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In June 1993, conjoined twin Amy and Angela Lakeberg became the focus of national attention. They shared a complex six-chambered heart and one liver; only one could survive separation surgery; and even her chances were slim. The medical challenge was great and the ethical challenges were even greater.
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There are increasing numbers of attempts to surgically separate conjoined twins. Almost every type of conjoined twins have been separated, with varying results. Surgeons must often make the decision as to the desirability and feasibility of separation. These decisions are complicated by ethical problems that involve patient privacy, the allocation of shared organs, and in some instances the necessity for one twin to die to save the other. Although life as a conjoined twin would appear to be intolerable, there are historical as well as current instances of conjoined twins who have progressed to adulthood as relatively well-adjusted individuals. Thus, in some situations, it may be better not to operate on these patients. At one time or another, when individual cases have been studied by theologians, all faiths have agreed that the sacrifice of one twin to save the other is ethical. When one twin is clearly stronger than the other and has the best chance for long-term survival, it also appears to be desirable to give that twin the shared organs that allow gastrointestinal and genitourinary function and ambulation. It is now possible to predict the pattern of shared organs in most cases based on an external examination. It is no longer necessary to subject these patients to prolonged, invasive tests, which may be dangerous and provide at best incomplete information. The surgeon should take great care to protect his patients' privacy and resist efforts by the media to create a "television circus"" over these patients.
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Two separate clusters of events in recent months have spurred public discussions over the questions of how and to what degree the public should be involved in resource allocation decisions. In England, a group of physicians unilaterally decided to deny bypass surgery to heavy smokers, and in the United States, uninsured parents of conjoined twins elected to seek separation of the twins despite heavy odds against their survival, raising questions of whether health care reform will stymie such decisions in the future.
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