Health Effects of the Separation of Conjoined Twins: An issue involving physical, ethical, and psychological dimensions

Health Effects of the Health Effects of the Separation of Conjoined Separation of Conjoined

Twins:Twins:

An issue involving physical, An issue involving physical, ethical, and psychological ethical, and psychological

dimensionsdimensions

IntroductionIntroduction

Imagine having a sibling constantly at your Imagine having a sibling constantly at your side, waking up every morning to find your side, waking up every morning to find your sibling lying right next to you. sibling lying right next to you.

Imagine having to do everything together, Imagine having to do everything together, even sitting on the same chair or riding even sitting on the same chair or riding the same bicycle. the same bicycle.

Then imagine that sibling being taken Then imagine that sibling being taken away from you. away from you.

Introduction continues….Introduction continues…. About one to every 70,000 to 100,000 About one to every 70,000 to 100,000

people go through this on a regular basis. people go through this on a regular basis.

. They are known to the world as . They are known to the world as conjoined twins conjoined twins

Although many don’t survive very long, Although many don’t survive very long, about 40 sets are born in the United States about 40 sets are born in the United States each year, and less then a dozen adult each year, and less then a dozen adult pairs are roaming the streets in the world pairs are roaming the streets in the world today.today.

History on Conjoined TwinsHistory on Conjoined Twins

Conjoined twins have interested people Conjoined twins have interested people throughout history, and their images have throughout history, and their images have been found in cave drawings and carvings been found in cave drawings and carvings many centuries back. many centuries back.

In the earliest times they were known as In the earliest times they were known as gods, or feared as bad omens and exiled, gods, or feared as bad omens and exiled, abandoned or killed. abandoned or killed.

Continues…..Continues…..

In later days they were viewed as In later days they were viewed as curiosities, and of the few sets whom curiosities, and of the few sets whom survived into adulthood, became circus or survived into adulthood, became circus or sideshow attractions, or went on to the sideshow attractions, or went on to the stage. stage.

Only in the last 30 years, has separation Only in the last 30 years, has separation techniques become increasingly techniques become increasingly sophisticated and conjoined twins were no sophisticated and conjoined twins were no longer looked at as freaks but individuals.longer looked at as freaks but individuals.

What are Conjoined Twins?What are Conjoined Twins?

Conjoined or Siamese twins are Conjoined or Siamese twins are named for the first well-known pair named for the first well-known pair from Siam (known as Thailand). from Siam (known as Thailand).

They are formed when identical They are formed when identical twinning goes awry. twinning goes awry.

The cause of the syndrome is The cause of the syndrome is unknown, but it’s suspected to be unknown, but it’s suspected to be caused by environmental factors. caused by environmental factors.

How Twins Become ConjoinedHow Twins Become Conjoined

It results when an embryo starts to divide It results when an embryo starts to divide but fails to complete the process, and the but fails to complete the process, and the result is not quite two children.result is not quite two children.

Wherever the embryo stopped dividing, Wherever the embryo stopped dividing, the twins that would have been, become a the twins that would have been, become a single entity. single entity.

It is believed that the first 13th and 15th It is believed that the first 13th and 15th days after fertilization the malformation days after fertilization the malformation occurs. occurs.

Continued….Continued….

The inner mass of the cell is split into The inner mass of the cell is split into equal halves, each capable of equal halves, each capable of forming a normal individual. forming a normal individual.

Complete separation of the inner cell Complete separation of the inner cell mass within the chronic vesicle does mass within the chronic vesicle does not occur and non-separated parts of not occur and non-separated parts of the otherwise normal twins remain the otherwise normal twins remain fused throughout development. fused throughout development.

Continued…..Continued…..

. In a normal embryo and fetus . In a normal embryo and fetus development every cell knows where it is development every cell knows where it is in the body, because the neighbors in the body, because the neighbors produce chemical messages. produce chemical messages.

If they are confused then conjoined twins If they are confused then conjoined twins don’t work properly and can result in a don’t work properly and can result in a single organism with two heads, two single organism with two heads, two hearts, four legs and arms. hearts, four legs and arms.

Risks involved in separating twinsRisks involved in separating twins

It can be a life and death decision, It can be a life and death decision, because it can involve sacrificing one because it can involve sacrificing one twin’s life in hope to save the other. twin’s life in hope to save the other.

Doctors have to convince themselves Doctors have to convince themselves that the present quality of life is so that the present quality of life is so worthless that the risky dangerous worthless that the risky dangerous surgery is justified and should be surgery is justified and should be performed. performed.

Continued….Continued….

Survival depends on the type and Survival depends on the type and extent of joining and on the presence extent of joining and on the presence or absence of associated anomalies or absence of associated anomalies

There is only a fifty-fifty chance of There is only a fifty-fifty chance of survival, so parents risk death of survival, so parents risk death of their child or children to give them a their child or children to give them a chance to live separate lives because chance to live separate lives because they believe it was the will of God.they believe it was the will of God.

Greatest RisksGreatest Risks

The greatest risks to conjoined twins The greatest risks to conjoined twins during and after separation are anesthesia during and after separation are anesthesia and surgical complications. and surgical complications.

Complications can include formation of Complications can include formation of blood clots in the newly constructed blood blood clots in the newly constructed blood vessels, intracranial bleeding, heart vessels, intracranial bleeding, heart complications and infections. complications and infections.

The critical period for conjoined twins is The critical period for conjoined twins is three to four days after surgery.three to four days after surgery.

Parents Objection to SeparationParents Objection to Separation

Some parents don’t want to risk losing Some parents don’t want to risk losing their children so they think it is not such a their children so they think it is not such a terrible option to leave their twins joined terrible option to leave their twins joined because they believe their children are because they believe their children are more able-bodied together than they more able-bodied together than they would be apart. would be apart.

Objection to separating twins gives twins a Objection to separating twins gives twins a chance of survival. chance of survival.

ThesisThesis

The risks that follow separating or The risks that follow separating or not separating conjoined twins in a not separating conjoined twins in a physical, psychological, and ethical physical, psychological, and ethical aspect.aspect.

The Physical AspectThe Physical Aspect

60% of conjoined twins are either 60% of conjoined twins are either stillborn or die within their first few stillborn or die within their first few days of life. days of life.

The opportunity for separation The opportunity for separation depends on the type of conjoined depends on the type of conjoined twins.twins.

Types of Conjoined TwinsTypes of Conjoined Twins

Thoracopagus: Joined at Thoracopagus: Joined at the chest. the chest.

The most common type of The most common type of conjoined twins, conjoined twins, representing 35% of all representing 35% of all conjoined twins. conjoined twins.

The heart is shared, and The heart is shared, and separation is rarely separation is rarely attempted for this reason.attempted for this reason.

Types of Conjoined TwinsTypes of Conjoined Twins Omphalopagus: Joined at Omphalopagus: Joined at

the chest or abdomen. the chest or abdomen. Similar to thoracopagus Similar to thoracopagus

twins, but in this case the twins, but in this case the twins do not share a heart. twins do not share a heart.

The second most common The second most common type of conjoined twins, type of conjoined twins, representing 30% of the representing 30% of the total. total.

Highest rate of separation Highest rate of separation survival. Usually, only the survival. Usually, only the liver is involved. Because liver is involved. Because the liver can regenerate the liver can regenerate itself, this scenario is itself, this scenario is preferred. preferred.


Pyopagus: joined at the Pyopagus: joined at the posterior pelvis.posterior pelvis.

Separation possible. Separation possible. The survival rate is The survival rate is high.high.


Parapagus: joined from Parapagus: joined from the thoracic cavity down.the thoracic cavity down.

Separation possible, Separation possible, depending on the depending on the number and sharing of number and sharing of internal organsinternal organs

Life with artificial limbs Life with artificial limbs is the result.is the result.


Ischopagus: joined at Ischopagus: joined at the pelvis. the pelvis.

Separation is Separation is physically possible, physically possible, however, excretion however, excretion and sexual and sexual impairment might impairment might result.result.


Craniopagus: Craniopagus: joined at the joined at the cranium.cranium.

Separation is Separation is possible, possible, depending on how depending on how much of the brain much of the brain is shared.is shared.

High risk of brain High risk of brain damage.damage.

The Ethical AspectThe Ethical Aspect

Even if there is a chance for physical Even if there is a chance for physical separation, the family must make an separation, the family must make an ethical decision. Should a separation ethical decision. Should a separation be attempted if one or both twins be attempted if one or both twins might not survive?might not survive?

Factors Complicating the Ethical Factors Complicating the Ethical Dilemma:Dilemma:

The survival rate: Often, one twin will The survival rate: Often, one twin will die at the expense of the other. die at the expense of the other. Should it be attempted if one twin Should it be attempted if one twin has a better chance of surviving than has a better chance of surviving than the other? the other?

The number and presence of organs: The number and presence of organs: if organs must be divided, the if organs must be divided, the doctors and family must decide how.doctors and family must decide how.

Factors Complicating the Ethical Factors Complicating the Ethical Dilemma:Dilemma:

Legal issues: In a number of cases, Legal issues: In a number of cases, courts have ruled that there is a courts have ruled that there is a moral obligation to save one twin moral obligation to save one twin over another. Following this logic, is over another. Following this logic, is it acceptable to kill one human being it acceptable to kill one human being in light of possibly saving another? in light of possibly saving another? Many legal questions ensue.Many legal questions ensue.

As such, in many cases, politics is As such, in many cases, politics is involved.involved.

The Psychological AspectThe Psychological Aspect

Many of the ethical debates are Many of the ethical debates are fueled by the basic assumption that fueled by the basic assumption that the twins want to be separated.the twins want to be separated.

Some of the most famous sets of Some of the most famous sets of conjoined twins, such as Chang and conjoined twins, such as Chang and Eng Bunker, refused to be separated Eng Bunker, refused to be separated when procedures became available.when procedures became available.


Twins go through the crucial Twins go through the crucial development of the first few years of development of the first few years of life with the presence of their life with the presence of their condition. As such, they develop a condition. As such, they develop a paradigm about the world that paradigm about the world that involves being conjoined. Separation involves being conjoined. Separation causes psychological turmoil by causes psychological turmoil by upsetting their way of looking at the upsetting their way of looking at the world. world.


Guilt Complex: If only one twin Guilt Complex: If only one twin survives, that twin is at risk for survives, that twin is at risk for developing a guilt complex about developing a guilt complex about being the one who lived. being the one who lived.

Family Mental Health: This ordeal is Family Mental Health: This ordeal is also psychologically taxing on those also psychologically taxing on those making the decisions. The family is making the decisions. The family is very vulnerable for guilt complexes very vulnerable for guilt complexes and depression.and depression.

SummarySummary

In the end, a family must make a In the end, a family must make a decision based on all three of these decision based on all three of these factors: the physical, ethical, and factors: the physical, ethical, and psychological aspects. psychological aspects.

The health effects are far reaching, The health effects are far reaching, going beyond the physical aspect going beyond the physical aspect and affecting the mental aspect of and affecting the mental aspect of both the twin and the family.both the twin and the family.

Possible Solutions:Possible Solutions: Should conjoined twins be surgically separated, causing the Should conjoined twins be surgically separated, causing the immediate death of one but enabling the other to survive, when inaction would lead to the immediate death of one but enabling the other to survive, when inaction would lead to the death of both, but when such separation was contrary to the strong religious beliefs of the death of both, but when such separation was contrary to the strong religious beliefs of the

parents?parents?

Separating conjoined twins is not only technically challenging; it can involves life and Separating conjoined twins is not only technically challenging; it can involves life and death decisions about whether one twin should be sacrificed in the hope of saving death decisions about whether one twin should be sacrificed in the hope of saving

the other.the other. Some pairs, depending on the degree of conjunction—in particular, the degree to Some pairs, depending on the degree of conjunction—in particular, the degree to

which they share internal organs—can be separated by surgery.which they share internal organs—can be separated by surgery. One ethical issue with separation is when the operation will result in the death of one One ethical issue with separation is when the operation will result in the death of one

twin (for example, in the case where they are sharing a heart.)twin (for example, in the case where they are sharing a heart.) The good effect must not be produced by means of the evil effect. I submit that the evil effect (the The good effect must not be produced by means of the evil effect. I submit that the evil effect (the

possible death of the one twin without essential organs) is not directly intended, at least as a means possible death of the one twin without essential organs) is not directly intended, at least as a means of producing the good effect (life for the other twin). of producing the good effect (life for the other twin).

ConclusionConclusion

The decision of separation when The decision of separation when dealing with Conjoined twins is an dealing with Conjoined twins is an extremely complicated one.extremely complicated one.

It is a decision that we feel should be It is a decision that we feel should be made solely by the parents. made solely by the parents.


This decision should not be made, This decision should not be made, however, without researching all the however, without researching all the facts related to Conjoined Twin facts related to Conjoined Twin separation.separation.

There is at best a Fifty-Fifty shot of There is at best a Fifty-Fifty shot of survival when it comes to separation.survival when it comes to separation.


Separation in most cases is based mainly Separation in most cases is based mainly on the fusion of the heart.on the fusion of the heart.

Type of FusionType of Fusion SeparationSeparationAtrial FusionAtrial Fusion PossiblePossible

Atrioventricular Atrioventricular FusionFusion

Not PossibleNot Possible

Single Heart Single Heart Not PossibleNot Possible


After researching this topic surgery, After researching this topic surgery, if possibleif possible, is the best solution., is the best solution.

Separation depends mainly on the Separation depends mainly on the number of shared vital organs.number of shared vital organs.


The most difficult thing when it The most difficult thing when it comes to separation of conjoined comes to separation of conjoined twins is the fact that there is a good twins is the fact that there is a good chance one or both of the children chance one or both of the children will die.will die.

SummarySummary

Separation is extremely riskySeparation is extremely risky

If at all possible surgery seems like If at all possible surgery seems like the best option for Conjoined Twinsthe best option for Conjoined Twins

SummarySummary

Parents should make the final and Parents should make the final and informed decision on separation. informed decision on separation.

Only after examining the physical, Only after examining the physical, ethical, and psychological aspects of ethical, and psychological aspects of a possible separation.a possible separation.

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Health Effects of the Separation of Conjoined Twins: An issue involving physical, ethical, and psychological dimensions