Indian J Palliat Care Home 

Year : 2018  |  Volume : 24  |  Issue : 1  |  Page : 9--15

Is every life worth saving: Does religion and religious beliefs influence paramedic's end-of-life decision-making? A prospective questionnaire-based investigation

Alexander Leibold1, Christoph L Lassen1, Nicole Lindenberg1, Bernhard M Graf1, Christoph HR Wiese2,  
1 Department of Anaesthesiology, University Hospital of Regensburg, Regensburg, Germany
2 Department of Anaesthesiology and Intensive Care Medicine, Herzogin Elisabeth Hospital, Braunschweig, Germany

Correspondence Address:
Alexander Leibold
Department of Anaesthesiology, University Hospital of Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg


Background: Paramedics, arriving on emergency cases first, have to make end-of-life decisions almost on a daily basis. Faith shapes attitudes toward the meaning and worth of life itself and therefore influences decision-making. Objective: The objective of this study was to detect whether or not religious and spiritual beliefs influence paramedics in their workday life concerning end-of-life decisions, and whether it is legally possible for them to act according to their conscience. Methods and Design: This is a literature review of prior surveys on the topic using five key words and questionnaire-based investigation using a self-administered online survey instrument. Settings/Participants: Paramedics all over Germany were given the opportunity to participate in this online questionnaire-based study. Measurements: Two databases were searched for prior studies for literature review. Participants were asked about their religiosity, how it affects their work, especially in end-of-life situations, how experienced they are, and whether or not they have any legal latitude to withhold resuscitation. Results: A total of 429 paramedics answered the questionnaire. Religious paramedics would rather hospitalize a patient holding an advance directive than leave him/her at home (P = 0.036) and think death is less a part of life than the nonreligious (P = 0.001). Otherwise, the Spearman's rho correlation was statistically insignificant for all tests regarding resuscitation. Conclusions: The paramedic's religiosity is not the prime factor in his/her decision-making regarding resuscitation.

How to cite this article:
Leibold A, Lassen CL, Lindenberg N, Graf BM, Wiese CH. Is every life worth saving: Does religion and religious beliefs influence paramedic's end-of-life decision-making? A prospective questionnaire-based investigation.Indian J Palliat Care 2018;24:9-15

How to cite this URL:
Leibold A, Lassen CL, Lindenberg N, Graf BM, Wiese CH. Is every life worth saving: Does religion and religious beliefs influence paramedic's end-of-life decision-making? A prospective questionnaire-based investigation. Indian J Palliat Care [serial online] 2018 [cited 2020 Aug 7 ];24:9-15
Available from:

Full Text


Religious belief is a very personal matter, which affects our private and our workday life on a daily basis. Human life is sacred to most of all the world's religions, but nonetheless bears the inevitability of death. The manner of how and when one dies was believed to lie in the hands of God, at least concerning the Abrahamic traditions. In the realm of modern medicine, however, our power over life and death has increased. Opinions on how far one should go, concerning medical treatment, to preserve or to save a life may differ.[1] The strength of one's religious belief varies from one person to another and thus may affect one's views and opinions toward life and death itself, this including medical topics such as abortion, preimplantation diagnostics, palliative medicine, emergency medicine, and more. Our investigation focuses on the prehospital treatment of terminally ill patients by German paramedics, highlighting the influence of the paramedics' religious beliefs and the judicial framework they have to work in.

There is no consent in Judaism, Islam, and Christianity nor Eastern traditions (e.g., Hinduism and Buddhism) nor indigenous faith systems on opposing suicide, physician-assisted suicide, and euthanasia, but abstaining from life-prolonging procedures is usually allowed by religious authorities.[1],[2],[3],[4],[5] Some religious people, for example, evangelical Christians in the US, seem to ask for life-prolonging procedures more often than nonreligious people.[1],[6],[7] In addition, Protestants were found to agree to euthanasia more than Catholics.[4],[5] Apparently to some devout people, "Four commonly invoked reasons are (1) hope for a miracle, (2) refusal to give up on the God of faith, (3) a conviction that every moment of life is a gift from God and is worth preserving at any cost, and (4) a belief that suffering can have redemptive value."[8]

Paramedics making an end-of-life decision may be influenced by their religious beliefs. Since 3%–5% of all prehospital emergencies concern outpatient palliative emergencies, every paramedic may find himself/herself in the situation having to make an end-of-life decision.[9] Prior surveys showed that religious belief does influence physicians in their decision-making, concerning withdrawal of life-sustaining treatment and prescribing life-shortening pain medication and euthanasia.[6],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19]

What also must be considered is the fact that paramedics are prohibited from withholding resuscitation by German jurisdiction, and therefore are obligated to initiate full resuscitation of patients with no vital signs, although they can of course express their opinions toward the physician's decision-making, if a physician is present.[9] If there is no physician present but there is an advance directive or do not attempt resuscitation (DNAR) order on scene, paramedics enter a jurisdictional gray area because they may either put aside such mentioned orders, being under time pressure, not being able to fully verify the order's authenticity, or they may adhere to its content in good belief of its genuineness. Only the presence of severe injuries, which are not compatible with life and/or definite signs of death (e.g., livor mortis), legally absolve paramedics from withholding resuscitation. This problem has been solved in England and Wales where the so-called Mental Capacity Act (2005) allows people to draw up an "Advanced Decisions to Refuse Treatment," such as resuscitation. Paramedics there are required by statutory law to respect this:[20] their guidelines permit them to withhold resuscitation when a formal DNAR order is in place, the patient is terminally ill, death is imminent and unavoidable, and resuscitation would not be successful.[21]

Our research hypothesis was that paramedics are influenced by their religious belief. To determine whether or not a paramedic's decision-making in end-of-life situations is influenced by his/her religious beliefs, how they decide given the current judicial framework, and how they would decide were there legal certainty are the main objectives of this study.


Two databases, PubMed ® and Google Scholar ®, were searched for relevant prior investigations exploring the influence of religious and spiritual (R/S) beliefs on end-of-life decision-making using five keywords: End-of-life decision, spirituality, religious belief, palliative care, and resuscitation.

After duplicates were removed and the findings were screened according to abstract and title for their design and relevance to our study, 31 articles were included in the investigation [Table 1]. Two researchers, who took into account the number and type of participants, study design, and results, analyzed the papers found. The search was completed in May 2015.{Table 1}

A prospective questionnaire-based trial was used as the study design using the online tool "www. q-set. de." In a pilot phase, the questionnaire was answered by 29 paramedics in written form, making sure the readability and appropriateness of the content. No modifications had to be made after the pilot testing. Afterward, the online questionnaire was accessible to paramedics all over Germany via links offered on the Malteser Hilfsdienst homepage (, which is one of the big companies offering emergency services and on the Deutscher Berufsverband and Rettungsdienst. V. homepage (, which is the professional association of German paramedics, for 6 weeks (May 4, 2014). In this period of time, 400 paramedics answered the survey, the round number being sheer coincidence, ~7/day. The 29 written copies were included in the investigation for no changes had been made in the questionnaire. Participants who answered the written form were excluded from the online questionnaire to avoid double answers. Comments or a presentation were not given in advance to avoid bias mistakes. The information gathered in the questionnaire is summarized in [Table 2].{Table 2}

Yes and no questions, free answers, and 11-point Likert scales were used for answers and tasks in the mixed methods questionnaire design. The Likert scales were interpreted as follows:

The median number of points plus/minus the standard deviation was interpreted as the average answers, the rest as extreme answers.

For example, with a median of 5 and standard deviation of 2, 7 people who answered 9–11 points on the question "Are you a religious person?" were rated as very religious and people who answered 1–2 points as not at all religious. The same interpretations were used for tasks, for example, 1–3 points as very insecure, 4–8 points as relatively confident, and 9–11 points as very confident.

Palliative care patients were defined as terminally ill patients with no hope of recovery, but who's symptoms and suffering can and must be alleviated and controlled (WHO Definition of Palliative Care).

Participants in the survey had to meet the following criteria: be an active member in an emergency ambulance service in Germany and participate in the investigation voluntarily. In accordance with the Declaration of Helsinki, all information was give anonymously.

IBM SPSS Statistics 22® (IBM Inc., Armonk, USA) and Microsoft ® Excel ® 2013 (Microsoft Inc. Redmond, USA) were used as software to analyze the gathered data. The Spearman's rho test was used to determine the association between two variables. P < 0.05 was considered statistically relevant for all tests. No Institutional Review Board approval was sought and obtained.


Twenty-seven studies investigated the influence of medical staff's R/S beliefs on their end-of-life decision-making concerning their patients. Five articles referred to patients,[6],[22],[25],[26],[34] two to family members,[6],[23] one to social worker,[13] and one to the general public.[16] In none of them, or indeed in any other papers, did we find that paramedics had been questioned so that this is, to the best of our knowledge, the first investigative study of paramedics' R/S beliefs and their influence on their work.

Eight articles used interviews, and 23 used questionnaires (two of them online) as the study design. The number of participants ranged from 12 to 4801, most of the investigations (20) had fewer than 500 participants. Seven studies showed no relevant influence of R/S beliefs on end-of-life decision-making [5],[12],[22],[24],[36],[39],[41] while the other 24 did indeed showed some.[5],[7],[6],[10],[11],[13],[14],[16],[17],[18],[23],[25],[26],[27],[28],[29],[31],[32],[33],[34],[35],[36],[37],[40]

A total of 429 paramedics completed our survey. The median age was 31, the median work experience was 8 years, the median number of emergencies per years was 500 (5% of them being dying patients and 3% of them being palliative care emergencies), and the median number of resuscitations was ten per year. About 24.2% were not at all religious, 3.1% were very religious, and 72.7% were moderately religious [Table 3]. Nearly 25.3% of the participants rated themselves as nonbelievers, 10.1% as having strong religious beliefs, and 64.6% as moderately believing. Around 30.4% were not at all influenced, 20.1% were strongly influenced, and 49.5% were moderately influenced by religious values in their workday life.{Table 3}

Nearly 72.2% of the participants stated that palliative care had not been part of their training and 59.2% had not attended further education in palliative care medicine. Almost 42.4% had personal experience with a palliative care situation.

Altogether 59.9% doubted the sense of resuscitating a dying patient and 89% shared this view about resuscitating a dying palliative care patient. Nearly 77.7% considered it ethical not to resuscitate a dying patient and 91.8% not to resuscitate a dying palliative care patient.

A comparison between R/S beliefs (all categories included) and questions about the ethics of withholding resuscitation and the rationality of resuscitation and the hospitalization of palliative care patients produced two statistically relevant P values. Paramedics considering themselves to be religious (1) would rather hospitalize a patient holding an advanced directive than leaving him/her at home (P = 0.036) than nonreligious and (2) think that death is not a natural part of life itself (P < 0.001). Religiosity and strength of belief correlate with attitudes toward euthanasia. Religious and believing paramedics find (3) professionally- and (4) physician-assisted suicide unethical (P < 0.0001), as well as (5) institutions that offer it, for example, "Dignitas" from Switzerland (P < 0.0001), and (6) are against their introduction in Germany (P < 0.0001). There was no significant association between religiosity and the following questions: (7) "Is death a part of life?" (P = 0.072), (8) "Is every human life worth living, no matter the circumstances?" (P = 0.057), (9) "Would you resuscitate a patient who holds an advanced directive that clearly states he/she does not want to be resuscitated?" (P = 0.642), and (10) furthermore, there were no differences between the religious denominations and accordingly the nondenominational [Table 3].

There was a strong correlation between work experience and the following questions: (11) "Is death a part of life?" (P = 0.032), (12) "Is withholding resuscitation ethical?" (P = 0.048), (13) "Are you confident about treating palliative care patients medically?" (P = 0.026), (14) "Would you hospitalize a patient who holds an advanced directive?" (P = 0.001), (15) "Would you resuscitate a patient who holds a DNAR order?" (P = 0.002), (16) "Are you cognizant of how to handle advanced directives legally?" (P = 0.009), and (17) "Do you always act according to the law?" (P < 0.0001). More experienced paramedics think that death is more a part of life than the less experienced, furthermore they would not hospitalize a patient who holds an advanced directive, would not resuscitate a patient who holds a DNAR order, and think that they know the legalities of handling an advanced directive legally but at the same time do not always act according to the law.

Paramedics whose training included palliative care medicine or who attended further education in palliative care medicine were (18) more confident in handling advanced directives legally (P < 0.0001) and (19) were more competent in treating palliative care patients medically (P < 0.0001) and (20) psychologically (P < 0.0001) and (21) their relatives psychosocially (P = 0.008). Surprisingly, they found it more reasonable to resuscitate (22) dying patients and (23) palliative care patients (P = 0.003; P = 0.008) and (24) to withhold resuscitation less ethical. They also knew the local facilities for treating palliative care patients better than their colleagues (25), a fact that seems to be important because, the better the facilities are known to the paramedics, (26) the more confident they are in treating the patients medically (P = 0.021), (27) psychologically (P = 0.018), and (28) their relatives psychosocially (P < 0.001).

Paramedics who have personal experience with a palliative care patient in their private surroundings were (29) better equipped to treat patients' relatives psychosocially (P = 0.027), but on the other hand (30) knew less of the local facilities (P = 0.002) and (31) had attended less further education on the topic (P = 0.001).


R/S beliefs can affect paramedics in judgment making, in our case concerning hospitalization, and can influence paramedics' opinion on whether or not death is a part of life.

However, other factors impact the matter even more. The current law in Germany prohibits paramedics from withholding resuscitation (P < 0.001) even if there is a DNAR order on scene.[9] Similar results were discovered in a survey among Muslim physicians, where the country of origin and practice rather than R/S beliefs played the major role in end-of-life decision-making. The Sharia law in Saudi Arabia, for example, states that decision of DNR is left up to the treating physicians, whereas the law in the USA states that patient autonomy is the highest priority regardless of religion.[24] In our study, 76.6% of the paramedics stated that they had no legal latitude in withholding resuscitation in a dying and terminally ill patient. "Failure to render assistance," "legal uncertainty," "only a physician may declare someone dead, so I have to start," "fear of jurisdictional consequences," and similar reasons were given by the paramedics as to why they would start resuscitation. These answers were repeated throughout the survey. About 74.5% would not resuscitate a dying patient who has an advance directive or DNR order, were there given legal certainty.

Only 9.8% of the participants in our study think that they are competent to handle advanced directives in accordance with the law, a fact that correlates with their training in palliative care medicine (P < 0.0001), and 72.2% stated that they had not received any. Over half of the respondents in the survey on Muslim physicians did not receive training in palliative care medicine either.[24]

More experienced paramedics would not always act according to the law, for example, they would not hospitalize a patient holding an advanced directive, would not resuscitate a patient holding a DNAR order, and consider themselves competent in handling an advanced directive legally. Work experience must, therefore, also be seen as an influencing factor. These results differ from the survey on Muslim physicians, where no correlations between work experience and end-of-life decisions were found, but agree with the study of Younger's et al. conducted in the US, where a stronger correlation between professional background and attitudes toward euthanasia was found, and also Davis' et al. study conducted in seven countries, where a negative correlation between work experience and holding to religious doctrines was found.[24],[39],[41]

The paramedics' abilities in treating palliative care patients medically and the patients' relatives psychosocially depend on whether or not palliative care was part of the paramedics' training and whether the paramedics attended further education and knew about the regional infrastructure for treating palliative care patients (P < 0.001; P = 0.021; 0.018; P < 0.001). The results of our research were absolutely comparable with those of the literature review. Study design, number and type of participants, and limitations were much the same as in the other investigations. Other studies, which showed influence of R/S beliefs, have in common that participants asked for more intensive treatment and more resuscitation and fewer life-shortening procedures for themselves or their patients.[6],[10],[11],[23],[25],[26],[34]


In summary, R/S beliefs can influence paramedics in their decision-making, but other factors, such as professional experience, professional background, special training, and legal frame work conditions, seem to have much greater significance.[24],[39],[41] In Germany, the current law and the lack of training and knowledge in the ever-more important field of palliative care medicine are limiting factors. England and Wales could be examples for German jurisdiction, giving paramedics a legal frame work they can rely on, as a substitute to the current gray area.[20] In the training program for paramedics in Germany, which is currently being adapted, palliative care medicine, including the required knowledge of the law and local infrastructure, deserves, in our opinion, much greater consideration.

Availability of data and materials

All data and materials are available upon reasonable request. Please direct your request to Mr. Alexander Leibold via email:

Limitations of the study

Reliability or validity testing was not applied to our survey study. Due to the unknown number of paramedics with access to the websites mentioned above, an accurate response rate could not be determined. As the survey completion was voluntary, bias may have affected the responses.

To increase the response rate, a game of chance was offered to participants with the opportunity of winning one out of three Amazon ® vouchers. Participants could write their email address anonymously at the end of the questionnaire. was used to determine the winners.


The author would like to thank Mary Leibold for her language corrections and Frank Flake for providing access to the Malteser Hilfsdienst homepage ( and the Deutscher Berufsverband and Rettungsdienst. V. homepage (

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Setta SM, Shemie SD. An explanation and analysis of how world religions formulate their ethical decisions on withdrawing treatment and determining death. Philos Ethics Humanit Med 2015;10:6.
2Bülow HH, Sprung CL, Reinhart K, Prayag S, Du B, Armaganidis A, et al. The world's major religions' points of view on end-of-life decisions in the Intensive Care Unit. Intensive Care Med 2008;34:423-30.
3Baeke G, Wils JP, Broeckaert B. 'There is a time to be born and a time to die' (Ecclesiastes 3:2a): Jewish perspectives on euthanasia. J Relig Health 2011;50:778-95.
4Anderson JG, Caddell DP. Attitudes of medical professionals toward euthanasia. Soc Sci Med 1993;37:105-14.
5Kitchener BA. Nurse characteristics and attitudes to active voluntary euthanasia: A survey in the Australian Capital Territory. J Adv Nurs 1998;28:70-6.
6Bülow HH, Sprung CL, Baras M, Carmel S, Svantesson M, Benbenishty J, et al. Are religion and religiosity important to end-of-life decisions and patient autonomy in the ICU? The Ethicatt study. Intensive Care Med 2012;38:1126-33.
7Dickenson DL. Are medical ethicists out of touch? Practitioner attitudes in the US and UK towards decisions at the end of life. J Med Ethics 2000;26:254-60.
8Brett AS, Jersild P. "Inappropriate" treatment near the end of life: Conflict between religious convictions and clinical judgment. Arch Intern Med 2003;163:1645-9.
9Taghavi M, Simon A, Kappus S, Meyer N, Lassen CL, Klier T, et al. Paramedics experiences and expectations concerning advance directives: A prospective, questionnaire-based, bi-centre study. Palliat Med 2012;26:908-16.
10Wenger NS, Carmel S. Physicians' religiosity and end-of-life care attitudes and behaviors. Mt Sinai J Med 2004;71:335-43.
11Curlin FA, Nwodim C, Vance JL, Chin MH, Lantos JD. To die, to sleep: US physicians' religious and other objections to physician-assisted suicide, terminal sedation, and withdrawal of life support. Am J Hosp Palliat Care 2008;25:112-20.
12Asai A, Ohnishi M, Nagata SK, Tanida N, Yamazaki Y. Doctors' and nurses' attitudes towards and experiences of voluntary euthanasia: Survey of members of the Japanese Association of Palliative Medicine. J Med Ethics 2001;27:324-30.
13Portenoy RK, Coyle N, Kash KM, Brescia F, Scanlon C, O'Hare D, et al. Determinants of the willingness to endorse assisted suicide. A survey of physicians, nurses, and social workers. Psychosomatics 1997;38:277-87.
14Richardson DS. Oncology nurses' attitudes toward the legalization of voluntary active euthanasia. Cancer Nurs 1994;17:348-54.
15Rurup ML, Onwuteaka-Philipsen BD, Pasman HR, Ribbe MW, van der Wal G. Attitudes of physicians, nurses and relatives towards end-of-life decisions concerning nursing home patients with dementia. Patient Educ Couns 2006;61:372-80.
16Ryynänen OP, Myllykangas M, Viren M, Heino H. Attitudes towards euthanasia among physicians, nurses and the general public in Finland. Public Health 2002;116:322-31.
17Vega Vega C, Moya Pueyo V. Attitudes towards active euthanasia and its legislation in Spain. Med Clin (Barc) 1992;98:545-8.
18Vega Vega C, Moya Pueyo V. The current panorama of euthanasia in Spain. Rev Clin Esp 1993;192:233-7.
19Young A, Volker D, Rieger PT, Thorpe DM. Oncology nurses' attitudes regarding voluntary, physician-assisted dying for competent, terminally ill patients. Oncol Nurs Forum 1993;20:445-51.
20Mental Capacity Act. Person who lack capacity. The Mental Capacity Act 2005:1-44.
21Joint Royal College of Ambulances Liaison Committee (JRCALC). UK Ambulance Service Clinical Practice Guidelines. Warwick: JRCALC; 2011.
22Delgado-Guay MO, Chisholm G, Williams J, Bruera E. The association between religiosity and resuscitation status preference among patients with advanced cancer. Palliat Support Care 2015;13:1435-9.
23Jaul E, Zabari Y, Brodsky J. Spiritual background and its association with the medical decision of, DNR at terminal life stages. Arch Gerontol Geriatr 2014;58:25-9.
24Saeed F, Kousar N, Aleem S, Khawaja O, Javaid A, Siddiqui MF, et al. End-of-life care beliefs among Muslim physicians. Am J Hosp Palliat Care 2015;32:388-92.
25Phelps AC, Maciejewski PK, Nilsson M, Balboni TA, Wright AA, Paulk ME, et al. Religious coping and use of intensive life-prolonging care near death in patients with advanced cancer. JAMA 2009;301:1140-7.
26Balboni TA, Vanderwerker LC, Block SD, Paulk ME, Lathan CS, Peteet JR, et al. Religiousness and spiritual support among advanced cancer patients and associations with end-of-life treatment preferences and quality of life. J Clin Oncol 2007;25:555-60.
27Bendiane MK, Galinier A, Favre R, Ribiere C, Lapiana JM, Obadia Y, et al. French district nurses' opinions towards euthanasia, involvement in end-of-life care and nurse patient relationship: A national phone survey. J Med Ethics 2007;33:708-11.
28DeKeyser Ganz F, Musgrave CF. Israeli critical care nurses' attitudes toward physician-assisted dying. Heart Lung 2006;35:412-22.
29Verpoort C, Gastmans C, Dierckx de Casterlé B. Palliative care nurses' views on euthanasia. J Adv Nurs 2004;47:592-600.
30Cuttini M, Casotto V, Kaminski M, de Beaufort I, Berbik I, Hansen G, et al. Should euthanasia be legal? An international survey of neonatal Intensive Care Units staff. Arch Dis Child Fetal Neonatal Ed 2004;89:F19-24.
31Musgrave CF, Margalith I, Goldsmidt L. Israeli oncology and nononcology nurses' attitudes toward physician-assisted dying: A comparison study. Oncol Nurs Forum 2001;28:50-7.
32Matzo ML, Schwarz JK. In their own words: Oncology nurses respond to patient requests for assisted suicide and euthanasia. Appl Nurs Res 2001;14:64-71.
33Musgrave CF, Soudry I. An exploratory pilot study of nurse-midwives' attitudes toward active euthanasia and abortion. Int J Nurs Stud 2000;37:505-12.
34Kaldjian LC, Jekel JF, Friedland G. End-of-life decisions in HIV-positive patients: The role of spiritual beliefs. AIDS 1998;12:103-7.
35Asch DA, DeKay ML. Euthanasia among US critical care nurses. Practices, attitudes, and social and professional correlates. Med Care 1997;35:890-900.
36Cartwright C, Steinberg M, Williams G, Najman J, Williams G. Issues of death and dying: The perspective of critical care nurses. Aust Crit Care 1997;10:81-7.
37Sørbye LW, Sørbye S, Sørbye SW. Nursing students' attitudes towards assisted suicide and euthanasia: A study from four different schools of nursing. Scand J Caring Sci 1995;9:119-22.
38Stevens CA, Hassan R. Management of death, dying and euthanasia: Attitudes and practices of medical practitioners in South Australia. J Med Ethics 1994;20:41-6.
39Davis AJ, Davidson B, Hirschfield M, Lauri S, Lin JY, Norberg A, et al. An international perspective of active euthanasia: Attitudes of nurses in seven countries. Int J Nurs Stud 1993;30:301-10.
40Shuman CR, Fournet GP, Zelhart PF, Roland BC, Estes RE. Attitudes of registered nurses toward euthanasia. Death Stud 1992;16:1-15.
41Youngner S, Jackson DL, Allen M. Staff attitudes towards the care of the critically ill in the medical Intensive Care Unit. Crit Care Med 1979;7:35-40.