Psychedelic Medicine - Hacking Psychiatry?!
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Wort <Informatik>SoundverarbeitungComputeranimationVorlesung/Konferenz
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Güte der AnpassungMomentenproblemRechter WinkelMultiplikationsoperatorVorlesung/Konferenz
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Computeranimation
Transkript: Englisch(automatisch erzeugt)
00:22
is Andrea Jungable. She is talking about drugs and how drugs affect the psychiatry, or this hard word. Why don't you do it, huh? I know now. And the question is, after the,
00:43
what is for both in English? Prohibition, right. After the prohibition in the 70s, not much thinking about how these drugs work and how could they improve psychiatry has been done. So now everybody's asking, is this the magic bullet cure? I don't believe so,
01:03
but more about this by Andrea. Well, warm welcome, please. So, hello everybody. I'm very happy to be here and able to talk to you on a topic that
01:20
is very important to me and I think very important to many people now and in the future. So the topic today is psychedelic medicine hacking psychiatry. And just to give away the punch line, it's not a magic bullet and will never be. But on the other hand, there are lots of things to know and think about in this context that I would like to introduce it to. But first,
01:41
a few words about myself. I'm a medical doctor, specialized in emergency medicine intensive care. I work and live in Berlin. And I'm also one of the founders of MIND, the European Foundation for Psychotic Science and its current medical director. One more sentence about us, that's our core team. So MIND is a members-based psychedelic science association. We have around
02:05
450 members worldwide and a core team of about 50 people. That is a nucleus of paid staff, lots of very dedicated, very good volunteers and great interns from different disciplines like the neurosciences, psychiatry, psychology and pharmacology, for example. So we
02:23
work to establish psychedelic science as an evidence-based method and also educate about it in Germany and Europe around it. Okay, but let's dive in at the deep end. Psychedelics. What are psychedelics? Well, the term comes from the Greek psychadelos, which could be translated
02:44
as manifesting the mind of the psyche. So mainly we're talking about psychoactive substances with a certain, well, capability of transforming one's perception, introspection, sensory qualities in a very typical way that is sometimes described as dreamlike, but not necessarily
03:01
so. The classic psychedelics that are also called hallucinogens, which I don't like as a term because they don't induce hallucinations. What they do is induce studio hallucinations. So somebody on a psychedelic substance usually in 99% of the time is aware that they have taken a substance and what they're experiencing is due to the substance. So it's not a hallucinogen,
03:24
but a pseudo hallucinogen. But these substances like the classics LSD, psilocybin or DMT function in a very specific way and they all are working on the neurogenic systems. So serotonin is one of the key neurotransmitters and there's one receptor, which is the 5H22A
03:43
receptor, which is like the smallest common denominator of all those substances, which doesn't say that they all work just on this one, but they affect a whole plethora of neurotransmitters and receptors, but this is the key where they all work. There are other substances that are classified as somehow psychedelic, like the antactogens.
04:03
Ecstasy, MDMA is one of the kind which works also on the serotonin system. Dissociatives like ketamine work more on the NMDA receptor and some others are just basically chemically random like Amanita, which is fliogaric mushroom or Datura or Salvia. Okay, this
04:20
is the only slide I'm going to bother you with this dry kind of science, but I think it's important to be clear about this because even though psychedelics are a pop culture meme, hardly anybody knows anything about it to be honest. Most people associate them with being drugs of the same danger profile as methamphetamine or opioids, think
04:43
there is an addiction factor, which in fact does not exist with classic psychedelics and basically it has been the dirty corner of perception for many people for a very long time. Recently things have changed a bit. Psychedelics have come mainstream. Firstly because there is a perception shift on drugs in general due to the cannabis perception
05:07
and medication changing and also because people like for example Michael Pollan who is a classic mainstream author writing on cooking and nutrition have turned to writing about psychedelics and another factor that has helped psychedelics in one way and harmed
05:22
them in another is the whole microdosing craze we have seen, especially in the tech and developmental scenes and especially in the Bay Area and Silicon Valley. Okay, but where do they come from? In this talk I am not going to speak about psychedelics,
05:42
psychoactive substances in other culture frameworks. There are cultures like in the Amazonian Basin or some Mazatec people in Mexico who have been using psychoactive substances and psychedelics in a very ritualized sense for millennia perhaps or at least centuries
06:03
but this is not us. So let's talk about what happened here in Europe or in the western world including America. This guy up here, sorry, that's the wrong one. The pointer isn't strong enough. We worked like this. This nice guy up here is Albert Hofmann.
06:22
In 1938 he was developing several substances that were supposed to work on atonia in postpartum women but also on other problems like blood pressure and he among other things developed the thing that later became LSD but back then he didn't see any sense in
06:42
pursuing it medically because it didn't work the way he wanted it to and he shelved it and for some reason in 1943 he took it out of the shelf again to retest it for other purposes and accidentally gave himself the first noted LSD trip. This happened not because it was a shitty chemist but because the amount that is needed to induce an effect
07:05
is so low as it has never been noted before in any other substance. So 20 micrograms of LSD can already produce a notable change in perception. So when he came out of that experience, this first one he had after accidentally dosing himself, he decided to
07:22
go for a trial on himself and trying to be safe he used what he thought was a very low dose of this substance he discovered which turned out to be 250 micrograms of LSD which was his, I hear the laughter, it's rather a high dose trip especially for somebody who
07:42
didn't know what was expected, expecting him out there in his own mind and this is the famous bicycle day trip where he rode home on his bike thinking that the world was collapsing around him basically so even this wasn't a nice trip the first one. So what happened next was that he reported to his superiors a xando chemical in Basel
08:01
and they had the idea of turning this into a substance for mainly doctors, psychiatrists, psychologists to experience what it would be like to be psychotic so its first application of LSD was as a psychotomimetic and as a psychotomimetic thousands of dosages were
08:22
distributed worldwide from the Czech Republic to Harvard University to everywhere and doctors tried it out. What happened then was that a small group of young ambitious psychologists around Timothy Leary tried it out too and thought this is not just something for doctors,
08:41
this is not just a psychotomimetic and brought it out basically into the real world and people experimenting with LSD quite a bit in the 60s before it was forbidden in 71 not because it turned out to be so dangerous, there were not so many accidents, not so many people had dire side effects but because the political will to cope with this substance
09:05
and its implications wasn't existent in the Nixon era. So 71 underground it goes into subculture but the genie was out of the bottle and it was not going to go back in and psychedelics, not only LSD but also well, and these days more than 500 new psychoactive
09:29
substances that have been brought up on the black market are around us and people use them. It's a societal reality that our juridical system doesn't keep up with to be fair.
09:41
So it's been in many subculture settings from people just going dancing and having a good time, to self exploration, to pseudo shamanic or shamanic settings and I think most people will at least know somebody who has experienced psychedelics at least once. And then something else changed. A few years ago, let's say 10 years ago, psychedelics
10:06
started coming back. There had been research, for example, at the University of Zurich around psychedelics before that already. There had been trials before but the big comeback of substances like psilocybin, LSD and MDMA as tools to augment psychotherapy was
10:29
within the last 10 or 15 years. So these people up here are some of the people worldwide working with these substances, trying to develop them into medications. So not over the counter
10:42
but prescription medications to be applied within the setting of psychotherapy. So the idea is never that somebody can walk into a pharmacy saying, oh, I'm depressed, I want to buy psilocybin to treat myself but to have a structured therapeutic session in which the effects can be contained and the benefits enhanced. So the ones that are most
11:03
promising these days are psilocybin for depression, which is already heading for the third stage, third and final stage of improvement as a medication within the USA and consecutively hopefully in Europe and MDMA, so what people want to find if they buy ecstasy,
11:23
not that they always get it, but MDMA is the substance they're trying to get for post-traumatic stress disorder. In the US, even the Veterans Association has jumped on the bandwagon and has spawned this research, which is interesting at least. But isn't that harmful? Aren't these substances very dangerous? Well, not in the way you think and not as
11:47
much as you might think. This graphic up here is something that was put together by a group of 40 experts who discussed what substances have what harm on the user and what harm on the people around the user. So, for example, alcohol is harmful for the
12:04
person, giving them liver disorder, making them addicted and so on and so on, but also because people get aggressive when they use it or drive dangerously, for example, when they're intoxicated, it's dangerous to others. If you check out, I have to walk over here now, sorry to the camera people, the substances we're talking about for treatment
12:26
are not up there with the very dangerous ones. We have the shrooms down here, the LSD is there, ecstasy is there, so very low danger to the user and almost no danger to other people. If you compare that to alcohol, heroin, tobacco, it's all up there. And, to be
12:46
quite fair, we are all part of a giant field study anyway, because these substances are being used. This is data from the 2017 Global Drug Survey, which is a self-reporting study where people talk about their own drug use and fill in forms online. This
13:03
is not a statistically sound sample of the general population, because to fill out that trial, you have to have a certain interest. But the people that have filled this out, we're talking about a number of over 115,000, 115,000 worldwide, say that they
13:22
have in their lifetime partially used LSD, where the number is, MDMA, mushrooms, LSD, so MDMA, 35% mushrooms, almost 25% LSD, over 22%. And if you look around you, of how many people do you know who ended up in an emergency department or in a psychiatric
13:44
ward due to only using those substances? Actually, looking at this giant field study, that the illegal market has provided us with, it seems to be rather safe, because these people are not using clear dosages of a clean substance, and still, there's hardly
14:02
anything happening. Okay, but what about microdosing? Well, we don't know much about microdosing, in fact. There are no scientifically randomised controlled studies
14:26
as to yet, the first ones are just starting. There are self-reporting studies where people have filled out online forums, and it seems to be that what people are on one hand trying to achieve is, yes, enhancing creativity, getting better work performance, but a lot
14:45
of them are trying to treat, cure, enhance their latent or apparent depression, and the other thing is, microdosing, which is defined mostly as using a very low, almost
15:04
subliminal dose of a psychoactive substance, such as LSD, is being done by people with all sorts. There are people microdosing MDMA and Ibogaine, which is, if you look at the receptor profiles, just insane, basically, and frankly, can't do what they hope it
15:20
does, and when we look at people who microdose, we can't say how much of the effect they're feeling is really from microdosing that substance, or if we have a top-notch first-rate placebo effect going on, where people feel much better because they have
15:41
taken this and believe in it. Let's not turn down placebo. Placebo is extremely valuable medically. It's actually shown that placebo effects, for example, enhance the endogenous opioid production, so your body revs up towards healing, towards feeling better with the placebo
16:01
effect, but this could also be done with a sugar pill, and there's one thing I just want to leave with you in this group. If anybody of you is microdosing and has LSD that are being activated in prolonged microdosing for a long time can be cardiotoxic
16:23
and possibly harm your heart. Again, there's no clear data about this yet. Just to leave it with you, if you suffer from a heart condition, don't. Depression, that key word I had with the microdosing as well, but let's go deeper into this because if we want
16:42
to talk about how psychedelic medicine can really make a difference in psychiatry, depression is the first-line thing to think and talk about, and why is that? Depression is a very
17:00
serious psychiatric disorder. People who are severely depressed, and that's many people, statistically in Germany, every eighth woman is likely to suffer from a severe depressive episode at one point in their life or the other. People who are depressed lose social functioning. They have very decreased life expectancy, partially through suicide, partially
17:25
because they don't manage to care for themselves. These people lose themselves and are being lost for others too, and there is treatment for depression, yes, but in
17:42
the worldwide epidemic, with rates from 3% of the population in China to 22% of the population in Afghanistan suffering from it, there have not really been new forms of treatment for two, two and a half decades. So the stuff we're working with is partially
18:02
working, partially not. About one-third of patients don't react to the medication at all, even though there's different types, and those who do usually have very low rates of acceptance because of the side effects, because many people use antidepressants, and the best combination is cognitive behavioral therapy, so what is called in German
18:23
Verheilten's therapy, cognitive behavioral therapy, in conjunction with antidepressants. That might work, but for some it doesn't, and those who take the medication don't feel well. It's not that they're back to normal, they're just less depressed, but
18:41
usually they're like dimmed in on all sides, so they are still not getting happy. Their libido is decreased, their activity levels are decreased. People are suffering quite a bit from the side effects, and it's really not nice. So, I was just to tell
19:00
you one little story. I told you I'm an emergency medicine doctor, and just to illustrate how bad depression can get. A few weeks ago, I was being called out to an attempt to suicide. A woman had jumped out of her window on the fourth floor. We found her
19:20
lying in her yard, and she was injured, badly injured, but still alive, and we stabilized her and took her to hospital, and when the nurse kind of pulled up her data in the emergency room, she went like, oh no, not again, because this woman had jumped out
19:42
the same window just half a year before. That's how bad this disease can be, so how desperate people get, and how terribly important it is for us not to look away but try to find better new therapies. And this is, in my opinion, with psychedelic
20:01
medicine, psychedelic therapy can be a real game changer. The one therapeutic application we have the best data for is psychedelics for treatment-resistant depression. There are several studies going on in the UK, in the States, in Switzerland, but also
20:21
in the Czech Republic, and so on and so on, and what they seem to be finding is that even though they're still working with small samples because you have to fan out, if you try to bring out a medication like that, you have to show first that it's safe with healthy people, and then you start with a small sample of sick people, and then you enlarge it from there, and they're now in this enlarging process.
20:45
That's treating depression with psilocybin, especially, does not only decrease depression in those patients, but also does one great thing, it decreases anxiety. We're not only talking about state anxiety, so how anxious people are at this very moment in living
21:03
their lives, but that trait anxiety, so how anxious people are as a part of their personality, which is a good thing to gauge how likely people are to relapse back into depression. People that are very anxious, very insecure about life, are far more likely to relapse.
21:23
Okay, so you see, there's a lot happening worldwide studying this, but this is Germany on that, a scientific desert. We're in the largest country, it's also the scientifically perhaps most important country when it comes to medical research
21:42
in Europe, and there's zilch happening. There hasn't been a study on psychoactive compounds in this context forever, like 30 years. The last one on intactogens, like 20 years ago, but studying psychedelic here hasn't happened, and we want to change that. So we as the MIND Foundation had perhaps, let's call it
22:13
groundbreaking, we had a groundbreaking conference this September in Berlin at the Charité buildings. We had 600 participants, over 50 speakers from
22:22
worldwide. Everybody basically, almost everybody, who's important in this dialogue scientifically was around. So from the pharmacology, the psychiatrist, the psychologist, the therapist, but also philosophers talking about a culture of altered states of mind have been around, and we have been trying to bring
22:43
this to the German public and try to lay groundwork for doing new science in Germany. And what's to come next is this. With our PIs, our principal investigator Gerhard Grunder, who is a pharmacologist from the University of
23:05
Mannheim, said we are about to apply for the first cyberdepressant study in Germany this next year. So in 2020, we're putting in the applications, we've already put the first paperwork in, and what we want to do is do a double
23:22
sentence study, both at the ZE-Mannheim and the Charité Berlin. Those are the two most renowned psychiatric research facilities in Germany, and it's a collaboration from the ZE, the Charité, and the MIND Foundation, each group contributing their knowledge, their capabilities, and their strengths. And
23:45
we want to do a double-blind, randomized, controlled, phase 2A study. Big word. This basically means that it's a top-notch level, internationally acclaimed study. This is how these studies need to be done to have any value. So it's double-blind, meaning that neither the patient nor the
24:04
therapist know what the patient is getting. It's randomized, so this gets assigned without anybody playing around with it, and phase 2 means that it's a safety and efficacy study. So not yet dose testing, and not yet comparing dosages, but just trying to make sure it works. And we are going to do that
24:24
in a 144-participant sample in total in two locations, which is huge. This will be the second or third biggest sample worldwide doing this, and the first one in Germany, as we said. And what we are going to test is 25 milligrams of
24:41
standardized GMP, so medical-grade psilocybin, versus two active placebos, one being a small dose of psilocybin, which used to be the standard thing to do, but now talking about microdosing, what is if the small dose already does something? And testing it against another placebo that isn't psilocybin,
25:01
which is some physical reaction, but is not psychedelic in this sense. So in this design, every patient will receive at least one, some two high dosages of psilocybin, so everybody who gets accepted will have his try. And the study design consists of preparation sessions, dosing sessions,
25:23
where people receive either placebo or psilocybin, and integration sessions. Integration is so important. And not only in a scientific study on this topic, but if people are working with psychedelics, experimenting with psychedelics themselves, integration is the key. To do something with the experience,
25:42
because if you don't work with it actively, the experience is going to fade, and you might remember something about what you learned, but it will not have the impact on you, your life, and how you, yeah, benefit from what you've seen and learned in that way. Right. Just one more sentence.
26:02
It's mixed funding. It's funding in progress. So we have some public money coming in, but we're also looking for donations and investment just at the side. And this is almost the end of my talk. What I want to say is the following. What we try at the moment is to establish safe and legal psychedelic
26:22
therapies in Germany, Europe, and the world. This is going to take time. If things go well, we might be there in five to ten years, five if things go really well. And I know that it's very tempting for many people to say, well, I can just go to somebody and have a psilocybin session.
26:41
I can go to somebody and have an ayahuasca session. And yes, you can, but be aware. If you do that because you're really suffering from a psychiatric disease, if you have a mental illness, if you really are in distress, be very careful with yourself. Because the thing is, you need somebody to really support you, really help you through, somebody who really knows what they're dealing with.
27:01
Because otherwise, you can do yourself more harm than good. This picture down there with the ambulance is a real picture. Right. That's what I wanted to say. Thank you very much for having me. If you're interested in what we're doing, check it out.
27:24
Andrea, thank you very much. That gives us plenty of time for some questions. People are lining up on the microphones already, so we start with microphone number two, please. Hi. Thank you for this amazing talk. That's really great.
27:41
Just one question though. Wouldn't that be a problem for a double-blind study if a person can surely tell if they're experiencing psychedelic effects? That is a problem, yes. But this is the way the authorities request the study to be done. And interestingly enough, there have been cases where people couldn't tell,
28:00
that people thought they were either on a small dosage, or thought they were on the high dosage, even though they were on an inactive placebo. So, the self-suggestive capabilities of people should not be underestimated either.
28:23
Okay, then we're going to jump over to number six. Thank you very much for the talk. I would like to hear your opinion on the fact that, like in the last 150 years, most drug agents were discovered in Germany,
28:45
and meanwhile, we have the pity of scientifically, Germany lying in Arizona. Right. Germany has two points that historically hold us back.
29:08
One is the forced human trials during the Nazi era, where substances, techniques were tested on concentration camp prisoners, and we have the Konter Gahn scandal, that harmed so many people
29:24
and led to, in all of the world, the stricter rules we have now. That's two reasons why Germany is so reluctant to expose itself in this kind of process. But still, it is a pity.
29:40
And I think it is about time that the German, not only government, but also the scientific establishment get to understand that they lose out, and they are trading behind a development that has started and will continue. And now we have a question from the internet, I hear.
30:02
Yes. For people struggling with depression, anxiety, or mental illnesses, what specific options are there in Europe with regards to psychedelic-assisted therapy? Well, one is that you can try to participate in the existing trials.
30:20
So, for example, in London, there's King's College and Imperial College, there's a group in Bristol working, there's also therapy happening in Switzerland and so on. And there's also, if you happen to be lucky enough to live in Switzerland, there's the so-called compassionate youth, where psychiatrists with special permits are allowed to use LSD and MDMA as therapeutic agents on a case-to-case basis
30:46
that they have to discuss with the authorities. So that's all we can say for now. Study participation or compassionate use. We just really hope that things will rev up and we'll be able to offer more in the future.
31:00
And microphone number four, please. Yeah, hello. Thank you very much for your talk. My question is more related to the history of the uses of psychedelics in the U.S. and to the MAPS association founded by Rick Doblin. But I was curious, how would you explain that MAPS is so actively criticising
31:24
the experiments led in the 1950s and 60s by the CIA and yet they accept donations of several million dollars coming from the Mercer family who are among the largest shareholders
31:41
of Cambridge Analytica, Breitbart News and they also accept, they accepted recently about three millions from members of Tea Party. Isn't it a bit of an irony here? That is a very good question.
32:03
The way I know Rick Doblin and many people from MAPS personally, I know that they're pursuing an honest goal. What they're trying to do is bring this into the world. They have been doing that since 1986.
32:21
So they've been on this for almost 35 years and he's dedicated his life to doing that. I don't fully understand his motives. I don't have to, to be honest, because I'm not speaking for him. I think there's a huge necessity for integrity because if we don't, as people working with us scientifically,
32:41
if we don't move along with the necessary integrity, we're opening the doors for other people to don't care at all. But on the other hand, finding the money, getting this done, and Rick was criticized a lot, for example, for accepting veterans,
33:01
snipers from Iraq into his therapy program. Like, okay, are you not getting people fit again to go out back to the battlefield? And I find this all very difficult because there is a thing that is called perpetrated PTSD. There is a thing of people only realizing afterwards what they have done.
33:22
And I would not, I would be very careful in judging people in distress. But you're very right. It's a very delicate topic and I think we all have to be very aware that there are thin passes we are threading in what we're doing there when we accept money that comes from sources that don't follow ethical standards.
33:44
Then we're going to switch over to microphone number five. Hello. I guess you have a really nice answer to the following statement. So, I hope you will share your answer. Little Krita tweeted today that the house is on fire and just that.
34:02
So, actually that means an adequate reaction would be to jump out of the window. So, you could argue that actually we should rescue all the people that are really down, like down and out because they cannot help us anymore. But actually we should get the people that are still happy to build a breast
34:20
instead of all getting them happy. What do you say? There's always two ways of dealing with the system. You can step out of it and you can try to change it from within. It is always very difficult to go from caring for the individual to things that are right for all.
34:49
And me being a doctor, for example, I have simply decided to put the individual in the centre of my concern and I think others need to put the greater good in the centre of their concern.
35:02
I think it's inconsolable. We can't do both at the same time. So, it's good to make your decision and do this what you do with all your heart. Then we're going to switch over to the internet again. Yes. Do you know of any studies or evidence corroborating the other side, like triggering mental illnesses by using psychedelics, for example, if you have a family history?
35:28
Well, doing a randomised control study with that would be unethical. So, what we have is the epidemiological and the anecdotal evidence that is found.
35:40
So, yes, if you have a predisposition for psychosis, for schizophrenia, for mental instability, there is a large chance of triggering that if you use psychedelics. On the other hand, many people try to self-medicate with substances, be it psychedelics or cannabis, because they're feeling they're already on the edge of some instability.
36:02
But the current paradigm for the study is to exclude people whose direct family is affected by psychosis. Number two just disappeared, so we're going to go straight over to four. I would like to ask you whether you changed your mind about anything related to psychedelics in the last few years,
36:23
or if you have seen something in research that really surprised you? Well, I am worried in a few respects.
36:43
For example, the whole development around the 5-meo scene, people using Bufa Alvaria's toxin for very, very strong, like they experience, sometimes risking their life doing it, this whole scene kind of lifting from the ground and going in a very strange direction, in my opinion.
37:02
This is kind of worrying me, because I think people are not taking the care they should be taking of themselves in what they're doing. But otherwise, I think scientific results we're seeing are rather consistent. It's very important to know that these are not magic bullets, and not expect too much.
37:20
You can't expect something to cure everything, and psychedelics seem to be a good idea for people who are rigid, not able to transcend something, but people who are already in a chaotic state are very unlikely to benefit. I think that's a very good basic rule, and this is something I see proven time and time again.
37:40
Number 5, please. Hi, thanks. Regarding set and setting, and how it can have such a huge influence on one's experience, can you comment on the setting of the new psilocybin study in the upcoming year? All the studies that are being done, set and setting, are being taken into consideration.
38:02
These people don't trip in a sterile, white hospital bed. They get to have their psychedelic experience in a warm, comfortable, organic, welcoming environment. For example, on a couch with a nice cushion, nice dim light, flowers, music is extremely important.
38:24
There have been really scientific works around what kind of music is beneficial for this. For example, at Imperial College as a specialist in this kind of music. And it's being taken very seriously, also those questions of how much physical contact is beneficial,
38:41
is allowed, what could harm the patient, is discussed very precisely in all those groups I know, because this is so much more than just a pill. This is really about making sure that people have a safe experience where they can come to healing inside themselves.
39:01
So we have time for one more question, number one please. I don't know if I want to hear the answer, but do you think it would help your cause if we would stop taking these drugs for fun? My answer to this is the following.
39:22
Imagine there was a food thing, something that tasted nice, let's say chocolate. And there were people who could only survive if they got chocolate, but because everybody else was doing it too and somehow not okay, it would be forbidden for everybody.
39:44
Then I would say, well, if you replace chocolate with LSD, I think there are people there who really need it and we have to be careful that recreational use and playing around with drugs doesn't spoil their chance to something life-saving because they need the chocolate.
40:01
You might get along without. But it's something we have to take into consideration. This doesn't mean it's wrong to have a psychedelic experience for your own benefit, for your own betterment, for your own fun. But just keep in mind if you're hindering with your wanting to have a good time, somebody who gets a life-saving therapy perhaps, then this is an ethical problem we are facing.
40:26
Andrea, thank you so much. That's your applause.
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