A Look Back at Bioethics: William L. Meadow, 1948–2019

William L. Meadow, MD, PhD, died at the age of 70 years on Saturday, September 14, 2019. Meadow was a consummate neonatologist, a devoted teacher, a great soccer coach, an accomplished a cappella singer, and an iconoclastic bioethicist. He pioneered the use of empirical research on neonatal outcomes and prognostication to ground the ethical analysis of decisions to withhold life-sustaining treatment from critically ill neonates.His work helped change the way neonatologists thought about and justified decisions to both initiate life support and withdraw it. When he began his work in bioethics, the prevailing wisdom was that decisions should be made in the delivery room using information that was available either prenatally or immediately upon birth. This approach informed many national policies about neonatal resuscitation. Those policies focused on predictors such as birthweight, gestational age, and Apgar scores. Meadow’s work showed that such approaches are objectionably inaccurate and, in many cases, would lead to withholding life support from neonates who might ultimately do well.His first study in this decades-long project simply looked at survival rates for infants of different birthweights in 2 cohorts. The first cohort included all live births. The second included only those neonates who were still alive at 72 hours of age. He showed that, by 72 hours of age, birthweight was no longer a predictor of survival. In fact, neonates born at 500 g who survived for 3 days had an over 80% survival rate, identical to much bigger infants. The article modestly concluded, “Generally, when we talk of survival rates to parents, ethics committees, or policy makers, we base our predictions largely on birthweight. The data presented here suggest that predictions should be corrected by including ‘day of life’ and that, when this is done, the prognostic value of birthweight rapidly diminishes.” (1)Meadow’s key understanding was that both prognosis and the accuracy of prognostication change quickly and constantly in the first days of an infant’s life. Much is unpredictable at birth but becomes more predictable by observing how an infant responds to therapy.Meadow liked to use whimsical analogies. In one article, he and colleagues made an analogy to predicting the outcome of a football game and suggested as a “proof of concept” the uncontroversial idea that it is easier to predict the outcome of a game at half-time than at the beginning. Half-time predictions are not perfect. But they are better. He then asked, “What if it turns out that prognostic information obtained for an individual infant during a trial of NICU therapy is indeed much more accurate than any combination of information available prior to birth? What if it further turns out that the prognostic significance of everything we knew before birth completely disappears within a week or two in the NICU. Then (here it comes), why exactly are we precluding some teams (infants and their parents) from starting the match at all?” (2)Over the next 2 decades, he tried to refine predictive models by considering objective illness severity scores, (3) the clinical intuitions of neonatologists, (4) and head ultrasonography results. (5) The ultimate goal of this work was to develop a truly personalized approach to prognostication and shared decision-making rather than one that took population-based data as the gold standard for predicting outcomes, despite their known inaccuracies in predicting that outcome for any individual neonate. (6)Through this work, Meadow gradually convinced neonatologists to be more patient and to implement trials of therapy for critically ill neonates, observe the results, and only then make decisions about life support. This led to far more accurate prognostication. He was beginning to work on assessing parental satisfaction with this approach when he had to retire due to illness.Meadow graduated magna cum laude from Amherst College in 1969, earned his MD in 1974 and his PhD in 1976 from the University of Pennsylvania. He began his pediatrics residency at the Children’s Hospital of Pennsylvania, followed by a year at the University of Chicago Hospitals in 1975 and a year at Children’s Memorial, also in Chicago. He completed fellowships in infectious diseases and medical ethics at the University of Chicago. He was, for decades, a member of the Core Faculty at the MacLean Center for Clinical Medical Ethics.In addition to his work in bioethics, he was also a dedicated neonatologist. He was always on service in July so that he could help the new neonatalogy fellows get to know the NICU. He loved being in the NICU. Meadow’s standard greeting for faculty, staff, and patient families was “Welcome to the NICU. You’re going to love it here.” His unique approach to pedagogy surprised many residents. Intensive care units can be frightening places. Bill found ways to lighten the mood. He made residents, parents, and nurses all feel a little more comfortable and thus a little more humane and competent.Once each year, he would work a night shift as a NICU nurse to better understand the nature of NICU nursing. He understood the need for multidisciplinary professional teams and for family-centered care.Meadow lectured extensively around the world. He published nearly 100 academic papers, 48 book chapters, and the book Neonatal Bioethics: The Moral Challenges of Medical Innovation (Johns Hopkins, 2008). His colleague Michael Schrieber noted that Meadow was a role model for work-life balance. “He had a difficult job but he somehow found the time to make it home for dinner with his family and to coach his kids. He inspired us to do the same.” (7)In 2016, friends and colleagues gathered at a festschrift in honor of Bill and his work. The festschrift lectures are on YouTube (https://www.youtube.com/watch?v=SwCvt01YAr4).In 2017, he was awarded the William Bartholome Award for Ethical Excellence by the American Academy of Pediatrics.Bill and his wife, Susan Goldin-Meadow, have 3 children. Xander is a senior database engineer, Nathanial a hospitalist, and Beanie is completing a fellowship in neonatology.In honor of Bill’s work, the University of Chicago and the Meadow family have created a Bill Meadow Endowed Lectureship that will focus on hot topics in pediatric bioethics. The first Meadow lecture, in April 2021, featured Dr Doug Opel and Dr Helene Gayle and focused on issues related to COVID vaccines. (8) Contributions to Bill Meadow Endowed Lectureship, in memory of Bill, may be made here: http://giving.uchicago.edu/bill-meadow.