Passive Euthanasia Research Articles

Euthanasia: History, Definitions and Clinical Guidelines from Classical Jewish Sources.

Background: End-of-life care is a central ethical problem for clinicians. The definition of euthanasia is complex and difficult causing confusion for its practical application. Historically, the term was abused leading to medical atrocities. We trust that during medical training and in continuous medical education programs ethical topics relevant for clinical practice should be addressed systematically in their cultural context. The awareness for these crucial topics will improve clinical performance.Objective: To define philosophical concepts, to present historical events, to discuss classical attitudes in modern bioethics and to analyze classical Jewish sources which are helpful to elaborate practical guidelines for clinicians in euthanasia and end-of-life care. Reflection on these concepts by discussing classical Jewish sources might help clinicians in their judgment and process of decision-making.Methods: A historical overview with philosophical definitions of the concepts of active versus passive euthanasia, physician assisted suicide etc are given. Sources from the classical Jewish literature are presented and analyzed also according to later traditional interpretation. Their relevance and application in modern clinical medicine is elaborated.Results: Philosophically, the distinction between active versus passive euthanasia is crucial. Jewish sources certainly support the obligation to ease the ongoing process of dying; there is no duty to prolong the agony of the actively dying patient, which is actually prohibited. On the other hand, no practical involvement is allowed to actively induce death of the terminal patient.Conclusion: The historical overview and the review of the literature support the need to define concepts of euthanasia for clinicians dealing with end-of-life issues, since this term caused historically and philosophically major confusion. Therefore, ethical issues should be included in formal training for physicians and other health care providers, in order to improve the clinical approach for these challenging aspects of clinical medicine. We believe, that classical Jewish sources might contribute to elaborate clinical definitions and to provide meaningful approaches for practical guidelines for clinicians.

A Scale to Assess Attitudes toward Euthanasia

The topic of euthanasia has been a matter of public debate for several decades. Although empirical research should inform policy, scale measurement is lacking. After analyzing shortcomings of previous work, we offer a systematically designed scale to measure attitudes toward euthanasia. We attempt to encompass previously unspecified dimensions of the phenomenon that are central to the euthanasia debate. The results of our pretest show that our attitude towards euthanasia (ATE) scale is both reliable and valid. We delineate active and passive euthanasia, no chance for recovery and severe pain, and patient's autonomy and doctor's authority. We argue that isolating these factors provides a more robust scale capable of better analyzing sample variance. Internal consistency is established with Cronbach's alpha=.871. Construct external consistency is established by correlating the scale with other predictors such as race and spirituality.

Person-Centered Planning and Communication of End-of-Life Wishes with People Who Have Developmental Disabilities

Person-centered planning is a common practice in most developmental disability systems. As people with disabilities are living to old age and being supported in the community as they age and die, there is an ever increasing need for advance care planning for people who have developmental and intellectual disabilities; that is, the organizing of advance directives. Since many people already have a personcentered plan, the author suggests that use of a good planning process might be a logical next step for helping people communicate their end-of-life wishes. The author is clear that this is not about active or passive euthanasia, but is about helping people clearly communicate their wishes in the context of increasing age, significant infirmity or terminal illness.

Apuntes sobre la eutanasia

In the Judeo-Christian tradition, human life is held to be sacred, a semblance of the divine and a gift from God which the individual cannot dispose of at his or her own will. Hence, these monotheistic religions have made of the crime of murder a transgression of God's own commandment not to kill and have extended the applicability of this commandment to the practice of euthanasia and suicide. On the other hand, some non-religious traditions offer plausible reasons favoring euthanasia. This is a delicate matter for physicians, since the Hippocratic tradition forbids euthanasia and because as care-givers they must also bear the psychological, moral and emotional burden of carrying it out. Physicians are trained to preserve life but not to bring it to an end. As human beings, they must always respect the principle of nonmaleficence, and as physicians they must always respect as well the principle of beneficence. It is difficult to accept the fact that ending a human life can be an act of beneficence. In order to differentiate between passive and active euthanasia, the concept of proportionality of medical acts must be brought into consideration. For instance, using high doses of opiates to alleviate pain or withholding the use of an extraordinary method of treatment are not passive acts aimed at ending the life of a terminally ill patient, but medical acts that are reasonable, judicious and proportionate to the condition and irreversibility of a patient's illness. Therefore, so-called passive euthanasia cannot be considered the same as euthanasia. On the other hand, medically assisted suicide is a deceitful form of active euthanasia. The aim of this act is to cause death and the physician is morally responsible for such a death, since he is providing the means for bringing a human life to an end. Many times the desire to die expressed by terminally ill elderly and helpless patients is a request for help and an expression of reproach against a society that allows for their abandonment and neglect.

Euthanasia Is Out of Control in The Netherlands

Euthanasia Is Out of Control in The Netherlands Stephen Drake (bio) The March 10 issue of the New England Journal of Medicine featured an article by two Dutch doctors defining a "problem" and a "solution." Drs. Verhagen and Sauer announced that a survey had found that, contrary to Dutch law, some infants with severe disabilities have been euthanized. In an effort to end "uncontrolled" euthanasia, they proposed adoption of a set of protocols, known as the "Groningen protocol," for legally euthanizing infants with disabilities and serious medical conditions. It's hard to believe anyone could be surprised by the news of this latest effort to expand the practice of euthanasia in the Netherlands. For the sake of brevity, one might compare Dutch euthanasia practices to a highway system. In this system, drivers are responsible for monitoring their own speed. As long as they tell officials how fast they're driving, the authorities generally won't issue tickets for speeding. Here's the hitch: the problem of speeding has become so problematic that every few years a driver is actually issued a ticket. In every reported case, the offender was given a slap on the wrist, and the speed limit was raised. Predictably, this just results in a general rise in the speed of traffic and further requests to raise the speed limits. This is, in effect, what happened in 1994 when Dr. Boudewijn Chabot was convicted of aiding the suicide of a woman in despair over the death of her two sons. It happened again in 2001 when Dr. Wilfred van Oijen was tried and convicted for "euthanizing" an elderly woman without her permission. The main difference between the Dutch system and the American system, I'd suggest, is one of degree. We've set the speed limits at a lower level and mostly resisted requests to raise them. However, there is significant evidence that at least some medical professionals in the United States would embrace legalization of infanticide based on disability. It wasn't that long ago that passive euthanasia of infants with Downs Syndrome and spina bifida was an accepted practice here, and it's still unclear to what extent the practice persists. The sentiment for facilitating the deaths of infants with disabilities is evident in numerous research studies. For example, in 2001, Streiner and colleagues published a study in Pediatrics comparing the attitudes of parents and health care professionals in "quality of life" assessments of premature infants. The study found that neonatologists and neonatal nurses were both more pessimistic about pediatric outcomes, and also more likely to judge death to be the best outcome, than were the parents or siblings of the same children. This study, conducted in Canada, is consistent with earlier U.S. studies that have demonstrated a bias on the part of medical professionals in devaluing the lives of infants with severe disabilities. No one should mistake this bias for anything other than what it is—an over-valuation of physical and mental norms, which is bigotry. That prejudice is often mistaken for objectivity in bioethics discussions. It's one reason most public discussion of euthanasia is tainted by misinformation. For example, the Associated Press story on the Groningen protocol misinformed readers that the protocol applied to "euthanizing terminally ill newborns." This is a gross distortion: Verhagen and Sauer made no attempt to hide that they were talking about newborns with "serious medical conditions." It's both puzzling and disturbing that this misinformation was met with total silence from the bioethics community. You would think that bioethicists, eager to claim expertise and promising to bring clarity to public debates, would have jumped all over the Associated Press report. This silence reinforces the cynical view that the righteous anger bioethicists express at outspoken disability advocates has less to do with providing clarity than with protecting turf. Bioethicists who appear in popular media often decry the simplistic way in which complex issues are addressed. On behalf of Not Dead Yet and other disability rights organizations, I have a not-so-respectful request: admit your failure to promote a complex and accurate public discussion of bioethical issues and make room for those of us who seem more...

Terri Schiavo: the Assessment of the Persistent Vegetative State in Accordance with German Law

The case of Terri Schiavo in the USA served to intensify the debate in Germany which itself had in part already been characterised by fundamentalism. Now that some time has elapsed and the political debate has quietened, this case is to be taken up again in discussing the permissibility and the prerequisites of passive euthanasia for patients in a persistent vegetative state. A short reconstruction of the facts of the case (II) is to be followed by a survey of the case law of the Criminal Panels (III) which is essential to understand the present legal policy debate to be discussed at a later stage (IV).

ATTITUDES TOWARD EUTHANASIA IN HONG KONG—A COMPARISON BETWEEN PHYSICIANS AND THE GENERAL PUBLIC

ABSTRACT This article reports the findings of a cross-sectional study that compared the attitudes of 618 respondents of a general household survey and a random sample of 1,197 physicians toward different types of euthanasia in Hong Kong. The general public was found to agree with active euthanasia and non-voluntary euthanasia and was neutral about passive euthanasia. On the other hand, physicians agreed with passive euthanasia, were neutral about non-voluntary euthanasia, and disagreed with active euthanasia. Factors affecting the respondents’ attitudes were also explored. The article ends with policy and research implications of the findings.

Ethical issues in resuscitation and intensive care medicine

The goal at the end of life is to provide quality care, respecting patient autonomy and offering opportunities for consent. Advance directives allow patients the opportunity to express treatment preferences in the event of their becoming incapacitated. While the law has a desire to support an individual's right to self-determination once incompetent, the broad non-specific nature of advance directives can make their application difficult. Do not resuscitate orders should be considered when the anticipated success rate is poor. It is essential to identify when cardiopulmonary arrest represents a terminal event. Adequate communication is essential. Brain death and organ donation raise many ethical issues. With respect to non-heart-beating organ donors, recent protocols have expanded their potential role to allow procurement of additional solid organs. Judgement decisions about whether or not to instigate a treatment are often based on the anticipated quality of life, which is linked to the concept of medical futility. This can be defined as treatment that cannot within a reasonable probability cure, ameliorate, improve or restore a quality of life that would be satisfactory to the patient. In turn, while healthcare resources must be fairly distributed, treatment decisions based on solely financial reasons must be avoided. Withholding or withdrawing treatment that hastens natural death, is permissible, provided the intention is not to kill the patient. However, the distinctions between voluntary passive euthanasia, physician-assisted suicide and active euthanasia are fraught with legal and moral difficulties. It is also acceptable to administer certain treatments that may have both a beneficial and a harmful effect, provided the intention is to provide the beneficial effect.

Ian Dowbiggin, A merciful end: the euthanasia movement in modern America, New York, Oxford University Press, 2003, pp. xix, 250, $28.00 (hardback 0-19-515443-6).

Nick Kemp recently produced a history of the British euthanasia movement ‘Merciful release’ (Manchester University Press, 2002). Now, with this new book by Ian Dowbiggin, we have a companion volume that charts the history of the euthanasia movement in modern America. Opening with the Jack Kevorkian case, Dowbiggin's book has six short chapters. The first charts the history of euthanasia as a concept and a practice from classical Antiquity to the Progressive era. The next, entitled ‘Breakthrough’, covers the period 1920–40, and the establishment of the Euthanasia Society of America (ESA) in 1938. The third chapter, called ‘Stalemate’, surveys the struggles of the ESA with the Roman Catholic church in the years 1940–60. Chapter four, ‘Riding a great wave’, deals with the period between 1960 and 1975, including the reinvention of the ESA with the idea of passive euthanasia in the 1960s. The following chapter, ‘Not that simple’, covers the splits that characterized the 1970s, and the emergence of new populist right to die organizations in the 1990s. The conclusion deals with the 1990s and beyond, a period when many Americans have come to believe that euthanasia or assisted suicide would be bad public policy, and when no conclusive outcome is in sight. Dowbiggin has had privileged access to the files of the euthanasia movement, and he is keen to explode the myths that euthanasia only began in the 1960s and 1970s, and that it should be seen as a triumphalist struggle. Other important themes that emerge from his admirably brief but wide-ranging study include the way that euthanasia intersected with other progressive social causes, such as birth control, abortion, and eugenics. Euthanasia was seen “as a critical component of a broad reform agenda designed to emancipate American society from anachronistic and ultimately unhealthy ideas about sex, birth, and death” (p. 30), but also was bedevilled by perennial fears that mercy killing would be extended to people with disabilities. Dowbiggin shows that support for euthanasia in the 1900s was due more to shifting ideas, attitudes, and social forces than to changes in medical practice and technology. Equally important have been the interchangeable social, biological, economic, and humanitarian justifications that have been advanced in its support. A final theme running through Dowbiggin's history is the tension between public authority and personal autonomy, between paternalism and individual freedom. He ends with the new issues posed by September 11, and concludes that the question of “where does the freedom to die end and the duty to die begin” remains unanswered (p. 177). One of the difficulties faced by Dowbiggin is that he has to contend with a large cast of individuals (Felix Adler; William J Robinson; Charles Francis Potter; Charles Killick Millard; Inez Celia Philbrick; Eleanor Dwight Jones; Joseph Fletcher; and Olive Ruth Russell among others). Similarly, by the 1970s the picture becomes very complex as the movement fractured into numerous smaller organizations with frequent name changes (the Society for the Right to Die; Concern for Dying; the Hemlock Society; Choice in Dying; Partnership for Caring, and so on). Nevertheless Dowbiggin has coped admirably with these problems to produce a thoroughly researched and well-written history that convincingly explains the reasons for the ebb and flow of support for euthanasia, locating these movements within wider national and international contexts. Dowbiggin is unable here to engage with the recently published Kemp volume. However, comparative studies of Britain and America (and elsewhere) would seem one obvious way to provide new perspectives on “society's long struggle to deal with the grim reality of human disintegration that we call death” (p. xiv).

The different ways of dying. Ethical reflections

Death Process is seen influenced by multitude of factors. It's not habitual that the patient decides about the circumstances of his death. In the terminally ill situation, the Palliative Medicine is considered the best option. Sometimes the death is produced as consequence of an action or omission, which raises ethical important dilemmas difficult to resolve. The similarities and differences between active euthanasia and passive euthanasia are analysed.

Consequences count: against absolutism at the end of life.

There has been a considerable amount of debate in the nursing literature about euthanasia, and especially the distinctions between acts and omissions, and killing and letting die. These distinctions are required by opponents of euthanasia to justify allowing some cases of passive euthanasia while forbidding all cases of active euthanasia. This paper adds to the debate by arguing that the position that absolutely forbids euthanasia is theoretically inconsistent. The paper first considers the place of moral theory in analysing moral problems, within the framework of the principles of biomedical ethics. It is argued that despite a moral pluralism that operates in many areas, the legal status of euthanasia is based upon an absolute deontological position against deliberate killing, which cannot be overridden by appeals to favourable consequences. In order that certain forms of passive euthanasia can be allowed, this position allows distinctions within three pairs of concepts--acts and omissions, killing and letting die, and ordinary and extraordinary means. A further method of justifying certain actions near the end of life is the doctrine of double effect. These paired concepts and the doctrine of double effect are analysed with special reference to their consequences. The application of the doctrine of double effect and the three distinctions relies on consideration of their consequences, allowing in practice what in theory is denied. This is important because it weakens the absolute case against euthanasia, which disallows any direct consequentialist appeal. If consequences count in the application of the doctrine and the distinctions, then they should also count directly prior to their application. This strengthens the argument for active euthanasia in certain cases.

Doctor and death

Doctors are instilled with the need to avert and repress death. By virtue of their profession, death is considered the enemy, their mortal enemy. In modern-day hospitals in particular there is a tendency to reduce the mystery of death to a biological and technical algorithm. A critical revision of fundamental medical conduct is underway as a compensatory countercurrent to this age-old way of thinking and acting. This shift in attitudes involves a humane concept of the physician. His task is not limited to healing and reconstruction, but sometimes merely requires discriminatory restriction to palliation and accompaniment. Ever more physicians are becoming aware of the fact that they are equally responsible for the quality of dying. In coping with death, ethical imperatives are effectively juxtaposed against technical ones. Educational deficits relating to care of the terminally ill and dying have been recognized and are being rectified. This major ideational revision has led to concrete signs of turnaround which are blazing the trail toward more humane and dignified dying: palliation, adapted in accordance with modern science, is experiencing a renaissance. The essential features of a comprehensive palliative therapy are outlined. Assistance during dying (accompanying the dying, passive euthanasia) is contrasted with assistance to die (active euthanasia).

Does empirical research make bioethics more relevant? "The embedded researcher" as a methodological approach.

What is the status of empirical contributions to bioethics, especially to clinical bioethics? Where is the empirical approach discussed in bioethics related to the ongoing debate about principlism versus casuistry? Can we consider an integrative model of research in medical ethics and which empirical methodology could then be valuable, the quantitative or the qualitative? These issues will be addressed in the first, theoretical part of the paper. The concept of the "embedded researcher" presented in this article was stimulated by the two questions, (1) how can we safeguard that our research will yield valid and meaningful results to practice? and (2), how can we convince clinical colleagues that medical ethics offers relevant contributions to the analysis and solution of problems? One tentative answer has been our effort to elaborate a coherent methodological research approach in the field of end-of-life issues integrating qualitative and quantitative as well as casuistic methodologies. This development is characterized in the second part describing the ECOPE Study (short title) "Ethical Conditions Of Passive Euthanasia." The achievements and limitations of the suggested approach of the "embedded researcher" are discussed referring to 3 examples of our joint studies about ethical issues concerning (1) critical decision-making in neonatology (2) limitation of treatment in intensive care (3) problems with doctor-patient conversation at the end-of life in oncology. Conclusions from our studies are put to discussion in the final part of the paper about how to further develop research in the field of end-of-life care and, maybe, clinical bioethics as a whole.

James W Rachels

James W Rachels

Medical murder by omission? The law and ethics of withholding and withdrawing treatment and tube feeding

When is it lawful and ethical to withhold or withdraw treatment and tube feeding? In recent years, the courts have handed down important decisions and medical bodies have issued professional guidelines on withholding and withdrawing treatment and tube feeding. A major criticism of these decisions and guidelines has been that while they prohibit the intentional hastening of a patient’s life by an act (‘active euthanasia'), they permit the intentional hastening of a patient’s death by omission (‘passive euthanasia'); and they prohibit actively assisting suicide, but permit passively assisting suicide. By focusing on the landmark decision of the Law Lords in the Tony Bland case, and on the guidelines on withholding and withdrawing treatment and tube feeding issued by the British Medical Association, this paper considers whether this criticism is sound, and concludes that it is.

Attitudes towards professional euthanasia in the range between grement in the society and personal preferences--results of a representative examination of the German general population

Several surveys of the German population concerning the attitude towards euthanasia in patients with terminal illness yielded contradictory results, ranging from high acquisition to high refusal rates. After a critical discussion of the methodological concepts of these investigations, we present the results of a representative study of 1957 German persons (age range: 14 - 96 years) which was performed by the institute USUMA in February 2001. Four different types of euthanasia were included in the study: active, passive, and indirect euthanasia as well as physician's assisted suicide. The affirmative response categories were "declared will and unbearable pain", "declared will", "referred will", and "in the responsibility of the physician". Additionally, we asked to state the personal preference in the case of an own incurable illness. The resulting frequency distributions stress the autonomy of the patients (declared will) and the legal forms of professional euthanasia (passive and indirect euthanasia), independent from the degree of pain. The rank order of the hypothetic personal preferences was: passive euthanasia (26.1 %), active euthanasia (21.1 %), indirect euthanasia (13.1 %) and assisted suicide (6.2 %). For each category the hypothetic personal will to utilize euthanasia personally is markedly lower than the consent to legalize euthanasia in the society. This points to a diminished readiness of the population to seek for euthanasia. Persons aged 60 years and above deny all types of euthanasia significantly more often than younger persons. Persons with subjectively bad health status prefer the category "in the responsibility of the physician" more often than healthy subjects. The representative study proves that there is no polarized public opinion concerning euthanasia, rather there is a picture of high complexity.

The Practice of Euthanasia

John Keown's informed and powerful argument against euthanasia features both an excellent exposition of its pitfalls and a strong confrontation with a question that remains controversial abroad: Are there circumstances in which withdrawal of treatment should be considered euthanasia? American readers of this book, who consider the question settled and are unfamiliar with cultural and legal differences in the way European countries and the United States have dealt with end-of-life issues, may be puzzled at first as to why this University of Cambridge lecturer in the law and ethics of medicine wants to address this question. But Keown's exposition will make even such readers, who believe we have wisely avoided many of the dilemmas Great Britain and other European countries are forced to face, realize that there are some dilemmas we have not escaped. To evaluate euthanasia, Keown examines its actual practice. He carefully provides evidence to show that legalization of voluntary euthanasia cannot be regulated and that it leads increasingly to involuntary euthanasia and to patients who are not ready to die or whose suffering could be alleviated by palliative medicine. Such a study relies heavily on the Dutch experience, since not only has the practice been legal in the Netherlands for some time, but two Dutch government-sanctioned studies (in 1990 and 1995), in which physicians participated anonymously and with impunity, have shown us what the actual practice entails. The Dutch studies play down a fact they cannot help but reveal, namely, that thousands of patients have their lives ended without their consent. The studies report 3,600 deaths in 1995 from assisted suicide and euthanasia and officially acknowledge between 900 and 1,000 involuntary deaths. But they refuse to describe as euthanasia, or involuntary (when a competent patient does not give consent) or nonvoluntary (when the patient is deemed unable to give consent) euthanasia, the 1,350 patients in 1990 or the close to 2,000 patients in 1995 whose physicians gave them large doses of pain-killing medication with the primary aim of ending their lives. In the course of my own studies of euthanasia in the Netherlands, I asked Paul Van Der Maas, the principal investigator of the Dutch government-sanctioned studies, why, if patients had consented to the drug overdose, these should not be considered euthanasia cases. He conceded they could be--the only difference was that the patients took longer to die. When asked why, if patients were put to death who had not consented (about a third of the patients), these cases were not considered nonvoluntary or involuntary euthanasia, Van der Maas could not give a reason, but he was not willing to consider recategorizing them. When one realizes that in one-quarter of the cases in which Dutch physicians give medications intending to end patients' lives, they do so without the patient's consent, that a third of Dutch doctors admit to having done so, that half of Dutch doctors feel free to suggest euthanasia to their patients, and that 60 percent of Dutch euthanasia cases are not reported to the authorities, one is inclined to agree with Keown that this is a system out of control. Keown is also concerned, however, that the data on the many thousands of Dutch cases where treatment (including tube feeding) was withdrawn without patient consent do not permit us to know whether the doctor was merely stopping a futile or burdensome treatment or intended instead to end the patient's life--referred to as This is an issue that has also troubled Keown in his own country because British law since the landmark Bland case has condoned passive euthanasia. Most of the concluding chapters of Keown's book deal with his concern with passive euthanasia and reflect some of the differences in approach to end of life care between Europe and the United States. In 1989, Tony Bland was left in a persistent vegetative state after being crushed by a crowd at a soccer game. …

Revisiting the problem of Jewish bioethics: the case of terminal care.

This paper examines the main Jewish sources relevant to end-of-life ethics, two Talmudic stories, the early modern code of law (Shulhan Aruch), and contemporary Halakhaic (religious law) responsa. Some Orthodox rabbis object to the use of artificial life support that prolongs the life of a dying patient and permit its active discontinuation when the patient is suffering. Other rabbis believe that every medical measure must be taken in order to prolong life. The context of the discussion is the most recent release of the "Steinberg Report," which proposes a law regulating end-of-life issues in Israel. It is argued that the Orthodox rabbis base their views on a strongly positivist concept of religious law. The rabbis deliberate the law as a manifestation of the will of God and try to stretch the law as much as possible in order to benefit the patient, even when it is good for the patient to die. Direct and active actions that kill are prohibited; certain forms of passive euthanasia and contrivances that terminate life support without needing direct human action are accepted.

The ethics of end-of-life decisions in the elderly: deliberations from the ECOPE study

Is age a factor underlying clinical decision-making? Should age be a criterion in the allocation of health care resources? Is it correct to criticize this approach as ‘ageism’? What role does ‘paternalism’ play? These questions are the focus of this chapter which takes an interdisciplinary perspective of clinical ethics in order to provide an ethical evaluation of the situation of the elderly in health care. First, the text of the chapter is based on the descriptive level referring to (a) clinical ethics consultation, (b) the ECOPE study on ‘Ethical Conditions of Passive Euthanasia’ focusing on decision-making, and studies about age as a factor in clinical decisions, such as the American SUPPORT study. Second, at the normative level, ethical deliberations are discussed for and against age as a criterion for allocating health care resources. Finally, it is suggested that the differences in evidence to be found about the role of age as a factor in clinical decision-making may be due to the different national health policies as well as to the insufficient awareness of ethical principles violated by covert ‘ageist’ attitudes.

MSJAMA. Legal status of physician-assisted suicide.

MSJAMA. Legal status of physician-assisted suicide.