Ethics, medicine, and health in South Africa.
Subject: Bioethics (Case studies)
Medicine (Practice)
Medical ethics (Case studies)
Author: Benatar, Solomon R.
Pub Date: 08/01/1988
Publication: Name: The Hastings Center Report Publisher: Hastings Center Audience: Academic; Professional Format: Magazine/Journal Subject: Biological sciences; Health Copyright: COPYRIGHT 1988 Hastings Center ISSN: 0093-0334
Issue: Date: August-Sept, 1988 Source Volume: v18 Source Issue: n4
Geographic: Geographic Scope: South Africa Geographic Name: South Africa; South Africa
Accession Number: 6685904
Full Text: Ethics, Medicine, and Health in South Africa

In many countries throughout the world, the health care professions and society as a whole are increasingly being confronted with ethical dilemmas. The spectrum of problems may be very similar across countries, but the specific issues raised by and the prominence given to a particular problem vary enormously from country to country. This divergence can be explained by differences in moral values and cultural traditions, in national development and priorities, in population structures and growth rates, in economies, and in ideologies underlying the struggle for political and economic power at national and international levels.

Although health care professionals are trained to provide care for ill patients as individuals and generally see this as their principal responsibility, it is increasingly necessary to reiterate to practitioners of Western medicine that health, medicine, medical education, and health care delivery systems cannot be considered in isolation from the political, economic, psychosocial, and communal factors that determine the milieu within which people live and that may promote their health or predispose them to disease.

South Africa is a country of paradoxes and contrasts. It is geographically beautiful, rich in natural and human resources, and has the potential to facilitate the economic development of many countries in southern Africa. [1] It is also a country in which the dehumanizing policies of apartheid have stultified and degraded the lives of millions, ingrained hatred, cynicism, and despair into many generations of its citizens, silenced or driven to other countries innumerable talented citizens, created an opposition in exile, and isolated the country internationally. This sociopolitical-economic milieu and its context have been alluded to in more detail elsewhere. [2]

The elimination of apartheid is the first and most important step towards reducing the very wide disparities between different groups in this country. Yet the road toward the reversal of this abhorrent policy and the establishment of an internationally recognized state in South Africa in which human rights are accorded to all on a nondiscriminatory basis has not been clearly identified, let alone embarked on. Moreover, other major social, economic, and political changes will be required, and debate centers on whether these can or should take place within the Western liberal paradigm or whether alternative ideological paradigms such as socialism offer greater potential for success.

Availability of Medical Services

Medical services in South Africa (comprising public, private, and voluntary organizations) are concentrated in major hospitals in urban centers and are typically Western in structure. They are equipped with most, but not all, modern diagnostic and therapeutic technologies, and focus predominantly on diagnosing and treating cardiovascular, neoplastic, degenerative, and infectious diseases, often in their advanced stages. Community hospitals are by comparison relatively poorly developed, especially in areas of high population density and low socioeconomic status where they are most needed. Family practice, primary care facilities, and ancillary medical services are disproportionately distributed among the affluent, and considerable development is needed in both urban and rural areas. Facilities for rehabilitation are likewise very inadequate. In addition, population growth and an influx of people into urban areas are creating demands that are outstripping the resources of teaching hospitals, resulting in erosion of the quality of clinical and academic functions. The and political circles. [9] The failure of Western, curative-oriented medicine to give adequate consideration to preventive, promotive, rehabilitative, and other social aspects of health care is particularly relevant in South Africa, where greater attention must be directed to the social underpinnings of health and disease. [10]

The lack of consensus on questions of allocation can be attributed to different views of the nature of medicine, as well as to broader questions such as what it means to be human, how communities should be organized, and to the underlying struggle for power between groups with different value systems. [11]

The challenges faced by participants in this societal debate are first and foremost to acknowledge that the ideological gap is considerably narrower than simplistically depicted by advocates of the extreme positions and to create the prospect for negotiated solutions. Whether South Africa can become a social democracy incorporating features of the welfare state (for all) and private enterprise in combinations similar to those found in other Western nations (with annual per capita income in excess of $12,000 U.S.) or will only be able to achieve a democratic form of socialism like Yugoslavia's (with annual per capita income of $2,000 U.S. as in South Africa today) will depend as much on whether its economy can be boosted to its full potential as on other considerations.

Occupational Health

The both industry and the state recognize the importance of occupational health is reflected in the history of efforts to promote mine workers' health in South Africa, and in research undertaken by the Medical Bureau for Occupational Diseases and the National Center for Occupational Health (NCOH) in Johannesburg. Their attention has focused predominantly on the mining industry, but in recent years there has been an escalating commitment to improving occupational health on a broader scale. Researchers at the NCOH and the Industrial Health Research Group (IHRG) at the University of Cape Town have conducted important studies of the sociological and social welfare aspects of occupational health and the epidemiology of occupational diseases. They have assisted in providing information and education in health and safety in occupational settings, and the services of the IHRG have been of great value to the independent black trade unions. However, much remains to be done to promote better working conditions and occupational health care services within a framework supportive of basic human rights.

Ethical Aspects of Medical Practice

The Physician-Patient Relationship. It is perhaps not surprising that patient autonomy has not emerged as a dominant force in medical practice in South Africa. Many patients, particularly those from lower socioeconomic groups, have had an inadequate education, face language and cultural barriers, and have become complacent about their subordinate role in society. Access to public hospitals unrestricted by financial considerations also tends to foster patients' expectation and acceptance of a paternalistic relationship with physicians. Public concern regarding human rights has focused on civil and political rights, rather than on rights to participate in medical decisionmaking.

Moreover, many health care professionals are (or are perceived to be) genuinely beneficent and altruistic. Even in the private sector, where patients are more educated and affluent, the traditional trusting relationship between doctor and patient has been preserved to a remarkable extent. Litigation has until recently been very uncommon. Malpractice insurance premiums have increased gradually over the years, but the maximum annual rate is R480 ($250 U.S.).

The movement toward patient autonomy is, however, gaining momentum, and students as well as established practitioners have become conscious of the conflict between professional paternalism and patient rights through political conflicts, programs on medical ethics at medical schools, and local medical publications. [12] It is hoped that in the movement toward greater emphasis on patient autonomy, ethical sensitivity will be enhanced and, while remaining linked to altruism and beneficence, will promote more effective communication with patients in an empathic, compassionate, and mutually respectful relationship.

Health Care for Detainees. Another bioethical issue of particular importance in South Africa is the role of health care professionals in caring for detainees and in opposing physical and mental torture. In 1982, the University of Cape Town Faculty of Medicine expressed concern that "detention and solitary confinement in jail or excessive and prolonged interrogation procedures present a high risk of injury and severe psychological disturbance, and an ever present possibility of suicide. As such these practices alone or in combination amount to torture...." [13]

The Faculty made several recommendations regarding the delivery of medical treatment to prisoners and detainees:

* The autonomy and judgment of the medical practitioner caring for the prisoner or detainee should at all times be paramount. No one should have the power to overrule such judgment, since under no circumstances can the health care professional practice his or her profession without ensuring that the health interests of his or her patient supersede all else.

* The rights of prisoners and detainees in respect of medical care should be statutorily defined and the prisoner or detainee should be informed of the right of access to medical attention.

* The need under certain circumstances for maximum security is understood, but this should not be at the expense of ensuring adequate facilities to enable the examining physician to discharge his responsibility to the patient in a proper professional manner.

* There should be clear instructions to ensure that the use of paramedical health service personnel is not in any way abused.

* The dangers of injury and depression resulting from isolation cannot be too greatly stressed.

* The standards laid down and adherence to them should come and political circles. [9] The failure of Western, curative-oriented medicine to give adequate consideration to preventive, promotive, rehabilitative, and other social aspects of health care is particularly relevant in South Africa, where greater attention must be directed to the social underpinnings of health and disease. [10]

The lack of consensus on questions of allocation can be attributed to different views of the nature of medicine, as well as to broader questions such as what it means to be human, how communities should be organized, and to the underlying struggle for power between groups with different value systems. [11]

The challenges faced by participants in this social debate are first and foremost to acknowledge that the ideological gap is considerably narrower than simplistically depicted by advocates of the extreme positions and to create the prospect for negotiated solutions. Whether South Africa can become a social democracy incorporating features of the welfare state (for all) and private enterprise in combinations similar to those found in other Western nations (with annual per capita income in excess of $12,000 U.S.) or will only be able to achieve a democratic form of socialism like Yugoslavia's (with annual per capita income of $2,000 U.S. as in South Africa today) will depend as much on whether its economy can be boosted to its full potential as on other considerations.

Occupational Health

That both industry and the state recognize the importance of occupational health is reflected in the history of efforts to promote mine workers' health in South Africa, and in research undertaken by the Medical Bureau for Occupational Diseases and the National Center for Occupational Health (NCOH) in

Johannesburg. Their attention has focused predominantly on the mining industry, but in recent years there has been an escalating commitment to improving occupational health on a broader scale. Researchers at the NCOH and the Industrial Health Research Group (IHRG) at the University of Cape Town have conducted important studies of the sociological and social welfare aspects of occupational health and the epidemiology of occupational diseases. They have assisted in providing information and education in health and safety in occupational settings, and the services of the IHRG have been of great value to the independent black trade unions. However, much remains to be done to promote better working conditions and occupational health care services within a framework supportive of basic human rights.

Ethical Aspects of Medical Practice

The Physician-Patient Relationship. It is perhaps not surprising that patient autonomy has not emerged as a dominant force in medical practice in South Africa. Many patients, particularly those from lower socioeconomic groups, have had an inadequate education, face language and cultural barriers, and have become complacent about their subordinate role in society. Access to public hospitals unrestricted by financial considerations also tends to foster patients' expectation and acceptance of a paternalistic relationship with physicians. Public concern regarding human rights has focused on civil and political rights, rather than on rights to participate in medical decisionmaking.

Moreover, many health care professionals are (or are perceived to be) genuinely beneficent and altruistic. Even in the private sector, where patients are more educated and affluent, the traditional trusting relationship between doctor and patient has been preserved to a remarkable extent. Litigation has until recently been very uncommon. Malpractice insurance premiums have increased gradually over the years, but the maximum annual rate is R480 ($250 U.S.)

The movement toward patient autonomy is, however, gaining momentum, and students as well as established practitioners have become conscious of the conflict between professional paternalism and patient rights through political conflicts, programs on medical ethics at medical schools, and local medical publications. [12] It is hoped that in the movement toward greater emphasis on patient autonomy, ethical sensitivity will be enhanced and, while remaining linked to altruism and beneficence, will promote more effective communicate with patients in an empathic, compassionate, and mutually respectful relationship.

Health Care for Detainees. Another bioethical issue of particular importance in South Africa is the role of health care professionals in caring for detainees and in opposing physical and mental torture. In 1982, the University of Cape Town Faculty of Medicine expressed concern that "detention and solitary confinement in jail or excessive and prolonged interrogation procedures present a high risk of injury and severe psychological disturbance, and an ever present possibility of suicide. As such these practices alone or in combination amount to torture...." [13]

The Faculty made several recommendations regarding the delivery of medical treatment to prisoners and detainees:

* The autonomy and judgment of the medical practitioner caring for the prisoner or detainee should at all times be paramount. No one should have the power to overrule such judgment, since under no circumstances can the health care professional practice his or her profession without ensuring that the health interests of his or her patient supersede all else.

* The rights of prisoners and detainees in respect of medical care should be statutorily defined and the prisoner or detainee should be informed of the right of access to medical attention.

* The need under certain circumstances for maximum security is understood, but this should not be at the expense of ensuring adequate facilities to enable the examining physician to discharge his responsibility to the patient in a proper professional manner.

* There should be clear instructions to ensure that the use of paramedical health service personnel is not in any way abused.

* The dangers of injury and depression resulting from isolation cannot be too great stressed.

* The standards laid down and adherence to them should come under constant peer review in order that these rules not be allowed to lapse by default.

The Faculty called on the appropriate ministers of state, the Medical Association of South Africa (MASA, a signatory to the Declaration of Tokyo), and the South African Medical and Dental Council to do everything within their powers to ensure in law proper protection and health rights for persons held in South African jails, and to guarantee "constant peer review." MASA subsequently made similar recommendations. [14]

Yet the inadequacies of the responses from the South African medical profession and the delays in mobilizing support for the commendable efforts of individuals and groups to expose and oppose the violations of the human rights of prisoners and detainees have been clearly described in a recent publication from the American Association for the Advancement of Science Committee on Scientific Freedom and Responsibility. [15] This document provides a detailed account of the events that followed Steve Biko's death in detention in 1977, and there is little doubt that the South African Medical and Dental Council and the medical profession through its official body, MASA, could and should have acted more promptly and with greater professional integrity.

Two conferences have been held recently in Johannesburg (under the auspices of the University of Witwatersrand) on "Emergency Law" and "The Health Care of Detainees--The Law, Professional Ethics, and Reality." [16] At the latter symposium, it was proposed that resolving many of the difficulties facing professionals dealing with prisoners and detainees must include:

* Clear recognition of the ethical issues involved.

* Condemnation of health care professionals' participation in activities even remotely connected with mental or physical torture.

* Formulating codes of practice to reflect the special circumstances facing medical personnel in prisons, and campaigning for mechanisms to implement these codes.

* Speaking out against the inhumanity of detention without trial and exerting pressure to change unjust laws.

* Providing professional support for prison health personnel and supporting those who may be victimized for taking highly principled stands.

* Pressing for legal formulation of clearer and fairer mechanisms of "due process" to handle problems that arise within the detention system as it exists. [17]

Publication of these proceedings will, it is hoped, help sensitize professionals and the public to the conditions and implications of detention, and rally both the legal and medical professions to oppose more cohesively injustices in South Africa and to act more vigorously as a conscience for our broader society.

The Moral Validity of Medical

Practice in South Africa

A question that professionals must ask, within the confines of a repressive authoritarian state where human rights are systematically violated, is whether their mere participation in such a society compromises their professional independence and moral integrity. I believe not. Many ascribe to whites who remain in South Africa, guilt by association with the apartheid policies that have had such devastating effects on the lives on many people and which so many South Africans detest. Yet these critics may be unaware of the intentions, actions, and aspirations of many fine institutions and people who are deeply concerned for the welfare of their fellow man and aspire to the highest human ideals in the practice of their professions. There is also little evidence to support the (often veiled) accusation that the practice of medicine in South Africa is less moral than elsewhere in the Western world. However, there are shortcomings in professionals' responses to violations of human rights in South Africa.

This inadequacy can be attributed to several factors. Global apathy about social affairs of which the medical and other professions have been accused (with some justification) reveals itself in South Africa in lack of widespread knowledge and interest in these issues. This complacency is further aggravated by censorship in literature and restriction of freedom of the press, which isolate and protect people from events and opinions around them. [18]

The South African medical community also lacks effective organization and consolidation of the efforts of those health care professionals who are involved and committed to societal change. The efforts of this small but growing group are becoming more visible through actions, statements, conferences, and publications.

South African professionals also receive minimal public support from international colleagues and institutions. With few exceptions, outsiders have either been silent or more willing to assume a position of moral superiority than constructively to encourage and assist South African professional and academic institutions to face up to situations they may have confronted themselves or with which they would have welcomed assistance under reversed circumstances. [19]

It has been suggested that a massive fantasy of reciprocal projection is being played out between South Africa and Western nations. South Africans of all races and ideological persuasions blame the West for contributing positively or negatively to the "enraging frustrations" in their country, while people in the West have used South Africa as "a ventilation valve for their own moral and political frustrations, finding it a convenient surrogate or an easy analogy for issues at home whose complexity has rendered them intractable." [20]

Estrangement from colleagues, like censorship of literature and the press, can result in the closing of minds, a restricted view of professional responsibilities, and complacency with the status quo. The personal and public support received by many individuals from perceptive and caring colleagues abroad undoubtedly plays an important role in overcoming constraints to maintaining personal and professional integrity.

The Challenge of the Future

The practice of medicine in South Africa, like that in many other countries, has its shortcomings. The clarity with which these are seen, the importance attached to individual issues by those of us in south Africa and by colleagues abroad, and responses to these issues will be influenced by the perspectives and value bases fromm which they are perceived.

There are laudable aspects to medical care in South Africa that should not be overlooked in the process of spotlighting deficiencies. Professionals take price in identifying with colleagues, fellow men and women from all walks of life, and with institutions in South Africa and abroad, who by their efforts and example help to make life better for many. With this pride is coupled an intense humility that arises from a sense of failure and futility engendered by the magnitude of the problems that must be overcome to achieve a peaceful and equitable future for all people in this country. Accusations of "bad faith" and indiscriminate public withdrawal of collegial support are likely to aggravate rather than alleviate the problems. This condemnatory approach should be discourged by all who believe that a new health service need not arise only from the ashes of an existing system that first must be destroyed.

In our rapidly changing society, the challenges for medicine over the coming years will be to broaden medical education to include study of African languages and culture and of the implement efficient primary health care teams, and to help create movement toward an open society in which medicine is practiced both scientifically and humanely within an equitable health service. [21]

For South Africa to evolve into a social democracy in which its wealth, talent, and resources can be fully developed and used for the benefit of all its people, there will need to be not only political change with democratization of the development process, a deep commitment to human rights, and an active de-alienation program, but also rapid expansion of the economy and reincorporation of South Africa into the world market. This cannot occur until whites and blacks in the country agree to make the compromises necessary to travel the path toward rapid and peaceful achievement of these objectives, and even then only if this is legitimated internationally and facilitated by the active economic and political support of other nations. The enormity of the advantages of such peaceful progress over civil war, revolution, and vulgar socialism in an impoverished economy justify dedication to this cause.

In discussing the impact of religious diversity on medicine, Samuel Gorovitz has stted that:

. . .dogmatism, fanaticism and ideology are the enemies of tolerance, of careful listening, of reason and of understanding and compassion for those who are different. They foster divisiveness and conflict and the health of the people of the world is far too important for us to accept that. Instead we should turn our efforts to identifying that core of principles on which we can agree, and should strive to have them adopted as a basis for an international code of ethics for health policy. We must live with the reality of disagreement about some issues, but we should do all we can to translate our considerable agreement into better health for mankind. [22]

Such an attitude (unlike academic boycott) is in keeping with Western liberal thought and the true scientific spirit, and the medical profession in free countries should consider how they could assist colleagues elsewhere who strive to attain the highest ideals to which all who practice medicine should aspire.

References

[1] The wealthiest and most technologically advanced country in Africa, South Africa generates 25 percent of the "gross continental product," producing, for example, 90 percent of steel and 50 percent of all electricity in Africa. Many countries in southern Africa are dependent on its transport system and economy, and there is a reciprocal flow of trade between forty-seven African states and South Africa.

[2] Paul Johnson, "The Race for South Africa," Commentary 80:3 (September 1985), 27-32; Solomon R. Benatar, "Medicine and Health Care in South Africa," New England Journal of Medicine 315:8 (August 21, 1986), 527-32; Peter L. Berger and Bobby Godsell, "Fantasies about South Africa," Commentary 84 (July 1987), 35-40.

[3] Derek Yach, Jack M.L. Klopper, and Steve P. Taylor, "Use of Indicators in Achieving 'Health for All' in South Africa, 1987," South African Medical Journal 72 (December 5, 1987), 805-807; Jack M.L. Klopper and Steve P. Taylor, "The Health and Wealth of South Africa," South African Medical Journal 72 (December 5, 1987), 799-801; Steve P. Taylor and Jack M.L. Klopper, "South African Health Care Expenditure 1975-1984," South African Medical Journal 72 (December 5, 1987), 802-804.

[4] National Health Services Commission, Report on the Provision of an Organised National Health Service for all Sections of the People of the Union of South Africa (Pretoria: Government Printer, 1944).

[5] The efforts of concerned practitioners to highlight gross inadequacies at Baragwanath Hospital in Soweto have met with repressive response by provincial health authorities. See S.R. Abkiewicz and one hundred colleagues, "Conditions at Baragwanath Hospital," South African Medical Journal 72 (September 5, 1987), 361; Solomon R. Benatar and Ralph E. Kirsch, "Baragwanath--a Hospital in Despair," South African Medical Journal 72 (September 5, 1987), 307 (and ensuing correspondence South African Medical Journal 73 [February 6, 1988], 143), 189-91.

[6] Faculty of Medicine, University of Cape Town, "Segregation on the Basis of Race at the New Groote Schuur Hospital," South African Medical Journal 71 (May 2, 1987), 601.

[7] C.D. Naylor, "Privatization of South African Health Services: Are the Underlying Assumptions Correct?" South African Medical Journal 72 (November 21, 1987, 673-78; "Resource Allocation in Medicine," in Ethical and Moral Issues in Contemporary Medical Practice, S.R. Benatar, ed. (Cape Town: University of Cape Town Press, 1985), 120-62; Solomon R. Benatar, "Medicine and Health Care," Energos 15 (1988), 21-28; "Privatization and Medicine,c South African Medical Journal 72 (November 21, 1987), 655-56.

[8] Benatar, "Medicine and Health Care in South Africa"; "A National Health Service for South Africa," South African Medical Journal 68 (December 7, 1985), 639.

[9] Benatar, Ethical and Moral Issues.

[10] National Health Services Commission, Report on the Provision of an Organized National Health Service; Vicente Navarro, Crisis, Health and Medicine: A Social Critique (New York: Tavistock Publications, 1986).

[11] Heribert Adam and Kogila Moodley, South Africa Without Apartheid: Dismantling Racial Domination (Cape Town: Maskew Miller Longman, 1986); Navarro, Crisis, Health, and Medicine; James Leatt, "Neither Adam Smith nor Karl Marx," Leadership South AFrica 5:4 (1986), 36-44; Erich H. Loewy, "Communities, Obligations and Health Care," Social Science Medicine 25 (1987), 783-91.

[12] "Medical Ethics," South African Journal of Continuing Medical Education 5 (April 1987); Solomon R. Benatar and Trefor Jenkins, "Teaching Medical Ethics in South Africa," South African Medical Journal 73 (April 16, 1988), 449-52.

[15] David McKenzie, "Medical Treatment of Prisoners and Detainees," South African Medical Journal 61 (May 8, 1982), 688.

[14] Ad Hoc Committee of the Medical Association of South Africa to Institute an Enquiry into the Medical Care of Prisoners and Detainees, "Medical Care of Prisoners and Detainees," South African Medical Journal 63 (May 21, 1983), Supplement; Trefor Jenkins, "Ethical Issues in the Medical Care of Prisoners and Detainees," South African Journal of Continuing Medical Education 5 (April 1987), 40a-49; Oliver J. Ransome, "Children in Places of Detention: A Code for Their Handling," South African Medical Journal 71 (June 20, 1987), Supplement.

[15] May Rayner, Turning a Blind Eye? Medical Accountability and The Prevention of Torture in South Africa (Washington DC: American Association for the Advancement of Science, 1987).

[16] Nicholas Hayson and Laura Mangan, eds., Emergency Law, (Johannesburg; Centre for Applied Legal Studies, University of Witwatersrand, 1987); Trefor Jenkins, ed., The Health Care of Detainees: The Law, Professional Ethics, and Reality (in press).

[17] Solomon R. Benatar, "Ethical Responsibilities of Health Professionals in Caring for Prisoners and Detainees," in The Health Care of Detainees, T. Jenkins, ed. (in press).

[18] Christopher Merrett, "Censorship: The Challenge to South African Universities," Theoria 64 (May 1986), 1-11; Richard Steyn, "The Press's Responsibility in a Polarised Society," Theoria 69 (May 1987), 15-27.

[19] For different views on this issue, see: Ralph Slovenko, "Commentary: South Africa," Journal of Psychiatry and Law 13 (1985), 233-331; John Maddox, "The Boycott of South Africa," Nature 327 (May 28, 1987), 269-76; W.D. Stein and M. Wallis, "Boycott of South Africa," Nature 328 (July 30, 1987), 374; Maurice McGregor, "Apartheid and the Academic Boycott of South Africa," New England Journal of Medicine 316:16 (April 16, 1987), 1022-23; Josuf Veriava et al., "Apartheid and the Academic Boycott of South Africa," New England Journal of Medicine 317:18 (October 29, 1987), 1161-62.

[20] Berger and Godsell, "Fantasies."

[21] Charles Simkins, Reconstructing South African Liberalism (Johannesburg: Institute of Race Relations, 1986); "Democracy and Government: A Post-Leninist Perspective," South Africa International 18 (1987), 19-29.

[22] Samuel Gorovitz, Panel IV. The Meaning Life, Suffering and Death. Health Policy, Ethics and Human Values--An International Diologue, XVIII CIOMS Round Table Conference, Z. Bankowski and J.H. Bryant, eds. (Geneva: Council of International Organizations of Medical Sciences, 1985), 311-12.

Solomon R. Benatar is chairman of the division and department of medicine at the University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa.
Gale Copyright: Copyright 1988 Gale, Cengage Learning. All rights reserved.