Dilemma involving twins

Shahar Madjar, MD

When the twins were born, there was little reason to celebrate. Their mother, Faith, noticed that her friends were no longer coming to visit. She noticed that people around her were whispering to each other. When she asked them what they were saying, they sometimes refused to repeat, and on other occasions they came up with something not worth whispering about. She knew that they were talking about the twins and about her, that they were avoiding her and the twins as if the condition was contagious. At night, Faith was crying. And when she went to the hospital for consultation, one doctor explained that such things just happened. Faith thought she heard him saying: “It is an accident of nature.”

The twins were conjoined.

At 22 months, Faith brought the twins to a hospital where doctors specializing in separating conjoined twins examined them.

The twins had two heads that were facing each other. They had two chests. But they were attached to each other from the xyphoid bone to the pelvis. They had only one belly button, one anus and one vagina. They had four arms, but only three legs. One of the legs had a duplicated foot with seven toes: one large toe in the middle, and three, smaller toes on each side.

Faith read online that conjoined twins are extremely rare. That the chance is 1 in 100,000 births. “Why does it have to be me,” she thought. She read that most conjoined twins are either stillborn, or die within the first day of their life. When her spirit was broken, she wondered whether it would have been better if her twins died too. At other moments, though, she was prepared to fight for the twins’ lives against all odds.

She read that conjoined twins are formed when a fertilized egg fails to completely split in the middle. If her twins were to complete the split, they would be separate, but hers were of the incomplete-split type — the failed one, and joined together.

Faith read that conjoined twins are always identical. Her girls looked similar, but one of the girls was larger, and always seemed more lively — she laughed louder and was more eager to play.

When the doctors looked at the CAT scan images of the twins, they found that the twins shared a single, long liver. Each twin had only one functioning kidney and a single ureter (the tube that drains the urine from the kidneys to the bladder). The ureters were draining into one common bladder. A part of the intestine was partially fused and another part was common to both twins.

The larger twin had an almost normal heart anatomy.

The smaller twin had a complex heart disease. Her heart could not support her own needs. Her life was dependent on her sibling’s circulation.

The lips of the smaller twin were blue and her oxygen levels were low. Several days after she arrived in the hospital, the smaller twin developed fever and appeared tired. She was less active than usual, she cried faintly and her nails turned blue. She coughed all the time. She initially responded to antibiotics, but soon thereafter her condition deteriorated again.

Without surgical intervention, it was likely that the smaller twin would die and that the death of the smaller twin would lead to the death of the healthier one.

Should the doctors intervene by performing surgery to separate the twins?

The answer seems simple when the question is formulated in mathematical terms: the twins are two persons. Doing nothing will most likely result in the death of both girls. Surgically separating the twins will most likely result in the death of one twin and the survival of the other. And since one life is better than none, surgery should be performed.

But the question, you see, is not one of numbers. It is an ethical dilemma: could observation alone, with the likely demise of both girls, be defended? Could surgery which would most likely result in interventional killing of one of the twins be justified? In other words, would sacrificing one twin in order to save the other be justified? And who should decide on the proper course of action?

What should the surgeons do? What did the surgeons decide to do? Were the lives of the girls saved?

I shall return.

Editor’s note: Dr. Shahar Madjar is a urologist working in several locations in the Upper Peninsula. Contact him at smadjar@yahoo.com or at DrMadjar.com.