October 2001
Volume 65 |
Number 10
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| Are
We Overlooking Fetal Pain and Suffering During Abortion? |
R. Frank White,
M.D.
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.
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R. Frank White,
M.D., is an anesthesiologist at Fort Sanders Regional Medical
Center, Knoxville, Tennessee. |
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