Evaluation of the Ethical Controversies in Separation Surgery of Conjoined Twins: A Review of the Literature.

This study aimed to evaluate the ethical controversies surrounding separation surgery of conjoined twins by examining the discussions in the relevant published literature. A critical review was conducted to study the ethical issues involved in the separation surgery of conjoined twins. A literature search on PubMed and Embase was performed on December 4, 2023, using the terms "ethics", "conjoined twins", and "separation". Relevant papers published in the last 10 years (2013-2023) were included. A total of seven papers were included: two were case reports and five were expert statements or opinions. The four pillars of ethics (beneficence, non-maleficence, autonomy, and justice) were a common approach adopted by most authors to analyse the ethical issues in the separation surgery of conjoined twins. Due to the need to consider the perspectives of two patients simultaneously, opposing arguments were common depending on the approach taken, especially when analysing the principles of beneficence and non-maleficence. All papers examined the possible difficulties in autonomy, with some exploring consent, specifically around decision-making. It was largely agreed that the parents should be the decision-makers due to the patients' lack of capacity, except in non-urgent situations, where patients should be given the opportunity to make their own decisions. Achieving equality in the distribution of shared organs and survival opportunities proved challenging. Other ethical principles were also discussed, such as the act-omission and double effect doctrines. Limitations of this paper included the limited geographical coverage of the studies, as well as the potential to miss relevant studies, including those conducted beyond the search period, those published in other languages, and those unpublished. From the overall results, there is no apparent definite answer as to whether separation surgery is justified. Due to every patient and situation being unique, the best approach should be decided on a case-by-case basis, guided by the four pillars of ethics, and with the involvement of families and ethical committees. Both the ethical considerations and other factors should be taken into account.