The birth of Siamese twins in Manchester England on August 8 has generated significant moral and legal debate around the world. Conjoined twins occur in approximately one of 200,000 live births and can often live fairly normal lives whether they remain in a conjoined state or are surgically separated. In this case, however, the girls are joined at the lower abdomen and share a heart and lungs. Mary (the twins' real names are not being used, as their identities remain hidden) is entirely dependent on her sister Jodie for life since she has no functioning heart or lungs of her own. Doctors predict that if the twins remain joined together both will die within six months, as Jodie's heart will eventually fail. They are therefore encouraging a separation of the two, which means of course that Mary would die since she does not have her own vital organs. The girls' parents, who came to England from an undisclosed country for expert medical help, are opposed to the medical separation of their daughters, citing religious grounds. They believe that nature should be allowed to take its course, and "If it's God's will that both our children should not survive then so be it."
This case has raised a myriad of legal issues. Should Mary be considered legally alive, since she has no heart and lungs? Would a separation of the two constitute unlawful killing? Do doctors have the right to take one human life to preserve another? Would the parents be guilty of manslaughter if no operation is performed and both die? And, whose interests are legally paramount in this situation? Not surprisingly, there are numerous competing legal interests, each of which are being represented by lawyers: Mary's, Jodie's, the parents', the doctors', the state's, and those of various special interest groups.
The case also presents a classic example of moral complexity in that the ethical course of action is not immediately clear. Complex ethical situations involve competing principles, virtues, and theological or worldview paradigms. They generally involve competing interest groups, each making legal and moral claims, and often embody competing sets of facts or empirical judgments about the case at hand. When confronted with a morally complex situation, we should never assume that one choice is as valid as another, but we must recognize that even if armed with moral absolutes or universals the ethical choice is difficult, sometimes tragic, and always cause for great humility. In complex dilemmas such as this in which we may not be able to choose the absolute moral good, we should seek the wisest resolution to a very difficult dilemma.
Though the Siamese twins case is indeed complex, there are compelling ethical grounds for surgical separation. One should not make this choice lightly, but it can be supported by solid moral reflection from within a clear Christian framework. The decision can also be sustained by an appeal to reason. The case for separating the twins, with a recognition that only Jodie will live, can be made through five basic propositions.
Proposition One: The intention behind separating the twins is not to kill, but to save the life of a human being.
Given the doctors' best judgment that neither twin will live without the separation, this is an attempt to save one human life in the midst of a very unfortunate situation. The surgical separation to save one life is analogous to an ectopic pregnancy in which a child is growing in the fallopian tube of a mother, rather than in her uterus. In such cases, a failure to operate and remove the child will almost certainly result in the death of both mother and child. Removing the child will indeed result in the loss of precious life, but it allows one (the mother) to live rather than allowing both to die. The Roman Catholic moral tradition allows for such actions through the doctrine of double effect, which says: when an action has two effects, one intended and the other unintended, the intended effect carries the moral weight. Other traditions have argued on similar grounds, noting that intentions must be considered in the difficult choices we must sometimes make.
In the case of Jodie and Mary, the intention behind the surgical separation is to preserve one human life, since it appears clear that neither twin would live without the procedure.
Proposition Two: Mary would already be dead if she were not conjoined to her sister.
Legal specialists have debated whether Mary is actually a living human being since she has no heart and lungs. Apparently she does not meet the criteria for brain death; therefore, we should be on the safe side and conclude that she is a living human being. However, the factual data regarding her situation is clear—she would not be alive if she were not conjoined to her sister Jodie. Barring a miracle, Mary has no possibility of continuing to live whether she remains joined to her sister or is separated from her.
Ethical decisions must always incorporate factual or empirical judgments about the situation at hand. Our moral norms do not arise from the facts of a case, but such facts ought to be considered when determining how to apply our norms. Factual realities often shed light on what courses of action are feasible and infeasible for a particular case. In this case the facts seem clear: Mary would not be alive if she were not joined to her sister, and she will not live if she remains joined to her.
Proposition Three: Preserving one human life is better than preserving none.
In this case the act of separating the Siamese twins will increase the likelihood that one lives, while allowing them to remain joined will almost certainly ensure that neither lives. Some oppose the surgical procedure on the grounds that it seems to be "playing God"—deciding who will live and who will die. While Mary's death would be tragic, taking an action with this unfortunate result may be the best recourse. We must seek to uphold the value and dignity of human life, and acting to preserve one life is better than failing to preserve either.
Proposition Four: When we can preserve human life, we have a moral obligation to do so, even if miraculous intervention could possibly be a means of preservation.
Some support a non-intervention approach on the grounds that God could intervene with a miracle to preserve the lives of both. However, as we face life and death issues, we cannot base our actions on the expectation of a miracle, though clearly we can pray for one. In the providence of God, miracles of this nature are not the everyday experience. God has created human beings, made in his image, to be stewards over the created world. This sometimes entails making difficult choices, even of a life and death nature. While we should never act to cause death, thousands of decisions are made daily in hospitals and nursing homes to legitimately withdraw treatment from terminal patients and allow divine providence and nature to take their course. Of course, families could—and sometimes do—refuse to make that decision, hoping that God will yet intervene to perform a miracle. However, rarely do such miracles occur. Thus, families commonly make their moral decisions within a framework of stewardship, reverence for life, and an understanding of the cycle of life which ends in physical death.
In the case of Jodie and Mary, the choice to separate the girls is the right moral choice. Certainly God could perform a miracle. However, as stewards of life who are faced with a profoundly tragic situation, we ought to act to preserve one life even if a miracle could possibly save both. Holding out hope that God could perform a miracle does not negate our responsibility to preserve human life when it appears likely that neither girl will survive unless we take action. Separating Jodie and Mary is not a rejection of divine power, but a humble recognition that God has created us to be moral agents who must sometimes make difficult choices in a finite, fallen world. Though a miracle is always possible, we should not let such a possibility override our taking action which could preserve the life of one twin.
Proposition Five: Considering consequences of our actions in complex ethical dilemmas is not a capitulation to utilitarianism in which the ends justifies the means.
Some have sided with the parents of Jodie and Mary, arguing that we should never do wrong in order to achieve good. They are certainly right to reject a moral decision based on the grounds of utilitarianism. Utilitarianism is a social calculus which fails to recognize the intrinsic goodness and value of each human life.
Though utilitarianism ought to be rejected as the basis for deciding the fate of Jodie and Mary, we must in the middle of complex ethical situations examine the potential results of the various options. Such consideration is not a capitulation to utilitarian ethics, but can be compatible with principle ethics, virtue/character ethics, or a theological foundation for making moral decisions. In each of these frameworks we come to the decision with norms and predispositions from beyond the moral situation itself. When our normative frameworks do not in themselves yield immediate clarity on what to do, it is sometimes wise to examine the potential results of our action. This does not push principles, virtues or theological paradigms to a back seat, but rather applies them in conjunction with the expected results of each course of action that we might take.
Choosing to surgically separate the Siamese twins will likely result in Jodie living and Mary dying, though Mary will not live with either course of action. Such a decision is not rooted in the greatest good for the greatest number of people. It is rooted in clear affirmations that life is precious and ought to be preserved, that God is providentially over all human affairs, and that God sometimes calls us to make difficult choices in the midst of complexity and even tragedy. Considering the anticipated results of surgical separation, that Jodie will live and Mary will not, is still acting within the confines of the biblical story and within a commitment to the dignity and value of all human life. It is not a surrender to utilitarianism and an ends justifies the means ethic.
Conclusion
Life sometimes presents us with hard choices. We must come to those decisions with humility, but also with a clear understanding of the facts, and a solid framework for understanding life, death, and the human vocation. In many ways the lives of both Jodie and Mary are too precious to be bantered about in the halls of litigation, where their value and dignity may give way to competing interests, legal history, and the technicalities of the adjudication process. Invariably the courts will probably decide their fate, but the situation calls for sensitive, yet clear moral reasoning. When the facts of the case are understood, when principles that have weathered the course of time are applied, when the great virtues surrounding human life are clarified, and when our roles on this earth before God are considered, the wise but tragic choice seems clear. The Siamese twins should be surgically separated so that one might live.