## Facts

- Conjoined twin girls, known as “Jodie” and “Mary,” were born joined at the lower abdomen.
- Each twin had her own brain and her own heart, lungs, and other major organs, as well as separate arms and legs.
- Mary’s heart and lungs were too weak to sustain her body without support from Jodie through a shared artery and circulation.
- Medical evidence was that, if Mary had been born alone in that condition, she would have died shortly after birth.
- Doctors believed the twins were two separate individuals, with separate brains and organs and distinct personalities and habits.
- If the twins were not separated, both were expected to die within about three to six months because Jodie’s heart would fail under the strain of supporting both.
- Separation surgery would require severing the shared artery; Mary would die within minutes of the operation, while Jodie would have a strong chance of living a worthwhile life.
- The parents, devout Roman Catholics, refused consent because they regarded both children as equal persons and believed that intentionally causing Mary’s death would be murder.
- The treating clinicians and hospital sought a court ruling authorizing the operation and clarifying that performing it would be lawful.

## Issues

1. Whether the court could authorize surgical separation of the twins despite the parents’ refusal, where the operation would almost certainly save Jodie but would inevitably cause Mary’s death.
2. Whether the proposed operation would amount to murder by the surgeons, or whether a recognized legal justification or defence would make the operation lawful.
3. Whether, for these purposes, the law should treat Jodie and Mary as separate persons with separate rights and welfare interests.

## Decision

- The Court of Appeal dismissed the parents’ appeal and upheld the declarations authorizing separation.
- The court held that it could permit the operation as a medical-treatment decision for children, based on welfare.
- The court concluded that surgeons performing the operation would not be criminally liable for murder, even though Mary’s death was foreseen and unavoidable.
- Ward LJ reasoned that the operation could be justified as defence of Jodie: Mary’s dependence was fatally harming Jodie, and separating them was no more than reasonably necessary to save Jodie’s life.
- Brooke LJ accepted a narrow defence of necessity on these facts, applying a three-part approach: the act must avert an unavoidable and irreparable evil, be no more than reasonably necessary, and not be disproportionate to the evil avoided.
- Robert Walker LJ agreed in the result and emphasized that the surgeons’ aim was to save Jodie; Mary’s death, though certain, was an effect of the life-saving treatment rather than the doctors’ objective.

## Legal Principles

- A court may authorize medical treatment for a child when consent is withheld, and parental views—while important—do not control the outcome where welfare requires a different decision.
- When two children’s welfare interests directly conflict and no option avoids fatal harm, the court may compare the likely outcomes for each child and authorize the course that saves life where possible.
- Defence of another may justify an act that causes death if the intervention is reasonably necessary and proportionate to protect the person threatened with death or serious harm.
- Necessity may operate as a justification in exceptional homicide cases where (1) the act is needed to avoid an unavoidable and irreparable evil, (2) the act goes no further than reasonably necessary, and (3) the harm caused is not out of proportion to the harm avoided.
- In assessing murder, the law distinguishes between an actor’s purpose and a consequence that is foreseen (even certain); in medical treatment, a life-saving purpose can matter to the analysis of intent and criminal liability.
- Where one twin has no realistic prospect of independent survival and is sustained only by draining the other’s life, the law may permit separation so that the viable twin is not required to die to keep the other alive.

## Conclusion

In re A held that the Court of Appeal could authorize separation surgery for conjoined twins over the parents’ objection because it offered Jodie a real chance of life and avoided the near-certain death of both children; the court also held the operation lawful under tightly limited criminal-law reasoning (defence of another, necessity, and analysis of intent), notwithstanding that Mary’s death would be inevitable.


In re A, [2000] 4 All ER 961 (2000)