Holocaust Memorial Day – Let’s not forget the leading role doctors played

Monday 27 January is Holocaust Memorial Day, marking the liberation of prisoners from the Auschwitz-Birkenau concentration camp 69 years ago.

The millions of Jews and others killed during the Holocaust have been remembered in services today across the UK.

More than one million people, mostly Jews, died at the Nazi camp (pictured) before it was liberated by allied troops in 1945.

But the horrific genocide of six million Jews was only the final chapter in the story.

What is far less well known is the role of doctors in the process.

Twenty-three physicians (see below) were tried at the so-called Nuremberg Doctors' Trial in 1946, which gave birth to the Nuremberg Code of ethics regarding medical experiments. 

Many others including some of the very worst offenders never came to trial (see list of main perpetrators here and full list here)

What ended in the 1940s in the gas chambers of Auschwitz, Dachau and Treblinka had much more humble beginnings in the 1930s in nursing homes, geriatric hospitals and psychiatric institutions all over Germany.

When the Nazis arrived, the medical profession was ready and waiting.

Germany emerged from the First World War defeated, impoverished and demoralised.

Into this vacuum in 1920 Karl Binding, a distinguished lawyer, and Alfred Hoche, a psychiatrist, published a book titled ‘The granting of permission for the destruction of worthless life. Its extent and form'.

In it they coined the term ‘life unworthy of life’ and argued that in certain cases it was legally justified to kill those suffering from incurable and severely crippling handicaps and injuries. Hoche used the term ballastexistenzen (‘human ballast’) to describe people suffering from various forms of psychiatric disturbance, brain damage and retardation.

By the early 1930s a propaganda barrage had been launched against traditional compassionate 19th century attitudes to the terminally ill and when the Nazi Party came to power in 1933, 6% of doctors were already members of the Nazi Physicians League.

In June of that year Deutsches Arzteblatt, today still the most respected and widely read platform for medical education and professional politics in Germany, declared on its title page that the medical profession had ‘unselfishly devoted its services and resources to the goal of protecting the German nation from biogenetic degeneration’.

From this eugenic platform, Professor Dr Ernst Rudin, Director of the Kaiser Wilhelm Institute of Psychiatry of Munich, became the principle architect of enforced sterilisation. The profession embarked on the campaign with such enthusiasm, that within four years almost 300,000 patients had been sterilised, at least 50% for failing scientifically designed ‘intelligence tests’.

By 1939 (the year the war started), the sterilisation programme was halted and the killing of adult and paediatric patients began. The Nazi regime had received requests for ‘mercy killing’ from the relatives of severely handicapped children, and in that year an infant with limb abnormalities and congenital blindness (named Knauer) became the first to be put to death, with Hitler’s personal authorisation and parental consent.

This ‘test-case’ paved the way for the registration of all children under three years of age with ‘serious hereditary diseases’. This information was then used by a panel of ‘experts’, including three medical professors (who never saw the patients), to authorise death by injection or starvation of some 6,000 children by the end of the war.

Adult euthanasia began in September 1939 when an organisation headed by Dr Karl Brandt and Philip Bouhler was set up at Tiergartenstrasse 4 (T4) (pictured right) The aim was to create 70,000 beds for war casualties and ethnic German repatriates by mid-1941.

All state institutions were required to report on patients who had been ill for five years or more and were unable to work, by filling out questionnaires and chosen patients were gassed and incinerated at one of six institutions (Hadamar being the most famous).

False death certificates were issued with diagnoses appropriate for age and previous symptoms, and payment for ‘treatment and burial’ was collected from surviving relatives.

The programme was stopped in 1941 when the necessary number of beds had been created. By this time the covert operation had become public knowledge.

The staff from T4 and the six killing centres was then redeployed for the killing of Jews, Gypsies, Poles, Russians and disloyal Germans. By 1943 there were 24 main death camps (and 350 smaller ones) in operation.

Throughout this process doctors were involved from the earliest stage in reporting, selection, authorisation, execution, certification and research. They were not ordered, but rather empowered to participate. 

Leo Alexander (right), a psychiatrist with the Office of the Chief of Counsel for War Crimes at Nuremberg, described the process in his classic article 'Medical Science under Dictatorship' which was published in the New England Medical Journal in July 1949.

‘The beginnings at first were merely a subtle shift in emphasis in the basic attitude of the physicians. It started with the attitude, basic in the euthanasia movement that there is such a thing as a life not worthy to be lived. This attitude in its early stages concerned itself merely with the severely and chronically sick. Gradually the sphere of those to be included in this category was enlarged to encompass the socially unproductive, the ideologically unwanted, the racially unwanted and finally all non-Germans.’ 

The War Crimes Tribunal reported that ‘part of the medical profession co-operated consciously and even willingly’ with the ‘mass killing of sick Germans’.

Among their numbers were some of the leading academics and scientists of the day; including professors of the stature of Hallervorden (neuropathology), Pernkopf (anatomy), Rudin (psychiatry/genetics), Schneider (psychiatry), von Verschuer (genetics) and Voss (anatomy). None of these men were ever prosecuted while of the 23 defendants at Nuremberg, only two were internationally recognised academics.

It is easy to distance ourselves from the holocaust and those doctors who were involved. However, images of SS butchers engaged in lethal experiments in prison camps don’t fit the historical facts; the whole process was orchestrated through the collaboration of internationally respected doctors and the State.

With the advantage of hindsight we are understandably amazed that the German people and especially the German medical profession were fooled into accepting it. The judgement of the War Crimes Tribunal in 1949 as to how they were fooled was as follows. 

'Had the profession taken a strong stand against the mass killing of sick Germans before the war, it is conceivable that the entire idea and technique of death factories for genocide would not have materialized...but far from opposing the Nazi state militantly, part of the medical profession co-operated consciously and even willingly, while the remainder acquiesced in silence. Therefore our regretful but inevitable judgement must be that the responsibility for the inhumane perpetrations of Dr Brandt (pictured left)...and others, rests in large measure upon the bulk of the medical profession; because the profession without vigorous protest, permitted itself to be ruled by such men.' (War Crimes Tribunal. 'Doctors of Infamy'. 1948)

A 2010 article in American Medical News covered the United States Holocaust Memorial Museum’s exhibition on medicalised killings under the Nazis. It concluded:

“‘The misguided scientific ideas of physicians and scientists were integral to Nazis' crimes against humanity and should serve as a reminder to doctors to put patients before political ideology ... As evil as these actions appear in retrospect, they arose out of a highly sophisticated German medical culture... More than half of the Nobel Prizes that were awarded in science through the 1930s went to Germans ... 'These doctors became killers, not despite their training but in the name of their science and training… All doctors and medical professionals need to know and understand this material.'"

Martyn Lloyd-Jones – a passion for Christ-exalting power

John Piper’s Christian biographies are a must if you enjoy inspirational MP3s. I listened to his fascinating treatment (both script and audio) of Martyn Lloyd-Jones again today on a ten mile run.

Martyn Lloyd-Jones (20 December 1899 – 1 March 1981) was a Welsh Protestant minister, preacher and medical doctor who was influential in the Reformed wing of the British evangelical movement in the 20th century who for thirty years preached from the pulpit at Westminster Chapel in London.

Many called him the last of the Calvinistic Methodist preachers because he combined Calvin's love for truth and sound reformed doctrine with the fire and passion of the eighteenth-century Methodist revival.

From the beginning to the end the life of Martyn Lloyd-Jones was a cry for depth in two areas—depth in Biblical doctrine and depth in vital spiritual experience. Light and heat. Logic and fire. Word and Spirit.

Again and again he would be fighting on two fronts: on the one hand against dead, formal, institutional intellectualism, and on the other hand against superficial, glib, entertainment-oriented, man-centered emotionalism.

Lloyd-Jones was not what we call a cessationist. In fact he came out very strongly against the Warfield kind of cessationism. In 1969 he wrote against ‘A Memorandum on Faith Healing’ put out by the Christian Medical Fellowship which relied explicitly on Warfield's arguments that the sign gifts (like healing) were ‘accompaniments of apostleship’ and therefore invalid for today since the apostles were once for all.

‘I think it is quite without scriptural warrant to say that all these gifts ended with the apostles or the Apostolic Era. I believe there have been undoubted miracles since then.’ 

When Lloyd-Jones spoke of the need for revival power and for the baptism of the Spirit and for a mighty attestation for the word of God today, it was clear that he had in mind the same sort of thing that happened in the life of the apostles.

Piper’s talk is a study of revival and the baptism of the Holy Spirit Lloyd-Jones teaching and is well worthy of study. He sums it up as follows:

‘Could we not then say, in putting all this together, that signs and wonders function in relation to the word of God, as striking, wakening, channels for the self-authenticating glory of Christ in the gospel? Signs and wonders do not save. They do not transform the heart. Only the glory of Christ seen in the gospel has the power to do that (2 Cor. 3:18-4:6). But evidently, God chooses at times to use signs and wonders alongside his regenerating word to win a hearing and to shatter the shell of disinterest and cynicism and false religion, and help the fallen heart fix its gaze on the gospel.’

I can imagine this raising eyebrows in some evangelical churches today, but Lloyd-Jones was equally critical of some of the excesses of the Pentecostal movement and Piper’s talk includes a fascinating critique (fully referenced in his text) which I reproduce below.  

Lest you think Lloyd-Jones was a full-blown charismatic incognito let me mention some things that gave him balance and made him disenchanted with Pentecostals and charismatics as he knew them.

1. He insisted that revival have a sound doctrinal basis. And from what he saw there was a minimization of doctrine almost everywhere that unity and renewal were being claimed. The Holy Spirit is the Spirit of truth and revival will be shallow and short-lived without deeper doctrinal roots than the charismatic tree seems to have.

2. Charismatics put too much stress on what they do and not enough emphasis on the freedom and sovereignty of the Spirit, to come and go on his own terms. "Spiritual gifts," he says, "are always controlled by the Holy Spirit. They are given, and one does not know when they are going to be given".

You can pray for the baptism of the Spirit, but that does not guarantee that it happens ... It is in his control. He is the Lord. He is a sovereign Lord and he does it in his own time and in his own way.

3. Charismatics sometimes insist on tongues as a sign of the baptism of the Holy Spirit which of course he rejects.

It seems to be that the teaching of the Scripture itself, plus the evidence of the history of the church, establishes the fact that the baptism with the Spirit is not always accompanied by particular gifts.

4. But even more often most charismatics claim to be able to speak in tongues whenever they want to. 

This, he argues is clearly against what Paul says in 1 Cor. 14:18, "I thank God I speak in tongues more than you all." If he and they could speak in tongues any time they chose, then there would be no point in thanking God that the blessing of tongues is more often given to him than to them.

5. Too often, experiences are sought for their own sake rather than for the sake of empowerment for witness and for the glory of Christ.

The aim is not to have experiences in themselves but to empower for outreach and making Christ known ...

We must test anything that claims to be a movement of the Spirit in terms of its evangelistic power...

The supreme test of anything that claims to be the work of the Holy Spirit is John 16:14—"He shall glorify me".

6. Charismatics can easily fall into the mistake of assuming that if a person has powerful gifts that person is thus a good person and is fit to lead and teach. This is not true. Lloyd-Jones is aware that baptism with the Holy Spirit and the possession of gifts does not certify one's moral fitness to minister or speak for God. The spiritual condition at Corinth, in terms of sanctification, was low and yet there was much evidence of divine power.

Baptism with the Holy Spirit is primarily and essentially a baptism with power ... [But] there is no direct connection between the baptism with the Holy Spirit and sanctification ... It is something that can be isolated, whereas sanctification is a continuing and a continuous process.

7. Charismatics characteristically tend to be more interested in subjective impressions and unusual giftings than in the exposition of Scripture. Be suspicious, he says, of any claim to a "fresh revelation of truth". (In view of what he said above concerning how the Holy Spirit speaks today in guidance, he cannot mean here that all direct communication from God is ruled out.)

8. Charismatics sometimes encourage people to give up control of their reason and to let themselves go. Lloyd-Jones disagrees. "We must never let ourselves go". A blank mind is not advocated in the Scriptures. The glory of Christianity is what we can "at one and the same time ... be gripped and lifted up by the Spirit and still be in control" (see 1 Cor. 14:32). We must always be in a position to test all things, since Satan and hypnotism can imitate the most remarkable things.

But I’m giving you only a taster. Let me recommend again John Piper’s MP3 (or, if you prefer, the online transcript).

Department of Health officials attempt to bring in nurse and home abortion through back door

Doctors will be able to authorise abortions without seeing women and nurses will be authorised to perform abortions and send women home to abort their babies under new draft regulations from the Department of Health.

The proposed wide-ranging changes are currently being rushed through in a ‘consultation’ process of which many key stakeholders are apparently unaware.

The consultation, ‘Proposed changes to the procedures for the approval of independent sector places for the termination of pregnancy’, outlines ‘Required Standard Operating procedures’ (RSOPs) which independent sector facilities must follow in order to be licensed and receive taxpayers’ money for carrying out abortions.

The main beneficiaries are thought to be the British Pregnancy Advisory Service (BPAS) and Marie Stopes International (MSI) which according to the Charity Commission have annual turnovers of £25m and £175m respectively.

This week the Sexual Health Team of the Department of Health announced that they were closing the consultation, which was launched only on 22 November, on 17 January, three weeks before the 3 February closing date advertised on their website.

The move led to a storm of protest from groups who thought they still had three weeks to prepare their submissions.

But now following an 11^th hour intervention by the government the original closing date has been restored.

Under the Abortion Act 1967 abortions can only be performed if two doctors affirm ‘in good faith’ that an abortion request meets at least one of the grounds set out in the Act.

Furthermore only a registered medical practitioner (RMP) can perform an abortion.

The role of nurses in abortion has thus far been limited. They cannot authorise abortions nor carry them out but can only administer drugs used for medical abortions once they have been prescribed by a doctor.

But this will change dramatically if the new regulations go through.

The proposals are outlined in two documents that can be downloaded from the Department of Health website. The first is the consultation document itself (12pp) and the second details the proposed procedures (34pp).

The most important part of the latter is section 3 on Required Standard Operating procedures (RSOPs). It is RSOPs 1 and 2 on pp10-12 that deal with nurse and home abortion.

RSOP 1 essentially says that it is not necessary for doctors to see the women in order to authorise abortions ‘in good faith’ – nurses or others can gather the information and all the doctors need do is sign.

‘We consider it good practice that one of the two certifying doctors has seen the woman, although this is not a legal requirement.’

Today it emerged in an answer to a parliamentary question from Edward Leigh MP that over half of all abortions may already involve no doctor actually seeing the pregnant woman.

RSOP 2 is worded in such a way that it could allow nurses both to carry out surgical abortions and also to prescribe abortion drugs. This would appear to be against the letter and intention of the law.

‘The RMP is not required to personally perform every action. Certain actions may be undertaken by registered nurses or midwives (who are not RMPs) provided they are fully trained and the provider has agreed protocols in place.’

Furthermore it also allows patients having medical (drug-induced) abortions to abort at home provided they have had their drugs administered in the clinic.

‘Both drugs for the medical abortion must therefore be taken in the hospital or approved place. Women may be given the choice to stay on the premises or to go home soon after taking the second tablet, to be in the privacy of their own home for the expulsion.’

Another RSOP (25) says controversially that babies up to 24 weeks who are being aborted do not need pain relief because they do not have the neural connections necessary to feel pain.

This is based on a highly contentious report on fetal pain from the Royal College of Obstetricians and Gynaecologists which one leading paediatrician has compared to the ‘Emperor’s new clothes’.

The fact that such radical changes to abortion practice are being introduced with such haste and so little transparency will no doubt raise eyebrows in government.

But the abortion industry, together with the RCOG, BMA and GMC, has clearly been working very hard behind the scenes to ensure that it happens as quickly and smoothly as possible.

The changes, if they are authorised as intended, could reduce doctors in independent ‘clinics’ to perfunctory rubber-stamps allowing nurses effectively to authorise and perform abortions.

The new developments come in the wake of the controversy over illegal sex selection abortions and illegal pre-signing exposed by the Telegraph newspaper last year. They also come in the same week it has emerged that several thousand ‘lost girls’ may have fallen prey to sex-selection in Britain.

This new consultation appears to be a reaction to these events and an attempt to formalise and establish practices at the very edge of the law which are already widespread.

But it could well fuel calls for a full and comprehensive enquiry into why the abortion law is apparently being reinterpreted and not upheld.

It is after all the duty of parliament to make laws; not abortion providers and not the Department of Health.

I would encourage every individual and organisation with an interest to take advantage of the restored closing date and make a submission. It is thankfully not yet too late to influence these developments.

News coverage of this story

'Abortion on demand' gets Government ‘green light’ (Daily Telegraph)

Majority of abortions are approved by doctors who haven't met the patient (Daily Mail)

New Government guidelines will allow 'rubber stamping' of abortions (Daily Telegraph)

Assisted suicide storyline on Coronation Street – Five myths about death and dying

This morning I took part in a debate on the Radio Four Today programme (listen here) about the assisted suicide story to be screened next Monday in a British television drama (see my previous blog on this here).

The ITV Soap ‘Coronation Street’ is running a story centred on Hayley Cropper, a transgender character who has been diagnosed with inoperable pancreatic cancer.

According to media reports she declines pain relief out of fear that it might confuse her sexual identity and dies after drinking a lethal cocktail, the contents of which are not specified. 

I am not opposed in principle to drama programmes dealing with this issue but as a doctor who has managed many dying patients I expressed concern this morning that all media portrayal of suicide or assisted suicide has to be done with the utmost care and sensitivity so as not inadvertently to steer vulnerable people toward suicide.

On the basis of the reports I have heard the programme runs the real risk of giving credence to five dangerous myths about death and dying.

First there is the myth that people dying of cancer want to die. The overwhelming majority don’t – they want good care and support. Over 7,000 people die from pancreatic cancer every year in England and Wales and it is never more than a handful who choose or desire to go down the suicide route.

Next is the myth that cancer pain cannot be controlled – in good hands it almost invariably can. This is why the pro-euthanasia lobby have essentially stopped using pain as an argument for changing the law.

Third is the myth that that effective pain relief produces confusion and is therefore to be avoided. Although sedation is sometimes necessary in order to help control severe pain in a dying patient this is in practice very rarely the case. Patients with cancer pain can tolerate much larger doses of pain medication than you or I and remain mentally alert.

More serious is the myth that that the lives of some sick and disabled people are not worth living and that it is therefore reasonable for people with these conditions to kill themselves. This is profoundly discriminatory and demeaning and simply panders to ignorant prejudice. This is why disability rights activists are so strongly opposed to any change in the law. They know they will be in danger from people who have made judgments about their lives.

Finally, there is the myth that suicidal thoughts in sick and disabled people should be managed differently from similar thoughts in people who are not sick and disabled. People who choose to end their lives usually do so because of a perception that they are alone and that no one cares about them, because of a loss of meaning and purpose or because they perceive their lives to be a burden on others. It is much more about the person than the disease. People who are suicidal need love, support, care and professional help, not for us to accede to their requests. It is utterly illogical to offer a glass of barbiturate to someone who is terminally ill whilst offering protection and care to a person equally suicidal with a mental illness.

The WHO’s international guidelines on suicide portrayal in the media refer to over 50 published studies, systematic reviews of which have consistently drawn the same conclusion, that media reporting of suicide can lead to imitative suicidal behaviours.

Bad media portrayals of suicide run the very real risk of putting the lives of very vulnerable people in danger.This phenomenon is variably termed suicide contagion, copycat suicide or the Werther effect. 

Werther was the subject of an 18^th century quasi-autobiographical novel by Goethe who killed himself after losing his lover. The book led to a spate of suicides amongst young people at the time, showing that fictional portrayals of suicide can be as dangerous as real stories.

The WHO guidelines specifically include the following:

·         Avoid language which sensationalises or normalises suicide, or presents it as a solution to problems

·         Avoid prominent placement of stories about suicide

·         Avoid explicit description of the method used

·         Take particular care in reporting celebrity suicides

Conversely, the Papageno effect refers to suicide portrayal which reduces suicide, usually by showing its detrimental effects on relationships and communities or by demonstrating how to overcome suicidal thoughts. The term comes from Mozart’s magic flute and has been popularised in a recent article in the British Medical Journal.

So in short, Werther effect bad, Papageno effect good.

The producer of the Coronation Street defended his depiction this morning on Radio Four. We will see how his programme actually measures up next week.

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My ten most formative Christian Books

Every Christian has his or her own favourite books. Here are ten of the books that I read as a young Christian medical student and junior doctor that were most formative for me and really set me on my way. All have been republished many times over and most are still in print. All but one are well known and recognised as classics.

Some of those by authors still living have been revised and updated since I read them. In each case I have tried to find the original covers I knew them by but have linked to the latest editions on Amazon.

Of the authors I have personally met only Ron Sider, in Cape Town in 2010 at the Lausanne Conference. I told him I had read his book as a medical student and that it had completely changed my life and I thanked him for his service to the church.  

It’s said that to see anything with clarity we need to stand on the shoulders of giants.  I continually thank God for these Christian giants through whose labours I have been helped to see things a little more clearly.  

1. Mere Christianity– CS Lewis

  

My father encouraged me all through my early teenage years to read CS Lewis, but it wasn’t until I became a medical student that I eventually did and wondered why I had not listened to him earlier. Mere Christianity was the first and became my favourite book to give non-Christians. I read about 20 CS Lewis books during my fourth year at medical school. My overall favourite was the Pilgrim’s Regress.

2. Issues facing Christians today – John Stott

John Stott’s ‘Basic Christianity’, ‘Contemporary Christian’ and ‘Cross of Christ’ are perhaps better known and I benefited from all of them but this was the one that most helped me apply a biblical mind to ethical issues and laid the framework for my understanding of social justice. So much of what I do today is based on the lessons it taught me. 

3. Knowing God – JIPacker

Our Christian Union at Auckland Medical School gave every member a copy of this back in the late 1970s. We had to read one chapter a week and then met in small groups to discuss it. No book helped me more to explode my inadequate concepts of God and to know him personally through the Scriptures. 

4. Evidence that demands a verdict – Josh McDowell

As a Christian medical student trying to witness to my friends whilst at the same time trying to deal with my own doubts this book was a life saver. Just brilliant on the person of Christ, historicity of the Bible, evidence for the Scriptures and full of great arguments, quotes and illustrations which I still use today.

5. The Cost of discipleship – Dietrich Bonhoeffer

This German pastor was hanged by the Nazis during the Second World War. This book of short pithy chapters is essentially an exposition of the Sermon on the Mount and turned my early complacent Christian faith upside down. The first sentence, ‘Cheap grace is the deadly enemy of the church’ sums up the message and led me to take Jesus’ teaching seriously, not just as something to be believed but to be obeyed.

6. Whatever happened to the human race? – Francis Schaeffer 

Schaeffer has written many brilliant books which were invaluable to me in finding a solid intellectual basis for my faith. The Trilogy ('The God who is there', 'Escape from Reason', 'He is there and He is not silent') and ‘How then shall we live?’ were particularly helpful to me but it was this one that really opened my eyes up about abortion and euthanasia and deeply challenged me to  think radically and biblically about these issues. 

7. The Calvary Road –Roy Hession

This little book was just what I needed when failing to experience victory in my day to day walk with God. It deals with intransigent inward secret sins – like resentment, unforgiveness and pride – which can so dangerously wound our spirits and curb our effectiveness. A second book by Hession, equally short, ‘Be filled now’ builds on its lessons. The Calvary Road brought me to the foot of the cross and hugely deepened my appreciation of God’s love and grace. 

8. The Pilgrim’s Progress – John Bunyan

Written by an uneducated puritan pastor while imprisoned in late 17^th century England, this book is allegedly the most read and translated in the world outside the Bible for good reason. There is nothing quite like it to teach you to earth Christian experience in Scripture. The founder of the Congregational Church John Owen sought unsuccessfully to get Bunyan out of prison but God would not let him be released until he had finished writing this classic. 

9. The Simple Life –Vernard Eller

This little book is not well known but it is a remarkable work on simple lifestyle which unpacks the later writings of Danish philosopher Soren Kierkegaard. It was my introduction to Kierkegaard and taught me the valuable lesson of reading the latter backwards - starting with ‘Christian discourses’ and ‘Ethical Discourses’ rather than ‘Either Or’ - and introducing me to his amazing re-workings of Christ’s parables for a post-Christian audience.

10. Rich Christians in an Age of Hunger

If I had not read this book as medical student I am quite sure that I would have got caught in the trap of Western materialism and never served in Africa, never developed a passion for developing world justice and probably never ended up in full time Christian ministry. It deeply convicted me and total changed my attitude to material possessions and as a result, my whole life course.

 I’m going to resist the temptation to name more and stop there. If you have not read those above then I can assure you it will be time well spent that will impact on your thinking, decision-making and without doubt your future Christian trajectory. There are lots of good Christian books. But don’t miss these classics. Be blessed.