What is it about?

We cannot know for certain whether a fetus or very premature baby actually feels pain. We can measure how its body and brain respond to potentially painful events, but those responses cannot tell us for sure what, if anything, is consciously experienced. This paper asks what doctors should do in the face of that uncertainty. When giving pain relief clearly improves a patient’s health or chances of survival, the answer is straightforward: give it, regardless of whether we can prove pain is being felt. But when the benefits are uncertain, giving pain relief can itself carry risks or delay treatment. It is tempting to say we should simply “err on the side of caution” and always provide pain relief. But that assumes giving pain relief is the cautious option. Sometimes intervening may cause more harm than not intervening. The broader argument is that science cannot make these decisions for us. We may never know what a fetus or newborn actually experiences. We therefore have to weigh the possible harms and benefits and make an ethical judgement about what to do. Uncertainty does not remove our responsibility to decide; it is precisely what makes that decision necessary

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Why is it important?

What is distinctive about the paper is that it shifts the fetal-pain debate away from trying to settle an essentially unresolvable question (whether and when a fetus consciously experiences pain) and asks what we should do given that uncertainty. Recent developments in neuroscience have weakened some of the confidence with which fetal pain was previously ruled out, particularly assumptions about the necessity of the cerebral cortex. But uncertainty does not automatically justify a precautionary approach, because interventions intended to prevent possible pain can themselves carry risks. The paper is timely because fetal and neonatal pain is increasingly being discussed in terms of precaution: if pain is possible, we should act as though it occurs. That sounds more neutral than it really is. Precaution is itself an ethical choice, and where both intervention and non-intervention carry possible harms, science alone cannot tell us which course is more cautious. The importance of the paper therefore extends beyond fetal pain. Similar problems arise whenever we have to make decisions about possible suffering in beings who cannot tell us what they experience, including very premature infants, animals and potentially artificial systems. The central message is that uncertainty cannot simply be eliminated or hidden behind a precautionary principle. It has to be acknowledged, the competing risks weighed, and a moral decision made

Perspectives

This paper matters to me because I have been thinking and writing about fetal pain for more than 30 years, and my own position has changed. When I first wrote about the subject in the 1990s, I was confident that the neuroscience allowed us to rule out fetal pain, particularly early in gestation. Over time, developments in our understanding of consciousness, pain and the role of the cortex made that certainty increasingly difficult for me to defend. That change of mind left me with a problem that motivated this paper. If I was too confident before, what should replace that confidence? One increasingly common answer is the precautionary principle: if fetal pain is possible, we should act as though it occurs. But I do not think uncertainty can bear that moral weight by itself. That matters especially in the context of abortion. Claims about fetal pain can be used to justify restrictions on abortion or additional requirements for women seeking one. I do not think that access to abortion should depend upon our being able to prove that the fetus cannot experience pain. If fetal pain is possible, that possibility deserves serious consideration, but it does not automatically settle what should be done, still less override the interests, choices and welfare of the pregnant woman. More generally, precaution sounds neutral and humane, but it is itself a moral position. Interventions have risks, restrictions have costs, and protecting against one uncertain harm can create other, sometimes much more certain, harms. Calling something “precautionary” does not remove the need to justify those trade-offs. So the paper reflects a shift in the question I have been asking. I used to ask, “Can the fetus feel pain?” I now think there may be limits to how confidently science can ever answer that question. The more important question may therefore be, “Given that we cannot be sure, what should we do?” And that uncertainty may be permanent. The fetus cannot enter the debate and tell us what it experienced, so science may never deliver the decisive answer that allows us to escape the moral problem. We still have to decide, about analgesia, about clinical practice, and, where relevant, about abortion, and we have to take responsibility for the values behind those decisions

Stuart Derbyshire
National University of Singapore

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This page is a summary of: Assessing fetal and neonatal pain: ethical implications of epistemic uncertainty, Journal of Medical Ethics, March 2026, BMJ,
DOI: 10.1136/jme-2025-111629.
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