[Addendum appended to 6/13/2007 & 6/19/2007 Testimony to Louisiana Legislature by W.A. Krotoski, M.D.]
One of the more recent articles i on the subject of fetal pain – and one cited by opponents of this type of legislation to provide full, informed consent to a woman intent on abortion – appeared in the Journal of the American Medical Association in January of 2005. Authored by an attorney with four physician co-authors, this article concluded that a fetus younger than 23 weeks of gestation could not feel pain, because the group was unable to identify visible microscopic nerve connections between thinking and pain-processing centers prior to that age.
However, in follow-up published responses, this conclusion was roundly criticized, as hormonal stress levels can be observed in the human fetus as early as 18 weeks of age ii, and hormonal measures of pain stress show activity in the thinking parts of the brain much earlier than the 29-30 weeks proposed by the attorney’s article iii for conscious pain.
Two quotes from the critiques are in order here:
(1) Dr. Laura Myers and her three colleagues from the Children’s Hospital, Boston, asserted iv that, although “[w]e do not know for certain [the full capacity of the fetus to feel pain] … we as clinicians should focus on methods to deliver effective anesthesia and analgesia safely. Better to err on the safe side from mid-gestation [18-20 weeks].”
This group “routinely provide[s] anesthesia and analgesia to fetuses as early as 19 weeks gestation for certain [surgical] procedures.”
(2) by Dr. Brian Sites of the Department of Anesthesiology at the Dartmouth-Hitchcock Medical Center in New Hampshire, cited the original article as “inaccurate and ethically disturbing,” indicating that those authors had chosen the upper (latest established) rather than the lower limit (earliest established) of brain connections identified, and that the fetus could be experiencing pain as early as 21 weeks (by data from that same study) v .
To reiterate, from a clinical point of view, it is “better to err on the safe side!”
i S. Lee et al., JAMA. 294:947-954 (2005)
ii X. Giannakoulopoulos et al., Lancet 344:77-81 (1994)
iii R. Slater et al., J. Neuroscience 26:3662-3666 (2006)
iv L. Myers et al., JAMA. 295:159 (2006)
v B. D. Sites, JAMA. 295:159-160 (2006)
[Addendum provided with 6/19/2007 Testimony]
Extract from Fetal pain perception and pain management, a review by Marc Van de Velde and others, published in Seminars in Fetal and Neonatal Medicine, v. 11, pp. 232-236 (2006):
“Fisk and co-workers … provided direct evidence that premature fetuses have hormonal and hemodynamic responses to invasive stimuli. They also showed that these responses can be blocked by analgesia.”
“Thanks to Anand and co-workers, we know that preterm neonates have hormonal stress responses following invasive interventions. These hormonal responses can be prevented by analgesia.”
“Peripheral receptors develop from the seventh gestational week. From 20 weeks gestation, peripheral receptors are present on the whole body.”
“Development of afferent fibers connecting peripheral receptors with [pain centers in the brain] starts at 8 weeks gestation.”
“[Spinothalamic] connections start to develop from 14 weeks and are complete at 20 weeks gestation … thalamocortical connections are present from 17 weeks gestation, and completely developed at 26-30 weeks…. From 16 weeks gestation, pain transmission from a peripheral receptor to the cortex [consciousness centers] is possible, and certainly completely developed from 26 weeks …”
“It is therefore safe to assume that the fetus feels more pain than the small infant.”
“Based on the data mentioned above, we can safely assume that the fetus reacts to painful stimuli from 24 weeks gestation and that it is possible that this occurs from 16 weeks gestation.”
“Because fetal pain is a realistic problem, we must provide, or attempt to provide, adequate pain relief during every situation in which the unborn child might experience potentially painful stimuli.”
“… successful analgesia in the fetus is achievable.”
“Several ways of administering analgesics to the fetus are available:
• transplacentally after maternal oral or [injection] administration; or
• directly to the fetus, using the intravenous, intramuscular, or intra-amniotic approach.”
“During open fetal surgery under maternal general anesthesisa, inhalational agents are considered to provide adequate fetal anesthesia and produce uterine relaxation essential for successful surgery. So [under these circumstances, i.e. open fetal surgery] additional analgesia for the fetus is unnecessary.”
“Two possible routes of administration for these drugs [opioids and muscle relaxants] are injection into the umbilical cord and intramuscular injection into the fetus. A similar approach could be used for late termination of pregnancy: administration of analgesics directly intravenously before a lethal fetal injection of potassium chloride or lidocaine is administered.”
“[M]aternally administered remifentanil [in low doses] produces effective maternal sedation and fetal immobilization through transplacental passage during these [endscopic] procedures.”
“Evidence is increasing that from the second trimester [13th – 14th week], the fetus reacts to painful stimuli and that these painful interventions might cause long-term effects. It is therefore recommended to provide adequate fetal pain relief during potentially painful procedures during in-utero life.”
• The fetal … [painful stress response] … system should be considered as functional from the beginning of the second trimester [13th – 14th week].”
• Fetal analgesia has to be provided as a routine during potential painful interventions.”
[June-July 2007, Resource Roundup, Volume 7, Nos. 6-7, The Hippocratic Resource (A Statewide Organization of Louisiana Physicians, Dentists, Nurses, Therapists and Other Health Professionals)]
www.LaDocs4Life.org or www.LaHealthProfs4Life.org
“I will give no deadly medicine to anyone if asked … I will not give to a woman an instrument to produce an abortion”
MEDICAL EXPERT TESTIFIES IN ABORTION CASE THAT FETUSES FEEL PAIN AFTER 20 WEEKS A type of abortion banned under a new federal law would cause ''severe and excruciating'' pain to 20-week-old fetuses.
''I believe the fetus is conscious,'' said Dr. K. Anand [pediatrician, Univ of Arkansas for Medical Sciences]. He took the stand as a government witness in a trial challenging the Partial-Birth Abortion Ban Act.
The act, which was signed by President Bush in 1/04, has not been enforced because judges in Lincoln, NE, New York and San Francisco agreed to hear evidence in 3 simultaneous, non-jury trials on whether the ban violates the Constitution.
Anand said fetuses show increased heart rate, blood flow and hormone levels in response to pain.
During the procedure, which doctors call ''intact dilation and extraction'' or D&X, a fetus is partially removed from the womb and its skull is punctured. It is performed in the second/third trimesters. Abortion rights advocates argue that the law will endanger almost all second-trimester abortions, or 10% of the nation's 1.3 million annual abortions.
The law would be the first substantial limitation on abortion since the Supreme Court legalized it 31 years ago in Roe v. Wade. Challenges to the ban were filed by several doctors being represented by the Center for Reproductive Rights, the National Abortion Federation and Planned Parenthood Fed of America. The issue is expected to reach the U.S. Supreme Court. U.S. District Court of NE: http://www.ned.uscourts.gov; Center for Reproductive Rights: http://www.crlp.org;
Nat’l Right to Life Committee: http://www.nrlc.org; Justice Dept: http://www.usdoj.gov [Kevin O'Hanlon, Associated Press, 4/6/2004