NRL News
Page 12
June 2010
Volume 37
Issue 8-9

British “Fetal Awareness” Report Does Nothing to
Rebut Conclusion Unborn Can Experience Pain at 20 Weeks

By Paul Ranalli, MD FRCPC

What are we to make of the typical headline associated with the recently released “Fetal Awareness” paper issued by Britain’s Royal College of Obstetrics and Gynecologists (RCOG)—that the human fetus cannot feel pain until 24 weeks’ gestation? Pro-abortionists and almost the entire media establishment on both sides of the Atlantic insist it rebuts the case that the unborn experiences pain no later than the 20th week. In fact, the report does nothing of the sort, as a closer examination makes clear.

The flaws in the RCOG report derive not just from a misreading of the science. Logical inconsistencies and a disturbing philosophy combine to leave the impression that the intent of the RCOG’s Working Party is not to offer a scientific update—as it was charged with doing by the British government’s Ministry of State for Public Health—but rather a partisan exercise in damage control.

In one sense, there is nothing really new here. The RCOG came to the same conclusion in its first report on the subject, in 1997. As the governing body of Britain’s obstetricians and gynecologists, including abortionists, it seemed somewhat convenient at the time that its interpretation of the science coincided with the latest gestational age at which most abortions are performed in the United Kingdom. Actually, the RCOG concluded that the fetus does not likely feel pain until 26 weeks’ gestation, but to be on the safe side, it moved its recommendation back to 24 weeks, because of the inherent uncertainty in dating a pregnancy. So in now declaring 24 weeks as the earliest juncture at which the unborn can feel pain, this latest report actually moves the RCOG’s consensus opinion back two weeks earlier in pregnancy than in 1997.

While the RCOG is moving in the right direction, it is still off. Based on our current understanding of the anatomical, hormonal, and behavioral development of the human fetus, the scientifically correct moment is 20 weeks.

The second point is that, in one stroke, this report invalidates the infamous August 24, 2005, article in the Journal of the American Medical Association (JAMA). “Fetal Pain: A Systematic Multidisciplinary Review of the Evidence” purported to show that the fetus cannot feel pain until 29 weeks. This absurd conclusion effectively ignored the pain felt by premature infants who are born and survive from 23 weeks onward, to say nothing of unborn children in the womb from 20 weeks, the real pain-capable threshold. Of course, the JAMA authors included committed abortion advocates, as was revealed at the time by Marie McCullough of the Philadelphia Inquirer. Now, they have even lost the backup of their own fellow abortionists in the United Kingdom, who have rendered the American study’s conclusion irrelevant by 5 weeks, back to the 24-week mark. Even more embarrassing for the profession in the U.S., the American College of Obstetrics and Gynecology (ACOG) recently issued a blithe denial, without qualification of gestational age, of the entire concept of fetal pain.

Three Categories of Problems

The problems with the new RCOG Working Party report can be grouped into three categories: scientific, logical, and philosophical.

1. Scientific. The authors correctly note that between 12-18 weeks, pain-bearing nerve fibers begin to rise up from a deep structure (the thalamus, which gathers pain inputs from the body below) toward the surface of the brain. The brain’s surface is called the cerebral cortex, and contains the one billion brain cells that create our consciousness and awareness, and issues commands for our voluntary actions. The cortex is also referred to as the “plate,” and the region just below it the “subplate zone.” This zone is present only in the fetus, and gradually disappears around 34 weeks, as the overlying cortical plate matures. Ascending pain fibers reach this subplate zone by 16-20 weeks, then make their final connections with the surface from 20-24 weeks.

The report appears to ignore emerging evidence that the subplate is not just a transient feature of the maturing fetal brain, but increasingly functions as a highly active zone of neuronal activity, creating a fetal awareness of incoming neuronal signals, including pain. While the pain pathway is initially crude, it is not absent.

By not acknowledging the latest research on the importance of the complexity of fetal subplate function, the authors are able to resist moving their chosen date of 24 weeks to a point earlier in fetal development. This is but one example of the disturbing manner in which the panel turned their back on inconvenient research and interpretations by leading scientists in the field, such as American fetal pain expert Dr. K.J. (Sunny) Anand, who point to 20 weeks as the point by which the unborn can experience pain.

The authors also introduce the concept that, even if pain signals reach the fetal cerebral cortex at an early stage, it doesn’t matter, because the fetus is not awake. This belief was not mentioned at all in the 1997 report, has not been a topic on the radar screen of fetal pain discussions in recent years, and appears to come out of left field. It is hard to avoid the impression that the authors view this new proposal as a kind of scientific trump card.

The evidence, such as it is, appears largely based on observations of fetal lambs in the womb. Brain-wave patterns are sleep-like, including both rapid eye movement (REM) sleep and the deeper non-REM sleep. To test their hypothesis that these sleeping lambs cannot feel pain, they “stressed” them by temporarily depriving them of the normal oxygen concentration in their blood, a maneuver known as hypoxic stress. While doing so, they observed little movement or distress in the fetal lambs. Their conclusion? The human fetus likely cannot feel pain in this dream state, even if all the pain wiring is hooked up.

Does this make any sense? To answer this, you don’t need to be a neuroscientist, you only need to step back and consider your own experience of sleep. While non-REM sleep can be deep, REM sleep (in which dreams take place) is quite light, as anyone knows when they waken from a dream “with a start” into instant awareness. Sleep is not coma, and the lighter stages of sleep even less so.

For the authors to imply that this sleeplike state obviates a potential for fetal pain is like saying that we shouldn’t worry about the suffering experienced by a victim in light sleep who is suddenly attacked and stabbed repeatedly. It should be obvious that, after a split-second delay, the pain will be all too palpable.

Also, the “stress” of diminishing the fetal lamb’s oxygen can hardly be equated to an abortion, as the authors seem to guiltily acknowledge: “While the lack of fetal movement during anoxic stress in sheep may not be the same as the response to acute surgical tissue damage in humans ... .” Or, for that matter, the horrific tissue destruction of a second-trimester abortion.

Nevertheless, despite the weakness of this observation, and the caveats buried within the text, the authors parade this point in both their conclusion and in a scripted section at the end of the report designed to reassure women, entitled “Questions some women ask.” For example, “Will the baby suffer/feel pain?”

“No, the fetus does not experience pain. In addition, increasing evidence suggests that the fetus never enters a state of wakefulness inside the womb.”

2. Logical. The authors go on to endorse the “it’s not pain, it’s a reflex” argument, which is both common and pivotal to the insistence that the unborn cannot feel pain until at least the 24th week, if not much later. They correctly note that reflexive movements away from a painful stimulus arise from deeper levels (spine, thalamus) without the need for voluntary awareness and reaction. But while reflexive response begins early in fetal development, and awareness of pain later, the persistence of reflex reactions (in adulthood as well) does not, by itself, deny conscious suffering from pain. Far from it. Again, consider your own experience.

When you accidently place your hand on red-hot stove burner, you quickly pull your hand away (the reflex) before the searing wave of pain hits you (conscious awareness). By their argument, seeing the initial reflexive movement somehow denies the second response: “Behavioral reactions can be mediated at a very low level in the brain and are not, therefore, evidence for experienced emotion or sentience.” But of course such “sentience” is in no way excluded either.

They try to support their position by pointing to the intact reflexes in children born with tragically severe brain malformations, including anencephaly, where the child has a rudimentary brain structure, but fails to develop the entire cerebral cortex. They also use the example of pain reflexes observed in children with the rare brain malformation called lyssencephaly, in which the brain maturation arrests at a point similar to a fetus of 22-24 weeks gestation. But this is not the same thing at all and as such is deeply misleading. In lyssencephaly, there is a lack of connections between deeper structures and the cerebral cortex, and abnormalities of another part of the pain system, the limbic system.

By contrast the unborn child who is developing without problems is rich in such connections at this stage. These analogies are scientifically invalid, and, more than anything, highlight the weakness of this argument.

The authors also try to dampen enthusiasm about our ability to witness “normal” baby behaviors, such as yawning, visible on exquisitely clear 4D ultrasound images. They point out that yawning is a protective lung reflex that maintains proper lung inflation: “While this protective reflex is unnecessary in the womb where oxygen is delivered by the umbilicus, it will be necessary soon after birth, and therefore the neural connections that mediate it need to be fully functional well in advance of birth.”

While this is all true, the authors fail to see the irony: this same argument can be turned against them and made to support the position that there is an early and gradual development of the pain system. Just as yawning prepares the unborn baby’s lungs to be ready for the sudden plunge into outside air, so too the fetal pain system needs early development and readiness in the womb to prepare for the moment of separation from the mother. Once outside and no longer protected by the comforting environment of the mother’s uterus, the newborn baby’s ability to feel pain and distress, and then draw the mother’s attention by crying, is absolutely critical for his survival and healthy growth.

3. Philosophical. Consider this quote from the RCOG report: “The fact that the cortex can receive and process sensory inputs from 24 weeks is only the beginning of the story and does not necessarily mean that the fetus is aware of pain or know it is in pain. It is only after birth, when the development, organisation and reorganisation of the cortex occurs in relation to the action and reaction of the neonate [newborn] and infant to a world of meaning and symbols, that the cortex can be assumed to have mature features ... . Thus, there is good evidence for claiming that the cortex is necessary for pain experience but not sufficient.” This kind of analysis—that pain is only genuine when someone “knows it is in pain”—bears the unmistakable imprint of Stuart Derbyshire, one of the paper’s authors. Dr. Derbyshire, a Birmingham psychologist, is a tireless and prolific denier of fetal pain based on just this type of analysis. As opposed to the hard science of embryology and physiology of fetal pain, Derbyshire favors a highly intellectualized approach to pain—that there can be no meaningful pain experience without the ability to interpret the pain in the context of higher cognitive awareness and prior experience. Its logical extension would find one ignoring the heartrending cries of a baby because she is too simple and inexperienced to fully appreciate pain.

However, this altogether misses the reality that higher-level cognitive functioning is not at all necessary for the reception and impact of such a primal experience as pain. To their credit, the paper’s authors seem somewhat uncomfortable with the intellectual line of argument. They note that official international definitions of pain “tend towards a view of pain as being a constituent part of higher cognitive function. There is disquiet in denying a rawer, more primitive form of pain or suffering that the fetus, neonate and many animals might experience.” But, they seem to then say, not to worry. They set aside these unpleasant thoughts with this bit of hand-waving: “One possible solution is to recognize that the newborn infant might be said to feel pain, whereas only the older infant can experience that they are in pain and explicitly share their condition with others as an acknowledged fact of being.”

The inclusion as a panel author of Derbyshire gives away the clear intent of the whole RCOG exercise: to minimize and deny the emerging reality of fetal pain awareness at 20 weeks or even earlier (when many second-trimester abortions are performed in the UK and elsewhere). In an era of increasingly aware and informed patients, this is becoming a problem for them.

Similarly—and quite strangely—the RCOG has minimized input from true fetal pain experts such as Dr. Anand and UK experts such as Drs. Nicholas Fisk and Vivette Glover. Dr. Glover has previously expressed a belief that fetal pain may be present as far back as 17 weeks’ gestation. This is a rather important omission.

To its credit the original 1997 RCOG report, while erroneous in setting 26 weeks as the age of fetal pain detection (with the recommendation to use 24 weeks, to be on the safe side) at least raised worrisome questions about the subject, and expressed a sense that doctors should err on the side of caution.

The new report, on the other hand, seems determined to err on the side of callousness. “Currently there is no immediately obvious way of resolving these arguments empirically,” the authors candidly admit, but in discussions of the need for specific anaesthesia for potential fetal suffering, they wave these concerns away.

The entire exercise suggests that abortionists on both sides of the Atlantic are thrashing around in trying to deal with the emerging evidence of fetal pain, which has resulted in a political report designed to seal off concern about fetal pain in abortion. The RCOG report is not a new contribution to science as much as a form of political cover for the horrific practice of late abortion, and perhaps a shaky attempt to reassure those who have to perform it. The giveaway comes on the last page of the report, with these sad words: “Consideration needs to be given to the education and support of clinical staff working in this difficult area.”

Paul Ranalli, M.D., FRCPC, is a neurologist at the University of Toronto.