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It might be that the strongest reason to prioritize GHD is because of flow-through effects, as you've suggested. But I don't think that those who prioritize GHD generally actually do so for that reason. They care about saving and improving people's lives in the near term, and the units they use (QALYs, income doublings, WELLBYs) and stories they tell (the drowning child) reflect that.

If GHD was trying to optimize for robustly increasing long-term human capacity, I think the GHD portfolio of interventions would look very different. It might include certain longtermist cause areas such as improving institutional decisionmaking. It would be surprising if the best interventions when optimizing for longterm flow-through effects were also the best when optimizing for immediate effects on individuals. If you're optimizing for flow-through effects, I agree that it's non-obvious whether GHD or AW is better, but I think you probably shouldn't be donating to either of those!

I think GHD donors choose GHD over AW simply because they care overwhelmingly more about humans than nonhuman animals. That's also why they usually ignore animal effects in their cost-effectiveness analyses, even though those effects would swamp the effects on humans for many GHD interventions. If they were trying to impartially help others in the near term, they would choose AW.

Here's a classification of GHD/AW which I think is more relevant to neartermists' revealed preferences: The best impartial neartermist interventions are AW. The best neartermist interventions ignoring nonhuman animals are GHD. Under that classification, fetal welfare would be GHD.

See in context

The Scale of Fetal Suffering in Late-Term Abortions

by Ariel Simnegar 🔸

Mar 17 20243 min read 25

226

Cause prioritizationLess-discussed causesFamily planningAbortionDraft Amnesty Week (2024)

Frontpage

The Scale of Fetal Suffering in Late-Term Abortions

Summary

Background

Surgical Abortion Procedures

LI (Labor Induction)[2]

D&E (Dilation and Evacuation)[5]

When Can a Fetus Suffer?

Content note: Blunt descriptions of abortion procedures.

This is a draft amnesty post.

Summary

It seems plausible that fetuses can suffer from 12 weeks of age, and quite reasonable that they can suffer from 24 weeks of age.
Some late-term abortion procedures seem that they might cause a fetus excruciating suffering.
Over 35,000 of these procedures occur each year in the US alone.
Further research would be desired on interventions to reduce this suffering, such as mandating fetal anesthesia for late-term abortions.

Background

Most people agree that a fetus has the capacity to suffer at some point. If a fetus has the capacity to suffer, then we ought to reduce that suffering when possible. Fetal anesthesia is standard practice for fetal surgery,^[1] but I am unaware of it ever being used during late-term abortions. If the fetus can suffer, these procedures likely cause the fetus extreme pain.

I think the cultural environment EAs usually live in tends to minimize concern for fetal suffering. Some worry that promoting care for fetal welfare will play into the hands of abortion opposers. However, as Brian Tomasik has pointed out, one can certainly support abortion as an option while recognizing the potential for fetal consciousness during late-term abortion procedures.

Surgical Abortion Procedures

LI (Labor Induction)^[2]

Gestational age: 20+ weeks.
Method: The fetus is administered a lethal injection with no anesthesia, often of potassium chloride, which causes cardiac arrest and death within a minute. The Human Rights Watch calls the use of potassium chloride for the death penalty without anesthesia "excruciatingly painful" because it "inflames the potassium ions in the sensory nerve fibers, literally burning up the veins as it travels to the heart."^[3] (Disclaimer: This describes an intravenous injection, whereas intra-amniotic or intra-fetal injections are more common in the case of abortion.) The American Veterinary Medical Association considers the use of potassium chloride without anesthesia "unacceptable" when euthanizing vertebrate animals.^[4]

D&E (Dilation and Evacuation)^[5]

Gestational age: 13-24 weeks.
Method: The fetus's limbs are torn off before the fetus's head is crushed. The procedure takes several minutes.

When Can a Fetus Suffer?

The traditional view of fetal sentience has been that "the cortex and intact thalamocortical tracts," which develop after 24 weeks, "are necessary for pain experience."^[6] However, mounting evidence of suffering from adults with disabled cortices and animals without cortices has cast doubt on the traditional view.^[7] "Overall, the evidence, and a balanced reading of that evidence, points towards an immediate and unreflective pain experience mediated by the developing function of the nervous system from as early as 12 weeks."^[8] 12 weeks is when the first projections are made into the fetus's cortical subplate,^[9] which will eventually grow into the cortex.

I am a layperson who doesn’t have the expertise to evaluate these studies. However, I don't see a good reason to have substantially less concern for 24+ week fetuses than for infants. Though the arguments for 12-24 week fetuses are weaker, it still seems plausible that they have some capacity to suffer. Given the potential scale of fetal suffering due to late-term abortions, it seems that this evidence is worth seriously examining.

Scale in US and UK

2021 UK^[10]

The following is a selection from the UK abortion data tables:

7a: Weeks from Gestation	13 to 14	15 to 19	20+
Total Abortions	5,322	5,528	2,686
D&E (%)	25%	74%	44%
LI with surgical evacuation (%)	0%	1%	18%
LI with medical evacuation (%)	0%	0%	20%

Assuming the given percentages are exact, this gives us:

Abortion Procedure	Abortions per Year (UK)
D&E	6,603
LI	1,076

2020 USA^[11]

36,531 surgical abortions at >13 weeks and 4,382 abortions at ≥21 weeks were reported.
In 2021 UK, 38% of the ≥20 week surgical abortions were LI, which we can assume as a prior on what percentage of ≥21 week surgical abortions in 2020 USA were LI.
My understanding is that USA surgical abortions at >13 weeks which aren't LI are always D&E.
These observations give us the following table:

Procedure	Abortions per Year (US)
D&E	34,866
LI	1,665

As this is a draft post, I have not estimated how many of these procedures occur each year worldwide. However, given the US and UK numbers, I would guess the amount is in the hundreds of thousands.

Interventions

At least one paper affirmatively recommends fetal anesthesia from 12 weeks: "Fetal analgesia and anaesthesia should thus be standard for abortions in the second trimester, especially after 18 weeks when there is good evidence for a functional connection from the periphery and into the brain." Further research would be desired to see whether advocacy for fetal anesthesia is cost-effective enough to be competitive with leading global health interventions.

^{^}
Saxena, Kirti N. “Anaesthesia for Fetal Surgeries.” Indian Journal of Anaesthesia, vol. 53, no. 5, 2009, pp. 554–9, www.ncbi.nlm.nih.gov/pmc/articles/PMC2900087/
^{^}
“Second Trimester Labor Induction Abortion.” Michigan Health and Human Services, www.michigan.gov/mdhhs/adult-child-serv/informedconsent/michigans-informed-consent-for-abortion-law/procedures/second-trimester-labor-induction-abortion
^{^}
“So Long as They Die: Lethal Injections in the United States: II. Lethal Injection Drugs.” Human Rights Watch, www.hrw.org/reports/2006/us0406/4.htm
^{^}
Leary, Steven, and Johnson, Cia. AVMA Guidelines for the Euthanasia of Animals: 2020 Edition. Members of the Panel on Euthanasia AVMA Staff Consultants. 2020.
^{^}
“Dilation and Evacuation (D&E).” Michigan Health and Human Services, www.michigan.gov/mdhhs/adult-child-serv/informedconsent/michigans-informed-consent-for-abortion-law/procedures/dilation-and-evacuation-de
^{^}
Derbyshire, S. W., & Bockmann, J. C. (2020). "Reconsidering fetal pain." Journal of Medical Ethics, 46(1), 3–6. https://doi.org/10.1136/medethics-2019-105701
^{^}
Ibid.
^{^}
Ibid.
^{^}
Kostović I, Judaš M. The development of the subplate and thalamocortical connections in the human foetal brain. Acta Paediatr 2010;99(8):1119–27. https://doi.org/10.1111/j.1651-2227.2010.01811.x
^{^}
Abortion statistics for England and Wales: 2021 Data Tables. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1125274/Abortion_Statistics_2021_data_tables_revision.ods
^{^}
Kortsmit K, Nguyen AT, Mandel MG, et al. Abortion Surveillance — United States, 2020. MMWR Surveill Summ 2022;71(No. SS-10):1–27. DOI: http://dx.doi.org/10.15585/mmwr.ss7110a1

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BellaMar 18 202439

Wow, thanks for drawing my attention to this (hadn't really considered it at all before).

My gut pessimistic instinct is that this'd be intractable to implement — at least in the US — because administering anaesthesia could perhaps be seen as an implicit admission of moral personhood. I also doubt anaesthesia would get much support from pro-life advocates, since they oppose abortions altogether.

I hope that I could be proven wrong about that, though. Maybe a good next step could be for someone to talk to some doctors who administer abortions & get a few reactions?

KirstenMar 19 202426

I can imagine a first step would be it being offered as an option to mothers. Many late term abortions happen with wanted babies after a serious diagnosis.

However this post doesn't seem to talk about the main drug used for late abortions in the UK? So I'm sceptical. https://www.nice.org.uk/guidance/ng140/chapter/Recommendations#medical-abortion-after-236-weeks

NickLaingMar 19 20246

Yep I was going to write something similar before I saw this comment. I think you may have nailed the main reason why anesthesia doesn't happen. Pro-life people won't support it, and pro-choice people would be uncomfortable with admitting the possibility of pain and the implications of that.

JBenthamMar 19 202411

For what it's worth, my impression is that the reason it's not regularly administered is because doctors think it slightly increases the risk of complications for the mother (e.g. bleeding) and would make the procedure slightly more expensive and time-consuming. That, plus the assumption that the drugs given to the mother during the procedure are sufficient. Also, there have been efforts by pro-life lawmakers to draw attention to fetal pain, though this is probably a tactic to increase anti-abortion sentiment in general.

From this 2015 Washington Post article:

"Fetuses are routinely sedated during surgery, for reasons beyond the fear that the operation might cause them pain. Anesthetics stop a fetus from kicking around, making the operation safer. And though a fetus might not be conscious of pain, its body can respond to pain and stress in ways that interfere with its recovery. Painkillers alleviate that problem. That can happen directly or indirectly. During fetal surgery, women typically receive general anesthesia or sedation, making them unconscious or semi-conscious and pain-free. These drugs pass through the placenta to affect the fetus. For more involved operations, doctors inject extra painkillers directly into the fetus...

For as long as the fetus is alive during the abortion, it will experience some anesthetic effects depending on what drugs the mother receives. But would indirect anesthesia suffice to provide the “adequate relief” from pain that HB 479 demands? Just to make sure, Olszewski would prefer that fetuses are anesthetized directly during an abortion. He says that doctors can readily learn how to use an ultrasound-guided needle to deliver a cheap dose of painkillers to the fetus."

Hugh PMar 19 20244

My weak intuition is that pro-life people would support anesthesia. For one reason, they may support it precisely because of the reason you give that pro-choice people do not support it (that is, the implications of moral personhood some people may infer). On the other hand, one counterexample to my intuition is the analogy to how some animal rights activists oppose welfare reforms or at least discuss them with a negative tone, due to a more absolutist or anti-incrementalist position.

But perhaps more importantly, if it's true that pro-life people generally would support it, I would expect that to make it less tractable, because there's a risk pro-choice people would react and be polarised against it if it was seen as a pro-life political weapon.

Richard Y Chappell🔸Mar 18 202434

Thanks for this. I find it very strange that fetal anesthesia isn't standard here: unless there's some countervailing medical reason (risk to the mother?) or very significant expense involved, it seems like a clear moral improvement.

...see whether advocacy for fetal anesthesia is cost-effective enough to be competitive with leading global health interventions.

fwiw, I think a better comparison would be leading animal welfare interventions. Those seem more similarly targeted at raw suffering-reduction, whereas most "global health interventions" serve to increase global productive capacity and so have positive expected flow-through effects that pure suffering-reduction does not. I grant that this is "human" rather than "non-human", so I get where you're coming from; I'm just suggesting that this isn't actually the morally relevant distinction between the two cause areas.

(I should probably write a full post someday about why I think the standard breakdown of EA cause buckets isn't well-conceived, even though it works well enough in practice because it's very close to something that I do think makes sense.)

Ariel Simnegar 🔸Mar 18 202416

I very much agree that it's a clear moral improvement unless there's some strong countervailing consideration. I would guess the greatest practical difficulty would be the intervention's adjacency to politically contentious issues, which might make it intractable.

fwiw, I think a better comparison would be leading animal welfare interventions

I agree that there are many similarities between this proposal and animal welfare interventions. However, since I think the best animal welfare interventions are orders of magnitude more effective than GHD, I'd far rather GHD funding be diverted to this than animal welfare funding. I also just don't think this intervention would be anywhere near the animal welfare cost-effectiveness bar, though it could conceivably pass the global health bar.

JasonMar 18 202413

In the US, abortion is often a private-pay surgery, and so keeping costs low is seen as more of a concern than with procedures for which insurance is usually footing the bulk of the bill.

I'm not sure how difficult fetal anesthesia is -- a skim suggests IM fetanyl might be used here. Injecting into the wrong area by accident seems easier than for a newborn, especially where the anesthesia is not performed by an experienced fetal surgeon.

Richard Y Chappell🔸Mar 18 20248

I think the comparison group should be based on principle, rather than pragmatic considerations of which bucket you'd rather divert funds from!

If it's true that GHD funds should be diverted to AW funds, then they should be diverted to AW funds, not to a very poor substitute for an AW cause.

I personally think it isn't obvious that GHD funds should be so diverted, precisely because of their greater potential for flow-through effects. But of course if that is the basis for GHD funding having a lower "bar" than AW funding, it cannot justify applying the low (GHD) bar to this cause (which lacks potential flow-through benefits).

Ariel Simnegar 🔸Mar 18 20248

Richard Y Chappell🔸Mar 18 20249

Thanks, this has been a helpful discussion.

I agree that most GHD donors don't consciously conceive of things as I've suggested. But I think the most coherent idealization of their preferences would lead in the direction I'm suggesting. It's even possible that they are subconsciously (and imperfectly) tracking something like my suggestion. It would be interesting to see whether most accept or reject the idea that fetal anesthesia or (say) elder care are "relevantly similar" to saving children. Since metrics like QALYs (esp. for young people) and income-doublings correlate strongly with capacity growth, I don't take them to be evidence either way.

I also agree that my suggested reconceptualization could lead to some broader changes to the GHD portfolio, though it's important not to forget the "robust" part of it. If you have a pessimistic prior about narrowly-targeted attempts to improve the long-term future, general improvements to human health, education, and economic growth seem like a pretty natural alternative to me.

But I'm afraid I've gotten pretty far astray from the topic of your original post! I've drafted up an attempt to explain my views on EA "cause buckets" more fully, and will aim to post it tomorrow. [Update: here!] Thanks again for the stimulating discussion.

titotalMar 19 202417

I did a skim through of the research here while debating pro-lifers and came away persuaded that fetal anesthetic past the first trimester probably should be encouraged as a precautionary measure, assuming it doesn't harm the mother. However there seems to be high uncertainty about the suffering experienced in the 12-24 week period and even some uncertainty up to 30 weeks. A fetus is not directly comparable to a grown human or a grown animal: if a bundle of connected neurons are receiving pain signals, I'm not sure that necessarily proves that some sentient entity is experiencing pain.

Regardless, I don't think this issue conflicts much or at all with the pro-choice position, which I strongly hold. first, if you use the anesthetic, then most of the suffering involved goes away. Second, it seems like increased abortion access might plausibly reduce fetal suffering: if someone is forced to fly to another state for an abortion, the abortion occurs later on, when more cortical pathways have been formed. (I would still support abortion for autonomy reasons even if this weren't true).

I have my doubts as to whether this can compete with animal rights, in terms of suffering reduction. Numerically there are about 20 billion factory farmed animals, which is 4 or 5 orders of magnitude higher than the number of late-term abortions each year. And the suffering from a late-term abortion only happens once, whereas an animal in a factory farm might suffer their entire life. And a grown cow certainly seems more sentient than a 13 week old human fetus. The only way I could see it competing is on tractability.

Ariel Simnegar 🔸Mar 19 20243

Happy to hear we agree on fetal anesthesia :)

I also very much agree that there's no conflict between this and the pro-choice position, and that increased abortion access would reduce fetal suffering in late-term abortions. (Although increasing abortion access has other, larger ethical problems---from a total utilitarian perspective, there doesn't seem to be much difference between preventing a fetus from living a full life and doing the same for an infant or adult.)

On comparing individual fetuses to individual farm animals, it's worth noting that a 13-week fetus has about half as many neurons as an adult cow. (Cows have 3 billion neurons, while 13-week fetuses have 3 billion brain cells. Since humans have a near 1:1 neuron-glia ratio, a 13-week fetus's neuron count should be about half as many as a cow's.) So on at least one metric, they'd be pretty comparable. Of course, I'm pretty sure this fact is swamped by the other facts about factory farming you gave.

I agree that this probably wouldn't be competitive with animal welfare. However, if we're holding it to the standard for suffering-reducing interventions for humans, it could plausibly be more competitive.

titotalMar 19 20244

It's been a while since I looked through it, but my impression is that the billion neurons of the fetus are hanging out on the cortical plate and havent fully migrated to their final configurations, which may affect things. My impression was that the cow exhibits far more evidence of sentience than the fetus, for example giving much more similar brain activity to a grown human on an EEG. However this was from a skim a few months ago, so I would be interested in a more thorough investigation.

I agree that this probably wouldn't be competitive with animal welfare. However, if we're holding it to the standard for suffering-reducing interventions for humans, it could plausibly be more competitive.

I think that even for someone who only cared about the suffering of humans and human fetuses but not animals (a hard position to justify philosophically), it would still be a hard sell, for the same reason as before: The suffering of humans can occur over long periods of time, whereas an abortion is relatively quick. In addition, even if a 13-week fetus experiences some pain, would it compare in intensity to a grown infant?

I think the only way it could compete would be if the intervention was very cheap and easy, like if there was an easy way to persuade a medical group to change their recommendations.

Nonetheless, I think it's a topic worth at least thinking about! It's important to be sensitive though, as this is a justifiably emotionally charged topic for a lot of people.

Timothy ChanMar 19 202413

Thank you for bringing attention to fetal suffering - especially the possibility of suffering of <24 weeks fetuses.

Others have already pointed out that the interventions of applying anaesthetics to fetuses has issues of political tractability, but I think there's also a dynamic that could result in backfire on moral circle expansion efforts to include fetuses and/or other "less complex" entities.

Most people haven't spent time thinking about whether simpler entities can suffer and haven't formed an opinion so it seems like they're particularly susceptible to first impressions. The suggestion that less developed fetuses can suffer would likely imply to them that early abortions are wrong. People who don't like this normative implication might decide (probably unjustifiably) to think less developed fetuses and by extension other "less complex" entities cannot suffer to absolve themselves of acting in ways that might increase fetal suffering. "Early abortions are not wrong -> early fetuses cannot suffer -> anything of "lower complexity" cannot suffer". On the other hand, first introducing the ideas abstractly and suggesting that we should care about simple entities "in general" sidesteps this and could lead people to eventually care about fetal suffering in an, admittedly indirect, but less politically charged way.

So between two strategies, (1) advocate for lower complexity entities in general, and (2) advocate for less developed fetuses, those concerned with moral circle expansion to fetuses and/or other simpler entities should probably focus on the first strategy.

(Personally, I'd prefer if people accepted that they act in ways that might increase suffering, while simultaneously aim to decrease suffering.)

aleneMar 20 202411

Thank you so much for looking into this important moral issue. I know it's a really hard thing to analyze and talk about objectively in our polarized culture. <3 <3 <3

lillyMar 19 20249

I don't have time to research this in depth, but am pretty sure this post is missing a lot of nuance about how anesthesia works in abortion. Importantly, because mother and fetus share a circulation, IV sedation that is given to the mother will—to some extent—sedate the fetus as well, depending on the specific regimen used. So it's not quite right to say "The fetus is administered a lethal injection with no anesthesia." Correspondingly, I think this post overstates the risk of fetal suffering associated with abortion.

Ariel Simnegar 🔸Mar 19 202416

This description of labor induction abortion says:

The skin on your abdomen is numbed with a painkiller, and then a needle is used to inject a medication (digoxin or potassium chloride) through your abdomen into the fluid around the fetus or the fetus to stop the heartbeat.

That sounds like local anesthesia for the mother, which from what I understand is achieved through an injection which numbs the tissue in a specific area rather than through an IV drip. So I don't think this protocol would have any anesthetic effect on the fetus, though I'm not a medical expert and could be wrong.

Based on this, I think the sentence “The fetus is administered a lethal injection with no anesthesia” is accurate.

lillyMar 19 20246

Again, I think this post is missing nuance; for example:

Induction of fetal demise is done through a variety of means in multiple respects--different medications are given (i.e., digoxin, lidocaine, or KCl) via different routes (i.e., intra-fetal vs. intra-amniotic). (Given that lidocaine is a painkiller, I could see a different version of this post compellingly making the case that to the extent clinicians have discretion in choosing what agents to use to induce fetal demise, they should prioritize using ones that are likely to have off-target analgesic effects.)
So, the link you post refers to a small minority of abortions, as it's only routine to inject the amniotic fluid (specifically) with potassium chloride (specifically) prior to the delivery of anesthesia in some second-trimester abortions.
Potassium chloride is a medication that's routinely given via IV to replete potassium. The dose has a significant effect on how painful this is, as does the route of administration; people tolerate oral potassium fine. Importantly, the fetus is not even being given KCl intravenously (vs. intra-amniotically or intra-fetally), so it's hard for me to infer from "it is sometimes painful to get KCl via IV" that it would be painful for a fetus to get potassium via a different route. Correspondingly, then, I don't think the "inflames the potassium ions in the sensory nerve fibers, literally burning up the veins as it travels to the heart" applies.

Ariel Simnegar 🔸Mar 19 20242

I agree that clinicians should use lidocaine or digoxin over potassium chloride (KCL) for the reason you gave.
I wrote that the injection is "often of potassium chloride", not always.
1. Given that the fetus is receiving a lethal dose of potassium chloride, I don't think adults tolerating a much smaller medicinal dose should tell us much about how painful a lethal dose would be?
2. I agree that the fetus isn't being given potassium chloride intravenously, although I didn't know that when I wrote the post (another commenter pointed it out). I'll add a line in the post disclaiming that comparison.

JasonMar 19 20245

It is common ground in the lethal-injection context that the administered fatal dose of KCl would be excruciatingly painful without proper anesthesia (although that is in an IV context). I don't know what dose is being used in abortions, but the lethal-injection dose is 100 to 240 mEq at once. I was given 15 mEq per hour in the hospital last month, although it can be done somewhat more quickly if there is an acute need. So I agree that adult toleration of a very gradual dose isn't helpful evidence here.

Henry Howard🔸Mar 18 20248

Aside from impossibility of quantifying fetal suffering with any certainty and the social and political intractability of this idea: potassium chloride is often directly injected into the fetal heart, not the veins, so the comparison to lethal injection or animal euthanasia might be wrong

LarksMar 18 20245

Would it be possible to analogously execute adults by injection into the heart if this was a more humane method?

Henry Howard🔸Mar 19 20244

Sounds very difficult when deadly drugs like fentanyl, midazolam and propofol can easily be injected through an intravenous line. You can't get an IV line on a baby in-utero, I think that's why injection into the heart is done in that case.

Ariel Simnegar 🔸Mar 18 20242

Thanks for that info! I didn't know that.