Serious issues are raised by the deaths this week of conjoined twins duringsurgery, writes Dr Muiris Houston, Medical Correspondent
Surgeons must be very careful
When they take the knife!
Underneath their fine incisions
Stirs the culprit - Life!
Emily Dickinson
Conjoined twins and attempts to separate them have consistently captured public attention. Some of that attention has been frankly voyeuristic and an unhappy reminder of 18th-century circus entertainment when those with anatomical peculiarities were paraded for the amusement of others.
This week, in the spotlight of intense media interest, the first attempt to separate adult twins joined at the head took place in Singapore. Iranian twin sisters Laleh and Ladan Bijani (29) had been prepared for the ground-breaking surgery for some months. More than a dozen doctors and a team of 100 health professionals, led by neurosurgeon Dr Keith Goh, carried out the operation at Singapore's Raffles Hospital.
Predicted to last for up to four days, the twins' operation came to an end on Tuesday after 52 hours. First Ladan died, followed 90 minutes later by Laleh, as the surgical team worked to separate the many tiny blood-vessels connecting their brains. Sustained haemorrhage caused a critical drop in blood pressure, which doctors were unable to reverse.
The operation ran into several major complications. The women's brains were more closely linked than had previously been thought. After the operation began on Sunday, doctors opened their joined skull. However, the bone proved thicker than had been estimated, leading to considerable delay.
Then the team inserted a vein from Ladan's thigh to replace a shared vessel that drained blood from the twins' brains to their hearts.
Next, five neurosurgeons began the delicate process of teasing apart their brains millimetre by millimetre. Ladan and Lelah were fully separated, but died on Tuesday from continous blood loss.
It was clear that the sisters really wanted to have the surgery despite the fact that the chances of a successful outcome were reckoned to be, at best, 50:50. They spoke of wanting to see each other face to face.
"We want to see each other," Ladan said, "without a mirror." Since the failed operation, however, their biological father, Dadollah Bijani, has said he tried to talk them out of the surgery. Alireza Safaian, the twins' adoptive father, claimed his daughters were the victims of propaganda in Iran and Singapore.
"They were used as laboratory mice," he said. "I read about the surgery three months ago but the ones who convinced them to go through with it did not let them come see us. Now my girls are gone and there is nothing I can do to bring them back."
The Bijani case raises serious ethical issues. Should doctors allow patients undergo such risky procedures? And while the operation was approved by the Singapore hospital ethics committee, were the principles of informed consent properly followed?
Mary Donnelly, law lecturer at University College Cork, is author of 'Consent: Bridging the Gap between Doctors and Patients' (Cork University Press). This is how she defines the ideal of informed consent: "A person gives an informed consent . . . if and only if the person, with substantial understanding and in substantial absence of control by others, intentionally authorises healthcare professionals to do something."
In the case of the Iranian twins, questions might be asked about the clause "in the absence of control by others". While it appears that they had been determined for some years to have surgery, it is reasonable to question whether they were overly influenced by medical professionals in Singapore and, as their adoptive father has indicated, kept apart from the views of relatives and friends in Iran. However, as Donnelly points out: "It is important that it is the patients and not any other interested party who sets the boundaries for who should be involved and how much that involvement should be."
The role of the medical profession in cases such as this is an interesting one. One could argue that the assembly of such a large medical team and the attendant hype was an example of doctors "playing god". It is equally relevant to point out that the now accepted practices of liver and heart transplantation had extremely poor success rates when first attempted.
Some health professionals argue that it is only the courage of patients (and their doctors) in these pioneering stages of medical science that allows life-saving procedures to develop and enter mainstream medical practice.
Conservative medicine would not have attempted to separate Ladan and Laleh Bijani. In 1988, Madjid Samii, president of the International Neuroscience Institute in Hanover, Germany, spent a month assessing the twins before deciding that their chances of survival were almost nil.
"There have been medical advances, but the problem then was the same as now," he said, in reference to the shared vein linking the twins' brains. It also emerged that another team of German doctors at University Hospital, Heidelberg turned the Bijanis away in 1997.
The TV pictures of the cloth-wrapped Ladan and Laleh Bijani - finally separated in death - was a poignant reminder of the aphorism: doctors differ and patients (unfortunately) die.