Separating conjoined twins is 'glatt kosher surgery'

April 21, 2005

By LEILA SPEISMAN
Staff Reporter, the CJN

Rabbi Chaim Rapoport, advisor to the chief rabbi of the British Commonwealth on medical ethics, said the recent separation of conjoined twins in Toronto was "glatt kosher sugery."

The so-far successful separating of conjoined twins Tinotenda and Tenashe Mufuka was the topic of a recent Torah in Motion program.

Children in a conjoined sate, he said, are in a precarious state. Their very existence when joined is a danger to both of them. If there is good reason to believe that the operation would be successful, then the risk is justified.

The event, held at Shaarei Shomayim synagogue, highlighted the efforts of fourth-year University of Toronto obstetrics and gynecology resident Dr. Rachel Spitzer, who delivered the twins in a small hospital in Zimbabwe and then arranged for them to be brought to Toronto, and Dr. Jacob Langer, professor of surgery, University of Toronto, and chief of pediatric general surgery at the Hospital for Sick Children, who separated the twins last March.

Nevertheless, Langer, Spitzer and Rabbi Rapoport all noted that the separation was not without questions of medical and Jewish ethics. These included the consideration of whether it would have been permitted to sacrifice one of the twins to save the other if that had been necessary (it wasn't necessary, as it turned out) or whether it was ethical at all to spend all that effort, time and money to save these children when the need in Canada is so great.

Spitzer was doing an elective in a 130-bed Salvation Army Howard Hospital in Glendale, Zimbabwe, when she met Elizabeth Mufuka, a mother in her 32nd week of pregnancy, whose midwives believed that she was carrying twins.

When Mufuka came to Howard Hospital, Dr. Paul Thistle, a former Torontonian working in maternal health there, diagnosed conjoined twins with a shared liver but separate hearts.

Spitzer said that she was never sure just how much Mufuka understood of what was going on, but she did realize that something was wrong.

"Consider," Spitzer said, dealing with such a complicated matter without a CT or MRI machine, no Internet closer than Harare, quite a distance away, and generally primitive conditions.

Nevertheless, she said, on July 20, 2004, she and Thistle delivered the twins by uncomplicated Caesarean section. Outside of cleft lips and palates, they were born "healthy and screaming."

Slides showed Tinotenda and Tinashe lying in a crib, joined from chest bone to the lower abdomen. Tinotenda was considerably smaller than his brother, indicating potential problems.

Spitzer sprang into action, contacting the Hospital for Sick Children and its Herbie Fund; Ve'ahavta: the Canadian Jewish Humanitarian and Relief Committee; the Salvation Army, who paid for the flights and an apartment in Toronto; and the Canadian Automobile Association, who provided adult health insurance.

Help also came from Shaarei Shomayim, B'nai Brith Canada lodges Forestdale Heights and Thornhill, IBI Group, the Bessin Family Foundation and many individuals.

After being cleared by Howard Hospital and by a pediatric cardiologist, the babies, their mother and a nurse made the arduous flight to Toronto in the fall. They had to be prepared for what they would find here, not just the urban environment but the winter weather.

Langer itemized the difficult preparation for separating the babies. They were both skinny and malnourished and had to be properly fed and cared for. The smaller size of one of them, he said, might have indicated that there wasn't enough bowel to enable them both to survive, or an inadequate blood flow, which would have the same effect.

As well, they shared a single umbilical cord, which sent the cord blood through the shared liver, Langer said.

The investigation was exhaustive, including X-rays, CT and MRI scans, echocardiograms, nuclear medicine tests, medical evaluation and nutritional assessments.

A team had to be assembled and their duties organized: a surgical team, anesthetists, critical care staff, occupational and physical therapists, nurses and ethics staff.

Some of the team members were needed because the twins couldn't move or roll over. As well, because of their cleft lips and palates, they had to be taught to drink.

The tissue joining the babies had to be expanded, so that it would be possible to cover the incision where the separation would occur.

The twins were separated in early March and so far appear to be doing well. At a recent press conference, the Hospital for Sick Children said that they were discharged from the hospital, and would come back for tests and treatments.

Reproduced with permission from The Canadian Jews News.

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