They are concerned about the impossibility of containing assisted suicide once it starts; about the financial inequalities in society and about fair access to medical care by the disadvantaged. Above all, they worry that the so-called “safeguards” of Oregon’s assisted suicide law are being disregarded. Kenneth R Stevens, MD
"Although the Oregon law requires counseling if the patient's doctor determines that he or she has a mental disorder or has his or her judgment impaired by depression, studies indicate that most doctors are not qualified to make such a determination" H. Hendin, MD
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Suicide lessons from Oregon
Assisted Suicide and Euthanasia: Oregon Tries the Dutch Way
Oregon during fall rivals states more famous for the beauty of their dying foliage, according to the north-west state's official website. That claim may be contentious, but in one thing Oregon is definitely unique in the American landscape: it has a law that allows doctors to help people kill themselves.
Next month marks the tenth anniversary of the state's physician-assisted suicide (PAS) law. Although Oregon's Death with Dignity Act was initially approved by state voters in 1994, legal proceedings kept it from becoming operational until November 1997. The first recorded legal assisted suicide deaths began at the start of 1998. According to the Oregon Department of Human Services, which monitors the Act, in the nine years from 1998 through 2006 there were 292 such deaths. Information regarding the 2007 calendar year will be released in March 2008.
The assisted suicide movement itself has acknowledged that physical pain is not the main reason for ending life. Oregon assisted suicide patients have been described by their doctors as being fiercely independent and controlling people. They fear dependency. Control and choice are the key words now used in the promotion of assisted suicide.
In the first four years (1998 to 2001) there were 91 deaths or about 23 a year. In the last five years (2002 to 2006) there were 201 deaths or about 40 a year. In 2006 there were 46 deaths; there were 65 prescriptions for lethal doses of secobarbital or pentobarbital written by 40 doctors. Currently about one in 700 deaths in Oregon is from assisted suicide.
Why have these Oregonians chosen to end their lives? Although the sponsors of the PAS law claimed that uncontrolled physical pain was the primary reason for legalizing assisted suicide, we have since learned that pain is not the main reason that some Oregonians have chosen it. The assisted suicide movement itself has acknowledged that physical pain is not the main reason for ending life. Oregon assisted suicide patients have been described by their doctors as being fiercely independent and controlling people. They fear dependency. Control and choice are the key words now used in the promotion of assisted suicide.
Less incentive to care
The arrival of "death with dignity" in Oregon has not created a health paradise. The national organization, Last Acts, issued a "report card" in November 2002 to states regarding their end-of-life care. Oregon was given a D grade for hospice care and an E grade for palliative care programs. There are concerns regarding pain management in Oregon. After four years of assisted suicide, an Oregon medical university study reported that there were almost twice as many dying patients in moderate or severe pain or distress as there had been prior to the law change.
Once a patient has the means to take his or her life, there is less incentive to care for the patient's symptoms and needs. A detailed report in the American Journal of Psychiatry in 2005 told of a depressed lung cancer patient in Oregon who had been committed to a mental hospital unit. During planning for his discharge, a palliative care consultant wrote that he probably needed attendant care at home, but providing for that additional care might be a "moot point" because he already had "life-ending medication" at home. His assisted suicide doctor did nothing for his pain and palliative care needs, but did offer to sit with him while he took the overdose. This seriously physically and mentally ill patient received poor medical advice and care because he had been prescribed lethal drugs.
An excuse for rationing care
Legitimising suicide for some can create danger for others. At a time of rising health costs administrators may build assisted suicide into their calculations. For instance, Oregon Medicaid covers the cost of assisted suicide, but not the cost of curative or local medical treatment for patients with cancer who have a less than a five per cent chance of living five years, even when that treatment can prolong valuable life. In 2003 Medicaid stopped paying for medicines for 10,000 poor Oregonians; this included patients with AIDS, those needing bone marrow transplants, people who are mentally ill and those with seizure disorders. In 2004 and the first half of 2005, an additional 75,000 Oregonians were cut from the health plan to keep the state budget balanced.
Even if an Oregon patient has Medicare or Medicaid coverage, there is limited access to health care. Sixty per cent of Oregon physicians limit or do not see Medicaid patients, and 40 per cent do not see Medicare patients. Seventeen per cent of Oregonians are without health insurance, and the share of Oregonians without health insurance has grown faster than in any other state over the past four years.Abuse of the law
The so-called “safeguards” in Oregon’s law are meant to limit access. It is to be expected, however, that when controlling-type people -- as PAS patients in Oregon allegedly are -- come up against the requirements of the law, something has to give, and so the boundaries around assisted suicide in Oregon have stretched.
Some of the legal requirements are: being an Oregon resident, being mentally capable, being diagnosed with a terminal illness that will lead to death within six months, and self-administering the prescribed medication. Predictably, there are reported instances of these rules not being followed. In any case, there is no protection for the depressed or mentally ill: in recent years, only five per cent of those dying from assisted suicide had a mental health consultation. In 2006, only two of the 46 patients dying from assisted suicide were referred for psychiatric evaluation, yet depression is the most common cause of suicidal thoughts.
There are published reports about a patient diagnosed by a psychiatrist as having dementia, who still received a prescription for lethal drugs. The drug is supposed to be self-administered and ingested, and yet we have media reports of cases where that has not occurred because the patient was not capable of doing it. Other reports concern two patients whose lethal medication entered the body via a feeding tube, one of them a PEG tube (feeding straight into the stomach) placed for the sole purpose of taking the lethal medication. Terminally ill people are reportedly moving to Oregon from other states because of Oregon’s assisted suicide law.
Many doctors are writing prescriptions for lethal drugs to patients for whom they have not previously cared and some appear to be making it their specialty. Dr Peter Rasmussen reported that 75 per cent of the patients who come to him regarding assisted suicide are people he has never seen before. In the past four years, one doctor each year has written between six and eight prescriptions.
One thing Oregon’s PAS law has not done: it has not reduced other suicides. Between 1999 and 2002 the state had a rate of suicide (not counting deaths from assisted suicide) among those 65 years of age and older that was sixth highest in the nation and one and a half times the national average.
At the same time there is no real monitoring of Oregon's assisted suicides. In the last three years the prescribing doctor was present at the time the patient took the lethal dose of sleeping drugs in only 29 of the 121 deaths. Knowledge of complications for the other 92 patients is obtained second- or third-hand. Following David Prueitt's failed assisted suicide attempt in January 2005, the state Department of Human Services (DHS) publicly stated that they had "not authority to investigate individual Death with Dignity cases -- the law neither requires or authorizes investigations from DHS."
An isolated anomaly - for now
With majorities voting twice -- in 1994 and 1997 -- in favor of legalization, it is unlikely that Oregon will repudiate assisted suicide in the near future. However, the north-west state has failed to be the predicted harbinger of assisted suicide spreading to other states. In keeping with its geographic fringe location, Oregon represents a solitary anomaly in legalizing assisted suicide. Voter referendums and legislative bills similar to Oregon’s assisted suicide law have failed in Alaska, Arizona, California, Hawaii, Maine, Michigan, Washington and Wisconsin. The failure of assisted suicide extended across the Atlantic where an Oregon-type assisted suicide bill was rejected in the British House of Lords in 2006. In early October 2007 the Washington State Medical Association rejected a proposal to be neutral in this area and strengthened its policy of opposition to PAS.
Why have PAS bills failed in other states? Because of the concern of a broad coalition of health care professionals, hospice workers, disability rights advocates, minority groups, pro-life advocates, and various moral and ethical leaders who have vigorously opposed the legalization of assisted suicides in these political jurisdictions.
They are concerned about the impossibility of containing assisted suicide once it starts; about the financial inequalities in society and about fair access to medical care by the disadvantaged. Above all, they worry that the so-called “safeguards” of Oregon’s assisted suicide law are being disregarded.
Kenneth R. Stevens Jr, MD, is Vice-President of the Physicians for Compassionate Care Education Foundation. The foundation promotes compassionate care for severely-ill patients without sanctioning or assisting their suicide. Members affirm that all human life is inherently valuable and that the physician’s roles are to heal illness, alleviate suffering, and provide comfort for the sick and dying.
April 1995, Vol. XII, Issue 4
Late last year, Oregon voters approved a law that would permit doctors to prescribe lethal drugs to patients judged to be in the last six months of life. Oregonians are setting out on a path that the Dutch have traveled for the past 20 years.
The Oregon law, now under a preliminary injunction pending a determination of its constitutionality, is the latest result of our failure to develop a better response to the needs of the terminally ill. Fear of dying in unbearable pain or of being kept alive in intolerable circumstances leads a frustrated public to action that only compounds the problem.
It is impossible to predict with certainty that a patient has only six months to live, which makes mistaken or falsified predictions inevitable. The Oregon law, like law in the Netherlands, permits assisted suicide when patients are neither in physical pain nor imminently about to die, and will encourage people who fear death to take a quicker way out.
A few years ago, a young professional in his early 30s who had acute myelocytic leukemia was referred to me for consultation. With medical treatment, Tim was given a 25 percent chance of survival; without it, he was told, he would die in a few months.
His immediate reaction was a desperate preoccupation with suicide and a request for support in carrying it out. He was worried about becoming dependent and feared both the symptoms of his disease and the side effects of treatment. His anxieties about the painful circumstances that would surround his death were not irrational, but all his fears about dying amplified them.
Many patients and physicians displace anxieties about death onto the circumstances of dying-pain, dependence, loss of dignity, the unpleasant side effects resulting from medical treatments. Focusing on or becoming enraged at the process distracts from the fear of death itself.
Once Tim and I could talk about the possibility or likelihood of his dying-what separation from his family and the destruction of his body meant to him-his desperation subsided. He accepted medical treatment and used the remaining months of his life to become closer to his wife and parents. Two days before he died, Tim talked about what he would have missed without the opportunity for a loving parting (Hendin 1994a).
Under Oregon law, he probably would have asked a doctor's help in taking his own life. Because he was mentally competent and did not meet the clinical criteria for a diagnosis of depression, he would have qualified for assisted suicide and would surely have found a doctor who would agree to his request.
Since the Oregon law, which uses guidelines like those in effect in the Netherlands that do not require an independently referred doctor for a second opinion, Tim would have been referred by a physician supportive of assisted suicide to a colleague who was equally supportive. The evaluation would very likely have been pro forma. He could have been put to death in an unrecognized state of terror, unable to give himself the chance of getting well or of dying in the dignified way he did (Hendin 1994b).
Although the Oregon law requires counseling if the patient's doctor determines that he or she has a mental disorder or has his or her judgment impaired by depression, studies indicate that most doctors are not qualified to make such a determination (Conwell and Caine 1991). Nor should psychiatrists and psychologists be sanguine at being reduced to the role, advocated in most legalization proposals, of simply determining if a patient is competent to make a decision regarding euthanasia. It was the fact that I was not the arbiter of this case that permitted the patient I described with acute myelocytic leukemia to talk freely about his fears of death and eventually to change his mind about wanting assisted suicide.
In the Netherlands, where there is legal sanction for assisted suicide and euthanasia, instances of inappropriately hastening death are common. Even in a film intended to promote euthanasia, Appointment with Death (K.A. Productions, 1993), that I was shown at the Dutch Voluntary Euthanasia Society, I saw an example. A young man, seemingly in his mid-30s, was diagnosed as HIV-positive. He had no physical symptoms, but had seen others suffer with them and wanted his physician's assistance in dying. The doctor compassionately explained to him that he might live for some years symptom-free. Over time the young man repeated his request for euthanasia and eventually his doctor acceded to it. The young man was clearly depressed and overwhelmed by the news of his situation. The doctor kept establishing that the young man was persistent in his request, but did not address the terror that underlay it. I was convinced that with a psychologically sensitive physician looking for more than repeated requests to die, more likely in a culture not so medically accepting of euthanasia, this young man would not have needed to be put to death.
The Dutch experience illustrates how social sanctions promote a culture that transforms suicide into assisted suicide and euthanasia and encourages patients and doctors to see assisted suicide and euthanasia-intended as an unfortunate necessity in exceptional cases-as almost a routine way of dealing with serious or terminal illness and more recently even with grief.
The Dutch like to point out that they have a relatively low suicide rate and that since the acceptance of euthanasia that rate has not increased, but dropped. But many of the cases of euthanasia are likely to be people who would have ended their own lives if euthanasia were not available to them. This was certainly one of the justifications given by Dutch doctors for providing such help. If any significant percentage of the euthanasia cases were to be included among the suicides, the Dutch figure would rise considerably.
In fact, the figures suggest that the drop in the Dutch suicide rate from a peak of 16.6 in 1983 to 12.8 in 1992 (in absolute numbers from 1,886 to 1,587) may well be due to the availability of euthanasia. More significant than the drop is the fact that it has taken place in the older age groups. In the 50 to 59 age group, the rate dropped from a peak of 21.5 in 1984 to 14 in 1992. Among those age 60 to 69 the rate dropped from a peak of 23.2 in 1982 to 14.5 in 1992. Among those age 70 and older the rate dropped from a peak of 31.3 in 1983 to 19.9 in 1992. These are remarkable drops of about 33 percent in these three groups. Of the 1,886 suicides in 1983, 940 were in the three older age groups. Of the 1,587 suicides in 1992, 672 were in the three older age groups. The drop of 268 suicides in the three older age groups was primarily responsible for the drop in the Dutch suicide rate. Comparing the five years of 1980 to 1984 with the 1988 to 1992 years provides statistically significant evidence of a drop in the older age groups that is not due to chance. These are the age groups containing the highest numbers of euthanasia cases (86 percent of the men and 76 percent of the women) and the greatest number of suicides.
The period of the last decade is the period of growing Dutch acceptance of euthanasia. It seems plausible that the remarkable drop in the older age groups is due to the fact that older suicidal patients are now asking to receive euthanasia.Among an older population, physical illness of all types is common, and many who have trouble coping with physical illness become suicidal. In a culture accepting of euthanasia, their distress may be accepted as a legitimate reason for euthanasia. It may be more than metaphorical to describe euthanasia as the Dutch cure for suicide.
How Dutch policy translates into practice with a psychiatric patient is evident in a case that has received international attention and has established assisted suicide for psychiatric patients as acceptable practice in the Netherlands. Psychiatrist Boudewijn Chabot assisted in the suicide of a physically healthy but grief-stricken 50-year-old social worker who was mourning the death of her son two months earlier (Hendin 1994b).
Chabot had accepted his patient, to whom he gave the fictional name of Netty Boomsma (Chabot 1993), into treatment in the summer of 1991 with the understanding, common in the Netherlands, that if she did not change her mind about not wanting to live, he would assist in her suicide. Netty appears to have used the agreement to mark time until Chabot felt obliged to fulfill his promise. He assisted in her suicide a little over two months after she came to see him, about four months after her younger son died of cancer at 20. Her first son had killed himself some years earlier following a rejection by his girlfriend. Netty had felt he might not have done so had she divorced her husband earlier and ended an unhappy family life.
Chabot described the case in a written account he sent a number of colleagues to satisfy the requirement for consultation. Although two did not think he should go forward and felt bereavement therapy was indicated, an expert in bereavement therapy thought it was futile and the majority agreed that Chabot should proceed. None felt it was necessary to actually see the patient.
Chabot described to me the scene the night he assisted in Netty's death. He went with a colleague to Netty's home and Netty had a friend with her. She said she wanted to go ahead. She asked to go to the room of her younger son. Chabot gave her a liquid as well as some capsules that a pharmacist had prepared for him. She opened the capsules as she had been advised and put them in some yogurt. Jokingly she asked him if he could not have given her some capsules before to practice. She sat down on the bed and asked them to turn on the record player which played a Bach flute sonata that had been played at her son's funeral. She took the glass and drank the liquid, saying that it was not too bad. While the music was playing Netty kissed a photograph of her two sons that was next to the bed. She asked her friend to sit next to her. Her friend stroked her hair. Netty said she had made a great effort to fix her hair and her friend was messing it up. The friend replied she would make it beautiful later. To Chabot, Netty said, "Why do young kids want suicide?" thinking of her son.
Chabot recalled saying to her after five minutes, "Think of your boys." In seven minutes she lost consciousness while being held by her friend. Then she slept. Her heart stopped in one-half hour.
Chabot insisted that Netty was not depressed, was not a patient, but simply a grieving woman who wanted to die. Netty had not exhibited the sad affect associated with depression; patients obsessively bent on suicide often do not. In the loss of pleasure that Netty experienced in activities she previously enjoyed, Netty surely met that aspect of the criteria established for the diagnosis of depression. In the sense, however, that any therapy would have required challenging the premises under which she came, and would probably have also included some trial on medication, no therapy could be said to have been undertaken with Netty so one can understand why Chabot does not regard her as a patient.
Chabot stated that if he did not agree to her terms she would have never come back. She had also threatened to take matters into her own hands. I asked why if she did not follow his prescription for treatment, he would feel obliged to follow hers. Certainly at the end he seemed to be succumbing to blackmail.
Chabot and a number of other Dutch therapists believe there is an obligation to assist in the suicide of a suicidal patient if treatment has not succeeded. They point to cases that they had been able to involve in psychotherapy because of the promise that if treatment did not work they would assist in their patients' suicides. Most therapists, however, find that such patients can be involved in therapy without such a promise by making it clear that they accept suicidal feelings as part of the therapy, are not uncomfortable or frightened by them, and will not go to any lengths to stop the patient's suicide, conveying that ultimately the patient is responsible for being alive.
Many suicidal patients come into therapy with sometimes conscious, but often unconscious, fantasies that cast the therapist in the role of their executioner. Netty seemed to be such a patient; she and Chabot also experienced a closeness in her death. A commitment on the therapist's part to become executioner if treatment fails plays into and reinforces these fantasies. It may also play into the therapist's illusion that if he or she cannot cure the patient no one else can either.
Some therapists also seem to have entered into the patient's fantasy of death as a reunion. Chabot's comment to Netty right before her death that she should think about her boys suggests that he too saw her death metaphorically as a return to her lost children. By metaphorizing death as something other than death, it is made to appear an attractive option. Not treating Netty as a patient but as a devoted mother whose desire to join her boys in death was not a sign of her disturbance but a legitimate and realizable goal makes it impossible to explore her guilt toward her children and her need for punishment.
From what Chabot was able to elicit in sessions with Netty, bereavement counseling was likely to fail with her, but psychotherapy less narrowly focused might have succeeded. Netty's personality problems far anteceded her bereavement. She said she became a person only when her first son was born and stayed alive only for the sake of her second son. Netty's guilt over her first son's suicide had sources that were deeper than her failure to have gotten a divorce. Caring for her second son seems to have had something of the quality of an atonement. One suspects that if therapy provided her with the opportunity to understand her relationship to her sons before deciding to join them in death, it might have engaged her.
No one should underestimate the grief of a mother who has lost a beloved child, but neither should one ignore the many ways life offers to deal with the feelings of loss, guilt and pain a child's death is likely to arouse. Certainly a decision to end life so soon after the death of her second son should not have been assisted or implemented. With or without treatment, time alone might well have made a difference.
The Dutch Supreme Court, which ruled on the case in June 1994, agreed with the lower courts in affirming that mental suffering can be grounds for euthanasia, but found Chabot guilty of not having had a psychiatric consultant actually see the patient. Although the court expressed the belief that a consultant's direct contact with a patient was particularly necessary in the absence of physical illness, it imposed no punishment since it felt that in all other regards Chabot had behaved responsibly. The case was seen as a triumph by euthanasia advocates, since it legally established mental suffering as a basis for euthanasia. Since the consultation can easily be obtained from a sympathetic colleague, it offers the patient little protection.
The acceptance of euthanasia for psychiatric patients who are suicidal seems the inevitable consequence of allowing such criteria as "competence" and "intolerable suffering" to determine the outcome rather than sound clinical judgment. The psychiatrist in some of the psychiatric cases is in the position of working to prevent suicide until the patient asks for his or her assistance in committing suicide and then the rules of the game change and the psychiatrist negotiates with the patient as to whose approach is best.
Seriously suicidal patients want suicide. In a society that makes euthanasia accessible for them they will be harder to treat, not easier. Many of them fantasize closeness in death with a person who kills them. When psychiatrists and general practitioners have complementary fantasies, euthanasia fulfills their needs as much as the patient's.
Dutch practice ignores what we know of the complex dynamics of the relation between the treatment of the suicidal and the desire of some who are seriously ill to end their lives. Suicidal patients are prone to make conditions of life that life cannot fulfill: "I won't live if I can't be in control," "without my husband," "if I lose my looks, power, prestige or health," or "if I am going to die soon." Depression, often precipitated by discovering a serious illness, exaggerates the tendency toward seeing problems in black-or-white terms (Hendin and Klerman 1993).
Although clinical and research experience confirm that the overwhelming majority of suicidal patients including the terminally ill suffer from a depression that can be treated, when a patient finds a doctor who shares the view that life is only worth living if certain conditions are met, the patient's rigidity is reinforced (Hendin 1995).
Many of us have known situations in which a doctor would have acted humanely by helping a terminally ill person die in the final weeks of illness. My observations in the Netherlands persuade me that legalization of assisted suicide and euthanasia are not the answer to the problems of the seriously or terminally ill.
The Netherlands has moved from assisted suicide to euthanasia, from euthanasia for the terminally ill to euthanasia for the chronically ill, from euthanasia for physical illness to euthanasia for psychological distress and from voluntary euthanasia to involuntary euthanasia (called "termination of the patient without explicit request"). The rationale for such extensions has been that to deny the right to die with assistance to the chronically ill who will have longer to suffer than the terminally ill or those who experience psychological pain not associated with physical disease is a form of discrimination. Euthanasia is preferred by patients and doctors as a safer and more certain way of assuring death so that assisted suicide is now used relatively infrequently.
Ending patients' lives without their request has been justified as necessitated by the need to make decisions for patients not competent to choose for themselves. The Dutch Government's own commissioned research has documented abuses of the system. In more than 1,000 cases a year, doctors actively caused or hastened death without the patient's request. In more than 5,000 cases doctors made decisions that might have ended or were intended to end the lives of competent patients without discussing the decisions with them (van der Maas, van Delders and Pijnenborg 1992).
Some euthanasia advocates defend the need for doctors to make decisions to end the lives of competent patients without discussion with them. One Dutch euthanasia advocate gave me as an example a case where a doctor had terminated the life of a nun a few days before she would have died because she was in excruciating pain, but her religious convictions did not permit her to ask for death. He did not argue, however, when asked why she should not have been permitted to die in the way she wanted.
Other advocates admit that a system in which doctors become used to playing a predominant role in making decisions about ending life encourages some to feel entitled to make decisions without consulting patients. Many of the professionals who are advocates of euthanasia conceded that abuses were common. In their published articles, however, they do not admit this since they see the issue of euthanasia as political.
Neither legalization of euthanasia nor opposition to it addresses the larger problem of how to care for the terminally ill. The call for legalization is a symptom of our failure to respond to the needs of the terminally ill and their understandable fear of artificial prolongation of the process of dying.
Yet the dangers threatened by legalization of assisted suicide are being avoided elsewhere in Western Europe where there is no great demand for legalizing assisted suicide or euthanasia. Care for the terminally ill is better in the Scandinavian countries than in the United States and in the Netherlands. Scandinavian doctors do not accept excessive measures for prolonging life in people who are virtually dead, but neither do they encourage people to choose death prematurely.
In the United States as in the Netherlands doctors are not sufficiently trained in the relief of pain and other symptoms in the terminally ill. Hospice care is in its infancy in both countries. We have not yet educated the public as to the choices they have in refusing or terminating treatment that prolongs a painful process of dying. And we have not devoted enough time in our medical schools to educating future physicians about coming to terms with the painful truth that there will be patients they will not be able to save but whose needs they must learn to address.
Psychiatrists and psychologists in the Netherlands played a relatively passive role in the growing normalization of suicide and euthanasia even though this has meant that patients who are basically suicidal, whether physically ill or not, are being assisted in death like those who seek relief in the last days of a terminal illness. We should learn from that experience to be more involved, educating the public that legalization may become a license to abuse and exploit the fears of the ill and depressed. Legalization constitutes acceptance of the view of those who are engulfed in suicidal despair that death is the preferred solution to the problems of illness, age and depression. It encourages the worst tendencies of depressed patients, most of whom can be helped to overcome their condition. "Normalizing" suicide as a medical option inevitably lays the groundwork for a culture that will not only turn euthanasia into a "cure" for depression but may prove to exert a coercion to die on patients when they are most vulnerable.
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3. Hendin H. Scared to death of dying. The New York Times. 1994b;Dec. 16, 1994.
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Source Assisted Suicide and Euthanasia: Oregon Tries the Dutch Way
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