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Health Care Ethics USA Anatomy of An Ethical Debate: Mary and Jodie During the autumn of 2000, our imaginations were captured by the haunting image of two babies, Jodie and Mary, joined together in a tragic perversion of the human form. While Jodie's heart and lungs were strong and healthy, Mary's were virtually useless. Because of their conjoined circulatory system, Jodie's organs kept both girls alive. A Solomonic dilemma faced the adults concerned with their fate. The best medical expertise was that to separate them would mean certain death for one, but to allow them to remain conjoined would mean certain death for both. Their physicians said, "We must separate to save Jodie's life!" Their parents said, "We can't kill Mary to save Jodie!" In the end, the courts intervened, and the girls were separated. As predicted, Mary died in the surgical suite. Jodie is now home with her parents, bright and healthy. But these are just facts. What interests us here are the ethical issues. For though we may have a gut instinct about what "should" have been done, those of us in Catholic health care cannot afford to make judgments on feelings alone. We need to understand the ethical foundations upon which such serious decisions need to be made. This case offers fascinating insight into just how such ethical analysis was carried out, even though to disparate conclusions, by a number of thoughtful minds. Since many of our sources cite double effect in their reasoning, it provides a good focal point for us here. Our discussion does not offer any conclusion about whether or not separation was ethically justifiable. It summarizes, instead, the insightful dialogue and debate. Principles We are told to "Do good and avoid evil." But this does not mean that no evil may be done to achieve good. It means that no moral evil may be done.1 The precept is not absolute in regard to physical evil, and distinguishing between moral and physical evil is facilitated through the process of double effect reasoning (hereafter, DER). It is DER that helps us determine, in a particular case, when circumstances make it morally permissible for us to allow or cause harm, and to determine moral responsibility for foreseen and unwelcome side effects of an act. It does this by helping us determine whether those effects are merely permitted as side effects of a good act (and tolerated as inevitable) or are directly willed and therefore morally evil. For example, when a parent takes a child to the hospital for an appendectomy, does that parent tolerate as inevitable the fact that the child's body will be cut open and that he or she will feel pain (physical evils), or does the parent actually will (a moral evil) the mutilation and suffering itself? If the former, DER might allow the action. The latter could never be justified. Volumes have been written about the nuances of DER, and scholars have debated it for centuries. For our purposes, however, one standard formula will be helpful. It states that a person may licitly perform an action that he or she foresees will produce a good effect and a bad effect, provided that four conditions are verified at one and the same time: (1) that the action in itself, from its very object, be good or at least indifferent, (2) that the evil effect not be intended, (3) that the good effect not be produced by the evil effect, and (4) that there be a proportionately grave reason for permitting the evil effect.2 In regard to Mary and Jodie, we must ask these questions: What was the act, and was it morally good, indifferent, or evil? Though Mary's death was clearly foreseen, was it intended or merely allowed? Was the saving of Jodie's life brought about by the death of Mary, or did her living and Mary's death result in parallel fashion from the act in question? Finally, was the saving of Jodie's life proportionate to the premature ending of Mary's? Discussion Let's begin our analysis of the ethical discourse with the argument of Cormac Murphy-O'Connor. He wrote that, "There are those … who would argue that one might embark on such an operation without having Mary's death as part of one's aim, and that her death would then be a foreseen but unintended consequence of a morally justifiable operation aimed at saving Jodie. But what is not possible is that one could embark on such an operation without foreseeing that it would do Mary no good but only lethal harm. And even if her death were merely foreseen, the invasion of her bodily integrity is nevertheless intended. The process of separation cannot be thought of with any plausibility as one of cutting into Jodie's body alone; Mary's body is necessarily cut into. And that violation of her bodily integrity is in the nature of the case lethal for her. It therefore cannot be justified." Albert S. Moraczewski agrees, identifying the act in question as "the surgical procedure, especially the cutting and clamping of the artery." He argues that the surgeons unjustly brought about a lethal injury to Mary, as they knowingly and freely severed the aorta and deprived her of her source of an adequately oxygenated blood supply. The act, he believes, is therefore morally evil, because in the choice freely made, an evil (the death of Mary) is included. Though Murphy-O'Connor had written that "the life that Mary has is, because of abnormal development, dependent on Jodie's blood supply," Moraczewski concludes instead that both girls had an "equal right" to the aorta's functioning. Philosopher Alex John London argues that this was not so, and that Jodie alone had a right to what he calls the "unrestricted use of her own vital functions." He also responds to Murphy-O'Connor's argument that "no duty exists to preserve life when the only available means to do so involves a grave injustice." As Murphy-O'Connor argues that there was no obligation to preserve Jodie's life through a grave injustice to Mary, so London argues that there was no obligation to save Mary's life through a grave injustice to Jodie. Since other caregivers unrelated to the separation could have, but chose not to offer Mary life support or transplantation on the basis of futility, given her serious pathophysiology, London argues that it was not fair to shift that life-prolonging burden to Jodie. It was not fair to suggest that she had an obligation to provide that life-support function, especially since it would entail the sacrifice of her own life. Catherine Dominic differs with Murphy-O'Connor and Moraczewski as well. Rather than seeing the act as "the cutting and clamping of the artery," she sees it as the restoration of Jodie's organs to her so that she might live. In this, she rejects the notion of there being any intrinsically evil lethal assault made upon Mary. Mary's death, which Moraczewski sees as included in the act itself, is seen instead by Dominic as the foreseen but unintended bad effect of the act undertaken (separation) to achieve the good effect of saving Jodie's life. Still, Helen Watt argues that DER cannot work here, since it requires that nothing the agent intends can be morally unjustified, and she likens this surgery to the removal of a heart from a living donor. "Even if the donor's death is not intended," Watt writes, and "is in no way part of the plan," what is intended is the changing of the donor's body in a fashion that she identifies as 'mutilation.' William E. May concurred in an early essay (a position he now disavows), saying that the mutilation of Mary's body takes place in the act itself, and that this act is clearly intended, even if her death is merely foreseen. Intentional mutilation would thus be intrinsic evil enough to deny the satisfaction of Condition One (DER), and the agent's intention to mutilate violates Condition Two (DER). Since Mary's fatal mutilation would be the cause of saving Jodie's life, Condition Three (DER) would also be violated. Christopher Kaczor, though, suggests that the girls had two separate bodies with some fused portion, and argues that it would thus be impossible to invade "Mary's portion" (at least in the mid-section), since that might also be equally Jodie's portion. He therefore dismisses any clear intrinsic evil of invading and mutilating Mary's body. Kaczor also questions the premise that the surgery "brought no good to Mary." He suggests instead that it gave each girl her rightful bodily integrity and physical autonomy, fleeting as that might have been for Mary. He points out that since the surgeons took nothing from Mary's body for the benefit of Jodie's, no mutilation took place, only separation. Watt counters that no, this was indeed mutilation, since the surgeons inflicted a wound from which Mary "would not recover." But Dominic reminds us that it was not a wound from which Mary could not have recovered! Further, Kaczor adds, bodily integrity is violated for the sake "only of others" in a number of instances, as when a living person donates an organ. And to the response that that is not a fatal occurrence for the donor, he and London, again, remind Watt that Mary's surgical wounds were not fatal in and of themselves. This discussion of mutilation is later revisited by May, when he reverses himself and concludes that the object of the surgeons was not "the surgical procedure, especially the cutting and clamping of the artery," but rather, was precisely "to separate the twins." They foresaw Mary's death, but it was outside the scope of their intention. Neither, May now argues, was Mary's death the means to obtaining or saving Jodie's life. This, May concludes, along with Dominic's contention that Mary's death was caused by her pathophysiology and not the separation, renders the act in its moral object permissible under the conditions of double effect. Conclusion That faithful, traditional scholars disagree about double effect reasoning in any concrete case should neither surprise us nor cause us to question its relevance as a moral principle. Sometimes the dilemmas we seek to settle may be so confounding that even the most eminent thinkers disagree. Yet the fact that the use of this subtle reasoning needs such exacting attention enhances rather than weakens its integrity. In the words of T. Lincoln Bouscaren, reasoning that can justify "the permission of even the gravest consequences, such as the death of innocent persons," ought not be too easy to manipulate.3 
Ann K. Suziedelis
Suggested Readings Cormac Murphy-O'Connor, "The Conjoined Twins Mary and Jodie: Ethical Analysis of Their Case," Origins 30 (October 5, 2000). William E. May. "'Jodie' and 'Mary': Separating the Maltese Twins." The National Catholic Bioethics Quarterly (Autumn 2001). Christopher Kaczor, "The Tragic Case of Jodie and Mary: Questions about Separating Conjoined Twins," at http://bellarmine.Imu.edu/faculty/ckaczor/articles/twins.html Catherine Dominic, "Separating the Twins Jodie and Mary," Ethics & Medics 26 (June 2001). Albert Moraczewski, "Against the Separation of Mary and Jodie," Ethics & Medics 26 (June 2001). Questions for Discussion
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