Conscientious objector or deserter?

The discussion we’ve had since Friday regarding the Bush administration’s latest foray into theocracy brought up some interesting points. We discussed implications of the draft regulations including likely limitations on access to safe and effective birth control. But there is another issue here that disturbs me greatly.

Last week we talked a little bit about medical ethics. I’m not an Ethicist (Mike! Are you reading?), but I am a “practical ethicist”, as are all health care providers. How do ethics inform the discussion of what care we can or cannot provide?

First, let’s take the gloves off for a moment. What is a “pharmacist”?

A pharmacist is a trained professional with an expert knowledge of medications. In the retail setting, their primary role is to dispense medications, but their actual role is far greater. Pharmacists check patients’ records for drug interactions, counsel patients on how to properly store and take medications, and communicate with doctors regarding potential problems with prescriptions. Pharmacists are not, in most settings, the patient’s clinician, and do not have the same type of (ethical) relationship to their customers as doctors do with their patients. They are, at the simplest level, technicians and scientists who help maintain the safety and integrity of patients’ medications. It is a great responsibility—one small mistake on the part of a pharmacist can kill, and one small mistake caught by a pharmacist can save a life.

When a pharmacist receives a prescription from a physician that they believe may pose a threat to a patient, they call the doctor. For example, if I were to write a prescription for levothyroxine 125mg daily, the pharmacist would call me up to see if I meant micrograms rather than milligrams (125 mg is a helluva lot of this drug). If I tell the pharmacist to shut up and dispense the damned drug as written, they might refuse to pending further research, discussion, etc. This often happens with opiates. I may prescribe a cancer patient a very large dose of morphine and the pharmacist will call me to confirm. I’ll explain that they have been on this dose and tolerated it well, and the pharmacist will likely be satisfied that I know what I’m doing.

A pharmacist that receives a properly written prescription for a medication that any reasonable doctor would consider safe may not ethically refuse to fill it. The doctor and patient are the ones who make the decision on what meds are proper. In this case the pharmacists only remaining job, after checking for allergies and drug interactions, is to fill the legal prescription. If they don’t wish to do that, they should be fired, just as the check-out clerk would be fired for refusing to ring up a candy bar (and no, it doesn’t matter how fat the customer is). It has come up frequently that pharmacists sometimes refuse to fill birth control pills. This is unconscionable. The doctor and patient have a clinical relationship; the pharmacist in this instance is an intermediary, and could theoretically be replace by a sophisticated vending machine. Hmmm….

__________

The relationship between physician and patient is a bit more complicated. There is an asymmetry in the power relationship—anything the doctor says and does is potentially coercive. The doctor and the patient both count on this asymmetry—a patient goes to the doctor for advice, a doctor hopes their position of authority will help persuade the patient to do what is necessary (more on this issue of autonomy vs. paternalism here).

If a doctor tells a patient that smoking is dangerous, the patient is likely to believe them and will treat the words differently than if they had come from someone else. The same goes for a doctor’s opinions. If I tell my patient that I love Obama and that voting for McCain would ruin the American health care system, I’m probably using my influence in a bit of a shady manner. If a young woman comes to me wishing to terminate a pregnancy, and I tell her it is tantamount to killing a child, it means something very different to her than if she sees it on a billboard. If I oppose abortion, and feel I wish to be a “conscientious objector”, to share that with the patient is no longer an act of conscience, but an act of coercion. It is a desertion of my duty as a physician. I have patients who are Jehovah’s Witnesses. I give them very detailed information about the medical (not moral) consequences of their beliefs, but I stop there.

Doctors are activists—activists for the rights and needs of our patients, to which we subsume our own values to a great extent. This is one of the great challenges of medicine, and if you’re not up to the task, it’s time to get out.

Comments

  1. #1 6EQUJ5
    August 3, 2008

    If a pharmacist can refuse to fill a prescription that goes against his religious pretenses, then the truck driver can refuse to deliver those items to the pharmacy, and the workers at the pharmaceutical company that makes them can refuse to work, and so on and so on and so on.

    Is a supermarket worker refuses to touch pork products because they are ritually unclean, do you find a work around to accommodate him?

    If a worker refuses to work, fire his ass on the spot, right in front of the customer. You will be doing your job as well as pleasing the customer.

  2. #2 Suricou Raven
    August 3, 2008

    “Is a supermarket worker refuses to touch pork products because they are ritually unclean, do you find a work around to accommodate him?”

    Here in the UK, we do – because if the employer does not, they run the risk of having the ex-employee and whichever lobbying group represents their religion taking very expensive legal action.

  3. #3 FutureMD
    August 3, 2008

    A better example would be someone who works at a pig slaughterhouse refusing to work because pigs are unclean.

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    August 3, 2008

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  5. #5 katie
    August 3, 2008

    I used to work as a clerk in a movie/video game rental place. I refused to rent an extremely violent video game (Manhunt) to a woman who was clearly renting it for her child (age about 7) who was also in the store.

    Yes, it was perfectly legal for her to rent that game for her son. But she clearly had no understanding of the game’s content (I had played it before and tried to explain the graphic nature of the game) and I felt it was unethical of me to rent it to her for her son to play.

    Thoughts?

  6. #6 decrepitoldfool
    August 3, 2008

    It would be precisely like me joining the army and then refusing to touch weapons because I disagree with violence.

  7. #7 decrepitoldfool
    August 3, 2008

    I was responding to the Pharmacist issue, not Katie’s question. In Katie’s case, it would be very like a pharmacist refusing to fill a prescription because he has noticed a dangerous drug interaction.

  8. #8 Karen
    August 3, 2008

    But, in Katie’s case, if I’d carefully explained the graphic violence of the game to the customer and she still wanted to rent it, I would feel obligated to do so. Perhaps she was renting it for teenage son and 7-year-old only thought he was going to play it. Perhaps she had to play it with him to really understand the “graphic” part of the violence. Either way, if it was legal for her to rent it, it would be wrong to deny it to her.

    If my pharmacist spotted a drug interaction problem with the cocktail of pharmaceuticals prescribed for me, I’d expect her first step would be to call the prescribing doctor and voice her concerns with him/her — not to categorically refuse fulfilling the prescription.

    If my pharmacist had an “ethical” problem with any of my prescriptions, I would expect my drugstore to deal with her intransigence quickly. They make a mint off of me and my insurance company every month. Just from a purely business point of view, they couldn’t risk the loss of business from irate customers.

    But then I live in a relatively civilized part of the country, where personal autonomy is an important value and inflicting one’s religious beliefs on others is not generally welcome.

  9. #9 ttch
    August 3, 2008

    What about a pharmacist in Oregon refusing to dispense a medication that the physician and patient agree is to be used for the patient’s physician-assisted suicide?

  10. #10 Owen
    August 3, 2008

    If physician-assisted suicide is legal, the drugs should be dispensed. Perhaps with a “I’m legally obliged to make sure that you know that if you take these you will die” question, but the prescription should be filled. Like everyone else says – it’s your job: if you can’t do it, find another one.

  11. #11 Bumper
    August 3, 2008

    You know, there do exist such things as robots that dispense medicine in pharmacies. Robots, along with computers, could radically transform the profession, and pharmacists wouldn’t even be necessary to dispense birth control or other controversial meds. It may be a ways off due to costs, but I see it happening eventually.

  12. #12 Bumper
    August 3, 2008

    Katie – as much as I agree that youngsters shouldn’t be playing graphic video games, I think you were out of line here, and had the parent complained about this, you should have been terminated. A parent is entitled to make these types of decisions and there is no illegality involved so you substituting your judgment for the parent’s is not acceptable. The best you can do is explain your concerns to the parent and perhaps show her a bit of the game, hoping that she wises up.

  13. #13 Anonymous
    August 3, 2008

    PalMd says,”A pharmacist that receives a properly written prescription for a medication that any reasonable doctor would consider safe may not ethically refuse to fill it. The doctor and patient are the ones who make the decision on what meds are proper.”

    What about a pharmacist who refuses to fill prescriptions that are not medically indicated? Is that unethical? If so, why?

    What about doctors (rather than pharmacists) who refuse to perform body piercings and/or cosmetic amputations? These things are legal, but they seem to lack medical indications. Should MDs be barred from practiceing medicine for refusing to perfom procedures when they aren’t medically indicated?

  14. #14 Bob
    August 3, 2008

    @ttch: is the prescription itself legal and legitimate? Does the pharmacist transfer the prescription to another less-ethically-conflicted pharmacist or pharmacy without unduly inconveniencing the patient?

    I have no issue with accommodating ethical or other issues of an employee, provided the profession’s duty to the public is upheld. Using one’s personal ethical outlook as a shield to actively interfere with the legitimate provision of care to a patient is unprofessional and those who insist its their right to deny care should be walked to the door, have their professional license pulled, and be thrown to a wolfpack of civil litigators.

    @katie: Is there a company policy on renting mature material to minors? If so, delegate up, or cite policy and apologize for not renting it to her (throw in a bit of compassion, too.) It’d be a different story if you were a librarian; I’m certain the ALA has a pretty strong code of ethics with regard to free access to information. It’d also be a different story if you were a medical professional; there’s a world of difference between denying someone prescribed medication which you must assume is medically necessary and which cannot be obtained elsewhere versus not renting out a game, something that is recreational and can be obtained elsewhere.

    I don’t harbor any ill will against Chick-fil-A for choosing to close on Sunday for religious reasons. I can get a chicken sandwich damn near anywhere and I’m not going to get sick or die if I don’t get one. The same can’t be said for a prescription so consequently we hold dispensing pharmacists to a higher standard.

  15. #15 PalMD
    August 3, 2008

    What about doctors (rather than pharmacists) who refuse to perform body piercings and/or cosmetic amputations? These things are legal, but they seem to lack medical indications. Should MDs be barred from practiceing medicine for refusing to perfom procedures when they aren’t medically indicated?

    Doctors are not ethically obliged to perform elective/cosmetic procedures, in most cases.

  16. #16 Anonymous
    August 3, 2008

    decrepitoldfool:

    In Katie’s case, it would be very like a pharmacist refusing to fill a prescription because he has noticed a dangerous drug interaction.

    No it wouldn’t, not even slightly. Unless you have epilepsy, video games are not dangerous and will not kill you.
    It would be like a pharmacist refusing to fill a prescription because they feel the colour of the box the medication comes in will clash w/ the customers clothing.

  17. #17 tincture
    August 3, 2008

    Woops, forgot to put a name in.

  18. #18 ttch
    August 3, 2008

    How about a pharmacist refusing to fill a prescription for a drug to be used in an execution by lethal injection?

  19. #19 nanoAl
    August 4, 2008

    Violent video games are more of a taboo than a danger. If the mother understands (and has no problem with) the violent nature of the game then she has every right to rent it for her child. Unless the mother didn’t understand then I’d have to say Katie was a little out of line.
    Drugs are entirely different, You simply cannot use a position of that kind of power to push any morality, its not your job. Give ‘em the damn drugs, let the pastors do the soul saving.

  20. #20 Eddie Janssen
    August 4, 2008

    I think that if the pharmacist made it publicly known that he or she will not provide services for treatment/medication a, b, c etc. and that a, b, c etc can be obtained by the other pharmacists in town everyone will be happy: the pharmacist has kept God pleased, the physicians know to which pharmacist they can send their patients and the patients get their medication.
    I know this proposed solution is a practical solution and avoiding the ethical problem. I also understand that in rural areas problems may arise. If there is commercial competition between pharmacists in the US, I am not sure how long ethics will win against sales.

  21. #21 Mongrel
    August 4, 2008

    You know, there do exist such things as robots that dispense medicine in pharmacies. Robots, along with computers, could radically transform the profession, and pharmacists wouldn’t even be necessary to dispense birth control or other controversial meds. It may be a ways off due to costs, but I see it happening eventually.

    Well in the UK at least every item that passes from the dispensary to a patient has to be double checked by a pharmacist, at the end of the day they’re the ones who are legally liable for everything that gets dispensed.

  22. #22 Chuck
    August 4, 2008

    There are pharmacies that do not carry items that the owners of the business find to be objectionable, regardless of the religious convictions of the pharmacists that work there. It is usually clearly stated what prescriptions cannot be filled at that location. Capitalism at work.

  23. #23 Natalie
    August 4, 2008

    ttch, I sincerely doubt that prisons pop down to the local drug store to get their lethal injection drugs. Something tells me they have other sources.

  24. #24 Annie
    August 4, 2008

    To have this convo without a medical ethicist or two participating leaves a lot of uncovered territory, IMHO.

    However, having served on medical ethics committeess for hospitals and nursing homes in the US over the years, I’ll throw in my copper-free .02 for consideration:

    First off, all licensed healthcare professionals, pharmacists included, DO indeed have patient advocacy as part of their roles. The physician-patient relationship is the usual primary relationship for patients, but that’s not always the case, either. Pharmacists are expected to advocate for patients in assuring that all parts of the prescription are correct: right drug, right dose, right frequency, right route, right time. They are expected to know about and question/withhold processing orders that do not assure compliance with all parts of the “rights” in a precription. Examples include drug interactions, allergies, sensitivities, duplicate orders (from multiple providers), cost considerations, insurance policy/formulary restrictions (you might have a legitimate prescription, but your pharmacist ascertains tht your insurer won’t cover that particular drug), and sometimes, the drug ordered isn’t appropriate for the condition diagnosed.

    OK then. Now to the ethic question about refusing to fill a prescription which DOES meet all of the critieria, but in which the dispensing pharmacist has a “moral or ethical objection.”

    That profession’s code of ethics calls for the pharmacist to have made his or her objections to carrying out any or all parts of his job to the employer PRIOR to actual patient contact. The employer or pharmacist has the duty to provide an alternate (and reasonable) means of access to filling the prescription.

    Failure to do that is a breach in the social contract between professional and patient. Patients who experience this should file a complaint with the appropriate state board of pharmacy.

    The previous post which explained the obligation of a professional and its cetering on the needs of the patient and not the profesional was spot on.

    In my own field, nurses have a professional obligation to make known any beliefs which would affect their ability to provide care in the appropriate circumstances PRIOR to an actual event so that the employer is aware and can take steps to assure that care can be provided safely if the situation is encountered.

    When HIV/AIDS was initially linked to the gay community, a few nurses and physicians refused to provide care, blaming patients with the accusations of immoral sexual behavior. They were sanctioned, and some were fired or had actions taken against their licenses, which is entirely appropriate.

    The current situation is no different. Licensed professionals may not impose their personal religious and ethical beliefs and values on others. Period. People can BELIEVE whatever they choose. They may not ACT on those beliefs when it interferes with the profession they are licensed to practice as regulated by the appropriate state board.

  25. #25 Annie
    August 4, 2008

    The Hastings Center for Bioethics has published around contraception issues before, and the link at my name goes to references there.

  26. #26 Dianne
    August 4, 2008

    If I oppose abortion, and feel I wish to be a “conscientious objector”, to share that with the patient is no longer an act of conscience, but an act of coercion. It is a desertion of my duty as a physician.

    The thing about being a CO is that you can’t be both a CO and a soldier simultaneously. If you honestly feel that abortion is murder then you should not work in an abortion clinic or any other place where you may be asked to perform or recommend an abortion. There are plenty of ways around this, for physicians and pharmacists both. One can work in a VA hosptial, where young, fertile women are rarities. Or a nursing home, to be even more certain. But don’t both claim to be an ob/gyn or a pharmicist willing to serve the general public and refuse to perform a significant proportion of your job.

  27. #27 Mike
    August 4, 2008

    It is pathetic how pharmacists are seen as glorified robots who do nothing but fill bottles with pills and then sell them.

    Pharmacists go through 4 years of underaduate training to obtain a bachelor’s degree, 4 years of Pharmacy school to obtain a PharmD, and then some go through 2 or 3 years of residency.

    I am not a pharmacist, but the lack of respect shown to these health care professionals who are properly addressed as “doctor” in a pharmacy setting is appalling.

  28. #28 bob koepp
    August 4, 2008

    Since somebody has mentioned the relevance of actual medical ethics to the discussion, I’ll point out a couple things that need closer scrutiny.
    1. That healthcare professionals have patient advocacy as part of their roles is correct. But the duty reflects expertise — healthcare professionals have a duty to advocate for patient’s health interests, but not their broader interests. Hence, whether a service is medically indicated is a relevant consideration.
    2. Refusing to provide a service is not generally understood, in either ethics or law, as a form of imposing on the person seeking assistance. It’s certainly not “coercive”.
    3. Freedom of conscience doesn’t just mean that people are free to believe what they want. It means they aren’t supposed to be compelled to act contrary to the dictates of their consciences unless it’s absolutely necessary.

  29. #29 Abel Pharmboy
    August 4, 2008

    I spent about ten years as a pharmacy professor. I understand firsthand the rigor of training most pharmacists have, although Mike’s point above refers to “old-fashioned: PharmDs – today, a PharmD can be had with only another two years past what used to be the BS (imho, the decision of ACPE and AACP to go PharmD as the entry-level degree was more economic than professional: Rx schools can now charge doctoral tuition for all 4 yrs of professional training – whether a PharmD should be called “doctor” is a discussion for another day).

    I know that the spam filter will hold up my comment if I put in both links to both URLs of my previous discussion of this issue. I hold that a state license to practice pharmacy represents a civil and professional pact to serve the citizens of the state period. If the FDA approves it and the doc prescribes it, the script should be filled as long as technical details of dose and drug interaction potential are addressed.

  30. #30 Abel Pharmboy
    August 4, 2008

    Here is where I view refusal of a pharmacist to fill a legitimate prescription as professional negligence.

  31. #31 Grimalkin
    August 5, 2008

    katie – that isn’t your place. You weren’t right to parent a child who isn’t your own (or for some other reason entrusted into your care by the parent/guardian). Just because you disagree with someone else’s parenting choices doesn’t mean that you have the right to interfere. Lord knows parents have a hard enough time already with strangers and acquaintances undermining their parenting.

    Just to give you an example, my cousin buys some “girly” toys for her son. He has dolls. Why? Because he likes dolls. She’s often been in a situation where store clerks will lecture her when they find out that the toys she’s buying are for a boy. What if we say that these clerks can refuse to sell her dolls because she will be “feminizing” her son? Isn’t that just the same as what you’ve done? They’ve decided that, by their own value system, a parent is raising her children wrong and have intervened. The only difference is that they stop at a lecture and do actually sell her the dolls.

    You were absolutely right to try to inform her of our graphic the game is, but beyond that your job is to sell games to customers who want them. You have no right to decide who can or cannot have a game (unless they are breaking a law or store policy, for example).

  32. #32 katie
    August 5, 2008

    Hey… thought I’d just add a few comments to my video game rental thing.

    There was a store policy: rent video games to children according to their rating system. In this case, the game was rated for people 18+. Where this is tougher is when a mother (who was clearly over 18) chooses to rent it–she legally could.

    But… how would you feel if a parent walked in a movie store and asked you to pick out the best porn for their 7 year old?

    That being said, as far as I know, there is no proof that harm is done to a kid from violent videogames (or porn for that matter… but that’s another story). But there is also no benefit. I’m not like a pharmacist because there is no potential harm to the kid because I don’t fill out the prescription.

    Just as an aside, I wonder if this thread would be different if I posted in Canada (that’s where this all occurred)… we have a slightly different take on liberalism.

  33. #33 Natalie
    August 5, 2008

    Bob koepp: “Freedom of conscience doesn’t just mean that people are free to believe what they want. It means they aren’t supposed to be compelled to act contrary to the dictates of their consciences unless it’s absolutely necessary.”

    Certainly, no one should be compelled to act against the dictates of their conscience. But no one has forced any pharmascist to become a pharmascist – this is a career path they choose freely. Part of the job (a large part of the job) is dispensing medications to anyone with a valid prescription. Pharmascists who refuse to do so should not have become pharmascists, and should be fired. They are refusing to do their job, which is a valid reason for termination, IMO.

  34. #34 Russell
    August 5, 2008

    If a doctor from the West were to spend some time working in Africa and,in a particular village,female circumcision were common practice should s/he refuse to perform it?

  35. #35 bob koepp
    August 5, 2008

    Natalie – An employer can fire an employee pharmacist for failing to perform “per contract.” No big deal there. But what about self-employed pharmacists?

    As for “refusing to do their job,” where is it written that the job of a pharmacist is to dispense medications to anyone with a valid prescription? What about a pharmacist who claims that his/her professional duty is to dispense medications that are medically indicated?

  36. #36 Natalie
    August 5, 2008

    Bob, it is actually a big deal, as this draft resolution would make it illegal to fire a pharmacist for such behavior. That is exactly the point.

    I don’t know if it’s written down anywhere that pharmacists are supposed to dispense medications. Are you arguing that this is not their main job duty?

  37. #37 bob koepp
    August 5, 2008

    No, pharmacist employees could still be fired for failure to perform per contract. What’s being proposed is placing certain limitations on the content of contracts — namely, that they can’t include clauses that discriminate on the basis of moral beliefs. I’ll leave it the lawyers to argue about whether that makes sense.

    My understanding of the professional duties of pharmacists is that their “main job duty” is to dispense substances for the treatment or prevention of medical pathologies. While there certainly are cases where the prevention or termination of a pregnancy falls under that umbrella, the simple fact is that “birth control” is usually not medically indicated, because a biologically normal pregnancy doesn’t qualify as a medical pathology. That being the case, it’s a stretch to claim that pharmacists who refuse to dispense contraceptives, abortifacients, etc., are violating any standards of professional ethics. I see their situation as analogous to that of MDs who conscientiously refuse to prescribe such drugs and/or to perform abortions when not medically indicated.

    Going the next step, I think this “debate” could largely be put to rest if we simply “demedicalized” the control of reproduction. If I was a woman, I’d resent having to go to a pharmacist to get a drug that can be safely and effectively self-administered.

  38. #38 katie
    August 5, 2008

    Hey, for that matter… I find it ridiculous I have to go to a doctor to get a prescription for birth control that I have been safely using for years. Especially when, by law (where I am), they can’t give you more than a six month supply at once. So…basically it’s a waste of time for the doc and me–I’m healthy, young, and just want a prescription written.

  39. #39 Chuck
    August 5, 2008

    I also find it ridiculous that I have to pay the extortion of doctor’s office fees for medications I have been regulating for decades. The only reason I go is due to the blackmail of getting that piece of paper and hearing a doctor reading test results that I already knew before I went for the visit.

  40. #40 PalMD
    August 5, 2008

    I’ve been driving over the same damned bridge for decades…I can’t understand why I have to pay a toll for engineers to tell me what I already knew…

  41. #41 Natalie
    August 6, 2008

    “No, pharmacist employees could still be fired for failure to perform per contract. What’s being proposed is placing certain limitations on the content of contracts — namely, that they can’t include clauses that discriminate on the basis of moral beliefs.”

    I think we are trying to say the same thing. It seems to me that, functionally, making it illegal to include certain things in a contract is essentially the same thing as making it illegal to fire a person for that same thing. I still find it ridiculous that the White House would consider this an appropriate use of government power.

    As far as medically indicated medicines go, I am not a health care professional so I really don’t know what the standard is for “medical necessity”. However, as someone who has used birth control, I resent the idea that it is not medically necessary. Certainly pharmascists fill prescriptions for things that are not a medical pathology – why should birth control be any different?

  42. #42 Chuck
    August 6, 2008

    “I’ve been driving over the same damned bridge for decades…I can’t understand why I have to pay a toll for engineers to tell me what I already knew…”

    That they have a monopoly and you can’t find another route that doesn’t require a toll.

  43. #43 Monado
    August 7, 2008

    Like a doctor refusing to treat you if you get hurt at a recreational activity because you’re just doing it for pleasure?

  44. #44 LittleMan
    August 25, 2008

    The slippery slope argument ought to make this issue nice and simple:

    Can an atheist cashier in a bookstore refuse to sell Bibles?

    If not, then a pharmacist cannot refuse to fill a prescription for birth control.

    And now for my two cents,

    Any employee’s job description is always to do what their employer has hired them to do.

    If you hire me on contract to recover your damaged computer hard drive, but I refuse to give you data when I find out it includes your dissertation on evolutionary biology (because I don’t believe in evolution, or some silly jazz), you can fire me and go hire someone else to do it. I’ve broken my contract obligation.

    The government is saying you can’t. And since pharmacists are regular employees, they’re effectively saying you can’t even go to someone else who will recover it for you.

  45. #45 LittleMan
    August 25, 2008

    Oops! Linked in and didn’t look at the date. Oh well – 3 weeks – not THAT bad.

  46. #46 PalMD
    August 25, 2008

    Our threads never close!

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    April 27, 2009

    wholesale pearl jewelry,silver jewelry.

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