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Mark Sullivan, MD PhD, Department Editor
Stuart W.G. Derbyshire, PhD
Editor’s note: Neonatal and fetal pain have been, and continue to be, difficult issues for the pain community. More recently than we would like to admit, surgery was done on neonates without anesthesia. This practice was justified by the belief that they were unable to feel pain. With the neonatal capacity to feel pain now established, attention has recently turned to the question of fetal pain. Stuart Derbyshire finds the new science of fetal pain interesting and valuable; but, he does not believe that science holds the answer to the morality of abortion.
In our previous Pain as Path columns, we have looked at pain as a path to ecstasy, enlightenment, or political power (through torture). Here we see pain used as a path to establish social consensus on a controversial issue. I think Derbyshire is correct in his view that although pain is a morally relevant experience, it does not itself determine the morality of an action, even abortion. Pain always occurs within a context that must be considered. If there is any consistent theme in the Pain as Path columns, this is it.
A recent report in the Journal of the American Medical Association by Lee, Ralston, Drey, Partridge, and Rosen (2005) has once more opened up debate about whether a fetus can feel pain. This debate has been ongoing since at least the late 1980s when Anand and Hickey published a review in The New England Journal of Medicine raising the possibility that the fetus is capable of experiencing pain (1987). This review was followed by evidence that the fetus can launch a hormonal stress response to invasive practice in the womb from about 18 weeks gestation (Giannakoulopoulos, Sepulveda, Kourtis, Glover, & Fisk, 1994) and subsequent discussion of fetal pain (Derbyshire et al., 1996).
Two things have broadly occurred as the debate about fetal pain has progressed. First, the discussion has become more scientifically informed due to increasing knowledge about fetal neuroanatomy and physiology. We now know that there are a series of important points in fetal development with potential relevance to the ability to process pain. At 7 weeks gestational age (GA), for example, the spinothalamic tract is considered to be an intact unit. The very first projections from the thalamus toward the cortex into the subplate are apparent from 12 to 16 weeks GA, with the major afferent fibers (thalamocortical, basal forebrain, and corticocortical) penetrating and forming within the cortical plate from 23 to 25 weeks GA (Hevner, 2000; Kostovic & Judas, 2002). Cortisol and -endorphin circulation increase following intrauterine needling of the fetus beyond 18 weeks GA (Giannakoulopoulos et al., 1994). Further studies have demonstrated that this hormonal stress response can be blunted when opioid analgesia is administered to the fetus (Fisk et al., 2001) and that the fetal stress response includes hemodynamic changes in blood flow to protect essential organs, such as the brain (Teixeira, Fogliani, Giannakoulopoulos, Glover, & Fisk, 1996).
Second, the debate over whether a fetus can experience pain has become increasingly political. Some state and national legislatures attempt to use fetal pain to restrict access to abortion. The U.S. federal government is considering legislation (The Unborn Child Pain Awareness Act, 2005) that would mandate that a pregnant woman seeking an abortion after 22 weeks GA be offered anesthesia or other pain-reducing drugs for administration directly to the fetus. Physicians who fail to comply with the bill could receive a $100,000 fine and might lose their license and/or Medicaid funding for a first offense. The politicization of the debate about fetal development is problematic because the type of evidence being offered by Lee and others simply cannot answer the central political question being posed: Is abortion right or wrong? Determining if the brain is sufficiently developed to experience pain will not reveal whether it is morally right to take the life of a fetus. Proving that a fetus cannot feel pain, assuming that were possible, would not be sufficient to justify the elimination of fetal life. Similarly, proving that a fetus could feel pain would not be sufficient to justify forcing women to give birth. Abortion is a political and social issue: It cannot be resolved with science. We will never develop a “fetalometer” to tell us when abortion is right or wrong (Derbyshire, 2005).
More provocatively, I would argue that the type of evidence offered by Lee and colleagues (2005) cannot indicate whether a fetus feels pain. The discoveries and understanding of fetal anatomy and physiology are both fascinating and exciting, but they simply cannot resolve the question of experience. To understand the experience of pain, we have to grapple with the nature of pain and with human psychology. Although Lee et al. do discuss the characteristics of pain, they minimize its importance by arguing that the psychological nature of pain presupposes the presence of functional thalamocortical circuitry. This tends toward a view of pain processing that regards pain as a direct product of neural circuitry rather than as a subjective experience made conscious by a developmental process that is both neurological and social (Derbyshire, 1999, 2005). Lee et al.’s article presents a construct of pain that centers on the development of neurocircuitry rather than on understanding subjective experience.
To some extent, therefore, the debate about fetal pain involves both “bogus” politics and science. Some politicians use the possibility of fetal pain to avoid engaging the difficult social and moral issues that have traditionally been raised about abortion. These politicians hope that arguments over life and rights will be replaced by undeniable facts of science that determine the conditions of an acceptable abortion. Some scientists, meanwhile, are using the empirical findings of neuroanatomists and neurophysiologists to avoid engaging the complex psychological and developmental issues posed by consciousness. These scientists hope that subjective arguments about fetal self-awareness, identity, and experience of pain will be replaced with empirical knowledge of the undeniable presence of anatomical structures that dictate conscious development. These hopes cannot be realized, and it is troubling that the sound and fury being generated in their pursuit may undermine scientific investigation and good clinical practice.
In the wake of the report by Lee and colleagues, Anand suggested the authors had “literally stuck their hands into a hornet’s nest.” Anand also argued that “we should give the fetus the benefit of the doubt if we are going to call ourselves compassionate and humane physicians.”
The idea that scientists will get stung if they offer an opinion, not to mention a scholarly review, about fetal pain is not conducive to broad discussion and understanding of the relevant issues. I have stated my own view on the topic of fetal pain (Derbyshire, 1999, 2005) that I expect to be judged first on the merit and content of the argument and only afterwards on the conclusion.
Lee et al. (2005) have provided a well-researched and scholarly review of neurological development that has implications for how we understand fetal pain. By failing to attend to the development of awareness and the subjective experience of pain, they are vulnerable to critique by those who would raise the possibility that more primitive processing allows for the experience of pain. Anand’s demand for the fetus to be given the “benefit of the doubt” follows directly from this thinking.
Providing this benefit of doubt, however, is not simple in practice. In cases of fetal surgery there is a moral imperative to avoid pain, but there is also an obligation to provide for the best possible outcome in terms of survival and normal long-term neurodevelopment. Currently there is no evidence-based fetal anesthesia or analgesia protocol defined for fetal surgical procedures providing data on these major clinical outcomes that are important to neonates and their families (Colvin, McGuire, & Fowlie, 2004). Enthusiasm for the administration of analgesia and anesthesia to the fetus undergoing surgical procedures must be tempered against the possibility of adverse effects on the fetus when it is undergoing dramatic neural development. Negative effects on the fetal environment may disturb the conditions facilitating normal neural development. Consequently, the most compassionate and humane course of action remains uncertain and surgeons must be left to make decisions based on their own judgment.
In cases of legal elective abortion, there is still the moral imperative to avoid pain; however, there also is an obligation to attend to the well-being of the pregnant woman. The most compassionate and humane course of action remains uncertain and clinicians should be left to make that judgment according to their training and experience.
Recent developments in the understanding of fetal development are interesting and exciting, but they do not answer the question of whether the fetus can feel pain. Answering that question will require a broader investigation of how human awareness develops and what experiences might reasonably be possible within the womb. When this debate is more mature, better direction might become available for those who perform surgical procedures on fetuses. In the meantime, it is reasonable to assume that physicians operate with compassion and make decisions according to the highest standards of humanity based on their experience and on what is definitely known about current conditions and future outcomes.
Fetal pain is an interesting and provocative topic, but it cannot resolve the legality or morality of abortion. The debate about fetal pain should continue without reference to abortion to open up the debate to the broadest possible array of scientific thought and encourage more scientists to to join the discussion without fear of being stung by politics.
Anand, K. J. S., & Hickey, P. R. (1987). Pain and its effects in the human neonate and fetus. New England Journal of Medicine, 317, 1321–1329.
Colvin, M., McGuire, W., & Fowlie, P. W. (2004). ABC of preterm birth: Neurodevelopmental outcomes after preterm birth. British Medical Journal, 329, 1390–1393.
Derbyshire, S. W. G., Furedi, A., Glover, V., Fisk, N., Szawarski, Z., Lloyd-Thomas, A. R., et al. (1996). For debate: Do fetuses feel pain? British Medical Journal, 313, 795–799.
Derbyshire, S. W. G. (1999). Locating the beginnings of pain. Bioethics, 13, 1–31.
Derbyshire, S. W. G. (2005, March). Late abortion and the “fetal pain” fallacy. Spiked-Online. Retrieved from http://www.spiked-online.com /Articles /0000000CA93C.htm
Fisk, N. M., Gitau, R., Teixeira, J. M., Giannakoulopoulos, X., Cameron, A. D., & Glover, V. A. (2001). Effect of direct fetal opioid analgesia on fetal hormonal and hemodynamic stress response to intrauterine needling. Anesthesiology, 95, 828–835.
Giannakoulopoulos, X., Sepulveda, W., Kourtis, P., Glover, V., & Fisk, N. M. (1994). Fetal plasma cortisol and -endorphin response to intrauterine needling. Lancet, 344, 77–81.
Hevner, R. F. (2000). Development of connections in the human visual system during fetal mid-gestation: A DiI-tracing study. Journal of Neuropathology and Experimental Neurology, 59, 385–392.
Kostovic, I., & Judas, M. (2002). Correlation between the sequential ingrowth of afferents and transient patterns of cortical lamination in preterm infants. Anatomy and Rec, 267, 1–6.
Lee, S. J., Ralston, H. J. P., Drey, E. A., Partridge, J. C., & Rosen, M. A. (2005). Fetal pain: A systematic multidisciplinary review of the evidence. Journal of the American Medical Association, 294, 947–954.
Teixeira, J., Fogliani, R., Giannakoulopoulos, X., Glover, V., & Fisk, N. M. (1996). Fetal haemodynamic stress response to invasive procedures. Lancet, 347, 624.
The Unborn Child Pain Awareness Act of 2005, S. 51. Retrieved from http://frwebgate.access.gpo.gov /cgi-bin /getdoc.cgi?dbname=109_cong_bills&docid=f:s51is.txt.pdf
Stuart W.G. Derbyshire is at the University of Birmingham School of Psychology in Edgbaston, UK.
