A painful separation.

Just after 7.00 A.M. on August 20, 1993, Siamese twins Angela and Amy Lakeberg were wheeled into an operating room at the Children's Hospital of Philadephia. Joined together from chest to belly, the seven-week-old twins shared a liver and a single, misshapen heart.

Seven hours later, the surgery to separate the twins was complete. Angela was whisked to the intensive care unit, and Amy's lifeless body was taken away to be prepared for burial.

News of the remarkable surgery traveled fast, touching off an intense national debate. Why did parents Ken and Reitha Lakeberg ask doctors to perform the operation? Should the surgeons have compiled?

BACKGROUND

Amy's and Angela's story began when a single fertilized egg inside their mother's womb started to split apart. If this egg had fully separated into two individual embryos, Amy and Angela would have been identical twins. But the egg never fully divided, and the girls were born connected.

Reitha Lakeberg found out that she was carrying Siamese twins during an ultrasound test last December. But the Lakebergs, who also have a five-year old daughter, did not learn the full truth about their twins--that they shared a single liver and heart--until Amy and Angela were born.

The frail heart couldn't possibly support two growing bodies, Dr. Jonathan Muraskas told the Wheatfield, Indiana, couple. It was only a matter of time until the overworked organ would give out, and both girls would die.

A CHOICE

One alternative: Surgically separate the twins. Muraskas, who was caring for the twins, advised strongly against it. The odds for success were just too slim, he said. In the past, when doctors separated twins who shared a heart, the surviving twin has always died within months

Convinced that the situation was hopeless, Muraskas and his fellow doctors begged the Lakebergs to let nature run its course. "We sort of pleaded with them to take the babies off the ventilator," he says.

But the Lakebergs were unable to accept that end. "When I hold them, I fall to pieces," Ken Lakeberg said in early August. "This is a nightmare."

After several weeks of soul-searching, the Lakebergs decided: Despite the slim odds for success, they asked the doctors to separate the twins.

Muraskas put the Lakebergs in touch with surgeons at Children's Hospital. Doctors there had a fair amount of experience with Siamese twins, having performed 10 previous operations to separate them.

After conducting a battery of tests on the Lakeberg girls, the doctors in Philadephia agreed to perform the separation (see "The surgery," left). Based on their tests, the surgeons decided that Angela has the best chance for survival.

PERSISTENT QUESTIONS

At the time of this writing--close to a month after the operation--Angela is in serious condition, upgraded from critical. And the debate about the operation continues.

Some say the operation was just too costly--totaling upwards of $1 million. They point put that the Lakebergs didn't have health insurance--Ken Lakeberg, a welder, has been out of work for two years--so the taxpayers of Indiana ended up footing much of the bill.

"That's no way to spend scarce resources," says medical ethics expert Arthur Caplan. "There are kids who need tetanus shots, pregnant women who need professional care, babies who need food."

And people all over the country are troubled by the Lakebergs' admission that they purchased fancy meals, a new car, and some $1,300 worth of cocaine with money that was donated to help pay those bills. Amid the public uproar, the Lakebergs have pledged to pay the money back.

Dr. John Puma, an expert on medical ethics, believes that the surgery has caused Angela unnecessary suffering. She will die after a few pain-filled months, he predicts. It would have been more humane to have left the twins alone, La Puma argues.

Dr. W. Hardy Hendren, a pioneer in surgery on Siamese twins, disagrees. Rejecting the idea that the twins couldn't possibly have survived with a shared heart, he says life would have been unbearably painful for both girls. "I've seen twins that have been left together. They can't walk. They can't even sit up," Hendren says. "And because they're always stuck face-to-face, they fight constantly."

What do you think?