5 Things to Know About A Touchy Issue: Fetal Pain
One of the first reproductive rights issues out of the gate in 2013 was fetal pain, with a last-minute successful attempt to temporarily block Georgia’s fetal pain bill, set to take effect on January first. Fetal pain is a particularly touchy issue in the abortion debate, because no one likes the thought of causing pain if it can possibly be avoided, but science doesn’t support many anti-choice claims made about fetal sensory perception and abortion procedures.
Researching fetal pain is made difficult by the fact that fetuses cannot communicate, so researchers are forced to rely on reflex responses as well as examination of fetal material donated to science, and analysis of neural pathways to see whether fetuses are capable of feeling pain and at what stage of development. This also requires an understanding of pain and sensory perception as emotional, physiological and philosophical concepts.
What is fetal pain? Speaking neutrally, it would be pain experienced by a developing fetus as a result of external stimuli or developmental problems. The term has become charged, however, because it’s often used in anti-choice legislation designed to discourage abortions. Some states have passed fetal pain laws, for example, requiring doctors to notify women that a fetus “may” feel pain and to offer analgesia during abortion procedures. Reproductive rights advocates argue this language is coercive and is designed to persuade women to change their minds before an abortion.
So, can fetuses feel pain? Yes, they can, but not right from the start. Pain is a complex sensation, and it requires the formation of nocioceptors (nerve cells that react specifically to pain) along with pathways to convey pain signals to the brain. This level of development doesn’t occur right away. And reflex responses aren’t necessarily an indicator of pain, because a reflex response doesn’t necessarily mean that a signal has traveled all the way into the cerebral cortex and been processed. Also, many argue, pain is an emotional experience, not just a physical one, which makes it a complex subject to study in this case; when we talk about “fetal pain,” do we purely mean a release of stress hormones and reflex responses related to a noxious stimulus, or do we also mean emotional distress, and how do we measure that in a fetus?
When can fetuses feel pain? This is, as one might imagine, a subject of heated debate; anti-choice groups argue that this occurs early in development, while reproductive rights advocates, as well as many scientists, doctors and researchers, believe it doesn’t occur before the third trimester of development, because the anatomical pathways simply aren’t there. In a review of available literature published in the Journal of the American Medical Association, researchers noted that: “Fetal awareness of noxious stimuli requires functional thalamocortical connections. Thalamocortical fibers begin appearing between 23 to 30 weeks’ gestational age, while electroencephalography suggests the capacity for functional pain perception in preterm neonates probably does not exist before 29 or 30 weeks.”
It’s important to distinguish between awareness and reflex reactions. Researchers have observed releases of stress hormones as well as other reflex responses prior to 23 weeks, indicating that some neural pathways are present. These pathways do not, however, travel all the way to the part of the brain that mediates awareness, which means that while the body responds, the complex parts of the brain do not.
So fetuses don’t feel pain at 20 weeks? It’s not likely, although this is the cutoff point chosen for many so-called “fetal pain laws” banning or restricting access to abortion. While fetal development has made tremendous progress at 20 weeks, the awareness of pain, versus reflex responses from a developing nervous system, is highly improbable, given the available scientific information. This is also, notably, well before the threshold of viability at 24 weeks; though advances in medicine mean that survival rates for preemies are constantly improving, chances are very slim for fetuses delivered before 24 weeks of gestation.
Is it possible to manage fetal pain? Absolutely — in fact, practitioners of neonatal medicine use anesthesia when they need to perform procedures in much the same way they use it on adults and children. These anesthetics can include muscle relaxers to reduce the risk of surgical complications, prevent reflex responses and limit developmental complications. It is also possible to administer medications designed specifically to limit the transmission of pain signals, and anesthesiologists use these when appropriate in consultation with patients and surgeons.
Medical practitioners argue that decisions about where, when and how to use anesthesia should be based on medical evidence and consultation with the patient along with the care team, rather than being dictated by law. Their ethical obligation to do no harm includes the careful management of cases in which they feel a procedure may cause distress.
Notably, for those concerned about fetal pain and abortion, 1.4% of abortions in the US are conducted at or after 21 weeks, meaning that the vast majority of pregnancy terminations occur well before there is any chance of pain awareness. Such procedures are typically performed in instances of dire medical necessity, such as critical pregnancy complications, or fetal anomalies incompatible with life. They can require the services of a specialist to ensure that the procedure is performed safely, and anesthesia may be used for both mother and fetus to reduce the risk of complications, making it unlikely that fetal pain occurs in these rare instances.
Photo credit: Phalinn Ooi