The sort of impossible ethical dilemma thrown up at the start of a new BBC documentary on Great Ormond Street Hospital aired tonight, is something to which Dr Joe Brierley has become well-accustomed.
The programme follows a set of conjoined twins, Marieme and Ndeye, who have defied all medical expectations to survive to two-and-a-half-years-old. The twins are conjoined in a certain way meaning they have shared circulation but separate hearts and lungs. While Ndeye’s vital organs are healthy, Marieme’s heart is desperately weak. If she dies, her stronger sister will die with her.
As their health deteriorates the hospital – and their father, Ibrahima – are forced to discuss whether or not they should operate to separate them: perhaps prolonging one twin's life but almost certainly ending another.
As chairman of the hospital’s ethics committee, Dr Brierley, a consultant in paediatric intensive care, leads a series of discussions with colleagues and the father of the girls to determine the best way forward. It is tense, painful viewing as they consider an effective death sentence.
“As a father, how do you get your head around the fact people are even thinking like that?” says Dr Brierley, 50, himself a father of four children, one of whom has suffered their own health complications. “If a decision like this doesn’t weigh on your mind you’re in the wrong job.”
Great Ormond Street Hospital is a world leader in treating conjoined twins, with patients arriving from across the globe. Just last month two-year-old sisters Safa and Marwa Ullah, from Charsadda in Pakistan, made headlines after undergoing 50 hours or surgery in three major operations to successfully separate their heads at the hospital.
But this rare disorder, which affects around one in 2.5m births, is far from the only sort of case which comes in front of the ethics committee – and increasingly in the digital age medical professionals can find themselves making decisions in the full glare of the public spotlight.
Readers will be familiar with the case of Charlie Gard, the 11-month-old baby who died in 2017 of a rare genetic condition following a protracted legal battle between his parents and Great Ormond Street Hospital over whether he should be allowed to travel to the US for experimental therapy. A High Court judge ruled in favour of the hospital which argued he should not travel and instead be allowed to die with dignity – a decision which attracted the opprobrium of the US President Donald Trump, among countless others.
Last year, another high profile and emotive case in Liverpool saw Alder Hey Hospital take the parents of 23-month-old Alfie Evans to court in order to allow him to die. At one stage, police had to block campaigners storming the hospital in protest at the decision.
Dr Brierley stresses he is not allowed to comment on the case of Charlie Gard due to patient confidentiality but insists the documentary was planned long before what he calls “the controversies”.
Still, it comes at an opportune time to reveal the complexity behind what critics deem callous decisions. “What I hope people see is really tough decision-making and children and families at the front of centre,” he says. "That is what you miss on social media – the complexities of how parents are routinely involved with this. They live with this and carry that burden.”
Earlier this year, new guidance was issued by the Royal College of Paediatrics and Child Health suggesting parents caring for sick children should be given more help to understand the possible impact on their personal lives of posting online or involving the media in their cases.
Dr Brierley admits concerns over the speed in which outrages are blown up on social media, shrouding the complexities of the ethical debates he and his colleagues face. “There are nuances and subtleties lost,” he says.
Great Ormond Street was one of the first hospitals in Britain to establish a clinical ethics committee, with a working party set up in 1995 eventually being formalised in 2000. Dr Brierley has worked as a consultant at the hospital since 2004. Nowadays, he says, the committee meets every Wednesday afternoon in the hospital boardroom and involves around 24 members boasting a multitude of skillsets including a philosophy professor, various ethicists, nurses, doctors, chaplains of numerous faiths, psychologists and – crucially – parents of children who have been treated at the hospital.
"Tough decisions are made every day in every hospital in the country and really well – but some cross a threshold," he says. Medical advances, he believes, have increased the need for such ethical debates as doctors are increasingly able to turn to ever more experimental treatments.
“Medicine has progressed hugely but we are doing more high-risk stuff,” he says, citing advances which mean children awaiting surgery can now be cared for at home on equipment such as heart machines and ventilators, previously only available in intensive care wards. “We are pushing the edges all the time and trying more things on children where even 10 or 15 years ago they would have died.”
The advent of technology also means parents are now far better educated on the rare disorders affecting their children. “It is the great democratisation of information,, and overall a largely positive thing, but it can cause difficulties,” he says. “The slight problem is lots of people have an opinion about stuff without having the knowledge and training.”
Religious beliefs can also prove a sticking point. In 2014 a High Court judge in London ruled that the young son of two devout Jehovah’s Witnesses who had suffered severe burns could be given a blood transfusion (by an unnamed hospital trust) despite religious objections from his parents.
In spite of such high profile cases, Dr Brierley insists “95 per cent” of the time, he and his colleagues come to an agreement with the parents “on a shared pathway from a really tough place”.
When the hospital decides to involve the courts he says it is “ultimately because a decision must be made”.
The parents of Charlie Gard, Connie Yates and Chris Gard, have proposed a new law allowing parents to move their child to another hospital if they disagree with the treatment decided by doctors. Dr Brierley argues such a move would be unnecessary.
“I don’t think the law would change most of the things we do,” he says. “We work with children and their families making decisions all the time predicated on parents and their views.”
Presently he estimates around 60 per cent of NHS trusts now have their own versions of ethics committees, a figure that is only going to increase. “We’ve got better at sharing our uncertainty with the parents and asking them, 'what would you like to do?'” he says.
As for Ndeye and Marieme – the conjoined twins in the programme – the decision was eventually taken not to operate. They remain alive in a hospice in Wales and are currently doing better than expected.
Surviving childhood is extremely unlikely, Dr Brierley admits, but he and his colleagues can only hope that on this they are wrong. “One always needs to have the humility to say: ‘I can’t predict the future’.”
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