AAPLOG Practice Bulletin No. 2: Fetal Pain

Issues in Law & Medicine, Fall 2018 | Go to article overview

AAPLOG Practice Bulletin No. 2: Fetal Pain


American Association of Pro-Life Obstetricans & Gynecologists*

Background

Pain Defined

The definition of "pain" is much debated among embryologists, family planning professionals, ethicists, and politicians. Certainly, the adult person's perception of pain is a complex physical and psychological interplay with long-term consequences for society1 Since psychology or behavior are currently impossible to detect in human fetuses, discussion of fetal pain is often seen as meaningless. However, in literature on non-human organisms, pain has been defined as "aversive behavioral and physiological reactions and a suspension of normal behavior in response to noxious stimuli that cause pain in other animals and humans."2 For the purposes of this document, pain will be defined this way.

Embryology and Fetal Development

In adults, painful stimuli are received by nociceptors in the skin and viscera; these communicate impulses via afferent sensory neurons through the spinal cord, are processed in the thalamus, and are received by the sensory cortex before a motor response is elicited. Adults also have reflex arcs that operate through motor neurons in the spinal cord's dorsal root ganglia, allowing the body to bypass the cortex for the sake of speed.3 Both of these neural pathways are associated with neurohormonal responses including epinephrine, cortisol, and endorphins. Nociceptive signaling differs throughout human development, with neonates using different structures than adults.4 In non-human animals, nervous systems are much simpler, with some of the lowest animals with three germ layers such as nematodes or octopi reacting to noxious stimuli with only nerves and ganglia.5'6

In fetuses, different structures have neurologic function at different times in development, analogously to the two sets of functioning nephrologic structures in fetal life.7 "Clinical and animal research shows that.. .the structures used for pain processing in early development are unique and different from those in adults, and that many of these fetal structures and mechanisms are not maintained beyond specific periods of early development. The immature pain system thus uses the neural elements available during each stage of development to carry out its signaling role."4'8'9

Van Sheltema et al. have argued that this means "the lack of development of certain connections is not sufficient to support the argument that fetuses can not [sic] feel pain until late gestation."10 Most agree that differences in structure imply some difference in function or potency, much like the fetal mesonephros; Killackey and Dawson noted that in rats, dividing early neuronal connections had disastrous consequences for developing later connections.10

Decades of histologic research have illustrated that sensory receptors, including nociceptors, are present throughout the fetus between 10 and 14 weeks gestational age, starting as early as 7 weeks.11'17 This begins in the perioral area at 7 weeks, followed by the palms and soles at 11 weeks, and the remainder of the integument by 20 weeks.18'19 Superficial nociceptors, followed later by nociceptors in viscera, are connected by afferent fibers from the spinal column to the thalamus and from the thalamus to the subcortical plate between 16 and 20 weeks gestational age.20'24 These afferent fibers "appear morphologically mature enough to synapse with subplate neurons" and cause a central response, possibly as early as 16 weeks' gestational age.22'25 Peripheral afferent fibers that control movement grow into the spinal cord at 8 weeks gestation.19 These are the three tissue components of a reflex are in the adult.

Experience of fetal surgeons and other physicians performing invasive procedures (e.g. peritoneal transfusion) matches these histologic findings. As early as 7.5 to 8 weeks' gestational age, a fetus moves in response to stimuli.24'26'28 "Responses to touch begin at 7-8 weeks gestation when touching the peri-oral region results in a contralateral bending of the head. …

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