Wednesday, February 27, 2008

Ouch! Bites That Hurt the Most

Mother Nature's Kings of Pain

Stings and Bites of Some Animals Are Almost Beyond Endurance, Victims Say

ABC News Medical Unit

Certain members of the animal kingdom have a talent for torture, as those of us who have been unlucky enough to experience it can attest.

Maybe you're swimming at the beach, hiking in the wilderness, or just cleaning out your basement  suddenly you're on fire, dancing or doubled over, staring at an almost invisible wound and wondering how something so small could hurt so horribly.

We have compiled a Top 10 list (in no particular order) of some of the most excruciating stings and bites nature has on offer. Some are potentially deadly, some are not. All are absolutely worth avoiding.

February Pain-Blog Carnival | How To Cope With Pain Blog

In Sickness and In Health reminds us to focus on the sweetness of the things we can do - no matter how odd they may be - like attending a 24-hour science fiction film marathon.

For another take on focusing on the positive, A Chronic Dose reports on her experience of shifting from the negatives - isolation, unproductiveness, disappointing friends - to all she's thankful for.  A great reminder to all of us.

Fighting Fatigue offers wonderful advice when shopping for clothes.  Although it might not land you a job on the runways of Paris, it'll make you more comfortable!

The First Ache, shared by Psychology of Pain, reviews the literature on fetal pain.  Thought-provoking!

What are all the benefits a personal health coach can offer?  Check out this post at CRPS/RSD A Better Life.

Spring is a time of new beginnings.  What about a new career?  When you live with chronic illness or pain, a different job is sometimes necessary.  Working with Chronic Illness offers resources for making career changes.

When the Body Decides to Stop Following the Rules - New York Times


When the Body Decides to Stop Following the Rules


Every day over breakfast, I fill three pillboxes. Fifteen pills in the morning, 3 at lunch and 8 before bed, for a total of 26. To my surprise, I find pleasure in the sorting, as it is one of the few moments when I can pretend I have some control over the bizarre war raging in my colon.

When I learned 11 months ago at age 29 that I had a chronic illness, I understood that my life was going to change. I knew I would stop eating certain foods, limit stress and think more strategically about when to have children. What I didn't anticipate was the loss of control over my life that I thought I had, until the gastroenterologist uttered the words "ulcerative colitis."

Tuesday, February 19, 2008


A blog about pain and neuroscience by Diane Jacobs, physiotherapist

Neuromatrix training

What is a neuromatrix?

Readers frequently ask about the definition of neuromatrix in relation to the brain and pain. Wikipedia and Google are not that helpful (yet), though there are some good links on Google to Ronald Melzack's pioneering work. (Melzack, 1999, 2001).

Cognitive Psychology is merging to some degree with neurobiology. While the term neuromatrix has emerged with the increasing knowledge of brain neuroscience, some of the older cognitive psychology writings provide good definitions and understanding of what we now call the neuromatrix.

I like "a map of event space in the system's coding space" (Dudai, 1989). So the coding space is all the possible combinations of connections in the brain. Pain or jealousy could be an event which would take up part of this space. The event space has been referred to by Melzack as the neurosignature. So a pain neurosignature exists within the neuromatrix. Moseley and I (Butler & Moseley, 2003), trying to be a bit trendy, refer to the neurosignature as a neurotag.

Of course it is all far more complex than this. A pain neurotag exists in a snapshot of time. It will change over time and context. Everyone's pain neurotags are different and even our own pain neurotags will be structurally different within the brain over time.

The term "representation" is also used in relation to neurosignature.

Hoping this makes sense!!

Butler, D. S., & Moseley, L. S. (2003). Explain pain. Adelaide: NOI Publications. 
Dudai, Y. (1989). The neurobiology of memory. Concepts, findings, trends. Oxford: Oxford University Press. 
Melzack, R. (1999). From the gate to the neuromatrix. Pain, Suppl 6, S121-S126. 
Melzack, R. (2001). Pain and the neuromatrix in the brain. Journal of Dental Education, 65, 1378-1382.

The Neurotopian: Pain For Dummies

Over the past few weeks I've tried to explain a few things about pain, you and your brain - and why science is important and how it helps us to understand ourselves.

I will of course continue to post about these topics - but the Pain for Dummies Series comes to an end with this posting.

To sum up the series:

Pain is incredibly complex - it involves the whole brain, it can (and must) be tackled using different approaches (hence biopsychosocial). And we are far from understanding it completely.

Most important however is the fact that there is such a thing as a "brain in pain" - a brain that has learned that there is pain to be expected regardless of what the person does - and that you can re-learn to be pain free!

That doesn't happen overnight of course - you'll need lots of patience - but there is a basic entry level for everyone. Find it and start (re)training - now!

Here's what I covered over the past few weeks:

Part I: What is Pain?, Pain and the Stress Response

Part II: The Multidimensionality of Pain and the Biopsychosocial Model

Part III: The Psychology of Pain

Part IV: Metacognition - the coolest feature you have and didn't know about

Part V: The social aspects of pain

Part VI: Can you handle the truth?

Part VII: What's this new approach all about?

Part VIII: Practice what you preach!

Part IX: What's the economy got to do with pain?

I hope that you can use some of the tips and tricks I put into my postings and that they will make your life easier - or better yet point you towards a pain-free future.

Coming up are a few postings about how we can tackle chronic pain from a therapeutic point of view - by exercising the virtual body and giving non-nociceptive feedback for example.

Why Paper Cuts Hurt So Much: The Mystery

The Peculiar Pain of Paper Cuts

Experts Offer Theories on How Such Little Cuts Can Hurt So Much

ABC News Medical Unit

They always strike when least expected - opening the mail, rummaging through notes, and in an instant, it's "ouch!" and you're sucking air in through your teeth.

Oh, the paper cut. Since the dawn of office work, it has been the one thing that can make even the most composed business person spew profanities. Somehow, that little cut stings more than any other nick - and it keeps hurting, too.

But why? Theories of office lore circulate the Internet - from the microscopic structure of paper, to the chemicals used in paper plants, to bacteria living on our faxes.

While dermatologists know which theories are wrong, the most annoying pain in the office still remains a bit of a medical mystery.

Hogging the Nerves

"Nobody really knows the answer," says Dr. Joseph Eastern, a dermatologist in private practice in Belleville, N.J. But, Eastern adds, there are a few good theories.

The first culprit would be our hands' nociceptors - the nerve fibers that send touch and pain messages to our brain, particularly the somatosensory cortex.

The hands hog more nociceptors than the arms, the legs, or the stomach, as a way to protect us.

"If we touch something hot or sharp, or in anyway painful, we are most likely to do it with our hands - and so, our hands should be a great judge of those bad or painful things," says Dr. Mark Abdelmalek, chief of laser and dermatologic surgery at Drexel University College of Medicine.

"If you had a paper cut on your thigh, it wouldn't hurt nearly as bad because the thigh doesn't deserve all that attention in the brain's somatosensory cortex," he says.

But the strategic concentration of nerves on our hands doesn't explain why paper cuts instantly sting in a way other scrapes and cuts on our hands do not.

To explain that, people often turn to the weapon - paper.

Don't Blame Just Hands, Blame Paper

Internet forum posts are full of blame for paper, and most are a little off the mark.

One frequent claim is that paper is porous, and therefore, a better host to bacteria than the clean surface of a razor or a knife. Cut yourself with paper, and you'll leave behind debris and bacteria to sting you.

But dermatologists don't always agree.

"Number one, bacteria don't cause pain," says Eastman. "You get pain with an infection, because your skin is inflamed, trying to fight off bacteria, but bacteria doesn't cause pain."

Second, says Eastman, "I don't know that there's any evidence that paper leaves behind more dirt and bugs than anything else you cut yourself with."

However, paper is still part of the problem. Paper is sharp, but it's duller than knives and razors. It's also more flimsy than needles and rocks. Unfortunately, for office workers, the combination of paper's unique qualities results in awful cuts.

The Perfect Painful Cut

The flexible, relatively dull edge of paper means paper cuts never go very deep. But while a dull, shallow cut sounds less painful, pain specialists say it's worse.

First, the dull edge of the paper is more likely to rip flesh than tear it. "This means paper could do more microscopic damage," says Eastman.

The microscopic damage hits the most sensitive nerves, too. The concentrated nerves on the hands have a very low threshold to activate and send a signal to the brain, says Dr. Carmen R. Green, associate professor of pain medicine at the University of Michigan.

Meanwhile, larger nerves, which send dull aching pain, are tucked safely away deeper in the flesh. "Sometimes, you can slice your finger open and it looks bad, but it doesn't hurt that much," says Green.

So, since a paper cut is shallow, and unlikely to bleed a lot, it will more likely sting, instead of produce a dull throb. Unfortunately, the shallow cut only brings more bad news.

Because paper cuts are shallow, they are less likely to bleed, clot and seal up the wound with a scab. That means the raw nerves are open to the air, and keep sending new messages of pain to the brain.

What To Do

Cover the cut. Sealing the wound will stimulate fewer pain receptors, and it will help the cut heal, says Dr. Nicole Neuschler, assistant professor of dermatology at the Weill Medical College of Cornell University in New York.

"People often don't try to seal the wound," says Neuchler. "But it could be as simple as Vaseline, liquid bandage, Super Glue or Crazy Glue."

Glucosamine: No Help for Hip Arthritis?

Glucosamine: No Help for Hip Arthritis?
Dutch Study Shows Popular Supplement No Better Than Placebo; Industry Disgrees
By Kathleen Doheny
WebMD Medical News

The popular supplement glucosamine, used by many arthritis sufferers, was found to be no better than placebo pills for relieving the pain of hip osteoarthritis or increasing the ability to do everyday activities, according to a new study from the Netherlands.

"In our study, there was not much room for doubt," says Rianne Rozendaal, MSc, the study's lead researcher.

"The differences between the glucosamine and placebo group were all very small," says Rozendaal, a researcher at the Erasmus Medical Center in Rotterdam, Netherlands.

But representatives of the supplement industry disagree, with one manufacturer saying the researchers may have focused on people too early in the arthritic process.
Glucosamine and Arthritis

An estimated 21 million Americans have osteoarthritis (or "wear-and-tear" arthritis) affecting the hips, knees, and other joints, according to the Arthritis Foundation. The condition is marked by the breakdown of the joint's cartilage, which cushions the bone endings and allows you to move easily.

A substance found naturally in healthy joint cartilage, glucosamine stimulates the formation and repair of cartilage, according to the American Academy of Orthopaedic Surgeons, but over-the-counter supplements come from animal or plant sources. Studies of the effectiveness of glucosamine have yielded mixed findings.
Study Details: Glucosamine and Arthritis

Rozendaal and her team assigned 222 patients, all with hip osteoarthritis that was generally termed mild, to take either 1,500 milligrams of glucosamine sulfate or a placebo pill every day for two years. On average, patients were in their early 60s.

About equal numbers in each group underwent total hip replacement surgery during the study. The researchers evaluated the patients at three, 12, and 24 months after they began the treatments, collecting information about the patients' pain levels and how well they could perform everyday activities.

X-rays were taken to measure the joint space in the hip. As osteoarthritis gets worse, this joint space gets narrower.

At the study's end, the pain scores of those who took the supplement didn't differ much from those who took the placebo, Rozendaal says. On the scale used, "the pain scores range from 0 to 100," she explains in an email interview, "where 0 equals no pain and 100 equals [the] most severe pain."

The average difference between groups in pain scores was a decline of just 1.5 points, she says. To be statistically significant, there would have to have been a difference of at least 10 points, she says.

"Our trial does not suggest an effect of glucosamine for hip osteoarthritis," she adds.

No differences were found between groups in the joint space narrowing, either, Rozendaal says. The study is published in the Annals of Internal Medicine.

In an editorial accompanying the study, authors from another Dutch medical center note that "the study is indeed negative" but caution that the results apply only to hip osteoarthritis. They conclude that the role of glucosamine in arthritis treatment is still under debate.

They also note that when the authors looked at a subset of people with osteoarthritis in other parts of their bodies, they found a small trend toward pain reduction and improved functioning, but the change wasn't significant.

A better group of patients to study would have been those with more severe arthritis because the disease progresses more rapidly then, and it might have been easier to see any effect of the supplement, wrote Johannes W.J. Bijlsma, MD, PhD, and Floris P.J.G. Lafeber, PhD, of the University Medical Center Utrecht.

"What they did was study people too early in the arthritic process," agrees Luke Bucci, PhD, vice president of research at Schiff Nutrition International in Salt Lake City, which makes a glucosamine supplement.

He says that "they were starting to see some small advantages for the glucosamine group."

The study findings don't surprise Jay Mabrey, MD, chief of orthopedics at Baylor University Medical Center in Dallas. Nor does he expect this study to be the last word on the supplement.

"There are people who really believe in this and I am sure they will proceed with their own studies," Mabrey says.

His advice about its use? "I don't discourage it, and that's different from encouraging [its use]," he says. "It seems about half my patients [who use the supplement] report some type of relief, but that could very well be placebo effect." When patients ask, he tells them: "So far the studies don't show any definite advantage." But "as far as we know," it doesn't appear to do harm, he says.

Sunday, February 17, 2008

A doctor's dilemma: prescribing pain pills is getting trickier - The Boston Globe

A doctor's dilemma: prescribing pain pills is getting trickier

By Dr. Victoria McEvoy

February 4, 2008

The young, adult male entered the Lawrence Memorial Hospital emergency room writhing in pain. "I think I am passing another kidney stone," he managed to croak before he doubled over.

The pain of passing a kidney stone is unimaginable and has been known to make the most stoic cry, vomit, or pass out. The patient was quickly triaged and examined. A urine sample confirmed the presence of red blood cells, which can be a sign of a passing stone. The physician who later recounted this story to me said he was eager to provide relief for this unfortunate patient - until his pleas for pain medication became more and more specific and demanding.

"What are you going to give me, Doc? Vicodin? Dilaudid? Percodan? Please hurry!" the patient said.

At this point, the seasoned emergency room staff, always on alert for the "frequent fliers" - patients who rotate from ER to ER, doctor office to urgent care center, looking for sympathetic ears to feed a drug habit - began to take a second look.

Detecting drug abusers is not always so easy, and while physicians and nurses want to relieve suffering, we have to be careful that our efforts to treat legitimate pain do not end up feeding addictions.

The Massachusetts Supreme Judicial Court has now given physicians another reason to pause before prescribing painkillers. The state's highest court allowed a lower court to hear a lawsuit resulting from a car accident in which a 75-year-old man, who was on various medications for medical ailments, killed a 10-year-old boy. The man, who had cancer, has since died, but the boy's family sued the man's physician because he had prescribed the medications without adequate (according to the lawsuit) instructions about driving.

The ruling means that providers may now face legal jeopardy for unintended consequences of prescribed medications.

I don't know whether the doctor in this case shirked his duty to his patient, but providers routinely discuss side effects of medications - whether patients follow them is an entirely different matter. It can also be hard to predict dangerous side effects. Everyone reacts differently to medication and combinations of medications. Unknown or complex drug interactions can create problems that were not predicted by research. And sometimes patients react one way when they first begin a drug regimen, and differently later on.

The SJC ruling has already had a chilling effect on my peers. Can we continue to treat patients for pain without worrying that they might get behind the wheel? Should we overreact and tell all of our patients on pain medications that they had better stick to sidewalks and mass transit? What about all the other medications besides painkillers that may have side effects that make driving unsafe?

One of my colleagues recently got in a tussle with a patient over what degree of pain relief was needed for an orthopedic injury. While physicians never want to have adversarial relationships with those in their care, the recent ruling may make these conflicts more frequent.

After giving a narcotic in the emergency room, another colleague has begun following patients to their cars if he's unsure whether they really have someone to drive them home.

Clearly, pain management is one of the most vexing problems for physicians. Recently, the Joint Commission, an accrediting board for medical institutions, put guidelines in place to ensure that providers paid enough attention to their patients' pain.

Of course, periodically an outlaw physician is arrested for running a "pill shop" where pain medications are given out indiscriminately for quick fees. But most providers want to do the right thing.

Most patients do, too, though there are some, like the man seen in the ER, who attempt to deceive physicians.

Pain is a subjective symptom and recent studies have confirmed biologic reasons for differing perceptions of pain. Providers ask patients to rate their pain using a zero-to-10 scale in an attempt to quantify their suffering. But at the end of the day, good judgment and clear patient doctor-communication is the best remedy.

While the Massachusetts case has not yet been decided, an outcome against the physician could have a chilling effect on prescribing practices. Doctors should outline possible side effects of medications, especially those that impair judgment, vision, or ability to drive safely. However, it is up to the patient to follow instructions and take responsibility.

Dr. Victoria McEvoy, medical director and chief of pediatrics of Mass. General West Medical Group and assistant professor of pediatrics at Harvard Medical School, can be reached at

Thursday, February 14, 2008

San Jose Mercury News - A's Harden says he felt pressure to pitch with pain

A's Harden says he felt pressure to pitch with pain
Right-hander: 'It's insulting. . . . I know what's best for myself'
By Joe Stiglich
Bay Area News Group

PHOENIX - Rich Harden said he is optimistic he can achieve his first injury-free season since 2004 but criticized the A's for their handling of his injuries in recent years.

"The whole year (last season) I've got people in the organization telling me I'm fine, that I've got to pitch with pain," Harden said after reporting to training camp Wednesday. "It's insulting, because they don't know what's going on."

Harden was intentionally unspecific with his finger-pointing. Asked who was applying this pressure, he said, "I've got a lot of stuff to say. I don't want to say it."

Harden, 31-18 with a 3.60 ERA during his career, was limited to 32 starts over the past three years because of injuries, and he had biceps tendinitis this winter.

Last season, the right-hander second-guessed a decision to have him pitch in relief as he tried to come back from a strained shoulder suffered in April.
Harden made three relief appearances in June but landed back on the disabled list because of the shoulder injury after lasting just 2 2/3 innings in a July 7 start. He said he partly went along with the idea to relieve in response to the perception within the organization that he wasn't tough enough to pitch through pain.

"That's what's frustrating - you get people in the organization questioning whether or not I can pitch with pain," he said. "That's what's hurt me in the past. I've gone out there (and pushed it too much)."

That played into his decision to bypass two starts scheduled in September to gauge his progress.

"I know what's best for myself," said Harden, 26.

General Manager Billy Beane was asked if he or anyone else pressured Harden to pitch against his will.

"I don't recall that," Beane said. "We were just trying to get him healthy as quickly as possible.

"As always, Rich's medical condition will determine whether he's ready to pitch, and he lets us know on a regular basis. Given the fact that he pitched very little last year, he obviously wasn't feeling good enough and therefore wasn't on the mound."

Smoking pot may slow MS sufferers' thoughts - health - 14 February 2008 - New Scientist

Smoking pot may slow MS sufferers' thoughts

People with MS who smoke pot say it helps with symptoms such as pain, but does that come at the expense of a clear head? A small preliminary study hints that people with multiple sclerosis who smoke marijuana may process thoughts more slowly than people with MS who do not.

If true, this could be problematic for MS sufferers – some 40% of whom already suffer cognitive dysfunction as part of their disease. Typically, MS patients can have slower reaction times and poorer working memory.

Omar Ghaffar and Anthony Feinstein at Sunnybrook Health Sciences Centre in Toronto, Canada, wanted to find out if smoking pot made things worse for MS patients and affected their mental health.

Pot-smoking in healthy people has been linked to psychosis, delusion, depression and anxiety, and MS patients report higher levels of anxiety and depression than the general public even without the drug.

The researchers recruited 140 patients with MS, 10 of whom said they were regular users of pot. All 10 had smoked at least once in the past month and gave various reasons for smoking, including "for spasticity and bladder symptoms" and "for the high".

The researchers tried to match each pot-smoker with four control members who were similar in age, education and disease progression.

Ghaffar and Feinstein administered several tests to measure aspects such as anxiety and depression, suicidal feelings and social support. They also assessed cognition, using a specialised test for MS patients, and a computerised version of a test that measured how quickly and accurately they recalled associations between symbols and numbers.

The researchers found that pot-smokers were more likely to have psychiatric issues overall such as anxiety or depression, but no more likely to have a diagnosis for a specific mental illness than those with MS who did not smoke marijuana. Nor did they fare worse on the cognitive test. They were, however, significantly slower on the symbol-digit matching test.

The study is preliminary, stresses Feinstein, but he believes it suggests the effects of cannabis on MS patients should be studied more carefully. "You've got a group that's cognitively impaired," he says, "and along comes cannabis which is like a second hit."

But Mark Ware, who studies pain control, at McGill University in Montreal points out just how few adverse effects of cannabis the study found. And even then, causality was unclear. Uncontrolled pain can also affect cognition, he notes.

Still, he is worried that neurologists and patients will be scared off by negative headlines. "Let's not throw out what could still be a useful treatment," he says.

In Canada, patients with MS can legally use cannabis for medical reasons.

Symptoms: Irritable Bowel Syndrome and Action by the Brain - New York Times

Women who suffer from irritable bowel syndrome may respond to pain signals differently from other women, leaving them more vulnerable to the intestinal discomfort that characterizes the disease.

That is the finding of researchers who exposed women with and without the syndrome to mildly painful stimuli and then watched how their brains responded using a functional M.R.I. machine. The study appeared Jan. 9 in The Journal of Neuroscience.

The researchers focused on the brain's ability to tamp down its response to pain if it knows that it is coming and that it will not be too severe. (It also does this if the pain will bring about a benefit, like the removal of a splinter.)

When women without irritable bowel syndrome were about to be given the pain stimuli after a warning, their M.R.I. showed their brains stepping down the brain response. But the women with the condition appeared unable to do so.

The finding suggests that people with the syndrome may suffer in part because they handle pain differently.

"That does not mean the pain is less real," the lead author of the study, Steven Berman of the University of California, Los Angeles, wrote in an e-mail message.


Patterns - Migraine - Opinion - New York Times Blog by Oliver Sachs


I have had migraines for most of my life; the first attack I remember occurred when I was 3 or 4 years old. I was playing in the garden when a brilliant, shimmering light appeared to my left — dazzlingly bright, almost as bright as the sun. It expanded, becoming an enormous shimmering semicircle stretching from the ground to the sky, with sharp zigzagging borders and brilliant blue and orange colors. Then, behind the brightness, came a blindness, an emptiness in my field of vision, and soon I could see almost nothing on my left side. I was terrified — what was happening? My sight returned to normal in a few minutes, but these were the longest minutes I had ever experienced.

I told my mother what had happened, and she explained to me that what I had had was a migraine — she was a doctor, and she, too, was a migraineur. It was a "visual migraine," she said, or a migraine "aura." The zigzag shape, she would later tell me, resembled that of medieval forts, and was sometimes called a "fortification pattern." Many people, she explained, would get a terrible headache after seeing such a "fortification" — but, if I were lucky, I would be one of those who got only the aura, without the headache.

I was lucky here, and lucky, too, to have a mother who could reassure me that everything would be back to normal within a few minutes, and with whom, as I got older, I could share my migraine experiences. She explained that auras like mine were due to a sort of disturbance like a wave passing across the visual parts of the brain. A similar "wave" might pass over other parts of the brain, she said, so one might get a strange feeling on one side of the body, or experience a funny smell, or find oneself temporarily unable to speak. A migraine might affect one's perception of color, or depth, or movement, might make the whole visual world unintelligible for a few minutes. Then, if one were unlucky, the rest of the migraine might follow: violent headaches, often on one side, vomiting, painful sensitivity to light and noise, abdominal disturbances, and a host of other symptoms.

More ...

Wednesday, February 13, 2008

Back Pain Spending Surge Shows No Benefit - New York Times

Back Pain Spending Surge Shows No Benefit

Americans are spending more money than ever to treat spine problems, but their backs aren't getting any better.

Those are the findings of a report in the Journal of the American Medical Association, which found that United States spending on spine treatments totaled nearly $86 billion in 2005, a rise of 65 percent from 1997, after adjusting for inflation. Even so, the proportion of people with impaired function due to spine problems actually increased during the period, even after controlling for an aging population.

"You'd think if you're putting a lot of money into a problem, you'd see some improvements in health status,'' said lead author Brook I. Martin, research scientist at the University of Washington's department of orthopedics and sports medicine. "We're putting a lot of money into this problem, and it's a big investment in health care expenditures, but we're not seeing health status commensurate with those investments.''

The report is the latest to suggest the nation is losing its battle against back pain, and that many popular treatments may be ineffective or overused. Researchers have produced conflicting data about the effectiveness of spinal fusion surgery for back pain, although one major study called Sport, for Spine Patient Outcomes Research Trial, showed that spinal surgery patients did better than patients receiving more conservative care, which included medications or physical therapy. However, some doctors have questioned whether surgical treatments, injections and narcotic pain medications are being used appropriately in many patients.

"I think the truth is we have perhaps oversold what we have to offer,'' said Dr. Richard A. Deyo, a physician at the Oregon Health & Science University in Portland and a coauthor of the report. "All the imaging we do, all the drug treatments, all the injections, all the operations have some benefit for some patients. But I think in each of those situations we've begun using those tests or treatments more widely than science would really support.''

To study spending trends in spinal care, the researchers examined annual household survey data from the Agency for Healthcare Research and Quality that was collected from about 23,000 people a year from 1997 to 2005. It included information from pharmacy and medical records and was used to estimate national spending and treatment practices.

The researchers found that people with spine problems spent about $6,096 each on medical care in 2005, compared to $3,516 in medical spending among those without spine problems.

During that time, the biggest surge in spending was for drugs. In 2005, Americans spent an estimated $20 billion on drug treatments for back and neck problems, an increase of 171 percent from 1997. The biggest jump was for narcotic pain relievers, such as OxyContin and other drugs, which increased more than 400 percent.

Outpatient treatment for back and neck problems increased 74 percent to about $31 billion during the period, while spending related to emergency room visits grew by 46 percent to $2.6 billion. Spending for surgical procedures and other inpatient costs grew by 25 percent to about $24 billion.
Despite the growth in treatment of back problems, the data show that the percentage of people with serious spine problems hasn't improved. In fact, it appears to have gotten worse.

Based on the sample, the researchers estimated that in 1997, about 21 percent of the adult population suffered from back or neck problems that limited their function. By 2005, that number grew to about 26 percent, after adjusting the numbers for age and sex.

It's not clear why more people appear to be suffering from back and neck pain. It could be that rising obesity rates are taking an added toll on the spine, researchers suggested. Or it could be that excessive treatment of back problems is leading to more problems.

"I do worry there is a combination of side effects and unnecessary treatments and labeling people as being fragile when they're really not,'' Dr. Deyo said. "The combination of those kinds of things may actually be in some cases doing more harm than good.''

Sunday, February 10, 2008

The First Ache - New York Times

The First Ache

  • By ANNIE MURPHY PAUL Published: February 10, 2008

Twenty-five years ago, when Kanwaljeet Anand was a medical resident in a neonatal intensive care unit, his tiny patients, many of them preterm infants, were often wheeled out of the ward and into an operating room. He soon learned what to expect on their return. The babies came back in terrible shape: their skin was gray, their breathing shallow, their pulses weak. Anand spent hours stabilizing their vital signs, increasing their oxygen supply and administering insulin to balance their blood sugar.

"What's going on in there to make these babies so stressed?" Anand wondered. Breaking with hospital practice, he wrangled permission to follow his patients into the O.R. "That's when I discovered that the babies were not getting anesthesia," he recalled recently. Infants undergoing major surgery were receiving only a paralytic to keep them still. Anand's encounter with this practice occurred at John Radcliffe Hospital in Oxford, England, but it was common almost everywhere. Doctors were convinced that newborns' nervous systems were too immature to sense pain, and that the dangers of anesthesia exceeded any potential benefits.

Anand resolved to find out if this was true. In a series of clinical trials, he demonstrated that operations performed under minimal or no anesthesia produced a "massive stress response" in newborn babies, releasing a flood of fight-or-flight hormones like adrenaline and cortisol. Potent anesthesia, he found, could significantly reduce this reaction. Babies who were put under during an operation had lower stress-hormone levels, more stable breathing and blood-sugar readings and fewer postoperative complications. Anesthesia even made them more likely to survive. Anand showed that when pain relief was provided during and after heart operations on newborns, the mortality rate dropped from around 25 percent to less than 10 percent. These were extraordinary results, and they helped change the way medicine is practiced. Today, adequate pain relief for even the youngest infants is the standard of care, and the treatment that so concerned Anand two decades ago would now be considered a violation of medical ethics.

But Anand was not through with making observations. As NICU technology improved, the preterm infants he cared for grew younger and younger — with gestational ages of 24 weeks, 23, 22 — and he noticed that even the most premature babies grimaced when pricked by a needle. "So I said to myself, Could it be that this pain system is developed and functional before the baby is born?" he told me in the fall. It was not an abstract question: fetuses as well as newborns may now go under the knife. Once highly experimental, fetal surgery — to remove lung tumors, clear blocked urinary tracts, repair malformed diaphragms — is a frequent occurrence at a half-dozen fetal treatment centers around the country, and could soon become standard care for some conditions diagnosed prenatally like spina bifida. Whether the fetus feels pain is a question that matters to the doctor wielding the scalpel.

And it matters, of course, for the practice of abortion. Over the past four years, anti-abortion groups have turned fetal pain into a new front in their battle to restrict or ban abortion. Anti-abortion politicians have drafted laws requiring doctors to tell patients seeking abortions that a fetus can feel pain and to offer the fetus anesthesia; such legislation has already passed in five states. Anand says he does not oppose abortion in all circumstances but says decisions should be made on a case-by-case basis. Nonetheless, much of the activists' and lawmakers' most powerful rhetoric on fetal pain is borrowed from Anand himself.

Known to all as Sunny, Anand is a soft-spoken man who wears the turban and beard of his Sikh faith. Now a professor at the University of Arkansas for Medical Sciences and a pediatrician at the Arkansas Children's Hospital in Little Rock, he emphasizes that he approaches the question of fetal pain as a scientist: "I eat my best hypotheses for breakfast," he says, referring to the promising leads he has discarded when research failed to bear them out. New evidence, however, has persuaded him that fetuses can feel pain by 20 weeks gestation (that is, halfway through a full-term pregnancy) and possibly earlier. As Anand raised awareness about pain in infants, he is now bringing attention to what he calls "signals from the beginnings of pain."

But these signals are more ambiguous than those he spotted in newborn babies and far more controversial in their implications. Even as some research suggests that fetuses can feel pain as preterm babies do, other evidence indicates that they are anatomically, biochemically and psychologically distinct from babies in ways that make the experience of pain unlikely. The truth about fetal pain can seem as murky as an image on an ultrasound screen, a glimpse of a creature at once recognizably human and uncomfortably strange.

IF THE NOTION that newborns are incapable of feeling pain was once widespread among doctors, a comparable assumption about fetuses was even more entrenched. Nicholas Fisk is a fetal-medicine specialist and director of the University of Queensland Center for Clinical Research in Australia. For years, he says, "I would be doing a procedure to a fetus, and the mother would ask me, 'Does my baby feel pain?' The traditional, knee-jerk reaction was, 'No, of course not.' " But research in Fisk's laboratory (then at Imperial College in London) was making him uneasy about that answer. It showed that fetuses as young as 18 weeks react to an invasive procedure with a spike in stress hormones and a shunting of blood flow toward the brain — a strategy, also seen in infants and adults, to protect a vital organ from threat. Then Fisk carried out a study that closely resembled Anand's pioneering research, using fetuses rather than newborns as his subjects. He selected 45 fetuses that required a potentially painful blood transfusion, giving one-third of them an injection of the potent painkiller fentanyl. As with Anand's experiments, the results were striking: in fetuses that received the analgesic, the production of stress hormones was halved, and the pattern of blood flow remained normal.

Fisk says he believes that his findings provide suggestive evidence of fetal pain — perhaps the best evidence we'll get. Pain, he notes, is a subjective phenomenon; in adults and older children, doctors measure it by asking patients to describe what they feel. ("On a scale of 0 to 10, how would you rate your current level of pain?") To be certain that his fetal patients feel pain, Fisk says, "I would need one of them to come up to me at the age of 6 or 7 and say, 'Excuse me, Doctor, that bloody hurt, what you did to me!' " In the absence of such first-person testimony, he concludes, it's "better to err on the safe side" and assume that the fetus can feel pain starting around 20 to 24 weeks.

Blood transfusions are actually among the least invasive medical procedures performed on fetuses. More intrusive is endoscopic fetal surgery, in which surgeons manipulate a joystick-like instrument while watching the fetus on an ultrasound screen. Most invasive of all is open fetal surgery, in which a pregnant woman's uterus is cut open and the fetus exposed. Ray Paschall, an anesthesiologist at Vanderbilt Medical Center in Nashville, remembers one of the first times he provided anesthesia to the mother and minimally to the fetus in an open fetal operation, more than 10 years ago. When the surgeon lowered his scalpel to the 25-week-old fetus, Paschall saw the tiny figure recoil in what looked to him like pain. A few months later, he watched another fetus, this one 23 weeks old, flinch at the touch of the instrument. That was enough for Paschall. In consultation with the hospital's pediatric pain specialist, "I tremendously upped the dose of anesthetic to make sure that wouldn't happen again," he says. In the more than 200 operations he has assisted in since then, not a single fetus has drawn back from the knife. "I don't care how primitive the reaction is, it's still a human reaction," Paschall says. "And I don't believe it's right. I don't want them to feel pain."

But whether pain is being felt is open to question. Mark Rosen was the anesthesiologist at the very first open fetal operation, performed in 1981 at the University of California, San Francisco, Medical Center, and the fetal anesthesia protocols he pioneered are now followed by his peers all over the world. Indeed, Rosen may have done more to prevent fetal pain than anyone else alive — except that he doesn't believe that fetal pain exists. Research has persuaded him that before a point relatively late in pregnancy, the fetus is unable to perceive pain.

Rosen provides anesthesia for a number of other important reasons, he explains, including rendering the pregnant woman unconscious and preventing her uterus from contracting and setting off dangerous bleeding or early labor. Another purpose of anesthesia is to immobilize the fetus during surgery, and indeed, the drugs Rosen supplies to the pregnant woman do cross the placenta to reach the fetus. Relief of fetal pain, however, is not among his objectives. "I have every reason to want to believe that the fetus feels pain, that I've been treating pain all these years," says Rosen, who is intense and a bit prickly. "But if you look at the evidence, it's hard to conclude that that's true."

Rosen's own hard look at the evidence came a few years ago, when he and a handful of other doctors at U.C.S.F. pulled together more than 2,000 articles from medical journals, weighing the accumulated evidence for and against fetal pain. They published the results in The Journal of the American Medical Association in 2005. "Pain perception probably does not function before the third trimester," concluded Rosen, the review's senior author. The capacity to feel pain, he proposed, emerges around 29 to 30 weeks gestational age, or about two and a half months before a full-term baby is born. Before that time, he asserted, the fetus's higher pain pathways are not yet fully developed and functional.

What about a fetus that draws back at the touch of a scalpel? Rosen says that, at least early on, this movement is a reflex, like a leg that jerks when tapped by a doctor's rubber mallet. Likewise, the release of stress hormones doesn't necessarily indicate the experience of pain; stress hormones are also elevated, for example, in the bodies of brain-dead patients during organ harvesting. In order for pain to be felt, he maintains, the pain signal must be able to travel from receptors located all over the body, to the spinal cord, up through the brain's thalamus and finally into the cerebral cortex. The last leap to the cortex is crucial, because this wrinkly top layer of the brain is believed to be the organ of consciousness, the generator of awareness of ourselves and things not ourselves (like a surgeon's knife). Before nerve fibers extending from the thalamus have penetrated the cortex — connections that are not made until the beginning of the third trimester — there can be no consciousness and therefore no experience of pain.

Sunny Anand reacted strongly, even angrily, to the article's conclusions. Rosen and his colleagues have "stuck their hands into a hornet's nest," Anand said at the time. "This is going to inflame a lot of scientists who are very, very concerned and are far more knowledgeable in this area than the authors appear to be. This is not the last word — definitely not." Anand acknowledges that the cerebral cortex is not fully developed in the fetus until late in gestation. What is up and running, he points out, is a structure called the subplate zone, which some scientists believe may be capable of processing pain signals. A kind of holding station for developing nerve cells, which eventually melds into the mature brain, the subplate zone becomes operational at about 17 weeks. The fetus's undeveloped state, in other words, may not preclude it from feeling pain. In fact, its immature physiology may well make it more sensitive to pain, not less: the body's mechanisms for inhibiting pain and making it more bearable do not become active until after birth.

The fetus is not a "little adult," Anand says, and we shouldn't expect it to look or act like one. Rather, it's a singular being with a life of the senses that is different, but no less real, than our own.

THE SAME MIGHT be said of the five children who were captured on video by a Swedish neuroscientist named Bjorn Merker on a trip to Disney World a few years ago. The youngsters, ages 1 to 5, are shown smiling, laughing, fussing, crying; they appear alert and aware of what is going on around them. Yet each of these children was born essentially without a cerebral cortex. The condition is called hydranencephaly, in which the brain stem is preserved but the upper hemispheres are largely missing and replaced by fluid.

Merker (who has held positions at universities in Sweden and the United States but is currently unaffiliated) became interested in these children as the living embodiment of a scientific puzzle: where consciousness originates. He joined an online self-help group for the parents of children with hydranencephaly and read through thousands of e-mail messages, saving many that described incidents in which the children seemed to demonstrate awareness. In October 2004, he accompanied the five on the trip to Disney World, part of an annual get-together for families affected by the condition. Merker included his observations of these children in an article, published last year in the journal Behavioral and Brain Sciences, proposing that the brain stem is capable of supporting a preliminary kind of awareness on its own. "The tacit consensus concerning the cerebral cortex as the 'organ of consciousness,' " Merker wrote, may "have been reached prematurely, and may in fact be seriously in error."

Merker's much-discussed article was accompanied by more than two dozen commentaries by prominent researchers. Many noted that if Merker is correct, it could alter our understanding of how normal brains work and could change our treatment of those who are now believed to be insensible to pain because of an absent or damaged cortex. For example, the decision to end the life of a patient in a persistent vegetative state might be carried out with a fast-acting drug, suggested Marshall Devor, a biologist at the Center for Research on Pain at Hebrew University in Jerusalem. Devor wrote that such a course would be more humane than the weeks of potentially painful starvation that follows the disconnection of a feeding tube (though as a form of active euthanasia it would be illegal in the United States and most other countries). The possibility of consciousness without a cortex may also influence our opinion of what a fetus can feel. Like the subplate zone, the brain stem is active in the fetus far earlier than the cerebral cortex is, and if it can support consciousness, it can support the experience of pain. While Mark Rosen is skeptical, Anand praises Merker's work as a "missing link" that could complete the case for fetal pain.

But anatomy is not the whole story. In the fetus, especially, we can't deduce the presence or absence of consciousness from its anatomical development alone; we must also consider the peculiar environment in which fetuses live. David Mellor, the founding director of the Animal Welfare Science and Bioethics Center at Massey University in New Zealand, says he was prompted to consider the role of fetal surroundings in graduate school. "Have you ever wondered," one visiting professor asked, "why a colt doesn't get up and gallop around inside the mare?" After all, a horse only minutes old is already able to hobble around the barnyard. The answer, as Mellor reported in an influential review published in 2005, is that biochemicals produced by the placenta and fetus have a sedating and even an anesthetizing effect on the fetus (both equine and human). This fetal cocktail includes adenosine, which suppresses brain activity; pregnanolone, which relieves pain; and prostaglandin D2, which induces sleep — "pretty potent stuff," he says.

Combined with the warmth and buoyancy of the womb, this brew lulls the fetus into a near-continuous slumber, rendering it effectively unconscious no matter what the state of its anatomy. Even the starts and kicks felt by a pregnant woman, he says, are reflex movements that go on in a fetus's sleep. While we don't know if the intense stimulation of surgery would wake it up, Mellor notes that when faced with other potential threats, like an acute shortage of oxygen, the fetus does not rouse itself but rather shuts down more completely in an attempt to conserve energy and promote survival. This is markedly different from the reaction of an infant, who will thrash about in an effort to dislodge whatever is blocking its airway. "A fetus," Mellor says, "is not a baby who just hasn't been born yet."

Even birth may not inaugurate the ability to feel pain, according to Stuart Derbyshire, a psychologist at the University of Birmingham in Britain. Derbyshire is a prolific commentator on the subject and an energetic provocateur. In milder moods, he has described the notion of fetal pain as a "fallacy"; when goaded by his critics' "lazy" thinking, he has pronounced it a "moral blunder" and "a shoddy, sentimental argument."

For all his vehemence in print, Derbyshire is affable in conversation, explaining that his laboratory research on the neurological basis of pain in adults led him to the matter of what fetuses feel: "For me, it's an interesting test case of what we know about pain. It's a great application of theory, basically." The theory, in this case, is that the experience of pain has to be learned — and the fetus, lacking language or interactions with caregivers, has no chance of learning it. In place of distinct emotions, it experiences a blur of sensations, a condition Derbyshire has likened to looking at "a vast TV screen with all of the world's information upon it from a distance of one inch; a great buzzing mass of meaningless information," he writes. "Before a symbolic system such as language, an individual will not know that something in front of them is large or small, hot or cold, red or green" — or, Derbyshire argues, painful or pleasant.

He finds "outrageous" the suggestion that the fetus feels anything like the pain that an older child or an adult experiences. "A fetus is biologically human, of course," he says. "It isn't a cow. But it's not yet psychologically human." That is a status not bestowed at conception but earned with each connection made and word spoken. Following this logic to its conclusion, Derbyshire has declared that babies cannot feel pain until they are 1 year old. His claim has become notorious in pain-research circles, and even Derbyshire says he thinks he may have overstepped. "I sometimes regret that I pushed it out quite that far," he concedes. "But really, who knows when the light finally switches on?"

IN FACT, "THERE may not be a single moment when consciousness, or the potential to experience pain, is turned on," Nicholas Fisk wrote with Vivette Glover, a colleague at Imperial College, in a volume on early pain edited by Anand. "It may come on gradually, like a dimmer switch." It appears that this slow dawning begins in the womb and continues even after birth. So where do we draw the line? When does a release of stress hormones turn into a grimace of genuine pain?

Recent research provides a potentially urgent reason to ask this question. It shows that pain may leave a lasting, even lifelong, imprint on the developing nervous system. For adults, pain is usually a passing sensation, to be waited out or medicated away. Infants, and perhaps fetuses, may do something different with pain: some research suggests they take it into their bodies, making it part of their fast-branching neural networks, part of their flesh and blood.

Anna Taddio, a pain specialist at the Hospital for Sick Children in Toronto, noticed more than a decade ago that the male infants she treated seemed more sensitive to pain than their female counterparts. This discrepancy, she reasoned, could be due to sex hormones, to anatomical differences — or to a painful event experienced by many boys: circumcision. In a study of 87 baby boys, Taddio found that those who had been circumcised soon after birth reacted more strongly and cried for longer than uncircumcised boys when they received a vaccination shot four to six months later. Among the circumcised boys, those who had received an analgesic cream at the time of the surgery cried less while getting the immunization than those circumcised without pain relief.

Taddio concluded that a single painful event could produce effects lasting for months, and perhaps much longer. "When we do something to a baby that is not an expected part of its normal development, especially at a very early stage, we may actually change the way the nervous system is wired," she says. Early encounters with pain may alter the threshold at which pain is felt later on, making a child hypersensitive to pain — or, alternatively, dangerously indifferent to it. Lasting effects might also include emotional and behavioral problems like anxiety and depression, even learning disabilities (though these findings are far more tentative).

Do such long-term effects apply to fetuses? They may well, especially since pain experienced in the womb would be even more anomalous than pain encountered soon after birth. Moreover, the ability to feel pain may not need to be present in order for "noxious stimulation" — like a surgeon's incision — to do harm to the fetal nervous system. This possibility has led some to venture an early end to the debate over fetal pain. Marc Van de Velde, an anesthesiologist and pain expert at University Hospitals Gasthuisberg in Leuven, Belgium, says: "We know that the fetus experiences a stress reaction, and we know that this stress reaction may have long-term consequences — so we need to treat the reaction as well as we can. Whether or not we call it pain is, to me, irrelevant."

BUT THE QUESTION of fetal pain is not irrelevant when applied to abortion. On April 4, 2004, Sunny Anand took the stand in a courtroom in Lincoln, Neb., to testify as an expert witness in the case of Carhart v. Ashcroft. This was one of three federal trials held to determine the constitutionality of the ban on a procedure called intact dilation and extraction by doctors and partial-birth abortion by anti-abortion groups. Anand was asked whether a fetus would feel pain during such a procedure. "If the fetus is beyond 20 weeks of gestation, I would assume that there will be pain caused to the fetus," he said. "And I believe it will be severe and excruciating pain."

After listening to Anand's testimony and that of doctors opposing the law, Judge Richard G. Kopf declared in his opinion that it was impossible for him to decide whether a "fetus suffers pain as humans suffer pain." He ruled the law unconstitutional on other grounds. But the ban was ultimately upheld by the U.S. Supreme Court, and Anand's statements, which he repeated at the two other trials, helped clear the way for legislation aimed specifically at fetal pain. The following month, Sam Brownback, Republican of Kansas, presented to the Senate the Unborn Child Pain Awareness Act, requiring doctors to tell women seeking abortions at 20 weeks or later that their fetuses can feel pain and to offer anesthesia "administered directly to the pain-capable unborn child." The bill did not pass, but Brownback continues to introduce it each year. Anand's testimony also inspired efforts at the state level. Over the past two years, similar bills have been introduced in 25 states, and in 5 — Arkansas, Georgia, Louisiana, Minnesota and Oklahoma — they have become law. In addition, state-issued abortion-counseling materials in Alaska, South Dakota and Texas now make mention of fetal pain.

In the push to pass fetal-pain legislation, Anand's name has been invoked at every turn; he has become a favorite expert of the anti-abortion movement precisely because of his credentials. "This Oxford- and Harvard-trained neonatal pediatrician had some jarring testimony about the subject of fetal pain," announced the Republican congressman Mike Pence to the House of Representatives in 2004, "and it is truly made more astonishing when one considers the fact that Dr. Anand is not a stereotypical Bible-thumping pro-lifer." Anand maintains that doctors performing abortions at 20 weeks or later should take steps to prevent or relieve fetal pain. But it is clear that many of the anti-abortion activists who quote him have something more sweeping in mind: changing perceptions of the fetus. In several states, for example, information about fetal pain is provided to all women seeking abortions, including those whose fetuses are so immature that there is no evidence of the existence of even a stress response. "By personifying the fetus, they're trying to steer the woman's decision away from abortion," says Elizabeth Nash, a public-policy associate at the Guttmacher Institute, a reproductive-rights group.

Another, perhaps intended, effect of fetal-pain laws may be to make abortions harder to obtain. Laura Myers, an anesthesia researcher at Children's Hospital Boston and Harvard Medical School who analyzed the Unborn Child Protection Act for the abortion-rights organization Physicians for Reproductive Choice and Health, concluded that abortion clinics do not have the equipment or expertise to supply fetal anesthesia. "The handful of centers that perform fetal surgery are the only ones with any experience delivering anesthesia directly to the fetus," Myers says. "The bill makes a promise that the medical community can't fulfill." Even these specialized centers have no experience providing fetal anesthesia during an abortion; such a procedure would be experimental and would inevitably carry risks for the woman, including infection and uncontrolled bleeding.

In his speeches about fetal pain, Senator Brownback often asks why a fetus undergoing surgery receives anesthesia but not a fetus "who is undergoing the life-terminating surgery of an abortion." Mark Rosen rejects the analogy. "Fetal surgery is a different circumstance than abortion," he says, pointing out that none of the objectives of anesthesia for fetal surgery — relaxing the uterus, for example — apply to the termination of pregnancy. That includes an objective identified just recently: preventing possible long-term damage. For the fetus that is to be aborted, there is no long term. And if there is no pain, as Rosen maintains, then there is no cause to put the woman's health at risk.

Rosen sees no contradiction in his position, only a necessary complexity. When he was in medical school, he says, he worked for a time at an abortion clinic in the morning and a fertility clinic in the afternoon — an experience that showed him "the amazing incongruities of life." In the three decades since then, he says he has come to believe that "there's a time for fetal anesthesia, and maybe there's a time not."

In their use of pain to make the fetus seem more fully human, anti-abortion forces draw on a deep tradition. Pain has long played a special role in how society determines who is like us or not like us ("us" being those with the power to make and enforce such distinctions). The capacity to feel pain has often been put forth as proof of a common humanity. Think of Shylock's monologue in "The Merchant of Venice": Are not Jews "hurt with the same weapons" as Christians, he demands. "If you prick us, do we not bleed?" Likewise, a presumed insensitivity to pain has been used to exclude some from humanity's privileges and protections. Many 19th-century doctors believed blacks were indifferent to pain and performed surgery on them without even that era's rudimentary anesthesia. Over time, the charmed circle of those considered alive to pain, and therefore fully human, has widened to include members of other religions and races, the poor, the criminal, the mentally ill — and, thanks to the work of Sunny Anand and others, the very young. Should the circle enlarge once more, to admit those not yet born? Should fetuses be added to what Martin Pernick, a historian of the use of anesthesia, has called "the great chain of feeling"? Anand maintains that they should.

For others, it's a harder call. When it comes to the way adults feel pain, science has borne out the optimistic belief that we are all the same under the skin. As research is now revealing, the same may not be true for fetuses; even Anand calls the fetus "a unique organism." Exhibiting his flair for the startling but apt expression, Stuart Derbyshire warns against "anthropomorphizing" the fetus, investing it with human qualities it has yet to develop. To do so, he suggests, would subtract some measure of our own humanity. And to concern ourselves only with the welfare of the fetus is to neglect the humanity of the pregnant woman, Mark Rosen notes. When considering whether to provide fetal anesthesia during an abortion, he says, it's not "erring on the safe side" to endanger a woman's health in order to prevent fetal pain that may not exist.

Indeed, the question remains just how far we would take the notion that the fetus is entitled to protection from pain. Would we be willing, for example, to supply a continuous flow of drugs to a fetus that is found to have a painful medical condition? For that matter, what about the pain of being born? Two years ago, a Swiftian satire of the Unborn Child Pain Awareness Act appeared on the progressive Web site Written by Lynn Paltrow, the executive director of the National Advocates for Pregnant Women, it urged the bill's authors to extend its provisions to those fetuses "subjected to repeated, violent maternal uterine contraction and then forced through the unimaginably narrow vaginal canal."

She continued: "Imagine the pain a fetus experiences with a forceps delivery, suffering extensive bruising during and after! Shouldn't these fetuses also be entitled to their own painkillers?" And in fact, both Nicholas Fisk and Marc Van de Velde have raised the possibility of administering pain relief to fetuses undergoing difficult deliveries. Obstetricians have yet to embrace the proposal. But Sunny Anand, for one, says the idea may have merit. Though he has "misgivings about messing with a process that has worked for thousands of years," he can envision an injection of local anesthetic into the fetus's scalp where it is grasped by the forceps or vacuum device. "Let's try and work out what's best for the baby," he says.

Annie Murphy Paul is at work on a book about the lasting effects of early experience.