In late 1977, Dr. C. Everett Koop made national headlines when he performed surgery on a pair of conjoined twins who shared one heart, separating the two infants. But the news didn’t so much center on the operation itself – at the time, Koop, the future U.S. Surgeon General under President Ronald Reagan, was a famed pediatric surgeon at the Children’s Hospital of Philadelphia and foremost authority on the phenomenon of conjoined twins – as on the fact that the separation took place only after weeks of debate involving top doctors and one of the generation’s foremost authorities on Jewish law.

For Koop, who related the story of the case to a group of college students at the Chabad-Lubavitch center serving Dartmouth College, the moral issues at stake – the attempt to save just one of the twins’ lives would invariably result in the sacrifice of the other – pushed him into a world where scientific judgment was questioned in the light of religious mandate. Even today, he looks back at the debate as a formative moment.

“I became, like I am tonight, a storyteller,” Koop told the students, all of them alumni and participants in the Sinai Scholars Society at Dartmouth. “I talk about what happened with these girls and what we could have done differently.”

Chabad at Dartmouth director Rabbi Moshe Leib Gray reached out to Koop after his Sinai Scholars class – part of a joint project of the Rohr Jewish Learning Institute and the Chabad on Campus International Foundation – came across a discussion of the case in their examination of the relevance of the Ten Commandments to the 21st century. The class was considering the Sixth Commandment against killing another person not only in the context of murder, but also in the context of some socially-acceptable manifestations of killing, such as dangerous surgical procedures and abortions.

Gray didn’t have far to look for Koop: the graduate of Dartmouth’s class of 1937 remains as the senior scholar at Dartmouth Medical School’s C. Everett Koop Institute.

Koop’s resulting presentation revealed to the students that just as the Talmud and later Jewish sages considered cases similar to such seemingly modern questions as abortion and experimental treatments, those who pondered the fate of the conjoined twins also reached back to Talmudic arguments.

The doctor, who is not Jewish, said that he referred the case to Rabbi Moshe Feinstein at the encouragement of the twins’ parents, who came from noted rabbinical families in Lakewood, N.J. Rabbi Moshe Dovid Tendler, an expert on medical ethics and a friend of Koop’s, also got involved in the case as a son-in-law of Feinstein’s.

Examining the Case

The rabbinical debate focused on whether or not either of the twins had a reasonable chance of survival remaining conjoined or being separated. Koop determined that one of the babies would certainly die with or without the separation procedure. If Koop operated, that baby would have to be sacrificed, but her twin had a slim, but reasonable, chance of survival.

Over the course of several weeks, the rabbis examined several different cases of one person’s right to live coming into direct conflict with another’s. Although Jewish law has a general standard that one person cannot be sacrificed to preserve the lives of a group, the Talmud provides an exception in a case where outside powers demand that a specific person be handed over to be killed. Other exceptions include when a fetus endangers the life of its mother and killing in self-defense against a pursuer. The question was how should the twins be viewed, as either equal claimants to life or as a manifestation of one twin pursuing the life of the other?

Koop, aware of the urgency of medical intervention, had little to do but wait for a decision.

“My problem was that I’m a doctor, I’m not a theologian,” he said. But, “it became clear that the decision was going to be made with theological law coming long before medical law. That, I understood completely.”

Finally, Koop received a call from a young man on behalf of Tendler, telling him that he could proceed with the operation.

As soon as Koop made the first incision, it became clear that his prediction was correct: the one baby would have died in either case.

“There was nothing we could do, we had to destroy one child to give the other life,” said the doctor. “We went through the maneuvers, and at about 8:30, the twins were separated. Still, I thought the chances of even one child surviving were pretty darn slim.”

The second twin died about three days after the surgery, leading some to ponder whether quicker medical action could have saved her.

Koop answered that he saw little value in asking “What if?” questions.

“Informed consent must of course be respected,” said Bret Tenenhaus, a graduating Dartmouth senior, “and was thus the reason he had to wait a few days before operating.”

Mackenzie Howell, a junior who serves as student president of Chabad at Dartmouth, appreciated Koop’s story for the example it provides of a concrete application of the Ten Commandments.

“Sinai Scholars is all about how the Ten Commandments are still relevant today, and here’s a real, live example of how these issues are still being debated,” said Howell. "However distinguished a surgeon he was, he knew he was in over his head and needed to consult someone who had a better handle on the issues.”