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The first-ever brain separation surgery on adult conjoined twins was performed by an international team of experts on July 7, which resulted in the tragic death of both sisters, Laleh and Ladan Bijani. Doctors and newspapers assure that Bijani sisters had been fully informed of the potential consequences of this risky procedure, including the chance of death of one or both of the sisters, before consenting to it. However, a close examination into surgeons' comments about the failed "treatment" raises an ethical question regarding what went on in the operation room.
According to all sources, the critical component of this surgery was how to deal with the thick vein that drained blood from their brain to their hearts. Several teams of experts had previously declined to operate on Bijani sisters because they shared this important vein, which meant that the chances of both sisters surviving the separation surgery was "almost nil," according to Madjid Samii, president of the International Neuroscience Institute in Hanover, Germany. Samii had evaluated possibilities for separating the Bijani sisters in as early as 1988, but had decided against the procedure because it was "virtually impossible." In 1997, another team of doctors in Germany also decided against surgery because they "thought one of the twins would die and the other would be at risk" since there was only one vein.
The team that actually operated on Laleh and Ladan attempted to solve the vein problem by using the vein grafted from Ladan's inner thigh in her brain, and "reroute" the shared vein inside Laleh?s head. But soon, Ladan's grafted vein congested, signaling failure for this plan. Associated Press reports:
... surgeons Monday night considered whether to call off the rest of the operation and leave the twins joined or "continue with final stage of the surgery, which we knew would be very, very risky," [Dr.] Loo said.
"The team wanted to know once again what were the wishes of Ladan and Laleh," Loo said. "We were told that Ladan and Laleh's wishes were to be separated under all circumstances."
"Very, very risky"? They knew that Ladan could not survive without the vein she was sharing with her sister, and the replacement (grafted vein from her thigh) did not work as hoped. That means that doctors knew for 100% certain that Ladan would die if they "continue[d] with final stage of the surgery." At that point, by choosing to go forward with the procedure that has absolutely no potential of improving Ladan's health, doctors made a conscious decision to murder Ladan in order to secure the vein for Laleh, instead of leaving them joined and alive. News stories that state that Ladan died 90 minutes before Laleh are not telling the whole truth: doctors focused on saving Laleh after they had made a conscious choice not simply to abandon Ladan, but to actively murder her, which resulted in the 90 minute gap.
The medical procedure in which one of the conjoined twins is deliberately murdered in order to give the other a "normal life" is not unheard of. According to Alice Dreger, the medical historian from Michigan State University, at least nine such surgeries have been attempted on conjoined children, although none of them "resulted in any long-term, healthy survivor." In all of these cases, Dreger states, none of the twin "chosen to survive ever actually survived to go home or even life free of a ventilator." Pragmatic difficulties aside, it is obviously in violation of every ethical code to intentionally sacrifice a patient's life in a medical procedure that have no potential whatsoever to help her or him. "It is unethical to treat children with unusual anatomies according to a different set of ethical guidelines than other children," says Dreger, who is also known as the expert on ethical issues involved in the surgical "correction" of intersex genitals.
Ladan and Laleh demanded the highly risky surgery in hope that they would be able to follow their separate paths, and accepted the possibility that they might die from surgical complication. But did Ladan actually consent to being sacrificed in an avoidable procedure in which she had no chance whatsoever to survive? Did Laleh consent to having doctors kill her sister instead of staying alive together? Or, did doctors presume that life as a conjoined twin was not worth living? When Ladan and Laleh expressed their wish to be separated, did they actually say that they would rather be murdered than conjoined? Ladan and Laleh may have consented to a high-risk procedure which may inadvertently kill them, but does that mean that Ladan gave up her right not to be murdered in a procedure that has no potential merit for herself?
Laleh's death was probably an unfortunate tragedy, but Ladan's death is a murder, an intentional and avoidable killing of a healthy adult woman by the medical professionals who viewed her life as less valuable than their own. When conjoined twins' lives are not valued as much as everybody else's, neither will intersex children's. Bijani sisters' story reminded me of a presentation by a doctor, an intersex specialist, who first stated that genital surgeries on intersex children should wait until the child is at least six month old because anesthetic might kill the baby, and then added that earlier surgery was permissible if it reduced parents' anxiety.
Posted by Emi on Jul 8, 2003