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PAPER
The ethics and politics of mindfulness-based
interventions
Andreas T Schmidt
Correspondence to
Dr Andreas T Schmidt,
University Center for Human
Values/Woodrow Wilson
School, Princeton University,
315 Wallace Hall, Princeton,
NJ 8544, USA;
andreas.schmidt@princeton.
edu, andreastschmidt@gmail.
com
Received 9 June 2015
Revised 2 March 2016
Accepted 31 March 2016
Published Online First
20 April 2016
To cite: Schmidt AT. J Med
Ethics 2016;42:450–454.
ABSTRACT
Recently, there has been a lot of enthusiasm for
mindfulness practice and its use in healthcare,
businesses and schools. An increasing number of studies
give us ground for cautious optimism about the potential
of mindfulness-based interventions (MBIs) to improve
people’s lives across a number of dimensions. This paper
identifies and addresses some of the main ethical and
political questions for larger-scale MBIs. First, how far
are MBIs compatible with liberal neutrality given the
great diversity of lifestyles and conceptions of the good
characteristic of modern societies? It will be argued that
the potential benefits of contemporary secular
mindfulness practice are indeed of a sufficiently primary
or all-purpose nature to qualify as suitable goals of
liberal public policy. Second, what challenges are
brought up if mindfulness is used in contexts and
applications—such as military settings—whose goals
seem incompatible with the ethical and soteriological
views of traditional mindfulness practice? It will be
argued that, given concerns regarding liberal neutrality
and reasonable disagreement about ethics, MBIs should
avoid strong ethical commitments. Therefore, it should,
in principle, be applicable in contexts of controversial
moral value. Finally, drawing on recent discussions
within the mindfulness community, it is argued that we
should not overstate the case for mindfulness and not
crowd out discussion of organisational and social
determinants of stress, lowered well-being, and mental
illness and the collective measures necessary to address
them.
INTRODUCTION
Recently, there has been a lot of enthusiasm for
mindfulness practice and its use in healthcare, busi-
ness and education. Increasing empirical evidence
makes mindfulness-based interventions (MBIs)
seem promising across a broad range of applica-
tions, particularly so for the treatment and preven-
tion of anxiety and depression. This paper
introduces some of the ethical and political issues
surrounding MBIs to academic population-level
bioethics.
i
Particularly, it discusses how far such
interventions are compatible with liberal neutrality;
how far it is a problem that mindfulness is applied
in settings whose goals are incompatible with the
ethics of traditional mindfulness practice; and what
role such initiatives should play in situations in
which stress and mental illness have social
determinants.
MINDFULNESS AND ITS BENEFITS
Although contemporary secular mindfulness prac-
tice draws in important ways on the Buddhist trad-
ition, I will distinguish between Buddhist
mindfulness and contemporary mindfulness prac-
tice.
2
The term ‘mindfulness’encompasses a range
of concepts and practices, all of which have import-
ant aspects in common but also differ in significant
ways.
3
A core idea of contemporary mindfulness is
bare attention, the state of mind and metacognitive
skill of directing attention towards, and being
receptive to, whatever is happening in the present
moment both externally and internally. Bare atten-
tion is usually combined with the attitude of non-
judging acceptance, of being curious and accepting
towards thoughts and experiences as they occur.
Mindfulness-based stress reduction (MBSR) was
originally developed by John Kabat-Zinn as a
group intervention to assist patients with chronic
pain.
45
Taught in an 8 week course, MBSR typic-
ally includes body scanning, simple yoga poses and
mindfulness meditation exercises. Mindfulness-
based cognitive therapy (MBCT) combines MBSR
with elements of cognitive therapy. MBCTwas ori-
ginally designed to prevent relapse in patients with
remitting depression.
67
One of the aims is to see
negative thoughts as mental events instead of
taking them at face value so as to prevent that such
thoughts have dysphoric effects. Similar to MBSR,
MBCT is usually taught in an 8 week course.
Besides MBSR and MBCT, other methods exist
that integrate mindfulness with other measures.
ii
MBIs are used in the treatment of depression,
anxiety and relapse prevention.
10–12
A growing
number of studies also look at other benefits of
mindfulness, including, but not limited to, its bene-
fits in terms of emotion regulation;
13
its use for the
treatment of substance abuse, problem gambling
and binge eating;
14 15
and its use for the treatment
of somatic conditions such as chronic pain.
5
Encouraging results have also been reported regard-
ing the benefits of MBSR for healthy individuals.
16
Overall, effectiveness studies of MBIs show prom-
ising results across a number of applications. There
is good evidence that MBIs are effective in the treat-
ment of depression, anxiety and relapse preven-
tion.
10–12
Increasing evidence has led the National
i
Some work has been done on ethical questions arising at
the individual level, for example, those confronting
mindfulness teachers.
1
ii
Such as Acceptance and Commitment Theory
8
and
Dialectical Behaviour Therapy.
9
450 Schmidt AT. J Med Ethics 2016;42:450–454. doi:10.1136/medethics-2015-102942
Public health ethics
Institute for Health and Care Excellence in the UK to recom-
mend MBIs for the treatment of patients with three or more epi-
sodes of depression.
iii
There is also reason to believe that MBIs
might be effective for a number of other psychological conditions
and have benefits for healthy individuals. MBIs are therefore also
gaining popularity outside medical contexts, such as mindfulness
programmes for schools,
17
businesses and prisons.
18
Overall, existing empirical studies give us reason to be opti-
mistic about the potential of MBIs to reduce stress, deal with
psychological conditions and increase well-being. In this paper, I
will assume there is sufficient reason for cautious optimism
about the effectiveness of MBIs as well as sufficient reason to
start thinking about the ethical and political questions that MBIs
might bring up. I will not assume that questions regarding the
effectiveness of MBIs are settled or that we have a very clear
sense of the precise magnitude of its potential benefits.
Effectiveness is of course a central element for an overall
ethical evaluation of MBIs. But there are other ethical and polit-
ical questions that MBIs might bring up to which I will turn
now.
LIBERAL NEUTRALITY
One set of worries concerns the question as to whether MBIs
constitute an illegitimate promotion of a particular worldview
or way of life. This is illustrated by criticism that has been
voiced when some schools in the USA and other countries
started integrating MBIs in their curricula. One of the most
common objections is that mindfulness practice is a religious
practice in disguise and thus has no place in secular educa-
tion.
19–23
In a number of cases, parents’objections have led
schools to discontinue their mindfulness programmes. In the
USA, it is unconstitutional to teach religious practice in public
schools. Pupils also do not have much choice over whether they
want to participate in such mindfulness practices or not. So,
worries about the historical religious roots of MBIs arise first
and foremost in educational settings, particularly for public
schools. To some extent, however, similar worries might also
arise for MBIs in healthcare settings. We might worry about
publicly funded healthcare systems, such as the National Health
Service in the UK, using MBIs as standard treatments to
promote particular ways of living. Besides their religious roots,
MBIs also seem a potentially very far-reaching and intrusive
type of treatment. Mindfulness practice is supposed to be inte-
grated throughout the day, potentially turning even trivial activ-
ities—such as brushing your teeth—into mindful activities. By
changing the way you think,MBIs try to change the way you
live. This makes MBIs, in a sense, more intrusive and far-
reaching than other treatments. For example, prescribing medi-
cation, or incentivising smoking cessation, does not require a
change in how people think and how they go about their daily
business.
Finally, similar worries might arise, though again to a lesser
extent, when mindfulness programmes are made mandatory for
employees in private companies, particularly if these companies
have diverse workforces. We might worry about companies
exercising too much influence over how employees should lead
their lives—particularly outside of work.
Underlying these worries might be the belief that it is not the
business of such institutions, particularly state institutions, to
promote particular lifestyles or conceptions of the good.
Philosophically, this can be expressed by a concern with liberal
neutrality: public policies should not aim to promote particular
conceptions of the good and in justifying institutions and public
policy we should only rely on reasons acceptable to people with
differing (reasonable) conceptions of the good.
24 25 iv
A strong
version of liberal neutrality would hold that a policy is strictly
impermissible, if it conflicts with liberal neutrality. However,
such a strong form is typically considered implausible, even by
those working within the liberal tradition.
27–29
I will thus
assume, for the sake of argument, that while neutrality is desir-
able, a concern for neutrality can be overridden by other norma-
tive considerations.
30
Accordingly, if MBIs were in conflict with
liberal neutrality, this would be a consideration but not necessar-
ily a decisive argument against MBIs.
I will now argue that including MBIs in schools, healthcare
settings and organisational settings is compatible with a concern
for neutrality. Discussing this point will also give us good reason
to promote strongly secular and ‘axiologically thin’versions of
mindfulness practice—something that will prove important in
following sections.
First, as mentioned above, many worry about the Buddhist
roots of mindfulness. Liberal neutrality implies that the state
should not promote particular religions. However, this
oft-expressed worry is not a problem for contemporary mind-
fulness practice. While MBIs in healthcare and schools draw on
and resemble traditional Buddhist meditative practices in
various ways, they do not make any metaphysical or religious
assumptions and are specifically designed to be secular.
Second, the goal of MBIs is to introduce mindfulness into all
areas of one’s life. So, while not promoting a particular religion,
one might worry that MBIs promote a particular spiritual and/
or meditative lifestyle. But, again, these worries are unfounded
for contemporary versions of mindfulness as used in schools,
businesses and healthcare settings. While MBIs include medita-
tion exercises, these exercises are not meant to replace other
activities we might find valuable. Instead, by incorporating tech-
niques into everyday life and by strengthening particular meta-
cognitive skills, mindfulness aims to facilitate (among other
things) that people are receptive to and aware of the experiences
they have in the present moment. Whatever one’s activities and
goals, MBIs are intended to help people pursue them in a more
focused manner, experience them more directly and often enjoy
them more. Importantly, MBIs are not intended to replace our
current activities or projects with meditation or spirituality. So,
while MBIs might have far-reaching effects on people’s lives, it
is compatible with a very broad range of lifestyles and not at all
committed to a spiritual, meditative or self-denying lifestyle.
Third, many liberals believe that the state should not be in
the business of ‘making people happy’. A worry about promot-
ing mindfulness, particularly in healthy populations, might be
that it seems that the state—or other public institutions or
iii
National Institute of Clinical Excellence (2004). Depression:
Management of Depression in Primary and Secondary Care. National
Clinical Practice Guidelines, Number 23. London, HMSO. Updated
2009.
iv
Neutrality is typically considered to be about state policies.
Accordingly, worries apply first and foremost to MBIs in public
education and, to a lesser extent, publicly financed healthcare.
Nonetheless, while maybe not a strong ‘justice constraint’for private
social institutions (eg, businesses), neutrality might still be valuable.
(Alternatively, we could hold that such institutions are part of the
Rawlsian ‘basic structure’or reject the idea that concerns of justice apply
only to the basic structure.
26
I will not try to solve these complex issues
here.)
Schmidt AT. J Med Ethics 2016;42:450–454. doi:10.1136/medethics-2015-102942 451
Public health ethics
corporations—takes it upon itself to make people happier.Does
this not seem like smuggling utilitarianism (or some form of
perfectionism) in through the backdoor? I think we can address
this worry without committing ourselves to utilitarianism or
perfectionism. Rawlsian liberals often believe that the goods
provided by just institutions and public policy should be such
that individuals have reason to want them whatever their
respective reasonable conception of the good (so-called ‘primary
goods’).
31
I think it is plausible to believe that the psychological
skills and benefits potentially facilitated through MBIs are of
such an all-purpose or primary nature. Some of the presumed
benefits relevant in this context are reduced anxiety, less stress,
better emotion regulation, improved interpersonal skills, better
attention and improved self-esteem.
13 32
These benefits will
improve one’s ability to pursue one’s conception of the good—
more or less—whatever the precise content of that conception
might be. Therefore, if the psychological all-purpose benefits of
mindfulness are real, they seem compatible with neutrality. This
also means we have reason to pursue MBIs, even if we do not
believe that the state (or private companies) should try to make
people happy.
Finally, we might worry that mindfulness promotion fails the
neutrality test, because it carries a certain ethical message. It is
sometimes argued that liberal neutrality also implies being
neutral on a class of ethical questions that are not considered
part of justice but to be decided within a person’s comprehen-
sive view of the good (one’s view on abortion is sometimes
given as an example). Is mindfulness committed to specific
ethical commitments that should be left to individuals to
decide? Here, we should again distinguish between more trad-
itional Buddhist practices and contemporary secular approaches.
Buddhism often includes relatively specific ethical prescriptions
(such as not to work in the meat industry). Contemporary
approaches, on the other hand, are not committed to substan-
tive ethical standards about what is good, bad, right or wrong.
While such practices often include compassion exercises, I think
the ability to be compassionate and mindful of those around
one should again be considered a general moral and social skill
rather than a particular, contentious ethical viewpoint.
So, overall, MBIs do not seem committed to any contentious
conception of the good. Instead, they can provide psychological
goods of an all-purpose or primary nature.
However, one might object that while the benefits of MBIs
are potentially valuable for the great majority of conceptions of
the good, they might still be incompatible with some very spe-
cific conceptions. Imagine, for example, your conception of the
good requires overthinking everything and leading a life of
anxiety and constant self-doubt. Think of the character George
Costanza in the sitcom Seinfeld, for example. Now, mindfulness
practice does seem incompatible with such a lifestyle. Is this a
problem?
To answer this worry, consider different ways in which theor-
ists spell out liberal neutrality.
First, effect neutrality requires that policies not have the effect
of making one particular conception of the good more successful
or widespread than another. Successful MBIs are indeed incom-
patible with effect neutrality, as they are likely to reduce the
number of people leading lives like George Costanza (or other
‘mindless’lifestyles). However, in the literature, effect neutrality
is typically considered an implausible rendering of neutrality. It
would rule out too many policies we intuitively believe should
not be ruled out by a concern for neutrality. For very rarely do
public policies have the effect of preserving the exact proportion
of followers for different conceptions of the good.
30
Second, an alternative rendering is neutrality of procedure:
public policies should be justified without appealing to the ‘intrin-
sic superiority of any particular conception of the good life’.
24
Do
MBIs fulfil neutrality of procedure? Above I argued that the poten-
tial benefits of mindfulness are valuable across a very broad range
of conceptions of the good. Accordingly, with respect to these con-
ceptions of the good, we need not make contentious assumptions
regarding their intrinsic value. But nor do we have to assume that
‘mindless’lifestyles are intrinsically worse. For MBIs typically
leave it to the individual to pursue mindfulness or not.
Mindfulness practice is in some respect similar to exercise: doing
mindfulness regularly and incorporating it into one’slifeisnot
easy and requires effort and persistence. If you do not want to
practice it—and prefer a ‘mindless’life—MBIs will not impose
any meaningful obstacles. This holds even if MBIs are a mandatory
part of a school curriculum. For even then, whether you adopt
mindfulness as part of your lifestyle is largely voluntary, as being
mindful requires effort and practice. So, the justification of MBIs
could simply be that it enhances opportunities to pursue concep-
tions of the good for a very broad range of conceptions of the
good while also leaving it open to the individual to pursue other,
incompatible lifestyles. Such a justification foregrounds the
opportunity-enhancing aspect of MBIs and does not assume that
one conception of the good is superior to another.
Third, neutrality of aims requires that public policies not
intentionally aim to favour or disfavour specific (reasonable)
conceptions of the good. MBIs are compatible with this render-
ing of neutrality for the same reasons proffered above: first, the
aim of MBIs is to extend opportunities to pursue conceptions
of the good—more or less—whatever those conceptions are;
second, MBIs do not intentionally disfavour mindless lifestyles
in an objectionable way, because they leave it to the individual
whether to pursue mindfulness or not.
Finally, treatment neutrality requires that policies not treat dif-
ferent people and their conceptions of the good differently by
placing disproportional obstacles or by providing disproportional
resources to one conception over another.
30
Here, we would
again hold that while MBIs promote opportunities to pursue a
very broad range of conceptions of the good, they do not make it
significantly difficult to pursue conceptions of the good incom-
patible with mindfulness. Because pursing a mindful life requires
effort and persistence, MBIs do not impose significant or dispro-
portionate burdens on those wishing to lead ‘mindless’lives.
Overall, MBIs, even those used in public schools, are compat-
ible with liberal neutrality. MBIs might contribute towards
primary psychological skills and benefits that are valuable—
more or less—whatever one’s life plans might be. This also gives
us reason to keep MBIs religiously, axiologically and ethically
non-committal so as to accommodate concerns of diversity and
liberal neutrality, something that will prove relevant for the
objections I discuss now.
MCMINDFULNESS
Recently, some strong criticism of contemporary mindfulness
practice has come from within the mindfulness community. The
charge is that contemporary mindfulness leaves out too much
of the original ethical and soteriological elements of Buddhist
practices necessary for right mindfulness. Contemporary mindful-
nessthusturnsanoldandrichworldviewinto‘McMindfulness’—
a watered-down marketable fashion fad bearing little resemblance
to its Buddhist origin.
23334
There are, at least, three different ways to read such criticism.
First, we might understand it simply as the charge that con-
temporary mindfulness is insufficiently true to its Buddhist
452 Schmidt AT. J Med Ethics 2016;42:450–454. doi:10.1136/medethics-2015-102942
Public health ethics
origins. I hope the discussion on liberal neutrality shows that
rather than being a problem, this should be considered a posi-
tive feature. To promote mindfulness in health policy and
diverse educational and organisational contexts makes religious,
axiological and ethical neutrality desirable.
Second, maybe the objection is rather that such watering
down comes at a cost, namely that contemporary mindfulness is
less effective than Buddhist mindfulness. Monteiro et al
2
argue
that contemporary mindfulness offers at best symptomatic relief,
whereas ‘traditional mindfulness approaches liberation from suf-
fering through a path of ardent practice focused on understand-
ing and uprooting the fundamental causes of suffering’. Such a
claim might be true. But it is hard to assess without empirical
evidence. As argued above, contemporary mindfulness should
not in principle be constrained in its development by Buddhist
tradition. But, of course, that does not mean that traditional
mindfulness might not continue to be a source of inspiration that
can be integrated into new evidence-based secular practices.
35
Third, maybe moving away from Buddhist tradition comes at
a different cost, namely that MBIs are being used for unethical
purposes.
36
One discussion revolves around the adaptation of
mindfulness techniques to military contexts, something that
seems at odds with Buddhist ethics. How should we respond
when mindfulness is used for purposes that conflict with
Buddhist ethical tenets? The main problem is that there is great
disagreement surrounding matters of morality. For example,
most people believe that sometimes the use of military force is
justified. Others disagree. Also, many believe it to be morally
permissible to work in the alcohol industry (which many
Buddhists will not). It is unlikely we will reach agreement on
these issues any time soon. But this does not imply that we
should not use mindfulness in contemporary pluralist societies
to improve the lives of even those who work for organisations
of controversial moral value. As seen earlier in my discussion of
neutrality, we have good reason for MBIs to be somewhat ‘non-
committal’to ensure that MBIs are widely applicable.
Moreover, there is little reason to expect that promoting con-
temporary mindfulness will make people do more bad than
good on balance. If anything, preliminary evidence suggests that
contemporary mindfulness practice can improve ethical
decision-making.
37 38
THE POLITICS OF MINDFULNESS
A more systematic objection to the recent mindfulness trend is
that mindfulness in its stripped-down contemporary form can
be instrumentalised to keep exploitative, stressful or otherwise
unhealthy conditions alive. Writing on the use of mindfulness in
corporate settings, Purser and Loy hold:
Curiously, the mindfulness movement has yet to engage in ser-
iously questioning as to why stress is so pervasive in modern cor-
porations. Instead, corporations have jumped on the mindfulness
bandwagon because it conveniently shifts the burden on to the
individual employee; stress is framed as a personal problem, and
mindfulness-based interventions are offered as means of helping
employees cope and work more effectively and calmly within
such toxic environments.
39
Presumably, precarious employment situations, longer work
hours, more inequality, less stable social ties and so on might all
result in reduced well-being, more stress and higher prevalence
of mental illness. Mindfulness, it could be argued, is being
instrumentalised as a coping mechanism for issues whose real
(or morally relevant) aetiology lies elsewhere. At its worst,
mindfulness might shift the burden of responsibility towards the
individual and might even lull them into accepting inhospitable
social conditions.
This objection can be interpreted in different ways. We might
first interpret it as saying that promoting individual mindfulness
practice makes matters worse, because it prevents necessary
social change. Marxists, for example, often believe that religion
and spiritual practice are part of the superstructure—the ‘opium
of the people’—that prevent rather than instigate real social
change. Writing from an epidemiological (not a Marxist) per-
spective, Pickett and Wilkinson argue that growing social
inequality is an important driver of stress and mental illness. In
a spirit similar to the above objection—though writing on a dif-
ferent topic—they argue:
The solution to problems caused by inequality is not mass psy-
chotherapy [or in our case: mass mindfulness intervention] aimed
at making everyone less vulnerable. The best way of responding
to the harm done by high levels of inequality would be to reduce
inequality itself.
40
Similarly, is it not fundamentally wrong-headed to try to
solve social ills through mindfulness promotion? While I think
the worry about instrumentalising mindfulness is serious, this
should make us reflect on how rather than whether we should
promote mindfulness.
First, MBIs cannot be the only measure to deal with stress,
mental illness and so on. But promoting mindfulness is of
course compatible with also promoting wider social change.
This is indeed a good argument not to overstate the role and
effectiveness of mindfulness. While mindfulness promotion is a
plausible part of a mix of policies, presenting it as a panacea
might risk either undermining its credibility or crowd out a dis-
course about necessary social change.
Second, even if the above argument—that we should look pri-
marily to the systematic drivers of stress and mental illness—is
correct, this does not mean there is no independent role for
mindfulness (and other similar interventions). Even in a social
utopia, most people would still experience personal hardships
and stress at some point in their lives. If mindfulness helps deal
with hardships and provides individuals with psychological all-
purpose benefits, then we have good reasons to consider its pro-
motion. This gives us a strong response to a ‘Marxist’critique
of mindfulness.
v
But we can also understand the objection differently: if mind-
fulness were practiced in richer and ethically committed ways,
as it was originally intended by Buddhists, mindfulness itself
would have the potential to be socially transformative. The
recent watered-down versions of mindfulness are problematic,
precisely because they undermine the potential that Buddhist
mindfulness has to transform problematic social conditions.
39 42
How should we evaluate this critique? First, it is of course an
open empirical question as to whether Buddhist mindfulness
actually has such transformative potential. This is hard to deter-
mine from the philosophical armchair. But, second, I think it is
a methodological mistake to expect Buddhism to provide us
with the moral and explanatory resources to identify our social
ills as well as the psychological and social toolkit to address
them. I think it preferable to keep MBIs ethically and axiologi-
cally non-committal while also drawing on secular social
v
Moreover, some of the drivers of stress—such as a growing number of
distractions and choices—might also have benefits worth keeping.
Learning how to ‘find peace in a frantic world’
41
might thus also help
one reap the benefits that come from the world being frantic.
Schmidt AT. J Med Ethics 2016;42:450–454. doi:10.1136/medethics-2015-102942 453
Public health ethics
science, psychology, epidemiology and philosophy to help us
identify and address social ills. Finally, our worry about diversity
and liberal neutrality resurfaces again. If we seek the promotion
of mindfulness as a matter of public policy or in business envir-
onments with diverse workforces, we have good reason not to
commit ourselves to substantial ethical and soteriological views.
This will of course not solve all our social problems. But expect-
ing mindfulness promotion to affect great social change in con-
temporary pluralist societies might strike one as unrealistic in
the first place. Achieving modest yet significant improvements of
people’s lives through MBIs, on the other hand, might be a real
possibility.
CONCLUSIONS
Mindfulness interventions hold good promise as public policy
measure to improve people’s lives across a number of dimen-
sions. I have discussed two main areas in which ethical and pol-
itical questions arise. First, is mindfulness promotion compatible
with liberal neutrality? I have argued that it is, if we avoid tying
mindfulness to any specific views on ethics, religion and the
good life. The potential psychological benefits of mindfulness
even qualify as psychological ‘all-purpose’goods such that one
has reason to want them, more or less, whatever the content of
one’s conception of the good life. Second, a number of ques-
tions arise about the role of mindfulness interventions in their
social, political and economic setting. In promoting mindful-
ness, we should be careful not to overstate its case and not to
crowd out discussion of other ( particularly social) causes of
stress, lowered well-being and mental illness. So, there is ample
reason to be hopeful about the benefits of mindfulness interven-
tions. But the current hype around it should not make us less
mindful of inhospitable social conditions and the collective mea-
sures necessary to address them.
Acknowledgements I thank Diana Heney, Hasko von Kriegstein, Dragos Petrescu,
and two anonymous reviewers for helpful comments.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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