Bioethics, healthcare policy, and related issues.
The anti-choice brigade has a peculiar fondness for chirpy slogans, including many that don’t even make any sense. (“It’s a Baby, Not a Choice”; “Attention, Rebellious Jezebels“) Among their most annoying tics are the constant equation of marginally-differentiated embryos with whatever else they can think of that seems to carry some kind of emotional punch but has no moral parallel with the issue at hand (toddlers, black slaves, Holocaust victims), betraying not the slightest comprehension that the equation of those persons with marginally-differentiated embryos is an insult to the people they are piggybacking their obsession on. But logical rigor is not a part of that movement. For that reason, children’s story-books are as meaningful a moral argument, to them, as anything else.
In particular, I have heard the catchphrase from Horton Hears a Who - Dr. Seuss’s paen to tolerance and understanding – used as an anti-choice slogan. The story, as I’m sure you recall, involves Horton, an elephant who, with his big ears and profound moral sensitivity, hears tiny noises coming from a small speck of dust he finds one day; listening carefully, he discerns that there is an entire world of microscopic creatures living inside the dust speck. When he reports it, he is declared insane by the moral troglodytes around him, who seek not only to imprison Horton but to commit genocide by boiling the dust speck to put an end to all such nonsense. Horton goes to heroic lengths to save the dust speck until the Whos inside finally succeed – by joining all their voices together equally, including that of the youngest child in the town – in making themselves heard and thus acknowledged as persons in their own right. Horton bountifully concludes: “A person’s a person no matter how small.”
As Wikipedia notes, the book was published in 1954, and the roles of the chief villains in the book seem to parallel that of Joseph McCarthy in his witch-hunts against unpopular or dissenting voices. It has been co-opted by anti-choice activists and organizations since then, however.
Which brings me to the point of this post, which is merely to predict and warn against a resurgence of ironically Seuss-based medical McCarthyism in the wake of the upcoming live/animated film version of the book, slated for release on March 14th. Seemingly unnecessary, given the existence of the lovely 1970 Chuck Jones animated version that brightened my childhood so long ago, the movie stars the annoyingly talented Jim Carrey, as well as Steve Carell and a raft of guest stars. It’ll probably be fun, but will probably kick off an incessant clangor of smug, misogynist voices chanting “A person’s a person no matter how small” with absolutely no appreciation of the irony that in doing so they thereby embrace the concept of “personhood” that the anti-choice movement usually tries to avoid or obscure.
I don’t advocate starting a slogan war over a children’s movie, nor do I advocate hanging women’s freedom from slogans and catch-phrases to begin with. But, as with the annual Roe v. Wade Day protests, organized clinic harassment, and the like, it’s as well to be aware of what’s coming.
UPDATE: It’s beginning. From the movie review page of Christianity Today: A Magazine of Evangelical Conviction:
Seuss’ beloved phrase, “a person’s a person, no matter how small” . . . embodies a principle as simple as it is profound, and speaks to so all areas of our lives and, indeed, our faith. It is a mantra that endows all created things with a sacredness and value found only in their Creator. While Theodor Seuss Geisel (aka Dr. Seuss) never intended his phrase to become a salvo in the abortion debate, many see in its simplicity the totality of the pro-life message.
The film also acts, equally inadvertently, as a model of religious conviction. “Faith is the substance of things hoped for,” says the writer of Hebrews, “the evidence of things not seen.” Contrasting the words of Hebrews 11:1, Sour Kangaroo tells Horton, “If you can’t hear, see or feel something, it does not exist.” But Horton is persuaded. He knows that the Mayor and the Whos of Who-ville are real, despite not being able to see them. In the same way, Horton’s immensity actually makes him invisible to the microscopic Mayor. When trying to describe Horton to the rest of the Whos, the Mayor frequently employs the sort of language one uses to describe a God who has yet to make himself visible to us.
Here we have a grand Christian missing-the-point Double Stuff.
Of course “a person’s a person” at any size. The question is, are the Whos persons? And the answer, again of course, is that they are. Why do we think so? Because we see that they are – they have houses and villages, a Mayor, a community, thoughts and interests and fears. They’re aware of themselves and care about what happens in their own lives. They have all the moral content of personhood, living lives of interest and value to themselves as persons. Sadly for them, they’re easy to overlook, which decreases the likelihood that their interests will be recognized, let alone valued. But nobody questions that their interests deserve consideration, as soon as it is recognized that they have interests. Which captures in a nutshell the utter boneheadedness of the attempt to analogize their plight to the issue of abortion. The Whos’ problem was that nobody knew they existed; as soon as their existence was demonstrated, their personhood was self-evident. (Once they were heard, they could claim their own interests, which is pretty good evidence of having some.) Not the most evil anti-dust-speck denizen of Seuss’s world denies the moral standing of the Whos, once it is known they exist. But no such question arises at all in regard of the human fetus. The controversy in that case is precisely the opposite of the one facing the Whos. We have always known the fetus exists – but even having seen them, there is no evidence whatsoever that fetuses are persons. It is not merely that they can’t be heard, like the Whos (or, more exactly, can’t speak at all) – it is that they have no thoughts to express, no awareness of themselves to get anxious about, no consciousness of their own existence, no interests, no values, no moral content to the biological processes that make up the sum and total of their lives for at least most of their gestational period if not beyond. The Whos are persons – no matter how small. Fetuses are not persons – no matter how big. That’s the crucial difference that is nowhere acknowledged in anti-choice nattering about tiny little dust-speck lives. And, ironically, that idiocy is actually expressed using the term “person” – but using it in a way utterly oblivious to its meaning, and to the moral difference between entities that are, and that are not, persons. Hilariously, Dr. Seuss uses the term correctly, but his anti-choice followers lack the perception to understand the moral meaning of even a Dr. Seuss story.
The second blunder is just as dumb. Virtually nothing in the second paragraph quoted above is correct. “Faith” may well be as dunderheaded as the Bible describes it to be – certainly it seems to be in common practice. But Sour Kangaroo is exactly right (speaking in somewhat metaphorical terms), and both Horton and Dr. Seuss know it. Horton does not know the Whos are real “despite not being able to see them” – he knows they are real because he perceives them (by hearing them, not by seeing them, but with his physical senses in any case). And it is precisely because the other jungle citizens finally gain physical evidence of the Whos’ existence (supplied by the purely physical process of sound amplification by increased power input) that they finally come to believe as well – and immediately change their minds about the existence of the source of the sensory input that was previously undetectable, after once detecting it. It may be that the Mayor of Whoville “employs the sort of language one uses to describe God”, when referring to the larger world, but if he does so he’s as dumb as a Christian movie reviewer. Why would his constituents believe him when he persists in talking like an idiot? The reason their world shakes and trembles, of course, is that it is subject to large forces imposed from outside – and when the citizens of Whoville gain clear knowledge of the source of those forces, they then change their minds about the existence of the elephant, just as the jungle citizens changed their minds about the existence of the Whos when presented with evidence. And both groups are justified in refusing to believe until they are presented with that evidence – but neither persists in a false belief when the evidence has been supplied. The story is a beautiful illustration of the scientific method. Not only does this reviewer not understand that, but, unlike either the Whos or Horton’s fellow jungle-dwellers, she is incapable of seeing what is put right in front of her. Throughout and throughout the Who story, people insist on physical evidence for claims of the existence of physical objects, and then accept the evidence as soon as it is made perceivable. This reviewer insists on claiming, in sheer defiance of that obvious sequence of events, that they are acting on “faith”. They simply are not – there’s no two ways about it – but you can be sure that fact will in no way stem the flood of false and stupid nonsense we’re going to hear about this – and related – issues.
Making with the sorely overdue link-love: two months ago, Amanda Marcotte (of Pandagon, and the best thing that ever happened to John Edwards) linked my prior post on right-wing propaganda about Margaret Sanger (as a way of attacking Planned Parenthood). She points out the fact that, in Sanger’s day, PP was actually anti-abortion (largely for reasons of the relative safety of the procedure, much lower then than now), and that the wingers seem to have no conception of the irony of their slanders.
The article generated a fascinating discussion thread, however (with minimal, but nonzero, trollage) - one that I only stumbled across today by following a visitor link (thanks!). I’m sorry to be so late on this but I encourage everyone to run over there; the discussion is interesting and, collectively, it includes a fascinating list of resources on the history of abortion, abortion and race, and sexual autonomy as seen from a variety of times and places, and presented in a variety of media (the rock-opera version of a 19th-century German play about the link between lack of sex ed and unplanned pregnancy sounds . . . wild – and I had no idea there was a whole list of early silent movies on the same topic!). Now I’ve got a lot more reading to do! So do you.
[NB: I began this review just after the movie came out, almost 15 months ago, and never finished it. Finally, sitting around this weekend, sick and procrastinating, I decided to get it off the books. Here it is, for whoever's still interested.]
The 2005 techno-thriller The Island hides a ham-handed anti-biotech message amidst its helicopters, gun battles, and explosions of various kinds. It trots out some of the standard “clone army” cliches, but goes beyond this, in places literally taking its dialog directly from the religious-right’s anti-science talking points. It fills a certain niche in the long line of biotech-nightmare morality plays, but with a particularly preachy, and notably slanted, take.
Saw a couple of offbeat movies recently, one pretty good, one very bad. Both had doctors in them, and they got me thinking about doctoring and what we want it to be.
What happens, f’rinstance, if your doctor’s a mobbed-up, drug-using, drug-pushing, fairly psychotic lowlife with sybaritic sexual tastes who doesn’t really mind seeing you die?
There was some head-squeezin’ taking place over my recent claim that many disabled persons believe “life with a disability is no more to be denigrated than life without one”. It’s just obvious to many people that having a “disability” makes your life objectively worse than otherwise, and presumably makes you objectively less happy than you would be without the disability. (A particularly stark example of this took place in an infamous encounter between utilitarian ethicist Peter Singer and disability activist Harriet McBryde Johnson, who uses a wheelchair, in which he insisted – against her objections – that having a “disability” was simply objectively worse than having some mere life difficulty such as being a victim of prejudice. I have always wondered at this in Singer, who, though controversial, is not usually unempathetic – at least, he feels chickens’ pain pretty intensely.) Seeing the disabled as “the disabled” makes it very hard not to respond to them in a way that foregrounds both the disability (rather than the person) and the observer’s interpretation of its significance.
This is an especially strong intuition for progressives for whom “helping the needy” is both a natural inclination and an inherent good (implicitly requiring that “being needy” is less good than not having a need, whereby one is “helping” by removing the need). Yet many people with disabilities would deny both that disability is necessarily an objective harm and that it necessarily makes them unhappy. Simultaneously, they are accutely aware of what is difficult for them that is not for those who do not have their disability, and many seek whatever aid is available – including medical treatment – to lessen that difficulty. Grasping this dichotomy is an important part of bringing disability into the range of human norm, and “the disabled” into the community of caring that progressives seek to build.
I attended an interesting conference session today on the relationship between bioethicists and the media. Most of the discussion focused on the ways the media distorts or simply does a bad job reporting controversial issues, especially on difficult or abstract subjects such as arise in bioethics. The question was pitched as “How should bioethicists relate to the media?”
Saw the X-Men movie this past week, and was struck by how explicitly the “biological deviance” theme was brought out in the plot. Of course, that is the main driver of plot tension throughout the three movies (and to some degree in the original comic books, I gather, though I haven’t read them). But, even more so than in the first two movies, the third installment delves into the bio-politics of “normalcy” and prejudice, in interesting, though somewhat complicated, ways.
It’s a juicy subject for a worthwhile discussion, and a welcome sign in these days of otherwise unbridled bigotry and repression.
I don’t have much interest in or concern for The Da Vinci Code in any of its manifestations, and even less for the predictable special-interest Catholic whining that accompanies almost any artwork touching on their preferred view of the world. However, one complaint about the newly-released film caught my attention. Fans of the book or movie will not be surprised, but I was not previously aware that one of the chief villains in the story is an assassin monk who has albinism. (What? No dwarf?) This makes approximately the gazillionth “deformed” villain in the history of movies, stage, and novels, and the albinos in particular – a polite but feisty bunch – are getting pissed about it.
Contrary to her assertions, it’s not her lifestyle liberals object to. (Contrary to her delusions of grandeur, nobody really cares how she lives her life – they just wish she would stop telling them how to live theirs.) It’s her enthusiasm for “little-helpmeet” misogyny that drives them to consider her an enemy. See if you can tell why:
[P]ity the poor married man hoping to get a bit of comfort from the wife at day’s end. He must somehow seduce a woman who is economically independent of him, bone tired, philosophically disinclined to have sex unless she is jolly well in the mood, numbingly familiar with his every sexual maneuver, and still doing a slow burn over his failure to wipe down the countertops and fold the dish towel after cooking the kids’ dinner. He can hardly be blamed for opting instead to check his e-mail, catch a few minutes of SportsCenter, and call it a night.
Ahhhh . . . . So, if all that is what is wrong with women, what would it take for them to be right?
Aside from the familiar, dreary 50s drudgery of it and the cheerfully creepy rape-positivism (she can’t initiate sex, she can’t refuse it, and she must not have sexual desires of her own – but she is obligated to satisfy her man on his whim no matter what), what’s inescapable is that women of the Flanagan mold must not have any self-directed lives of any kind, nor any “philosophical inclinations” to think their own interests and values matter; they exist for the sexual gratification of, and personal service to, their husbands, and are judged (by Flanagan) on how well they perform those functions.
Where have I seen this before . . .?
Oh, yeah. Now I remember. (more…)
Just saw the film Hard Candy, directed by David Slade (who has done almost nothing but music videos previously), and starring Patrick Wilson and a remarkable Ellen Page, who comprise almost the entire cast. Rated R for no good reason. The story revolves around the relationship between a precociously intelligent 14-year-old girl and a somewhat creepy early-30s photographer who pursues her online and then in person. When they meet, she suspects he is a pedophile responsible for the disappearance of another teenage girl – and then turns the tables on him in an act of revenge or vigilante justice.
The movie is somewhat unevenly paced – the first half hour is a tour-de-force of acting from both main characters, as they alternately engage in an exploratory flirtation and then each retreat to more age-appropriate demeanors; the moment when the plot takes its definitive twist and goes off in a new direction is also the moment when the director seemingly forgot what the movie was about, however. The second half is less a psychological intrigue than a straightforward vengeance tale. The result is a weird mashup of Lolita and Death and the Maiden, as directed by David Cronenberg. However, leaving aside the inconsistency, there are some provocative things in it, and some questions raised about how we are to understand young sexuality, our revulsion by pedophilia (and our protective impulses toward young girls especially), and our common impulses toward destructive retribution in response.
The castration scene was notable, too.
In order to discuss the moral/philosophical issues raised by the film, it is necessary to discuss the plot content. The material below the jump contains plot spoilers. Please come back after you’ve seen the film, if you prefer not to have the plot revealed.
I saw the just-released Neil Young concert film, “Heart of Gold”, last week, and it was lovely. In terms of production values, it is far from Jonathan Demme’s best work – at certain times it looked distinctly amateurish – but it does a perfectly acceptable job of conveying the concert performance and the music, which is all that really matters. It’s a simple film – a straightforward record of the best of two nights’ performances at Ryman Auditorium, Nashville (the “Grand Ol’ Opry”), by Young and a huge group of backing musicians, some of them major stars in their own right, with little filler or “backstage secrets” nonsense to break it up. It contains a few chuckles – one of Young’s longtime bandmembers recounts that he slipped in the back door of his first recording session with Young, decades ago, and they had recorded five tracks together before introducing themselves; Young also explains from the stage that the “old man” in his hit song of that name (“Old man take a look at my life / I’m a lot like you were . . .”) was the caretaker on his farm, who couldn’t believe that a “rich hippie” had enough money at such a young age to buy a big spread like that. Mostly it just contains people making music, and the movie rarely gets in the way of its own story, which is a very good thing. Young comes across as a gentle, wise man moved by a kind of sweet longing for connection with friends and family. (It is hard to believe he once wrote “Southern Man” or “Ohio”.) In fact, I was struck by how many of his songs are explicitly about friendship, and how much he values it the older he gets – they far outnumber his songs about romantic love, the standard grist for the country/rock mill.
It’s a very enjoyable movie whether you’re a Neil Young fanatic or not. I recommend it to anyone. But enough of that. It was the bioethics content of the concert that I really wanted to comment on.
You come alert on a subway train in a bleak part of town you’ve never seen before. You don’t know why you’re there or how you got there. Thinking about it some more you realize you can’t recall anything that’s happened to you recently, or in fact anything that has ever happened to you, or what your own name is. You’re carrying a backpack; you open it up and it contains no ID or money, nothing with your name on it. It holds only a few cryptic items, a set of keys you don’t recognize, and a scrap of paper with a name and phone number you also don’t remember. The train stops. You’re at Coney Island, early in the morning, and you don’t know why you’re there, or who you are.
A Sound of Thunder, a liberally-screwed-up adaptation of the classic, and poignant, Ray Bradbury short story of the same name, hit theaters this weekend. Owing to some sort of mixup, I went to the fillums tonight hoping to see something else that wasn’t playing, and opted for this instead. Mistake.
Still, it has often been said that, if you really love films, you like even bad films. This one offers a few things to think about in the midst of its multivalent badness.
I just saw Grizzly Man, an enthralling documentary assembled by Werner Herzog from video footage shot by Timothy Treadwell – a self-styled wilderness protection activist who lived in close proximity to a population of grizzly bears in the Alaskan wild for lengthy periods 13 years running. In 2001, Treadwell was killed and his body eaten by one of the bears he idolized.
The movie provides a fascinating, at times heartbreaking, look at a man so clearly obsessed by his idealized notions of good and bad, and of nature and people, that he was led to make extremely questionable decisions. Though he is obviously rational and articulate, Treadwell’s demeanor and language, and the beliefs he expressed about his relationship with the bears, call his competency to evaluate and control his own behavior into question. As a strong autonomy advocate who defends people’s right to make virtually any self-interested decision they like, especially in the area of healthcare, I found the sight of someone who unquestionably would pass any test of mental competency, but was unquestionably reckless literally to the point of death, very challenging. The movie left me worried about the ways in which simple “competency” does not capture the range of human mental capacity and frailty, and puzzled how best to defend autonomy while recognizing that not every decision made by a rational person is rational.
I recommend the movie to those who also puzzle over the nuances of the autonomy/paternalism debate, and in its own right to anyone interested in a fascinating, troubled character following his own dreams in an unimaginably breathtaking – and dangerous – setting.
I recently saw an episode of the TV show “House” – about a misanthropic internist at a teaching h0spital and his awe-stricken residents who engage in extended, heated debates over otherwise ordinary clinical diagnoses, but spend strangely little time dealing with the actual practical matters of patient care. (The premise of the show is that “Dr. House” – the show’s title refers to the doctor, not the hospital – is such a renowned diagnostician that he is allowed the privilege of not carrying a patient load, but simply hanging around the building inserting himself into whatever weird diagnostic mysteries turn up and pulling amazing clinical feats out of his ass . . . a privilege that apparently extends to his residents as well.) After viewing my first and only installment of the show, I was contemptuous of its lack of realism and its typical TV overdramatization – the doctor bursting into an OR in street clothes and spitting onto a surgical field in order to stop a (suspiciously-quickly-arranged) liver transplant that only he realizes is the result of a faulty diagnosis, or the entire team of residents racing out to a patient’s home to dig up his dead cat for an autopsy, conducted by Dr. House himself, that will confirm the patient’s illness (. . . dig up his dead cat?).
I also hated the show for the violence it did to medical ethics, and the wrong impressions it was likely to leave in the public mind. In the episode I saw, a doctor pleads with the hospital transplant coordinator to “see what she can do” to bump a patient up the transplant waiting list “because he’s too sick to wait another day” – with not a word about the fact that transplant waiting lists are specificially prioritized by patient need already or that no one would, or would be able to, arrange special priority. Dr. House, in the meantime, orders his resident to deliberately lie to the teenage patient’s father about the patient’s condition in order to get the father to authorize the treatment House thinks is appropriate – nobody in the show ever suggests that House could just tell the father that’s the treatment he thinks is appropriate. The entire group of residents is nonplussed by the suggestion that they should not just give the standard treatment for the most obvious diagnosis if it will interfere with treatment for a possible, but less likely, illness they have not yet ruled out. (“Differential diagnosis” is apparently not taught at their medical schools.) The doctor and the father later engage in a fistfight over what treatment to apply – nothing in the entire episode suggests that the patient’s proxy has independent decisionmaking authority, or even hints at “shared decisionmaking” or “informed consent”. (From what I understand, the “backstory” is that Dr. House is angry and irritable due to constant hip pain – for which he is morphine-addicted – resulting from a botched surgical procedure, which he had explicitly refused to authorize but which his wife authorized as his proxy when he became unconscious, with the justification that because he was unconscious she then had the authority to override his previously-expressed decision. Apparently even Dr. House doesn’t have patient autonomy, in Dr. House’s world.)
An article in today’s New York Times comments on the show as well, noting similar lapses in realism:
My wife, a general internist, finds the show absurdly “unrealistic.” “Doctors don’t do that,” she cries whenever a House physician blithely ignores the boundaries of medical subspecialties. (The same doctors, for example, might perform cardiac catheterization, gastrointestinal endoscopy, bone-marrow biopsy and liver ultrasound.)
(The article, by Sandeep Juahar, MD, laments the most unrealistic aspect of the show: “It portrays a world where doctors have time to solve problems” – whereas, in reality, house staff are so overworked that they simply don’t think about the intellectual puzzles of medicine anymore, but simply process patients through procedures. He blames this partly on legally-mandated reductions in shift length, which is a controversial claim, but he’s probably right about the general trend. At any rate, that’s not what concerns me about the show, though.)
I resent these kinds of shows because of the unrealistic expectations they create. In some cases, they raise public hopes too high – the widely-watched “ER” (a fascination among many ethicists) was criticized for the fact that patients in the show’s emergency department never died; the public came to expect that any emergency or trauma death was malpractice. (I have read recently that the cop shows have the same effect: prosecutors have complained that jurors, having watched forensic-investigation shows, now expect that every case requires the extensive lab work, DNA testing, blood analysis, and other techniques – some of them fictional – that these shows highlight, and that defendants cannot be convicted without evidence from tests and machines that in some cases do not even exist in real life.) Worse, though, is when they distort actual practice, and especially when they show misbehavior that, in real life, would be unlikely or impossible.
The public already fears that transplant waiting lists are manipulated (such beliefs were widespread after Mickey Mantle’s liver transplant). For shows like “House” to suggest that doctors in ordinary hospital practice openly attempt to get – and succeed in getting – special treatment for their patients is irresponsible. For a show that aired only weeks after Terri Schiavo’s death to suggest that patient proxies are not authoritative decisionmakers only adds fuel to a controversial misunderstanding that, as we saw too well, can have terrible consequences. To suggest that perfectly ordinary diagnostic reasoning is somehow controversial, or that the fact that a treatment team could entertain multiple working hypotheses about a diagnosis is somehow scandalous or the source of conflict, leads patients to imagine that being faced with a difficult diagnosis is by definition poor medical practice. Some dramatization is expected, but to suggest that doctors have to engage in physical confrontation, or bodily intervene to protect patients from hastily-scheduled abusive surgery, is a disservice.
I have the same reaction to medical scandal-mongering of the Robin Cook/David Rorvik type: claims that doctors are deliberately killing patients to harvest their organs, or have cloned a human being, presented as plausible “insider knowledge”, are similarly irresponsible. (I don’t have the same objections to clearly science-fictional works like Frank Herbert’s “White Plague”, or Micheal Crichton’s “Andromeda Strain”, where the technical material is somewhat plausible but there was no attempt to deceive the public.) Deliberately inflaming public passions – and misconceptions – about momentous issues is a tawdry way to make your fortune, and has serious consequences.
As has often been remarked, the “doctor shows” on TV have played a significant role in shaping the public understanding of the medical profession and medical practice (the “Dr. Kildare” meme is still powerful decades after that show went off the air). I don’t want to claim that these shows have to regard themselves as public-service entities – for one thing, the unreality of the shows can be a powerful communicative element (“M*A*S*H” was never regarded as a realistic medical show, but it riffed on our expectations regarding doctors and nurses to say important things about medicine and our society), and for another, I don’t want to open a second front for “Parents Television Council” crabs to gripe about. And I certainly don’t want to suggest that these shows should become cheerleaders for the professions they portray, like the old “FBI” series was for J. Edgar Hoover. But some sense of responsibility – especially in fiction shows that pretend to portray reality, as opposed to clearly dramatized shows – is in order. In reaping the public’s attention, and the advertising dollars it brings, it’s not enough to provide a sensation in return; some thought should be given to whether what you’re saying to the public is true, and whether the expectations you’re leaving them with are plausible. Fictional shows are not true in the strict sense, but they can be believable. Believable fiction that creates false beliefs, however, is as irresponsible as a lie. Some lies can hurt.
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