Judging a moral minefield

The judges hearing the appeal against separating Siamese twins were always going to face a legal and moral dilemma - whether to cause the death of one to save the other's life, as this report on the issues written before the verdict reveals.

The decision whether to separate Mary and Jodie, Siamese twins who share a functioning heart, has been likened to the judgement of Solomon.

In the Old Testament, Solomon ordered a child claimed by two women to be severed in two. He did it so he could find out who was the real mother, and give the baby to her.

We don't normally allow people to kill one person to save another

Jonathan Glover, bioethicist

The three senior judges hearing the parents' appeal against separating their one-month-old twins say they have lain awake at night grappling with the dilemma.

The parents, who are Roman Catholics from a remote Mediterranean community, believe the operation is "not God's will".

Should the surgeons separate the twins, the weaker girl will die immediately. Without the operation, both girls may have just months to live.

High hopes

Jonathan Glover, director of the Centre of Medical Law and Ethics at King's College London, says the case is a moral minefield because two lives are at stake.

"Obviously there's a case for doing it - chances are that one life will be saved. But we don't normally allow people to kill one person to save another."

It was not God's will that [Mary] should live because it was not born with the capacity to live

Lord Justice Ward

He says another ethical hurdle is whether the parents have the right to decide or whether the courts should take over.

"It is further complicated because they come from a very different culture where religious objections carry more weight. Here, theirs is regarded as a minority view, to be treated with respect at best."

The parents, who cannot be named, came to St Mary's Hospital in Manchester for the birth because their country did not have suitable medical facilities.

When they refused permission to operate on religious grounds, the hospital went to a higher power - the judiciary.

Mr Michael Maresh, the consultant obstetrician caring for the mother, said at the time that the case required the judgement of Solomon: "That is why it went to the High Court."

In the appeal court last week, Lord Justice Ward attempted to summarise the case from a religious viewpoint.

"It was not God's will that [Mary] should live because it was not born with the capacity to live," he said.

"Nobody in their right mind would hook this child to a life support system given the utter deformity of her heart and lungs."

Professor Glover says the prime ethical consideration should be the impact on those affected: "We should be very reluctant to override the parents' strongly expressed views."

Awkward distinction

Unlike doctors, who have to make life-or-death decisions nearly every day, judges in such cases have time to ruminate on their decision.

Tony Bland: Died after a four-year legal battle

Refuge of a sort might be found in exact philosophical distinctions between "positive" acts and "mere" omissions, even though their consequences might be the same.

In 1989, 18-year-old Tony Bland fell into a coma after being injured in the Hillsborough stadium disaster that killed 95 fans.

His parents eventually asked doctors to withdraw food and let him die. The law lords finally granted permission after four years, and Tony died nine days later.

Although nobody killed Tony Bland, he died from the decision to withdraw food and support.

The lawyers acting for St Mary's Hospital in the Siamese twins case have a similar fine line to tread.

There is, it is argued, an important moral distinction between operating to save one girl's life, which has the consequence of another's death, and taking a decision to kill.

"While it's not lawful to take a life, it is lawful to withhold food and medical treatment," Mr Glover said.

It might be argued, he added, that withdrawing the blood supply to Mary by separating her from her stronger sister might have parallels with the principle of withholding food. But it is by no means clearcut.

"Although withdrawing the blood supply could be analogous, it is hard to argue that is not killing someone."