Fetal Pain - A Discussion

This issue was the subject of four articles in the Britsh Medical Journal 27 September 1996 

The issue of whether fetuses feel pain has recently been raised repeatedly as a cause of concern by anti-choice parliamentarians (see Abortion Review no 56). 

In July, David Alton MP (Lib Dem: Liverpool Mossley Hill) secured an adjournment debate during which he argued that the Department of Health should take action on the matter. `First,' he suggested, `a circular could be issued to health authorities and to doctors, drawing their attention to the conclusions of latest research and recommending action to anaesthetise foetuses before any invasive procedure, such as needling or uterine surgery liable to cause trauma to the fetus. Secondly, in the interest of a fully informed decision, any parents who are considering giving permission for such procedures should be alerted to the possibility that pain will be inflicted on their unborn child.' Failing the introduction of such measures Alton warned that `legislation may be the only way to ensure that the suffering and the pain currently inflicted on the foetus will be alleviated'. 

This debate was accompanied by an Early Day Motion, eventually signed by eleven MPs calling on the Department of Health to disseminate information `to medical staff and mothers and come forward with proposals for avoiding pain in pre-term surgery and abortion'. 

Alton has suggested that it should be made a criminal offence to inflict pain on the unborn child and has announced his intention to seek legislative amendments and changes in codes of practice to secure this. 

Currently the Government does not appear to accept that there is a need for legislation, although in replying to David Alton's motion, Health Minister, the Hon Tom Sackville MP (Con: Bolton W) suggested that there may be a need for more research on abortions after 24 weeks gestation. Nor does the Government appear to accept the anti-choice interpretation of current research. It was notable that Sackville used the opportunity of the adjournment debate to stress that the conclusions of a recent report commissioned by the Department of Health `do not support the view that before 26 weeks, foetuses feel or perceive pain.' 

However, this is unlikely to be the final word on the matter. Following this statement a Department of Health spokesperson reportedly told the Catholic Herald that the Government was aware of `considerable diversity of opinion within society and the medical profession. The Government does not have one view on foetal sentience; they listen to a whole range of opinions-personal, medical and scientific.' Newspapers have reported that Alton is determined to make legislation on fetal pain an issue for the next parliamentary term. 

The anti-choice concern about fetal sentience or pain is clearly a tactic to undermine public confidence in the current abortion legislation and to exploit understandable concern that the abortion procedure should not cause suffering. It is a rather disingenuous stance, as those who promote it-being opposed to abortion in principle-would not support abortion even if it were clearly established that the fetus were incapable of any awareness. 

The anti-choice movement do not primarily oppose abortion on the grounds that the fetus feels pain any more than the pro-choice movement support a woman's right to abortion on the grounds that the fetus does not feel pain. Both perspectives are informed by other concerns. 

However, given the claims by those who oppose abortion on principle that science supports their views, it is useful to examine the relevant research closely. Such an examination supports Sackville's assertion that before 26 weeks gestation (and arguably after this time), fetuses do not feel pain. 

The research to which Sackville referred in the Adjournment Debate was commissioned by the Department of Health, and presented to them in May 1995 by Maria Fitzgerald, Professor of Developmental Neurobiology in the Department of Anatomy and Developmental Biology at University College London. Fitzgerald had been asked to review the current medical knowledge in this area. 

Through an examination of the biological development of the fetus, Fitzgerald first rules out the possibility of fetal pain prior to 26 weeks gestation. Those who argue that a fetus can feel pain early in gestation point to experiments which show that a fetus responds to touching at 7.5 weeks. At this point touching the mouth or the surrounding region results in the fetus bending its head away. Similar responses can be observed with the hands at 10.5 weeks and the rest of the body and lower limbs at approximately 13.5 weeks. Shortly after the development of touch sensitivity repeated skin stimulation results in a generalised movement of all limbs, which gives the impression that the fetus is stressed and is taken by some as experience of pain. 

This movement is however, understood to be a reflex response, not dependent on a conscious appreciation of pain. Fitzgerald states that, prior to 26 weeks gestation, `any discussion of "perception" or "conscious" reaction to stimuli is inappropriate'. She writes that: `[i]t is important to emphasise the movements evoked at this stage are of a reflex or spontaneous nature only, even if they involve extensive body regions and therefore inter-segmental and brainstem connections. The cortex is not a functional unit at this stage ... and therefore any discussion of "perception" or "conscious reaction" is inappropriate.' 

Summarising her paper she clearly states that `evidence shows that little sensory input reaches the developing cortex before 26 weeks and therefore these reactions to noxious stimuli cannot be interpreted as feeling or perceiving pain.' 

This is important as it undermines the broader aim of those who oppose abortion to use this research to challenge the provision of abortion at earlier gestations. 

Abortions later than 26 weeks gestation are very uncommon. In 1992 just 60, of more than 150,000 abortions in England and Wales were carried out at gestations later than 24 weeks. Nevertheless, the possible fetal response in these few late terminations warrants attention, particularly as almost all of these abortions are carried out for reasons of fetal handicap and are of wanted pregnancies in circumstances where the putative parents are often very emotionally vulnerable. 

Fitzgerald becomes more equivocal regarding the possibility of fetal pain once the fetus passes 26 weeks gestation. This is because the nerve fibres which are believed to be responsible for passing `pain messages' begin to reach the higher brain areas at 26-34 weeks gestation. Fitzgerald's suggestion that responses to noxious stimuli prior to 26 weeks cannot be interpreted as pain because the brain `is not a functional unit' begs the question of whether the biological development of the fetus is so advanced after this time that it may now be able to experience pain. This point remains controversial among those who work in pain research. 

It can be argued that the capacity of the fetus to feel pain hinges not on its biological development but on its conscious development, and that unless it can be demonstrated that the fetus has a conscious appreciation of pain post-26 weeks gestation, then the responses to noxious stimulation are still essentially reflex responses, exactly as those prior to 26 weeks. Fitzgerald does not address this point. However, the suggestion that there is a direct relationship between stimulus and pain-even in adults-is hugely controversial. 

The idea that pain occurs as a direct consequence of an injury in the same way that a bell rings as a direct result of pulling a bellrope is one that is accepted by many lay-people, but no longer holds much currency with those researching into pain mechanisms. Those working with, or researching into pain have largely rejected the concept of a specific `pain line' associated with a `pain centre'. This `specificity theory' has been rejected because the definition of pain based on a direct relationship between injury and response failed to resolve many issues in pain research. Interpretations of injury based on a direct relationship between stimulus and pain are inadequate because they fail to account for the variable link between stimulus and pain experience. Specificity theory cannot explain, for example, why soldiers wounded in battle rarely ask for analgesia in comparison with civilians wounded in accidents, why patients after amputation complain of pain in their `phantom-limb', or why people can sometimes sustain major injury without experiencing pain. The variable link between pain and injury suggests that pain is a multidimensional experience incorporating emotional and cognitive factors. 

Many pain specialists believe that in its later stages of development the fetal brain begins gradually to organise and elaborate stimulus information by encoding the memory of the activation of reflex motor responses. At this point the fetus may begin to show evidence of knowledge as to which things may result in reflex aversive movement. This `knowledge' however, is still unconscious. Conscious sensory experience and associated voluntary response is proposed to arise over time as a result of self-observation and efforts to cope with arousing situations. While some biological development is obviously necessary for this stage to be realised, it is a mistake to say that biological development is sufficient. The capacity to experience pain is part of a developmental process which the fetus is yet to experience. Many specialists believe that the final necessary stages in the experience of pain can only develop after a child has been born and it is mistaken to refer to `fetal pain' at any stage of development. Dr Fitzgerald suggests in her paper that `true pain experience' develops `postnatally along with memory, anxiety, and other cognitive brain functions'. 

David Alton obviously disputes this interpretation and anticipated it in his adjournment debate speech claiming that it was `bunkum' and relied on an understanding of pain as a `metaphysical experience' and not as he believes `a physical fact'. It should be noted that in this interpretation he is relying on outdated theories which are at odds with the theories of those who are currently working in this field.