Question of ethics..?

[TeaHatingBrit]

So recently in Calgary - an 60 year old woman gave birth to twins.

 

It was under unusual circumstances though, the woman wanted to undergo in vitro fertilization in Canada, but was refused. So she went to India to get the procedure done, and following that - she came back to Canada.

 

She delivered birth to the children (who were premature) in Canada..

 

I am not going to say anything about this topic yet, I want to her your ideas.

 

http://www.calgaryherald.com/Health/Giving+birth+ethical+problems/1268907/story.html

 

 

Cheers

[imagine]

Just a few things that come to my mind right away:

 

- She'll be too old to properly care for her children.

- Many risks involved with pregnancy in old age (e.g. the children are born premature, as is what happened).

- Resources could have been better allocated: (e.g. could have used doctors' time and effort toward impregnating someone who is young)

[stan1983]

Don't forget that the canadian health care system is no responsible for the care of these infants in the future, tax payers money. She went against Dr.'s medical advice in canada and looked elsewhere to get the procedure done.

[~me~]

I agree with what has been said above, but I think we're forgetting cultural issues here

 

The woman is East Indian. I can tell you that for East Indian women to not have children is very difficult; they feel it's a vital part of their lives. Also, family networks are typically very strong - even if (God-forbid) this woman dies while her twins are very young, there will presumably be many relatives who will be willing to take care of her twins.

 

But then there are the negatives as well as mentioned above; it's a tough one -- but then again, all ethical dilemmas are

[switcheroo]

If children are so important, why now? Why not earlier? I know she says she tried to have babies before, but lots of the techniques available today have been available for a long time. Even 10 years would make a big difference, at least in my mind.

[hkmedbound]

this is very similar to the women in the states who gave birth to octuplets...

http://www.timesonline.co.uk/tol/life_and_style/health/article5600866.ece

 

where do physicians draw the line regarding patient autonomy.

[youngdad]

So whats the question?

[truffle]

this is very similar to the women in the states who gave birth to octuplets...

http://www.timesonline.co.uk/tol/life_and_style/health/article5600866.ece

 

where do physicians draw the line regarding patient autonomy.

 

some extra info: that californian woman is a fame whore. she's planning to make $$ from those babies, as she hired two publicists soon after the octuplets were born. she's single, has no job and lives in her parents' basement with her 6 other children, all from in vitro fertilization.

 

here's my opinion about the ethical issue in the case of the octuplets:

the fertility doctor who gave her all 8 embryos at once is a tard and shouldn't have done it. for pre-menopausal women that young, 1 and maximum 2 embryos should be implanted at once. you only plant 2 or more in older women whose uteruses are less receptive or women prone to reject embryos.

obviously the 8 fetuses were going to be born prematurely. the doctor is costing the american medicare millions in NICU and later care for those 8 babies (medicare because the woman doesn't have a job). when those babies grow to be adults, they will be much more likely to develop metabolic syndrome, diabetes, heart disease, etc. (approx. 2x the chance of people who were born at term). and also the mother is at risk for health problems during and after pregnancy. yeah sure the woman wanted all 8 embryos and has her right to patient autonomy, but the doctor was doing harm by giving her all 8.

 

more info on the canadian case:

i also heard the 60 yo canadian woman had to stay in the hospital (i think it was the ICU) for a few days after the birth. she's lucky she didn't die of hypertension, hyperglycemia and whatnot.

at first, 3 embryos took. she had to get a reduction. and for her health's sake and her babies' sake, i think she should have reduced her pregnancy to one fetus to minimize her chance of premature labor. her twins are now at a high risk for problems later in life, and thats going to cost canadian taxpayers.

 

my opinion:

even if having children is very important in her culture, i think the canadian doctors were right to not help her have children for the reasons listed above (i.e. health of babies and mother, taxpayers' money). it's not like her life will be at stake if she's ostracized, but having children put her life and health at risk.

if the doctors had known that she was going to go to india to get it done, they could be excused to give her in vitro fertilization after they have done everything they could to dissuade her from going to india. they could've had more control of the procedure. for instance, they could have controlled the quality of the donor eggs and embryos better. and they might have convinced her to reduce the 3 embryos to one for the sake of her health, her baby's health and for saving taxpayers' money. the canadian doctors might have known her plan to go to india if she trusted them enough to tell them, or if the doctors communicated enough.

[sailor_d198]

this is very similar to the women in the states who gave birth to octuplets...

http://www.timesonline.co.uk/tol/life_and_style/health/article5600866.ece

 

where do physicians draw the line regarding patient autonomy.

 

Physicians should draw the line regarding patient autonomy when the safety/well-being of another individual will be negatively affected by their 'autonomously-made' decision.

 

I'll play the devils advocate here:

 

In the case of the 60 yr old mother, would it truly have been better for her twins had they never been born? Can it be assumed that their quality of life under the care of their aging, yet clearly loving and devoted, parents will be so bad that they should have never been given a chance at life? The answer to this question is not obvious, as it seems that these children will grow up in a loving environment. The potential for psychological 'trauma' resulting from confusion over their genetic background doesn't differ from the same trauma that could potentially occur from children who were adopted, or from children born to a younger mother receiving in vitro fertilization.

 

In this case the important right to patient autonomy needs to be balanced against the harm done to the children by being born into such an environment.

 

I think it is also important to consider that, unlike in the case of adoption, we are not comparing the parenting skills and abilities of this couple against other potential adoptive parents. We are comparing the lives of these children born to these parents against non-existence. These children would not have existed otherwise, so can we say that this would have been a better alternative?

[truffle]

Physicians should draw the line regarding patient autonomy when the safety/well-being of another individual will be negatively affected by their 'autonomously-made' decision.

 

I'll play the devils advocate here:

 

In the case of the 60 yr old mother, would it truly have been better for her twins had they never been born? Can it be assumed that their quality of life under the care of their aging, yet clearly loving and devoted, parents will be so bad that they should have never been given a chance at life? The answer to this question is not obvious, as it seems that these children will grow up in a loving environment. The potential for psychological 'trauma' resulting from confusion over their genetic background doesn't differ from the same trauma that could potentially occur from children who were adopted, or from children born to a younger mother receiving in vitro fertilization.

 

In this case the important right to patient autonomy needs to be balanced against the harm done to the children by being born into such an environment.

 

I think it is also important to consider that, unlike in the case of adoption, we are not comparing the parenting skills and abilities of this couple against other potential adoptive parents. We are comparing the lives of these children born to these parents against non-existence. These children would not have existed otherwise, so can we say that this would have been a better alternative?

 

the psychological trauma argument is much harder to make than the biomedical one (i.e. physical health of the children, mother). i would not make it in an interview because what you say may be regarded as prejudice. i might just gloss the psychological trauma aspect over.

[SpanishFly]

ok since you all have done good jobs at looking at the situation from both angles heres another one (thats also quite relevant to Canadian docs):

 

Is it ethical to require physicians to practice in a rural/remote area not of their choice for a pre-arranged time?

[truffle]

ok since you all have done good jobs at looking at the situation from both angles heres another one (thats also quite relevant to Canadian docs):

 

Is it ethical to require physicians to practice in a rural/remote area not of their choice for a pre-arranged time?

 

you can argue against it from a constitutional standpoint (right to work, labor law, basic liberties, etc.). you can argue for it based on evidence of the shortage in rural areas and the patients' right to live. (i am against it, because it's a serious and inexcusable infringement of personal liberty, and it sets an example for the state/labor bodies to do the same to other occupations, and there are ways to encourage physicians to work in rural areas, rather than force them).

[meme me]

ok since you all have done good jobs at looking at the situation from both angles heres another one (thats also quite relevant to Canadian docs):

 

Is it ethical to require physicians to practice in a rural/remote area not of their choice for a pre-arranged time?

To answer your question, I don't think it's ethical to force physicians to work in a certain area.

 

I do however, think that it would be a great idea for medical schools to implement mandatory rural placements for their students... whether it's a clerkship placement or even something less substantial. (E.g. MUN requires all 1st years to spend two weeks in a rural placement, shadowing a physician.) The best way to recruit graduates and have medical students consider pursuing rural medicine is to have them experience it. Rural medicine isn't for everyone, but I think there are individuals who write it off before really understanding how interesting it can be.

[japlanet]

It's certainly not ethical to require *all* med graduates to work in underserviced areas. I'd argue that it's equally unethical to offer preferential admission to people from such areas on the assumption that they will return there.

 

Other possibilities which I think are much better - return of service agreements - by which an underserviced area helps out a med student with tuition/paying them a salary while in school under contract that they work in a particular area for, say, 10-15 years afterward. *But* without any affect on the admissions process - they would still have to get in on their own merits, but would just go into less debt.

 

Or, what about a system in which people who are fully qualified for medical school but would otherwise be rejected for a lack of seats (i.e. the first few students on the waitlist each year after all the spots have filled) are offered admission into special 'reserve' seats in each school on the condition that they serve a certain area after graduation (and could certainly turn this offer down and reapply next year if they aren't willing to do that).

 

I think these options are more 'fair' and 'ethical' than allowing people from the North with a 3.5 GPA into medicine over a GTA resident with a 3.9 (here, I'm using GPA as a demonstration of one student being a better medical school candidate than the other, though I realize that GPA alone does not predict this, you get my point) on the assumption that the northern student will return (which is not enforced or required at all).

[meme me]

It's certainly not ethical to require *all* med graduates to work in underserviced areas. I'd argue that it's equally unethical to offer preferential admission to people from such areas on the assumption that they will return there.).

If you're arguing this as unethcial (geographical preference), then it's got to hold true for all preferrential admission treatment based on geography, not just for a school located in an underserviced area.

 

Other possibilities which I think are much better - return of service agreements - by which an underserviced area helps out a med student with tuition/paying them a salary while in school under contract that they work in a particular area for, say, 10-15 years afterward. *But* without any affect on the admissions process - they would still have to get in on their own merits, but would just go into less debt.

These already exist, although 10-15 years seems a bit long. I think the problem with this sort of fix is that the incentive is financial... I do believe these are necessary and perhaps can remain as part of the solution, but I think we've also got to recognize that if we're going to sustainably fix the issue of underserviced areas, we need physicians who want to be there for reasons other than debt.

 

Or, what about a system in which people who are fully qualified for medical school but would otherwise be rejected for a lack of seats (i.e. the first few students on the waitlist each year after all the spots have filled) are offered admission into special 'reserve' seats in each school on the condition that they serve a certain area after graduation (and could certainly turn this offer down and reapply next year if they aren't willing to do that).

I think this option is far less ethical than preferrential admission based on geography. "Well Joey, not bad... not quite good enough to work in the city when you graduate, but if you're willing to work up north for a few years, we'll take ya."

[rmorelan]

I do believe these are necessary and perhaps can remain as part of the solution, but I think we've also got to recognize that if we're going to sustainably fix the issue of underserviced areas, we need physicians who want to be there for reasons other than debt.[/Quote]

 

I agree, but I actually don't think you can find them. For entirely logical reasons there is a bias towards urban areas for doctors. To name a few:

1) The specializations are normally in urban areas becauses of the supporting equipment/staff and economy of scale. That is 1/2 of all doctors right there, and explains why so few service rural areas.

2) Doctors do not exist in a vaccuum of course, they have families and significant others. A large fraction of those significant others are also professionals and it is harder develop professionally in most fields if you live in rural areas. Not impossible of course, but just harder so there is often pressure outside of the doctor to live in non rural areas.

3) It is harder to take any time off of your practise in a rural area - there are fewer people who can cover for you. These put additional stress on a doctor in rural areas vs. urban ones without any form of compensation.

 

and there if of course more I don't think we are open enough about these underlying logical reasons for why rural medicine isn't as popular and what effect that has. The second law of economics is that people will respond to incentives and disincentives and this appears to be what is going on.

 

There are of course many people who would prefer rural medicine for personal reasons, but I guess my point is when you apply the law of averages here there is a serious bias against rural medicine, which is manifested in the reality of the shortages. Which speaking as someone who was from a rural area really, really sucks! (Imagine it take 10 days to get a doctors appointment, you have a bad bacterial infection, there is no such thing as a walk in clinic, and it takes hours and hours to drive to an emergency room, followed by hours and hours back).

 

There are two main ways to combat these - one is simply financial, and the other is preselecting people who have a positive bias for rural medicine. The former is expensive and must be maintained infinitely. The latter introduces a selection bias in acceptance or interviewing, which really annoys people (it's a form of affirmative action). One of those selection methods is geography (people from rural areas do tend to return there - we have studies:) ), another is to somehow verify a person want to practise medicine in a rural area (say via probing interview questions).

[silvermen85]

the psychological trauma argument is much harder to make than the biomedical one (i.e. physical health of the children, mother). i would not make it in an interview because what you say may be regarded as prejudice. i might just gloss the psychological trauma aspect over.

 

Patient autonomy is based on their capacity to make a well informed decision with regard to their current medical situation. In this case, obviously the patient is rather "pushed" into making a decision by her family members that could have endangered hers and the children's lives. But on the other hand, if the patient truly feel the need to have a baby and understand the risks involved but are willing to take that risk, should she be deprived of reproductive right? In Canada, a fetus is not considered a legal entity until it is born therefore does not have any legal rights. So the woman has total autonomy regarding the medical procedure even if it could potentially harm her and the baby. Similar to abortion issue, it is the will of the mother that will determine the fate of the unborn child. Very controversial .

[japlanet]

If you're arguing this as unethcial (geographical preference), then it's got to hold true for all preferrential admission treatment based on geography, not just for a school located in an underserviced area.

 

I agree, I don't think that admission should be based on anything except ability, however a medical school chooses to judge that.

 

If a city/region/government chooses to fund additional seats for military/Aborginal/geographic groups, that's fine, but those seats should be competed for seperately (as in the case of military/Aboriginal seats), and regional candidates should not have an advantage when competing for the general seats.

 

I think this option is far less ethical than preferrential admission based on geography. "Well Joey, not bad... not quite good enough to work in the city when you graduate, but if you're willing to work up north for a few years, we'll take ya."

 

Well, my point was that it is generally agreed that there are more qualified candidates than seats, so why not take some of those qualified candidates who would otherwise be turned down, and give them this option.

 

What you're saying, "Well Joey, not bad... not quite good enough to work in the city when you graduate, but if you're willing to work up north for a few years, we'll take ya." - This is what programs which select based on geography ARE bascially saying, by accepting students that would otherwise be deemed not qualified on the *assumption* that they will work in certain areas.

[silvermen85]

I agree, but I actually don't think you can find them. For entirely logical reasons there is a bias towards urban areas for doctors. To name a few:

1) The specializations are normally in urban areas becauses of the supporting equipment/staff and economy of scale. That is 1/2 of all doctors right there, and explains why so few service rural areas.

2) Doctors do not exist in a vaccuum of course, they have families and significant others. A large fraction of those significant others are also professionals and it is harder develop professionally in most fields if you live in rural areas. Not impossible of course, but just harder so there is often pressure outside of the doctor to live in non rural areas.

3) It is harder to take any time off of your practise in a rural area - there are fewer people who can cover for you. These put additional stress on a doctor in rural areas vs. urban ones without any form of compensation.

 

and there if of course more I don't think we are open enough about these underlying logical reasons for why rural medicine isn't as popular and what effect that has. The second law of economics is that people will respond to incentives and disincentives and this appears to be what is going on.

 

There are of course many people who would prefer rural medicine for personal reasons, but I guess my point is when you apply the law of averages here there is a serious bias against rural medicine, which is manifested in the reality of the shortages. Which speaking as someone who was from a rural area really, really sucks! (Imagine it take 10 days to get a doctors appointment, you have a bad bacterial infection, there is no such thing as a walk in clinic, and it takes hours and hours to drive to an emergency room, followed by hours and hours back).

 

There are two main ways to combat these - one is simply financial, and the other is preselecting people who have a positive bias for rural medicine. The former is expensive and must be maintained infinitely. The latter introduces a selection bias in acceptance or interviewing, which really annoys people (it's a form of affirmative action). One of those selection methods is geography (people from rural areas do tend to return there - we have studies:) ), another is to somehow verify a person want to practise medicine in a rural area (say via probing interview questions).

 

I don't know if preselecting people with a bias towards rural medicine is a good or ethical idea. The key is how do you attract people to work in rural areas without sacrificing the quality of care. Simply using geographical preference as an important selection criteria may also jeopardize the quality of doctors you get in those areas. I do agree with your financial incentive idea, I think government plays a major role in attracting physicians to remote areas either providing enough financial incentives. True it might be initially expensive to do so, but in the long run, the benefit will out weight the cost. Many local and national government have taken similar approach to help other professions/industry, Singapore for example spends billions on recruitment of world-class scientist and boosting up their biotech industry and many years later, it is now a major center for biotech development. Alberta is doing the same thing now, although the recent drop in oil price could affect this process.

[rmorelan]

Patient autonomy is based on their capacity to make a well informed decision with regard to their current medical situation. In this case, obviously the patient is rather "pushed" into making a decision by her family members that could have endangered hers and the children's lives. But on the other hand, if the patient truly feel the need to have a baby and understand the risks involved but are willing to take that risk, should she be deprived of reproductive right? In Canada, a fetus is not considered a legal entity until it is born therefore does not have any legal rights. So the woman has total autonomy regarding the medical procedure even if it could potentially harm her and the baby. Similar to abortion issue, it is the will of the mother that will determine the fate of the unborn child. Very controversial .

 

Very messy Canada I don't think recognizes the "reproductive right" in this way. For instance generally we do not provide medicare payments for the fertility treatments. No one has a right to direct access to treatments assisting in fertility. If we did some of my poorer infertile friends would VERY happy

 

Although I hear Quebec is loosening up that rule!

[truffle]

I'd argue that it's equally unethical to offer preferential admission to people from such areas on the assumption that they will return there.

 

your argument is quite easy to refute.

 

if your claim stands, then it's unethical:

- for med schools to give preferential consideration to applicants of aboriginal descent

- for any university program to give preferential consideration to people of aboriginal descent, or disadvantaged groups (e.g. harvard has this summer research program that favours african americans and latinos because there aren't enough of them in science)

- for any university to offer scholarships preferentially to disadvantaged individuals

- for companies to advertise for jobs in the southern parts of canada, when the jobs are in northern parts of canada (i.e. anyone who wants the job must move to northern canada)

- etc. etc.

 

it's one thing to force everyone to work in rural areas after graduation, it's another thing to give preference in the admission process to people who are more likely to work in rural areas. the first action is an infringement of people's liberty. the second action gives some opportunity for everyone to study medicine. it is totally allowable because medical care is still in some aspects an industry where supply and demand should ideally be matched.

[truffle]

Patient autonomy is based on their capacity to make a well informed decision with regard to their current medical situation. In this case, obviously the patient is rather "pushed" into making a decision by her family members that could have endangered hers and the children's lives. But on the other hand, if the patient truly feel the need to have a baby and understand the risks involved but are willing to take that risk, should she be deprived of reproductive right?

 

you have some good points, but IMO your argument applies more when patients refuse treatments.

even if she understands the risks of having a child at 60, doctors can refuse her request because 1) doctors should not actively do harm and giving her embryos would be doing active harm, 2) doctors should not refuse treatment but she doesn't strongly need any treatment except for psychological reasons, but this can be offset by physical harm.

yeah she has her reproductive rights, but in vitro fertilization is a medical intervention that enhances people's chances. not giving her in vitro fertilization IMO is not an infringement of her reproductive rights, but only deprives her of possible enhanced chances. also, a woman in her situation (60 yo) cannot be reasonably expected to have kids naturally, so her reproductive rights cannot be assumed (it's like nature taking away her rights already).

 

In Canada, a fetus is not considered a legal entity until it is born therefore does not have any legal rights. So the woman has total autonomy regarding the medical procedure even if it could potentially harm her and the baby. Similar to abortion issue, it is the will of the mother that will determine the fate of the unborn child. Very controversial .

 

i am aware of this, but my argument was based on health risks to the baby and medical costs after birth. you can argue that the patient of the fertility doctors is the woman, and the baby after birth likely won't be their patient. this only weakens my argument, but doesn't refute it.

 

abortion is not a similar issue. under canadian laws, abortion is like removing an unwanted growth on your body (e.g. corn on your foot, benign cyst in your ovary). (i'm just saying this for comparison's sake, not because it's my personal opinion. and i hope i'm not offending anyone). this definitely is not equal to in vitro fertilization.

 

abortion doesn't have a high risk of harming the mother, whereas in vitro fertilization can harm the mother who is 60 yo. abortion leads to a dead fetus, who is not a patient. in vitro fertilization can lead to live babies, who can become patients.

[silvermen85]

your argument is quite easy to refute.

 

if your claim stands, then it's unethical:

- for med schools to give preferential consideration to applicants of aboriginal descent

- for any university program to give preferential consideration to people of aboriginal descent, or disadvantaged groups (e.g. harvard has this summer research program that favours african americans and latinos because there aren't enough of them in science)

- for any university to offer scholarships preferentially to disadvantaged individuals

- for companies to advertise for jobs in the southern parts of canada, when the jobs are in northern parts of canada (i.e. anyone who wants the job must move to northern canada)

- etc. etc.

 

it's one thing to force everyone to work in rural areas after graduation, it's another thing to give preference in the admission process to people who are more likely to work in rural areas. the first action is an infringement of people's liberty. the second action gives some opportunity for everyone to study medicine. it is totally allowable because medical care is still in some aspects an industry where supply and demand should ideally be matched.

 

 

On one hand, selection process should not be based on race, ethnicity, gender, religious background etc. Put it this way, if these criteria are used during selection process, then what prevents certain school to only select certain population not others? You may have in your hand allegations regarding to profiling. On the other hand, there is a need for greater representation of minority physicians in the community. Especially for the multi-cultural landscape of Canada, many people would feel more comfortable with doctors who can speak their native language and understand their cultural concerns. As it stands right now, the representation of those minority groups in the medical profession does not match their representation in the population. So the key is to maintain a balance, in that consideration should be given, but not to the point it jeopardize the integrity and overall objectiveness of the selection process. Keep in mind that the goal of the medical profession is ultimately to best serve the community's need.

[clobliss]

I'm a little late in the game, but as far as the 60 yr old mother goes, nobody here mentionned agism and sexism as being discriminaqtive reasons to deny her the chance of IVF. When Trudeau had a baby at like 70 or something like that everybody was happy for him and nobody wondered how ethical it was. We live in a society were mothers and fathers are equally responsible for their children and so gender shouldn't play a role. The issue here really is that this woman is 60 yrs old and is putting herself through a risky pregnancy because of age alone. Younger women who do the same aren't questionned in their decision to put themselves in a medically precarious situation. For example, women with a history of hypertension are still eligible for IVF although the risk of pre-eclampsia and a plethora of other health issues is much greater. Even in high risk pregnancies, women cannot be forced to deliver their baby in hospital, despite the clear risk of complications. So really, if we aspire to eliminate agism in medical care, the biomedical argument should extend to any high risk pregnancy, regardless of age. Personally, I would advise against it based on the health risks. But in my opinion, denying her a shot at IVF is an infringement on the autonomy principle.

[meme me]

I agree, but I actually don't think you can find them. For entirely logical reasons there is a bias towards urban areas for doctors. To name a few:

1) The specializations are normally in urban areas becauses of the supporting equipment/staff and economy of scale. That is 1/2 of all doctors right there, and explains why so few service rural areas.

2) Doctors do not exist in a vaccuum of course, they have families and significant others. A large fraction of those significant others are also professionals and it is harder develop professionally in most fields if you live in rural areas. Not impossible of course, but just harder so there is often pressure outside of the doctor to live in non rural areas.

3) It is harder to take any time off of your practise in a rural area - there are fewer people who can cover for you. These put additional stress on a doctor in rural areas vs. urban ones without any form of compensation.

 

And there's also a whole list of entirely logical reasons for students wanting to practice in rural areas:

1) Scope of practice for family doctors... as a family doctor in a rural area, the depth of you're skill-set would kill that of a family doctor in an urban area.

2) The challenge!

3) Doctors in a rural areas often act as a sort of pillar in the community. You don't leave work when you leave the office. You're still the community physician at your son's hockey game.

4) Ability to function as a health care advocate beyond your practice and in the community... opportunities for becoming highly involved in public health.

 

Etc... now this list does not appeal to everyone, there's no question. Obviously, specialization is a problem in rural areas. And the lifestyle is different, but it shouldn't be regarded as inherently worse as it often is. My point is that the positives often get glossed over because of the bias that exists among new students - most of whom have probably been going to school and living in urban settings for at least four years prior to begining school - and if students can get exposed to rural medicine and see it and feel it and experience it then I think without question we would have a greater number of graduates pursuing it. Literature supports this idea: http://www.ices.on.ca/webpage.cfm?site_id=1&org_id=77&item_id=3154&morg_id=0&gsec_id=3154

 

So I would disagree that you can't find them. If you nurture their interest or at least recognize the possibility that they may exist, I think you'd be surprised.