Reprinted with
permission from The Philadelphia
Inquirer (October 16, 1977)
It was a very low-key press conference, and only
half a dozen reporters had come out to hear the doctors tell how they had just
separated Siamese twins.
Sitting behind a long table on the stage of a mostly empty auditorium,
the doctors explained that one of the girls had died because the twins together
had only one and one-half hearts. Some questions were asked, and then the
conference was over – an anticlimactic ending to one of the most intense dramas
ever played out at Philadelphia’s world-famous Children’s Hospital.
No one in the audience realized it, but the
operation had probably provoked more debate, more soulsearching on the part of
the staff and more concern about the law than any other surgery at Children’s
in recent years.
At issue was one painful fact:
The surgeons knew that in an attempt to save one of
the twins they would have to kill the other.
The one-and-a-half hearts were strong enough to
support only one child. Thus the doctors knew that one twin would die soon
anyway, and that without the surgery this would lead to the death of her
sister.
During the weeks preceding surgery:
·
Several rabbis and other
learned men met four to five hours every night for eleven days discussing the
ethical issues. The parents, who are deeply religious Jews, refused to allow
surgery without rabbinical support.
·
Nurses and doctors at
Children’s brooded about the certain death of one of the twins. A few refused
to participate.
·
Dr. C. Everett Koop, the
hospital’s chief of surgery, was so concerned about being prosecuted for
premeditated murder that he obtained a court order for protection.
For all, it was a time of the most intense
self-examination. No other surgery could more dramatically demonstrate the
growing number of moral and ethical dilemmas confronting the medical profession
as science extends its control over life and death.
Born only hours earlier at a distant community
hospital in New Jersey, the twins looked surprisingly strong when they arrived
by helicopter September 15.
They were joined at the chest, and they seemed to
be hugging each other with their wizened, newborn faces only a few inches
apart. Their respiration rate and their color were comparatively good,
indicating that their blood was getting adequate oxygen.
But Dr. Paul Weinberg, a cardiologist summoned from
home late at night, knew that something was desperately wrong the moment he
looked at the twins’ electrocardiogram (EKG) and listened to their chests with
a stethoscope.
He could hear only one heartbeat. And the EKG
tracing suggested that there was only one heart.
Special X-ray studies the next day showed that the
twin designated as Baby Girl B had an essentially normal, four-chamber heart
that was fused to the stunted two-chamber heart of her sister, Baby Girl A.
The hearts were joined along the walls of the left
ventricles, the main pumping chambers that push the blood through the body.
The connecting wall was only one-tenth of an inch
thick – far too thin to be neatly divided in order to give each twin what
belonged to her.
And even if this were possible, the stunted heart
of Baby Girl A would not be able to support the child for long.
The doctors felt that they could not leave the
babies the way they were either. They knew it would be only a matter of time
before the overworked one and one-half hearts would start to fail, killing both
babies. No twins joined at the heart like this had ever lived more than nine
months.
But separating the twins was a job for the
surgeons, not a cardiologist.
Dr. Koop is a large man with a Lincolnesque beard
and the dominating bearing of an Army general. He also has the unique
qualifications to deal with the medical and ethical dilemmas posed by the
twins’ lethal union.
Twice before he had separated twins – a rare
operation few pediatric surgeons do even once – but neither case involved a
shared heart. Moreover, Dr. Koop, a Presbyterian, is a deeply religious man who
has frequently spoken out nationally about the sanctity of human life.
The growing public acceptance of abortion is a
source of outrage to Dr. Koop, and he is concerned about the growing trend in
medicine to let, or even help, defective newborns die.
In a speech to the American Academy of Pediatrics entitled “The Slide to Auschwitz,” Dr. Koop said: “Perhaps more than the law, I fear the attitude of our profession is sanctioning infanticide and in moving inexorably down the road from abortion to infanticide, to the destruction of a child who is socially embarrassing, to you-name-it.”
It was ironic that such a man should be called upon
to do this operation – an operation that would, with certainty, leave one child
dead.
But as soon as he examined the twins, Dr. Koop knew
that had to be done. Without waiting, he placed a call to the twins’ father and
arranged a meeting.
The twins had been born to a deeply religious,
Orthodox Jewish family of rabbinical scholars. The father himself is a
rabbinical student to whom nothing matters more – not even life itself – than
God, the teaching of his religion and biblical ethics.
One axiom of biblical ethics is the infinite worth
of human life.
Since this ethic implies that all human life is
equal – that one life is worth no more or less than another – would he consider
it moral to kill Baby Girl A so that Baby Girl B could live?
This was much too difficult and important a
question for the young rabbinical scholar, only in his early twenties, to try
to answer on his own, so he consulted the rabbis in his community and the
rabbis in his and his wife’s families. Soon Rabbi Moshe Feinstein, dean of
Tifereth Jerusalem seminary in New York City, was called in.
No less a man could be called upon to try to solve
the dilemma confronting the parents of the twins. So Rabbi Feinstein agreed to
consider the question.
Word spread through Children’s Hospital that
surgeons were planning to sacrifice one of the Siamese twins.
The hospital had said little, so the rumors were
sometimes inaccurate.
Mrs. Jane Barnsteiner, who is Catholic and the
associate director for clinical nursing, was asked about the twins by head
nurses as she went about the hospital each day on her rounds.
The Catholic nurses, of whom there are many, were
particularly concerned that the surgeons might be doing something that violated
the teachings of their church.
The word “sacrifice” was used so much by the nurses
in discussing the matter that Mrs. Barnsteiner herself became con- cerned and
decided to consult a priest.
At the same time, the nurses in the operating room
were becoming particularly uneasy because they knew that they would be called
upon to participate in the surgery, if it took place.
Winifred Betsch, assistant director of the
operating room complex, was also consulted by her nurses.
Odd as it might seem, operating room nurses rarely
witness death – only two or three of the 5,700 patients operated on each year
at Children’s Hospital die in the operating room. Medicine has developed such
effective life-support systems that doctors are almost always able to get the
patient at least to the intensive care unit.
So the nurses were very disturbed by the prospects
of beginning surgery in which it was already known beforehand that one of the
patients would be taken out of the room dead.
Miss Betsch said that she would consult a priest. A
Catholic herself, she would not want to participate in the surgery if it went
against her church.
The twins’ father and rabbis met with Dr. Koop on
September 20. And then, three days later the rabbis met again with Dr. Koop,
but this time alone.
Rabbi Feinstein did not, himself, attend the conferences but instead
sent his son-in-law, Rabbi M. D. Tendler, a noted Jewish authority on medical
ethics, a professor of Talmudic law and chairman of the department of biology
at Yeshiva University in New York.
Time and again Rabbi Tendler put the same question
to Dr. Koop in different ways because the answer would be so important to the
rabbinical discussion that would ensue.
Are the twins one baby or two babies?
If the twins were only one baby with two heads,
then it would be ethical to remove Baby A as an unnecessary appendage.
If they were two babies with distinct nervous
systems, however, then that would require more scholarly discussion.
Each time Rabbi Tendler asked the question in a
different way, Dr. Koop would come back with the same unequivocal reply: With
the exception of the chest connection at which their livers were joined, as
well as their hearts, the girls were separate human beings with their own
separate brains and nervous systems.
In fact, the nurses in the intensive care unit, who
were quickly developing affection for the twins, could see their different
person- alities developing even at this early age.
Baby Girl B was much more contented and calm. Baby
Girl A tended to be irritable. But they were both alert and made eye contact
when someone came near.
Dr. Koop told the rabbis he felt strongly that the
twins should be separated and as soon as possible because the hearts could fail
at any moment.
He said, however, that he would not seek a court
order to force the parents to agree, because the chances of saving both babies,
even with surgery, were very slim.
Only a half-dozen times before, as far as was known, had Siamese twins
been connected with their hearts fused like this. So far, none of the babies
separated has survived for more than a few days.
But with surgery, there was at least a theoretical
chance of saving one of them. Without surgery there was no hope at all.
It was getting late and it was Friday. The rabbis
wanted to get home before sundown, the beginning of the Sabbath. So they got up
and said good-by, saying they would discuss the matter and make their decision
as soon as possible.
The surgeons, cardiologists and other medical
people were not at all happy about the prospect of delaying surgery any longer
than necessary.
It would take several days, if not weeks, to get
together the complex surgical team, do the necessary preoperative tests and
make the other plans.
Concerned that the babies might take a sudden turn
for the worse, Dr. Koop ordered elaborate planning for the operation, even
though the parents had not agreed to it.
If the parents should say no, nothing but
professional time would be lost. But if the babies’ health should suddenly
fail, at least the team would be ready to move immediately if the parents
approved.
Dr. Henry L. Edmunds, Jr., chairman of the section
on cardio- thoracic surgery, was uneasy about all the unknowns in the case, and
he said so when the twenty doctors and nurses assembled in the third-floor
meeting room on September 30 after many informal conferences in the past
several days.
When a surgeon prepares to do heart surgery, he
usually has a fairly good idea at least of what the heart will look like.
But Dr. Edmunds had no idea what he would find.
Dr. Weinberg’s special X-ray movies showed only
parts of the heart chambers and little about how much blood was going into the
heart muscle – vital information Dr. Edmunds would need before he dared tie off
any blood vessels.
Because it would be too dangerous to sever the
heart of Baby B from the heart fragment of Baby A, Dr. Edmunds decided to put
all six chambers into Baby B’s chest. Dr. Edmunds is the type of surgeon who
feels uncomfortable unless he has all the facts, and in this case he faced a
wealth of unknowns.
Would Baby B’s chest be large enough to accommodate
such a large heart?
What would happen when Dr. Edmunds cut the section
from Baby A off from its natural circulatory system? Would it die, like a
gangrenous leg without a blood supply? Or would it be nourished by Baby B’s
circulation through some unknown circulatory connection?
And what about the electrical conduction that
caused the heart to beat? Cutting the A heart section off from its natural
nervous system might cause it to beat wildly, throwing the B heart into a
lethal condition called fibrillation.
Dr. Koop shared Dr. Edmunds’ concern about the
chest cavity being too small. Last summer he had been consulted on a similar
Siamese twin case in Switzerland in which the chest appeared to have been
closed too tightly to allow the six-chamber heart to beat unimpeded. The
rescued twin died shortly after surgery.
Dr. Koop told Dr. Edmunds, however, that he thought
they could solve the problem by surgically building a large enough chest
cavity, using the ribs of Baby A as grafts if necessary.
There were other concerns of equal importance, and
they were all examined at the meeting.
Dr. Weinberg tried to describe to the doctors all
that he knew about the heart from his X-rays. He used a colored, clay model he
had constructed as a visual aid.
Pointing to the model, he said he thought Baby B’s
circulation was partly supplying the stunted heart of Baby A by passing through
a hole between the ventricles where the two hearts touched. This blood from
Baby B might be enough to nourish the muscles of Baby A’s section of the heart,
keeping it healthy. If so, this would make it possible to cut the heart off
from Baby A’s circulatory system and give Baby B a healthy six-chamber heart.
But he could not be certain.
More X-ray studies, called angiography, in which
dyes are injected directly into the heart’s chambers, would be needed.
Dr. Weinberg would also find out, if possible, more
about the coronary arteries feeding the one and one-half hearts. Dr. Ed- munds
would need to understand this clearly in case he had to graft vessels from the
coronaries of the B heart to the A section to provide an extra blood supply.
Two pediatric anesthesiologists, Drs. John J.
Downes and Russell Raphaely, were worried because the twins’ airways were of a
configuration that would make it difficult to insert anesthesia tubes.
The anesthesiologists were concerned also about the
surgeons’ plan to turn the babies over during surgery to get at both sides.
This would make it difficult to keep the thirteen blood monitoring lines and
tubes connected to the twins from getting tangled up.
The meeting ended at 5 pm.
They would need time for Dr. Weinberg to run his
studies and for more planning sessions. Dr. Koop tentatively decided to do the
surgery in eleven days. That would be October 11.
Eleven days would be ample time to finish the
medical preparations.
But would that be enough time for the rabbinical
scholars to complete their meditations?
On October 3, the intensive care unit nurse
assigned to the twins noticed changes in the heart rate, respiration and
electro- cardiograph tracings to suggest that Baby Girl A might be going into
heart failure.
This was an ominous sign – one that the
cardiologists had been predicting would come eventually and that everyone had
been dreading.
The nurse summoned the physician on duty and the
decision was made to start administering digitalis, a drug used to strengthen
heart activity.
Because of the strange physiology of the heart, the
doctors could not be certain that the twin was in heart failure, but the signs
were disturbing enough to justify the drug.
Dr. Koop was notified of the change in the twins’
condition. He did not think it serious enough to put the surgical team on
alert.
Besides, he still had heard nothing from the twins’
parents or the rabbinical scholars. The only contact since their meeting the
week before had been a telephone call from Rabbi Tendler, who asked two
somewhat odd questions.
If the surgeons wanted to, Dr. Tendler asked, could
they give the six-chambered heart to Baby A instead of Baby B?
Dr. Koop could not understand why he was being
asked such a question, but he told them no. The circulatory system was set up
in such a way that the transfer could be made only to Baby B.
Then Rabbi Tendler asked whether Dr. Koop was
certain that Baby Girl B would also die, even with the surgery.
Dr. Koop said that Baby B probably would die
regardless of what was done, but that it was not a certainty.
Rabbi Tendler thanked Dr. Koop for the information,
said that they hoped to make a decision shortly and then hung up without
explaining the reasons for the questions or where the rabbis stood.
Dr. Koop held three meetings with the nurses and
other personnel during the week to offset the growing concern about the
surgery.
Many of the nurses who attended the meetings were
from the operating rooms.
At each session Dr. Koop described how both babies
were doomed if nothing was done and how there was a remote possibility of
saving at least one if surgery was attempted.
Since Baby A was being kept alive through the extra
work being done by Baby B’s heart he viewed Baby A as a burden – even a
parasite – and as such it was morally right to save Baby B by removing the
parasite.
The nurses were pensive at these meetings, but they
did not seem outraged or disapproving, especially after Dr. Koop got through
his explanation.
Most of the questions were technical rather than
ethical.
Dr. Koop said they asked him what could be done if
the twins started to die before surgery could begin. They also asked whether
the child’s chest would be normal after surgery, and whether there would be
closed-circuit television to show the operation to the hospital staff, as there
was in 1974, when Dr. Koop separated twins born in the Dominican Republic.
Only one person – an operating room nurse,
confronted Dr. Koop with the difficult question: “How do you feel,” she asked,
“as a Christian and a doctor, to do an operation like the one you’re planning?”
Dr. Koop stared back at the woman just as sternly
and, after thinking for a moment, replied with a low, measured voice.
“I can watch two babies die slowly over the course
of several months,” he said, “or I can watch one die swiftly and the other
possibly live.”
The nurse did not seem satisfied, so Dr. Koop continued, “no one likes
to say, ‘I’m going to kill one baby so that the other can live.’”
Dr. Koop finished the meeting, which was attended
by about twenty nurses, checked on the twins’ condition and found that they
seemed stronger. Then he met with a lawyer from the firm of Dechert, Price
& Rhoads.
Dr. Koop was becoming increasingly worried that he
might be prosecuted for premeditated murder.
It was not a farfetched concern; under Pennsylvania
law any citizen can bring a criminal complaint, and any number of legal
agencies on the city, state and federal levels could decide to respond.
Dr. Koop said he did not seek protection from a
civil malpractice suit. He was convinced that the parents were not the kind of
people to sue after giving permission to do the surgery.
But he was concerned about a criminal action and
said flatly that he would not do the surgery without adequate legal protection.
It was a difficult legal question that would involve time-consuming searches
for legal precedent.
Time was short, so Dechert, Price & Rhoads
immediately assigned four lawyers to the case.
The rabbis had been discussing the twins for almost
a week. Rabbi Feinstein had even moved into the house of his son-in-law, Rabbi
Tendler, for the duration of the discourse. Every night after dinner he would
meet with Rabbi Tendler and his three sons – one a physician and rabbi and the
other two rabbinical students – to discuss ethics.
Speaking only Yiddish or Hebrew, they would talk
late into the night until they reached an agreement. As soon as this happened
one of them would take the opposite position and they would turn around and
argue or discuss in that direction.
“Two men jump out of a burning airplane,” Rabbi
Tendler said in one discussion, using an analogy. “The parachute of the first
man opens and he falls slowly and safely to earth.
“The parachute of the second man does not open. As
he plunges past his friend, he manages to grab onto his foot and hold on. But
the parachute is too small to support both of them. Now they are both plunging
to their death.
“It is morally justified,” Rabbi Tendler concludes,
“for the first man to kick his friend away because they would both die if he
didn’t, and it was the first man who was designated for death since it was his
parachute that didn’t open.”
“Ah, yes,” replies Dr. Yaakov Tendler, the son who
is a rabbi and physician. “But take the case of the baby who is being born.
Something goes wrong just as the baby’s head comes out of the vagina. It is
stuck and the baby cannot be pulled out.
“The choice would be to either kill the baby and
dismember it to get it out of the mother’s body, or let them battle it out to
see who wins. Biblical ethics demands that you take a hands-off policy. You
have two human beings in conflict with each other. Neither is guilty of a
crime. You have no right to select the life of one over the other.
“It is only in the unique situation in which the
child is in the uterine world, totally dependent on the mother for sustenance,
that the mother’s life takes precedence over the fetus.
“In the case of the twins,” Dr. Yaakov Tendler
argues, “you have a situation where both heads have come into the world, each
one making an independent claim to life. You have no right to forfeit one for
the other.”
All of the heads in the room nod solemnly, then a
third person speaks.
“But then there is the case of the caravan
surrounded by bandits. If the bandits demand that the caravan surrender a
hostage for execution or else everyone would be killed, it would be wrong to
sacrifice someone.
“But on the other hand, if the bandits named a
particular member of the caravan, it would be morally justified to give up this
person because he had been designated for death. So it is with the twin who has
been designated for death.”
“But wait!” insists one of the others in the room.
“Has one of the twins been designated for death?”
And so a phone call is placed to Dr. Koop.
“Could Baby A survive if the heart was given to
her? Is Baby B also designated for certain death or is there a possibility –
remote though it might be – that Baby B could survive with surgery?”
The word had come down independently from different
Catholic priests that the surgery would be ethical under church law, and Mrs.
Barnsteiner and Miss Betsch passed the word to the nurses under them.
“God expects us to act when we can act,” concluded
one priest, the Reverend Francis C. Meehan, associate professor of moral
theology at the Seminary of St. Charles Borromeo in Overbrook.
“Not to choose is to choose to allow both of the
babies to die,” Father Meehan told the nurses. “It was not the doctors who
would be killing the baby, because they would save the girl if they could, but
the terminal event that had already started for her. Death may come sooner –
not because they chose it for the child but as an indirect result of their
attempt to save the other child.”
Father Meehan’s words and those of the other
priests were reassuring, but as the time approached for surgery three
anesthesio- logists and two Catholic nurses asked not to be put on the case.
Six of the seven nurses who would participate in
the surgery, including Miss Betsch, however, would be Catholic.
On October 6, only five days before surgery was
scheduled, word reached Dr. Koop that the rabbis had finished their
deliberations. They were in favor of the surgery. The father had agreed to it.
The body of Baby Girl A, however, would have to be
returned home for burial before sundown on the day of surgery. Dr. Koop gave
assurance that this would be arranged.
The final planning session came on October 7.
The new X-ray studies by Dr. Weinberg indicated
that holes of unknown size did connect the left ventricle in Baby Girl B with
the left ventricle in Baby Girl A. This suggested the possibility that Baby
Girls B’s circulation might be able to sustain this section of heart.
Dr. Weinberg had also been able to obtain the
preserved speci- men of a similar, six-chamber heart that had been flown down
from Harvard University.
Dr. Edmunds spent several hours with the specimen,
examining how the heart chambers were connected and where the blood vessels fed
into the muscle.
During surgery, he would not have time to examine the throbb- ing heart
of the twins. He might have to make quick decisions under much pressure, so he
wanted to know as much as possible beforehand.
The most important tactical question confronting
the surgeons was when to cut off the circulation of Baby Girl A. This would
immediately kill the child and possibly threaten the heart.
No one knew how the heart would respond to the
sudden drop in the volume of fluid it must push and to the loss of the entire
circulatory system of Baby A.
Dr. Edmunds wanted to cut off the blood supply of
Baby A from the circulatory system of Baby B as soon as possible during
surgery. This would kill Baby A, but it would also protect Baby B’s heart from
the poisons that would start pouring into the blood the moment Baby A’s tissue
started to die.
When tissue dies, it releases lactic acid and
potassium into the blood. These biochemicals shut down the heart if they reach
sufficiently large concentrations.
The surgeons decided to simultaneously tie off the
carotid artery and the jugular vein, which take blood to and from the brain,
the vena cavae, which supply the top and bottom parts of the body, and the
aorta, the principal artery from the heart.
When they did this, would the heart start beating
wildly and ineffectively in the lethal frenzy of fibrillation? Or would it
adapt quickly without any threat to Baby B?
The surgeons would find out on Tuesday, October 11.
Former District Attorney Arlen Specter, who
represented the hospital in the case, felt that the only way to insure adequate
protection for Dr. Koop was to get a court order authorizing him to do the
surgery.
The three-judge panel of the Family Court heard Dr.
Koop and the lawyers present their arguments in an empty courtroom on October
10, which was Columbus Day, a holiday when the building would otherwise have
been closed.
The arguments presented by the lawyers were
surprisingly similar to the positions taken by the rabbis during their eleven
days of discourse.
Common law in Pennsylvania states that death comes
after the heart stops, the lawyers argued. Since there is only one complete
heart, the twins constituted one person and to remove one would be only to
remove an appendage, like a gangrenous leg.
The judges dismissed this attempt at logic, which
probably was just as well as far as the lawyers were concerned, since modern
medicine tends to define death as the cessation of brain rather than cardiac
activity.
The lawyers then went to their second line of
reasoning and judicial precedent, which said that what might appear to be a
crime is not a crime if a court rules that the good outweighs the bad and
accordingly hands down a court order.
Because there is greater good served by saving one
child instead of losing both of them, the court would be justified in issuing
such an order, the lawyers insisted.
Then they cited a legal treatise on two mountain
climbers, a survival story almost identical in principle to Rabbi Tendler’s
analogy about the parachute jumpers:
A mountain climber who falls from his perch is
saved from instant death by a rope attached to a partner who has a more secure
hold. But the hold is not so secure that he can keep both himself and his
friend from plunging to their deaths. Because under such circumstances both
would die, the climber with the more secure hold would be justified in cutting
the rope.
The court apparently agreed with this logic. After
a few minutes of deliberation it authorized Dr. Koop to proceed with the
surgery.
It was scheduled to begin at 6 am the next day.
It was a cold, black morning and the sun had not yet risen. The streets
outside Children’s Hospital were deserted and quiet. It was still too early for
the bustle of traffic.
Inside the hospital, brightly lit Operating Room Three was hectic with
the activity of a dozen people preparing the room for surgery.
At 6:05 a voice yelled out, “They’re here.” All
faces turned to see a white-coated aide wheel in an isolette from the intensive
care unit. It contained the twins.
It had been an emotional parting from the intensive
care units. Several of the nurses touched the twins and said goodbye. One nurse
explained to the person from the operating room that the twins might be a
little cranky because they had been up most of the night playing.
They would be very good, the nurse said, if they
were given their pacifiers. Outside in the hallway, one of the nurses hid her
face because she was weeping.
She had spent a lot of time taking care of the
twins, and the thought that she would never again see Baby Girl A was more than
she could take.
The twins were put to sleep immediately with
nitrous oxide, and the lengthy business of preparing them for surgery was
begun.
Dr. Koop walked in, still drowsy from sleep. He had
slept overnight in the hospital, as is his practice before particularly
difficult surgery.
It takes him all night to prepare himself mentally
for difficult surgery and he didn’t want to risk being distracted by heavy
traffic on the highway, a flat tire or some other extraneous happening.
For the moment there was nothing much for Dr. Koop
to do, so he wandered about the operating room suite, talking to nurses. Dr.
Edmunds had been up operating in another case for several hours already, having
been called in for emergency heart surgery. He would be exhausted before the
day’s end.
Dr. Koop and his close assistant, Dr. Louise
Schnaufer, who had assisted at the other two twin operations, did not begin
their ritualistic ten-minute scrub until 8:40.
And it wasn’t until 9:25 that the first incision
was made into the tissue connecting the two twins, glistening brown from the
Betadine disinfectant they had been washed in.
The anesthesiologists were concerned because the
amount of oxygen detected in the blood was less than normal, indicating a
ventilation problem either on the part of the equipment or the physiology of
the twins.
By 10:10, four hours after the twins had been put
to sleep, the oxygen level in the blood had dropped to dangerously low levels,
despite the increased concentrations anesthesiologists were deliver- ing. But
there was nothing anyone could do at this point but proceed and hope.
By 10:35 the surgeons had isolated the major blood
vessels. Sutures were pulled loosely around them, ready to be tied off
simultaneously on signal.
At precisely 10:40, Dr. Koop gave the signal and he
personally tied off the carotid artery feeding blood to the brain of Baby Girl
A.
Death was instantaneous.
For several long minutes the surgeons and everyone
else in the room braced themselves for the reports from the anesthesiologist
monitoring the surviving twin.
Would all the oscilloscopes and digital readouts
start to turn bad, indicating that the heart was going into fibrillation?
There was nothing. In fact, the oxygen level in the
blood mysteriously started to improve.
It was up to Dr. Edmunds now. Working swiftly he
tied off the major blood vessels of Baby A’s partial heart. He was in luck.
There was no need to make any grafts. He wouldn’t even have to cut into the
pericardium, the protective sac around the heart.
Everything was moving along beautifully, several
hours ahead of schedule because no one was running into any of the anticipated
problems. Even the anesthesiologists had no trouble getting the tubes down the
babies’ throats.
Quickly the surgeons separated the heart and lungs
from Baby A and all the other tissue connecting one baby to the other.
At 11:25 the separation was complete in every
respect. Only the two heart chambers and lungs of Baby A remained attached to
Baby B. The lungs were subsequently detached.
Wrapping the shell of Baby A into a green surgical
drape so no one would see her, Dr. Koop gently and respectfully carried the
body of the infant to a sterile table at the other end of the operating room.
They put her on a sterile table on the chance that
they might need rib bones or skin as grafts to help close the gaping wound in
her sister’s chest. But it was not to be needed.
The rest of the operation went without incident.
Dr. Koop built an ample chest around the large, throbbing heart now in the
anatomically proper place, and closed the wound.
If the girl survived, she could grow up to lead an
essentially normal life. Her larger-than-average rib cage probably would not be
conspicuous. The skin was even put back in such a way that she would have
breasts in the proper place.
By 1:30 it was all over, and Dr. Koop flopped down
on a seat in the operating room lounge to fill out the death certificate.
“Cause of death,” he said, reading aloud to himself
as Miss Betsch stood nearby waiting for him to complete the form, “hypoxia
(lack of oxygen) due to operation to separate Siamese twins.”
One hour later, an exhausted Dr. Koop and the other
tired members of the team were conducting a press conference.
Baby Girl B was back in the intensive care unit,
alone this time, in stable but critical condition.
And the body of her sister was in a vehicle
speeding home for burial before sundown.
“The decision to perform surgery was made although it
was
known that one twin would not survive because the
shared heart could only go to one child.”
“Baby
B, the surviving twin, died three months later of liver
failure and overwhelming infection.”
From the Children’s Hospital of Philadelphia’s website, www.chop.edu/clinical/surgery/twins/facts.shtml
Source: ASSIA – Jewish Medical Ethics,
Vol. IV, No. 1, February 2001, pp. 14-21