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ORIGINAL ARTICLE  
Year : 2016  |  Volume : 6  |  Issue : 1  |  Page : 20-26
Qualitative assessment of ethical issues in dental practice: An expert opinion


1 Department of Public Health Dentistry, AECS Maruthi Dental College, Bengaluru, Karnataka, India
2 Department of Public Health Dentistry, Yenepoya Dental College, Mangalore, Karnataka, India
3 Department of Public Health Dentistry, M R Ambedkar Dental College and Hospital, Bengaluru, Karnataka, India

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Date of Web Publication11-Oct-2017
 

   Abstract 

Aim: The aim of this study is to assess the ethical issues in dental practice using the experts opinion.
Methodology: The study was conducted among 15 bioethicists. The bioethicists working in various healthcare institutions and nongovernmental organizations were interviewed with the open-ended questions to describe the possible ethical challenges that now exist in dental practice. They were also questioned regarding the influence of ethical issues on dental profession, patients, and community. Further, they were probed how to overcome such an ethical challenge in dental practice. The statements given by bioethicists were analyzed using common coding, constant comparative method, and inductive approach of qualitative data analysis. Attempts were made to look into the theoretical insight of the statements and discrepancies in coding were discussed among the investigators until the consensus was reached. Finally, 18 categories of perceived ethical challenges in dental practice emerged.
Results: The ethical challenges were issues such as competence of dentist, conflict of interest, overtreatment, lack of time, practicing defensive medicine, paternalism, confidentiality and its limit, informed consent, infectious diseases, lack of awareness, management issues such as commercialization of dental practice, high cost of dental care, training of dental professionals, hospital management policies, advent of new technologies, and lack of guidance from professional organizations.
Conclusion: The study helped identify the present ethical challenges prevailing in dental practice in Indian scenario. It also helps sensitize the dental professionals in maintaining and providing quality dental care. It is important to incorporate ethical standards in daily dental practice. It is needed to provide appropriate training methods in the dental profession for continuing toward acceptable ethical behavior in dentistry.

Keywords: Conflict of interest, dental ethics, informed consent, paternalism, qualitative analysis

How to cite this article:
Kemparaj VM, Panchmal GS, Jayakumar H L, Kadalur UG. Qualitative assessment of ethical issues in dental practice: An expert opinion. J Educ Ethics Dent 2016;6:20-6

How to cite this URL:
Kemparaj VM, Panchmal GS, Jayakumar H L, Kadalur UG. Qualitative assessment of ethical issues in dental practice: An expert opinion. J Educ Ethics Dent [serial online] 2016 [cited 2017 Dec 17];6:20-6. Available from: http://www.jeed.in/text.asp?2016/6/1/20/216513



   Introduction Top


In the past decades, the practice and the profession of dentistry have seen the paradigm shift. In recent years, there has been a steady increase in ethical problems in day to day dental practice. Studies have shown that general physicians encounter ethical issues in medical practice almost every day. The scenario is not very different in dentistry. Medical ethics affects almost every decision made in the dental clinic. The National Survey of practicing dentist in America citied issues such as overtreatment, poor quality work of another dentist, deceptive advertisement, criticizing work of other dentists, drug abuse, referral issues, pirating of the patients, physician inadequate communication skills are as few of the ethical issues seen in dental practice. Due to rise in health literacy, there is also increase in malpractice litigation against dental practitioners.[1],[2]

The universal principles of bioethics, i.e., beneficence, nonmaleficence, autonomy and justice along with the derivative rules such as veracity, fidelity, privacy, and confidentiality are only prima facie binding. Even among proponents of the same principles, there is a wide disagreement in the application of these principles for particular cases. The disputes are because of the different weightage and conflicting nature of the bioethical principle involved in same case scenarios. Hence, these ethical principles have to be weighed and balanced in decision-making before diagnosing and delivering oral healthcare services to the patient and community.[3]

The goal of clinical ethics is to assure the patient safety, improve the quality of healthcare services and wise judgment to resolve the ethical problems that arise in dental practice.[4]

In the field of empirical research, there is a growing concern that quantitative methods alone are inadequate in establishing the evidence. the phenomena of ethics is largely intertwined into the fabric of healthcare professions, and human lives. Qualitative methods have begun to play an important role. The qualitative findings are arrived from real-world settings where the phenomenon of interest unfolds naturally.[4],[5]

Common sense, clinical experience, being a good person, and having a good intention may not guarantee that we will know how to respond appropriately to the present ethical dilemmas in dental practice. Ethical dilemmas provoke a powerful emotional response, and strong emotions often are a clue to the presence of an unresolved ethical issues.[6] However, there is a wide knowledge gap in the research regarding the ethical challenges in dental practice in the Indian scenario. Therefore, the study attempts to understand an expert's opinion on ethical challenges in current dental practice in Indian scenario.


   Methodology Top


Sample size

The purposive and judgmental sampling method was used since it was considered to be an ideal method of sampling in qualitative research methods.[7] The sample size was calculated using terms of thematic code prevalence. Cronbach's alpha of 0.70 is considered to be an acceptable measure of reliability. Studies have shown that Cronbach's alpha of 0.70 could be achieved within 12 interviews and the data saturation occurs within this 12 interviews.[8],[9] Hence, the sample size was determined as 12. Accordingly, 15 bioethicists were purposively approached, of them 12 gave consent and participated in the study, with the response rate of 80%.

Bioethicists are persons working in healthcare facilities such as hospitals, faculties in teaching institutions such as medical, dental, and nursing colleges, administrators in nongovernmental health organizations, research scholars, and law practitioners.[10],[11]

Study design and data collection

A grounded theory approach was used. The grounded theory approach starts with the open-ended questions and assumes that the participants know something about the research question. A standardized general interview guide was developed to gather information to ensure that the same general areas of information are collected from each interviewee. The bioethicists were interviewed with the open-ended questions to describe the possible ethical challenges that now exist in dental practice in Indian scenario. They were also questioned regarding the influence of ethical issues on dental profession, patients, and community. Further, they were probed how to overcome such an ethical challenges in dental practice.[12] Probing words such as informed consent, confidentiality, and autonomy were used whenever required. The bioethicists were interviewed in a convenient place both for the bioethicists and investigator with the in-depth, open-ended questions. Interviews ranged from 15 to 25 min. All the interviews were audio taped. Field notes were also taken down by the investigator during the interview, and elaborate memo writing was done after each interview. Interviews were transcribed by the two investigators separately to avoid interviewer bias and were later compared for coding. The interview brought the significant information related to ethical challenges in dental practice.

Data analysis

Common coding technique and constant comparative method of qualitative data analysis were used for coding statements given by bioethicists. According to the constant comparative technique, as new transcripts were reviewed and new codes emerged, new quotes were compared with previous codes in an iterative process. Grounded theory approach was used as it is an inductive method of data analysis moving from particular to general ideas. Attempts were made to look into the theoretical insight of the statements. The investigation attempted to analyze 46 dental ethics related incidents citied from bioethicists. The aim of the analysis was to generate the conceptual category and its relative subcategory. Coding was done in two stages: initially the transcripts were coded into 6 categories and 21 subcategories. Any discrepancy during the coding was discussed among the investigators until the consensus was reached. Finally, 18 categories of ethical challenges in dental practice were noted [Table 1].
Table 1: The categories of ethical issues

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   Results Top


This exploratory study attempted to analyze the bioethicist's opinion on perceived ethical challenges in current dental practice among Indian dentists. Fifteen bioethicists were contacted and requested to participate in the study. Of 15 bioethicists, 12 gave consent and 3 did not participate due to time constraints. In-depth, open-ended interview was conducted on 12 bioethicists (5 medical fields, 2 dentistry, 1 scientist, 2 nursing, and 2 working in nongovernmental organization) with age ranging from 29 years to 65 years. Among them, 5 were males and 7 females. The bioethicists provided responses related to dentist or patient issues, management issues, and the policy of professional organizations.

Dentist issues/patient issues

Professionalism

Professionalism relates to the behavior expected of one in a learned profession. Professionalism is expressed as the dimensions of competence, ranging from comprehension to clinical skill, behaviors attributing to empathy and communication, the healthcare provider's dedication to placing the needs of the patient above his or her own needs and concern for the quality of clinical care. One of the bioethicists opinion on professionalism was “Nowadays doctor lack commitment towards their patient…”. In essence, the term reemphasizes the necessity of dental professionals to prioritize the well-being of the patients they serve. Professionalism is a pathway for quality dental care and professional satisfaction.[13],[14],[15]

Competence of the dentist

One of the bioethicists citied that “The dentist should be willing to refer the patients to the other dentist if he feels that the work is beyond his competence.” Another bioethicists related to competence of the dentist stated that “there is also a lack of expertise even with specialists.” General dentist and specialists should be ready to restrict patient care to areas in which they are trained. Therefore, dentists should understand his or her limitations of competencies. Bioethicists feel that “This is not only related to technical skill but also moral, and it shows his character development.” Similar observations were found in the studies of the Kress et al. in which a new patient has had substandard dental work that needs to be replaced. In another study done by Rosenbaum et al., healthcare professionals also reported discomfort related to feeling inadequately prepared to perform healthcare duties and its handling.[2],[16],[17],[18]

Communication

The importance of communication is a key factor in allaying potential mistrust between dental professionals and patients.[17] Bioethicist said, “lack of effective communication can hamper doctor-patient relationship which in turn leading to increase in malpractice litigation.”

Defensive medicine

Due to increasing consumerism and increase in malpractice litigation against doctors, health professionals have started with defensive medicine. Defensive medicine is a doctor's deviation from their usual behavior to reduce complaints by patients. The United States Congress define defensive medicine as the action of ordering tests, procedures, avoidance of high-risk patients or procedures with the primary aim, of reducing malpractice liability. One of the bioethicists said “The doctors have started practicing defensive medicine…” “Dependency on investigating procedure even when treatment can be performed without investigating procedure…”. This is in agreement with the studies done by Porter and Grey on dentist in Queensland Australia and study done by Jonathan et al. and Kress et al. The present study showed that even poor knowledge and skill of health professional could also contribute to defensive medicine by healthcare professionals.[2],[11],[19],[20]

Overtreatment

Overtreatment means unnecessary, inappropriate, excessive or fraudulent treatment and thus constitute unethical conduct and a breach of the integrity of the health profession. One of the bioethicists stated that “Filling a tooth when not required, for financial gains.” Winslow reported that issue of dentists who over-diagnose and over-treat patients for financial gain is as twice as often as any of other ethical issue. The main motives for overservicing are economic survival and financial gain. On contrary, literature has shown that sometimes dentists may over-treat unintentionally due to out-dated treatment philosophies or when criteria for diagnosis and effective patient oral healthcare are not clear, leading to variation in treatment decisions. Sometime patient-initiated demand for treatment can also end in overtreatment.[21],[22]

Treatment error

The goal of a dentist or any medical profession is to perform his or her duties to the best of his or her abilities without error, sometimes errors do occur. Bioethicists emphasized some of the issues related to treatment error like improper treatment and poor maintenance of sterilization protocol. The bioethicists cited “there are instances were in sometimes dentist do extraction of the wrong tooth.” This is in line with the study done by Jonathan and Gunes Sahinkesen. Patients were wronged owing to procedure and regulation (60, 17.9%), patients wronged owing to bureaucratic reasons (57, 17.1%), insufficient condition about patient examination, and treatment (40, 11.9%) occurred most frequently and prescription without examination of patient (36, 10.7%). In these situations, it is best if the dentist remains truthful and informs the patient of any discrepancies immediately. The bioethicists stated related to sterilization procedure as “Clinics do not follow proper sterilization protocol as a result patient might suffer from reinfection.” The reason could be that in a National Survey of practicing dentist in America study citied that maintaining occupational safety (OSHA) requirements as an ethical issue due to cost and time constraints.[2],[6],[11]

Conflicts of interest

Conflicts of interest are the conditions in which professional judgment concerning a primary interest, i.e., patient's welfare tends to be unduly influenced by a secondary interest such as financial gain.[23] For example, bioethicists said “kick backs from pharmacy companies to increase the revenue.” “It is observed that the more the kick back the doctor gets, the more is the selling of medicine.” Bioethicists observed that “some oral surgery procedures are being performed in general anesthesia for financial gain even when it can be performed under local anesthesia.” “There is also some sense of greediness in today's doctor…”which can be due to lack of moral and ethical development in today's dental professionals.

Paternalism

Paternalism is to act as a father. Bioethicists had opinion that “In a country like India even though the principle of autonomy tells us that patient should be given full right to decide on the treatment but the treatment decision is a shared or joint decision of dentist, patient and his family.” The best possible explanation can be given from the review on confusion ethics. Confusion ethics has a very different understanding of this self-determination. The center of each person's life is not himself or herself but the family. The autonomy can only be spoken of as a collective rather than an individual privilege. Asian people are not as individualistically oriented as their counterparts in the West, especially in their demands for self-actualization. Historically, family, community, or the greater self always carry a greater weight in Asian value system than individuals.[3]

Confidentiality and its limit

It is the dentist responsibility to provide dental care in patient's best interest. Bioethicists cited that there is “increase in breach of confidentiality…” The accepted standard of confidentiality is that nothing must be revealed to anyone else without the patient's permission with exceptions that relevant ancillary personnel, such as record keepers, will need to know some of the facts to perform their job. In some of the instances, there requires a certain amount of breach of confidentiality and one of the bioethicists also cited “one should know the limit of confidentiality…”[1],[15] Patient may be suffering from infectious diseases and which might spread the disease to other people, such instances requires breach of confidentiality. This is in line with the study done by the National Survey of America also reported fear of infectious disease as one of the ethical issues in healthcare practice.[2]

Informed consent

According to the bioethicists, informed consent is “providing the patient information related to a treatment procedure, the risk and benefit involved. Information should be provided to the patient level of understanding.” The nature of informed consent does not mean that patients would expect to be signing a contract confirming their willingness to receive treatment but rather that they have been given a fair and balanced assessment of the situation. In the study done by Jafarey and Farooqui, most of the participants felt that it was the physician's duty to bring the patient into the decision-making process. The majority also felt that the process of informed consent needs to be individualized. Starting from giving basic information related to patient diagnosis and treatment procedures. Then going further based on the patient's demand for oral healthcare. Most participants agreed that it was perfectly acceptable to use alternative or deceptive words since the patients already knew or suspected wrong with them. This will help the patient keep calm and less anxious about the oral health status and treatment procedures.[1],[3],[24],[25]

Ethics of disclosure

Bioethicists had the opinion that “one should understand how much of disclosure about the patient condition is necessary… especially in our Indian context.” In a study done by Rosenbaum et al., residents reported to not only having compromised in telling the truth and but also involved in manipulating information due to pressure from families, patients, and peers. Contrary to this, in the study on doctors and nurses in Barbados by Hariharan et al., participants identify informing patients about wrongdoing, informed consent, as statements of everyday ethical issues.[1],[16] At this point, it is important for the health professionals to disclose the information related to illness to the concerned person for whom it might get affected. In other instances, it is required to get a physician consultation or opinion before the treatment is performed; hence, it might require the disclosure of information.

Lack of time

Bioethicists stated that “due to overcrowding in some clinics each individual patient is not getting sufficient time for interaction, diagnosis, and treatment.” It may lead to poor or undiagnosis of some clinical conditions which required treatment thus making patient suffer. In the study done by Jonathan et al., Panel showed that waiting period in some cases compromise the health status and also contributes for psychological distress. This is also in agreement with the study done by Porter on dentists in Queensland Australia.[4],[8]

Management issues

Commercialization of dental practice

In the name of smile makeover patient receive unnecessary treatments which can affect the patients health negatively…”. Appearance and smile generate a significant psychosocial impact. Hence, while treating patient the dentist behavior must reflect gentleness and the decision for such procedures should be based upon risk versus benefit where benefit of the patients outweigh the risks involved in the procedure. Bioethicists had also concern for people and society and stated that “It is a right to every individual for the basic healthcare, and it applies even to dental practice. Dentistry has become expensive for the common man to avail treatment…”. “Rising and high cost is also a factor; many people cannot afford basic dental treatment…”. This is in agreement with the study done by Porter and Grey on practicing dentist in Queensland Australia.[20]

Management policies of hospitals

Bioethicists reflected on management policies of hospitals and citied “some hospitals create pressure on the doctors to perform all investigative procedure even though when it is not required. This is causing the financial burden on patients, mental trauma and adding the time factor to it…”. Because of these reasons, patients are suffering without availing the oral healthcare services.

Advancement of new technologies

The technological advancement has led to the increase in the cost of the dental treatment. The bioethicists have questioned these advancement and stated “The question is the relevancies of these new technologies in day today practice…”.

Training of doctors

Bioethicists felt that the present scenario of dental education should change the way the ethics have been taught in dental school. The present scenario overemphasis the knowledge and skill while least importance is given to the clinical ethics which is the heart of healthcare training.[1],[6]

The role of professional organization

Bioethicists questioned that “most of our knowledge regarding dental ethics is western…”. There is a clear lack of ethical guidelines in the Indian setting.


   Discussion Top


The present study attempted to provide expert's opinion on ethical challenges in current dental practice in Indian scenario. Bioethicist's were considered to have a unique knowledge of medical ethics. Bioethicists are the person involved in ethics consultation, clinical ethicists, members of ethics committees, ethicists providing policy advice to government on health programs, ethicists attached to academic affiliations, and ethicists engaged in public outreach programs. Hence, bioethicist's were selected as research population for the study of ethical challenges in dental practice.[10],[11]

Since qualitative study allows some degree of flexibility in data collection and analysis qualitative method of research was chosen for present study. The qualitative health science research uses the general inductive approach for data analysis since it helps in reframing, structuring, and condensing the extensive raw data into small categories and summarizing the results.

Despite the small number of sample size, bioethicists provided varied numbers of ethical challenges related to dental practice were obtained. The investigation attempted to analyze 46 dental ethics incidents citied from bioethicists which was finally categorized into 18 categories related to dentists, patient, and management issues.

Professionalism, competence, and communication

Professionalism expands on the basic principles of ethics to include the conduct, character, aims, and qualities that characterize a professional. It should accompany the use of superior knowledge, skill, and judgment to the benefit of patient and society, before any consideration of self-interest.[13],[14],[15] Dentists should keep up the basic levels of competency required for delivering effective oral healthcare delivery. The lack of competence has serious consequences on the oral health and psychosocial well-being. Due to the rapid progress of the medical knowledge, dentists have to study continuously to maintain their competence at high standards.[2],[16],[17],[18] Communication should be achieved through management of expectations, reassurance, and a clear explanation of what is happening and why. A good communication would lead to improved trust and confidence in dental care practitioner. Thus, contributing to the high-quality dental care.[17]

Defensive medicine, treatment error, and medical error

Deviated dental professional behavior such as defensive medicine, overtreatment, and treatment error could be due to lack of professional skill and knowledge. Even though dentistry is a noble profession, it has become more commercial. Nexus between doctors, the practice of cross reference as a routine is also burdening patients psychologically and financially.[23]

Paternalism

Traditionally, the dentists always had a high degree of clinical autonomy regarding the place and the way they practice their profession. This system has worked well when the expertise and skill of the profession have been used to relieve the burdens of the dental caries, periodontal diseases and malocclusion, but the historical roots of this tradition contain certain limitations. It can involve a dentist overriding the autonomous decision of a competent patient for that patient's own benefit. Paternalism in Indian context should not lead to negative consequences. Dentists tend not to serve patients, to heal and treat them. Formerly, the word of the dentist was the last but now patients, third parties, hygienists, assistants, employee dentists all have a their own voice. These multiple voices take the issue into different magnitude. It is the dentist's responsibility to determine the decision-making capacity of each patient, the patient's values and personal preferences, treatment choices, costs, possible complications, and expected outcomes.[14],[15],[26]

Confidentiality

Bioethicists were concerned regarding the limits of confidentiality when the patient suffering from infectious diseases the priority should be given to the other people who can get affected from the diseases of the patient.

Autonomy and informed consent

German philosopher Emmanuel Kant says that according to autonomy every person has the ability to understand notions of right or wrong and to act accordingly. In Jonathan's study, the panel of experts says that there is a huge gap in the process of informed consent in theory and practice. Sometimes, the patients cannot understand what is right and wrong related to their diagnosis and treatment procedures. Sometimes, informed consent is not taken for all the procedures in patient understanding, but the treatment would have been carried out taking granted that informed consent is obtained.[1],[3],[24],[25]

Waiting lists

Hadorn and Holmes have developed a method of clearing waiting lists through setting priority based on clinical indications. Surgical services should be moved away from waiting list so that the patients receive care within the reasonable limit of time with the defined level of priority. Assessment of urgency of care should also be established so that priority would be given to patients with the greatest benefit using the principle of utilitarianism were the principle goal is to achieve the maximum possible health gain with the available funds.[27]

Commercialization

Commercialization of dental practice was one more concern of the bioethicists. Referral charges, billing, and cost are few of the top challenges as reported by Daniel J. Schulte in the Michigan Dental Association Annual Session 2009. The National Survey of practicing dentist in America and in the study, done by Kress et al. have citied high operating costs such as infection control requirements, staff benefits, equipment, and supplies as a cause for increasing in the cost of dental care.[2],[4],[20] Daniels and Sabin have developed a health policy “accountability for reasonableness” as a model for priority setting based on benefit, performance, and demand for the due process by public and patients.[4],[28]

Professional education should pay attention to character formation of an every dentist as it is central to moral life. Role modeling by faculty members should be done to build a sustainable community of clinicians focused on the ethical concerns for patients and societies. Different clinical teaching methods like role play, standardized patient, and internet based cases scenarios should be used. Enhancing professional communication skill and teaching clinical ethics at the chair side with staff having both clinical and ethical skills should be done.[1],[6] The literature has shown that advancements in biotechnologies, such as cloning and stem cells, have increased the issues about social tolerance of risk and attitudes toward globalization.[4]

There is an inadequate role of professional organizations because of cultural difference in east and west, the adoptions of western ideas in India will undoubtedly encounter the ethical problem. The National Survey of practicing dentist in America also cited professional organization issues involving the inadequate action of associations related to professional practice.[2]

Limitations

Generalizability of the results

Generalizability of qualitative research is questionable since the results are applicable to the study particular group of population and also in that region. Further, the study participants were not the representative of general dental practitioners, and it could be possible that some ethical challenges could be out of their purview. Further research to analyze the perceptive of general dental practitioner's ethical conflicts in dental practice was done and will be reported.

Since the coding is more a subjective nature, a varied interpretation could be possible, but attempts were made by doing multiple coding to reduce the investigator bias.

Recommendations

The process of decision-making in a clinical setting

Participatory and the concept of shared decision-making between doctor and patient from the beginning of clinical encounter are required. Give all necessary information for the patient so that they can make an informed choice. The dentist should put oneself in place of the patient before treating them. Every dentist should say no to an unnecessary investigative procedure. If at any process when the dentist are is in doubt one should not hesitate to go for the second opinion. Medical educators should pay more attention to the building of moral character of health professionals.

Professional education should focus on analytic skills to enable healthcare professionals to identify and adjudicate the ethical principles. Interactive continuing dental education programs should be conducted as it provides an opportunity to practice skills and thus giving positive healthcare outcomes.

The self-regulation is unique to the medical profession. Professional bodies should intervene when necessary. Establishment of the clinical ethics consultation committee separately from the institutional ethics committee should be done in healthcare institutions. Dental council should also take an active role in monitoring the dental practitioners.


   Conclusion Top


The study provides an effective strategy in bringing the ethical challenges to public attention. It sensitizes the dental professionals regarding the importance of dental ethics in the oral healthcare delivery. The study also helps identify ethical challenges in daily dental practice, thereby resolving ethical issues with patients, colleagues, and community. Dental education should incorporate appropriate training methods in the dental curriculum and thus contribute to continuing toward acceptable ethical behavior in the practice of the dental profession. This would help in providing quality oral healthcare to patients and society at large.

Acknowledgment

We would like to thank all the bioethicists who participated in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

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Correspondence Address:
Vanishree M Kemparaj
Department of Public Health Dentistry, AECS Maruthi Dental College, Hulimavu, Bannerghatta Road, Bengaluru - 560 076, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-7761.216513

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