The Truth About the Work of Dr. Tiller

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Registered: 06-24-2009
The Truth About the Work of Dr. Tiller
Sat, 02-06-2010 - 9:54am

By Ethel Peterson
February 5, 2010

DODGE CITY, Kan. - I was moved to write this article after reading the fascinating one concerning third trimester abortions and the flood of comments that followed. It made me think that there are many facts still not revealed about what happens in these cases. My knowledge comes from the time I visited Dr. Tiller's clinic as a new State Representative in the Kansas House. We had been invited, if we were interested in coming to Wichita, to learn what really happens there. I sent in my RSVP and arrived at the gate to present my ID. Dr. Tiller had been shot in the arm previously, so there was, already, a tall fence--a barricade, really, around the clinic. I drove my car to the gate and the guard at the gate allowed me to drive into the compound. There were protesters across the street, holding signs.

I parked my car and was welcomed into the clinic by an attendant, who explained the procedure we would follow. I was allowed to pick a client's case, without a name. It was a mother who had allowed her case to be included so that I might be able to "follow the case along." Then I was introduced to Dr. Tiller. He proceeded to explain the initial process of a client just arriving. He encouraged me to ask any questions along the way. I had lots of them, and he answered every one fully and completely. "My client" had been a young married woman who had learned near the end of her fifth month of pregnancy that there was something terribly wrong with her baby. She lived in the Southern US and had been very uncomfortable with the summer heat and reasoned that was why she had been feeling worse lately. This was her first pregnancy. The doctor immediately sent her to another doctor for consultation and they then sent her to a specialist.

That specialist ran tests and consulted yet another authority. By that time she was well into her sixth month. At last they came to the ghastly decision that her baby's brain was forming partially outside of its head. They were unsure if some other organs might also be forming outside the body.They did not believe the baby could live. The mother and her husband were devastated. This was a much-wanted baby! They talked with her parents. All were very opposed to abortion, but decided they probably had no choice. By the time they had made the decision, she was in her seventh month. They went to their doctor with their decision. He informed them that their state law did not allow third term abortions. He could not perform one.

On that day, they started the process of birthing, but the baby was, of course, born dead. It had suffered no pain. That was the reason for the shots. After the baby was born, the doctor took the child and laid it in the mother's arms. Dr. Tiller presented her with a tiny receiving blanket to wrap the baby in. Using a Polaroid camera, he took a picture of the baby, and one of the mother holding the baby and gave them to her. He had asked them ahead of time of their religious preference, and if they had requested it, he would have had a minister present for a brief service there. As it was, the father said a prayer, and it was over.

Dr. Tiller told me that he had a copy of that baby's picture and that he would show it to me, if I wanted to see it. He warned me that it was not a pleasant thing to see. I asked to look at it. Then he said, "Can you guess what the mother said when she saw the baby?" I couldn't. He told me the mother said quite breathlessly, "Isn't she beautiful?! And look at her tiny little hands. They are perfect." Dr. Tiller's eyes were moist as he said to me, "They all do that. No mother ever sees the awfulness. They all see the beauty! That's the reason I can do this work."

George Tiller's favorite quote was "Trust Women." I think he was right. If you want to end abortions, do the many things we need to do to end the reasons. Provide good solid sex education if your concern is the teens possibly becoming sexually active too early or without any sense of responsibility. But let's quit acting like every pregnant women is just an over-sexed teenager who doesn't know enough to make her own decisions.

This isn't what the anti-abortion folks think, and I understand that. What I don't understand is how anybody in the world can think it is right to walk into a church and shoot a man in the forehead at point-blank range. Roeder thought he shot a baby-killer. He shot a good, Christian man, who was a husband, father, grandfather, friend, and a man of great courage. There are other abortion doctors who have to live in fear. If they are as good-hearted and decent as Dr. Tiller, they will probably continue to work and do their best. I recently received a communication from Julie Burkhart, who worked in Tiller's clinic. She has started an organization dedicated to protecting the lives of other abortion providers in the US. She calls the organization, "Trust Women." How appropriate. I hope we all do!

iVillage Member
Registered: 04-10-2003
Mon, 02-08-2010 - 1:03pm

The Science and Politics of Fetal Pain
Commentary by Dr Stuart Derbyshire
The following paper was written in 1996, in response to the debate about whether fetuses feel pain. Comments or questions about it can be sent / e-mailed to the author at the addresses below.
Stuart W. G. Derbyshire, Ph.D. Asst. Professor
University of Pittsburgh Medical Center,
PET Facility, Room B-938 PUH,
200 Lothrop Street, Pittsburgh,
PA 15213-2582.
Phone: 412-647-0736
Fax: 412-647-0700

The Science and Politics of Fetal pain - Doing the Wrong Thing?

In 1987, the Lancet published an article unequivocally demonstrating that neonates receiving fentanyl anaesthesia in preparation for surgery had improved clinical outcome as compared with neonates who only received nitrous oxide and curare (1). This research, and subsequent studies, (2)(3) led to a major reconsideration of analgesic practice with regard to neonates. In 1992, the New England Journal ran an editorial calling on clinicians to 'Do the Right Thing' concluding that 'it is our responsibility to treat pain in neonates and infants as effectively as we do in other patients'(4). Since then it has become common place to assume that neonates feel pain (5)(6). The assumption that neonates feel pain has led inevitably to speculation that the fetus may also experience pain (7). While the discussion about neonatal pain remained largely confined to the pages of medical texts, the discussion around fetal pain has attracted the attention of several major British newspapers and led the British parliament to discuss the curtailing of abortion (8)(9). Given the sensitivity of this issue in the United States (10), it is surely only a matter of time before this issue crosses the Atlantic. This article evaluates the evidence for and against fetal and neonatal pain and considers the implications for current clinical practice, abortion procedure and the contemporary understanding of pain.

The Evidence that the Fetus or Neonate can Feel Pain

Anand's seminal work on the use of fentanyl with neonates undergoing surgery demonstrated that the major hormonal response to invasive practice could be significantly reduced with fentanyl added to the anaesthetic regimen. Specifically it was demonstrated that plasma adrenalin, noradrenaline, glucagon, aldosterone, corticosterone, 11-deoxycorticosterone and 11-deoxycortisol levels were significantly greater in the non-fentanyl group than the fentanyl group up to 24 hours after surgery. The reduction of the 'stress response' to surgery by fentanyl was considered to be responsible for the improved clinical outcome of the fentanyl group who required less post-surgical ventilatory support and had reduced circulatory or metabolic complications. Anand and his colleagues later advanced these important and impressive findings in a report indicating that neonates receiving deep anaesthesia during surgery had improved post-operative morbidity compared with those neonates who received lighter anaesthesia. The reduced hormonal response and improved clinical outcome following invasive surgery in conjunction with anaesthetics used for pain relief in adults led naturally to the conclusion that the neonate could feel pain and that this pain needed to be controlled.

Dovetailing with the work of Anand and his colleagues was that of Fitzgerald. Fitzgerald has examined the developing nervous system of the rat and human fetus with special regard to the developmental neurobiology of pain (11)(12)(13). Fitzgerald has reviewed the biological development of the fetus and examined the possibility of fetal pain at each stage of development. The impression that a fetus experiences sensation is apparent at 7.5 weeks gestation when reflex responses to somatic stimuli begin. At this point touching the peri-oral region results in a contralateral bending of the head. The palms of the hands become sensitive to stroking at 10.5 weeks and the rest of the body and hindlimbs become sensitive at approximately 13.5 weeks. Shortly after the development of sensitivity, repeated skin stimulation results in hyperexcitability and a generalized movement of all limbs. This hyperexcitability has been interpreted as evidence for the presence of a functional pain system, reflecting an immature but intact pain response with early hypersensitivity to stimulation (14). This is not a view which is widely accepted, however, and is rejected by Fitzgerald herself. Prior to 26 weeks the thalamocortical fibres have not yet penetrated the cortical plate (15), and it seems unlikely, therefore, that the cortical structures considered necessary for pain are responding to noxious stimulation. The evidence for cortical involvement post 26 weeks is enhanced by behavioral studies which have demonstrated that the response to noxious stimulation becomes more focused and organized and can be better discriminated from other distress responses after 26 weeks (16). As with the hormonal response to surgery, the behavioral responses can be reduced with the use of appropriate anaesthetic adding support to the suggestion that these responses are related to pain perception (17).

Having established that the necessary neurobiology for pain is in place after 26 weeks and that behavioral responses to noxious stimulation are present in very premature babies of approximately 26 weeks gestation, it is logical to suggest that a fetus of 26 weeks gestation or more will launch a similar hormonal response to invasive practice as that observed in the neonate undergoing surgery. In 1994 Giannakoulopoulos and his colleagues from the Queen Charlottes Hospital in London, England successfully demonstrated that intrauterine needling to obtain a blood sample from fetuses of 20-34 weeks gestation resulted in a hormonal stress response analogous to that seen by Anand et al seven years previously (18). They demonstrated that needling the innervated intra-abdominal portion of the umbilical vein rather than the placental cord, which is not innervated, resulted in increased cortisol and []-endorphin concentrations in fetal plasma. If this group can now demonstrate that the hormonal and neural 'stress response' can be prevented with the use of appropriate anesthetics then they will have mirrored the criteria which have led to the widespread acceptance of 'neonatal pain'.

The Evidence Against

The undisputed discovery that the neonate and fetus launch a hormonal and neural response to invasive practice can not be considered definitive proof that there is an experience of pain. An experience implies that sensations have been interpreted in a conscious manner. Even when combined with the observations of behavior and improved clinical outcome when using anesthetics, there is still no proof that there is an experience of pain. Although all of these phenomena are associated with the notion of 'pain', none of them adequately describe or explain the phenomenological experience of 'pain'. These phenomena may exist independently of conscious experience. The relationship between the physiological responses of nociceptors, the hormonal and other responses of the CNS and the behavioral outcome of these changes to the psychological response has yet to be determined (19).

Unless it can be reasonably suggested that the fetus has a conscious appreciation of pain post 26 weeks gestation, then the responses to noxious stimulation post 26 weeks are still essentially just behaviorally complex reflex responses, similar to the responses prior to 26 weeks. Despite the importance of providing evidence for the conscious appreciation of pain, the fetal and neonatal literature largely tries to ignore this issue. Anand, for example, highlighted the clinical findings with neonates as being of greater importance than 'any philosophical view on consciousness and 'pain perception''. Giannakoulopoulos et al distanced themselves from any implied fetal pain experience with the statement 'a hormonal response cannot be equated with the perception of pain'. In a report for the British Department of Health (Foetal pain: an update of current scientific knowledge. A paper for the Department of Health May 1995) Fitzgerald even went so far as to say that 'true pain experience postnatally along with memory, anxiety and other cognitive brain functions' leaving confusion as to what the 'untrue' pain experience of a fetus may be. More recently Lloyd-Thomas and Fitzgerald have suggested that if feeling and pain are properly understood then the fetus cannot be said to feel pain (20).

Such equivocation is perhaps not surprising in view of the general failure of material interpretations, i.e. interpretations which focus specifically upon the biological properties of human beings (21), to deliver a coherent account of human consciousness (22). Nevertheless, if a proper assessment of neonatal and fetal pain is to be undertaken, then we should examine the structure of the psychological experience 'pain', as the biological structures have been examined, and then work backwards to the fetus and neonate to decide whether it is likely or possible that these psychological structures are in place.

As Fitzgerald has identified, pain experience is now widely seen as a consequence of an amalgam of cognition, sensation and affective processes, this amalgam is commonly described under the rubric of the 'biopsychosocial' model of pain (23). Pain is no longer regarded as merely a physical sensation of noxious stimulus and disease, but is seen as a conscious experience which may be modulated by mental, emotional and sensory mechanisms and includes both sensory and emotional components. The whole biopsychosocial concept emphasizes the multidimensional nature of illness, injury and pain rather than emphasizing pain as purely a physical fact of illness or injury. Pain has been described as a multidimensional phenomena for some time (24) and this understanding is reflected in the current IASP (International Association for the Study of Pain) definition of pain as 'an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage' (25).

If this 'multidimensionality' is the basis of conscious pain experience, it seems unlikely that we can attribute this experience to the neonate or unborn fetus, which is naive as to all the cognitive, affective and evaluative experiences necessary for pain awareness. This is accepted in the current definition of pain that is further extended to state: 'pain is always subjective. Each individual learns the application of the word through experiences related to injury in early life.' Pain does not, so to speak, spring forth 'from the depths of the person's mind' prior to any experience, but is gradually formed as a consequence of general conscious development.

A further reason to doubt the viability of fetal pain post 26 weeks gestation is the development of the fetal cortex. Although it is true that the thalamocortical fibres penetrate the cortical plate at approximately 26 weeks gestation, the cortical regions which have been identified as important in processing the suffering components of pain (26)(27) do not become fully responsive until after birth (28). These structures, especially the anterior cingulate cortex (29), have a plasticity which allows for learning and adaptation and therefore retain the capacity to have a more dynamic relationship with conscious awareness. Interestingly, this capacity is not shared by the structures associated with sensory detection, such as the somatosensory cortex, which develop earlier but are less likely to have an involvement in the processes associated with pain experience. The concept of pain as a product of learning and adaptation is pursued in more detail under Implications for Pain Research.

The Implications for Current Clinical Practice

The debate about fetal pain need not affect clinical practice involving the fetus or neonate. Evidence that the stress response, which the fetus and new-born launches in response to physical insult, has known detrimental consequences is acceptable even to those who do not accept that pain is experienced. New borns who have been operated on without analgesia show increased mortality compared with new-borns who receive analgesia. There is also evidence that early physically stressing experiences may produce detrimental changes in later responses to potentially painful experience, such as inoculation (30). Therefore, in the cases of invasive practice where there is a clear clinical rational for the use of anesthetics, which does not rely upon the additional diagnosis of pain, the withholding of analgesia for fetus' and neonates should remain an unethical practice. As exciting advances in fetal surgery are being made continuously, it is imperative that similar clinically orientated research be carried out with the fetus.

Where the clinical advantage of anaesthetic is less clear, however, it is probably wise to avoid potentially dangerous procedures for the fetus or neonate, and probable uncomfortable procedures for the mother. There are those who argue that, while there is no consensus on this issue, clinicians should act according to the precautionary principle of assuming that pain is experienced until it is conclusively proved otherwise. However, as few clinical procedures are entirely risk free it seems more appropriate to reserve any form of intervention for occasions when it is known to be necessary.

A consideration of vaginal childbirth helps to place the discussion about fetal pain into some context. Childbirth is known to give rise to the hormonal and neural stress response which has been used as evidence for fetal and neonatal pain, this has led at least one popular British newspaper to run an article questioning whether babies feel pain during childbirth (31). It seems unlikely, however, that a process which the very vast majority of people have passed through is having long term detrimental consequences, and there is evidence which suggests the contrary to be the case (32)(33). It is still unknown exactly what the consequences of a hormonal stress response may be both for adults (34) and newborns. Under these circumstances an increase in relatively problematic anaesthetic, or even surgical practices such as caesarean section, to avoid fetal/neonatal 'pain' seems unnecessary and irrational (35)(36).

The Implications for Abortion Procedure

Fetal pain is obviously an important issue for those carrying out fetal operations and other invasive practices, but it is also of interest for those involved in abortion procedure and for those motivated to restrict the current abortion legislation. The broadly accepted conclusion that recorded responses to noxious stimulation prior to 26 weeks gestation are reflex responses, not dependent on conscious appreciation, is important as it eliminates much of the generated concern regarding abortion. In 1994 just 94 abortions, out of more than 160,000 carried out in the UK, were later than 24 weeks (37). If it is accepted that consciousness is essential to the pain experience, and that consciousness is contingent upon psychological development, it would follow that even after 24 weeks gestation it would be more appropriate to describe fetal reaction to stimuli as reflex responses than as pain.

Guidelines on the termination of pregnancy for fetal abnormality issued by the UK Royal College of Obstetricians and Gynaecologists (RCOG) draws on the work of Fitzgerald (1995) which suggests strongly that the immaturity of the fetal nervous system prevents conscious awareness of pain before 26 weeks gestation. The document argues that 'it follows that up to this gestation the method of abortion should be selected to minimise the physical and emotional trauma to the woman' (38).

Regardless of one's own views on whether late term induced abortions may cause pain to the fetus, the issue warrants special attention because almost all late terminations are of wanted pregnancies where the putative parents may be emotionally vulnerable. Often, during counselling, they express concern about what the fetus may 'feel' during an abortion. In these circumstances it is common for the putative parents to think of the fetus as a 'baby' and to attribute to it the qualities that they anticipated their child would have were it to be born. In such cases good sympathetic clinical practice would require steps to be taken to reduce the concerns of the woman.

In the UK, the RCOG recommends that measures to stop the fetal heart should be taken in all terminations after 21 weeks gestation. This is to ensure that there is no possibility of the abortion resulting in a live birth. After 26 weeks the guidelines suggest that it is not possible to know the extent to which the fetus is aware and so after this gestation it is suggested that 'methods used during abortion to stop the fetal heart should be swift and involve a minimum of injury to fetal tissue.' Even if the fetus is not aware, as we suggest, these guidelines would be appropriate to avoid unnecessary distress to the woman.

The paramount interests of the woman in abortion procedures is an important principle. Arguments that with viability the fetus becomes a patient and the doctors' responsibilities towards the woman need to be balanced against those of the fetal patient remain controversial (39)(40). The view that the pregnant woman is the patient while the fetus is cared for on behalf of the woman endures among many clinicians and is in my view the ethical stance (41)(42).

Concern about fetal suffering is raised by those who oppose abortion in principle as a reason to restrict some methods of abortion. In both the US and the UK legislative changes have been proposed which would outlaw a late abortion procedure known by gynaecologists as intact dilation and evacuation and by opponents of abortion as 'partial-birth abortion'. In both countries the method was defended by the medical establishment on the grounds that there may be circumstances when such practice was in the interests of the woman. It was for this reason that President Clinton exercised his right of presidential veto in respect of the Partial Birth Abortion Ban Bill of 1995 (H.R. 1833/S 939) which had been approved by Congress. Clinton correctly stated that: 'By refusing to permit women in reliance on their doctors' best medical judgement, to use this procedure when their lives are threatened or when their health is put in serious jeopardy, Congress has fashioned a Bill that is neither consistent with the Constitution nor with sound public policy' (43).

The Implications for Pain Research

The implications of accepting the notion of neonatal and fetal pain for pain research are profound. The consequence of such a view is to undermine the current theoretical outlook of most pain researchers, namely the 'biopsychosocial' model of pain, the undermining of the current definition of pain (44)(45), and the return of ideas more closely resembling the discredited ideas of 'specificity' theory(46).

In the absence of any conceptual framework to account for a fetal/neonatal experience of pain, the fetal literature is drawn inexorably towards the discredited ideas of 'specificity' and 'pain centers'. Within the discussion of fetal pain, pain fibres (or peptides or neurotransmitters) are proposed to be stimulated and relay information to suggested pain centers somewhere in the brain. As for specificity, a painful stimulus therefore becomes that which activates the pain center, and pain becomes activity in the pain center. Specificity theory, however, has long been rejected because the definition of pain based on a direct relationship between stimulus and response has failed to resolve many of the major issues in pain research. Interpretations of injury based on a direct relationship between stimulus and pain cannot account for the variable link between stimulus and pain experience. This variable link is well documented (47)(48)(49)(50), and is a consequence of the fact that pain experience is a multidimensional phenomena contingent upon processes involved in general conscious awareness, namely evaluative, emotional and cognitive processing. The biopsychosocial model of pain has also encouraged a less 'specificity biased' view of central pain neurology which has long been dogged by specificity theorists searching for pain centers (51). Classical neurology has viewed the central projection to the somatosensory cortex as essentially a pain center, a region necessary and sufficient for the experience of pain (52). The information about noxious stimuli that travels via the spinothalamic tract to excite the lateral group of thalamic nuclei interconnected with somatosensory cortex, undergoes few alterations between the spinal cord and cortex (53). Excitatory responses in monkey somatosensory cortex are generally restricted to both innocuous and noxious mechanical and thermal stimuli. Somatosensory neurons have receptive fields that are small or at least confined to one limb and always contralateral (54). Such a system is ideal for providing detailed information about the location and characteristics of particular noxious stimuli but is not well suited for processes associated with affective and cognitive responses to noxious stimuli. The conscious appreciation of pain cannot be explained within this system, instead a 'neuromatrix' (55) of regions, incorporating anterior cingulate, prefrontal and insula cortices which show a plasticity with learning and development, is proposed as necessary for the experience of pain. Functional imaging studies have now demonstrated that a number of cortical regions are activated in response to pain which conform to the concept of a neuromatrix (56)(57).

While the neuromatrix is an important step away from specificity, a step which is threatened by the concept of neonatal and fetal pain, so long as the neuromatrix is seen as sufficient for pain experience it will fall foul of the same problems that the materialist accounts of consciousness face and can ultimately be reconciled with neonatal and fetal pain. The only way to avoid the failings of materialism, avoiding the view that the higher mental functions are fixed a priori or that consciousness is a product of metaphysical forces (58), is to see consciousness, and within it the experience of pain, as a consequence of developmental processes which the fetus and newborn baby are yet to pass through. According to one developmental model of pain, stimulus information is eventually organized and elaborated in the central nervous system with respect to three hierarchical mechanisms (59). The first two mechanisms in the hierarchy are perceptual-motor processing followed by schematic processing. Both these mechanisms are considered preconscious. Perceptual-motor processing involves the activation of an innate set of expressive motor reactions to environmental stimuli. Schematic processing involves the automatic encoding in memory of the experience to produce a categorical structure representing the general informational and sensory aspects of pain experiences. A set of conscious abstract rules about emotional episodes and associated voluntary responses is proposed to arise over time as a consequence of self observation and conscious efforts to cope with aversive situations. While rather mechanistic and far from ideal, this model outlines how the pressure of interacting with others gradually forces the subordination of our instinctual, unconscious, biology to our developing conscious will.

The response of fetuses and neonates to invasive practice is a valuable research area that should lead to better clinical practice in the future. Basing this research upon the assumption that there is pain experience, however, could lead to the hasty introduction of unnecessary and possibly detrimental anaesthetic procedures as well as increasing the distress faced by those women who seek abortion. In addition, the focus on fetal pain is likely to result in a considerable challenge on the current understanding of pain - a challenge which will push back the past 30 years of pain research and undermine the contemporary conceptual framework for understanding pain. Such changes do not appear to be advantageous and may even be damaging to the pain field in general and to the treatment and understanding of nociceptive responses in the fetus and newborn baby.


(1) Anand KJS, Sippel WG, Aynsley-Green A. Randomised trial of fentanyl anasthesia in preterm babies undergoing surgery: effects on the stress response.
Lancet 1987; 1: 243-248.

(2) Anand KJS, Hickey PR. Halothane-morphine compared with high dose sufentanil for anesthesia and postoperative analgesia in neonatal cardiac surgery.
N Engl J Med 1992; 326: 1-9.

(3) Fitzgerald M. Pain and analgesia in neonates. Trends Neurosci 1987; 10: 344-346.

(4) Rogers MC. Do the right thing: Pain relief in infants and children.
N Engl J Med 1992; 326: 55-56.

(5) Fitzgerald M. Developmental biology of inflammatory pain.
Br J Anaesth 1995; 75: 177-185.

(6) Anand KJS, Hickey PR. Pain and its effects in the human neonate and fetus.
N Engl J Med 1987; 317: 1321-1329.

(7) Richards T. Can a fetus feel pain?
BMJ 1985; 291:1220-1221

(8) Hansard 1995; 236 (136): 906-914

(9) Derbyshire SWG. Comment: Do fetuses feel pain during abortion?
Abortion Review 1995; 57: 1-2.

(10) Annas GJ, Caplan A, Elias S. Sounding Board: The politics of human-embryo research - avoiding ethical gridlock. N Engl J Med 1996; 334: 1329-1332.

(11) Fitzgerald M. Spontaneous and evoked activity of foetal primary afferents in vivo.
Nature 1987; 326: 603-605.

(12) Fitzgerald M. The prenatal growth of fine diameter afferents into the rat spinal cord - a transganglionic study.
J Comp Neurol 1987; 261: 98-104.

(13) Fitzgerald M. Neurobiology of fetal and neonatal pain. In Wall P, Melzack R, eds. Textbook of Pain. Churchill Livingstone, 1994: 153-163.

(14) Barr RG. Pain experience in Children. In Wall P, Melzack R, eds Textbook of Pain. Churchill Livingstone, 1994: 739-765.

(15) Mrzljak L, Uylings HBM, Kostovic I, van Eden CG. Prenatal development of neurons in prefrontal cortex: a qualitative Golgi study. J Comp Neurol 1988; 271: 355-386.

(16) Craig KD, Whitfield MF, Grunau RVE, Linton J, Hadjistavropoulos HD. Pain in the preterm neonate: behavioural and physiological indices. Pain 1993; 52: 287-299.

(17) Fitzgerald M, Millard M, McIntosh N. Cutaneous hypersensitivity following peripheral tissue damage in newborn infants and its reversal with topical anaesthesia. Pain 1989; 39: 31-36.

(18) Giannakoulopoulos X, Sepulveda W, Kourtis P, Glover V, Fisk NM. Fetal plasma
cortisol and ?-endorphin response to intrauterine needling. Lancet 1994; 344: 77-81.

(19) Wall PD, McMahon SB. The relationship of perceived pain to afferent nerve impulses. Trends Neurosci 1986; 9: 254-255.

(20) Lloyd-Thomas AR, Fitzgerald M. Reflex responses do not necessarily signify pain.
BMJ 1996.

(21) Crick F. The Astonishing Hypothesis: The Scientific Search for the Soul.
Simon & Schuster, 1994.

(22) Chalmers DJ. Facing up to the problem of consciousness. JCS 1994; 1: 1-16.

(23) Waddell G. A new clinical model for the treatment of low-back pain.
Spine 1987; 12: 632-644.

(24) Melzack R, Casey KL. Sensory, motivational and central control determinants of pain. In Kenshalo D, ed. The Skin Senses. Springfield Ill: Thomas 1968: 423-443.

(25) Merskey H. The definition of pain. Eur J Psychiatry 1991; 6: 153-159.

(26) Jones APK, Brown WD, Friston KJ, Qi LY, Frackowiak RSJ. Cortical and subcortical localization of response to pain in man using positron emission tomography. Proc R Soc Lond 1991; 244: 39-44.

(27) Derbyshire SWG, Jones AKP, Devani P et al. Cerebral responses to pain in patients with atypical facial pain measured by positron emission tomography. J Neurol Neurosurg Psychiatry 1994; 57: 1166-1173.

(28) Chugani HT, Phelps ME. Maturational changes in cerebral function in infants determined by 18FDG positron emission tomography. Science 1986; 231: 840-843.

(29) Gabriel M. Functions of anterior and posterior cingulate cortex during avoidance learning in rabbits. In Uylings H, Van Eden C, De Bruin J, Corner M, Feenstra M eds. Progress in Brain Research. NY: Academic press 1990; 85: 467-483.

(30) Taddio A, Goldbach M, Ipp M, Stevens B, Koren G. Effect of neonatal circumcision on pain responses during vaccination in boys. Lancet 1995; 344: 291-292.

(31) Feger H. Babies feel the pain of childbirth, say doctors.
Sunday Express 1996; Jan 28: 17.

(32) Sangild PT, Hilsted L, Nexo E, Fowden AL, Silver M. Secretion of acid, gastrin, and cobalmin-binding proteins by the fetal pig stomach: developmental regulation by cortisol. Exp Physiol 1994; 79: 135-146.

(33) Wenderlein JM, Ritz-Schafer R. Is moderate labor stress for newborn infants an advantage? Pilot study of postpartum weight gain of 791 newborn infants. Geburtshilfe Frauenheilkd 1994; 54: 65-68.

(34) Salmon P. Anxiety and stress in surgical patients. Br J Hosp Med 1992; 48: 531-532.

(35) Glasser M. Cesarean section: science or ritual surgery?
Med Hypotheses 1991; 34: 73-80.

(36) Francome C, Savage W. Caesarean section in Britain and the United States 12% or 24%: is either the right rate? Soc Sci Med 1993; 37: 1199-1218.

(37) Abortion Statistics Series AB 1995; 19 (HMSO).

(38) Royal College of Obstetricians and Gynaecologists, Termination of Pregnancy for Fetal Abnormality in England, Wales and Scotland. 1996; pp. 12.

(39) McCullough LB, Chervenak FA. Ethics in Obstetrics and Gynaecology. Oxford University Press, New York 1994.

(40) Chervenak FA, McCullough LB, Campbell S. Is third trimester abortion justified? Br J Obstet Gynaecol 1995; 103: 187-189.

(41) Sirisena J. Correspondence. Is third trimester abortion justified? Br J Obstet Gynaecol 1996; 103: 187-189.

(42) Derbyshire, SWG. Locating the beginnings of pain. Bioethics 1999; 13: 1-31.

(43) Furedi A. Clinton vetoes ban on abortion methods. Abortion Review 1996; 59: 7.

(44) Anand KJS, Craig KD. New perspectives on the definition of pain. Pain 1996.

(45) Derbyshire SWG. A response to Anand and Craig on new perspectives on the definition of pain. Pain 1996.

(46) Wall PD. Why the definition of pain is crucial. In Wall P, Melzack R, eds. Textbook of Pain. Churchill Livingstone 1989: 1-18.

(47) Beecher HK. Measurement of Subjective Responses. Oxford University Press, New York 1959.

(48) Kosambi DD. Living prehistory in India. Sci Ameri 1967; 216: 105-114.

(49) Carlen PL, Wall PD, Nadvorna H, Steinbach T. Phantom limbs and related phenomena in recent traumatic amputations. Neurology 1978; 28: 211-217.

(50) Melzack R, Wall PD, Ty TC. Acute pain in an emergency clinic: Latency of onset and descriptor patterns. Pain 1982; 14: 33-43.

(51) Jones AKP. Do 'pain centres' exist? Br J Rheum 1994; 31, 290-292.

(52) Albe-Fassard D, Berkley KJ, Kruger L, Ralston HJ, Willis WD. Diencephalic mechanisms of pain sensation. Brain Res Rev 1985; 9: 217-296.

(53) Vogt BA, Sikes RW, Vogt LJ. Anterior cingulate cortex and the medial pain system. In Vogt BA, Gabriel M eds. Neurobiology of cingulate cortex and limbic thalamus: A comprehensive treatise. Birkhauser, Boston 1993: 330-360.

(54) Kenshalo DR, Isensee O. Responses of primate S1 cortical neurons to noxious stimuli.
J Neurophysiol 1983; 50: 1479-1496.

(55) Melzack R. Phantom limbs, the self and the brain: The D.O. Hebb memorial lecture. Can Psychol 1989; 30: 1-16.

(56) Hsieh JC, Belfrage M, Stone-Elander S, Hansson P, Ingvar M. Central representation of chronic ongoing neuropathic pain studied by positron emission tomography. Pain 1995; 63: 225-236.

(57) Vogt BA, Derbyshire SWG, Jones AKP. Pain processing in four regions of human cingulate cortex localized with coregistered PET and MR imaging. Eur J Neurosci 1996; 8: 1461-1473

(58) Eccles JC. How the Self Controls its Brain. Springer Verlag, 1994.

(59) Leventhal H. A perceptual-motor theory of emotion.
Adv Exp Psychology 1984; 17: 117-175.


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Registered: 04-10-2003
Mon, 02-08-2010 - 1:04pm

Foetuses May Not Feel Pain in Early Months

Researchers Say Fetuses Likely Don't Feel Pain Until Late in Pregnancy


CHICAGO Aug 23, 2005 — A review of medical evidence has found that fetuses likely don't feel pain until the final months of pregnancy, a powerful challenge to abortion opponents who hope that discussions about fetal pain will make women think twice about ending pregnancies.

Critics angrily disputed the findings and claimed the report is biased.

"They have literally stuck their hands into a hornet's nest," said Dr. Kanwaljeet Anand, a fetal pain researcher at the University of Arkansas for Medical Sciences, who believes fetuses as young as 20 weeks old feel pain. "This is going to inflame a lot of scientists who are very, very concerned and are far more knowledgeable in this area than the authors appear to be. This is not the last word definitely not."

The review by researchers at the University of California, San Francisco comes as advocates are pushing for fetal pain laws aimed at curtailing abortion. Proposed federal legislation would require doctors to provide fetal pain information to women seeking abortions when fetuses are at least 20 weeks old, and to offer women fetal anesthesia at that stage of the pregnancy. A handful of states have enacted similar measures.

But the report, appearing in Wednesday's Journal of the American Medical Association, says that offering fetal pain relief during abortions in the fifth or sixth months of pregnancy is misguided and might result in unacceptable health risks to women.

Dr. Nancy Chescheir, chairman of obstetrics and gynecology at Vanderbilt University and a board director at the Society of Maternal-Fetal Medicine, said the article "will help to develop some consensus" on when fetuses feel pain. "To date, there hasn't been any."

The researchers reviewed dozens of studies and medical reports and said the data indicate that fetuses likely are incapable of feeling pain until around the seventh month of pregnancy, when they are about 28 weeks old.

While brain structures involved in feeling pain begin forming much earlier, research indicates they likely do not function until the pregnancy's final stages, said the report's senior author, UCSF obstetric anesthesiologist Dr. Mark Rosen.

Fetal Pain
A Systematic Multidisciplinary Review of the Evidence

Susan J. Lee, JD; Henry J. Peter Ralston, MD; Eleanor A. Drey, MD, EdM; John Colin Partridge, MD, MPH; Mark A. Rosen, MD

JAMA. 2005;294:947-954.

Context Proposed federal legislation would require physicians to inform women seeking abortions at 20 or more weeks after fertilization that the fetus feels pain and to offer anesthesia administered directly to the fetus. This article examines whether a fetus feels pain and if so, whether safe and effective techniques exist for providing direct fetal anesthesia or analgesia in the context of therapeutic procedures or abortion.

Evidence Acquisition Systematic search of PubMed for English-language articles focusing on human studies related to fetal pain, anesthesia, and analgesia. Included articles studied fetuses of less than 30 weeks’ gestational age or specifically addressed fetal pain perception or nociception. Articles were reviewed for additional references. The search was performed without date limitations and was current as of June 6, 2005.

Evidence Synthesis Pain perception requires conscious recognition or awareness of a noxious stimulus. Neither withdrawal reflexes nor hormonal stress responses to invasive procedures prove the existence of fetal pain, because they can be elicited by nonpainful stimuli and occur without conscious cortical processing. Fetal awareness of noxious stimuli requires functional thalamocortical connections. Thalamocortical fibers begin appearing between 23 to 30 weeks’ gestational age, while electroencephalography suggests the capacity for functional pain perception in preterm neonates probably does not exist before 29 or 30 weeks. For fetal surgery, women may receive general anesthesia and/or analgesics intended for placental transfer, and parenteral opioids may be administered to the fetus under direct or sonographic visualization. In these circumstances, administration of anesthesia and analgesia serves purposes unrelated to reduction of fetal pain, including inhibition of fetal movement, prevention of fetal hormonal stress responses, and induction of uterine atony.

Conclusions Evidence regarding the capacity for fetal pain is limited but indicates that fetal perception of pain is unlikely before the third trimester. Little or no evidence addresses the effectiveness of direct fetal anesthetic or analgesic techniques. Similarly, limited or no data exist on the safety of such techniques for pregnant women in the context of abortion. Anesthetic techniques currently used during fetal surgery are not directly applicable to abortion procedures.

Author Affiliations: School of Medicine (Ms Lee), Department of Anatomy and W. M. Keck Foundation for Integrative Neuroscience (Dr Ralston), and Departments of Obstetrics, Gynecology and Reproductive Sciences (Drs Drey and Rosen), Pediatrics (Dr Partridge), and Anesthesia and Perioperative Care (Dr Rosen), University of California, San Francisco


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Registered: 04-10-2003
Mon, 02-08-2010 - 1:05pm

Study: Fetus feels no pain until third trimester
Brain structures do not function until later in pregnancy, researchers say

Updated: 12:57 a.m. ET Aug 24, 2005
CHICAGO - Doctors should not be required to discuss fetal pain with women seeking abortions because fetuses likely can’t feel pain until late in pregnancy, according to a review critics say hardly settles the contentious topic.

Researchers at the University of California, San Francisco reviewed dozens of studies and medical reports and said the data indicate that fetuses likely are incapable of feeling pain until around the seventh month of pregnancy, when they are about 28 weeks old.

Based on the evidence, discussions of fetal pain for abortions performed before the end of the second trimester should not be mandatory, according to the study appearing in Wednesday’s Journal of the American Medical Association.

The review, researchers say, is an attempt to present a comprehensive, objective report on evidence to inform the debate over fetal pain laws aimed at making women think twice before getting abortions.

Critics angrily disputed the findings and claimed the report is biased.

“They have literally stuck their hands into a hornet’s nest,” said Dr. Kanwaljeet Anand, a fetal pain researcher at the University of Arkansas for Medical Sciences, who believes fetuses as young as 20 weeks old feel pain. “This is going to inflame a lot of scientists who are very, very concerned and are far more knowledgeable in this area than the authors appear to be. This is not the last word — definitely not.”

Proposed federal legislation would require doctors to provide fetal pain information to women seeking abortions when fetuses are at least 20 weeks old, and to offer women fetal anesthesia at that stage of the pregnancy. A handful of states have enacted similar measures.

The review says medical evidence shows that brain structures involved in feeling pain begin forming earlier but likely do not function until around the seventh month, when fetuses are about 28 weeks old.

Some scientists say younger fetuses show pain by moving away from a stimulus, but that likely is a reflex action and not an indication that they are actually feeling pain, said UCSF obstetric anesthesiologist Dr. Mark Rosen, the study’s senior author.

Offering fetal pain relief in the fifth or sixth month, when brains are too immature to feel pain, is misguided and might result in unacceptable health risks to women, the authors said.

Dr. Nancy Chescheir, chairman of obstetrics and gynecology at Vanderbilt University and a board director at the Society of Maternal-Fetal Medicine, said the report “will help to develop some consensus” on when fetuses feel pain. “To date, there hasn’t been any.”

Study not politically motivated
The sponsor of the proposed federal fetal pain legislation, Sen. Sam Brownback, R-Kan., says he’s prepared for “a robust debate” on his measure in light of the new review.

He said Wednesday’s JAMA report “seems to me to fly in the face of common experience and common sense.”

Brownback, often mentioned as a potential presidential candidate in 2008, thinks discussing fetal pain is one way to curb abortions without making them illegal.

“I’m pro-life and if a woman decides not to abort her fetus with this information, that would certainly be fine by me,” Brownback said.

The measure pending in Congress would affect about 18,000 U.S. abortions a year performed in the fifth month of pregnancy or later, said Douglas Johnson, legislative director of the National Right to Life Committee. He said the review is slanted.

Dr. Catherine DeAngelis, JAMA’s editor-in-chief, said the decision to publish the review was not politically motivated.

JAMA does not publish “politically motivated science. We publish data-based, evidence-based science,” she said.

Rosen said researchers “tried to review the literature in an unbiased fashion. This was a multidisciplinary effort by experts on anesthesia, neuroanatomy, obstetrics and neonatal development.”

Risks to mother
When doctors operate on fetuses to correct defects before birth, general anesthesia is given to the mother primarily to immobilize the fetus and to make the uterus relax. Anesthesia during fetal surgery increases the mother’s risks for breathing problems and bleeding from a relaxed uterus, the researchers said.

Rosen said those risks are medically acceptable when the goal is to save the fetus but there is not enough evidence to show any benefit from fetus-directed anesthesia during an abortion.

Administering anesthesia directly to the fetus is also sometimes done but generally to reduce the release of potentially harmful fetal stress hormones, Rosen said. There is little research on its effects.

But Anand said the study’s authors excluded or minimized evidence suggesting fetal pain sensation begins in the second trimester and wrongly assume that fetuses’ brains sense pain in the same way as adult brains.

While Anand has testified as an expert witness for the government in court cases opposing some late-term abortions, he said he is not anti-abortion and that his views are based on years of fetal pain research.


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Registered: 04-10-2003
Mon, 02-08-2010 - 1:06pm

Fetus Cannot Feel Pain, Expert Says
04.14.06, 12:00 AM ET

FRIDAY, April 14 (HealthDay News) -- Fetuses cannot feel pain, therefore U.S. legislation requiring doctors to tell women that the fetus will feel pain, or to provide pain relief during abortions, has no scientific basis and may harm the women involved, a leading expert contends.

"This is an unwarranted piece of legislation because there is good evidence that the fetus cannot feel pain at any stage of gestation," said Stuart Derbyshire, senior lecturer in psychology at the University of Birmingham, U.K.

He authored an review of the available data on the subject in the April 15 issue of the British Medical Journal.

"I don't think the question of pain resolves the argument about abortion," said Derbyshire, who said abortion remains a social, moral and political question. However, he said that, based on the evidence, "it's illegitimate to use the possibility of pain as a way of trying to prevent abortion from occurring, because the possibility of pain doesn't exist."

Some other experts agreed.

"No one wants to inflict pain in fetuses unnecessarily, nor do physicians want to put the mother at risk by the unnecessary administration of analgesics to treat her fetus, not her," said Dr. Henry J. Ralston, a professor of anatomy and neuroscience at the University of California School of Medicine, San Francisco. "I agree with Dr. Derbyshire's primary conclusion, that 'Legal or clinical mandates to prevent pain in fetuses are based on limited evidence and may put women seeking abortion at unnecessary risk.'"

The U.S. government is presently considering legislation that would require doctors to inform women seeking abortions that "there is substantial evidence that the process of being killed in an abortion will cause the unborn child pain."

The legislation would additionally require that a fetus of more than 22 weeks' gestational age receive anesthesia before the abortion procedure. Doctors who refuse to comply could be fined $100,000 while also losing their license and their Medicaid funding.

More than a dozen state legislatures -- including those in New York and California -- have debated such bills. Several states have already passed laws.

Congress is also considering whether to require doctors to provide anesthesia to fetuses in all cases of abortion after 22 weeks of gestational age.

But is there enough evidence to conclude that fetuses actually experience pain?

After examining the available neurological and psychological literature, Derbyshire says "no."

The neural circuitry needed to process pain is complete, if not mature, by 26 weeks' gestation, he said. "From about 26 weeks you can talk about there being a complete system in terms of biology, a link from the skin to the spinal cord to the brain, and we know that set-up is reasonably functional," Derbyshire explained.

But to properly experience pain, the mind must also be developed, something which cannot happen until after birth. The mind permits the subjectivity of pain, said the U.K. expert, who has previously served as an unpaid consultant to Planned Parenthood of Virginia and Planned Parenthood of Wisconsin, as well as the U.K.-based Pro-Choice Forum.

"The key thing is representational memory," Derbyshire explained. "If you want to discriminate pain from hunger, from vision, or from any other sensational experience, you need to be able to label it in some way, and that will come from interactions with the primary caregiver," -- in other words, after birth.

"I agree that pain is a complex sensory experience that requires activation of many regions of the cerebral cortex and that 'Without consciousness there can be nociception but there cannot be pain,'" Ralston said. "I do not know when that necessary neural circuitry is fully developed and functional, but it certainly is not established by 20 weeks gestational age, as encoded in legislation in several states in laws penalizing physicians for not informing mothers about pain in their fetuses."

The problem with the actions encoded in the legislation is that it could put the mother at risk, according to Derbyshire.

"It does introduce risks to the mother if we start to inject drugs to the fetus and increase the time of the procedure," Derbyshire said. "That would be unnecessary and involve unnecessary costs and risks."


iVillage Member
Registered: 12-24-2009
Tue, 02-09-2010 - 5:19am
LOL...John Edward (its Edward NOT"S" )
iVillage Member
Registered: 03-07-2008
Tue, 02-09-2010 - 10:16am
Why should the woman's home state be identified so YOU can decide if her reasons for seeing Dr Tiller were good enough?
iVillage Member
Registered: 07-25-2008
Tue, 02-09-2010 - 3:27pm
"Why should the woman's home state be identified so YOU can decide if her reasons for seeing Dr Tiller were good enough?

I must be a poor writer.

iVillage Member
Registered: 02-15-2005
Tue, 02-09-2010 - 3:28pm

So you really do believe the dead can feel pain? Wow.

Life is simpler when you plow around the stump.

iVillage Member
Registered: 03-07-2008
Tue, 02-09-2010 - 3:45pm
Sorry, my bad.
iVillage Member
Registered: 06-24-2009
Fri, 02-12-2010 - 10:09am

< Hosptials do late term terminations for birth defects, it's not like Tiller was the only place she could go. >

From the full article:

" They went to their doctor with their decision. He informed them that their state law did not allow third term abortions. He could not perform one.

They called a doctor across the state line, where third term abortions were allowable if it were necessary to save the life of the mother. The doctor had not indicated that this was the case. Neither had he indicated that it was not. They didn't know. Finally someone heard about George Tiller up in Kansas."

< I cannot imagine it's in the mother's best interest to be sent home after delivering so late in the pregnancy, KWIM? >

There is nothing in the article that addresses this as an issue. I'm curious as to why you assume that Dr. Tiller did not care for his patients properly.