Twins’ dilemma — the conclusion

Shahar Madjar, MD

The Bioethics Committee convenes monthly, on Mondays, at 7:00 AM sharp. They meet on the 12th floor of the hospital. There are seven members: 3 doctors, a lawyer, a priest, a bioethicist, and a representative of the community. Dr. Wise is the chairperson.

Dr. Wise knew the committee members’ love for endless philosophical debates. She also knew that the case that she would present on that particular Monday – the twins’ dilemma – requires a timely decision.

Dr. Wise presented the case of the conjoined twin girls: “The twins were admitted to the hospital a week ago. They are conjoined. One of the twins is well; the other is sick but is still alive. Doing nothing would most likely result in the death of both girls. Surgically separating the twins would most likely result in the death of one twin and the survival of the other. Can we proceed with a surgery to separate the twins?” She asked.

The committee members looked at the pictures of the twins, and the images that were obtained at the radiology department. 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 four arms, but only three legs.

“A real problem,” one of the members said. “Awful,” another member agreed.

“We believe it is surgically possible to separate the twins,” a doctor from the Department of Pediatric Surgery said.

“The real question is whether sacrificing one twin in order to save the other could be justified,” the bioethicist said.

“But if doing nothing will most likely result in the death of both girls and surgically separating the twins will most likely result in the death of only one, isn’t it better to separate them?” Sara, the community representative asked.

“Imagine a similar situation,” the priest said, “in which the twins are not conjoined but separate. So, we would have two twin sisters. One of the sisters is smaller, and very sick, but her heart is functioning well. The other sister is healthy except she has a complex heart disease. Would you support sacrificing the smaller, very sick twin with the good heart to save the life of the other twin. Would that be justified?”

Sara was not so sure anymore. There was silence first, then an animated debate that led nowhere. The time was 7:45. The twins, their mother, and the surgeons were waiting for a decision.

Dr. Wise looked at Sara, at the priest, and at the other members of the committee. “So what is the right thing to do? What is the moral thing to do? Perhaps,” she said, “it is time to apply the four principles of bioethics.” The bioethicist nodded. The committee members agreed. They reviewed the case in light of these principles:

Beneficence, or the intent to do good for the patient: in the conjoined twins case, surgery would most likely result in a longer life to the healthier twin.

Non-maleficence, or the intent to not harm the patient: surgery may result in the death of one of the twins, and would potentially harm the other.

Autonomy, or respect to patient’s decision: the twins cannot make a decision regarding their medical treatment. Their mother could, and her wish should be considered and honored.

Justice, or provide fair distribution of medical resources: because of the great expense of surgery and its uncertain results, it is not clear whether this treatment is justified.

And there were other ethical principles to consider: the wish of the twins themselves (if they could tell us their wish), in the context of their life story; the true intent of the medical intervention; the morality of acting vs. letting nature take its course.

The committee discussed these principles. The mother expressed her wish to proceed with the surgical separation of the twins. The surgery was technically challenging. It took several surgeons of different specialties and 14 hours to separate the twins. As expected, the smaller twin died during surgery.

The larger twin survived the operation. After several weeks of recuperation, she was able to crawl, and stand with assistance. Her doctor believes that she will do well.

On her way home, on the airplane, Faith, the mother of the twins, held her baby close to her chest. The twin was sleeping, her eyes closed. “So precious,” Faith whispered as she passed her hand over the twin’s hair, “my baby, you are so precious.”

Dr. Wise and the bioethics committee are scheduled to meet again on the upcoming Monday, at 7:00 AM sharp. On the agenda, there is a another case to discuss.

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