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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);

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

• 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

• 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)

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

• 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.