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The conjoined twins of Malta: direct or indirect killing?

In November 2000, at St. Mary’s Hospital in Manchester, England, Jodie and Mary, conjoined since birth, underwent surgery to separate them. As a consequence of this surgery, Jodie lived and, as of this writing, appears to be thriving. Her twin sister, Mary, did not survive the surgery. Their story begins some eight months earlier on the island of Malta when their mother, who was approximately four months pregnant, had an ultrasound that revealed that she was carrying conjoined twins. A doctor at the hospital, who had trained at St. Mary’s Hospital and knew of its excellence, advised the parents to seek treatment there. Once in England, and at a latter stage of the pregnancy, it became clear that the difficulties with the twins were greater than had originally been thought. In light of these difficulties the doctors advised the parents to terminate the pregnancy. The couple, deeply religious Roman Catholics, refused this option and decided to continue with the pregnancy. The twins were born on August 8, 2000. From the time of their birth to the day of the surgery some four months later, the case of Jodie and Mary gripped the public interest and their case received intense international coverage in the media. Every aspect of the case, medical, legal, and ethical, was analyzed and commented on. In this present article, I will deal principally with the ethical issues surrounding the surgery and its aftermath. I will conclude, tentatively, that the surgery was morally permissible under the principle of double effect. In order to arrive at this tentative conclusion, I will examine first the medical condition of each of the twins prior to the surgery; second, I will look at the nature of the operation to separate the twins.1 Finally, based on the facts of the surgery, I will