AMANCIO, Aliah Aira CRUZ, Christine Angelic

BASAS, Kristine CRUZ, Kathrina

BUENVIAJE, Lorraine Tuesday BARRETTO, Lois Dwayne
CABIJE, Christa Joy CORNEJO, Patrick Kent
CALANOG, Hershe Anne CRUZ, Khylle Bryan

Conjoined Twins Case Analysis: Universal Ethical Egoism

BSN 2-01 Group 1

Dilemma: In August 2000, conjoined twins, named Mary and Jodie were born in a hospital in
Manchester England. Their spines were fused, and they had one heart and one pair of lungs
between them. Jodie, the stronger one, was providing blood for her sister.

The prognosis was that without intervention, both girls would die within six months. The only
hope was an operation to separate them. This would save Jodie, but Mary would die
immediately.

Should the twins be separated?

I. Introduction

Through the perspective of Universal Ethical Egoism, everyone should act solely in their
own best interests. With different perspectives people would formulate different choices
regarding the given situation. The decisions that people will be making would be based on each
of their own self-interest. Either the choice is to refrain from the intervention and eventually let
both girls die or to separate the twins even though knowing that only one can be saved, it
depends on every person's own interest exclusively.

The intervention that we agreed to do is to separate the twins, since most of us agree that
saving one child is better than losing both. Seizing the opportunity of one child to live which is
what we think is the best possible choice regarding the situation but as well as our self interest
which is to at least have one child alive for them to take care of. The separation will also give
Jodie a chance of a better quality of life. Knowing the fact that Jodie is much stronger than
Mary, this shows that the fittest will survive and in this case it is Jodie. As we know parents will
most likely come out with the decision which can provide the best interest for their children.
Focusing on a child's quality of life and obtaining a realistic outlook on whether their child is
going to live a long,healthy, and happy life as possible. So at this point death mercy will happen,
Separating the twins, enabling Jodie a chance to live life while Mary will die immediately.
 If the intervention was refrained, both children will be dead by six months. The parents
will lose both Jodie and Mary if there is no operation to occur. This decision would be made if
the parents' self interest was not wanting to see the child suffer from birth defects, So even if
Jodie survived the operation she is still not guaranteed to live a normal life. It will greatly affect
the parent’s mental capacity in which they will mourn for the loss of what they had hoped for
their kids. Financial support can also be a factor since operations cost too much and the family’s
financial situation might be bad. There is no guarantee that the surgery will be a success since
they are conjoined twins which makes their body being complex. Lastly, social judgement, since
her birth defect might cause disparities among other children. It may also cause low self esteem
and social isolation that can provide influence to family’s quality of life. Parents, particularly
mothers, bear the burden of responsibility for their child's illness and are constantly blaming
themselves.

A. Statement of Facts

We would like to emphasize on the factual statements we obtain from the scenario itself that will
help in providing a foundation as we lay out more relevant issues pertaining to it. This will guide
us as we discuss and analyze the situation and view from the perspective of Universal Ethical
Egoism. The following are the significant cues:

(a) Mary and Jodie are conjoined twins

(b) Spines are fused, one heart and one pair of lungs
(c) Jodie, the stronger one, was providing blood for her sister.
(d) Without intervention, both girls would die within six months
(e) Only hope was an operation to separate them
(f) Operation would save Jodie, but Mary would die immediately

B. Relevant Issues

Based on the situation given, two relevant issues exist wherein choice is between two
conflicting alternatives. The prognosis was that without intervention, both girls would die within
six months. The only hope was an operation to separate them, but only one of them will survive.
These conflicting alternatives open numerous interpretations.

a) Choice to refrain from intervention, and both girls would die within six months.

This issue is opposite to the other alternative in question because it pertains to the choice
not to perform any intervention to save the life of either one of the girls. Choosing not to perform
any intervention is a matter of great concern for the case because it entails numerous discussions
as to why the choice is even considered in the first place. The discussion includes parents not in
favor of children suffering from birth defects, no financial support, success of operation, and
social judgment. This issue may stem from the fact that the parents wish to have no procedure
done to their children or parents are against unfairness or unequal treatment.

(b) Choice to separate the twins, but only one will be saved.

The issue of separating the twins with saving only one is purely about getting a second
chance at life. The decision to separate the twins will give Jodie a chance to live while Mary
would die right away. Unlike the first issue, there is an action made to save any of them. A
choice will be made and carried out. It's a source of concern because varied perspectives exist on
why that one child should be spared rather than none. The rational and sentimental perspectives
linked with seizing the opportunity to live and having better autonomy of the body for improved
quality of life are to be discussed further.

C. Discussion of Issues

Below are the possible rationales that can be considered in order to select the right
intervention to be done following the situation of the ethical dilemma presented in the case:

a. Through permanent union both the girls are presented to death within six months
however the succeeding are the grounds that was pondered that lead to choosing this
decision.

● Parents would not want children suffering from birth defects.

Looking after children with birth defects can have a severe influence on
the parents’ mental and physical health. According to Lemacks, J. et. al. (2013),
similar to those parents who would go through if their child had died, parents of
children diagnosed with birth defects also go through phases of loss and grief, the
parents did lose the “normal,” healthy child they had hoped for. Since even before
children are born parents would often envision life with their children. Learning
about their children’s birth defects diagnosis can significantly affect parents and
mourn for the loss of what they hoped for. In the study of Clowes (2021), 2.44
million women over the period of 1996-2020 had abortions and 0.69% of these
are caused by birth defects.

Taking care of a child with a birth defect can influence parents’ physical
and emotional health detrimentally. Numerous parents go through despair, worry,
and anxiety, which if left untreated can have a negative effect on the rest of the
 family. These emotions can be accompanied by embarrassment, humiliation, or
guilt. Mothers who are the primary caregiver of the children are overwhelmed and
unable to cope because of the circumstances together with the father who often
find themselves helpless, claiming they are responsible to protect their children
from birth defects but unable to do so.

● No Financial Support

Looking at the situation financially we are not only considering surgical

cost. There are many factors that can affect the family finances such as medical
cost, special equipment, health related charges, and changes that need to be
applied in the house. The family has to completely adjust their standard of living
and this can be very costly. With this in mind, the average cost of operation for the
conjoined twins are about 1.5 million dollars to 4.6 million dollars depending on
the procedures to be performed (Odoom, 2015). Such that, there is an average of
18 thousand pounds or 24 thousand dollars income for an average family in
England from 2019 to 2021 (Salary Explorer, 2021)

Birth defects are one of the leading causes of infant mortality. 40% of the
conjoined twins are not alive when they are born. Thus, the amount of time to live
is shortened as organs cannot support them (Seattle Children's Hospital. n.d.).

Other special-needs children are abandoned because their families cannot

afford to pay for their medical treatment. Medical operations, including
emergency surgery, are frequently postponed unless families can pay in advance.
Family’s quality of life is negatively impacted because of birth defects, necessary
interventions, hospital stays, surgeries, and procedures. Finances, connecting with
people, and marriage relationships are all the things that could also get affected.
For parents who have lost hope, abandonment may appear to be the only option
(LWB, 2013).

● Success of Operation.

According to Afzal, A. R. (2021), conjoined twins that survive until birth

can be divided into two groups: those who can be surgically separated and those
who cannot. For conjoined twins who share key organs, the prognosis and life
expectancy are more uncertain as mentioned in the problem given.

In cases like, Thoracopagus or conjoined twins who often lie face to face,
share common sternum, diaphragm, upper abdominal wall, or have conjoined
 heart, there are no known survivors according to Children’s Hospital of
Philadelphia. Moreover, success rate for separating conjoined twins vary
depending on the connection.When conjoined twins share a heart, success of
surgical division is usually not possible (2020). The survival rate of conjoined
twins who share the same heart only falls between 5% to 25%.

On July 8, 2003, in the operation of Iranian conjoined twin, the two died
in the midst of separation surgery. Due to the complexity of the body’s anatomy of
conjoined twins, massive amounts of blood are lost in the operation which results
in them falling to a critical state. It ends after 53 hours of complex surgery (BBC,
2003).

To add to the precedent, recovery after surgery requires close monitoring

of nutritionists, developmental pediatricians, and other specialists to ensure they
thrive and they grow. For parents with children who have birth defects, they
already suffer from normal worries of being a parent; however, having to look
after children with special-needs this comes with anxiety and fear. They usually
feel unprepared to care for a special-needs child and are concerned about how
they will cope financially and emotionally.

● Social Judgment

For many parents, especially mothers they carry the heavy burden of
causing their child’s illness and constantly blame themselves. Seeing their child
being burdened with the illness and constantly needing medical attention causes
them to get overwhelmed with their child’s demand pushing them into lasting
torment. According to Lemacks, J. et. al. (2013), several studies have found that
the more severe the child’s symptoms, the poorer the parent’s pshychosocial
functioning becomes over time.

As the child grows, birth defects may cause apparent disparities between
her and her peers. If surgical adjustments have been made, the scars that are left
behind by operation may elicit curiosity from outsiders. Parents can offer
protection in the early years by explaining the circumstances. However, as she
continues to grow she is left alone to guard herself from torment based on
differences. The social isolation and low self-esteem that might result from these
circumstances can have a significant influence on the family's quality of life.
b. Separation through choice. According to the hospital, the other twin’s death will
provide the other the twin the chance for a good quality of life

● Seize the Opportunity to Live

In the study of Spitz and Kiely (2000) with regards to success rates of
surgery for conjoined twins, in the 7 pairs of infants to undergo separation
surgery, 4 lived, which means there is a 28% chance of survival in the operation to
be done. It is to be emphasized that this data is for the general type of conjoined
twins and not specific to one classification.

Presently, according to Afzal, A. R. (2021), generally any type of

conjoined twins have poor prognosis. The overall survival rate is about 7.5% and
only 60% of surgically separated patients survive. Thankfully, current surgical
methods have considerably improved the success rate of separation procedures
and the prognosis of post separation survival. Presently, there is no known cure
for birth defects however, there are still ways to reduce the symptoms and manage
the condition. A lot of conjoined twins can survive than in the past because of the
advances in technology and surgical techniques such as postnatal imaging, three
dimensional modeling, and simulation based clinical rehearsal. Surgical
intervention such as internal imaging, tissue expansion, and cadaveric transplant
for vital organs shared between twins, these can lead to better prognosis and
successful operation (Afzal, 2019).

A parents’ love is immeasurable. When it comes to decision-making,

parents always choose the option that is in the best interest of their child. In the
study of Feudtner, et. al., (2015), there are certain attributes parents show when it
comes to finding resolution and caring for their child. Amongst these are focusing
on the child’s health, making informed medical decisions, focusing on the child's
quality of life, keeping a realistic outlook, and most especially making sure that
the child would have a long life as possible.

● Better Autonomy of Body

The situation given clearly insinuates that it is better for Jodie to be kept
alive since she is the stronger twin with a higher rate of survival as Mary depends
on Jodie’s life expectancy. The relationship between the complexity of their
anatomy favors Jodie better, this translates that Mary functions in a parasitic
manner whereas attaching herself to Jodie to divide her twin’s autonomy between
the two of them.
 Following the hospital's viewpoint, letting the other twin die would
provide the other twin the chance of a good quality of life as this makes Jodie the
sole responsible for her autonomy. Meaning, she would no longer be in charge of
her twin sister Mary’s life.

After the separation, Jodie would live her life without the burden of being
accountable for her twin sister's existence. There would also be no more
complexity within her anatomy meaning she will claim the quality of
self-governing of her own bodily function.

D. Analysis

Based on the discussion of issues, it has been determined that it is in most people’s
interest to separate the twins and save Jodie. Different perspectives were considered in this
decision, highlighting the viewpoint of healthcare providers alongside the parents and even Jodie
herself.

First, from the perspective of healthcare providers, the prerogative to try and save at least
one of the children would be their top priority. Saving one life of two is better than none at all.
To save neither of the children would also have a chance to leave a bad reputation on the
providers as the lack of action to save them would be a form of neglect, other conditions
notwithstanding. It would be in the best interest for them to be labeled as saviors, instead of
bystanders who chose not to do anything at all. Financial benefits would also, of course, be
considered when the parents would agree to have their children separated. Though it seems very
cold when viewed from a profiteering perspective, it could not be denied that the medical
institution would benefit from it nonetheless, in experiences, money, and even staff esteem.

Second, in the perspective of the parents, they may want to separate the twins so that they
would have the chance to at least take care of one child. Though it would be immensely
regrettable to have the loss of Mary’s life, Jodie’s life would still matter. If the birth of the
congenital twins is a primipara (first pregnancy) case, then Jodie would hold a much more
significant and sentimental value to the parents. It would be easier to grieve for one than two
children.

Third, in the perspective of Jodie, being separated from her twin would allow her to have
a better quality of life. Living with two heads and providing blood for her sister would prove to
be much more complicated in the future if they ever survive. If her parents do not give her a
chance to live, then it would also be a missed opportunity of large-scale proportions. The
proposition of having a future, in the first place, is immensely paramount.
 Essentially, separating the twins is the lesser (and better) of two evils, and it is why this
point is chosen for the case. But once again, it would ultimately be the decision of the parents,
especially considering that there would be unseen factors that could affect their choices. Their
own self-interests would weigh more on the fates of their own children.

E. Conclusion

The ethical dilemma brought by the case of the conjoined twins, Jodie and Mary, has
solicited many perspectives. These perspectives were narrowed down into a choice between
letting the twins die within six months or separating them so that one can flourish. Moreover, the
stated options were established with reasons that the discussants have considered to arrive at a
rational decision.

Reasons for letting the twins die were based on the parent’s perspective, financial
considerations, the success of the operation, and the emotional and mental functioning of the
surviving twin, Jodie. From the parent’s perspective, it would be emotionally and mentally
demanding to raise the child with the remains of her demised twin. The parents would still have
to undergo the process of grieving for the lost twin and for the hope of having normal children.
Letting both twins die would also liberate the parents from costs brought about by the surgery
and postoperative measures. This will dramatically change their lifestyle and might affect the
future of the surviving twin. Furthermore, even without the coercion of financial instability, the
success of the operation should still be considered. This is because when conjoined twins share
vital organs, the success rate of the operation plummets. Lastly, having the remnants of her
deceased twin, Jodie may be subjected to the unjust eyes and thinking of society.

Alternatively, the discussion has also predicated ground reasons for the choice of saving
one of the twins. These reasons were principally towards the well-being of the more capable
twin, Jodie. The first reason asserts that since Jodie is well enough to supply blood and oxygen
for both of them, she is competent to live on her own. Since most medical tests point that she has
a chance to live, the chance should be given. This chance strengthens as medical advancements
have increased the probability of success and lessened the risk of complications. Another reason
for separating the twins is to give jodie a better quality of life by providing her the autonomy to
her body and body functions. Given that Mary is dependent on Jodie’s cardiac and respiratory
functionings, it will be an immense ease of workload for Jodie if Mary is dissociated. This will
give Jodie better utilization of her body functions, promoting her quality of life.

Upon discussing the attributed reasons for each choice, it has been arbitrated that
separating the twins would be the less unpleasant and undesirable of the two choices.
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