In the previous video, we learned about cycle notation for permutations, and it's a much more preferred way of representing permutations in this abstract adverse setting. Now, products of permutations can easily be computed using this cycle notation, much easier than we were doing it before, with that two row tableaus. So, for example, suppose we have two cycles, say, sigma tau, much like the two examples you see right here. So, we have two cycles, sigma is 1, 3, 5, 2, and tau is 2, 5, 6. So, we can think of these as two cycles that live inside of the group S6. We first can compute sigma of x, or I guess in this case, tau would come first. So, what if we want to compute something like sigma tau of, say, 2? What does that mean in this situation? Well, sigma tau of 2, what you would do is you would say, well, tau sends 2 to 5. So, this would become sigma of 5, and then 5 sends 2, or sigma sends 5 back to 2. And so, what we see here is that sigma tau of 2 would actually fix 2, and that's what's illustrated right here. Tau sends 2 to 5, and sigma sends 5 back to 2. And so, composition, you just read both cycles the way they are, right next to each other, reading right to left, because again, the function on the right will interact with the element first. So, if we're trying to compute this thing, we might be like, okay, what happens to 1? Well, 1 is sent to 1 by tau. So, notice here in tau, you don't see a 1. The fact you don't see 1 means 1 is fixed, tau doesn't do anything to 1. So, tau sends 1 to 1. Then, sigma will send 1 to 3. And so, then the compositum will give that tau sigma, excuse me, sigma tau will send 1 to 3. And so, then we record that right here. So, sigma tau sends 1 to 3. Well, now, what does sigma tau do to 3? Well, tau will send 3 to 3, because again, we don't see 3 here, so 3 is fixed by it. Then, in this situation, sigma sends 3 to 5. So, then the composite will be that sigma tau sends 3 to 5. So, we then record that right here. What happens to 5? Well, now in this situation, tau sends 5 to 6. And sigma doesn't do anything to 6, so it leaves it fixed. So, then the compositum will send 5 to 6 right here. Nextly, tau sends 6 to 2. We see that right here. And then, sigma will send 2 to 1, which we see right there. So, the composite will send 6 to 1, like so. And then, as 1 was the first number that started this cycle, we actually erase it and put a left parenthesis. Like we already computed, 2 will be sent to itself. And the same thing happens to 4, right? Tau doesn't do anything to 4, nor does sigma. So, 4 is left fixed. And so, the product of this 4-cycle by a 3-cycle is in fact a 4-cycle. And so, this is what we do in general, that we just kind of list the elements one by one and say it out loud if you need to. So, for example, if we switch up the order here, take tau times sigma this time. So, tau comes first. If we want to compute the cycle containing 1, we're like, okay, sigma sends 1 to 3. And then, tau sends 3 back to 3, so the composite would be 3. 3 is sent to 5 by sigma. 5 goes to 6 by tau, so 3 is going to go to 6. 6 is left fixed by sigma. Tau sends 6 to 2, so the composite will be, whoops, 2. Next, sigma will send 2 to 1, and tau will do nothing to 1, so we get back a 1. That starts the cycle over again, so we close it off. Then the next number we haven't used yet would be a 4. What happens to 4? 4, sigma doesn't do anything to 4, neither does tau. So, that would just be a 1-cycle, we're just going to erase that. Then the next one would be 5, which admittedly, that's the last element, so it has to be a 1-cycle. But if you go through the argument here, sigma sends 5 to 2 and tau sends 2 to 5. So, that's a 1-cycle, so we're just going to erase it. And we see that tau sigma is likewise a 4-cycle. But one thing to notice here is that this is not the same 4-cycle. Sigma tau is 1, 3, 5, 6, and tau sigma is 1, 3, 6, 2. This is an example that permutation multiplication is non-commutative. We don't anticipate that switching up the order of permutations will give us the same result. It's actually very rare when permutations will commute with each other. Let's do another example of this, a little bit more complicated. So, we talked about multiplying cycles together. But what if we just take general permutations that are not necessarily cycles? Well, what we saw earlier in the previous video is that every permutation can be written as a product of disjoint cycles. So, if we take a 4-cycle like 1, 6, 1, 6, 2, 4, and then a 2, 3-cycle, 1, 3, and 4, 5, 6, then their product will actually be a product of a 4-cycle, a 2-cycle, and a 3-cycle. And we just go through all three pieces together. So, if we ask what happens to 1, moving right to left, the first cycle doesn't do anything to 1, the next one goes to 3. So, this would send 1 to 3, and then the last cycle doesn't do anything to 3. So, the composite would be 1 goes to 3. The next step, well, where does 3 go? Well, the first one doesn't have a 3, the second one will send 3 to 1, and then the last one will send 1 to 6. So, the composite will be that 3 goes to 6. How about the next one? Well, the first cycle again going right to left, 6 goes to 4, this doesn't have a 4, 4 goes to 1. And so, this then closes up the cycle to get a 3-cycle. Next, we'll do the cycle of the 2. This doesn't have a 2, this doesn't have a 2, 2 goes to 4. So, the composite will be a 4. Then we do 4, 4 goes to 5, this doesn't have a 5, this doesn't have a 5. So, we then record a 5. Which then, that should finish it up for us, because I think we've done all six elements. But if you have any doubts, just go through it again. 5 goes to 6, this doesn't have a 6. 6 goes to 2, so that closes up the cycle. So, the product of Sigma Tau right here is a 3-3 cycle, 1-3-6 and 2-4-5 that we see here on the screen. Let's do another example here. Let's do Tau Sigma, so we're just going to switch things around here. So, this time Sigma comes on the right and then Tau comes on the left. We'll compute the product the same way. So, we'll do 1, 1 goes to 6, 6 goes to 4, this doesn't have a 4. So, then we record a 4. 4 goes to 1, this doesn't have a 1. 1 goes to 3, so we end up with a 3. And the next one we're going to get is 3, this doesn't have a 3, this doesn't have a 3. 3 goes to 1, and that closes the cycle. We'll start the next cycle with a 2. 2 goes to 4, 4 goes to 5, this doesn't have a 5. So, we record 5. The next one we're going to have is 5, this doesn't have a 5. 5 goes to 6, this doesn't have a 6. So, we record 6. That's all 6 elements, so that should finish it up. But again, for due diligence here, if we want to finish it up to make sure we made no errors, 6 goes to 2, this doesn't have a 2, this doesn't have a 2. So, then we finish it up. So, we see that Tau Sigma is the 3, 3 cycle, 1, 4, 3 and 2, 5, 6. Notice again, this is not the same element as 1, 3, 6 and 2, 4, 5. I mean, you'll notice that they're both 3, 3 cycles. Which, they have the same cycle structure, but Sigma Tau is not equal to Tau Sigma. Again, this is non-commutative. But this idea of cycle structure, something we'll come back to, that although the elements don't commute with each other, their cycle structure is preserved even when you commute things. Now, I do want to, of course, tell us that just because most permutations don't commute, doesn't mean that there's never commutations. Sometimes they do commute. Take, for example, the permutations Pi, which will be 1, 2, 3. And Rho is the 3 cycle, 4, 5, 6. So, notice here that if we were to do this, if you take Pi times Rho, you get something like this. But what happens when you go through the elements, right? If you go through the elements, you'll end up with, okay, let's see, 1, this doesn't have a 1, 1 goes to 2. So, the product is 1 and 2. Next, 2, let's see, this doesn't have 2, 2 goes to 3. So, we get a 3. Then, the next one, this doesn't have a 3, 3 goes to 1. So, we close off that cycle, then start the next cycle, 4. 4 goes to 5, this doesn't have a 5. Then, 5 goes to 6, this doesn't have a 6. And then, that's the last one, so we close it off as well. Wait a second, when I took the product of these two guys, I just ended up with the exact same thing I had before, interesting. All right, well, what about the other side? I don't need to write that on the screen twice. What about this one right here? So, if we do 1 goes to 2, this doesn't have a 2. Then, we'll do 2 goes to 3, this doesn't have a 3. Then, we get 3 goes to 1, this doesn't have a 1. So, that closes up the cycle, so another 1, 4. This doesn't have a 4, 4 goes to 5. This doesn't have a 5, 5 goes to 6.  That's just this guy again, right? So, these 2, 3 cycles actually commute with each other. And, if you're kind of following off the argument there, the main reason that we are able to commute with each other is that these 2 cycles are in fact disjoint. As I was going through the cycle constructions, I kept on being like, oh, this cycle doesn't involve that element, this doesn't use that one, this doesn't use that one. That happened every single time. And so, what we actually see in greater generality is that if you have 2 disjoint cycles in your permutation group, then disjoint cycles always commute with each other. And, this is actually part of the unique factorization of permutations and cycle notation. The ordering of the cycles doesn't matter because they actually commute with each other. And, we're going to prove this fact right here. So, imagine we have 2 cycles. Sigma, let's say it's the cycle containing elements a1, a2, up to ak, it has a length k. Then, say that tau is the cycle b1, b2, up to bl. I do not claim that k and l are the same lengths. These can be different lengths. So, what we want to do is we need to show that sigma tau equals tau sigma. Now, these are permutations and as such, they are functions. How do you show that 2 functions are equal to each other? Well, you pick an arbitrary element of its domain and then argue that the images are the same. So, we have to prove that sigma tau equals x, sorry, sigma tau of x equals tau sigma of x. If you choose x to be an arbitrary element of the domain and argue that the images are equal, this will actually prove that the assignment by the 2 functions is the same. And if the assignments are the same, then the functions are the same because after all, functions is the relationship. So, in this direction, we're going to choose an arbitrary element x and argue that sigma tau and tau sigma do the same thing to x. Now, there's a couple possibilities, right? The first possibility is that x could be an element ai that is involved in the permutation sigma. So, we can still see it on the screen right here. Now, by assumption, sigma and tau are disjoint cycles. So, if x is equal to a1, then x can't equal any of the bj's. Therefore, tau will do nothing to sigma. It'll be a fixed element. And so, then we see that if you take sigma tau of x, well, because x is a1, tau won't do anything to it. So, this will just become sigma of ai. And then, sigma will send that to ai plus one where that number i plus one will reduce mod k. So, like, if i was k, then i plus one, we just mean one in that situation. So, it'll cycle around. Okay, so that's what sigma tau of x is. But on the other hand, if we take tau sigma of x, well, x is ai, which sigma, what does it do to ai? It sends it to ai plus one, but tau doesn't do anything to an a. I mean, it only does stuffs to b, so we end up with ai plus one. So, it does the same thing. If x was equal to ai, well, what if x was equal to bj? Well, if x is equal to bj, again, if the cycles are disjoint, sigma won't do anything to a b, but then tau will just progress bj to the next one, bj plus one, reducing, of course, the index mod l. And so, it's the exact same type of argument. You're gonna get, as we saw just a moment ago. Well, what if x is neither a nor b? Because those are only possibilities because a and b are disjoint. In that case, both sigma will leave x fixed because it's not an a, and tau will also leave x fixed because it's not a b. And so, you end up seeing that sigma tau of x just becomes sigma of x, which is an x, which is the same thing as tau sigma of x, which is a tau of x, which is an x. And so, in all three possibilities, we see that sigma tau of x equals tau sigma of x. Therefore, because the function agrees for every element of the domain, the two functions are equal to each other. This proves that disjoint cycles will commute with each other. And that's not to say those are the only times that permutations commute with each other. Like, for example, if you take one, two, three, and you times that by one, three, two in this situation, these are not disjoint cycles, but I would claim that they commute with each other because what happens is one goes to three, three goes to one, so one is fixed. Two goes to one, one goes to two, so two is fixed. And then in this case, we also have a three goes to two and two goes to three. So this is actually the identity. That's because one, two, three and one, three, two are permutation inverses of each other. But if we switch this thing around, you're gonna see the same thing happening. One goes to two, two goes to one, so one's fixed. Two goes to three, three goes to two, so two is fixed. And then three goes to one, one goes to three, so three is fixed. These are, this is also the identity. So in this situation, these things are not disjoint cycles, they can commute. So there is some commutation in the symmetric group. We can guarantee it for disjoint cycles, but we don't anticipate it in general. But the cycle notation is very, very useful nonetheless in helping us compute the product of permutations.


So I would no doubt get a lot of hate for this video, but guess what, if I cared I would not post it. Diablo 4 is sinking, the choices the devs are making are just ruining the overall experience of the game. After patch 1.1.0 I had a little hope. They then did that campfire chat, that live campfire chat, where they all looked miserable because their choices for the game went completely against what their own fanbase enjoyed about Diablo 4. I mean this is some bungee type shiz if I've ever seen it. Has it gone guys, my name is dpj and if you do enjoy the video leaving a like really helps out and if you like what you see and want to see more be sure to subscribe. So Diablo 4 started out as a really good game, it was far from perfect but it was fun. The levelling was questionable, the enemy scaling was also questionable, but overall at first it seemed like we were getting a lot through our time from this ARPG. Inevitably nerfs were always going to land and updates were always going to come, because like from developers these days it seems they are just out of touch with their communities. We played this kind of game to have fun, to be rewarded, to feel special, yet these are the very thing to take away from the player. Diablo 4 at a good pace about it felt great being overpowered in many ways, this is the point, this is the reason we play, this is what it's all about, this is what the player seeks and this is that end game goal, this is why players play, create builds and work on such, what's the point to the player playing to build up a character only for the developers to nerf it before we even get there because our means of doing so is being stripped away and slowed down, that doesn't make sense. Now whether you are a casual player, a hardcore player, you cannot be happy with how they are seemingly trying to do business, the business model right now and I have no doubt about it is to suspend players for reaching their goals and to get them playing longer without running out of things to do, I mean this would be nice if it wasn't for these goals to result in the player being affected in a negative manner which makes the game less fun, less pacey and overall a boring place to be. 1.1.1 resulted in many many players giving up on the game, I'm not sure exactly how much but from the reports I've seen it's millions, I mean sorry we have your money now, the fun ends and work begins and that's the point, playing Diablo 4 now feels like more work and less fun.  Now I absolutely have no doubt there are systems in place to indeed keep the player invested, developers these days no doubt spend a lot of money in research for these kind of systems, ones that indeed hang that beautiful legendary in front of your eyes just out of arms reach and a way in which the human brain works because it's so close we just keep trying to catch it, when they eventually give in and feel we deserve it we catch it yet to discover it's something completely pointless to us but it's that small chemical reaction within our brains that trigger upon us getting back what we've been chasing, this reaction is something we get addicted to so we keep going and going and going, even when there's nothing else to chase the addiction is still there. Sorry guys but I have entered rehab I can see clearly now Diablo 4 is a mess and it's a mess because it's been made a certain way using certain systems which were never going to last forever in fact they didn't last long at all the systems started to fail and the devs then decided to try and keep the player base active, in doing so they seriously slowed things down and they take away from the player in regards to nerfs, from this point of 1.1.0 I knew all was about to fail, the campfire chat I watched and allegedly thought they realized they made mistakes and were going to work with us to bring the game back into their light, waiting truth because with season 1 they were introducing a system where hearts would make the player stupid powerful they knew they had to pull back on player builds but what about the XP why limit this, why make it so the player has to grind more, work harder to level up, this in my opinion is because they want you playing for longer, they want you here for when that next season arrives or at least interested. Little do they realize Diablo 4 and the XP system well for me isn't actually what makes me play daily, it's the loot chase for me, yes certain loot is tied to a certain level but long after you reach a level 100 you are likely to still be chasing that specific loot for your build so limiting XP and the way they did this in a way in which they nerfed this system was a pointless intervention with just pissed players off and added insult to injury. And they are still doing this now, they are now nerfing players being able to earn XP via using the nightmare dungeon reset glitch, this is common in 1.1.2 I think this arrives the 15th of August, it's a glitch which requires a group, I will say this doesn't affect me much as I play mostly solo or my powers have moved on from this game and I can't really blame them but again it requires a group they are nerfing this so won't be able to do this anymore. You know I wonder if they ever asked themselves why players will continue to seek out methods of improving XP gains, is it because the level in this game is a part of that addiction players have and the faster they can do this the better, it also adds pace players alike, nobody likes a game where you can run 10, 20 dungeons and not level up, yes I mean these are glitches, they shouldn't really be in the game but at the end of the day they are so popular with the community because all of the means are just too slow and boring and when a game is made slow and boring half its community will leave which is what we saw previously with 1.1.0. Now again my gripe isn't about the fact they are nerfing said dungeon reset farm, it's a fact they spoke of no substitute, players want to reach that max level because they see as progress to start properly on what they want to build, slowing that progress down does nothing but take away from the player and how they don't see this is kind of worrying to me, most players including myself would love to level multiple characters, yes I game for a living but I also have an actual real life, I don't want to spend my entire day working on Diablo 4 especially when I feel I get nothing in return, I really doubt even for the time I've put in I will get 2 characters to a level 100 within season 1 without pulling out what's left of my hairline, the game is seriously just a slug now, once you get to that end game it doesn't even get much better, this is because what's on offer here is truly limited, even at end game rewards are dire. Now they do have things in this game rewards called ubi unix, these are ultra ultra rare items barely anyone in the world has, what I want to introduce is ubi unix and tie them to the highest of highest leveled nightmare dungeons, maybe even tie them behind using one life, we need rewards to chase, we have ubi unix in the game but because they're like their drop rates so low and it's all based on RNG most of us no matter how much we play will never ever see these, to be honest looking at the ubi unix in the game right now I can't really see one that would work for my builder anyway but even still, having items in the game which even the most active players would never get, having items in the game which even the most active players who would rather load up the abloh 4 over brushing their own teeth would never see to me you just know it isn't worth it, I mean there are a million and one things they could do or change should make the remainder of their community happy but all they decide to do is nerf things further which is doing nothing but slowing down the pace of the game and they do this because of a set few but what it does is nothing but impact the millions of players who casually play for fun, yes you could argue Diablo isn't a casuals game, I would have agreed with you on past games but Diablo 4 most definitely was advertised as a game everyone could jump into and have fun which was the case for me at first, you didn't even have to be a Diablo fan to play D4 and enjoy it again I'm the perfect example of this, millions played and enjoyed the game upon release who hadn't touched a previous Diablo game, it's like they suckered us all in, suckered in all these new players all into drop all the systems into plays which were just too much, it's resulted in the game being on death's door, now it doesn't matter who I watch within the Diablo 4 community kind of thing to do it wise to be honest I don't watch many because most of them just suck up to everything they do but again it doesn't matter because 90% of the comments I am seeing within the comments sections people are unhappy with the choices developers have made and plan to make, now you can't keep everybody happy I know this but when there isn't a balance at all and the majority are pissed you know s**t is sinking now I actually made this video because most of my other videos have strayed away from my thoughts on the game I'll just post guides and leave them be but when I'm seeing a lot of negativity I thought I'd give you guys my stance on what's going down here and how I feel in regards to the Diablo 4 but guys tell me what you think down below about the overall state of this game do you think it's a sinking ship let me know on that note the end of the video has arrived if you enjoyed it leaving a like really helps out if you like what you see and want to see more be sure to subscribe and hopefully guys I'll see you on that next one


Hello and welcome to today's AFCB TV preview show here in the Superstore at Vitality Stadium. There was no game last week but we've got two coming up in the coming days and both myself and matchday commentator Chris Temple will be going through it all ahead of time. Here's what's coming up. We'll be looking back at that 2-0 victory over West Ham United 10 days ago. We'll also be discussing the Cherry's latest recruit in Chris Meppham. And we'll be looking ahead to tomorrow night's game against Chelsea here at Vitality Stadium. But first, let's start 10 days ago with that 2-0 victory over West Ham. Goals from Callum Wilson and Joshua King saw the Cherry's get all three points. And a new look back five can inspire the Cherry's back to winning ways here. This fixture finished 3-3 last season with Callum Wilson's late controversial equaliser on the edge of the six-yard box. Wilson looking to break out. He's got Fraser who scoops it past his man. Can he keep that one in Ryan Fraser? He gets his head up to see who's arriving in the middle for him. Fraser continues the run. Diop slides in, catches Fraser late, runs to Callum. Wilson! What a finish with the Cherry's top scorer and he smashed it with his right foot. No chance for Allianski, deadlock broken. Eight minutes into the second half for McGwan West Ham Nill. Well, it was great way by Fraser to make up all that ground on this left-hand side. Got the cross, crossed the pace of goal and as you say, it just sat up nicely. And Callum smashed it home into the back of the net. Great way by Fraser. Another assist in the column of Ryan Fraser. Another goal in the column of Callum Wilson as it looped up its span. It couldn't have sat up more perfectly for Callum Wilson and he couldn't have found the corner more accurately than he did just inside the box. Absolutely incredible. Carlin Ball, keeper routed to the ground right in the top corner. That takes Callum Wilson to ten Premier League goals for the season. It's already his best Premier League scoring season in the Cherry shirt but he hits double-figures. Ryan Fraser also now goes to double-figures in terms of assists. It makes him the first Scotsman since Gary McAllister will owe to contribute ten Premier League assists in a season. We're going back 20 years, I say. I'll go on back a bit. They try and put Brooks through. There's a real chance here for a second. Brooks to King! Joshua King from close range puts the game to bed. And those nervy couple of minutes of added time will no longer be nervy. It's a double for Bournemouth over West Ham this season. Two-nil they leave. Well, a big three points for the Cherries there. Extended highlights are available for free on AFCB TV. Chris, that was a much-needed win, wasn't it? Much-needed, absolutely. What a goal from Callum. I'm sure the goal of the season contenders by the end of the season and the moment of quality that game needed to, I guess, a moment of individual brilliance from Callum to break the deadlock. Obviously there was sigh of relief when Joshua King put the second in. Nice move down the right. It was powerful around the stadium. Eddie's celebration at the end, you could really see exactly what that meant in terms of the long overdue win and the performance as well. And both teams, you know, it was physically a tough game. Lots of tackles were going in. And two teams that I think will be very close to each other in the table come the end of the season. So, yeah, nice to come. Those games can fall either way. Nice to come out on the right side of it, for sure. And against Everton, the performance was very much there, but the result wasn't so it's great to have that three-point. Yeah, I think the team felt hard done by a way. Everton, the conditions were horrible up there. It was a real sapping game as well. And bearing in mind that you think of Dan Gosling had just come back and Adam Smith obviously was back in the team. In terms of having them back, I guess the other side of it is that it was a tough game for those guys early on in their recovery, if you like. So, yeah, for them to be back in the mould is absolutely fantastic. And, yeah, a lot of times this season, Bournemouth haven't quite got what they've maybe deserved from matches and Everton away would be another one. But those are the games probably you're not expecting. You know, if you're looking at the start of the season, you'd say they're going to be the tough games to get something from. So to perform well in defeat is much better than going there and getting absolutely outplayed. Yeah, a great technique. Because, you know, as we said at the time, that could end up in the car park or it'll end up in the top corner. And I'm sure in training a few of them do end up, you know, hitting the pavilion roof or something. But you can see the confidence, I guess, when you're in the form that Callum's been in this season. And a lot of things he is hitting in the back of the net. It was no real surprise to see it in the top corner. Yeah, and a great moment of quality. I still go back to the fact... I can't believe Ryan Fraser didn't get an assist for that. The official Premier League rules, there's something about if a defender changes the path of the ball, lots of people were tweeting me when I put it out there saying how is that not assist for the wee man who ran half the length of the pitch with the ball and then put a cross in that was deflected. Didn't get an assist for it, but in all but name, the Fraser Wilson combination continues to contribute in every column. And of course, Joshua King. That was a big goal for him as well. He hadn't scored since November, so he's back on the football sheet again. Yeah, important for him as well because he doesn't want all the weight on Callum in terms of the goals. He's quite been at his best this season. He obviously deputised as the number nine, if you like, when Callum was injured. Remains to be seen if Callum's fit for this game as well, which we'll come on to later on. But obviously, you know, with Joshua King, we'll know that people like Dominic Solanke are getting closer to being fit. Other people have proved themselves capable of playing in that number 10 role. I think Joshua King will always be pretty much a first pit because of the physicality he brings. He's a completely different player in terms of that side of the game to a David Brooks Stanislaus or a Ryan Fraser in that role. But obviously, Dominic Solanke's a bit more of the physical presence. So I think Joshua King will know he needs to continue to step up to ward off a bit of the challenges, I guess, for his place. And it's worth mentioning Art of Broke as well, starting in goal last week. What did you make of his performance? I didn't think he did a lot wrong. It was a solid enough debut from him. I guess debut in inverted commas. A return to Premier League action after a long time out. I think nice reward for him as well and brilliant in terms of working, waiting for his chance. We spoke to him after the game, the club did as well and you could see the beam in his face at a clean sheet, a win and just being back in the team. I think he instilled a bit of confidence in the back four. His distribution seems to be calm and composed. He's a very calm and composed character. But he's still got a rocket in him. If the defence need it as well, he's proved himself a great shot-stopper. And of course, coming up against Chelsea now, he repelled pretty much everything they threw at him. That's going to be a good omen for this game coming up as well. That was the first one since Brighton in the league so that'll give more confidence to the team. When you think of the new look back five, if you include Arta Borich and Adam Smith back at left back and Nathaniel Klein at right back and those two have been switching, which is a nice option to have as well. If you've got with respect to Simon Francis, you're not going to see him switching to left back during a game. It's nice to have that versatility, obviously Klein and Smith are both right backs but are both very capable of playing left back. So Adam Smith, I think, has added a real a real energy to the team. I think his particular return has been a real boost. Not just going forward, but I think I spoke to Steve Crook after the game and he said that Adam Smith's he came in at halftime and had a real rallying call for the lads as someone who's only just come back. So I think he's an important character and in the absence of Simon Francis as well, he's quite a big character in the squad. And we spoke last week about the gap between not only three points, but three points can go such a long way. You can climb three or four places if it goes your way. Yeah, absolutely. Again, it's concertinering up a little bit and the middle section of the table are just sneaking away from one or two of the clubs hovering above the bottom three, if you like. So yeah, when you look at the games coming up again though, it's amazing to think that all of the big six are coming up again or a lot of the big six are coming up again. So that again makes those three points against West Ham look really important. Absolutely. Well, since we last spoke about Chris Meppham who arrived here at Vitality Stadium, let's take a look at what he had to say to AFCB TV. We've had the names Chris Meppham and Bournemouth close together for a long time and finally they're now together and you've signed them the dotted line. How does it feel to be here? Yeah, I'm delighted to be here, like you said. It has taken a long time to get a signature on a dotted line but like I said, it's been worth the wait. And for me, I'm delighted to be here and I can't wait to start training tomorrow with the boys and seeing all new faces. We're looking at the players' perspectives, fans and working at the club. We see the link and we're sort of hoping it's going to happen. What's it like as from the players' perspective, potentially moving or maybe not? Yeah, it's hard. There's been a lot of back and forth between the two clubs and obviously two windows now Bournemouth have tried to come in for me and Brentford weren't really in the position to let me go and this time it seems like it was more likely to happen than not. Like I said, I didn't want to get ahead of myself until it finally happened and I got a phone call from my agent yesterday sort of telling me that the medical was going to be today and hopefully if I pass the medical then I'll sign on the paper and that's what's happened so I'm really, really pleased that it's finally happened. And there's other clubs who have had their names mentioned alongside yours. Was Bournemouth the only place you ever wanted to come? Yeah, genuinely. I think they were there the first window so after I played, I think, eight or nine games for Brentford, the team that was linked to me and I think because they were the first team and there's lots of like about the club Eddie Howe's a great manager and what he's done here is massive so to be working under him is going to be really good and I like the sort of family feel to the club and like I said after they came in the first time and then obviously he's shown interest last time they've been very persistent with it and for me I can take a lot away from that and it sort of fills me with confidence that they feel like I'm the right player for the football club. Well, that was Chris Meppam after signing for the club this time last week. Chris, it's been no secret that the club have been after his signature for a while so it's great to have that one over the line, isn't it? Yeah, I think Eddie's been a long time admirer just I guess until it's absolutely over the line even if you're favourite to sign him there's always a chance that another club could come in at the 11th hour so nice to get him over the line a bit like, you know, you look at other signings David Brooks and Dominic Solanke similar age, similar pedigree in terms of British he's obviously a Welsh international teammate of David Brooks as well hasn't played since before Christmas he's had a little bit of a niggle Eddie said at the moment in terms of getting him up to match speed it's not just about picking up his physical fitness but also getting up to how Bournemouth want to play and the level he needs to be a part of this team so I'm not sure how immediately we'll see him of course said to back I would guess it's probably about the most solid pair of individuals at the moment in the team in terms of first names on the team sheet so yeah, it's great to have an option realistic cover as well with all due respect to Jack Simpson it's somebody coming in who has been playing regularly at championship level so yeah, he's a right-sided centre half so I guess with Jack Simpson as well you've now got a cover of each side of the centre half duos I think it probably spells the end for Tyrone Mings in terms of he looks likely to head out the door maybe in the next couple of days we'll wait and see on that one but yeah, a real quality signing and again these days fees are inflated of course they are but I trust that his judgement with these sort of players we've seen Lewis Cook's worked out well David Brooks has worked out very well so I think Chris Meppam is another one of those who if he can get in the team we'll probably see him sooner rather than later and as you say, he hasn't played since before Christmas but 26 appearances for Brentford in his country this season so he's really got that much sharpness there hasn't he yeah, let's not underestimate how good a league the championship is there's not a huge gap between the top of the end of the championship these days Brentford of course are I guess the similarities to Bournemouth and they're by no means the biggest club in the championship so Chris Meppam I guess for him it's probably, of course going to the Premier League is a daunting step but it's probably quite a good transition this club is, of course it's bigger than Brentford in a lot of respects and the standard he's playing is going to be bigger and more intense but it's probably quite a nice transition geographically it's not too far he's a West London boy so to uproot your life down to the coast is not too bad rather than ending up in Newcastle or somewhere so yeah no really encouraging signing and hopefully by all accounts he's settled in well with the lads already and he's making his presence known so we're excited to see what he can bring on the pitch and you said about that transition he obviously knows David Bricks from Wales so that will give him confidence coming into the new setup that he already knows someone yeah I think anytime you go somewhere it doesn't matter what walk of life for you if you go somewhere new and you know somebody there already then that's got to help I'm sure David, I think there was some communication that he made about what it was like here and David Bricks had some favourable things to say which he hoped he would have so maybe a little nudge across the line in terms of I guess the final seal of approval that he was coming to the right place but he listened to his early comments about the training I think that's going to be something he's going to enjoy as well so yeah having a mate in the camp is always useful and for Chris Meppham he can obviously see David Bricks he's come here in the summer and he's had a brilliant six months so for him that must have been such a big factor in the coming years he'll see what Eddie Howe has done for players he'll see what Eddie Howe has done for Lewis Cook who's ended up in the England squad hopefully he'll get back there pretty soon David Bricks, Ryan Fraser even since his loan spell in the championship at Ipswich as well every other player that came here in the early 20s most of them have proved to be success stories so yeah for him I think he could probably have gone elsewhere and not been right in the mix maybe a fringe player that's not really particularly useful for somebody if you're going to make the move to the Premier League you've got to have a realistic chance of playing we probably won't see him week in week out because the centre half pair as I say unless anything happens to them, touch wood it won't then they're going to be a difficult pair to oust and of course cup competitions are no longer a factor this season but it does give the option of playing three at the back all of a sudden you've got a very live third centre half option to play on the right so yeah who knows exactly when we'll see him hopefully a good move and we'll blossom even further and as you say that centre back pairing is so tight at the moment but it will create some healthy competition for them all you always need competition in every spot in the squad it'll drive people on and just again the sort of mental side of having extra bodies to call on all of a sudden you're not looking around saying God's always going to have to play this week she's going to have to bring her boots because there's nobody else fit I mean that really would be scrapping the barrel by the way but you know to have people like Adam Smith all of a sudden back to have Dan Gosling back to have some options in centre midfield as well rather than having to play whoever happens to be fit so yeah again touch wood nothing happens to cook or acke but it's great to have those extra bodies and when you look at the bench as well if you need to change something you look at the bench all of a sudden you've got a little bit more strength there as well definitely another really good signing for the Cherries well next up here at Vitality Stadium is a visit of Chelsea tomorrow night this time last year it was quite an evening at Sanford Bridge so let's remind ourselves of what happened last Katie Howell about transfers as well there'll still be an hour of the deadline left when we speak to him as the Cherries put Calla Wilson in and Calla Bridge Glenn Murray scored there Dan Gosling scored there and now Calla Wilson in the very same net same for the Cherries fans who've made the trip to West London wild once more five minutes into the second half champion Chelsea Neal Cherries won that's very intricate they've somehow worked it beautifully and Wilson back to Stanislaus Stanislaus finished, it's in can play 21 minutes to the second half here 2-0, corner Bournemouth in it comes towards that was a good opportunity comes back to Stanislaus time to shoot, Stanislaus there deflected in, no shame in celebrating against his former club and why wouldn't you when you're sign of 10-ling champions well what a win that was goes from Calla Wilson, Junior Stanislaus and Nathan Akke securing a memorable victory at Stanford Bridge certainly I can't believe it was only a year ago it seems like so much has happened since then but yeah that still goes down for me as the greatest winning the club's history winning at the then champions yeah absolutely huge and of course let's not forget even more recently just before Christmas Cherries went there and obviously lost 1-0 in the league up and kept them out till the 84th minute even in the league earlier in the season kept them out till late in the game as well Bournemouth and Chelsea have had some competitive games last season was only 1-0 here in the Premier League as well so yeah even though Chelsea often have a lot of the ball Bournemouth have defended very well against them but just going back to that 3-0 I think we've said it before it was a pinch yourself moment when you particularly when the third one went in because even at 2-0 you're thinking okay well they only need one back and then it might be slight panic stations but as soon as the third one goes in it's good night and just as far as Cherries fans who were there that night they'll probably struggle to find a better night sure you know if Cherries went to Man City in one then it would maybe surpass it but as things add at the moment that's got to be right up there and hopefully yeah a similar performance would be very nice this time round and of course as you say the two games this season against Chelsea they've been so tight up until 70 minutes earlier in the season and then in the Cup it took Eden Hazard to come on and score a deflective goal so there's plenty to be positive about yeah in those games as well I think of Nathan Acke had a great chance in one of the games when it was 0-0 so again against the big teams in the next six games with four of the big teams coming up it's got to be about taking your chances we've seen it this season when Bournemouth haven't taken their chances but it's against the big teams and it does come back to haunt you so hopefully now almost drawing a line on those games against the big six earlier in the season some different bodies, different personnel around the spirit's a bit better hopefully now a bit more confidence Callum Wilson firing still the opportunities when they come along hopefully will be taken they've had spurs in the League Cup and they've had another game against Sheffield Wednesday in the FA Cup so their squad could be quite fatigued going into the game yeah they obviously rotated a bit for the Cup match Eden Hazard obviously didn't play he's the one that I'd love to see rested for the League game but that's obviously not going to happen they had a funny week too obviously because they played pretty badly at Arsenal and lost in that game and obviously Arsenal then got turned over by United at home so everybody's sort of beaten everybody in that little circle but then as you say two cup games and two decent wins for them I'm going to tip a little bit Sarri still seems to be under pressure because they're so far off the top pair if you like and what is it 13 points behind Liverpool at the moment so yeah people will say that Sarri's up in the betting as the next Premier League manager to go which when you're fourth on the table seems a bit harsh but those are the standards at the minute at the top of the table they've obviously bought in Iguain which I'm sure that signing will have settled a few Cherry's fans down who thought that Callum Wilson might be heading there obviously there's still two days or whatever it is so until the deadline has passed and Callum Wilson is still locked in a cupboard somewhere here then they'll probably never quite relax but I think when a club have been linked with your main striker and they sign a striker from somewhere else that will always be quite nice and we've mentioned Hazard there as well as Higuain they've got some real stars to look out for tomorrow night don't they? yeah I mean they keep coming don't they I mean Higuain hopefully he's still it'll be his first Premier League game so hopefully he's still settling in he didn't have a whole lot of chances against Sheffield Wednesday but they didn't really need him to have a lot of chances it was probably quite a nice game for him to take his first steps into English football of course it shouldn't be forgotten he actually played here for Real Madrid in the famous friendly a few seasons back and actually scored within a couple of minutes of coming on so his one previous visit to the Vitality Stadium has been a scoring one I think he was probably a slightly different player he's probably slightly more at the peak of his powers then I'm not saying he's on the wane by the way because if he scores tomorrow night everyone will go because he's been out on loan from Juventus to Milan and now he's gone to Chelsea and they have struggled for goals they have struggled for an out and out number nine Eden Azar has been playing there which is not his favourite position they are the lowest away scorers Chelsea have the big six they've only scored 19 goals this season I say only that's quite a few more than the cherries have scored away but yeah in terms of firepower they have been a little bit short so they'll be hoping he's the answer for them and in terms of our team New Delhi House just said in his pretty much press conference if he's not going to play wouldn't it? He had a bit of a knee injury against West Ham which when he came off people probably thought he was you know it had been a bit of a risk to play with his hamstring issue that he'd had but he has had a knee injury knocking around so we'll wait and see how much that impacts him hopefully the 11 days since the West Ham game will be useful by the time the match comes around Dominic Solanke I think he's getting closer he obviously had an early February date to put on his involvement when he first signed but I gather he's getting a bit closer whether tomorrow night is a bit soon we'll wait and see but there's obviously some big games coming up including in his old place Liverpool I'm not actually sure whether he's allowed to play against Liverpool he's a permanent signing so I'm pretty sure he probably is whether Nathaniel Klein can I'm not sure but anyway we'll get to that when we get to Liverpool but in terms of the striking options yeah be a massive boost if Callum was fit I think we saw in the game that he didn't play that they missed him so yeah you always want your top score for it yeah for sure if you are coming we look forward to seeing you here but if not make sure you keep an eye across all of our social media channels and our website for the latest updates thanks for joining us


For many years John was one of the associate directors of the center and has trained literally dozens of the fellows here So probably many people in the audience have been greatly influenced by John John is currently the director of children's mercy bioethics center at children's Mercy Hospital in Kansas City And it's a professor pediatrics at the University of Missouri Kansas City School of Medicine He's offered several books including do we still need doctors? Neil Neal ethics in the last physician Walker Percy and the moral life of medicine He's served as both the president of the American Society of Law Medicine and Ethics in the American Society of Bioethics in Humanities And John will be speaking about 22 weekers Boy, you look up tough act to follow in the dictionary and they've Dave Sheeter Myers picture Gonna talk about 22 weekers But I thought in this topsy-turvy week that has been so emotional in so many ways We ought to spend a moment thinking about Leonard Cohen who died last night And I have a couple of his lyrics to meditate on Maybe meaningful for this week. Everybody knows the boat is leaking. Everybody knows the captain lied Everybody's got that broken feeling like their father or their dog just died He also had a song about hope and democracy in the United States And he thought democracy might return and he wrote it's coming from the sorrow in the street the holy places where the races meet From the homicidal bitchin that goes down in every kitchen to determine who will serve and who will eat From the wells of disappointment where the women kneel to pray for the grace of God in the desert here and the desert far away Democracy is coming to the USA To the shores of need past the reefs of greed Through the squalls of hate Rest in peace Leonard. Yeah Also, let me just apologize. I'm a little jet lag. We just return from a tour through India Where we did three bioethics conferences with the team from children's mercy, but also on Gira Patel and Gira you out here Not yet. She's coming today who trained at the McLean Center and Thinking of the talks earlier this morning. I mean if you start thinking about health disparities the problems we face in the US are Minuscule compared to the disparities between the US and the rest of the world So I'm a little jet lag. So this might be a little bit incoherent, but I will try my best. So Thinking about 22 weekers, most of my talk will be about this graph. Isn't it beautiful? I'm sure you can all interpret it, but let me walk Those of you who are having a little trouble through it. This was a study from the NICHD Neonatal Research Network that looked at how many babies got treated in 24 of the leading children's hospitals in the United States So across the top is 22 23 24 25 26 weeks each dot is The value of how many babies got treated and the lines are standard Errors so what you can see is at 24 to 26 weeks almost all babies receive what they call the active treatment There were a few outliers at 23 weeks Every center offered treatment to some babies and some offered treatment to every baby But at 22 weeks five hospitals provided active treatment to no babies. They've apparently had a policy We just don't treat 22 weekers But seven hospitals offered active treatment to every 22 weaker and the rest the other 12 were Somewhere in the middle Turns out that hospital policies are the strongest predictor of survival for babies under 25 weeks in hospitals that treat more such babies save more such babies and hospitals that restrict treatment Policies that restrict treatment lead to avoidable deaths The hospital with the best survival rates the University of Iowa reports 40 to 50 percent Survival for 22 weekers and higher survival rates than most other places for their 23 and 24 weekers Here are their stats from the University of Iowa In between 2006 and 2014 48 percent survival for 22 weekers and 88 percent for 24 weekers and this is how they compare to the Vermont Oxford Network a large consortium of NICUs and the neonatal research network, Iowa is clearly the outlier there at every week of gestation by about a factor of three or four at 22 weeks. How do they do it? They do it by a concerted effort that involves both obstetricians and Pediatricians so that every baby or every pregnant woman after 20 weeks gets anti-natal steroids something that the American College of Obstetrics and Gynecology does not recommend They have a standardized protocol that you can't see here But you can see that it's complicated, but they follow it in the first hour of life for these Tiny babies and part of it includes innovative techniques of ventilating where every baby is put oops every baby is put on a high-frequency Chet ventilator from the moment of birth which reduces barotrauma and leads to better neonatal Lung function So my central question for the talk is this Since most centers many centers don't treat any of these babies Is there any other situation in which a patient has a disease that is uniformly fatal without treatment and some centers report? 40 to 50 percent survival rates and other centers not only do not offer the treatment But argue that it would be unethical to offer the treatment and many bioethicists support them. I Think probably not it's weird So I know what you are thinking the gestational age is a predictor of mortality and severe neurocognitive Impairment parents don't want their tiny babies saved and it costs too much all of these are wrong some more than others gestational age Is a predictor of mortality, but at this gestational age range 22 to 25 weeks While it is associated with survival it is not Associated with neurologic impairment among survivors That is the 22 weekers who survived do just as well or just as badly as the 25 weekers who survived There's some data from a big study in England Published in the New England Journal of Medicine in 2000 where they looked at their babies less than or equal to 23 24 and 25 and what you can see these are all measures of Disability what you can see is basically no difference At the different weeks of gestational age within this narrow range at the borderline of viability similar data from Iowa 22 weekers of the same rates of IVH Intraventricular hemorrhage bronchopulmonary Displasia and neurocognitive impairment as 23 24 weekers So if if the goal of treatment is to reduce the number of survivors with neurologic impairment to the only sensible policy would be to Cut off treatment at 26 or 28 weeks where they You really start to see the fall off And it's a seeming paradox Since more babies survive with disability at higher birth weights than at lower ones even if the rates of disability are higher in Smaller babies, and here's a thought experiment to show that imagine a group where there was 90 percent survival and 20 percent of Survivors had severe disability versus a group that had 20 percent survival and 50 percent of the survivors had severe disability 20 percent of 90 is 18 50 percent of 20 is 10 so the overall number of impaired survivors That society would have to take care of if you will is much higher in the almost twice as high in the higher survival rate than in the Lower survival rate But in this area people seem oddly impervious to that should say data Take for example a recent statement by ACOG and the Society for Maternal and Fetal Medicine They say delivery before 23 weeks typically results in neonatal death Irrespective of newborn resuscitation five to six percent survival and among survivors Significant morbidity is universal 98 to a hundred percent Both claims here are just wrong. They're not fact-based, but here's where they come from a sort of I think almost Willful misinterpretation of the data. Here's the data from the neonatal research network Overall survival was five percent So in that sense the ACOG statement was quoting a Factoid that you could take from this study, but the survival rate of babies who got active treatment was 23 percent And only 22 percent of babies got active treatment So if every baby got treated the overall survival rate would probably be somewhere closer to 20 percent Or to look at it another way it depends which question you ask This is from another NICHD study and here the question was how to how how many babies survive without impairment? And you could put in birth weight and gestational age and this is online There's a neonatal outcomes calculator, and if you put in how many 500 gram 23 week They don't go down to 22 by the way How many 500 gram 23 week singleton survive unimpaired they break it down by boys whose moms didn't get steroids boys Mom's did girls with no steroids girls with steroids. There's three things to note here among 23 weekers There's a four-fold difference in unimpaired survival the girls are 18 percent and the boys five Survival rates double if the moms are given steroids And this doesn't distinguish death from disability in the survivors. So you can ask a different question Not how many 500 grammars survive unimpaired, but how many of the 23 weekers who survive are unimpaired and from that same calculator. It's a very different statistic So if you think the treatment is worth doing if you can get greater than 50 percent good outcomes Depends whether you consider a good outcome only among survivors or to put it another way Is it worth worse to have tried and failed then not to have tried at all Is it better not to offer a treatment and let a preemie die or to offer a trial of therapy and withdraw if things looks bad? Why do people do this it seems and I offer this tentatively it seems that there's simply a bias against pre-means Considered these two cases for example a previously healthy two-month-old baby develops a fever irritability listlessness and a rapidly spreading rash A lumbar puncture shows that he has meningitis If the baby survives he will likely have severe neurologic impairment or a baby born at 23 weeks 550 grams with Apgars of three and six and he's intubated and give an oxygen in his color and tone improve In many hospitals initial treatment would be considered optional for the baby in case two But I would suggest is automatic for the baby in case one Even though the prognosis is better for the preemie than it is for the two-month-old with meningitis Or another thought experiment babies born at 22 weeks and 500 gram gestation with Apgars of three and six Or an 84 year-old without an advanced directive comes to the ER diaphoretic shorter breath with chest pain and ST elevation Here are the survival rates for that 85 year-old Unadjusted survival rates about 15% to overall and as I pointed out here are the achievable survival rates for the 22 weaker while many people would say that CPR for that 84 year-old might not be the best thing I'm not aware of any policy hospitals that have policies to say We absolutely will not offer CPR to any such patients without even discussing it with them and their family There is something about preemies here was a study that Annie Jean Vieille did in Canada with residents and nurses Gave two case vignettes one identified the patient as a 24-week preemie and the other just described a patient And gave outcomes that were those of 24 week preemies in that institution at the time and asked people Would you resuscitate and what they found among the nurses and the residents was if you said it's a 24-weeker They were half as likely to resuscitate as if you simply gave them the outcomes of a 24-weeker But didn't say what the gestational age was Many people think parents would not want treatment for such babies surveys of parents suggest that this is also not true Here are the sorts of data That suggests that this was a study of physicians nurses parents of Children who had been extremely low-bate with birth weight babies in this study. They actually the Kids who had been low birth weight babies were now teenagers and they surveyed them as well The question was I believe an attempt should be made to save all infants regardless of birth weight The parents and the teens were much more likely to strongly agree than the physicians and nurses who mostly strongly disagreed with that or Percentage of people who thought it was appropriate to try to save babies at all costs This is healthcare workers mothers of term babies and parents of preemies In fact, it seems that in all these studies parents who've had experience in the NICU are the ones most likely to say That we should try to save babies at all costs Or here was one where they asked Doctors nurses and parents to rank three states death Severe impairment or moderate impairment that is which would you think is the worst outcome here with severe impairment being wheelchair Dependent with the intelligence of a one-year-old unable to speak read write in continent with no activities Independent activities of daily living Is severe disability worse than death the doctors and nurses 55% of the doctors and nurses said that it was but the parents of preemies it was only 25% So my modest proposal is that neonatologists and professional societies should simply stop using gestational age as a Basis for policies about which babies to treat and instead treat even the most premature babies the way we treat Every other patient that is talk to the parents surrogate decision makers Examine the patient and then make a recommendation about whether treatment is indicated radical suggestion. I know There is An elephant or actually two elephants in the room One is abortion politics to save 22 weekers Is it to admit the Roe v. Wade framework was wrong and to raise questions about the rights of fetuses at a gestational age where abortion is still legal and the other is institutional political culture In order to get the kind of outcomes that they get in Iowa there needs to be cooperation between Neonatologists and obstetricians perinatal care has to be a seamless hole There has to be an agreement to make a commitment to both develop the kind of obstetric services and the kind of neonatal services that enable this high survival rate and That would take a tremendous shift in the institutional cultures at most hospitals in the u.s. Today But if we ask parents many will want treatment and if we're asking them an offering treatment I think we have an obligation to put in place the kind of systems that would lead to good outcomes with treatment to Ask parents and have them request 22 weekers when the obstetricians don't give Antinatal steroids to pregnant women at 21 and 22 weeks and where the NICU isn't set up to provide the kind of care that this baby's Need is a cruel hope so we can learn from places like Iowa about best practices And in Iowa they've actually created a subunit within their NICU that they call the tiny baby unit Which is sort of a NICU on steroids and that's how they get those outcomes So in conclusion survival rates are improving for 22 weekers non-treatment is a self-fulfilling Prophecy of policy in favor of treatment will be welcomed by most parents and my prediction is we will see more and more Centers begin to emulate Iowa and treat more 22 weekers with better outcomes And outcomes across the country will improve banks You norm John that was great Peter singer Jeff McMahon and more recently Dominic Wilkinson neo-natologist philosopher whose book you called the best book in bioethics in the last 20 years I disagree with you. I think it's the best in the last 40 years But all three of them have at least raised questions about the moral status of even normal newborns Arguing that moral status has something to do with an entity that has hopes plans dreams values aspirations And this is why we don't give dogs the same moral status as other human individuals So under that view Treating preemies and even newborns differently than Three-year-olds or five-year-olds or 84 year olds would have some coherent basis And since you so praise Wilkinson's book, but maybe not every chapter of it. I'm interested in your thoughts about that What say that again Philosophy that would treat newborns at any gestational age as non-persons would be an internally consistent Philosophy although it would lead to very different treatment patterns than I think Tom Wilkinson would Endorse that is it would allow non-treatment Presumably up to some post birth age at which point some magical physiological transformation would occur that Somehow would confer personhood on somebody who the day before didn't have it I Actually didn't read Dom Wilkinson's Book in quite that way. I mean I think what he was talking about was more how we use predictors for babies in whom treatment has already been started and how bad the likelihood of disability would have to be before we would withhold or withdraw treatment John you talked about the sort of exceptionalism of the University of Iowa Can you speak to what the factors are that led to that culture there and how that came about? It's a great question. I can't I cannot answer except to speculate based on a visit that it was leadership within neonatology and an institutional culture in which collaboration between neonatology and and obstetrics had already existed and continued to exist, but how that came about John thank you I Wonder if you think there might be an analogy to spina bifida You know in the 70s. We had the Lorber camp Saying only treat the best of them And you had the MacLone camp saying treat all of them and study the outcomes and it took a long time For people to be convinced of the data which said that treating all of them You get the same outcomes as if you treat only the best 15 percent It seems to me this moving target and trying to believe your data is Part of the problem. I'm wondering what you think Just to be clear about what I'm arguing here today It is not That here's a double negative. It's not that it's inappropriate to consider Disability as a long-term outcome and severe disability as a reason to withhold or withdraw treatment What I'm talking about here is an institutional policy not even to offer initial treatment categorically to a group of patients, so Maybe to the extent that In the 60s and 70s People tried to develop scoring systems for the severity of my lumen ingesiel and say if it's above a certain level We shouldn't offer treatment. There's an analogy, but I think even in those cases What they would do is recommend non-treatment, but still offered if the parents insisted that's very different than the many centers who Just do not even discuss and say we have a policy 22 weeks No, no discussion My sense was that there were places that had a categorical policy if you didn't meet these Criteria, they weren't going to treat you So you had you know people saying we don't know that yeah We have to offer treatment and we have to study it and see whether that hypothesis is true That's that was my understanding If that's true then the analogy would be a good one. Yeah, right So everybody loves data and I hear you saying we're not getting data here because of these dichotomous policies and and I think the third elephant maybe in the room is disability ethics How health care professionals specifically have this and we see it over over again in ethics consultation This quality of life by us So to respond to your question about another disease that might be somewhat like this I was thinking about childhood leukemia in the 70s Where the treatment itself not the underlying condition, but the treatment itself craniospinal radiation high-dose anthrocycline caused a lot of disabilities in exchange for the potential for cure It's not a perfect fit, but at least it gets us there and what we did in oncology was we got data Good good point like Chrissy's question I'd have to go back and look at whether there were places Where if you got a diagnosis of ALL in 1970 People said even if you want it, we're not gonna do it Do you know whether that's the case? And I think it was more I think it was more discouragement of treatment and saying, you know This is experimental and we don't think it's gonna work and there's gonna be a lot of pain and suffering But if you want it, we'll do it And again by my analogy once some centers started reporting good outcomes I'll bet there weren't many centers that said no, that's unethical. We're gonna continue not to offer that Good morning, Dr. Lantos You've done a remarkable work over the particularly over the last 10 years in this area with preemies and what we call micro preemies and You might know I'm a narrativist. I'd like to ask you particularly I would never do it in a crowd other than this one I think but you're a grandfather of a Previously 23-weeker who is now 10 years old and he was born at that weight He was born at 23 weeks one day at five about 500 grams By two days he missed the mark for which that hospital would not have treated him Will would not be here. I Wonder how much or not how much but in what way has your own Close-up experience Watching and being there with a family who went through it How much in what way has that influenced or helped you to think about these things? For those of you who don't know Martha's my wife and And the grandmother of that preemie Personal experience is Shape shapes our views on almost everything and watching Anna and Mitch and Will go through that will was actually a twin and the other twins Sam died at one day So they offered treatment to both twins Outcomes were radically uncertain and We were blessed that will both survived and did very well He was left with what would be classified by the NIC HD classification system as a severe Impairment that is he is severely visually impaired and thus would fall into the statistics About either dying or surviving with a severe impairment. He's also an A student and Played soccer and is a pretty good pizza maker He has a little bit to learn on that count But we've also worked with a group of pediatricians who have had babies in the NICU and I think our experience is mirrored in that group we've published a couple of papers together now and Going through the experience doctors React just the way Parents do it's interesting somehow Common humanity Trump's professionalism and so In the surveys my guess would be that most doctors who have had a baby in the NICU Would fall out looking more like the parents in those surveys that like the health professionals One more. Oh, yeah, you're back Yeah, one more if there's time Getting back to Wilkinson If you had an a preemie if you had a predictor machine and you knew with a hundred percent certainty Yep, that in a preemie was going to turn out to be profoundly impaired such that death would Arguably be in that child's interest that continued survival was not in his or her interest if you had that situation I'm guessing you would be much more tolerant of parents and doctors in Concert agreeing not to provide aggressive treatment for that baby if that's true And you can just tell me if I'm if I got that wrong if you Wound up and if you found out at age one two or three that the child had turned out that way So now that it is a hundred percent that the child is in a state where you think continued Survival is not in his or her interest particularly with more medical treatment If it were would it be appropriate to act in a way that would end that child's life at that point and if that were Easy or if that were acceptable then might not more Doctors be willing to treat aggressively at the front end. So I'm interested in your thoughts about that So just to be clear about what you're asking you're saying should we legalize euthanasia for severely impaired three-year-olds Something like that. Yeah They have been No, they have not in Belgium actually in Belgium. It's for children who have decisional capacity They're about to in the Netherlands I Don't think it would make the decisions any easier for the same reason that it doesn't seem to Make decisions in the NICU easier to know that you can withhold or withdraw life-sustaining treatment later That is it's still a struggle and doctors We'll discuss with parents when they have predictors of just that sort of severe neurocognitive impairment whether to withhold or withdraw treatment And the more severe the Impairment in the NICU the more likely it's going to be severe impairment later in life And many parents choose not not to withhold or withdraw treatment I think the number of cases in which The scenario you describe would actually play out would be so minuscule with the likelihood that it could reflect back on Decisions in the delivery room or the first weeks of life is also minuscule. I Also think I mean a good Clinical example of the scenario you describe would be trisomy 13 or trisomy 18 where we have virtually a hundred percent accurate prediction that Kids are either going to die or be severely impaired. I think that's a perfect situation for shared decision-making But what we found somewhat surprisingly is even given that information many parents choose life-perlonging treatment and Again, all I'm arguing is that should be the paradigm for 22 weekers