Reflections on the birth of conjoined twins.pdf

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                                                           hopeless view that medical science will                  claims of happiness are claims from
                                                           not exceed its current bounds of                         someone’s point of view — from the
                                                           achievement. Ken Walker’s views on                       perspective of a single human being
                                                           the recent birth of twin girls joined at                 whose unique collection of past experi-
                                                           the head in British Columbia1 sadly re-                  ences serves as a context, a lens, a
                                                           flect the attitude that such situations                  background for her evaluation of her
                                                           are beyond our ability to manage, now                    current experience. As much as the sci-
                                                           and forever. Of course, this would be                    entist might wish for it, there isn’t a
                                                           the case if the trial-and-error approach                 view from nowhere.”
                                                           (the essence of scientific progress)                        Walker suggests that our concerns
                                                           were to be abandoned.                                    about the conjoined twins recently
                                                              The smiles of the conjoined twins’                    born in British Columbia should be pri-
                                                           doctors 1 reflect hope and courage.                      marily financial in nature. I am moved
                                                           Medical anomalies, particularly of this                  to quote Kurt Vonnegut, who wrote (in
                                                           kind, will remain a tragedy only if we                   Breakfast of Champions) that a life not
Reflections on the birth of                                abandon our gifts as humans to dis-                      worth living combined with an un-
                                                           cover and improve.                                       quenchable will to live is a combination
conjoined twins                                                                                                     often seen on this planet.
                                                           Richard F. Poole MB ChB                                     I am glad that Walker is not my doc-
How refreshing it was to read Ken                          Hudson, Que.                                             tor, and that he does not have the
Walker’s article.1 He has the courage to                                                                            power to decide who should and who
                                                           Competing interests: None declared.
speak out on a subject from which                                                                                   should not be born. Or have that by-
most of us shy away. The major con-                                                                                 pass, appendectomy, arthroscopic knee
cern of physicians since the time of                                                                                surgery, etc.
Hippocrates has been to help prevent                                                                                   After all, we will all end up as worm
                                                           1.   Walker K. The tragedy that should never have hap-
pain and suffering; the concept of sav-                         pened. CMAJ 2007;177:312.                           feed. Timing is, of course, everything.
ing lives at all costs is a modern aberra-                 DOI:10.1503/cmaj.1070125
tion. In the time of Hippocrates, de-                                                                               Beverly R. Akerman MSc
formed or malformed babies were put                                                                                 Professional Writers Association
out on the hillside to perish. Of course                   I was interested in Ken Walker’s article1                 of Canada
such a practice would be abhorrent to-                     as I had just read a discussion of the                   Montréal, Que.
day, but one has to reflect on the enor-                   happiness of conjoined twins in a new
                                                                                                                    Competing interests: None declared.
mous cost to our current system of per-                    book by Harvard psychologist Daniel
forming heroic procedures on patients                      Gilbert.2 Gilbert comments on twins
whose viability is doubtful.                               Lori and Reba Schappel, who are joined
                                                           at the forehead and share a blood sup-                   1.   Walker K. The tragedy that should never have hap-
Glanville Davies BSc MB BCh                                ply, part of a skull and some brain tis-                      pened. CMAJ 2007;177:312.
Surrey, BC                                                 sue. The twins feel that, even were it                   2.   Gilbert D. Stumbling on happiness. Toronto: Vin-
                                                                                                                         tage Canada; 2006.
                                                           possible, they would reject surgery to
Competing interests: None declared.                                                                                 DOI:10.1503/cmaj.1070126
                                                           separate them. Gilbert writes, “So
                                                           here’s the question: If this were your
                                                           life rather than theirs, how would you                   I read with interest the Salon article by
                                                           feel? If you said, ‘joyful, playful and op-              Ken Walker. 1 I am concerned that
1.   Walker K. The tragedy that should never have hap-
     pened. CMAJ 2007;177:312.                             timistic,’ … try to be honest instead of                 Walker reduces the discussion about
                                                           correct. The honest answer is ‘despon-                   the case of the recent birth of conjoined
                                                           dent, desperate and depressed.’ In-                      twins in British Columbia to an argu-
                                                           deed, it seems clear that no right-                      ment about the expected health care
Doctors have one duty to fulfill above                     minded person could really be happy                      costs.
all others: the alleviation of suffering.                  under such circumstances … in an ex-                         In my view, we as physicians should
Implicit in this duty is the attempt to                    haustive search of the medical litera-                   first discuss ethical considerations. The
correct all forms of malady, including                     ture, [a] medical historian found the                    twins’ mother refused to have an abor-
the gestational anomaly leading to the                     ‘desire to remain together to be so                      tion: Should her physicians or society
birth of conjoined twins. Abortion in                      widespread among communicating                           have forced her to have the procedure
such a case would be a eugenic pre-                        conjoined twins as to be practically uni-                without her consent? Now that the
emptive strike perhaps based on the                        versal.’” In sum, writes Gilbert, “all                   twins have been born, to what amount

                                                          CMAJ • November 6, 2007 • 177(10)                                                                        1235
                                                         © 2007 Canadian Medical Association or its licensors

of health care and social services (if                   sociation and organizations that repre-      Quality, Safety and Health
any) are they entitled? Who is qualified                 sent medicine, nursing, pharmacy and          Information
to ascertain the quality of their life?                  health care institutions.”1 We find it cu-   Calgary Health Region
   If we focus solely on monetary is-                    rious that patients and their families,      Jan M. Davies MSc MD
sues in discussing this case, does this                  the most important stakeholders, are         Professor of Anesthesia
mean that all decisions about whether                    not mentioned in this list. The guide-       University of Calgary
or not to treat patients should be based                 lines use an arbitrarily chosen definition   Bruce MacLeod MD
                                                                                                      Medical Director
primarily on the expected costs of treat-                of an adverse event: “an unexpected
                                                                                                      Clinical Safety Evaluation
ment? We need to consider whether                        event in health care delivery that results
                                                                                                      Calgary Health Region
Walker’s way of thinking fits with our                   in harm and is not attributable to a rec-    Calgary, Alta.
own attitudes and beliefs about what it                  ognized complication.”5 This definition
means to be a physician.                                 markedly restricts the scope of disclo-      Competing interests: None declared.
                                                         sure and is not patient focused.
Manfred Gogol MD                                            For patients, the distinctions be-
Department of Geriatrics                                 tween the terms errors, adverse events       REFERENCES
Krankenhaus Lindenbrunn                                  and unexpected complications are not         1.   Levinson W, Gallagher TH. Disclosing medical er-
                                                                                                           rors to patients: a status report in 2007. CMAJ
Coppenbruegge, Germany                                   important. Patients experience harm,              2007;177:265-7.
                                                         and regardless of how members of the         2.   Waite M. To tell the truth: the ethical and legal im-
Competing interests: None declared.                                                                        plications of disclosure of medical error. Health
                                                         health care community and legal pro-              Law J 2005;13:1-33.
                                                         fession wish to classify it, patients who    3.   Lemon MR, Hobgood C, Hevia A. Disclosing med-
                                                                                                           ical error: a professional standard. Semin Med
                                                         have suffered harm expect and deserve             Pract 2004;7:24-33.
1.   Walker K. The tragedy that should never have hap-
                                                         a timely, supportive and informative         4.   Reason J. Managing the risks of organizational ac-
                                                                                                           cidents. Aldershot (UK): Ashgate Publishing; 1997.
     pened. CMAJ 2007;177:312.                           conversation about their concerns. In-       5.   Canadian Patient Safety Institute. Draft national
DOI:10.1503/cmaj.1070127                                 deed, in 2003 the College of Physicians           guidelines for the disclosure of adverse events. Ed-
                                                                                                           monton: The Institute; 2007. Available:
                                                         and Surgeons of Ontario recognized       (accessed
                                                         this with the publication of their policy         2007 Sept 12).
Disclosing medical errors                                on disclosure of harm.6                      6.   College of Physicians and Surgeons of Ontario.
                                                                                                           Disclosure of harm. Policy no 1-03. Toronto: The
                                                                                                           College; 2003. Available:
The commentary on disclosing errors                      W. Ward Flemons MD                                /disclosure.htm (accessed 2007 Sept 12).

to patients by Wendy Levinson and                        Vice President                               DOI:10.1503/cmaj.1070114
Thomas Gallagher 1 perpetuates the
confusion created by others.2,3 Levin-
son and Gallagher suggest that errors
alone lead to harm; if harm is not
caused, it is “by chance or because the
error was corrected before harm could
occur.” Statements like this suggest
that they have not based their writing
on a model of accident causation, such
as Reason’s well-referenced “Swiss
cheese” model,4 which describes the
complex interplay of the actions of
workers, local triggering factors and la-
tent conditions that weaken, breach or
bypass defences, thereby contributing
to adverse outcomes. Statements such
as “some adverse events are preventa-
ble — these events can be called errors”
are inaccurate; the terms error, adverse
event and harm are not synonymous.
   Levinson and Gallagher make refer-
ence to national guidelines for the dis-
closure of adverse events that the Cana-
dian Patient Safety Institute is
developing with stakeholders “includ-
ing the Canadian Medical Protective As-

1236                                                     CMAJ • November 6, 2007 • 177(10)

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