By Kai Tang
Introduction
The ethical and practical implications of assisted dying have been hotly debated topics across the world for the last forty years. The recently introduced Voluntary Assisted Dying Bill 2023 (ACT) has been championed as the most progressive instrument of its kind in Australia, serving as the next step in the nation’s long journey towards nationwide legalisation of medically assisted dying. Whilst this new legislative regime promises additional freedoms for those who are terminally-ill, several advocacy groups have expressed concern regarding whether these freedoms come at the cost of safeguards designed to protect vulnerable individuals from exploitation. This article seeks to provide context to this debate and explore the weight of arguments levied against the new bill.
The History of Assisted Dying
The Oxford English Dictionary defines ‘euthanasia’ as the ‘act of inducing a gentle and easy death’ [1]. Medically assisted dying refers to voluntary euthanasia employed in a medical context with the aim of reducing suffering for terminally ill patients. Such processes may be passive, such as withdrawal of life-supporting equipment, or active, such as the administration of a lethal substance to cause death, at the request of the patient.
The practice of euthanasia has been conceptually bound to the practice of medicine since antiquity. The first-century writer Valerius Maximus was amongst the first to detail the existence of such practices [2]. During his travels to the island of Kos, Valerius witnessed an elderly stateswoman address her fellow citizens in a brilliant oration regarding her decision to end her own life by way of poison [3]. Some 400 years prior, this island would coincidentally serve as the birthplace of Hippocrates, who strictly forbade his students from administering poisons to their patients or advising upon such matters [4]. Aided by the dominant cultural influence of Christianity, Hippocrates’ position would retain its eminence in the heart western medicine for millennia. Consequently, the topic of assisted dying remained taboo for scholarly debate even until the 21st century [5].
As the years passed, individual physicians would silently and privately contemplate this difficult ethical issue. In a treatise examining medical ethics and theology, seventeenth-century surgeon Michael Boudewijns lamented how physicians would frequently encounter patients who could no longer bear the pain and beg for their lives to be shortened, advising his colleagues to galvanise their hearts against these requests [6]. Those who respected their patients’ wishes did so in secrecy, fearing prosecution, imprisonment, and capital punishment.
Only within the last forty years has this narrative seen any change. In 1984, the Dutch Supreme Court ruled in favour of Dr. Schoonheim, who having administered a lethal morphine injection at the request of his 95-year-old patient, raised the defence of ‘noodtoestand’ (emergency) against the charge of mercy killing [7]. In their judgement, the court clarified the scope and operation of the defence by balancing the conflicting duties of the doctor to abide by the law and render assistance to their patient, ruling that the latter would prevail in the context of medically assisted dying provided the patient’s autonomy is sufficiently protected [8]. Consequently, the Netherlands became the world’s first jurisdiction to bestow legal sanction upon the practice of medically assisted dying, with Schoonheim sounding the starting pistol for a worldwide push towards legalisation. Today, assisted dying schemes are available in nine countries, allowing thousands of people to approach the end of their lives with dignity [9].
What is Voluntary Assisted Dying?
The term Voluntary Assisted Dying (‘VAD’) is used to describe the form of active euthanasia available to terminally ill individuals enabled under Australian legislative frameworks. The term encompasses the process from the patient’s first request for assisted dying to the administrative processes following their death, and should rightfully be distinguished from foreign assisted dying programs which involve substantially different procedures and eligibility criteria. However, many legislated assisted dying schemes operate according to the same core principles.
For example, the Dutch voluntary euthanasia/assisted suicide (VE/AS) legislative scheme functions as an protection against criminal liability under the Dutch Penal Code, reflecting its origins in criminal law [10]. These protective provisions were introduced into the Dutch Penal Code through Termination of Life on Request and Assisted Suicide (Review Procedure) Act 2002 (Netherlands) (‘Review Procedures Act’), and lists a series of ‘Due Care Requirements’ that doctors must follow to avoid prosecution:
“(i) The patient's request to die must be voluntary;
(ii) the request is well-considered;
(iii) the request is durable and persistent;
(iv) the patient's pain is unbearable with no prospect of improvement;
(v) a second doctor must be consulted; and
(vi) euthanasia or assisted suicide is performed with due medical care.” [11]
Reflections of these core principles have been identified in assisted dying legislation from jurisdictions across the world, arising both independently of or taking inspiration from the Review Procedures Act [12]. In Australia, these principles have been adopted into the colloquially-termed ‘Australian model’ for assisted dying, which involves:
“Strict eligibility criteria, including that a person must be suffering unbearably from a terminal illness, disease or condition;
thorough request process: three requests, including one in writing, with accessibility options, witnessed by independent witnesses;
provision of support and information through a government-run Care Navigator Service and pharmacy service;
two health professionals, who meet training and eligibility requirements to independently assess a person’s eligibility, at least one of whom is responsible for ensuring the person is informed and supported regarding all of their end-of-life and care options;
strict requirements for prescription, management and administration of a VAD substance with criminal offences for mismanagement;
health professionals and health services may object to being actively involved in facilitating VAD, as long as they do not hinder access; and
an independent oversight body monitors compliance, records data, and exercises other oversight functions.” [13]
All VAD frameworks currently exist as some variation of this model, owing to Australia’s long and tumultuous history in attempting to legalise assisted dying over the last 25 years. To understand why VAD exists in its current form, we must first examine the history of VAD in Australia.
History of VAD in Australia
The global community’s first foray into establishing a statutory VAD program was pioneered by the Northern Territory in 1995, with the passage of the Rights of the Terminally Ill Act 1995 (NT). This act permitted terminally ill patients experiencing unacceptable degrees of suffering to request assistance from their medical practitioner to end their own lives [14]. Despite public opinion polls showing significant support for VAD at the time, the conservative administration became horrified at this development [15]. In response, the Euthanasia Laws Act 1997 (Cth) was passed, which functionally removed the Territories’ power to legislate in respect to euthanasia [16]. During the 9 months where assisted dying was legalised in the NT, 7 individuals accessed the scheme and 4 people died under the act; all were terminally ill and suffering from the latter stages of metastatic cancer [17].
Despite repeated and persistent attempts to legalise VAD, no Australian jurisdiction was able to successfully establish a legislative scheme until the passage of the Voluntary Assisted Dying Act 2017 (Vic) (‘Victorian Act’) by the Victorian Government. The Victorian Act was developed with the vision of establishing a ‘safe and compassionate framework’ to provide those suffering from terminal illnesses to ‘choose the timing and manner of their deaths’ [18]. The scheme became operational in June 2019, and since then 912 Victorians have been allowed to die in this dignified manner [19].
However, the establishment of this framework was not without controversy. In the leadup to the development of the Victorian VAD Bill, the Australian Medical Association issued a position statement opposing the proposed legislation, stating that doctors ‘should not be involved in interventions that have as their primary intention the ending of a person’s life’ [20]. Additional safety concerns regarding potential abuse of vulnerable individuals were raised during the public consultation process [21]. Despite these concerns, no instances of non-compliance regarding patient eligibility have ever been identified [22]. The Victorian VAD scheme is widely regarded as safe, effective and successful, prompting many other Australian jurisdictions to enact similar provisions legalising VAD.
Following Victoria, Western Australia was first to develop its own VAD scheme, passing the Voluntary Assisted Dying Act 2019 (WA) [23]. Tasmania, South Australia, Queensland and most recently New South Wales followed suit, each gradually enacting more progressive provisions [24]. Public discourse in each state was inundated by personal experiences of those who had witnessed loved ones endure brutal suffering at the end of their lives. This overwhelming public support served as the main driving force behind a wave of legalisation efforts. Currently, all Australian states have operating VAD frameworks.
In 2022, the Federal Government passed the Restoring Territory Rights Act 2022 (Cth), which served to repeal the Euthanasia Laws Act 1997 (Cth). For the first time in 25 years, Territorians were free to decide for themselves whether to establish a VAD scheme. Following this, the ACT was the first to develop a legislative instrument providing for VAD, which is expected to be passed into law later this year [25]. The NT Government has recently concluded community consultations to determine the feasibility of a VAD bill, and the expert advisory panel responsible for collating the gathered information is expected to provide its report by July 2024 [26]. It is currently uncertain whether the NT will align with other Australian jurisdictions and re-establish its VAD framework.
Procedures for Accessing VAD
Slight variations exist in the administrative processes of each VAD scheme in Australia, but all frameworks operate under similar principles, seeking to support and respect terminally-ill individuals in relation to their end-of-life choices whilst placing their wellbeing and safety as the paramount priority and consideration [27].
As a general rule, all Australian VAD procedures involve the following steps:
1. First request
In all Australian States, the VAD procedure formally starts when a patient makes their first request to a medical practitioner. Such a request must be voluntary, autonomous and made unambiguously with the intention of accessing VAD [28].
The context in which this discussion takes place is strictly regulated by each state. In Victoria and South Australia, all healthcare workers are strictly prohibited from initiating conversations substantially relating to VAD. In all other states, registered medical practitioners can discuss VAD in the context of providing comprehensive information about treatment and palliative care options [29]. In some states, other registered health practitioners may also initiate such discussions, provided they also advise the patient to discuss this with a registered medical practitioner [30].
2. First Assessment
Upon receiving a patient’s first request, a medical practitioner may choose to accept or refuse to assist the patient in accessing VAD. If the medical practitioner chooses to accept the request, they become the patient’s ‘Coordinating Practitioner’ (although specific terminology may differ in some states) [31]. If the practitioner chooses to refuse the request, they may do so upon one of two grounds;
a. The practitioner is not sufficiently qualified to serve as the coordinating practitioner.
Many jurisdictions have specific qualification and training requirements for medical practitioners seeking to facilitate the VAD process. All states currently require interested medical practitioners to undergo approved VAD training, and some additionally require practitioners to possess a certain number of years’ work experience post specialisation and/or expertise relating to the condition(s) the patient may be suffering from [32].
b. The practitioner conscientiously objects to participating in VAD.
In most states, the practitioner must refer the patient to another healthcare provider who they believe to be likely able to assist, or provide them with the contact details of the state’s VAD Care Navigator Service/other prescribed information. In Victoria and South Australia, the practitioner is not obligated to take any additional steps following refusal [33].
The Coordinating Practitioner is responsible for conducting a ‘First Assessment’ to determine the patient’s eligibility for accessing the VAD. In all states, an eligible patient must have been diagnosed with “at least one disease, illness or medical condition that is:
a) advanced, progressive (or ‘irreversible’ in Tasmania), and will, or is expected to, cause death;
b) incurable (in Victoria, South Australia and Tasmania only);
c) expected to cause death:
a. within 12 months in the case of a neurodegenerative disorder; or
b. within 6 months for other conditions, illnesses or diseases (except for Queensland where a person can apply for voluntary assisted dying if they are expected to die within 12 months); and
d) causing suffering that cannot be relieved in a way considered by the person to be tolerable.” [34]
Additionally, the patient must meet certain residency rules within the state, be of a minimum age and maintain decision making capacity throughout the VAD process [35]. If the Coordinating Practitioner deems the patient as eligible, they must refer the patient to another independent medical practitioner for a ‘Consulting Assessment’.
3. Consulting Assessment
The ‘Consulting Practitioner’ is responsible for Consulting Assessment to independently determine the patient’s eligibility for VAD. The Consulting Practitioner is similarly bound by qualification and training requirements. Neither the Consulting or Coordinating Practitioners may be related to the patient or receive any material benefit from their participation in the VAD process [36].
In cases where the patient may be suffering from a complex series of ailments, the Consulting Practitioner may be unable to identify whether the patient meets the statutory eligibility criteria. Under such circumstances the Consulting Practitioner may seek the specialist opinion of additional medical practitioners regarding the patient’s conditions [37].
If the Consulting Practitioner also determines that the patient is eligible for VAD, the patient may subsequently make their second and final requests for the administration of the assisted dying medication.
4. Second & Final request
All current jurisdictions require eligible patients to make a second and third (Final) written request for VAD to their coordinating medical practitioner following their Consulting Assessment. Depending on the state, either one or both requests must be witnessed by an independent third party. Often a statutory ‘cool-down’ period of 5-9 days is implemented between the first and final requests to ensure the patient’s decision is enduring and voluntary, with exceptions in place for patients in acute situations [38]. Following the patient’s final request, the Coordinating Practitioner may apply for a permit to prescribe a VAD substance.
5. Dispensing and administration of substance
The VAD substance consists of certain medications which cause painless death upon consumption or intravenous injection. Due to its dangerous nature, VAD substances must be distributed by authorised suppliers and stored in locked boxes after being dispensed. Most states have established specialised dispensing services for individuals seeking to access VAD in rural and remote areas. Patients seeking VAD must also nominate a contact person to return any remaining unused substance upon the patient’s death [39].
Most Australian VAD frameworks mandate self-administration of VAD substances through an oral route when possible. For individuals unable to swallow or digest the substance, they may request medically assisted intravenous administration of VAD medication by a medical practitioner (or in some jurisdictions, nurse practitioners or registered nurses). In some jurisdictions, the process of administering the VAD substance must be witnessed by a third party [40].
6. Mandatory reporting & Oversight
Each state has established oversight bodies to ensure legislative compliance in the clinical administration of the VAD scheme. Each Coordinating Practitioner is required to notify the State VAD Board of each substantial progression in a patient’s journey towards accessing VAD, generally within 2-7 days of each step occurring [41]. Subsequently, it is the responsibility of the State Boards to review such reports and determine whether legislative requirements have been met, and to publish compliance data in annual reports.
Select Committee on the Voluntary Assisted Dying Bill 2023, Legislative Assembly for the Australian Capital Territory, Inquiry into the Voluntary Assisted Dying Bill 2023 (Report, Feb 2024), 7.
The Voluntary Assisted Dying Bill 2023 (ACT)
Work on establishing a new VAD framework for the ACT began immediately following the passage of the Restoring Territory Rights Bill 2022 (Cth) [42]. In June 2023, the ACT Government published a Listening Report which consolidated the findings of a two-month community consultation period, commencing February that year [43]. Community submissions showed that much of the ACT public stood in favour of a new assisted dying framework, largely owing to the demonstrated success of the ‘Australian Model’ of VAD [44]. In light of this success, the Voluntary Assisted Dying Bill 2023 (ACT) (‘ACT Bill’) was introduced on the 31st of October by Labor MLA Tara Cheyne, the incumbent ACT Minister for Human Rights [45].
The ACT Bill proposes an access pathway which, while largely synchronous to the Australian Model, aims to address many unnecessary barriers to access by omitting several strict statutory restrictions present in other VAD jurisdictions. Expectedly, this progressive approach has been subject to extensive criticism. Public submissions in response to the ACT Legislative Assembly’s Inquiry into the operations of the ACT Bill highlighted several major safety concerns associated with the expansion of eligibility criteria and streamlining of administrative processes.
In response, the Select Committee on the Voluntary Assisted Dying Bill 2023 (‘Select Committee’) formulated 27 recommendations to the ACT Government, advocating for amendments to be introduced to protect all individuals involved in the VAD process from exploitation and/or unintentional statutory non-compliance [46]. Of these, four warrant particular attention;
1. Allowing all health workers to initiate discussions relating to VAD.
Section 152(2) of the ACT Bill permits ‘relevant health professionals’ such as social workers, counsellors or ‘health practitioners’ to initiate conversations about VAD with patients, provided the patient has been informed of other palliative treatment options and advised to speak to their treating doctor [47]. This provision has been celebrated as a ‘compassionate and common sense approach’ towards regulating how VAD conversations should be conducted, allowing individuals interested in accessing the scheme to receive early support [48].
However, concerns regarding the removal of this ‘crucial safeguard’ protecting the patient from the power imbalance inherent in clinician-patient relationships were raised by numerous pro-life organisations [49]. Additionally, the term ‘health practitioners’ was not defined in the ACT Bill, which caused confusion regarding which professions had a statutory obligation to refrain from initiating discussions about VAD [50]. Consequently, the Select Committee recommended for the ACT Government to introduce amendments setting out the specific obligations for health practitioners in initiating VAD conversations.
2. Removal of 6/12-month life-expectancy requirement for VAD eligibility.
The current ACT Bill substantially departs from the conventional Australian model by intentionally omitting the 6/12-month ‘life-expectancy’ eligibility requirement adopted in almost all other states. Instead, the Bill requires individuals seeking eligibility to have an advanced progressive condition and be in the ‘last stages of their life’ [51]. As submitted by the ACT Government, the choice to omit a timeframe of death was inspired by approaches adopted by international jurisdictions (Netherlands, Belgium, Canada etc.), and that requirements examining the patient’s levels of function and quality of life may serve as more effective indicators of eligibility [52]. This makes the ACT the first jurisdiction to effectively abolish a systemic barrier unfairly preventing individuals with certain neurodegenerative conditions for which life-expectancy is difficult to estimate from accessing VAD.
However, the ambiguity of the term ‘last stages of their life’ was subject to significant criticism. Public submissions highlighted how this term could be misconstrued as ‘being of advanced age’ or as re-introducing a life-expectancy requirement where clinical opinion would replace the 6/12-month restriction [53]. In response, the Select Committee has recommended for this term to be amended in a clarifying manner, a need which has since been acknowledged by the ACT Government [54].
3. Absence of ‘cooling off’ period between consultations and requests.
Several Australian jurisdictions require ‘cooling off’ periods between successive requests and assessments; for example, Western Australia imposes a 9-day period between the first and final request, implemented with the intention of ensuring that the patient’s decision was voluntary, constant and well-considered [55]. The absence of such a period in the ACT bill was due to two factors; first, that the VAD process naturally takes a number of days, making the implementation of a ‘cooling off’ period redundant; and second, that many exceptions to the period were being granted in other states [56]. However, community submissions were unilaterally in favour of the implementation of some form of waiting period between requests as a minimum safeguard, fearing some individuals would be ‘hurried through’ the process by overzealous actors. Ultimately, the Select Committee’s recommendation reflected Go Gentle Australia’s suggested 48-hour period between a patient’s first and last requests [57].
4. Proposed amendments in the 3-year review
Section 159 of the Bill foreshadows a parliamentary intention to open the proposed scheme to non-residents and children, in addition to a potential embedment of the scheme into advanced care plans following a 3-year review period [58]. This highly contentious aspect of the bill attracted substantial attention in a number of submissions; although non-resident, pediatric and advanced care VAD are available in many international jurisdictions, they have all been staunchly rejected in Australia, and will likely form the cornerstone of much future debate [59]. It remains unclear how this will be addressed by the ACT Government going forward, although it has been anticipated that any proposed changes will likely be implemented after 2030 [60].
Summating the Select Committee’s findings, it can be ultimately concluded that the current ACT Bill is not sufficiently mature to administer a fully-fledged VAD scheme. The ACT Government is expected to draft a report in response to the Select Committee’s recommendations in June 2024; following the implementation of suggested amendments, the ACT public can expect to receive a VAD framework which will better serve and protect community interests.
Conclusion
The long-anticipated arrival of VAD has brought comfort and peace to thousands of terminally-ill Australians, allowing our loved ones to approach the end of their lives with dignity and agency. Existing barriers in state VAD frameworks may serve to protect vulnerable individuals, but such protections are afforded at the expense of participants forced to endure suffering under unnecessary administrative burdens. Whilst immature, the ACT Bill remains a future-orientated adaptation of the Australian model, taking inspiration from the success of both domestic and international assisted dying schemes to formulate a considered approach towards enhancing access without compromising safety. The success of the ACT model will likely inspire legislative reform in other Australian jurisdictions, serving as the next step in Australia’s journey towards developing a safe, effective and internationally exemplary assisted dying framework.
Endnotes
Oxford English Dictionary (online at 15 April 2024) ‘euthanasia’.
Michael Strolberg, ‘Active Euthanasia in Pre-Modern Society, 1500-1800: Learned Debates and Popular Practices’ (2007) 20(2) Social History of Medicine 205, 207.
Valerius Maximus, Memorable Doings and Sayings, Book II in DRS Bailey (ed) Memorable Doings and Sayings, Volume I: Books 1-5 (Harvard University Press, 2000) 171.
Hippocrates Ancient Medicine. Airs, Waters, Places. Epidemics 1 and 3. The Oath. Precepts. Nutriment. tr WHS Jones (Harvard University Press, 1923) 299.
Australian Medical Association, ‘AMA Position Statement - Euthanasia and Physician Assisted Suicide’ (2016).
Strolberg (n 2) 207.
Alkmaar Case, Nederlands Jurisprudentie [1985] No.106, Supreme Court, 27 Nov. 1984.
Margaret Otlowski, Voluntary Euthanasia and the Common Law (Oxford University Press, 1997) 400-401.
Katharina Bucholz, ‘Where Assisted Suicide Is Legal’ Chart: Where Assisted Suicide Is Legal | Statista (Webpage) < https://www.statista.com/chart/28133/assisted-dying-world-map/>.
Kumar Amarasekara and Mirko Bagaric, ‘The Legalisation of Euthanasia in the Netherlands: Lessons to be Learnt’ (2001) 27(2)Monash University Law Review 179.
Ibid 185.
Death with Dignity Act, 127 ORS §§1.01-5.01 (1997).
ACT Government, Voluntary assisted dying in the ACT: report on what we heard, June 2023, 3-4.
Rights of the Terminally Ill Act 1995 (NT) s 4.
Tracee Kresin et al, ‘Attitudes and Arguments in the Voluntary Assisted Dying Debate in Australia: What Are They and How Have They Evolved Over Time?’ (2021) 18(12327) International Journal of Environmental Research and Public Health 1, 4-6.
Stephen Duckett, ‘The long and winding road to assisted dying in Australia’ (2019) 54(4) Australian Journal of Social Issues 386, 387.
DW Kissane, Annette Street and Philip Nitsche, ‘Seven deaths in Darwin: case studies under the Rights of the Terminally Ill Act, Northern Territory, Australia’ (1998) 352The Lancet1097-1099
Second Reading Speech, Voluntary Assisted Dying Bill 2017 (Vic).
Voluntary Assisted Dying Review Board, Annual Report July 2022 to June 2023 (Annual Report, June 2023).
Australian Medical Association (n 5) 3.1.
Victorian Government, Ministerial Advisory Panel on Voluntary Assisted Dying: Final Report (Final Report, July 2017) 80, 89, 92.
Voluntary Assisted Dying Review Board (n 19), 27.
Kerstin Braun, ‘Looking back to look forward—the history of VAD laws in Australia and future law reform in the Australian territories’ (2024) 32 Medical Law Review 42, 49-50.
Ibid.
ACT Government, ‘Voluntary assisted dying laws in the ACT’ Voluntary assisted dying laws in the ACT – Justice and Community Safety Directorate (Webpage) <https://www.justice.act.gov.au/justice-programs-and-initiatives/voluntary-assisted-dying-laws-in-the-act>.
Northern Territory Government, ‘Voluntary assisted dying (VAD) in the Northern Territory’Voluntary assisted dying (VAD) in the Northern Territory | Have your say and help us develop the Northern Territory framework for Voluntary Assisted Dying(Webpage) <https://haveyoursay.nt.gov.au/vad>.
See Voluntary Assisted Dying Act 2022 (NSW) div 2, Voluntary Assisted Dying Act 2021 (Qld) div 2, Voluntary Assisted Dying Act 2021 (SA) s 8, End-of-life Choices (Voluntary Assisted Dying) Act 2021 (Tas) s 3, Voluntary Assisted Dying Act 2019 (WA) div 2.
ACT Government, Voluntary assisted dying discussion paper, February 2023, 15.
Ibid 24.
Ibid.
Ibid 14; see also End-of-life Choices (Voluntary Assisted Dying) Act 2021 s 5 (definition of ‘PMP’).
ACT Government (28), 21.
Ibid 26.
Ibid 7, 8.
Ibid 10-12.
Ibid 22.
SeeVoluntary Assisted Dying Act 2021(SA) s 36,End-of-life Choices (Voluntary Assisted Dying) Act 2021(Tas) s 32.
ACT Government (28), 17.
Ibid 18.
Ibid 18, 19.
Ibid 33.
Select Committee on the Voluntary Assisted Dying Bill 2023, Legislative Assembly for the Australian Capital Territory, Inquiry into the Voluntary Assisted Dying Bill 2023 (Report, Feb 2024), 2-3 (‘Select Committee’).
ACT Government (n 13).
Ibid 3-4.
ACT Legislative Assembly,Minutes of Proceedings, No. 104, 1493.
Select Committee (n 42).
Voluntary Assisted Dying Bill 2023 (ACT) s 152(2) (‘ACT Bill’).
Dying with Dignity NSW, Submission No 77 to Select Committee on the Voluntary Assisted Dying Bill, Inquiry into the Voluntary Assisted Dying Bill 2023 (14 December 2023) 4.
Select Committee (n 42) 26-27.
Ibid 24-25.
ACT Bill (n 47) s 4 (definition of ‘advanced’).
Select Committee (n 42) 11.
Ibid 12-14.
Ibid.
Ibid 35.
Ibid 35-36.
Ibid.
Ibid 41.
Ibid 43.
Ibid 42, 44.
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