(dated September 2, 2005):
I.- Controversies and Updates in Organ Transplantation Ethics in France:
I am from France (Paris) and I'm trying to investigate about brain-dead donor ethics. In France, for the time being, transplantation Specialists defend the point of view that it is just out of the question to mention that brain death could be a questionable concept, especially when they are being asked this question by somebody from the public (closed-door medicine syndrom still striking in France, Doctors are suffering from it!). Nearly each and every French transplantation Specialist claims that a brain-dead donor is dead since brain death is death. There are just no other alternatives in their opinion. They justify their statement by referring to the August 2004 Amendment of the French Law of Bioethics. This Amendment is re-defining death as brain death. That is: the definition of death no longer includes the arrest of cardio-pulmonary functions: as of August 2004, brain death suffices. Brain death = death.
I am currently developing this Blog in order to show that the whole transplantation problematic involves issues, updates, controversies that are a great deal more complex than just the few explanations the non-specialist broad public is being (reluctantly?) provided with by the transplant-medicine community... Generally speaking, the transplant-medicine community points out that brain death is a concept allowing to legally state that a brain-dead patient is dead. Technically, however, this is another story: still breathing, with a working vascular system, the brain-dead patient seems sound asleep. By no means he seems to be dead. Says Dr.K. Ganapathy, Neurosurgeon, Apollo Hospitals, Chennai, India: "A dead brain in a body with a beating heart is one of the more macabre products of modern technology". And speaking of the effect of brain death on the family, he says: "Brain death has created a new class of dead people that does not conform to society’s expectations of normal death and dying. Brain death also causes great stress for the family and friends".
To download the recent scientific study: "Brain Death and Organ Donors", by Dr. K. Ganapathy, Neurosurgeon, Apollo Hospitals, Chennai, India, click here.
Source: Neurosurgery on the web.
My aim is to show that in other countries, like Japan, Germany, Denmark, a long-lasting debate has been involving the whole society, and in these countries (and others) it is acknowledged that the brain death concept has been plagued with some serious philosophical and biological inconsistencies.
I am referring to following "white papers", i.e. articles from the scientific press:
1.- "Role of Brain Death and the dead-donor rule in the ethics of organ transplantation". Article by RD Truog and WM Robinson, in: Critical Care Medicine N°31, September 2003, p.2391-2396.
2.- "Does it matter that organ donors are not dead ? Ethical and policy implications", in: Journal of Medical Ethics 2005, N°31, p.406-409.
3.- "A definition of human death should not be related to organ transplants". By C. Machado, President of the Cuban Commission for the Definition and Determination of Death, Institute of Neurology and Neurosurgery. In: Journal of Medical Ethics 2003; N°29: page 201-202.
4.- "Chronic 'brain death': meta-analysis and conceptual consequences". DA Shewmon, Department of Pediatrics, UCLA Medical School, Los Angeles, CA, USA. In: Neurology, Vol 51, Issue 6 1538-1545.
==> Read other scientific publications by Dr. Shewmon
("white papers" abstracts).
5.- "Brain Death: Reconciling Definitions, Criteria and Tests", by A. Halevy and B. Brody, in: Annals of Internal Medicine, 1993, N°119, p.519-525.
Of course this is a non-exhaustive list...
The Journal of Medical Ethics also provides with abstracts and some full text versions of articles regarding transplantation ethics. To read a selection of these articles, click here.
In Japan, the law allows people to choose between brain death and traditional death. Indeed, Japan could serve as an example, and France should at least listen to the lesson. Unfortunately, for the time being, we cannot seem to see this happening in France!
When asking in June 2005 a French Transplantation Coordinator (working in a Parisian suburb Hospital) about the arrested heart organ removal (non heart-beating donation), she told me it was too new a process to discuss it, especially with a person from the public, so she was not sure she could tell me much about it. Later, on August 2nd, 2005, Law Amendment N°2005-949, related to the procurement and graft of organs, tissues and cells, was published (Journal Officiel - French version) : kidney and liver removal, as well as the removal of some tissues and cells, shall also be performed on non heart-beating Donors. Before August 2nd, 2005, these organs, tissues and cells could be removed from brain-dead Donors (i.e. with functioning heart and lungs, thanks to artificial respiratory devices), or from living Donors (live kidney and liver removal). This new Law Amendment, including non heart-beating donation, should entail a raise in the number of organ Donors, especially with regards to kidney, liver, tissues and cells donation. In addition, the possibility to perform live Donor kidney removal using minimally invasive surgery (robotic surgery, French version) should also allow the organ donation to progress.
Generally speaking, I wish the French transplant medicine-community would take more into account what is happening in other countries, where debates involving the public opinion are taking place and have been doing so for a long time (again: Denmark, Japan, Germany...).
However, the new Law Amendment of August 2005 in France reminds of the already existing situation in Spain, where organs, tissues and cells procurement is working out better (increased number of Donors) thanks to the possibility of harvesting on non heart-beating Donors. It has been recently established that harvesting on non heart-beating Donors has allowed a 20 per cent-increase in organ donation in Spain.
For the time being, it is obviously impossible for a French person from the public (a non-specialist) to sort out the whole situation about the brain-death concept. The only thing French Doctors, Transplant Coordinators (nurses) and other transplantation specialists will ramble on and on about is: brain death is death... and conversely! I find this situation regrettable, even frustrating, and truly hope this Blog will help people from the public (like me!) find out whether they believe in the "traditional" concept/definition of death (i.e.: heart-lung functions arrested and brain destructed), or if they believe in the definition of death as "brain death" (i.e.: beating heart, functioning lungs, brain destructed). In the first case ("traditional death"), they are not likely to become a "brain-dead Donor", in the second case ("brain death"), they are likely to become a "brain-dead Donor".
You may ask: why ask all these questions?! If your brain is dead, then you're dead!!
To be honest, I happened to witness by chance, a couple of years ago, an organ removal (or harvesting) case on a brain-dead Donor (Donor was a 8-year-old child), and I find it hard to believe this kiddo was dead, as he was breathing and his heart was beating (of course thanks to the respiratory devices). The kid just seemed sound asleep!!
So I wanted to find out: if you happen to be a brain-dead Donor and if your organs are being removed (or harvested), is it 100 per cent sure you are not feeling any pain at all? I've asked this question to about 14 Transplantation Specialists (Physicians, Associations), and nearly all of them (about 95 per cent) answered: as a brain-dead Donor, you could not possibly feel any pain at all: you would be dead!! They were positive about that.
Yet some French physicians, nurses, and part of the French public opinion do question the viability of the brain-dead Donor concept (i.e. the Dead-Donor rule in the Organ Transplantation process): they are suspecting that, instead of being dead, the brain-dead patient would rather be dying. According to my experience, questioning and/or expressing concern about the viability of this (new) legal definition of death as Brain Death (since August 2004) is not politically correct in France.
Why? How's that expressing doubts about the brain death concept is not politically correct? Well, to start with, Physicians do need as many brain-dead donors as possible, to provide patients on waiting lists with organ(s), save their patients' life (waiting lists are breeding quickly, and so are technologies and knowledge related to transplantation, and last but not least, Physicians' reputation will be thriving on this transplant activity). Not to be forgotten the reputation of Health Centers (Clinics, Hospitals, etc) cutting-edge and state-of-the-art transplantation surgeon teams work in! A lot of money is at stake here, and a lot of people could potentially be saved! One brain-dead donor can potentially save the life of 7 to 8 people: two kidneys, one heart, valve, lung, liver, corneas, all sorts of things that can benefit living people!...
What I found out by inquiring for this Blog: considering the possibility, or probability, that death might be a process rather than an event, brain-dead donors might be "imminently dying" instead of dead.
A debate should be organized in France, involving public and political opinion(s). We should all be aware of the existing options. Presently, this is not the case: French Doctors are asking people: "-Are you willing to donate your organs or not?"; They do not ask them: "-Which death do you believe in? Brain death, or 'traditional death'?". By putting the emphasis on the organ donation instead of putting it on the sort of death people believe in, the question cannot be correctly answered. I would like to point out this lack of transparency and effectiveness in the communication from French Transplantation Specialists to French public opinion.
Let's try and wrap this up: dying or dead "brain-dead" patient?
"Brain death is not for diagnosing somebody who is dead. It's for creating a fiction for the determination of death, in order to get organs," says Dr. Paul Byrne, a Toledo, Ohio physician who has studied the subject of brain death for 20 years.
Says Dr. Andronikof, Ph.D., Head of Antoine Béclère Hospital Emergency Department (casualty ward), France:
"Nowadays, research scientists are working in fields which the major civilisations have always considered as sacrosanct: life, death and mankind. And consciences are accepting these exploits by adapting as fast as technology advances. In the book by J. Dauxois and Dr M. Andronikof, Casualty Ward Doctor, published by Editions du Rocher, January 2005, Marc Andronikov, doctor in charge of the casualty ward at Antoine Béclère Clamart hospital, who embodies all the enlightenment of Orthodox Christianity, effectively overturns all the weak consensus on scientific progress.
Have we any right to refuse?
Technically, anything can be done to mankind. It is possible… but do we not have a right to refuse? Do we not have the right to consider ourselves and to consider others as more than an assembly of interchangeable organs and tissues ? What treatment can one accept? Who is to decide what becomes of our bodies when consciousness is lost?… Is it admissible that a doctor in the casualty ward should be able to decide that a patent, who is condemned, must absolutely be revived using the full range of respiratory and circulatory machines… in order to be able to transplant his/her organs ? Since the 1976 Caillavet law, the consent of the patient is implicit and anyone who has not wilfully declared that they are opposed to the taking of their organs, is taken as accepting such practices. But who is aware of the fact?
'Death is not death'
Death is no longer defined as the ceasing of the three vital functions; nowadays, only cerebral death is considered in the scientific world and by the law as death but surely this definition which authorises the taking of organs from patients in irreversible coma must be a scientific mistake? It is claimed that the brain determines death because brain damage is currently irreversible whereas other organs, the heart, lungs can be replaced, by artificial means. Medical realities and the person as such are defined according to what is technically achievable today. Whereas death is a process, since all the functions do not cease at the same time... But the notion of cerebral death enables organs which are not affected to be taken before they are damaged.
Therefore 'the concept of equivalence between death and irreversible coma is based on three major errors: considering continuity as a point in time, considering a part as the whole, considering the foreseeable future as an event already achieved.' "
Source:
Genethique.org - Press Review, Monthly Letter N°62, February 2005.
According to Dr. Christopher De Giorgio, Professor of neurology and neurological surgery at the University of Southern California, "You can keep somebody on life support for a few days or a few weeks at the longest, but generally people do not survive past two weeks who are truly brain-dead." Dr. Paul Byrne, a Toledo, Ohio Physician who has studied the subject of brain death for 20 years, cites cases of brain-dead individuals who have survived for long periods of time, even years.
Assuming that the brain-dead patient is dying and not dead, that death is a process rather than the result of a process, means that "Brain Death" is a fiction, invented to allow Organ Donation. Which steps should be taken, in this case? I've came up with the following:
- tell the truth and no longer try and conceal it.
- Help people (public opinion + brain-dead patients' family) make the right choice. In my opinion, here's the alternative:
Alternative N°1)-I'm too afraid that somebody could possibly remove my organs when I would not be completely dead (I am too afraid that somebody would intrude in my dying process, I'd rather Physicians let me die in peace). Sorry, but I will not help save the life of up to 8 people thanks to my own death, I'm too afraid I would suffer in the process. In this case, I am objecting to donating my organs. Or: brain-dead patient's family are not giving their consent for patient's organs removal.
Alternative N°2)- The scenario is familiar: tragic accident, young victim, distraught family. Follow-up media coverage reports approvingly of the donation of the brain-dead victim's organs. The family expresses relief that some good has arisen from what could have been merely a senseless tragedy. In other words: I know that if I was to become brain-dead, therefore a potential organ donor, I could save the life of some people by donating my organs. Even if I could survive as a brain-dead patient for one more week, or two, or a few days, it doesn't matter. What's to be called life when you're brain-dead anyway? To me, brain-dead is dead. Living like a vegetable does not sound much like being alive. I prefer to help other people instead, no matter if that means somebody will intrude in my dying process, in order to remove my organs before I am totally dead. In this case, yes, I am an organ donor. Or: brain-dead patient's family are giving their consent for patient's organ removal.
I am quoting Dr. Alan Shewmon: "The Dead Donor Rule: Lessons from Linguistics"
Kennedy Institute of Ethics Journal - Volume 14, Number 3, September 2004, pp. 277-300, The Johns Hopkins University Press:
"American society traditionally has assumed a univocal notion of 'death,' largely because we have only one word for it and, until recently, have not needed a more nuanced notion. The reality of death-processes does not preclude the reality of death events. Linguistically, 'death' can be understood only as an event; there are other words for the process. Our death vocabulary should expand to reflect multiple events along the process from sickness to decomposition. Depending on context, some death-related events may constitute a more obvious discontinuity than others and more justifiably may be considered 'death' within that context. There is no reason to assume a priori that there must be an overarching, unitary concept of death from which all diagnostic criteria must derive.
Regarding organ transplantation, the relevant question is not 'Is the patient dead?' but rather 'Can organs X, Y, Z . . . be removed without causing or hastening death or harming the patient?'"
II.- International Controversies and Updates in Organ Transplantation Ethics
Source:
"THE DEFINITION OF DEATH: CONTEMPORARY CONTROVERSIES". Author: Bryan Jennett
Glasgow, UK. Published in: OXFORD JOURNALS. BRAIN – A Journal of Neurology
Brain, Vol. 123, No. 2, 408-411, February 2000, Oxford University Press.
"This book about brain death is as much to do with legal and philosophical considerations, public attitudes and public policy as with clinical aspects. It arose out of a conference in 1995, but is much more scholarly and coherent than a conference proceedings—with authors referring to each others' chapters and the Editors writing an introductory commentary to each group of chapters. Each chapter has its own reference list and all are well written, making the book as a whole a rewarding read. Its focus is on the US, but there are chapters on specific public policy problems in Denmark, Germany and Japan.
The Editors' introduction to the whole book raises the possibility that the public consensus following the report of the President's Commission might be about to deconstruct. The threat is from debates about whole brain, higher brain and brainstem definitions, and when death occurs, although they acknowledge that there has been little public interest in these academic controversies.
Reviewing the cultural context of the evolution of brain death, an historian details reactions to the 1968 Harvard criteria. A major aim was claimed to be the avoidance of prolonged futile life-support and promoting death with dignity, rather than to aid the harvesting of organs. But the media focused only on the transplant issue and there followed no fewer than 11 feature films on the theme of murders to provide donor organs. Initially, the AMA [American Medical Association] did not want doctors to be ruled by guidelines, and lawyers did not think doctors should decide on their own. However, the President's Commission in 1981 largely resolved these issues. Laws were passed recognizing brain death, but leaving doctors to devise and apply criteria. The concept was `sold' to the public on the basis of whole brain death, the President's Commission rejecting the alternative higher brain definition (declaring death once consciousness is permanently lost).
Those of us who were involved in the development of the UK Colleges' criteria in 1976 and in the furore over the BBC Panorama programme `Transplants—are the donors really dead?' in 1980 will find Plum's review of diagnostic criteria of particular interest. That TV programme in 1980 amounted to a challenge to the purely clinical criteria established in the UK, as contrasted with the use in many other places of confirmatory investigations, in particular the EEG. Plum points out that with increasing confidence in clinical guidelines many institutional codes in the US no longer require laboratory confirmation. According to the American Academic of Neurology in 1995 and the recent New York State guidelines detailed by Plum, EEG is not mandatory provided the clinical tests have been repeated with an interval of 6 hours. Indeed Plum tabulates six papers reporting EEG activity after brain death had been clinically evident, stating that none of these patients made any recovery, even to the vegetative state. He reviews alternative confirmatory tests, in particular stressing their unreliability. He notes that nonetheless some US hospitals still insist on them, as do some European countries. He concludes his review with a defence of the brainstem criteria, which in practice are those used by doctors who maintain that death of the whole brain is the basis of brain death. The Editors comment that `readers will judge whether Plum's conclusion is a savvy compromise or the beginning of a more widespread retreat from the notion of whole brain death'.
Pallis (the only British author) makes a more aggressive defence of the brainstem criteria, pointing out that these render irrelevant the anomalies that trouble those concerned to diagnose whole brain death. These include the persistence after brain death of EEG activity and of neurohumoral regulation of ADH secretion. Other neurologists here deal with this matter of how much of the brain must be dead by emphasizing that death is a process rather than an event, and that what matters for the whole brain definition is that there should no longer be any clinical evidence of critical or integrative brain function. This reiterates the assertion of the President's Commission that mere physiological activity, not discernible clinically, is irrelevant. In spite of these various doubts about the validity of the claim that the whole brain is dead, it is concluded that the criteria for brain death are probably the most reliable and valid in the whole of medical practice. That there is evidence that many doctors in the US do not always assiduously apply all of them does not make these criteria any less valid.
There is debate about the time of death—which functions have to have ceased and when it is known that cessation is irreversible? Several authors refer to the different purposes for which it has seemed necessary to define death, but one chapter is entitled the `Unimportance of Death'. This considers it unrealistic to expect the same criteria to define when it is appropriate to withdraw treatment, to harvest organs or to dispose of the body and assets of the deceased. Only for the last purpose is it necessary to define death, and for that the traditional cardiac criteria are required.
The demand for legislation about brain death in the US came largely from doctors seeking protection when harvesting organs, according to a leading academic lawyer who believes that if transplantation had evolved more slowly and gained gradual acceptance, no legislation would have been necessary. He and other contributors believe that doctors exaggerated the risk of litigation in these circumstances. Protection for doctors was supposedly gained by claiming that brain-dead organ donors were dead, but this insistence on the `dead donor rule' was an unexamined assumption. Indeed it has led to the offer also of a higher brain definition of death, which would declare vegetative patients dead in order to allow treatment to be withdrawn and organs taken. But treatment is regularly withdrawn from a wide range of patients for whom it is considered futile without any suggestion that they are already dead, and in the litigious climate in which medicine is practised in the US no doctor has ever been successfully prosecuted for such withholding or withdrawing of treatment. It would be better to accept criteria for treatment withdrawal and for organ removal without requiring the clinical and legal contortions needed to declare death. This could also allow donation from anencephalics without deciding that they are dead. It is ironic that the UK, one of the few countries where brain death legislation has been deemed unnecessary, is the only place that requires court approval before artificial nutrition and hydration can be withdrawn from patients in the persistent vegetative state.
The chapter titled `The conscience clause' notes that there have been formal objections to brain death from Orthodox Jews and some fundamentalists and Catholic pro-life campaigners. In some American states, the law is that death shall be pronounced when whole brain death criteria are satisfied, in others that death may be pronounced, leaving it to the doctor's discretion. Only in New Jersey is there specific provision for religious objectors, in an individual case, to insist on asystole before death is declared. Veatch argues that it is difficult to limit such choice to those with religious objections, and that all people might be given the choice to accept their own death being declared by cardiac, whole brain or higher brain criteria, via an advance directive or appointed surrogate. Whole brain death would be the default definition, if no opinion had been expressed.
The Editors' introduction to three chapters on public attitudes contrasts the absence of public discussion of brain death with the continuing interest in debating when life begins. The push for further redefinition of death comes from a small group of academics who seem concerned at the public's lack of concern. Surveying the empirical literature on attitudes there is much more debate about transplantation than specifically about brain death. The public remains confused about brain death, the vegetative state and coma and the possibility of recovery from each. The chapter on Christian fundamentalism comments on the tendency of adherents to be suspicious of technological advances and strong on the sanctity of life. Whilst against euthanasia and the higher brain definition of death, however, most groups accept whole brain criteria for death and are not opposed to transplantation. The chapter on Jewish attitudes accepts that many Jews do not follow the dictates of the Orthodox. The latter reject treatment withdrawal or refusal, with personal autonomy much less respected than by other religions. Transplantation is approved but there is still debate on whether the whole brain definition of death is acceptable—many Orthodox Jews would reject it.
The section on problems in three other countries illustrates, the Editors claim, concerns that exist under the surface in the US. Before Denmark passed a law accepting brain death in 1990, kidneys were taken from patients whose hearts had stopped but in whom it was usual to attempt to restart the heart by resuscitation before removing the organs. In 1985 a Committee on Transplantation recommended accepting brain death criteria and the Minister of Justice proposed a Bill in 1987, which met with surprising opposition in the media. A Council of Ethics was set up in 1988, with only three doctors among its 17 members; this was to deal with genetics and assisted reproduction, but it also took up the brain death debate. Its report in 1989 recommended taking organs once brain function had ceased during the death process, but that the time of death was when the heart later stopped. There followed an unprecedented public debate, actively promoted by the Council. It distributed 14 000 copies of its report across the country, set up more than 200 local debate meetings and sent a video film to more than 500 local groups. More than 1000 newspaper articles were written. Public opinion was 80% in favour of the minority on the council, who recommended declaring death when the brain death criteria were satisfied. The law passed in 1990 was virtually identical to that proposed in 1987 before the public debate.
In Japan the story was quite different and much more fractious. The debate has been going on for 30 years but was partially resolved by a law passed only in 1997, many years after other countries, and 12 years after a Committee was set up by the Ministry of Health to consider the matter. Throughout this time one paediatric neurologist had organized steady opposition to brain death, which she saw as just an aid to transplantation. Several scandals involving transplant surgeons kept up a negative reaction to brain death, although by 1988 the Japanese Medical Association voted to accept the concept. But there were divisions between specialties; the association of neurologists and psychiatrists feared that the handicapped might become unwilling donors. In 1992 a cabinet committee was deeply divided, but a majority decision was in favour. However, this was rejected the next day by the Minister of Justice and the police. Some resistance rested on the traditional lack of good communication between Japanese doctors and their patients, leading to mistrust of the medical profession. There was, however, persistent search for public consensus, with support increasing from 29–55% between 1983 and 1995, as reflected in 15 national surveys. Although some of the resistance was based on traditional values the debate was largely secular with no participation by religious organizations. The recent law applies only to patients for whom permission has been given for organ donation.
In Germany there was early acceptance of brain death, and this practice went unchallenged for over 20 years, but then ran into trouble. Two months before the Harvard criteria, a German committee published similar criteria and further guidelines came in 1982. Both Protestant and Catholic churches accepted brain death and transplantation and there were few dissidents. However, the drafting of legislation in 1995 to legalize what had already become accepted practice stirred up opposition leading to public hearings for the Parliament. The Berliner Initiative against brain death comprised many doctors, theologians and others. However, medical associations and scientific societies supported the whole brain definition, and the churches did not retract their earlier support. Eventually the law was passed in 1997. The opposition arose partly from memories of the Nazi period, together with concern at the persisting paternalism of German doctors, limited public debate and the lack of organizations promoting patient rights.
These accounts of years of acrimonious dispute in three countries should make us grateful that our few months of debate in 1980/81 seemed to settle the matter quite quickly. But the lesson of Germany, where a peaceful consensus was challenged after many years, and the fears of the editors of this book that the same might happen in the US, should alert us to the need to maintain good practice in this sensitive field. This means ensuring not only that all involved are fully informed about the UK criteria, but that they apply them rigorously; also that they deal sensitively with the families involved.
The section on public policy faces the fact that public perception is more important than scientific reality, and this is reflected in how the law takes liberties with biology. For example, it treats adoptive parents as fully parents, and acknowledges change of sex although the chromosomes remain the same. Law is supposed to reflect the will of the public, raising in this area how much the public wants or needs to know about the ambiguities of the biology of death or can understand them. Can the public cope with death as a process and life as a transitional category? Would debate about the higher brain definition of death undermine confidence in whole brain or brainstem definitions of brain death? It is interesting that the three countries that have had the most heated debates over the issues have each in the end come to accept the concept of brain death.
The final section on `The future of death' acknowledges that in academic biological and philosophical circles there are challenges to the whole brain concept, but that only minority religious groups wants to return to the cardiac criteria. The need is to minimize harm from prolonged futile treatment or from premature organ removal. It seems better to decouple death from the sequence of perimortal actions and to allow free choice from a menu of alternative definitions of death.
The final chapter by a Yale law professor is a masterly summary. He considers that the calls for changes in definitions and the law are not persuasive, albeit accepting that the present criteria for brain death are conceptually incoherent. These criteria are clearly useful clinically, and if all were applied there would be few false positives. There is serious doubt whether changes would increase the availability of organs or reduce prolonged futile treatment and its cost in distress to families and in dollars. There is already choice regarding treatment refusal or withdrawal and the donation of organs. To impose choice about when death is declared would be ideologically polarizing, the danger of which is seen in the sometimes violent controversy about abortion. His soundbite is that the US needs another such divisive issue like it needs a second hurricane Andrew. Indeed, he admits that this might imply that the manuscript of this book might have been better burnt than published. Less cynically, he hopes that it will not provoke public controversy, but will rest quietly on library shelves so that `in 10 years we might reconvene to try to explain the persistence of the confusions we had identified' ".
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