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S1 Ep65: Patient autonomy with Jeffrey A. Singer, M.D. · Off the Chart: A Business of Medicine Podcast

• Speaker 1 00:00:00 We doctors these days. We have it drilled into us from our earliest days in medical school that we need to respect patient autonomy if they refuse, and even if we think they're making a terrible mistake, we just have to respect that. It's it's their body, their healthcare. Speaker 2 00:00:25 Welcome to Off the Chart: A Business of Medicine podcast featuring lively and informative conversations with health care experts, opinion leaders and practicing physicians about the challenges facing doctors and medical practices. I'm your host, Austin Littrell. This episode features a conversation between Medical Economics senior editor Richard Payerchin and Dr. Jeffrey A. Singer, a general surgeon and senior fellow at the Cato Institute. Dr. Singer joins the show to talk about patient autonomy and, his new book about informed consent in medicine, "Your Body, Your Health care." Speaker 3 00:01:01 I'm Richard Payerchin, reporting for Medical Economics. With me today is Dr. Jeffrey A. Singer, a general surgeon in private practice. He's a senior fellow at the Cato Institute Department of Health Policy Studies, and he's also the author of the new book, "Your Body, Your Health care." Speaker 3 00:01:19 Dr. Singer, thank you for joining us today. Speaker 1 00:01:21 Thank you very much for having me. Speaker 3 00:01:23 Today we're going to talk about some of the concepts and history in your book, your body, your healthcare, and maybe more broader general sense. Can you explain how did this book come about? Speaker 1 00:01:34 Cato has its own in-house publishing, like a lot of academic centers do. And, there was sort of a call for new books to, to be written by their scholars. And my director, Michael Cannon, who's the director of health Policy Studies, is a health economist. He suggested that I write a book. He he pointed out to me, you know, all of the policy areas that you've been working on over these years? I mean, my eighth year there now. you could kind of link them together by one overarching principle, which is, what we at Cato called the presumption of liberty or the presumption of autonomy. In other words, we start with we are all autonomous adults, that we have inherent rights. Speaker 1 00:02:20 And this is, of course, from John Locke and the enlightenment that the purposes of, of government is to secure these rights, not to infringe on these rights. So we start there. And if you look at all of the policy areas that I've been working on, you could, Every point I make really gets down to where the government is interfering in the autonomy of adults by by dictating, really, to patients everything from, what kind of health care practitioners they're allowed to get advice from or get help treatment from, dictating, what kind of facilities they can access, dictating what kind of medicines they can access to treat their conditions, and whether or not they need to get a permission slip from another autonomous adult like themselves. that's another way of saying, prescription. who's who's licensed by the state? a licensed health care practitioner. And, it dictates what we even non-medical medicines, what we can put into our body, whether it's a food or a substance that is mind altering. So I link together all of these policy areas that I've done considerable work, and I've published white papers and policy analyses, and the research has largely been done, and I kind of reorganized it and repurposed it in separate sections and chapters, but linked together by this one theme of the presumption of autonomy. Speaker 1 00:03:58 I point out that we doctors these days, we have it drilled into us from from our earliest days in medical school that we need to respect patient autonomy, that we can't really do a test or procedure or anything to a patient without their informed consent. and it should be a fully informed consent to the best of our ability and that if, if they refuse and even if we think they're making a terrible mistake, we just have to respect that it's it's their body, their health care. So that's and that's the way we are. But it wasn't always that way. I point out that, in fact, it's a relatively recent development. maybe right from about the time I got out of medical school in the late 70s. you know, we we all are very aware of, for example, the infamous Tuskegee experiment where the public health officials were not letting, African-American men with syphilis know that there was a treatment for it because they wanted to trace the course of syphilis from beginning to end for research purposes. of course, there were the live human experiments during the World War two in the Holocaust. Speaker 1 00:05:08 There are many, many examples. And recently in the 1970s, a survey done by the Journal of Oncology of American oncologists learned that, the majority of them, I think it was 60%, said that they withhold a certain amount of prognostic information from their cancer patients because they're concerned that if they had that information, they may not participate in the treatment plan they have for them, because they may get too pessimistic. Well, that that's not informed consent. So it's a relatively recent development. Things really began to to change around 1908. There was a very famous case that probably a lot of law students learn about, Sloan Dorf versus Society of New York Hospital, a woman named Mary Sloan from the early in 1908. of course, doctors know in those days we didn't have the imaging studies we have today. And getting to an examination under anesthesia was a very common way of getting more detailed information. the doctor suspected she had a uterine tumor. He asked to do an exam under anesthesia, and she said under condition that you just examine me, you don't do anything else. Speaker 1 00:06:15 And then we discuss your findings, and I decide after that what we're going to do. So the doctor took her to the operating room to UUA and palpated a uterine tumor and proceeded to perform a hysterectomy. And she had a bunch of complications. fortunately, she survived, but she was upset, and she went to court, and she won in the first round. And then the hospital appealed. And on an appeals court, this is New York Court of Appeal. It was called, Sloan versus Society of New York Hospital. Mary's, Judge Benjamin Cardozo, who wrote the majority opinion for the New York Court of Appeals. People probably know that he later became a very highly respected Supreme Court justice. There's even a law school in New York City named after him. So he said, and I'm paraphrasing, every adult of sound mind owns their own body, and to do something to them without their consent constitutes an assault. And in this case, Mary was assaulted. So that was the first time something like that was actually said in case law. Speaker 1 00:07:19 There were several other similar kind of lawsuits around the country at that time, but like I said, it took it took another 60 years or so for that to finally become ingrained in medical ethics. So the patient doctor relationship now respects autonomy. However, there's a third person in the exam room. It's the government. And the government dictates all of these things that I mentioned a few minutes ago. So, in short, the government does to us adults every day what Mary Sloan Dwarf's doctors did to her. Speaker 4 00:07:56 Say, Keith, this is all well and good, but what if someone is looking for more clinical information? Well. Speaker 5 00:08:02 Then they want to check out our sister site, Patient Care Online, the leading clinical resource for primary care physicians. Again, that's patient care online. Com. Speaker 3 00:08:15 We live in an era when thankfully there is a ton of scientific development. There's everything from labor saving devices to thinking saving devices, so to speak. If you consider the computer and AI, hopefully something that will make our lives easier. Speaker 3 00:08:29 The complexity, though, has grown. And where I'm going with this one is with their training and experience, physicians develop a sophisticated knowledge of medicine. Medical treatments and procedures are becoming more and more complex, and patients may not have that same base of knowledge. How important is it for doctors to have communication Skills to inform their patients. Speaker 1 00:08:53 Well, no, I think it's very important. And some doctors. I mean, I think we all try, but, you know, again, we're humans, so sometimes we're we're rushed or we got a bunch of other crucial things going on at the same time, which is kind of distracting us so we don't give enough information. And this is actually the with the advent of AI platforms like ChatGPT or Grok or the several of them. Now, I think this is empowering because, and I've been impressed. I've if anybody has tried to just go on ChatGPT, that's what I like to use. And I've just for kidding around, I plugged in some, you know, signs and symptoms and lab tests and says, what could this be? And it spits out a very sophisticated differential diagnosis with explanation. Speaker 1 00:09:38 And then I say, could you give me references to that? And it gives me references. So, this is empowering because especially, you know, there's a physician shortage and some people have to wait a long time to get into a doctor, and they don't get the kind of time they want. They could. It's never been a better time to do your own due diligence and make your own health care decisions than it is now with AI. In addition, and I talk about this in this earlier part of the book, when we get into the scope of practice, you know, as medicine has become more complex, some of the other allied medical fields, like nurse practitioners or pharmacists or, there's a, a there extra trained clinical psychologists who become, prescribing psychologists. Seven states allow that. So in these other fields, we should doctors the medical association fights this. But there's a lot of things that we are overtrained for now that people who used to be under trained are trained for. And we shouldn't fight efforts, by those organizations to get the, the licensing, apparatus out of their way so that people can get access to those people. Speaker 1 00:10:49 So it's still in 20 states. Nurse practitioners aren't allowed to practice independently. My state they are. But in in 30 states there are. But in 20 states they're not or in about five states. pharmacists also, by the way, in Alberta and Ontario and in Australia and the UK, pharmacists can, test and treat for routine everyday things like a UTI or a vaginal yeast infection or, strep throat. and so instead of having to take time off from work, to see a doctor and wait for hours in their overcrowded office rooms, offices, you could stop off in those states at a pharmacy. and the pharmacist will do the same test to see if you have a strep throat or check for UTI. And they know about drug interactions. They'll prescribe you an antibiotic. And in the event that that doesn't work, then they'll say, okay, well, then you'd better go see your doctor, because this is now beyond my scope. But those are the kind of things that, we should patients should be able to avail themselves of so that we doctors can focus more on the stuff that are much more complicated that we have the training for. Speaker 1 00:12:01 But unfortunately, state licensing laws and their attendant scope of practice laws create these barriers so that as these new fields are coming up and the nurse practitioners in those other 20 states want to be able to open up a practice in a rural, underserved area and practice independently. Their state chapter of the medical Association fights it and says, we're only thinking about the safety of the patient. Well, first of all, I don't believe them. I think they're thinking about themselves. But even if that's true, it's again, it's the it's your body, your health care. So it's paternalistic to put what you think is in the patient's best interest, ahead of what the patient thinks is in the patient's best interest. And these are the points I actually make in the book. Speaker 3 00:12:43 One thing you got me kind of wondering about was with the licensing requirements. and I have I'm going to have a I'm going to have a pandemic question for you here. We'll get to that. But now I'm kind of curious because telehealth is really big in our space. Speaker 3 00:12:57 And with the cross state licensing lines and the some allowances for practice and some restrictions on practice. Can you talk a little bit about how patient autonomy and informed consent might drive reforms, for better or for worse, involving telehealth and telemedicine? Speaker 1 00:13:17 Yeah, that's a good question. And I don't think I take that on too much in my book, but I've written quite a bit about it. So first of all, some states still most do now, but some states still don't allow telehealth within their own state. and obviously, particularly when you're living in a state like Arizona where we have a couple of big cities, but the rest is very spread out in rural, not only instead of having to drive 150 miles to see the doctor if you he can conduct a visit by telehealth, that's great. But it's also easier to get second opinions because you don't have to keep driving all over the place. You could do that by telehealth. now, my state of Arizona, well, first, licensing laws stand in a way. Speaker 1 00:14:02 So if you live in, say, Texas, and you want to get a second opinion from some expert at the Cleveland Clinic, you'd have to go take a plane there. Because unless that expert, the Cleveland Clinic, goes through the process of getting a license to practice in Texas, that expert is not allowed to provide medical advice to you. They don't have a license in Texas. So, during the pandemic, because everybody was locked in and there was a need for health care even more than ever. states relax those laws. And they said, you know, you can get telehealth services from a practitioner who's not licensed in our state as long as they have a good license in good standing, whatever they are. But then when the pandemic was over, they all went back to business as usual. Arizona in 2021, they actually put that in statute. So in my state of Arizona, if you're in any one of the licensed health professions, any one of them, and you have a license in good standing in any of the 58 states, 50, 50 states, you can provide telehealth services to people in Arizona. Speaker 1 00:15:15 Now, they require that you register with the relevant licensing board so they could verify that you indeed are who you say you are, and you have a license in good standing. And you have to attest that if you were to get sued for malpractice, you agree that the case will take place in Arizona courts under Arizona's standard of care guidelines. But but anybody who wants to give telehealth services to Arizona's can without that license blockage. Florida passed Something not quite as comprehensive, but similar. But for the most part. You got this state license barrier. There is a actually a fix. We have a paper out from the Cato Institute about this called liberating. Telemedicine came out a few years ago. there's a fix that Congress can do that is completely in keeping with federalism. And article one, section eight of the Constitution, which gives Congress to regulate authority, to regulate commerce between the states. It gives that authority for that. So Congress can pass a law that says, for the purposes of telehealth, the locus of care is defined as the state in which the practitioner is licensed, because right now, what's in the way is the locus of care issue. Speaker 1 00:16:33 so if if you're in Texas and you get telehealth from a doctor in Ohio and you're angry and you want to complain, if you complain to the Ohio Medical Board. They'll say, well, you're in Texas. And the locus of care was in Texas, so we can't help you. And then if you complain to the Texas Medical Board, they say, well, that doctor's licensed in Ohio. We don't have any jurisdiction there, so we can't help you. But if you have congressmen, okay. It's like sort of like it did when it made daylight savings time that we all go on daylight saving time the same at the same time, and we all go off at the same time because there was a period when it was different in different states. So same kind of thing and say, okay, the locus of care is wherever the practitioner is licensed. So if you have a complaint, if you got telehealth services, you're texting, you got telehealth services from a doctor in Ohio and you're not happy. Speaker 1 00:17:17 You can complain to the Ohio Licensing Board, because that's where the locus of care is. And that's a fix. Speaker 3 00:17:23 That really is startling to to think that some states I didn't I wasn't aware of that. I thought that there was at least a degree of telehealth allowable in every all 50 states. It would make sense. I mean. Speaker 1 00:17:32 Well, you'd have to get a license in that state to do it. Speaker 6 00:17:34 Yeah. Gosh. Speaker 3 00:17:36 I just I can't help but think that with the physician shortage, there's going to be more demand. I mean, the population is growing, the population of docs is going down. There's there's just going to be more and more demand. Speaker 1 00:17:46 I'm sorry to say this, but guess who fights against this? Our guys. Okay. I testified remotely, before the Idaho Legislature, encouraging them to do their what we did in Arizona, which is allow practitioners. And I know it's a very rural state, you know, and, the Idaho Medical Association testified against it. I was the only physician saying it's a good idea. Speaker 3 00:18:14 Now, having said that, upholding some standard of care for patients, respectful to, you know, the training and experience that physicians get versus the NPS and the Pas, because that's I mean, that conflict, it's that's also, frankly, big in our space because a lot of the family physicians are afraid that the NPS and Pas are going to go into individual independent practice and eat their lunch. Speaker 1 00:18:38 Well, you know what? It's again. Remember, I'm a libertarian free market, and I don't believe in protectionism. So I definitely empathize with the doctors. But it's not up to you to decide you. I'm saying you, doctor, to decide who an autonomous adult can get health care advice from. And the other thing I point out is the license, by the way, historically, and I get into this in the book, there was no licensing of anything in this country until the late 1800s. The AMA is part of its mission statement was when it was created in 1840s, was to get doctors licensed, and at that time there were about 4 or 5 competing schools of medical thought. Speaker 1 00:19:20 You know, the science hadn't been as advanced as it is today. And the the ancestors of the MDS thought we got to take control of this. And by licensing, and eventually they did so by the end of the 19th, the 1800s, early 20th century, by having each state chapter of the AMA. Fight for it. And what happened in the early days was the State Licensing Board consisted of representatives of the state chapter of the AMA, and they would not let you get a license to practice medicine unless you graduated from an AMA accredited medical school. And did your residency in an AMA accredited residency program. Just starting to sound like a cartel to you? Because that's what it is now. Those still organizations still exist. They have different names. There's a liaison committee on Accreditation of medical schools, but it's all AMA created and they're monopolies. Speaker 5 00:20:15 Oh, you say you're a practice leader or administrator. We've got just the thing. Our sister site, physicians practice your one stop shop for all the expert tips and tricks that will get your practice really humming again. Speaker 5 00:20:27 That's physicians practice. Speaker 3 00:20:32 Definitely did want to get to the pandemic question because I think that from 2020, you know, we we went through the pandemic. There were vaccines that were created to provide immunity against Covid 19. We're in a great period. And since then there's been debate and we're in a great period of debate. Now, in the second Trump administration and the leadership of Department of Health and Human Services. Can you talk a little bit about informed consent and how that relates to government or private industry mandates for vaccines or opposition to vaccination? Speaker 1 00:21:06 Well, first of all, I have a problem with RFK because even though he's now giving some lip service to the MMR vaccine, he's got a history of being, you know, making these unfounded claims that it causes autism and skepticism about all sorts of vaccines. I think vaccines are probably one of the most important medical. The reason why so many people are living so much longer these days is largely due to vaccines. It's one of the greatest advances in in health care. Speaker 1 00:21:37 On the other hand, I don't believe again, I believe in autonomy. So I don't believe we have the right to force someone to get vaccinated if they don't want to be, because it's insult. We're actually taking the sticking something in their body against their will. but there is a legitimate role for the government when it comes to public health matters, like, and public health is the is in the classical liberal sense, defined as issues where what you do can affect the health of others, even if you don't know about it. It's unintentional. So, for example, you know, dumping contaminated waste in the in in a public place where you can get other people infected or having a highly contagious and lethal disease that you're spreading around unknowingly to your neighbors. So these these are roles where you know, this, this can't get it's not going to get settled by tort law. And, you know, people look spontaneous looking after their own interest. So. So there's a role for government here to act as a referee or an umpire. Speaker 1 00:22:42 So the government could say if you don't want to get vaccinated, then you're going to have to be isolated because you're threatening other people. I'm fine with that, as long as you don't force them to get vaccinated. And I know and it's it's not dogmatic. I know there are some libertarians who say, well, there are some extreme cases where actually the government can compel, but it's a very high bar. For example, let's say you have a highly lethal disease like smallpox or Ebola. And if you refuse even isolating, who's not good enough. So I you know, I hate to do this to you, but you're going to kill people unless we do this to you. But but that's a very high bar. And Covid didn't meet that bar. So, as a general rule, let's just say as a general rule, I don't think you have the right to force people, but I think it's very legitimate for a public health agency to inform people how beneficial it would be and to take a positive, you know, stance towards it. Speaker 1 00:23:38 another thing I have problems with is the public health agencies in recent years have had mission creep. So, for example, telling making decisions about what you do that could affect your neighbors is in is legitimate. But making decisions about what you do that only affects you is not. There's no role for the government there. So you could tell me that as long as I refuse to get vaccinated and I have this highly contagious disease, I have to stay isolated indoors. That's fine. But you can't tell me that I'm not allowed to to, smoke tobacco or smoke cannabis or, or or even engage in a certain certain kind of foods containing food coloring that if I'm okay with the food coloring and I'm not convinced that it's harmful. you know, if you don't like food coloring, well, you know, there's a whole bunch of sections in the supermarket called Organic Foods that says no preservatives, no coloring. That's fine. Nobody's forcing you, but I'm okay with it. So these are areas which that I call personal health matters, not public health matters. Speaker 1 00:24:42 And in there, the government is intruding all the time, like we just recently, of course, the FDA Commissioner McCarry and HHS Secretary Kennedy said they're going to ban, eight different, petroleum based food colorings, which there's absolutely no scientific evidence that they're harmful. And, by the way, so many things, including when you buy vitamin A that's petroleum based. So using the word petroleum base is scary. But once you develop the product, it's not petroleum you're consuming. It just, you know, it just was a byproduct of it. So anyway, you know, if, if for whatever reason, I'm okay with the less expensive brand of cereal and I like the colors, now you're telling me I can't have that? It's not like other people who don't like it can't get an alternative. Why are you doing that? It's not your business as the government. Now you're stepping on my enemy. So the same thing with the Covid pandemic. In the early days, we knew very little about it. Speaker 1 00:25:45 We were very frightened that it might be maybe as bad as something like Ebola. So it was very reasonable in the very beginning, before we had any information to sort of hunker down. but then it didn't take more than a few months to find out that it wasn't what we originally thought. And, yet the public health agencies seemed unwilling to entertain alternative strategies from intelligent and well-educated people in the public health space. They. Because you had this government monopoly. And now we look back. You know, schools were kept closed here for in some states for two years where they were open within a few months in the rest of the world. We looked back on these mistakes and people who even suggested, hey, you know, the schools are open in Europe, why can't we open them here? You were derided as some sort of fringe doctor. So that's a separate thing. I wrote a piece for reason magazine in 22 about this called Against Scientific Gatekeeping, in which I said, you know, our public health agencies need to be much more willing. Speaker 1 00:26:49 That doesn't mean, you know, if you tell me the earth is flat, I don't have to be willing to entertain that. But you should be much more. these agencies are much more willing to to entertain plausible hypotheses and not dismiss them out of hand, because that's what science science advances. So there's another area where I would have a problem. And then there was the regulatory area. For example, people in other parts of the world were using tests for Covid, and we hadn't even we were like two months behind the rest of the world before the FDA approved tests for Covid, because, again, you had this government monopoly that was kind of bureaucratic and and sclerotic. And even then, when they finally approved tests, they were tests that you couldn't, they were they at first, they weren't self-administered. You had to go to a doctor to get the test, or you couldn't get the answer right away. You had to go to a doctor to get the answer. so again, this is all paternalistic and and it's not allowing us to make our own health care decisions. Speaker 1 00:27:51 In Europe, people were able to test themselves to see if they had. Before you go to a, you know, a social gathering, you say, well, before I come over to your house for dinner, let me test myself. Make sure you don't have Covid because I don't want to give it to you. But you couldn't do that here because the tests had to be read by a doctor in the early days and the early tests. So there's a whole lot of area for criticism. I don't get into Covid very much in my in my book, I here and there, I have some references to the pandemic, but my book is more kind of, more general and and broad. It's broad based. Speaker 3 00:28:25 And our main audience is primary care Positions. What would you like to say to them specifically, or what would you like them to know? Speaker 1 00:28:34 I'd like to know. I like them to know. I think they're very important. They're the front line of of health care in this country. I can understand that. Speaker 1 00:28:43 They in many cases, they feel sort of under siege. They're among the lowest paid of the medical specialists and oftentimes very overworked. And when they hear that, there are other fields coming up, like nurse practitioners or physician assistants that can offer many of the same services they offer. I totally understand them not being happy about that, you know? but on the other hand, we always every time we have a threat, there's other things we we find out there are other things we could do. It frees us. So allowing these other, affiliated health professions to practice the full extent of their training, take some of the load off of you, the family practitioner, and allows you to focus on the more complicated things that need more expertise and more time. And I mean, we see this in surgery too, now with the advent of GLP ones. There's been a huge drop off in bariatric surgery and, and but you know what? I assure you that the surgeons will find some other, heretofore not surgically treatable problem that they can treat surgically. Speaker 1 00:30:00 It always it always seems to happen. Speaker 3 00:30:03 What advice would you give to medical students or early career physicians about balancing their own clinical judgment with respect for patient autonomy? Speaker 1 00:30:11 Well, yeah, and I have to deal with this myself, even though I've been in practice all these years. I think you got to keep working at it, because it's one thing to to be able to, you know, recite back our ethical credo that we have to respect autonomy. Give informed consent. It's another thing to overcome some of your own personal biases or issues. Like I say, you could be rushed. You could be, have five different things going on at the same time. So, what I find myself doing when I, when I interact with my patients during my clinic hours, it's like a little person on my shoulder here whispering in my ear. Have you been careful to cover everything? did you ask them if they have any questions? I'm actually doing that to myself. Because, you know, I'm guilty of not of not giving all the information that I could. Speaker 1 00:31:07 Myself. We're all. You know, like I say, we're humans, so we make mistakes. So what I could, urge is that, don't ever stop reminding yourself, and do, like, you know, checklist in your own mind. Did I, did I tell the person everything? Am I leaving anything out? and and also remind yourself that, you know, be patient. If they have a lot of questions, they're not necessarily, as, educator or sophisticated as you are on these issues. So be patient. And if they don't, even if you think they're making the biggest mistake in the world and they're going to wind up, you know, dying in a few weeks because they didn't listen to you just got to respect that. Speaker 3 00:31:51 I really enjoyed our conversation, honestly. So, hopefully we'll get a chance to talk again sometime. Speaker 1 00:31:55 Because it's like you flip a switch and I just. Speaker 3 00:32:00 You know what? Like I said, hopefully we'll get a chance to talk again real soon. Speaker 1 00:32:03 Yes. Speaker 1 00:32:03 Thank you. Have a good. Speaker 3 00:32:04 Day. You as well. Thank you so much. Speaker 7 00:32:06 Bye. Speaker 2 00:32:20 Once again, that was a conversation between Medical Economics senior editor Richard Payerchin and Dr. Jeffrey A. Singer, a general surgeon and senior fellow at the Cato Institute. On behalf of the whole Medical Economics and Physicians Practice teams, I'd like to thank you for listening to the show and that you please subscribe on Apple Podcasts, Spotify or wherever you get your podcasts, so you don't miss the next episode. Also, if you'd like the best stories that Medical Economics and Physicians Practice publish delivered straight to your email six days of the week, subscribe to our newsletters at medicaleconomics.com and physicianspractice.com. Oh, and be sure to check out Medical Economics Pulse, a quick hitting news podcast that offers concise updates on the most important developments affecting your practice, your bottom line and the broader health care landscape delivered by the editorial team at Medical Economics. Off the chart: A Business of Medicine podcast is executive produced by Chris Mazzolini and Keith Reynolds and produced by Austin Littrell. Speaker 2 00:33:08 Medical Economics, Physicians Practice and Patient Care Online are all members of the MJH Life Sciences family. Speaker 7 00:33:14 Thank you.