Ethics, Law, and Society Forum – November 13, 2018 – John Sullins

Ethics, Law, and Society Forum – November 13, 2018 – John Sullins


[ Music ]>>Today though I am pleased
to welcome myself to the Center for Ethics and Law Society at
Sonoma State lecture series and I’m going to be giving
a talk on robotic surgery and ethical issues that
arise in that world. So this is based
on some work that, I’ve been following
robotic surgery for about five years or so now. And I wrote a paper early on
in that process which a lot of this is based on and it’s
my second highest cited paper. It gets read all the time. And it’s one of the very
first papers written on the ethics of
robotic surgery. So it’s kind of interesting but
of course everything changes with a topic like this. The technology for a robotic
surgery is just growing in leaps and bounds. And this particular machine
right here is actually not the machine that you’ll see on
operating floors as much now. Why I’m getting back
into this topic is over the winter break I
have to have a surgery done by this particular machine. And so of course being
involved in surgery like that is an emotional and
frightening sort of thing. And it was really comforting
to have had this paper that I wrote four years
earlier, so my rational, common, rational self could talk to my
current more emotional self. And I could make some
better decisions about how to go forward on this. So I thought it might be
useful for some of you because the truth of the
matter is as we go forward, if you find yourself in need
of surgery in the future, it’s probably going to have
to have something to do with this kind of technology. So let’s take a look
at what it’s all about. So we have here this first
robotic surgery device was approved in 2000 by the FDA. And by 2013, the time that I
wrote this paper originally, there had been 367 surgical
procedures and already by that point, there was 105
million worldwide and 27% of all hysterectomies are
done with this machine. And 87% of all prostatectomies,
that’s a hard word to say, were done by that machine. It’s closer to 99% now. So this is some new facts
as of just last month. So at this particular time
there’s 107, I’m sorry, 1700 of these machines installed
in hospitals around the world. 775 patients worldwide have
had this procedure done in the last year. I mean up to the last year. So you can see it’s, since 2013
it’s actually sort of doubled in the number and it took 13
years to get up to 300,000 and now it’s doubled
in this time. 3 out of 4 prostate
cancer surgeries are done by this Da Vinci
surgery machine. More men choose this
for prostate cancer than any other treatment. It’s got a pretty good rate of
success with that treatment. Women are using it
for hysterectomies and other surgeries that
require dexterity and it seems like there’s a better
chance of success when you remove the
prostate with this machine than with radiation treatment. But there’s also problems
with this machine. So what are some of the issues and I believe this is what
we’re going to spend a lot of time thinking about. So do we, are there particular
costs when it comes to safety? There’s definitely money costs. So as we’ll see in a moment, these surgeries are
much more costly to do. You can see how it works here
is these are the surgeons right here and they’re looking in kind of a virtual reality
glasses, right? And so they see this stuff
in kind of a 3D view. And this is the patient
right here. And then there’ll be a nurse
monitoring what’s going on with the machine. And then some other technicians
watching up on the video to make sure things
don’t go wrong. Things do go wrong in this
kind of surgery, so there’s, the machine itself
isn’t foolproof at this particular time
because it’s still kind of new. So we’re going to have to ask
ourselves, are engineer, sorry, injuries and other kind of engineering problems
being reported correctly? Is there what we’ll be primarily
interested in here is some of the different breach of trust
that we have with surgeons. How does robots enhance
or get in the way of that? And then we’ll talk a little
bit about reverse adaptation, which is when we change society
to fit in technology rather than changing the
technology to fit our society. So this is a new slide,
couple new slides too, just very recent report. So we have a couple of doctors
here who have done some studies about robotic surgery, the
risks and rewards of it. They are telling us that
this is rapidly expanding, any hospital you go into, if any
of you guys are getting involved in the medical world in
any way, you’re going to run into this technology. It’s growing really quickly. It’s definitely showing some
interesting short-term benefits. It’s, but it has usually, depending on what
we’re talking about, similar long-term effects. So one of the main benefits of robotic surgery right
now is decreased time, recovery time in the hospital. So what they can do instead of
having to really open you up so that you can get human
hands in there to mess around with the organs or
whatever they’re working with, all they have to do is put
this tiny little incision and the robotic arms go in
and then they spread out and then they work inside
you like a spider, right? Like spider legs. And so that means that
the incision in your body, that to get inside
is much smaller and of course heals
faster, right? So you spend less
time in the hospital. It’s kind of odd. You’ll spend more time on the
table than with a open surgery. But you’ll, so the robotic
surgery actually takes longer, but you will spend less time
in recovery in the hospital. But, long-term effects,
it’s probably a wash as to whether you had open
surgery or robotic surgery as to which one was better. So it’s a complicated
story, right? So that means that there’s
some area for improvement, some reduction, we need to reduce the error
in robotic surgery. Need more standardized training. Need more training in general
if this is the direction that we want to go in, is what
these doctors are talking about. Stanford just last month
released a big study, really important,
interesting study. Now what they’re looking at is only a particular
kind of surgery. So this is for kidney
cancer if you’re going to remove the entire kidney. So it’s really important
to pay attention to that when you read this because it
looks kind of bad initially. So they studied from 2003 to
2015 in 416 different hospitals. They washed all the kidney
removals that were done with this machine and
without this machine. And they noticed that there
was no difference in results. So whether a robot did it or a
human did it in an open surgery, your survival rates weren’t
increased or decreased. But you did pay you know, 2,700
dollars more for the robot. So the robot was more expensive
than the standard surgery. Now, if he says, so this is the
quote from the lead author here. They put his name up? There he is. So Dr. Kim tells us that
“There is a certain incentive to use very expensive equipment. So imagine you’re a
hospital administrator and you bought this
really expensive robot, you’ll want to use it, right? But it’s also important
to be cognizant as to how our healthcare
dollars are being spent. Although robotic surgery
has some advantages, are those advantages relevant
enough for this type of case to justify an increase in cost?” Now, really important to
take this into consideration because this is basically the
surgery that I have to have done so I was particularly worried
about this when I read this. But on closer look I
noticed what they’re talking about is the removal
of the entire kidney. Now if, sometimes if the
cancer is small enough, they just remove a
part of the kidney. Right? And when they
remove a part of the kidney, it turns out that the robot
is tons better, right? Tons better than a
human open surgery. So if you’re just going to cut
in, take the whole kidney out, and then sew them back
up, that’s one thing. But if you’re going to go in
and try to actually do surgery on the kidney itself, it turns out that the little tiny robot
hands are extremely useful in that. Because what they do is
they have to scoop it out, then they have to fold
it back together and sew up the top of the kidney. So if you’re going to do that, then the robot actually
makes sense. So when you’re reading
studies like this, you have to really pay attention
to what we’re talking about. He’s just talking about one
particular kind of surgery. In that particular
kind of surgery, the robot wasn’t very useful. But in other kinds of
surgery, maybe it is. Okay, so here’s some
of the issues to think about when we’re talking about adding robots
to the medical world. This is a really interesting,
when I did this research, I had no idea that this
was even a concern. But it is a concern. As we move to robotic
surgery, our surgeons, like if you’re going into
medical school now and you go down the direction
of being a surgeon, especially if you’re going to
get into neurology, you’re going to learn robotic surgery. That’s the thing that
you’re going to learn. You’re going to come up in
that world and you’re going to do a little bit of
open surgery, but not, it’s not going to
be your specialty. Now, that means that doctors
your age, as they go forward, are going to be thinking
in that world. But now if you are a surgeon
in other parts of the world where we don’t have, you
know, the greatest hospitals, these patients, right, what
kind of surgery are they going to have offered to them? They’re going to have only, their only choice
is open surgery. Now, here’s an interesting thing
that I didn’t really realize. Is that doctors from the western
world develop new techniques and those new techniques
then find their ways over into hospitals like this. But if you guys are being
trained only on robots, machines that are
super expensive that these hospitals are never
going to be able to afford, then what you learn
will not be transferable to the third world, right? So we’ll basically
be splitting up like as two distinct human
species, right? One that’s very robot
oriented and one that isn’t. So we have to ask ourselves,
are we setting ourselves up? It’s going to have an
ethical question, right? Are we doing, are we
doing the best that we can for all the people in the world? We’re certainly doing the
best we can for ourselves, but does that translate
to being useful to other people in the world? Okay, so that brings us
into the interesting world of surgery ethics, which I
found out to my surprise, medical ethics is a big topic. It’s been a topic forever. But as it turns out,
surgery ethics is only about 20 years old. So people have only been talking
about the ethics of surgery for less than 20
years, which is odd because this is ancient
surgery, right? Not the [inaudible]
modern surgery. It seems like it has effects that ethicists should have
been paying attention to. But up to 20 years
ago, surgeons thought that surgery ethics was
kind of an oxymoron, a word that made no sense. But that’s been changing. And there has been a growing
new world of surgery ethics. And so what I tried to do
was try to apply robotics to the existing world
of surgery ethics. Okay, so people who study this
and worried about the ethics of surgery have identified
four or so things that are not just
medical ethics, right? They’re specific to surgeons. And what’s specific to
surgeons is this fact that they are super
physically intimate with you. More so than your
regular doctor. They are literally
inside your body, right? They open you up and they
are inside your body. So they are the most
intimate person that you will ever be
encountered in your life because they are going
to be, they’re going to know everything
about you, right? In intense detail. But the other odd thing about
it is this relationship, while extremely intimate,
is extremely fast. So surgeons just deal with
you as a patient really quick and then they’re onto the next
patient, the next patient, it’s like an assembly line. So they’re not like
your personal doctor, who you might see time and
time again over years and years and develop a more sort
of human relationship. So your relationship with your
surgeon is an odd one, right? A strange one that’s
intensely intimate but also intensely fast. Other things we have to think
about is the informed consent. In surgery it turns
out to be an issue because quite often
they will open you up and they will be looking inside, they meant to be doing
one procedure and then when they open you up,
they see some other stuff that needs to work. And it’s not like they can
just wake you up and say “Hey, we’ve got another surgery
we want to do with you, do you consent to that?” Right? And then turn
you back off, right? They can’t do that to you. It would be an awful
experience to have that happen. I had a friend who had
that happen by mistake. He was in a surgery, he starts
coming out of it, and he feels like this incredible pain, and
the nurse sees his eyes sort of coming into consciousness, and then the only thing he
remembers is her turning the knob, right? To give him more gas, whoo. And so you don’t want to wake
up in the middle of a surgery. Right? It’s an awful experience. So, we can’t wake you up, we
can’t get informed consent if we want to extend
the procedure. So oftentimes surgeons make
the call themselves, right? So they often find themselves
in a position where they have to just decide what’s
best for you without actually
having talked to you. There’s also the problem
with industry relationships. So surgeons have a very tight
relationship with the industry, especially the robotics
industry, because robotics engineers don’t
know jack about surgery, right? And surgeons don’t know
anything about robotics. In order for this thing to work, they have to work very
closely together and that means that surgeons get a little
piece of the cut, right? When these machines are built. So when you go in and
you’re a surgeon it says “I totally recommend this
robotic procedure,” you have to ask yourself is that because
they’re getting extra money for doing that? Is it really the
best thing for you or is it the best
thing for the surgeon? Right? So industry
relationships are going to be a very important
thing to think about. And then outcomes reporting,
surgery is all about, has a lot of intense
outcome reporting and that can actually sort
of harm robotics surgery because this is a
new technology, of course things are
going to be going wrong and those things get
reported really quickly and that might cause us to not
consider robotic surgery in ways that maybe we ought to. So all this is what we’re
going to try to talk about. So let’s talk a little bit about
this industry relationship. There’s a real possibility
of conflict of interest here. So as I said, right,
you need the surgeons to help with the innovations. The surgeons of course
like to get involved because they can make a little
bit extra money on the side. Being part of these corporations
that are producing these things. Even if you’re just doing
open surgery like this surgery with a scalpel, if you’re a
surgeon, and you’ve figured out some new technique that is
better than the old technique, you can patent that and make
some money off of that, right? So surgery has always
been about, it’s a much more technological, the doctors are much
more directly involved in the technology than any
other form of medical practice. So we have to really watch
out for conflicts of interest. So when, if you are in a
position where you have to ask, you know, where you’re kind
of playing robotic surgery, first thing you want to ask
is do you have a conflict of interest? How much money are
you making on this? Are you involved in the
patents of this machine that we’re going to use? And make a good informed
decision based on that. Outcomes reporting turns
out to be easier in surgery than any other practice. It’s usually directly
obvious, right, if we’re doing the surgery and
we cut something incorrectly and that patient bleeds out
and dies, it’s pretty obvious that it was the surgeon’s
fault, right? That caused that. If you’re taking some kind
of a medication and ten years from now you die, was it because
of that medication or not? Right? That’s a much
more difficult cause and effect relationship. Surgery is almost always super
direct and so surgeons pay for that literally out of
their pockets sometimes. So this has currently
had a negative impact on robotic surgery. Every time a big accident
happens, you’ll notice that the stock in
companies that are you know, the stock in Intuitive Surgical,
for instance, will drop a lot. Probably in the interest of
ethics I should probably mention that I do own stock in Intuitive
Surgical, and I’m not trying to get you to buy it or
sell it, but you should know that I have a small
financial interest in this. Okay, so here’s some of
the interesting, you know, game that surgeons have to play
that are, some interesting, you know, dilemmas,
ethical dilemmas, that come up only in surgery. We’ve already talked about
the scope of informed consent. The next thing is do
you tell the patient that you left some gauze
in them, for instance, and before you sewed them
up you realize you forgot to pull the gauze out
and then you pulled it out a little bit later in the
procedure than you expected to? Is that something
you’re going to disclose to the patient afterwards? Are you just going to shake
their hands and let them head out the door as if
nothing happened? Are you going to
disclose the fact that quite often these
are new people, right? There’s a surgery is a
skill that has to be learned by younger surgeons following
around older surgeons and learning the skills
by watching and doing. For instance, when my
wife had a C-section, I remember the moment was
very frightening to us because we were dealing
with this doctor and then right the day
before, he said “Oh I’m going to add this other guy in,” and
it was this young guy, right? A new guy and he said
“Oh, I’m so excited, it’s going to be my
very first surgery.” And we’re like we’re going to
be your very first surgery? But that goes now to the ethics
of the individual, right? Which we also have
to talk about. Do you have the ethical
right to demand that we not teach this
guy, right, on me, right? Because it’s me. I don’t mind if he
learns on you, right? But I don’t want him
learning on me, right? But he’s got to learn
on somebody, right? So does a patient really have
the ethical right to demand that learners are not in
the [inaudible], right? So this is a constantly complex
game that surgeons have to play. And then we talked about
the decisional capacity. Sometimes you have it, and
sometimes you have the luxury of thinking about a
surgery for a long time, other times you don’t. So one of the people I was
talking to about this kind of surgery that I’m going to be
involved with, he had no choice, he walked into his
doctor’s, his doctor said, he looked at the scan
of him and said look, you’ve got like stage 4 cancer, I’ll see you tomorrow
morning, right? And by the next morning
his kidney was gone, right? So that guy didn’t have any
time at all to really think about any of this stuff, right? Had less than 24 hours
to make the decision, life-changing decision. So surgeons put you in those
positions, how do they do so in an ethical manner, right? And that’s the amount of
respect your autonomy is about [inaudible] and
considered justice. For instance, one of the
question these asked me, which was clearly an
ethical question, was whether or not I wanted, if they needed
to give me a blood transfusion, whether or not they, I
wanted them to do that. And I remember when they asked
me that question I’m like that’s so stupid, like why
wouldn’t you, right? Of course give me a
blood transfusion, I don’t want to die. But they said, but then I
asked her and she said well, actually there’s
certain religions that just won’t do that, right? And so it’s not a technical
question, of course technically, they want to give you
the blood transfusion. And they suggest a
blood transfusion. But for religious reasons, some
people will decide against that. And just die I guess. Okay, so this brings
up a great example, bringing up this problem
of paternalism, right? So as a surgeon, a surgeon
may know that your chances of surviving a surgery are
a lot higher if you consent to the blood transfusion. But do they, their point
of view is always go for the blood transfusion,
but do they get to boss you around
or not, right? So paternalism is a
big issue with this. Respecting a person’s
particular autonomy, maybe they just don’t want, maybe they do, would
prefer to die. And have some of these
procedures done on them. The problem about surrogacy,
sometimes the patient is kind of out of commission already,
an accident has happened, they are unconscious,
they’re not going to be conscious before
the surgery starts. And then who gets to make the
decisions about that person? Which relatives, you know,
because you can have situations like this where the
relative says no, I don’t think rich Uncle Jim
really wants this surgery done, I think he’d rather die
and leave his estate to me. So you’re going to
listen to that surrogate? It’s a problem, right? And then beneficence in
the proposed procedures. Are you thinking about
what’s good for the patient and not just what’s good for
you or good for your hospital or good for society in general? Okay, so we have truth
telling is really important. Especially when we’re in the
world of robotic surgery. Like I said, report, report. When you report something bad,
people sell off the stock. When you report something
good, people buy the stock. So you would see that at
least from the company’s point of view their motivation
would be to really promote
the good things about remote robotic surgery
and play down the bad things because it really affects their
bottom line and it can lead to law suits and
different things like that. So the problem here
that these doctors and other researchers
tell us in their paper is that a position may
not conceal or refrain from disclosing medical care in
the hopes of avoiding a law suit or unpleasant emotions
and embarrassment. So this is an ethical decision
that surgeons have to make. Sometimes they’re trying to protect themselves
from a lawsuit. Sometimes they’re
just embarrassed that they made a mistake. Regardless of that, the
ethicists in this report suggest that truth telling is always
important in this world, reporting errors
and how they happen. Okay, we talked a little
bit about this already. Your decisional capacity
as a patient. People making good decisions. One thing that I noticed
just in my own experience that I didn’t think about when
I wrote this paper is the, when you’re this person,
right, you’re kind of grasping for straws, and you’ll
do almost anything. So I think you’re more
susceptible, easier to, you’re far less skeptical
when you’re in that position of your doctor than
you might be otherwise. So your doctor may be able to
cause, influence your decisions in ways that they might not
have influenced your decision if you were in a less
vulnerable state. And then we talked a
little bit about this. The unethical requests
by a patient don’t have to be honored by a doctor. So if the patient is
making an ethical request, like I don’t want the new
surgeon involved with me, just because I’m
worried about myself, that may actually be
an unethical request, one that we can ignore,
actually. Also, an unethical request
is I want the most expensive, best surgeon possible. Right? Why do you get that
and somebody else doesn’t? Because their time is limited. We should hope that there’s
a system in place deciding who gets which surgeons, which cases really require
the best surgeon in the world. In which case, this
can be delegated down. Okay, so here we’re talking
about, this is the world that I normally work in, is
the world of robo ethics, which is an also new,
20 years or less old, ethical research area. And so what we’re
looking at here is some of the work from robo ethics. It looks like this,
that can be applied to the specific instance
of robot surgery. This is just a look
at an earlier version of the robotic surgery machine. They started building
these things, researching these
things, in the 70’s. And they’re just now starting
to make it into the millions of dollars in profits for
building these machines and hundreds of thousands
of uses. So, one of the things we have to
remember about robotic surgery, which is very different,
most of the time innovations in surgery have come
from surgeons themselves. This is one of the very
first innovations in surgery that come from outside surgery. It was developed, last summer
I was at SRI in Stanford, a little research
RND think tank. And in there, they have one
of the very first prototypes of the Da Vinci machine. And they did all the prototyping
and discovery of this, just engineers did this, and
then they sold it and then that company decided to try
to pull surgeons in and decide if it could be used in a profitable way
in actual surgery. So it wasn’t that surgeons
came up with this idea, wow, we really need robots;
instead it was engineers that said you guys
really need robots. So here’s an early case,
so and what we’re worried about here is was surgery
robots a solution looking for a problem, right? In the early days, it looks
exactly like that’s what it was. It was a solution
looking for a problem. It wasn’t that surgeon
said we have this problem, we really need you
guys to help us fix it. It went the other way around. And so one of the early things that they were doing
was they were doing, removing thyroid glands. So that’s that thing
right here, right? On your throat. Can have problems,
usually cancer, right? So if we need to get rid of
that thing, how do we do it? Well it turns out that
in an open surgery, they cut your neck right,
and they pull it out, and then what you’re left
with is this big scar, right, that looks like this on your
neck for the rest of your life. But with the robot, I can’t
remember where they go in. They go in in a really
surprising place. I think it might be in your
back or somewhere in your arm, and then they go up and
then they remove the thyroid and they pull it back out
through the hole, right? So what’s really cool about this
is that there’s no scar, right? You can have your
thyroid removed and you don’t look any
different than you did before. So patients of course
really like this, right? For reasons of vanity, right. As it turned out, though, your chance of survival
was greatly increased if you went with
the scar, right? Turned out that the regular
open surgery had a huge benefit in survival rate. So what we’re worried
about is early like think, you know, early 2000’s, right? Were some people
who are dead now, did they make the decision based
on something stupid, right? About a beauty concern,
a cosmetic concern. And it winded up
costing them their lives. Other concerns we have
is optimism bias, right? Because we’re really
optimistic about these machines. The people that use
them and design them, they’re really excited about it. And does some of that
optimism seep into the surgeon, who then assumes that
the machine is better in this particular instance
than it might actually be? It has a very steep
learning curve. What that Stanford study, one
of the things they said to think about was the results
spoke for themselves. The results were that it
was just more expensive and it’s mostly more expensive
because it takes more time to do the surgeries
than it would, an open surgery is much faster than doing all this fiddly
stuff with a machine. Which has to be calibrated
and you have to make sure everything’s going
right, and if something’s wrong, you can to pull the arms out, replace the head,
put it back in. With all kinds of stuff. These technicians are
working the entire time. Along with the machine. So along with that comes
a steep learning curve, more time being spent in
surgery, more money being spent, therefore, on all of this. And that what happens
then is that we report, what comes up in
the report, is this, it looks like maybe the
robots aren’t any better and all they are is
just more expensive. But what the Stanford doctor
said was well, we’re looking at a very new piece of technology built
from 2000 to 2013. Those were people
that were learning. Nobody knew how to
use one before 2000 because it didn’t
exist before 2000. So everybody was learning, even your most senior
surgeons were learning on the job with these things. So of course it weigh probably
worse in the teens and right around the turn of the surgery
than it would be now, right? They cautioned, they said
maybe now it actually, we’re going to actually start
seeing some real benefits from this. Okay, so here we get into
stuff that’s a little more philosophical. So when we’re, these are
more philosophical concerns about robotic surgery. You’ll remember, see these
people right here are some surgeons, right? And they’re working on somebody,
and this is a prototype machine, it isn’t actually in use, but you’ll notice,
where’s the patient? Not in that room, right? Not in that room. So remember when I said that surgery was a super
intimate thing, right? The surgeon has literally got
their hands in your body, right? We’re now changing
that relationship so that the surgeon could
be some place very far away from you. We may get to the point
in the next few decades where you might not even ever
meet your surgeon, right? Your surgeon might be
somebody very far away. So some of the ways that robot
surgery was initially sold was you know, ask yourself why did I
see the early prototypes at SRI and [inaudible], [inaudible],
SRI tends to be a research group that gets most of its money
from the Department of Defense. Why do you think the Department of Defense is interested
in robotic surgery? What happens to soldiers? They get wounded, right? They get wounded. Are they wounded in
a convenient place where you can just pull
them into the hospital? No, they’re wounded in places
far in the world, right? But danger is in
dirty places, right? It’s where they get wounded. Do you want to send
your best surgeons to dangerous, dirty places? No, you don’t want
to send your surgeons to dangerous, dirty places. It’s best if your surgeons
are here in Washington, right? And they’re working on a
soldier in Afghanistan. Right? Through this technology. Right. So that’s the reason
it was initially developed was so that we could
get extreme distance between the surgeon
and the patient. Right. So maybe, it turned
out that that didn’t work. But why do you think
that didn’t work? Do you ever lose connection
with your internet? What happens if they’re
doing a heart surgery and you lost connection
with the internet, your surgeon is 40,000
miles away from you, right? It’s a bad thing, right. And even like if they don’t lose
connection, there can be latency in the signal, which
can cause the machine to not operate the way
it’s meant to operate. So it turned out that we
couldn’t really distance the surgeon too far. Right now the surgeon is just
like five feet away from you because that turns out to
be sort of the optimum. But we’re working
on that technology and that technology
is changing every day. And we’re extending the distance between the patient
and the surgeon. Another thing is economy. So this is just a
practice machine. But imagine now we’re going to
distance the surgeon so far away from you that the surgeon
isn’t actually going to be present at all, ever. It’s just the machine that
you’re going to interact with? So you’ll just put you on a
conveyor belt, and you’ll run into the room and then the
machine will do the cataract machine or whatever on your
eye, and then you’ll go out the other side and
another patient will come in right after, do another
cataract surgery, right? And it’ll just be like on
a conveyor belt, right? And there will be
no surgeon involved, the machine will just be
programmed to do the surgery. That would be complete
autonomous surgeon. So currently we don’t have
machines much like that. I’ll show you here in a moment
we do have some interestingly fully autonomous
machines in medicine. But the desire is to move
more and more of that there. Because surgeons are
expensive people to hire. And we may, people who
own hospitals may be able to see a huge savings
if they don’t have to hire surgeons at all. Or maybe you hire just two
surgeons for the entire system. And robots are doing
most of the work, right? And then we have to worry about
reverse adaptation, right? So here, maybe we’ll get
to the future where just like you have your own printer and maybe you have your
own 3D printer now, maybe you’ll have your
own surgery box, right? And you’ll just do the
surgery at home, right? Or you’ll rent it from Best Buy. And a tech Geek will
show up and set it up, and they’ll do brain
surgery in your house. I don’t know. That’s a weird world but
not an inconceivable world. Okay, so here’s something
that I started thinking about. So I built this little table and
I put two factors on it, right, from fully human
controlled machines to fully autonomous machines. And then machines where you
have very little human contact and then machines where you
have you know, sorry, machines or humans that are in direct
contact with your body. And so we looked at
what’s available right now. So these are machines that you
can interact with right now. And they’re placed
on this table. So the one that is most common
is this Da Vinci machine and it is not autonomous at all. It is fully controlled by a human who’s operating
all of those lines. I know it sort of looks
like a robot, but it’s not. It’s a teleoperated machine. It’s not making any
decisions on its own. Humans make every decision
before it does anything. An interesting example of a fully autonomous medical
machine is this CT scanner. I don’t know if you’ve had a CT
scan before, but this machine is so autonomous that when
you go into the room, there’s just a technician there,
there’s no doctors in the room. They don’t need a doctor. This machine does everything a
doctor would do all by itself. And they just put
you on the table, and the machine just
does its whole thing. Goes in, does the scan, it
even talks to you, right? The machine itself talks to you, it says “hold your
breath,” “breathe,” right? And it just does, it does
everything all by itself. It’s a really fantastic,
interesting machine. So that’s an example of fully
autonomous, very low-contact, machine doesn’t touch you,
people don’t touch you, it’s just a, it feels like
magic when you have it done. These things are, I can’t
remember which one this is. One of these is a
bone milling machine. So if you have a surgery
where they have to grind down some bone, that
sort of tedious job, and they have a machine that they will just start
grinding the bone down and then they don’t have to
watch it, it does it by itself. And then over here would be
future machines possibly, right? These would be machines that are
autonomous like the CT scanner but have direct contact
like the Da Vinci machine. So you just imagine kind of marrying these two
machines together. And that would be a
machine that could do like an open heart
surgery on you without any human interaction. These machines we
should never develop. They are a human
controlled, little contact, I don’t even know
what they would do. So that’s just kind
of a blank area. Okay, so let’s get
this really quick. This is kind of the punch line. When is it best to trust
robotic surgery, right? When are we doing the right
thing by making the choice to do this kind of surgery? Right? So we have to
ask ourselves these, I think these questions
initially are important. It’s all about telesurgery
right now. These things do increase
the distance between the surgeon
and the patient. That is something that
has to be addressed. Latency and risk is
really an important thing. How are we going to be able
to get these things to work? One of the things they
want to be able to do, this is really crazy but
if you think about it, imagine you’re an astronaut
on your way to Mars. You need a surgery, we didn’t
take a surgeon with us, right? How do you get that surgery
done, we’re going to have one of these Da Vinci
machines on the space ship. And you’re going to get the
surgeon on Earth is going to try to do a surgery, you know,
close to Mars, right? How are we going to
deal with the latency and risk in those situations? And then just you know, the fact that these things are
frightening looking. I spent all my time thinking
about these machines, I’m still scared [inaudible]. I hope when they wheel me
in I’m already knocked out, I don’t even want to see it. They’re just really the most,
I mean, they look exactly like that evil machine
in Star Wars that tortures Princess Leia. Okay, so we are now
kind of at the end. Let’s see, I’m going to
skip over that and talk about this for our last minute. So what are, what should
we be concerned about? We have to remember that
operation time is up, recovery time is lower,
so we have this weird kind of cost benefit analysis we
have to worry about right now with the technologies we have
in the hospitals right now. We have to work on trying to
cross that digital divide. How are we going to make
these things cost efficient so that we can take
what we learned, new, positive strategies
and give them to the rest of the
world as well. We have to make sure that profit
seeking isn’t the thing that’s motivating this. We’re actually doing it because
it’s better for patients, not because it’s more
lucrative for surgeons. And then future surgery
ethics that we’re going to have to think about. Surgeons are going
to soon, very soon, have to make this decision. Like right now, we can give
you sort of replacements of your arm, as these
replacements get better, surgeons are going to have
to make this decision, patients are going to come
into them and say get rid of my arm, I’m tired of it. There’s nothing wrong with it, but I just want a
robot arm, right? The robot arms are better. And I want the iArm, right? And I want you to
install the iArm, or the ii, right, in my head. Surgeons are going to have to
make those decisions based on, it’s like cosmetic
surgery, right? But in a really super weird way. Same thing with surgical
enhancements. And then when we
get to the point of fully autonomous surgery
machines, are we going to admit those machines into
the, are we going to treat them like we treat surgeons? Or is the art of surgery going
to be something that becomes so de-skilled that we don’t even
give them any social benefit? Right now you’d be
really impressed if I told you I was a surgeon,
you’d be really impressed. You’d buy me a drink. In the future, you might
not care because that job is like lower than a
technician, right? Because all the skill
is in the machine not in the surgeon themselves,
right? So those are the ethical things
to think about in surgery. Hopefully gives you
something to think about. And I’ll talk to you guys not
next week, but the week after. Thank you. [ Music ]

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