Parenting, by nature, means to seek to keep our children from experiencing unnecessary pain. We force our children to wear helmets, carefully supervise their first interactions with dangerous tools, and warn them about interacting with people who could physically or emotionally harm them. Our children rely on us to be safe, and it is our duty to protect them.

For some parents, this duty presents a vexing question even prior to their children being born. Faced with a serious genetic diagnosis, these parents are offered the option of ending the child’s life in utero to avoid a lifetime of suffering. Indeed, Western medical culture often encourages this choice as the compassionate thing to do – the way, in this heartbreaking situation, of somehow fulfilling the protective parental charge.

I will return to the implications of this choice later. But it also raises an immediate question for parents pursuing an abortion: Does that procedure in itself cause pain? This question is relevant not just to “termination for medical reasons” but for any abortion, and is of moral concern to those on both sides of the debate.

The Royal College of Obstetricians and Gynecologists (RCOG) and the American College of Obstetricians and Gynecologists (ACOG) have each offered major statements directed at this question, in effect concluding that the fetus cannot “experience” pain before twenty-four weeks gestation. These statements are phrased as to be reassuring, but the evidence they cover is not so simple, as at least one of their own signatories acknowledges.footnote

Each of these questions intrinsically comes down to the desire to avoid pain, or believe that pain has been avoided. The catch is that the pain in question is the pain of those who cannot speak for themselves. What do we take into account in making these decisions? Does our changing understanding of the pain invited or avoided change anything about the terms of the debate?

Can a Fetus Feel Pain?

RCOG’s 2010 statement on fetal awareness features a frequently-asked-questions section for expectant parents; eight of the eleven questions involve the baby’s capacity to feel pain.footnote Clearly it is of concern to parents even at the point of seeking an abortion. To which RCOG answers definitively, “No, the fetus does not experience pain.” (In this report, the terms “fetus” and “baby” are used interchangeably.) The report both surveys the latest research on fetal awareness and argues that even fetuses who appear to respond to painful stimuli do not “experience” pain consciously before at least twenty-four weeks. A 2022 update to the report strongly suggests that even “pain perception before twenty-eight weeks of gestation is unlikely.”footnote Drawing heavily on this survey, ACOG produced its own statement with a clear takeaway: “The science conclusively establishes that a human fetus does not have the capacity to experience pain until after at least 24–25 weeks.”footnote Both the American and the British statements draw political implications from this conclusion: ACOG insists that any abortion ban that invokes fetal pain is “a misunderstanding and misrepresentation of the science.”

However, “the science” is not so conclusive. To explain why, we start with a basic explanation of how we experience pain in our developed brains. A nociceptor – a neuron designed to detect tissue damage or distension – first detects a painful stimulus when, for example, you touch a hot stove. This neuron sends a signal all the way to your spinal cord, where a second neuron receives the signal and passes it on to your thalamus inside your brain, which in turn sends the signal a third time to your cortex. The cortex, being the center of higher brain functions, can recognize that your hand is touching the stove and take other actions to reduce the pain. However, the first neuron can also activate other neurons in your spinal cord to generate a reflex withdrawal from the pain without your brain ever experiencing pain. (This is how, for example, your knee moves without your effort when a doctor taps your knee to test your reflexes.)

The first neuronal connection between peripheral tissues and the spinal cord forms around eight weeks in a gestating fetus, while the second connection between the spinal cord and the thalamus forms around eighteen weeks (which is when the first reflexes withdrawing from touch can also be demonstrated, such as when a needle is introduced into the womb). The third connection between the thalamus and the cortex does not form in a gestating fetus until at least twenty-four weeks, and since the cortex is assumed to be necessary to experience pain this is what RCOG and ACOG take as the “conclusive” evidence for their answer. Some also argue that chemicals in the womb inhibit the fetus’s ability to ever be aware of its surroundings in any meaningful way.footnote Thus, any responses that one sees in utero (such as a fetus moving away from a sharp object introduced into its environment) are taken to be reflexes and not indicative of any true pain sensation.

Regardless of the circumstances, it is the duty of every medical provider, friend, and family member to declare: No, you are not better off dead than alive. There is hope.

It is worth remembering that prior to the late 1980s, it was generally assumed that newborns did not have the higher functions of their cortex necessary to subjectively feel pain, and so neonatal analgesia (pain relief) and anesthesia (numbing a particular area of the body or the entire body) were not routinely practiced. The babies would communicate in the only way that babies can that they were in distress, but this was written off as reflex. It was only after studies were done convincingly demonstrating that children who are already born can feel pain that practices changed.footnote

Similarly, advancements in fetal surgery allow for all kinds of interventions meant to benefit the fetus, for which fetal analgesia and anesthesia are now routinely recommended. It may be argued that these practices are helpful not for pain relief but simply to reduce fetal movement for the procedure, but the American Society of Anesthesiologists Committees on Obstetric and Pediatric Anesthesiology and the North American Fetal Therapy Network explicitly base their recommendation on the fact that “it remains uncertain exactly when a fetus has the capacity to feel pain.”footnote

The real wrinkle in the research, though, is the existence of subplate neurons: these neurons form from about twelve weeks’ gestation onwards, and they are an intermediate step in the connections between the thalamus and the cortex. More and more evidence is emerging that they can mediate the experience of pain just as well as the mature thalamocortical neurons can, which means that fetuses in the womb could experience pain as early as twelve weeks. Even one of the principal authors of the RCOG report has affirmed this new evidence, and coauthored a paper with a colleague who has opposite convictions on abortion to consider the implications.footnote

If these subplate neurons do allow a fetus to experience pain, then it is much more appropriate to say that the development of our capacity to feel pain is more of a continuum than a discrete event.footnote Those who perform fetal surgery are now being urged to treat every one of their patients as if they might feel pain, and their peers who are not being operated on ought to be treated similarly. Just as we acknowledge now that neonatal pain, while slightly different from that of adults, is just as real and meaningful, so too we must acknowledge the reality of fetal pain. Will acknowledging that reality change anything? That will depend on how we answer an even more fundamental and important question.

Spare the Sufferer a Life of Suffering?

Many people who defend abortion are willing to consider moral questions around abortion after the point at which a fetus feels pain. However, even if one establishes that a fetus can feel pain or that the likelihood of feeling pain increases with gestational age, the later an abortion is performed, the more likely it is to be performed for reasons related to fetal defects, at which point one finds oneself up against arguments for preventing future suffering.

The appeal to parents is that it is in the best interests of that child to abort him or her in order to spare that child a lifetime of pain. Presumably, the choice is made by many that it is better for children who will be born with a genetic anomaly or similar defects to suffer quickly (if at all) and be killed rather than to endure pain throughout their lives. Is it truly better that these children not be born into a world that can be downright cruel, struggling through life with bodies and minds that may be permanently disabled?

First of all, we have to acknowledge that prenatal diagnosis is not always an exact science. Errors can be made, data can be misinterpreted, and even when a diagnosis is correct the severity of the condition in question cannot be known with certainty. Some parents have been happily surprised to find that the problem they were warned about turned out to be nothing to worry about at all. Some malformations are lethal but easily corrected with surgery; the child then goes on to live a perfectly happy and normal life. I remember one patient of mine who agonized over whether she should abort her child with a severe defect. I was shocked when she brought that two-week-old child into the office for a routine checkup; he was in perfect health but for a healing scar on his chest.

Still, there are times when a genetic condition ascertained in utero is as serious as it seems. Some conditions are so lethal that children born with them should receive hospice care to help them die peacefully and naturally. Other times, however, genetic anomalies involving multiple organ systems mean such children must undergo a number of surgeries and treatments after they are born and then they will still be mentally disabled and dependent for the rest of their lives. Some suffering is inevitable – and not quickly resolved.

Photograph by Mohammed

For these cases, what should we say? When a judgment is made that someone is better off dead as early as possible before experiencing suffering, my mind immediately turns to people I have cared for with mental health conditions. Quite often patients in the grip of psychiatric illness believe they are better off dead than alive, and with the amount of misery that these poor souls have been inflicted with (or have inflicted on others), the case for suicide seems quite compelling to them.

In that situation, it is the duty of every medical provider, friend, and family member to declare, regardless of the circumstances: No, you are not better off dead than alive. There is hope. Whatever suffering you are in now can be alleviated, no matter how difficult it might be. Don’t kill yourself. We must make a similar appeal on behalf of those who cannot say whether or not they would prefer to live or die.

My work as a family doctor in sub-Saharan Africa brings me into contact with many children who suffer from genetic anomalies or cerebral palsy due to oxygen deprivation during birth. Since maternal and neonatal care is not always what it should be and genetic screening is so rarely performed, this is not at all uncommon. I also regularly encounter those who have suffered serious head trauma or survived severe brain infections. Most of these people do not live independent lives and never will; their impairments do incur extra expenses and responsibilities for their caretakers. Yet they themselves are glad to be alive, glad to be wandering around the tea fields and cow pastures of the South Rift Valley, and glad to be with their families. And if the energetic efforts of their families and their communities to care for them and raise funds for their treatment are any indication, the people who love them are glad that they are alive too.

I can’t help but contrast this outlook with one in a more developed nation where living with a disability has become almost unthinkable. In Sarah Zhang’s harrowing Atlantic article, “The Last Children of Down Syndrome,”footnote she describes the effect of a well-funded healthcare system in Denmark where virtually every pregnancy is screened for genetic anomalies and abortion is available to all: in 2019, only eighteen children with Down syndrome were born. Seven were born to families who knew the diagnosis and chose not to get an abortion, the others to families who either declined the screening or had a false-negative test. Some years in Denmark, zero children with Down syndrome are born.

This, Zhang points out, leads to a scarcity of medical professionals who can care well for children with disabilities for lack of a patient base to train or work with. It burdens parents with a choice that previous generations of humans have never had to face, suggesting that they are taking away opportunities or joy from other children in the family if they choose to welcome a sibling who is disabled. Perhaps worst of all, it isolates and stigmatizes those who are born with disabilities or who become disabled later on.

It is often suggested that a more robust system of welfare for families and children and better prenatal care would reduce the number of abortions in the United States. I do find this argument compelling in some respects – certainly, I support better healthcare and social safety nets as goods in their own right – but we should take Denmark’s statistics as a warning: a society in which welcoming the disabled is optional is one in which far fewer persons with disabilities are welcomed. And a society that prioritizes avoiding pain and anesthetizing suffering is one that eventually is forced to close off the possibility of life in more ways than one.

What will it take to invite these children into life and reduce their suffering? The social and political movement against abortion is hindered by the fact that those who make pronouncements against it are often too comfortable with the assumptions and machinations that drive our culture of death. Welcoming those who are suffering rather than killing them entails asking more of us collectively than our individualist society prepared us for.

Psalm 51 speaks of the womb as “the secret place” where its author was taught wisdom by God, evoking an impression of consciousness dawning in the darkness. It is difficult to imagine a study that would definitively demonstrate the moment that a fetus becomes sentient of pain. It is impossible to design a study that would give us a “scientific” answer about what to do after – or before – that point. Asking whether or not we should relieve unborn children of a potential life of pain by preventing them from joining us in this world of pain is the wrong question, because to do so is neither our prerogative nor our responsibility.

The only answer is another question: How will we collectively deal with that harsh reality and help one another through it?

Some pains can indeed be relieved, others can only be shared. The most obvious place that this sharing happens is within families, where a web of unchosen obligations between people emerges from the raw connection of flesh and blood. Families, however, need more – they need other people who can walk beside them and share in their sufferings. There are many others who have no family support, and they also need people who are willing to be there alongside them.

When we fulfill our unchosen obligations to those in need, we declare to the world that their lives are valuable. When our time, energy, money, and tears are spent on behalf of those who are less than autonomous and independent agents, we shore up a culture of life and prove that autonomy is not the greatest good. When we choose to share their burden, we demonstrate that chasing painlessness is at its heart a quest to permanently anesthetize ourselves and other people. We can then turn to any of our neighbors, even if their faces are hidden from us inside of a womb, and say that their pain is not theirs alone to bear.

Footnotes

1. Derbyshire, SW, Bockmann, JC, “Reconsidering Fetal Pain,” Journal of Medical Ethics 2020; 46:3–6.
2. Royal College of Obstetricians and Gynecologists, “Fetal Awareness: Review of Research and Recommendations for Practice.”
3. Royal College of Obstetricians and Gynecologists, “RCOG Fetal Awareness Evidence Review, December 2022.”
4. American College of Obstetricians and Gynecologists, “Facts Are Important: Gestational Development and Capacity for Pain.” October 31, 2022.
5. Mellor David J., Diesch Tamara J., Gunn Alistair J., Bennet Laura. 2005. “The Importance of ‘Awareness’ for Understanding Fetal Pain.” Brain Research Reviews 49:455–71.
6. Anand K. J. S., Phil D., Hickey P. R. 1987. “Pain and Its Effects in the Human Neonate and Fetus.” New England Journal of Medicine 317:1321–29.
7. Chatterjee D., Arendt K. W., Moldenhauer J. S., Olutoye O. A., Jagroop Mavi Parikh, Parikh J. M., Tran K. M., Zaretsky M. V., Zhou J., Rollins M. D. 2021. “Anesthesia for Maternal-Fetal Interventions: A Consensus Statement from the American Society of Anesthesiologists Committees on Obstetric and Pediatric Anesthesiology and the North American Fetal Therapy Network.” Anesthesia & Analgesia 132 (4): 1164–1173.
8. Derbyshire SW, Bockmann JC, “Reconsidering fetal pain,” Journal of Medical Ethics 2020; 46:3–6.
9. Thill B, “Fetal Pain in the First Trimester,” Linacre Quarterly 2021; 89 (1):73–100.
10. Zhang, Sarah, “The Last Children of Down Syndrome,” the Atlantic. December 2020.