The twins decision:
One must die
so one can live

Reprinted witl, permission
from tf?e Pflifadefphia Inquirer
Sunday, October 16, 1977


  The twins decision:
One must die so one can live

At Children's Hospital, a surgical team separates the Siamese twins, who were joined at the heart


The surgery: An
agonizing choice

Parmts, doctors, ra,bbis

By Donald C. Drake
,,rau,rer fifedErr 1rritnr

It was a very low-key press confer-
ence, and only half a dozen reporters
had come out to hear the doctors
tell how they had just separated
Siamese twins.

Sitting behmd 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-a-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 pro-
voked more debate, more soul-search-
ing 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 at-
tempt 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 sur-
gery:

o Several rabbis and other learned
men met four to five hours every
night for 11 days discussing the
ethical issues. The parents, who are
deeply religinus Jews, refused to
allow surgery without rabbinical sup-
port.

o Nurses and doctors at Children's
brooded about the certain death of
one of the twins. A few. refused to
participate.

o Dr. C. Everett Koop, the hos-
pital's ihlef of surgery, was so con-
cerned about being prosecilted for
;-f:-emeditated murder tbat he ob-
tained a court order for protection.
For all, It was a time of the most
intense self-exammation. No other

surgery could more dramatically
,lemonstrate the growing number of
noral and ethical dilemmas con-
`ranting the medical profession as
science extends its control over life
Ind death.

B:rn only hours earlier at a distant
:lmmunit)r hospital in New Jersey,
le twms looked surprising!y strong
nen lhey arrived by helicopter Sept.

They were joined at the chest, and
`ley seemed to be hugging each oih-
r w1t.h their wizened, newborn faces
thy a few inches apart. Their res-
,ration rate and their color were
Tmparatively good, indicating that
+eir blood was getting adequate
uygen.

But Dr. Paul Weinberg, a cardi-
rll,sgi?t summoned from home late at
..iaht, knew that something was des-
.Wrately wrong the moment he look-
-d at the twins' electrocardiogram
+ ERG) and listened to their chests
with a stethoscope.

0n.e heartbeat

He could hear only one heartbeat.
Anti the EKG tracing suggested that
there was only one heart.
Special X-ray studies the next day
howed that the twin designated as
%by Girl B had an essentially nor-
:nal. four-chambered heart that was
`.lsed to the stunted two-chamber
ireart of her sister, Baby Giri 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
ctunted heart of Baby Girl A would
not be able to support the child for
Inng.
`The doctors felt that they could
not leave the babies the way they
were either. They knew it WOUND be
nnty a matter of time before +ho

in dilemma

overworked 1% hearts wctuld start tir
fail, killing both babies. NO twms
loined at the heart like this had ever
lived more than nine months.

But separating the twins was a job
fc,r the surgeons, not a cardiologist.

Dr. Kaop is a large man with a
Lincolnesque beard and the domi-
nating bearing of an Army general.
He also has unique qualifications to
deal with the medical and ethical
dilemmas posed by the twins' lethal
union.

Twice befare he had separated
twins--a rare operation few pedi-
atric surgeons do even once -but
neither case involved a shared heart.
Moreover, Dr. Koop, a Presbyterian,
IS a deeply religious man who has
Yequently spoken out nationally
about the sanctity of human life.

The growing publfc 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 Acad-
emy of Pediatrics entitled "The
Slide to Auschwitz," Dr. Koop said:

"Perhaps more than the law, I fear
the attitude of our profession in sanc-
tioning infanticide and in moving
inexorably down the road from abor-
tion to infanticide, to the destruction
of a chrld who is socially embarrass-
ing, to you-name-it.n

It was ironic that such a maa
should be called upon to do this oper-
ation - 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 fa-
ther himself is a rabbinical student
to whom nothing matters more - not
even life itself - than God, the
teachings of his religion and biblical
ethics.


One axiom of biblical ethics is the
infinite worth of human life.

A difficult question

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 im-
portant a question For the young rab-
binical scholar, only in his early 20%
to try to answer on his own, so he
consulted the rabbis in his commu-
nitv and the rabbis in his and his
wiiee's families. Soon Rabbi Moshe
Feinstein, dean of Tifererh Jerusalem
seminary in New York City, was
called in.
The S&year-old Rabbi Feinstein
has for many vears served as final
arbiter in questions of Jewish law
and ethics. Scholars throughout the
world have sought his counsel in ethi-
cal dilemmas. I& written responses
to these questions are periodically
printed in a series of books entitled
"The Letters of Moshe" to guide all
JPh?s.

No less a man could be called
upon to try to solve the dilemma con-
fronting the parents of the rwins. 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 ho.wital had said little, SO the
rumors were sometimes inaccurate.

i~#s. Jan'e Barnsteiner, who is
Catho!ic and the associate director
,?or clinical nursing, was asked about
the twins bv head nurses as she
went about `the hospital each day
on her rounds.

The Catholic nurses, of whom there
are man:], were particularlv con-
cerned' that the surgeons might be
doing something that violated the
teachings of thmeir church.

The word "sacrifice" was used SO
much by the nurses in discussing
the matter that Mrs. Barnsteiner
herself became concerned and de-
cided to consult a priest.

.4t the same time, the nurses in
the operating room were becoming
particularly uneasv 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 conculted by her nursks.
Odd as it might seem, operating
room nurses rarely witness death -
only two or three of the 5,700 patients
onerated on each year at Children's
Hnspita! die in the operating room.
X?ediL:i:le has developed such effec-

tive life-ynpport 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
churah.

The ttin's father and rabbis met
with Dr. Koop on Sept. 20. And then,
three days later the rabbis met
agai,n witi Dr. Koop, but tiis time
alone.

Rabbi Feinstein did not, himself,
attend the conferences but instead
sent his son-in-law, Rabbi M. D. Ten-
dler, a noted Jewish authority on
medical ethics, a professor of Tal-
mudic law and chairman of the de-
partment of biology at Yeshiva Uni-
versity in New York.

One or two lives?

Time and again Rabbi Tendler put
the same question to Dr. Koop in dif-
ferent ways because the answer
would be so important to the rabbini-
cal discussion that would ensue.

Are the twins one baby or two ba-
bies?

If rhe twins were only one baby
with two heads, then it would be ethi-
cal to remove Baby A as an uruneces-
sary appendage.

If there were two babies with dis-
tinct 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 witi the same une-
quivocal reply:

With the exception of the chest con-
nection at which @heir livers were
joined, as well as their hearts, the
girls were separate human beings
with their own separate brains and
nervous systems.

10 fact, the nurses in the intensive
care unit, who were quickly develop-
ing affection for rhe twins, could see
their different personalities develop-
ing even at this early ag.
Baby Girl B was much more con-
tented and calm. Baby Girl A tended
to be irritable. But they were both
alert and made eye contact when
someone ca.me near.

Dr. Koop told the rabbis he felt
strongly that the twins should be sep-
arated and las soon as possible be-
cause the hearts could fail at any
moment.
He said, however, that be 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 h.alf-dozen times before, as
far as was known, had Siamese twins
been connected wirh their hearts
fused like this. So far, none of the ba-
bies 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.
The rabbis listened and said they
understood. They were impressed by
this big doctor with the beard, sur-
prised bv his knowledge of the Bible
and medical ethics.

They had not expected to Find a
surgeon who read the Bible before
work every morning.

It was getting late and it was Fri-
day. 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 par-
ents had not agreed to it.

If the parents should say no, noth-
ing 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., chair-
man of the section on cardiothoracic
surgery, was uneasy about all the un-
knowns in the case, and he said so
when the 20 doctors and nurses as-
sembled in the third-floor meeting
room on Sept. 30 after many infor-
mal 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 slpecial X-ray mov-
ies showed only parts of the heart
chambers and little about how much
blood was going into the heart mus-
cle -  viatl iaformation Dr. Ed-
munds 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 t\, 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 the case he faced a
wealth of unknowns.

The unknowns

Would Baby B's chest be large
enough to accommodate such a large
heart?

What would happen when Dr. Ed-
munds cut the section from Baby A
off from its natural circulatory Sys-
tem? Would it die, like a gangrenous
leg without a blood supply? Or would
it be nourished by Baby JYs circula-
tion through some unknown circula-
tory connection?

And what about the electrical con-
duction that caused the heart to
beat? Cutting the A heart section off
from its natural nervous system
might cause it to beat wildly, throw-
ing 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 wh'ich the
chest appeared to have been closed
too tightly to allow the six-chamber
heart to beat unimpeded. The res-
cued twin died shortly after surgery.
Dr. Koop told Dr. Edmunds, how-
ever, 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 all were exa-
mined at the meeting.
Dr. Weinberg tried to describe to
the doctors all that be knew about *
the heart from his X-rays. He used a
colored, clay model he' had con-
structed 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 be-
tween 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-rav studies, called arrgiog-
raphy, in wfiich dyes are injected di-
rectly into the heart's chambers,
would be needed.
Dr. Weinberg would also find out,
if possible, more about the coronary
arteries feeding the 1% hearts. Dr.
Edmunds 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 con-
figugration that would make it dif-
ficult to insert anesthesia tubes.
The anethesiologists were con-
cerned also about the surgeons' plan
to turn the babies over durinrg sur-
gery to get `at both sides. This would
make it difficult to keep the 13 blood
monitoring lines and tubes connected
to the twins from getting tangled up.
The meetina ended at 5 o.m.
They wouib need timk for Dr.
Weiaberg to IUI his studies and for
more planning sessions. Dr. Koop
tentatively decided to do the surgery
in 11 days. That would be Oct. 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 Oct. 3, the intensive care unit
nurse assigned to tie twins noticed
changes in the heart rate, respiration
and electrocardiograph tracings to
suggest that Baby Girl A might be
going into heart failure.

This was an ominous sign - one
that the cardiologists ;lad been pre-
dicting would come eventualIy and
one that everyone hlad been dreading.

The nurse summoned the physician
on duty and the decision was m,ade 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 rhat the twin was in heart fai-
lure, 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.

The rabbi cdZs

Besides, he still bad heard not'hing
from the twins' parents or the rab-
binical scholars. The only contact
since rheir meeting the week before
had been a telephone call from Rabbi
Tendler. who asked two somswhcat
odd questions.

If the surgeons wanted to, Dr. Ten-
dler 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 +lch 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 Ten&r asked whether
Dr. Koop was certain that Baby Girt
B would also die, even with the sur-
gery.

Dr. Koop said that Baby B prob-
ably 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 questicns or where
the rabbis stood.

Dr. Koop held three meetings with
the nurses and other personnel dur-
ing tihe week to offset the growing
concern about the surgery.

Many of the nurses who attended
tie meetings were from the operat-
ing rooms.

At each session Dr. Koop described
how both babies were doomed if
not;hing was done alnd 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 out-
raged or disapproving, especially
after Dr. Koop got through his expla-
nation.

Most of ahe questions were techni-
cal 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,
sternly looking at him, "as a Chris-
tian 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 20
nurses, checked on the twins' condi-
tion and found that they seemed
stronger. Then he met with a lawyer
from the firm of Dechert, Price 8~
Rhoads.

His concern

Dr. Koop was becoming increas-
ingly worried that he might be prose-
cuted 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 pro-
tection 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 sur-
w-y
But he was concerned about a
criminal action and said fIatly that

he would not do the surgery without
adequate legal protection. It was a
difficult legal question thalt would in-
volve time-consuming searches for
legal precedent.
Time was short, so Rechert, Price
& Rhoads immediately assigned four
lawyers to the case.

The rabbis had been discussi~ng the
twins for almost a week. Rabbi Fein-
stein had even moved into the house
of his son-Saw, Rabbi Tendler, for
tie duration of tie discourse. Every

night after dinner he would meet
with Rabbi Bndler 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 un-
til 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
ariplanc," Rabbi Tendler said in one

Large medical team and a vast array of apparatus were required for the operation


dbcussion, using an analogy, "The
parachute of tihe fir.st man opens and
he falls slowiy and safely to earth.
"The parachute of the second man
does not open. As he plunges past his
friend, he ma,mges to grab onto his
foot and hold on. But the parachute
is too small to support both of them.
Now bhey aare both plunging to their
death.

"It is morally jmtified," Rabbi
Tendier concludes, "for the first man
to kick his friend away because they
would both die if ihe didn't, and it
was the first man who was desig-
mted for death since it was his para-
chute that didn't open."
Another andogy
"Ah, yes," replies Dr. YRCOV Ten-
dler, the son who is a rabbi and phy-
sician. "Rut take the case of tie
baby who is being born. Something
goes wrong iust as the babv's head
come.s crut of the vagina. It `is stuck
and the baby cannot be pulled out.
"The choic- would be to either kill
the baby and dismember jt to get it
out of the mother's body, or let them
battle it out to se-e who wins. Biblical
erhics demands that you take a
hands-off policy. You have two
human beings in conflict with each
orher. Neither is guilty of a crime.
You have no right to select the life of
one over the other.

"It is only in tie unique situation
in which the child is in the uterine
world.  tutally dependent on the
mother for sustenance, that the moth-
er's !ife takes precedence over the
fetus.

"In the case of the twins," Dr.
Yacov Tendler argues, "you have a
situation where both heads have
come into the world, each one mak-
ing an independent claim to life. >'OU
have no ri&t to forfeit one for the
other."

,411 of the heads in the room nod
solemnlv, then a third person speaks.
"But then there is the case of the
caravan surrounded by bandits. If
nhe 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 ban-
dits named a particular member of
the caravan, it wfiuld be nioitally
justified to give up this person be-
oause he had been designated for
dea?h and then it would be f&i.& to
give up the lives of all along rrlit?i the
life of the one designated for death.
So iZ is with the twin who has been
designated for death

"Bat wait!" insists one of the oth-
ers in the room. "Has one of #e
twins been designated for death?"'
And so a phone call is placed to
Dr. Koop.

"Could Baby A survive if the hart
was given to her? Is Baby B also

iesignated for certain death or ti
here a possibility - remote  oW&
t might be - that Baby B  ?
            cou d m-
dive with surgery?'

The word had come down indepen-
jently from different Capholic priests
:hat the surgery would be ethical
.mder chur:ch baw, and Mrs. Barn-
;teiner and Miss Betsch passed the
Arord to the wrses under them.
"God expects us to act where we
Dan act," concluded one priest, the
Rev. Francis C. Meehan, associate
professor of moral theology at the
Seminary of St. Chlarles 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 killifig 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 th& at-
tempt to save the other child."
Father Meehan's words and those
of the other priests were reassuring,
but as the time approached for SW
gery rhree anesthesiologirrts and two
Catholic nurses asked not to be put
on the case.

Six of the seven nurses who would
participate in the surgery, i@u+g
~~`lietsch, however, wo& be
On Oct. 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
buriai before sundown on the day of
surgery. Dr. Koop gave assurauce
that this would be arranged.
The final planning session came an
Oct. 7.
The new X-ray studies by Dr.
Weinberg indicated that holes of un-
known size did connect the left ventri-
cle in Baby Girl B with the left ven-
tricle in Baby Girl A. This suggested
the possibility that Baby Girl B's cir-
culation might be able to susttiu this
section of heart.
Dr. Weinberg had also been able to
obtain the preserved specimen of a
similar, six-chamber heant that, had
been flown down from Harvard Uni-
versity.
Dr. Edmunds spent several hours
with the specimen, examining how
the heart chambers were conneca
and where the blood vessels fed into
the muscle.
During surgery, he would not have
time to examine the throbbing heart
of the twins. He might have to make
quick decisions under much pressura,

so he wanted to know as much as
possible beforehand.
The most important tactical ques-
tion confronting the surgeons was
when to cut off the circillation 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 vo-
lume of fluid it must push and to the
~CLSS of the entire circulatory system
of Baby A.

I%,-Edmunds wanted to cut off the
blood sltpply of Baby A from the cir-
culation 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 hiochemicals shut down the
heart if they reach sufficiently large
concentrations.
The surgeons decided to simultane-
ously tie off the carotid artery and
the jugular vein, which take blood to
and from the brain, t&e 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 inef-
fectively in the lethal frenzy of fiibril-
lation?. Or would it adapt quickly
w&hour any threat to Baby B?
The surgeons would find out on
Tuesday, Oct. 11.

Former District Attorney Arlen
Spectm, who represented the hospital
in t&e case, felt that the only way to
insu!re adequate protection for Dr.
Koop was to get a court order au-
thorizing him to do the surgery.
Similar position8
A three-judge panel of the Family
Court bard Dr. Koop and the law-
yers wesent their arguments in an
empty courtroom on C&t. 10, which
was Columbus Day, a holiday when
g,bu;~~~g would otherwise have
The. argiments presepted by the
lawyers were surprisingly similar to
the positions taken by tie rabbis dur-
ing t&t. 11 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 per-
son and to remove one would be only
to remove an appendage, like a
gan,greacus leg.
The judges dismissed this attempt
at logic, which probably was just as
well as far as the lawyers were con-
cerned, since modern medicine tends
io define death as the cessation ot


brain ratirer than cardiac actiLitp.

The lal.vyers then went to their sec-
ri:ld 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
iosing both of them, the court would
be justitied 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. Rut the hold
is not so secure that he can keep
both himself and his friend from
plunging to their dea!hs. 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 de-

liberation it authorized Dr. Koop to
proceed with the surgery.
It was scheduled to begin at 6 a.m.
the next day.

It was a cold, black morning and
the sun had not yet risen. The streets
outside Children's Hospita! were des-
erted and quiet. It was still too early
for the bustle of traffic.

Inside the hospital, brightly lit Op-
erating Room Three was hectic with
the activity of a dozen people prepar-
ing the room for surgery.


At 6:OS 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.

Tears in the hallway

It had been an emotional parting
from the intensive care units. Several
:~f the nurses touched the twins and
<air! qood-by. 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 pacifi-
ers. Outside in the hallway, one of
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 imme-
diately with nitrous oxide, and the
lengthy business of preparing them
for surgery was begun.
Dr. Kbop 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 dis-
tracted by heavv- traffic on the high-

way, a flat tire or some other extra-
neous happenmg.,

For the moment there was nothing
much for Dr. Koop to do, so he wan-
dered 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 sur-
gery. He would be exhausted before
the day's end.
Dr. Koop and his close assistant,
Dr. Louise Schnaufer, who had as-
sisted at the other two twin opera-
tions, did not begin their ritualistic
lo-minute scrub until 8:40.
And it wasn't until 9:2S that the
first incision was made into the tis-
sue connecting the two twins, glisten-
ing brown from the Betadine disin-
fectant they had been washed in.
Oxygen level low

The anesthesiologists were con-
cerned because the amount of oxygen
detected in the blood was less than
normal, indicating a ventilation prob-
lem either on the part of the equip-
ment or the physiology of the twins.

By lO:lO, four hours after the twins
had been put to sleep, the oxygen
leve! in the blood had dropped to
dangerously low levels, despite the
increased concentrations anesthesiol-
ogists were delivering. But there was
nothing anyone could do at this point
but proceed and hope.

By IO:35 the surgeons had isolated
the major blood vessels. Sutures
were pulled loosely around them,
ready to be tied off simultaneously
on signa!.

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 sur-
geons and everyone else in the room
braced themselves for the reports
from the anesthesiologists monitoring
the surviving twin.
Would all the oscilloscopes and di-
gital readouts start to turn bad, in-
dicating that the heart was going into
fibrillation?

There was nothi,t;g. In fact, nhe OX-
ygen level in the biood mysteriously
started to improve.

It was up to Dr. Edmunds now.
Working swiftly he tied off the
major blood vessels of Baby A's par-
tiall heart. He was in luck. There w-as
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 r,unning
into amy of the anticipated problems.
Even the anesthesiologists had no
trouble getting the tubes down tie
babies' t&-oats.

The heart of Baby Girl B (shaded area) was fused to the heart of Baby Girl A. The wall connecting the two hearts
was only 1 i 10th of an Inch thick, far too thin to permit surgeons to separate the two. In surgery, Baby Girl I-J'S heart
chambers were isolated from her body by tying off the blood vessels and moving the entire, six-chamber fased heart
into the chest of Baby Girl B. Doctors hoped that blood from Baby Girl B would support the two extra chambers by
leaking through holes 111 the wall that joined them (arrow).


Quickly the surgeons separated the
heart and lungs from Baby A and all
the other tissue connecting the one
baby to the other.

At If:25 the sepalration \:a~ com-
plete in every respect. OnI: t.he two
heart chambers and lungs oi Baby A
remained attached to Baby R. The
lungs were subsequently deta:hed.

Wrapping the shell of Baby A into
a greea 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 tthe operating room.
They put her on a sterile table on
Uhe chance that they might need rib
bones or skin as grafts to help close

the gap@ wouod in her sister's
chest. But it 1m.s not to be needed.
The rest of the operation went
without incident. Dr. Koop built an
ample chest around the large, throb-
bing heart now in the anatomically
proper place, and closed the wound.

l'f 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 oa a seat in the
operating room lounge to fil! 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 inten-
sive uare unit, alone this time, in sta-
ble but critical condition.
And the body of her sister was in a
vehicle speeding home for burial be-
fore sundown.

Dr. C. Everett Koop

Rabbis M. D. Tendler and Moshe Feinstein


EDITORIAL COMMENT

Drama at Children's Hospital

Inquirer medical writer Donald C.
Drake's behind-the-scenes account of
last week's operation to separate
Siamese twins sharing the same heart
had the suspense and impact of a
television drama, with one important
difference. It was true.

It was a complex operation, but it
was, as Mr. Drake revealed, far more
than that. Medical technology was in-
volved, but so were questions of
ethics, morality, religion and law.

The disciplines converged on the
same moral dilemma. Was it right to
perform an operation in which the
death of one might save another? Im-
agine two men jumping from a hum-
ing airplane. One parachute opens;
the other does not. The second man
grabs the first. The parachute is strong
enough to support only one. Is the
first man morally justified to kick the
other off?

Were the doctors morally justified
to kill one twin so the other could

use the single heart?

The decision was yes. Given the
agonizing choice, it no doubt will be
debated endlessly. But there can be
no argument, only admiration, for the
performance of the participants.

Those include the parents of the
twins, Orthodox Jews, who demanded
religious guidance before approving
the operation. They include the rabbis
who pondered, debated and prayed
for wisdom,  and the doctors and
nurses who demonstrated great sen-
sitivity for the moral and legal issues
before performing so skillfully in the
operating room. They include. the law-
yers and judges who brought the law,
ethics and science into harmony.

In the end, the drama at Children's
Hospital may have a sad ending. It is
a true story, no script writer can
guarantee a happy conclusion. But it
is that very life and death reality
which gives reason for deep apprecia-
tion to the coinpassion, concern and
professionalism of the participants.

Reprinted with permission
from the Philadelphia Inquirer
Tuesday, October 18, 1977