A Painful Moral Question

by Dr. Nileema Conlon Vaswani in

Pain is a major consideration in medical treatment. Many medical procedures are carried out under anaesthesia to minimise pain to the patient. We often take painkillers such as ibuprofen or paracetamol to alleviate pain. When carrying out a medical procedure, a medical professional might say to the patient, "This might hurt a little" or "Tell me if this hurts". Patients often ask for pain-relieving medication. Even when patients are at the very end of their lives, most people would prefer a painless death to a painful one.

Communicating about how much pain one is experiencing is helpful to the medical profession and decision-makers when determining whether or not to offer pain relief. The question is what ought medical professionals to do if a patient were unable to communicate regarding one's levels of pain. Ought one to assume that the person is in pain and provide pain relief or ought one to assume that in the absence of this information, the person is not experiencing pain?

There will be some cases where medical professionals will be able to determine whether the patient is likely to experience pain and can, therefore, provide appropriate pain relief. As long as there is a "model of pain", i.e., a case where pain is typically experienced or not experienced, the decision as to whether or not to administer pain relief is not a difficult one. The problem occurs if we have no model of pain to guide our decisions.

This week, most MPs in the UK have rejected the proposal to lower the upper limit for abortion. The upper limit currently stands at 24 weeks. The argument is based on two factors: survival rates and pain. The argument from "survival rates" claims that babies under 24 weeks very rarely survive so there is no reason to lower the abortion limit on those grounds. The argument from "pain" claims that there is not as yet compelling evidence to suggest that foetuses under 24 weeks experience pain so to avoid abortions before 24 weeks on grounds of pain is unnecessary.

Our article "When Life Ends at Its Very Beginning: Moral Considerations for Lowering the Deadline for Abortion" (20 October 2007) explored the argument from survival and argued that low survival rates in 23-week old babies did not provide a sufficient moral basis for abortion. Further, we considered the issues of abortion and euthanasia together and argued that, as it would be illegal to perform an act of euthanasia on a 23-week old baby, regardless of its chances of survival, it seemed difficult to justify the aborting of a 23-week old foetus. If, indeed, this is what the law allowed, then our determinations of what is right and wrong are being made on the basis of labels and location. The fact that the same being is called a foetus if unborn and a baby if born ought not to accord it different moral statuses. Living inside the womb at the same age as a baby who lives outside the womb at that age ought to confer the same rights on that being.

One of the reasons why some MPs have rejected the proposal to alter the upper limit of 24 weeks is because they are unconvinced that the foetus actually experiences pain. The report prepared by the Science and Technology Committee, based on which MPs have considered the proposal to lower the limit, has taken into account the views and work of various experts in the field. These views are mixed. But rather than carrying out an analysis to determine the most compelling piece of research, it is important to take a step back and ask ourselves how changes in medical law are normally brought about.

On major issues in medicine, a public consultation is usually carried out. A critical part of this consultation is that those who are likely to be affected by the decision be consulted. Of course, it is possible for women of various viewpoints to air their views on various aspects of abortion. However, regardless of how much research is done and how many viewpoints are considered, we will never know for sure if the foetus experiences pain and to what degree.

In the absence of this information, there are two routes one can take. One is to treat an older foetus, say of 23 weeks, the same as one treats a baby of 23 weeks. If we believe that a baby of that age is capable of experiencing pain, then we ought to use that as our "model of pain" when thinking about a foetus of the same age. The other route, which leads to the same conclusion, is to err on the side of caution and assume that the foetus experiences pain. Based on this assumption, and the central role that pain assumes in other medical contexts, the upper limit for abortions ought to be lowered.

One might argue that lowering the upper limit, even on grounds of pain to the foetus, wrongs the mother. To ensure that our discussion on abortion includes both the mother and the foetus, it is important to consider some of the reasons for abortions that are published in the report from the Science and Technology Committee. The reasons include not knowing that one was pregnant, not sure about having an abortion, not realising that one was pregnant because of irregular periods, changes in one's relationship with one's partner, not knowing what an abortion entailed so the delay in asking for one, etc.

Part of the problem with this data is that all the women interviewed underwent abortions at 13 weeks or later. As the current debate surrounds abortions that occur much later, it would have been more accurate to separate the data in a way that revealed the reasons for abortions after 20 weeks. While every case of abortion is different and it is difficult to comment on the strength of individual reasons, some of the reasons such as not knowing that one was pregnant are unlikely to be applicable to a pregnancy that has advanced as far as 23 weeks.

Once again, instead of attempting to evaluate individual reasons, it is important to step back and consider whether any of these reasons would have moral force if we were talking about a baby instead of a foetus. Most of the reasons would not apply, of course, as they pertain to either not knowing that one is pregnant or to not knowing whether or not to have an abortion. Consider, however, the reason that states that one's relationship with a partner changed or broke down. This reason, as a reason for abortion, is legal but if a mother of a 23-week old baby found that her relationship with her partner had broken down, she would not be allowed to ask that a medical procedure be carried out to end the life of her baby. Most people would agree that the latter is morally appropriate in which case, the former also ought to be morally and legally inappropriate.

From a scientific viewpoint, it is important that research be challenged and more and more evidence sought to establish the accuracy of a claim. However, in cases such as foetal pain, where the accuracy of the claim that foetuses do experience pain, may never be established, it is important to play morally safe and assume that foetuses, especially older ones, do experience pain.