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Testimony of Dr. Paul Liu, Board Certified in Pediatrics, Pediatric Critical Care Medicine, and Anesthesiology; Clinical Assistant Professor of Pediatrics, University of Arizona College of Medicine, Tucson, AZ.
Before Committee on State Affairs of Texas House of Representatives in public hearing on PreBorn Pain Bill: HB 2364 in 83rd Legislative Session, April 10th, 2013.
“I am an anesthesiologist, and I am also a pediatrician. I do critical care medicine for children. My name is Paul Liu. I am for the bill. I am here basically to substantiate the facts that fetuses do feel pain at 20 weeks. I think that the question was raised is whether or not what is developed in the fetus at 20 weeks… generally it is accepted that all pain receptors are present, especially around the mouth, throughout the body, et cetera. The train tracks are there from the skin receptors all the way to the spinal cord, from the spinal cord all the way to what we call the thalamus, which is a structure deep inside the brain. From the thalamus, there are normal fibers in the adult and in a term infant that permeate to what we call the end plate, and goes into the end plate into the cortex of the brain. And those fibers are not there at 20 weeks. They begin to develop around 23-24 weeks. And I think that this is the point at which the arguments begin as to whether or not the fetus can feel pain. Because as an adult, we have those fibers, and that is how we transduce pain. The absence of those fibers does not mean that a child cannot feel pain. That’s how we feel pain as an adult and as a term infant. There are neurotransmitters, what we basically call little hormones: noreponephrine, dopamine, serotonin, things like that that permeate, and also what we call substance, P, that’s for pain, that actually can permeate through that area and transduce signals of pain through that. How do we know that? Well, the proof is in the pudding, so to speak. You know, the question is whether or not children feel pain – or babies feel pain. They can’t tell us. A newborn can’t tell us, “I hurt, you poked me there.” What he does instead is he withdraws his limb, he cries, if you measure heart rate, that goes up; if you measure his blood pressure, that goes up. If you do extensive blood testing you’ll see that all these stress hormones go way up, because he feels pain. If you do that to a fetus in utero, and you’ve heard that said, that even on an ultrasound as they do intra uterine sampling of blood and things like that, and they actual get the needle and poke the little critter, he feels the same thing. He moves away. You can actually see some of these infants cry. You’ll see them withdraw, you’ll see their heart rate go up and their blood pressure go up. This is why when they do fetal surgery, they provide fetal anesthesia. Because it does that. And they also see that if they don’t provide fetal anesthesia, long-term wise, the fetuses that don’t get the anesthesia don’t do quite as well as the ones that do. Because they went through the stress response without any accumulation. So in book, if you walk like a duck, you quack like a duck, you probably are a duck. We can’t quite ask the fetus, “Did you feel this?”
The second thing I want to say, basically, is about the article that Representative Farrar was talking about, the JAMA article from 2005, that says that basically neonates cannot feel pain up until about 29 weeks gestation. I think they state that as a very factual thing. Unfortunately, that is a very poorly written article. We have in medicine what we call not peer review, but journal club. And what we do in journal club is we look at articles that have been published, and we look at it very critically in view of what is that article saying, what is it not saying, and what are other articles that have previously existed before it, or around it; what have they said about the same thing. And as one looks at this article, you’ll find that there is actually a conflict of interest. One of the significant authors is a director of an abortion clinic in San Francisco. That should have been disclosed when that article was published; it was not. Technically it was not a conflict of interest, because this article deals with fetal pain, and abortion clinics don’t necessarily deal with that… but they really do, in some ways.
The second interesting thing about this article is that they come up with a statement that fetuses, or infants really cannot feel pain up until 28-29 weeks. I daresay that is not medical practice, even back in 2005. I think you would be hard pressed to find a neonatologist or a pediatric anesthesiologist that would not have given analgesia, or some type of sedative or pain reducing thing to any infant that is at 27, 28, 29 weeks, which is not unusual to be alive and requiring surgery. I think it would be malpractice for them not to do that, even in 2005.
The third point is that we need to learn from out past. Our failure to learn from our past causes us to repeat the same mistakes. When I began my training in 1980, and I am an old man… I have been doing pediatric critical care, anesthesia and pediatrics for a very long time. We were told as interns that neonates did not feel pain. We would routinely have infants that were 26-27 weeks gestation, and would try very hard to resuscitate and keep them alive. And at times we were successful at 26 weeks. Most at 30, 32 we were very successful. We were told that these little critters did not feel pain, and so when we were doing chest tubes, other procedures that required incisions, things like that, we would not routinely anesthetize them. In 1986-87, Anand came out with a landmark article saying basically they do feel pain. And you know what? He was right, we were wrong. We were told for all these years that they do not feel pain, that their crying, their heart rates and increased blood pressure, their intracranial bleeds and things like that were because of other reasons. In reality, as we looked back, we were causing them pain. All because we were told the children were not capable of feeling pain at this age. They were wrong. All I have to say is that as we look back, we would be vey stupid, basically, to repeat our mistakes of the past. Fetuses do feel pain. You see that on ultrasound as people do procedures. If it quacks like a duck, sounds like a duck, walks like a duck, you know, it’s a duck.”