Underrating, learned Senior Counsel, whom we had appointed as mimics curiae, Mr… Paella Cissoids, learned senior counsel for the Dean, KEMP Hospital, Iambi, and Mr… Chainman Chalked, learned counsel for the State of Maharajah’s. 2 2. Euthanasia is one of the most perplexing issues which the courts and legislatures all over the world are facing today. This Court, in this case, is facing the same issue, and we feel like a ship in an uncharted sea, seeking some guidance by the light thrown by the legislations and Judicial pronouncements of foreign countries, as well as the submissions of learned counsels before us.
The case before us is a writ petition under Article 32 of the Constitution, and has been filed on behalf of the petitioner Arena Rhombohedra Shantung by one Ms. Pink Varian of Iambi, claiming to be a next friend. 3. It is stated in the writ petition that the petitioner Arena Rhombohedra Shantung was a staff Nurse working in King Edward Memorial Hospital, Pared, Iambi. On the evening of 27th November, 1973 she was attacked by a sweeper in the hospital who wrapped a dog chain around her neck and yanked her back with it. He tried to rape her but finding that she was menstruating, he atomized her.
To immobilizers her during this act he twisted the chain around her neck. The next day on 28th November, 1973 at 7. 45 a. M. A cleaner found her lying on the floor with blood all over in an unconscious condition. It is alleged that due to strangulation by the dog chain the supply of oxygen to the brain stopped and the brain got damaged. It is alleged that the Neurologist in the Hospital found that she had plantar’ 3 extensor, which indicates damage to the cortex or some other part of the brain. She also had brain stem contusion injury with associated cervical cord injury.
It is alleged at page 11 of the petition that 36 years have expired since the incident and now Arena Rhombohedra Shantung is about 60 years of age. She is featherweight, and her brittle bones could break if her hand or leg are awkwardly Arena Shantung Case – Supreme Court of India By Coelenterate her skin is now like paper mace’ stretched over a skeleton. She is prone to bed sores. Her wrists are twisted inwards. Her teeth had decayed causing her immense pain. She can only be given mashed food, on which she survives. It is alleged that Arena Rhombohedra Shantung is in a persistent negative state (p. s. ) and virtually a dead person and has no state of awareness, and her brain is virtually dead. She can neither see, nor hear anything nor can she express herself or communicate, in any manner whatsoever. Mashed food is put in her mouth, she is not able to chew or taste any food. She is not even aware that food has been put in her mouth. She is not able to swallow any liquid food, which shows that the food goes down on its own and not because of any effort on her part. The process of digestion goes on in this way as the mashed food passes through her system. However, Arena is virtually a skeleton.
Her excreta and the urine is discharged on the bed itself. Once in a while she is cleaned up but in a short 4 while again she goes back into the same sub-human condition. Judged by any parameter, Arena cannot be said to be a living person and it is only on account of mashed food which is put into her mouth that there is a facade of life which is totally devoid of any human element. It is alleged that there is not the slightest possibility of any improvement in her condition and her body lies on the bed in the KEMP Hospital, Iambi like a dead animal, and this has been the position for the last 36 years.
The prayer of the petitioner is that the respondents be directed to stop feeding Arena, and let her die peacefully. 4. We could have dismissed this petition on the short ground that under Article 32 of the Constitution of India (unlike Article 226) the petitioner has to prove violation of a fundamental right, and it has been held by the Constitution Bench decision of this Court in Giant Gaur vs… State of Punjab, 1996(2) SEC 648 (vide paragraphs 22 and 23) that the right to life guaranteed by Article 21 of the Constitution does not include the right to die.
Hence the petitioner has not shown location of any of her fundamental rights. However, in view of the importance of the issues involved we decided to go deeper into the merits of the case. 5 5. Notice had been issued by this Court on 16. 12. 2009 to all the respondents in this petition. A counter affidavit was earlier filed on behalf of the respondent no’s. 3 and 4, the Iambi Municipal Corporation and the Dean, KEMP Hospital by Dry. Mar Ramada Bazaar, Professor and Head in the said hospital, stating in paragraph 6 that Arena accepts the food in normal course and responds by facial expressions.
She responds to commands intermittently by making sounds. She makes sounds when she has to pass stool and urine which the nursing staff identifies and attends to by leading her to the toilet. Thus, there was some variance between the allegations in the writ petition and the counter affidavit of Dry. Bazaar. 6. Since there was some variance in the allegation in the writ petition and the counter affidavit of Dry. Bazaar, we, by our order dated 24 January, 2011 appointed a team of three very distinguished doctors of Iambi to examine Arena Shantung thoroughly and submit a report about her physical and mental condition.
These three doctors were : (1) Dry. J. V. Davit, Professor and Head, Department of Anesthesia, Critical Care and Pain at Data Memorial Hospital, Iambi; (2) Dry. Roof Guardians, Consultant Neurologist at P. D. Hindu, Iambi; and 6 Municipal Corporation Medical College and General Hospital. 7. In pursuance of our order dated 24th January, 2011, the team of three doctors above mentioned examined Arena Shantung in KEMP Hospital and has submitted us the following report: "a; Report of Examination of Ms. Arena Rhombohedra Shantung Jointly prepared and signed by 1. Dry. J. V.
Davit (Professor and Head, Department of Anesthesia, Critical Care and Pain, at Data Memorial Hospital, Iambi) 2. Dry. Roof Guardians (Consultant Neurologist at P. D. Hindu Hospital, Iambi) 3. Dry. Niles Shah (Professor and Head, Department of Psychiatry at Locally Talk Municipal Corporation Medical College and General Hospital). L. Background As per the request of Hon… Justice Kathy and Hon… Justice Mishear of the Supreme Court of India, Ms. Arena Rhombohedra Shantung, a 60-year-old female patient was examined on 28th January 2011, morning and 3rd February 2011, in the side-room of ward-4, of the K.
E. M. Hospital by the team of 3 doctors biz. Dry. J. V. Davit (Professor and Head, Department of Anesthesia, Critical Care and Pain at Data Memorial Hospital, Iambi), Dry. Roof Guardians (Consultant Neurologist at P. D. Hindu Hospital, Iambi) and Dry. Niles Shah (Professor and Head, Department of Psychiatry at Locally Talk 7 Municipal Corporation Medical College and General Hospital). This committee was set up because the Court found some variance between the allegations in the writ petition filed by Ms. Pink Varian on behalf of Arena Armchairs Shantung and the counter affidavit of Dry.
Bazaar. This team of three doctors was appointed to examine Arena Rhombohedra Shantung thoroughly and give a report to the Court about her hysterical and mental condition It was felt by the team of doctors appointed by the Supreme Court that longitudinal case history and observations of last 37 years along with findings of examination will give a better, clear and comprehensive picture of the patient’s condition. This report is based on: 1 . The longitudinal case history and observations obtained from the Dean and the medical and nursing staff of K. E.
M. Hospital, 2. Case records (including nursing records) since January 2010 3. Findings of the physical, neurological and mental status examinations performed by the panel. 4. Investigations performed during the course of this assessment (Blood tests, CT head, Electroencephalogram) II. Medical history Medical history of Ms. Arena Rhombohedra Shantung was obtained from the Dean, the Principal of the School of Nursing and the medical and nursing staff of ward-4 who has been looking after her. 8 It was learnt from the persons mentioned above that 1 . Ms.
Arena Rhombohedra Shantung was admitted in the hospital after she was assaulted and strangulated by a sweeper of the hospital on November 27, 1973. 2. Though she survived, she never fully recovered from the trauma and brain damage exulting from the assault and strangulation. 3. Since last so many years she is in the same bed in the side-room of ward-4. 4. The hospital staff has provided her an excellent nursing care since then which included feeding her by mouth, bathing her she has not developed a single bed-sore or fracture in spite of her bed-ridden state since 1973. . According to the history from them, though she is not very much aware of herself and her surrounding, she somehow recognizes the presence of people around her and expresses her like or dislike by making certain types of vocal sounds and by waving her hands in certain manners. She appears to be happy and smiles when she receives her favorite food items like fish and chicken soup. She accepts feed which she likes but may spit out food which she doesn’t like. She was able to take oral feeds till 16th September 2010, when she developed a febrile illness, probably malaria.
After that, her oral intake reduced and a feeding tube (Role’s tube) was passed into her stomach via her nose. Since then she receives her major feeds by the Role’s tube, and is only occasionally able to accept the oral liquids. Malaria has taken a toll in her physical condition but she is gradually recuperating from it. 6. Occasionally, when there are many people in the room she makes vocal sounds indicating distress. She calms down when people move out of her room. She also seems 9 to enjoy the devotional songs and music which is played in her room and it has calming effect on her. . In an annual ritual, each and every batch of nursing students is introduced to Ms. Arena Rhombohedra Shantung, and is told that "a;She was one of us"a;; "a;She was a very nice and efficient staff nurse but due to the mishap she is in this bed-ridden state"a;. 8. The entire nursing staff member and other staff members have a very impassioned attitude towards Ms. Arena Rhombohedra Shantung and they all very happily and willingly take care of her.
They all are very proud of their achievement of taking such a good care of their bed- ridden colleague and feel very strongly that they want to continue to take care of her in the same manner till she succumbs naturally. They do not feel that Ms. Arena Rhombohedra Shantung is living a painful and miserable life. Ill. Examination Lila. Physical examination She was conscious, unable to co-operate and appeared to be unaware of her surroundings. Her body was lean and thin. She appeared neat and lean and lay curled up in the bed with movements of the left hand and made sounds, especially when many people were present in the room.
She was febrile, pulse rate was 80/min, regular, and good volume. Her blood pressure recorded on the nursing charts was normal. Respiratory rate was 15/min, regular, with no signs of respiratory distress or breathlessness. There was no pallor, cyanogens, clubbing or sisters. She was tendentious (no teeth). 10 Skin appeared to be generally in good condition, there were no bed sores, bruises or evidence of old healed bed sores. There were no skin signs suggestive of nutritional efficiency or dehydration. Her wrists had developed severe conjunctures, and were fixed in acute flexing.
Both knees had also developed conjunctures (right more than left). A instigators feeding tube (Roles tube) was in situ. She was wearing diapers. Abdominal, respiratory and cardiovascular examination was unremarkable. Bibb. Neurological Examination wakefulness but without any apparent awareness (see Table 1 for detailed assessment of awareness). From the above examination, she has evidence of intact auditory, visual, somatic and motor primary neural pathways. However no definitive evidence for awareness of auditory, visual, somatic and motor stimuli was observed during our examinations.
There was no coherent response to verbal commands or to calling her name. She did not turn her head to the direction of sounds or voices. When roused she made non-specific unintelligible sounds ("a;uh, ayah"a;) loudly and continuously but was generally silent when undisturbed. Menace reflex (blinking in response to hand movements in front of eyes) was present in both eyes and humidifies but brisker and more consistent on the left. Papillary reaction was normal bilaterally. Funds could not be seen since she closed her eyes tightly when this was attempted.
At rest she seemed to maintain 1 1 preferential gaze to the left but otherwise gaze was random and undirected (roving) though largely conjugate. Facial movements were symmetric. Gag reflex (movement of the palate in response to insertion of a tongue depressor in the throat) was present and she does not pool saliva. She could swallow both teaspoonfuls of water as well as a small quantity of mashed banana. She licked though not very completely sugar smeared on her lips, suggesting some tongue control. She had flexing intercourse of all limbs and seemed to be incapable of turning in bed spontaneously.
There was what appeared to be minimal voluntary movement with the left upper limb (touching her wrist to the eye for instance, perhaps as an attempt to rub it). When examined/disturbed, she seemed to curl up even further in her flexed fetal position. Sensory examination was not possible but she did seem to find passive movement painful in all four limbs and moaned continuously during the examination. Deep tendon reflexes were difficult to elicit elsewhere but were present at the ankles. Plantar were withdrawal/extensor.
Thus neurologically she appears to be in a state of intact consciousness without awareness of self/environment. No cognitive or communication abilities could be discerned. Visual function if present is severely limited. Motor function is grossly impaired with quadripartite. Ills. Mental Status Examination 1 . Consciousness, General Appearance, Attitude and Behavior : Ms. Arena Rhombohedra Shantung was resting quietly in her bed, apparently listening to the devotional music, when we entered the room. Though, her body built is lean, she appeared to be well nourished and there were no signs of malnourishment.
She appeared neat and clean. She has developed conjunctures at both the wrist 12 joints and knee Joints and so lied curled up in the bed with minimum restricted physical movements. She was conscious but appeared to be unaware of herself and her surroundings. As soon as she realized the presence of some people in her room, she started making repetitive vocal sounds and moving her hands. This behavior subsided as we left the room. She did not have any involuntary movements. She did not demonstrate any catatonic, hostile or violent behavior.
Her eyes were wide open and from her behavior it appeared that she could see and hear us, as when one loudly called her name, she stopped making vocal sounds and hand movements for a while. She was unable to her eyes, she was able to blink well. When an attempt was made to feed her by mouth, she accepted a spoonful of water, some sugar and mashed banana. She also licked the sugar and banana paste sticking on her upper lips and swallowed it. Thus, at times she could cooperate when fed. 2. Mood and affect : It was difficult to assess her mood as she was unable to communicate or express her feelings.
She appeared to calm down when she was touched or caressed gently. She id not cry or laugh or expressed any other emotions verbally or non-verbally during the examination period. When not disturbed and observed quietly from a distance, she did not appear to be in severe pain or misery. Only when many people enter her room, she appears to get bit disturbed about it. 13 3. Speech and thoughts : She could make repeated vocal sounds but she could not utter or repeat any comprehensible words or follow and respond to any of the simple commands (such as "a;show me your tongue"a;).
The only way she expressed herself was by making some sounds. She appeared to have minimal language impression or expression. 4. Perception : She did not appear to be having any perceptual abnormality like hallucinations or illusions from her behavior. 5. Orientation, memory and intellectual capacity : Formal assessment of orientation in time, place and person, memory of immediate, recent and remote events and her intellectual capacity could not be carried out. 6.
Insight : As she does not appear to be fully aware of herself and her surroundings, she is unlikely to have any insight into her illness. ‘V. Reports of Investigations Via. CT scan Head (Plain) This is contaminated by movement artifacts. It shows generalized prominence of operational scull and ventricles suggestive of generalized cerebral atrophy. Brainstem and cerebellum seem normal. Chemic foci are seen in left centum semi- oval and right external capsule. In addition a small left prairie-occipital cortical lesion is also seen and is probably chemic. 14 N.B..
EGG The dominant feature is a moderately rhythmic alpha frequency at 8-10 Haze and 20-70 microvolt which is widely distributed and is equally prominent both interiorly and posterior. It is not responsive to eye- opening as seen on the video. Beta at 18-25 Haze is also seen diffusely but more prominently interiorly. No focal or paroxysmal abnormalities were noted Vic. Blood Reports of the hemoglobin, white cell count, liver function tests, renal function tests, electrolytes, thyroid function, Vitamin 812 and 1,25 thyroid Vita DO levels are unremarkable. (Detailed report from KEMP hospital attached. V. Diagnostic impression 1) From the longitudinal case history and examination it appears that Ms. Arena Rhombohedra Shantung has developed non-progressive but irreversible brain damage secondary to hypoxia-chemic brain injury consistent with the known effects of strangulation. Most authorities consider a period exceeding 4 weeks in this irreversibility. In Ms. Arena’s case, this period has been as long as 37 years, making her perhaps the longest survivor in this situation. 2) She meets most of the criteria for being in a permanent vegetative state (PAS).
PAS is defined as a clinical condition of unawareness (Table 1) of self and environment in which the patient breathes spontaneously, has a stable circulation and shows cycles of eye closure and opening which may simulate sleep and waking (Table 2). While she has evidence of intact auditory, visual, somatic and motor primary neural pathways, no definitive evidence for awareness of auditory, visual, 15 anatomic and motor stimuli was observed during our examinations. VI. Prognosis Her dementia has not progressed and has remained stable for last many years and it is likely to remain same over next many years.
At present there is no treatment available for the brain damage she has sustained. VI’. Appendix evil a. Table 1. CLINICAL ASSESSMENT TO ESTABLISH UNAWARENESS (wade EDT, Johnston C. British Med SIT MULLS RESPONSE Journal 1999; 319:841-844) DOMAIN OBSERVED AUDITORY AWARENESS Sudden loud noise (clap) Startle present, ceases other movements Meaningful noise (rattled steel tumbler and spoon, film songs Non- pacific head and body movements of sass) Spoken commands (;quota;close your eyes;quota;, ;quota;lift left hand ;quota;: in Unable to obey commands.
No specific or reproducible English, Marital and Kanji) response VISUAL AWARENESS Bright light to eyes Papillary responses present Large moving object in front of eyes (bright red torch Tracking movements: present but inconsistent and poorly rattle) reproducible Visual threat (fingers suddenly moved toward eyes) Blinks, but more consistent on left than right Written command (English, Marital: close your eyes) No response SOMATIC
AWARENESS Painful stimuli to limbs (light prick with Wi deathward, maximal in left upper limb sharp end of tendon hammer) Painful stimuli to face Distress but no co-ordinate response to remove stimulus Routine sensory stimuli during care (changing position in bed Generalized non specific response presence but no coordinated and feeding) attempt to assist in process MOTOR OUTPUT Spontaneous Non-specific undirected activities.
Goal directed – lifting left hand to left side of face, apparently to rub her left eye. Responsive Non-specific undirected without any goal directed activities. Conclusion: From the above examination, she has evidence of intact auditory, visual, somatic and motor primary neural pathways. However no definitive evidence for awareness of auditory, visual, somatic and motor stimuli was observed during our examinations. Viii. Table 2.
Application of Criteria for Vegetative State (Aberrant JELL. Neurology clinical Practice 2010; 75 (supply. 1): Ex. Animation findings : whether she meets Criteria ASS-ASS) Criteria (Yes [No / Probably) Unaware of self and environment Yes, Unaware No interaction with others Yes, no interaction 16 Yes , no sustained, reproducible or purposeful behavioral response to visual, auditory, tactile or b behavioral response, but : noxious stimuli 1. Resisted examination of funds 2.
Licked sugar off lips No language comprehension or expression Yes, no comprehension No blink to visual threat Blinks, but more consistent on left than right Present sleep wake cycles Yes (according to nurses) Preserved autonomic and hypothalamic function Yes Preserved cranial nerve reflexes Yes Bowel and bladder incontinence Yes VIII. References 1 . Multi-society Task Force on PAS. Medical aspects of the persistent vegetative state. N Engle J Med 1994; 330: 1499-508 2. Add EDT,Johnston C. The permanent vegetative state: practical guidance on diagnosis and management.
Bruit Med J 1999; 319:841-4 3. Casino JET, Shall S, Chills N, et al. The minimally conscious state : Definition and diagnostic criteria. Neurology 2002;58:349-353 4. Aberrant JELL. Current controversies in states of chronic unconsciousness. Neurology 2010;75;ASS;quota; 8. On 18th February, 2011, we then passed the following order : ;quota;Len the above case Dry. J. V. Davit on 17. 02. 2011 handed over the report of the team of three doctors whom we had appointed by our order dated 24th January, 2011. He has also handed over a CD in this connection.
Let the report as well as the CD form part of the record. On mentioning, the case has been adjourned to be listed on 2nd March, 2011 at the request of learned Attorney General of India, Mr… T. R. Underrating, learned Senior Advocate, whom we have appointed as mimics curiae in the case as well as Mr… Shaker Naphtha, learned Senior Advocate for the petitioner. We request the doctors whom we had appointed biz. , Dry. J. V. Davit, Dry. Roof Guardian and Dry. Niles Shah to appear before us on 2nd March, 2011 at 10. 30 A. M. N the Court, since 17 t is quite possible that we may like to ask them questions about the report which they have submitted, and in general about their views in connection with euthanasia. On perusal of the report of the committee of doctors to us we have noted that there are many technical terms which have been used therein which a non-medical man would find it difficult to understand. We, therefore, request the doctors to submit a supplementary report by the next date of hearing (by e-mailing copy of the same two days before the next date of hearing) in which the meaning of these technical terms in the report is also explained.
The Central Government is directed to arrange for the air travel expenses of all the three doctors as well as their stay in a suitable accommodation at Delhi and also to provide them necessary conveyance and other facilities they require, so that they can appear before us on 02. 03. 2011. An honorarium may also be given to the doctors, if they so desire, which may be arranged mutually with the learned Attorney General. The Dean of King Edward Memorial Hospital as well as Ms.
Pinky Varian (who claims to be the next friend of the petitioner) are directed to intimate the brother(s)/sister(s) or other close relatives of he petitioner that the case will be listed on 2nd March, 2011 in the Supreme Court and they can put forward their views before the Court, if they so desire. Learned this Order forthwith to the Dean, KEMP Hospital. The Dean, KEMP Hospital is requested to file an affidavit stating his views regarding the prayer in this writ petition, and also the condition of the petitioner. Copy of this Order shall be given forthwith to learned Attorney General of India, Mr…
Shaker Naphtha and Mr… Underrating, learned Senior Advocates. 18 Let the matter be listed as the first item on 2nd March, 2011;quota;. . On 2. 3. 2011, the matter was listed again before us and we first saw the screening of the CD submitted by the team of doctors along with their report. We had arranged for the screening of the CD in the Courtroom, so that all present in Court could see the condition of Arena Shantung. For doing so, we have relied on the precedent of the Unmurmuring trials in which a screening was done in the Courtroom of some of the Nazi atrocities during the Second World War.
We have heard learned counsel for the parties in great detail. The three doctors nominated by us are also present in Court. As requested by us, the doctors team submitted a supplementary report before us which states : Supplement To The Report Of The Medical Examination Of Arena Ramadan Shantung Jointly prepared and signed by 1. Dry. J. V. Davit Corporation Medical College and General Hospital). Iambi February 26, 2011 19 INDEX Introduction 3 Terminology 4 Glossary of Technical terms 7 Patton 11 3 Introduction This document is a supplement to the Report of Examination of Ms.
Arena Rhombohedra Shantung, dated February 14, 2011. On perusal of the report, the Hon… Court observed that there were many technical terms which a non-medical man loud find it difficult to understand, and requested us to submit a supplementary report in which the meaning of these technical terms in the report is also explained. We have therefore prepared this Supplement to include a glossary of technical terms used in the earlier Report, and also to clarify some of the terminology related to brain damage. Finally, we have given our opinion in the case of Arena Shantung.
Terminology The words coma, brain death and vegetative state are often used in common language to describe severe brain damage. However, in medical terminology, these terms have specific meaning and significance. Brain death A state of prolonged irreversible cessation of all brain activity, including lower brain stem function with the complete absence of voluntary movements, responses to stimuli, brain stem reflexes, and spontaneous respirations. Explanation: This is the unresponsive, has no reflex activity from centre in the brain, and has no breathing efforts on his own.
However the heart is beating. This patient can only be maintained alive by advanced life support (breathing machine or ventilator, drugs to maintain blood pressure, etc). These patients can be legally declared dead (brain dead’) to allow their organs to be taken for donation. Arena Shantung is clearly not brain dead. Coma Patients in coma have complete failure of the arousal system with no spontaneous eye opening and are unable to be awakened by application of vigorous sensory stimulation. 0 Explanation: These patients are unconscious. They cannot be awakened even by application of a painful stimulus. They have normal heart beat and breathing, and do not require advanced life support to preserve life. Arena Shantung is clearly not in Coma. Vegetative State (VS..) The complete absence of behavioral evidence for self or environmental awareness. There is preserved capacity for spontaneous or stimulus-induced arousal, evidenced by sleep-wake cycles. .I. E. Patients are awake, but have no awareness.
Explanation: Patients appear awake. They have normal heart beat and breathing, and do not require advanced life support to preserve life. They cannot produce a purposeful, co- ordinate, voluntary response in a sustained manner, although they may have primitive reflexive responses to light, sound, touch or pain. They cannot understand, communicate, speak, or have emotions. They are unaware of self and environment and have no interaction with others. They cannot voluntarily control passing of urine or stools. They sleep and awaken.
As the centre in the brain controlling the heart and breathing are intact, there is no threat to life, and patients can survive for many years with expert nursing care. The following behaviors may be seen in the vegetative state : Sleep-wake cycles with eyes closed, then open Patient breathes on her own Spontaneous blinking and roving eye movements Produce sounds but no words Brief, unstained visual pursuit (following an object with her eyes) Grimacing to pain, changing facial expressions Yawning; chewing Jaw movements Swallowing of her own spit
Nonplussed limb movements; arching of back Reflex withdrawal from painful stimuli Brief movements of head or eyes toward sound or movement without apparent localization or fixation Startles with a loud sound Almost all of these features consistent with the diagnosis of permanent vegetative state were present during the medical examination of Arena Shantung. 21 Minimally Conscious State Some patients with severe alteration in consciousness have neurological findings that do not meet criteria for VS… These patients demonstrate some behavioral evidence of conscious awareness but remain unable to reproduce this behavior consistently. This