NEAL CONAN, host:
This is TALK OF THE NATION. I'm Neal Conan in Washington. Last Friday, four pharmacists filed a lawsuit in Madison County, Illinois, against Walgreens. They claim the drugstore chain violated their rights under Illinois' Healthcare Right of Conscience Act when Walgreens placed them on unpaid leave for refusing to dispense morning after pills. According to the Right of Conscience Act, workers cannot be forced to act contrary to their conscience.
Walgreens said the chain was just trying to fulfill its requirements under another state law which requires all Illinois pharmacies to dispense contraceptives without delay. As this story illustrates, healthcare has become the main front in the struggle between a person's moral beliefs and the requirements of his or her job, not just pharmacists but doctors and nurses, as well, and the issues go beyond abortion to include inVitro fertilization, physician-assisted suicide, even some services for gays and lesbians. At the heart of the matter is the idea of a right of conscience. Where's the line between an individual's religious belief and ones duties as a licensed professional? What about the rights of patients?
Later in the program, Writer Allen Kurzweil joins us to explain the physics and the metaphysics of the potato chip, but first healthcare workers and conscience. If you've encountered this line as doctor, nurse, pharmacists or patient, gives us a call. Our number is 800-989-8255. That's 800-989-TALK. Our e-mail address is firstname.lastname@example.org. Rob Stein joins us now, a reporter for the Washington Post who's been covering this issue. He's with us from the Post studios here in Washington, DC. Nice of you to be on the program today, Rob.
Mr. ROB STEIN (Reporter, Washington Post): Hi, Neal. It's nice to be here.
CONAN: Madison County in Illinois is hardly the only place where the rules that govern healthcare workers are on the table. Where else is this happening?
Mr. STEIN: That's right, Neal. This is an issue that seems to be intensifying around the country. At the moment, at least 18 states are considering at least 36 bills that would address this issue in one way or another.
CONAN: Mm hmm.
Mr. STEIN: And about half of them are bills that deal specifically with pharmacists, but the other half, if not more, are, broaden it out considerably to cover other kinds of healthcare workers and other kinds of services.
CONAN: And are these bills, some of them, to force them to perform services, or are some of them to protect them from performing services that violate their conscience?
Mr. STEIN: There are a handful of bills. About six states right now are considering bills that would require pharmacies or pharmacists to fill prescriptions, but another 18 states and 36 bills, are bills on the other side that would essentially protect workers, either pharmacists or other kinds of healthcare workers, in situations where they do not want to provide some sort of service because they feel it runs contrary to a personal moral or religious beliefs.
CONAN: And as we saw in Illinois, some states have them both.
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Mr. STEIN: That's right, that's right. It gets very complicated because a lot of the states have multiple bills on either side. Some of them are specific to pharmacists, some of them are much broader, and some of them address only certain services, like abortion or contraception. Some of them are extremely broad that would essentially allow any worker to refuse to provide any kind of service.
CONAN: Mm hmm. So and it goes certainly beyond pharmacists to include doctors and nurses in the healthcare field.
Mr. STEIN: That's right, that's right. And that's what's, you know, caused a lot of debate across the country in these states because it's unclear, exactly, sort of where people will be drawing the line. It could apply to nurses. It could apply to technicians. It could apply to nurse's aids. It could apply to physician's assistants. It could apply to contraception, abortion, end of life issues. It's a whole host of areas, and because they're worded so broadly, and they're worded broadly on purpose because they want to leave the door open for future controversies that present themselves in the healthcare field.
CONAN: Mm hmm.
Mr. STEIN: So that's where it's raising a lot of concerns.
CONAN: Well, could it apply to the truck driver who's delivering boxes full of the morning after pill or Viagra, it doesn't matter what the substance is, something that violates his or her conscience?
Mr. STEIN: Well, at the moment, these bills do specify healthcare workers, but they're very broad in that sense, and, for example, there was a case of a ambulance driver, an EMT in Illinois who was fired after she decided that she could not take a patient to a hospital for an abortion. And this is a case, a suit that's currently pending in Illinois over that case. So you can see sort of the spectrum of workers who could be covered by this sort of thing.
CONAN: Mm hmm. Now, so right of refusal or right of conscience does not necessarily just pertain to the medical profession.
Mr. STEIN: Well, it, no, it doesn't just pertain to the medical profession. The bills that I'm talking about, they all do specify healthcare workers. But the way they define healthcare workers is very broad, and the areas in which people would be protected for expressing their personal beliefs is also very broad. It's basically anything that an individual would consider to run contrary to their personal, moral or religious beliefs, and as you can guess, that could be very broad.
CONAN: That can be very broad indeed. If you'd like to join us in discussing this problem, our number is 800-989-8255. Our e-mail address is email@example.com, and let's talk to Lucille, Lucille calling us from Hillsboro, California.
LUCILLE (Caller): Hi, I'm a retired school nurse and have had many years' experience as an OB/GYN nurse, and my opinion is I'm very sympathetic to people who are put in this position. I'm just suggesting that they need to seek employment in, for instance, a Catholic hospital where they would never be asked to dispense RU486 or the morning after pill or whatever.
I do hope out of this format today, you might come up with a protocol or something for people to proceed if they've had their rights violated in this respect. I inquired at my Walgreens pharmacy regarding their protocol on dispensing the morning after pill, not that I'd ever want it. If they had told me they wouldn't dispense it, I would have taken my business elsewhere.
CONAN: Mm hmm.
LUCILLE: And I wouldn't, if I were a Seven-Day Adventists, want to be a doctor. I mean...
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LUCILLE:...you can't go into a field and force your beliefs on other people, and when they have medical needs, if you can't provide them, then you, perhaps, should not be in that field.
CONAN: And Rob Stein, Lucille is not hardly the only person to have such an opinion.
Mr. STEIN: That's right, and that's what people are trying to come to terms with here is that when you have somebody who's in a job that they have, on the one hand, they have their professional responsibilities, on the other hand, they have their personal beliefs which can, and those two can conflict. And sometimes that what happens is people get into a profession thinking that it's not gonna be a problem, and then medical science advances in a way that suddenly creates a conflict for them. The law...
CONAN: The law can also change sometimes.
Mr. STEIN: That's right. But, for instance, a lot of these pharmacists, but when they became pharmacists, there was no such thing as a morning after pill that they were filling prescriptions for. That got approved, and suddenly they were in a position where they were being asked to fill prescriptions for something that they found morally offensive.
CONAN: Lucille, thanks very much for the call.
CONAN: Joining us now is Dr. David Stevens, a physician and bioethicist, executive director, also, of the Christian Medical Association. He's with us now from his office in Bristol, Tennessee. Thanks very much for being on this program with us today. Dr. DAVID STEVENS (Physician and Director, Christian Medical Association): Great to be with you, Neal.
CONAN: I just wanted to ask you about the point that we just heard. Obviously, if people are upset about something that they're asked to do, well, if you're a pharmacist and this happens with some regularity, maybe you ought to think about another line of work.
Dr. STEVENS: Well, we don't want to just have people in a field of service such as medicine that have been ethically neutered, so to speak, in other words, only can do what's been approved or dictated by the government. In fact, people of ethical bent may be the last line of defense for some patients as medicine becomes a place where profit and cost is becoming an increasing issue, and some program, or whatever, could actually put them in jeopardy.
Probably a good analogy, Neal, is this. You know, you join the military, and you come in with this set of expectations, but if the government asks you to go slaughter civilians, you'd say, no, I have a right of conscience. I'm not going to do that. And these issues that we're talking about are not about providing services to any race or any people of certain behavior or whatever, but it's when you become morally complicit in an act, such as ending the life of a human being. And in that situation, if a patient came to me and asked for an abortion, I would explain to her that I don't do abortions. I would counsel her about that, and then she'd be free to get those services somewhere else and I would welcome her back to my practice after she had that abortion, but I cannot be complicit in the act of taking a human life. I took the Hippocratic Oath that says I will not to that.
Dr. STEVENS: And that's what's governed medicine for 2,000 years.
CONAN: There are circumstances, though, people would say, where denial of a service like that, whether a doctor or a pharmacy, or some other place in the healthcare chain can, effectively, as a practical matter, deny his or her right to that service.
Dr. STEVENS: It's been very difficult to, people have said that, but really demonstrate where that happens. We need to realize that we're talking about a basic Constitutional right in the First Amendment, where it says that Congress shall make no law respecting the establishment of religion, or prohibiting the free exercise thereof. This is a Constitutional issue.
Our founding fathers thought it so important, they fought a Revolutionary War over it. And if we begin to dictate what people have to think, and against their held religious beliefs, an act of helping to destroy human beings, or something like that, then we are taking away some of the freedom, and that may just affect the health profession now.
CONAN: Mm Hmmm.
Dr. STEVENS: But sooner or later, it's going to affect all of us. Can the government dictate our actions?
CONAN: And, obviously, we've been talking more or less within the broad sphere of abortion, one way or another, but there are other issues that do come up, including, as technology develops, issues that will be real puzzles in the future.
Dr. STEVENS: Well, there will be, and we're increasingly a morally, ethically complex society. And technology, unfortunately, is racing ahead of our ability to come to agreement in our countries on a lot of these ethical issues, so there's going to continue to be conflict.
But this isn't about giving moral lectures to patients, this is just about saying, one pharmacy saying, I don't dispense that; here's another pharmacist that does. We're pitting a patient's right of convenience; I may have to go to another pharmacy, versus a healthcare professional's right of conscience, a very big and important issue. The two really don't compare.
CONAN: Well, just talk about pharmacies for a minute. If Walgreen's, just to pick a name out of a hat, was involved in the suit in Illinois, says, this is our policy, should a pharmacist who works for Walgreen's be able to say it's their policy from eight to four, but not from four to midnight when I'm on?
Dr. STEVENS: Well, you need to make sure your employer knows your position on these issues and they can do staffing in that situation to try to correct for that. They may not place you in a pharmacy where you'd be the only pharmacist. There's other things that we do for accommodating people's religious beliefs. We do that all the time in this country in other areas, but we cannot just give a license to some group, or a business, to violate people's closely held moral beliefs, especially in life and death type situations.
CONAN: But couldn't Walgreen's say, as a condition of your employment, you agree to sign this statement that I will dispense any legal prescription?
Dr. STEVENS: Well, you know, it's interesting that the groups who have been really pushing this hard have been the pro-choice groups. And I don't think the irony is lost on the American people that those who talk about choice, and rock under that banner, are stamping on the rights of other individuals to have choice.
CONAN: Stay with us, if you would, Dr. Stevens. also Rob Stein is still with us. More of your calls also after we come back from a break: 800-989-8255
I'm Neal Conan. It's the TALK OF THE NATION, from NPR News.
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CONAN: This is the TALK OF THE NATION. I'm Neal Conan, in Washington. Today we're discussing the line between an individual's religious beliefs and one's duties as a licensed professional. Four pharmacists in Illinois sued Walgreen's Drugs last week after they were fired for refusing to sign a pledge promising to dispense the morning-after birth control pill.
Our guests are Washington Post reporter Rob Stein and physician David Stevens. Of course, you're invited to join us at 800-989-8255. You can also send us email: talkatnpr.org.
Bring another voice into the conversation. Now Robin Shapiro is with us from the studios of member station WHAD in Milwaukee, Wisconsin. She's director of the Center for the study of Bioethics at the Medical College of Wisconsin in Milwaukee. Thanks very much for being with us today.
Ms. ROBIN SHAPIRO (Director, Center of Bioethics, Medical College of Wisconsin): It's a pleasure.
CONAN: I know you've been listening to what Dr. Stevens had to say. As a bioethicist, where do you stand?
Ms. SHAPIRO: Well, Neal, I couldn't disagree more with David Stevens' point that he tried to make about ethically neutered physicians, if they actually are required to give patients information about services that are reasonable medical alternatives, and about how to access them. And the reason I say that is because if we go back to the turn of the last century, we have seen that it has been very well established in law and in ethics that individuals have the right to make their own decisions about their healthcare.
The only way that they can do that in an informed way is if they're properly, adequately informed by their physician about the reasonable medical alternatives that might be available, otherwise the direct, the right to direct your own medical course really makes no sense.
So, if we have a situation where laws are protecting physicians and other healthcare providers and, as Rob so eloquently described, some of these statutes are very broad. If we have a situation where laws are protecting healthcare providers who refuse to do that, we are depriving individuals of these very basic rights to, again, direct their own medical course.
CONAN: So, you're focusing on the right of the patient, as opposed to the right of the healthcare worker.
Ms. SHAPIRO: Absolutely, and I agreed very much with what Lucille had to say, which is, that in certain professions, we have to go into with our eyes open, and being a physician is not the only example. I myself, as an attorney, know that I have an obligation in ethics and law to act as an advocate for my client.
Might there be times when what the client has done, or wants to do, or the position that he or she wants me to defend is something that I disagree with personally? Absolutely. We send people into war. Might they disagree with the notion of killing people? They might. We expect them to do their job. I'm expected to do my job.
CONAN: Well, wait a minute. There is a provision for conscientious objector.
Ms. SHAPIRO: There is, but you certainly could have somebody, if you're, and I assume you're talking about the military.
CONAN: Yes, well you said we send people off to war, yes.
Ms. SHAPIRO: Yes, and at the extreme there are situations so conscientious objectors can be excused, just as I believe, in certain situations, and we can talk about this, we can have physicians who can step aside, and have somebody else provide healthcare for the patient who is needing it. Although in emergencies, I think that wouldn't be so, just as...
CONAN: And there is, as Dr. Stevens was pointing out earlier, there, if you are given an unlawful order to, for example, massacre prisoners, you're allowed to say, I will not obey that order.
Ms. SHAPIRO: Yes, but if you have a person who, let us suppose, believes as a general rule that killing is not a good thing, it doesn't qualify as a conscientious objector, is expected to go to war and do something that he or she doesn't think, generally, is a good thing, that's something that we expect.
CONAN: Mm Hmmm. Let's get some more listeners involved in the conversation. And let's go to Perry(ph) Perry's calling us from Salt Lake City, in Utah.
PERRY (Caller): Yes, Neal. A quick question here: what's to keep, let's call them conscientious objector laws, from moving into other areas, other professional areas, or occupations? For instance, the advertising exec who would refuse to stretch the truth about a product, or the waitress who becomes a vegan and suddenly refuses to serve her customers meat, or even journalist who would refuse to cover, say, a gay pride parade?
CONAN: Mm Hmmm. First of all, Rob Stein, the laws that are being considered, are they anything like that broad?
Mr. STEIN: At the moment, no. All the laws that are currently being considered really are targeted specifically at the healthcare field and healthcare workers. And I think the reason for that is, because the speed of which medical research is accelerating is really creating a lot of ethical ambiguities for people that they didn't expect to face in their jobs, the field embryonic stem cell research, for example, didn't exist until recently. And end of life care is another one that's creating these new ethical fault lines and so that's sort of where your PERRY: But as Rob said, that's at the moment, what would prevent people in other professions from demanding such protection?
CONAN: Why don't we ask Dr. Stevens?
Dr. STEVENS: I think we need to understand we're talking about life and death issues here. We're not talking about your prejudices or your thinking about foods or that type of thing. We're talking about taking life, destroying embryos, morning after pill, 45 percent of the time prevents a developing human being from implanting in the uterus. These are life and death issues. These are not lesser things.
In those issues, right of conscience comes to the forefront. And as Robin was saying, I'm not talking about not giving informed consent or counseling patients. I do that all the time, but I will refuse not to do their abortion when they ask for it, just as she would refuse to commit perjury if one of her clients asked her to do so in court. There's a place where you draw the line and you will not participate.
PERRY: But in the beginning of your program, you did mention that there are some who refuse to provide services to gay people and we're talking about personal conscience here, so why couldn't this personal consciousness be spread to other professions, other occupations? What would stop it?
Dr. STEVENS: The only issue that's happened, yeah, the only issue with right of conscience in dealing with gay people is in providing in-vitro fertilization services. Yeah, I, many people, and I do, take care of homosexuals, and take care of their diseases.
I take care of people, I worked in Sudan. I took care of murderers and rapists and did that and cared for those people and gave them excellent care, but the situation where I participate in an act where I am facilitating it, that becomes moral complicity in that act, whether it's doing an abortion or some other service, and that's what this is about. It's not about a broader picture where you're bringing in all sorts of other issues.
CONAN: So... Ms. SHAPIRO: David, I have...
CONAN: Go ahead, I'm sorry. I didn't mean to cut you off.
Ms. SHAPIRO: Sorry, I didn't mean to interrupt, but I have to disagree because there are some proposals that really would go as far as what we've been talking about. For example, in Michigan, in the spring of 2004, a bill called the Conscientious Objector's Policy Act, would have allowed providers, the facilities, managed care organizations to refuse to participate in any healthcare service to which they had a moral, religious, or ethical objection, broadly stated just like that.
So conceivably, under that act, one who had a problem with a gay person could refuse, on the basis of that act, to provide care or services, and be protected by that law. So, I don't think that the bill, the proposals and some of the acts that have been passed are as narrowly focused as what David is suggesting.
CONAN: Perry, thanks very much for the call.
PERRY: Thank you very much, Neal. It's an issue I'm sure we'll be hearing a lot about.
CONAN: I suspect you may be right on that, Perry. Let's go now to Jesse. Jesse's calling us from Tulsa, Oklahoma.
JESSE (Caller): Hello, Neal. How are you?
CONAN: Very well. Go ahead, Jesse.
JESSE: Yes, I am a pharmacy student and I, we have classes that kind of deal with these issues and one of the things that us as a pharmacist go into, you know, the school. This is a choice that we make and we understand when we go into it that we are to uphold the law. And I also understand, I'm a Christian, and I don't particularly want to, I don't like this law, but I understand that, as the law stands, this is a woman's choice to get the morning-after pill.
And so I would like to think that the companies that you work for, especially in this law, in particular where this isn't a retroactive law. In other words, the pharmacists went in not intending having to do this.
JESSE: And now they're trying to oppose the law, so maybe there ought to be a way that pharmacists who have conscientious problems delivering this, dispensing this medicine, usually there's more than one pharmacist on duty, so maybe another pharmacist could dispense it.
CONAN: Yeah, usually there is, but in, I'm sure you know, in Oklahoma, there are places that where that's not the case and, indeed, where there's only one drugstore in town.
JESSE: That is true, and then again, like one of your panelists said, they can if the pharmacist so chooses, especially in an independent pharmacy, they could just make that choice to say, I'm sorry we don't dispense this drug. Walgreen's down the street in the next town might do that.
CONAN: Mm Hmmm.
JESSE: And they have that right, especially as a private entity, a private company, but it is a, for new students coming in, this is a challenge for us now...to see laws like this. Now our ethics are really going to be challenged.
CONAN: Dr. Stevens, I wonder, do you think that ethical situations like this ought to be discussed in broader terms in medical schools and nursing schools as well?
Dr. STEVENS: Absolutely so and there's more and more discussion about this. We actually work on 200 campuses across the country where we have student chapters and bring in guest speakers and we talk about these issues. There are things that people need to face and realize there are going to be issues in their practice. But, you know, we need to understand a lot of this focuses around the abortion issue and human life.
If we say that only people can go into the medical profession who are pro-choice we're eliminating half the people in this country. And a lot of very compassionate present doctors, nurses, and others and future ones as well. We dare not put some sort of litmus test on any profession. It works very well to say I'm sorry I don't participate in that and there's the doctor that does, but give you the option of not being forced to do something that violates your conscience.
CONAN: Robin Shapiro?
Ms. SHAPIRO : I agree with that if it can happen that way. In other words, I am all for trying to respect to the greatest extent possible everybody's ethical and moral backgrounds and beliefs. However, again, the focus here is the doctor-patient relationship and the patient's right to direct her own medical course with respect to legal, reasonable, medical alternatives. So that, if we have a situation where a health care provider doesn't want to provide a certain procedure or treatment he or she should be obligated to give information about where that can be accessed and in an emergency if that can't happen then I do believe that it has to be provided nonetheless.
We should note, I think, that the courts have weighted in on this. In a case out of California a young woman was taken to the E.R. of a religiously controlled hospital after she was raped and she was not informed about or offered emergency contraception. She sued, looking for relief from the court that require the hospital in the future to provide rape victims with information and access to the service or to stop treating rape victims. And the court found for her, finding that in order for her to meaningfully exercise her right, again to control her own medical course she would have to be provided with enough information to make an intelligent decision in that regard.
CONAN: Jesse, how much time you have left?
JESSE: I have time. I do have a question--on a case like that though, in an emergency situation there are a lot of hospitals that are religious organizations that refuse to perform abortions. And, so, how would they inform someone in an emergency like that?
CONAN: I'm not sure that that comes up all that often, abortion not being generally an emergency procedure.
JESSE: Yeah. My broader comment on this law is, why is it--when we make laws we ought to think of ways in which people--especially like a moral conscience law like this, there ought to be provisions put in there for people who already have jobs and who are already pharmacists or doctors or whatever profession that we're talking about, in which those that have problems with that can get around it or there ought to be provisions to allow for that.
CONAN: Ok Jesse. Thanks very much.
JESSE: Thank you.
CONAN: And good luck with the rest of pharmacy school.
JESSE: Thank you very much.
CONAN: Bye-bye. We're talking today about the line between conscience and professional duties. You're listening to Talk of the Nation from NPR News. And let's get another caller in. This is Ali. Ali calling from Columbus, Ohio.
ALI (Caller): Yes, hi there. Thanks for taking my call. I actually have a couple of more comments and sort of questions as well I guess for Dr. Stevens. I'm a physician myself and I actually am an administrator of a community hospital as well. My first comment is that, you know, when it comes to ethical conflicts what we think is that the patient's right to best care and the patient's autonomy always comes before any possible moral beliefs of a physician or a health care provider. That's number one. That that probably supersedes any physician's, you know, personal belief.
The second comment is that if a physician or another health care provider chooses not to provide an essential service then as an administrator I have the right not to hire that person or to fire that person because I believe that that essential service is needed in my facility and to our patients.
CONAN: Mm hmm. Doctor...
ALI: Those are the two comments.
CONAN: Doctor Stevens.
DR. STEVENS: Well by taking a professional license you do not in fact step out of your personal morality. I mean, that's kind of ridiculous. You have taken additional responsibility but that doesn't mean you've given up your integrity as a person. And to think that the patient has all the rights and the doctor has none is pretty ridiculous. We call this a profession of medicine because we've professed to use our knowledge in a certain manner.
And it's only been in the last thirty or forty years where every doctor wasn't taking the Hippocratic Oath saying that he would not perform or participate in an abortion. And many physicians still take that oath. So to say that the patient can force you to participate in something that is morally repugnant to you turns medicine into a vending machine. You just come to the doctor and he gives you what you want and doesn't give you counsel or anything else, even if it violates his beliefs.
The second thing is this. Just because something is legal doesn't mean it's moral. And we need to understand that difference and I think Martin Luther King, and what we were talking about in the news hour with his wife, says that very clearly. All we have to do is look back in our history, back into the 1860s and some of the decisions the Supreme Court made concerning slavery and realize that the two are not synonymous and therefore the law is not the ultimate arbitrator in these issues, that there has to be moral conscience in any society to give us all guidance.
CONAN: Mm hmm. Ali thanks very much for the call.
ALI: Thank you.
CONAN: And before we go, we just have a minute left, Rob Stein where is this all heading?
Mr. STEIN: Well, it looks like it's heating up this year. There were--we have many more bills pending in many more legislatures this time this year than we had this time last year. So clearly this is an issue that is getting a lot of attention on both sides. People are working very hard. They're seeing it sort of as a litmus test really for how the states are going to deal with a lot of these issues down the road. And I think as medical research accelerates we're only going to see this kind of conflict escalate as more and more treatments come into the clinic and come into the doctor's office that people have ethical problems with.
CONAN: Rob Stein, a reporter for the Washington Post joined us from their offices there. Thanks very much.
Mr. STEIN: Thank you Neal.
CONAN: Dr. David Stevens, a physician and bioethicist, an Executive Director of the Christian Medical Association joined us from his office in Bristol, Tennessee. Thank you sir for your time today.
DR. STEVENS: Great to be with you.
CONAN: And Robin Shapiro, Director of the Center for the Study of Bioethics at the Medical College of Wisconsin joined us from the studios of member station WHAD in Milwaukee. Thank you for your time today as well.
Ms. SHAPIRO: Thanks Neal.
CONAN: When we come back from a short break, a fresh take on a classic snack. Writer Allen Kurzweil uses potato chips to explain the Universe. We'll be back after the break. I'm Neal Conan. It's Talk of the Nation from NPR News.
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