DATE: 20110330 |
DOCKET: C51555 |
COURT OF APPEAL FOR ONTARIO |
Cronk, Blair and LaForme JJ.A. |
BETWEEN |
Tyler Cleveland, Emily Cleveland, and Abigail Cleveland minors by their Litigation Guardian, Chris Cleveland, Chris Cleveland, personally, and Kim Cleveland |
Plaintiffs (Respondents) |
and |
Hamilton
Health Sciences Corporation (
|
Defendant (Appellant) |
Harry C.G. Underwood and Meighan E. Leon, for the appellant |
Brian J.E. Brock, Q.C., for the respondents |
Heard: October 6, 2010 |
On appeal from the decision of Justice Joan L. Lax of the Superior Court of Justice dated December 15, 2009, reported at 2009 CanLII 70130 (ON S.C.). |
H.S. LaForme J.A.: |
[1] Since 1965, all
[2] PKU is caused by a defect in the activity of the phenylalanine hydroxylase enzyme, resulting in the body’s inability to metabolize phenylalanine (“phe”), an amino acid. If left untreated, PKU can interfere with normal brain development and, among other things, result in permanent brain damage.
[3] The Guthrie test is part of the Ontario Newborn Screening Program and aims to identify those infants with treatable forms of PKU as early as possible. Infants with PKU normally begin treatment around one month of age.
[4] In 1996, the testing of all newborn blood specimens for
PKU in
[5] Elevated levels of phe, which reflect a condition called “hyperphenylalanemia” (“hyperphe”) may, but need not, be confirmatory of PKU. Considerable variation in phe levels can occur. In summary, levels of phe:
● |
ranging between 40-80 μmol/L[1] and usually under 120 μmol/L |
) ) |
generally appear in a healthy patient |
● |
consistently above 480 or 600 μmol/L, but less than 1200 μmol/L |
) ) |
indicate atypical (mild) PKU |
● |
below 480 or 600 μmol/L |
) ) |
indicate persistent benign hyperphe |
● |
below 480 or 600 μmol/L, normalizing within a few weeks to months |
) ) |
indicate transient hyperphe |
● |
mild levels to levels as high as 1200 μmol/L |
) ) ) |
may be indicative of a rare disorder called “biopterin deficiency” |
● |
greater than 1200 μmol/L |
) ) |
indicate severe classical PKU |
[6] Tyler and his twin sister were born on September 5,
1996.
[7] Dr. Whelan ordered a third Guthrie test to be taken at
one month of age. The third test was
reported by the Crown Lab as “not elevated”. No further clinical or laboratory follow-up was arranged for
[8] In 1998, as a result of developmental concerns,
[9] In
the fall of 1999, after
[10]
[11] Following
[12] The action against the Crown was settled on the basis
that the Crown would be held severally liable for its apportioned share of
liability, to the extent that the Crown Lab caused or contributed to the
damages suffered by the
[13] The
[14] In 2004, after this litigation was commenced,
[15] The trial judge made the following findings concerning
1) the result of the Guthrie test of
2) consistent with what would be expected in a case of
classical PKU, it was likely that
3) the Crown lab underreported the Guthrie test results on
4) the true phe value of
[16] The trial judge recognized, correctly, that the law required that Dr. Whelan’s conduct be assessed on the basis of “the degree of care and skill which would reasonably be expected of a prudent and careful practitioner of the same experience and standing in the same circumstances”: see Crits v. Sylvester, [1956] O.R. 132 (C.A.), at p. 143, aff’d [1956] 1 S.C.R. 991. In Dr. Whelan’s case, the degree of skill required was that of a similarly situated and experienced metabolic specialist.
[17] The trial judge further indicated that, “[t]he honest and intelligent exercise of judgment satisfies [a practitioner’s] professional obligation to take reasonable care in the circumstances, although he may have been wrong” (citations omitted). This, too, was correct.
[18] The trial judge’s central findings concerning the standard of care applicable to Dr. Whalen were as follows:
1) it was reasonable to repeat the Guthrie test after a
borderline elevated phe value of 240 μmol/L
on
2) two elevated phe values, as occurred in
3) in ordering a third Guthrie test rather than a
diagnostic test after two elevated phe results, Dr. Whelan focused on whether
phe levels requiring treatment had been reported in
4) with two positive Guthrie test results just above the screening cut-off, the standard of care required the use of a more accurate test to investigate further; and
5) the important question that Dr. Whelan had to answer
was whether it was safe to discharge
[19] In the result, the trial judge concluded that Dr. Whelan’s conduct fell below the standard of care in ordering a third Guthrie test in circumstances where the reasonable and prudent decision was to order a quantitative diagnostic test. She found that Dr. Whelan committed “a negligent error of clinical judgment”. However, she held that Dr. Whelan bore a lesser degree of fault than the Crown. The trial judge apportioned liability 75% to the Crown and 25% to Dr. Whelan. Dr. Whelan appeals the trial judge’s liability decision.
[20] Although Dr. Whelan raises several grounds of
appeal, his core argument is that this appeal concerns his discretion to choose
between two tests to rule out PKU in
[21] Dr. Whelan goes on to argue that reasonable physicians could disagree as to which test was the most appropriate test to administer. Accordingly, there had to be good reasons, grounded in recognized clinical practice, for holding that his exercise of judgment fell below the standard of care.
[22] The essence of Dr. Whelan’s argument is that, in arriving at her findings of fact, the trial judge ignored, disregarded, or misapprehended the evidence of his expert witness, Dr. Clarke. In support of this argument, he submits that the trial judge failed to apply ter Neuzen v. Korn, [1995] 3 S.C.R. 674, and the line of cases associated with it.[3] In ter Neuzen at para. 38, the Supreme Court held:
It is generally accepted that when a doctor acts in accordance with a recognized and respectable practice of the profession, he or she will not be found to be negligent.… As L’Heureux-Dubé J. stated in [Lapointe v. Hôpital Le Gardeur, [1992] 1 S.C.R. 351]…(at pp. 363-64):
Given the number of available methods of treatment from which medical professionals must at times choose, and the distinction between error and fault, a doctor will not be found liable if the diagnosis and treatment given to a patient correspond to those recognized by medical science at the time, even in the face of competing theories. [Emphasis in original.]
[23] This court has recognized this principle in numerous cases. See for example, Connell v. Tanner (2002), 158 O.A.C. 268; Rowlands v. Wright (2009), 250 O.A.C. 394; Brain v. Mador (1985), 9 O.A.C. 87, leave to appeal to S.C.C. refused (1985), 13 O.A.C. 79 (note) (S.C.C.).
[24] Dr. Whelan’s submissions suggest that if a defendant is
able to advance proof that one reputable body in the community of medical
professionals in
[25] This argument proceeds on the premise that by ignoring or misapplying the applicable authorities, the trial judge misdirected herself on the law of negligence, leading her to wrongly disregard the defence expert evidence. Dr. Whelan also argues that the trial judge’s failure to adequately consider the defence expert evidence resulted in palpable and overriding errors of factual determination on both negligence and causation issues.
[26] The respondents, on the other hand, submit that in all cases of medical malpractice, the question is whether there was a duty of care between the doctor and patient and, if so, whether the standard of care that applied in all the circumstances was breached, leading to damages. If Dr. Whelan’s approach were taken to the extreme, they argue, it would unfairly insulate physicians from liability in all cases where conflicting expert evidence as to the standard of care is led.
[27] The respondents contend that the overarching theme of Dr. Whelan’s arguments is simply that the trial judge should have accepted the evidence of Dr. Whelan and his expert, Dr. Clarke, over the evidence led by the respondents through their experts, Dr. Vallance and Dr. Chakraborty. The respondents say that Dr. Whelan’s claim that he was engaged in the exercise of clinical judgment is not supported by the trial judge’s findings of fact or by the evidence.
[28] I would dismiss the appeal. First, I disagree with Dr. Whelan’s contention that the principles enunciated in ter Neuzen are engaged in this case. I conclude that the trial judge’s interpretation and application of the law were correct. Second, in my view, the trial judge did not ignore, misapprehend or misapply the evidence. Indeed, I conclude that her findings were based on a fair and proper consideration of all the evidence.
[29] Given the focus of Dr. Whelan’s appeal, it will be useful to set out, in a brief fashion, the expert evidence that the trial judge considered. The experts called by the respondents were:
(i) Dr. Adeli: Head of Clinical Biochemistry at the Department of
Paediatric Laboratory Medicine at the Hospital for Sick Children, Professor in
the Department of Laboratory Medicine at the University of Toronto, and Fellow
of the Academy of Clinical Biochemistry. Dr. Adeli discussed the storage history of the blood spots from
(ii) Dr. Vallance: Medical doctor with a sub-specialty in biomedical
genetics, Director of the Newborn Screening Program of British Columbia, and Director
of the Biomedical Genetics Laboratory and Division Head of the Clinical
Biochemistry Program at Children and Women’s Health Centre of British Columbia.
She is also a Clinical Professor of
Pathology and Laboratory Medicine in the Faculty of Medicine at the
(iii) Dr. Chakraborty: Specialist in paediatrics and medical biochemistry, Assistant Professor of Paediatrics and Pathology and Laboratory Medicine at the University of Ottawa and the co-head of the testing laboratory for the Ontario Newborn Screening Program. Dr. Chakraborty’s opinion was that Dr. Whelan’s decision to order a third Guthrie test, following two borderline positive results, did not meet the standard of practice of clinical or laboratory medicine at the relevant time.
[30] The expert evidence called by Dr. Whelan was:
(i) Dr. Clarke: Specialist in paediatrics and biochemistry, former Head of Genetic Metabolic Diseases Program and Head of Division of Clinic Genetics at the Hospital for Sick Children, and Director of Postgraduate Medical Education in Medical Genetics at the University of Toronto. Dr. Clarke has also pursued clinical research for over 35 years on PKU and the impact of treatment for children with PKU, as well as serving as member and later Chair of the Ministry of Health’s Advisory Committee on screening newborns for inherited metabolic diseases. Dr. Clarke disagreed with Dr. Vallance and Dr. Chakraborty on the standard of care. His opinion was that Dr. Whelan’s management of the case met the standard of care of a metabolic specialist in 1996.
[31] I intend to first discuss Dr. Whelan’s submission that the trial judge erred by failing to apply ter Neuzen in this case. I will then examine his argument that the trial judge further erred by committing palpable and overriding errors of factual finding.
[32] Like all medical malpractice cases, the issues in this case are ones of tort and negligence law. In Mustapha v. Culligan of Canada Ltd., [2008] 2 S.C.R. 114, at para. 3, McLachlin C.J., writing for the Supreme Court, explained that a successful action in negligence requires the plaintiff to demonstrate that:
1) the defendant owed a duty of care;
2) the defendant’s behaviour breached the standard of care;
3) the plaintiff sustained damage; and
4) the damage was caused, in fact and in law, by the defendant’s breach.
[33] McLachlin C.J. went on to make clear that these steps are sequential and separate. Thus, the first question for the court to decide in a negligence action is whether the defendant owes the plaintiff a duty of care. If a duty is owed, the second question is whether the defendant’s behaviour breached the applicable standard of care.
[34] The concepts of duty of care and standard of care are
distinct but closely related. In Ryan v.
[A] discussion of duty centres around its existence, while the standard of care clarifies what the content of the duty is. Where there is no duty there is no negligence.
...
A duty of care either exists or it does not.… [W]hen the language of “duty” is framed in terms of its degree or content, what is really at issue is not the duty but the applicable standard of care. While the distinction is obvious, courts from time to time seem to lose sight of that principle. [Citation omitted].
[35] A standard of care,
therefore, is the amount
of care required by certain people under certain situations and is a measure of
care that satisfies the duty. In this
case, there is no issue that Dr. Whelan owed the respondents a duty of care. At trial, the contentious issue was whether,
on the established facts, Dr. Whelan’s conduct in ordering a third Guthrie test
for
[36] This appeal is thus about how the second of the four elements of negligence – whether the defendant’s behaviour breached the standard of care – is established in a medical malpractice case where there is competing expert evidence. Specifically, the issues are 1) what standard of care applied to Dr. Whelan in the circumstances; and 2) whether Dr. Whelan breached that standard by ordering a third Guthrie test, rather than a diagnostic test, for Tyler.
[37] The standard of care applicable to Dr. Whelan required that his conduct be assessed on the basis of “that degree of care and skill which could reasonably be expected of a normal, prudent practitioner of the same experience and standing”: Crits at p. 143. A specialist, however, is held to a higher standard than is a generalist. As the Supreme Court elaborated in ter Neuzen at para. 33:
In the case of a specialist, such as a gynaecologist and obstetrician, the doctor's behaviour must be assessed in light of the conduct of other ordinary specialists, who possess a reasonable level of knowledge, competence and skill expected of professionals in Canada, in that field. A specialist, such as the respondent, who holds himself out as possessing a special degree of skill and knowledge, must exercise the degree of skill of an average specialist in his field. [Citations omitted.]
[38] Dr. Whelan argues that the trial judge erred by failing to apply what he terms the “ter Neuzen principle” or the “respectable minority principle”.[4] This principle holds that where the practice followed by a doctor is adhered to by at least a respectable minority of competent medical practitioners in the same field; it is not for the court to prefer the practice of the majority over that of the respectable minority. In other words, a doctor who acts in accordance with a respectable minority body of medical opinion will normally be absolved of negligence: see for example, Ellen I. Picard & Gerald R. Robertson, Legal Liability of Doctors and Hospitals in Canada, 4th ed. (Toronto: Thomson Carswell, 2007) at p. 362.
[39] Dr.
Whelan’s invocation of the respectable minority principle proceeds in this
fashion. First, he relies on Dr.
Clarke’s testimony that Dr. Whelan’s decision to order a third Guthrie test
following
[40] Dr.
Whelan next emphasizes that, in his testimony, Dr. Chakraborty, one of the
respondents’ experts, acknowledged that he would respect and rely on Dr.
Clarke’s opinion. Dr. Whelan therefore
contends that Dr. Clarke’s opinion on the applicable standard of care,
supported by Dr. Chakraborty’s testimony, constituted evidence of a respectable
minority body of medical opinion on the established practice for a third PKU
test in
[41] I would not give effect to this argument on this record.
[42] This
is not a case where the trial judge erred by simply preferring one body of
medical opinion over another respectable and competing body of medical opinion
concerning the appropriate medical practice. This is a case where the trial judge
considered and weighed the conflicting testimony of the expert witnesses on the
operative standard of care. She
concluded that Dr. Clarke’s opinion on the standard of care suffered from a
number of frailties and was not sufficiently reliable to establish the existence
of a respectable minority opinion. The
trial judge therefore accepted the evidence of Dr. Vallance and that of Dr.
Chakraborty that, in
[43] In
his testimony, Dr. Clarke emphasized that at the time of the original testing
of
[44] The
trial judge concluded that there were three key difficulties with Dr. Clarke’s
evidence on this issue. First, his
opinion rested on the premise that the relevant question at the time of
determining the appropriate third test was whether
[45] For example, Dr. Vallance testified that after a second positive phe result, as occurred in this case, a baby has about a 50% chance of being diagnosed with PKU or a variant. Although Dr. Clarke disagreed, Dr. Chakraborty criticized Dr. Clarke’s analysis and expressed the opinion that after a second Guthrie test resulting in a borderline positive phe value, a patient is at increased risk of having PKU. In his view, the available scientific data supported up to a 50% chance of some babies being diagnosed with PKU after a second positive phe result. Accordingly, in these circumstances, a quantitative test should be conducted to determine if treatment or early intervention is required. The trial judge accepted this evidence, stating:
Two
elevated [phe] results should have raised a level of suspicion that [
[46] Second,
the trial judge, in effect, concluded that Dr. Clarke’s evidence on the
significance of
[47] The trial judge rejected this inconsistent hypothesis. She put it this way:
I do not understand how a second positive Guthrie at 240 μmol/L can be both reassuring and suspicious…. On Dr. Clarke’s analysis, a third screen [a third Guthrie test] with no rise in phe would be more rather than less reassuring.
I see no error in this reasoning. Indeed, I agree with it.
[48] Moreover,
contrary to Dr. Clarke’s contention that
[49] Third, Dr. Whelan’s evidence of his own practice did not accord with Dr. Clarke’s view that diagnostic testing was not required until evidence of treatable hyperphe had emerged. Dr. Whelan testified that babies with three successive Guthrie test results at untreatable phe levels of 240 μmol/L were subjected to diagnostic testing. In other words, Dr. Whelan’s practice at the relevant time did not support the suggestion that diagnostic testing need not be undertaken until an indication of treatable hyperphe, evidenced by a rise in phe levels, existed.
[50] The trial judge regarded all these factors as cogent reasons for rejecting Dr. Clarke’s opinion on the content of the applicable standard of care. I agree.
[51] The courts have recognized that the respectable minority principle does not absolve a doctor from liability in negligence whenever there is a conflict in the expert evidence led at trial concerning the reasonableness of a doctor’s conduct: see Kangas v. Parker and Asquith, [1976] 5 W.W.R. 25 (Sask. Q.B.), at pp. 38-39, aff’d [1978] 5 W.W.R. 667 (Sask. C.A.); Cope v. Layden, [1984] A.J. No. 175 (C.A.); Kehler v. Myles (1988), 64 Alta. L.R. (2d) 97 (C.A.), at p. 106, leave to appeal to S.C.C. refused (1989), 95 A.R. 236; Alakoozi v. Hospital for Sick Children (2004), 187 O.A.C. 187 (C.A.), at paras. 5-7. As Picard and Robertson point out in Legal Liability of Doctors and Hospitals in Canada at p. 364, “were it otherwise, nearly every medical negligence case would be resolved in favour of the doctor, because they almost always involve a conflict of expert evidence.”
[52] The
decision of the Manitoba Court of Appeal in Anderson
v. Chasney, [1949] 4 D.L.R. 71, aff’d [1950] 4 D.L.R. 223 (S.C.C.) is
instructive in this regard. In
That question, however, must continue to be one for the petit jury empanelled to try the case, if it is a jury case, and for the Court where it is not. The experts remain witnesses to give their expert opinions in assistance of the jury or the Court to determine whether there was negligence or not. The opinions of the experts are not conclusive.
See also pp. 88-89.
[53] Moreover, courts have the discretion to assess liability even in the face of uncontradicted evidence of common professional practice. As L’Heureux-Dubé J. stated in Roberge v. Bolduc, [1991] 1 S.C.R. 374, at p. 437:
The fact that a professional has followed the practice of his or her peers may be strong evidence of reasonable and diligent conduct, but it is not determinative. If the practice is not in accordance with the general standards of liability, i.e., that one must act in a reasonable manner, then the professional who adheres to such a practice can be found liable, depending on the facts of each case. [Emphasis in original.]
[54] In this case, the trial judge essentially concluded that the expert evidence did not establish that Dr. Whelan’s decision to order a third Guthrie test in the face of two successive borderline elevated phe levels, instead of ordering a diagnostic test, accorded with a practice adopted by a respectable minority of the medical profession. In other words, on the totality of the evidence in this case, the respectable minority principle was simply not engaged. I see no reversible error in the trial judge’s conclusion on this issue.
[55] Once the trial judge had determined what the standard of care required, the question of breach was rather simple. Having found that the applicable standard required the ordering of a diagnostic test after the positive screening tests, the factual question was simply whether or not Dr. Whelan had ordered such a diagnostic test. The answer was that he had not and thus that he had breached the standard of care. One could imagine a case where the factual determination of whether or not a breach had occurred would be more complicated and perhaps require further expert evidence, but that was not the case here.
[56] As I noted above, the overarching theme of Dr. Whelan’s arguments is that the trial judge should have accepted the evidence of Dr. Whelan and his expert over the evidence of the respondents’ experts. In this context, he attacks the trial judge’s factual findings on several grounds. I view it as unnecessary to address each of these grounds separately. Rather, I will discuss those submissions that I believe have relative merit.
[57] The first argument relates to the trial judge’s finding
that Dr. Whelan negligently exercised his clinical judgment in choosing a
third Guthrie test because he did not inform himself as to whether
[58] First, as I have said, Dr. Whalen asserts that there were no practice protocols in place that expressed the standard of care in the circumstances of this case. That is, at the time of the 1996 testing, no protocol existed to guide the Ontario Newborn Screening Program or any of its five regional centre staff as to the appropriate test to be conducted following two borderline elevated phe values in a newborn on Guthrie tests. Therefore, he says, the decision was one for the exercise of his clinical judgment, based on his clinical experience.
[59] Dr. Whelan’s counsel in oral argument stated that clinical judgment, in this case, means “adopting a protocol or standing order which is informed by the doctor’s clinical experience and consistent with logic and common sense”. Thus, he argued, the decision in question was a matter about which reasonable physicians could disagree. Accordingly, there had to be good reasons, grounded in recognized clinical practice, for holding that Dr. Whelan’s exercise of judgment fell below the standard of care.
[60] Dr. Whelan, as regional consultant, was responsible for
[61] Thus, in spite of his position, Dr. Whelan does not
appear to have made any specific clinical decisions with respect to
[62] The trial judge was very much alive to this issue, noting that “the honest and intelligent exercise of judgment”, even if mistaken, satisfies a doctor’s professional obligation to take reasonable care in the circumstances. In para. 55 of her reasons, she rejected the argument that what occurred in this case was the exercise of clinical judgment by Dr. Whelan. After reviewing the relevant evidence, she concluded:
[63] In light of this finding, Dr. Whelan’s assertion that he exercised clinical judgment is without any factual support. Dr. Whelan’s evidence as to the reasonableness of a decision that was not made by him, as the respondents note, is no more than historical reconstruction posed in a way that was designed to give it the appearance of immediate direct contemplative thought. No such contemplation occurred here. I would reject this argument.
[64] Next, Dr. Whelan submits that the evidence of Dr. Chakraborty should have been given less weight than it was. This is because, in his testimony, Dr. Chakraborty acknowledged that providing an opinion in this case required him to apply in a retrospective way what he knows now but did not know in 1996. And, as the trial judge noted at para. 37:
Hindsight has no role to play in evaluating conduct that is said to fall below a reasonable standard of care. Practices change and standards evolve. As much as possible, one must try to go back and experience the event as it was then. [Citations omitted.]
[65] Dr. Whelan’s counsel at trial objected to Dr. Chakraborty’s qualifications to give expert evidence on the standard of care as it existed in 1996. Dr. Chakraborty, who is the current head of the Ontario Newborn Screening Program, had his qualifications carefully reviewed by the trial judge as a result of this challenge. The trial judge held that he was qualified to provide the proffered opinion evidence. That ruling has not been appealed. The trial judge, therefore, was entitled to consider Dr. Chakraborty’s expert opinion evidence and to assign to it the weight, if any, that she considered appropriate.
[66] Further, even if the trial judge had given little or no weight to Dr. Chakraborty’s evidence, the evidence of Dr. Vallance still conflicts with that of Dr. Clarke. Moreover, for the reasons I have outlined above, the trial judge would still have had a firm basis on which to reject the evidence of Dr. Clarke. There is, therefore, no substance to this argument.
[67] Finally, Dr. Whelan argues that because PKU is
associated with high concentrations of phe long before one month of age,
[68] I have already discussed the trial judge’s
consideration of this issue. She found
as a fact, on all the expert evidence, that
[69] Moreover, in his own evidence, Dr. Whelan said that he
would have sent
[70] The respondents’ experts, Dr. Vallance and Dr.
Chakraborty, both testified that in light of
[71] All the respondents’ experts agreed that the amino acid
quantitative blood test would provide
[72] I conclude that Dr. Whelan has not provided any grounds for this court to interfere with the decision of the trial judge. First, the trial judge’s determination of what constituted the standard of care and her application of that standard of care to Dr. Whelan’s conduct were correct. Second, the findings of the trial judge were supported by the evidence presented to her. She was entitled to accept or reject all or part of the evidence of any witness. And, on my review of her reasons and the record as a whole, I conclude that Dr. Whelan has not established that the trial judge committed any palpable and overriding errors that would support this court’s intervention.
[73] For the reasons herein, I would dismiss the appeal. Pursuant to the agreement of the parties, I would award the respondents their costs of the appeal, fixed in the amount of $25,000, inclusive of disbursements and taxes.
RELEASED:
“MAR 30 3011” “H.S. LaForme J.A.”
“EAC” “I agree E.A. Cronk J.A.”
“I agree R.A. Blair J.A.”
[1] Micromoles per litre.
[2] Millimoles per litre.
[3] This
line of cases referenced by Dr. Whelan includes: Brimacombe v. Matthews (2001), 87 B.C.L.R. (3d) 75 (
[4] While it is true that this principle is sometimes referred to as the ter Neuzen principle, this naming is unhelpful because ter Neuzen involved two distinct principles. Although the court did mention what is known as the respectable minority principle, the focus of the decision was the principle that in some cases the trier of fact can reject a standard medical practice as inherently negligent where the practice is “fraught with obvious risks”: see ter Neuzen at paras. 41-42.