The Frontal Cortex

Fetuses and Pain

The Times Magazine had an interesting article on whether or not “preterm infants” can experience pain. “Experience” is the key word in that sentence:

In a series of clinical trials, he [Kanwaljeet Anand] demonstrated that operations performed under minimal or no anesthesia produced a “massive stress response” in newborn babies, releasing a flood of fight-or-flight hormones like adrenaline and cortisol. Potent anesthesia, he found, could significantly reduce this reaction. Babies who were put under during an operation had lower stress-hormone levels, more stable breathing and blood-sugar readings and fewer postoperative complications. Anesthesia even made them more likely to survive. Anand showed that when pain relief was provided during and after heart operations on newborns, the mortality rate dropped from around 25 percent to less than 10 percent. These were extraordinary results, and they helped change the way medicine is practiced. Today, adequate pain relief for even the youngest infants is the standard of care, and the treatment that so concerned Anand two decades ago would now be considered a violation of medical ethics.

But the benefits of pain relief weren’t limited to newborns. Anand eventually discovered that even extremely premature infants reacted to invasive medical procedures.

“So I said to myself, Could it be that this pain system is developed and functional before the baby is born?” he told me in the fall. It was not an abstract question: fetuses as well as newborns may now go under the knife. Once highly experimental, fetal surgery — to remove lung tumors, clear blocked urinary tracts, repair malformed diaphragms — is a frequent occurrence at a half-dozen fetal treatment centers around the country, and could soon become standard care for some conditions diagnosed prenatally like spina bifida. Whether the fetus feels pain is a question that matters to the doctor wielding the scalpel.

Obviously, the question of whether or not fetuses feel pain is a loaded political question: the existence of fetal pain is one of the more popular arguments used by abortion opponents. The article goes on to cite numerous scientists who disagree with Anand’s conclusions and argue that fetuses are simply exhibiting a “reflex,” and not actually experiencing pain.

The problem with debates like this is that the premise of the debate is fundamentally flawed. People are trying to transpose a binary political fight – you are either pro-life or pro-choice – onto a biological gradient. They are looking for black and white answers in the murky gray world of neuroscience. From the perspective of the brain, it’s pointless to try to define the single moment (or week or month) when babies begin to experience pain. There is no switch in the cortex that suddenly activates our nociceptive pathways. If cellular biology knows anything, it’s that life is a gradient. Our consciousness slowly accumulates. When we try to translate that gradient into definitive markers, when we attempt to say that experience begins here (or here or here), we ignore our biological reality. Yes, life is precious, sacred, etc., but this sacredness is an emergent property, which slowly unfolds over the course of a 9 month cellular cycle. These biological facts aren’t comfortable, and they go against many of our dearest intuitions, and neither side gets exactly what it wants, but unless we admit that the development of life doesn’t come with stark signposts, this tiresome debate is going to go on and on.

Comments

  1. #1 Derek James
    February 13, 2008

    While it’s true that development is a gradient, when it comes to actual policy, lines have to be drawn. Not all 18 year olds are equally mature, but that’s the legal boundary for voting. The alternative would be to assess everyone individually, which has all sorts of problems.

    With embryos/fetuses, it would make sense that there is some threshold at which any response to painful stimuli can be measured, even if that response is graded as the fetus develops. I think it’s sad that the issue is so emotionally-charged that it’s often difficult to have a calm, reasoned discussion though.

  2. #2 Doc
    February 13, 2008

    Jonah,
    You are right that life doesn’t come with signposts. Human Growth and development in a neverending and fascinating process that I take a career interest in. the problem is for ethical problems such as research into stem cells or legal determination of fetal right to life or birth control or a host of other issues society needs some kind of standard. I discussed some about it,trying to determine possible solutions, in a post about stem cells a href=”http://mormonmd.wordpress.com/2008/01/28/stem-cells-bridging-the-divide-part-one/”>here.

    It is the lack of a standard that makes these debates linger on forever and ever. Perhaps you are correct that neuroscience can’t provide that kind of standard. I believe politicization of science can often make for very bad science. I would even go so far that once a scientific debate becomes a political one, the objectivity that makes it science at all is gone.

    However, ethical questions do need to be handled somehow. I can’t fault people for trying to look to science for some kind of guidance.

  3. #3 amybuilds
    February 13, 2008

    I can’t believe anyone would would ever operate on infants or preterm infants without pain management or anesthesia, that just boggles my mind. Why in the world would it be logical that an infant does not feel pain? And doctors wonder why patients don’t always trust them.

  4. #4 David
    February 13, 2008

    I see that biologically you are stating that the material body is slowly composed without a specific boundary between consciousness and unconsciousness, validity and invalidity, as it were. However, I think you might step to far in stating that sacredness is similarly composed on a gradient; I’m not sure as to whether you are implying that the physical development of life’s biological systems is equivalent to sacredness, or that one gives rise to the other. The analogy doesn’t hold on close inspection.

    When you state that life is sacred, I assume that you actually mean consciousness; killing animals for food is a common practice, and antibiotics are prescribed without (generally) considering the ethics of microscopic genocide. But this is a tricky place to insert neuroscience as a decider or even an indicator, since it could lead to truly horrible interpretations (and has in the past). But perhaps you’re arguing that neuroscience cannot be invoked by either side with impunity, that it is a two-edged sword. But then we’re no closer to an agreement, since biology does not address the real spirit of either side’s argument; it is just a tool in the fight. As to the real sources of the debate, I’ll have to recuse myself, since I only really understand one of the two perspectives.

  5. #5 Anne-Marie
    February 13, 2008

    They also fail to take into account the difference between physiological pain perception and actual suffering (the emotional distress accompanying bodily harm). This has been an issue in the animal welfare world for a long time, and has never really been resolved.

  6. #6 Ian
    February 13, 2008

    Derek’s comment: “The alternative would be to assess everyone individually, which has all sorts of problems.” is at the heart of many issues. Current all too many of these issues are decided by the lowest common denominator. The so-called “age of majority”, the speed limit, the age at which one can drink, vote, own a gun.

    In this day and age, our priority not only ought to be assessing our children individually, but acknowledging that , perhaps for the first time, we have the money and technology to do it – if we were willing to expend the resources and effort. The fact that we evidently are not is a crime.

    There’s no reason, for example, why we could not tie a person’s qualification age for a given threshhold to that person’s achievement in school, their behavior in society, their level of maturity, their willingness to take and accept responsibility, and other such measures.

    Of course, this system’s key word is “measures”, and again, of course, none of this would have much bearing on the issue raised in this blog, but if our aim is to mature as a society, it’s high time we started striving for that aim instead of blindly pretending we’ve achieved it.

  7. #7 Joshua Zelinsky
    February 13, 2008

    I really don’t understand why the issue alters the abortion debate much at all. Whether an entity feels pain or not has no bearing on whether or not any right or desire for it to live should override another entities right to personal bodily integrity.

  8. #8 amybuilds
    February 14, 2008

    Perhaps the reason we still use the lowest common denominator for setting the bar rather than individual measures is not because we lack the ability or drive but because as a society we lack the compassion to do it justly.

  9. #9 tennischick
    February 15, 2008

    i’ve always found it unfortunate that the argument in favor of abortion has gotten suckered into a defensive position regarding the whole issue of when life began. the thinking seemed to be that as long as the embryo could be considered non-life, then one should have the right to terminate it. that fetuses feel pain can and should be used by pro-lifers to argue that abortion is therefore wrong. serves the pro-choices right for allowing their stance to be forced into this limited corner.

    the reasons for abortion actually have nothing to do with whether the embryo is a living organism. the problem has to do with the quality of life that organism will experience after birth.

  10. #10 ken
    February 16, 2008

    there is comma missing in your last sentence.

  11. #11 ken
    February 16, 2008

    there is a comma missing in your last sentence.