Download MP3 – 1:01:03
In this podcast, two authors discuss recent research regarding fetal pain: John Bockmann, co-author of “Reconsidering Fetal Pain” (2020) and Dr. Bridget Thill, MD, MS, author of “Fetal Pain in the First Trimester” (2021).
Here’s a link to the five slides Bridget Thill discussed, including working links to the sources in the footnotes. (Opens PDF)
- 00:00 Introduction
- 01:47 Background on fetal pain and “Reconsidering Fetal Pain”
- 10:47 Keys to this unlikely, productive collaboration
- 13:39 Fetal pain: Advances in understanding
- 16:30 Current science and treatment of fetal pain
- 19:47 Cortex needed for pain?
- 22:40 Are fetal responses to pain just reflexes?
- 27:10 How did we get fetal pain so wrong?
- 29:52 A lack of compassion or a lack of understanding?
- 33:30 Recognition of fetal pain
- 38:19 Correlation with behavior, not overreliance on hypotheses
- 41:02 Pain assessments are calibrated to patient response, not brain imaging
- 42:10 Correlation with clinical behavior
- 42:56 Specialized pain assessment tools for different stages of development
- 45:23 Fetal Pain 101
- 45:45 Slide 1: An Evolving Understanding of Pain
- 46:33 Slide 2: Development of Fetal Pain Pathways
- 47:36 Slide 3: Responses to Pain in Fetus & Extremely Preterm Infant Under 24 weeks
- 49:00 Slide 4: The Fetal Pain Paradox
- 49:37 Slide 5: Levels of Consciousness
- 50:50 Future fetal pain research
- 52:37 How to receive updates regarding fetal pain
- 53:22 Pro-choice response to “Reconsidering Fetal Pain”
- 55:34 How to talk–and not talk–about fetal pain
- 59:36 Summary on fetal pain
[In this podcast, two authors discuss recent research regarding fetal pain: John Bockmann, co-author of Reconsidering Fetal Pain (2020) and Dr. Bridget Thill, MD, MS, author of Fetal Pain in the First Trimester (2021).]
ERI Fetal Pain Podcast
Josh Brahm with Bridget Thill, M.D. and John Bockmann
Monday, April 11, 2022
Josh Brahm: Well, welcome back to the Equipped for Life Podcast. I have two very special guests with me today; let me introduce them real quick, and we are going to dive into a great discussion.
We’ve got John Bockmann here, who’s a military physician assistant and co-author of Reconsidering Fetal Pain with Dr. Stuart Derbyshire. Some of you have already heard a little bit of that story from either me, or perhaps Secular Pro-Life, so we’ll be talking about that.
We’re also joined by Dr. Bridget Thill, who’s a former Air Force general practice physician who cared for military personnel in the U.S. and overseas before transitioning to medical bioethics. She received her master’s degree in medical bioethics from the University of Mary, and she works as an independent researcher and writer in medical bioethics.
So we will be talking about fetal pain today, and particularly what these two researchers, who just know way more about this than I do, have been learning in the last several years about this topic. But before we get into kind of the real scientific details, I want us to take a few minutes and talk about, how did this paper that John wrote with Dr. Stuart Derbyshire happen? So for those of you that don’t know, basically, John—pro-life guy—reached out, here’s my understanding, reached out to a pro-choice researcher who’s been very public, and published multiple times, on fetal pain, and had roughly the standard line saying pain probably couldn’t begin before, like, 24 weeks. And then you have some kind of correspondence with him, and it ends with you guys co-authoring a paper saying that fetal pain might begin as early as, I think, 13 weeks; you will correct whatever I get wrong. But that is a huge deal.
So just at a persuasion level, at a dialogue level, how did that happen? Tell us the story.
1:47 Background on fetal pain and Reconsidering Fetal Pain
John Bockmann: Well thanks for that glowing introduction, Josh, and I’m as amazed by that story as anyone.
It didn’t happen all at once, I’ll say that right now. It happened over the course of several years, many conversations—some in person, probably most via e-mail. As you may note, he is in charge of the imaging center at [the] National University of Singapore. So, time differences, great geographical distances, and so it’s a very unlikely meeting.
But as you pointed out, it all began with me reaching out to him—and him just coming back. I was shocked and surprised, because I had read about him throughout my research for my fetal pain thesis in PA school—2015, I had just started PA school, kind of a mid-life change—and his name came up on every, pretty much everything to do with pain at all, and certainly on fetal pain. He was part of the Working Party that wrote what many considered to be the last word, the authoritative word on the topic of fetal pain: Royal College of Obstetricians and Gynaecologists’ 2010 report on fetal awareness. So that report said, No fetal pain before 24 weeks, as you mentioned—and then, the kicker was—or possibly at any point during pregnancy, during gestation.
Josh Brahm: Oh really!
John Bockmann: Yes, a lot of people don’t realize that. So that paper really was like, yeah, these neurologic structures are necessary, but they may not be sufficient, because the fetus may be in a soporific state; sort of like, sleepy, anesthetized. That was the hypothesis, because they did some research on fetal lambs. So they’re like, if we extrapolate to the human fetus, then we can infer that the human fetus is never awake during gestation at any point. Just wakes up, just as he’s being born.
Josh Brahm: Wow.
John Bockmann: Yeah, so that was his position, just to clarify. The daylight came when I read a 2013 article in the New York Times, in which he seemed to be walking back that position. He was like, “That [fetal sleep] is a really interesting position, but I’m afraid it just doesn’t work.”
That bothered me, and I saw it and put it aside. There are huge amounts of—Bridget knows—huge amounts of research that bear on fetal pain. Philosophy, to neurology, to anesthesiology, to pediatrics—you name it. Every single thing you can think of. So I put that aside, and I was about to have to turn in my fetal pain thesis in 2016, May 2016—it’s been almost 6 years now—and I was like, you know what? I really gotta know. Because [Stuart Derbyshire’s] everywhere. If he thinks there might be a little smidge of daylight, then I’m curious. This belongs in my thesis.
So I emailed him. And the next morning—I emailed him during class—and the next morning, I came back and there was a full-page response. I couldn’t believe it. So that began, basically, several years of talking. We wound up meeting; that’s a story in itself. Very interesting. Couldn’t hope to duplicate it if I tried.
Josh Brahm: Go one level deeper. I know you don’t want to tell all the details, but I’m so curious. Tell us, maybe at a 10,000-foot view, what those few years were like. What was the evolution; what were the catalysts to his mind being changed in a massive way? Tell us a little bit about that.
John Bockmann: Yeah. So in RCOG 2010—that’s what I call it for short; Bridget and I are on the same page—in RCOG 2010 it just mentions the idea that there could be a rawer—R-A-W-E-R, more raw—pain experience, other than something that’s more cerebral, fully understood, cognitive; requiring, in the view of the authors of that report, a cerebral cortex, the last portion of the brain to develop evolutionarily and developmentally.
And so the idea of no pain until I think maybe a year postnatally in some cases, some people thought. But there was this little thing [a sidebar] inside RCOG 2010; it acknowledged there could be some raw-er version of pain that didn’t require all this “knowing that I’m in pain;” it could just be “being in pain.” And so that struck me. Both Bridget and I picked up on this as possibly authored by Stuart [Derbyshire]. It turns out we were correct.
Josh Brahm: Huh.
John Bockmann: And it’s “DAR-bshr” by the way; that got me for years. I didn’t know until I met him, and then I was like, “Really, that’s how you pro…? That’s wrong. You pronounce your name wrong.”
Josh Brahm: I’ve been getting it wrong for years!
John Bockmann: So anyway, let the record show.
All that to say, a lot of Stuart [Derbyshire]’s change in mind had to do with the idea that maybe, maybe we don’t need to force this more mature definition of pain onto a fetus, because if we do that, then it also applies to animals; it applies to very young postnatal humans. And what’s the justification for that? And frankly, as Bridget and I both agree, there really isn’t any. And…ah, let’s give them about 5% credit: there’s very little reason to do that.
So that was the first thing. It’s the definition of pain; it doesn’t have to be too complex; it can be pretty basic, such that an infant, an animal, or even a fairly mature fetus—or even a younger fetus—could feel pain.
Secondly, there’s the idea that the cortex I mentioned earlier—the outer part of the brain—needs to be developed and connected to the spinal cord and periphery, the fingertips or wherever, in order to feel pain. The cortex is the higher-level thinking, the cognition. You may have heard of the frontal lobes; that’s the prefrontal cortex right up here [pointing to forehead]. That synthesizes a lot of our response to stimuli; the decision making. It’s the executive brain, essentially.
So what we found, in a couple of very key papers, was that the cortex seems not to be required. In fact, there were some purportedly specific areas that dealt with pain. They were called the “pain matrix.” And everybody was certain, through functional MRI–magnetic resonance imaging, fMRI—that these areas lit up when the patient was feeling pain; they didn’t light up when they weren’t feeling pain. So that just proved that these areas, the pain matrix in the cortex, was the key, the capstone to the pain experience, without which we would not have pain.
Well, a couple studies with Feinstein—2016—Feinstein and Salomons. Salomons, Tim Salomons was involved in both papers. One of them had to do with Roger. He didn’t really have these pain centers. He’d had some brain damage earlier on; he was a middle-aged guy. He lost some of his brain, his pain centers—almost all of these pain centers, the pain matrix—and yet he had, not less pain. He had more pain. He had hyperpathic pain.
And there’s a lot more to it than that, actually, but I’ll spare you the details. But that point seems to be that the less of these pain centers you have, the more pain you feel. That was a striking study.
Secondly, there was another study with Tim Salomons, this time as the lead author: “The Pain Matrix in Pain-Free Individuals.” These individuals that he studied had congenital insensitivity to pain (CIP). They put them through noxious stimuli testing. The pain centers—purported pain centers—lit up. But the patients with CIP felt nothing.
And so we’re like, okay. These pain centers of the cortex: what are they telling us? We don’t need them, apparently, to feel more pain. And if we have them, it doesn’t guarantee we feel pain at all. And lookit: on the fMRI imagery, they’re lighting up, but they still feel no pain.
So as we said in the paper, this seems to neatly dissociate pain from the cortex. I mean, we realize there are other possible studies that may suggest the contrary, but this seemed to be a pretty clean break. A pretty strong break, I would say.
10:47 Keys to this unlikely, productive collaboration
Josh Brahm: Okay, so before I turn things over to Bridget, and we’ll get more into the science of this, I have one more question for you, John, about this paper. A lot of the people who listen to us are learning, generally speaking, about dialog, about persuasion, about philosophy; how do we have better conversations with people who believe different things than us. And I’m just wondering; you had a really interesting experience. What advice would you give people, generally speaking, on how to be persuasive? What is it that you think you did well in your interactions with—now I don’t even want to say his last name because I’m going to screw it up—
John Bockmann: DAR-bshr! DAR-bshr. It’s like, forget what you read. Like, when you see the color orange but the word says “red” you’re supposed to say “red,” even though you’re seeing orange. That’s like Derbyshire.
So yeah, good question Josh. Bridget and I have talked about this…I think this is at least as big a story, in most ways, in many ways at least, as the actual paper itself: the collaboration behind it.
Stuart Derbyshire is an inveterate pro-choice activist, scientist, skeptic of fetal pain. And so I really can’t take credit. And let me say this: Without Stuart’s openness, none of this would’ve happened. I would have had zero chance—and in fact, this is true for most people that I’ve come in contact with, at least on a superficial level.
Like, yeah, I’m always looking for an opening. But unless they’re open, it’s not going to happen. So I would say, just don’t force anything. Just be curious. I was curious.
The other part of it is, I did ask a lot of questions, and he was gracious enough to engage me in conversation. I did have some background in philosophy, and arguing online, and evolutionary stuff, and I obviously had done my homework, so I knew the stuff that he had written; I knew the stuff that was out there. So that gave me, I think, a measure of credibility.
Yes, he’s a friendly guy. I would have never guessed that, necessarily, from some of his more vociferous denunciations of fetal pain.
And then finally, I couldn’t bear it anymore. And I said, “Stuart, this RCOG 2010 paper is wrong. And I think we agree this part of the paper is absolutely wrong, and I think the world needs to know that it’s wrong. Because we’re getting hammered in the pro-life area for saying that fetal pain exists when this paper, quite erroneously, and not scientifically, says fetal pain’s not possible before 24 weeks.
So that’s when Stuart was like, “Hey, you wanna publish a paper together?” Yeah, but on what? On what?
Honestly, staying open, just being friendly, using whatever I had at my disposal, I think, is the answer to how this happened.
13:39 Fetal pain: Advances in understanding
Josh Brahm: That’s just an amazing story.
Okay, so Bridget. Let me jump back to you; you’ve been super patient. I’ve got some questions for you, and then hopefully we can … about this. So I’ll say, Bridget’s put together some really cool slides for us, so Bridget, don’t wait for me. At any point that feels natural for you, just kinda walk through those. You can just kinda make that happen.
So here’s my first question for you. Late last year, the Supreme Court hears the oral arguments with Dobbs. Our team listened to it live; we did a two-and-a-half hour livestream the next night about it, and if people are wondering about that, they can find that in the podcast feed.
But one of the interesting things that happened, and I’m sure you both know about this, was this idea that, one of the pro-choice lawyers argued that, hey, we don’t need anything more restrictive about abortion because we don’t really have any new information since Casey v. Planned Parenthood in ‘92. What new things have developed there?
And then fetal pain got discussed a little bit, and Justice Sotomayor said only a small fringe group of doctors believe that fetal pain begins before 24 weeks. So Bridget, tell us why? Why is she wrong? What has been learned since 1992 about fetal pain?
Bridget Thill: I think a great deal has been learned–starting with the very obvious fact that in the past 20 years, we’ve had the advent of 4D ultrasound technology, which has absolutely revolutionized the ability to observe fetal behavior. And fetal behavior actually reflects fetal neurodevelopment. So, when we’re trying to correlate what is actually going on neuroanatomically, we look at how the fetus is behaving. And grainy, old ultrasounds from 1992 are very different than the 4D ultrasounds that we capture now, that everyone is used to seeing. There are lots of people who have those pictures on their refrigerators of the 3D ultrasounds.
A lot has changed. We can see what the fetus is doing. And a lot of the studies that have come out in the last few years specifically look at how the fetus responds to anesthetic injection [into the fetal thigh] during fetal surgery. And there are prominent facial expressions of pain, which are similar—if not exactly the same—to what we see in preterm infants in the neonatal intensive care units. The same facial expressions that are indicated—of pain indicators—of those ages are also present in the fetus, even before cortical milestones are achieved, prior to 24 weeks.
So that is fascinating. There is just an abundance of new research and evidence that points in the direction of fetal pain perception in utero prior to 24 weeks gestation.
16:30 Current science and treatment of fetal pain
Josh Brahm: So Bridget, you wrote a paper [Fetal Pain in the First Trimester], and yours is even more recent than John’s. So maybe talk to us a little bit, kind of walk us through maybe compare and contrast your paper with John’s and walk us through what your understanding is of fetal pain, as of right now, in 2022.
Bridget Thill: Absolutely. So, I think there are several things in that. Comparing and contrasting to John’s and Stuart Derbyshire’s paper, John’s absolutely right. Derbyshire’s name is on everything related to fetal pain. He is one of the authors that I’ve seen again and again throughout, and certainly that was through that I reached out to several authors of fetal pain. Like John has said, I have found and have been pleasantly surprised by the fact that they have been very forthcoming, receptive, and responsive to my questions, and it’s been a great dialogue in order to do that.
So, what I’ve discovered with fetal pain. First of all, that the cortex is not necessary for fetal pain perception, as John discussed. That we have the same reactions to pain in the fetus are present before 24 weeks and they are also present after 24 weeks. So, there’s no change that happens at the 24-week milestone of these fibers connecting to the cortex that shows their importance. Instead, we can see all the same markers: the fight-or-flight responses, the facial expressions of pain, and also behavioral changes to pain, prior to 24 weeks.
And then in clinical practice, we also see that we are treating pain in the neonatal intensive care units at 21-23 weeks gestation in these very earliest, extremely preterm infants, and pain is recognized by these neonatologists and those caring, like the nurses, caring for these infants in the NICU. [See here, p. 3, Neonatal Pain and Sedation Scale (NPASS)).
Then in the field of fetal surgery, the fetal surgeons are using pain medication during fetal surgeries as early as 15-16 weeks gestation [See here and here]. They’ve had new recommendations come out just this past year. Anesthesiology groups that have recommended pain medications in all fetal surgeries to “blunt any perception of pain.” [p. 1167]. It’s really remarkable. There’s a lot out there.
At a very basic level, women need to be informed that the fetus can [potentially] feel pain, whether they are contemplating abortion or whether they are having fetal surgery for some sort of condition of their fetus during pregnancy.
Josh Brahm: Real quick question about the fetal surgery: Does anyone know the youngest babies who have had fetal surgery done, like the famous Baby Samuel picture? I think he was 20 weeks, if I remember right?
John Bockmann: He was, like, 21 weeks.
John Bockmann: Frankly, that goes back to the 1960s with Sir Liley from New Zealand, the founder of fetology. He was doing percutaneous blood transfusions, needle-based blood transfusions, for children as young as 16 weeks, even back in the 1960s.
19:47 Cortex needed for pain?
Josh Brahm: So, when I was looking into fetal pain, probably 12ish years ago, maybe 13 years ago. I actually had a really great volunteer. He was a pro-life paraplegic who has learned a lot about the nervous system since having become paralyzed. He spent over a year trying to research this for me and it was difficult. It was so complicated and he wasn’t a doctor or a scientist, so there was some kind of limitation there.
I remember back then hearing and feeling pretty open-minded to the argument from people like Dr. Derbyshire who was saying you have multiple different components to the nervous system that are all necessary to feel pain and they also have to all be connected. It’s not just a matter of the first few of them coming online, they all need to come online, and they all need to be connected, or else you are not going to have electricity get from point A to point B. That made sense to me. Another thing that made a lot of sense to me. I basically want you to respond to both of these.
The other thing that made sense to me that pro-lifers are pointing at early 2-D ultrasounds, the Silent Scream movie is kind of the most famous, where you’ve got this ultrasound of a baby during an abortion, and kind of this idea, look at how the baby is moving around. And other people were saying those are just automatic nervous system things. So, I heard both those arguments, and maybe they’re right, and so, it seems probably they weren’t. So help me understand why both of those arguments turned out not to be correct.
Bridget Thill: I would say one of the compelling arguments against the necessity of the cortex is studies they’ve done and they stimulate the cortex. As surprising as it sounds, one of the gold standards for determining what areas of the brain are needed for something is to use electrical stimulation to those areas, usually in patients with epilepsy. They’ve done this multiple times in different studies on hundreds of patients and they’ve stimulated various areas of the cortex, and they did not cause pain, in a reproducible, ‘this is necessary for pain’ sort of way.
What they did find was that the thalamus would cause pain. Stimulation of the thalamus would cause pain. This really raised the question, wait a minute, just as the two studies John referenced, people keep saying the cortex is necessary for pain, but we can’t prove it. Then you also have these extremely preterm infants, less than 24 weeks, who do not have those cortical connections, and they are demonstrating pain responses. So we are watching the behavior, not just the neuroanatomy. And I think that’s a key part. John, feel free to jump in here, but I’ll touch on the reflex issue quickly.
22:40 Are fetal responses to pain just reflexes?
I think what most people think of when they think of reflexes is the knee jerk, the patellar reflex, in the doctor’s office. You tap on the knee, the leg kicks out, and then goes back to a relaxed position. Reflexes are stereotyped movements, they are predictable. You have a motion and then it goes back to baseline.
I will tell you one of the compelling pieces of testimony that I read was from a 2019 Ohio State legislature and a radiologist [Dr. Gary L. George, M.D.] was giving testimony there and I referenced this in my article. He was in the room for a feticide procedure and this happened during what is called a selective reduction. It was a woman who was pregnant with triplets. They were trying to reduce the triplets down to just twins. During this procedure what happens is a long needle is inserted through the maternal abdomen, through the uterus, and the needle then has to penetrate through the chest into the heart of the fetus, and inject a lethal medication.
As this radiologist watched this procedure, what happened was that as the needle touched the chest of this fetus who was less than 18 weeks gestation, there was immediate flailing and as the radiologist described it, this fetus was fighting for its life. So, the person doing the procedure, the OB/GYN, attempting to do this procedure, had to try two or three more times because the fetus kept moving away, and again, flailing at each attempt. They actually had to then move the needle to a different fetus and were eventually successful.
I think another compelling part of that testimony was that during the procedure, the monitor was turned toward the pregnant woman, and she just broke into tears as she watched the reaction of the fetus on the screen and the technician was told to move the screen away so that she could not view it. The testimony of the radiologist said this was not a reflex. A reflex is [a] stereotyped behavior. Flailing does not represent a reflex.
Josh Brahm: Anything that you would add to that, John?
John Bockmann: Absolutely, and I agree 100%. Bridget and I have talked about this a number of times. So, Sir A.W. Liley, the father of fetology, talked about…he said, strictly speaking, we don’t know if the fetus feels pain, yes. But all I can say is that it responds with vigorous, violent responses to things you and I would feel as painful. You know, injection of cold, cold water or needle prick.
Magda Denes, who is no pro-lifer by any means, wrote an article, and I forget the name, Commentary Magazine? I think it was something about performing abortions; something like that. Powerful…I’m not sure if that was the one that she mentioned, but she has a book also that describes fetal response, [“In Necessity and Sorrow” (1976) – of which the Commentary piece was an excerpt], and I think there was a mention of that in the Magda Denes article in Commentary Magazine online, available.
Also, there’s an article called “What I Saw at the Abortion”[Also available here]. It talks about the same thing–this outside observer’s reflections on what happened. And he saw the needle going in, he saw it flurrying around, and he’s like, “What’s going on in there? That fetus is having a response.”
There’s also, of course, on the scientific side, [this paper from] 1994; you thought Derbyshire was a tough name to pronounce. Giannakoulopoulos, I think is [the lead author’s] name. Definitely Greek, solid Greek name for you. [He] and [his] colleagues…that is the one, Bridget, where they saw the increase in hormones and the violent responses to percutaneous needle poking of the fetus [“vigorous body and breathing movements” of the fetus in response to needles inserted into the fetal trunk for blood transfusions: p.77]
These stress hormones, these pain hormones, these endogenous opioids, are going way up, skyrocketing, and the fetus is flailing around in early gestation, mid-gestation. [Also, see this paper from Gitau and colleagues (2001) discussing beta-endorphin response in 18-week fetuses, the youngest tested.]
So all these things, yes, I would agree that the fetus responds in every way as if she feels pain, and it’s incumbent on us [to prove she can’t]…That’s not at all what we would expect if she does not feel pain. We would expect more like what we see when we anesthetize the fetus: that placid, quiescent, calm non-response, essentially, to these violent interventions. We would expect to see that if the fetus really did not feel pain. Instead, what we see [are] these violent, vigorous responses.
27:10 How did we get fetal pain so wrong?
Josh Brahm: Ok, so, I have a question. Either of you feel free to answer. You might not have an answer to this question. What you just described raises a huge question for me. If the father of fetology, Dr. Liley, says this thing that seems very reasonable: we don’t know for sure if it feels pain, but it sure acts like it feels pain, and that was in the 60’s, then how did people like Dr. Derbyshire and so many other scientists get this so wrong?
And as you think about that, I offer one possibility, I know even philosophers, even scientists, fall into the trap of confirmation bias. So if for example, if you have a Christian scientist coming from a “young earth” place, they might just read an ‘old earth’ kind of piece just a little bit differently, right, than someone who is completely open-minded or who is already in kind of the “old earth” camp. I know we try not to do that, I’m sure we’re all taught about confirmation bias in college, but it’s almost automatic, everyone does it at least a bit, and it’s just a matter of degree how much we do it. It would make sense to me basically in the end, that we are all in confirmation bias land to some extent, and for sure, a pro-choice researcher or scientist, who would want to believe for multiple reasons that fetal pain cannot begin until 24 or later weeks.
So that’s one possible guess, but tell me, how did people get this from 1960 to 2010 saying maybe fetal pain doesn’t even begin until 24 weeks or later? How?
John Bockmann: Back in the 1850s [actually 1848], with the first issue of what later became the Journal of the American Medical Association, a doctor described anesthetizing humans. He said there’s really no need to anesthetize the newborn because they’re not going to remember it anyway, and they are easy to control. We essentially progressed from then until the early 1980s not at all. [“Indeed, the facility of controlling a [young infant], together with the fact that it has neither the anticipation nor remembrance of suffering, however severe, seems to render narcotism unnecessary” – Bigelow, H. J. (1848). Ether and chloroform: a compendium. Transactions of the American Medical Association, 1.]
29:52 A lack of compassion or a lack of understanding?
Josh Brahm: Clarification question on that. That sounds to me like a lack of compassion; not so much [that] we don’t think they are feeling any amount of pain. Am I wrong?
Bridget Thill: I can jump in here. One of the things that certainly I found, I went back to research this, because I had the same question that you did, Josh, “How did we do this?” I think some of it started with the fact that I think we’re all familiar with the fight or flight response in which movements get more vigorous and there’s a very visible reaction [to pain]. What was happening in some of the early research that happened in the 1900s into the 1950s and 1960s. They did experiments, I should say research, they did research on newborns. They did pinpricks, electric shocks, pinching, and various different things and they found in these really preterm infants, they weren’t reacting [to a painful stimulus] like older infants and healthy children would. So they started to think they were just insensitive [to pain]. What has come to be realized through research is that it is a fight, flight, or freeze response, and some of these youngest and sickest babies, were actually, due to lack of energy reserve, not responding. They might give one response, and then their responses would be subtle, but they weren’t as great as maybe other children or older infants, and so they were dismissed. What came to pass especially with some of the studies in the 1990s [studies of male infant responses to circumcision without analgesia] and the Anand study in the 1980s, was that they realized and they measured the stress hormone levels, and they found out that these babies did worse [when not given pain medication].
So it’s not too surprising if they weren’t using pain medication for babies, they weren’t even considering the fetus. They even thought newborn babies back in the 1960s were blind and minimally conscious, if at all. So we’ve come a long way in our understanding.
I think the one other thing as far as giving pain medication to infants undergoing surgeries, back in the 1980s and prior, they weren’t sure they could do it safely. There was no standard protocol for it and they actually thought these critically ill infants, the youngest and the sickest, actually maybe do more harm than good if they used pain medications. Two things that also occurred during that time period that also changed, in addition to the studies that they did on these preterm infants, there was one study in particular, they gave half pain medication before surgery, and half they didn’t. There was a drastic difference in their stress hormone response, their outcomes were worse.
That study was published about the same time that two women also shared their stories in the news media. These two women in the 1980s had both had preterm infants who had had surgeries without pain medications. They just were horrified. They had no idea that that was going on. There really hadn’t been an informed consent process that they had been made aware of that their babies were not receiving pain medication. One of the babies ultimately died. The other one had significant sequelae as far as sensitivity, extreme sensitivity, to pain in the areas that had been operated on, for years afterwards. That combination of the studies with public outcry really revolutionized neonatal pain medicine and then after that was acknowledged, then the question could be raised, “How about the fetus?” [See also: Lawson, J.R., 1986. Letter to the editor: The Jeffrey Lawson story. 1986. Birth, 13, pp.124-5; Harrison, J. 1986. Letter to the Editor: The Edward Harrison story. Birth 13, pp.124].
33:30 Recognition of fetal pain
Josh Brahm: Does that bring us then to the 1980s, like that explains what was going on until that point? Help me understand, we’ll go back to John, and back to Bridget. From the 1980s to 2010, I don’t want to jump all over Dr. Derbyshire, because we’re so proud of him for being so open-minded and willing to change his mind. Given that he was the primary name, this 30-year gap there and again, you’ve got Dr. Liley in the 1960s, it sure seems like fetal pain might be a real thing. Can you help me understand what that gap was?
John Bockmann: That is the heart of the question, isn’t it? I don’t really know except that this idea has been around for a while with Rene Descartes in the 1600s, with the pineal gland being the seat of humanity. According to Rene Descartes–you know, “I think, therefore I am.” Well, animals couldn’t think and they didn’t have real souls, so their cries when they were being cut open alive, during vivisection in his day, were just the sounds of deranged springs. They were just automata; they were just machines.
And so to some degree, I think that attitude did affect [the view of pain] up to today. I think that is still a very powerful idea. It just highlights how much philosophy and linguistics play a role in guiding the science and the interpretation of the science.
But I think that [some skeptics are] trying to say, “Hey listen…you’re going to say”–and I think this [was] true of Stuart–“according to this pain definition,” (which is [from] the International Association of the Study of the Pain (IASP) dates back to the 1970s),
“these patients, [and even] animals and young children, can’t feel pain. Is that what you want from this definition? Because that’s what I’m going by. According to this [definition of pain], here’s what the neurology says to me.”
…I think that was the sticking point–and to the extent that there is a sticking point, that is it…the definition of pain. And also, I think abortion does play a role, for sure.
35:45 Correlation with fetal behavior
Josh Brahm: Anything that you would add, Bridget?
Bridget Thill: Yes, just one thing that I would add there, is that sometimes the history of medicine repeats itself. We look back 50-60 years, maybe to the 1950s, and we’re thinking we were doing lobotomies then. We think, what were we thinking? Now we’re looking back 40 years to the 1980s, we were doing surgeries on preemies without pain medications, what were we thinking? There is a progression and evolution in the understanding of medicine that occurs, and so if anything it should teach us caution. One of the things I think in medicine we’re all taught is correlation, correlation, correlation. When we see a screen, when we see a lab value, we’re supposed to correlate it with the patient. If the screen shows that there’s a flat line, but the patient is talking to you, you’re going to believe your patient.
That’s an important thing. I think that’s something we always need to look at. Let’s look at what the fetus is actually doing. Let’s not just say, “It doesn’t have cortical connections, therefore it can’t feel pain.” Let’s actually see now that we have the ability to have 4-D ultrasound, how is that fetus behaving?
I think one of the interesting things, and John’s aware of this study as well, is that one of the things that comes up too, is maybe the pain pathways are there, but certainly not the pathways for consciousness. The fetus can’t possibly be conscious in the first trimester. When we look at consciousness, what are we looking at: we’re looking at the ability to respond to the environment, the ability to do planned motor activity, not just reflexes, but planned motor activity.
There was a fascinating study done on twins that looked at exactly that. They were trying to differentiate twins in utero and to see were they moving reflexively or were they moving with some sort of intentionality. What they found at 14 weeks, by 14 weeks, was that these twins would differentiate the way in which they would touch inside the uterus. If they were reaching out to the other fetus, the velocity of that movement was very slow. When they were reaching out to the uterine wall, though, the velocity was faster. When they were reaching to their face, which were the more sensitive mouth or eye region, the velocity was also slow.
So there was a differentiation, and the slowest velocity of all, was actually when they were reaching out toward the other fetus. So it was fascinating, that even [by] 14 weeks gestation, they showed action planning, they showed a kind of learned behavior in the velocity of movement going on at that time. It’s just amazing and fascinating that that can occur.
38:19 Correlation with behavior, not overreliance on hypotheses
Josh Brahm: It seems like then, what I hear you say, Bridget, when it comes to, especially, anesthesia, but other parts of medicine. I think I heard this analogy from you, but it makes me think of it now. It’s the opposite of what pilots are supposed to do when they’re in the clouds: don’t trust your instincts, trust what your dials are saying, because they’ll keep you alive. It’s the opposite: if your patient is saying this hurts or is acting a certain way, even if it seems to be going against what data you think that you have, then you should be paying attention to your patient.
Bridget Thill: Yes; trust your patient, not your instruments. And then when you’re flying, you trust your instruments, not your instincts.
John Bockmann: Let me put forth the other view. Yes, it is like flying in the clouds, in a way. So the instincts– I’m a pilot–so in the plane, we are context-deprived if we’re not looking at our instruments. We’re just using the seat of our pants. Proprioception, in medical terms. What we think, when we’re going by our senses, it’s wrong, because our senses [can be] fooled by our inner ears. I won’t go into the flight physiology.
We have fewer data points available in the clouds if we’re not looking at our instruments.
But…with the fetus–even if we’re not [using our instruments by] measuring their heart rate, and their catecholamine release, and their endogenous opioid release, and coding their facial expressions and their movements–even if we’re not doing those things, we still have a rich, and I would say a richer, supply of data points just from our own experience, our innate interpretive ability, of that baby’s nonverbal cues, to what they…are feeling inside.
…We have a rich supply of data, richer than any instruments that we could ever bring to bear on the fetus.
In fact, we tried in Bernardes’ paper, for example, where [Bernardes] codes exquisitely all the [fetal] facial expressions, the eyebrow furrows, the grimaces, all the things the fetus does in response to pain…let’s say, “invasive stimuli” [injection of anesthesia into the fetal thigh during surgery]. We categorize, we count them up, we chart them, all these things.
But really, our human perception that’s innate and built-in is very finely tuned to nonverbal interpretation. That is a rich source [of data], even richer [than aircraft instruments or facial coding], but we can’t really get a handle on [it] unless we can measure it. We know if someone is in pain just by looking at them, I would argue.
41:02 Pain assessments are calibrated to patient response, not brain imaging
And by the way, in one of those papers–for Roger, the adult who felt more pain despite his lack of pain centers in his brain–they did the same thing with him to find out if he had pain: they judged by his actions, they categorized them, they rated them against his peers.
They did not actually use any data from the fMRI, from his brain scans, in order to determine that he felt more pain, not less, not no pain.
They used all his reactions. And they’ll say–I’ve talked to Tim [Salomons] on this; I believe him to be a good-faith researcher and defender of no fetal pain, all right. But Tim said, “We took his verbal report.” And what I said to Tim is, “Look, Tim, [the verbal report is] still a patient response; it is a surrogate measure of pain.”
We don’t actually have any objective measure of pain that we can put you on a scale and say, “Aha, that guy’s feeling pain.” If we did, the person who invented it would be very rich.
We don’t have that, so we have to take these surrogate measures of pain, [and] we usually use our eyes and our ears and our experience.
42:10 Correlation with clinical behavior
Bridget Thill: And that’s one thing, too, that I have read and heard from pediatricians in the field for decades. They look back at how pediatrics used to be, when they were harshly immobilizing infants to do painful procedures, and they just shake their heads. They said, “We saw all of their behaviors. We saw the grimaces; we saw the crying; we saw the tensing, and so forth. But we were told that that couldn’t possibly represent pain, and [that the babies] weren’t going to recall it.”
…What we’re learning from that is, let’s look. Let’s correlate. Let’s see what the behavior actually is. And let’s not dismiss behaviors based [on] what our hypotheses about their neuroanatomy might be.
42:56 Specialized pain assessment tools for different stages of development
And I think, just to add to that: one of the things that was revolutionized when neonatal pain was acknowledged was pain management and pain assessment tools. And they were specialized. They were specialized for the stage of development of the infant. And that will need to occur as well for the fetus. Because developmentally, [they can only make] certain facial expressions at certain gestational ages. And…the musculature doesn’t even develop until 16 weeks.
So, prior to that, that cannot be an assessment tool, because you don’t have the facial musculature there to assess in exactly the same way in which you would, say, an infant. So there will have to be, obviously, an adjustment there to correlate with the appropriate stage of development.
Josh Brahm: If anything, maybe be extra cautious. Err on the side of being too compassionate.
So Bridget, let’s get to the million-dollar question here–maybe this would be a good time to walk through your slides. Help us understand…how early do you think fetal pain might begin, as far as we understand everything right now, and why.
Bridget Thill: There’s evidence that shows the possibility that fetal pain can exist in the first trimester [<14 weeks gestation]. To differentiate further than that, we’re going to need further testing. We’re going to need further studies. And I think that’s going to just explode in the next 20 years. I think there’s going to be–especially as fetal surgery is exponentially on the rise–a great deal more research.
One of the limitations right now with fetal pain assessments is that it is a crowded surgical field. When fetal surgery is going on, you have one ultrasound dedicated for whatever the procedure is, and then another ultrasound to maybe examine just what the fetal responses are; like, the facial expressions, and so forth.
I think those sorts of things, and new technology, are really going to increase in the next 10 to 20 years; they’re going to revolutionize that. They’re going to help delineate when exactly in the first trimester that might be possible. But certainly we’re seeing, behaviorally, with action planning and so forth, that the fetus is capable of awareness of external stimuli as early as the first trimester. And that’s really remarkable.
45:23 Fetal Pain 101
Josh Brahm: Okay. So maybe walk us through the slides–Fetal Pain 101.
Bridget Thill: Okay. Do I need to share them or do you have them?
Josh Brahm: I have them in front of me. And for those of you on the audio podcast: I will link to a pdf or something where you can follow these on your phone, if you want to. And for the video version, I’ll just drop these onto the video. But walk us through.
Bridget Thill: Sure. And a lot of this is a summary of what we’ve already talked about.
45:45 Slide 1: An Evolving Understanding of Pain [see references on slides]
The first slide, “An Evolving Understanding of Pain,” is really highlighting the fact–especially that top timeline there–that in the 1980s, we only thought the older infant was capable of pain. In the 1990s, that progressed to believing, “Okay, the newborns can feel pain.” In the 2000s, “Okay, the third-trimester fetus–they’re pain-capable.” In the 2010s, it’s in the second trimester. More recently, with John and Stuart Derbyshire’s paper here in the 2020s, that’s down to the first trimester [<14 weeks gestation]..
So we can see over the space of just 40 years how much our understanding of neuroscience and fetal development, and pain management, has changed. That certainly should give us a voice of caution; making sure we are erring on the side of providing pain management in these cases.
46:33 Slide 2: Development of Fetal Pain Pathways [see references on slides]
In the second slide, it talks a little more about the neuroanatomy that’s involved; why there are [different] hypotheses about when pain perception can occur. So as John talked about, the pain pathways have to start, with pain receptors, say in the skin. Then they go to the spinal cord, the brainstem, and the thalamus–and then to a unique fetal structure called the cortical subplate, which wasn’t even discovered until 1974. And there’s been a tremendous amount of research on that in the last five to 10 years, and it’s shown that the subplate is really acting as a precursor for the cortex. So instead of waiting until the cortex takes over–which, in its permanent circuitry, doesn’t even occur until after birth, and continues in the postnatal time period–we know that the cortical subplate has a really prominent role. Neuroscientists think that has a prominent role, even early on, in perception. So the bottom line on that is, the cortical subplate is functional in the first trimester, and that’s what John and Stuart’s paper really highlights as well.
47:36 Slide 3: Responses to Pain in Fetus & Extremely Preterm Infant <24 weeks [see references on slides]
The next slide talks about what the responses are. In an extremely preterm infant–less than 24 weeks–and the fetus less than 24 weeks, the pain responses are exactly the same. We have that fight-or-flight-or-freeze response, as we talked about, where we’re thinking of is cortisol, we’re thinking of adrenaline types of markers. And we’re thinking of how that changes. When we have a painful procedure and an adult experiences pain, we’re going to have an increase in those stress hormones. Their heart rate’s going to change; their oxygen levels are going to change; their blood flow’s going to change. And that same thing occurs in the fetus. The same thing occurs in the preterm infant of the same age. And early on, this doesn’t involve the cortex.
Then those facial expressions of pain: we know those occur as well before 24 weeks’ gestation. And we know those behaviors as well, which have been described as vigorous body movements, limb movements, are pain assessment tools that have been validated by the American Academy of Pediatrics as early as 23 weeks’ gestation. And they use these limb movements as signs of pain. The clenching of the fingers, the clenching of the toes, the splaying of the fingers, as indicators of pain. And we certainly see body movements in the fetus as well.
So that just highlights the fact that we need to be looking at the responses, not just dismissing them because of the neuroanatomy.
49:00 Slide 4: The Fetal Pain Paradox [see references on slides]
This kind of puts that in chart form. We have the fetus and preterm infant; they both have an immature cortex; they both have an active and functioning cortical subplate. They have the facial expressions of pain, the fight-or-flight response to pain, the body movements in response to pain.
But for some reason, in clinical practice, the preterm [infant] will receive pain medication, but the fetus–according to the American College of Obstetricians and Gynecologists, and according to the Society for Maternal Fetal Medicine–cannot possibly experience pain. So the same responses that are in the preterm infant are therefore judged not the same in the fetus.
49:37 Slide 5: Levels of Consciousness [see references on slides]
And then the last slide talks about levels of consciousness. This is always a big one. And we know this intuitively, I think. Any of us who have had children and watched their development: it occurs over a spectrum. We’re not the same as we develop from infancy into adulthood. And the same thing occurs with consciousness. There’s a basic level of consciousness that occurs and that’s mediated below the level of the cortex. And that’s the one we talked about that occurs [by] 14 weeks’ gestation in these twins’ action planning, where there’s learning going on. There’s planned motor activity, and not just reflexes.
Certainly the cortex is important. We know the cortex will help us remember the past; it will help us reflect on the present; it will help us anticipate the future. A preterm infant, an infant, a toddler is not able to do that because the cortex is not developed sufficiently. So we have to judge developmentally according to, like John said, the ability to feel a raw-er sense of pain, of just being in pain, without having to reflect on it. That’s still ethically significant. And I think that’s enough.
50:50 Future fetal pain research
Josh Brahm: That’s super helpful. Okay, we are almost out of time. I have one more question for Bridget and then a couple for John.
Bridget, what do you know about future research? Is there anyone working on the next paper right now; is there a direction that people are going, at least that you would be allowed to talk about? When could we expect a better sense of maybe when in the first-trimester pain might begin–any ideas?
Bridget Thill: Sure; that’s a great question, and I think and I hope that studies such as these are going to continue. And I’m aware that there are going to be several publications coming out this summer on the topic of fetal pain. So that’s something to look for.
I think there are also new modalities being investigated, from a technological perspective, to try and assess the fetus. Because if we are going to give pain management, we also have to assess, “Is it working?” One of the concerns with fetal surgery is the risk of preterm labor after fetal surgery. So one of the questions that arises is, “Is the injection that you gave the fetus at the beginning of fetal surgery–is it sufficient? Do you need post-operative pain management? And if you do, how technically is that going to be done?
So there are questions like that, that could also improve fetal outcomes in fetal surgeries that need to be looked at. There is constant research going on from the fetal surgeons, from pain researchers, neuroscientists that really is fascinating; that I think is really going to open up this field.
52:37 How to receive updates regarding fetal pain
Josh Brahm: All right, I lied: one more question for Bridget. For laypeople who are like, ‘Ooh, I want to find out about the new things coming out this summer,’ what do people need to be following if they want to learn about that? Is there a certain medical journal?
Bridget Thill: I would recommend, if people are interested in knowing what peer-reviewed journal articles are coming out, you can go to PubMed, create an account, and you can set up alerts, and you can select your fields. You can select fetal pain, fetal analgesia, fetal anesthesia, and you will get a lot of information very quickly, and it will keep you updated on what is the latest out there.
53:22 Pro-choice response to Reconsidering Fetal Pain
Josh Brahm: John, I’m wondering what the pro-choice response has been to your paper. I know the pro-life response has been, for the pro-lifers who heard about it, thought it was amazing; just the story behind the paper is about as fascinating as what was in the paper. But what has the pro-choice response been to it? When it first came out, I had read that Dr. Derbyshire was having his reputation, his career–at least as far as advocating for the pro-choice side–had certainly been affected. But what can you tell us about the response?
John Bockmann: Silence, for the most part. There was a brief flurry at the beginning. I know I talked to, I think she’s the current CEO of British Pregnancy Advisory Service, just briefly on Twitter, and she said, “Well, what about the woman’s pain?” I said, “Well, we already treat that.”
And then she said, “Well, what about the fetus’ pain, the baby’s pain, when he or she is being born?” And I didn’t respond; Stuart jumped in there. But in fact, it’s well known–certainly in the obstetric-gynecological community, and in fact we were taught this in PA school, and it’s borne out by many obstetric anesthesia books, for example–that the pain and the stress of birth actually helps prepare the fetus; actually confers survival value, by helping to maintain the fetus’ temperature, to clear the lungs, and many other things that benefit the fetus’–and now, the newborn’s–survival.
So, it does seem that yes, [being born vaginally is] very stressful, I’m sure. But it’s also salubrious; let’s call it that. It’s good for the fetus, good for the baby. In fact, babies born by c-section are subject to transient tachypnea of the newborn–TTN…
At any rate. All that to say: no significant response, but I anticipate more forthcoming. Because they’re not going to let this stand. If it gets out in the mainstream, it’s not going to stand [uncontested]. And that’s fine. You know, bring it on. We’ll see what’s out there; I’m eager to see it.
55:34 How to talk–and not talk–about fetal pain
Josh Brahm: Okay. A final question, and both of you can feel free to respond, but I’ll actually start by giving my answer. Add anything you’d like to add, or feel free to push back if you disagree with me. But basically my question is, How should pro-life advocates talk about fetal pain, and what mistakes should they avoid?
The two mistakes that I can think of, and they’re at either end of the spectrum: one, the most obvious one being, “Pro-life people shouldn’t be saying that abortion is morally wrong because of fetal pain. Because if it turns out that fetal pain begins at 10 weeks, well, a lot of abortions happen before 10 weeks, and we’re still against those. So it’s not all just about pain, and I know a lot of pro-lifers want to jump to, “Look, you wouldn’t treat an animal this way, so we shouldn’t treat babies this way.” But they can end up going too far, and I talk about this in my “faulty pro-life arguments” talk. Like, we can go so far as to say, “This is why, or the main reason why, abortion is wrong,” and it seems like something to avoid.
And on the other end of the spectrum–and this is a weirder case, but this did happen to me–when after I gave a talk after a relatively friendly audience, an older pro-life woman came up to me and told me her theory that fetal pain actually begins probably within a few days of fertilization. Like, at the blastocyst stage. And I was like, “Whyyy? Why should I believe that?” She didn’t really have anything outside of, “Well, maybe the soul feels pain,” or something like that. That seemed a little kooky on the other end of the spectrum. But I’m interested: any thoughts that you guys have; how should pro-life people talk about this subject as laypeople, and are there any mistakes that they ought to try to avoid?
John Bockmann: Yeah, thanks for that question, Josh. Because immediately after Stuart’s and my paper came out, there was an article in The Daily Mail that said, “Fetuses CAN feel pain at 12 weeks.” And this was a big paper for me, okay, and I kind of panicked because that’s not what…we didn’t approach that certainty in our paper at all.
And so I emailed the editor straight away, and I was like, “Please change that headline to this.” And she said, “Okay.” And they changed it the next day, or that day, to “Fetuses MAY feel pain.” [https://www.dailymail.co.uk/news/article-7903507/Unborn-babies-feel-pain-24-week-abortion-limit-scientists-say.html] It was much better.
But then I see it again. I just recently published an op-ed at National Review a couple of weeks ago, and I think Life News–I didn’t realize they were going to pick it up, but you know, my name is on it–and they changed the headline to…I can’t remember what it was, but speaking in very certain terms about fetal pain.
And I don’t mind–and okay, so I get it. I do get it. But it’s not certain; it’s only certain “in relation to”–[for example] what we know about animals. If we say animals can feel pain, then I think, yeah, by the same standards, fetuses of certain gestation can feel pain. If you say animals can feel pain, based on their behaviors, then we owe it to fetuses to say, yes, those same behaviors, or similar behaviors, responses, indicate fetuses can feel pain as much as the animal. If a newborn can feel pain, based on these behaviors, then a fetus, doing those same behaviors, those same responses, can also feel pain.
So I think we have to be careful how we talk about it. Accuracy matters. [If] we lose our credibility, that is difficult to regain.
Josh Brahm: Completely agree with that. Anything you would add to that, Bridget?
Bridget Thill: I agree with John. I think that overselling what is being said is going to lose credibility. And that is something that is very important. Yes, is fetal pain possible in the first trimester? Yes. But to definitely say it starts at this week, or this week, is really extending beyond what we know. And so I think we have to be careful if we’re going to try to back up what we say with science, we need to be intellectually honest, and present the facts, and not distort them.
59:36 Summary on fetal pain
Josh Brahm: Yeah. So this is a fantastic third thing that you’ve added to my list. But this brings up one more question, then. I’ve had a lot of experiences with pro-life people who at least seem to get irritated with me when I try to add a lot of nuance to a simple, very concrete statement. And here you are saying, “We’ve got to be careful to not make more concrete statements than what we know.”
And so, do you have some kind of a sound byte-y, accurate way you would encourage pro-life people to use when answering? If a pro-choice person directly asked them: “When do you think fetal pain begins?”–what would be the accurate, but kind of in-a-few-sentences way, for them to respond to that?
Bridget Thill: Fetal pain may be possible in the first trimester [<14 weeks gestation].
Josh Brahm: That’ll do!
You guys are awesome. I’m so grateful for the research you’re doing. It helps people like me. We want to be accurate; we don’t want to ever give medically false information, or non-factual information, and the level of time and research you guys have put into something that is so complicated is really, really important. I’m so grateful for you guys for coming on the show. Thank you so much.
John Bockmann: Thank you, Josh.
Bridget Thill: Thank you so much.