The Unborn Child Pain Awareness Act: Bad Medicine on The Hill
Early in December 2006, the “Unborn Child Pain Awareness Act” mercifully failed to pass in the U.S. House of Representatives. The appallingly misguided act would mandate any woman undergoing termination after 20 weeks of pregnancy to sign a statement acknowledging the supposed pain that her “unborn child” would feel during the procedure. The act would also require doctors to offer anesthesia for the fetus and to give the patient a brochure that must contain the following statement: “There is substantial evidence that the process of being killed in an abortion will cause the unborn child pain, even though you [the patient] receive a pain-reducing drug or drugs.”
“Killed?” “Unborn child?” Like any pro-choice person, I could go on all day about the philosophical problems with that statement, but as a medical student and soon-to-be doctor, I’m more disturbed by the medical inaccuracy of the act’s claims. This is only one example among many of medically-oriented politico-legal statements that conservative lawmakers churn out as they strive to stay afloat in the increasingly technical and often inaccurate national abortion debate. These lawmakers spout sweeping medical conclusions as though they were handed down from the mount, despite at-times-overwhelming medical evidence supporting the opposite conclusion.
There is, in fact, very little evidence that fetuses experience pain. The world of prenatal screening, fetal therapy, and fetal surgery blossomed in the 1980s, giving rise to large amounts of research into fetal pain, anesthesia, and analgesia. Although pain is a complex phenomenon not easily measured in humans, anatomical and functional studies of the brain in premature infants have been done. A particularly thorough review of scientific research on fetal pain and anesthesia appeared in the Journal of the American Medical Association (JAMA) in August of 2005. Authors concluded that a fetus does not have the capacity to feel pain before 29 or 30 weeks of gestation.
The House act’s first piece of evidence for fetal pain is that “at least by 20 weeks after fertilization, an unborn child has the physical structures necessary to experience pain.” This statement clouds the distinction between “feeling” or “sensing” pain and “experiencing” pain. While the fetus’s limbs have nerve fibers that connect to its spinal cord, and thus, in scientific terms, may indeed have the capacity to “feel” pain, the fetus does not have the higher-order architecture at 20 weeks to actually “experience” pain. The experience of pain is a combination of physical stimulus, consciousness of the stimulus, and emotional response to the stimulus. A painful stimulus must activate a nerve, which must conduct an impulse to nerves in the spinal cord, which must connect with the perception relay center in the middle of the brain, the thalamus. This must be connected to the surface of the brain, where perception is processed, for the fetus to actually experience pain. Anatomical studies of the pain connections between the thalamus and cortex have not been done in human fetuses, but scientists have demonstrated that visual and auditory pathways through the thalamus do not connect to the surface of the brain until 24-26 weeks of gestation. Another study showed that other general thalamic fibers did not reach the cortex until 28-30 weeks of gestation.
The presence of the structures to sense pain does not necessarily indicate the ability to experience pain. Consciousness is necessary for pain perception, and scientists have used electroencephalography (EEG) to measure electrical activity on the surfaces of the brains of premature infants to look for consciousness as a sign of a functioning pain perception. Premature infants do not demonstrate brainwaves associated with wakefulness in children and adults until 29-30 weeks after conception, and so it is likely that consciousness as we know it does not exist before this point. Also, it is not until even later, 34 weeks, that the electrical activity between the two brain hemispheres becomes synchronous, which may also be important in consciousness and pain perception.
Congressional evidence for fetal pain also included the observation of fetuses withdrawing from surgical instruments during intrauterine procedures. This is also a failure to differentiate “sensing” pain and “experiencing” it. JAMA authors make two comments regarding this observation: First, a reflex withdrawal from pain is based in the spinal cord and can happen without an organism being conscious of the pain—this is “sensing” the pain or stimulus without “experiencing” it. The classic example is the one in which a person touches a hot stove and withdraws her or his hand seconds before actually feeling pain. Second, the authors point out that a fetus withdraws its limbs with almost any stimulation of the skin, not just potentially painful stimuli.
JAMA authors also commented on fetal facial expressions. Behavioral studies show that, during invasive procedures, fetuses grimace or make facial expressions similar to adults and children in pain. However, these responses have only been noted after 28-30 weeks and were absent at 25-27 weeks.
The act goes on to present the routine use of fetal anesthesia during fetal surgical procedures as evidence that anesthesia is required during late-term terminations. Physicians use fetal anesthesia for fetal surgeries such as repairing a hole in the diaphragm or repairing a detected defect in the uro-genital system. However, the authors of the JAMA article point out that anesthesia is not used to manage fetal pain in such cases. Anesthesia has safety benefits during fetal surgery regardless of the lack of pain perception, including the inhibition of fetal movement, uterine relaxation, and prevention of biochemical responses which could distort neural development. These are long-term concerns that are not relevant if the pregnancy is being terminated.
So, when reviewing the bill and available information, how did our lawmakers fare with finding this research and synthesizing it into an intelligent vote? Not well. The House voted on the bill (HR 6099) through an expedited protocol that, luckily, requires a two-thirds majority to pass the act. The chamber voted 250-162 in favor of the bill, 25 votes short of passing it, with 210 Republicans voting in favor of the legislation and an incredible 40 Democrats crossing the aisle.
If you’ve spent any time on Capitol Hill, you know that most lawmakers don’t even read the legislation before they vote on it. Also, almost all votes are determined before a bill reaches the floor through an intricate bargaining system centered around party politics, constituent wishes, career ambitions, and a pinch of free-thinking on the part of the lawmaker. Congressional floor debates are no more than an elaborate show for the American people and press, often with sensationalistic testimony and ass-kissing among the ranks. If and when a salient, reasonable point is made, it often falls on deaf ears.
This “Unborn Child Pain Awareness Act” is no exception; during the measly 20 minutes of debate, Congressman Rush Holt of New Jersey even cited the JAMA 2005 article, sharing the main conclusion and stating, “The review also concludes that administering ‘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.’” As I read the transcript of the floor debate, I thought, “Thank God someone is paying attention.” But any hope for our lawmakers was extinguished by the reality that this didn’t stop 250 people from voting for the act anyway.
Truthfully, few Congress members understand the scientific method, and impartiality is not intrinsically valued in a representative government; such hand-wringing is territory of the Justice Department. If some Southern gentleman believes that life begins at conception and envisions a miniature person in mom’s womb, then no JAMA paper is going to convince him otherwise. Cultural ethos and political goals influence lawmakers’ conclusions on healthcare just as they do gun laws or prayer in school. As a result, a law’s medical language, passed by both houses of Congress and signed by the President of the United States, can be completely inaccurate, as we saw with the “Partial Birth Abortion Ban” of 2003.
Not all congress members are oblivious to this; according to Science News, Congresswoman Lois Capps of California said, “We are wasting time today on a bill that is laden with rhetoric but very little science.” In addition, Congresswoman Betty McCollum of Minnesota stated that the bill “would actually require a medical professional, under federal law, to give women inaccurate and potentially harmful information.”
Still, according to conservative sources like the Southern Baptist Convention Baptist Press, the voting result encouraged sponsor Rep. Chris Smith of New Jersey, who said the vote was “proof-positive that we can pass this legislation despite the unwillingness of some extreme pro-abortion members of Congress.” Smith promised to re-introduce the bill, and Senator Sam Brownback of Kansas is slated to re-introduce a similar bill (S. 51) in the Senate in the 110th congress.
Given the passing of other abortion laws with untrue statements about fetal pain, such as the “Partial Birth Abortion Act” with its assertion that fetal pain is “a medical fact,” I wouldn’t be too surprised to see this bill eventually passed in both houses and signed into law by our esteemed president. However, while the “Partial Birth Abortion Act” got snagged by a Supreme Court ruling on a state-level predecessor, I see no precedent or constitutional violation to take the “Unborn Child Pain Awareness Act” into the Roberts Court, as unfortunately, there is no constitutional amendment demanding medically-responsible laws. Hopefully someone will be able to plead the case that the act places undue burden on the patient by making her sign a statement that she is “killing” her “unborn child.”
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SIN (Science in the News)
Too often, the media’s reporting on scientific findings and issues becomes a professional game of Telephone, with each re-telling adding an extra layer of misunderstanding, miscommunication, erroneous information, and dumbed down simplification. Each week, we will take a recent news story and attempt to excavate the original truth behind the hype, correcting the errors of the media’s coverage, commenting upon reoccurring issues with the science-to-public pipeline, and analyzing the motives and machinery behind these distortions.