Introduction: The birth of live conjoined twins in a community can draw considerable attention to the appropriate ethical issues. Discussion: The management requires the skills of a multi-disciplinary team of clinicians who have seldom faced the challenge. The team leader must draw together principles of a medical, social, cultural, religious and legal nature in reaching the best outcome. Often the basic question is whether one child should die or both? At times the question is raised whether it is justifiable to sacrifice one life to save the other. In these days of high technology, surgeons can be tempted to go a bridge too far. In reaching this decision there can be numerous hidden conflicts of interest. Increasingly the final decision needs to be made and approved by the courts so as to protect the rights of the twins and to ensure surgical intervention is not an unlawful act.