Editor's choice

BMJ 1996; 313 doi: (Published 28 September 1996) Cite this as: BMJ 1996;313:0

The pain of fetuses, the newborn, and burnt childrenWhen paediatric anaesthetists were asked in 1988 whether the newborn experienced pain, one in 10 said no and a quarter didn't know. Only one in 10 “always or usually” used systemic opioids when newborn infants were having major surgery. A survey reported today shows that now all anaesthetists believe that the newborn suffer pain, and nine out of 10 always or usually use systemic opioids when newborn infants are having major surgery (p 787). This is a substantial and sudden change. The authors suggest that the change is because of new data, but perhaps it is driven more by fashion and social change than by science. This substantial change in opinion and practice gives a pungent context to the question of whether fetuses can feel pain. Doctors, scientists, and a philosopher attempt to answer the question on p 795, and they do not reach a confident conclusion. “Currently,” write two authors, “we have no direct way of assessing pain in fetuses (p 796).” “Whether the fetus feels pain,” write two others (p 795), “hinges not on its biological development but on its conscious development…. Children and adults come to a conscious appreciation of pain through a developmental process which the fetus has yet to experience.” The philosopher takes a similar line (p 796): “I do not think we can experience pain unless we are aware of ourselves and our own bodies.” A scientist and an obstetrician see it differently (p 796): “Even if the nature of the experience changes with development this does not prove that immature humans cannot be distressed by pain.” They think that the baby's experience during labour and delivery “deserves more attention.”

What we all can agree about is that small children suffer severe pain when burnt, yet the death of children by fire doesn't seem to generate as much excitement in the British parliament as the question of fetal pain. Ian Roberts and Chris Power point out that pedestrian accidents and accidents caused by fire and flames were the leading specific causes of child injury deaths in 1991 (p 784). They then show that in the early 80's children in social class V were 3.5 times more likely to die from injuries than children from social class I; by 1989-92 this differential had increased to 5.0 times. On p 814 Dr Roberts asks in a letter why the government won't distribute free smoke alarms to poor families. A study published in the New England Journal of Medicine suggests that such a move can reduce deaths by 80%. The answer of the inhabitants of the Department of Health is that it is a matter for people other than them.

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