Why They're Mad at JAMA

The Houston Chronicle reports that the editor of a prominent medical journal was inundated with hate email over its recent publication of a literature review concluding that fetuses are incapable of feeling pain until late in pregnancy.

Dr. Catherine DeAngelis, editor in chief of The Journal of the American Medical Association, said today she had to take a walk around the block after receiving dozens of "horrible, vindictive" messages.

"One woman said she would pray for my soul," DeAngelis said today. "I could use all the prayers I can get." She said she is a staunch Roman Catholic and strongly opposes abortion, though she also supports women's right to choose.

"Your license should be stripped," DeAngelis said, reading aloud from the 50 or so e-mails that came to her office. "You're hypocrisy," "You should get a real job," "Eternity will definitely bring justice for you," others wrote.

Critics said the article in Wednesday's JAMA was a politically motivated attack on proposed federal legislation that would require doctors to provide fetal pain information to women seeking abortions when fetuses are at least 20 weeks old, and to offer women fetal anesthesia at that stage of the pregnancy. A handful of states have enacted similar measures.

Not that I'm a theologian, but is not the objection to abortion based on the notion that the fetus has a soul? The hate mailers come across the same way as the most rabid animal "rights" activists, but at least the former explicitly base their idea on the notion that animals feel pain. Of course, I'm not saying that the pro-lifers now buy into Peter Singer's creed. But still: Why all the ruckus over a dry scientific review?

The similarity is no mere coincidence. Neither group identifies possession of a rational faculty as the basis for rights. This implies their conception of "rights" is a mere litany of special privileges rather than manifestations of the use of reason by an animal whose tool of survival is his mind. In other words, they have no rational argument for what they call rights. Lacking the ability to appeal to reason to persuade others to accept their beliefs, then, they must resort to other means, such as deception, appeals to emotion (More on this later.), or force (or the threat thereof) to convince others to act in accordance with them. All of these methods are attempts to cause opponents not to act upon what their own minds are telling them. This is why bullying is part and parcel of all such movements.

But few in these movements immediately become angry or threatening when confronted with someone they disagree with. So what elicited such frothing at the mouth? The article's abstract (summary), freely available online reads as follows.

Context Proposed federal legislation would require physicians to inform women seeking abortions at 20 or more weeks after fertilization that the fetus feels pain and to offer anesthesia administered directly to the fetus. This article examines whether a fetus feels pain and if so, whether safe and effective techniques exist for providing direct fetal anesthesia or analgesia in the context of therapeutic procedures or abortion.

Evidence Acquisition Systematic search of PubMed for English-language articles focusing on human studies related to fetal pain, anesthesia, and analgesia. Included articles studied fetuses of less than 30 weeks' gestational age or specifically addressed fetal pain perception or nociception. Articles were reviewed for additional references. The search was performed without date limitations and was current as of June 6, 2005.

Evidence Synthesis Pain perception requires conscious recognition or awareness of a noxious stimulus. Neither withdrawal reflexes nor hormonal stress responses to invasive procedures prove the existence of fetal pain, because they can be elicited by nonpainful stimuli and occur without conscious cortical processing. Fetal awareness of noxious stimuli requires functional thalamocortical connections. Thalamocortical fibers begin appearing between 23 to 30 weeks' gestational age, while electroencephalography suggests the capacity for functional pain perception in preterm neonates probably does not exist before 29 or 30 weeks. For fetal surgery, women may receive general anesthesia and/or analgesics intended for placental transfer, and parenteral opioids may be administered to the fetus under direct or sonographic visualization. In these circumstances, administration of anesthesia and analgesia serves purposes unrelated to reduction of fetal pain, including inhibition of fetal movement, prevention of fetal hormonal stress responses, and induction of uterine atony.

Conclusions Evidence regarding the capacity for fetal pain is limited but indicates that fetal perception of pain is unlikely before the third trimester. Little or no evidence addresses the effectiveness of direct fetal anesthetic or analgesic techniques. Similarly, limited or no data exist on the safety of such techniques for pregnant women in the context of abortion.Anesthetic techniques currently used during fetal surgery are not directly applicable to abortion procedures.

I can see several things here that might have upset anti-abortionists, but the article itself goes into much greater detail. Anyone who read it would have been reminded of Terri Schiavo, and probably of anti-abortion videos by the following passage.

Although widely used to assess pain in neonates, withdrawal reflexes and facial movements do not necessarily represent conscious perception of pain. Full-term neonates exhibit a cutaneous withdrawal reflex that is activated at a threshold much lower than that which would produce discomfort in a child or adult. This threshold increases with PCA, suggesting that the capacity of the neonate to distinguish between noxious and nonnoxious stimuli is maturing. Furthermore, flexion withdrawal from tactile stimuli is a noncortical spinal reflex [link added, search "reflex"] exhibited by infants with anencephaly and by individuals in a persistent vegetative state who lack cortical function [italics added].

Why do I think this article raised such a firestorm? It cuts off at the knees one of the tactics used by the anti-abortionists to elicit sympathy for their cause. No one with a grain of decency would wish to hurt an infant. The idea that a fetus could feel pain is thus a powerful asset to the anti-abortion camp. This article calls the entire idea into question, possibly removing this tactic from the anti-abortionist arsenal. This is why the editor got all the hate mail.

-- CAV