A question of medical ethics

By any measure the pioneering surgery that was performed in Singapore's Raffles Hospital on Tuesday was an historic event, the magnitude of its medical significance undiminished by the fact that the patients died. Even so, for millions of people in their Iranian homeland -- and no doubt also for the doctors and staff at Singapore's Raffles Hospital -- the deaths of Laleh and Ladan Bijani were quite understandably a tragedy of the highest magnitude.

The Bijani twins died of massive blood loss on a hospital operating table at the end of a 50-hour-long operation that was conducted by a team of 28 specialists and 100 assistants. It may be noted that from the start, the chances of success looked slim. Never before had an operation to separate two enmeshed brains been performed on a pair of Siamese twins who were already adults with 29 years behind them.

Dr. Loo Choon Yong, the chairman of Raffles Hospital, openly admitted afterwards that he and his team were taking a great risk performing the operation. "We knew that one of the scenarios was that we may lose both of them," he told reporters at the hospital. "We were hoping to try and do better than the worst odds. But alas, we didn't make it."

In fact, Laleh and Ladan knew that too but were nevertheless willing to take the risk. Both of the twins had degrees in law. But while Ladan had wanted to lead a separate life practicing as a lawyer in her home town Shiraz, Laleh aspired to be a journalist in Teheran. Obviously, in order to fulfill those disparate ambitions, each of them had to live a separate individual life.

Dr. Keith Goh, the neurosurgeon who led the operation, apparently soon encountered some major complications that caused the procedure to take much longer than initially expected. In the first place the doctors found that the two brains were more closely linked than expected. Then, the women's blood pressure became unstable, swinging from high to low as the operation proceeded.

Ladan began losing blood at 2 p.m. Singapore time, well into the operation, and died half an hour later. Surgery was continued on Laleh, but about 90 minutes later she too gave up the struggle.

In Iran, where millions of people grieved on learning of Ladan and Laleh's deaths, President Mohammed Khatami offered to pay for the full cost of the operation, which is estimated to run to as much as US$300,000.

Needless to say, no sane person will doubt the good intentions on the part of the doctors and staff of Singapore's Raffles Hospital. Nobody doubts, either, that if anybody had had a chance of bringing the operation to a successful end, Singapore's hospitals and doctors with their excellent reputations would be among them.

Still, a few questions do arise. For one, was it morally responsible and medically accountable for doctors to perform an operation of which it was known beforehand that the chances of success were slim, if they existed at all? After all, twins joined at the head are comparatively rare, being found only once in every two million live births. And German doctors in 1996 had already refused to operate on the Bijani twins on the ground that it could be fatal to try to separate them at their age. But the Bijani twin's insistence on leading separate lives whatever the risks further obviously confounds the issue.

It seems that the issue of risk-taking in the medical profession will forever remain a subject of debate among learned observers and experts alike, but especially so among practitioners of the medical profession. Given the advances that continue to be made in medical science and procedures, the problem is where to draw the line between what can be considered safe and what is unsafe. Until a clear-cut, legally binding answer on the question can be given, it seems that the burden of responsibility will continue to have to be borne by the practitioners.