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NEAL CONAN, host:

This is TALK OF THE NATION. I'm Neal Conan in Washington.

In some hospitals and clinics and medical practices across the country, some nurses and doctors refuse to perform certain medical procedures because of their personal beliefs. These healthcare workers argue that their convictions preclude participation in procedures that violate their conscience.

It's largely but not entirely a reflection of religious beliefs, and while the issue is not new, it's growing, along with pharmaceutical innovations like the morning-after pill, technologies that can keep patients alive on machinery, and political shifts like Oregon's approval of physician-assisted suicide.

Some doctors refuse to prescribe Viagra to unmarried men, anesthesiologists in California refused to participate in an execution, and, of course, there's abortion. The fight over the right of conscience and a patient's right to care has sparked debate in hospitals, courts, state legislatures and in Congress.

Later in the program, we'll talk with specialist Kristen King, host of Armed Forces Radio's most popular program in Iraq, and your letters. But first, a medical crisis of conscience.

If you're a doctor or a nurse, have these issues come up in your hospital or clinic or your practice? We'd also like to hear from patients who found themselves in the middle of this debate. Our number here in Washington is 800-989-8255. That's 800-989-TALK. Our e-mail address is talk@npr.org.

Rob Stein is a staff writer at The Washington Post whose article on this appeared in Sunday's Post. There's a link to it on our Web site, npr.org. Rob Stein joins us from the Post's office here in Washington, and it's nice to have you back on TALK OF THE NATION today.

Mr. ROB STEIN (Staff Writer, The Washington Post): Thanks, Neal. It's nice to be back.

CONAN: Do we have any indication of how many nurses or physicians are involved in this, how widespread this is?

Mr. STEIN: You know, there - nobody's really tracking this sort of thing. Nobody's really keeping hard numbers on this sort of phenomenon. But it's clear from the conversations that I've had with healthcare workers around the country over the last few months that this is something that is causing a lot of passionate feelings and concern among both healthcare workers and among patients.

On the one hand, you have healthcare workers who feel like they're being asked to do things that conflict with their deeply held personal moral or religious beliefs. And on the other hand, you have patients who feel like they're being denied access to legal medical care that they're entitled to.

CONAN: And have some of those patients taken their - these people to court?

Mr. STEIN: Yeah. What's happened is that when these two interests come into conflict, what will sometimes happen is you'll have patients who will sue their providers or file complaints against them when they feel like they've denied access to something.

CONAN: Mm-hmm.

Mr. STEIN: And on the other hand, you'll have healthcare workers who've been disciplined or fired or suffered some sort of penalty who will be suing their employers, charging religious discrimination.

CONAN: Yet, in some cases, if an anesthesiologist, for example, you cite in your article, declines to participate in a sterilization, the patient may never know.

Mr. STEIN: Yeah, and that's an important point to make, that in the overwhelming majority of these cases, this happens all the time. It's sort of a routine thing that happens in hospitals and clinics and doctor's offices. And most of the time, they've - the healthcare workers in the clinics and the facilities, they find a way to settle it informally.

Someone will say I don't feel comfortable doing this, and another - a coworker will step in and take over for them, and it happens quietly behind the scenes, and, as you said, often times, patients may not even be aware of it. But what happens is every once in awhile, through the specific circumstances, there'll be a conflict that occurs and that's when you have these flare-ups.

CONAN: In some circumstances, is this not a reflection of, well, you know, insufficient information made available to the patient. For example, Catholic hospitals don't do abortions. Everybody knows that.

Mr. STEIN: That's right, and sometimes what happens is that patients will either be taken to a hospital not realizing that it's run by a religious institution, and when they get there, they - like a typical example is a woman who'll give - have child - give birth to a baby, and then oftentimes afterwards, she'll decide she wants to undergo a voluntary sterilization. Then she'll find out, no, we don't do that here. You have to go elsewhere.

And sometimes patients will just show up at a doctor's office not realizing that the particular provider that they're seeing has these beliefs, and then they'll discover - and they'll say, no, I don't feel like I can do this, not comfortable, and it'll come as a shock to them because they weren't expecting it.

CONAN: And I wonder is there a history of this debate over a right to conscience in medicine that predates Roe v. Wade?

Mr. STEIN: Yeah, I mean, there is a long history of it. I mean, if you go back historically, you have doctors refusing - not feeling comfortable doing lots of things. I mean, there was a time when, for example, vivisection was something that was debated and doctors didn't feel comfortable doing that. And it's evolved over time and with different circumstances. And it really in this country, as you said, it's when Roe versus Wade was passed is when it became a prominent issue.

And in the wake of that, most every state passed what they called a conscience law which specifically permitted doctors and nurses who did not want to participate in abortion from stepping away and not being forced to do so. When Oregon passed its physician-assisted suicide law there was a provision specifically in there again saying doctors and nurses should not be forced to participate.

CONAN: Mm-hmm. Let's turn now to Nancy Berlinger, deputy director and associate for religious studies at The Hastings Center in Garrison, New York. She joins us from our bureau in New York City, and it's nice to have you on the program today.

Dr. NANCY BERLINGER (Deputy Director and Associate for Religious Studies, The Hastings Center): It's an honor.

CONAN: Is there an obligation for doctors and nurses as professionals to care for their patients?

Dr. BERLINGER: Absolutely. The bottom-line of professional ethics in medicine is - professional ethics, in general - is always do your duty. That makes a profession different from a job, that there's special training, there's special credentialing, there's special privileges, but at the bottom-line there's a duty.

And in medicine the duty is always to the care of the patient whether it's the cure of the patient, the treatment of the patient, the prevention of harm. But a professional in medicine whether a doctor, a nurse, a technician, a pharmacist, always works in a system that is organized around the health and wellbeing of the patient. So, yes, that duty to care is always about placing the patient's needs above one's own needs.

CONAN: And, in your view, does professional responsibility always trump personal conviction?

Dr. BERLINGER: Well, that's a very interesting thing because we - especially the field that I'm in, in bioethics, we talk a lot about the patient as a whole person, but we also talk about physicians as whole people. And I don't know anyone who would say, well, I don't really care about my doctor's values. You know, maybe some people would say that...

CONAN: Mm-hmm.

Ms. BERLINGER: ...but if you're in a relationship with someone, you generally want them to bring their values. You want to know that they care about you, that they care about their profession, that they're not - they're going to keep you safe, that they're going to try to avoid mistakes. If we try to control for every sort of belief I think we're going to run into some problems because if we try to make laws that say, none of your beliefs can have anything to do with the performance on your duty, we're touching on areas like clinical judgment, candor, empathy; it's hard to control for those things.

CONAN: Mm-hmm. So what you're saying is that there have to some gray lines here?

Ms. BERLINGER: Well, ethics is sometimes called the gray area.

(Soundbite of laughter)

Ms. BERLINGER: And you can see why. Yes, so when we try to work these things out, we understand - you mentioned abortion earlier.

CONAN: Mm-hmm.

Ms. BERLINGER: There are areas in our society and in many society's where reasonable people can disagree, will always disagree, and can agree to disagree. But when we go inside of a profession and a professional context and in a situation where one group holds more power than another group - the one with credentials, the one with the power to write the prescriptions or to provide or withhold treatment - we're not having a philosophical debate or religious debate, we're talking about the care of a vulnerable individual. And that is the - that always has to take precedence when we're in that context.

CONAN: But who gets to decide whether it's - well, it's okay to refuse to perform an abortion, that's personal belief, that's okay. Yet, as Rob Stein cited in his article, doctors who decline to prescribe Viagra to unmarried men, that's not okay?

Ms. BERLINGER: We seen an inconsistency here, do we not? This happens in bioethics in a number of different ways. When we have a lot old arguments, many things in bioethics happen at the beginning and the end of life. And we cited some of those examples. But often when new drugs, new technologies come online, we're not sure how to think about them and sometimes we wind up making some rather capricious decisions. I mean, yesterday, Rob and I were having a conversation about this based on his Post article, and the question came up that an awful lot of these cases have to do with women and reproduction.

CONAN: Mm-hmm.

Ms. BERLINGER: And so the Viagra case looks very strange because it has to do with men, and we're not quite sure what is the proxy for what? I mean, a lot of things seem to be a proxy here for ongoing debates over abortion, but there are other things that we may not even know what we're even talking about yet. With Viagra are we saying that we want to control who has sex?

Or are we saying that we maybe a pharmacist in the community knows something about someone who is trying to deny them something? We don't know - this is -these are new ways of thinking about very old arguments. But to return to your point, who decides? Well, healthcare takes place inside of a system. I mean, anytime you give everyone a drug - anyone a drug, I go to a pharmacist, I hand over my prescription; well, a doctor gave that to me, the pharmacist has to check to make sure the doctor didn't make any mistakes.

But we all play our part in this system; my insurer plays a part because I hand over that card, too. And the decisions have to be discussed not at the counter - not at the counter, not at the bedside, because, again, remember I'm the patient, I'm the vulnerable one in this.

CONAN: Mm-hmm.

Ms. BERLINGER: I'm on the receiving end. I'm trusting professionals.

CONAN: More and more broadly at the emergency room, or even the operating room.

Ms. BERLINGER: Exactly, exactly. So the place to have these conversations is yes, sometimes it's in the ethics committee, and hospitals tend to have ethics committees to deal with things like this. And sometimes it's the ethics committee that says, you know, we don't want to be dealing with these things sort of off the cuff or reactively or when the patients been prepped. Because if we just say, okay the patient has been prepped and the anesthesiologist has objected, well what do have to do then? We have to go find another anesthesiologist who presumably was busy with another patient.

So there is a domino effect, we don't want to imperil anyone's health, anyone's safety, inside of a system. So we better have thought this through earlier and have understood not only what are people's rights, but what are their duties, and what are the consequences of refusing to perform a duty that is normally associated with your role?

CONAN: Stay with us, if you will, we have to take a short break. We're talking with Nancy Berlinger, who's deputy director and associate for religious studies at The Hastings Center. And with Rob Stein, a staff writer at The Washington Post who wrote an article called Rights of Conscience in Sunday's edition. Again, if you'd like to take a look at the piece there's a link to it on our Web page, npr.org.

If you'd like to get involve in the conversation, give us a phone call. Our number 800-989-8255, 800-989-TALK. Our e-mail address is talk@npr.org. I'm Neal Conan. We'll be back after the break. This is the TALK OF THE NATION from NPR News.

(Soundbite of music)

NEAL CONAN, host:

This is TALK OF THE NATION. I'm Neal Conan in Washington. The issues are divisive: sterilization, physician assisted suicide, abortion, execution. We're talking about the debate over patient care and the right of doctors to say no to certain practices.

Our guests our Rob Stein, staff writer at The Washington Post, and Nancy Berlinger, deputy director and associate for religious studies at The Hastings Center. And of course you're invited to join us.

If you're a doctor or a nurse, have these issues come in your hospital or your clinic or your practice? We'd also like to hear from patients who may have been involved in this debate. Our number is 800-989-8255, 800-989-TALK. The e-mail address is talk@npr.org. And let's talk with Pauline(ph). Pauline calling us from Eugene, Oregon.

PAULINE (Caller): Hello.

CONAN: Hi, you're on the air. Go ahead.

PAULINE (Caller): Thank you for taking my call.

CONAN: Sure.

PAULINE (Caller): Well as an operating room nurse with a 38-year history in my profession, I think we need, as professionals, to have a clear definition of the responsibility of a professional before I personally can address my own personal feelings and convictions based on my religions practices in the practice of my profession.

CONAN: Mm-hmm.

PAULINE (Caller): And, so much of what we're going to hear today is based on the right to life issues with abortion, and et cetera. But I think if we open this door, we're opening a can of worms because it's a very slippery slope before we make decisions based on no abortions to how far can we go in this decision making. And I propose a question to all of your panel, that if we make these decisions, where do we stop?

And do we stop at saying no, we can't allow a 85-year old to have a heart/lung transplant? Or even another five-vessel bypass because they refuse to stop smoking and lose weight and do the things they need to be able to prolong their lives without taking a half million dollars of the precious, too-few health dollars, to provide the end of life care? It's a very dangerous thing.

CONAN: Nancy Berlinger, how do you answer that question?

Ms. BERLINGER: Oh, this is very interesting. First of all, Pauline, this -you're like my dream caller, because you're both...

(Soundbite of laughter)

Ms. BERLINGER: You're a medical professional - you mentioned you're from Oregon. Is that correct?

PAULINE (Caller): Right.

Ms. BERLINGER: Because Oregon, as you may know, recently, their Oregon Health Sciences University has a very interesting - they released it publicly - a conscientious objection policy that's one of the most comprehensive and ethically thought through policies that I've seen. And you might want to take a look at it. There was some interesting coverage of it when it came out last fall. And it talks about physician-assisted suicide, abortion, contraception, and life sustaining treatments, some of the examples you mentioned.

But it also talks about the process whereby these individual beliefs about these issues can or cannot co-exist with the duties of a healthcare professional. So it is possible to take - to sit down away from the passions of the moment, and certainly away from the bedside or the O.R. or the pharmacy counter where - when these things break into the media, and have a conversation and see what's possible and what's not possible. So again, that's an interesting example from Oregon trying to do this.

But to your other point about where do we stop, how far do we go? I gave a talk about this issue a few months ago actually at the AMA, at the American Medical Association, and one of the audience members was a physician who had practiced for maybe 60 years. And he had said he thought that there was in our cultural understanding in a pluralistic society a shift in what we understood by the word conscience, that this was a hard thing for us to get a hold of.

There may have been a point at a more homogenous time at our nation's history where we all had a common understanding of what we meant by culture and how it related to religious beliefs or other values. But he thought our contemporary sense of consciousness has kind of gotten mixed in with it, so we tended to think, well, anything I have a strong feeling about might be a conscience issue.

And that that could be very distracting cause we can have strong feelings about all sorts of things but they might be in isolation from one another.

CONAN: Mm-hmm.

Ms. BERLINGER: So this encourages us. I thought that was a very good point, because we really do have to say what are the consequences of a professional saying I refuse to do something.

CONAN: Mm-hmm.

Ms. BERLINGER: What are the consequences for that professional, not just for the patient.

CONAN: Let's bring another voice into this conversation. Robert Scheidt is a retired surgeon and chairman of the Ethics Commission of the Christian Medical and Dental association. He's with us by phone from his home in Van Wert, Ohio.

Dr. Scheidt, nice to have you on TALK OF THE NATION as well.

Dr. ROBERT SCHEIDT (Chairman of the Ethics Commission, Christian Medical and Dental Association): Hi, thanks for inviting me.

CONAN: And let me put Pauline's question to you, where does it stop?

Dr. SCHEIDT: Well, there should be lines and there should be reasonable lines. If I were going to put things in kind of an order of priority I would say the health of the patient comes first. And I would distinguish between what a patient needs for their health or what they just want. I think we must make that decision.

And then the doctor himself has the right of refusal on the basis of conscience. But he has an obligation to be sure that he's practicing factually accurate and rational medicine, number one. And number two, that his conscience is well informed. I thank your previous speaker in saying this isn't necessarily the equivalent of strong feelings is quite accurate.

CONAN: Pauline, thanks very much for the call.

PAULINE (Caller): Thank you.

CONAN: Appreciate it.

PAULINE (Caller): You know, in response to the physician's comment just now, if we use reasonable action to make our decisions with, the health of the patient comes first, but how do we weigh the health of one patient who is 85 at end of their life versus the possibility of saving 10,000 lives with better food and immunizations.

CONAN: Mm-hmm.

PAULINE (Caller): You know, do I, as an operating room nurse at that point, have the right to say I think this is ridiculous and I'm not going to do this case. Of course, I do not.

CONAN: Pauline, thanks very much.

PAULINE (Caller): That doesn't mean that it shouldn't open the can of worms that we should discuss...

CONAN: It's a big can of worms, there is no question about that. We appreciate your phone call.

PAULINE (Caller): Thank you.

CONAN: Okay, let's go on now and talk with - this is Andy. Andy is calling us from Toledo, Ohio.

ANDY (Caller): Hi, I'm a going to be a starting med student. But one of the ironies going in with this conversation is, you know, when you're applying to med school they actually ask you what you'll do in these situations and I kind of think that's nice that they do it. But, you know, going to making another comment about the professional duty, I think that's its very important that a doctor does do there professional duty but at the same time, you know, it's kind of hard to just say you can't completely ignore your personal ethics either. I mean, me being a Roman Catholic, if I perform an abortion I will be excommunicated from my faith.

CONAN: Mm-hmm.

ANDY (Caller): And it's one of those things that, you know, if someone comes to my office and needs it, you know, I'll be sure to refer to someone who doesn't have the same beliefs that I have. But, I mean, it's - you know, to me it is just something that is just something that's a lot more complex than just one personal belief.

CONAN: What's the difference between your doing it or just referring a patient who wants an abortion to somebody else who will do it?

ANDY (Caller): You know, I've often dealt with this issue and often discussed it, and it's one of those things that yeah, in a way I am being complicit by referring it to someone else to do it. But in a way, you know, I got to do what's best for the patient. But I, you know, I just can't really live with myself if I'm, in fact, doing the abortion.

CONAN: Yes, Rob Stein, there were some healthcare givers in your article who said they would decline to refer somebody else.

Mr. STEIN: That's right. I mean that's the solution a lot of people but forth to get around this. Is that, okay, if you don't feel comfortable doing it, then at least you can refer the patient elsewhere. But there are a lot of healthcare workers - I spoke to a lot of pharmacists, there are doctors who did not feel comfortable doing that. They felt that that would make them equally complicit with the act.

We were talking about Oregon University and I spoke to a doctor there right after that policy came out and he was livid because that policy required him to refer patients elsewhere for physician assisted suicide, and he was morally opposed to that, felt he could have no participation in it whatsoever.

CONAN: Dr. Scheidt is this an issue in your association?

Dr. ROBERT SCHEIDT: Yes, it certainly is. I think if the situation is acute and the life of the patient is in the balance it takes precedence. However, in any elective situation, I should think the doctor would have the right not even to refer. There would be time then for the patient to find a doctor to accommodate his wishes.

CONAN: Nancy Berlinger, wanted to get your input.

Dr. BERLINGER: Oh, thanks. The issue that this raises here - and I was very glad that your caller raising the issues - a student at the beginning of their career thinking about these issues is a wonderful thing to hear about. And being able to pars it saying that there are ways, and medicine allows you to do this, to say you could have a situation where you in some situations could decide not to do something but to refer the patient onward.

Because there is another very important duty in medicine and that is non abandonment of a patient. And this is taken very, very seriously in medicine. It doesn't just have to do with a situation of conscientious objection. It could be simply that you and a patient have reached the end of your ability to have a trusting relationship of some kind. You cannot help this patient in some way or you're closing your practice down. And medicine takes this very, very seriously.

So it is very important that we never would be in a situation of trying to control the outcome to say, because of my beliefs not only will I not perform this service, but I will make it hard for you to receive any medical care, perhaps. I mean, imagine a situation where this is a primary care provider or an emergency situation.

Again, that goes to power imbalance between the patient and the physician. And so we have to be very mindful that these rights do not exist in isolation from one another. And I do think that the referral process, which is in most codes of ethics and most policy statements on this, seems to be - if it is possible to make it work in practice - seems to be a way of managing these conflicts.

CONAN: Andy, thanks very much for the call. Good luck with your studies.

ANDY: All right, thanks.

CONAN: Let me ask you, Dr. Scheidt, how did you work these issues out in your practice? You're retired now, but did you learn about these in medical school as Andy is?

Dr. SCHEIDT: No, you're talking to a man who's older than you might expect. I'm 71 and I graduated from medical school in 1960. Consensus at that time was abortion was wrong and there were very few ethical dilemmas. However, you do learn about them as you go along. I don't think you learn ethics, per se, in medical school. I think you learn it when you're a child. You learned it from your parents, you learned it from your church, you learned it from your community.

It's already there when you get to medical school, and perhaps that's part of the dilemma for students who are now coming on board. But I practice in a community who shares my values. We're a very conservative farm community where I practice, and I face very few of these particular ethical issues.

CONAN: All right, let's see if we can get another caller on the line. And we'll turn to another caller from Oregon. This is Paul. Paul calling from Portland.

PAUL (CALLER): Hi, thanks. I guess I'm a student of public policy and I'm thinking that in order to kind of nip the problem in the bud, I think screening questions in the hiring process could be developed so that people - these professionals know what they're getting themselves into. To understand and get a feel for how these applicants feel about sensitive issues.

And if they're not willing to do it, then maybe they're not choosing the right career or maybe these people could be pushed down a path within a discipline that wouldn't put them in a situation where they'd have to perform these sensitive duties.

CONAN: Mm-hmm. Rob Stein, did this come up in your article, you know, where is the appropriate place to address these issues?

Mr. STEIN: Yes, it did come up. And that's, I mean, on the one side that's one of the solutions. People say, look if you can't do your job, if you can't do the duties of this profession, you should either not get into it in the first place or you should get out and find a new profession.

CONAN: Mm-hmm.

Mr. STEIN: Where the rub is is the march of technology. You know, if you're a pharmacist, for example, and you became a pharmacist 5, 10, 15 years ago, there was no such thing as the morning after pill. You didn't have to worry about it. And then suddenly (unintelligible) came along and you were faced with this moral choice. Physician assisted suicide, you know, another new development that suddenly people are having to grapple with.

So what do you do with a person in that situation? Well, one argument is you say you have to change professions. This is now a new duty of your profession, if you can't fulfill it, you have to leave. The other side says, well, you know, I could do everything else in my profession. I'm very good at my job. I'm a respiratory therapist in an intensive care unit and everything else I do, I do well and I love my job. I just don't want to have to disconnect a ventilator tube on somebody.

CONAN: We're talking about conscience, care, and medical ethics. And you're listening to TALK OF THE NATION from NPR News.

And let's get an e-mail in. This from Whitney in Kansas City, Missouri.

I'm 19-years-old and take birth control pills, not as a contraceptive but to help with other issues such as menstrual cramps and skin. I have been refused service at a number of different drug stores, mainly in more rural areas, because of my age and cashiers moral values about unmarried young girls being sexually active. I'm not using the pills for that reason, but even if I was I don't think it's fair that I have to search for a drug store that's willing to sell my prescription to me.

Dr. Scheidt, any advice for her?

Dr. SCHEIDT: Yes. I really think that's a terrible situation for her to be in. I regret that very much. I think that the drug stores and physicians and even institutions like Catholic hospitals should place what they're not going to do, where they're not going to serve, in some kind of visible form right up front. So people know what they can expect and what they cannot expect from that hospital.

CONAN: Truth in labeling.

Dr. SCHEIDT: Yes.

CONAN: Would that work, do you believe, Nancy Berlinger?

Dr. BERLINGER: Well, there's a problem with that, and I think your - the listener who e-mailed you put the nail on the head right there. She's taking a contraceptive for another purpose. And there are many, many drugs that are used for more than one purpose. And if she is to go to a drug store that it says we will not fill prescriptions for contraceptives if you are using them not to get pregnant, but it's okay if you're using them for something else. That's - you can see how that's going to be a problem.

I mean, you know, either you're telling people that they should lie, when they go in and say no, don't - whatever - don't worry, I'm not having sex. Or, you know, or you're going to wind up with a rather legalistic solution. That really works against the fact that in, as Rob said, the march of technology is such that there are new drugs coming online all the time, new technologies. And there are multiple uses for technologies because this is science. We find new applications for older drugs.

So I do think that we do rely on pharmacists to be the safety check. You want your pharmacists to call up the doctor if they say, you know, there's an extra zero on this prescription pad, is this correct. But you don't want them second guessing the doctor's intent in terms of the care of the patient. And that could be a problem, if we're relying on a sign as a screener. Again, we're trying to solve the problem at the pharmacy counter in that case by telling people to go elsewhere.

CONAN: Rob Stein, we just have a few seconds left, but I did want to ask you that it seems more and more that these issues are being resolved. Yes, they're being addressed in medical schools, in hospital ethics programs, and on the fly in a lot of places, but more and more in legislatures, including Congress.

Mr. STEIN: Yes, there's proposed legislation pending in more than a dozen states around the country on both sides. There's legislation that would require pharmacists to fill prescriptions and legislation that would allow them not to fill prescriptions. And there are also several - three or four bills pending in Congress. Three or four that would specifically address the pharmacist issue. There's a bill that would require hospitals to offer rape victims the morning after pill. And there's a Workplace Religious Freedom Act, which some people think would protect healthcare workers.

CONAN: Rob Stein's article, there's a link to it on our Web page, npr.org. Rob Stein, of The Washington Post, thank you. Our thanks also to Nancy Berlinger, of The Hastings Center, and to Robert Bob Scheidt, M.D., the chairman of the Ethics Commission of the Christian Medical and Dental Associations. This is NPR News.

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