Dr Anand’s Casebook

Apologies, in advance, for yet another post on the subject of abortion but having just watched the relevant segment of last night’s Newsnight and the comments of both Nadine Dorries and a representative of the Christian Medical Fellowship, there is a very specific point that needs dealing with.

Both Dorries and Mr CMF – there was no caption giving a name – referred to research into foetal pain by a Dr ‘Sunny’ Anand of the Department of Paediatrics, University of Arkansas Medical School, which the claim has been ignored by the Royal College of Obstetricians and Gynaecologists and Department of Health. They also claim/imply that Dr Anand has been excluded from giving evidence to the Science and Technology Committee and imply that this is because the committee is biased and endeavouring to ensure that only evidence in support of retaining the current 24 week upper limit on abortion.

There is not one single shred of truth in any of these claims and imputations, which I will now prove.

First let’s deal with Dr Anand, whose comments – by telephone – appear on Newsnight with a caption indicating that his name is ‘Dr K S ‘Sunny’ Anand’.

This is incorrect. A search on the PubMed database returns articles by what appear to be several doctors with the name Dr KS Anand, all living and working in India, none of whom work in the field of paediatrics and neonatal or foetal pain.

Dr ‘Sunny’ Anand is actually Dr K J Anand, and is listed as the author/co-author of 106 research papers, which is a good solid portfolio of published research.

As far as Dr Anand’s work on foetal and neonatal pain is concerned, there appear to be four specific papers that could been of specific interest to the Science and Technology Committee, these being:

1. Pain assessment in preterm neonates.

2. Current controversies regarding pain assessment in neonates.

3. Controversies in neonatal pain: an introduction.

4. Neurodevelopmental changes of fetal pain.

Of these four papers, only the first – Pain assessment in preterm neonates – has actually been published, in March 2007 in the journal ‘Pediatrics’.

The remaining three papers, including the critical paper on foetal pain (and I will not use US spellings) have not, to date, been published. PubMed shows them to be ‘in review’ and due for publication in the journal, ‘Seminars in Perinatology’ on 31st October 2007.

The simple reason why Dr Anand’s work does not feature in submissions from the RCOG, BMA or DoH is because the research is not due to be published until next week.

In fact, in the submissions to the committee from all interested parties, including those of the Christian Medical Fellowship and other ‘pro-life’ organisations there is not one single reference to either Dr Anand or to any of these four research papers, nor, indeed, would one expect there to be given that one has been in print for only six months and the other three are not currently in print.

So far as the allegation that Dr Anand has been excluded or not invited to address the committee, well as member of the committee, herself, Nadine Dorries should know perfectly well that the process by which parliamentary committees invite witnesses – other than those from government, the civil service and other areas of the public sector, is by publishing an open call for written submissions to the committee. The committee states its brief and the information/opinions it is seeking, and it is then up to any interested party to submit their written views, opinions and evidence to the committee for consideration.

Based on the submissions received, the committee will then invite people to appear before the committee to give evidence in person.

As already noted, not only single submission to the committee FROM ANY SOURCE, refers to Dr Anand, his work or any published research paper on which he is cited as the author or co-author.

And Dr Anand, himself, has not made any written submission to the committee.

As I’ve said previously, interesting and valuable as Dr Anand’s work appear to be, in the context of debating abortion it is of limited value.

This is the published abstract from Anand’s paper of foetal pain:

Pain in the developing fetus is controversial because of the difficulty in measuring and interpreting pain during gestation. It has received increased attention lately because of recently introduced legislation that would require consideration of fetal pain during intentional termination of pregnancy. During development, sensory fibers are abundant by 20 weeks; a functional spinal reflex is present by 19 weeks; connections to the thalamus are present by 20 weeks; and connections to subplate neurons are present by 17 weeks with intensive differentiation by 25 weeks. These cells are important developmentally, but decline as a result of natural apoptosis. Mature thalamocortical projections are not present until 29 to 30 weeks, which has led many to believe the fetus does not experience emotional “pain” until then. Pain requires both nociception and emotional reaction or interpretation. Nociception causes physiologic stress, which in turn causes increases in catecholamines, cortisol, and other stress hormones. Physiological stress is different from the emotional pain felt by the more mature fetus or infant, and this stress is mitigated by pain medication such as opiates. The plasticity of the developing brain makes it vulnerable to the stressors that cause long-term developmental changes, ultimately leading to adverse neurological outcomes. Whereas evidence for conscious pain perception is indirect, evidence for the subconscious incorporation of pain into neurological development and plasticity is incontrovertible. Scientific data, not religious or political conviction, should guide the desperately needed research in this field. In the meantime, it seems prudent to avoid pain during gestation.

The critical information here lies in this passage:

Physiological stress is different from the emotional pain felt by the more mature fetus or infant, and this stress is mitigated by pain medication such as opiates. The plasticity of the developing brain makes it vulnerable to the stressors that cause long-term developmental changes, ultimately leading to adverse neurological outcomes. Whereas evidence for conscious pain perception is indirect, evidence for the subconscious incorporation of pain into neurological development and plasticity is incontrovertible.

It would appear that what Dr Anand has established is that a foetus can experience physiological stress similar to and consistent with what we understand to be pain from around 20 weeks gestation.

That does not mean ‘pain’ in the sense that we understand it as adults – there is no conscious response at this stage of even a rudimentary nature, but rather that subjected to external stimuli that could/would cause pain in a mature adult, the foetuses body will respond physiologically and biochemically (in terms of the production of certain hormones) in manner consistent with an adult individuals autonomic response to pain.

This, Dr Anand indicates, can affect the ongoing neurological development of the foetus and lead to adverse outcomes. What kind of adverse outcomes I cannot say, as the paper has not been published and I cannot, therefore, read and comment on Dr Anand’s precise findings…

…and nor can the Science and Technology Committee, the RCOG, BMA, etc.

This – if verified by peer review – is clearly relevant to doctors undertaking invasive clinical interventions during pregnancy where – and this is crucial – the intention is that the foetus will be carried to term and result in a live birth.

In the case of a second trimester abortion, the adverse outcomes indicated by Dr Anand are of no relevance whatsoever, because the foetus will not be developing to full term. It really doesn’t matter if this autonomic response would affect further neurological development, because such develop ceases with the termination of the pregnancy.

The development of the capacity, in the foetus, to respond autonomically to external stimuli of any kind, in addition, tells us nothing whatsoever about the foetuses notion ‘humanity’ – this is essentially a philosophical question in any case and on that cannot be resolved on a purely scientific basis at our current state of knowledge and understanding of how the brain works.

The relevance of Dr Anand’s work to clinical practice in abortion is NOT that it provides grounds for a reduction in the current upper limit of 24 weeks, It may, however, constitute an argument for the use of anaesthesia in second trimester abortions at or after 16-18 weeks gestation, not because this necessarily ensures that the foetus does not experience pain – it still not clear whether it does in any meaningful sense in any case and certain has no capacity to process pain at a conscious level until the third trimester, but such a practice could, and probably would, reassure both doctors conducting abortions, and more importantly, women undergoing abortions at this stage that the procedure is being carried out in as humane a manner as possible.

That’s the clinical relevance of Dr Anand’s work.

Now we come to big question.

Given that neither the Christian Medical Fellowship, or any other ‘pro-life’ group has included any reference to Dr Anand and his work in any of their submissions to the Science and Technology Committee:

1. Just when, exactly, did they become aware of his work and was this before or after the submitted their written evidence to the committee?

2. If before, why did they not include such references in their submission to the committee?

Dorries, one suspects, may not have been aware of Dr Anand’s work until whenever she saw last week’s Dispatches documentary on abortion.

However, the website of the Christian Medical Foundation has two references to Dr Anand in their student publication, ‘Nucleus’, which do not relate to the current ‘controversy’, one from October 2005 and another dating back  to January 1998, and yet its submission to the committee not only fails to make any reference to Dr Anand, but it fails to make any reference to foetal pain at all.

This could be a simple oversight in the compilation of its submission.

It could also be that the CMF were unaware of Dr Anand’s recent, unpublished, work at the time the submission was drafted and forwarded to the committee.

Or, it could also be that, that the CMF is fully aware that, as scientific evidence, Dr Anand’s work is of strictly limited relevance and value in relation to abortion and amounts to, at best, a possible argument in favour of the use of anaesthesia in late second trimester abortions and, as such, it it not an argument that would stand up to scrutiny under questioning by a reasonable well-informed committee of the House of Commons.

It is, however, an argument that sounds persuasive to ‘the man/woman in the street’ – to the layperson lacking in sufficient background in the relevant sciences necessary to appreciate the limitations of Dr Anand’s work.

In that last possible scenario, a ‘pro-life’ group might quite easily come to the conclusion that it is not only better to omit any reference to Dr Anand, thereby ensuring that his work is NOT scrutinised by the committee, but also that, because his work does – admittedly – have considerable emotional ‘pull’ on those who do not fully understand or appreciate the science behind it or its limitation in relation to this specific date, there might be ample opportunity to stoke uneducated public sentiment and call into question, if not damage outright, the credibility of the committee, by holding the information on Dr Anand’s work until the last minut, before producing it like rabbit out of a hat.

In the circumstances, I believe that the committee would, if possible, be well advised to request copies of Dr Anand’s recent papers and to ask if he would provide a written submission to the committee on his work, one that commented specifically on how he views its scientific/clincial applicability, or otherwise, in the area of abortion.

And it should, of course, inquire as to whether, even at short notice, Dr Anand would be willing – and available – to appear before the committee to answer questions. From what I can see of his published work, he seems a very credible, diligent and professional researcher, the kinds whose opinions the committee should be seeking.

I also think that the committee should, if possible, recall the representative of the Christian Medical Foundation – who I believe has already given evidence – and make further inquiries as to when it became aware of Dr Anand’s work and why, if this was indeed before making its submission, it did not refer to it, Dr Anand or any other evidence or data on foetal pain.

18 thoughts on “Dr Anand’s Casebook

  1. Unity,

    Since you redesigned your website, I can’t read it! I am visually impaired and my browser is set 800×600 – when I look at your website it always misses off the first few words on the left hand side. You can’t even scroll across to read them – they are just missing.

    Can you change it back so it is readable? I’d have emailed you about this personally, but I can’t find an email address on the site.

  2. I agree that Dr Anand should be called to give evidence, the committee’s findings are incomplete without it. In addition, Professor Stuart Campbell, who has developed the 4D technology, should also be called to give evidence. It is bizarre that he has not already been invited given the new information that this technology has brought with it!

  3. Anne:

    The problem with Prof Campbell’s work is that it actually tells us very little that we don’t already know and nothing that is particularly germane to the debate at hand.

    Interesting though his images are, the fact remains that the visual appearance of the foetus is relatively unimportant other than as a measure of whether development is progressing at the expected rate and the expected. It may have some diagnostic value in identifying some physical abnormalities but otherwise it’s an interesting curio.

    All that we have learned through Campbell’s work is that, at various stages, foetuses can carry out certain autonomic actions that simulate conscious behaviours that will emerge at a later stage of development.

    The critical point is that these are NOT conscious or voluntary behaviours – those areas of the brain that are responsible for conscious thought and voluntary activity/movement do not connect the spinal cord and other critical systems in the the nervous system until 26-28 weeks gestation nor do these areas begin to develop even the rudimentary capacity for ‘behaviour’ before that point.

    It’s rather like servicing a petrol engine – you can strip it down and manually turn the crank and move the pistons and valves to see it ‘working’ but it still ain’t going run under its own steam until you hook up the fuel pipe, starter motor and spark plugs.

    Again, I have to say that Professor Campbell had as much opportunity to submit evidence to the inquiry as any other doctor – more so than Dr Anand who, being based in the US, would not necessarily have been aware of the inquiry at the time the call for evidence went out.

    That he didn’t make a submission may mean nothing, but it may also suggest that he is well aware of the limitations of his work when it comes to shedding light on the key developmental issues and has chosen not to have is subjected to direct scrutiny.

  4. could you clarify – have all experts who have been invited to give aural evidence, made written submissions?
    You could say that all evidence presented is nothing new to those who are experts in this field. But the select committee is just a bunch of MPs who probably don’t know very much about this issue and they should draw on the widest availability of expertise. It seems very strange that they have not called Prof Campbell, at the very least his research must have a contribution to make in more accurately assessing the gestational age of the fetus.
    The committee’s findings cannot be construed as fully conclusive if they fail to engage with such obvious experts.

  5. To clarify, Anne, the process for this and other committees is that an open brief is published, with relevant press notices, requesting submissions/evidence. The brief explains what the committee is investigating and provides general guidance on the format of submissions, word limits, and in general terms what kinds of information they may be looking for.

    From there is any interested/relevant party may individually or collectively submitted written evidence to the committee for consideration.

    The committee can, and does, make decisions on who, from those submitting written evidence, it wishes to call in to call oral evidence but should do so for valid reasons – there may be points the committee wishes to clarify or scrutinise/explore in more detail, etc. It has some latitude at the oral stage, not least because time is limited, but should use that latitude responsibly.

    So far as calling someone in who has not submitted written evidence, the committee can do that, but will generally only do so in relation to ministers and other public servants. It wouldn’t, ordinarily, ask to see a specific ‘expert witness’ if that individual or organisation has not first submitted written evidence.

    That goes for the majority of committees on open inquiries of this kind although, quite naturally, committees like the public accounts committee that specifically scrutinise government and public services work a little differently.

    As for the relevance of Campbell’s work to assessing gestational age, I can’t say for sure how relevant that may or may not be, not having seen anything comparing his system to conventional ultrasound. It may result in greater accuracy, it may not but in any case its relevance is still rather limited as this is only a factor in the relatively small number of abortions that take place at and around whatever the upper limit is – currently 24 weeks – in terms of verifying that the procedure will be on the right side of the law.

    It still doesn’t really add anything substantive to the debate about where the upper limit should lie, not in scientific terms.

    What needs to be recognised here, Anne, is that none of the clinical issues that are being raised; foetal pain, ‘viability’ or Dr Campbell’s images are either particularly illuminative and they certainly don’t settle anything in a medical/scientific sense. The attention they are getting, particularly from the ‘pro-life’ side is based almost entirely on the fact that each as a measure of emotional ‘pull’, which they hope will sway public opinion to their side of the argument.

    I should add the committees eventual findings are not intended to be fully conclusive, in any case, merely to inform further debate in parliament. It is not in the brief of the committee to attempt to make definitive statements on the upper limit, they are merely reflect on what, if anything, current scientific/medical knowledge can add to the wider debate.

  6. thanks for clarifying on that. I’ll check out how the published written evidence list correlates with the expert witnesses called later, no time now.

    Incidentally, it is in the brief of the committee to investigate the ‘examination techniques that may inform definitions of foetal viability’. I’ve copied the relevant bit below. In light of this the omission of evidence on the newest of examination techniques – ie 4D imaging seems extremely odd.

    I would prefer that the committee concluded that the images had nothing to contribute once they had a chance to question the expert, rather than that view being dismissed on the presumption that there is nothing to add, this is the purpose of having such an inquiry.?

    The inquiry will focus on:

    1. the scientific and medical evidence relating to the 24-week upper time limit on most legal abortions, including:

    (a) developments, both in the UK and internationally since 1990, in medical interventions and examination techniques that may inform definitions of foetal viability; and

  7. Campbell’s work has – from what I’ve seen of the written evidence – been raised and addressed by other submission, from both sides of the debate.

    Whether the committee feels that that evidence is sufficient for its purposes or not, I can’t say – its a fair question to throw at them.

    That said, when the question of ‘relevance’ was put to Campbell in the Dispatches documentary, he did rather dissemble and try to avoid being pinned down on the question of its precise scientific/medical value.

    I’ve explored this at some length in other posts, but the facts are that questions of viability, etc. are of limited value and problematic for a variety of reasons.

    To quickly take the viability argument, how far does that go?

    Without extensive clinical intervention a foetus at 24 weeks gestation is not viable, it only because of advances in technology that foetuses born that stage survive at all.

    Now if that’s how we define the cut of point for abortion, where could the technology take us in future and how far are those who deploy viability as justification for reducing the upper time limit on abortion prepared to go?

    What about incubation in an artificial womb right from conception?

    What about foetal transplantation?

    What about using genetic engineering to create gestational hosts using other species?

    These are outside the scope of current technology but valid hypotheses, and one’s that call in to question the value of relying on viability as an argument let alone as a means fo determining the legal cut-off point for abortion.

  8. Thanks for the response, Dr Anand.

    As (I hope) I stated, I harbour no questions as to the overall value of your work in the field or reputation – 106 listings on PubMed speaks for itself – and am certainly not suggesting that you take sides on this issue. Your welcome reference to the importance of treating your work as science and not through the lens of religion/politics in the abstract to your most recent paper was duly noted.

    What I am concerned about is the extent to which research, like your own, is being taken up and politicised by various lobby groups and – from what I can see – often presented as something other than it actually is.

    Science has its limitations is such debates, but that said I personally would have welcomed a contribution from yourself to the committee, if only to allow your work to be placed into its proper scientific context within the overall debate. I’m no expert here, but having studied foetal neurobiology during the course of my degree (psychology) it seems to me that you have much to add to our understanding of key elements of foetal development and I’d be very optimistic, on the strength of what I’ve seen, that it will lead to significant improvements in clinical practice where the intention is to take the pregnancy to full term.

    How relevant it may be in terms of abortion is a different matter, not least as the political climate here is very different to that in the US, but that’s a question that the committee should have explored.

    I can’t speak for the RCOG in terms of the comments on their website, but what I can say for certain is that at least ione of the organisations complaining that work has been omitted from the committee’s deliberations, was verifiably aware of your work prior to making their own submission and, for reasons best known to them , chose not to refer to it, or to the question of foetal pain.

    In all, perhaps what we are discovering here are the limitations of parliamentary committees as a basis for considering scientific questions when, perhaps, a better and more exacting review might have carried out under the aegis of a clinical body. One thinks, perhaps, of the Nuffield bioethics committee.

    Good luck with your work, in any case, Dr Anand.

  9. Thanks for the questions above. I am the General Secretary of the Christian Medical Fellowship and gave oral evidence before the Science and Technology committee on 17 October, representing the Alive and Kicking Alliance, of which CMF is one of ten member organisations.

    As far as I know I am the only person to have mentioned Professor Anand’s work in either written or oral evidence before the committee.

    Video – http://www.publications.parliament.uk/pa/cm/cmsctech.htm#evid
    Transcript – http://www.parliamentlive.tv/Player/index.aspx?Encoding=7422

    We did not include reference to Dr Anand’s work in our written evidence as we had chosen not to cover fetal sentience – each submission was limited to 3,000 words and it was not possible to cover everything.

    I personally became aware of Anand’s work only when he appeared in the Dispatches programme and then learned from colleagues working in the field that he was an authority on neonatal pain. His review in Seminars in Perinatology was not published until this month which is why we did not refer to it in our written evidence, but we did supply the committee with a copy of the review paper to back up our oral evidnce as we felt it was relevant to the debate on upper time limits for abortion.

    This was simply because the RCOG and others were referring only to Derbyshire/Fitzgerald et al in making their case for no fetal sentience below 26 weeks and we felt that Anand’s persepctive needed also to be on the table.

  10. Can you please stop banging on about abortion Unity. If I want to have pro-choice viewpoints shoved down my throat I can go to a pro-abortion campaign website.

  11. Nothing in the review recently published by Professor Anand and colleagues challenges the generally accepted idea that the fetus cannot possibly experience pain before 26 weeks gestation. Most pain experts believe that the cortex is vital to pain experience and the cortex is not matured or

  12. Thanks for commenting Stuart.

    The attempts to make a moral argument through science are deeply concerning. Arguments over life, rights and the sovereignty of a woman

  13. Stuart Derbyshire I think it is actually disingenuous of you to suggest that sentinece has nought to do with abortion when you have actually used the fetus’s supposed lack of sentience repeatedly as a justificaton for the practice.

    Having just read your own article on partial birth abortion on the bpas website I think that you need to be honest about your own ideological convictions and affiliations and the way they may be shaping your own position. You have been the darling of the prochoice movement for many years because your views on fetal sentience suit their agenda but you need to have the humility to acknowledge that other experts do not share your conclusions ratherthan pretending there is a consensus. That is what peopel are objecting to. And you need also to have the humility to include scientific references in your submissions to parliament. I was surprised that you saw fit not to include a single reference in your submission to the S&T cttee but simply gave your credentials as an expert.

    I would like to see you publicly debate Anand on this – either face to face – or as a head to head in a peer reviewed medical journal rather than sniping at him in unpublished private memos to the science and technology committee. How about it? I would be happy to help arrange it and I am sure that we could find a major newspaper to sponsor it.

    The minority report of dorries and spink has summarised the state of play – I think quite fairly – as follows:

    ‘We may never know for certain when foetuses first start to feel pain and there is no clear consensus amongst experts in the field.

    There are two main schools of thought. The first, represented to this enquiry by Fitzgerald, Derbyshire and the RCOG, is that foetuses cannot feel pain until 26 weeks gestation, because that is the stage of development at which mature neural connections between the thalamus and cerebral cortex are first present. The second view, expounded in a review article by Anand et al published in Seminars in Perinatology in October 2007 (and also presented by the same author to the US Congress in 2005), is that foetuses feel pain using different neural mechanisms than adults and that these are present at earlier than 20 weeks gestation. Both schools are however agreed that conscious perception of pain cannot be inferred from observing anatomy, stress hormone levels and movements alone.

    The alternative view supported by Anand et al argues that the more traditional Fitzgerald/Derbyshire/RCOG view ignores significant evidence, specifically that: a) sensory processing in the human brain develops well before birth;b)the subplate zone is functional well before the cerebral cortex develops; c) the key mechanisms of consciousness are located below the cortex (in areas that develop in early gestation); d) fetal behaviors suggest memory and learning as the highest-order evidence for perceptual function; and e) other lines of emerging evidence in the field of

    He argues that three major flaws beleaguer the scientific rationale behind the RCOG viewpoint and other reviews purporting to rule out fetal pain:
    First, pain perception is presented as a hard-wired system, passively transmitting noxious impulses until

  14. I have no interest in getting involved in a flame war with Peter Saunders (or anyone else) but it is probably important that I respond to his material concerns and suggestions:

    1. [Stuart Derbyshire has] used the fetus

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