The ethics and morals involved in this decision are too complex for me. I believe they are too complex for you as well. Therefore I referred it to an old rabbi on the Lower East Side of New York. He is a great scholar, a saintly individual. He knows how to answer such questions. When he tells me, I too will know.
These words, referring to Rav Moshe Feinstein, were reportedly uttered in 1977 by none other than Dr. C. Everett Koop, then chief of surgery at Children’s Hospital in Philadelphia, who was later to become the surgeon general of the United States during the Reagan administration. He made this statement to his staff when deliberating the ethics of a morally wrenching dilemma. Conjoined twin girls who shared one heart were born to a Kollel family in Lakewood, New Jersey. The heart had six chambers (a heart normally has four chambers) and without surgical intervention both twins would die within a year since the abnormal heart was unable to sustain both babies. The only chance of even one twin surviving was to sacrifice one twin in order for the other to survive., The parents brought the babies for medical care to one of the world’s leading hospitals, Children’s Hospital in Philadelphia.
This situation posed a moral and legal dilemma that needed to be resolved in many venues. Dr. Koop sought and received legal immunity from being prosecuted for the murder of a twin. Catholic doctors and nurses sought the guidance of their theologians to permit their participation in the surgery. The parents of the twins would give their consent to the surgery only if Rav Moshe Feinstein permitted sacrificing one twin to save the other. When Dr. Koop, a deeply religious man who studied Bible every day, was challenged by his staff as to the morality of killing one baby in order to save another, he replied that Rav Feinstein would provide the necessary moral guidance in this most difficult situation.
In the end, Rav Moshe Feinstein permitted the surgery after considerable deliberation and even fasting over this weighty matter. He did not, however, issue a written explanation for his ruling. Moreover, other great poskim such as Rav Yaakov Kaminetsky (as reported by Professor Zev Lev in Tradition Summer 1997 p. 80) disagreed with this ruling. A number of suggestions were offered to explain Rav Moshe’s decision but none was convincing. Finally, in the Fall 1996 issue of Tradition (pp. 106-110), Rav J. David Bleich offered a convincing explanation of this ruling based on another ruling of Rav Feinstein that appears in Teshuvot Igrot Moshe Y.D. 2:60.
Sacrificing One Life to Save Another
Normally Halachah forbids sacrificing one life to save another. This principle is articulated by the Mishnah (Ohalot Ch. 7 Mishnah 6):
A woman whose life is endangered in hard labor is permitted to have the pregnancy terminated. However, once the head of the baby has emerged, one cannot touch it as we are forbidden to kill one individual to save another [ein dochin nefesh mipnei nefesh].
This principle is reinforced by the Talmud Yerushalmi (Terumot 8:4) which states:
If a group of individuals on a journey encounter evildoers who say to them ‘Give us one member of your group or we shall kill the rest of you’ let them all be killed and not release even one Jewish soul [afilu kulan neheragin lo yismasru nefesh achat b’Yisrael].
Accordingly, not only can we not kill an individual in order to save the life of another individual, we cannot even kill an individual even to save the lives of numerous people.
A Possible Exception to the Rule
The Yerushalmi poses a serious question on this principle from the episode related in Shmuel II Ch. 20. The Navi records the story of a “wise woman of the town of Avel Beit Ma’achah” who hands over the rebel Sheva ben Bichri to King David’s general Yoav ben Tzeruyah. She did so in order to spare the entire town from being destroyed by for harboring Sheva ben Bichri. The Navi apparently condones the actions of this woman as it refers to her with the complimentary title “wise woman”. Accordingly, the Yerushalmi is puzzled why she is complimented when she sacrificed the life of one in order to save the lives of others.
The Yerushalmi cites two explanations for why the case of Sheva ben Bichri differs. Rabi Yochanan explains that Sheva differs because he was designated for death by Yoav ben Tzeruyah. Reish Lakish explains that the situation of Sheva is different because according to Halachah, Sheva deserved the death penalty, as one who rebels against the king may be put to death (Rambam Hilchot Melachim 3:8).
The debate between Rabi Yochanan and Reish Lakish remains unresolved as Rishonim debate whose opinion should be followed. The Rama (Y.D. 147:1) and the Taz (ad. loc. 7) disagree as to whether we follow Rabi Yochanan or Reish Lakish. This debate however appears to be entirely irrelevant to the case of the twins in Children’s Hospital. Neither child was “designated for death” nor was either baby guilty of a capital crime which would permit sacrificing one child to save the other.
Rodeif
Another circumstance in which Halachah permits killing one individual to save another, is a situation of rodeif (Rambam Hilchot Rotzeiach Ushmirat HaNefesh 1:9). One must kill an individual who is attempting to kill someone. Perhaps one of the twins can be construed as a rodeif since she is threatening the life of her twin. The Rambam (ibid.) seems to believe that even a baby potentially may be classified as a rodeif even though it has no malicious intent.
Nonetheless, the status of each twin as a rodeif neutralizes the license to kill one to save the other. Rav Akiva Eiger (Ketubot 33b) states that Halachah forbids lethal intervention in a situation of mutual pursuers. For example, if one were witness to the duel between Aaron Burr and Alexander Hamilton one would be forbidden to kill one of them to save the life of the other. Similarly, since each of the two twins pursues the other’s life, the Halachah does not grant permission to kill one to save the other. This case is similar to the aforementioned Mishnah in Ohalot which forbids killing the baby in order to save the mother after the baby’s head has emerged from the birth canal.
Saving a Mother by Killing a Fetus
However, there is a situation in which Halachah permits killing one of two mutual pursuers to save the other. The aforementioned Mishnah in Ohalot states “A woman whose life is endangered in hard labor is permitted to have the pregnancy terminated”. Rambam (ad. loc.) explains that the fetus is considered to be like a rodeif to the life of the mother. This interpretation is astounding, since if the fetus is construed as a rodeif, why is it forbidden to kill the baby to save the mother after it has emerged from her body? For a list of sources of the solutions offered to resolve this difficulty, see Rav Bleich’s Contemporary Halachic Problems 1:347-349.
Rav Moshe Feinstein (Teshuvot Igrot Moshe Y.D. 2:60) resolves the problem as follows. Rashi (Sanhedrin 72b s.v. Yatza Rosho) asserts that a fetus is considered only potential life until it emerges from its mother’s body. This manifests itself in Halachah’s exempting the murderer of a fetus from death. Thus, explains Rav Feinstein, the mother and the fetus are mutual pursuers but “unequal pursuers”. The mother is pursuing only a potential life yet the fetus is pursuing one who is fully alive. Accordingly, the fetus is a qualitatively greater rodeif than the mother. Therefore, Halachah sanctions destroying the fetus to save the life of the mother.
Rav Bleich’s Explanation of Rav Moshe’s Ruling
Rav Bleich argues that the same reasoning applies to the case of the conjoined baby sisters. The sisters were unequal pursuers since the right-side twin had no chance of survival for more than a year even if the left-side twin were to be sacrificed. The left-side twin, however, had a very reasonable chance of survival if the other twin were to be sacrificed. The right-side twin’s life expectancy is regarded as only chayei sha’ah (temporary life; see Avodah Zarah 26b and a full explanation in Gray Matter 3:28-35) while the right-side twin enjoyed the possibility of achieving a normal lifespan.
Thus, the baby twin girls could be construed as “unequal pursuers”, since the left-side baby pursues only chayei sha’ah whereas the right-side baby is pursuing one with a possibility to live a normal lifespan. It follows that the right-side twin is a qualitatively greater rodeif than the left-side twin and thus the right-side twin may be sacrificed in order to save the left-side baby. Thus, Rav Bleich offers a cogent explanation for Rav Moshe’s ruling.
One the other hand, Rav Yaakov Kaminetsky might have rejected the analogy between the situation of the twins and that of the pregnant woman because the inequality between fetus and mother is far greater than the gap between the twins. The difference between the mother who is classified as alive and the fetus who constitutes only potential life is a qualitative and fundamental difference as opposed to the twins both of whom constituted a full life. I thank Rav Chaim Schertz of Harrisburg, Pennsylvania for providing this insight.
Conclusion
Rav Moshe’s ruling was implemented in practice by Dr. Koop and the right-side twin was sacrificed in order to save the life of the left-side twin. Sadly, the left-side twin died a few weeks later not due to complications from the surgery but due to contracting hepatitis B from a blood transfusion. Although the loss of both of these precious children constitutes an enormous tragedy, a bit of a silver lining in this very dark cloud is the great Kiddush Hashem and honor of Torah generated by the enormous respect Dr. Koop accorded to Rav Moshe Feinstein and his ruling. May the study of Rav Moshe’s ruling serve to honor and elevate the neshamot of these two dear young infants.