 I'm Bree Andrews. When Mark Siegler asked me to think about today's tribute, he told me that he'd asked Bill to do a presentation at this conference and that Bill was to cover the future of Neonatal Ethics. And so I've talked to a lot of our colleagues in Neonatology about what he might have said. So today this is his vision in our voices. I'm going to try to represent our colleagues here in Neonatal and Pediatric Ethics and then many of our colleagues across the country. Some write in Bill's old family when we hope that Beanie will join us some point soon for the McLean Center Ethics Fellowship. And then our international colleagues who have helped us keep this vision of what Bill thought about Neonatal Ethics alive. So the first ethical principle that Bill taught us was don't abandon your patients or your trainees or your colleagues. Identify the bedside need first. A lot of times that starts with a pregnant mother or the parents of a baby who are in distress. At the end of the day we are confronted with a difficult ethical problem that our parents and our patients will have to live with in a way that we do not. So that if we think to ourselves it might be easy to wash our hands of this to walk away from the 22 week mother pregnant 22 weeks and say we don't do this here. We don't resuscitate babies like this. That's fairly easy for us but really complex for the patient and that we can help see them through this and sit by the bedside and think through what would be best for them. Usually our parents and our babies especially in the ICU are in transition their pre or post delivery. They're impacted by ICU care and its complexities and they're often in a situation they didn't anticipate and so we stick with the parents and that's really important. That was one of his cardinal thoughts about Neonatal Ethics and it's the current principle and it's the future principle. Next is find the data. He really loved the philosophical aspects of Neonatal Ethics but he really wanted us to have data about what was best to have to move forward. He would say systematic ethical debates are better handled with data. You can define the epidemiology of the problem, the cost of the problem. He had beautiful sides about the cost of Neonatal Medicine which is very little compared to the cost of adult ICU medicine and proportions more money towards survivors and non-survivors which isn't as true in adult medicine. And so he would say let's make a comparison to adult medicine or a problem in adult medicine of a similar magnitude. And the data should guide our ethical practices even when finding and analyzing data is hard. He always made it seem easy or fun but I think at the end of the day we were trying to define this data and get good data sets about how to manage small problems but problems that needed a lot of ethical fortitude. He would ask which kind of data matter. He would always say what do others in our field do for infants like this? He was invited incessantly as a visiting professor and he often just wanted to go on rounds and ask people how do you take care of your babies? What do you do with this problem? So he might say how might another unit care for an infant like this? He'd ask his colleagues, he surveyed his colleagues about data often. He'd say what's the epidemiology of this problem? How many infants live and die this way? And he instructed us to find people to answer these questions. He was formative in the discussion about what do we do at 22 weeks, trisomy 13 and 18, congenital diaphragmatic hernia especially in that way. What happens to these babies at other places? How do other people handle this problem? And then when some of us said what do we do? What's the mechanism of this problem? He supported us going to the bench or to translational research because he knew that and that was the beginning of his career in bench science. So data matters. In neonatal clinical research, he used to say the lone hanging fruit has already been picked. So we've got to look a little higher in the trees. Key neonatal problems have been studied and improved upon. We've learned how to keep babies warm and moist. We have IV nutrition. We have antinatal steroids and surfactants. We have copious ventilation strategies. We have these specialized long lines and surgical lines. We know how to manage infection and we have intricate cardiovascular support for infants. We also have genetic data which is, I think, going to be an ethical dilemma moving forward. But how do you get at the higher fruit? And I think he would say the way you get it is to study infants in a large scale. We found out in neonatal ethics that that gets complicated. The support trial gave us pause to consent widely, even though it appeared to our ethics colleagues that support was ethical, that it was a large scale consent of infants across the world to either have low oxygen targets or high oxygen targets. Most of the neonatal community believed we were literally blinding infants by permitting high oxygen targets, when in fact, when it was studied widely, the children with lower oxygen saturations did worse. But they didn't do worse than patients who didn't enroll in the study. And so he loved that we keep track of infants. We build large data sets. And maybe not even consent them for study just yet, but think about data we have and what practices already exist and to think about how to analyze that data. This graph, I think, was initially made by Joanne Legata and then lots of us have utilized it over the years, but Bill loved this graph. So we have to try to think about how to predict outcomes in neonatology. It involves time and also money. Again, he gave great money examples. We always talk about this period of prenatal counseling where we have data and these calculators to think about what are the risks and statistical numbers. He always argued parents can't understand the statistics. Parents at that point can choose no resuscitation or a premature infant is born. There's a delivery room resuscitation and the baby will either live or die in the delivery room, which will allow us to go on to NICU care. This was his favorite topic for a long time, which is a trial therapy where you get to know the infant and you get to see if it's the baseball game where we're in the second or the third or the fourth inning rather than deciding before the game has started, where we watch the baby and we find out more about them and we add clinical data and clinical intuitions to our projections. This has been my space for a long time, which is what do you do after NICU discharge? I take care of these babies when they go home. It's much harder to predict what they'll do at that point or it's not as hard, but they have parents don't have as many choices at that point. He loved this part and he dealt with this a lot beautifully and gave us a sense that we can partner with families in this part of the journey more so than deciding too early or waiting till it's too late. But I think one thing that surprised us and surprised him, and this will be well received by Julie and some of our OB colleagues, is that we were starting to get at shared decision-making with obstetricians about how we should handle these patients. I showed him some data this summer where we looked at every baby who was admitted to our hospital who delivered it 22 weeks and thought about them with our OB colleagues, and we developed consensus. And I think that he would have loved that we're filling that gap, that allowing that space to be filled in that trajectory to try to develop some consistency between services and that practices can align and make important impact on maternal and neonatal ethics. He also thought that you could ask parents and that it was really important to ask parents what they thought of our decision-making later. So we worked with Marin Arnold, and he would do this again and again to try to make sure we were doing the right thing for the families, is to ask parents what they thought of our approach. So he asked parents very thoughtfully, was trying and failing worth the neonatal experience in the ICU or was trying and surviving with a child with developmental disabilities worth it. And he was reassured that most parents believed trying was valuable, meaning the baby was important, and that suffering did not cause regret later. And he taught Marin Arnold how to do this work, and she's done this beautifully. Hey, lastly, you've got to show the little folks how to practice neonatal medicine and ethics. He believed in the McLean Center. He loved coming to teach the fellows about how to be good practitioners. And he taught us every day how we thought about medicine and ethics therein. He stood up for his colleagues and his trainees when there's confusion or disorganization, which there's a lot of, right? Hospital settings are fraught with confusion and disorganization, and he always figured out a way to have a kind, warm voice and to say, we're going to move through this and we're going to help this family, and I'm going to help you because he protected us. So you remind your trainees that what they think is important, that they have valuable intuitions and principles, make it simple for them to practice. This is the Bill 1-10 in the NICU. He could get any intern to say, these are the 10 things I need to know today to take care of these babies. And he made it simple for everyone. But when it's really difficult, he taught the little folks, the younger generation of trainees that he would absorb some of the discomfort. So we have to continue to do that for our junior colleagues. So in closing, when you're on the brink of a meaningful ethical perspective, listen to his voice in your ear. He almost always would say, you've got that just right, Brie, you've got it right. And then stick with me. And he'd take you on some amazing journey that you weren't expecting about how to take care of these babies. And that's the future of me in etology. You know, stick with him. Think about where he would have taken you because he always was going to take you somewhere really wonderful. Thank you.