From triple helix - Spring 2019 - Fetal analgesia guidance: After three decades the Department of Health recognises fetal pain
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The 18th century philosopher Jeremy Bentham wrote of animals: 'The question is not "Can they reason?", not "Can they talk?", but "Can they suffer?"' Professors Glover and Fisk, in their 1999 paper (1) say that Bentham caused such a change in attitude towards animals that in the UK, even frogs and fish are required by Act of Parliament to be anaesthetised during invasive procedures.
Within the living memory of some clinicians, medical students were taught that unborn babies did not feel pain and did not need such consideration.
It was not until 1997 that the first official investigation by the RCOG recommended fetal analgesia for diagnostic or therapeutic procedures on the fetus in utero at or after 24 weeks - notably omitting abortions. After the Science and Technology Committee's paper on abortion in 2007, (2) the Department of Health commissioned a second review by the RCOG which was published in 2010. (3)
This RCOG report remains in place as the official position on fetal awareness, despite drawing both national (4) and international (5) criticism (including from CMF (6)) for flying in the face of scientific literature.
However, it now seems the Department of Health has finally done a U-turn, despite maintaining their denial of the existence of fetal pain as recently as January 2019. (7) Following an announcement that fetal surgery to address spina bifida in utero will be made routinely available on the NHS, (8) the Government was asked about fetal pain relief in such cases. In response, a written parliamentary answer on 14 February this year, states that: 'Pain relief for the unborn baby will be delivered intra-operatively. This is administered before the fetal surgery, after the uterus is opened…The surgery takes place between 20 and 26 weeks of gestation.' (9)
Will this guidance be extended to other invasive procedures? What will be the lower limit for the use of fetal analgesia? Will the current NICE Consultation on Terminations consider fetal analgesia for abortions? (10) Will DFID change its guidance on late term abortions that the British government funds overseas? (11) And will any of this influence the Dáil in drafting Ireland's new abortion legislation? (12)
To achieve the best patient care and to restore trust, surely the way forward now is for a comprehensive, fully transparent review around fetal awareness by a multidisciplinary team, including expertise in paediatrics, fetal surgery, neurology and anaesthesia. They should use the scientific evidence to inform a compassionate clinical approach and recommend a starting point for fetal analgesia that errs on the side of caution.
Review by James Evans, CMF guest blogger
1. Glover V, Fisk N M. Fetal pain: implications for research and practice. British Journal of Obstetrics and Gynaecology 1999; 106(9):881-886
2. House of Commons Science and Technology Committee. Scientific Developments Relating to the Abortion Act 1967. Twelfth Report of Session 2006-07; 1. bit.ly/2u5RmFM
3. Fetal Awareness Review of Research and Recommendations for Practice. Report of a Working Party of the Royal College of Obstetricians and Gynaecologists March 2010. bit.ly/2u6SBEy
4. Platt MW. Fetal awareness and fetal pain: The Emperor's new clothes. Arch Dis Child Fetal Neonatal Ed 2011; 96(4):236-237 (July)
5. Ranalli P. Royal College of Ob-GYN "Fetal Awareness" Report Does Nothing to Rebut Conclusion Unborn Can Experience Pain at 20 Weeks. National Right to Life News 15 July 2010. bit.ly/2u6Gasv
6. Saunders P. Senior neonatologist brands official report on fetal awareness as 'Emperor's new clothes'. CMF Blogs 5 February 2011. bit.ly/2u9q01n
7. Foetuses: Pain: Written question - 204402; Asked by Sir John Hayes (South Holland and The Deepings) 20 December 2018, Answered by Jackie Doyle-Price (Department of Health) 10 January 2019. bit.ly/2ucEk9e
8. Therrien A. Spinal surgery for unborn babies to be available on NHS. BBC News (Online) 22 December 2018. bbc.in/2u6UWiO
9. Spina Bifida: Surgery: Written question - 217544 Asked by Fiona Bruce (Congleton), 06 February 2019, Answered by Jackie Doyle-Price (Department of Health), 14 February 2019. bit.ly/2udwbkV
10. Termination of pregnancy: NICE Guidelines in development (expected September 2019). bit.ly/2u6VNA2
11. Taylor P. The 'unmet need' for contraception and abortion in the developing world. CMF Blogs 8 October 2018. bit.ly/2ucGgP2
12. Burns S. Heated exchanges as TDs consider changes to abortion legislation: Harris says law will not allow women to seek terminations on basis of sex, race, disability. The Irish Times 7 November 2018. bit.ly/2uahJKG