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Conjoined Twins: Doctors Debate Ethics of Separation Surgery

Jupiterimages/Thinkstock(CLEVELAND) -- The decision to separate conjoined twins would be easy if it guaranteed a better life for both babies.  But the possibility of one or both twins dying or becoming severely disabled because of the surgery or the separation's effects weighs heavily on parents and doctors, according to a new report.

Two-year-old twins joined at the head were the focus of the report on the bioethics of separation surgery.  The girls, who were unnamed, shared kidneys and veins that drain blood from their brains, making separation surgery a risky undertaking unlikely to benefit both of them equally.  But leaving them joined could also threaten their health, not to mention their independence.

"In this case, every ethical principle is sort of turned on its head," said Dr. Devra Becker, a plastic surgeon at UH Case Medical Center in Cleveland and senior author of the report published Monday in the Plastic and Reconstructive Surgery journal.  Those principles, including informed consent, the duty of doctors to heal and avoid harm, and the tenet that health care resources should be distributed fairly, form the framework of Becker's report.

The girls traveled with their parents to Rainbow Babies and Children's Hospital in Cleveland from Italy for separation surgery.  They are craniopagus twins -- the rarest form of conjunction affecting one in 2.5 million births.  Based on published cases, the odds of both twins surviving separation surgery are 33 percent -- the same odds for both twins dying.

"Few will debate the benefit of separation if the surgical risk is [zero].  Similarly, few will advocate for separation if the procedure guarantees the deaths of the twins," Becker and colleagues wrote in the report.  "The ethics of separation becomes more complex when the morbidity of separation lies between [zero] and 100 percent or if one twin will benefit more from the separation than the other."

Following the risky, not to mention expensive procedure, the larger twin would need a kidney transplant or lifelong dialysis to live.  The smaller twin would be at risk for brain damage.  But left together, the girls were at risk for kidney failure and cardiovascular disease.

The procedure could also give both twins the chance for a normal life.

After thoroughly weighing the risks and benefits, the Italian twins' parents and the medical team decided to move forward with the procedure.  The larger twin, who would be left without kidneys, would go on dialysis until she was strong enough for a transplant.  And the risk of brain damage in the smaller twin would be minimized by doing the procedure in stages.  The benefits of separation for both twins, both medical and otherwise, outweighed the risks.

But during the procedure, the surgeons noticed the layer of tissue covering the twins' brains was dangerously tight -- a twist that tipped the risk-benefit scale.  The surgery was aborted, and both twins recovered.

Copyright 2011 ABC News Radio

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