Euthanasia: "To Kill or Not to Kill"
That is The Question
Euthanasia is a complex and controversial topic. In our society today, there are political, medical, and moral controversies concerning euthanasia. It is an issue that challenges our hearts and our minds. The ultimate goal of this paper is to argue against the use of active euthanasia as an option for the deliberate ending of a persons life with the intent of reducing that persons suffering. In this paper, I will first give a brief overview of the ethical debate about euthanasia. Secondly, I am going to put forth the best argument that I can to defend the position of active euthanasia. Finally, I will put forth the best argument that I can against the active euthanasia position.
Brief Overview of The Ethical Debate of Euthanasia
The word "euthanasia", derived from the Greek "eu-thanatos" meaning simply "a good death", "is subject to widely differing understandings, and the distinction between active and passive euthanasia (killing and letting die) is frequently collapsed into one term." In his article "Active and Passive Euthanasia," James Rachels believes that there is no moral difference between active and passive euthanasia. Rachels writes "If a doctor lets a patient die, for humane reasons, he is in the same moral position as if he had given the patient a lethal injection." Rachels concludes that active euthanasia can be "the morally preferable option."
In order to avoid confusion in the debate about euthanasia, it is necessary to distinguish euthanasia from the mere termination of treatment, and to have a clear definition of terms. For the purposes of my paper, active euthanasia is defined as the deliberate ending of a persons life with the intent of reducing that persons suffering. A good example of active euthanasia is the act of giving a lethal injection. In their article "Euthanasia - A Critique", Peter Singer and Mark Siegler state that there is a distinction between active euthanasia, i.e. giving a lethal injection, and such other acts such as the decision to forgo life-sustaining treatment, such as use of ventilations, CPR, dialysis, tube feedings or the administration of analgesic agents to relief pain. They conclude that "Physicians must become more responsive to the concerns of patients that underlie the movement for euthanasia and must provide better pain management, more compassionate terminal care, and more appropriate use of life-sustaining treatments."
Those who advocate the use of active euthanasia argue that people today have a fear of being forced to endure destructive pain, or to live out a life of unrelieved, pointless suffering. Advocates of active euthanasia also argue that "modern medicine has failed to reassure us that it can manage our dying with dignity and comfort and therefore, this fact leads to the demand that we must be in control, masters of our own fate." The proponents of active euthanasia argue that patients whose illnesses cause them unbearable suffering should be permitted and have a right to end their distress by having a physician perform euthanasia. Euthanasia is a more humane than forcing a patient to continue a life of unmitigated suffering. Dying patients also have the right to know their condition, to choose or to reject the treatment regimen, to choose or reject attempts to prolong their life, and to decide fully as to the disposal of their remains. Derek Humphrey writes "Most, but not all, terminal pain can be controlled with the sophisticated use of drugs, but the point these leaders miss is that personal quality of life is vital to some people. If ones body has been so destroyed by disease that it is not worth living, that is an intensely individual decision which should not be thwarted." Humphrey also states that the patient has a right to control the medical treatment which he or she receives, even the right to request and receive euthanasia. A dying patients basic human rights are seen to be violated when they lack the knowledge and power to make decisions which, in turn diminishes their dignity as human persons.
Those who advocate that active euthanasia is never a option as a medical treatment argue that; (1) if a person seeks to end his/her life by active euthanasia, then he/she intrinsically contradicts the value of his/her autonomy, (2) active euthanasia violates the fundamental prohibition against killing, except in the case of self-defense or defense of others, (3) there would be a general reduction of respect for human life if official barriers to killing are removed, (4) if made a public policy, active euthanasia could lead to involuntary euthanasia and (5) active euthanasia would undermine the integrity of medicine and the patient-physician relationship. Opponents of active euthanasia will also argue that a person can never intend or cause the death of himself/herself or of another person who suffers from a terminal illness or other type of intolerable suffering, because by the very nature of the act, it would be considered suicide or murder. Those who are against active euthanasia understand that there is a demand for active euthanasia, as a response "to the fear of entrapment in a technologically sophisticated, seemingly uncaring world of medicine, but unrestrained freedom to end ones life or to have it ended by a physician ought not to be the only response to that fear; nor is such a response without grave social implications." What they, who argue against euthanasia, will conclude is not to sanction euthanasia, but rather that "we reject the notion insisting that we utilize any intervention capable of sustaining life--indifferent to the pain, suffering and burden to the individual whose life, or dying, is being prolonged." Advocates against euthanasia conclude that there must be better palliative care for those who suffer tremendously and for the terminally ill, rather than to actively terminate their lives.
Case for Active Euthanasia
I will be using the arguments of two different advocates of active euthanasia; James Rachels and Derek Humphrey. In the article "Active and Passive Euthanasia", James Rachels argues that "there is no necessary moral difference between active euthanasia (killing) and passive euthanasia (letting die) and that active euthanasia can often be more humane." Rachels wants to challenge the following statement adopted by the American Medical Association on December 4, 1973:
The intentional termination of the life of one human being by another--mercy killing-- is contrary to that for which the medical profession stands and is contrary to the policy of the American Medical Association. The cessation of the employment of extraordinary means to prolong the life of the body, when there is irrefutable evidence that biological death is imminent is the decision of the patient and/or his immediate family. The advice and judgment of the physician should be freely available to the patient and/or his immediate statement.
He uses the familiar type of example to begin his argument:
A patient who is dying of incurable cancer of the throat is in terrible pain, which can no longer be satisfactorily alleviated. He is certain to die within a few days, even if present treatment is continued, but he does not want to go on living for those days since the pain is unbearable. So he asks the doctor for an end to it, and his family joins in the request.
He then supposes what the doctor can do with the patients request. Rachels supposes that the doctor follows the conventional doctrine set in motion by the American Medical Association and withholds treatment because the patient is in terrible pain and he/she is going to die anyway. He writes that the doctor, by simply withholding treatment, allows the patient to die even though the patient may suffer a lot more "than he would if more direct action were taken and a lethal injection given." Rachels believes there is a very good reason to use active euthanasia rather than passive euthanasia, once the initial decision not to prolong the patients agony has been made. It is part of the humanitarian impulse that leads us to endorse the option to reduce the amount of suffering a patient must endure in order that the patient may die quickly and in peace.
Rachels believes that passive euthanasia "can be relatively slow and painful, whereas being given a lethal injection is relatively quick and painless." He believes that the conventional doctrine leads to decisions concerning life and death made on irrelevant grounds. He uses the following example to demonstrate these decisions:
Consider the case of the infants with Downs syndrome who need an operations for congenital defects unrelated to the syndrome to live. Sometimes, there is no operation, and the baby dies, but when there is no such defect, the baby lives on. Now an operation such as that to remove an intestinal obstruction is not prohibitively difficult. The reason why such operations are not performed in these cases is clearly, that the child has Downs syndrome and the parents and doctor judge that because of that fact it is better for the child to die.
Rachels argues, using this case, "It is the Downs syndrome, and not the intestines, that is at issue. The matter should be decided, if at all, on that basis, and not be allowed to depend on the essentially irrelevant question of whether the intestinal tract is blocked." So in this case, Rachels argues, what is the difference if you let the child die or kill it?, the intended result is the same.
Rachels poses the question, Is killing, in itself, worse than letting die? He uses two cases where the intention to do an act are the same but Case 1 is brought about by killing and Case 2 is brought about by allowing to die. They are as follows:
Smith stands to gain a large inheritance if anything should happen to his six-year-old cousin. One evening while the child is taking a bath, Smith sneaks into the bathroom and drowns the child, and then arranges things so that it looks like an accident.
Jones stands to gain a large inheritance if anything should happen to his six-year-old cousin. Like Smith, Jones sneaks in planning to drown the child in his bath. However, just as he enters the bathroom Jones sees the child slip and hit his head, and fall face down in the water. Jones is delighted; he stands by, ready to push the childs head back under if it is necessary, but it is not necessary. With only a little thrashing about, the child drowns all by himself, "accidentally," as Jones watches and does nothing.
The only difference between these cases, Rachels claims, is that Smith killed the child and Jones allowed the child to die. Rachels points out that it does not matter how the child died, but rather that the motive and end of Smith and Jones were the same. He states that if Jones pleaded his case in court that he did not kill the child, but rather stood there and allowed the child to die, then the courts would still charge him with killing the child. Rachels makes a strong case that "If letting die were in itself less bad than killing, this defense should have at least some weight. But it does not. Such a "defense" can be regarded as a grotesque perversion of moral reasoning."
According to Rachels, "the bare difference between killing and letting die does not, in itself, make a moral difference. If a doctor lets a patient die, for humane reasons, he is in the same moral position as if he had given the patient a lethal injection for humane reasons." He does realize that the crucial issue with the AMA policy is "the intentional termination of the life of one human being by another," but states that the intention of allowing a person to die and the intention of giving a patient a lethal injection are not morally relevant. Rachels reiterates that "in passive euthanasia, the doctor does not do anything to bring about the patients death, but rather the patient dies of whatever ills are afflicting the patient: the illness is the cause of death. In active euthanasia, however, the doctor does something to bring about the patients death; he kills him because the doctor caused his patients death." A doctor in either case is doing something whether he allows the patient to die or gives him a lethal injection. As Rachels pointed out before, killing and allowing to die are not the same thing, but there is no moral difference between them, because the agents motives and ends are same. Rachels also reasons that "it is considered bad to be the cause of someones death and that death is regarded as a great evil. However, if it has been decided that active or passive euthanasia is desirable in a given case, it has also been decided that it this instance death is no greater an evil than the patients continued existence." He makes a good argument here, because death is supposedly inevitable in either case, so according to Rachels, if a doctor allows a patient to die or gives him a lethal injection, then the motives and ends, in are case, are the same.
Derek Humphrey is another advocate of active euthanasia. Some of his arguments for active euthanasia are a little different from James Rachels, but he makes a good defense for the "right to die" utilizing practices of active euthanasia. Humphrey makes a distinction between suicide, which is deliberately ending ones own life, and self-deliverance, which is when an irreversibly ill person makes a rational decision to end his or her own life. He believes that active euthanasia can be justified by the following reasons:
1) Advanced terminal illness that is causing unbearable suffering to the individual. This is the most common reason to seek an early end.
2) Grave physical handicap which is so restricting that the individual cannot, even after due consideration, counseling and re-training, tolerate such a limited existence. This is a fairly rare reason for suicide -- most impaired people cope remarkably well with their affliction -- but there are some who would, at a certain point, rather die.
Humphrey posits that, for those people who have a terminal illness that causes unbearable suffering or a grave debilitating handicap which incapacitates the person so much that his/her life is miserable, life is not a good to the person any longer and, therefore, his/her life is not worth living. Humphrey does believe that there should be some ethical parameters for active euthanasia and uses the following list to determine whether or not a person can, in good conscience, justify the act:
1. The person is a mature adult. This is essential. The exact age will depend on the individual but the person should not be a minor who come under quite different laws.
2. The person has clearly made a considered decision. An individual has the ability nowadays to indicate this with a "Living Will" (which applies only to disconnection of life supports) and can also, in today's more open and tolerant climate about such actions, freely discuss the option of euthanasia with health professionals, family, lawyers, etc.
3. The euthanasia has not been carried out at the first knowledge of a life-threatening illness, and reasonable medical help has been sought to cure or at least slow down the terminal disease. We do not believe in giving up life the minute a person is informed that he or she has a terminal illness. (This is a common misconception spread by our critics.) Life is precious, you only pass this way once, and is worth a fight. It is when the fight is clearly hopeless and the agony, physical and mental, is unbearable that a final exit is an option
4. The treating physician has been informed, asked to be involved, and his or her response been taken into account. What the physician's response will be depends on the circumstances, of course, but we advise people that as rational suicide is not a crime, there is nothing a doctor can do about it. But it is best to inform the doctor and hear his or her response. For example, the patient might be mistaken -- perhaps the diagnosis has been misheard or misunderstood. It used to be that patients raising this subject were met with a discreet silence, or meaningless remarks, but in today's more accepting climate most physicians will discuss potential end of life actions.
5. The person has made a Will disposing of his or her worldly effects and money. This shows evidence of a tidy mind, an orderly life, and forethought -- all something which is paramount to an acceptance of rational suicide.
6. The person has made plans to exit that do not involve others in criminal liability or leave them with guilt feelings. As I have mentioned earlier, assistance in suicide is a crime in most places, although the laws are gradually changing, and very few cases ever came before the courts. But care must still be taken and discretion is the watchword.
7. The person leaves a note saying exactly why he or she is taking their life. This statement in writing obviates the chance of subsequent misunderstandings or blame. It also demonstrates that the departing person is taking full responsibility for the action.
His list of ethical parameters is extensive and it shows that the decision to end ones life by active euthanasia should be rationally well thought out. Humphrey also bases his rationale on the fact that people take their lives everyday, i.e. assisted suicide, using drugs, and/or plastic bags. He finds that police, paramedics and coroners put a very low priority of the investigation of suicide when evidence comes before them that the person was dying anyway, and there was a note from the deceased.
Humphrey also supports the work of hospice programs. He writes "hospices make the best of a bad job, and they do so with great skill and love. But not everyone wants a lingering death, not everyone wants that form of care. Today many terminally ill people take the marvelous benefits of home hospice programs and still accelerate the end when suffering becomes too much." He states that most but not all terminal pain can be alleviated with the sophisticated use of drugs. He believes that extraordinary means should not be used if it prolongs the suffering of the terminally ill patient, and there should be no conflict between hospice and euthanasia.
Humphreys critics ask the following questions: Is that last period of love and companionship with family and friends worth hanging on for? Is one depriving oneself of a valuable period of good life? He answers these questions by saying "Euthanasia supporters enjoy life and love living, and their respect for the sanctity of life is as strong as anybody's. Yet they are willing, if their dying is distressing to them, to forego a few weeks or a few days at the very end and leave under their own control."
Humphrey makes a strong case for active euthanasia. He does not believe that active euthanasia should be considered until all other options have been looked at and carefully evaluated. But, if all other options fail, then we should at least have the right to die by self-deliverance.
Case Against Active Euthanasia
In The Declaration on Euthanasia by the Catholic Church, the bishops state "By euthanasia is understood an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated. Euthanasia's terms of reference, therefore, are to be found in the intention of the will and in the methods used." The bishops also state that "the word is used in a more particular sense to mean "mercy killing" for the purpose of putting an end to extreme suffering, or having abnormal babies, the mentally ill or the incurably sick from the prolongation, perhaps for many years of a miserable life, which could impose too heavy a burden on their families or on society." The bishops of the Catholic Church as well as those who are against active euthanasia make the claim that one can never intend the death of oneself or the death of another person. They claim that there is a moral difference between active and passive euthanasia which is contrary to what James Rachels states in his article.
First, it is critical to the debate that we have a clear concept of the language we use to define terms. There is a lot of "verbal engineering" that takes place among those who advocate euthanasia. Kenneth Overburg S.J. uses the following example to show that words can have implied meanings:
Take for example, the two words killing and murder. What is implied in each? Killing indicates that one person has ended the life of another. That is an unfortunate event, indeed an evil. But we do not know if it is a justified killing, for example, in self defense. Murder describes the same physical act--one person has ended the life of another--but also includes a moral evaluation--this was an unjustified act, and so a moral evil.
Roughly, "killing" implies an activity, and "allowing to die" implies a certain passivity. But when we use the term "allowing to die", it can be either justified or unjustified. Overberg writes "Justified allowing to die means one does not needlessly interfere with the dying process. This implies a certain passivity, yet may include withdrawing life-support systems. Unjustified allowing to die means one fails to take steps that ought to be taken." In the case unjustified allowing to die, if one intends the death of a person and allows a person to die, such as in Rachels Jones case, it would be murder. But if the agent were negligent, where the agent did not intend the death of a person, then the action is still unjustified, but it isnt murder."
Before we can tell whether or not there is a moral difference between passive and active euthanasia, we must determine the difference between doing(killing) and allowing (letting die). I will use the article, "Actions, Intentions, and Consequences: the Doctrine of Doing and allowing(DDA)," by Warren Quinn to show that there is a difference between the two. Quinn makes reference to Rachels, who rejects DDA, argument of the adult who deliberately lets a child cousin drown in order to inherit a family fortune. He agrees that this type of act is atrocious and it does not seem any different than killing the child. Quinn states that "the objection seems to presuppose that if letting someone die is ever more acceptable than killing someone, it must be because some intrinsic moral disvalue attaches to killing, but not to letting die." He does not formulate the DDA as the view that allowing to die is more acceptable than killing, but rather as a difference in the violation of rights:
The basic thing is not that killing is intrinsically worse than letting die, or more generally that harming is worse than failing to save from harm, but that these different choices run up against different kinds of rights--one of which is stronger than the other in the sense that it is less easily defeated. Such relations between rights are possible because the moral blame for the violation of a right depends very much more on motive and expected harm than on the degree to which the right is defensible.
Quinn uses the rationale that Phillipa Foot borrowed from law but applied to morality, the distinction between positive and negative rights. He writes,
Negative rights are claim rights against harmful intervention, interference, assault, aggression, ect. and might therefore seem to proscribe harmful positive agency, whether by action of the agent himself or by action of some object to which, by strategic inaction, he lends a hand. Positive rights, on the other hand, are claim rights to aid or support, and would therefore seem to proscribe harmful negative agency.
Quinn says that we seem to intuitively know that negative rights are harder to override and take precedence over general positive rights. He writes "If there is going to be precedence, it clearly has to be precedence of negative rights." Quinn uses the example of the human person, who is constituted of body and mind. He says that the mind and body are parts and aspects of the person and for this very reason, "he/she should have primary say over what may be done to them-not because any arrangement best promotes overall human welfare, but because any arrangement that denied him that say would be a grave indignity." Quinn concludes from this reasoning that in giving a person authority over his body and mind, morality recognizes his existence as an individual with ends of his own. "Quinn seems to suggest, from this conclusion, that life is a good worth living even if we suffer, because we should not violate the negative rights of a person. He might posit that most people will believe that life is intrinsically good which is contrary to Derek Humphreys view."
People have a right to live the lives they want to without being forced by another person. As Quinn states later on in his article, "negative rights define the terms of moral possibility. Their precedence is essential to the moral fact of our lives, minds, and bodies really being ours. We think respect for rights a good thing precisely because we think people have them--and, if my account is correct, that they have them because it is fitting that they should."
Quinn concludes that "there is nothing absurd in saying that the adult acts as badly when he lets the child drown as when he drowns the child, while insisting that there are contexts in which the child would retain the right not to be killed but not the right to be saved." Rachels example is poor, because the intent was to kill the child in both cases. By killing the child in Rachels example, the adult violated the negative rights of the child not to be harmed. In the other case, although the adult did not seize the child and allowed the child to drown, he, nevertheless, did act by choosing to let him drown. In the second case Jones never had the intention of saving the child, so therefore he violated the childs positive rights, but planned to violate the childs negative rights. "In both cases, the intention and ends were the same." The distinction in the nature of the acts of killing and allowing to die is accompanied by a difference in causation. In one case, Smith seeks to cause the death of the child and employs direct means to achieve this result. In the other case, Jones accepts but does not cause the childs death, but he intended the death of the child. Rachels assumes that the doctor in the case of active euthanasia has the same intention and end as the doctor who allows a patient to die, when in fact both doctors do not share the same intention, means of carrying out the intention, or end for the patient they are treating.
If we use Quinns idea between negative and positive rights, we can see that there is a distinction between active euthanasia (killing) and passive euthanasia (allowing to die). In a case where a patient is terminally ill and death is imminent, to actively kill another person, except that of self defense, violates the negative rights of that person. For Quinn violating a negative right isnt worse than violating a positive right. He does make a distinction that negative rights are harder to override than positive rights and, therefore, take precedence over positive rights. The doctor in this case intends to kill and cause the death of the patient, in order to relieve the suffering of the patient. If a doctor allows the patient to die, he is not the cause of death, but by doing nothing, he violates the patients positive rights to help. The doctor in this case, does not intend the death of the patient, but rather accepts the fact that he cant help the patient and that the patient will only get worse, so he allows the patient to die of the illness or ailment as comfortably as possible. In this case it is harder for the doctor to override the negative right not to kill the patient than letting the patient die of the illness that caused him/her to be in the fatal situation. Since I have shown that there is a difference between active and passive euthanasia and that killing a patient is not a justified means to alleviate terminal pain and suffering, Rachels argument that there is no necessary moral difference between active and passive euthanasia is not correct.
Derek Humphrey tries to make a finer distinction between suicide and self-deliverance. he considers suicide to be done out of emotional or psychological stress and self-deliverance to be done out of a rational consideration before taking ones life. Then again, the same argument that applies to Rachels also applies to Humphrey. The act of intentionally killing one person by another, as in the case of active euthanasia, is a violation of that persons negative rights. Just because someone rationally considers their own death does not change the nature of the act nor does it make killing, for the sake of relieving terminal suffering, any better.
I believe that the Doctrine of Double Effect(DDE) also determines that the taking of one life by another is wrong. The DDE, as stated by John of St. Thomas, says the following:
If an act, not evil in itself, has both good and bad effects then it may be permissible if (1) the evil effect is not intended; (2) the good effect is not produced by means of the bad; (3) on balance, the good done outweighs the harm.
The act of intentionally killing of a terminally ill patient, no matter if it is to relieve suffering or other incapacitating illnesses, cannot be justified by DDE, for (1) Killing intentionally a patient is evil in itself; (2) the evil effect of death is intended; and (3) the good effect of relieving the suffering is brought about by killing the patient. Neither Rachels nor Humphrey can justify the killing of terminally ill patients based on this doctrine, but then again they do not appeal to it for the justification of active euthanasia.
Two of the other words that are extremely important and commonly used are "ordinary means" and "extraordinary means." The terms "ordinary means" and "extraordinary means" are controversial and ambiguous as to their meanings. It would seem that "ordinary means" are those medical procedures that ought to be done in order that the patient would receive basic human needs and care. "Extraordinary means" of life-support seems to mean those medical procedures that are optional to keep a patient alive, but the benefits produced by these means may be less than the burdens imposed on the patient or family. The distinction between "ordinary means" and "extraordinary means" is not always clear. Advocates for and against active euthanasia agree that one must make use of ordinary means of medical help and that extraordinary means are optional. Kenneth Overburg recognizes that there are two problems when these words are used in the debate:
First, ethicists are not referring to medical procedures alone when they speak of ordinary and extraordinary. They are speaking of the overall effort made to keep the person alive in relation to how those efforts will help the patient pursue lifes purposes. Secondly, even if one equates the terms ordinary and extraordinary solely with medical procedures, as many people do, whether a procedure is ordinary or extraordinary depends on upon what medical help is available in a given time and place. Also, since medical technology is developing much more rapidly than medical-moral reflection and analysis, the defining of procedures that are ordinary and extraordinary have also changed in light of new medical advances.
Anti-active euthanasia proponents say that we are never obliged to use extraordinary means to prolong life, but with the patients consent, a doctor can interrupt extraordinary means, where there is no hope of recovery. The Catechism of the Catholic Church states,
Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be legitimate; it is the refusal of "over-zealous" treatment. Here one does not will to cause death; ones inability to impede is merely accepted. The decisions should be made by the patient if he is competent and able or, if not, by those legally entitled to act for the patient, whose reasonable will and legitimate interests must always be respected.
In the case of passive euthanasia, a doctor merely accepts the condition that he cannot help the patient to recover, therefore he allows the patient to die from the already existing fatal pathology. The doctor does not intend to kill the patient, whereas in active euthanasia, the doctor effectively causes the death of the patient. A patient may also "refuse forms of treatment that would only secure a precarious and burdensome prolongation of life," because the patient may come to accept the condition that he is going to die of the existing fatal pathology.
If the patient is suffering terribly from the illness and death is imminent, the ordinary care owed to the patient cannot be discontinued, but painkillers can be used to alleviate suffering even if doing so will shorten the length of days the person has to live, because one is not intending the death of the patient. Palliative is used most often to make the terminally ill as comfortable as possible. Advocates against euthanasia know that palliative care for the terminally ill is not perfect, but with current and future medical advances, it is and will get better. Humphrey thinks that palliative care is good, but there should be the option for active euthanasia. But, as it was determined earlier in this paper, one cannot justify the taking of one life by another person as in the case of active euthanasia.
There is a valid fear among people today of being kept alive at all costs using extraordinary means. In many cases euthanasia does initially seem to be the merciful response. But, active euthanasia cannot be justified as an option for medical treatment. We must try to increase the quality of palliative care for the dying and make them as comfortable as possible. The taking of life, even though for a good motive, is an action which will undermine our humanity.
Dean Perri, Seminarian, St John's Seminary, November 8, 1996
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