A caregiver from the dominant U.S. culture and a patient from a very different culture can resolve cross‐cultural disputes about treatment, not by compromising important values, but by focusing on the patient's goals.

A caregiver from the dominant U.S. culture and a patient from a very different culture can resolve cross‐cultural disputes about treatment, not by compromising important values, but by focusing on the patient's goals.

Although ethics consultation is offered as a clinical service in most hospitals in the United States, few valid and practical tools are available to evaluate, ensure, and improve ethics consultation quality. The quality of ethics consultation is important because poor quality ethics consultation can result in ethically inappropriate outcomes for patients, other stakeholders, or the health care system. To promote accountability for the quality of ethics consultation, we developed the Ethics Consultation Quality Assessment Tool. ECQAT enables raters to assess the (...) quality of ethics consultations based on the written record. Through rigorous development and preliminary testing, we identified key elements of a quality ethics consultation, established scoring criteria, developed training guidelines, and designed a holistic assessment process. This article describes the development of the ECQAT,.. (shrink)

Context: Although ethics consultation is commonplace in United States (U.S.) hospitals, descriptive data about this health service are lacking. Objective: To describe the prevalence, practitioners, and processes of ethics consultation in U.S. hospitals. Design: A 56-item phone or questionnaire survey of the "best informant" within each hospital. Participants: Random sample of 600 U.S. general hospitals, stratified by bed size. Results: The response rate was 87.4%. Ethics consultation services (ECSs) were found in 81% of all general hospitals in the U.S., and (...) in 100% of hospitals with more than 400 beds. The median number of consults performed by ECSs in the year prior to survey was 3. Most individuals performing ethics consultation were physicians (34%), nurses (31%), social workers (11%), or chaplains (10%). Only 41% had formal supervised training in ethics consultation. Consultation practices varied widely both within and between ECSs. For example, 65% of ECSs always made recommendations, whereas 6% never did. These findings highlight a need to clarify standards for ethics consultation practices. (shrink)

Empirical research pertaining to cardiopulmonary resuscitation (CPR), clinician behaviors related to do-not-resuscitate (DNR) orders and substituted judgment suggests potential contributions to medical ethics. Research quantifying the likelihood of surviving CPR points to the need for further philosophical analysis of the limitations of the patient autonomy in decision making, the nature and definition of medical futility, and the relationship between futility and professional standards. Research on DNR orders has identified barriers to the goal of patient involvement in these life and death (...) discussions. The initial data on surrogate decision making also points to the need for a reexamination of the moral basis for substituted judgment, the moral authority of proxy decision making and the second-order status of the best interests standard. These examples of empirical research suggest that an interplay between empirical research, ethical analysis and policy development may represent a new form of interdisciplinary scholarship to improve clinical medicine. (shrink)

The Ethics Consultation Quality Assessment Tool (ECQAT) establishes standards by which the quality of ethics consultation records (ECRs) can be assessed. These standards relate to the ethics question, consultation-specific information, ethical analysis, and recommendations and/or conclusions, and result in a score associated with one of four levels of ethics consultation quality. For the ECQAT to be useful in assessing and improving the quality of healthcare ethics consultations, individuals who rate the quality of ECRs need to be able to reliably use (...) the tool.We developed a short course to train ethics consultants in using the ECQAT, and evaluated whether the participants (1) achieved an acceptable level of calibration in matching expert-established quality scores for a set of ethics consultations, and (2) were satisfied with the course. We recruited 28 ethics consultants to participate in a virtual, six-session course. At each session participants and faculty reviewed, rated, and discussed one to two ECRs. The participants’ calibration in matching expert-established quality scores improved with repeated exposure at all levels of ethics consultation quality. Participants were generally more accurate when assessing consultation quality at the dichotomous level of “acceptable” (scores of three or four) versus “unacceptable” (scores of one or two) than they were with a more specific score. Participants had higher rates of accuracy with the extreme ratings of “strong” (level four) or “poor” (level one). Although participants were highly satisfied with the course, only a minority of participants achieved the prespecified acceptable level of calibration (that is, 80 percent or greater accuracy between their score and expert-established scores). These results suggest that ECQAT training may require more sessions or need modification in the protocol to achieve higher reliability in scoring. Such trainings are an important next step in ensuring that the ECQAT is a tool that can be used to promote improvement in ethics consultation quality. (shrink)

To promote ethical practices, healthcare managers must understand the ethical challenges encountered by key stakeholders. To characterize ethical challenges in Veterans Administration (VA) facilities from the perspectives of managers, clinicians, patients, and ethics consultants. We conducted focus groups with patients (n = 32) and managers (n = 38); semi-structured interviews with managers (n = 31), clinicians (n = 55), and ethics committee chairpersons (n = 21). Data were analyzed using content analysis. Managers reported that the greatest ethical challenge was fairly (...) distributing resources across programs and services, whereas clinicians identified the effect of resource constraints on patient care. Ethics committee chairpersons identified end-of-life care as the greatest ethical challenge, whereas patients identified obtaining fair, respectful, and caring treatment. Perspectives on ethical challenges varied depending on the respondent's role. Understanding these differences can help managers take practical steps to address these challenges. Further, ethics committees seemingly, are not addressing the range of ethical challenges within their institutions. (shrink)

This paper proposes an ethical framework for rationing publicly financed health care. We begin by classifying alternative rationing criteria according to their ethical basis. We then examine the ethical arguments for four rationing criteria. These alternatives include rationing high technology services, non-basic services, services to patients who receive the least medical benefit, and services that are not equally available to all. We submit that a just health care system will not limit basic health care to persons unable to pay for (...) it. Furthermore, justice in health care requires limiting publicly-financed non-basic health care, striving for equality in access to basic health care, and relying on medical benefit to ration non-basic health care. (shrink)

Context: Although ethics consultation is commonplace in United States hospitals, descriptive data about this health service are lacking. Objective: To describe the prevalence, practitioners, and processes of ethics consultation in U.S. hospitals. Design: A 56-item phone or questionnaire survey of the “best informant” within each hospital. Participants: Random sample of 600 U.S. general hospitals, stratified by bed size. Results: The response rate was 87.4%. Ethics consultation services were found in 81% of all general hospitals in the U.S., and in 100% (...) of hospitals with more than 400 beds. The median number of consults performed by ECSs in the year prior to survey was 3. Most individuals performing ethics consultation were physicians, nurses, social workers, or chaplains. Only 41% had formal supervised training in ethics consultation. Consultation practices varied widely both within and between ECSs. For example, 65% of ECSs always made recommendations, whereas 6% never did. These findings highlight a need to clarify standards for ethics consultation practices. (shrink)

Clinical ethics consultation is largely outside the scope of regulation and oversight, despite its importance. For decades, the bioethics community has been unable to reach a consensus on whether there should be accountability in this work, as there is for other clinical activities that influence the care of patients. The American Society for Bioethics and Humanities, the primary society of bioethicists and scholars in the medical humanities and the organizational home for individuals who perform CEC in the United States, has (...) initiated a two‐step quality attestation process as a means to assess clinical ethics consultants and help identify individuals who are qualified to perform this role. This article describes the process. (shrink)

To promote ethical practices, healthcare managers must understand the ethical challenges encountered by key stakeholders. To characterize ethical challenges in Veterans Administration facilities from the perspectives of managers, clinicians, patients, and ethics consultants. We conducted focus groups with patients and managers ; semi-structured interviews with managers, clinicians, and ethics committee chairpersons. Data were analyzed using content analysis. Managers reported that the greatest ethical challenge was fairly distributing resources across programs and services, whereas clinicians identified the effect of resource constraints on (...) patient care. Ethics committee chairpersons identified end-of-life care as the greatest ethical challenge, whereas patients identified obtaining fair, respectful, and caring treatment. Perspectives on ethical challenges varied depending on the respondent's role. Understanding these differences can help managers take practical steps to address these challenges. Further, ethics committees seemingly, are not addressing the range of ethical challenges within their institutions. (shrink)

Although clinical ethics consultation is a high-stakes endeavor with an increasing prominence in health care systems, progress in developing standards for quality is challenging. In this article, we describe the results of a pilot project utilizing portfolios as an evaluation tool. We found that this approach is feasible and resulted in a reasonably wide distribution of scores among the 23 submitted portfolios that we evaluated. We discuss limitations and implications of these results, and suggest that this is a significant step (...) on the pathway to an eventual certification process for clinical ethics consultants. (shrink)

Effective Altruism is a popular social movement that encourages individuals to donate to organizations that effectively address humanity’s most severe poverty. However, because Effective Altruists are committed to doing the most good in the most effective ways, they often argue that it is wrong to help those nearest to you. In this paper, I target a major subset of Effective Altruists who consider it a moral obligation to do the most good possible. Call these Obligation-Oriented Effective Altruists (OOEAs), and their (...) movement Obligation-Oriented Effective Altruism (OOEA). I argue that insofar as this variety of OOEA seems to commit us to refrain from helping the people right in front of us, there is something intuitively wrong about it. In response, I introduce an alternative model that embraces partiality: Mutual Aid. Mutual Aid is a network of community members, usually from the same geographical region, who share a commitment to offer, receive, and exchange material goods, wealth, and social support. I recommend Mutual Aid as a liberatory model, which—through empathy, solidarity, and care—mobilizes community building and provides a catalyst for community advocacy. As such, we should resist the claims of OOEAs that partially distributing our funds to people or causes we care about is morally wrong or even less than ideal. We do not have a moral obligation to use our funds “effectively;” rather, we have a broader obligation to address human suffering, and Mutual Aid is one moral alternative for discharging this duty. (shrink)

In this paper we argue that moral deference is prima facie obligatory in cases in which the testifier is a member of a marginalized social group that the receiver is not and testifies about their marginalized experience. We distinguish between two types of deference: epistemic deference, which refers to believing p in virtue of trusting the testifier, and actional deference, which involves acting appropriately in response to the testimony given. The prima facie duty we propose applies to both epistemic and (...) actional deference, though defeaters may quash either or both obligations. Even if one fails to epistemically defer to the marginalized testifier, we argue that they may still be ethically obligated to act in accordance with their testimony. (shrink)

The use of deception in medical care is highly suspect in this country. Yet there is one condition for which deception is often used as a diagnostic tool. Nonepileptic seizures, a psychiatric condition in which emotional or psychological conflicts manifest themselves unconsciously through bodily symptoms, are currently diagnosed by a procedure called “provocative saline infusion.” The test is fundamentally deceptive, requiring the physician to intentionally and directly lie to the patient, causing the patient to believe that the administered solution caused (...) his seizures. Without such deception, the test might be useless. (shrink)

From 1956, when the complex ultrastructure of meiotic chromosomes was discovered, 1 until 1985, when the isolation of meiotic chromosome cores was reported, knowledge of the molecular structure of the meiotic chromosome was at best a dream. The dissection of meiotic chromosome structures has become a realistic challenge through the arrival of isolated symptonemal complexes (SCs), monoclonal and polyclonal antibodies against SCs, the possibility for screening expression libraries for genes that encode SC proteins, the isolation of SC‐associated DNA, and the (...) development of techniques for the in situ recognition of DNA sequences in the context of the meiotic chromosome structure. (shrink)

Much ink has been spilled on the pros and cons of U.S. president Barack Obama's decision not to strike the regime of Syrian president Bashar al-Assad after that regime launched a deadly chemical weapons attack in 2013. Often missing from those debates, however, are the perspectives of Syrians themselves. While not all Syrians oppose Assad, and not all opponents endorsed intervention, many Syrian oppositionists resolutely called for Obama to uphold his “red line” militarily. As part of the roundtable “The Ethics (...) of Limited Strikes,” this essay analyzes diverse expressions of such opinion and finds that they highlight three dimensions of the ethical case for limited strikes against Assad. First, they remind us that the ethical context of the red line question was many Syrians’ sense of abandonment by the international community. Second, they emphasize the ethical stakes of the limited strikes; namely an opportunity to hold the Syrian regime accountable, weaken it from within, and thus change the equation of the war. Third, they make sense of the ethical consequences of the nonintervention outcome, and especially its effect in deepening civilians’ despair, accelerating extremism, and convincing Assad and his allies that they could kill with impunity. These views controvert both legalistic arguments precluding military intervention and assumptions that U.S. intervention is always imperialist and warmongering. In this case, consideration of the case for military intervention from the viewpoint of those on whose behalf the intervention would have taken place challenges us to think deeply about circumstances in which limited strikes might be not only ethically justified but also imperative. (shrink)

While it is largely agreed upon that solidarity is a kind of unity among persons, this agreement is short-lived – for if solidarity involves unity, what kind of unity is this? That is, does solidarity coalesce around shared identity or simply fellow-feeling? Shared action or fate? Or is solidarity merely a matter of commitment to a particular cause to achieve certain ends? Below, I look to examples of Mutual Aid to reject a piece-meal model of solidarity (where solidarity is this (...) but not that) in favor of a more pluralistic account. The notion of solidarity need not be constrained, all or nothing, by a specific strain of interpretation. Instead, we should recognize that solidarity is a matter of variety and degree. (shrink)

Background: The traditional approach to resolving ethics concerns may not address underlying organisational issues involved in the evolution of these concerns. This represents a missed opportunity to improve quality of care “upstream”. The purpose of this study was to understand better which organisational issues may contribute to ethics concerns. Methods: Directed content analysis was used to review ethics consultation notes from an academic children’s hospital from 1996 to 2006 (N = 71). The analysis utilised 18 categories of organisational issues derived (...) and modified from published quality improvement protocols. Results: Organisational issues were identified in 68 of the 71 (96%) ethics consult notes across a range of patient settings and reasons for consultation. Thirteen of the 18 categories of organisational issues were identified and there was a median of two organisational issues per consult note. The most frequently identified organisational issues were informal organisational culture (eg, collective practices and approaches to situations with ethical dimensions that are not guided by policy), policies and procedures (eg, staff knows policy and/or procedural guidelines for an ethical concern but do not follow it) and communication (eg, communication about critical information, orders, or hand-offs repeatedly does not occur among services). Conclusions: Organisational issues contribute to ethical concerns that result in clinical ethics consults. Identifying and addressing organisational issues such as informal culture and communication may help decrease the recurrence of future similar ethics concerns. (shrink)

Part III: Now presents solely, clinical ethics. --.

Filmmaking is one of the most complexly layered forms of artistic production. It is a deeply interactive process, socially, culturally, and technologically. Yet the bulk of popular and academic discussion of filmmaking continues to attribute creative authorship of films to directors. Texts refer to “a Scorsese film,” not a film by “Scorsese et al.” We argue that this kind of attribution of sole creative responsibility to film directors is a misapprehension of filmmaking processes, based in part on dubious individualist assumptions (...) about creative minds. Such a misapprehension is effacing the public value that a more inclusive and accurate understanding of filmmaking offers. By “public value” we mean the potential to enhance social and cultural well-being, particularly in working lives and collaborative undertakings in the screen industries. Better understanding of the systemic and social nature of creativity in filmmaking can potentially help in democratising aesthetics, which we consider a clear public good. (shrink)

How does emigration affect access to and struggles for power in sending states? For competing groups in the homeland, emigration presents a contradiction: demographic losses but possible economic gains. Wins and losses from this trade-off evolve with shifts in who migrates, to where, and when. I illustrate these relationships in the case of Lebanon since 1860, focusing on the balance of power among sectarian communities. The country’s first migratory wave concentrated material benefits and population deficits in the Christian community. It (...) also encouraged subsequent emigration that, over time, involved more Muslim Lebanese, as well. Such broadening diffused the profits of labor abroad. Due to changes in destinations and historical circumstances, however, many of these migrants remained more connected to their homeland. This aided social mobility for their communities without sapping resident strength. Outmigration thereby helped redistribute human and material resources among sects, and hence created the demographic and material foundations of the competition for power. (shrink)

J.L. Austin argues that ordinary language should be used to identify when it is appropriate or inappropriate to make, accept, or reject knowledge claims. I criticize Austin’s account: In our ordinary life, we often accept justifications rooted in racism, sexism, ableism, and classism as reasons to dismiss knowledge claims or challenges, despite the fact such reasons are not good reasons. Austin’s Ordinary Language Epistemology (OLE) classifies the discounting of knowledge claims in classic cases of epistemic injustice as legitimate ordinary maneuvers. (...) I provide recommendations for revision of OLE and offer a means of distinguishing between dismissals in cases of epistemic injustice and their legitimate counterparts. (shrink)

Why do some national movements use violent protest and others nonviolent protest? Wendy Pearlman shows that much of the answer lies inside movements themselves. Nonviolent protest requires coordination and restraint, which only a cohesive movement can provide. When, by contrast, a movement is fragmented, factional competition generates new incentives for violence and authority structures are too weak to constrain escalation. Pearlman reveals these patterns across one hundred years in the Palestinian national movement, with comparisons to South Africa and (...) Northern Ireland. To those who ask why there is no Palestinian Gandhi, Pearlman demonstrates that nonviolence is not simply a matter of leadership. Nor is violence attributable only to religion, emotions or stark instrumentality. Instead, a movement's organizational structure mediates the strategies that it employs. By taking readers on a journey from civil disobedience to suicide bombings, this book offers fresh insight into the dynamics of conflict and mobilization. (shrink)

Philosophical discussions of film are divided in their treatment of the subject rhythm in film editing. Analytic philosophers tend to avoid discussion of it, while continental philosophers give it expansive consideration. This chapter aims to bridge these two traditions by analytically articulating what rhythm is, how it is shaped, and what it is for, while still respecting that it is, in both a film editor’s and an audience’s experience, a felt phenomenon. In order to do this, consideration is given both (...) to the firsthand perspective of experienced editors and the articulations of philosophers. This synthesis of practice and theory reveals how an understanding of the editor’s embodied cognitions, affective responses, and expert actions in shaping rhythm can shed light on rhythm’s effect on audiences. The chapter finds that rhythm in film editing is time, energy, and movement shaped by timing, pacing, and trajectory phrasing for the purpose of creating cycles of tension and release. (shrink)

As biomedical citizen science initiatives become more prevalent, the unique ethical issues that they raise are attracting policy attention. One issue identified as a significant concern is the ethical oversight of bottom-up biomedical citizen science projects that are designed and executed primarily or solely by members of the public. That is because the federal rules that require ethical oversight of research by institutional review boards generally do not apply to such projects, creating what has been called an ethics gap. -/- (...) Working to close this gap, practitioners and scholars have considered new mechanisms of ethical oversight for biomedical citizen science. To date, however, participants’ attitudes about ethics and oversight preferences have not been systematically examined. This information is useful to efforts to develop ethical oversight mechanisms because it provides a basis for evaluating the likely effectiveness of specific features of such mechanisms and their acceptability from the perspective of biomedical citizen scientists. -/- Here, we report data from qualitative interviews with 35 stakeholders in bottom-up biomedical citizen science about their general ethics attitudes and preferences regarding ethical oversight. Interviewees described ten ethical priorities and endorsed oversight mechanisms that are voluntary, community-driven, and offer guidance. Conversely, interviewees rejected mechanisms that are mandatory, hierarchical, and inflexible. Applying these findings, we conclude that expert consultation and community review models appear to align well with ethical priorities and oversight preferences of many biomedical citizen scientists, although local conditions should guide the development and use of mechanisms in specific communities. (shrink)

The speed and scale of the COVID‐19 pandemic has highlighted the limits of current health systems and the potential promise of non‐establishment research such as “DIY” research. We consider one example of how DIY research is responding to the pandemic, discuss the challenges faced by DIY research more generally, and suggest that a “trust architecture” should be developed now to contribute to successful future DIY efforts.

In lieu of an abstract, here is a brief excerpt of the content:Editors’ NoteJames M. DuBois, Ana S. Iltis, and Heidi A. WalshFrom childhood, David Slakter had undergone tests and invasive procedures to monitor his nephritis. It was not a surprise when in 2015, doctors told him he needed a kidney transplant. The wife of a childhood friend was a close match and gave him one of her kidneys. Before his transplant, aerobic exercise was difficult; a few months after transplant, (...) Slakter could ride his bike, hike, and work out with a personal trainer. He no longer had to weigh food or gauge his potassium consumption, a concern for people with kidney failure. For Slakter, “life post-transplant has been a significant improvement.”Individuals or family members of those who have received an organ transplant from a living or deceased donor share their stories in this issue of Narrative Inquiry in Bioethics. The symposium is titled “Receiving the Gift of Life: Stories from Organ Transplant Recipients.” Organ transplantation can extend an individual’s life by decades. It can also greatly improve an individual’s quality of life, as was Slakter’s experience. At the same time, organ transplantation is expensive and stressful. Recipients can experience complications, including organ rejection, and there are few appealing alternatives.After her heart transplant, author Leilani R. Graham required four open-heart surgeries, ECMO, and an intra-aortic balloon pump. She experienced delirium, necrotizing pneumonia, and severe muscular atrophy that required her to re-learn how to walk. She struggled with weight gain, explosive mood swings, hair loss, and was terrified that her body would reject the new heart. For Graham, “[Transplant] was not the miracle [she] was hoping for.” Graham says she felt unprepared for and inadequately informed about what to expect after her transplant, which left her “battered, beaten, and bruised” with a 12-inch line from neck to navel and “bullet holes” up and down her torso from the chest tubes. When reflecting on her experience post-transplant, Graham says, “It wasn’t the physical trauma that hurt the most. It was that no one seemed surprised [by the aftereffects of transplant].” Seemingly no one, that is except Graham, who calls on transplant providers to “prioritize empathy.”The symposium editors are Jason T. Eberl and Tristan McIntosh. Three commentary articles, written by Macey Leigh Levan, Heather Lannon, and Vidya A. Fleetwood, Roslyn B. Mannon & Krista L. Lentine, offer important insights into the authors’ stories. The editors thank Mid-America Transplant, the UCSF Lung Transplant Program, Donor Connect, William L. Freeman, MD, MPH, MJIL, CIP, Janet Monk, and the individuals who gave anonymous donations to support the publication of this issue, an open-access VOICES edition of the symposium, and accompanying teaching guides.The research article in this issue, “‘A Shell of My Former Self’: Using Figurative Language to Promote Communication about Patient Suffering,” was written by Tyler Tate, Elizabeth Stein, and Robert A. Pearlman. The relief of suffering is a primary goal of medicine. However, the authors note that clinicians often miss or ignore suffering because they focus on the causes rather than the experience of suffering, or the subjective nature of suffering makes it difficult to discuss. The authors believe that “the key to communicating about suffering lies in finding [End Page vii] the right kind of words to describe the experience” and say that figurative language offers a promising approach. In their research, the authors performed qualitative analysis on 52 works of literature and identified 254 excerpts of figurative language with themes of non-physical or psychological suffering. The authors found 13 salient themes: brokenness, diminishment, disorientation, drowning, emptiness, imprisonment, battle, darkness, isolation, invisibility, lifelessness, punishment, and torture. The authors reiterate that developing a shared language of suffering could foster a therapeutic patient-clinician relationship and improve clinicians’ ability to recognize and address a patient’s experience of suffering.María Susana Ciruzzi wrote the first of two case studies included in this issue. “The Sword of King Solomon” addresses a tragic and difficult subject—how to navigate the situation posed by conjoined twins when “any decision will produce damage and suffering.” The case involves two infant male patients born at 37 weeks gestation as omphalo-ischiopagus conjoined twins... (shrink)

Marie was 15 when her abdominal pain began. After two years of negative work-ups, countless visits to gastroenterologists, and over 70 days of high school missed, she found herself readmitted to the hospital. “Refractory abdominal pain” was her ostensible diagnosis; “troubled teen” who was “going to be difficult” was embedded in the emergency department’s sign-out. When the medical team arrived to meet Marie, she was huddled in the corner of her hospital bed, silent and withdrawn. Her intern noted the numerous (...) scars cutting across her forearms as she felt for her radial pulses. Marie squirmed in pain when the intern palpated her abdomen.The ED’s work-up had been negative for abdominal pathology. When the... (shrink)

Despite increasing evidence that the traditional lecture is inefficient for student learning, such methods remain the central paradigm for teaching logic. In this paper, I identify the deficits of the lecture model and outline the many benefits of flipping the logic classroom—namely that students can absorb information at their own pace, freeing classroom time for active learn- ing activities, and allowing the students to come prepared to actively engage in deeper levels of learning. I provide advice for curricular change from (...) the traditional model, and guidance for flipped classroom implementation. I also offer suggestions for the best use of newly available class time, and advice for keeping students accountable for learning the information prior to class. Last, I consider common challenges with the flipped classroom model. I acknowledge possible obstacles to flipping the undergraduate logic course and address these challenges with potential solutions. (shrink)

Cutting Rhythms is about rhythm in film editing. It breaks down the issue of rhythm in an accessible way that allows filmmakers to apply the principles to their own work and film scholars access to creative practice principles. This book offers possibilities rather than prescriptions. It presents questions editors or filmmakers can ask themselves about their work, or that scholars can pose in the analysis or evaluations of work.