Themes

"Rosen’s own hard look at the evidence came a few years ago, when he and a handful of other doctors at U.C.S.F. pulled together more than 2,000 articles from medical journals, weighing the accumulated evidence for and against fetal pain. They published the results in The Journal of the American Medical Association in 2005. “Pain perception probably does not function before the third trimester,” concluded Rosen, the review’s senior author. The capacity to feel pain, he proposed, emerges around 29 to 30 weeks gestational age, or about two and a half months before a full-term baby is born. Before that time, he asserted, the fetus’s higher pain pathways are not yet fully developed and functional. What about a fetus that draws back at the touch of a scalpel? Rosen says that, at least early on, this movement is a reflex, like a leg that jerks when tapped by a doctor’s rubber mallet."

"Likewise, the release of stress hormones doesn’t necessarily indicate the experience of pain; stress hormones are also elevated, for example, in the bodies of brain-dead patients during organ harvesting. In order for pain to be felt, he maintains, the pain signal must be able to travel from receptors located all over the body, to the spinal cord, up through the brain’s thalamus and finally into the cerebral cortex. The last leap to the cortex is crucial, because this wrinkly top layer of the brain is believed to be the organ of consciousness, the generator of awareness of ourselves and things not ourselves (like a surgeon’s knife). Before nerve fibers extending from the thalamus have penetrated the cortex — connections that are not made until the beginning of the third trimester — there can be no consciousness and therefore no experience of pain. Sunny Anand reacted strongly, even angrily, to the article’s conclusions. Rosen and his colleagues have “stuck their hands into a hornet’s nest,” Anand said at the time. “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.” Anand acknowledges that the cerebral cortex is not fully developed in the fetus until late in gestation. What is up and running, he points out, is a structure called the subplate zone, which some scientists believe may be capable of processing pain signals. A kind of holding station for developing nerve cells, which eventually melds into the mature brain, the subplate zone becomes operational at about 17 weeks. The fetus’s undeveloped state, in other words, may not preclude it from feeling pain. In fact, its immature physiology may well make it more sensitive to pain, not less: the body’s mechanisms for inhibiting pain and making it more bearable do not become active until after birth."

"Even birth may not inaugurate the ability to feel pain, according to Stuart Derbyshire, a psychologist at the University of Birmingham in Britain. Derbyshire is a prolific commentator on the subject and an energetic provocateur. In milder moods, he has described the notion of fetal pain as a “fallacy”; when goaded by his critics’ “lazy” thinking, he has pronounced it a “moral blunder” and “a shoddy, sentimental argument.” For all his vehemence in print, Derbyshire is affable in conversation, explaining that his laboratory research on the neurological basis of pain in adults led him to the matter of what fetuses feel: “For me, it’s an interesting test case of what we know about pain. It’s a great application of theory, basically.” The theory, in this case, is that the experience of pain has to be learned — and the fetus, lacking language or interactions with caregivers, has no chance of learning it. In place of distinct emotions, it experiences a blur of sensations, a condition Derbyshire has likened to looking at “a vast TV screen with all of the world’s information upon it from a distance of one inch; a great buzzing mass of meaningless information,” he writes."

"Mark Rosen was the anesthesiologist at the very first open fetal operation, performed in 1981 at the University of California, San Francisco, Medical Center, and the fetal anesthesia protocols he pioneered are now followed by his peers all over the world. Indeed, Rosen may have done more to prevent fetal pain than anyone else alive — except that he doesn’t believe that fetal pain exists. Research has persuaded him that before a point relatively late in pregnancy, the fetus is unable to perceive pain. Rosen provides anesthesia for a number of other important reasons, he explains, including rendering the pregnant woman unconscious and preventing her uterus from contracting and setting off dangerous bleeding or early labor. Another purpose of anesthesia is to immobilize the fetus during surgery, and indeed, the drugs Rosen supplies to the pregnant woman do cross the placenta to reach the fetus. Relief of fetal pain, however, is not among his objectives. “I have every reason to want to believe that the fetus feels pain, that I’ve been treating pain all these years,” says Rosen, who is intense and a bit prickly. “But if you look at the evidence, it’s hard to conclude that that’s true.”"

"Whether the fetus feels pain is a question that matters to the doctor wielding the scalpel. And it matters, of course, for the practice of abortion. Over the past four years, anti-abortion groups have turned fetal pain into a new front in their battle to restrict or ban abortion. Anti-abortion politicians have drafted laws requiring doctors to tell patients seeking abortions that a fetus can feel pain and to offer the fetus anesthesia; such legislation has already passed in five states. Anand says he does not oppose abortion in all circumstances but says decisions should be made on a case-by-case basis. Nonetheless, much of the activists’ and lawmakers’ most powerful rhetoric on fetal pain is borrowed from Anand himself."

"Even as some research suggests that fetuses can feel pain as preterm babies do, other evidence indicates that they are anatomically, biochemically and psychologically distinct from babies in ways that make the experience of pain unlikely. The truth about fetal pain can seem as murky as an image on an ultrasound screen, a glimpse of a creature at once recognizably human and uncomfortably strange."

"“Before a symbolic system such as language, an individual will not know that something in front of them is large or small, hot or cold, red or green” — or, Derbyshire argues, painful or pleasant. He finds “outrageous” the suggestion that the fetus feels anything like the pain that an older child or an adult experiences. “A fetus is biologically human, of course,” he says. “It isn’t a cow. But it’s not yet psychologically human.” That is a status not bestowed at conception but earned with each connection made and word spoken. Following this logic to its conclusion, Derbyshire has declared that babies cannot feel pain until they are 1 year old. His claim has become notorious in pain-research circles, and even Derbyshire says he thinks he may have overstepped. “I sometimes regret that I pushed it out quite that far,” he concedes. “But really, who knows when the light finally switches on?”"

"IF THE NOTION that newborns are incapable of feeling pain was once widespread among doctors, a comparable assumption about fetuses was even more entrenched. Nicholas Fisk is a fetal-medicine specialist and director of the University of Queensland Center for Clinical Research in Australia. For years, he says, “I would be doing a procedure to a fetus, and the mother would ask me, ‘Does my baby feel pain?’ The traditional, knee-jerk reaction was, ‘No, of course not.’” But research in Fisk’s laboratory (then at Imperial College in London) was making him uneasy about that answer. It showed that fetuses as young as 18 weeks react to an invasive procedure with a spike in stress hormones and a shunting of blood flow toward the brain — a strategy, also seen in infants and adults, to protect a vital organ from threat. Then Fisk carried out a study that closely resembled Anand’s pioneering research, using fetuses rather than newborns as his subjects. He selected 45 fetuses that required a potentially painful blood transfusion, giving one-third of them an injection of the potent painkiller fentanyl. As with Anand’s experiments, the results were striking: in fetuses that received the analgesic, the production of stress hormones was halved, and the pattern of blood flow remained normal. Fisk says he believes that his findings provide suggestive evidence of fetal pain — perhaps the best evidence we’ll get. Pain, he notes, is a subjective phenomenon; in adults and older children, doctors measure it by asking patients to describe what they feel. (“On a scale of 0 to 10, how would you rate your current level of pain?”) To be certain that his fetal patients feel pain, Fisk says, “I would need one of them 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!’ ” In the absence of such first-person testimony, he concludes, it’s “better to err on the safe side” and assume that the fetus can feel pain starting around 20 to 24 weeks."

"The conclusion suggested in the section above is further strengthened by consideration of the increasing body of evidence which shows that there are several suppressors in utero which act to inhibit neural activity in the fetus to a far greater degree than is seen postnatally in the infant. The uterus plays a key role in providing the chemical and physical factors that together help to keep the fetus continuously asleep. We propose that this is achieved, among other things, through the combined"

"Here we consider one final issue: whether nociceptive inputs may have deleterious consequences even if the “endogenously anesthetized” fetus does not consciously perceive pain at the time of stimulation. Can exposure to noxious stimuli initiate a cascade of events that sensitize the nervous system, or can repeated pain exposure in preterm infants contribute to attention, learning, and behavior problems later in life? It is critical to appreciate that not only is most of"

"We have considered whether the fetus, once its nociceptive pathways are complete, can feel pain in utero in a psychological manner akin to adult pain experience, and whether regardless of this the physiological responses to nociceptive input may lead to altered behavior later in life. We conclude that there is currently no strong evidence to suggest that the fetus is ever awake, even transiently; rather, it is actively kept asleep (and unconscious) by a variety of endogenous inhibitory factors."

"The processing of nociceptive stimuli requires peripheral sensory receptors, afferent and efferent sensory and motor pathways, and subcortical and cortical neural integration of the related impulse traffic. The development of nociceptive pathways has been extensively reviewed by others and is not the subject of this review. In brief, however, it is generally agreed that an integrated pathway exists by 24–28 weeks of gestation and that"

"IN FACT, “THERE may not be a single moment when consciousness, or the potential to experience pain, is turned on,” Nicholas Fisk wrote with Vivette Glover, a colleague at Imperial College, in a volume on early pain edited by Anand. “It may come on gradually, like a dimmer switch.” It appears that this slow dawning begins in the womb and continues even after birth. So where do we draw the line? When does a release of stress hormones turn into a grimace of genuine pain?"

"Our understanding of when the fetus can experience pain has been largely shaped by neuroanatomy. However, completion of the cortical nociceptive connections just after mid-gestation is only one part of the story. In addition to critically reviewing evidence for whether the fetus is ever awake or aware, and thus able to truly experience pain, we examine the role of endogenous neuro-inhibitors, such as adenosine and pregnanolone, produced within the feto-placental unit that contribute to fetal sleep states, and thus mediate suppression of fetal awareness. The uncritical view that the nature of presumed fetal pain perception can be assessed by reference to the prematurely born infant is challenged. Rigorously controlled studies of invasive procedures and analgesia in the fetus are required to clarify the impact of fetal nociception on postnatal pain sensitivity and neural development, and the potential benefits or harm of using analgesia in this unique setting."

"Whether the fetus can truly experience pain, at least in some way analogous to how adults emotionally understand pain, has been debated extensively over recent years and is of importance given continuing advances in fetal surgical and diagnostic procedures. This question has considerable implications for the management of invasive fetal procedures, particularly as fetal analgesic and anaesthetic treatment is complex and not without risk for the fetus. Prevention and treatment of pain are basic human rights, regardless of age, and if fetal interventions are to progress, then a greater understanding of nociception and stress responses is required. The timing of the neuroanatomical maturation of the nociceptive system is now well understood, and the final critical cortico-thalamic connections appear to be present by 24–28 weeks of gestation. This suggests that the fetus could potentially be able to feel pain by the third trimester, at least in a rudimentary fashion. This concept is said to be supported by studies which show that nociceptive stimuli elicit physiological stress-like responses in the human fetus in utero. However, physiological processing of a nociceptive stimulus and perceiving a nociceptive stimulus as painful are not the same. There are both a physiological and an emotional or cognitive aspect to pain perception, and indeed a significant element of learning [56]. Certainly, processing can be independent of perception, as is demonstrated during surgery under general anesthesia, for example, where nociceptive stimuli can still elicit subcortically mediated physiological stress responses despite unconsciousness. Thus, to emotionally experience pain, we must be cognitively aware of the stimulus (a cortical process), and this in turn requires that we must be conscious. The key question then is not about the anatomic completion or functionality of nociceptive pathways in utero, but whether the fetus is ever conscious and thus aware. In general, discussion of fetal pain perception tends to treat the fetus as an unborn newborn; i.e., that responses of the newborn represent an adequate surrogate for the fetus. The assumption is thus made that if the newborn (including the preterm newborn) can experience wakefulness (and therefore consciousness), and apparently feels pain, then so too must the age-equivalent fetus. Furthermore, evidence for fetal wakefulness (and again therefore consciousness) has been based on how certain fetal responses “resemble” newborn sleep–wake behaviors, rather than a true determination of fetal wakefulness per se. Given the complexities of studying the fetus, extrapolation from or to the newborn state is understandable. Systematic studies of fetal neurological function suggest, however, that there are major differences in the in utero environment and fetal neural state that make it likely that this assumption is substantially incorrect. This has important implications for our understanding of fetal pain perception. The current review critically evaluates the hypothesis that unlike the newborn, the fetus is actively maintained asleep (and unconscious) throughout gestation and cannot be woken by nociceptive stimuli. The evidence is examined with reference to fetal sleep–wake states, the role of cortico-thalamic gating in cortical arousal during sleep, and the unique contribution that certain inhibitory neuromodulators make in utero to cortical suppression. Finally, we briefly discuss the validity of the hypothesis that suggests that the nociceptive input may have long-lasting deleterious effects regardless of whether the fetus is asleep or not."

"Twenty-five years ago, when Kanwaljeet Anand was a medical resident in a neonatal intensive care unit, his tiny patients, many of them preterm infants, were often wheeled out of the ward and into an operating room. He soon learned what to expect on their return. The babies came back in terrible shape: their skin was gray, their breathing shallow, their pulses weak. Anand spent hours stabilizing their vital signs, increasing their oxygen supply and administering insulin to balance their blood sugar. “What’s going on in there to make these babies so stressed?” Anand wondered. Breaking with hospital practice, he wrangled permission to follow his patients into the O.R. “That’s when I discovered that the babies were not getting anesthesia,” he recalled recently. Infants undergoing major surgery were receiving only a paralytic to keep them still. Anand’s encounter with this practice occurred at John Radcliffe Hospital in Oxford, England, but it was common almost everywhere. Doctors were convinced that newborns’ nervous systems were too immature to sense pain, and that the dangers of anesthesia exceeded any potential benefits. Anand resolved to find out if this was true. In a series of clinical trials, he demonstrated that operations performed under minimal or no anesthesia produced a “massive stress response” in newborn babies, releasing a flood of fight-or-flight hormones like adrenaline and cortisol. Potent anesthesia, he found, could significantly reduce this reaction. Babies who were put under during an operation had lower stress-hormone levels, more stable breathing and blood-sugar readings and fewer postoperative complications. Anesthesia even made them more likely to survive. Anand showed that when pain relief was provided during and after heart operations on newborns, the mortality rate dropped from around 25 percent to less than 10 percent. These were extraordinary results, and they helped change the way medicine is practiced. Today, adequate pain relief for even the youngest infants is the standard of care, and the treatment that so concerned Anand two decades ago would now be considered a violation of medical ethics. But Anand was not through with making observations. As NICU technology improved, the preterm infants he cared for grew younger and younger — with gestational ages of 24 weeks, 23, 22 — and he noticed that even the most premature babies grimaced when pricked by a needle. “So I said to myself, Could it be that this pain system is developed and functional before the baby is born?”"

"In contrast to fetal surgery requiring regional or general anesthesia, minimally invasive fetal procedures do not involve maternal laparotomy or hysterotomy and instead use needles or endoscopy to access the fetus. For the sake of reducing pain, the increased risks of general anesthesia are unjustified for these procedures; adults typically undergo similar procedures with no analgesia or only local analgesia."

"Pain is an emotional and psychological experience that requires conscious recognition of a noxious stimulus. Consequently, the capacity for conscious perception of pain can arise only after thalamocortical pathways begin to function, which may occur in the third trimester around 29 to 30 weeks’ gestational age, based on the limited data available. Small-scale histological studies of human fetuses have found that thalamocortical fibers begin to form between 23 and 30 weeks’ gestational age, but these studies did not specifically examine thalamocortical pathways active in pain perception. While the presence of thalamocortical fibers is necessary for pain perception, their mere presence is insufficient—this pathway must also be functional. It has been proposed that transient, functional thalamocortical circuits may form via subplate neurons around midgestation, but no human study has demonstrated this early functionality. Instead, constant SEPs appear at 29 weeks’ PCA, and EEG patterns denoting wakefulness appear around 30 weeks’ PCA. Both of these tests of cortical function suggest that conscious perception of pain does not begin before the third trimester. Cutaneous withdrawal reflexes and hormonal stress responses present earlier in development are not explicit or sufficient evidence of pain perception because they are not specific to noxious stimuli and are not cortically mediated."

"In the context of abortion, fetal analgesia would be used solely for beneficence toward the fetus, assuming fetal pain exists. This interest must be considered in concert with maternal safety and fetal effectiveness of any proposed anesthetic or analgesic technique. For instance, general anesthesia increases abortion morbidity and mortality for women and substantially increases the cost of abortion. Although placental transfer of many opioids and sedative-hypnotics has been determined, the maternal dose required for fetal analgesia is unknown, as is the safety for women at such doses. Furthermore, no established protocols exist for administering anesthesia or analgesia directly to the fetus for minimally invasive fetal procedures or abortions. Experimental techniques, such as administration of fentanyl directly to the fetus and intra-amniotic injection of sufentanil in pregnant ewes, have not been shown to decrease fetal pain and are of unknown safety in humans."

"Anesthetics and analgesics are commonly used to alleviate pain and discomfort. Despite ongoing debate regarding fetal capacity for pain, fetal anesthesia and analgesia are still warranted for surgical procedures undertaken to promote fetal health. When long-term fetal well-being is a central consideration, evidence of fetal pain is unnecessary to justify fetal anesthesia and analgesia because they serve other purposes unrelated to pain reduction, including (1) inhibiting fetal movement during a procedure; (2) achieving uterine atony to improve surgical access to the fetus and to prevent contractions and placental separation; (3) preventing hormonal stress responses associated with poor surgical outcomes in neonates; and (4) preventing possible adverse effects on long-term neurodevelopment and behavioral responses to pain. These objectives are not applicable to abortions. Instead, beneficence toward the fetus represents the chief justification for using fetal anesthesia or analgesia during abortion—to relieve suffering if fetal pain exists."

"Although widely used to assess pain in neonates, withdrawal reflexes and facial movements do not necessarily represent conscious perception of pain. Full-term neonates exhibit a “cutaneous withdrawal reflex” that is activated at a threshold much lower than that which would produce discomfort in a child or adult. This threshold increases with PCA, suggesting that the capacity of the neonate to distinguish between noxious and nonnoxious stimuli is maturing. Furthermore, flexion withdrawal from tactile stimuli is a noncortical spinal reflex exhibited by infants with anencephaly and by individuals in a persistent vegetative state who lack cortical function. Behavioral studies have also identified a distinct set of neonatal facial movements present during invasive procedures such as heel lancing but absent during noninvasive procedures. These facial movements, which are similar to those of adults experiencing pain, were evident in neonates at 28 to 30 weeks’ PCA but not at 25 to 27 weeks’ PCA. Facial movements may not necessarily be cortically controlled. One study found no difference in facial activity during heel lancing of neonates with and without significant cortical injury, suggesting that facial activity even around 32 weeks’ PCA may not represent conscious perception of pain."

"Hemodynamic and neuroendocrine changes in fetuses undergoing stressful procedures have also been used to infer pain perception. As early as 16 weeks’ gestational age, fetal cerebral blood flow increases during venipuncture and transfusions that access the fetal hepatic vein through the innervated fetal abdominal wall but not during venipuncture and transfusions involving the noninnervated umbilical cord. Increased cerebral blood flow is not necessarily indicative of pain, as this response is thought to constitute a “brain sparing” mechanism associated with hypoxia and intrauterine growth restriction."

"Because pain perception probably does not function before the third trimester, discussions of fetal pain for abortions performed before the end of the second trimester should be noncompulsory. Fetal anesthesia or analgesia should not be recommended or routinely offered for abortion because current experimental techniques provide unknown fetal benefit and may increase risks for the woman. Instead, further research should focus on when pain-related thalamocortical pathways become functional in humans. If the fetus can feel pain, additional research may lead to effective fetal anesthesia or analgesia techniques that are also safe for women."

"Recent research provides a potentially urgent reason to ask this question. It shows that pain may leave a lasting, even lifelong, imprint on the developing nervous system. For adults, pain is usually a passing sensation, to be waited out or medicated away. Infants, and perhaps fetuses, may do something different with pain: some research suggests they take it into their bodies, making it part of their fast-branching neural networks, part of their flesh and blood. Anna Taddio, a pain specialist at the Hospital for Sick Children in Toronto, noticed more than a decade ago that the male infants she treated seemed more sensitive to pain than their female counterparts. This discrepancy, she reasoned, could be due to sex hormones, to anatomical differences — or to a painful event experienced by many boys: circumcision. In a study of 87 baby boys, Taddio found that those who had been circumcised soon after birth reacted more strongly and cried for longer than uncircumcised boys when they received a vaccination shot four to six months later. Among the circumcised boys, those who had received an analgesic cream at the time of the surgery cried less while getting the immunization than those circumcised without pain relief. Taddio concluded that a single painful event could produce effects lasting for months, and perhaps much longer. “When we do something to a baby that is not an expected part of its normal development, especially at a very early stage, we may actually change the way the nervous system is wired,” she says. Early encounters with pain may alter the threshold at which pain is felt later on, making a child hypersensitive to pain — or, alternatively, dangerously indifferent to it. Lasting effects might also include emotional and behavioral problems like anxiety and depression, even learning disabilities (though these findings are far more tentative). Do such long-term effects apply to fetuses? They may well, especially since pain experienced in the womb would be even more anomalous than pain encountered soon after birth. Moreover, the ability to feel pain may not need to be present in order for “noxious stimulation” — like a surgeon’s incision — to do harm to the fetal nervous system. This possibility has led some to venture an early end to the debate over fetal pain. Marc Van de Velde, an anesthesiologist and pain expert at University Hospitals Gasthuisberg in Leuven, Belgium, says: “We know that the fetus experiences a stress reaction, and we know that this stress reaction may have long-term consequences — so we need to treat the reaction as well as we can. Whether or not we call it pain is, to me, irrelevant.”"

"Other investigators measured increases in fetal plasma concentrations of cortisol, β-endorphin, and noradrenaline associated with intrauterine needling procedures, finding that increases during blood sampling from the hepatic vein were greater than those during sampling from the umbilical cord. However, these neuroendocrine responses do not constitute evidence of fetal pain, because the autonomic nervous system and hypothalamic-pituitary-adrenal axis mediate them without conscious cortical processing. Additionally, these responses are not specific for painful stimuli. Plasma noradrenaline concentrations may increase after umbilical cord transfusion, and plasma β-endorphin concentrations may increase after repeated cordocenteses. Plasma cortisol and β-endorphin concentrations increase during innocuous activities such as exercise. Moreover, in adults, neuroendocrine stress responses may persist despite well-controlled postoperative pain. Vital signs also have been used to assess neonatal pain."

"Another histological study of 12 specimens found that afferents from unspecified thalamic regions reached the developing prefrontal cortex in 1 preterm neonate of 27 weeks’ developmental age, concluding that thalamic fibers begin entering the cortex between 26 and 28 weeks’ developmental age (28 and 30 weeks’ gestational age). A different study found that thalamic afferents had not reached the somatosensory cortical plate by 22 weeks’ developmental age (24 weeks’ gestational age). By 24 weeks’ developmental age (26 weeks’ gestational age), the density of cortical plate synapses increased, although these were not necessarily from thalamic afferents. Based on these studies, direct thalamocortical fibers that are not specific for pain begin to emerge between 21 and 28 weeks’ developmental age (23 and 30 weeks’ gestational age)."

"Despite this developmental role, no human study has shown that synapses between subplate and cortical plate neurons convey information about pain perception from the thalamus to the developing cortex."

"The histological presence of thalamocortical fibers is insufficient to establish capacity for pain perception. These anatomical structures must also be functional. Although no electroencephalographic “pain pattern” exists, electroencephalography may be one way of assessing general cortical function because electroencephalograms (EEGs) measure summated synaptic potentials from cortical neurons."

"Nociception may be characterized by reflex movement in response to a noxious stimulus, without cortical involvement or conscious pain perception. Nociception involves peripheral sensory receptors whose afferent fibers synapse in the spinal cord on interneurons, which synapse on motor neurons that also reside in the spinal cord. These motor neurons trigger muscle contraction, causing limb flexion away from a stimulus. In contrast, pain perception requires cortical recognition of the stimulus as unpleasant. Peripheral sensory receptor afferents synapse on spinal cord neurons, the axons of which project to the thalamus, which sends afferents to the cerebral cortex, activating any number of cortical regions. Sensory receptors and spinal cord synapses required for nociception develop earlier than the thalamocortical pathways required for conscious perception of pain. No human studies have directly examined the development of thalamocortical circuits associated with pain perception. The developmental age at which thalamic pain fibers reach the cortex has been inferred from studies of other thalamocortical circuits, which may or may not develop at the same time as thalamic fibers mediating cortical perception of pain."

"Somatosensory evoked potentials (SEPs) may also provide evidence of pain processing in the somatosensory cortex, although they are not used clinically to test pain pathways. SEPs test the dorsal column tract of the spinal cord, which transmits visceral pain sensation to the somatosensory cortex via the thalamus. SEPs with distinct and constant N1 components of normal peak latency are present at 29 weeks’ PCA, indicating that thalamic connections with the somatosensory cortex are functional at that time."

"Pain is a subjective sensory and emotional experience that requires the presence of consciousness to permit recognition of a stimulus as unpleasant. Although pain is commonly associated with physical noxious stimuli, such as when one suffers a wound, pain is fundamentally a psychological construct that may exist even in the absence of physical stimuli, as seen in phantom limb pain. The psychological nature of pain also distinguishes it from nociception, which involves physical activation of nociceptive pathways without the subjective emotional experience of pain. For example, nociception without pain exists below the level of a spinal cord lesion, where reflex withdrawal from a noxious stimulus occurs without conscious perception of pain. Because pain is a psychological construct with emotional content, the experience of pain is modulated by changing emotional input and may need to be learned through life experience. Regardless of whether the emotional content of pain is acquired, the psychological nature of pain presupposes the presence of functional thalamocortical circuitry required for conscious perception, as discussed below."

"Merker’s much-discussed article was accompanied by more than two dozen commentaries by prominent researchers. Many noted that if Merker is correct, it could alter our understanding of how normal brains work and could change our treatment of those who are now believed to be insensible to pain because of an absent or damaged cortex. For example, the decision to end the life of a patient in a persistent vegetative state might be carried out with a fast-acting drug, suggested Marshall Devor, a biologist at the Center for Research on Pain at Hebrew University in Jerusalem. Devor wrote that such a course would be more humane than the weeks of potentially painful starvation that follows the disconnection of a feeding tube (though as a form of active euthanasia it would be illegal in the United States and most other countries). The possibility of consciousness without a cortex may also influence our opinion of what a fetus can feel. Like the subplate zone, the brain stem is active in the fetus far earlier than the cerebral cortex is, and if it can support consciousness, it can support the experience of pain. While Mark Rosen is skeptical, Anand praises Merker’s work as a “missing link” that could complete the case for fetal pain."

"A portion of life, every moment gets torn out of me hurting, and flees away."

"My heart itself is a wound, no medicine can cure it. It deepens further if stared at, and hurts more if touched."

"Let my pains remain with me."

"(May) the dead body of agony remain asleep resting its head on a pillow of flowers."

"There is an art in taking the whiplash of suffering full in the face, an art you must learn. Let each single attack exhaust itself; pain always makes single attacks, so that its bite may be more intense, more concentrated. And you, while its fangs are implanted and injecting their venom at one spot, do not forget to offer it another place where it can bite you, and so relieve the pain of the first."

"Now, all of this raises important questions about what one means by "evidence,"or "medical information,"because the ultra-sound image is presented as a document testifying that the fetus is "alive," is "human like you or me,"and "senses pain.""The Silent Scream has been sharply confronted on this level by panels of opposing medical experts, New York Times editorials, and a Planned Parenthood film. These show, for example,that at twelve weeks the fetus has no cerebral cortex to receive pain impulses;that no "scream"is possible without air in the lungs;that fetal movements at this stage are reflexive and without purpose;that the image of rapid frantic movement was undoubtedly caused by speeding up the film (cameratricks);that the size of the image we see on the screen, along with the model that is continually displayed in front of the screen, is nearly twice the size of a normal twelve-week fetus, and so forth."

"“A 20-week fetal pain bill is actually teaching people that it’s OK to kill children under 20 weeks,” said Ragon. “The incrementalism actually even teaches people that that’s morality. Because some people, unfortunately, derive their morality from the legislation that goes on around them. It’s supposed to be the other way around.”"

"May my pain remain drunk singing its own love songs."

"The term 'psychogenic' assumes that medical diagnosis is so perfect that all organic causes of pain can be detected; regrettably, we are far from such infallibility... All too often, the diagnosis of neurosis as the cause of pain hides our ignorance of many aspects of pain medicine."

"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.”"

"pain acts like a leaven for both word and thought, quickening your sense of reality and the true logic of this world. Without pain you cannot distinguish the creative element that builds and sustains life from its opposite-the forces of death and destruction which are always for some reason very seductive, seeming at first sight to be logically plausible, and perhaps even irresistible."

"When pain can't bless, heaven quits us in despair."

"Pain is a gift that God gives to His creatures."

"Everything that happens to us, such as pain and joy, blessings and misfortunes, significant events (such as successes and good fortune, accidents or the death of loved ones), insignificant events (such as daily work at home, in the office or at school), everything, everything will take on a new meaning because it is offered to us by the hand of God who is Love. He wants, or allows, everything for our own good. And sooner or later we will realize, looking with the eyes of the soul, that a golden thread links events and things and composes a magnificent embroidery: God's design for each of us."

"For I consider that the sufferings of the present time do not amount to anything in comparison with the glory that is going to be revealed in us. For the creation is waiting with eager expectation for the revealing of the sons of God. For the creation was subjected to futility, not by its own will, but through the one who subjected it, on the basis of hope that the creation itself will also be set free from enslavement to corruption and have the glorious freedom of the children of God. For we know that all creation keeps on groaning together and being in pain together until now."

"The multidimensionality of pain perception, involving sensory, emotional, and cognitive factors may in itself be the basis of conscious, painful experience, but it will remain difficult to attribute this to a fetus at any particular developmental age."

"Tell me your relation to pain, and I will tell you who you are!"