Issues requiring ethical decision making frequently occur in today's healthcare setting, particularly as technologic advances stretch society's ability to understand and cope with the dilemmas they sometimes create. By its very nature, an ethical question has no right or wrong answer. Likewise, by its very nature, the decision to perform the surgery to separate the twins has been perceived as an ethical dilemma by many on opposing sides of the question -- some questioning the wisdom of performing the procedure given the complex nature of informed consent in this case and the debatable status of the technology needed to predict a successful outcome, others bitterly defending the rights of the twins, regardless of the risks. Yet others fail to appreciate the ethical nature of this situation, and some are even offended by that suggestion. So it was no surprise to us when we published a Newsmaker Interview with Dr. Ian Kerridge, MPhil, FRACP, FRCPA, on the deaths of the conjoined twins Ladan and Laleh Bijani during a failed attempt to separate them, that almost immediately we began receiving email letters from our readers. I have decided to share some of the comments we received as of July 21, 2003. Although the situation that ignited this round of debates is not related to organ transplantation, so many issues in transplantation are debated from an ethical platform, which is why I decided to post this on the Medscape Transplantation Home Page.
Some of you, including Peter Scottney-Turbill of Mount Isa, Queensland, Australia, thanked us for the interview. Mr. Scottney-Turbill writes, "Thank you for including the article, Conjoined Twin Surgery Raises Ethical Questions. The questions raised are indeed thought-provoking and, in particular, the question pertaining to informed consent." Another reader writes, "I read the interview with interest ... and wonder what are the scientific and surgical ramifications of this never-before-tried surgery? The moral implications? The social, legal, and interpersonal implications? Won't this 'failure' give surgeons and others who work with conjoined twins MUCH more information on how to approach adult conjoined twins who want separation? And competent conjoined adult twins who've never before considered separation, won't they be given a bit more hope?"
But most who wrote were pointedly critical of Dr. Kerridge's remarks and equally of our decision to post the interview. In fact, Maureen Campbell of Holland, Michigan, writes, "Asking this question publicly of someone who has admittedly not been involved with the two women and their various consultants throughout this problem is in bad taste. Perhaps even unethical." Another reader agrees, "Whether he [Dr. Kerridge] is right or not in his questioning, since he does not know what counseling, evaluation, and process was completed (by his own admission), he is in no position to validly answer these questions. He even questions the validity of the team's counseling and process when they had findings that they did not expect, yet he feels it acceptable to make comments about things of which he is not aware. His interview should have been dismissed."
"I am sorry, but not surprised, to see the ethicists pouncing on this story. The twin ladies from Iran were intelligent women who realized their risk and exercised their autonomy. This is as it should be. No ethicists needed," writes another reader, contending that there was no ethical dilemma. Anne Marie Talsky of Milwaukee, Wisconsin, agrees, "How can Dr. Kerridge and some of the other bioethicists who have been second-guessing this case say there was no biological imperative? Have they lived for 29 years joined at the head to another individual? Can they even imagine how horrible that could be? Until they've walked that mile, they have no right to judge this case."
Nancy K. Bryant of Leander, Texas, disagrees that there is no ethical dilemma, questioning who has the right to make such decisions, but also suggests that our current state of technology somehow gives us greater [and perhaps inappropriate] freedom to debate such issues when she writes, "The global firestorm and criticism seems incredibly invasive of individuals' rights to make decisions about their healthcare. It is beginning to appear that the information age has created the unusual environment where everyone and his dog can now demand the right to oversee and perhaps subvert individual decisions, because, I suppose, the global body knows what is best for each of us [more] than we ourselves know."
And still others, including Lawrence Barnes of Bangkok, Thailand, condemn the surgical team ... for "victimizing the twins" in a case of "blatant malpractice," claiming a "breach of ethics" occurred when the surgical team attempted the operation without adequate availability or use of critical imaging technology.
As the editor of Medscape Transplantation, I sincerely appreciate each and every reader who takes the time to write to express his or her opinion, regardless of whether the message is positive or negative. It is in this same spirit of freedom of expression that the Medscape Medical News team goes to great lengths on a regular basis to bring you the thoughts and opinions of experts and leaders from around the world on late-breaking medical and surgical news. Agree with all the "hullabaloo" or not, the death of the Bijani twins has sparked numerous debates -- ethical and otherwise -- among people from a variety of disciplines from around the globe, and these debates will undoubtedly continue for some time.
My thoughts? First, it is likely that had the separation procedure been successful (even though we probably would still have done the interview), I wouldn't have received a single letter or be writing this editorial. That being said, I have to disagree that ethical discourse is synonymous with making judgments about whether something is right or wrong. In fact, as far as I can tell, the approaches are very different, maybe even polar opposites. I also disagree with the suggestion that the information age has created an environment for ethical discourse. Since our beginning, we [people] have been asking and debating ethical questions, in one form or another; it is inherent in our nature and some would argue that it is one characteristic that sets humans apart from other species. What the information age has done is to not only enhance the means by which each and every one of us can express ourselves, but it has also expanded the audience to global proportions. Again, I thank those of you who wrote for sending your thoughts and comments and allowing us this opportunity to share them with the world.
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