Thread by @realBockmann

1. On fetal pain, most media cite 1 of these 2 studies:

-Lee, et al. in Journal of the American Medical Association (JAMA 2005) bit.ly/3jroNtG
-Royal College of Obstetricians and Gynaecologists (RCOG 2010)

For clarification & context, I'll discuss JAMA 2005 here.

2. Context:

Both say pain only possible w/ functional cerebral cortex (I call this "cortical necessity")

▫️ JAMA 2005: pain not possible before 29-30 wks
▫️ RCOG 2010: pain not possible before 24 wks, maybe never due to what I call "fetal sleep"

US fetal pain laws claim 22 wks

3. Also:

▫️ RCOG 2010's 24 weeks is far closer to US fetal pain laws--22 weeks--than to JAMA 2005's 29-30 weeks

▫️ media often refer to a "consensus" on fetal pain

▫️ No! & consensus = politics ≠ science

▫️ Atlantic was right: "very little consensus" bit.ly/3jCcRW9

4. JAMA 2005 findings:
▫️ withdrawal "reflexes" & stress hormone responses ≠ fetal pain
▫️ fetal pain requires functional connections from thalamus to cerebral cortex (my "cortical necessity")
▫️ connections not functional/no pain before 29-30 wks

5. More findings:
▫️ fetal anesthesia [routinely given] is NOT for pain but for fetal immobilization, stress response, &
▫️ "preventing possible adverse effects on long-term neurodevelopment and behavioral responses to pain"
👁‍🗨anesthesia given for later pain, not current pain?

6. In other words, fetal anesthesia does NOT address the fetus' pain while she's a fetus, it addresses her pain *after she's born*?

Clever.

7. On anesthesia supposedly not for pain, only for "inhibiting fetal movement":

▫️ fetus responds to invasive procedures w/ vigorous movements, stress & pain relieving hormone release, breathing & heart rate increase
▫️ also "What I saw at the abortion" bit.ly/2RX0nwQ

8. See also B.E. Rollin's "Animal Pain" (1985), in which he tells of a vet school dean insisting "Anesthesia and analgesia have nothing to do with pain...they are methods of chemical restraint"

Rejoinder: "What the hell do they need restraint for if they are not in pain?"

9. Animals and infants have long been unable to feel pain:
▫️ 1985: analgesia "so rare in ordinary veterinary practice"
▫️ 1987: “minimal or no anesthesia in newborns, particularly if they are premature"

Rollins: bit.ly/2HBUfbg
Anand & Hickey: bit.ly/3jAYBfY

10. Infant Jeffrey Lawson had open heart surgery in 1985 with paralytic but without anesthesia
▫️ mom found out & raised hell
▫️ anesthesiologist said newborn's crying and withdrawal could be "a simple reflex"

wapo.st/3kAsfTZ

11. On "reflexes"
▫️ if we uniformly apply the mechanistic filter by which we're considering fetal pain, then we lose the ability to infer pain in adults
▫️ “All movements bearing the name of voluntary in physiology are reflex in a strict sense” - Sechenov bit.ly/2GeXQYP

12. Baby Jeffrey was paralyzed & awake for this 1.5hr op:
▫️ holes cut on both sides of his neck and chest
▫️ incision from his breastbone to his backbone
▫️ ribs pried apart
▫️ ligation of ductus arteriosus (offshoot of aorta)

He died 5 wks later.
bit.ly/2HJnwkA

13. Long before JAMA 2005, in the journal's first issue, Dr. Henry Bigelow denied infants require anesthesia because they

▫️ are easily controlled, and
▫️ "have neither the anticipation nor remembrance of suffering"

14. In Rene Descartes' day, vivisection was common because animals couldn't feel pain

▫️ Animals were machines; their cries were "nothing but the noises of some small springs that were being deranged"
(Andre Gombay, Descartes--Oxford: Blackwell, 2007, p.ix)

15. As an aside: the USDA defines a painful procedure for animals as
▫️ "...any procedure that would reasonably be expected to cause more than momentary pain or distress in a human being..."
▫️ requires animal be given pain/distress relieving medication
bit.ly/2JdWgLJ

16. So the human fetus responds to pain much the same as an adult does
▫️ evasive action
▫️ increased heart/breathing rates
▫️ endorphin release

Opioids attenuate these responses.

But supposedly the fetus can't feel pain until 29-30 wks.

What else would we expect her to do?

17. What *could* the fetus do to prove she feels pain?

We say she can't; therefore, she can't.

"Within the medical/scientific community, concepts of pain are based on its semantic definition rather than the actual experience it signifies." -KJS Anand
bit.ly/31Q96Gq

18. Maybe, as @ExecDean_Fisk suggested in 2008, the fetal patient would need to "come up to me at the age of 6 or 7 and say, 'Excuse me, Doctor, that bloody hurt, what you did to me!'"

Barring that, he says, assume pain at 20-24 weeks.

NYT article: nyti.ms/3owvi1W

19. But even this self-report of pain, sometimes promoted as the "gold standard", is a surrogate measure

In my clinical practice, reported pain vs exam findings vary widely by the patient; I must take a variety of data into consideration
▫️ history, labs, imagery, etc.
= CONTEXT

20. Despite giving every indication to the contrary, the fetus can't feel pain, per JAMA 2005, for one reason:

cortical necessity

No functional cortex = no psychological awareness of pain, the paper says.

But, crucially: it never substantiates this.

21. In summary:

▫️ JAMA 2005 relies on cortical necessity but does not substantiate it
▫️ cortical necessity seems incongruent with prima facie evidence for 2nd trimester fetal pain
▫️ and so, JAMA 2005's findings do not seem to apply

22. Bonus:

JAMA 2005 discusses fetal age:
▫️ "gestational age" (GA) = time since 1st day of last menstrual period
- easy to figure, most commonly used

▫️ "conceptional age" (CA) is time since fertilization: GA - 2 wks

▫️ note: CONCEPTION=FERTILIZATION
bit.ly/3kCoT2M