Pain is distinct from nociception.
Nociception is defined as the “neural process of
encoding noxious stimuli” (IASP 2017), while pain is
defined as an unpleasant experience “associated with, or resembling that associated
with, actual or potential tissue damage” and suffering as the state of being in
pain.
While nociception and pain perception typically occur concurrently, dissociation is
possible.
.
External awareness of pain represents an unreflected experience of “being in pain”
(Derbyshire and Bockmann 2020, 5), such as a neonate
wo experiences, but will not remember, pain from a heel lance. In contrast,
internal awareness, represents a self-reflective experience
of knowing that one is in pain
Neurodevelopmentally, the self-reflective experience of pain does not emerge until
cortical synapses develop during the first 2 years of postnatal life
nociception still can occur below the level of the injury,
In the fetus, awareness and perception are thought to progress gradually along a
continuum, rather than as a binary switch activated by cortical
development at 24 weeks gestation
Four hypotheses have been proposed regarding structures or functions necessary for
pain perception: 1) cortical necessity after 24 weeks
gestation (RCOG 2010; SMFM et al. 2021; Stanojevic et al. 2021); 2) cortical
subplate beginning at 12 weeks gestation; (Derbyshire and
Bockmann 2020); 3) brainstem and thalamus (Brusseau 2008; Merker 2007; Sekulic et
al. 2016), which are present after 7–8 weeks gestation
(Derbyshire 2006, 2008); and 4) the onset of fetal consciousness, estimated at
varying gestational ages (Lee et al. 2005).
As noted by researchers in 2019, “It is now recognised that the developing motor
and sensory systems are able to function long before
they have completed their neural maturation”
The necessity of an intact cortical system has also been questioned by studies
which describe the occurrence of pain perception in children
and adults with severe damage to or absence of the somatosensory cortex (Aleman
and Merker 2014; Merker 2007). Research of infants and
children born without a cortex (anencephaly and hydranencephaly), in which the
highest functioning level of brain tissue is the brainstem
(anencephaly) or diencephalon (hydranencephaly), have demonstrated intact awareness
of pain, accompanied by crying, avoidance, and
withdrawal, as well as the ability to be soothed. Hasta las 12 semanas de
gestación, el feto no ha desarrollado la corteza cerebral,
que es lo que distingue a la vida humana de la animal o vegetal. Jorge Carpizo, ex
rector de la UNAM
Instead, ablation of the thalamus blocked the pain response (Brusseau 2008;
Lowery et al. 2007; Marchant 2014). Similar findings are reported in studies of
patients with Déjerine–Roussy syndrome. In this thalamic
pain syndrome, isolated lesions in the thalamus due to stroke or metastases result
in debilitating pain triggered by minor stimuli, such
as light touch (Klit, Finnerup, and Jensen 2009). Ablation of these thalamic
lesions alleviates pain (Patel et al. 2017).
The authors conclude that cortical structures may be necessary for “regulation of
pain rather than providing the decisive substrate for
pain’s conscious experience” (1499).
Due to significant gaps in medical knowledge, it is unclear how adult pain
perception translates to the unique “structures and mechanisms
used for pain processing during fetal or neonatal life” (Lowery et al. 2007, 276)
These studies, however, challenge the hypothesis of
cortical necessity and support the hypotheses of pain perception via the cortical
subplate or subcortical structures prior to 24 weeks gestation.
In 2020, 10 years after the Royal Collage of Obstetricians and Ginceologists
report was released, a review on fetal pain by Derbyshire and
Bockmann stated that, based on existing
research, the potential for fetal pain exists once thalamic projections reach the
subplate beginning at 12 weeks gestation. This study is
of particular significance as Derbyshire, a principal author of the 2010 RCOG
report, previously held that fetal pain was not structurally
possible until 24 weeks gestation
Other research of human infants and children born without a cortex have
demonstrated intact awareness of pain (Aleman and Merker 2014;
Sekulic et al. 2016). Research with decerebrate and decorticate experimental
animals (cortex surgically removed) has likewise demonstrated
the ability to perceive and respond to pain, with crying, fear, and avoidance
(Sekulic et al. 2016). These studies suggest an emerging level
of consciousness once the brainstem, including the thalamus (diencephalon), is
present during fetal development (Brusseau 2008), not as an
all-or-none event occurring at a distinct gestational age (Derbyshire 1999). This
line of analysis raises the possibility that
fetal pain perception and awareness, mediated at the level of the thalamus and
brainstem, may be possible after 7–8 weeks gestation, or at
the level of the thalamus and subplate, from 12 weeks gestation.
physiological and endocrine signs are not present until 13 weeks.
Fetal response to noxious stimuli increases with gestational age and development.
Such responses include withdrawal reflexes, whole body
movements away from the noxious stimulus, and facial expressions. Ethically
questionable research conducted in the 1930s to 1960s by
University of Pittsburgh anatomists, Hooker and Humphrey, sought to determine fetal
motor responses to tactile stimulation (Hooker 1936,
1942, 1952; Humphrey 1964). Their research utilized more than 150 intact, living
fetuses obtained from surgical abortions via hysterotomy
(or less commonly through spontaneous preterm delivery) which were immediately
suspended in saline solution. Fetal responses to repeated
stimulation of the skin and musculature with monofilaments or bead-tipped glass
rods were recorded, until demise occurred 8–20 min after
placental separation (Hooker 1942). Fetal withdrawal reflexes to tactile
stimulation of the perioral area were noted, beginning at 7.5
weeks gestation, showing “generalized movement of the head and upper trunk away
from the stimulus
Denial of fetal pain capacity beginning in the first trimester, potentially as
early as 8–12 weeks gestation, is no longer tenable.
