Introduction
The case Re A (conjoined twins: surgical separation) [2000] 4 All ER 961 presents a complex legal scenario centered on the proposed separation of conjoined twins, specifically addressing the legal and ethical implications of performing an operation that would lead to the death of one twin to save the other. Conjoined twins, a rare phenomenon, occur when monozygotic twins do not fully separate during embryological development. The core legal question in this case revolves around whether a surgical procedure, which would directly cause the death of one twin, could be considered lawful. This required the Court of Appeal to examine the application of intention in criminal law, the act versus omission distinction in medical settings, and the defense of necessity. The court grappled with fundamental requirements of these principles, specifically with the interplay between the intention of the medical professionals, the cause of death, and the moral implications of their choices.
Conjoined Twins: A Medical and Ethical Overview
Conjoined twins, a developmental anomaly, arise from incomplete separation of a single fertilized egg. This results in twins who are physically connected, sharing anatomical structures to varying degrees. The level of connection may range from minor skin attachments to shared vital organs. Medical interventions for conjoined twins are complex, involving detailed diagnostic imaging, surgical planning, and post-operative care. The ethical aspects of treating conjoined twins are equally intricate. The case of Re A highlighted the particularly difficult considerations that come into play when surgical separation is proposed but would lead to the death of one twin. Medical professionals are bound by principles of non-maleficence and beneficence, requiring them to minimize harm while optimizing patient well-being. When dealing with conjoined twins, these principles often conflict, as saving one twin might necessitate sacrificing the other.
The Facts of Re A: A Factual Foundation
The factual matrix of Re A is crucial to understanding the legal principles that came into play. The conjoined twins, referred to as Mary and Jodie in the case, were joined at the lower abdomen. Mary had severe brain abnormalities, no lungs and was entirely dependent upon Jodie's circulatory system. Medical experts stated that if no surgical intervention occurred, both twins would die. Separation of the twins was considered the only way for Jodie to survive but would inevitably lead to the death of Mary. The doctors sought a declaration from the court stating that such a procedure would be lawful. The parents of Mary and Jodie opposed the separation on religious and moral grounds and this brought the matter to the Court of Appeal.
The Court's Analysis: Intention and the Act-Omission Distinction
Robert Walker LJ, in the Court of Appeal, analyzed the issue of intention, focusing on the purpose of the surgical procedure. He explicitly stated that the purpose of separating the twins was to save Jodie’s life, not to cause the death of Mary. Although Mary’s death was a foreseen and unavoidable consequence, it was not the direct intention of the surgeons. He drew attention to the distinction between a direct intention, where a desired outcome is aimed for, and a case where the consequence, although inevitable, was not the purpose. He rejected the lower court’s application of the act and omission principle derived from the Airedale NHS Trust v Bland [1993] AC 789 case, stating that the case was not about a withdrawal of medical treatment but a positive act of surgery. It was also his contention that to apply the act versus omission distinction would be ethically questionable in this context. Robert Walker LJ's legal reasoning centers on a direction based interpretation of intention.
The Defense of Necessity: Balancing Evils
Brooke LJ, while agreeing with the overall outcome, provided a different legal analysis focusing on the legal defense of necessity. He stated that the surgeons would inevitably be found to have intended to kill Mary because her death was a virtual certainty resulting from the surgery. Brooke LJ then addressed whether the defence of necessity could apply in the current circumstances. He cited three requirements for the defense of necessity to apply: first, that the act is needed to avoid an irreparable evil; second, that the steps taken do not exceed what was reasonably necessary to achieve the objective; and third, that the evil caused must not be disproportionate to the evil avoided. In the case of Re A, the court found that these requirements were met. The irreparable evil was the death of both twins. The operation was the only way to save Jodie’s life and therefore a reasonable step and that the loss of one life to save another could be considered proportionate. Brooke LJ then addressed the moral objections to using necessity as a defence to murder, specifically the problem of who should judge such a necessity and whether it would lead to a separation between morality and law. The court found that neither of these problems were an issue in Re A due to the fact that the death of Mary was already inevitable.
Further Considerations and the Appeal
The appeal in Re A was ultimately dismissed, and the operation to separate the twins was allowed to proceed. The court's decision hinged on the principle that while the rights of each child had to be respected, the welfare of Jodie was paramount. This reflected an approach where the court could weigh the interests of each child against one another. The trial court had based part of its reasoning on the notion that separating the twins was in the best interests of both, however, the appeal court corrected this and stated that the focus of the decision should be on a balancing of interests. It was also acknowledged that the views of the parents should be given significant respect.
Re A (Children) (Conjoined Twins: Medical Treatment) (No 1) [2001] Fam 149
Following the initial decision in Re A, a related case, Re A (Children) (Conjoined Twins: Medical Treatment) (No 1) [2001] Fam 149, further addressed the legal complexities. This case reaffirmed the application of the defense of necessity and clarified specific points from the previous court ruling. The Court of Appeal reaffirmed that it is the welfare of the children that must be the primary concern, while also stating that it was not in the best interests of Mary for the separation to occur. The court further re-emphasized the requirements for the defence of necessity to apply. The court had to balance the best interests of each child against the other, leading to the conclusion that the balance fell in favour of Jodie. The court upheld the initial judgement. These decisions have influenced the legal landscape of conjoined twins separation, particularly in the British legal system.
The Long-Term Impact: A Normal Life for Jodie
The commentary on the case makes clear that the surgical procedure was carried out and that Jodie survived. It further states that Jodie went on to live a normal life, which is of course the outcome which was the focus of the courts. The successful separation of the twins in Re A illustrates the practical implications of the legal decision. The real world impact was to allow Jodie to live, a life that she could not have otherwise had if no intervention occurred. The facts of the case are particularly useful for examining the way that the law approaches complex moral issues. It is very rare that the law has to deal with these issues as they relate to children as the primary reason that these issues come before the courts is a genuine desire to do what is best for the welfare of a child. The Re A case remains an important one in the area of medical law.
Conclusion
The legal analysis presented in Re A (conjoined twins: surgical separation) demonstrates a complex application of criminal law principles in a medical context. The court's examination of intention focused on the purpose of the action rather than its foreseen consequences, emphasizing the importance of direct intention in determining culpability. The application of the necessity defense, as outlined by Brooke LJ, showcases how the legal system grapples with tragic and unavoidable dilemmas, balancing the sanctity of life against competing interests. Cross-topic connections can be made to cases concerning medical negligence and bodily autonomy which would be useful to further understanding in this area of law. The legal reasoning within Re A has implications for the legal treatment of other complex medical interventions and reinforces the importance of considering the specific details of each case when considering legal and ethical requirements. By reference to the case of Re A, we see the framework that is used to consider the difficult situations involving conjoined twins when they require medical intervention.
