Fetuses and Comatose People Needing Analgesia: Prejudices to Delete

Image by Khusen Rustamov from Pixabay

Progresses in pain treatment still find obstacles in the earliest and last stages of life, when the subject cannot express him/herself.

Many are still the black holes about the perceptions of comatose patients [1] and we still know very little about the real pain percep-tion in vegetative patients: researchers are still wondering if cortex activation is necessary for experiencing pain or if the spino-thalamic connections are sufficient. Only one scale exists for pain in patients recovering from coma [3] and it has not yet received the necessary attention and spread. No routine tests to assess pain in comatose patients or in patients in vegetative state exist. However, cerebral cor-relates of pain processing are found in patients in minimally conscious state, more widespread than in vegetative patients. These findings support the idea that these patients need analgesic treatment [4].

On the other bank of life span, fetal surgery is the newest surgical specialty; as the field has matured, it has grown to encompass nu-merous different types of fetal interventions [5]. This has raised the problem of fetal pain, and the response has been to give anesthesia directly to the fetus during these procedures; nonetheless, specific scales for fetal pain do not exist and great uncertainty exists on which drugs should be used to sedate and anesthetize the fetus. Fetal pain is still a matter of debate, not on its existence, but rather on the gesta-tion epoch by which it appears [6].

Last but not least, amidst these two edges of human life, concerns have also been raised for another category of non-verbal patients: mentally challenged patients, who allegedly do not receive the necessary analgesic care, and in some cases they may undergo death as the result of a misinterpretation of pain signs [7].

Fetuses, mentally challenged people and comatose patients can show unexpected sensibility that recent studies have shown; nonethe-less, none of these categories receive enough attention. It seems that some kinds of patients have not a full citizenship for the access to pain treatment. It is the population that some philosophers describe as non-persons, as they recognize personhood only to those who can be aware and independent [8]. For example, Fletcher [9] put forward 15 criteria for personhood and used intelligence and intelli-gence quotient (IQ) scores as a dividing line between persons and nonpersons. Individuals below IQ40 fell into an unclear category, and individuals below IQ20 were considered definitely not persons. Nonetheless, even recently scholars affirm that awareness is a precon-dition for pain feeling: “Thus pain perception by humans or other animals requires the ability to evaluate the environment and form a subjective judgment about the value of the incoming flow of nociceptive information. Therefore pain requires consciousness” [10]. This can lead to underrecognizing pain and disregarding pain treatments in some categories of patients and we fear that this can overshadow the progresses made in the last few years in another field where fragile patients are involved: neonatology. Notice that neonatal pain was recognized for the first time and accepted in scientific literature, only by the end of the last century

The main cause of the stall of anesthesia in these scenarios, is the lack of an insight capable to see beyond the appearances and beyond the dogmas that some categories of patients do not feel pain at all or that their reactions are not interpretable. Even the current definition of the word “pain” is not of help. In fact, IASP defines pain as “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”, adding that “Pain is always subjective. Each individual learns the ap-plication of the word through experiences related to injury in early life” [11] and this definition associates pain with the awareness and the ability to feel emotions that the above quoted categories – in particular newborns – cannot have in a proper sense. IASP in its official definition also makes the example of pricking as a stimulus that does not provoke pain, as it is not unpleasant (“Experiences which re-semble pain but are not unpleasant, e.g. pricking, should not be called pain”) [11]; nonetheless, this clashes with the everyday experience of babies, for whom pricks that are acceptable by competent adults, are a real torture [12].

Thus, we are facing a new frontier of pain research: the pain of unverbal and unrational patients, for whose suffering many signs show the necessity of a new and creative approach. The mere fact that they do not claim for relief, that they do not show traditional pain signs or that they have neurologic anomalies is not sufficient to withhold any analgesic intervention and any deeper analysis of their pain state. A new research into these patients’ pain is necessary, because it is a hidden and unexplored jungle, where minimal and subtle pain signs are to be spotted and interpreted, where a specific lingo should be learnt and new measures should be created.
Carlo Bellieni

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