Story
Year 2075:
Sarah has been noticing pain in her chest the past couple weeks and it has been getting more severe the last few days. She finally decides to go see a doctor and her doctor tells her that she has plaque in her arteries and is at high risk for a stroke. She will need a coronary artery bypass as soon as possible. The doctor informs her about a surgical robot at his hospital that is capable of completing a coronary artery bypass entirely by itself, without the need for a human surgeon. He says the robot is worth $2 million and is actually more precise than humans.
Sarah is very nervous about the procedure because she has a rare pre-existing condition that puts her at higher risk for complications and she is unsure if she is willing to trust a robot to do the procedure. She brings up her concerns with the doctor and he assures her that the robot has successfully completed the operation many times. He also tells her that if she wants the procedure to be done by a human surgeon she will have to wait at least 2 months. The hospital has been hiring less human surgeons now that robots can do many of the common surgical procedures. Consequently, their schedules fill up far in advance and prioritize operations that cannot be done by surgical robots.
Since Sarah does not want to wait to get the operation done and her doctor has convinced her that robotic surgery is actually more safe than human surgery, she agrees to schedule the surgery with a robot. She calls the hospital’s Financial and Billing Assistance Center to make sure her insurance will cover the cost of the procedure. She is put on hold for about 30 minutes then a woman picks up the phone and says “Unfortunately robotic surgery is not covered by public insurance policies”. Sarah had been diligently saving money for the last couple years so she could afford the out of pocket cost if absolutely necessary, but it does not seem right that such a common and vitally important operation would not be covered by insurance. She decides to call other hospitals to explore her options.
What are Surgical Robots?
Surgical robots are becoming increasingly advanced and common in the healthcare industry. These robotic systems can be controlled by surgeons’ direct actions, automatic and programmed before the operation, or semi-automatic constraining the surgeons movements [6]. Surgical robotics is especially useful for minimally invasive procedures where it can reduce patient recovery time and possibly increase accuracy and precision [7]. Surgical robots can also be helpful for neurological procedures that require very fine, delicate movements that are difficult for surgeons to perform without robotic assistance [7].
Discussion Questions
Click the + on the right of a question to view related perspectives and potential starting points for considering these ethical concerns.
Does Sarah fully understand the risks involved with robotic surgery? Has Sarah discussed the risks enough with her doctor to be able to give informed consent? [1,6,9]
- “Family verbal or written informed consent should be obtained, with patient assent if appropriate, with emphasis on the innovative nature of the device or procedure” [1]
- “Patients present with a wide variety of educational and cultural backgrounds, which should be considered during the informed consent discussion. Perhaps due to the aggressive marketing of robotic surgery or patients’ desire for the latest technology, patients generally seem enamored with robotic surgery.”[1]
Why might the doctor be motivated to recommend robotic surgery over human surgery? [5,6]
- “Hospital staff may try to persuade patients to accept the robotic procedure in order to pay off the costs of buying and installing the system” [5]
Has the hospital unnecessarily spent money on expensive surgical robots to appear more “innovative” when human surgeons may be a safer and less expensive option? [1,3,6]
- “But a common optimism bias among surgeons and institutions creates a tendency to overestimate the positive effects of the new.” [6]
What would people who cannot afford robotic surgery do when there are no human surgeons available? [3]
- “As the cost of new technologies is expected to be high and in various health care systems may not be covered or only partially covered by the public insurance, many patients may not be able to afford robotic treatment and the benefits of the new technology” [3]
Does the robot have experience operating on people with Sarah’s pre-existing condition? How might a lack of training data for pre-existing conditions and minority groups create unintended bias in robotic surgery? [5]
- “A robot might, for example, be subtly slower or a bit less precise given situations that were rare in its training set, and the effects of these small differences may be hard to detect on a case‐by‐case basis, while still contributing to biased outcomes when analyzed at the population/subpopulation level” [5]
Will less human surgeons be entering the medical field when so many jobs are being taken over by surgical robots? [8,9]
- “who cares if the surgeon is denied a chance to become excellent at surgery if the machine that replaced her provided a better outcome?” [9]
- “ if the systems became more autonomous and allowed the surgeon to become deskilled, then professionalism and excellence would be diminished and with it the ethical value of the work done” [9]
Who would be held accountable if there were complications in Sarah’s surgery— the hospital, the robot company, the doctor, the technician? [3,4,8]
- “As in surgical practice, the grounds for liability with robotic surgery include damage to patients, causality, illegality and guilt. Nevertheless, litigation with the use of robotic surgery may be complex.” [3]
Will people begin to lose trust in the healthcare industry if surgical robots are unreliable? [6,8,9]
- “ surgical innovation can potentially cause increased mortality and morbidity compared to standard techniques. Surgery in itself is not benign and there are risks from infection, anesthesia and longer hospital stays. But there are also possible financial and psychological harms as well as loss of trust in the 4 medical professions.” [6]
How will Sarah’s information and privacy be protected after the robot has access to all of her medical records? [8]
- “Robotics research and use of robots in healthcare raise questions about which data are collected, how they are stored, who has access to them, who owns them, what happens to them, and so on.”[8]
Themes
(Primary) Professional Responsibility, Transparency and Explainability, Fairness and Non-discrimination, Safety and Security, Accountability
(Secondary) Human Rights
Resources
- Geiger, J. D., & Hirschl, R. B. (2015). Innovation in surgical technology and techniques: Challenges and ethical issues. Seminars in Pediatric Surgery, 24(3), 115-121. Retrieved November 18, 2020, from http://www.sciencedirect.com/science/article/pii/S1055858615000347
- Larson, J. A., Johnson, M. H., & Bhayani, S. B. (2014). Application of Surgical Safety Standards to Robotic Surgery: Five Principles of Ethics for Nonmaleficence. Journal of the American College of Surgeons, 218(2), 290-293. Retrieved November 18, 2020, from http://www.sciencedirect.com/science/article/pii/S1072751513011939
- Mavroforou, A., Michalodimitrakis, E., Hatzitheofilou, C., & Giannoukas, A. (2010). Legal and ethical issues in robotic surgery. International Angiology, 29(1), 75-9. http://ezproxy.wpi.edu/login?url=https://www-proquest-com.ezpxy-web-p-u01.wpi.edu/docview/365962762?accountid=29120
- O’Sullivan, S., Nevejans, N., Allen, C., & et Al. (2019). Legal, regulatory, and ethical frameworks for development of standards in artificial intelligence (AI) and autonomous robotic surgery. Int J Med Robotics Comput Assist Surg, 15(1). Retrieved November 18, 2020, from https://onlinelibrary-wiley-com.ezpxy-web-p-u01.wpi.edu/doi/full/10.1002/rcs.1968.
- O’Sullivan, S., Leonard, S., Holzinger, A., & Allen, C. (2020). Operational framework and training standard requirements for AI‐empowered robotic surgery. The International Journal of Medical Robotics and Computer Assisted Surgery, 16(5). Retrieved November 18, 2020, from https://onlinelibrary-wiley-com.ezpxy-web-p-u01.wpi.edu/doi/full/10.1002/rcs.2020.
- Sharkey, N., & Sharkey, A. (2013). Robotic Surgery: On the Cutting Edge of Ethics. Computer, 46(1), 56-64. doi:10.1109/MC.2012.424
- Siciliano, B., & Khatib, O. (2016). Springer handbook of robotics. Berlin: Springer, p.1516. https://link.springer.com/referencework/10.1007%2F978-3-540-30301-5
- Stahl, B. C., & Coeckelbergh, M. (2016). Ethics of healthcare robotics: Towards responsible research and innovation. Robotics and Autonomous Systems, 86, 152-161. Retrieved November 18, 2020, from http://www.sciencedirect.com/science/article/pii/S0921889016305292
- Sullins, J. P. (n.d.). Ethical trust in the context of robot assisted surgery. Retrieved November 18, 2020, from http://doc.gold.ac.uk/aisb50/AISB50-S17/AISB50-S17-Sullins-Paper.pdf
Image Credit
Creator: “Cmglee”—https://commons.wikimedia.org/wiki/User:Cmglee
Source: “Uploaded Work”—https://commons.wikimedia.org/wiki/File:Cmglee_Cambridge_Science_Festival_2015_da_Vinci.jpg
License: “CC BY-SA 3.0”—https://creativecommons.org/licenses/by-sa/3.0/
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