Miyata, Inkuyo, L. Subramaniam, Monks of the Dip Tse Chok Ling Monastery, Rustavi Choir, Ciro Hurtado, Brother.
 
If you are interested in purchasing this film you can do so at www.hartleyfoundation.org. Just click on “Masterworks” on the homepage for more information. Both the VHS version and the DVD version of the film are priced at $19.98.



spacer 9/1/2004 Vol. 1, No. 15
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Professional Practice
Wilson Mertens, MD: The Importance of Spiritual Counseling in the Care of Cancer Patients
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Advocacy
The Rev. Russell Myers,  Sheilia Withrow, B.S.N. & Craig E. Litz, MD: Chaplains and Institutional Review Boards
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Education & Research
Chaplain Michael Pollitt: Spiritual Withdrawal in Chemical Dependency
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Spiritual Development
The Rev. Cari Jackson: The Power of Choice
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EthicsWalk
An Ethical Dilemma Affecting Clergy:  The First Amendment and Title VII
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spacerReviews
Macky Alston reviews the film
Baraka: A World Beyond Words
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