Week 2- Principles of Healthcare Ethics

Learning Objectives

Demonstrate knowledge of the Ethical Principlism and related principles.

Explore ANA and ICN codes and identify common ground.

Discuss ethical issues in global health.

Understand the application of ethical principles to global health.

Content List
Learning Objectives ....................................................................................................... 1
Introduction .................................................................................................................... 2
Ethical principles of Autonomy, Beneficence, Non-maleficence and Justice ............... 3
Autonomy ................................................................................................................... 4
Beneficence ................................................................................................................ 4
Non-Maleficence ........................................................................................................ 5
Justice ......................................................................................................................... 6
Professional Ethics and Codes: ...................................................................................... 7
The ANA Code of Ethics for Nurses ............................................................................. 7
A common theme of ANA and ICN codes .................................................................. 11
Application of ethical principles to global health ........................................................ 12
Harm prevention, public good and individual liberty .............................................. 12
Health promotion and equity .................................................................................... 13
Public health surveillance......................................................................................... 14
Public Health Services ............................................................................................. 15
References .................................................................................................................... 18

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Introduction

In Ethics or moral philosophy, the concept of Ethical Principlism was emerged

(DeMarco, 2005) and contain four principles: autonomy, beneficence, non-

maleficence, and justice (Figure 1) (Di Nardo et al. 2019). It could be said that bioethics

is a field of applied philosophy, which also involves the social sciences, in its attempt

to provide answers and solutions to ethical questions and dilemmas, which arise in the

fields of biology and healthcare. The study and analysis of ethics, however, can take a

variety of approaches, depending on the principles, rules, and norms (Ostman, Nasman,

Eriksson, and Nystrom, 2019). The principle-based approach must accept, at a

minimum, the existence of certain regulatory standards or a certain framework for

action as a basis of ethical reasoning (Childress, 2005). Nurses practicing in today’s

health care environment face increasingly complex ethical dilemmas. Keeping public

safe requires significant moral courage and resilience (ANA, nd). Other stakeholders

and authorities have also to tackle challenges on a global scale and they are facing

ethical dilemmas. For example, although many public policies are adopted in order to

improve equity and protect people’s rights, these frequently fail to prioritize the health

rights of citizens (Godard, Haddad, Huish, and Weinstock, 2018). On this ground, the

prominent ethical principles will be analyzed as well as their application to global health

(Keeling and Bellefleur 2016).

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 Figure 1. The four principles in healthcare. (Clipboard health, 2021)

Ethical principles of Autonomy, Beneficence, Non-maleficence and Justice

Every moral principle is binding, unless it conflicts with another moral principle, in

which case a choice between them is necessary (Lindridge, 2017). However, in the field

of health it is difficult to follow principles or rules that are absolute or not subject to

controversy. This is because, the healthcare sector accepts people with a multiple

clinical conditions and different ethical principles seem to be applicable in different

cases. Over time, the four ethical principles have been supported for their contribution

to the analysis of ethical issues that arise in healthcare. In addition to these four

principles, Beauchamp and Childress (2001) argue that there are additional rules that

can be applied to healthcare ethics, such as the obligation to tell the truth, the protection

of privacy, and the maintenance of confidentiality, as well as informed consent. Many

of these rules are considered to be derivatives of the main four principles of Bioethics.

An example is the disclosure of the truth to patients, which is a result of the principle

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of respect for autonomy, as the patients cannot make autonomous decisions about their

health without adequate and honest information (Childress, 2005).

Autonomy

The concept of autonomy is related to concepts such as respect for the individual,

informed consent and fundamental human rights (O’Neill, 2002) and implies that the

person has capacity for self-determination. People can have different preferences about

care options and they can consent to the treatment or refuse it (Di Nardo et al. 2019).

Informed consent is the process by which fully informed patients can participate in

decisions that concern their health care and the effects on their future lives. Informed

consent derives from legal and ethical law, according to which the patients have the

right to decide about interventions on their own bodies (Bowman, 2011).

Beneficence

This principle which can also be seen in the Hippocratic Oath is linked to performing

interventions that produce benefit directly to the patient. According to this principle,

there is the obligation to protect and defend the rights of others and provide lifesaving

support to people in danger (Beauchamp and Childress, 2001). This principle can be

applied to the individual level by offering help to each suffering person and at the level

of the general public by applying health preventative measures. Benefit for the patient,

however, may not be straightforward and the values, beliefs and culture of the patient

may affect how benefit is perceived (Di Nardo et al. 2019). There are also other issues

to consider, for example, helping one person can harm either oneself or another, such

as when performing a medical intervention to a patient or receiving an organ from a

donor for transplantation, respectively. In this and many other similar cases, this

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principle contradicts the principle of non-harm, as it becomes apparent that the

application of an action can have a double effect. Therefore, the following criteria

should be taken into consideration: the recipient of the assistance must be at significant

risk, the support provided must be directly related to the risk and/or prevent it, and the

benefit to the recipient must be significantly greater than the donor's harm. (Galanakis,

2005). Often the choice of a decision on a bioethical issue requires the ability to strike

a balance between the ethical principles that govern it. Ethical decisions also need the

presence of moral values on the part of the subject, which aims to make such a decision.

Non-Maleficence

This principle is related to not causing harm and this is presented in the Hippocratic

Oath as well. In case harm is unavoidable, it should be minimized and the benefits of

an intervention should outweigh the risks and any side effects (Di Nardo et al. 2019).

Healthcare professionals need to assess the risk-benefit ratio (Crellin and Ania, 2002).

According to Beauchamp and Childress (2001), examples of applying the principle of

non-harm are not killing and not inflicting suffering on others. One of the main dangers

that lurks in the practice of medicine and finds application in issues of this kind is the

so-called "slippery slope argument". The central idea of the argument is that when a

person accepts a particular situation, it is very difficult not to accept more extreme

situations than the original (Hope and Hope, 2004). The problem is that the slippery

slope argument describes one situation that has occurred at a given point in time in the

past, however it cannot predict that a similar situation will occur in the future (Louhiala,

2003)

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Justice

The principle of justice includes the notions of fairly and equitably distributed health

care regardless of personal characteristics such as age, social statues, disability etc. This

involves prioritization and proper allocation of resources (Marseille and Kahn, 2019).

In health care there are three types of justice: the distributive justice, rights-based and

the legal justice. People should be treated with respect and without discrimination (Di

Nardo et al. 2019). The application of the principle of justice is often based on certain

criteria. Determining the form and content of these criteria has preoccupied societies

since ancient times. Historically, the protection of public health has often been

accompanied by legislation. In fact, health law is considered to be one of the primary

forms of law. The right to health includes health care, prevention, proper nutrition,

hygiene and protection from water and air pollution. More recently, it has included the

occupational health prevention in order to mitigate chronic injuries and diseases as a

result of unhealthy and dangerous working conditions. According to the Universal

Declaration of every person has the right to a certain level of health and well-being for

himself and his family, which includes food, clothing, housing, health care etc. In recent

years minimum health-related rights or the right to receive basic health care have been

discussed for example, vaccinations, the treatment of various diseases, the provision of

geriatric care and more. Rights are also recognized in special health-related conditions,

such as motherhood, childhood, old age, the presence of mental illness, participation in

clinical trials and medical research, people with disabilities etc. Another issue in

healthcare is the distribution and use of the available resources to health which is

directly related to the view of health as a private or social good. This needs prioritization

and criteria setting such as legitimacy and impartiality.

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Professional Ethics and Codes:

According to ANA (nd), nurses have the moral obligation not only to protect public and

patients but also to protect themselves. They have the duty to prioritize health and

safety, preserve wholeness of character and integrity, improve skills and abilities, and

develop professionally and personally. Nurses’ professional commitments are deeply

virtuous including compassion, courage, clinical competence, integrity, fairness,

trustworthiness, wisdom, and many others. Nurses are not obligated to take on extreme

risks to prove their value as heroes do. Unconscious adoption of heroism blurs the

ethical edge of professional practice and the important distinction that nurses must

preserve their own safety and health in order to take care of others. Nurses should not

take unnecessary risks for themselves and their loved ones in order to be a hero at work

and healthcare facilities should be a safe place for nursing practice providing all the

necessary equipment to protect nurses (ANA, nd).

The ANA Code of Ethics for Nurses

The ANA Code of Ethics is consisted of nine provisions (Figure 2):

• Provision 1. The nurse practices with compassion and respect for the inherent

dignity, worth, and unique attributes of every person.

• Provision 2. The nurse’s primary commitment is to the patient, whether an

individual,

• family, group, community, or population.

• Provision 3. The nurse promotes, advocates for, and protects the rights, health,

and

• safety of the patient.

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 • Provision 4. The nurse has authority, accountability and responsibility for

nursing

• practice; makes decisions; and takes action consistent with the obligation to

provide optimal patient care.

• Provision 5. The nurse owes the same duties to self as to others, including the

responsibility to promote health and safety, preserve wholeness of character and

integrity, maintain competence, and continue personal and professional growth.

• Provision 6. The nurse, through individual and collective effort, establishes,

maintains, and improves the ethical environment of the work setting and

conditions of employment that are conducive to safe, quality health care.

• Provision 7. The nurse, in all roles and settings, advances the profession through

research and scholarly inquiry, professional standards development, and the

generation of both nursing and health policy.

• Provision 8. The nurse collaborates with other health professionals and the

public to protect human rights, promote health diplomacy, and reduce health

disparities.

• Provision 9. The profession of nursing, collectively through its professional

organizations, must articulate nursing values, maintain the integrity of the

profession, and integrate principles of social justice into nursing and health

policy (American Nurses Association, 2015).

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Figure 2. The principles of ANA code of ethics (American Nurses Association, 2015)

The ICN Code of Ethics for Nurses

Nurses have four fundamental duties: to promote health, to prevent disease, to restore

health and to alleviate discomfort. Nurses have to show respect for human and cultural

rights, the right to life and preferences, and dignity regardless of individual attributes

such as: age, colour, culture, disability or illness, gender, sexual orientation, nationality,

politics, race or social status. Nurses are responsible for preserving and promoting

public, patients’ and family health (Figure 3).

1. Nurses and people. The nurse’s primary professional duty is to care for people

respecting human rights, values, customs and spiritual beliefs of the individual, family

and community. The nurse must deliver accurate, sufficient and timely care, take

accurate information and patients’ history and gain consent of treatment and care. The

nurse holds in confidence personal information and uses judgement in sharing this

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information. The nurse is responsible for treating vulnerable people advocating for

equity and social justice in resource allocation, access to health care and other social

services. The nurse should be respectful, responsive, compassionate and trustworthy.

2. Nurses and practice. Nurses should maintain their skills and competencies up to date

through regular trainings. Professional and personal growth is essential for this role.

The nurse maintains a standard of personal health such that the ability to provide care

is not compromised. The nurse uses judgement regarding individual competence when

accepting and delegating responsibility. The nurse should abide by nursing standards

and code of conduct in order to promote the profession to the public and maintain a

positive image of the profession enhancing the trust of the community to the nurses.

The nurse, in providing care, examines that use of technology and scientific outputs and

evidence are in line with the safety, dignity and rights of people. The nurse should

promote an ethical behaviour and be open to the dialogue.

3. Nurses and the profession. The nurse assumes the major role in determining and

implementing acceptable standards of clinical nursing practice, management, research

and education. The nurse should practice by applying evidence-based knowledge and

regularly update knowledge on the field of nursing. The nurse is active in developing

and sustaining a core of professional values. The nurse, acting through the professional

organisation, participates in creating a positive practice environment and maintaining

safe, equitable social and economic working conditions in nursing. The nurse practices

to sustain and protect the natural environment and promote an ethical environment.

4. Nurses and co-workers. The nurse must remain professional and be a team player

respecting relationships with co-workers in nursing and other fields. The nurse has the

duty to safeguard individuals, families and communities when their health is

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endangered by a co-worker or any other person. The nurse takes appropriate action to

support and guide co-workers to advance ethical conduct (ICN, 2012).

Figure 3. The ICN Code of Ethics for Nurses.

A common theme of ANA and ICN codes

ANA and ICN codes of ethics for nurses have similarities. First of all, the application

of those codes is universal and can be applied to all settings and roles. The principles

are non-negotiable, provide guidance for ethical practice in nursing and focus on values,

people, relationships, professionalism and personal growth. Both codes promote values

such as: respect, privacy and advocacy. Nurses are responsible for patients,

communities and themselves. They should ask in compliance with standards, and

deliver safe and quality care promoting a secure and healthy environment. Nurses

should promote health, prevent illness and alleviate discomfort (Butts and Rich, 2019)

In more detail, the two codes have similarities regarding the first principle where the

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respect for the human rights is mentioned. Code 2 of ICN is similar to ACA provision

6 as they both support the compliance to standards and the provision of quality care.

Code 3 and provision 7 promote the concept of professionalism and the personal and

professional development of nurses through research, training and adherence to

standards and policies. Code 4 and Provision 8 state that nurses should work as team

players respecting colleagues.

Application of ethical principles to global health

Global health ethics represent the process of applying moral value to health issues that

produce a worldwide effect or require action to be taken at a global scale. It is important

to highlight the fact that global health ethics are concerned with macro-level health

phenomena. Global health ethics tries to address issues in a wide geographical area by

developing common values and universal norms for responding to global health threats

(Stapleton et al. 2014). Global issues include the childhood malnutrition, the lack of

access of vulnerable groups to antiretroviral therapy to fight HIV, restricted healthcare

provision to immigrants and asylum seekers, maternity issues and inaccessibility to

appropriate healthcare facilities, medicines and blood components, and skilled

healthcare personnel. Women living in underprivileged locations or of low income are

more likely to experience those limitations to care (Breakey, Corless, Meedzan, and

Nicholas, 2015).

Harm prevention, public good and individual liberty

Individuals have a right to privacy and to freedom of movement. However, because

infectious disease threatens public health it may be reasonable to limit people’s privacy

and liberty in order to protect the community. Thus, strategies such as closing schools,

cancelling social events, and quarantining infectious cases might be considered

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especially during a pandemic. In instances where outcomes are uncertain and

potentially detrimental, evidence-based and balanced restrictions may be justified by

values such as solidarity and reciprocity. Regarding the treatment or prevention debate,

it has to be stated that public health practice and policy is founded on the idea that

prevention is better than waiting for harm to occur that needs to be treated. Prevention

is affordable, practical, and based on the moral statement that prevention can reduce

suffering that can be caused by an illness. At the same time, when resources are limited,

promoting prevention may reduce available resources to treatment. Determining how

to allocate scarce resources between prevention and treatment can therefore raise

difficult ethical issues related to distributive justice. For example, scientists working in

disease prevention have recently determined that providing antiretroviral therapy to

people infected with HIV may significantly lower the risk that they will transmit the

virus to uninfected sexual and needle-sharing partners. However, this approach may

lead to the use of antiretroviral therapy in persons who do not need it for their own

clinical benefit (WHO, 2015).

Health promotion and equity

Non-communicable diseases are a global problem that rises across the world and are

caused by the social determinants of health and lifestyle choices, such as smoking

tobacco, drinking alcohol, excessive eating and lack of workout. Policies for example,

tobacco restrictions, have been put into effect in order to mitigate the prevalence of

non-communicable diseases. However, autonomous adults generally have the right to

engage in risky behaviour, as long as their actions do not put other people directly at

risk. In this context, it is difficult to define the actions and ethical obligation of

governments and at what extend they have to act and adopt relevant policies (WHO,

2015).

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Public health surveillance

Public health requires robust data and tools to early detect the disease and threats to

health within a population. The derived information may help with prioritization of

resource allocation, the adoption of appropriate policies etc. The question though, is

how the need for accurate disease surveillance data be balanced against the principle of

individual autonomy. For example, in the mid-1980s, blood samples that had been taken

for clinical purposes were stripped of identifying information and tested for HIV, in an

attempt to estimate the prevalence of HIV infection in the population. Supporters of

this practice maintained that it was ethical to perform HIV tests without patient consent

because the samples did not carry any identifying information, and the results of the

tests could provide important information about the prevalence of HIV in the

community. Critics expressed concerns about the fact that patients who tested positive

for HIV would not be informed of the results of their tests. In the early years of the HIV

pandemic, when no treatment was available, there was a consensus that, given the

population-level benefit of gathering accurate data on the prevalence of HIV infection,

this mode of surveillance was ethical and, in fact, might be obligatory for states

confronting the emerging epidemic. Over the past decade, however, as prospects of

treating HIV have improved, the argument has shifted. Today, anonymous testing of

blood samples for HIV would probably not be approved by an ethics committee, as it

would be considered ethically inappropriate to identify individuals as HIV-positive

without being able to follow up with treatment. This example shows how ethical policy-

making is a dynamic process that must be adapted to the evolving situation (WHO,

2015).

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Public Health Services

Global health requires essential Public Health Services (Figure 4) (CDC, 2014) which

are:

1. Monitor health status to identify community health problems.

The purpose is to provide accurate and periodic assessment of the community’s

health status, detect health risks through statistics, analyzing data and using records and

appropriate tools and technology, and identify assets and resources.

2. Diagnose and investigate health problems and health hazards in the community.

The goal is to explore health threats and detect them in a timely manner, provide

services for diagnosis, and conduct response plans to address major health

threats.

3. Inform, educate, and empower people about health issues.

This includes initiatives such as training in order to enhance knowledge and shape

attitudes, inform decision-making choices, develop competencies and behaviors for

healthy living, promote programmes and partnerships in the community to improve

health and disseminate health information through a variety of channels.

4. Mobilize community partnerships and action to identify and solve health

problems.

This can be achieved by identifying stakeholders and building formal and informal

partnerships to improve public health.

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 5. Develop policies and plans that support individual and community health

efforts.

This step needs the development of policies and emergency response plans to protect

health and guide public health practice and seek and allocate resources towards the

expected goals.

6. Enforce laws and regulations that protect health and ensure safety.

This step entails the review, assessment and revision of laws, and regulations, the

education about legislation needed to protect and promote health and the enforcement

of laws.

7. Link people to needed personal health services and assure the provision of

health care when otherwise unavailable.

This includes the identification of vulnerable groups that face difficulties in accessing

health care services, the ongoing care management, the culturally appropriate and

targeted health information for vulnerable groups and the enhancement of

transportation systems and other enabling services to improve accessibility to

healthcare facilities.

8. Assure competent public and personal health care workforce.

This can be achieved by assessing and educating the workforce as well as maintaining

the expected standards.

9. Evaluate effectiveness, accessibility, and quality of personal and population-

based health services.

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This incorporates an ongoing assessment, quality improvement and performance

management.

10. Research for new insights and innovative solutions to health problems

This includes the research and implementation of innovations that could promote public

health, the establishment of links between public health practice and

academic/research settings and the enhancement of epidemiological studies, health

policy analyses and public health systems research.

(Ortmann et al. 2016).

Figure 4. Essential Public Health Services. (Ortmann et al. 2016)

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References

American Nurses Association (2015) Code of ethics with interpretative statements.

Silver Spring, MD.

ANA (nd) Provision 5: Self care and Covid19. Code of Ethics for nurses, pp. 1-6.

Available at: https://www.nursingworld.org/~4a1fea/globalassets/covid19/provision-

5_-self-care--covid19-final.pdf

Breakey, S., Corless, I., Meedzan, N. and Nicholas, P. (2015) Global Health Nursing in

the 21st Century. Chapter 4. New York, NY: Springer Publishing Company. Available

at: https://ebookcentral.proquest.com/lib/UNICAF/detail.action?docID=2166649

Butts, JB., . Rich, KL., (2019) Nursing Ethics across the curriculum and into practice.

5th edition, Jones and Bartlett learning, USA.

Beauchamp, T. and Childress, J. (2001) Principles of Biomedical Ethics (5th edn). New

York: Oxford University Press,

Bowman, D. et al. (2011) Informed Consent: A Primer for Clinical Practice, Cambridge

University Press. Available at: ProQuest Ebook Central,

http://ebookcentral.proquest.com/lib/UNICAF/detail.action?docID=833520.

CDC (2014) The 10 Essential Public Health Services, An Overview.

Available at:

https://www.cdc.gov/publichealthgateway/publichealthservices/pdf/essential-phs.pdf

Childress, J. (2005) A principle-based approach. A Companion to Bioethics. Kuhse H,

Singer P (eds). Malden, MA: Blackwell Publishing.

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Clipboard health (2021) How the 4 Principles of Health Care Ethics Improve Patient

Care. Available at: https://clipboardhealth.com/how-the-4-principles-of-health-care-

ethics-improve-patient-care

DeMarco, JP. (2005) Principlism and moral dilemmas: a new principle. Journal of

Medical Ethics, 31, pp. 101-105.

Di Nardo, M., Dalle Ore, A., Testa, G., Annich, G., Piervincenzi, E., Zampini, G.,

Bottari, G., Cecchetti, C., Amodeo, A., Lorusso, R., Del Sorbo, L., Kirsch, R. (2019)

Principlism and Personalism. Comparing Two Ethical Models Applied Clinically in

Neonates Undergoing Extracorporeal Membrane Oxygenation Support. Frontiers in

Pediatrics, 7. Doi:10.3389/fped.2019.00312.

Godard, B., Haddad, S., Huish, R., and Weinstock, D. (2018) Introduction to Ethics and

Global Health. BMC Med Ethics, 19 (51).

ICN (2012) The ICN code of ethics for nurses. Geneva, Switzerland. Available at:

https://www.icn.ch/sites/default/files/inline-

files/2012_ICN_Codeofethicsfornurses_%20eng.pdf

Keeling, M. and Bellefleur, O. (2016). Principlism and frameworks in public health

ethics. Montréal, Québec: National Collaborating Centre for Healthy Public Policy.

Lindridge, J. (2017) Principlism: when values conflict. Journal of Paramedic practice.

Available at: https://www.paramedicpractice.com/features/article/principlism-when-

values-conflict

Marseille, E., and Kahn, J.G. (2019) Utilitarianism and the ethical foundations of cost-

effectiveness analysis in resource allocation for global health. Philos Ethics Humanit

Med, 14 (5). Doi: https://doi.org/10.1186/s13010-019-0074-7.

UHRINN 302 – Ethical Principles and Practice Page 19 of 20

O’Neill, O. (2002) Autonomy and Trust in Bioethics. Cambridge: Cambridge

University Press.

Ortmann, L.W. et al. (2016) Public Health Ethics: Global Cases, Practice, and Context.

Public Health Ethics: Cases Spanning the Globe. Public Health Ethics Analysis. H.

Barrett, D., W. Ortmann, L., Dawson, A., Saenz, C., Reis, A., Bolan, G. (eds) Springer,

Cham.

WHO (2015) Global health ethics. WHO, Luxembourg. Available at:

https://apps.who.int/iris/bitstream/handle/10665/164576/9789240694033_eng.pdf

Ostman, L., Nasman, Y., Eriksson, K., and Nystrom, L. (2019) Ethos: The heart of

ethics and health. Nursing Ethics, 26 (1), pp. 26–36.

Stapleton, G, Schröder-Bäck, P, Laaser, U, Meershoek, A, Popa, D. (2014) Global

health ethics: an introduction to prominent theories and relevant topics. Glob Health

Action. Doi: doi: 10.3402/gha.v7.23569. PMID: 24560262; PMCID: PMC3925811.

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