In a landmark case, the British Court of Appeal has decided unanimously to permit the separation of conjoined twins, an operation that will kill one in the hope of saving the other. The court overruled the wishes of the parents who were in favor of letting "God decide."

The parents can appeal to the House of Lords and the European Court of Human Rights. The courts will have little time to act, however, if they are to save the stronger twin, known as Jodie. Unless there is an operation, the twins, who were born in August, have just three to six months to live. Doctors say, though, that even an operation will not guarantee Jodie's survival.

The senior judge, Lord Justice Alan Ward, summed up the dilemma after making the historic ruling on Friday: "Do you kill one to save two, or do you let two die? Nothing could be more stark than that." But the judge denied that an operation would violate the sanctity of human life, describing it instead as "doctors coming to Jodie's defense."

The twins' real names have been withheld to protect their identities, but the court has said it can now be known that the parents, who are Catholics, come from the Maltese Island of Gozo. On their island, where most attend Mass and abortion is illegal, Father Emmanuel Curmi echoed the parents' views: "Life is in the hands of God."

Jodie has been described as the "life support machine" of her twin sister, dubbed Mary. Summing up, Ward said: "Mary is alive only because she sucks the lifeblood of Jodie. Her parasitic living will soon be the cause of her sister's death." Jodie has the twins' only heart and lungs and is supplying oxygenated blood to Mary, who is putting on weight at Jodie's expense. The court had to decide whether to leave it to nature, as the parents wished, or to kill one to save the other.

Ward said Mary had been "living on borrowed time." The judge told the court: "It's like flipping a double-headed coin, saying, 'Yes, you can murder Mary,' and saying, 'No, you can murder Jodie.' It is the most awful dilemma to contemplate."

The ruling has divided medical opinion. John Harris, professor of medical ethics at Manchester University, criticized the court for forcing the parents to "violate fundamental beliefs." Richard Nicholson of the Bulletin of Medical Ethics, published in London, said it was "simplistic" to say it was right to kill one twin to save the other. The editor of the British-published Journal of Medical Ethics, Professor Raanon Gillon, told journalists it would have been "far better to let the parents decide," though he personally believed the operation should go ahead.

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Los Angeles surgeon Dr. Harry Applebaum, who has separated Siamese twins, backed the court's decision. "I would hate to see both twins die when one could be saved," Applebaum said. "Most doctors would try to salvage somebody who can have a fairly normal life." Dr. Harvey Marcovitch of the Royal College of Pediatrics and Child Health added that in a complex case like this it was "right that law should make the final decision."

The parents have maintained throughout, however, that such a decision should rest only with the giver of life, God. They told the court: "We cannot begin to accept or contemplate that one of our children should die to allow the other to survive. That is not God's will."

The parents were supported by an anti-abortion alliance and the head of the Roman Catholic Church in England and Wales, Archbishop Cormac Murphy-O'Connor. The archbishop insisted that separating the twins was "morally impermissible" and that Mary was "innocent" and had "done nothing which could justify killing her." She had the same "basic worth and dignity" as Jodie, he maintained. "There is a fundamental moral principle at stake: no one may commit a wrong action that good may come of it." Murphy-O'Conner argued that it was not acceptable for the court to override the rights of the parents, who were acting in the best interests of their children.

Nevertheless, Ward insisted the law had an obligation to intervene: "Whose job is it to decide questions of life and death? The court's. It's not a job we ask for, but a job we have to do."

The key legal arguments revolved around whether a decision to allow the operation would amount to legally sanctioned murder. Simon Taylor, representing the parents, said: "Mary's death is a means to an end: Jodie's independent life. And the only means to achieve that end being to separate Mary from her blood supply ... you do have to kill to separate." However, Tim Owen, on behalf of Jodie, provided the argument that persuaded the court: "My submission is that this is not an intentional deprivation of life. The operation is performed with the intention of saving Jodie's life, and the consequence of Mary's death is a side-effect ... the outcome of doing nothing is the death of everyone."

As a direct result of this ruling others could die, Murphy-O'Connor argued. "A precedent might be set in English law that might allow an innocent person to be killed or lethally assaulted to save the life of another," he said after the hearing. Ward denied that assertion, however, describing the case as "unique" and unlikely to be repeated.

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The war of words over life and death is set to continue. Unless the condition of the twins deteriorates, no operation will be carried out until the family decides whether to appeal. The House of Lords or the European Court of Human Rights could yet rule in their favor. Next month the European Convention of Human Rights becomes part of English law. It was claimed in court that literally cutting off Mary from her source of life, Jodie, would deprive her of a fundamental human right under the Convention, the right to live.

Outside the court, family lawyer John Kitchingman told journalists the parents were deeply disappointed with the ruling and considering their next move. "They always thought it would be better not to have the operation because of their religious convictions, and I don't think they are changing that," Kitchingman said. "I will be advising them, and they will be making a decision. They will only do what they think is in the best interests of the children."

The Official Solicitor, Laurence Oates, said he also was considering a further appeal on behalf of Mary, for whom there had been "no happy solution." The Official Solicitor legally represents children in civil cases.

Before the historic ruling Ward said he felt "desperately" for the parents. "One heart's bleeds for the family," he said, but the case was dealing with difficult questions of law "which have not been fully explored for centuries." He added: "It has been excruciatingly difficult."

Asked how he believed the public would view the court's decision, he said: "Fifty percent of the population will agree, and 50 percent will think we have gone completely potty."

Related Elsewhere

Visit the American Bioethics Advisory Commission homepage to read more about personhood.

Or visit the ABAC's English counterpart, the British Society for Ethical Theory.

Read the story of two other conjoined twins, and learn about the decision their parents made in this New York Times piece, "2 Babies, 1 Heart and 1 Chance at Survival."

Recent media coverage of the twins' case includes:

The Ultimate SacrificeThe Washington Post (Sept. 24, 2000)

Court OK's Separation of Conjoined TwinsThe Dallas Morning News (Sept. 24, 2000)

Parents of conjoined twins say they'll leave surviving girl behindVirtual New York (Sept. 24, 2000)

Why Change the Rules for Twins Like Them?The Washington Post (Sept. 23, 2000)

British Judges OK Surgery to Separate TwinsLos Angeles Times (Sept. 23, 2000)

Court rules Siamese twin 'sucks lifeblood' of siblingThe National Post (Sept. 23, 2000)