Ageism Research Paper

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This research paper examines the relevance of the concept of ageism for bioethics. Ageism is defined as the display of negative attitudes or behavior toward individuals or groups based on their age, which results in age discrimination. After a brief description of the historical context, two concepts of ageism are distinguished: a general one and a more specific one. The latter concerns negative stereotypes and age discrimination of older people, which is the focus here. Following a brief outline of the ethical and legal framework of criticizing ageism, the main areas of bioethical concern are analyzed. Individual medical staffs may have negative stereotypes about older people, which could result in discrimination and disadvantages in health care. Another main area is the health-care system itself, because the public perception of older people as a burden on social services could generate repeated requests for age-based rationing, which can have ageist elements. A major field, which might benefit from population aging as well, is antiaging medicine, the representatives of which have been repeatedly accused of ageism. The exclusion of older people from participation in medical research may also partially constitute a result of ageism. Finally, the importance of countering ageism from a global health perspective is justified and highlighted in the conclusion of this research paper, which may be of particular relevance for bioethics and training future medical staff in medical ethics.


Research into “ageism” or the impact of negative stereotypes about age groups on individual attitudes and behaviors is a fundamental goal of social gerontology, the sociological branch of the basic science of aging. Social gerontologists not only analyze individual convictions and institutional structures in light of their conceptions of ageism, but they also try to reduce age discrimination. This is obviously not merely a theoretical project, but a practical and ethical one that encourages interdisciplinary cooperation. However, “ageism” as an object of analysis has gained relatively little attention in the bioethical literature or empirical ethics. At the same time, especially in view of the current demographic transition and population aging, the fields of health care and nursing constitute areas in which negative stereotypes could result in discrimination of age groups or otherwise harm them. Therefore, this essay identifies main areas of concern in the research on ageism in the field of bioethics as well as some key issues in each of them. The main areas span from possible shortcomings of individual doctor patient relationships and publicly funded health care to antiaging medicine and medical research. One of the results of this overview is that to counteract ageism will be an important task for bioethics and training in bioethics in the future.

History And Development: Background Of The Issue

The term “ageism” was coined by the American physician Robert Butler in 1969 modeled after the concepts of racism and social class discrimination for which he thought there was a much greater awareness (Butler 1969). In 1974, Butler became one of the first directors of the National Institute on Aging in the USA and is also the founder of one of the first American geriatric wards at Mount Sinai Hospital. Butler’s article introducing the concept in its title and to the scientific readership of the gerontologist reflects the context in which it was conceived. This context is framed more by political activism than scientific research. The example Butler provides is the protest against a housing project in a high-income area where an apartment building was planned, allegedly mostly for poor elderly black women. The other residents in this area protested against this new building as well as the prospect of having these new neighbors. Butler points out that these complaints were not only based on prejudice against social class and race but against age as well. At the same time, he notes, older people are mostly segregated from the rest of the population in poor neighborhoods. Prejudice and discrimination emerge as two major themes of this report on ageism. When Butler published his article, as Bill Bytheway highlights in his essay on “Ageism” in the Cambridge Handbook of Age and Ageing, the Gray Panthers became active against the Vietnam War and advocated a mutual understanding and cooperation between the generations (Bytheway 2005). But, very shortly after this agenda of political activism to counter ageism, scientific research began to develop around the concept. Corresponding research addresses the subjects of ageism in individual attitudes and behavior as well as social institutions. A third major theme in aging research is closer to Butler’s original activist contribution: the fight against stereotypes about the elderly in pursuit of better knowledge and understanding.

After Butler had created the term “ageism” in a call for social and political action against the attitudes and behaviors it characterizes, the phenomenon itself immediately became subject to scientific scrutiny in various philosophical and cultural studies. For example, in her classical study on old age, Simone de Beauvoir summarizes the knowledge of many different disciplines of the field of aging and old age and demonstrates that negative attitudes and behavior directed against old age and the elderly are not merely a result of our contemporary culture and its obsession with youthfulness. She shows that the behavior of traditional societies already ranges from reverence to abuse and, in the more extreme cases, even to killing, particularly in cultures living in an environment with scarce resources. High regard for the elderly often ends once they begin to show signs of cognitive decline. Literary genres such as lament or derision of old age have a long history, and prominent examples can be found in Greek and Roman history. Famously, Aristotle warned the orator addressing the elderly about their squinting, fearful, and egoistic character. Greek and Roman comedy and poetry depict the elderly as stubborn, avaricious, and ridiculous individuals who are often involved in inappropriate and indecent love affairs. The works of authors such as Aristophanes, Juvenal, and Horace are rich in mockery and humiliations of old age and the elderly. As an advocate of the elderly, especially those who have a low socioeconomic status, De Beauvoir develops an agenda for the wellbeing and recognition of the elderly against the background of discrimination and rejection, both of which characterize the situation of her contemporaries (Beauvoir 1970).

Another important pioneer in research on ageism is the medical sociologist and gerontologist Erdman Palmore who began working on the subject by the time Butler had published his article mentioned above. His work on stereotypes and ageism has become famous in the field of gerontology, particularly his “Facts on Aging Quiz.” This questionnaire mixes true statements on aging, old age, and the elderly with stereotypes such as: “The majority of old people are unable to adapt to change.” The quiz is a tool to measure ageism and the public’s knowledge of old people and encourages its users to reflect on themselves. Since Palmore published the first version in 1975, it has been revised and adapted to newly available information and many other contexts (Palmore 2005).

Butler’s, De Beauvoir’s and Palmore’s work are thus shaped by a combination of scientific research and advocacy for older people. In more general terms, this combination also characterizes the field of social gerontology as a whole. In the introduction to the Handbook of Social Gerontology, Dale Dannefer highlights the fight against negative stereotypes and ageism on the one hand and the development of positive models of aging on the other as the central concern of social

gerontology. The practical goal to reduce ageism and age discrimination consequently guides the research agenda of the scientific discipline, at least as experts such as Dannefer define it (Dannefer and Phillipson 2010). Therefore, the concept of “ageism” becomes particularly important in social gerontology, which is led by its practical and theoretical agenda to discover and reduce ageism in social institutions and individuals.

A Specific And A General Definition Of “Ageism”

As described in the last section, the concept of “ageism” is used in a more specific sense in the field of social gerontology. In this context, it can be defined as a combination of attitudes and behaviors directed at old age and the elderly that are based on negative stereotypes and lead to age discrimination. This also shapes the way social institutions and norms refer to the elderly, leading to negative prejudice, pejorative judgments, and the exclusion of older people based on the idea that they all show the same typical traits. However, it is extremely difficult to even determine who is considered as “old” in contemporary societies. Sociological research often divides the advanced stages of life into a third age (65–80) and a fourth age (above 80) and highlights the diversity of individuals in each group and between those groups.

In a more general sense, the concept of “ageism” refers to not only these specific groups of older people but others as well. For instance, even young people are allegedly subject to negative stereotypes and face corresponding discriminatory behavior. A second distinction, which is introduced by some experts, is ageism based on negative or positive stereotypes. The common ground for either positive or negative characterizations of old people may be the perception of their uniformity. Thus, even positive stereotypes deny their diversity and individuality. While negative stereotypes appear to be more problematic, positive ones may have undesirable consequences as well, such as exaggerated expectations. In medical practice, health care, and related fields, the specific sense of “ageism” directed against older people has gained more attention. This can be justified by empirical evidence for the different types of “ageism” and the resulting discrimination, as described in the following section on the ethical dimension of the problem. Due to demographic change and population aging, the impact of negative stereotypes and the discrimination against the elderly have become more visible and thus should be submitted to bioethical reflection and scrutiny. Therefore, the focus here will lie on “ageism” directed against old people on the basis of negative stereotypes.

Ethical Dimension

Ageism, Equality, And Basic Rights

The ethical problem raised by “ageism” is not to determine why it is wrong or when it could be justified, but to ascertain how to judge “ageism.” The difficulty here is identifying its manifestations correctly and developing appropriate strategies to counter them. As with other forms of discriminatory attitudes and behavior based on negative stereotyping of particular groups, “ageism” and the resulting age discrimination violate the fundamental principles of equality and human dignity. Such concerns have been raised more frequently in recent years due to the awareness of global population aging. This may very well be the reason for the absence of age discrimination in human rights documents such as the International Covenant on Civil and Political Rights (ICCPR) adopted by the UN General Assembly in 1976. The ICCPR includes two articles, Articles 2 and 26, dealing with distinction or discrimination according to group affiliation. “Age” is not mentioned in the list and may fall under “other status.” Recognizing the increasing importance of protecting the rights of older people and meeting their needs as their global number increases, the UN organized a “First World Assembly on Ageing” in 1982 in Vienna. It published a set of recommendations entitled “Vienna International Plan of Action on Aging,” which was adopted by the UN General Assembly 1 year later. This report contains the following principle regarding “ageism”: “h) an important objective of socioeconomic development is an age-integrated society, in which age discrimination and involuntary segregation are eliminated and in which solidarity and mutual support among generations are encouraged.” The next step in taking political action on the level of the UN were “principles for older people” adopted by the UN General Assembly in 1991 as part of the resolution 46/91, which proposes 18 principles to guide national legislation. The goal of these principles is to improve the situation of older people, to protect their dignity, and to grant them equal rights. Finally, a “Second World Assembly on Ageing” was organized in Madrid in 2002, the results of which are published in a report. In reference to the Vienna International Plan of Action, the report confirms the goal to eliminate all forms of age discrimination. Article 5 adds: “We are determined to enhance the recognition of the dignity of older persons and to eliminate all forms of neglect, abuse and violence” (UN 2014).

These UN documents highlight the importance of health and access to health care for older people as well as the significance of appropriate institutions for specific needs of the elderly, such as rehabilitative facilities and nursing homes. Obviously, medicine and health care are fields in which “ageism” can have a particularly negative effect on the rights and dignity of older people. Therefore, bioethicists, particularly those whose interests include clinical ethics, the ethics of care and just health, should be aware of “ageism.” In 2012, the World Health Organization celebrated a world health day with the motto “ageing and health.” One of the main goals of this action was to stand against stereotypes of old people. The following sections will examine related discussions relevant to bioethics, health care provision and the doctor patient-relationship, and the allocation of health care resources. The specific fields of antiaging medicine and medical research also deserve special attention.

Medical Care: Harming Patients, Withholding Treatment, And Neglecting Autonomy

Well-known negative stereotypes about old people are characterized by representations of their being – among other things – frail, dependent, unproductive, and inflexible. As a consequence, old age is seen as a part of life that has no value of its own. From this perspective, creativity and physical and psychological vigor uniformly decline, and older age is merely characterized by losses and degenerative processes. Corresponding stereotypes often prevail when demographic change is described by the media as a looming disaster, such as the “silver tsunami,” which is based on the assumption that the elderly will be a huge burden on the various systems of social security, especially the field of health care.

Such negative stereotypes are often supported by little individual or general knowledge about older people, their diversity, and the different situations they might find themselves in. The more somebody knows about aging and old age, the more negative stereotypes lose their influence, resulting in more positive attitudes. At the same time, many studies using versions of the facts on aging quiz show little knowledge about old age and older people in society. Unfortunately, medical professionals seem to be no exception.

This lack of knowledge, often correlated with ageist prejudice and behavior, could generate many disadvantages and problems for older patients. Health care is a particularly sensitive field for ageism as many negative stereotypes describe typical health traits or psychological traits of older people. If health-care professionals share an ageist culture, this leads to age discrimination with particularly poor outcomes, such as worse or false treatment compared to other age groups. Indeed, Robert Butler, who worked as a geriatrician, states that he first encountered ageism in medical school. At the time – in the 1960s – he was taught little about aging and also believes that there was a fundamental lack of knowledge on the subject of human aging in the medical school. He was even shocked by the language used in textbooks to refer to older people (Butler 2005). Since then, the awareness of the problem seems to have slightly improved, but studies have repeatedly shown that negative attitudes toward older people and little interest in their health problems or in geriatrics still prevail among health-care professionals. The same applies to medical students, the difference being that small interventions such as exchanges between students and older people acting as their mentors may have a positive effect (Bernard et al. 2003).

The consequences of medical professionals’ negative attitudes toward the elderly can be divided into three categories: direct harm, the denial of benefits, and lack of respect for the patient’s autonomy. Direct harm may be the result of abuse or aggressive behavior based on the perception of older people as being of lesser value or possessing negative traits. Such abuse may range from actual violence to humiliating behavior in nursing homes. For example, older people could be treated as objects, or their basic human dignity could be violated in a variety of situations (Nordenfelt 2009). If doctors perceived the elderly’s health problems as part of “normal” aging, their otherwise manageable diseases or symptoms could go untreated. An example is treatment of pain. The corresponding stereotype states that “Pain is a natural part of ageing”; thus, both doctors and patients may believe that not only can some types of pain not be treated but that the person suffering from them has to adapt and learn to live with chronic pain as well (Thielke et al. 2012). Denying patients treatments because stereotypes give the impression that they would not benefit from them, despite the fact that they clearly would, is a step toward rationing on the individual micro-level of the doctor-patient relationship. Such implicit rationing can also be performed consciously by giving lower priority to older patients in general when it comes to waiting times, health-care resources, or simply allocating less time for personal communication.

Finally, doctors may also disregard the autonomy of their older patients due to negative stereotypes and the resulting attitudes. Different ideas about older people may contribute to this: for instance, the assumption that older people do not understand new information and technological developments, that there is a uniform cognitive decline in old age, or that old age is some kind of second childhood. Doctors may then not make enough effort to explain treatment options and as a result cannot ensure the appropriate informed consent from older patients. In general, health-care professionals who believe that the cognitive abilities of their patients are diminished or who work with demented patients may be inclined not to respect their wishes, even if they are still able to express them. However, autonomy, in the sense of self-determination, may also be understood in degrees, and there may be many ways to communicate wishes and preferences :, including those for basic needs such as mobility and food, which still remain open to patients suffering from a progression in dementia. This may require time and encouragement. Therefore, health-care professionals should not only respect the autonomy of older patients, including those suffering from dementia, but also try to promote and increase their autonomy according to their individual situation and needs (Defanti et al. 2007).

In sum, ageism in health care may have a severe impact on the health and well-being of older people. The negative effects described above could lead to a general lack of trust in medical doctors, nurses, and health-care institutions. Not only could patients suffer from a lack of self-respect or value, but they may also forego their health needs altogether and decide not to seek medical help at all as a result of this mistrust or lack of confidence.

Age-Based Rationing

The same attitudes caused by negative stereotypes regarding old age and the elderly, which lead to implicit rationing and the denial of beneficial treatment on an individual level, also contribute to frequent political and public discussions about introducing “age-based rationing” in publicly funded health care. “Rationing” can be understood as withholding beneficial treatment. “Age-based rationing” uses chronological age as a criterion for denying patients who exceed that age a particular type of medical intervention. Critics see this as an expression of ageism, based on the implicit or sometimes explicit assumptions that all older people are in bad health or that they are less valuable members of society. Uniform age-based rationing can be hard to justify, especially if one considers the simple fact that age limits are quite arbitrary, seeing as health varies greatly among older people. But, for proponents of such rationing, it is even harder to argue why it should not simply be prohibited as age discrimination because it is in violation of the international legal standards mentioned above.

Nevertheless, suggestions of age-based rationing might appear timely and even founded on intergenerational justice considering demographic change as a presumed reason for ever rising health-care costs and older people as consuming an ever higher disproportionate part of health-care resources. For instance, Leonard Fleck argues that if spending on health-care services for older people continues on the same course in the USA, there will be a huge economic and political challenge due to aging baby boomers. He points out the example of an artificial heart device, which may generate costs of $105 billion. Even though he uses the argument that not all older people can benefit in the same way, he considers age-based rationing to be appropriate in this case (Fleck 2010). However, costs could be saved by other means, and there are better ways to set priorities than focusing solely on a patient’s age. In general, it is unclear how much demographic change contributes to rising health-care costs. This rise depends on many factors, as in Fleck’s own example regarding technological innovation, and the biggest part of a person’s consumption of healthcare resources occurs on average in the last year of life. These costs decrease with age such that an increase in life expectancy may reduce this cost factor in the health-care system (Seshamani and Gray 2004). The fact that we all grow older and potentially need more health-care resources in the latter days of our lives is not a fundamental problem of intergenerational justice, provided that future generations are not deprived of the same opportunities as a result of the behavior of current ones (e.g., financing their needs with excessive debt).

Obviously, the necessity of savings and the needs of older people as a cause of rising costs alone are not sufficient reasons to justify age-based rationing. Ethical arguments for the legitimacy of this criterion have to be put forward, but they are by no means immune to the criticism for being ageist. The main contributors of such arguments in the field of bioethics are Daniel Callahan, Norman Daniels, and John Harris. Callahan’s position may be most vulnerable to the criticism for being ageist for he argues that there is a “natural life-span” in which all experiences can be made that constitute a complete human life and that make sense for a particular individual. Beyond this “natural life-span,” which he sets at the biblical age of “threescore and ten” (70), new experiences or activities cannot offer anything of value to the person who has them or to others. This opinion obviously conforms to the idea that older people are merely a homogeneous group and that old age as a part of life has no particular value of its own, at least not beyond a certain age limit. Daniels and Harris have conceived different strategies that avoid such assumptions about older people. Daniels argues that older people themselves, who had to distribute resources throughout their lives, would be prudent to spend for health care rather in earlier stages of their lives and should thus favor age-based rationing in their own rational decisions. Harris calls the share of older people “fair innings,” which, he believes, justifies priority of younger people in at least some cases. For an overview of these positions, see Fleck (2010).

However, Harris is well aware of the problem of ageism and argues against implicit ageism based on quality-adjusted life-year assessments in the National Health Service in the UK. In general, using QALYs as a measure for the allocation of health-care resources among individuals leads younger people having priority due to the fact that they have more years of life expectancy to gain. Furthermore, their quality of life could also be evaluated as higher than older individuals who are considered to have chronic illnesses. An example that Harris refers to is a drug used for treating Alzheimer’s disease that is not financed by the NHS, even though this drug is not more expensive than others funded by the NHS. Harris highlights that the decision not to provide the drug is based neither on its cost nor on decisions made out of compassion as to who should have priority, but simply based on QALYs. He argues that this is ageist for the following reason: when the evaluation of the cost-effectiveness of this particular drug for this specific group of patients is measured against QALYs, it amounts to the value judgment that the higher life expectancy of these patients provided by the drug does not have enough value for society. In opposition of such considerations, and opposed to any general rationing based on chronological age for that matter, he formulates the principle of age indifference: “An individual’s entitlement to the concern, respect, and protection of the community does not vary with age or life expectancy or with their quality of life.” If this principle is not respected and people are discriminated according to their potential life expectancy, which could be gained, their genetic disposition for diseases, or their poor health, this is not only a violation of fundamental rights. It will also lead to the fear of being denied social support and a low sense of personal worth. This adds to the fatal consequences of ageism in health care (Harris 2005).

Antiaging Medicine And The Biology Of Aging

The desire to stop or reverse the effects of physical aging is at least as old as some of the oldest myths of humanity. Gilgamesh, the mythic king of ancient Babylon, was shocked by the death of his friend Enkidu and searched for eternal life and youth. Although his search was successful, he still was overcome by human weakness and the need for sleep. While he was asleep, a snake ate the herb promising rejuvenation. Gilgamesh thus had to resign to old age and mortality and went on accepting his fate. The current trend of antiaging medicine, however, contradicts the moral of the “Epic of Gilgamesh.” Many different kinds of interventions, ranging from cosmetic surgery to food supplements, serve to renew the promises of staying young and living longer.

From the perspective of ageism research, antiaging medicine fulfills the conditions of ageism and assists in achieving its very basic goal: to fight aging and its manifestation. There is a fine line between devaluing aging and discriminating the elderly. Aging and the appearance of old age have become something that must be prevented and is denied, insofar as it does in fact still occur. Physical aging is considered to be a disease in need of treatment, and older people have consequently come to be viewed as uniformly sick. Whoever has not given enough effort to appear younger or remain healthy bears the responsibility for not using preventive measures, not making prudent lifestyle choices, and failing to take advantage of the different medications on the list of antiaging doctors. Old age, as a phase of life, has become something of no value that should be replaced by a prolonged middle age. Negative attitudes toward aging, old age, and older people are promoted in society and subsequently internalized. Ageism is reproduced and reinforced.

Experts in biology of aging or biogerontology have repeatedly and sharply criticized the proponents of antiaging medicine, dubbing them “snake oil sellers” and the like. Biogerontologists deny the existence of any safe and effective intervention to influence aging. Nevertheless, they may be accused of willingly or unwillingly supporting and promoting ageism. For John Vincent, a social gerontologist from the UK, biogerontology is part of a wider antiaging movement and can be said to share at least some of the goals of antiaging medicine that qualify them as ageist. Vincent confirms that biogerontology comes from an ageist culture, reinforces ageist stereotypes, and implies that old age has no value of its own. According to him, the ageist approach of biogerontology is clearly expressed in its basic definitions of biological aging. From the perspective of these definitions, aging is an exclusively degenerative process that is accompanied by a permanent and constant decline, resulting in the loss of all kinds of functions. The challenges of population aging, however, can only be solved by creating a positive culture of old age and valuing later life and older people (Vincent 2006).

Medical Research

As in medical practice, negative stereotypes can result in many disadvantages for older people in the context of medical research as well. From a perspective of justice and fair subject selection in medical research, the main problem lies in the fact that older people are underrepresented in clinical trials. Sometimes the reason is simply an upper limit for the chronological age of participants in the inclusion criteria of the trial protocol. Such limits, which discriminate potential trial participants based on their age, could be founded on negative stereotypes such as low competence as in the inability to meet informed consent requirements. In addition, there may very well be a lack of effort to even pursue the inclusion of older people to improve the situation. If there is in fact an increase in the need for preventive, diagnostic, therapeutic, and rehabilitative interventions for older people, medical research into their healthcare needs is crucial (Hendricks and Cutler 2005).

Ageism And Global Health

Ageism has the potential to negatively affect the health and well-being of older people. Is this merely a problem of industrialized Western societies with their consumerist, youth-oriented culture and aging population? No, it is not for the following reasons: firstly, population aging has been a well-established global demographic trend for quite some time, an occurrence that is found in low-and middle-income countries as well. Life expectancy has been increasing around the globe, and fertility rates have been on the decline in most of the world’s regions. The problems regarding pensions, health care, and nursing care, which all industrialized countries are confronted with, are likely to be more severe in countries that lack the resources and the infrastructure to provide the corresponding social support. In addition, resources for families used to provide informal care may suffer as well.

Secondly, while perceiving a general rise in older age groups as a burden might increase with global population aging, negative stereotypes and the resulting negative behavior directed toward these groups are not limited to Western civilization. In her classical study on old age, Simone de Beauvoir demonstrated that negative stereotypes about old age and older people are found across historical and contemporary cultures. In traditional societies, treatment of older people ranges from reverence to generational conflict and extends as far as killing incapacitated elderly people. Even the societies that usually venerate their elders in recognition of their experience and wisdom often lose their respect once the effects of cognitive decline manifest themselves.


The moral judgment that a person or institution is ageist should be made with caution and appropriate evidence, as it is associated with strong accusations. It has the potential to stop any discussion because it implies that there has been a violation of fundamental norms such as equality, human dignity, and basic human rights. Moral indignation could be useful in discovering ethical problems and subsequently finding an appropriate solution for them, but it does not always make for the better argument. Such moral indignation is reflected in the attitude of some comments that perceive any negative evaluation of aspects of aging or old age as ageist. However, in the case of some of these aspects, such as biogerontological perspectives on senescence, this view may very well be justified, but their negativity must be thoroughly examined from an ethical perspective. Some social gerontologists are also wary of the consequences of an overly positive evaluation of old age, especially when it comes to the so-called fourth age of 80 and older (Dannefer and Phillipson 2010).

Ageism is nevertheless a real threat to not only the rights but also the health and well-being of older people across the globe. Negative stereotypes and the perception of population aging as a potential social and economic disaster may exacerbate this threat. Beyond low-quality medical care and age-based rationing, attitudes like those of Richard D. Lamm, a former governor of Colorado, may become more widespread. Lamm stated that sick old people “should die and get out of the way” (Bytheway 2005). Similar opinions may be deeply rooted in traditional and modern stereotypes. They are reflected in concerns about liberalization policies for active euthanasia and physician-assisted suicide. Indeed, pressure on older people to forego care and maybe even end their lives has to be carefully considered in order to prevent abuse of more liberal options for self-determination at the end of life, as Lamm’s statement proves. Therefore, countering ageism by educating the public and future medical professionals in particular about aging and older people would be a step in the right direction, one that should be taken on a global level. Viewing older people as “us” instead of “them” could be helpful, seeing as we are all getting older.

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