Tears for Ladan and Laleh as debate rages over surgery

The death of the Iranian conjoined twins Ladan and Laleh Bijani raises questions over whether the highly risky operation to separate them should have been allowed.

As family and friends of the sisters who had kept vigil outside Raffles Hospital in Singapore wept at the loss, their adoptive father spoke of his anguish. Alireza Safaian, a doctor, rescued the twins after finding them abandoned by the hospital that had cared for them after the 1979 Iranian revolution. He said: "We shared a house for 27 years and I feel a great emptiness. When they took them to Singapore I knew they would bring back their bodies."

Medical ethics experts said the case raised difficult issues over whether the risks of the operation were reasonable, whether both twins wanted the operation equally and whether both fully understood what they were embarking on.

Jonathan Glover, professor of medical law and ethics at King's College London, said every operation carried risks and unless the odds against success were overwhelming it was right to present patients with the choice. "The risks were very high in this case," he said. "I would want to know a lot about what they were told, whether they understood it and what their quality of life together was like. Were they both in agreement or was one dominant and hustling the other into the operation?

"Normally it would not be desirable to operate where the risks were so high. But these were exceptional circumstances. If they both wanted it over a long period of time and were unwavering then I feel it was their life and they had the right to make that decision."

Michael Wilks, chairman of the British Medical Association's medical ethics committee, said: "You cannot take the view that doctors should not do things because they are risky. Otherwise there would be no heart transplants. On the other hand, it is fair for doctors to say they won't do something because they do not believe it is in the patient's best interests.

"It was a pretty stark choice these sisters faced. Who among us would say we would live in those circumstances? They were both, presumably equally, determined they wanted to take the risk, and were highly informed, and I don't think there is any argument against it. To my way of thinking a consistent desire to take that risk is to be applauded."

Almost from childhood, the 29-year-old sisters had expressed the desire to be separated. Born into a poor family of 11 children in Firouzabad, southern Iran, they displayed strong, distinct personalities. Ladan was talkative and wanted to be a lawyer while Laleh was quieter, more introspective, and wanted to be a journalist.

The Iranian government, recognising they could not compete individually in university exams, granted them a joint scholarship to study law at Tehran University in 1994, after Laleh agreed to help her more dominant sister realise her ambition to be a lawyer. But their physical handicaps and desire to be separated led them to take more than six years to obtain their degrees instead of the usual four.

Their hopes rose in 1996 when doctors in Tehran arranged for them to travel to Germany to be assessed for possible surgery. But they returned heartbroken after the German specialists told them surgery was too dangerous because they shared a vein that drained blood from their brains.

Last year, with the help of an Associated Press reporter in Tehran, they were put in touch with Keith Goh, the surgeon in Singapore who successfully separated 18-month-old Nepalese twins who were joined at the head. The Iranian sisters arrived in Singapore last November and began seven months of tests and counselling to determine their suitability for surgery. Throughout that time they never wavered in their determination. The chance of success was assessed by Dr Goh as no better than 50:50, but even such daunting odds did not deter them. Ladan Bijani said: "If God wants us to live the rest of our lives as two separate, independent individuals, we will."

As scans were being done last Saturday to check the blood flow to the sisters' brains, doctors discovered another, medical reason for the surgery: the blood pressure inside their shared skull was more than twice what it should be. This finding led them "to believe this is something quite necessary, not cosmetic or frivolous", Dr Goh told a news conference late on Saturday.

Almost from the start, the operation to separate them, which began at noon on Sunday, ran into difficulties. Their fused skulls were thicker than expected and took longer to cut through. Then their brains, although separate, were found to be adhering strongly to each other because of the length of time they had lain pressed together, adding to the difficulty of the dissection surgery.

Early yesterday as the international team of 28 surgeons and 100 medical staff completed the dissection, having rerouted the vein that drained blood from both brains with a substitute vein taken from Ladan's thigh - the procedure the German surgeons considered too risky - the sisters were separated. But doctors were unable to stem the bleeding and both sisters died within 90 minutes of each other. "The twins lost a lot of blood and were in a critical situation as the surgery was coming to an end," the hospital said in a statement.

When they were asked last year if one of them was ready to die to give the other independence, Laleh said: "We have waited [so long] because we didn't want to choose such a difficult option."