Ep36 "What is Insanity?" Part 1

Published Nov 27, 2023, 11:00 AM

What is the insanity defense? Are some people’s brains so different that it makes sense to use a different legal category? How does a legal system decide where the dividing line is? How are science and law strange bedfellows? Join us for the first of two episodes about the insanity defense: where it comes from, where it's going, and why it is so difficult to decide where to draw our societal lines. 

What is the insanity defense? Are some people's brains so different from yours that it makes sense to categorize them differently under the legal system? How could a mother kill her children? Can you commit a crime without meaning to? How does a legal system decide how to rule on these issues? And how are science and law strange? Bedfellows? Welcome to the Inner Cosmos with me, David Eagleman. I'm a neuroscientist and author at Stanford and in these episodes we sail deeply into our three pound universe to understand why and how our lives look the way we do. Now, we all hear the word insane, somebody is acting insane, something like that. But the first thing to note is that insanity is not a medical term. It's not used in psychiatry or neuroscience. It's instead a term used by the legal system. And I'm going to do a two part episode about the insanity defense, where it comes from, and why it is so difficult as a society to decide where we want to draw our lines in the sand. What I mean is, sometimes a person commits a crime and we say they're clearly different from us, but we're not sure quite how and we're not sure if that should release them from culpability. As we're going to see, there is no hard and fast line where we as a society can say, oh, that person is on this side of the line and this person isn't. Now, this is a theme I've expressed in various ways in all of these episodes, which is, but brains are very different from one another, and most everything that we are interested in lives on a spectrum, and more than a spectrum, on a very complicated landscape. People are very different on the inside, and the question is how do we build rules as a society to make things run well. So let's get started. What I want to tell you about is a young woman named Andrea So. By the time Andrea was a teenager, she held the world by the tail. She was the valedictorian of her high school. She was the captain of her swim team. She was a member of the National Honor Society. By twenty two years old, she became a registered nurse and she worked at M. D. Anderson Cancer Center in Houston, Texas. And her life got even better when she met the man of her dreams, a guy named Rusty, at their apartment complex and Four years later, they got married, and they announced to friends and family that they were going to have as many babies.

As nature allowed.

So their first child was born ten months later, and over the next six years they had four more handsome and healthy children. One June morning in two thousand and one, Rusty left the house for his work at NASA, and as soon as he left, Andrea turned on the bathtub, and one by one she held her beloved children down under the water until they drowned. Her oldest child, who was seven years old, saw his six month old sister face down in the bathtub, and he tried to flee, but Andrea chased him and caught him and drowned him next to his sister's floating body. She laid the bodies of the youngest four on the bed, and she left the eldest in the bathtub. And Andrea later told a homicide sergeant that she had considered killing her.

Children for two years now.

People often grabbedavitate towards stories of crime, saft's, assaults, murders, and so on. Because these acts are so distant from what they could contemplate themselves. We are tantalized that someone could behave in a particular way, and we are always confronted with a question how should society respond? So our intuition seems to provide ready answers to these questions. But new light on a lot of these questions comes from a field that at first blush seems far away from the prison system, and that is neuroscience. The past century has made it really clear that a person's behavior and a person's brain are inextricably linked. When someone goes on a new medication, their behavior can change. When they get a degenerative brain disorder, their behavior can change when they develop a brain tumor, or they get a traumatic brain injury. Their behavior can change in the presence of drugs or alcohol, or stress, or strokes or schizophrenia. There are alterations in decision making and the appetite for risk, and this is why questions about crime inevitably lead to the doorstep of brain science. Now, when we're children, we try to understand how a criminal must feel. From our own point of view, we often conclude that a criminal must feel bad for what he or she has done. But as we mature, it becomes clearer that people can be really different on the inside. Although we all look similar, we each live in a somewhat different cosmos inside our skulls, and this understanding has led legal systems to try to contend with this variety. Now, the simple approach is to assume that each perpetrator sees the world the same way. The reason this is a simple and straightforward approach is because it allows everyone to get equal punishment for the same crime. But it has become clear to societies over a long time that this viewpoint falls short. Now in many episodes in this podcast, we've seen that different people can have very different realities on the inside. And in today's episode and next week's will come to understand what this teaches us about crime, and what crime teaches us about the brain. Dozens of new questions and new issues spring from the intersection of neuroscience and the law, and this is what these next couple episodes are about. And I want to make one critical note first, which is that a deeper understanding of the brain and its related behavior doesn't let anyone off the hook. Explanation is not exculpation. Our society still needs to keep violent aggressors and bad acts durs off the streets. Instead, a meaningful understanding of the brain can provide a rational basis for sentencing, and it can provide customized rehabilitation. When crimes arise from biological problems, there are often meaningful rehabilitative strategies available. Sometimes we have better options than assuming that incarceration is the single available solution. So let's return to Andrea. Although she was a top student and a popular athlete, her success is masked deeper problems.

She suffered from bolimia.

She was routinely caught in the cogwheels of depression, and at least once in her teenage years, she admitted to a friend that she was considering suicide. And what developed over time is that after the birth of her fourth child, Andrea fell under the grip of postpartum depression. Postpartum means after birth. So one day, in tears, she called her husband, Rusty at work. He came rushing home to find Andrea distraught.

She was shaking.

Uncontrollably, she was chewing on her fingers, and the next day she attempted suicide by overdosing on pills. So Rusty looked around desperately for psychiatric care. And Andrea was admitted to Houston's Methodist Hospital psychiatric unit, but then she was discharged six days later because of insurance restrictions, and so things continued to get worse for Andrea. She was prescribed an antidepressant, but the medicine only slightly improved her condition, and her doctor gave her samples of an antipsychotic drug and she flushed those pills down the toilet. So four weeks after being discharged from the hospital, Andrea attempted suicide again. This time she held a knife to her throat before her husband intervened. So she returned to psychiatric care and she was diagnosed with a major depressive disorder, and eventually it was determined that Andrea suffered from postpartum psychosis. Postpartum meaning after birth, and psychosis is a condition in which thought and emotions are so affected that one loses contact with reality. So as you can imagine, postpartum psychosis is a mental health emergency in which a mother has a distorted sense of reality after giving birth. She can have delusions and hallucinations and paranoia, and in the worst cases, mothers work to harm themselves or their babies. Now, thankfully, this is rare. It's something like one in a thousand births, but this is what Andrea suffered from. So she was put on antipsychotic medications and her mental state improved, and that allowed her to return to a normal life. And she eventually gave to her fifth child and everything seemed okay. But shortly after that birth, her father died and that was very hard on her, and it took her hard won composure and it smashed it. She stopped taking her antipsychotic medications. So one morning in June, Rusty left the house for work, which left Andrea alone with the children. Now this was directly against the advice of their psychiatrist, who advised him to never leave Andrea alone, but Rusty assumed he could do it just this once because his mother was driving over to the house to take over and she would be there in an hour. But it was in that hour that Andrea filled the tub and murdered all their children. After she laid the children on the bed, she called the police, saying she needed an officer. She then called Rusty and said to him, it's time.

Now.

What happens when a case like this goes to a court of law. In the case of Andrea, both the prosecution and the defense agreed that she was mentally ill. Why was that straightforward for them to agree because thousands of pages documented her successive psychiatric hospitalizations, So neither party in the trial raised any question about that her postpartum depression had blossomed into a full psychosis, and she had been suffering under this for years, and the media attention surrounding Andrea's story led the whole nation to consider difficult questions about mental illness and criminal responsibility. Was Andrea culpable in the normal sense that we think about culpability? What is the right thing to do with a person like Andrea? On the one hand, her psychology just wasn't like other peoples.

She was delusional.

On the other hand, a lot of women faced difficult emotions and thoughts after the birth of their children, but most of them would come close to imagining an active murder. What happened in the trial is that digging into Andrea's history revealed even more. She confessed that she had not been a good mother to her children, and she worried that they weren't developing correctly. Now, she didn't mean this in a general way. She meant this in a very specific way. In her view, she had been marked by Satan, and the only way to save her children from the fires of hell was to kill them. If she didn't drown them in the tub, she believed they would be doomed to eternal punishment. For Andrea, murdering her children was the only path to their salvation. So Andrea's lawyers pled not guilty by reason of insanity. Now, the idea of that plea is that because of her mental illness, she is absolved of culpability. That means she's not blameworthy. In other words, the plea of not guilty by reason of insanity translates to, yes, I committed the crime, but I have the mitigating circumstance that I was legally insane.

This type of.

Argument is known in the law as an excuse. It's a type of defense that reduces the defendant's culpability or blameworthiness. So let's dig into this notion of culpability. How do we assess culpability? Why do we ever consider anybody culpable? To understand this, we need the concept of mensreea, which is Latin for guilty mind. So the standard test for criminal liability is often summarized in the phrase the act does not make the person guilty unless the mind is also guilty. In other words, let's say my arm knocks somebody off of a cliff. Well, I'm liable for that, but I'm not if I have a neurological disorder that causes my arm to spasm and sporadically swing around outside my control. The act has clearly happened, which is I knocked a person off the cliff, but as there was no guilty intent behind it, I wouldn't be criminally liable. The concept of mens rea allows us to not punish people for acts that are committed reflexively. For example, things that have come up in courts are a military veteran who reflexively shoots an intruder or a man who stabs somebody while he is sleepwalking.

I'm going to do an episode on that legal case soon.

The idea of doing an act but not having mens rea a guilty mind. This also applies if I commit a criminal act under duress. For example, if someone holds a gun to my head and says, shoplift that laptop, or I'm going to kill you. If I shoplift the laptop. In that situation, I'm not considered criminally liable because I don't have a guilty mind, my life is under threat. So with any criminal case, the first question is whether the mind is guilty. In other words, is there mensrea. If not, the defendant is not criminally liable. Now, as it turns out, there are levels of complexity to the concept of mensrea. There are levels of having a guilty mind, and the legal system concludes that there are different degrees to which a person can be liable. So let's dig into this for a moment. Let's say that you walk into a dark room and you end up destroying a bunch of porcelain statues. Now, let's say you knew that the room can contained the statues, and your aim was to cause as much damage as possible. In this case, the intuition of the legal system is that you are clearly liable for the damage. But now imagine a second scenario. You entered the dark room and you were aware that it was full of valuable statuary, but you didn't mean to break the statues. You understood that it was almost certain that you would break some of them as you fumbled around for the switch. In this scenario, we're inclined to think that you are guilty, but that you're not as culpable as the first scenario, in which you purposely sought to cause damage. Now, let's consider a third scenario. You skateboard into the dark room knowing that their statuary inside, but this time your intention was to ride to the light switch without damaging anything. But things went wrong and you ended up breaking some statues, despite the fact that you had good intentions to only turn on the light switch. The act is there, the statues are broken, but the mind seems to have had a different level of guilt. And let's consider a fourth scenario in which you walked into the dark room with no idea that statuary was in there. You walked in there with the intention to just seek some alone time to meditate because you just had an argument with someone and you needed some quiet, and you ended up accidentally breaking somebody's statuary. You didn't know there was a light switch. You were simply looking for somewhere quiet to sit. Now, all these scenarios have led to the same outcome. Somebody's beautiful porcelain statues are shattered, but the men's rea is not the same. The first case exemplifies the legal term of intentional or purposeful. You had every objective of going in there and busting up those statues. That's the highest level of mensrea. In the second case, there was knowledge. You didn't go in there intending to break stuff, but you went in knowing this was a near certain outcome of your actions. The third scenario is classified as recklessness. There was a large risk that skateboarding to the light switch was going to break some valuable statues, and choosing this action was a real difference from how the average person would act. The fourth scenario is called negligence, which assumes that a reasonable person would have taken more care when entering a dark room with which he wasn't familiar. So having a guilty mind isn't one thing, but there are different levels. Take homicide as an example. The guilty act is something that results in the death of another person. But if you intended that your conduct would result in the loss of life you shoot somebody, that's murder. But if that wasn't your intention, if something you did accidentally led to the death of somebody else, then it is classified as manslaughter. In a typical criminal case, there is a readily identifiable level of mensrea. Either someone meant to do it, or they should have known better, or they were just being reckless, or they were being negligent. That seems to cover most situations, but there are a few defenses in which one can argue that mensrea is completely absent. One of those is the infancy defense. If you are a child, it is assumed that you cannot reasonably be held responsible for your actions. So many countries have a policy called Doley incapax, which just means that if a child is under ten years old, he cannot be held legally responsible for his actions because he doesn't understand their nature and consequences. So what does it mean for Andrea or anyone to plead insanity. It means, yes, I committed the act, but the mensrea was not there. Because I couldn't understand the nature or consequence of my actions, I can't be said to have had a guilty mind. Why do we need an insanity defense? Well, in the case of Durham versus the United States nineteen fifty four, the circuit judges summarized the need this way, quote, the legal and moral traditions of the Western world require that those who of their own free will and with evil intent commit acts which violate the law, shall be criminally responsible for those acts.

Our traditions also require that where such.

Acts stem from and are the product of a mental disease or defect, moral blame shall not attach, and hence there will not be criminal responsibility end quote. In other words, we need an insanity defense because some people are incapable of normal decision making and should not be held morally or criminally responsible for their decisions in a mature system of criminal law. Everybody agrees on this. Now, in different episodes, we'll see what kind of different mental illnesses look like that makes somebody incapable of normal decision making. But from the legal point of view, this all immediately raises a question, how do you know if somebody is just faking it? Or a related question, how do you know if someone has a mental illness but that's not actually why he committed the crime. So these are the tough questions right at the intersection of brain science and the legal system. Now, as I said at the beginning, insanity is not a medical term. There's no way that you can take a person into a clinic or laboratory and perform a brain scan and confirm ah, yes, that person is insane. It's purely a legal term, so how to really think about it in a courtroom? This blossomed in the case of a young Scottish woodcutter named Daniel McNaughton in January of eighteen forty three. McNaughton was suffering from paranoid delusions. He publicly griped that he was being followed by spies from the Tory political party, and privately he was hearing a voice in his head, which he assumed to be the voice of God. The voice told him that to end this persecution by the Tories, McNaughton should assassinate the British Prime Minister, Robert Peel. So McNaughton stalked him for two days, and on the third day he waited for Peel to emerge from the Prime Minister's office, and then McNaughton followed him, and he pulled his gun out from his pocket and shot him fatally in the back. McNaught was captured right away and charged with murder. It turns out McNaughton had made a mistake. It wasn't Robert Peel he had murdered, but instead a British civil servant named Edward Drummond. This was the first sign to the police that's something was a little strange about what was happening here now. At McNaughton's trial, the prosecution called two people to the stand, his landlady and someone who had known him at school, and both testified that he generally seemed of sound mind. But then the defense came up. He had a well known and eloquent lawyer who argued that McNaughton was clearly deranged. He suffered from paranoia, He had delusions of persecution from the government. He had command hallucinations, which is where you hear a voice in your head that tells you to do things. The lawyer brought nine medical experts to the stand, all of whom testified that McNaughton.

Was clearly out of touch with reality.

The prosecution was unable to muster a single medical experts say otherwise, so the jury didn't even need to retire. They concluded that Daniel McNaughton was clearly insane, and given this conclusion, he was sentenced to commitment for life at the State Criminal Lunatic Asylum at Bethlehem Hospital. But many British people were displeased with this outcome. Among them was a woman whose voice carried the weight of a monarch, Queen Victoria. She had previously been the target of assassination attempts, and she represented the anger of the public. How can one commit murder and just say he's not responsible. He ended the life of an innocent man. Shouldn't something be done beyond a sentencing to a hospital? And how do we know he's not simply faking insanity? So Queen Victoria drew upon an ancient right to call the judges to explain their reasoning. She put a list of questions to the panel of judges, who sat down over the course of days and shaped their response to the Queen, and in eighteen forty eight this charted the future of the insanity defense, leading to the codification of what is known as the McNaughton rule.

What they wrote is this quote.

To establish a defense on the ground of insanity, it must be clearly proved that at the time of committing the act, the party accused was laboring under such a defective reason from disease of the mind as not to know the nature and quality of the act he was doing, or if he did know it, that he did not know what he was doing was wrong.

End quote.

So let zoom in on the important words here. First, because of a disease of the mind, a person may not understand the nature and quality of his act. For example, if I have a mental illness and I pull the trigger of a gun, but I have no understanding that a bullet is going to come out of the barrel, then I don't understand the nature and quality of the act I'm committing. And the second issue they point to is the inability to distinguish.

Right from wrong.

So even if I know how a gun works, it's possible that my deficit leaves me unable to distinguish what I should do from what I shouldn't. And let me just fill this out with another example. Someone could fail the first part of the mcnonton test, the cognitive component, if they think that they're shooting at a target but really it's a person. Or they could fail the second part, the moral component, if they knew they were killing a person, but they thought that a divine force was commanding them to do it. Now, this codification of the insanity defense impressed the United States, so within ten years they'd adopted it for themselves and This soon formed the foundation of the insanity defense.

Around the world.

As a result, in a trial in which the insanity defense is raised, the job of the court is to first assess whether the accused person was suffering from a mental disease when the crime was committed. If not, then they are criminally responsible. But if the person was subject to a mental disease, then two questions are posed. Did this person understand the nature and quality of the act and could he distinguish right from wrong? So let's zoom in on the first step, which is the sanity evaluation. Did the person have a mental disease at the time of the crime? For the purposes of an insanity defense, courts will generally accept a major mental illness, such as a psychosis, which is a mental state in which there is a loss of contact with reality. Courts are less likely to accept, for example, the diagnosis of a personality disorder, meaning something about your personality that might inhibit your social progress, like obsessive compulsive disorder or narcissistic personality disorder or borderline personality disorder. Now, while we're talking about the sanity evaluation, you've surely heard the term psycho But what exactly does that mean? Does it describe someone who is separated from reality or does it instead describe an aggressive person who has no regard for other people's feelings. Okay, so this is a trick question. Psycho is a meaningless term invented by Hollywood. In the movie Psycho, they were referring to a psychopath, also known as a sociopath. And I'll be doing an episode soon on psychopathy people like Ted Bundy, But somebody with a psychosis, which is what we're talking about today, has an abnormal condition of the mind that separates them from reality. And it's a generic psychiatric term in the same way that we talk in medicine about somebody having a fever, which can be caused by many underlying conditions. So psychopathy like Ted Bundy and psychosis like Andrea Yates, these are both men descriptors, but their world's apart. Will meet psychopaths in future episodes, but for now, we're going to move into the world of psychosis. People suffering with a psychosis have this lack of contact with reality, and this typically translates into wildly incorrect ideas about events going on around them or about their self identity. They might have delusions like I'm President Biden's special advisor or Eyeshot Tupac. A person with a psychosis often perceives things that aren't there. They report things like, when I'm not looking, everybody sticks their tongues out at me, and when I whirl around to look, they all stop. A lot of features tend to go along with the psychosis, like confusion, depression, abnormal displays of emotion, disorganized thoughts and speech, and sometimes suicidal thoughts. A psychosis can come with mania or false beliefs or mistaken perceptions, and often paranoia.

And pretty commonly a person hears.

Hallucinatory voices and sometimes those voices will seem to tell him to do something. That's the command hallucination. So why does psychosis matter for the legal system. Well, if you're disconnected from reality when you commit a crime, you were not operating with a guilty mind, a conniving, planning guilty mind. So, for example, given Daniel McNaughton's deep psychosis, the British judges found it difficult to insist that he had a guilty mind in the way that they normally see with other people. So let's return to Andrea Yates. How should a juror analyze her plea of not guilty by reason of insanity. In her trial, a picture of mental illness came into sharp focus. Her illness had been documented in thousands of pages. She had been hospitalized four times, and she'd been diagnosed by independent psychiatrists with postpartum depression and psychosist She had been helped by medication for the psychosis, but when she stopped taking the pills, her mental situation got worse, and things got even worse after the death of her father. Moreover, the jury learns that she had a spiritual mentor, a guy named Michael Warniki, who was a fire and brimstone minister who insisted to his congregants that any fault of the children is the fault of the mother. And of special note, he insisted that children will burn in hell if they're not raised correctly by the mother. Now, Andrea's family was worried about her connection with this preacher. She seemed to hang on his every word. This guy was really charismatic, and Yates later told the jail psychiatrist quote, it was the seventh deadly in My children weren't righteous, They stumbled because I was evil the way I was raising them. They could never be saved. They were doomed to perish in the fires of hell end quote. So what happened at the trial, Well, the prosecution enlisted a famous psychiatrist, again named Park Deets. He had previously served as a psychiatrist in a whole bunch of famous trials like those of the unibomber and John Hinckley and Susan Smith, so his presence was very weighty there. And Deets argued that Andrea Yates was not insane under Texas law. So he said, essentially, yes, she has a history of mental illness, but the important question is whether she was able to distinguish right from wrong, good from evil when she committed her crimes. So in court, this is how the dialogue went. Deets said, before you did it, did you think it was wrong? And Yeates said no. And he said why did you not think it wrong? And Yates said, if I didn't do it, they would be tormented by Satan. It was a bad choice. I shouldn't have done it. There was distress, but I still felt that I had to do it. Indeeds said, as you drowned each one, did you think it was the right thing? To be doing, and Yets nodded her head in affirmation. So Deets was working with this line of questioning to establish that this was not a psychotic state but instead part of a criminal plan. He said later quote, if it's true that she believed that killing the children would save them, then why would she not want it to happen. She would want to talk about it so it came true and the children would be saved. So I concluded at that point that she's keeping it secret. She knows that other people are going to stop her, that it's wrong, that it's a bad idea.

She admits that she knows people will stop her. End quote.

In other words, he prodded her over this issue. Why did she suffer the angst over doing it? If she had really believed that drowning her children was the right thing to do, then she should proceed without delay. Instead, she waited until her husband left for work, and then she started the bathtub. Afterwards, she felt remorse about the crime, but if she had felt she successfully saved her children from eternal damnation, she might feel gratified.

Now.

Dietz's arguments were compelling, but did they hold water well. One difficulty is that people can be internally conflicted, and I've done a different episode about the team of rivals inside your head. So imagine that your horse breaks its leg and you have to shoot it. You may love the horse and feel anguish over having to shoot it, while still believing that the act has to be done. The fact that you are conflicted doesn't mean that you're lying when you say that it's the right thing to do. But more on that later. For now, what I want to note is that Dietz's line of questioning came down to what's sometimes known as the cop at the elbow test.

Would she have done.

This if a police officer were standing there at her side? If she wouldn't have done it, then the jury should conclude that Andrea knew what society considered right and wrong, irrespective of her internal sense of it. And Deets argued that Andrea indeed knew right from wrong. She contemplated murdering the children for two years, but stopped herself after the horrific act. Guilt caused her to cover the bodies on the bed. She herself called the police to be arrested. She felt that the death penalty was a punishment she deserved. And in fact she requested it. Her religious position told her that she needed to burn and suffer about this. She believed that God would judge her actions badly. So Deets raised all these points to argue that she clearly knew right from wrong and therefore was not legally insane. And Dietz's potent arguments also had an unexpected twist. He pointed out that Yates got the idea of drowning her children in the bathtub from an episode of the television show Law and Order, a show on which Deets happened to be a consultant. In the episode, he told the jury a woman drowns her children in the bathtub and was found not guilty by reason of insanity. And Rusty Yates indeed testified on her questioning that Andrea Yates watched Law and Order often. So this point landed on the jury, making them question whether the insanity defense really applied to Andrea. But something wasn't normal about Andrea's thinking. I mean, after all, despite the common challenges of motherhood and concerns about spiritual waywardness, it's astoundingly rare for a.

Mother to murder her children.

So the legal question and then shifts. What if Yates actually did know right from wrong but was unable to stop herself, would discount for the insanity defense. Now this is a cliffhanger because I'm not going to tell you what happened until next week, and at that point we'll tie this into what the insanity defense has to do with a United States congressman who committed murder, what it has to do with Loraina Bobbitt, who emasculated her husband, and what it has to do with John Hinckley who tried to assassinate President Reagan.

All of this points to the complex question.

Of how we as a society need to think about drawing a bright line in the sand between insane and not insane, which might seem like a simple determination, but it's actually incredibly complexified by the fact that there is no natural line in biology. The fact is that science and the law are strange bedfellows. The legal system is forced to be categorical. The judge and jury are tasked with deciding whether a defendant is or is not insane. But neuroscience sees that brains can be very different from one another, and it's usually on a smooth spectrum, such that someone might be more or less separated from reality, and it's often not such an easy call to determine what to do. So what is the right thing to do here? And what were the surprises that came out next in the trial of Andrea Yates?

Tune in next week to find out.

Go to Eagleman dot com slash podcast for more information and to find further reading. Send me an email at podcasts at eagleman dot com with questions or discussions, and I'll make sporadic episodes in which I address these.

Until next time. I'm David Eagleman, and this is Inner Cosmos.

Inner Cosmos with David Eagleman

Neuroscientist and author David Eagleman discusses how our brain interprets the world and what that  
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