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Chapter I CONJOINED TWINS – AN INTRODUCTION Twinning has fascinated human beings over centuries

Chapter I
CONJOINED TWINS – AN INTRODUCTION
Twinning has fascinated human beings over centuries. Conjoined twins has been observed in a wide range of mammalians and non-mammalians, it seems that the phenomenon is more commonly encountered in humans. They have interested people throughout history and their images have been found in cave drawings and carvings many centuries back. In the earlier times they were known as gods, or feared as bad omens and exiled, abandoned or killed. In later days they were viewed as curiosities and of the few sets who survived into adulthood became circus and sideshow attraction. Only in the last 30 years separation techniques became increasingly sophisticated and conjoined twins are no longer looked at as freaks but individuals.

The odd births of conjoined twins have been both nightmare and fantasies and their very presence is a challenge for a unique selfhood. 60% of the conjoined twins die in the utero others being terminated and are stillborn. With the developments in obstetrics, clinical genetics and molecular genetics, it might be possible to understand why twinning takes place in human being.

Improved survival rates for conjoined twins are due to advances in perinatal and postnatal diagnosis techniques, meticulous interpretation of the special investigations and correct anesthetic and surgical management carried out by the experienced multidisciplinary team. With the help of extensive clinical experience, it is learned that the anatomical configurations encountered are very complex, with unexpected anatomical variation frequencies identified during surgery. Conjoined twins is said to have dramatic metaphysical implications. The number of people would have to be determined not by the number of organism, but by the number of brains.

Conjoined twins also called as monozygotic twins undergo different processes during early human development that can give rise to monozygotic twinning. New technologies and large study groups have led to improved documentations of frequency and complications in twin pregnancies and long term outcomes. Artificial reproductive technologies have led to a pronounced raised in numbers of dizygotic and monozygotic twins. Although spontaneous dizygotic twinning is clearly associated with increased concentration of follicle – Stimulating hormone and ovulation of more than one egg, cause of monozygotic twinning remains elusive. (THE LANCET. Vol 362 August 30, 2003)
The birth of conjoined twins is often unexpected resulting in obstructed labor with difficult transvaginal delivery or emergency C-section surgery. These complications can be avoided by a planned C-section surgery at 36-38 weeks, when the lungs reaches maturity and the high rate of still births can be prevented. Children weighing less including Thoracopagus and Ischiopagus can be delivered vaginally. Despite those who are born normally sustains no damage to the connectors. Immediate postnatal management of revitalization and stabilization of the twins is to be considered followed by a thorough physical examination with special investigation to define the relevant anatomy. If emergency surgery is anticipated, the conjoined twins should undergo echocardiography and plain roentgenography which provides limited but essential information
The site of conjunction will determine the type and order of special investigations. The information obtained will determine the surgical approach, the timing of separation, the allocation of organs and structure and the eventual prognosis regarding survival and functional outcome. Important structures to evaluate are cardiac, hepatobiliary, intestinal, urogenital and spinal systems. The use of diagrams, 3D organ models and surgical rehearsal of the procedure will ensure the best possible outcome. Despite all these investigations and careful analysis of findings, preoperative interpretation may still be difficult with incorrect conclusions drawn.

The problem with the view of twins as entangled singletons is that it assumes something about the nature of human individuality (that having a body physically separate from that of others is an essential part of it) that cannot be philosophically justified. It sees conjoinment as a defect to be corrected. The two in one body view sees conjoinment a physical state that has both advantages and disadvantages while recognizing the value of the advantages. It seems that ethical and legal concepts designed to deal with confrontation are not always helpful in elucidating the nature of the conjoined relationship. Unlike most “contractual” relationships, which are premised on arrangements made between physically independent people, conjoined twins have an unbroken history of physical interdependence. There never was a time when they were not together. So it does not make sense to pretend that their conjoined relationship was something entered into through negotiation, or to treat it as something that can be broken on the assumption that their physical entanglement was not negotiated, as it were, “at arm’s length”.

There may well be an intimate relationship between the physical boundaries and the moral boundaries of conjoined twins. If being the individual you are, and if notions of privacy, autonomy, dignity, and individuality are all tied up with the bodies we inhabit, then surely the same should be true of conjoined twins. Dreger argues that their individuality certainly is, in that it is constituted in part by their intimate physical involvement with one another. Living adult twins conjoined at the head), reveal the many contradictions, ironies, and paradoxes of lives lived in and around such bodies. (An article by Dreger)
A study on conjoined twins:
There are two different sorts of twinning arguments, each with the same startling conclusion. They correspondent to two sorts of twinning cases. The most familiar are those where two head, each with its own brain, emerge from a single torso. The star example is the Hensel twins, born in 1990 and recently graduated from university. Their torso contains two hearts, two stomachs, two spinal cord merging at the tailbone, and four lungs (Two conjoined), but only one liver, one intestine, and one set of reproductive organs. Each brain controls the limbs on its own side and not those on the other. These are called double – brain twinning cases (The medical term is “dicephalus”). Double – brain twinning cases appears to be two organism but one person. Two torsos and two sets of limbs attached to a single head, with one cerebrum and two cerebella. Two organism share one brain. These are called shared-brain twinning cases (“cephalopagus” in the medical literature).This would imply all by itself that there are two people in the double – brain case.

The exact mechanism for the development of conjoined twins cannot be clearly explained. It appears that there is an alteration in the normal development process of monozygotic twins which fail to separate from each other. Two theories are widely held, related to the subject from each other. The fissure theory postulates that it is a failure of complete separation of embryonic disc in the 15th to 17th day of gestation. The Fusion theory suggestion that a second fusion arises between the two originally separate embryonic discs (autopsy findings on a pair of conjoined twins a pair of conjoined twins by Dr. William Owoti, P.O Box 2891-40100)
To see how these two types of theories differ in general, imagine taking out those areas of a brain which sustain the mind and transplanting them into another human organism or body in which those brain parts are missing. This organism will be as similar as an identical twin would be. After a successful operation, it there is someone with their mind in the latter’s body, it may be like someone with his memories, interests, personality traits, and so on, in a different, but similar body. Then, on psychological theories, the person in this body will have the mind-supporting areas of his brain and will have received a new body. This will be an extreme case of organ donation which have received not merely a new heart, new kidneys etc., but a whole new body.

Human twinning is a fascinating experiment of nature from which a great deal can be learnt about early human development and predisposition to disease. However, the more that is learnt about these early stages of development, the more caution I suggested in interpreting findings on twin studies used to understand complex diseases. Documentation of zygosity at birth is strongly recommended for all same sex dichorionic twins, since DNA testing can easily be done on cord blood at that time. The long term implications for predisposition to disease, transplantation, and inclusion in twin studies demand that this type of testing becomes part of routine care in the developed world.

It is learnt from researches that many twin pregnancies are lost or convert to singleton pregnancy. Most twins are lost very early in pregnancy. New techniques of imaging and hormone analysis have enabled recognition that many twin pregnancies convert to twin pregnancies. Theoretically however, the singletons that started out as monozygotic twins are still at risk for the congenital anomalies that are frequent in monozygotic twins. Thus, singletons that are born with these types of anomalies might have started as a monozygotic twin.

It is estimated that only one in eight individuals originating as a twin actually goes on to be born as a twin. Many twins are aborted spontaneously. The abortion rate is three times higher than that for true singletons. It is noteworthy that if less than a third of twins actually come to term, and 10 percent of live born monozygotic twins have a congenital anomaly at birth, then more than 70 percent of the monozygotic twin conceptions have some type of problem.

Cardiovascular and respiratory failure remain the most frequent causes of death in the immediate postoperative period. Further operations may be required for secondary wound closure and skin grafting. There is long term hidden mortality or morbidity. A number of infants died later from factors such as unresolved aspiration, bronchopneumonia, cerebral anoxia and malaria.

Conjoined twins are more difficult to be transported than individual newborns and the transport team should be suitably prepared and equipped. It is essential to stabilize each child prior to transportation. Where necessary airways must be secured to ensure adequate ventilation. Normothermia, and adequate fluid supply, and safe positioning is important. A separate transport team should be assigned to each individual child. Cardiopulmonary resuscitation, should it be necessary, is very difficult and has a poor prognosis, particularly in children joined at the thoracic and abdominal region. Due to defective anatomy, chest compressions may not be possible and may also cause damage to the intestines and liver.

The cardiac arrest or death of one twin is frequently an indication for emergency surgical separation, and failure to achieve urgent separation will result in the death of the second twin. Positioning of the babies for separation surgery must be planned with each of the surgical specialties involved in the procedure. Each stage of the separation, an order of procedures the positions required and the placement of lines, airways and monitoring must be considered. The table should be large enough to accommodate both twins and meticulous care with the use of protective rests and padding is important. Simulation has been used to plan positioning, movements and transfers in advance of the separation procedure.

Medical Facts:
Conjoined twins are a rare occurrence that presents significant challenges to both parents and healthcare personnel as it is accompanied by severe morbidity and mortality as well as religious, moral, ethical and legal issues. Many theories have been proposed to explain their occurrence. Twins are either monozygotic or dizygotic. An incomplete splitting of monozygotic twins results in the formation of conjoined twins. They are physically connected to head, chest or pelvis causing some of them to share some internal organs. 40 to 60 percent of the conjoined twins are still born. 35 percent survive only for one day. They have an overall survival rate of somewhere between 5-25 percent. Still birth and morality rate are extremely high in dicephalus twins. Dicephalus twins had a remarkable 11 – day survival. Rarely three – and four dicephalus twins live to adulthood.

Conjoined twins are classified according to the major site of attachment followed by the suffix “pagus” which in Greek means (fixed). They are Tharacopagus (42%) joined from chest thorax to umbilicus- Parapagus(14.5%) fused at lower abdomen and pelvis, has genitourinary anomalies- Omphalopagus(5.5%) joined at head, brains, and are usually separate, Skull meninges and venous sinuses are involved- Craniopagus (3.4%) fused at head- Ischiopagus(1.8%) joined from the hip to pelvis, share genitourinary and gastrointestinal tracts, many have different number of legs – Rachipagus (1.0%)spine is fixed with neural tubes- Pyopagus(1.0%) buttocks fixed with sacrum and coccyx anomalies- Parasitic(3.0%) incomplete twins attached to other twin at any location, some unspecified types form the rest (21.4%) of conjoined twins. In general, few conjoined twins survive due to heart, lung, abdominal and neurological malformations often present even in unshared structure.

Conjoined twins from the moment they enter the world, face a myriad of social and psychological problems. It is not easy to provide care for conjoined twins as it can be very challenging. They suffer various physical and medical challenges.

Result of studies suggest that adequate materials of folic acid consumption could affect the number of twins coming to term. In several studies looking at the role of folic acid supplementation, findings have shown that more twins came to term and are born than would be expected. These twins do not seem to show that usual excess of congenital anomalies generally seen in twins. Results of other analysis are less convincing but might relate to populations that are at reduced risk of folic acid dependent congenital anomalies.

Conjoined twins are always monozygotic. They result from an incomplete monozygotic twinning event and raise in about 1 in 100000 births and are about 1 in 400 monozygotic twin births. Conjoined twins are thought to develop after 14 days of embryonic development, because at above this time the primitive streak sets up lateralization assuming monozygotic twinning and follow the typical human developmental schedule.

Comparison of monozygotic and dizygotic twins are frequently used to estimate the environment and heritable factors that contribute to complex diseases. This comparison estimates twin pregnancies, births, and early childhood. Growth of twins in utero is not typical of singletons. The effect of intrauterine growth on later adult diseases could also be a typical. All twins can be expected to have many kids of in – utero differences, such as placental flow in monozygotic twins and the amount of microchimerism (small number of cells that originate from another individual) in dizygotic twins.

A study on twins need to be viewed with some reservation. Twins may not be representative of singletons in relations to some complex diseases. Furthermore increasing use of artificial reproductive technologies, presence of high concentration of gonadotropins, intentionally broken or abnormal zona pellucidas, and physiological abnormalities related to culture media might have effect on childhood or adult disorders not yet fetal – material microchimerism during pregnancy. More fetal – material microchimerism takes place with complications of pregnancy, such as pre – eclampsia or bleeding, which are typically seen in twin pregnancies.(THE LANCET. Vol 362 August 30, 2003)
REVIEW OF ARTICLES AND NEWSPAPERS
Farah and Saba Shakeel Case:
“The journal of law and medicine” in June 2011, Indian newspapers carried a story about the plea by the father of twins joined at the head that doctor be allowed to carry out a mercy killing of his conjoined twin daughters Farah and Saba Shakeel who were reported as suffering terrible headaches, joint pain and slurred speech as they grow older. Their father’s meagre wage had to support a family of eight members and could not afford the ongoing medical treatment that the twins required or the cost of medical investigations to find the cause of the girl’s increasing pain. Their father who runs a tea stall could not bear the medical expense, their parents rejected an offer by the crown prince of Abu Dhabi to pay for the separation surgery because there was a one – in – five chance that one or both the girls would die during the six operations needed to separate them. After separation, Saba would receive kidney transplant because only Farah had kidneys.

A law student Aarushi Dhasmana became aware of the conjoined twins’ suffering in 2012 and filed a PIL (Public Interest Litigation) in which she sought the setting up of a high level committee of medical experts for the purpose of examining the possibilities of separating the twins. She said the twins’ hapless parents had made fervent appeals for the mercy killing of their daughters if all attempts to separate them failed.

The petition was heard on 16 July, 2012 by Judges Radhakrishnan and Dipak Mishra JJ. The court ordered that a team of medical experts examine what medical assistance could be provided to the twins, and that the state of Bihar/Union of India bear the entire cost of medical expenses to save the lives of the conjoined twins. On 30 July, the Supreme Court ordered that the twins and their parents be flown to the all India Institute of Medical Science in New Delhi for medical investigations, at the expense of the state. However the twins’ parents refused this, saying they only wanted financial resistance to look after the girls, the court then ordered the medical team to travel to Patna to examine the twins.

On 31 October, the medical team reported back to the court the conjoined twins’ parents and brother refused to allow investigate such as CT scan and MRI scans to be performed. The reports said the parents were not willing to take any risk including the risk involved in investigations. Instead, the brother and the parents handed over a written submission requesting financial help. (The journal of law and medicine)
Lakewood Case:
The 1977 Lakewood case appears to be the first case in which court approval was sought before sacrificial separation surgery. The twins’ shared a liver and one fused six -chambered heart. The parents agreed to the surgery knowing that the one twin could not survive the procedures the surgeons were concerned that they might face charges of premediated murder and refused to go ahead with the surgery without court approval. The three judge panel of the family court in Philadelphia heard arguments from lawyers that the greater good would be served by saving on child instead of losing both, and that there would be no crime if a court ruled that the good outweighs the bad.

The lawyers used an analogy of a mountain climber who falls but is saved because he is roped to another climber. However, the second climber’s hold is not secure enough to prevent both from plunging to their deaths and would therefore be justified in cutting the rope to save himself. The family court agreed with the logic in this argument and after a few of minutes deliberation, authorized the surgery. There is no written record of the hearing or decision. The weaker twin died during the surgery and the survivor died 47 days later after contracting hepatitis B from a blood transfusion. (The journal of law and medicine)
The ‘Re A’ (Children) Case:
The second case in which court sanction was sought is Re A (Children) Conjoined twins identified as Jodie and Mary, were joined end-to-end at the hip, and shared an aorta and inferior vena cava. Mary’s heart was abnormal and she has no functioning lung tissue. Mary would therefore not survive separation surgery. She lived only because she received oxygenated blood pumped by Jodie’s heart and she would not have been able to be resuscitated after birth had she been a singleton Mary also had very poorly developed primitive brains.

The parents were devout catholic and did not want twins separated if this meant the sacrifice of one twin so the other might survive. Instead, they wanted the twins left untreated they accepted that this was God’s will. The hospital however, sought a court declaration that it would be lawful and in the children’s best interest to perform separation surgery. On the outset the surgical separation is not just separating the shared organs but it is a call for recognizing the individuality of the conjoined body (The journal of law and medicine)
Nolan Case:
Alyssa and Bethany Nolan were born in Brisbane on 3 May 2001, joined at the head. Although they had separate brains, they shared cranial draining veins and Bethany had no kidneys or bladder. On 25 May, Bethany’s health declined and her death appeared imminent.
The twins’ parents gave permission for the girls to be separated, knowing that surgery would be fatal for Bethany. The state of Queensland applied to the Supreme Court for an order that the surgery would be lawful. Chestman J granted the declaration, relying on the duty imposed by section 286 of the Criminal Code on the people who have care of children under 16 years, in conjoinment with the excuse in section 282, to find the surgery would be lawful. Section 282 relieves both doctors from criminal responsibility if they perform in good faith and with reasonable care for the benefit of the patient provided it is reasonable under all the circumstances. (The journal of law and medicine)

Chapter II
REPRESENTATION OF CONJOINED TWINS IN LITERATURE
Conjoined twins struggle and dilemmas are represented through literature in the form of dramas, fictional prose, songs and documents. Their social encounter can also be understood through a vast number of newspapers, souvenirs, booklets and memoirs. The concept of their origin has also intervened us to explore the areas of enquiry such as colonialism, slavery, sexual science and marginalization which has helped us to understand what it is like to live two opposite fates like love and betrayal in one soul.

The research on the Siamese twins – “Chang ; Eng” has helped us to understand their struggle between otherness and sameness, unity and diversity, exotic, and normalcy. Wu – A specialist in disability studies and comparative ethnic studies, in her research says that each of them possessed many discrete trails that opposed those in other in important ways.

WU’S Representation on conjoined twins “Chang and Eng” for literature.

Chang Bunker was friendly, outgoing, alcoholic, shorter in stature and had a temper, for instance Eng was quite, withdrawn, teetotaler with wider intellectual interest. One body, two individuals, “Wu says, adding that their differences extended to different physical peculiarities and reactions to physical stimuli, a fact that fascinated physician.

Even in terms of their shared traits and identities, they representatively confounded public assumptions about their origins, physical abilities and social selves. Possessed of some qualities that could have left them, economically marginalized and socially dispossessed, these exotic, disable oddities used other qualities to become agent of their own.

THE GIRLS by Lori Lansen:
Rose and Ruby sisters, best friends, confidents and conjoined twins. When Rose, the bookish sister, sets out to write her autobiography, it inevitably becomes the story of her short but extraordinary life with Ruby, the beautiful one. From their awkward first steps – Ruby’s arm curled around Rose’s neck, her foreshortened legs wrapped around Rose’s hips – to the friendship they gradually developed for themselves in the small town of Leaford, this is the profoundly affecting chronicle of an incomparable life journey.

Since their birth, Rose and Ruby Darlen have been known simply as “the Girls”. They had friends, fallen in love, had jobs, loved their parents and followed their dreams. But the Rose and Ruby sisters are special. Now nearing their 30th birthday they are history’s oldest craniopagus twins, joined at the head by a spot the size of a bread plate.

As Rose and Ruby’s story builds to an unforgettable conclusion, Lansen aims at the heart of human experience – the hardship of loss and struggle for independent, and the fundamental joy of simply living a life. This is a breath talking novel, one that no reader will soon forget, a heartrending story of love between sisters.

ONE by Sarah Crossan:
Tippi and Grace, two sisters, two hearts, two dreams, two lives, but one body.

Grace and Tippi are conjoined twins, joined at the waist, defying the odds of survivals for sixteen years. They share everything, and they are everything to each other. They would never imagine being apart. For them that would be the real tragedy.

But now, they are growing up and they are developing different opinions and don’t always agree .This novel is written from Grace’s point of view which is very effective. The writing style is different – it is written almost poetically and in paragraphs and sentences of very different lengths.

But something is happening to them. Something they hoped would never happen. And Grace doesn’t want to admit it. Not even to Tippi. The story is about how long they can hide from the truth and how long before they must face the most impossible choice of living their lives.
GEMINI by Sonya Mukherjee:
Seventeen years old conjoined twins Clara and Hailey have lived their lives in the small town, no one stares at them anymore. But there are cracks in their quite existence, and they’re slowly becoming more apparent. Clara and Hailey are at a crossroads. Clara wants to stay close to home, avoid all attention and study the night sky. Hailey wants to travel the world, learn from great artist, and dance with mysterious boys.

As high school graduation approaches, each twin must untangle her dreams from her sister’s, and figure out what it means to be her own person.

FALSE HEARTS by Laura Lam:
Orphan Black meets inception: two formerly conjoined twins sisters are ensnared in a murderous plot involving psychoactive drugs, shared dreaming, organized crime, and a sinister cult. Raised on the closed cult of Mana’s hearth and denied access to modern technology, conjoined sisters Taema and Tila dream of a life beyond the walls of the compound. When the heart they shared begins to fail, the twins escape to San Francisco, where they are surgically separated and given a new artificial hearts. From then on they pursue lives beyond anything they could have previously imagined.

Ten years later, Tila returns one night to the twins’ home in the city, terrified and covered in blood just before the police arrived and arrested her for murder – the first homicide by a civilian in decades. Tila is suspected of involvement with the Rattle, a powerful crime syndicate that deals in the flow of zeal, a drug that allows violent minds to enact their darkest desire in a terrifying dreamscape. Taema is given a proposition to go undercover as her sister and perhaps save her twins’ life. But during her investigation Taema discovers disturbing links between the twins’ past and their present. Once unable to keep anything from each other, the sisters now discover the true cost of sharing secrets
DARIN STRAUSS
Early life:
Strauss was born in the Long Island town of Roslyn Harbor. He attended Tufts University, where he studied with Jay Cantor. After attending graduation school at New York University, he played guitar in a band with Jonathan Coulton.

Career:
His ALA Alex Award-winning, best-selling 2000 first novel Chang ; Eng, – a runner-up for the Barnes ; Noble Discover Award, the Literary Lions Award, a Borders Award winner, and a nominee for the PEN Hemingway award, among others — is based on the lives of the famous conjoined twins Chang and Eng. Chang ; Eng was a Los Angeles Times Best Book of the Year, a Newsweek Best Book of the Year. The rights to the novel were optioned to Disney, for the director Julie Taymor; the actor Gary Oldman purchased the rights from Disney. Strauss and Oldman are together adapting Chang and Eng for the screen.

Strauss’s second book, The Real McCoy (2002), was based on the life of the boxer Charles “Kid McCoy” “The Real McCoy” was named a “New York Times Notable Book”, and one of the “25 Best Books of the Year,” by the New York Public Library. It was after this novel that Strauss won a “Guggenheim Fellowship” in Fiction Writing.
Strauss’s third novel, More Than It Hurts You, his first in a contemporary setting, was published by Penguin Putnam in 2008. The book made a number of year-end best-book lists, and was also a national bestseller—reaching as high as #3 on both the Denver Post and Rocky Mountain News lists, and #6 on the New York Post list, in July, 2008. Publicity for the book was strong, and Strauss blogged about his extensive book-tour for Newsweek, and was featured on The Late Show with Craig Ferguson-Good Morning America.
He appeared on This American Life in a July 2008 episode titled “Life After Death,” in which he talks about the effects of a traffic accident during high school, in which a classmate on a bicycle swerved in front of his car, and was killed. Although he could not have avoided the accident, and was not at fault, he still felt guilty, and it affected him for decades.

His next book, Half a Life is an essay-length memoir based on his traffic accident; it was published by McSweeney’s in September, 2010, and was excerpted in GQ magazine, and This American Life, and also in The Times and The Daily Mail (UK). Half a Life was named an Entertainment Weekly Must Read and a New York Times Editor’s Pick—and a Best Book of the Year by NPR, Amazon.com, The Plain Dealer, The San Francisco Chronicle, among many others. A critical favorite in the UK, Half a Life was called “a masterpiece” by Robert Mc Crum in The Guardian,3 “one of the best books I have ever read” by Ali Catterall on The BBC, as well as “precise, elegantly written, fresh, wise, and very sad … indicative not only of a very talented writer, but of a proper human being” by Nick Hornby Half a Life won the 2011 National Book Critics Circle Award (Autobiography).

Background of author:
Darin Strauss (born March 1, 1970) is a best-selling American writer whose work has earned a number of awards, including, among numerous others, a Guggenheim Fellowship and the National Book Critics Circle Award. Strauss’s most recent book is Half a Life, which won the 2011 NBCC Award for memoir/autobiography.

Darin Strauss writes novels whose main characters lives in the shadow edge of the society. The first novel – Chang and Eng is a passionate retelling of the lives of the original Siamese twins otherwise loss of history and myth and was acknowledged by critics.

In this stunning novel, Darin Strauss combines fiction with astonishing fact to tell the story of history’s most famous twins. Born in Siam in 1811 – on a squalid houseboat on the Mekong River – Chang and Eng Bunker were international celebrities before the age of twenty touring the world’s stages as a circus actors, they settled in the American south just prior to the civil war. They eventually married two sisters from North Carolina. Fathering twenty – one children between them, and lived for more than seven inches apart, attached at the chest by a small band of skin and cartilage.

Woven from the fabric of fact, myth and imagination, Strauss’s narrative gives poignant, articulate voice to these legendary brothers and humanizes the freakish legend that grew up around them. Sweeping from the far east of their lives in America, Chang and Eng rescues one of the nineteen century’s most fabled human oddities from the sideshow of history, drawing from their extraordinary lives a novel of exceptional power and beauty.

They become famous. They tour the world. They great royalty. They are toasted in London. They are stared at by carnival crowds. Chang and Eng were the only conjoined twins on record to have a family. Their story led a chivalrous life to outdo the circumstances of their survival. From poverty to wealth, from hopeless solitude to boundless love. Strauss reveals the longing of two different men bonded together by common flesh.

Works:
Novel:
Chang & Eng (2000)
The Real McCoy (2002)
More Than It Hurts You (2008)
Nonfiction
Half a Life (2010)
Selected anthologies
Lit Riffs (2004)
The Dictionary of Failed Relationships (2004)
Coaches (2005)
A People’s Fictional History of the United States (2006)
An Encyclopedia of Exes (2004)
Bloodshot: An Insomnia Anthology (2007)
Brooklyn Was Mine (2008)
Brothers (2009)
The Book of Dads (2009)
Top of The Order: Best-selling writers on Baseball (2010)
Other
Mr. Beluncle, by V. S. Pritchett; Strauss wrote the new introduction (2005)
Long Island Shaolin, one of the first Kindle Singles—short works published by Amazon; other Kindle Single debut authors include Jodi Picoult and Rich CohenAwards and honors
2011: National Book Critics Circle Award, Winner
2011: New York University’s Alumnae Achievement Award, Winner
2010: “Editor’s Choice,” The New York Times2010: “Best Books of the Year,” NPR2010: “Best Books of the Year,” The Plain Dealer (Cleveland, Ohio)
2010: “Best Books of the Year,” Amazon2010: “Best Books of the Year,” San Francisco Chronicle2008: “Best Books of the Year,” Denver Post2008: “Book of the Summer,” GQ Magazine2006: Guggenheim Fellowship, Winner
2005: “Outstanding Dozen” teaching award, New York University, Winner
2002: “Times Notable Book,” The New York Times2002: “25 Best Books of the Year,” New York Public Library2000: “10 Best Novels of the Year,” Newsweek2000:”Best Books of the Year,” Los Angeles Times2000: ALA Alex Award, Winner
2000: Barnes & Noble Discover Award, Runner-up
2000: NYPL Literary Lions Award, Finalist
Critical reception:
Strauss has been called “a brave new voice in literature” by The Wall Street Journal, and “one of the most sharp and spirited of his generation,” by Powell’s Books, “sublime” and “brilliant” by the Boston Globe.
“Darin Strauss has written a daring and bold debut: the perfect mixture of historical research and imagination to unveil the two very separate lives – and the shared life of Chang and Eng”.
-Galaxy Craze, author of By the Shore
“What a remarkable first novel!! Darin Strauss immerse us in the turbulent lives of the historic Siamese twins Chang and Eng with consummate skill, intelligence and sympathy”
-Joyce Carol Oates
‘Strauss writes movingly and perceptively from the heart of a man who has spent the first half of his life dreaming of freedom and the second craving an impossible romantic intimacy.’
-Daily Telegraph
‘This striking evocative story, with its subtle language and word-play, is told from the perspective of a man seeing the world from a unique position –with the brother always looking over his shoulder.’
-Scarlet Thomas, Scotland on Sunday
‘Chang and Eng were born on the Mekong River in 1811, bound together by a ligament between their chests which gradually lengthened to allow them to stand and live side by side. Kept locked up by the king of Siam, then taken to Europe and America as freaks, they settled in the America South, marrying two sisters, fathering 21 children and living into old age.

Strauss has taken the historical evidence and the myths and turned them into something extraordinary immediate; he has Eng his narrator, bringing the reader right side inside the head of a man bound to another. And with sympathy, imagination and sharp writing, he has made it work rather well.’
-The Times
‘Strauss’s novel – its humour, its humanity, its aching sadness – makes for a fine memorial.’
-New York Times
CHAPTER III
CHANG AND ENG
Birth and childhood:
Chang and Eng were born in a fisherman family of Siam, Thailand near the Mekong River in 1811. It was the beginning of a summer like spring, a rainy mid-night in the rainiest season. There was no light and a candle helped providing scarce light. Jun, a mid-wife was helping the mother to deliver Chang and Eng. They lay closely crammed together, facing head to feet. Jun happily exclaimed to everyone that Nok has delivered a healthy male twins.
All the relatives and neighbors who gathered there merrily welcomed the twins and there was a lot of excitement among everyone to see the babies, but when Jun took the boys to bath them discovered they couldn’t be separated. She screamed and dropped the boys into the floor. Their father, aunt and neighbors were all in huge screams and shock. Chang and Eng had a full distinct body – with two pairs of arms and legs, two heads and chest, hearts and minds – but everyone noted their breastbone bounded together with a twisted ligament. They were considered not as two children, but as one curse on the family
While the world is not a place of wide spread kindness, a few oysters thrive in a sea of clams. Their mother was graceful enough to keep herself calm. She sat up and took them into her arms twisted the ligament. Now Chang and Eng faced each other. She cooed into their face and patted their cheeks. Nok, banished the midwife, aunts and all the neighbors from the houseboat. Once everyone has gone, Nok was bathing the new ones and the neighbors were peeking in but the mother did not acknowledge anyone she was busy drying and dressing the babies. , They four of them lived a normal life for six years, until word a word came from Bangkok that king Rama wanted the twins dead.

When Chang and Eng were young children of Mekong, the world was an island of unknowing. Their houseboat floated apart from any other by half a mile. But their parents took all effort to make them understand that they are not so different from other children.

The news of spectacular delivery brought droves of sight seers and soon physicians came forward to suggest methods of separations but all that was in vain. Chang and Eng’s mother was a sweeter temper. She worked without end to ensure their childhood to be a pocket of softness in a callous life. She raised them as normal boys not pitied or slighted. Nok, kept them utterly isolated from other children, she taught them to sing speak and to help out around the house.

Chang’s frailty made leasing to walk difficult. Their little connector did not allow them to walk equally. They walked in side steps. It took a while to walk together. The twin’s father showed them how to defend themselves. On the river, in the mornings and at night, before and after the day’s work, they were taught warlike art of China’s Shao-Lin temple. They were also taught flips in the air together, the better to master grace and agility. Being off of the ground was a brazen maneuver, especially for conjoined fighters and it urged the limits of their attuned movement and their father was wise to educate them Gung Fu, for the boys to encounter other children with their fighting arts. They also learnt the art of fishing and cultivating crops from their father. Their affection and bonding became strong. The brothers were joined at the sternum by a piece of cartilage, and though their lives were fused they were independently complete.

King Rama’s Captives:
When they were seven their Aunt Ping informed them that King Rama wanted the double-boy dead. Considering them as a bad omen. They were all living a happy life together. But now the parents had a fear of their children getting killed by the king’s men. They were arriving with their knife’s blade to kill the doubles. They were taken to the kingdom as they desired a look at the double-master before killing them. The mother pleaded for mercy but helplessly kissed their hands tearfully as the children were taken from her grab.
Chang and Eng were captivated by king Rama III and were imprisoned in a cell where they could hardly stretch themselves. The room was dark except for a stripe of sunlight. With no windows, no blankets or berth to sleep. The king gave a word that he will encaptivating them after they served for a period of as entertainers in the king’s court.
Chang and Eng performed a string of their backflips. Their ability to walk on four hands and their Gung-Fu moves which were painful to be performed moved the audience. They could carry 20 stone men. They grew in number and in loudness as they gathered and under the clamor of gasps and ringing voices they soon made up a crowd. The captivity that the twins suffered brimmed with the habiliments of nobility. They thought that they will be remain captivated until their death to be exhibited to foreigners whoever visits the king’s court, until one night the king entered in their cabin and informed them that they will receive schooling. Nao, the king’s men would come to their chamber to give them history and language lessons. This went on for some years.
Chang and Eng are at their thirteen now. King Rama sent a word of encaptivating them and it’s now time for them to unite to their family. The next day they were awakened by Nao and he draped took the long route away from the capital and down of the tributaries of Mekong a blanket over their heads to avoid the crowd and carried them in a pull – cart.

At the sea:
When the cart stopped, they lifted the blankets to find them beyond the palace gates. As they approached their familiar corners the brothers felt thousand and one emotions swimming through their brains. The river different now and the landscape has totally changed. It was late in 1823 that cholera has gutted Mekong and their father has been among the first to die in the epidemic. Chang and Eng are left only with their mother and when they saw their mother and she looked like a stranger to them. She pushed the man aside and ran to the lips of the shore. She began to scream and extended her arms towards the arriving junk. She lifted them with a grunt.

Chang and Eng were grown up and took the responsibilities of their living arrangements. They spent their leisure with their mother explaining all that happened in lord Rama’s could and how much they missed her. The lack of father seemed less than an opportunity. Mother spent her time crying or sitting with them. They lived an utter life in deep poverty. Their tuna nets had been sold, trinket tables were broken. They sat on the dinghy tied to their houseboat trolling the river with their hands but only few were available for their food and nothing left out to be sold. They could often see their mother moaning and crying for these boys thinking that they could have work if were separate boys.

At the age of fifteen, the brothers started their own business of raising ducks and selling eggs to the local merchant for cash. They became duck vendors after a short time.

Circus and freak shows:
Once upon a Mekong morning two men Coffin and his friend walked into their houseboat and promised to change their world. He told of his plan to take Chang and Eng America and England, republic of which were never heard before and they can soon become rich allowing them to be a circus attraction which would bring great honor to their families and nation. Captain Coffin assured their mother that they would be treated with respect and the money they earned will be given to them and they’ll be back in a years’ time. Nok, was in a confusion but terribly helpless. With lots of anguish spread in their heart they left Mekong again. Mother hugged them and bid good – bye. They came the ship’s whistle and Chang and Eng left their mother and had begun their journey to New York. The Captain addressed to introduce the double – boy to the crew and they raised a collective eyebrows at the sight of the brothers. A day passed in silence. They gave up their eating having the fear of the crew.
From the next day, Coffin started teaching them English and trained them to walk on the two decks. The crew also educated them to play checkers despite of their newness to the language. The memories of their mother were haunting the boys. Eight months passed away at the sea and their synchronicity had become a delight to the crew and they often played with the doubles and had fun. After travelling seven thousand, five hundred and twenty nautical miles, the sachem crew approached New York Harbor.

Coffin left the twins in Hunter’s hand and his horse -drawn carriage took them through the vivid agitation of nighttime in New York. The passed through the sequence of marks, the stone and bricks of Hanover Square followed by Stately Putnam Bookseller and the Gray theatre on Chatham street. The brothers gazed through the window of the carriage and hunter command them to close the curtains so as to avoid their existence. Before anyone could notice their presence from the crowd. They spent their night in New York in seclusion. Hunter took them to the landscape of isolated farm and escorted them to a widow Sachs and he introduced her reveal about Chang and Eng to anyone before they are introduced to crowd. The next morning Hunter picked the boys from Sachs. He brought two white sailors suit and a pair of sailor’s caps for their performance and they literally stood before the crowed. They played checkers struggling into their sailor’s pants and they were highly appreciated for their debut performance did somersaults, handstands and backflips.

After the performances they were put up in a cage which had a placard hung which read “THE MONSTER”. Together with the casual visitors the freak child had trouble making out the audience thousands of raised voices and scrambled feet were close to them in shouts and snots and filled the tent with declarations of disbelief and wonder. The crowd rushed the cage pushing Hunter aside and they plunged their hands through the bars trying to grab their connecting band. It looked as if the crowed was throwing invisible darts at them. Hunter drew the curtains and the crowed followed after them for at least a minute. The night after their first performance in New York, they sat with promoters in Mrs. Sach’s house where he appreciated them for the good beginning but muttered to get quite better with the next performances. Hunter had a tight hold on Chang and Eng and he smoothed his greatcoat with the money that the people paid to see these brilliant creatures.
He arranged a press meeting where the good men of newspaper, doctors, circus enthusiasts and Mr. Barnum a promoter spectated the Siamese twins. After the meeting, on the way back to their New York City, Chang and Eng tried to escape to find way back to Siam. They ended up to a populated section of the town where people gathered and started at the conjoined boys they pulled the boys and glanced at them. The crowed swallowed them and the air around them was blocked and they were knocked down unconscious. The boys awakened and discovered them in police station. Hunter arrived and smiled as if he loved the boys and took the boys with him. Hunter’s behavior with the boys worsened and it seemed very painful for them and they tried all attempts to escape from the clutches of Hunter.

The shows became routine and Mr. Barnum tried convincing the boys for his show but Hunter always eyed on him and took the Siamese twins to England. The crossing to England took nearly twenty six days and they tried all possibilities to make a way to their home. Their first night in London was a silent coach ride through the capitals grey attractions. They London Bridge stood pointing at the stars. They stayed at the beautiful meadows. Hunter has alerted his London connections about the arrivals of conjoined twins and the meadows was crowded with gawkers and a group of English newspaperman.

London was another success for the freak-child and they started charging their admission. They crowd was enormous and they escape plan. One dark and foggy morning in London, Chang and Eng gave a special performance at the residence of the Duke of Angouleme after which they became the toast of London. The strangest of reporters appeared in the “Times of London” and their story heaped fictions upon fictions. They toured the continent with Hunter and performed everywhere took them. The Bunkers have been away from Siam for four years. Now eighteen, they decided to take leave from Hunter as they reach New York. On a dark night near the end of the journey when they were asleep a young man grabbed Eng’s hand placed a note which carried instructions on where and how rendezvous secretly with Barnum once they arrived in New York.

Chang and Eng became the most celebrated attraction of the world. The brothers decided to join Barnum as they dint want to return to Siam as failures. They planned another try to escape more finely planned then their last effort. The doubled – bulk leapt together and grabbled the top branch and shimmed their way down into Barnum’s carriage. Barnum was friendly enough to help the brothers. He sketched the poster of Chang and Eng and hung it all over the city this time it read “CHANG – ENG: THE UNITED SIAMESE BROTHERS”.
The brother are finally free not and had a great deal of enthusiasm for breathing a free air in Siam. But it is if no life without their mother. As youths, they had to take up their responsibilities, they wondered in street searching for accommodations. After a few months of their own exhibitions they become a biggest attractions but did not stop performing. They grew rich but did not carry on like a rich man. Most of year they stayed at the playhouse and in tour picked low cost hotels when on road. It went on for years until they met their wives.

Double courtship and wedlock:
Chang and Eng first met Sarah and Adelaide Yates in Wilkesboro inn. Mr. and Mrs. Yates were the innkeepers. The girl looked incredulously at them as if they were a horse turned into man (Chang had fallen for Yates and he had a smile never like before). The desire of women for them was an inconceivable thing. Chang had forgotten very important details of their very being and had fallen for Yates and she reciprocated. Eng was clear not to give their friendliness more meaning than it deserves. Mrs. Yates tries all opportunities to put her girls on a wedlock with Chang and Eng despite of their oddities as they were celebrated freaks. The double boy spent their days from one exhibit hall to the other. Eng started noticing the gentle landscape of Sarah’s face. Sarah was a homely beauty. Rather than a flood of passion, love came to them as curios and distant spectate. Eng resolved to his brothers wish to experience the Matrimonial joy as other human beings.
When Chang and Adelaide started seeing each other Eng fell isolated. It did not made a sense for two of them to marry one girl it was easier to be two plus two rather than two and one. While Chang had dreams of his married life with Adelaide Eng ended up unsuccessful in his quest for Sarah’s heart. Chang and Adelaide designed plans to force Sarah to spent time with Eng to win her affection. Sarah was indifferent for his charm. Adelaide acted as a sincere collaborator and her efforts worked out. Sarah reciprocated Eng’s love and they were a pair of couple bound together by circumstances.

The double wedding was set up very quickly and court proceeding begun for proving that neither Sarah nor Adelaide were committing bigamy by marrying conjoined twins. Though the legislation of North Carolinians had no such act look that they were caught in made them feel that there would be such an addiction in the court’s ledger. They had to choose Bunker as their last name to appear Americans. They became Chang and Eng Bunker now. Just when it seemed everything was coming off easily, life again became a hardship.

The brothers had to try their separation one more time to save Sarah and Adelaide from disgrace. Despite the risk they tried the separation when it meant winning their rights to wed. Just like the earlier attempts in London, New York, Philadelphia and Paris the physicians of Wilkesboro also convinced it unsafe. The crowd began its approach. Bunker’s marriage was considered as a lustful perversion. The crowd did not acknowledge two wives for one man. The protestors aimed their guns at Chang and Eng and they decided to fight back. Their house was set ablaze to burn them alive but the brothers managed to free themselves from the clutches of fire and the next morning marked their wedding day Chang and Eng could not take their eyes off as the Yates sisters walked the aisle.
Chang and Eng offered the sisters their forearms and with the rituals the marriage concluded and all the four walked the aisle. Though the situation seemed immoral and shocking to the outside world they had an alternate mastery to remain pure. That is how they avoided allegations of improper relations between their wives and them. Chang and Eng financed the money they saved. After years of touring to build their home. It was a desolate and peaceful place. Next to the house stood a burn in which they sheltered animals and stored hay, corn and firewood. In the backyard was the shed that completed their modest estate.

Chang and Eng were thirty four years old and their hair greyed. They owned a double – plotted farm, a fertile twenty – six and half acres of land where they grew corn and a twenty seven and half acres pf land for raising of hogs. They had slaves to work on their farm. Later they developed an argument with them. With no workers for their farm they decided to auction it. Their house caught fire and there was a heavy loss. With the shortage of money the relationship went bitter. Chang and Eng had arguments for everything and nothing and so did Adelaide and Sarah. Chang had grown quarrelsome to Adelaide too. Eng somehow managed to maintain the essence of their relationship. Their marriage became a complicated one. Their household were separated as the sisters felt it difficult to live together and it was too small for their twenty one children. In the American civil war broke out. Chang’s son Christopher and Eng’s son Stephen both served the confederate army. The twins lost most of their money with the defeat of the confederacy and became very bitter. They returned to public exhibitions, but this time they had a little success, never the less they maintained a high reputation for honesty and integrity and they were highly respected by their neighbors.

Later years and death:
In 1870, Chang suffered a stroke and his health declined over the next four years. He also began drinking heavily. Chang’s drinking did not affect Eng as they did not share a circulatory system. Despite his brother’s ailing condition Eng remained in good health. Chang was injured after falling from a carriage. He then developed a severe case of bronchitis, On January 17, 1874, Chang died while the brothers were asleep. Eng awoke to find his brother dead and cried, “Then I am going”. A doctor was summoned to perform an emergency separation, but it was too late. Eng died approximately three hours later.

Doctors from Philadelphia, Pennsylvania approached the families and received permission to take the remains for examination and autopsy. The autopsy revealed that Chang had died of a cerebral blood clot but Eng’s cause of death remains uncertain. Doctor theorized that Eng died of shock and fear of his impending death.

As to the question of separation, it was found that the band of cartilage included portions of the peritoneal cavities of each twin and that their livers were joined by a thin strip of liver tissue. It was concluded that the twins could not have been safely separated, as they would have died from the blood loss that would have resulted from such an operation. The livers were preserved, and after the autopsy a plaster death cast of the torsos were made.

Sara Anne Bunker (Eng’s widow) died on April 29, 1829 and Adelaide Bunker (Chang’s widow) died on May 21, 1917.

The preserved fused livers of the Bunker brothers and plaster death cast is currently displayed at the Mutter Museum, where they were made permanent exhibitions. Numerous artifacts and their travel ledger, are displayed in the North Carolina collection gallery in Wilson library at the University of North Carolina at Chapel Hill, this includes the original watercolor portraits of Chang and Eng.

When Chang and Eng, the world – touring conjoined twins and sideshow stars, came to Boston for a week of appearance in Darin Strauss first Novel, reporters were waiting with questions.

It is difficult to imagine a more deviating from normal predicament, it is all the more to Strauss’s credit that he locates at its core some pretty universal tendencies to carve connection, to resist it when it is finally made and then to regret the damage done by that resistance. By homing in on basic humanity of the twin’s story and working it with such sympathy Strauss manages to move Chang and Eng from the sideshow stage, placing them at the center of a story of heroic longing.

They died in 1874, within hours of each other. In between, they became international celebrities among the most successful show business draws of their day. They entertained royalty and other in Europe, Asia and the United States with feats of strength and acrobats and that almost every step of the way, they encountered doctors peddling gruesome plans to separate them. The twins never elected, however to test the medical expertise of their day.

Strauss has a talent for letting historical context – the details of their father’s life as fisherman on the Mekong River. Eng tells their story in deathbed “paroxysms of memory” that carry him back to the twin’s first encounter with gawking strangers, their detention by king Rama of Siam and the start of their public lives in New York. Surprisingly enough the action in Chang and Eng” really pricks up when they settle down in Wilkesboro, North Carolina. There they defend themselves from mob action build a house, destroy it court sisters, marry them produce 21 children.

The twins also fight each other several times. Neither can win such a contest, of course. But the battles still seem inevitable because Strauss has so successfully drawn each as an Individual. Their connection makes fighting between themselves inadvisable, it also frustrate most other attempts at individual agency. At one point, irritated by Chang’s excessive drinking. Eng joins a temperance society. When he travels to lecture the “Maidens of temperance” on the evils of alcohol, he must bring Chang with him. Chang drinks from a flask through most of Eng’s harangue.

The novel’s other unions are no less troublesome. The twins double courtship of double marriage to and complex sleeping arrangements with the sisters Sarah and Adelaide Yates make memorable scene that somehow never strains credulity.

“The dream of state is to be one, while the dream of the individual is to be two”
– Jean – Luc Goddard
CHAPTER IV
SOCIO CULTURAL, PHYSIOLOGICAL AND PSYCHOLOGICAL STRUGGLES OF “CHANG AND ENG”
Socio Cultural struggle
At Birth:
“Twins!” Jun exclaimed. “We have twins, healthy and male!”(Chang and Eng p-23).

The birth of twins is fascinating and it is always celebrated. The news of their birth excites everyone. The moment they enter their world, they are welcomed with a way too much of importance and attention. Every moment of their life is looked upon with wonder and they gather everyone’s attention.

Jun dropped us to the floor with a crash. The midwife saw Chang and me as a single monster. (Chang and Eng p-25).

Conjoined twins though a category of twins, their inappropriate attachments make them look like monster. Birth of conjoined twins is a natural phenomenon that occurs when a fertilized egg splits and develops into two individuals. It is believed if the embryo splits after 13 to 15 days of conception and the separating process stops before getting complete and the resulting twins are conjoined. They should neither be considered as curse nor as an ill omen.

…the king wanted to kill the double – child, the bad omen (Chang and Eng pg. 38).

A society where the birth of twins is marveled and celebrated, conjoined twins though a wonder are sometimes defined as a curse. They are negatively judged and they have excessive fear of being closely watched and criticized in social situations. They are discriminated and marginalized in the society because of their oddities and they have to endure a lot of efforts to transcend the condition of their existence. Conjoined twins, from the moment they enter the world, face a myriad of social problems. As infants, toddlers and children’s, there is way too much of affection and even the joy of their birth is celebrated and specialized. Painful, loneliness and being ignored becomes the side effect of adulthood separations.
Conjoined twins face a myriad of social challenges from the moment they enter this world. Conjoined twinning is one of the most fascinating human malformation. Treating them can be a daunting challenge for the physician. With the advancement in technology the conjoined fetus can be detected before the gestation period through a MRI scan which provides greater details about their attachment and the organs they share depending on the type of attachment, physicians can decide whether separation is possible after the birth. In some case where it is unsafe to separate their attachments, physicians suggest for a legal termination of the fetus. Some uneducated parents, in their ignorance are unaware of such advancement. Anticipating their advancing struggles, the parents either kill or abandon their conjoined child.

Childhood:
Early on, Chang’s frailty didn’t make learning to walk any easier. Our little connector did not allow us to stand side by side. My brother’s chin nearly touched mine, day and night. (Chang and Eng p – 29)
Conjoined twins, by this time starts facing struggles in learning, writing and understanding skills apart from their physiological struggles. Conjoined twins are often born premature because of which their language and communication skills are delayed. If they are not premature also speech delays because they are the children of the same age and conjoined who have to fight for attention. The verbal delay is also because the more dominant of the twins makes a lead to answer the questions directed to them which demotivates the other twin to open up with his ideas. The conjoined twins have to suffer a discomfort and restlessness to cope with each other’s signs and language as well as from the society they live in.

Other developmental skills like interacting with the society and family fosters a competition-like one speaks well and is easily understandable while the other is less easily understandable. Sometimes health considerations can also account for developmental factors. Attention seeking becomes their strategy. The easiest way to stop a tantrum is to divert their attention. Taking them out for a change could work greatly. As there is a big deal of attention seeking storming within them. Outing may help in keeping them away from all strategies and stress.

Conjoined twins have a lot of issues to deal with the external world. Their internal issues should be prevented by disciplining them as studies shows that one among the two of the conjoined twins is dominant in many cases. He may outshines the submissive co – twin. They are to be taught to respect each other in every step and instantly seek apologies whenever they go wrong. If disciplining one child is a challenge then disciplining a conjoined twin is much greater than a challenge. So the twin rivalry should be cuddled in their childhood because if it corrected now it may take stronger roots later on.

Twins are also siblings and all siblings fight. Our society sees twins as soul mates, inseparable from the moment of conception, their happiness depend solely on the strength of their bond. The pressure to fulfil these cultural expectations may prove too much for some multiples, resulting in anger and resentment towards the one person they believe is holding them back – a co twin.

.Adolescence:
… But now my brother knew love, that unfathomable word I would never even have said aloud, like the untellable name of Rama or God Himself. I understood nothing of what lay ahead of us – of me – and a panic gripped my heart (Chang and Eng p – 62).

As their life diverge, it becomes more difficult to maintain a sense of equality and sameness. They struggle to be known and get noticed because they are always compared and related to each other. A struggle to overcome these comparisons and competitions develops a conflicts and tension prevails to maintain a sense of equality and sameness. When this occurs the submissive among the conjoined twins find it difficult to enjoy the success at work and relationships. They feel disrupted and guilty when they fail to keep the balance with their co- twin. They feel abandoned and betrayed when the paths of their lives diverge and change. Career choice is a major issue among conjoined twins as people think they have the same aptitude. Although they look similar, most conjoined twins are poles apart when it comes to making choices. Nonetheless, twins are subjected to constant advices from the people about the choices they make in their life. They need to compromise with their career choices and settle down with a mutual choice between them.

Conjoined twins have difficulties in handling conflicts they cannot move a part from each other after a fight or an argument. They always focus to win the arguments rather than agreeing or compromising on it with a fear that the one among them will become a center of attraction. Accepting each other’s differences and comprising in all situations will help them get along, unless, they cannot handle such situations of their own. Living a life a conjoined twins eliminates the possibilities of true privacy twins, especially conjoined twins appear to harbor more resentment towards one another as they grow older because they have worked diligently to establish a balanced and harmonious relationship over the cause of their lives.
Twins are also subject of misconception. Most of the twins eventually find a solution to overcome the issues among them. It is very pitiful that conjoined twins who are believed to be soulmates and best friends have a great difficulty in keeping up the basic concept of togetherness like compromise, empathy and above all the acceptance of differences. Offer as much privacy as possible, insist on respect for each other’s personal belongings. Never insists on sharing, as they deserve their own things.

Conjoined Twins’ Marriage Considered Unethical:
…Surely what they were protesting, I thought, was the idea that the husbands were one, the wives two. The Yates girls, it had been hissed, were after lustful perversion.

The throng’s murmur was now a roar.

Conclusions, not deliberations, propel action. Reason cannot bring strangers to one’s perception of the world. No dialogue can bridge the great divisions. Chang and I decided to fight (Chang and Eng p-132)
Chang and Eng have been the oddest of the odd to overcome the legal proceedings. They married the Yates sisters and fathered twenty – one children. It involved a great risk and consequences. Luckily for Chang and Eng the North Carolinians had no legislation forbidding the conjoined twins’ marriages.

Most countries of the world considers it unlawful and marriage is allowed only after a surgical separation. Marital relationship is something very private and should be a secret affair between a husband and wife. No other person can be involved in this. It is unethical for a married couple to have their intimacy in the presence of a third person. Hence it is unlawful for conjoined twins to marry. The chastity of a women is a matter of concern here. They are also denied their rights for marriage and some of them are forced into prostitutions. If someone were to marry conjoined twins, it would be considered as polygamy and marriage certificate is not granted in such cases.

A wife can be sexually intimate only with her husband whom she has married but in the case of conjoined male twins, she would be intimate with not only the one twin she consented to marry but also with the other twin in virtue of the twins’ shared body. So in consummating the marriage she and her brother-in-law would be committing adultery. On the other hand, if she attempts to consent to marry both twins, this would be considered as an act of bigamy.

Psychological Struggles
Mental trauma at their birth:
… Father looked at this crying twin boys and tried to vomit but produced no more than a taste of bile. He ran from us and cringed on the far side of the cabin (Chang and Eng p-24)
Conjoined twins have to face a lot of struggles both psychological and physical from the time of their birth to the end of their life hence conjoined twinning is not only a great challenge for the twins but also a great trauma for their parents
Advancements in technologies are of greater help to a conjoined twin’s mother to know that she is to have a conjoined child. From the moment she learns it, she develops a mental trauma. Conjoined twin’s parents has a great concern for their child to find an acceptance from the family, relatives and the society. Since they are considered as a curse and a bad omen their presence is avoided. Their parents are isolated from every family gatherings and society.

Caroline, born in a family of twins expected a birth of twins. Being told her twins were conjoined twins was more than shocking for her. Since then, tears never dried from her eyes. Frustration kept following her. Her husband took off. He never set eyes on his children (Karimi and Blessing) when they needed him the most. Caroline struggled a lot to raise funds for their surgical separation singlehandedly. Parents of children born with unusual anatomies do not possess the same unusual characteristics as their children and thus lack insight on the experiences of those with the anomalies. They therefore, are unable to understand what actions to take in this situation. In the past, there was discrimination against conjoined twins. While most people today do not have such primitive prejudices towards conjoined twins.

The following is a quote from the Lancet, as respected a medical journal then as it is today: “The monster here described was born at full term and survived four and a half days; its two components behaved as two separate individuals and died within a few minutes of each other”. 
According to the Research presented in the annual meeting of the European Society of Human Reproduction and Embryology parents of conjoined twins suffer more mental trauma as well as health issues than the parents of singletons. A good mental health during pregnancy is very essential for the growth and development of the fetus. But in the case of conjoined twins the parents suffers more depression, sleeping problems, social dysfunction and anxiety than the parents of singletons.

Parenthood for the conjoined children comes with a great responsibilities and it is more demanding for fathers and mothers of conjoined twins, since their parenthood demands an economic responsibility as well as a responsibility to be more available and to take part in infant care.

Childhood:
“Chang was taken off guard; he always managed to discount that we were
Miles apart in temperament” (Chang and Eng p – 19).

The comparisons, competitions, assumptions, and estrangement are quite obvious among conjoined twins but the struggle that these twins have to encounter takes a toll. Comparison not only make them angry about the one who is comparing them but also towards their counterpart to whom they are compared, Our society sees them as one but fails to understand that they are one with different characteristics. Treating them as two separate individuals would help. Allow them to explore their own interests and hobbies. Never insists the differences in their behavior as a way of shaming. Reward their good behavior to make them feel content and pleased. Get along with the twins to honor their accomplishments.
Most conjoined twins are characteristically different from each other, they have unique qualities. However, if one is better than the other, it creates a lot of problems for the other twin to cope with the constant competition. Parents, teachers and friends start comparing the two in terms of good and bad, which worsens with age. In fact there are times when this competitive feeling makes either one dominating or suppressive.

Estrangement is an emotional experience. If the anger between the conjoined twins is left unresolved it becomes difficult to bring it to terms later. No therapist can repair this fractured bond. Loneliness and underlying anxiety are common in all estrangements. Tension is left unresolved. They are not ready to compromise and come to terms. Estrangement that grows out of anger, disappointment and resentment is very complicate. Fortunately, twins who managed to get along and resolve their differences do not suffer from estrangement. Parents can play a vital role in developing the twins’ individuality and also their bonding.
Agreeing that their fights are normal and expected, can be a possible solution. Estrangement that is more disastrous is “twins with murderous rage” who cannot tolerate to be with one another because they have been totally pitted against again each other. Their roles of oppositions are so strong that any closeness is very short lived. There is no solution to end up estrangement and to resolve the endless fight.
Some twins are judgmental and are ashamed of one another because they receive negligence in parenting. Although out spoken and well-spoken the conjoined twins use up all of their strategies for fighting to change the other’s point of view and to finalize who is right and who is wrong. As they grow into older years they can accept that they are disconnected. Regret about estrangement can be less profound because of insight and acceptance. Parents have to work on the individual development and twin attachment supporting one another is not treacherous or burdensome as it is with estranged twins. However, deep trust and easy communication can make a difference. Install the value of co-operation and not competition. Involve them in teamwork.

Isolation:
Hunter brought us to a place known as up- town, a landscape of isolated farms… (Chang and Eng p-172).

The difficulty and struggle of being in a monitoring position after being the center of attention is clearly challenging for twins. Dasha and Masha, Born in January 1950, were hidden from public view since both and subjected to a verity of medical experiments. Their delivery was by caesarean section. On awaking the mother was told that her babies had died shortly after birth. This was a lie by Stalin’s Soviet Medical authorities who indeed took the girls away to a medical institute in the Moscow region to be experimented. They were isolated from the society. The doubles need to have a good co-operation and understanding to avoid psychological problems with themselves. They are looked upon with amazement but as days grow people start losing interest. As a result the adult twins suffer solitude.
Conjoined twins feel a responsibility towards the welfare and happiness of their co twin. Uncomfortable with the role of guardian many twins pull away distancing themselves from their co twin.

Dominance and Submissiveness:
I represented a shudder of annoyance; I always noticed things before he did. If ever trouble made Chang react, I had already responded moment earlier, the way a flash of lightning precedes the dull boom that rushes to catchup with its skin. (Chang and Eng p 36)
The twins could not be more different on the inside. As their personalities grow, the difference between them becomes more apparent and it feels inevitable that only one can emerge at the top of the twin’s pecking order.
The challenge with the twins is that one among them is a dominant and the other a submissive twin. The dominant twin will continue to speak for the other sibling and his decisions rules. Psychological dominance enforces opinions, mannerism and the dominant twin decisions it through manipulation, it is the one to worry about. It has been studiedthat if psychological dominance continues into adulthood, the submissive is more likely to suffer from depression and other psychiatric problems such as anorexia, but it’s not a plain sailing for the dominant either.

As language develops, it’s common for one twin to talk for another. The verbally dominant twin may respond to questions directed to the co – twin and they may ask questions and explain situations for their submissive partner. The submissive can become dependent on this verbal crutch, leading to delays in his own speech development. The dominant twin would learn he could take things away from his brother without consequences and the mellow twin would learn that he wasn’t safe from his brother. The conjoined twins’ parents have to cuddle with both and not let the aggressive twin to suppress the other.

Physiological Struggles
Childhood:
Whosoever has been a Christian child and yet no and again
wanted to take to one’s heals and hasten off on the double quick;
whosoever has thought it about unbearable, at least once toward
evening in November, to stand pat, attending to his business and
the like – he will understand the wanderlust agitating the yellow
blood of the baby Siamese Twin– Monster. The Bound – Duo were
toddling by the entry to their floating skipper when they
were beguiled by some Oriental music from a theatre drifting
by; the Double – Boys embarked toward it, and fell, in a topple, into
the river directly. Thrashing about like the oddity they are, the
Twins have made a quite a fanfaronade! The crew of an
aquatic laundry eventually came to Chang and Eng’s salvation,
and the Twins were evermore attracted to music! (Chang and Eng p – 30)
The foremost physiological challenge that any conjoined twin faces is the shape and structure of their body. They are attached to each other in many different ways. They are looked down and degraded for their oddities. They are laughed at, locked up and hidden because of their appearance. They are considered as an ill omen and are either killed or secluded from the society which is more difficult than the physical death. Living life as a conjoined twins completely eliminates the possibilities of true privacy. It is often the physically small, sickly type that becomes the submissive. Perinatal complications appear to be predictive of submissiveness. Many studies of sibling’s interactions among twins indicate that twins are asymmetric in their relationship and enact complementary roles relative to one another.
The conjoinment effects the mental processes for those twins who are connected at their heads. When one of the twins is hit or pricked the other could feel the pain. Their body sensors work together if they have a single brain and when one of the twins write the other is stimulated by the anticipation of words. The other type of conjoinment where they are attached from their waist, it is seen that if one of them suffers a stomach pain the other can also feel it.

An infant conjoined twin struggles to coordinate with each other in order to accomplish simple and basic chores such as crawling, sleeping and eating. Physical activities like walking, running, playing, and swimming must be a joint team effort. Abby and Brittany, conjoined twin girls can also type on a keyboard at a normal rate and drive a car. However, because they are considered two different people, they each have their own licenses. They went for their college degrees and each has their own certified teaching degree from Bethel University.

Exhibitions and Experiments:
Together with the casual visitors there were relays of professional skeptics-doctors ,newspapermen-who stepped up into our cage , not content with the dim lighting, like near sighted proofreaders getting as close as possible. From the front of our cage hung a large and gay placard that read THE MONSTER (Chang and Eng p-176)
Dasha and Masha, Born in January 1950, who were hidden from public view since both and subjected to a variety of medical experiments. They were burnt, frozen, kept forcibly awake, starved, injected with radioactive and other harmful substances and electrocuted to test their conditional reflexes. In one experiment scientist would prick needles in one twins and access the other for reactions, toss one into a tub of ice Water and check the other’s body temperature. They were offered nothing of the love and affection that most children’s get. The difficulty and struggle of being in a monitoring position after being the center of attention is clearly challenging for twins. They are looked upon with amazement but as days grow people start losing interest. As a result the adult twins suffer solitude.

The twins become a medium of entertainment for the people but their own life turns from miserable to impossible .Their end is always a tragic one – fatal and pathetic. The Fate of the conjoined twins was usually to be exhibited to the public. It was the easiest way for them to earn their living. In many cases it so happened that they are kept away from the parents for experiments which is sometimes fatal and inhuman.
“Mille and Christine” were sold by their father when they were ten months old, fourteen months after the original sale, they were sold to showman – Brower. They were called “Two – headed Nightingales” for their singing and dancing abilities and where exhibited state fairs. Brower was conned by a Texas adventure, who abducted the girls for his show business. They were handled by several managers till the “Emancipation proclamation” ended their slavery (Page 6 History of the two – headed girls). While such exploitation is unlikely today in most societies, being conjoined draws obvious public attention, and it is likely that if they had been born today, they would have been separated.

Initially Chang and Eng suffered in the hands of many agents who exploited them for their financial gains but they used their mysterious origins and physical anomaly for profit, creating considerable wealth from the deliberate and self-orchestrated display of their bodies before audiences around the world. Conjoined twins were considered as freaks in the past and were confined only for exhibitions and show business and their basic humanity was foregrounded. They had a feeling of bodily insecurity and vulnerability .While in the past many individuals judged to be corporeally deficient have escaped life-threatening attempts to normalize them because they could not afford the costly surgeries . Even if one of the twins is dead the other refused to be surgically separated from her deceased sibling, even when this procedure had a fairly high likelihood of success and the failure to undergo the procedure signified certain and imminent death.

The most famous example of this willingness to die together rather than to live on without one’s conjoined twin, is the so-called Bidden den Maids who were born in 1100 and lived for 34 years. “When one died” Dreger tells us, “the survivor refused offers of separation, declaring, ‘As we came together we will go together.’ This sister then died six hours later.” (The Wall Street Journal, 7/9/03)
Conjoined twins’ Oddities:
… taking a seat without breaking the chair, reaching for something just beyond my grasp and not being jerked backward, and, much later, making love – these seemed like locked doors before we build our own passkey. I have seen two rummies trying to support each other in an attempt to get home unscathed, and I doubt that act is as difficult as it is simply to move when you are the “Siamese twins,” unequal in height and temperament. I was always a little taller.

The Bunkers represented more than who and what they were as actual people. The twins came to represent unity from difference for many reasons, one of which is that even though they shared a body, they were far from identical individuals. Each of them possessed many discrete traits that opposed those in the other in important ways. Chang Bunker was friendly, outgoing, alcoholic and shorter in stature and had a temper while Eng was a quiet, withdrawn teetotaler with wider intellectual interests. One body, two individuals and their differences extended to different physical peculiarities and reactions to physical stimuli, a fact that fascinated everyone around them.
Even in terms of their shared traits and identity they repeatedly confounded public assumptions about their origins, physical abilities and social selves. But they took hold of their own lives, and ultimately assumed considerable class privilege where they married white sisters, had 21 children between them, operated a family plantation and owned slaves themselves.

The Bunkers upended that practice as well, hiring their own managers, running their own entertainment enterprise and benefitting financially from their own business. Possessed of some qualities that could have left them economically marginalized and socially dispossessed. These exotic, ‘disabled’ oddities used other qualities to become agents of their own success whereas the fate of other conjoined twins in the history was confined to show businesses and prostitutions.
Conjoined twinning is considered as a human abnormality that generally arouses deep fears, trembling experiences and melancholic fascinations for all human beings with no oddities.
As a result the conjoined twins have to encounter a great deal of challenges from the society for their individual personhood. Chang and Eng, the most famous in the history of conjoined twins have been a classic example to prove individuality of conjoined twins by living a normal life despite their oddities. They remind us that their oddities are not their disabilities.

In the present scenario where everyone wants to look good and compete for the same it’s very tough to for conjoined twins to live with such physical oddities and to exist as an individual personality. Parents and the physicians play a very important role to give them a normal and a most deserving existence. We all know how it feels to be judged or judge ourselves based on appearance and the challenges we face in varieties of ways because of our physical realities. We alter some of our physical selves through diet, exercises and plastic surgeries. By doing so we get a happiness and contentment. But conjoined twins lives their complete life with their oddities.
Desire for being loved:
Veena and Vani born in Hyderabad, where abounded by their parents, after the doctor said an attempt to separate them would kill them. Living a life a conjoined twins eliminates the possibilities of true privacy twins, especially conjoined twins appear to harbor more resentment towards one another as they grow older because they have worked diligently to establish a balanced and harmonious relationship over the cause of their lives. As their life diverge it becomes more difficult to maintain the sense of equality and sameness. When one among the twin becomes the center of attraction or loved more for their wit, liveliness and for being extrovert the discrimination of other twin gives rise to twins rivalry, twin’s egotism and twin’s murder. Parents can divert any conversation from relatives who compares their physical appearances or any destructive traits to their self- esteem and relationship.

Being the same age and same sex, Conjoined twins are grouped together. They often share a bedroom, a classroom and same friends. They never get a chance to do anything without their co twin. And when they are unable to articulate need for space, they desire to break free from living life as a pair, it can manifest itself in other ways such as resentment towards the other. Twins lack privacy and the chance to fly solo. Sharing parental attention can create deep insecurities and a sense of inadequacy. Twin closeness with each other provides harmony. Although, twin fighting is very common, some fights which can turn in twin’s estrangement is painful and troubling. Parent’s love and affection can provide barrier against this. Twin teenagers feel the sacrificing of their privacy and sibling’s rivalry in sharing the love of their parents and friends.

Conjoined twins are viewed as entangled singletons and the intention to physically separate them suggests that the primary aim of medical intervention should be separation. Of course, this may not always be possible, as in the recent case of Courtney and Natasha May it was discovered that in the utero the two had separate umbilical cords leading to the placenta, separate arms, legs and head, but to share a four chambered heart, which was distorted and slightly larger than normal. Their parents had originally decided on separation, sacrificing Courtney. In the event, after birth it was decided that the operation was not feasible. In Jodie’s and Mary’s case, this view of separation as a benefit in its own right adds weight to balance the bad effect of Mary’s death. Every conjoined twin has a desire to be loved and accepted by the society and their near ones but when their affection is not reciprocated it demotivates them and they lose all of their strength to withstand the society.

CHAPTER V
PHILOSOPHICAL AND ETHICAL ISSUES OF “CHANG AND ENG”
Surgical Separation:
“We must”– the surgeon furrowed his brow – “hang the boys for ninety days across a cord of fine catgut.” The physicians ignored Mother and Father’s confused interjections, and said “this will be the positioned at the centre of that connecting ligature so they will dangle like a pair of saddlebags” (Chang and Eng p – 28)
Surgery to separate conjoined twins has advanced to a stage where many twins who historically had to remain connected or die can now be successfully separated. However, this is not universally the case, and conjoined twins raise fascinating philosophical and ethical issues. They can be joined anywhere at the head, chest, abdomen, hips, and so on. More importantly, there is a whole spectrum cases with different degrees of bodily overlapping.
The twins can be joined by a thin sliver of skin or they can be extensively fused. The “fusion” can be so extensive that in some cases, it is no longer correct to talk about “twins” because there is only one individual with some extra organs. When the organic overlap is insignificant, they can be easily separated by a surgery, which is indicated by the fact that the first recorded separation of conjoined twins in which both of them survived occurred as early as 1689. When the overlapping is relatively slight, this is likely to impoverish the life-prospects of the twins to a comparatively smaller extent, and surgical separation of them is probably easy.
Conjoined twinning is one of the most fascinating human malformation. Treating conjoined twins can be a daunting challenge for the surgeon as well as anesthesiologist. There are numerous conjoined twins in today’s society. Surgical separations occur more frequently and with greater success than before. Surgery to separate conjoined twins may range from relatively simple to extremely complex, depending on the point of attachment and the internal parts that are shared.

Most cases of separation are extremely risky and life threatening. In many cases, the surgery results in the death of one or both of the twins, particularly if they are joined at the head craniopagus. If future medical investigation reveals that the girl’s conjoined state does in fact pose a threat to the life of one or both them, such that both would die if they are not separated but that only one could survive separation surgery, the question of consent becomes more complex and other issues need to be considered.

If the twins are minor and the decision rests with a court, judges would have to consider the lawfulness of the proposed operation. If the twins are adult, their consent may be irrelevant. In India, as in England and Australia, the fact that person has consented to being killed does not alleviate the person who causes the death, including doctors, from criminal responsibility to homicide. Therefore, even if one of the sisters consent to being killed so that her siblings could survive, the death of the sacrificed twin would still raise the possibility that doctors who perform the surgery could be convinced of manslaughter. If the twins were opposed to sacrificial separation surgery, doctors could face murder charges. Section 97 of the Indian penal code 1860 permits self – defense to be used only in response to an offence to the person.

The English doctrine of necessities incorporated into Section 81 of the Indian Penal Code but the element of the defense are not the same Further, Section 81 states that there is no intention to cause criminal harm and also that this section has no application to sacrificial separation surgery. Therefore, if the conjoined twins themselves were to consent to surgery that would be a sacrifice of one to save the other, criminal liability for homicide on the part of the doctors is a live issue. There is also a possibility that the surviving twin could be charged as an accessory. A future possible impediment to sacrificial separation of twins is the right of life. The constitution of India would mean the court is “duty bound” to save the life of one twin, against parental wishes. This suggests that the right to life to mandate the sacrifice of one twin is at odds with the broad interpretation given to the Article by Indian judges.

In a series of cases, the right to life has been extended to include a right to good food and a right to a pollution – free environment. Article 21 enquiries that no – one shall be deprived for his or her life or personal liberty except by procedure establishment by law and this procedure must be reasonable, fair and just and not arbitrary, whimsical or fanciful. Article 21 guarantees the protections of life “and by no stretch of the imagination can extinction of life be read into it”. It could be argued, therefore, that Art 21 might forbid sacrificial separation surgery and that it would not compel the active killing of one person to save the life on another, In a medical context, an omission to provide treatment, that is where treatment is withdrawn or withheld can be lawful, but the positive act of killing, even if done with good motives, is not.

The apparent readiness of the judges to sacrifice one twin is surprising in a country where judges have been discreet to declare lawful the withdrawn of life support from patients in a persistent vegetative state. It was only in 2011 that an Indian court took this step for the first time and declared that it would be lawful to turn off the life support of a patient who had been in a vegetative state for nearly 40 years. Doctors are allowed to carry out a mercy killing to end their sufferings if no funding for their treatment was forthcoming. Further, judges would need to address the fact that sacrificial separation surgery involves a positive act on the part of the doctors, and until now, a death that is caused by a positive act on the part of the doctor has been regarded as unlawful. If the conjoined twins and their parents are opposed to separation, there will be a need for compelling reasons for a court to override them. Even if the twins and their parents did consent to surgery that could save only one twin, the criminal law obstacles may be challenging.

The argument from separate mental lives had three claims. Talk of private mental lives is a first claim. A private mental life is one that isn’t shared, and no mental life is shared even if there is only one person there. The first claim in the case of conjoined twins Abigail and Brittany should be that Abigail has just one mental life, realized exclusive in one brain, and Brittany likewise has just one mental life realized exclusively in another. Since they have different mental lives, it follows that they are two peoples. But to assert as a premise that each person has her own mental life different from that of the other is to assume the point at issue, namely that there are two people. If people were animals and Abigail were Brittany, neither would have just one mental life. And the argument provides no reason to dispute this.

The second claim, that each twin feels sensation on only one side of her body, also presume that there are two people, each with different sensation. Otherwise no one would feel sensation on only one side of her body. Again there is no reason left to think otherwise.

The third claim, that each twin has exclusive control over the limbs on one side of her body, is in fact consistent with their being just one person: no limbs are under the joint control of two peoples. The intended claim is that each twin can control the limbs on just one side of the body. But that again assumes the point of issue.

The related thought is that the twins could be separated: one head could be removed and attached to a new torso and set of limbs, leaving that other in place. If the operation went well, the result would be two people even animalists will agree, as there would then be two organism. And both twins would survive: the operation really would separate them, rather than creating a new person. But the two resulting people cannot both be the original organism. Since one thing cannot be identical to two things. Someone might have argue that the twins could have separate interest.

Medical complications threaten the organism’s life, and the surgeons can save it only by amputating one of the heads, but one head is less robust and the operation is more likely to succeed if that one goes. It may be in the interest of the organism as a whole, and of the person with the stronger head, to have the weaker head removed. But if the one with the stronger head and the one with the weaker head have different interests, they have to be different people. If there is only one person there, it is presumably in her interest to have the weaker head amputated. She may believe that this goes against her interest, with this thought realized in the brain the surgeons want to amputate. It would be based on the belief that the operation will kill her. Both beliefs would be understandable.

According to animalism both are false, just as her belief that she has only one head and is one of a pair of conjoined twin is false. It is in the interest of the person with the weaker head to have that head amputation, because she is also the person with the stronger head. Although she may not realize it, she is going to survive, and no one is going to die.
The surgical separation of conjoined twins present challenge and undoubtedly requires a multidisciplinary team. An unequal external unions, especially in the right – sided twin, mandate through education of the anatomy of conjunction before planning the surgical procedure required to separate and individualize the twin. The first successful surgical separation took place in 1689 and more than 1200 cases has been reported in the literature by 2000.(Original Articles on Conjoined Twins September 2006, Vol 96, No 9 SAM)
When separation is feasible with a reasonable chance of success it should be carried out. When surgery is not possible, custodial care should be offered and nature be allowed to take its course; where one twin is dead or has a lethal abnormality and cannot survive independently from its normal twin and if not operated both the twins could die, separation to save the healthy twin should be attempted. To maintain hemodynamic stability, blood volumes transfused ranged is from 10% to 450% of the estimated blood volume.

Blood loss could be especially extensive in Thoracopagus and Ischiopagus separation, and relative changes in position of the two infants during surgery leads to significant shifts in blood volumes. Owing to cross – circulation, pharmacokinetics and pharmacodynamics are inconsistent, especially in Thoracopagus twins, and altered drug response must be expected. Anticipated problems after separation include respiratory insufficiency, hemodynamic instability, fluid imbalance, temperature control, sepsis, wound closure and residual organ dysfunction.

Major factors that will govern successful separation include the order of separation, the distribution of organs between the twins, meticulous aseptic surgical techniques, the reconstruction of divided organs and structure and wound closure. It is also necessary to distinguish between structures that are shared by both twins and those belongings only to one to one of them. Allocation of shared organs usually involves the anus, rectum, genitourinary tract, lower spine and spinal cord. Unexpected anatomical variations are often encountered, including previously unrecognized cardiac, gastrointestinal, hepatobiliary, spinal and genitourinary anomalies. Operation time is prolonged with the separation of the more complex thoracopagus and Ischiopagus twins, where it is in the order of 7–13 hours and 13-19 hours, respectively.

The surgery to separate conjoined twins seeks to physically disjoin monozygotic twins who were born connected in one or more parts of their bodies. The earliest records of an attempted separation have been documented in Constantinople in 945 A.D; however, the first successful separation of twins, who were bonded by a band of flesh, occurred in 1689 in Germany. Since then, it has been a rare procedure.  Because twins are often bonded in complicated ways, and share body parts and organs, separation surgery is difficult and in some cases, impossible. In addition to strict medical reasons for undergoing separation surgery, parents of conjoined twins have opted for surgery based on psychosocial reasons.
The fact that separation surgery is strongly encouraged as the norm for conjoined twins raises fundamental moral questions. An attempt to create individuals who are “normal” by the standards established in our society often hurts the conjoined twins by creating “terribly incomplete individuals. As a result of surgery, twins are frequently weakened. They may lack some of the body parts possessed by ordinary individuals and are forced to struggle with disability and chronic health issues.  Thus, the desire to create “normal” children who fit into society must be considered along with the physical harm that the separation surgery will almost certainly cause.

Another moral issue raised by this contested surgery concerns the autonomy of the children on whom the surgery is being performed. The consensus among surgeons mirrors the philosophy of Heinz Rode, a pediatric surgeon at Cape Town Children’s Hospital, who stated “that Siamese twins are born to be separated. However, this view ignores the desires of the conjoined twins themselves. It is unclear whether conjoined twins, if allowed to remain as such until the age of consent, would decide to undergo this highly invasive procedure. In fact, there has only been one case in which the pair of conjoined twins, Laden and Laleh Bijani, who were allowed to make the decision when they reached the age of maturity in their country, chose separation surgery for themselves. In recent years, it has become the norm for parents to immediately request separation surgery in order to save their children from isolation.

Nonetheless, the issue of patient autonomy is an essential one to consider. While the parents of conjoined twins are responsible for their children’s well-being, unless one or both of the parents had at one point been conjoined and undergone separation surgery, they can never access the personal, physical experience of being born conjoined. While parents may be tempted to follow what most others have chosen before them – separation surgery – their decision will not take into consideration the actual desires of their conjoined children. Separation surgery at this early stage in the children’s lives will rid the children of their human agency, disallowing them to make one of the most intimate, personal choices a human being can make.

One commonly presented rationalization is that it is morally permissible to save the life of one twin by sacrificing the weaker infant when the weaker twin will succumb to complications caused by its physical frailty. The surgery is therefore justified because at least one of the twins will be saved, whereas if the surgery is put off, both of the twins are likely to die. By carrying out the surgery, the doctors attempt to make the best of a difficult situation and are providing the parents with at least one healthier twin. By forfeiting the life of the other twin, the doctors are also preventing the inevitable suffering that the twins will incur when their health deteriorates due to the burden of the sickly twin.

Separation surgery requiring the sacrifice of a twin can be compared to the following thought experiment originally presented by Raanan Gillon. In this hypothetical situation a set of twins is born, and one of the twins, who possesses both a healthy heart and lungs, will unavoidably die in a few months regardless of intervention for other reasons. The other twin has a feeble heart and poor lungs, and will also die unless she is provided with a compatible heart; however, only her identical twin’s heart and lungs are compatible. Some individuals believe it is appropriate to sacrifice a twin who will inevitably die. Thus taking away the small amount of time he or she has been given to experience life, in order to save the other, healthier twin. However, it would be outrageous to entertain that this is permissible in the case of identical twins, who are not conjoined, invalidating the use of this logic on conjoined twins. Human life has intrinsic value, and thus it is morally impermissible to kill one person in order to save another. Despite their physical bondage to one another, conjoined twins are two separate human beings and therefore, there is “no reason for treating them according to a unique moral framework simply by virtue of their conjoinment.

Surgery in cases where there is no urgency is often further justified by stating that it is morally impermissible to deny parents to chance to “normalize” the appearance of their conjoined children by having them undergo separation surgery. Parents legally exercise complete authority over their infant children in every medical situation, because in most societies, children under the age of 18 are judged to be incapable of making an informed decision concerning any medical situations they face.  This applies to decisions of conjoined twins regarding whether they wish to undergo separation surgery. 
Separation surgery is encouraged as the norm for twins born conjoined, especially during the first few months of the infants’ lives in order to enable the siblings to “assimilate into the world of the normal. In most nonemergency separations, the main reason for undergoing the surgery is not physiological. It is the desire to make children who have very unusual anatomies look fairly usual, thus freeing them from the stigma of conjoinment and enabling them to enjoy aspects of life they would otherwise be unable to enjoy. Because the parents are trying to improve the quality of life of their children, and shield them from ridicule and torture, it can be argued that when surgery is performed in non-emergency situations and it is expected that they will not suffer from long-term health repercussions, the surgery is morally justifiable.

The denial to the earlier discussed objection is that separation surgery is not always pursued by parents as a result of their act with the welfare of their children. Parents strive to make sure their conjoined twins undergo separation surgery so that they can resolve their own identity crisis. According to Dreger- A Historian “they seek surgical fixes because of the genuine anguish they are feeling about their own identities” as parents. Because of these parents’ limited experience in dealing with other children possessing unique anatomies, they know only how normal parents are supposed to behave, but they can’t be normal parents, if they do not have a normal child”.

Additionally, most conjoined twins who have been given the chance to grow up and decide if they wish to have surgery performed, do not choose normalizing surgeries for themselves and report being comfortable in their bodies. When asked, they even say that their usual state is preferable. Although it may be tempting to say that conjoined twins feel this way because they have adapted to their situation and that they would have lived more fulfilled lives had they been separated.

We should be reluctant to dismiss or second guess the self-appraisal of people with lives that differ greatly from our own, both culturally and anatomically. People can live fulfilling lives in a variety of circumstances, so it should not be hastily concluded that conjoined twins will live terrible lives due to their condition. People born without this condition have no knowledge of what it is like to live as a conjoined twin. This lack of knowledge may lead society to jump to conclusions that are not necessarily true, as can be witnessed by the testimonies of conjoined twins, who have not been separated at birth.
Accounts provided by the conjoined twins themselves highlight their happiness despite their unusual situations.  Surgery to separate conjoined twins, in cases where postponement does not put the lives of either of the twins at risk, should be deferred until the twins can make their own informed decision.

Moral Arguments:
…Though our situation seemed immoral and shocking to the outside world it was through what we would we certain to remain pure (Chang and Eng p – 150)
Generally, a normal human being can be either good or evil at one time. They have different and individual qualities. They are responsible for their actions. As far as, conjoined twins are concerned they can be a fusion of opposite, where one of them can be a good and generous person that generally leads to kind action contrary the other can be a selfish and a wicked actions. These wicked action shatters the good actions. In such actions an innocent person is blamed for no reason.
If there is just one person he is at once good or evil. He has utterly two different characters. He can see his counterpart doing wrong but could not get rid of his behavior. There are two characters one guilty and the innocent. Hence it is unjust for someone to bear the consequences for the wicked actions that did not result from his character. This appears to hold an innocent person responsible for actions he had nothing to do with. They suffer an inner conflict. Their twin vibes which allows them to feel each other’s joy and pain and even communicate each other without words does not allow the good to come out. The negative vibes overloads the good vibes here. This twins experience an emotional degradation because of their difference in their character.
It is a fundamental principle of criminal law that only those found guilty of offences should be punished. In many instances where conjoined twins have fallen foul of the criminal law both twins were equally involved and could be charged as principal offenders. So, for example, Chang and Eng were arrested for assault in Alabama when they came to blows with a doctor who tried to examine the band joining them in front of a crowd. The twins were fined $350, but the charges were dropped. They were also fined $200 after they lashed out at a man who was harassing them. However, any sentence meted out where only one of the twins was involved in offending usually affects the innocent twin as well.

Another fundamental principle in western law is that a person must be convicted of a crime before the state can deprive him or her of his or her freedom. Imprisoning a guilty twin would require imprisoning the innocent twin as well.

On the other hand, it could be argued that the innocent conjoined twin is no different to the innocent family members of criminals who are executed or jailed for lengthy periods. However, it is one thing to recognize that innocent family members can be harmed when a family member is jailed. It is quite unreasonable for the authorities to put someone in jail for a crime that he or she had no part in. Indeed, the innocent twin could potentially bring an action for false imprisonment.
A magistrate tasked with determining whether a man, who had been struck by Chang Bunker after the man squeezed Chang’s hand too hard, was clearly aware of this. The man applied for an assault and battled. The magistrate told him he could have one for Chang, but if he arrested Eng, he would be subjected to a false imprisonment charge. The Bunkers were joined at the chest by a band of fibrous tissue. In the end, perhaps allowing both to go free is the only real option. This is what the court did when Lucio and Simplicio Godina were arrested after the car they were driving hit a street cart in Manila. In this instance, Lucio was driving a custom-designed car. He was sentenced to five days in jail but Simplicio argued that he was an innocent man and therefore could not be jailed. The judge let both go free.

Most conjoined twins develop their own secret language. To outsiders it sounds like babbling but the twins comprehend it with perfect clarity. Some conjoined twins can even hear each other’s thought. They have same thought and feel the same emotions. In cases where the twins are joined at the head they can often hear one another’s thoughts. This becomes problematic when one twin is thinking ill about the other one. Suppose one of the twin is generous and good and the other is selfish and wicked in simple words if one brain realizes good character that generally leads to good character while the other realizes a selfish character that often leads to wicked actions who has to be blamed.

Ethical considerations which need to reconcile the best options Ethical consideration, which need to reconcile the best options for the twins and their parents, are playing an increasing role in present day decision making. Sacrifice of one twin because of inability to sustain life alone is the controversy that evokes the most anguish. The decision on whatever is rendered more complex by those surviving living conjoined twins who have consciously elected not to be separated and report that they have lived socially acceptable lives.

Being conjoined does not necessary negate individual development. Religious views may only support minimal surgical interface, especially when one twin will be sacrificed at surgery. We cannot accept one baby must die so that the other one may live. ‘It is not God’s will’, which differs from the legal opinion but the conditions for ownership of organs and the justification of removal of organs for transplantation which causes the death of the donor raise questions concerning when, if ever, it is morally acceptable to sacrifice one of us to save another. If the requisite surgery is easily accomplished and risk-free, there is a strong moral reason for performing it, since this will probably enhance the life-prospects of the twins still further, because being conjoined in all forms brings along some disadvantages, such as reduced privacy and exposure to public curiosity.

It is, however, customary to qualify the act-omission doctrine with the doctrine of the double effect which declares it morally permissible to kill or harm a few of conjoined twins in the process of saving or benefiting a greater number of them. Thus, the doctrine of the double effect claims that there is an important moral difference between harmful effects which are intended by the agent as means or ends and ones that are merely foreseen but unintended.

According to common sense morality, we do have a right to defend ourselves from threats of our lives, by intentionally killing the aggressors, not only if they are responsible for the assault on our life, but even if they are innocent agents who threaten our lives without being responsible for doing so. But, first, it is controversial whether, if the threats are innocent, third parties have a right to interfere on behalf of the victims and kill the threats. It is arguable that only the victims themselves have this right; third parties should remain passive and let they have fight it out between themselves.

None of the conjoined twins has a stronger right to the shared organs which are insufficient to sustain the life of the brains and minds of both of them. These twins are like two drowning individuals who are both clinging to a plank which is incapable of supporting both of them. Neither of these individuals is in the process of killing the other, and it is no more morally permissible for the strong one to push the weaker one off this plank than it would be for the stronger one to rob the weaker one of a plank that she has acquired in order to save her own life. It is still less permissible for others to help the stronger one to act in these ways. 
So, we can’t see any reason why the separation case and the transplant case described are not morally permissible. If the conjoined twins believe that they have absolute rights to their bodily parts which makes it wrong to their consent, whatever the consequences may be, then neither operation would be permissible nor the separation. But if they believe that these rights are not absolute, but could permissibly be set aside without their consent if the consequences are good enough, then both operation and separation could be permissible.

In the case of Conjoined Twins-Mary and Jodie, the consequences of depriving Mary of the use of the healthier heart—to which she has a shared right when she is a conjoined twin and a sole right when she is a separate twin—are overall reasonably good enough, since it does little to reduce her life-prospect, but a great deal to enhance Jodie’s life-prospect (The Journal of Medicine and Philosophy-Oxford University Press)
Since there is no homogeneity regarding the conditions of potential separation surgery cases, several factors must be taken into consideration when determining if such surgery is prudent.   There are four distinguishable categories of cases that are likely to arise in the consideration of separation surgery, and the moral permissibility of surgery varies based on the circumstances within each class of cases.
The first is an emergency situation: separation surgery is performed because medical personnel have determined that, without immediate medical intervention, both twins will die immediately. In these circumstances, the doctor undertake all necessary measures in order to save at least one of the infants.  If medical personnel have determined that only one of the infants is dying, measures must be taken to save this twin, even if the other is healthier. Regardless of the circumstances in this case, saving one of the twins should not be done at the expense of the other. Instead, the doctor must first attempt to separate the twins in a way that gives the twins equal chances of survival. However, if the situation is becoming dire and the chances of saving both the twins dwindle, the surgical team redirect its effort in an attempt to save one of the twins’ life. The other three cases are considered when the surgery is performed in non-emergency circumstances. In all of these non-urgent cases, it is morally incorrect to perform the surgery. 
The first of these classes of non-emergency cases involves conducting a separation surgery in situations in which medical personnel have determined that it is likely that one of the twins will be saved at the expense of the life of the other twin. Such a surgical procedure is ethically impermissible because questions that arise as to which twin should be sacrificed for the benefit of the other. In many of these surgeries, the more robust twin – the twin possessing more of the internal organs – is slated for survival. It is morally wrong to select one of the twins to be saved by receiving all of the organs that were meant for the pair of infants.

Conjoined twins are born to share the intertwined body that they have been given. Multiple religious texts including the Talmud, the central basis of Judaic thought, state that one may not commit murder for self-preservation. If we take the modern egalitarian perspective that all lives have equal value, killing one twin in order to save the life of the other twin becomes immoral since the life of the more robust twin has been placed on a higher level than that of the less robust twin.

The second non-emergency situation addresses cases in which a separation surgery is performed on twins both who have a good chance of survival but will suffer from tremendous disabilities and chronic health issues after surgery. The ethical impermissibility of surgery in these circumstances becomes particularly evident when it has been observed that nonemergency separation surgeries almost never improve the health of either twin. In fact, they often leave the children’s bodies at least temporarily and often permanently- much more ill and impaired than before and they may significantly reduce life expectancy.
Surprisingly, surgeons define a separation surgery to be successful if it results in the mere short-term survival of at least one twin. Such a conclusion is fundamentally flawed as there are a multitude of examples wherein twins were left with severe health and quality of life issues post separation surgery thus calling into doubt the “success” of the surgery.  For instance, the results of one such “‘successful’ separation left one twin with no legs and stomas for stool and urine. In another each twin had one leg, genitourinary and gastrointestinal complications and was growth retarded. Such examples highlight the moral impermissibility of performing surgery in these cases.

The third and final non-emergency category of cases concerns when separation surgery is performed resulting in the survival of both of the twins without the outcome of significant health issues later in life. In such cases, the decision whether to undergo surgery or not must be awarded to the conjoined twins. In cases where waiting does not risk the life of either twin, the presumption should be to accept surgery until the twins can decide for themselves whether or not they would prefer to be separated or remain conjoined.

Although this justification for surgery may seem logical, it is inherently immoral to sacrifice a weaker twin in order to save the life of the healthier twin. There are two outcome possibilities in such a surgery. If the surgeons decide to save the more robust twin, they intentionally end the life of the feebler twin and harvest his or her organs. If the surgeons, together with the parents, opt to not interfere with the conditions of either of the children, they end up passively killing them both by allowing them to die. Although society considers it morally troubling if doctors do not attempt to perform a surgery when they are able to save one twin, it can also be observed that they are simply allowing nature to run its course and are refraining from performing the surgery on the grounds of incompetence. Therefore, because the surgeons lack the ability to save both of the twins, they are not justified in killing one of the twins in order to save the other.

Foreseen Death:
Eng lies on his side, facing Chang; his finger find the wrist where the pulse would have been. Legs and forearms are twined beneath the quilt, Eng spasmy and prickling under their weight. He tries to pull free and his double dances with him – Chang’s head flops about like the head of a rag doll. Eng collapse back, feeling each hair on his body acutely, and all the sweat underneath his wedding ring. Eng is alone. The smell is asphyxiating. Time is a fish caught in their father’s nets.

Eng rubs his brother’s chest as if Chang simply is cold. The bedsheet falls to the floor. Eng hits him with a close fist, but Chang’s breast will not rise. Eng is certain his own soul will go to heaven, but the fears his brother’s is destined for elsewhere.

Eng’s life full of leering faces, slander, and unlikely love begins to recede. Like an exile looking upon his native city as be sails away into darkness, he is seized by memory, it being the wondrous strange hand pulling him back to the fading shores of his past.

“We have decided,” I said angrily, “that we would rather simply look upon pretty girls, chastely, than take up residence in graveyard (Chang and Eng p-59)
The presence of two healthy hearts is a necessary condition for the good life-prospects but such duplication is a rarity. Only four known instances of this type of conjoined twins have ever survived into adulthood. Most have congenital heart defects or other organ anomalies makes the life-prospects of the twins poor in the absence of surgical separation. Then the other condition, that the surgical separation of them is medically difficult and risks making life-prospects worse for at least one of the twins, kicks in and creates a fear of death in them( The Journal of Medicine and Philosophy-Oxford University Press)
In many cases the other conjoined twin will die as well because of the shock and fear of their impending death. Most conjoined twins share a blood supply and some vital organs. If one twin dies, there are many issues which results in the death of the other twin. Most serious among them are the sepsis in the blood supply and failure of shared organs. The doctor need to perform an immediate separation.

Imagine having a sibling constantly at your side, waking up every morning to find your sibling lying right next to you, having to do everything together, even sitting on the same chair or riding the same bicycle, then imagine that sibling being taken away from you that moment will surely make the twins anticipate their death
Twins’ Rivalry:
…Privately I often read books for escape. Though it would be years before Chang would began to drink, we started to fight more often. I did not know that I could forgive him-(Chang and Eng p-273)
Jealousy among twins is a major issue of concern that when turns stronger results in twins` Rivalry. Avoid favoritism by all possible means, stay neutral and never compare. Do not always treat them as one. Twins need break from each other. They are built-in playmates ever since they met inside mother`s womb. They have been sharing almost everything from day one of conception. Acknowledge that and respect it.

…We quarreled as I imagine other brothers do, perhaps, a little more troublesomely, due to what’s obvious. (Chang and Eng p – 29)
“I hate him,” I said. But Mother brushed me aside and sat up straight. “A double –boy must never fight among yourself.” Her face was very serious. “Other argue and are capable of escaping each other. You do not have that advantage. You may as well cut off your heads.” She brought her hand to my soft cheek and to Chang’s pallid one, and she smiled. “Alright, Bean Sprout?” she asked Chang. “All right, Eng?” she asked me.

Calm down, I said to myself. I am sorry.

I cannot calm down, I still have to linger in this bed, I said to my self
Ignore it, I said to myself. And I am sorry.All right, I will ignore it.

I was acquiring the silence learning how to remain true to the talk that stirred in my own heart and, instead of articulating the tragedy of my situation, recount it to myself (Chang and Eng p 30-31)

Allow them to choose their own hobbies. It’s easy to fall into the trap of pointing out differences between the twins. Over the time this can fuel rivalry. Think twice before pointing out something negative. The parents need to think of their conjoined twins` differences in a positive term rather than letting negative labels fixed on them. The terms that highlight an interesting trait can be used to describe them. Even when parents avoid comparisons, rivalry between twins comes up. Although competition and envy take a backseat with age, what creeps in are ego clashes, concerns if the one looks better with age and if they live a better life. Twins experience these internal conflicts. It bitter their relationship further, and hence what looks like the ideal pair if siblings gradually twins into people who hardly extend a hand to each other.

Conclusion:
Life is deprived of everything from romantic love to the choice of waking up in the morning to have a career of their own or to alone at a toilet. Confined to the bodies of each other the conjoined twins can never experience a word called as privacy. These two people has no privacy either to bathe or to excrete
The twins are to be paid due attentions and cared for throughout their lives and cared for throughout their lives and treated one amongst us to prevent them feeling alienated. The Human Rights Commission have to intervene to stop using conjoined twins for scientific experiments. Conjoined twins Masha and Dasha, were offered nothing of love and affection like the normal children since they were taken for research by the Soviet Medical team. Many other conjoined twins who are tortured in the context of researches and experiments should be prevented from the trauma.

In case of Vani and Rani the Hyderabad conjoined twins who were abounded by their parents because of poverty, the girls considered to be a bad omen would have been deemed by the society. The efforts taken by the government to bear the medical expenses are to be applauded. The parents of conjoined twins should not permit their children for exhibitions and experiments. Estrangement within the conjoined twins can be avoided by giving equal preferences and due attention to them.

Surgical separation proved to be a possible way out for these struggles which possibly means that the conjoined twins will be able to live as independent healthy individuals. They no longer have to be confined to the body of each other and will be able to move freely. On the other hands it involves a life taking risks like anesthesia and surgical complications. There are numerous important categories of cases that are to be considered for the separation of conjoined twins. Separation surgery is morally permissible only when performed in an emergency situation.
Performing a separation surgery in a non-emergency case where one of the twins is saved at the expense of the death of another twin should not be allowed. Similarly, performing a surgery that will cause both or one of the twins to end up with severe health concerns must also be prohibited. The separation surgery which results in surviving of both the conjoined twins but with some health complications, should not become the accepted norm. As an alternative, it must be left for the twins to decide mutually whether to get separated or to remain conjoint.

Once the twins are done with their autonomous decision of the surgical separation, then the numerous risks that are involved in such separation surgeries are to be considered as it has severe health consequences alongside. There are many risks and challenges that accounts in the dosages of anesthesia for conjoined twins, either for separation surgery or for MRI and also for many other assessment procedures for the surgeons as well as the anesthesiologists since there is a great responsibility of saving two lives at the same time.

The crossed circulation systems of the twins, distribution of blood volume throughout the intertwined body and the effects of these issues on anesthesia are the important considerations that must be taken into account during the surgery. Separation surgeries take a extremely long amount of time, thus making the application of anesthesia for such extraordinary lengths could be difficult for anesthesiologists and dangerous for the patients. Recent technological advances in radiologic imaging, computer modeling, improved surgical anesthesia techniques have all improved survival rates. However, separation surgery is still a long way from being safe.

The surgical separation of conjoined twins can be postponed until they are mature enough to make decisions of their own. In many cases it is seen that it is hardly ever possible because separation is a live option in which life-prospects are poor due to extensive organic fusion. So, delaying means inviting death. It would be wise if someone else makes the decision on behalf of the conjoined twins.

The deliberations of just or fair equality oppose this practical reason of exploiting the life-prospects of the twins taken together. It is also that unjust or unfair to make one twin so much better off at the expense of the other. The separation which takes advantage of the natural inequality between the twins to further augment their life-prospect intensifies an initial natural inequality which appears unfair. Still, even though this anxiety for just equality has significant weight, it is reasonable to think that it is outweighed if one party wins a lot by there being unfair inequality, and the other party loses comparatively little, as is the situation with respect to Jodie and Mary. It should be accepted, though, that such weighing of gains in respect of life-prospects overall against losses in respect of equality have to be done in an intuitive fashion and cannot be shown to be objectively right or wrong.

However, the decision is made more morally complicated by the fact that there are further moral considerations that could be taken into account where the parents opposed the surgical separation because they thought it wrong to kill one infant to save the other. That this is wrong is an implication of the act-omission doctrine, the doctrine that it is more difficult morally to justify actions of causing harm, for example killing one of the conjoined twins than omissions to benefit, for example letting one of us die by omitting to make efforts to save life. The parents believe that by omitting to perform surgery here, they would be letting both of these twins die in the near future instead of doing what would ensure a better life-prospect for one at the price of killing the other.

Such an argument might have broad implications for organ retrieval and transplantation, both in children and adults. It implies that healthy organs should be taken from dying people (children or adults) to save the lives of other people requiring organ transplantation. At present, such organ transfers require both that the donor be brain dead (or that the heart has stopped for some period non heart beating donors) and that the family consents. But from an ethical perspective, this may be too restrictive. Perhaps organ transmissions should be encouraged even when the child or adult is not brain dead but has such vague life-prospects that euthanasia becomes a reasonable option. In the Netherlands, such organ retrieval euthanasia might be legally possible.
The concept of “organ retrieval euthanasia” could be justified in adults who have given their accord to organ retrieval in the face of impending and certain death. However, there have been some case in which this decision was taken from the parents and placed in the hands of legal courts. The law should be changed so that transplantation in the latter case becomes permissible as separation in the conjoined case. Perhaps, the law should also be changed to allow more liberal organ recovery from children as well as adults, who will certainly die, but whose organs could save the lives of many others. This would require revision of the “dead donor” rule which states that people must be dead before organs are removed to a rule that allows taking organs from people who will imminently die provided that, if competent, these people give their consent. (Wilkinson and Savulescu, 2012).

However, if the law is changed in this way, the decision must be left with parents or family in the case of individuals who are not capable of informed consent. If it were up to the courts to decide about the separation of conjoined twins, it is hard to see why it should not also be up to them to decide about transplantation in the case of separate twins or in other cases of paediatric organ transfer. But this is surely hard to believe. Moreover, if the parents could not be entrusted with the power to decide on behalf of their children, it might be asked whether they could be entrusted with the power to make such decisions themselves. What this would amount to is giving parents and persons themselves the power to retrieve organs while their child or they themselves were alive, but in such a critical medical condition that they would immediately die, a practice which has been called “organ retrieval euthanasia.”
There are considerable conditions under which it may be permissible to surgically separate the conjoined twins. But there are many unseparated conjoined twins who have gone on to live good lives. There is an ever-present risk that separations are not performed in the interests of the twins but to make them adapt to typecasts of human existence, or out of disgust or superstition. It is an accepted fact that conjoined twins who have become old enough to appraise their own situation usually do not wish separation.
The best interests of the twins is to give the chance of life to the child whose actual bodily condition is capable of accepting the chance to her advantage even if that has to be at the cost of the sacrifice of the life which is so unusually supported. If we cannot distinguish between defect and difference, then conjuncture surely has to be seen as something that may be a disadvantage in living life in our society, but may also have advantages. It might be argued that what seems advantageous to conjoined twins, only seems so because they cannot conceive of what it is to be separate, and this leads to a distorted view of the conjoined life. It could also be retorted, however, that we singletons cannot conceive of conjoined life and so also have a distorted view of it. We do not see things as they are, but as we are.

Negativity and hopelessness will not help the conjoined twins to deal with social anxiety. It takes a lot of hard work and determination to find peace. Overcoming these painful and emotional experiences takes time. Their families and friends have to be patient with this transition. They can freak out and make friends to have a peaceful existence.
Since prevention is better than cure the fetus can be prevented from conjoinment by avoiding high dosages of folic acid supplements which is one of major reasons for attachments in conjoined twins. Hence, there has to be a proper check on it. Further there are advanced medical techniques that clearly shows attachments of the fetus. MRI scans helps greatly to have a perinatal diagnosis of the conjoined fetus which further aids in performing an immediate surgical separation of the conjoined birth so as to give them a normal and a peaceful life. The best compromise is to change conjoined twins physically to conform to society’s constraints and views, or to some extent to change the constraints and views of society to accommodate conjoined twins.

Red Cross Memorial Children’s hospital serves as a regional referral Centre for the management of conjoined twins. Unborn twins have been referred for advice either to plan the mode of delivery because of obstetric implications or for consideration of pregnancy and the related ethical and moral considerations. Ideally the immediate perinatal management of the babies is also planned. Once born, they are referred for appropriate investigation and surgical management and the therapeutic options ranging from conservative, non-surgical management to emergency or planned surgery.

Prenatal diagnosis allows careful planning for delivery and for preoperative assessment. Emergency surgery may be required, but it is preferable to delay surgery to allow growth and the completion of investigations. Inevitably, the ultimate prognosis will not be possible. Detailed preoperative assessment is essential to determine the best surgical approach, reconstruction methods and ultimate outcome. Despite successful separation some children are left crippled and disabled, requiring lifelong follow-up and care.
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