Human Values in Medicine—From Core Human Values (Universal Values) Perspective

DOI: 10.4236/jss.2020.84026   PDF   HTML   XML   75 Downloads   204 Views  

Abstract

According to Sathya Sai Baba, an Indian philosopher, educationist and philanthropist, human values have their derivative from the concept of divinity. In other words, human values are the characteristics of God in human condition. He postulated the five human values, viz: Love, Truth, Right Action, Peace, Non-Violence. Within each value, there is a range of sub-values and they are expressed in medical ethics values. Medical ethics, on the other hand, is a system of moral principles that apply values to the practice of clinical medicine and in scientific research. These values include the respect for autonomy (self-determination), non-maleficence (non-violence), beneficence (charity), justice (equity). Sai Baba points out the subtle difference between human values and ethics, namely, that ethics is a system conceived by humans without underpinning the role that divinity plays. Taken together with their sub-values, these five basic principles encompass a full vision of human potential, namely, the fulfillment of the quest of the intellect for truth, the channeling of the will into satisfying expression through right conduct, the resolution of the conflicts of human emotions and interactions in the achievement of inner and outer peace, the expansion of the heart in the flow of love and the realization of perfect sympathy of all creation through non-violence. Human values in medicine, apart from being the moral benchmark for relationship between physician and patient, necessitate ensuring that clinical and management practices are consistent with widely accepted ethics standards, norms, and expectations. In recent years, scientism as a goal has frequently led to the neglect of the humanism inherent in medical practice that the science of medicine has assumed precedence over the art of medicine. The pedagogy of Sai Baba’s value-based healthcare helps to elicit the human values inherent in every human being.

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Oji, C. (2020) Human Values in Medicine—From Core Human Values (Universal Values) Perspective. Open Journal of Social Sciences, 8, 363-375. doi: 10.4236/jss.2020.84026.

1. Introduction

What is the use of acquiring high education if one is found wanting in virtues? What is the value of such education? What is the use of ten acres of barren land? Instead a small piece of fertile land is good enough. Sathya Sai Baba (1926-2011).

To educate a man in mind and not in morals is to educate a menace to society. Theodore Roosevelt (1859-1919).

Many forms of present day schooling lay emphasis on the ingestion of facts and their subsequent regurgitation during examinations. The outcomes are two world wars between 1914 and 1945 that caused over 72 million deaths; Russia’s dictatorship of Josef Stalin and China’s Mao Tse Tung brought about the death of over 107 million innocents; the combined arsenal of over 20,000 nuclear warheads world-wide is sufficient to render the planet inhabitable several times over; every year 3.1 million children die of hunger-related diseases, 21,000 people every day, one person every four seconds. If we look at the common theme underlying all this darkness, we can say that it is the wanting of something from the world, rather than the wish to give and serve the world, selfishness instead of selflessness, I instead of We (Farmer Ron & Suwanti Farmer, 2015a).

The Human Values Education programme, with its emphasis on the five core values of Love, Truth, Right Conduct, Peace and Non-violence, had its genesis during the 1970s and 1980s in schools throughout India, Thailand, United Kingdom and Zambia. It was based on a multi-faith educational model proposed by Sathya Sai Baba, a spiritual teacher who was also Chancellor of the Sathya Sai Institute for Higher Learning, one of the foremost universities in India. The foundation principles of Human Values Education are that:

· The five universal Human Values of Love, Truth, Right Conduct, Peace and Non-violence encompass all the noble values, have endless depth and breadth in their beauty, purity and power, and lie within every human being in full measure, largely hidden from conscious awareness like diamonds inside a mountain.

· The ideal aim of education is to bring forth these Human Values in every student to the fullest extent possible.

· The essential catalyst for the manifestation of Human Values in students is for the teachers and parents themselves to become inspiring, noble exemplars of the five values in action (Farmer Ron & Suwanti Farmer, 2015b).

Other values are, of course, important. For example, the common framework used in the analysis of medical ethics is the “four principles” approach postulated by Tom Beauchamp and James Childress in their textbook Principles of biomedical ethics (Gillon, 1994). It recognizes four basic moral principles. These principles are:

Autonomy: the patient has the right to refuse or choose their treatment. This is freedom. Freedom enhances Peace. Autonomy, therefore, is a sub-value of Peace.

Beneficence: a practitioner should act in the best interest of the patient. It is a sub-value of both Right conduct and Love.

Non-maleficence, to not be the cause of harm. Also, “Utility”, to promote more good than harm. It is a sub-value of non-violence, which also means non-injury by thought, word or deed.

Justice: a sub-value of right action and love that concerns the distribution of scarce health resources and the decision of serving others with social justice of who gets what treatment (Beauchamp & Childress, 2013, Beauchamp & Childless, 2009a, Beauchamp & Childless, 2009b).

An appreciation of Human Values Education will develop along with a deeper understanding of what each one of the five values, namely, Love, Truth, Peace, Right Conduct and Non-Violence, represents.

LOVE

Esoteric meaning: In its esoteric sense, the highest Love is unbounded; neither increasing nor deceasing; constant as a fixed distant star. It is like the sun, shining equally on all, regardless of praise or censure. Love is nurturing, sustaining, attracting, expanding, unifying and self-sacrificing. Love is life. Who we are, is love. All there is love.

Practical meaning: In practice, those seeking to live according to Love, will try to be gentle, caring, empathetic, compassionate and forgiving towards others. They will find joy in in serving others; be loyal in friendship, practise tolerance and patience; and strive to restrain anger, greed, desire, envy and jealousy. They will be good listeners. They will be looking for the innate goodness in all, and loving everyone the same and unconditionally. They will be happy for others’ happiness. They will seek to overcome all difficulties with Love.

TRUTH

Esoteric meaning: Scientists and seers remind us that we are all waves on the one vast limitless ocean of energy. It is this oneness that defines Truth, often referred to as God or Universal Consciousness, the one reality that manifests as all this apparent diversity. To know one’s true self is to know Truth, as when the bubble bursts, it knows itself to be the entire ocean. We are not separate from anything or anybody; we are in every cell as life and in every atom as activity. I am in you and you are in me.

Practical meaning: Those seeking to live practically according to Truth, will do their best to be honest with themselves and with others, and will be true to their word. They will seek to develop their intuition, together with a sense of enquiry, open-mindedness, detachment and fearlessness; and will seek to discriminate between right and wrong by diligently listening to their conscience. They will cultivate the feeling of being connected to everything and everybody, remembering that what we do to others, we do to ourselves.

PEACE

Esoteric meaning: Abiding in perfect Peace, we are not troubled by fear, desire, envy, hatred, greed or any of the tormenting passions – they are only transient mid-images on the unchanging screen of universal consciousness. We therefore experience unshaken tranquillity, not swayed by praise or blame, profit or loss, joy or sorrow, regarding them merely as two sides of the same coin, for all is One.

Practical meaning: In its practical application, those seeking to be in Peace, will practise self-discipline, patience, tolerance and non-attachment. They will look before speaking and acting; avoid or neutralise anger; place limits on satisfying their desires; learn to still themselves for reflection and prayer; try to love and serve all; and strive always to be true to their conscience. They will aim to regard all events as auspicious; develop humility; smile in times of difficulty; and cultivate optimism. They will remind themselves that Peace is to be found within and not outside oneself.

RIGHT CONDUCT

Esoteric meaning: Right Conduct guides the whole universe-from atom to galaxy-in an exquisite dance of power and perfection. Every single thing is subject to rules, which define “correct action” in the content of its special place in the universe – its unique duty, nature and function. To align ourselves with the current of Right Conduct, we need to ask of each action whether it will lead us closer to, or away from Love, Peace Truth and Non-Violence.

Practical meaning: Those seeking to practise Right Conduct will show respect for society’s laws, their parents and elders, and the customs and practices of other cultures and faiths. They will aim to be healthy, tidy, punctual, dutiful, reliable and responsible; to live simply; to study and work diligently; to respect elders; and to take on duties and responsibilities willingly. They will develop self-reliance, self-discipline and enthusiasm. Underlying all this, is a commitment to be true to the inner guidance of conscience, which prompts all of Nature to be uniquely and perfectly Itself.

NON-VIOLENCE

Esoteric meaning: The two essential components of Non-Violence are understanding and love, understanding the Oneness of all creation nurtures care in our thoughts, words and deeds. The key to curbing violence is minimising ego-centred desires. Recognising our kinship with all of Nature, we hold to the supreme maxim: “Help ever, Hurt never”.

Practical meaning: Those trying to practise Non-Violence will try to avoid expressing anger, resentment, envy, jealousy and bitterness, instead, doing their best to cultivate Love and Peace. They will cultivate gentleness, kindness and friendliness with all; having sympathy for the pain and difficulties of others, and so being unwilling to hurt or insult others in thought, word and action. They will avoid finding fault with others, and will practice forgiveness and forbearance when abused.

None of the five Human Values can stand alone. There can be no Love without Peace, Truth, Right Conduct, and Non-Violence. Our behaviour can only be regarded as Right Conduct if at the same time we are feeling, thinking, and behaving peacefully; we are not practising Non-Violence if our heart is closed and our behaviour lacks integrity. Each of the Human Values is defined by the other four, although Love ultimately has primacy.

The primacy of Love can be understood a little more by referring to the following loose formulation:

Love + Thought = Truth.

Love + Action = Right Conduct.

Love + Feeling = Peace.

Love + Understanding = Non-Violence (Farmer Ron & Suwanti Farmer, 2015a).

The purpose of this paper is to highlight the key message of Sai Baba’s Human Values in education and particularly in medical education, namely, the inclusion and teaching of the core human values and their ramifications in the curricula of medical schools; the need for clinicians to apply and maintain these human values, while carrying out their duties in order to ensure that the dignity of the patient is protected, the accentuation of the fact that the ideal health care lies in the physical, mental and spiritual wellbeing of a person, finally, to emphasize that the doctor-patient relationship is a divine bond.

Research Process: we searched journal articles and reputable textbooks relating to Human Values Education and biomedical ethics.

Teaching Strategies and Techniques in Human Values Education (Farmer Ron & Suwanti Farmer, 2015b).

There are eight Teaching Strategies recommended for Human Value Education, namely,

1) Quiet Time.

2) Mindfulness (Silent Sitting).

3) Wise Sayings.

4) Story Telling.

5) Peaceful Mind, Open Heart.

6) Service Learning.

7) Unity of Faith.

8) Role Modeling.

1) Quiet Time as a Teaching Strategy: Human Values Education uses the term Quiet Time to describe any period that has been set aside, mostly at the start and close of the school day, during which the class or whole school is quietly engaged in sitting or lying silently, in singing, praying, exploring a wise saying, repeating an affirmation, participating in rituals and/or hearing a moral story. Prayers and rituals are an opportunity for the student to experience the sacred, the grand mystery and beauty that runs like an underground stream beneath all of life’s surface troubles and joys. Each student knows through own life’s experiences that society uses rituals to convey how some event or time is valued by the society or community (e.g. birthdays, Mothers’ Day, etc.) sufficiently to warrant the group coming together to celebrate, reflect or to resolve grief.

2) Mindfulness as a Teaching Strategy: In the early history of Human Values Education, any period of sitting quietly while focussing on the breath, or on an image or sounds was referred to as Silent Sitting, in large part because of the advice given by Sathya Sai Baba on the benefits physical stillness. He said: Why do we ask people to sit straight and to sit quiet in meditation? Because when the body is straight and quiet, the mind inside is also straight and quiet. If you cannot control your body, how can you control your mind? The first thing is to control your body by having all the limbs and body organs in a steady manner. The basis for the mind wandering is that your physical body is also wandering. So, the first thing you have to do is to give up the continual wandering of the physical body.

In psychology, education and other disciplines, there has been an explosion of interest over the past 10 to 15 years in the practice of focusing the mind on the present, on the “NOW”, so much so that the term “mindfulness” is now in common usage. For this reason, Human Values Education refers to this teaching strategy as Mindfulness, which can include the following:

· Sitting or lying still.

· Focus of the mind on the breath, body parts, external sounds, the experience of eating and walking etc.

· Guided imagination of light illuminating different parts of the body, and then throughout the whole world.

· Repetition of special words, either in time with the breath (e.g. “I breath in peace, I breath out restlessness”), or independent of the breath (e.g. “I am now being kind to more and more people every day”).

· Visualising being courageous, confident, happy, forgiving, and so on, in specific situations.

3) Wise Sayings as a Teaching Strategy

Words of wisdom can have a transforming effect upon us, particularly if reflected upon and repeated over and over again in a heart-felt way. Some well-known aphorisms, like Mahatma Ghandi’s “Be the change you want to see in the world”, have become imprinted in the minds of millions, gradually moulding the cultural mores towards goodness, wisdom and compassion. The aims of Wise Sayings teaching strategy are as follows:

· To learn quotations, phrases, affirmations or prayers that succinctly illustrate character traits the student would like to develop.

· To encourage students to re-program their minds with the wisdom of the ages so that, according to the maxim “whatever a person thinks, so he becomes”, their habits and character will increasingly manifest their innate Human Values.

· To develop a supremacy of thinking, in both the conscious and sub-conscious minds, that will enable the students to automatically turn towards the Highest in themselves, and look for the best in others.

4) Story Telling as a Teaching Strategy

Whether the source be Zen, Christian, Sufi, indigenous tribes, Hindu, ancient Greece, Chinese oracles or mystics, verbal and pictorial teaching stories have always played a key role in passing on to the younger generation the values and social mores of the family, society and nation. We all think of our lives as a set of chronicles, some of which are allied to the life drama of others. Stories told to the students can range from personal experience stories to passed-down myths and made-up fables, creation stories and folk tales, revealing episodes in the lives of saints and other great people, historical events, news items, stories from sacred books and many other stories.

5) Peaceful Mind, Open Heart as a Teaching Strategy

Human Values Education is using the Peaceful Mind, Open Heart to describe teaching strategies evolved from recent developments in psychology, neurophysiology, and values education strategies for teaching students how to calm their mind, soften the heart and be happy, confident and secure. The term Peaceful Mind, Open Heart is often used by modern day leaders of Buddhist retreats and teachers of mindfulness. Human Values Education recognises that these simple words represent the essence of the five Human Values of Love, Truth, Peace, Right Conduct and Non-Violence, each one of the Human Values must be present, at least to some degree, if we are to experience the joy of a balanced mind amidst feelings of love and compassion for all. To live with a peaceful mind and an open heart necessitates abiding in each one of the universal Human Values, neglect or contravening just one of the Values will both agitate the mind and trouble the heart, for example, considering the virtue of honesty (an aspect of Truth): if we tell an untruth, our mind will always have to be on guard against exposing the deception, and consequently, our heart will close one of its doors so that we can distance ourselves from the other in fear.

6) Service Learning as a Teaching Strategy

Here are three most relevant definitions of Service Learning:

· Service learning is a teaching and learning strategy that integrates meaningful community service with academic study to enrich learning, teach civic responsibility and strengthen communities (Fiske, 2002).

· Service learning is an activity that combines service activities with learning objectives, with the intent that the activity benefits both the recipient and the students’ provider of the service. The service is to be conjoined with structured reflection that helps the student to learn and understand the value, skills and academic content (Holland, 2008).

· Service learning is a teaching method, which combines community service with academic instruction as it focuses on critical reflective thinking and civic responsibility. Service learning programs involve students in organized community service that addresses local needs, while developing their academic skills, sense of civic responsibility, and commitment to the community (APA, 2009).

Some of the advantages of Service learning are:

· Student engagement: this is evidenced by increased attendance and motivation learning. Students are able to explore more deeply, engage in dialogue to ensure understanding and become more connected with the activities. Improves higher order thinking skills, skills such as analysis, problem-solving, decision-making, cognitive complexity and inferential comprehension are improved because student learning is exposed to real world tasks that require these skills.

· Improves higher order thinking skills such as analysis, problem-solving, decision-making, cognitive complexity and inferential comprehension are improved because student learning is exposed to real world tasks that require these skills.

· Develops important personal and social skills for young people. Character development such s trustworthiness, responsibility and compassion.

· Develop stronger links/connection to their schools, communities and society. Service learning can assist young people to understand and believe that they can make a difference in their schools, communities and society.

When projects requiring selfless loving and selfless service are enacted, there is no gain for the student other than n opening of the heart and the development of an urge to serve the suffering and the down-trodden, or to address a pressing need that benefits the whole community.

7) Unity of Faiths as a Teaching Strategy

As one of the eight teaching strategies used in Human Values Education, Unity of Faiths can play an important part in students’ awakening to the beauty and grandeur of their true Self, the treasure within, the exquisite face behind the veil. The Unity of Faiths teaching strategy in Human Values Education has as objective the development of a clear understanding in the students that all Faiths proclaim the same universal message, and so prepare them for a life without separation, exclusiveness and possible bigotry. The ideal outcome is that the students will whole-heartedly respect the differences between the Faiths and recognise them as valid, each one having its own precepts and principles, yet all extolling the virtues of attaining purity of mind and heart.

The components of Unity of Faiths teaching strategy include the following:

· History of the different Faiths.

· Different religious places of worship.

· Festival days of the different Faiths.

· Identifying the principles that unite all Faiths, such as Love, Truth, Right Conduct, Peace, non-violence.

Some of the techniques that can be used within the Unity of Faiths teaching strategy are:

· Story telling.

· Group discussion using Socrates Circle strategy (Copeland, 2005).

· Role play of how unity underlies all Faiths.

· Integrating the history and the wisdom of different Faiths in various lessons.

8) Role Modelling as a Teaching Strategy

This is a dynamic phenomenological reality rooted in the intangible moral behaviour exemplified by role models. In the Sathya Sai Education in Human Values (SSEHV), the concept of role modelling and socialisation has emerged as a pivotal one in medical ethics education. This concept may be akin to what (Hafferty, 1998) refers to as “the hidden curriculum”. Human values in medicine cannot be taught but rather, can be learnt through observational and situational reality learning, and through experiential participation (Kenny, Mann, & MacLeod, 2003). In this manner, students will acquire authentic ethical competence through knowledge, socialisation and role models, and it will become an internalised, qualitative professional identity rather than a mere add-on tool or technique (Hafferty & Franks, 1994). According to (Swick, 2000), the values and behaviour that individual physicians demonstrate in their daily interactions with patients and their families, and with physicians and other professional colleagues, become the foundation on which medical professionalism rests.

Doctor-Patient Relationship: Human values teach us that the doctor-patient relationship is a divine bond. Humanistic qualities of doctors and human values have been known since times immemorial. The sanctity of the physician-patient relationship stems from the noble role of the medical profession, and is secured by medical ethics, compassion and confidentiality. There is an intense personal relationship between the physician and the patient, which should be honoured and respected. Humanistic behaviour combined with expert medical knowledge and clinical judgments create a deep impact on the patient and his family. Nowadays, the noble medical profession has acquired a more commercial attitude. Degrees are gained as means only for earning a livelihood. Priorities having been changed, each patient is seen as a source of extracting money. Since more new patients bring in more money, little time is given to each patient. The divine values of love, compassion and sacrifice have been tainted with hypocrisy. Hence, people have also developed an attitude of mistrust towards the doctors. Because of a selfish few, an otherwise divine bond between the two is not available. Diseases are half-cured when the doctor talks to the patient with love and consideration. The sick and the disease respond favourably to the doctor’s treatment once he starts talking to them with love and with a smiling face. However, if the doctor wears a grim expression, the patient loses heart. Doctors should administer the injection of courage and encouragement as calcium is administered to the weak. It is essential that doctors should have the sterling virtues of love and compassion. Compassion is more important than money. Doctors are in the field of medicine and are supposed to be skilled persons. After they have acquired thorough knowledge, it is also important to develop communication skills. The confidence of vast knowledge should be seen in his movements, the so-called body language, through decency and respect. At the same time, he has to be humble in speaking without any touch of arrogance. The doctor must explain medical terminology in simple words that anybody can understand. A doctor should himself reflect the knowledge he has gained. He should be concerned about himself, be clean, hygienic, eat nutritious food, thus keeping his own self healthy; taking care not to become a victim of disease by a mere careless approach. Moderation in all aspects of life is the key to success. Moderation in talk, in the food he eats, in what he sees and listens (Human Values Input in Medical Education). As the doctor works hard, he understands the truth of life. No doubt, he has a job to save lives, at the same time, he realizes that beyond certain limits he is helpless. Then he becomes a bystander in the final events when they become inevitable. This is where he learns compassion. Ultimately, it results in the patient receiving better treatment. In short, the doctor has to be a true human being. To show concern, to be committed, and to radiate compassion will turn the doctor into a near super-natural being. By these efforts, he will develop tremendous confidence and faith in the patient with whom he is dealing. What will such a doctor earn by doing so? He will earn tremendous goodwill, job satisfaction, and respect from all. Worldly pleasures, material and monetary gains will also follow but they will be of secondary importance to him (Talbot Parsons, 1954).

2. Discussion

As the field of human values in medicine or as the case may be, medical ethics, continues to develop and change throughout history, the focus remains on fair, balanced, and moral thinking across all cultural and religious backgrounds around the world (Coward, 1999, Brow, 2002). Human values (medical ethics) encompasses beneficence, autonomy, non-maleficence and justice as they relate to conflicts such as euthanasia, patient confidentiality, informed consent, and conflicts of interest in health (Appel, 2006, Ruger, 2014, Guldal & Semin, 2000). In addition, medical ethics and culture are interconnected as different cultures implement ethical values differently, sometimes placing more emphasis on family values and downplaying the importance of autonomy. This leads to an increasing need for culturally sensitive physicians and ethical committees in hospitals and other healthcare settings (Coward, 1999, Brow, 2002, Ahmed, 2000). However, the medical ethics curricula have effectively de-emphasized the above-stated values in favour of the abstracted Western value-complex of individualism. The factors that make up the de-emphasising of humanistic values are: the evolution of medicine from a simple physician-patient relationship into a pluralistic, commercialised healthcare industry (Kenny, Mann, & MacLeod, 2003); the rise and dominance of principium in the wake of the unprecedented biotechnology revolution and the rise in socio-political awareness that followed the Second World War (Beauchamp & Childless, 2009c); and the philosophical erosion of virtue-based ethics. Accordingly, concern for the physician’s personal virtue was eclipsed by the emphasis on general bioethical principles aimed at monitoring the broadened medical industry (Kenny, Mann, & MacLeod, 2003). Hence, the challenge remains: how to steer medical ethics education towards producing the desirable person-centred, value-sensitive physician in view of the unprecedented, and potentially dehumanising, ethical complexities of the biotechnology revolution. A review of medical ethics education over the last four decades indicates that it has become imperative that humanistic values be articulated and integrated into the traditionally science-based medical education curriculum (Doukas, McCullough, & Wear, 2010). Integrating the humanistic values with biomedical science from the beginning of medical training highlights and reinforces the indispensability of these values in medicine (Kanter, Wimmers, & Levine, 2007). As a result, medical ethics education today must be geared towards promoting value-laden, person-centred healthcare delivery systems that address the daily needs of patients and their families (MacRae, 2001). There are many challenges in attempting to harness a value-laden curriculum in education in human values. In the first place, the heavy workload during medical training limits the necessarily time-consuming process of ethical enquiry. Second is the issue of the suitability of faculty as role models for the medical students. There is evidence that virtuous role-modelling is profoundly more effective than formalised medical ethics coursework in transmitting medical morality (Goldie, 2000). More importantly, since the ultimate aim of education in human values in medicine is to re-affirm the human dignity of the patient (Consensus Statement by Teachers, 1998), there is an urgent need to appraise and clarify the concept of human dignity in contemporary bioethics. Notwithstanding, if properly conceived, the dignity of the human person essentially arises from the inalienable intrinsic value of the human being, for simply being a member of the natural kind of embodied rational nature that constitutes the human person (Lee & George, 2008). The dignity of the human person is the source of all authentic human values and is rooted in a comprehensive account of human nature and the notion of the human good.

The concept of the Sathya Sai Education in human values in medicine calls for a deeper inquiry into the notion of human dignity, the nature of the human person, the true human good and what constitutes the unitary good of the patient. Furthermore, this concept emphasizes the duty of the physician in educating patients in healthy living (life style) and thus prevent frequent visits to the physician and hospital.

3. Conclusion

In conclusion, the challenge for the proponents of Human Values Education is to aim for that goal whereby each one of the five Human Values of Love, Truth, Peace, Right Conduct and Non-Violence is recognizable both within ourselves and in every person that we meet, regardless of our apparent failings and the wrong-doing of others. The philosophy of this approach is that the Human Values are the foundation, the substance and the essence of every cell and atom in the universe.

According to Sathya Sai Baba, the cultivation of Human Values alone is education. Whoever tries to understand the Human Values of Love, Truth, Right Conduct, Peace and Non-Violence properly, who practices these values and propagates them with zeal and sincerity, can alone be described as a truly educated person.

Acknowledgements

I am especially thankful to Rev. Fr. Charles Ogada, Prof. Chris. Obionu, Mr. Ben Chukwura and Mrs. Sheela Sridhar for their useful review of the manuscript.

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

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