Pro-Abortion Fetal Pain Study: An Overplayed Hand
Paul Ranalli, MD

It has generally been assumed ... that neonates [newborns] may not perceive pain or may perceive it only minimally. Assumed by whom? Certainly not by those of us at the bedside of critically ill infants, who see them flinch from procedures, startle in response to loud noises ... . Why then has surgery in neonates been conducted without anaesthesia? Is this barbarism, as some have suggested? -- Dr. Anne Fletcher (1987), Children’s Hospital Medical Center, Washington.

Fetal Pain: a systematic multidisciplinary review of the evidence is a highly controversial, scientifically flawed study published in the August 24/31 issue of the Journal of the American Medical Association (JAMA). Authored by medical student (and former NARAL activist) Susan Lee and four doctors, the seven-page-long study purports to conclude that the human “fetus” cannot feel pain until 29 to 30 weeks gestation.

Setting aside the glaring moral and political underpinnings of this topic, from a purely scientific and clinical perspective, this article is an appallingly substandard mix of self-contradictory analysis, suspicious omissions, and scientifically erroneous conclusions.

The following is a brief catalogue of these deficiencies.

Undisclosed bias

Lead author Susan Lee previously worked as a lawyer for NARAL, while another author, Dr. Elizabeth Drey, is the medical director for the largest San Francisco abortion clinic, which annually aborts 600 babies between 20 and 23 weeks of age. Dr. Drey is also on the staff of the Center for Reproductive Health Research and Policy (CRHRP), a pro-abortion advocacy center with a mandate to develop late abortion methods, and train doctors to perform late abortions.

This background in abortion advocacy is not disclosed by the authors. Drey’s staff position at CRHRP, and the income source of the abortion clinic where she works, would appear to demand a disclosure here. Moreover, the spirit of disclosure appears to me to be violated by Drey and Lee. The article is not original research, but a review of existing research, and thus is much more subject to interpretive bias. Moreover, the late abortions that are of such interest to CRHRP are exactly the period of fetal life under discussion.

To make a comparison, were this an article on a new drug, the new ethical standards would demand that the authors disclose any important relationships to pharmaceutical companies. In the case of fetal pain, the equivalent would be any relationship to an “abortion provider.” When called on her conflict, author Dr. Drey was quoted as saying, “I think my presence ... should not serve to politicize a scholarly report.”
Incomplete review

The authors made much of the exhaustive nature of their review. One wire service reporter was led to believe that “nearly 2,000” studies were reviewed (actually, there are 96 references), but the authors admit these were confined to English-language articles.

While we cannot all read foreign languages, there are interpreters who can. Many of these articles are also accompanied by an English abstract (summary), including an authoritative fetal pain review in 2000 authored by four French authors. This study, which the authors missed, is more recent than many of the references cited in the JAMA article, and acknowledges the possibility of fetal pain perception after 20 weeks gestational age.

A more subtle form of omission occurs when the authors reference Dr. K.J. Anand’s landmark study published in the New England Journal of Medicine in 1987, Pain and its effects on the neonate and fetus. The text that refers to the article discusses the definition of pain, but avoids Dr. Anand’s major observations: that the final anatomical pain connections start to reach their destination on the cortical surface of the brain at 20 weeks; that the 20-week fetus has the full complement of 1 billion neurons; and synchronous brain wave (EEG) activity exists by 22 weeks.

For nearly two decades, Dr. Anand has been recognized as one of the world’s foremost authorities on the subject of pain in the fetus and newborn. Following his breakthrough research in the anaesthesia department of Boston Children’s Hospital and Harvard Medical School, Dr. Anand was given the prestigious honour of writing a state-of-the-art special review article on the topic for the New England Journal of Medicine. In an accompanying editorial, Washington neonatologist Dr. Anne Fletcher stated, “The excellent review ... should dispel the now outmoded notion that newborns are insensitive to or immune from pain.”

Could it be that the authors wanted the appearance of a complete reference list (they could hardly ignore Anand’s major study), but were unwilling to expand on its content, since it undermines their thesis that no fetal pain is possible before 29–30 weeks? Dr. Anand, one of the world’s foremost authorities on fetal pain, told Knight Ridder reporter Marie McCullough, “They have literally stuck their hands into a hornet’s nest. ... [T]his is going to inflame a lot of scientists who are very, very concerned and are far more knowledgeable in this area than the authors appear to be. This is not the last word—definitely not.”

Self-contradiction

After devoting much of their analysis attempting to debunk the possibility of fetal pain perception before 29 weeks, the authors spend much of the second half of their review questioning whether specific forms of analgesia could be effective at relieving fetal pain during an abortion—pain they simultaneously deny exists.

The authors also contradict themselves on specific scientific points. First, they detail studies that document anatomical pain neuron connections reaching the surface cortex of the brain as early as 21 weeks (it’s actually 20 weeks). Yet their Conclusions section misstates this as 29–30 weeks. Also, they correctly review data that show normal brain-wave (EEG) signals recorded in newborn preemies as young as 24 weeks (it’s actually 22 weeks). Yet their Conclusions section distracts readers by referring to the age at which conscious (non-sleeping) EEGs are more commonly seen—”around 30 weeks.”

In dismissing the use of analgesia for the fetus in abortion, the authors talk about the lack of any evidence of potential effectiveness or safety. Yet they ignore a paper quoted in their own review that describes an animal experiment in which an anaesthetic given by direct intra-amniotic injection (by needle into the baby’s amniotic sac in the womb) resulted in fetal blood concentrations that would control postoperative pain in human adults. Moreover, by missing the 2000 French fetal pain paper, they did not review the proposed fetal anaesthesia protocol proposed by those pediatric experts.

Ignoring the obvious

Premature babies are now viable at a birth age of 23–24 weeks. The nation’s Neonatal Intensive Care Units are full of tiny struggling preemies, many in the 23–30 week gestational age range under discussion in this paper.

The only difference between a child in the womb at this stage, and one born and cared for in an incubator, is how they receive oxygen—either through the umbilical cord or through the lungs. There is no difference in their nervous systems. The implication of this paper’s conclusion is that these newborn babies—no longer fetuses—cannot feel pain either. But the evidence demonstrating that they do is immense.

Physiologic responses to painful stimuli have been well documented, with over 20 years of research, in newborns of various gestational ages. Pain-induced changes in hormones, metabolism, and heart and breathing function are similar to those of adults, only greater.

For example, endorphins—the body’s internal narcotic chemical—are released in large amounts into the blood of newborns subjected to distress. Painful diagnostic procedures inflicted on preemies and newborns, such as the lancing of the baby’s heel with a sharp piece of metal to draw a blood sample, reliably jolt the heart rate and blood pressure upward; sweating and breathing changes are also observed.

Simply giving a topical anaesthetic cream to newborn babies before circumcision will prevent these changes in heart rate and blood pressure, whereas giving a “pacifier” to the baby (a baby placebo, as it were) does not alter the babies’ response to pain. Dr. Anand has concluded that “current knowledge suggests that humane considerations should apply as forcefully to the care of neonates (newborns) and young, nonverbal infants as they do to children and adults in similar painful and stressful situations.”

Were the JAMA conclusions to be accepted, the effect would be to set back humane pediatric medicine 20 years, back to a time—barbaric, to paraphrase Dr. Fletcher’s remarks—when doctors still believed babies could not feel pain. This article’s conclusion is so ghastly (not to mention counter-intuitive), it may take some time for its import to sink in with the medical community, and the public at large.

This substandard, out-of-step review article—so manifestly created in response to proposed fetal pain awareness legislation—may well come to be seen as an overplayed hand, setting the abortion industry on a collision course with the humane modern practice of child-centered pediatric medicine.

Paul Ranalli is a neurologist at the University of Toronto.