Does the Fetus Feel Pain?

I teach embryology to wonderful first year medical, nurse anesthetist and PA students.  Last week, one of my students asked me, humbly and thoughtfully, if (and when) a fetus feels pain. Because of recent publicity concerning late term abortions, I knew this was a question about more than fetal physiology.

Let’s talk embryology.

I am very, very confident that the blastocyst doesn’t feel pain. I am equally confident that babies at the time of birth do feel pain. So, there must be a moment during development when nerves to sense the pain, nerves to transmit the pain, and a brain to perceive the pain come together to make it possible to perceive noxious stimuli. I’m not a developmental neurologist, so I can’t claim to be an expert, but based on published research, those three things are present somewhere around 22-24 weeks gestation. For those that are concerned about abortions that happen after 22-24 weeks, It’s important to realize that only 1.3% of abortions occur after 21 weeks gestation and 80% of these for serious birth defects.

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 Let’s talk suffering.

As healers, we seek to relieve suffering. Let’s be clear – that’s not the same thing as the “pain” I mentioned above. Let me give you a couple of (real life) examples.

A developmentally delayed 15 year old is raped by her cousin who threatens her if she tells anyone. Over the next two months, the girl becomes progressively withdrawn, depressed and even suicidal. Her mother takes her to her pediatrician who is able to convince the girl to tell her what happened. She sends the appropriate labs, including a pregnancy test, which is positive. Her pediatrician recommends termination of the pregnancy, and refers her to a gynecologist and a pediatric psychiatrist. Because of her depression and suicidality, both of these physicians also recommend termination of the now 14 week pregnancy.

A young couple comes to their gynecologist for a routine screening ultrasound.  Something isn’t quite right, so they are sent to the maternal-fetal medicine clinic for a more detailed ultrasound. They are at 18 weeks gestation, which means 22 more weeks until term. They receive horrible news. The fetus they are carrying has a fatal disorder and will not survive after birth. After a few weeks, they return to their doctor in tears. The emotional burden of carrying the pregnancy to term is causing them immense suffering.

Let’s talk ethics.

We teach our medical students to take complex situations like deciding to terminate a pregnancy and use an “ethics workup” to help guide decision making. The ethics workup starts with defining everyone who might be affected by the decision. For example, in the first case I mentioned above, that would be the 15 year old patient, the fetus, the patient’s mother, and the doctors. Then, based on the possible outcomes (to terminate or not to terminate the pregnancy), we consider the outcomes with appeals to consequences, professional obligations, ethical rights and virtues. What this process does is allow us to understand the complexity of the situation and the choices being made, rather than just going with our “gut reaction”.

Let’s talk about listening.

When I was Dean of Student Affairs, the “Pro-Life” group on campus invited a speaker that the “Pro-Choice” group felt strongly should not be allowed to speak. I asked the leaders of both groups to meet with me. They were pre-clinical students who had not yet experienced dealing with patients and families facing complex and heartbreaking decisions. I recognized that their conflict was a great learning opportunity, a chance to learn to work through a situation where colleagues disagreed. I asked them to develop a plan together on how speakers should be invited, a plan that I insisted reflect the culture of tolerance at our medical school. They did not disappoint. Their plan was amazing and included attending each other’s meetings and reviewing speakers for each other before invitations were issued. They also wrote a beautiful statement to be read at the beginning of each meeting explaining that they were there to learn from each other and to listen. They went even further and added that disrespectful comments or intolerance would result in being asked to leave the meeting. What a great example for us all – to listen to learn, and to do so with kindness and tolerance.

As physicians we are absolutely allowed – even encouraged – to include our personal views when making a thoughtful, ethical decision about caring for a specific patient.  Although it’s not a common event, physicians are allowed to choose not to care for a specific patient as long as they refer them to a different doctor. What physicians are not allowed to do is to impose our views on our patients, or our colleagues.

Compassion: Lessons from Roshi Joan Halifax

It’s not often that a talk completely changes the way I think about something.

I’ve been thinking and speaking about compassion fatigue for many years.  I recently had the privilege of hearing a wonderful talk by Roshi Joan Halifax. She made a strong and convincing case that “compassion fatigue” is a misnomer… and that we should think about this in a very different way.

We can never have too much compassion nor can true compassion result in fatigue.  

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Empathy and compassion are not the same thing.

Empathy is a necessary prerequisite for compassion, but compassion goes beyond empathy. Empathy is the ability to be with someone who is suffering, to be able to feel what they are feeling. Compassion, on the other hand, is being for someone who is suffering, being moved to act and find a way to relieve their suffering.

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Link to Roshi Joan Halifax TED talk “Compassion and the true meaning of empathy”

Self-regulation is the key to being able to remain compassionate and this skill can be taught.

We all respond to situations of suffering with “arousal”, a state that varies in intensity depending on the severity of the suffering, and our own memories and experiences.   How you respond to this state determines whether you can stay present, effective and compassionate.  Roshi Joan Halifax offered the mnemonic “GRACE” as a way to teach this skill to medical students, residents, physicians, nurses and other health care professionals.

G:  Gather your attention. Take three deep breaths.  Be present.

R: Recall your intention.  We choose careers in medicine to help heal the sick and to reduce suffering.  It’s not easy to remember this intention when we are overwhelmed.  But, in the moment we are faced with a human being who is suffering, we must let our own response (and the demands of the day) go and remember why we are here.

A:  Attend to yourself.  Being able to detect what is going on in your own body is the same “wiring” you use when you feel empathy.   After gathering your attention and recalling your intention, pay attention to what is going on in your body.  Watch your breath, feel where there is tension, pay attention to sensations.

C:  Consider what will really serve.  Moving from empathy to compassion is defined by considering the actions that will relieve suffering.  Really consider the person and the situation and decide what is most likely to improve the situation.

E:  Engage ethically.

“Developing our capacity for compassion makes it possible for us to help others in a more skillful and effective way. And compassion helps us as well.”  Joan Halifax

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Religion and Spirituality

People who are ill or hurting often turn to their religious roots for solace.  The mind and body connection is a powerful one, and one that can contribute to good patient care.  Spirituality in medicine can take an overtly religious tone, but only if both the physician and patient are completely comfortable.  No matter what your religious background, you will care for patients whose belief system is different from your own.  The true root of spirituality in medicine is compassion. Regardless of your religious background and your personal beliefs you can cultivate a philosophy of compassion.  Both you and the patients you care for will do better because of it.

 The workday can be onerous and fatigue can make you lose perspective.  It is important to find something greater than you and spend some time there everyday.  The most efficient method is to look inside of yourself by just sitting.  Learn to just sit.  It is harder than it sounds, but very powerful when achieved.  Slow your breathing, close your eyes and let the thoughts go.  Concentrate on your breathing and relax all your muscles.  Don’t fidget, don’t move.  When the thoughts start running (and they will), just acknowledge them and let them go.  Try to get to a moment (and that it all it will usually be) when your mind is silent and your body relaxed.  This is the moment to listen.  Being able to quiet yourself this way is very conducive to allowing your mind to work on the “big picture”.  If you spend even 10 minutes everyday in this kind of meditation, you will be surprised at how some of the things that are worrying you become “solved”.

 Work at finding beautiful places where you can sit for a minute or walk.  Nature is one of the most powerful spiritual experiences.  If you have a favorite place to hike or be outside, take some pictures and blow them up for your house or call room.  Put beautiful plants in your house and then take care of them. (Dead plants are a bad way to cultivate spirtituality…)  Watch for the surprising moments of beauty in a day and notice them.  Look for the flower blooming outside a patient’s room, the proud look of a father watching his two-year-old totter into the hospital, a new painting on the wall.

Cultivate a sense of wonder.  Have you ever seen anything more incredible than a beating heart in a surgeon’s hand?  Allow yourself a moment to be amazed in the middle of the day.  People have incredible resilience at times – notice it and appreciate it.