There is no such thing as 'fetal pain'
Pain specialist Dr Stuart Derbyshire argues that the misguided discussion of fetal pain will have serious negative consequences for the treatment of pregnant women and for scientific practice
In June a group of anti-abortion parliamentarians published a tract asserting that fetuses experience pain from the tenth week of gestation. Such a debate seems a strange preoccupation for politicians who cannot be expected to know one end of a nerve cell from another, but it has since been the subject of questions to ministers and parliamentary debates. The issue will be re-raised when MPs and peers return from their summer recess and a self-appointed 'pro-life' committee of inquiry reports.The agenda of those who have raised the issue of fetal pain is clear. If they can establish that fetuses feel pain it is bound to generate public unease about abortion procedures. Already the anti-abortion lobby is talking in terms of 'the pre-born' writhing in agony as they are ripped limb from limb--not a pretty thought, however pro-choice you might be.
The discussion also helps to encourage the assumption that there are no qualitative differences between fetuses and babies. It fosters the notion that fetuses are just 'pre-born' babies with the same capacities--and so are worthy of the same care and treatment. The consequence of this would be to reduce the status of the woman to that of a 'walking womb', with no right to decide what happens to her pregnancy. But then her rights tend routinely to be ignored as all eyes focus on the fetus.
It is not surprising that the anti-abortion lobby has raised this issue. But it is surprising that its views have struck a chord with the medical establishment and with 'pro-choice campaigners'. Everybody seems to agree that this is a 'difficult' issue which needs careful consideration. Even the most strongly pro-choice voices appear to concede that fetal pain experiences might be possible after 26 weeks of pregnancy. More equivocal voices suggest that the pro-choice argument should evade the issue by arguing for easier access to abortion before 10 weeks.
What needs to be said is simply this. Fetuses do not and cannot feel pain--not at 10 weeks, 26 weeks or 30 weeks--because pain-experience depends on consciousness and fetuses are not conscious.
The question of fetal pain became an issue for some of the medical profession in the mid-1980s, as a consequence of research which indicated that a fetus is capable of a behavioural response to sensory stimulation. Advances in fetal surgery, which now include placing valves into the heart and injecting red blood cells into the liver to prevent anaemia, meant that neonatal surgeons and experts in embryology were becoming increasingly concerned about the potential consequences of invasive practice, including the concern that the fetus may feel pain. This concern was given a major boost by research from Dr Anand, then a research fellow at the John Radcliffe Hospital, Oxford, which demonstrated that neonates--new-born babies--undergoing surgery had a much improved clinical outcome if they received anaesthetics of a kind usually reserved for controlling pain during adult surgery.
It may come as a shock to hear that, until very recently, it was not considered necessary to use anaesthesia with new-born babies. But the reasons are entirely rational. The use of anaesthetic is not without risk. Even in adults there is a small risk of respiratory depression which can be fatal; for a new-born baby with underdeveloped lungs this risk is heightened, becoming greater if the baby is premature. In addition, it was widely assumed that the new born lacks the biological sophistication necessary for pain-experience. Anand's work overturned these assumptions.
The work of Anand is complemented by that of Professor Maria Fitzgerald from the Department of Anatomy at University College London. For over a decade, Fitzgerald has investigated the nervous system of the rat fetus and the human fetus, with special regard to the developmental neurobiology of pain. She concludes that several basic mechanisms must be connected up in the human being in order for pain to be experienced. The peripheral nerve fibres (that is, the nerves in your outer skin and inner organs) have to be connected to your spinal cord, which in turn needs to be connected to your brain. There are then several circuits within the brain which have to be operational and connected before the biological pain system is operational. According to Fitzgerald's studies, the final link in the pain system (between a cluster of grey nuclei in the brain stem, the thalamus, and the outer rim of the brain, the cortex) is completed at approximately 26 weeks' gestation.
The suggestion that the biological system for pain is operational after 26 weeks is bolstered by studies of invasive procedures. Touching the fetus prior to 26 weeks often results in a generalised response. Repeated skin stimulation, for example, results in hyper-excitability and a generalised movement of all limbs of the body. Such behaviours are characteristic of a purely reflex response. Observations of the fetus after 26 weeks, however, indicate localised movement and avoidance responses to invasive needling. Behavioural studies with very premature babies have demonstrated that the response to noxious stimulation becomes more focused and organised, and can be better discriminated from other distress responses after 26 weeks.
It is now also clear that the fetus of post-26 weeks' gestation launches a stress response to invasive needling, entirely analogous to the response shown by Anand in new-born babies. In 1994 a team at Queen Charlotte's Hospital in London successfully demonstrated that intrauterine needling to obtain a blood sample from fetuses of 20-34 weeks' gestation resulted in a hormonal stress response, as indicated by increased cortisol and ß-endorphin concentrations in fetal plasma.
As a consequence of this research, the previous objections to the use of anaesthetics in the new born and the fetus, on the grounds of danger and minimal biological development, are now untenable. After 26 weeks, the human fetus has the necessary biological apparatus for pain, shows a localised behavioural response to stimulation, and launches a hormonal stress response to needling. But is this sufficient evidence to conclude that the fetus can experience pain?
Whether or not the fetus feels what we understand as pain hinges not on its biological development, but on its conscious development. Unless it can be reasonably demonstrated that the fetus has a conscious appreciation of pain after 26 weeks' gestation, then its responses to noxious stimulation are still essentially reflex responses, exactly as those prior to 26 weeks. This is appreciated in varying degrees by the experts.
Xenophon Giannakoulopoulos and his colleagues at Queen Charlotte's admitted that 'a hormonal response cannot be equated with the perception of pain'. In a paper written for the Department of Health, Fitzgerald even went so far as to say that 'true pain-experience [develops] postnatally along with memory, anxiety and other cognitive brain functions' ('Fetal pain: an update of current scientific knowledge', May 1995). In other words, to claim that a fetus feels pain makes as little sense as suggesting that it has kept a mental diary of its time in the womb.
As Fitzgerald has pointed out, pain-experience is now widely seen as a consequence of an amalgam of cognition, sensation and affective processes, described under the rubric of the 'biopsychosocial' model. Pain has been understood as a multi-dimensional phenomenon for some time, and this understanding is reflected in the current International Association for the Study of Pain (IASP) definition of pain as 'an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage' (H Merskey, 'The definition of pain', European Journal of Psychiatry, Vol6, 1991).
If this 'multi-dimensionality' is the basis of conscious pain-experience, it makes no sense to attribute this experience to the neonate or fetus which is naive as to all the cognitive, affective and evaluative experiences necessary for pain-awareness. This is accepted in the current IASP definition of pain, which is further extended to state that 'pain is always subjective, each individual learns the application of the word through experiences related to injury in early life'. Pain does not somehow spring forth 'from the depths of the person's mind' prior to any experience. That would be an essentially metaphysical view of pain, which logically suggests that all the higher mental functions should be present at, or before, birth.
In other words, the experience of pain is a consequence of developmental processes through which the fetus and new-born baby have yet to pass. According to one developmental model of pain, stimulus information is eventually organised and elaborated in the central nervous system with respect to three hierarchical mechanisms. The first two mechanisms in the hierarchy are perceptual-motor processing followed by schematic processing. Both these mechanisms are considered pre-conscious. Perceptual-motor processing involves the activation of innate motor reactions to stimulation. Schematic processing involves the automatic encoding in memory of these stimuli and associated reactions to produce a categorical structure representing the general informational and sensory aspects of aversive stimuli. In addition, it is suggested that a set of conscious abstract rules about emotional episodes and associated voluntary responses arise only over time, as a consequence of self-observation and conscious efforts to cope with aversive situations.
While far from ideal, this model does outline how the pressure of interacting with others gradually forces the subordination of our instinctive, unconscious biology to our developing conscious will. The model shifts us away from a static interpretation of pain towards one in which the reflexive responses to stimulation are developed, and subordinated, according to the dynamics of developing awareness. Pain can then logically be understood as a conscious, developed response which a fetus could never be capable of experiencing.
The failure of the medical and scientific community to tackle the issue has allowed the idea that a fetus can feel pain to gain momentum, strengthening the anti-abortionists' hand. The emotive notion of fetal pain has gone largely unchallenged in the medical journals, the newspapers and in the House of Commons. Last year, anti-abortion crusader David Alton MP introduced an adjournment debate in which he insisted that information on fetal pain should be issued to women considering abortion (Hansard, 136, 1995). This debate was followed by an early day motion calling on the Department of Health to disseminate information 'to medical staff and mothers' and to 'come forward with proposals for avoiding pain in pre-term surgery and abortion' (Hansard, 140, 1995).
It has also been proposed that the Abortion Act and the Criminal Justice Act be amended to make it a crime to inflict pain on the fetus. The Rawlinson committee (a noted anti-choice organisation set up in 1993 to examine the implications of the 1967 Abortion Act) was recently resurrected to examine the question of fetal pain. Although, in the interests of balance, I was invited to give evidence to the committee, it seems likely that it will eventually come out in support of the existence of 'fetal pain' and recommend further restrictions on access to abortion.
The attempt to undermine public confidence in the provision of abortion is only one negative consequence of the misguided discussion around fetal pain. The discussion is also encouraging researchers to take an anti-scientific stance, which denies the possibility of answering the question 'do fetuses feel pain?' and undermines the current, well-supported model of pain.
The emotional hype around fetal pain is also likely to have a detrimental impact upon medical research and practice beyond the cry for restricting abortion. Earlier this year, the Daily Express ran a headline suggesting that babies may feel pain during childbirth. This view was based on the research from Queen Charlotte's Hospital and was endorsed by one of its principal researchers. It seems unlikely, however, that a process which the overwhelming majority of people has passed through--being born--is having long-term detrimental consequences, and there is some evidence to suggest that the increased hormonal release around birth is important in stimulating growth and regulating development. Such work is likely to be overlooked if fetal pain becomes an accepted view. Acceptance of fetal pain will mean that anaesthetic practice may be introduced when there is no clear rationale for its use and where it is likely to be at least uncomfortable, if not dangerous, for the mother-to-be. How long will it be before someone calls for an increase in Caesarian sections to avoid fetal/neonatal 'pain'?
Good clinical research into the effects of anaesthesia on the fetus and the new-born baby is clearly required. But misguided sentimentality about the possibility of fetal pain can only have negative consequences--including undermining the very basis of the clinical research itself.
Reproduced from the defunct British Magazine Living Marxism issue 93, September 1996