Conjoined or Siamese twins: should such twins be separated against the wishes of their parents, where one is certain to die?



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The issue
On September 22, 2000, the British Court of Appeal ruled that doctors should go proceed with surgery to separate to female conjoined twins, despite the fact that the surgery would result in the certain death of one of the two girls.
The twins and their parents come from the island of Gozo, off Malta. Malta has an arrangement with the British Government which allows some of its citizens to access health care in Britain. It was for this reason that the twins were brought to England when the hospital where they were born was unable to give them the specialised care they needed.
British medical advice was that the twins should be separated so that one of the girls would be able to live. The parents did not want the surgery performed and so the case came before the British courts.

What they said ...
'It is outrageous that what is deemed a lesser life can be snuffed out in the optimistic hope that the other twin will survive surgery'
Dr Mary Knowles, of the anti-euthanasia group, 'First Do No Harm'

'Though Mary has a right to life, she has little right to be alive. She is alive because, and only because, she sucks the life blood of Jodie, and her parasitic living will soon be the cause of Jodie ceasing to live'
Lord Justice Ward



Echo Issue Outline 2000 / 33 - 34
Copyright © Echo Education Services
First published in The Echo news digest and newspaper sources index.

Issue outline by J M McInerney

Background
General information on conjoined twins
The phrase 'conjoined twins' is the appropriate term for twins that are physically connected.
This term is preferred because the phrase 'Siamese twins' sounds discriminating and was associated with people regarded as freaks in the past.

Twins can either be the result of the fertilisation of two separate eggs by two sperm or be caused through the splitting of one fertilised egg early in its development from which point two genetically identical but separate embryos develop. Twins formed from one egg are referred to as monozygotic twins.

Conjoined twins are always identical. The developing embryo begins to split into identical twins but then stops part way leaving the partially separated egg to mature into conjoined foetuses.

Conjoined twins are more often female than male (ratio of 3:1) They occur as often as once in every 40,000 births but only once in every 200,000 live births.

Conjoined twins may be caused by genetic and environmental conditions which are responsible for the failure of twins to separate after the 13th day after fertilisation. Seventy percent are female - even though monozygotic twins are more frequently male than female. Forty percent are still born. Sevety-five are still born or die within 24 hours.

The current controversy: The prognosis for each twin, with and without surgery
The following description and assessment of the twins' medical condition and prognosis is taken, with minor modifications, from the introduction to the Court of Appeal's ruling. It is based on the medical advice offered the Court.

Jodie and Mary are conjoined twins.
They each have their own brain, heart and lungs and other vital organs and they each have arms and legs. They are joined at the lower abdomen.
They can be successfully separated, but the operation will kill the weaker twin, Mary. That is because her lungs and heart are too deficient to oxygenate and pump blood through her body.
If Mary were not a conjoined twin, she would not have been viable and resuscitation would have been abandoned. She would have died shortly after her birth.
Mary is alive only because a common artery enables her sister, who is stronger, to circulate life sustaining oxygenated blood for both of them. Separation would require the clamping and then the severing of that common artery. Within minutes of doing so Mary will die.
If the operation does not take place, both will die within three to six months, or perhaps a little longer, because Jodie's heart will eventually fail.

A comparison of the twin's physiology
Internally each twin has her own brain, heart, lungs, liver and kidneys and the only shared organ is a large bladder which lies predominantly in Jodie's abdomen.
Jodie has an anatomically normal brain, heart, lungs and liver. Her bowel is also normal and appears to be totally separate from that of her twin, Mary. There is an abnormal vertebra in the lower thoracic area of the spine. She has two kidneys and a full spinal cord. She has two normal lower limbs.

Mary is severely abnormal in three key respects.
Firstly she has a very poorly developed "primitive" brain. The brain scan showed various abnormalities including reduced cortical development.
The second problem is with Mary's heart. Hers is very enlarged, almost filling the chest with a complex cardiac abnormality.
Thirdly there is a virtual absence of functional lung tissue.

Internet links

The full ruling of the Court of Appeal can be found at HERE
This is a very lengthy document (some 130 pages), but is well sub-headed and is clearly written. It treats all aspects of the case -
* the twin's medical condition,
* the rights of the parents,
* the basis on which the law might be able to override the parents' wishes and
* the potential criminal implications of performing surgery which will end the life of one twin.

A summary of the position of each of the appeal judges can be found at http://www.courtservice.gov.uk/judgments/siamese_summ.htm
This does not replace a reading of the full ruling, but if the summary is read first it may make reading the full ruling a simpler task

The British Medical Journal (BMJ) supplies on-line access to articles going back to 1994. This service is free.
On September 30, 2000, the BMJ published an editorial examining the reasons behind the Appeal Court ruling that the conjoined twins, Jodie and Mary, should be separated, even though it would mean Mary's immediate death.
The editorial also explores in some detail the legal ramifications of this ruling and claims, 'This decision acknowledges that the making of a hard choice in favour of one life over another may be defensible in legal terms.'
The editorial was written by Alexander McCall Smith, professor of medical law, University of Edinburgh
The editorial is titled 'The separating of conjoined twins'. It can be found at http://bmj.com/cgi/content/full/321/7264/782

Also on September 30, 2000, the BMJ published a news report titled 'Conjoined twins should be separated'. The article was written by Clare Dyer, the legal correspondent for BMJ. It explains the legal justification offered for the Appeal Court's ruling.
It can be found at http://bmj.com/cgi/content/full/321/7264/783/a

The British newspaper, The Independent, published an article on September 29, 2000, indicating that the twins' parents would not appeal against the latest ruling requiring the surgical separation of their daughters. The article is titled, 'Parents end legal fight over Siamese twins' and was written by Cherry Norton, The Independent's social affairs editor.
The article also gives further information on the decision and its legal ramifications. This article suggests the decision will have limited legal implications. It can be found at http://www.independent.co.uk/news/UK/Legal/2000-09/twins290900.shtml

On September 22, 2000, the BBC conducted an interview with Raanon Gillon, professor of medical ethics at Imperial College London and editor of the Journal of Medical Ethics.
The interview was titled, 'Ethics expert: twin decision wrong'. In the interview Professor Gillon explains why he believes the Court of Appeal ruling was wrong in overriding the wishes of the twins' parents.
The interview can be found at http://news.bbc.co.uk/hi/english/health/newsid_937000/937057.stm

The Times newspaper has a section of its Internet site given over to the twins case. The site can be found at http://www.the-times.co.uk/news/pages/tim/2000/09/23/timnwsnws02032.html
This sub site has sections dealing with the legal and medical implications of the the case; the Appeal Court ruling; the judges who made the ruling and the media's treatment of the case.

The Times also has another section of its site listing links to a collection of Times
articles dealing with Jodie and Mary's case. The list of links can be found at http://www.the-times.co.uk/onlinespecials/britain/siamese/story1.html

Professor William B. Bondeson of the Department of Family and Community Medicine University of Missouri-Columbia has a section of his site containing media treatments of difficult medical issues. One of these is a recent American case where two conjoined twin girls were separated in circumstances that would result in the immediate death of one and the probable death of the other. The article considers the ethics of such decisions. It also asks whether they can be justified on financial grounds.
The article is titled, 'The Ultimate Choice' and was written by Anastasia Toufexis. It can be found at
http://web.missouri.edu/~philwb/choice.html

The Michigan State University has reproduced an article published on April 4, 1998 considering the ethical and practical justifications for separating conjoined twins. It is titled, 'Conjoined or "Siamese twins": To separate or not to separate' and was written by Alice Dreger, Michigan State University's medical historian.
The article is generally critical of the decision to separate and looks particualrly at the very low chances of survival normally had by either twin.
The article can be found at http://www.newswise.com/articles/1998/4/TWINS.MSU.html

Zygote, a Virtual Library of Developmental Biology, has a section of its site titled, 'A Social History of Conjoined Twins'. It gives information on conjoined twins dating back to the ancient world and considers the significance they were believed to have at different times in history.
The material can be found at http://zygote.swarthmore.edu/cleave4b.html

Arguments against conjoined twins being separated against the wishes of their parents.
1. The operation is likely to result in the immediate death of one twin.
Dr Mary Knowles, of the anti-euthanasia group, 'First Do No Harm', has stated, 'It is outrageous that what is deemed a lesser life can be snuffed out in the optimistic hope that the other twin will survive surgery.'
According to this line of argument, the desire to save Jodie's life does not justify killing Mary.
Cormac Murphy-O'Connor, the Catholic Archbishop of Westminster, has stated, 'I have been particularly concerned that a precedent might be set in English law that could allow an innocent person to be killed, or lethally assaulted, even to prolong the life of another.'
The Catholic Archbishops of Malta have issued a group statement claiming, 'No authority may eliminate or sacrifice the life of a human person, not even to save another life.'
One of the justices who ruled on the case stated of the children's parents, 'They simply cannot bring themselves to chose life for one at this frightful cost to the other.'

2. The operation may not succeed in saving the life of either twin.
There is the possibility that the stronger twin, Jodie, will either not survive the separation surgery or will not survive beyond a short period after it. At one point Jodie's chances of survival were put at 65 per cent. However, the longer the two girls remain connected, the smaller Jodie's chances of survival are thought to be. It has also been suggested that if the separation is carried out as an emergency procedure (presumably after Mary has died) then Jodie's chances of survival could be as little as 40 per cent.

3. The parents consider it wrong to attempt to save one child if this means killing the other.
The twins' father has stated, 'We cannot begin to contemplate that one of our children should die to enable the other to survive.'
Archbishop Murphy-O'Connor has stated, 'The refusal by the parents of Jodie and Mary to consent to surgery to separate them involves no injustice towards either of their children ... In particular, respect for the rights of both their children makes any other choice on their part morally impossible.'

4. The parents' religious beliefs incline them to accept their children's condition.
The girls' parents are Catholics and appear to reject medical intervention which would kill Mary and may save Jodie at least in part on religious grounds. They have stated that they do not believe that it is 'God's will' that they should kill one of their daughters in order that the other should live.
The twins' paternal grandmother gave the view, 'It is up to the parents to decide, and to them and to us it is God's will, not for a court to decide.'
Similar views have been expressed by a number of others living on the island of Gozo. Father Julian Refalo Rapa, the local priest, has stated, 'The two poor creatures must be left because they were created by God and we have to let nature take its course.'
Another woman living on the island has stated, 'I have three children and I just can't imagine such a horrible situation. All I know is it should be left to the will of God.'

5. The decision is legally and morally the responsibility of the children's parents.
It has been argued that the parents, as the children's guardians, are the people who are entitled, at law, to make judgements about the treatment their children will receive.
It has been claimed that this is not a case where medical authorities or a court need to intervene to protect the lives of children because their parents are making decisions that are not in their best interests.
Nicola Davies, QC, is the lawyer for the British Attorney-General who assisted at the Court of Appeal. She stated that in her view the parents would not be guilty of a criminal act, such as criminal negligence, in refusing to consent to an operation to separate their twin daughters. Davies argued that, even if refusing the surgery resulted in Jodie's death, her parents would not have committed a crime.
Davies has stated, 'In this case the parents are facing a dilemma, the like of which few parents have ever faced.
'They are not having to deal with the difference between right and wrong, but the difference between right and right.
'It is right to operate on Jodie. It is right not to operate on Mary.'
Morally, it has been argued that parents, as those who brought children into the world, care for them through infancy and childhood and generally love them most, are the people who should make decisions about the medical care a child should receive.
This point has been made by the twins' paternal grandmother, who has stated, 'It is up to the parents to decide ... not for a court to decide.'

6. Her parents may not be able to support Jodie, even if she survived.
If Jodie survived she would not be able to return home to Gozo for many years. Doctors have estimated that after the separation surgery she may have to spend a further five years in British hospitals undergoing further corrective surgery.
This would present grave difficulties for Jodie's parents who have little money and no financial backing. They would have major difficulties trying to live in Britain in terms both of supporting themselves and meeting their daughter's medical expenses.
The parents also anticipate there would be significant difficulties when they finally returned to Gozo. They believe there is a social stigma in their country against disabled children and their parents as such children are seen by many as a punishment from God. It has been suggested that the lives of Jodie and her parents would remain difficult even if Jodie overcame her medical problems.
On a purely practical level it has been suggested that when Jodie finally returned to Gozo as a disabled person the island would be unable to offer her the support services she would require.
Maria, a nurse at the island's hospital, has said, '... if they are separated so Jodie survives, then she will be disabled and there are no facilities here.'

Arguments in favour of conjoined twins being separated against the wishes of their parents.
1. The argument of necessity - one twin's death will allow the other to live.
The operation has been justified by the Appeal Court judges as a defence of Jodie's life.
They have acknowledged that the operation will result in Mary's death but have argued that without the operation both twins will die. The judges summarised the dilemma in this way. '[The doctors] ... are under a duty to Mary not to operate because it will kill Mary, but they are under a duty to Jodie to operate because not to do so will kill her.'
The taking of Mary's life to save Jodie's has been justified using the legal principle of 'necessity'. The principle of necessity is normally invoked to justify the actions of someone who has killed another person in order to save his own life.
The argument of necessity was seen by the Appeal Court judges as justifying the actions of those doctors who would be ending Mary's life if they perform separation surgery.
It has been claimed that this surgery is necessary as it is the only way that Jodie's life can be saved.

2. The weaker twin is not independently viable.
It was stressed by the Appeal Court judges in their ruling that Mary was going to die whether the surgery were performed or not.
In passing their judgement, the judges described Mary as 'designated for death' and 'unviable'.
Mary has also been deemed to be incapable of 'independent existence'. It has further been claimed that she would already be dead if she were not receiving life support. (This last comment appears to refer to the fact that Mary cannot be fed orally and is being fed by tubes.)
It has also been noted that if her lung and cardiac were not being supplemented by her twin's organs then Mary would not currently be alive.

3. The weaker twin is undermining the development and threatening the survival of the stronger twin.
The Appeal Court judges also echoed the medical advice that Mary was developing at the expense of Jodie. They described Mary's physiological relationship with Jodie as 'parasitical'. They argued that one person did not have the right to continue to live if it were at the expense of another.
This point was made by Lord Justice Ward.
Lord Justice Ward stated, 'Though Mary has a right to life, she has little right to be alive. She is alive because, and only because, she sucks the life blood of Jodie, and her parasitic living will soon be the cause of Jodie ceasing to live.'
Medical experts have claimed that Jodie's heart is circultaing oxygenated blood for both girls as mary's cardiac function is severely impaired. It has further been claimed that the strain of this dual load will ultimately fatally damage Jodie's heart, resulting in the death of both twins.

4. Both twins will die if the surgery is not performed.
Doctors have claimed that if the twins are not separated both will eventually die. The weaker twin, Mary, will die first and then her sister Jodie is also very likely to die. It has been claimed that even if emergency surgery is performed to separate the two (presumably after Mary has died) Jodie's chances of survival are only some 40 per cent.
The certainty that Mary would die and the probability that both twins would die without surgical intervention was stressed by Lord Justice Ward, one of the three Appeal Court judges. Lord Justice Ward stated, '... the question is simple - do you kill one to save the other, or do you let two die?'
The same point was made by the international conjoined twins support group, Conjoined Twins International. A spokesperson for the group stated, 'Conjoined twins are special people but if a life can be saved then it is worth it.'

5. The decision to go ahead with surgery that will kill one twin will set no legal precedent.
The Appeal Court judges have argued that they believe the case will set no legal precedent. They have argued that their ruling has grown out of the unique circumstance of the case and that it would not be applicable under different circumstances.
The Court of Appeal acknowledged that it had no clear precedent on which to operate because the circumstances of the case were unique. 'The tragic situation of Jodie and Mary is very rare in medical terms, and it appears to be unprecedented anywhere in the world in terms of full consideration of the legal position by a court.'
Interestingly, the court appears to believe that its ruling is unlikely to set a precedent for the same reason. The British Medical Association has also claimed that it believes it is appropriate for courts to make a ruling when there is conflict between parents and doctors. The Association has also claimed that it does not believe that the current case will set a precedent.

6. Surgery will be in the best interests of both twins, including the child that will definitely die as a result of the separation.
This point has been made by Lord Justice Walker who stated, 'The surgery would plainly be in Jodie's best interests, and in my judgement it would be in the best interests of Mary also.'
The Court of Appeal was told that if the twins remained fused Mary would have a seventy-five per cent or more chance of developing hydrocephalus which would be "extremely difficult" to treat.
The effect of untreated hydrocephalus is to increase brain damage. She is at risk of suffering epilepsy. Lack of sufficient oxygen will progressively cause cellular damage and brain damage. In the view of the neonatologist, her condition is not immediately terminal but severe.
One of the specialists who offered evidence to the Court of Appeals stated, ' ...my perception of the quality of her [Mary's] life is that it would be so poor that I do not feel that it is a life that she will enjoy.
I think her limitations would be so severe that ... development and progress would be so severely interrupted ... that in my view it is acceptable to acknowledge that Mary should be allowed to die ...'

Further implications
It now appears all but certain that the surgery to separate the two twins will go ahead. The parents have decided not to challenge the Court's ruling. They now appear concerned to raise funds through selling their story to the media, presumably to help them finance the care that Jodie will need if she survives.
The major legal and ethical concern surrounding this case appears to be whether one life should be taken in order that another can continue. This was the point raised by Cormac Murphy-O'Connor, the Catholic Archbishop of Westminster, who stated, 'I have been particularly concerned that a precedent might be set in English law that could allow an innocent person to be killed, or lethally assaulted, even to prolong the life of another.'
It remains to be seen whether the ruling will, as the Appeal Court judges hope, set no precedent.
Also of interest is the fact that the ruling overturns the wishes of the parents regarding the medical treatment of their children. Again, it will be interesting to note the extent to which this ruling sets a precedent in this manner.


Newspaper items used in the preparation of this outline
Available as a press cuttings package (with an issue outline reprint): price: $21.50 (NO LONGER AVAILABLE)

Sources
The Age
6/9/00 page 15 news item by Simon Mann, 'Twins' fate in hands of English court'
9/9/00 page 32 news item by Simon Mann, 'Twin dilemma divides the world'
24/9/00 page 1 news item by Simon Mann, 'Sister must die to save twin'
24/9/00 page 2 analysis, 'A rare condition'
24/9/00 page 2 analysis by Sandra Laville, 'Agony all round in a case to test a Solomon'
25/9/00 page 8 news item by Christina Lamb, 'Villagers back parents: twins' fate is a decision for God only'

The Australian
6/9/00 page 9 news item by J Walker, `Fate of Siamese twins put on hold'.
25/9/00 page 32 news item, 'Bishops condemn twins ruling'

The Herald Sun
16/9/00 page 27 analysis by Helen McCabe, 'The heartbreak twins'
24/9/00 page 27 news item, 'Siamese twins appeal poser'

Analyses of TWO newspaper item on this issue

Article analysis one: news report

Article headline: Sister must die to save twin
Author: Simon Mann
Published in The Age, September 24, 2000, on page 1.

The fact that the story is published on page one of the newspaper suggests that the editor considers it has high interest. The headline is bald, arresting and has strong emotional appeal. It suggests a dreadful trade in which one twin sister must die that the other can live. Despite its dramatic quality it is not a particularly exploitative headline. It does not use the term 'Siamese' and there is no indication that the twins are conjoined until the end of the lead paragraph. Despite this relative restrain, the headline is still likely to attract considerable reader attention because of the dreadful dilemma it describes.

The news report opens with a succinct statement of a British Court decision and the extent of the controversy it has caused. The lead paragraph is a single sentence. It begins with a catalogue of those who either support or dispute the ruling, 'Church leaders, lawyers, doctors, ethicists and the people of a tiny Mediterranean island'. The range of people interested suggests the significance of the ruling and is likely to interest the reader. Setting 'three senior British judges' against 'the people of a tiny Mediterranean island' suggests the sort of David and Goliath contest which is also likely to evoke the reader's sympathy for the people of Gozo who oppose the ruling. The ruling itself finishes the sentence. Referring to the twins who must be separated by the names assigned to them for the court case, 'Jodie' and 'Mary', helps to personalise the case and further arouse the reader's interest and sympathy.

The next four paragraphs indicate the main opponents of the ruling; the judges justification for their ruling and suggest that the Appeal Court's finding may be challenged. It is stressed that the parents are 'devout Roman Catholics'. For most readers this would explain their opposition to any procedure which would result in the death of one twin as Catholics are generally supposed to believe in the sanctity of human life. The consequences of the ruling are presented dramatically. 'The operation ... would mean certain death for ... the weaker of the two girls'. To this point it is probable that the reader's sympathies reside with the twin whose life will be lost and with her parents who oppose the ruling.

The article goes on to outline the reasons for the judges' decision. Mary is described as 'unviable' and 'designated for death'. The inverted commas used within the article indicate that these descriptions of Mary are being quoted from the court ruling. It is also claimed that Jodie, the healthier twin, has a legal right to be separated and given the chance of a 'full life'. These justifications of the court's ruling may not appeal to readers. The term 'unviable' applied to Mary appears a cold and clinic reference to the child's limited life span, while 'designated for death' seems an unnecessarily dramatic and unsympathetic way to describe Mary's prognosis. The unsympathetic impression is strengthened with a reference to Mary as 'parasitic'. It is not possible to know whether these comments reflect the overall tenor of the ruling, however, as quoted, readers may find them alienating and react negatively to the court's judgement. It is also not possible to say if this is a deliberate bias in the news report's presentation of this material, however, whether deliberate or not the effect is likely to be the same.

Paragraphs six and seven go some way toward redressing the balance in the piece by offering more effective support for the court's decision. One of the three judges on the Appeal Court is said to have expressed 'profound sympathy for the twins parents'. The same judge is said to have twin girls of his own. This is likely to suggest to readers that the judge will have been very careful in reaching his decision as he would have particular empathy with the parents' situation. The judge is also said to have found the decision 'excruciatingly difficult'. This reported admission serves to give a further human dimension to the court and to make it appear that the decision was reached only after the most careful consideration. Finally, paragraph seven ends with a lengthier quote from the Appeal Court's ruling which states that the judges had to chose between the death of both twins or the survival of one and the death of the other. This is a more compelling argument than referring to the weaker twin (who relies on her sister's circulatory and respiratory function) as 'parasitic'.

The article then gives a fairly detailed description of the twins' physiology and where they are conjoined. This is necessary information if the reader is to appreciate the court's decision and the position of the parents. However, once again the article avoids the sensational and the exploitative. This description of the twin's condition is not given until paragraph ten and when given is brief and restrained. Further, no great feature is made of Mary's impaired brain function. Her brain is simply described as 'primitive' in what appears to be a quote from the court's ruling. This again suggests discretion and restraint.

The article concludes with a series of paragraphs, some supporting and some opposing the court ruling. These include comments from the girls' parents, an anti-euthanasia group, the Catholic Archbishop of Westminster, Malta's director general of health, a medical ethicist and Conjoined Twins International. Some of these groups support the court's, others oppose it. The overall effect is to canvass the issue thoroughly without appearing to favour one side over the other.

Article analysis two: news report

Headline: 'Siamese twins appeal poser'
Published in The Herald Sun on September 24, 2000.

The headline is brief and attracts attention because it refers to Siamese twins, a topic likely to have sensational appeal and because it refers to an 'appeal poser'. Using the phrase 'Siamese twins' rather than the more technical 'conjoined twins' has two effects. It is more likely to be understood by the general reader than is the more technical term. Further, Siamese twins has side-show connotations which are liekly to pique some readers' curiosity. In addition, 'poser' is a colloquial term referring to a difficult question. On reading the article it becomes apparent that the 'poser' is whether or not the parents of the twins will appeal a court ruling requiring that their daughters be separated. Without this information the heading is sufficiently obscure to leave the reader curious as to what the 'poser' is. The use of the colloquialism is likely to further attract the attention of the less well educated readership which The Herald Sun generally serves.

The material in this news report is presented in a very simple and direct manner. Each of the paragraphs, with the exception of the conclusion, is a single sentence. The article does not present both views on the question of whether the twins should be separated. Instead it suggests a fairly straightforward case in favour of the separation.

The opening paragraph states simply that three of Britain's top judges have 'ruled that doctors should kill one ... daughter to save the other'. This sentence does not avoid the significance of the decision. It states quite directly that one child is to be killed and it presents this as a choice between one life and another.

The second and third paragraphs elaborate this point. The twin who is to die, Mary, is described as having a heart and lungs which are 'useless'. This does not not prompt distaste for the court's ruling in the same way that quoting the judges' description of Mary as 'unviable' and 'designated for death'. Compared to these terms, 'useless' seems to indicate simply and unemotively that the weaker twin will inevitably die.

The third paragraph takes this further citing the authority of doctor's who have claimed that Mary id beyond help and then claiming that as Jodie's heart is sustaining both girls, her weaker sister is 'draining her life away'. This last phrase is a graphic description of the effect Mary is having on Jodie but it does not strip her of Mary of her humanity in the way the term 'parasitic' (which is quoted in The Age's report of this case) does.

The necessity of the operation is clinched in the fourth paragraph, in which doctors are again cited, apparently having claimed that without the operation both girls will be dead in a matter of months. The repeated references to 'doctors' and their opinions serves to give apparently expert support to the judges decision as all the medical opinions cited are in accord with the court's ruling. It would be interesting to know if there are other doctors, ethicists or others, apart from the girls' parents, who are against the court's ruling. The article does not tell us this. The only opinions it cites support the court's ruling and so the impression created is that the article supports the court's ruling. A fairer balance of quotes would be necessary if the article is to display the sort of objectivity the reade expects of a news item.

In paragraph five the girls parents are described as 'staunch Roman Catholics'. This is likely to suggest to readers that they may be opposed to the operation on religious grounds as the Catholic Church generally promotes the sanctity of all human life. It is difficult to know what effect this information is likely to have on readers. For some it may suggest that the parents' beliefs should be respected. For others it might imply that the parents have not made an objective decision as their judgement has been clouded by their religious convictions.

The sixth paragraph heightens the tension in the news item by indiacting that if the parents do not appeal the operation might be carried out within the next month. This adds a particular sense of urgency and immediacy to the item.

The article concludes with a fairly extended quote from one of the judges arguing that although Mary has a right to life she has little right to be alive. The judge then goes on to explain that she is living at the expense of her sister and that Mary's continued living will prove fatal to Jodie. When the entire quote is given the judge's reference to Mary as 'parasitic' seems less repellent. He did not use the term to describe Mary herself, instead her referred to her 'parasitic living'. This suggests that it is her means of remaining alive, not the child herself, which is 'parasitic'.

Thus the overall impact of this article is to support the court's decision. There is almost no attempt made to show any other point of view. The only tension created in the story centres around whether the twins' parents will appeal the judgement and if and when the operation will go ahead. The question of whether the court's ruling were appropriate is not addressed at all.