To Separate

I. Introduction Conjoined twins are identical twins whose body part/s is fused together. It is because they do not fully separate from each other due to incomplete division of the fertilized ovum. They will be connected at certain points of the body and may tissues, organs or limbs. It is a rare case and only few of them survive. For some reason, female conjoined twins have more shot for survival than their male counterparts. There is no identified reason for this. It is not known whether more female twins are actually conceived, or if simply more female conjoined sets survive the pregnancy. Approximately 70% of conjoined twins are female. Conjoined twins are genetically identical. Thus, they always have the same sex. They develop from the same fertilized egg, and they share the same amniotic cavity and placenta. Twinning occurs by the either releasing of two eggs by the woman instead of the usual one or she produces only one egg that divides after fertilization. If she releases two eggs, which are fertilized by separate sperm, she has fraternal twins. When a single, fertilized egg divides and separates, she has identical or paternal twins. In the case of conjoined twins, a woman only produces a single egg, which does not fully separate after fertilization. The developing embryo starts to split into identical twins during the first few weeks after conception, but stops before the process is complete. The partially separated egg develops into a conjoined fetus. There are different types of conjoined twins and they are classified according to the place on the body where the twins are connected. The types of conjoined twins are as follows:  Upper trunk and head (front/back) Cephalopagus - A rare form of conjoined twins that are joined from the top of the head down to the umbilicus, with a separate lower abdomen and pelvis. Two fused faces are on opposite sides of the head.

 Head Craniopagus - Conjoined twins that are connected only at the cranium (head). They share bones of the skull and occasionally brain surface, but will have separate trunks, with four arms and four legs. About 2% of conjoined twins are craniopagus.

 Brain, head and chest Epholothorapagus - A combination of cephalopagus and thoracopagus conjoined twins. The twins are joined at the head and chest, sharing a brain, fused hearts and gastrointestinal tracts.  Trunk (front/back) Omphalapagus - One of the most common type of conjoined twins, these individuals share an anterior connection of the trunk, usually at the abdomen, but the connection can range from the thorax down to the umbilicus. Omphalopagus twins may share a liver, gastrointestinal or genitourinary functions, bur rarely share a heart. There are four arms, four legs and two pelvises.  Rear end Pygopagus - Conjoined twins that are connected at the posterior (rump). Pygopagus twins, about 19% of conjoined sets, have separate hearts but may share a spinal cord. There is one anus, two rectums, four arms and four legs.  Chest (side to side) Thoracopagus - The most common type of conjoined twins, these individuals share an anterior (face-to-face) connection of the upper half of the trunk, through the chest wall from the thorax down to the umbilicus. Thoracopagus twins almost always share a heart. There are four arms, four legs and two pelvises.  Lower body (side to side) Parapagus - Conjoined twins that share a lateral connection of the lower half of the body. The connection between upper bodies varies. The heart may or may not be shared.

 Lower body (front/back) Ischipagus - A rare type of conjoined twins that share an anterior connection of the lower half of the body. The heart is not involved. History One of the earliest documented cases of conjoined twins were Mary and Eliza Chulkhurst. They were born in Biddenden, County of Kent, England in the year 1100, and were joined at the hip. Another set of famous conjoined twins was Eng and Chang Bunker, who were born in Thailand (then called Siam) in 1811. The term Siamese twin was coined as a reference to Eng and Chang, who achieved international fame shortly after leaving Siam as teenagers. They were joined at the lower chest and shared their liver. Throughout the history, conjoined twins have fascinated people for centuries. They have been worshipped as gods and feared as “monsters”. They play a role in our myths and are a part of circus sideshows. They were believed to be just mere myths and legends but in reality, conjoined twins do actually exist even though it is fairly rare occurrence. Exact statistics are not known, but it was estimated that there is 1 in 85,000 births. About 1 in 200 sets of identical twins are born conjoined. Arise of Ethical Issues The issue about conjoined twins would not be complete without talking about the twins’ separation. Back then, when our technology wasn’t that beneficial, conjoined twins were left fused. There were no enough scientific explanations back then if it would be possible to separate conjoined twins due to different factors such as beliefs, inadequate scientific knowledge and paraphernalia. The Siamese twins, Eng and Chang Bunker, proved to many that even though

having that kind of condition, they can still live like normal twins. They were able to marry two sisters and nearly had two dozen children. They even became successful businessman and ranchers in North Carolina. But as our technology capacity improve, there had been cited ways in how to separate conjoined twins, and that is to surgically separate them. The surgical separation of conjoined twins

is a delicate and risky procedure, requiring extreme precision and care. Therefore, the decision to separate twins is a serious one. Separation of conjoined twins is usually performed at a very young age. Mortality rates for twins who undergo separation vary, depending on their type of connection, and the organs they share. Success rates of separating conjoined twins have improved over the years but it is still an issue if it would be morally ethical to separate them. The separation of conjoined twins tackles many issues regarding the moral and ethical implications in decision-making to surgically separate them. Religious grounds, medical and political fields, and parents’ rights are the major basis of the major decision. In this paper, the researchers will tackle the ethical and moral issues in making the major decision to separate conjoined twins considering the different grounds wherein question “To Separate or Not to Separate” conjoined twins arises. With the different types of conjoined twins mentioned above, this paper will be mainly concerned with the types and cases that necessarily need decision regarding separation. Such cases are twins sharing vital organ/s, dependent twins, twins endangering each other’s life, and many more which generally involves possible termination of one or both if not surgically separated. If you’re one of the parents, will you allow surgical separation of your children considering the risks? As a doctor who is concerned with the case, would you consider separation

of the conjoined twins in order to comply with your duties as a medical practitioner? In a nut shell, would you or would you not consider separation of conjoined twins? *mention the advantages and disadvantages II. Review of Related Literature In order to determine the possible answer to the questions about the surgical separation of conjoined twins described in this paper, the researchers gathered significant information and reliable data. This is to consider that decision to perform surgical separation to conjoined twins is so risky. It might be a good idea to have some philosophical laws as basis for the decision since this are the most reliable basis of ethical decisions. In Emmanuel Kant’s Categorical Imperatives which was derived form the concept of duty, one is ought to do his duty if he wants to be morally good regardless of his will or desires. Categorical imperatives are principles that are intrinsically valid; they are good in and of themselves; they must be obeyed in all situations and circumstances if our behavior is to observe the moral law. The categorical imperative, however, may be based only on something that is an "end in itself". That is, an end that is a means only to itself and not to some other need, desire, or purpose. Kant believed that the moral law is a principle of reason itself, and is not based on contingent facts about the world, such as what would make us happy, but to act upon the moral law which has no other motive than "worthiness of being happy. In line with Emmanuel Kant’s categorical imperatives, medical practitioners ought to do their job. In relation to the case of surgically separating conjoined twins, it is their obligation to do their job in order to be morally good. If they won’t comply with their duty, it will be as they had done an immoral act. They are obliged to do what they could to ensure their patients' welfare. It is their duty to sustain life and relieve pain or suffering.

Furthermore, principle of double effects plays a great role in decision-making for the medical process concerned in this paper. Below are the principles used to evaluate morality of an act: •

the nature of the act is itself good (e.g., its nature is to relieve someone of pain or distress);

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the intention is for the good effect and not the bad;

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the good effect outweighs the bad effect in a situation sufficiently grave to merit the risk of yielding the bad effect (e.g., risking a patient's death to stop intolerable pain); and

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the good effect (relieving pain) does not go through the bad effect (e.g., death)

Another philosophical law of interest to the separation of a conjoined twin is Utilitarianism which states that the moral worth of an action is solely determined by its contribution to overall utility. It is thus a form of consequentialism, meaning that the moral worth of an action is determined by its outcome—the ends justify the means. Act utilitarianism states that, when faced with a choice, we must first consider the likely consequences of potential actions, and from that, choose to do what we believe will generate the most happiness. A rule utilitarian, on the other hand, begins by looking at potential rules of action. To determine whether a rule should be followed, he looks at what would happen if it were constantly followed. If adherence to the rule produces more happiness than otherwise, it is a rule that morally must be followed at all times. Rule utilitarian would then add that there are general exception rules that allow the breaking of other rules if this increases happiness. Motive utilitarianism proposes that our initial moral task be to inculcate motives within ourselves that will be generally useful across the spectrum of the situations we are likely to encounter. In this sense, intentions are the only thing that matter, because the consequences cannot be known with certainty until the decision has already been made.

Stewardship Moreover, natural law states that a moral act should follow the natural process of an object. Alteration can be therefore an immoral act. Specifically, it is a common law which is based on the nature of an object. Survival of Conjoined Twins Conjoined twins occur in one out of every 50,000 births. Many such pregnancies are terminated before birth, or the infants are stillborn. Conjoined twins are always identical and of the same sex. They are more often female than male, by a ratio of 3:1. Conjoined twins are more likely to occur in Africa, India, or China than in the United States. Conjoined twins have appeared in triplet and quadruplet births, but no cases of conjoined triplets or quadruplets have ever been reported. Most parents of conjoined twins are younger than 35 years old. Approximately 50% of women who are pregnant with conjoined twins will develop excess fluid surrounding the fetuses, which can lead to premature labor and an increased risk of miscarriage. Conjoined twins joined at the abdomen (omphalopagus) are more likely to be breech babies. In breech births, infants are born feet or buttocks first instead of head first. Most omphalopagus conjoined twins are born by cesarean section to increase their odds of survival. Conjoined twins can be born with a complication called hydrops, which causes excessive fluid to build up in an infant's body and can be life-threatening. Those who survive past birth may experience congenital heart disease, liver or kidney disease, physical or mental disabilities, and intestinal blockages.

Survival and ability to separate the twins depends upon the type of conjoining. While some conjoined twins can do very well after separation, in other cases, separation may be impossible, or may mean the loss of life of one of the twins. If twins share vital organs, separation is far more difficult, as organs tend not to be split. This is the case with twins joined at the spine as well, as surgery can frequently cause paralysis or death. If they have separate sets of organs, chances for surgery and survival are greater than if they share the same organs. Conjoined twins are generally classified three ways: •

73% are connected at mid torso (at the chest wall or upper abdomen)

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23% at lower torso (sharing hips, legs or genitalia)

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4% at upper torso (connected at the head)

In some cases, conjoined twins have one healthy twin, and one very unhealthy, called parasitic. In these cases, separation is necessary to protect the healthy child. It is frequently tragic and difficult for parents to make such decisions, since agreeing to separation surgery is essentially agreeing to allow one child to die. On the other hand, the choice not to separate parasitic twins tends to mean both twins will die. When conjoined twins cannot be separated they frequently are able to manage through living a very different lifestyle. Difficulties occur when the twins share the same reproductive system, or excretory pathways. Others suffer from postural difficulties if they are joined at the head. Life expectancy for conjoined twins who cannot be separated frequently depends on how many organs are shared. If heart, lungs, liver, or kidneys are shared, providing the work for two bodies may be very difficult. In some cases, the conjoining is almost always fatal during the first few days of life.

Conjoined twins who share a heart have a low rate of survival. Twins who share a heart and brain tend to be considered non-viable. In other cases, called inclusion twinning, one twin absorbs the body of a dying twin while still in utero. Sometimes the surviving twin must undergo surgery to removed skeletal portions of the other twin’s body. Separation attempts seem most successful in Saudi Arabia, where 9 separations have been performed in the last 15 years with a 100% survival rate. Usually doctors will not undertake separation without the possibility of at least one of the children surviving the surgery. The courts have sometimes stepped in, as in England, where a judge ordered the separation of two children despite the parents’ strong objection. The two twins were parasitic and the weaker twin did die. It is hoped that with greater understanding, and perhaps with fetal surgery techniques, rate of survival in separation may increase, offering conjoined twins the same chance as other infants to live a healthy and productive life. The majority of conjoined twin pregnancies are not successful. However, most conjoined twins who undergo a planned surgical separation several months after birth do survive. The survival rate for conjoined twins who need an emergency separation at birth is approximately 44%. Currently, Scientists are still searching for the cause of conjoined twins. They believe a combination of genetic and environmental factors may be responsible for this rare condition.