Are We Overlooking Fetal Pain and Suffering During Abortion?

Editor’s Note: Recognizing that the topic of abortion is controversial, I believe that it is important to address specific neurophysiological issues for those cases where therapeutic abortion is performed. This article is not printed to stimulate dialogue on the ethics of elective abortion.
— M.J.L.

I had a case come to me as an emergency. The patient was a young woman, pregnant around 19 weeks’ gestation. These dates are not always perfect. She had an infection. The obstetrician, a physician I trust very much, does not normally perform elective abortions. She informed me that the fetus had no chance to live and that the mother was seriously endangered by prolongation of the pregnancy. She requested the assistance of another surgeon with experience in the type of abortion needed to dismember and remove the fetus at this stage of pregnancy.

My busy private practice does not include elective abortions. The chances were remote that I would ever need to participate in second-trimester pregnancy termination as an emergency. I had no special need to learn about anesthesia for abortion or fetal development as regards pain and suffering. Having trained in the early 1980s, I had not been taught to be concerned with fetal pain. How was I to approach the anesthetic?

In querying my colleagues from various academic institutions, I am left with the distinct impression that residents are still not being taught that the fetus can feel pain. Those responsible for educating us on the subject seem to be avoiding the issue. A former ASA officer admitted that ASA has tried to stay away from the abortion issue. A new practitioner with our group had done anesthetics for abortion with a spinal, and fetal pain never came up as an issue at her training program. Of course, we cannot prove that the fetus feels pain.

As a practical matter, we must take the best of competing theories in their proper context and make decisions based on incomplete information. We should be humble enough to see the contributions of those outside our profession. We also should make special efforts to see that our political and cultural beliefs do not impede our judgment. We should err on the side of pain prevention. Perhaps anesthesiologists should be at the forefront to address pain and suffering.

Some have suggested that the fetus may suffer more intensely because of the uneven maturation of fetal neurophysiology.1 The fetus has less developed inhibitory systems, a neurochemical response level several folds above adult levels for similar adverse stimuli, higher nociceptor density than adults and coordinated characteristic grimacing in response to distal pain stimulus.1,2 Anesthetic and Obstetric Management of High-Risk Pregnancy states that “there is no longer any controversy whether the fetus perceives pain.” 3 In a survey of British neuroscientists, 80 percent of respondents felt that the fetus should receive pain control after 11 weeks of development so that error could be on the side of preventing pain. 4

It was once taught that the infant and the preemie do not feel pain. We now know that these young patients react more intensely to pain than adults and may require more anesthetic. An extrapolation to fetal nociceptive capacity may be very appropriate.

Even with general anesthesia and quick delivery, the cesarean baby arrives, often with a vigorous complaint, perhaps a bundle of unconscious reflexes at this point. But if this neonate were to have immediate surgery, the current standard of care would dictate that anesthesia be administered with the assumption that the infant was capable of experiencing pain. When a fetus undergoes in utero surgery, the mother might receive general anesthetic, and the baby sometimes receives additional anesthetic drugs. In abortions, preparation time is typically short. During termination, the fetal vital signs are not monitored. I am not aware that fetuses involved in abortion procedures receive supplemental parenteral anesthetics. 5 These procedures sometimes involve maternal regional anesthetics that do not assist in adequately anesthetizing the fetus.

A British commission on fetal sentience summarized that “...there is a considerable and growing body of evidence that the fetus may be able to experience suffering from around 11 weeks of development.”
The commission warned against prejudging abilities of a baby before birth by comparison with a baby’s post-birth abilities. 6

Perhaps under ultrasound guidance, the surgeon could test fetal reaction with a probe, and this could help suggest that anesthetic levels have not yet been reached. Perhaps the obstetrician should inject some type of anesthetic directly accessible to the fetus.

What should we tell a mother who needs or requests anesthesia for abortion? We cannot assume that she is uncaring about fetal pain. We might assume that the mother thinks we know more than we really do about fetal suffering. We have a responsibility to give proper informed consent about these issues.

Regardless of the position one morally takes with respect to abortions, they will continue to be performed worldwide by physicians and other “lesser trained” individuals. To at least address the possibility that fetal suffering exists, future research may guide us to eliminate the pain during this controversial procedure.


References:

1. Wright, JA. Senate Judiciary Committee. January 21,1998. <http://www.senate.gov/~judiciary/wlconj21.htm>.
2. Anand KJS, PR Hickey. Pain and its effects in the human neonate and fetus. New Engl J Med. 1987; 317(21):1321-1327.
3. Corke B, Seals J. Anesthetic & Obstetric Management of High Risk Pregnancy, ed: Datta S. Boston: Harvard Medical School; 1996.
4. Growing Pains. The London Telegraph, June 26, 2001. <www.telegraph.co.uk/et?ac=005362210364775&rtmo=q
KqXRsJ9&atmo=rrrrrrrq&pg=/et/00/10/12/ecfabort12.html>.
5. Ellison N. Senate Judiciary Committee. November 17, 1995. Hearing record, 226.
6. Human Sentience Before Birth: The Commission of Inquiry into Fetal Sentience. 1996. CARE (Christian Action Research & Education) and The House of Lords. June 26, 2001.


www.asahq.org/Newsletters/2001/10_01/sb1001.htm