Thursday, June 18, 2015

Infants, Fetuses, and the Complicated Issue of Pain

Anti-abortion activists have been attempting to argue that fetuses are capable of feeling pain at a certain stage of development and therefore legalized abortion should be limited to only the earlier periods.  Whether or not one agrees with this logic, it would at least seem that medical science should be able to make such a determination about pain or no pain.  Interestingly, the concept of pain is not well defined.  In fact, medical specialists have argued for centuries over whether or not neonates (recently born infants) are capable of experiencing pain.  Given that, how accurate might they be in figuring out what a fetus might be experiencing?

Joanna Bourke, a British historian, has produced a fascinating book on the subject of pain: The Story of Pain: From Prayer to Painkillers.  She convinces us that pain is an elusive quantity.  There is no way of measuring it directly.  A physician must depend on the description of the pain by the patient or draw her own conclusions based on evaluating the signals of pain being expressed by the patient.  It is well known that expression of pain is a learned response that varies from one culture to another, from one gender to another, and from one generation to another.  It is also well known that extreme physical injuries can be endured with little or no pain, and extreme pain can be experienced with no discernible cause.  As Bourke expresses the situation:

“As a type of event, pain is an activity.  People do pain in different ways.  Pain is practised within relational, environmental contexts.  There is no decontextual pain-event.  After all, so-called ‘noxious stimuli’ may excite a shriek of distress (corporal punishment) or squeal of delight (masochism).  There is no necessary and proportionate connection between the intensity of tissue damage and the amount of suffering experienced since phenomena as different as battle enthusiasm, work satisfaction, spousal relationships, and the color of the analgesic pill can determine the degree of pain felt.”

Pain is experienced both as a sufferer as an observer of the sufferer (think physician or nurse).

“….people perceive pain through the prism of the entirety of their lived experiences, including their sensual physiologies, emotional states, cognitive beliefs, and relational standing in various communities.”

A physician confronted with a patient claiming to suffer pain must try to deduce a diagnosis from the symptoms as well as judge the level of the pain and decide what, if anything, must be done about it.  For the latter task, the physician has his knowledge, his experience, and his biases at his disposal.  Given those meager resources, some rather outrageous conclusions have been reached by the medical community over the years.  Here the focus is on the varying beliefs concerning the ability of young infants to experience the sensation of pain.

“….for much of the eighteenth and early nineteenth centuries, infants were believed to be exquisitely sensitive to noxious stimuli.  This changed from the 1870s, with many scientists and clinicians claiming that infants were almost totally insensible to pain, a belief that was only debunked from the 1980s.” 

Bourke points out that ether and chlorophorm came into common use as anesthetics in the mid nineteenth century.  The belief that infants felt little if any pain, being common at the time, meant that infants were subjected to surgical procedures and were less likely to receive an anesthetic and even a post-operative analgesic than an adult.

“The author of Modern surgical Technique (1938), for instance, claimed that ‘often no anesthetic is required’, when operating on young infants: indeed ‘a sucker consisting of a sponge dipped in some sugar water will often suffice to calm the baby’.”

The claim that pain insensibility in children was proven wrong in the 1980s does not mean that medical practitioners immediately became concerned about pain in infants.

“A study in 1995 revealed that pre-term infants were subjected to an average of sixty-one painful procedures while in the neonatal intensive care unit.  In another study, published in 1987, neonates were subjected to about three invasive procedures an hour.  In addition, neonates were actually less likely to be given analgesia than older children.”

There are reasons why physicians would hesitate to administer anesthetics or analgesics to recently born infants, but Bourke claims the data indicates that attempting to ease pain actually improved the health outcomes of the infants.  Nevertheless, to this day, there is reluctance to practice effective pain-management on infants.

“In the late 1980s, although 80 per cent of paediatric anaesthetists believed that neonates felt pain, only 11 per cent would prescribe opiate analgesia after major surgery.  Even as late as 1998, a leading expert admitted that ‘assessing the presence and severity of pain in children has proven surprisingly difficult’ and was contributing to the ‘undermanagement of pain in young children’.  In a 2010 paper, not only did 50 to 90 per cent of the nurses believe that children over-reported pain, they also consistently gave less pain relief to infants than had been either prescribed by the hospital physician or recommended by national standards.”

Given that pain management in infants remains contentious to this day, is it likely that the questions surrounding the issue of pain that might be experienced by a fetus is going to be resolved in an orderly and scientific manner?

“The late twentieth century also saw the emergence of heated debates about the sentience of embryos and very prematurely born infants.  These wars were driven largely by the pro- and antiabortion movements, but also by an increased emphasis on the phenomenological and psychological dimensions of pain.  As a result, the tension between people arguing that embryos and very young humans were acutely sensitive and those insisting on their inability to truly feel became increasingly polarized and politicized.”

Various arguments can be made about when a fetus might begin to experience pain based on when certain stages in the evolution of the nervous system and brain are reached, but none of these things can prove pain is experienced.

Bourke indicates that there are data that suggest a way out of this dilemma.  It has been noted that:

“….’surgical manipulation of an unanesthetized fetus would stimulate its autonomic nervous system’, while operations on premature infants showed that many physiological indicators of stress….could be observed.  Crucially, these indicators decreased when adequate anesthesia was provided.”

These indicators of stress suggest pain, but do not prove it; the administration of anesthesia eliminates the indicators of stress and thus eliminates any indication of pain.  If one is concerned about a fetus suffering pain, there is an obvious step to take.

Anesthetize the fetus before performing an abortion!

Unfortunately, the antiabortion troops are not interested in practical solutions.  Their goal is to gain political capital and there is no limit to what they are willing to do.

In 1984 the film The Silent Scream was made available.

“It purported to reveal ‘abortion from the victim’s vantage point’.  Using ultrasound imaging, the film showed a ‘child’ (as Dr Bernard Nathanson, the narrator and physician in the film called the 12-week-old foetus) being ‘torn apart, dismembered, disarticulated, crushed, and destroyed by the unfeeling steel instruments of the abortionist’.”

Bourke reminds us that what the film actually shows is a bunch of people associated with the pro-life movement murdering what they believe to be a child.

“The film which can be seen as a ‘snuff film’ in the sense that antiabortionists participated in the killing of a ‘child’ was seen by around 150 million people.”

So much for being pro-life!

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