Autonomous Robots in Pediatric Surgery

Autonomous Robots in Pediatric Surgery
December 14, 2020 No Comments Brave New World Apara Sharma

In “Good” Hands? The Ramifications of Using Autonomous Robots in Pediatric Surgery

By Shefali Kamilla

Photo by Bailee Darbasie of The da Vinci Surgery System at the Mike O’Callaghan Military Medical Center

In the past decade, the development of artificial intelligence (AI) systems have been rapidly flooding the healthcare industry. These technological advancements are so prevalent in healthcare that robots have the potential to be involved in high-risk, life-threatening situations. Specifically surgical robots have attained the ability to perform laparoscopic procedures in which the robotic “surgeon” can repair human organs by cutting tiny incisions and manipulating thin robotic arms to conduct the finest procedures. In some cases the robots are controlled in real-time by a human surgeon; however, currently the advancements allow AI to take over and perform procedures with less human involvement. As innovations continue, these robotic surgeons are predicted to gain even more functionality to perform much higher risk, complex procedures on any human, including children. 

Certainly, the application of this technology involves our concerns about research ethics and poses questions about responsibility, accountability, and justice. What are the implications of putting this new technology into practice on human lives? The future will appear different, but to what extent is this advancement ethical? What are the ramifications of utilizing semi-autonomous, and one day autonomous, surgical robots on the youngest children? To what extent are parents qualified to understand the application of these surgical robots? Should emotion play a role in the parent’s decision-making process regarding these robots? These questions will be addressed in this paper.

Table of Contents

Abstract

Imagine this hypothetical case: your newborn child was just diagnosed with a heart condition that is fatal and will most likely kill him/her before they reach the age of 10. Options are limited. At your child’s size, the traditional surgical option has a 30% success rate. One alternative, semi-autonomous robotic surgery performed by the Da Vinci Surgical System, can perform a similar surgery with a less invasive approach. The robotic surgical system is more precise than human surgeons; however, your child will be the first test case of this pediatric robotic heart procedure outside of a clinical setting. Studies conducted on several different robots have achieved varying levels of success using these robotic systems. While the systems have proven to be more effective and less dangerous, much like humans, data reveals that the robotic systems do sometimes malfunction. The use of a semi-autonomous surgical robot to operate on your child’s condition could provide data that will aid as the system is further developed to efficiency. As a parent, what option should you choose for your sickly newborn? Do you have a responsibility to think about the future of the healthcare industry?

In the past decade, the development of artificial intelligence (AI) systems have been rapidly flooding the healthcare industry. These technological advancements are so prevalent in healthcare that robots have the potential to be involved in high-risk, life-threatening situations. Specifically surgical robots have attained the ability to perform laparoscopic procedures in which the robotic “surgeon” can repair human organs by cutting tiny incisions and manipulating thin robotic arms to conduct the finest procedures. In some cases the robots are controlled in real-time by a human surgeon; however, currently the advancements allow AI to take over and perform procedures with less human involvement. As innovations continue, these robotic surgeons are predicted to gain even more functionality to perform much higher risk, complex procedures on any human, including children. 

Certainly, the application of this technology involves our concerns about research ethics and poses questions about responsibility, accountability, and justice. What are the implications of putting this new technology into practice on human lives? The future will appear different, but to what extent is this advancement ethical? What are the ramifications of utilizing semi-autonomous, and one day autonomous, surgical robots on the youngest children? To what extent are parents qualified to understand the application of these surgical robots? Should emotion play a role in the parent’s decision-making process regarding these robots? These questions will be addressed in this paper.

A specifically contentious context for the use of these robotic technologies is pediatric surgery. This is a promising field for the application of semi-autonomous robots since traditional pediatric surgery has additional risks that are not as present in adult surgery, namely the patient’s size, age, or weight. Furthermore, pediatric patients are distanced from the decision about how to conduct the surgery or the level of trust being levied on these robots. As these surgical robots advance, ethical considerations arise regarding a parent’s autonomy, technology companies’ responsibilities, and the justice concerns of saving some lives while others will be lost. This paper will examine these key ethical issues and more regarding the development of this technology.

The primary question I will address here is: “To what extent is it ethical for autonomous artificial intelligence robots to replace human surgeons and perform pediatric surgery?”

This paper will first examine the ethical considerations regarding this new healthcare system, focusing on the United States, through the lens of many stakeholders; second, this paper will examine the various ways the surgical robots interact with neonatal patients’ lives as AI continues to expand and reshape the surgical system.

The first section will provide a brief background of the history of surgical procedures followed by a discussion of the current regulations behind the manufacturing and training standards. Next, I will provide an overview of robot autonomy and artificial intelligence networks. The next section focuses on the application of robotic surgical technology in pediatrics. The subsequent discussion of parental autonomy regarding the application of robots will lead to an evaluation of the responsibilities of doctors, technology companies, and hospitals with regards to the development of robotic systems. Then I will assess the justice concerns that arise from the expansion of these systems. Ultimately, after some concluding ideas, I will reveal my final thoughts regarding what I believe the most ethical future with these surgical robots should be. 

After the ethical analysis of this technology, I reason that this development should continue with regulations that prevent it from expanding too rapidly to an extent that causes more harm than benefits. For one, as the technology moves beyond the clinical processes the systems should be integrated gradually, since eventually more benefits will occur, but with all of this development maintaining parental autonomy is vital to sustain these benefits.

Section One Name Here

This section will provide an overview of the history of surgery by discussing the increased range of surgical procedures from historic methods to current procedures and the associated risks.

Robotic Surgery Autonomy Level 1.0

The first human surgery was performed as early as 1200 BC – 600 BC by the founding father of surgery, Sushruta Samhita, in the Himalayas. He described free-graft rhinoplasty in his journal:

“Then, a piece of skin of the required size should be dissected from the living skin of the cheek, and turned back to cover the nose, keeping a small pedicle attached to the cheek. The part of the nose to which the skin is to be attached should be made raw, by cutting the nasal stump with a knife. The physician then should place the skin on the nose and stitch the two parts swiftly, keeping the skin properly elevated, by inserting two tubes of the castor-oil plant in the position of the nostrils, so that the new nose has proper shape. The skin thus properly adjusted, it should then be sprinkled with a powder of liquorice, red sandal-wood, and barberry plant. Finally, it should be covered with cotton, and clean sesame oil should be continually applied. When the skin has united and granulated, if the nose is too short or too long, the middle of the flap should be divided, and an endeavour made to enlarge or shorten it.”  

Sushruta Samhita, the first surgeon

Since Samhita’s time, surgery has become an integral part of healthcare. Hospitals and healthcare insurance companies alike have advanced because of technological advancements in surgical procedures. 

Surgery has advanced because of the increased manufacturing of surgical tools, equipment, devices, and, in this century, robotic technologies. These advances in healthcare technology have been very useful in determining a patient’s condition before, during, and after surgical procedures. Since Samhita’s time many surgical instruments have been developed to aid surgeons in accuracy and increased patient care. Scalpels, scissors, clamps, and needles are now mass-produced in factories that have transformed the execution of surgery. Innovation then led to machines that perform essential pre and postoperative vital sign monitoring and maintenance. Machines, such as thermometers, scales, and blood pressure monitors, are used before surgery to help medical professionals assess a patient’s condition to ensure they are not exposed to more danger through a brutal, lengthy operation. 

Technology has also helped make the patient’s experience better. For example, online databases are used to keep records of patients’ files online, so information can be accessible to all relevant healthcare providers. Online systems have allowed patients to receive more advanced care because of the increase in collaboration among healthcare professionals. Technology is also used after surgical procedure to aid in rehabilitation, prosthetics, and other forms of assistance. Paro, for instance, is a robotic seal that helps calm patients in nursing homes, and MANUS is a therapy system that replaces human personnel that typically help patients repeatedly perform movements as rehabilitation (Datteri and Tamburrini 4). Furthermore, technology is used for medical imaging such as x-rays, CAT scans, MRIs, etc., which provides doctors with insight into the anatomy of a patient, and allows them to plan before opening the patient up for surgery. Endoscopic imaging has been used for both diagnostic and surgical planning, resulting in enhanced patient care.  

Technological advancements have led to the development of scopes and cameras that are used to aid surgeons during the procedure itself. These devices provide more specific and real-time feedback in high definition, that a human surgeon can not obtain as quickly. These imaging technologies have advanced surgery by providing surgeons with numeric feedback where the surgeons previously relied solely on tactile feedback. Now, many surgeries that were previously very risky that have high success rates. Nonetheless, it is important to note that no procedure is without risk and there is still a possibility, even if by a small margin, for failure. Even these surgeries that have attained higher success rates are still not perfect.

Robotic Surgery Autonomy Level 1.5

The next level of surgical technologies is surgical assistant robots, which aid surgeons during the procedure by actively performing part or all of the surgery. It includes technology with similar functions as those mentioned above, but with enhanced capabilities. An example of a surgical assistant robot is a camera, that was mentioned above but is developed to be voice-controlled. This camera helps the doctor by providing a hands-free view of the operation area, so that the surgeon can focus on their hand movements throughout the procedure. Accuracy is increased as the surgeon controls solely the patient rather than the technology, and the patient’s body, simultaneously.

Robotic scrub nurses that hand surgical instruments with voice commands, such as Quirubot, are also a form of surgical assistant robots

(Perez-Vidal et al.).

While these robotic assistants may not drastically change the functions performed in the operating room, they do have an impact on the hospitals as a whole. The human nurses that used to be in operating rooms handling surgical instruments can now go out and focus on patient care. 

The surgical assistant robots most involved with patient care are those that aid in positioning.

For example, in 1983 the Arthorobot was the first of its kind to autonomously position a patient’s leg based on voice commands (“Arthrobot – the world’s first surgical robot”). Also, in 1985 the Puma 200 was used to precisely orient a needle for brain surgery (Kwoh et al.).

While the human surgeon took over for the actual procedure, the autonomous orientation of the needle was a major step in surgical technology innovation.

Robotic Surgery Autonomy Level 2.0-3.0

Minimally invasive robots have transformed the level of involvement technology has during surgical procedures. These robot arms are physically inside the patient’s body performing the procedure, which goes beyond robots that position patients for human surgeons to take over. There are, however, varying degrees of autonomy that these robots have attained. Since the turn of the century these innovations have been rapidly tested and applied in initial clinical settings, and now when surgeons feel it is the best option. In the past decade the use of these surgical robots has grown exponentially providing surgeons with more accuracy.

Semi-autonomous surgical technology was introduced to pediatric medicine in July 2000 and reported in April 2000, when a Nissen fundoplication – a surgery used to treat esophageal reflux disease and hiatal hernia – was performed on a child.

(Bruns et al.)

This was the first robotic minimally invasive surgery in pediatrics. Positive results were reported within the first year of the application of this procedure in clinical trials (Stein et al.). Furthermore, the AESOP and Zeus systems were developed at the turn of the century as traditional laparoscopic robots, but eventually advanced into the Da Vinci Surgical System: an advanced general laparoscopic robot. In traditional laparoscopy, the human surgeon is still heavily involved in the procedure directly controlling the robot; it is a semi-autonomous operation. Currently, the only possible “autonomy” the robot has is that it is physically touching the human, and the surgeon loses their direct tactile contact with the patient. However, current laparoscopic surgical systems, such as The Da Vinci Surgical System, are pushing beyond traditional laparoscopy where a human surgeon simply maneuvers a robotic arm. Current advancements have given robotic systems more autonomy. For example, the ratio between surgeon hand movement and robot gestures has changed. The current ratios are manipulated, so a large surgeon’s hand motion is mimicked by the robot on a smaller, more precise scale. This allows human surgeons to drastically move their hands, which is typically dangerous when inside of a patient while obtaining more accuracy. Furthermore, surgical robots can detect human hand tremors and not transfer these motions to their surgical movements. This provides robotic precision that human surgeons simply could not attain, since preventing slight human hand tremors is not always possible. 

Today we are at the face of a paradigm shift that will completely transform the definition of surgery. While currently there is no level 4 digital surgery, the current surgical systems are moving even beyond the radical shift that occurred in the past 25 years with minimally invasive procedures becoming the dominant methods. Surgery is becoming even more robot dependent as it has shifted from level 1 post operative machines to surgical-assistant robots and now moving past traditional laparoscopy. This brings up concerns regarding the pace of innovation. Will we in another 25 years look back at the procedures of the last 50 years and reject the past? This development may cause surgeons in the future to not master traditional surgical methods because they are viewed as unsophisticated. However, what are the implications when in reality the advanced AI methods have downfalls too?

The Regulations & Responses To Surgical Robots

The Regulations

This section will discuss the current and prior laws and regulations on the evolving field of semi-autonomous surgical robots. Any medical innovation must undergo clinical trials before becoming the routine practice. There are many forms of clinical trials for the various medical innovations, but any type of semi-autonomous surgical robot trial is a subset of treatment trials because it provides a new approach for surgery. There are four major phases of the clinical trials each applying the new treatment option to more patients. The first phase tests the approach on a small group to determine the safety and evaluate side effects. Next, the innovation is applied to a wider group; safety and effectiveness are evaluated. In phase three the technology is utilized by a large number of people, so the effectiveness and safety are further determined as it is compared to other methods. Finally, the innovation is phased into practice as the risks and benefits are further discussed (“Clinical Trials: How they Work; Why Participate”). Before the products can be brought to the market, The United States Food and Drug Administration (FDA) reviews trials and accepts or declines the products (“FDA 101: Clinical Trials and Institutional Review Boards”). 

Surgeons performing a heart operation
“10” by axelle.geelen is licensed under CC BY 2.0 by Axelle Geelen

The AESOP system was the first surgical robot to be approved by the FDA in 1994. AESOP followed voice commands to move an endoscope inside a patient’s body. Since then, the FDA has approved many surgical robots (Datteri and Tamburrini). Currently the most common advanced general laparoscopic robot is the Da Vinci Surgical System, which was the first minimally invasive robot to be FDA-approved. However, this does not  necessarily mean that the United States is ahead of other countries with surgical technology. The ROBODOC system was used in other countries for many years before the FDA finally approved it for use in the United States in 2008. This indicates that the United States is regulating the advancement of this technology more strictly than other parts of the world, leaving open the question of whether the US is restricting the development of this technology too much.

Ross reveals one possible reason for the hesitation to legally approve these new technologies is that “a failure to place adequate guardrails around such technologies can lead to severe consequences, as they have in other industries” for example: 

The most dramatic example is the case of Boeing’s 737 Max airplane, where investigators are examining what went wrong with flight control software that automatically pushed down the nose of the plane, resulting in crashes that killed 346 people. In the ongoing investigation, both Boeing and the Federal Aviation Administration are now facing questions of whether the software was adequately vetted, and whether pilots were properly trained to use it.

Casey Ross, National Technology Correspondent

Currently, the only AI surgical devices that the FDA has approved are locked algorithms which cannot improve by machine learning. FDA regulations continue to evolve as these technologies are produced, working to balance dependence on machine learning and gold-level safety (“Statement from FDA Commissioner Scott Gottlieb”). 

The FDA has put other measures in place to regulate these robotically-assisted surgical (RAS) devices, like the AESOP and Da Vinci systems. MedSun: Medical Product Safety Network was launched by the FDA in 2002 as a way for the FDA to partner with the clinical community, and improve RAS devices. MedSun is an online network where all surgical device malfunctions are reported. KidNet is the subnetwork that focuses specifically on medical devices in neonatal and pediatric care (“MedSun: Medical Product Safety Network”). The FDA hopes that networks like this will increase collaboration between hospitals as these innovations are applied. Furthermore, this consolidated information will help the FDA and other organizations like the American Board of Surgery make decisions about future regulation.

The Responses To This Technology & Required Training

This next section will focus on the FDA’s and The American Board of Surgery’s interactions with hospitals and surgeons directly as they regulate this technology, and the way the laws impact these individuals and organizations. The FDA is not involved in the training required to use these surgical robots:

The FDA does not regulate the practice of medicine and therefore does not supervise or provide accreditation for physician training nor does it oversee training and education related to legally marketed medical devices. Instead, training, development, and implementation is the responsibility of the manufacturer, physicians, and health care facilities.

(FDA Statement, “Computer-Assisted Surgical Systems”)

Also, generally, the FDA has not been very active in regulating the use, prices, or advertisement of these surgical devices which presents a problem for the future. When there are few regulations, there is a greater potential for the technology to be implemented prior to proper testing. Therefore, stakeholders need to step up and create regulations for how these devices will be used throughout the world. 

The American Board of Surgery (ABS) is one organization that has taken the responsibility of regulating and mandating training guidelines for utilizing robotic surgical technology. For one, exposure to robotic systems during surgical residency is becoming more common, and the ABS supports this. Acclimating surgeons to this technology early in their career provides them with more time to master utilizing the systems. Surgeons that are already practicing will need to go back and attain training before obtaining privileges to use these devices. Moreover, the ABS states that all surgeons need to be assessed. Hospitals may have varying beliefs about the required training necessary to obtain competency with these technologies, and surgeons may have varying beliefs regarding their skill levels. 

“creating a safe framework for robotic credentialing means that all surgeons must comply with the steps if they expect to use this   technology—regardless of their prior use, level of seniority or frequency of use”

(Courtney A. Green, Department of Surgery, University of California San Francisco, San Francisco, CA, USA, et. al.)

The consensus is that while organizations like ABS are mandating training, hospitals maintain the responsibility to carry out this teaching. International consensus was reached in 2006 of when the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the Minimally Invasive Robotic Association (MIRA) recommended that surgeons understand how to operate with and without robotics, as well as obtain the understand of removing robotic devices during surgery and ability to proceed alternatively (Herron and Marohn 12). These recommended minimum training requirements state that before surgeons gain the privilege to use robotic devices surgeons can either complete a residency and/or fellowship program that incorporates minimally invasive training or should undergo traditional hands-on training with these technologies in dry lab environments. SAGES and MIRA also declare that, when possible, facilities should assess and document the surgeon’s competency with this equipment (Herron and Marohn 14-15). With regards to this assessment there are two described roles:

“Preceptors responsibly observe the procedure, give advice, and must intervene if the operator gestures are inadequate or the patient is generally at risk. The second one, the proctor, validates a surgeon’s competence; he gives to the hospital recommendations about the surgeon’s results based on his observation in the operating room. Based on these indications, the hospital will recommend to the surgeon a preceptor, or will allow privileges or restrictions about procedures a surgeon can or can not perform.”

Alessia Ferrarese, Department of Oncology, San Luigi Hospital, Regione Gonzole 10, Orbassano (Torino), Italy, et al.

This technology also impacts hospitals in ways other than training surgeons. For one, hospitals have been buying the da Vinci Surgical System, regardless of the financial burden, as a way to elevate their status. Within the medical community, semi-autonomous systems are becoming the standard, forcing hospitals into purchases they cannot afford, but are obliged to buy to maintain accreditation. In some cases, hospitals believe that applying these robots to unique cases will help them stay competitive with other healthcare facilities. Recognition is significant to hospitals as it brings in patients, allowing them to not only serve their purpose, but also turn a profit. While these semi-autonomous robots are becoming a requirement for hospitals to meet the standard, many hospitals are buying this technology then struggling to eat the costs.

Hospitals are overexerting their budgets for this technology despite that fact that “in addition to the higher costs associated with the $2 million purchase cost of a da Vinci robot, plus the increased costs of some of the attachments, are reports of adverse events, including deaths, injuries (such as to the bladder, kidney, and ureter during surgery), and malfunctions”.

(Wilensky)

This demonstrates that hospitals are not considering patients but rather their reputation when purchasing these devices, which means that hospitals need to reevaluate how to uphold their financial and ethical responsibilities. Healthcare providers are straying from the focus of their work, the patient, because of this innovation.

Lastly, technology companies are supporting this innovation because it is in their financial interest to do so. The top robotic surgery company in the United States is Intuitive Surgical, developer of the ludicrously expensive da Vinci Surgical System. This company is followed by Stryker, Accuray, Smith & Nephew, Mazor Robotics, Auris Health, Medtronic, Globus Medical, Zimmer Biomet, and Stereotaxis on the top 10 list (iDataResearch).

Over the past 25 years, the FDA has regulated these robots to ensure that they are safe devices when entering the marketplace. While the FDA has not been able to make a lot of guidelines, since they are primarily focused on the devices, not their application, measures have been put in place to make room for further regulations. As the FDA does not make guidelines regarding the use of drugs or devices, the ASB has mandated training requirements to close any gaps in knowledge. Medical schools and hospitals are given the responsibilities of administrative training, so their surgeons are adequately prepared for the application of this technology. The hospitals are forced to oversee training because it could become a liability concern since more failures could occur that will impact the surgeons, patients, and the hospital as a whole

An Overview Of The Capabilities of Robots

This next section will discuss the various levels of autonomy surgical robots can attain focusing on the amount of human intervention because the level of human involvement determines the level of autonomy of the surgical robot. An overview of AI that results in this robotic autonomy will be provided.

(Based on image “Medical robotics—Regulatory, ethical, and legal considerations for increasing levels of autonomy”)

The Levels of Semi-Autonomous Surgical Robots

The first level of autonomy, level zero, was before technology was integrated into the surgical process. The technology was only directly involved during pre and post-operation exams to aid with checking vitals. During the actual procedure the human surgeon was involved with all functions, and decision making. This level is a completely manual operation. As surgical assistant robots were developed level 1 was attained since the technology was involved during the procedure itself. Telerobotic capabilities exist; however, the human surgeon is still continuously involved, and the robot is present simply to aid or enhance the surgeon’s performance not to remove any of their tasks. 

Level 2 is the beginning of minimally invasive technologies, specifically the traditional laparoscopic robots that still need humans to be very involved. As depicted in the image, this is task-level autonomy because the surgical robot completes specific tasks that the human surgeon dictates. In this level, the human does not step back as the robot performs, but rather is prepared to take over when the robotic task is complete. 

As advancements have given previously simple surgical equipment more autonomy, level 3 is attained. This is when the laparoscopic robots start to stray from the traditional concept of a human surgeon controlling a patient’s fate directly, at all times, simply with technological assistance. Level 3 skews the patient-surgeon interaction, for example, as surgeon hand tremors are transferred to a small precise robotic motion. However, as depicted, this is not complete autonomy. Even with the most advanced level 3 systems the human is highly aware and involved in supervising the machine. 

Level 4 is the beginning of autonomous robots performing tactically on their own with the human only approving the procedure.

“the robotic system will not be a simple extension of the surgeon’s eyes and hands, but will also deliver cognitive processes, i.e. it will be able to think. Surgery 4.0 will get “flesh and bones” into a digital platform that will include robotics but will not only focus on them”

(Savvas C Hirides, Athens Medical Center Robotic Surgery Program and Petros Hirides, Athens Medical Center) 

An example is the Smart Tissue Anastomosis Robot (STAR) that was used in the Boston Children’s Hospital (“A first in medical robotics: Autonomous navigation inside the body”). Although even systems like STAR are not completely autonomous – the human surgeon or other human technicians must still select the program that the robot should complete. But, after human approval this robot can complete suture without human intervention: 

“The system’s actuated laparoscopic suturing tool implemented image‐based commands to perform specified tasks. It outperformed human surgeons in laparoscopic suturing, exhibiting higher accuracy, consistency, and faster speed. They further demonstrated that STAR’s in vivo supervised autonomous procedure is superior to surgery undertaken by expert surgeons. Likewise, with robotic‐assisted surgery techniques in ex vivo porcine tissues. Such positive results confirm the potential for autonomous robots. They are shown to improve the efficacy, consistency, functional outcome, and the feasibility of implementing surgical techniques. However, the key question remains as to whether the robotic suture is better in terms of failure rates? If failure is defined as bursting pressure, then the answer is affirmative in this case”

(Shane O’Sullivan, Department of Pathology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil et al.)

There is hesitation to give robots complete autonomy because we do not understand the full dependability of semi-autonomous robots since the success rates fluctuate based on the system and the procedure. Also, full robotic autonomy, known as level 5, will not be gained until robots are operating without any human supervision or fallback option. In 5th level autonomy the procedure selection process is removed from the human surgeons, and a human cannot get involved when the technology appears to malfunction. This demonstrates a transfer of trust when the robot is left alone with human life. Right now we are not at level 5, and will not be regardless of the level of the innovation until we feel that surgical robots have demonstrated the ability to perform extremely effectively autonomously. 

An Overview of Artificial Intelligence (AI)

This next section will briefly discuss AI learning and the different subnetworks that interact with discussing Machine Learning (ML) and other similar systems. The four main branches of current AI research are in machine learning, natural language processes, artificial neural networks, and computer vision.

Supervised learning and unsupervised learning are both types of Machine Learning (ML) that result in gained AI knowledge and determine a robot’s responses to future procedures.

In a study of the success of ML, the technology can “predict patient lung cancer staging by using International Classification of Diseases (ICD)-9 claims data alone with 93% sensitivity, 92% specificity, and 93% accuracy, outperforming a decision tree approach based on clinical guidelines alone (53% sensitivity, 89% specificity, and 72% accuracy)”.

(Hashimoto et al.)

Natural Language Processing can detect patterns in a human inputted language such as the frequency of phrases that relate to the success level of a procedure or patient satisfaction level. Specific to surgeons this software is used to process reports providing doctors with information about the success of previous procedures. It can also detect the significance of different phrases such as differentiating between irritated and tired “with a sensitivity of 100% and specificity of 72%” (Hashimoto et al.). Artificial Neural Networks (ANN) are multi-layered databases that make connections among the mass amounts of input data. This is a complex analysis of the data allowing surgeons to understand the statistically best approach. “ By using clinical variables such as patient history, medications, blood pressure, and length of stay, ANNs, in combination with other ML approaches, have yielded predictions of in-hospital mortality after open abdominal aortic aneurysm repair with a sensitivity of 87%, a specificity of 96.1%, and accuracy of 95.4%”  (Hashimoto et al.). AI has obtained the ability to interpret images, through Computer Vision, and use this data in deciding courses of action. This capability enables robots to visually detect a problem and react faster than humans while obtaining accuracy. “For example, real-time analysis of laparoscopic video has yielded 92.8% accuracy in automated identification”  (Hashimoto et al.). 

All of these AI systems work together to synthesize information, learn, and improve surgical outcomes. While the software is not always perfect it has demonstrated significant strides in increasing accuracy with time and frequency. Synergistic relationships form when the 4 AI systems work together, rapidly increasing the capabilities of AI technologies, although,

“AI is not a ‘’ magic bullet’’ that can yield answers to all questions. There are instances where traditional analytical methods can outperform ML or where the addition of ML does not improve on its results”

(Daniel A. Hashimoto, Harvard University, Associate Director of Research at the Surgical Artificial Intelligence and Innovation Laboratory at the Massachusetts General Hospital, et al.)

The Application of Surgical Robots in Pediatric Surgery

This section will focus on pediatric surgeries – specifically, the frequency and necessity of these procedures to keep newborns alive. Pediatric surgery has its scope because it requires unique instruments and procedures. Neonates have much smaller organs, body size, and weight than adult patients. This makes it more complex for surgeons because they can not always see the procedure they are performing – space and accuracy are major obstacles in pediatric surgeries. While space remains a challenge with semi-autonomous robots, more accuracy can be attained. 

While all types of surgery, regardless of the patient’s age or medical conditions, come with a lot of risks, pediatric surgery historically has been even more difficult for surgeons. Therefore, the advancement of surgical devices has the potential to be a major advancement that helps these pediatric patients as well as improves technology overall. In pediatrics, the increase of surgical robots has allowed for more complex procedures because it provides precision in a field that requires small surgical instruments for success. A major constraint in pediatric surgery is the small size of patients specifically when they are newborns. Robotic surgery allows more pediatric surgery to occur because the robotic arms can perform smaller more precise incisions than human hands. It is important to look at pediatric surgeries because there is a unique reason for why robotic surgery is necessary because of the age, size, and potential for life that these children have. 

A significant number of neonatal patients require surgery to survive within their first few weeks, if not days, of their life. 

In the University of California San Francisco “approximately 15% of all infants admitted to the UCSF ICN [had] a primary surgical diagnosis (in addition to those with congenital heart disease). For many of the other patients, surgical problems develop during their hospitalization”

(University of California San Francisco Intensive Care Nursery)

This demonstrates that it is a field within all surgery that needs focus since there is at least 15% of newborns that need more advanced procedures at just one hospital. However, some may argue that 15% is still below 50% and therefore funds should not be spent on advancing technologies that can only benefit a small portion of the population. However, while the advancement of semi-autonomous surgical technologies has a lot of predicted benefits for pediatric patients, innovation will help the industry grow overall. The progression of these technologies in a pediatric focus can lead to these robots application in the wider field of surgery which will eventually benefit many more patients than just the children. Nonetheless, progress must start somewhere so applying this technology to pediatric cases is a beneficial way to get results. 

In recent cases regarding the application of semi-autonomous surgical robots in pediatrics there have been mixed results. While there are many observed benefits, robotic surgical intervention on neonatal patients has also resulted in higher risk. In a study of 100 cases with pediatric robotic surgery, where the smallest patient was 2.2 kg at 6-days old, it was concluded that robotic surgery is effective (Sandler). However, in patients under 3kg space became an issue. Although size has historically always been a limitation with traditional pediatric surgery, robotic procedures handle this limitation with more accuracy than the human pediatric surgeon (Sandler). In this same review, 13 cases were converted to open surgery, 4 specifically due to equipment failure, demonstrating that increasing the level of technology caused more harm than human surgeons in some cases.

Conversely, in the United States over half of the harmful surgical errors are due to human errors (Kommers). Also, it has been concluded, in another report from The Institute of Medicine, that 50% of surgical incidents (caused by human surgeons) were otherwise preventable.

The majority of the human error cases resulted in negative lasting impacts afterwards such as a slipped hand in the operating room resulting in a punctured organ or the leaving of tools inside of a patient (Proctor et. al.). Therefore, while the robots are not perfect neither are human surgeons and the medical field will never be completely perfect. There will always be some mistakes and exceptions, so there is a need to balance the negative yields of the human surgeon and the robotic surgeon. The analysis of the 100 pediatric cases concluded that average procedures lasted 7 minutes longer for technology to set up and maneuver, and they observed a need for more of a robotic nursing team. They found that scrub nurses obtained increased responsibilities as these technologies took responsibility away from the lead surgeons. This was because the scrub nurses needed to maintain the technical aspects of the surgeries such as setting up the machines as the surgeons stepped back (Meehan and Sandler). 

“for gynecologic surgery, particularly hysterectomies, the second most common surgery for women, robotic surgery does not appear to improve results. A study reported in JAMA of 250,000 hysterectomy patients in 441 hospitals found that the outcomes of da Vinci robot surgery were no better than those using laparoscopic surgery”

(Gail Wilensky, Geisinger Health Board of Directors, Chair of the Governance Committee, Patient Experience Academic Affairs and Quality Committee)

While this study does not focus on pediatric patients it demonstrates that semi-autonomous robots may not be a big improvement, and given the high expenses of this technology and the training demands, human surgeons should instead focus on developing their pediatric surgery skills rather than transitioning their jobs to robots.

In sum, there are 5 main levels of surgical technologies, and the current systems have obtained capabilities that are more frequently advancing into the level 2-3 capabilities. It is significant to indicate that the advancements that have elevated robot autonomy have occurred very rapidly, and are planned to continue to occur at this rate. However, the final levels of full robotic autonomy will rely on the human acceptance of the robots, and surgeons relinquishing their responsibilities. This surgical technique has been applied heavily to the field of pediatrics because there are more risks in this area with traditional surgery. There has been a success through increased precision, but there have also been cases with increased harm. Therefore, to what extent should this surgical technology be advanced through an analysis of the impact on pediatrics?

A Parent’s Autonomy In Healthcare Decisions Involving Surgical Robots

The Significance of Trust in the Patient-Physician Relationship

In general, parents have the right to make healthcare decisions for their child, including whether they are willing to have their infant undergo a procedure that involves the use of a surgical robot. Caregivers may hesitate to allow artificial intelligence technology to control the future of their loved ones rather than a human surgeon that they can connect with emotionally and grow to trust. A significant part of healthcare is the interaction between healthcare providers and patients. Patients need to trust their doctors for the best patient care experience to occur. Patients feel that this is an integral part of their experience, 

“when a patient presents with a health problem to the surgeon, either emergently or electively, he seeks the skills and advice of an expert who possesses the knowledge and skills inaccessible to the nonsurgeon. The patient thus trusts the surgeon with his life, well-being, and private information”

(David Axelrod, Robert Wood Johnson Foundation Clinical Scholars Program, Departments of Medicine and Surgery Section of General Surgery, University of Michigan Medical School)

In January 2000, when the application of this technology was rising, “69% of Americans [were] losing faith in physicians” which demonstrates the correlation between a compromised patient-surgeon relationship and the increased usage of surgical robots (Axelrod). Furthermore, when patients die as a result of a surgery failure their family or loved ones are less likely to sue if they feel that the surgeon did everything that they could. Therefore, parents are less likely to sue hospitals when trust is instilled between the medical caregivers and the guardians. In this way the trust and understanding, obtained through human interaction, that human surgeons do everything they can to save the lives of their patients is a significant aspect of healthcare that may be compromised with the advancement of semi-autonomous surgical robots. Therefore, these technologies could hurt the field of surgery as a whole. Parents are more likely to sue hospitals if they do not trust the surgeons when a loved one dies. When medical professionals reveal surgical errors, regardless of the patient’s state, people are more likely to sue.

This was revealed when 1,018 respondents, who previously displayed confidence in their caregivers, were provided with the full malpractice information 38% would sue (Helmchen). Therefore, when a child dies it is assumed that lawsuits from parents may rise frequently.

In this way the patient’s trust of doctors is an important aspect that should interest both parties. If there is potential that trust will be lost as this technology is developed then maybe it should not be advanced at all. Furthermore, maybe parents should not obtain the ability to use the robotic option if they put hospitals and other healthcare systems at risk of lawsuits. While parents do not obtain the right to dictate how a surgery is performed – that is the responsibility of the hospitals to propose and complete treatment that the hospital is equipped to undergo – parents may regret their decisions if the hospitals fail when applying this technology. If the surgeons claim the robotic option is the best while still revealing that it is a new option, parents could lose their faith in the healthcare facility, and lawsuits could rise. A lawsuit caused by a da Vinci Surgical system failure could not just decrease the use of surgical robots, but limit other programs in the hospital that many patients rely on due to financial tolls. 

Parents may not choose a robotic procedure simply because they did not grow up with this much innovation around them and therefore do not feel comfortable with it. While this may be a valid decision it could put the lives of their children at risk. When decisions are made solely, or heavily reliant on, gut reactions, mistakes can be made. Also, parents are not healthcare providers. Therefore, it is difficult for them to understand the extent to which these technologies work in comparison to other options such as a human surgeon. Even if the technology is explained in detail, they might still be unable to grasp all of the details from a medical standpoint since they are emotionally connected to the case.

Informed Consent

Parents of these pediatric patients lose autonomy when the technology is advertised as the best possible option, discussed at a higher standard than in reality it is. As surgeons discuss possible procedures with caregivers, questions about true informed consent arise, when tone or skewed short term statistics can impact a decision.

Specifically, families are told to consent to the physicians rather than to request the physicians. This indicates an underlying bias as the healthcare providers’ words reveal to the patient which option the hospital believes they should choose.

(Strong 4).

This recommendation does not always align with the patient’s and/or their family’s personal beliefs. In these cases the patients are not just being informed about their healthcare, but rather inherently persuaded to agree to undergo the treatment their doctors believe is best. Specific to robotic surgery, surgeons may portray these methods as optimistic because they could cure the patient as well as elevate the surgeon’s status. 

Furthermore, informed consent for robotic surgery is more complex because the success of the procedure does not just rely on the doctors’ surgical knowledge. Success is also becoming more dependent on the technical knowledge of the robotic procedures. A patient’s opinion of AI can also impact informed consent, such as if they have a fearful perception or overly confident perception of the technology (Schiff and Borenstein). The portrayal of the learning curve also impacts because the proper use of the machine as well as the medical knowledge both impacts the curve. Parents may be informed that robotic surgeries are increasing in success, but this is primarily in hospitals that provide rigorous robotic training. With all of this in mind is advised that surgeons:

Integrate the information already present in the [informed consent] (causes of the disease, consequences of the disease if not treated, focus on the proposed technique, possible consequences if treated and risk of reintervention with related consequences) with data on the surgeon’s experience in [robotic surgery], the number of procedures of the department and the regional map of expertises by the procedure.

(Alessia Ferrarese, Department of Oncology, San Luigi Hospital, Regione Gonzole 10, Orbassano (Torino) et al.)

The best medical decision balances the patient and their family’s values with the health care professional’s knowledge. This allows the parent to determine the procedure that is not just predicted to be the most effective medically but also aligns with their morals. Doctors need to provide medical advice and assist in the decision-making process, but should not project their personal beliefs onto the parent. This balance can be difficult to attain but is vital for the most effective and ethical informed consent process.

A Parent’s Responsibility

While parents may not feel comfortable with surgical technologies they have a responsibility to protect their children’s lives. The caregivers should not have the option to choose a procedure for neonatal patients that may not yield the best results. They should not put their child in harm’s way, even if it is just a small percentage. Therefore, paternalistically parents have a responsibility to think solely about their child, and the healthcare that is best for that individual patient. When making healthcare decisions the parents are not concerned about the implications their decision could have on other stakeholders such as the future of science, but this should not be their concern. 

Innovation contains a lot of unknowns; therefore, parents may want to protect children from this. There is a lot of fear that surrounds surgery whether AI or not so parents may want to perform the surgery with the most predictability. Yet, without caregiver approval AI cannot be applied which will slow the advancement of technology. Without developmental improvement technology will stay at a stagnant level, not improving or saving any more pediatric lives. The technology needs to be applied in at minimum higher phases of the clinical trials in order to detect the main ramifications. It can be tested in labs and controlled experimentation, but the reality of all the unforeseen possible errors will only be revealed through gradual integration into the actual healthcare system as becoming regular practice.

Furthermore, how many mock setting trials will be enough to prove that the technology is safe?

The first application of a specific surgical robot could be viewed as a test because of all of the risks; however, there are risks with every surgery. Is every surgery considered a test of the current technology whether new development or old? When should we simply accept that the innovation is better and understand risks will always exist?

Parents have a responsibility to help their children and do what is best for them on an individual level while hospitals also have a responsibility to consider the greater good of saving many lives. This tension between these two stakeholders demonstrates one of the major tensions and debates involving these surgeries. Legally the parents have the final binding decision on what type of treatment they would like their child to undertake however, this forces medical caregivers to compromise their responsibilities and values because of focusing only on the individual.

On the other hand, if AI surgery is predicted to have the highest success rate do parents have an obligation to choose this procedure even if it provokes more fear for them? Parents have to weigh their responsibilities to do what is best for their children between what they trust is the best and what scientifically appears to be the most successful situation. If surgical technologies are proven to be significantly better then parents should choose this option with no contemplation. However, parents’ responsibility is to care for their children, and while they may not be comfortable with AI robots performing surgery on their child, they must keep their child as the center of attention.

Balancing A Parent’s Autonomy With Compassion For Having A Sick Child

Compassion is also a focus of the autonomy argument because pediatric surgery is already a stressful situation for parents and caregivers. Therefore, other options or additional procedure choices, such as semi-autonomous robotics, should not be shared if it will cause more harm through emotional stress. There needs to be compassion for the parents and their situation caring for their sick children. They should not be forced to think about the bigger picture and other children while in a time of distress. Deciding whether to use a new technologically advanced procedure can be a difficult decision for a caregiver who simply wants the best outcome for their loved child. Caring for a child is stressful to begin with, and it causes a lot of emotional distress when your newborn child has a condition that requires them to have surgery at such a young age. It can cause more distress when doctors offer a surgery performed by a robot when this already appears to loved ones as a drastic situation. Loved ones of patients may feel that since their loved ones can not be treated by human surgeons, as robotic methods are an option, their family member is in an even worse condition causing more fear and stress. Providing the option for AI surgery, while it may seem more effective, can overall cause more pain. Therefore, if human doctors are able to successfully perform a pediatric surgery that a newborn requires, then should this be the main option proposed to the caregivers? There is no reason to make parents have even more stress when they just want their child to survive. Caregivers are not experts in the fields of computer science and surgery, therefore, forcing them to decide on what type of surgery is uncompassionate. Professionals should use their responsibilities to decide what they believe is the best surgery for a pediatric patient and advise accordingly. 

Nonetheless, doctors have a responsibility to follow the idea of honesty and transparency. They must inform patients of circumstances even if this informing will cause distress. Additionally, caregivers have a right to understand all possible treatment options, even the ones that doctors believe are very risky since ultimately they decide which type of procedure will occur – robotic or traditional. Regardless of the emotional draw parents are required to consent to the approach that occurs. Doctors must use compassion to instill trust in the surgeon-patient/parent relation (see section Informed Consent for more). Understanding the emotional draw of these medical decisions can aid surgeons in discussing these options with parents. Surgeons should inform parents of all of the treatment options because the parents deserve full autonomy. However, healthcare professionals should utilize compassion as these conversations are held. The doctors can be compassionate for the parent’s emotional toll while also providing them with the necessary information to obtain full autonomy over their child’s treatment. 

The Financial Burdens of Surgical Robots

These semi-autonomous surgical technologies are increasingly expensive machines for hospitals, and therefore the robotic procedures tend to be more costly than traditional methods. Insurance companies vary in the medical issues they cover, therefore, 

“it is preferable that each hospital develops with the insurance company an insurance contract specific and personalized for its needs”

(Sidonia Maria Săceanu Obstetrics and Gynaecology Clinic, Craiova Emergency County Hospital, Phoenix Medical Centre al.)

This does not always occur meaning it can be difficult for hospitals to keep parent autonomy when insurance companies refuse to aid caregivers with this large financial cost. Therefore, do parents and caregivers still maintain the right to autonomy when these surgical procedures are so expensive? Hospitals cannot afford to make every child a charity case, but it can also be detrimental to insurance companies to fund these surgeries that are still in clinical stages. When a robotic procedure is in clinic stages it may result in multiple procedures – open and robotic – that will be more costly in the long run (Bertolini). Insurance companies and hospitals will suffer if parent autonomy is completely maintained. Therefore, there are questions regarding who should cover the costs of these surgeries as technology is more expensive but human surgeons are still an option that exists. Should healthcare providers be responsible to cover both options?

Further questions arise such as what responsibility do healthcare companies have to give patients options for their treatment? Are health insurance providers only responsible for making sure clients have a way to get the minimum treatment they need or do they also need to consider the comfort of their clients? Do health insurance companies have a responsibility to provide clients with options? Do parents or other caregivers deserve the autonomy to choose the type of procedure (whether it is AI technology or a human surgeon) that they feel most comfortable with? Currently, insurance companies are willing to cover some expenses, but not all for robotic surgery. Specifically they fund traditional laparoscopic procedures that have gained frequency in the past 25 years. They are more hesitant to cover the costs of new, more autonomous procedures when other less expensive methods are available. However, with laparoscopic methods that have developed over the past decade insurance companies are more inclined to cover these costs than open surgery because the minimally invasive methods have yielded better results. Therefore, when the companies decide to cover the robotic rather than open methods that save more money (Bertolini et al.) The responsibilities of insurance companies to cover costs will be further investigated later on in this paper. 

In conclusion, many factors could limit a parent’s autonomy to decide if they want their child to have semi-autonomous robotic procedures. Parents are faced with a stressful situation, parental responsibilities, personal values about innovation, and financial burdens which complicates their decision and the number of information doctors should provide them with. An ethical analysis is suggesting that while many factors threaten a parents’ autonomy, compassion and trust should guide a surgeon in their responsibility to discuss all options. 

Evaluating The Impact On Various Stakeholders Through Responsibility

A Doctor’s Responsibility

Doctors are impacted by the development of innovations and while these technologies can help them fulfill their role as life-savers it can also destroy other aspects of their job. While doctors have an obligation to beneficence, meaning do good, they must also follow the ethical principle of nonmaleficence which means “do no harm”. 

Learning new surgical procedures and adapting to new technologies is part of doing no harm since improving and adapting means treating patients most effectively. Understanding that they may not be able to perform surgery as well as a robot is an important realization that must occur for surgeons to advance their care capabilities. Additionally, adapting to work with innovations such as semi-autonomous technology can aid in performing advanced procedures and saving more lives. If surgeons truly care about the fundamental principle of their job, saving lives, they should be willing to adapt to and use new technology. Surgeons must accept that mistakes will be made because they are humans. They must be willing to move on accepting that technology has outperformed them in certain aspects, and can do their job better. An analysis based on virtue ethics might suggest that surgeons have a good intent to use robotic surgeries to save lives that they did not trust in their abilities could easily do.

This indicates that doctors are considering the impact of their decision to utilize surgical technology which makes the advancement ethical from a virtue lens; the surgeons have an ethical objective.

The surgeons may believe that using AI may allow them, as humans, to continue to study and advance in other procedures while the robot can perform a pediatric surgery without the potential for their human errors. Doctors understanding their limits and advising patients of the best procedure while understanding human and AI limitations is important in causing the families to consent to the procedure that will save their child’s life. 

However, when surgeons start to not trust their abilities because they believe technology can do it better it goes against beneficence; the surgeons are not doing – all of the possible – good. While it is unlikely that surgeons will be reluctant to try, this hesitation to attempt all that they can be considered unethical. Surgeons may however be reluctant to accept surgical technology for ethical reasons such as the robots will replace their jobs. Healthcare professionals have to train for years; the advancement of surgical robots could replace those years of study. Nonmaleficence, do no harm, is a guiding principle that doctors abide by. Surgeons study extensively to become experts whereas the impact of medical robots is just beginning to be analyzed; harm may be prevented by doctors resisting to participate in clinical trials involving technology that is made by those distanced from the medical field. Also, surgeons may lose their jobs with an increase of this technology, and they have other responsibilities such as to their families. Therefore, while the advancement of surgical technology may be best for their patients it could be detrimental to the surgeons themselves.

Should human surgeons be forced to compromise their responsibilities for their professional obligations?

Until there is evidence that one is going to completely lose their profession due to these robots, I believe the surgeons should adapt to these surgical robots. The advancement of this technology does threaten the jobs of humans directly involved in the operating room, but in the immediate situation healthcare professionals are still needed. 

In medical school, doctors abide by the Hippocratic Oath which entails doing all that they can to save a patient (when this aligns with the patients’ wishes). Therefore, while they may not be happy with their shifting profession, surgeons should accept robotic training. While the application of their job is evolving, the fundamental principles stay the same. They are required to follow the principle of beneficence, to do good, and save lives, even if this is completed in a different scope. Surgeons are following the principle of beneficence by promoting a technology that could help patients in the best way possible. They are doing good by giving patients the treatment and care they believe will help the patient most – even if this means the doctors need to become less involved and more reliant on technology. 

As the field of medicine shifts, patients are not the only ones impacted as the healthcare system is altered. Healthcare providers will be affected as their roles are replaced or changes due to AI becoming more advanced. Their credentials required to become a surgeon will change as a new, unique skill set is required to make sure that the emerging surgeons can work with the developing technology. In some hospitals it is believed that residents first must master, to an extent that is still relevant in practice, open surgical methods before attempting to master robotic methods. However, it can be considered a waste of time and resources to train surgeons to complete procedures without robotic aid when in reality soon they may soon always be using the robots. 

Technology Companies’ Obligations

Technology companies and those developing AI technology have a unique interaction with the pediatric patients. Considerations must be made regarding the responsibilities these companies have as their innovations advances further into the healthcare field, but the companies are not directly involved in the medical field. The technology companies are distanced from caring for patients where their innovations are applied.

Technology companies, such as Intuitive Surgical which develops the da Vinci Systems, are typically not considered medical companies which would mean they do not have to consider the medical patients when developing robots.

However, now the actions and mistakes of these companies can directly affect people involved in the healthcare community which leads to the questions, who should be responsible when a child dies as a result of this technology malfunctioning? Are technology companies responsible for a child’s death even if this is not what they planned on dealing with when innovating?

Technology companies can claim they are developing the robots correctly, and it is the hospital’s fault when malfunctions occur such as due to inadequate training. Hospitals on the other hand may claim that the AI is unpredictable, and out of their scope of teaching. These differing opinions regarding who is responsible when technology malfunctions and the refusal of accountability makes a slippery slope. Concerning autonomous self-driving cars, no consensus has been found about who is responsible. Some believe that technology companies should be blamed when the car’s program fails. However, others believe it is a passenger’s choice to ride in an autonomous car so they are at fault. The difference with semi-autonomous surgical robots is that surgeons and hospitals stand between the patient and the technology companies. Since hospitals must buy the robotic systems that surgeons must recommend using to parents that decide the procedure for their child, technology companies may feel desensitized from the implications of their actions.

Revenue and the future of the cooperation is a main concern for technology companies, as they want to bring in money that will help the organization grow. Furthermore, the stockholders just want the machines to succeed in the market so that the value of the company will increase. While technology companies have a responsibility to their stockholders to turn a profit by bringing new technologies to market, their actions can also affect the fate of sick children. Focusing solely on the future of innovation rather than developing the current robots to the best standard, before selling them, makes a dangerous situation. What is the result when technology fails and children are killed because technology companies do not deeply consider the impact of solely producing for the sake of money?

From the developer’s standpoint, the user of the surgical technique is considered the surgeons who still somewhat “control” the robots or “press the button” to turn on the AI programs. Therefore, the surgeons are placed in a position to be blamed by developers when it fails. However, should the human surgeon be blamed if the robot fails while performing autonomously, with lessened surgeon control?  What role does this person play when the innovations fail? There is a significant relationship between these two stakeholders, the technology companies vs. the human surgeons, and their differing goals revolving around this technology. While the main goal should be to save the children that need surgeries there are differing perspectives of approaching this. Consequently, these two parties have different plans for how to react when a child dies which causes debate regarding accountability for technology malfunctions. Focuses on technology companies, they are responsible to make the best innovations that are the most effective. They should aim to make technology that will be safe for humans. Specific for surgical technology, they should be focused on developing systems that provide precision and are dependable rather than innovative but frequently malfunction. While developing technology can never be harm-free, technology companies need to be accountable for their mistakes when innovations fail. This accountability should be evident as the companies work to alter their innovations so the technology can aid the surgeons more effectively.

In between the technology companies and the surgeons are the hospitals that determine whether to offer these robotic procedures in their facilities. As healthcare organizations they should not promote technologies that may hurt patients. Finally, doctors have a responsibility to decide the best procedure that should be done to save the child’s life. If they do not trust technology or believe it will be the most effective option then they should not use that procedure. But, once again, it also follows the principle of nonmaleficence to understand human limitations. Although, healthcare professionals should only perform surgeries they fully understand. Performing surgeries with technology that is still relatively new, puts surgeons’ jobs at risk, and the children being operated on. There needs to be a future that maintains a balance between both improvement and caution.

Hospitals’ Countering Missions

Hospitals have a responsibility to improve healthcare and serve their patients by doing everything they can to eliminate pain, cure, and when applicable – meaning the patient wants it – prolong life. Therefore, hospitals could use their money to make sure some individual children have the best care, but then the organization may lack funds to improve other facilities and care for all. This could be considered choosing the care of a few over the increased level of care and treatment available to the greater community. These organizations are forced to balance their responsibility to think about the greater good vs. responsibility to give each patient the best care. Through a utilitarian perspective hospital facilities are meant to take care of many lives meaning they should fairly manage their funds, so many lives can be saved. However, not saving some patients due to costs could be considered inflicting harm or at least not preventing pain, which is a fundamental part of their job. Furthermore, buying and advertising a robot that only a small percentage of patients can afford or benefit from, does not follow this principle. 

Non-maleficence is also a fundamental principle of healthcare. Hospitals have a responsibility “to do no harm” through always striving to do more good than harm. When hospitals choose to deny care or surgery based on a patient’s family’s socioeconomic condition children may suffer. The hospital may inflict harm on a child as a consequence of utilitarian thinking. The hospital could be inflicting harm by prolonging a painful condition, by not performing a pediatric surgery, so those funds can be used elsewhere.

Utilitarians dictate hospitals should only buy the robotic systems if they make it accessible to as many people as possible.

But, fairness issues arise if hospitals are forced to cover the costs of AI surgeries when parents cannot afford the procedure, but it is the best possible patient care. In these cases the hospitals are covering the costs of an advanced technology, but the funds could have been used in a different situation to benefit more patients. 

Surgeons, technology companies, and hospitals all obtain varying levels of responsibilities to the patient at hand and the future of these surgical innovations. Surgeons have the duty to save the most lives which is complicated when it is unclear if overall these robotic systems cause more benefit or harm. Furthermore, technology companies traditionally do not have a duty to medical patients however, they are now manufacturing robots that could save or end a life – can these corporations be held responsible when the robots kill? Hospitals also remain a stakeholder between the surgeons and the technology companies. They have the responsibility to bring in the best equipment that will save the most lives, but they also have a responsibility to consider their future as technology companies consider their organization’s growth and surgeons consider their personal obligations.

A Just Analysis of Implications of Expanding Semi-Autonomous Robots

Access To These Technologies

It is a justice issue that only the pediatric lives of the kids whose parents can afford the very expensive semi-autonomous robotic procedures can attain access to these medical procedures. As of right now AI surgeries are expensive and this is impacting the extent of care certain children receive. For example, when a child’s parents do not have an insurance plan, when procedures are not covered by the insurance plan, or when the hospital cannot accept the patient’s plan. Newborns in particular should not suffer because of the preexisting economic condition their parents had before they were brought into the world. Should newborns be forced to obtain traditional surgery that has different risks because of the socioeconomic status of their parents?

Some may argue that the parents should have been more responsible and only decided to have a child when they could afford all of the expenses. But, the need for neonatal surgery may not be predictable until late into the pregnancy, and at that point, it is usually too late for the primary caregivers to save up a lot of money to fund the procedure. If they were not in the best place financially some may argue that it was not a smart decision to bring the child into this world. However, people can be doing financially well, but still unable to afford these expensive medical bills. Also, parents have the personal autonomy to decide when they want to have children. Further, it is extremely important to remember women can get pregnant when they do not want to, and in this case the need for neonatal surgery is possible. A mother may be unable to afford a new robotic surgical procedure because she was forced into a pregnancy, or does not believe in abortions. 

Some common robotic pediatric surgeries that have greatly expanded due to this technology are gastrostomy tube/button placement which can be performed on neonates through the laparoscopic endoscopic gastrostomy tube method, neonatal necrotizing enterocolitis which is commonly used on premature children, and liver biopsies that have benefited from the increased precision (Lin and Pimpalwar).

Should these procedures only be accessible to those who can afford it? How should hospital facilities handle pediatric patients whose parents can not afford their children’s care?

It is a justice issue if only certain lives can be saved with this technology based on socioeconomic status. Additionally, even if there is not a major difference in the mortality rate between human surgeons and AI surgeons, minimally invasive procedures provide a better experience for the patient. The question is whose main responsibility is it to cover the costs of a sick child whose parents or caregivers can not afford treatment or do not have insurance? Should children be forced to have a risky surgical procedure done by a human surgeon because their parents can not afford an AI technology procedure? It is not just to make innocent, young children suffer as a result of their parent’s economic condition. The children were brought into this world and need surgery to survive. Therefore, preventing a very young neonatal patient from receiving necessary surgery could be considered preventing potential life from the living. This is especially true when a newborn will die without a successful procedure. 

Nonetheless, the advancement of surgical technology could increase healthcare access globally. Since robotic procedures require a different set of skills more lives could be saved by those with less medical schooling. As technology advances, the training required to operate these robots is much shorter compared to the years of education traditionally required to become a surgeon. In this way the advancement of robotic surgery can resolve prior justice concerns as advanced procedures will be brought to areas with less advanced healthcare. 

Applying New Technology To High Potential Lives

Doctors have a responsibility and duty to save lives, specifically pediatric surgeons must prevent children from dying. When this ideology is transcribed to surgical technologies it is then dictated that the robots should advance because they have the potential to save more lives even if in the process some lives will be lost or harmed (through prolonging pain). In the process, as it is whenever testing an innovation, there will be failures. In surgery patients are always lost regardless of the technology available. This is unfortunately an inevitable part of the medical field. However, during the clinical trial process children will die because of the surgical robots.

Regardless of the number of patients that may be saved by the advancement of these robotic procedures, the fact that a singular life has been lost due to technology malfunctions is potentially unethical.

This valuing of the greater good over the singular life at hand brings up concerns. Traditional pediatric surgeries may be more difficult and less effective because of the baby’s small size, but these methods may be more ethical than testing new products on young lives. While applying any new technology is dangerous, in this realm the application can kill a life that never had the opportunity to live. The question is if technology in clinical phases should be tested on pediatric patients before there has even been a lot of studies, let alone perfection, done on adult surgeries that are generally easier for trained human surgeons to complete? 

Value Of A Child’s Life

The application of surgical technology has caused fewer children to die in the United States which is good; however, as new technologies are continuously introduced the impact of these technologies will change. We are expanding technology that is meant to save lives, but it does not always result in benefits. Therefore, we need to consider the value of a child’s life with the importance of expanding pediatric care. 

Each individual has a unique definition of quality of life depending on what they view as happiness, success, etc. It is typically accepted that quality of life changes based on age, health, etc. If a child is in a painful or sick condition, requiring surgery, during that period of distress the child is considered to obtain a low quality of life. Surgeons work to eliminate this pain. 

The child’s potential to live a fulfilling life after the surgery also has an impact on whether the AI systems should be applied to the child’s condition. What if neonatal surgery cannot prevent further health complications, though it may prolong life? Should the technology only be applied when it is predicted that all of the newborns’ pain can be eliminated? This is a justice concern if only the treatments surgeons believe will eliminate all pain occur because the definitions of pain and quality of life are subjective. Should patients in clinical trials only be those that have no other hope of survival and it is predicted the robotic procedure will completely cure the problem or should it be patients where the robotic procedure will help the patient but not cure them entirely? In both situations there will be benefits for the future, but the benefits for the patient will vary. Removal of all pain is still not always possible with traditional methods; therefore, robotic surgery should be applied because it eventually will cure more of the medical problem, even if not all. With parental consent extraordinary measures should be applied to not just eliminate the most pain, but also advance the application of these technologies.

Also, with more research, technology can develop to not just eliminate immediate pain, and prolong life, but attain higher accuracy to cure more complex medical problems. This will result in more potential lives being saved over time.

A Consequentialist Analysis

There is a fear of killing innocent children through the use of robotic surgical technology, but robotic technologies show significant promise by removing human error in the field of medicine. And as we saw, human error has historically impeded surgeons from their prime directive to save lives in a non-negligible number of cases. However, risking a child’s life in the name of technological advancement will have an immense emotional negative impact on the surgeons that give up their involvement for robots to develop. On the other hand, overprotection of patient lives and surgeon guilt could lead to a standstill in innovation, preventing an even more successful future. These technologies require trials to improve. Without attempting to trust the technology with pediatric lives there is no way for doctors, computer scientists, hospitals, etc., to understand the full extent to which these technologies can perform. There is no basis to improve upon if the limits are never tested.

From a consequentialist standpoint the development of AI surgeons would be viewed as ethically permissible because while malfunctions may occur this would lead to changes and more advancements in the technology.

Eventually these advancements lead to improvements in the technology to save many more lives. There is a learning curve that will exist and frequently does with innovations; however, in this situation, children may be put in harm’s way for testing so future children can survive. This demonstrates inequality if certain children have access to a life that others were previously denied. 

But, does this mean that children born with birth defects that require immediate surgery should become a baby for science? While the child may need a surgical procedure and a robotic procedure could be even more effective to treat the child, this is still forcing them into experimentation at a young age. This is especially true now as traditional surgical methods still exist for the same medical conditions. As stated earlier, the unknown requires testing to expand, but testing results in many failures before success. In cases where babies are harmed because of the unpredictability of AI, we can claim that the children do not die not directly because of the human surgeons, but rather due to the inaccuracy of surgical robots. However, a robot can not be held accountable for their mistakes when human surgeons are recommending the procedures. But, if robots can not be held accountable then who should be? If the doctors are accountable, they should continue to utilize the traditional methods they are comfortable with even if the success rates are lower than robotic procedures.

While the robotic procedure may be more effective the surgeon would need to be accountable for malfunctions that occur regardless of their comfort with the technology. Therefore, to prevent this accountability concern the surgeons should only use robotic methods when they deem necessary.

This is especially true for the scenarios where human surgeons could most likely perform a procedure, whether drastically different or similar to the robotic path, that would have resulted in saving the child’s life. While a more invasive human procedure may cause more lasting damage than a robotic procedure, I believe the ramifications of a robot malfunction are worse. 

Therefore, I believe that AI surgeries should be integrated into healthcare with caution. Nonetheless, if an innovation is not forced into the market, then advancement will never occur; waiting for perfection will cause a standstill in research since perfection is unattainable. Therefore, I believe that the surgical technology needs to be advertised very carefully, clearly outlining when it can surpass traditional methods vs. when it has proven to be more effective. 

While the initial expansion of semi-autonomous surgical technology may seem ethical, a consequentialist lens reveals that it could cause an unjust future. Since these surgical robots are extremely expensive, they will create a greater divide among people that can and can not afford this level of healthcare. This begs the question: should only some lives be saved? If not, then we are faced with how to make the innovation commercially viable. Furthermore, while these surgical technologies can benefit pediatrics greatly, they may not have as large of an impact in other sectors of surgery, raising concerns about adequately using resources for the greater good. As technology continues to advance the future of surgical robots must be evaluated carefully to determine the ethicality of the systems, not only now but in the future as they continue to decrease human intervention. 

Conclusion

Robots are “taking over,” becoming prevalent in many parts of human society from face recognition devices in schools to self-driving cars. Humans are growing increasingly dependent on technology; whether we approve of it or not. In surgery there are greater risks involved with increased technological dependence like machine malfunctions leading to human death. Therefore, considerations regarding the implementation of these surgical robots are significant. Computer scientists and technology companies have the autonomy to experiment in controlled environments that do not harm any humans’ lives. These innovators, however, will not succeed in placing their innovations out into the marketplace without the acceptance from patients, hospitals, and doctors. While technology companies are the innovators that determine the level of technology that exists, everyone else controls the response to these developments.

Specific to the integration of robotic surgical devices in pediatrics, the response relies immensely on ethical parent-surgeon communication that results in effective informed consent.

(Schiff and Borenstein)

While advancements may now seem beneficial, there needs to be considerations of the impact on future human generations. Humans are setting themselves up for failure by developing technology that is more advanced than us.

What will happen when, through machine learning, AI capabilities far surpass the abilities of even the best human surgeons?

It is dangerous for technology to be able to perform tasks on a human body that trained surgeons can never pursue themselves. This is reducing human autonomy may cause problems later on when the devices are performing countless procedures with no human fallback option. Problems will arise when there is little human expertise in controlling these robots. The human surgeons abide by the Hippocratic Oath, which prevents them from doing more harm than good, but this ideology cannot be transcribed to a robot. So, when does technology go too far? 

Since humans develop these robots some may believe that the robotic systems will always help or benefit people. Contrarily, the reports of malfunctions already demonstrate that this is not entirely true. Dead children do not benefit or help anyone. 

This leads to the question of the responsibility various stakeholders have to not just save the patient, but also impact the future. The surgeries made common practice today will set a precedent for the future of healthcare. As already evident with the use of robotic technologies to elevate hospitals above their competitors, once the technologies start to spread in one area of society it floods to the rest. Problems arise when the surgical technology was ethically developed to be applied to one realm of society, aiding surgeons in saving lives, not promoting various healthcare organizations against each other or creating disparities in access to healthcare. 

Despite all of these concerns about a future with AI in all aspects of life, there is a promise for an ethical future with surgical technology. There are benefits for surgical technology to replace human surgeons in some aspects, but not all. 

My Final Claims

I believe that the development of these surgical technologies should not be limited. Technology companies should have the right to innovate as much as they would like. Everyone has a right to create and invent as long as there are no malicious intentions behind that innovation.

Concerning surgical technology, the fundamental intent is to aid surgeons in saving lives. This is an ethical intent therefore, the development of these systems should continue.

However, when these inventions are produced to be sold, there is always a risk to human life or corruption through unethical advertising. The companies innovating these surgical robots cannot be allowed to put technology on the market that is not proven to be safe and successful. Therefore, the FDA should continue to regulate these devices prior to commercial implementation, but the production and development can continue unregulated (until human clinical trials start to occur).

Since the FDA does not regulate the training required for these technologies, other organizations or regulatory bodies need to continue to take over and regulate training for these technologies. Presently the American Board of Surgery has been involved with training regulations and should continue this process. Even hospitals should obtain more responsibilities in assessing their surgeons’ competence with these innovations, ideally through an organization-specific process. Organizations need to step up and take over, even if it means hospitals are required to develop a detailed training process. Without regulations, there is no way to monitor the application of these technologies, which, history has shown, often leads to undesired consequences. 

With the proper regulations, innovation should occur because it will lead to more lives saved down the line. The technology will develop, malfunctions should be corrected, and the robotic systems will increase accuracy and effectiveness in preventing medical problems. Also, since these systems require less human surgeon medical knowledge, the procedures can be brought to areas that previously lacked the means to obtain advanced surgical procedures. In this way, the advancement of robotic surgery will increase access as doctors with less training can perform more advanced procedures and more lives will be saved in areas where they would previously have been lost. 

While I understand that the costs of these robotic surgeries are extremely prohibitive, I believe that insurance companies should be compelled to cover these procedures. Parents deserve the right to autonomy even if this means that it could be difficult for an insurance company. In the future when there is a larger range between the success rates of traditional and robotic methods, the government should consider requiring insurance companies to cover these costs. Since very few children need surgery, the cost spread across all of the customers would even out and the insurance company will likely recoup their losses. While this may initially raise the price of insurance for all, which is unethical since more people will bear this financial burden, insurance companies are more inclined to cover the costs of these technologies when they have reason to believe that these procedures will cost less in the future, due to increased accuracy, shorter hospital stays, and less treatment. Therefore, while insurance prices may initially rise, the rise is due to optimism in costs dropping in the future which will benefit many.

Also, doctors should continue to evaluate the way they discuss these technologies.

Significantly, tone and word choice in the medical discussion should be studied to make sure it does not impact a parent’s informed consent.

This will make sure that technology is not forced into society in situations where traditional methods are still preferable. While the innovation and application of this technology should continue under the correct circumstances, I believe that parents should still obtain the right to autonomy over their children’s medical decisions.

Retaining parental autonomy is vital in making sure this technology is integrated into society at a steady rate, so it can be accepted without becoming too cost prohibitive.

While some parents may not be able to afford the procedures they want, striving to provide parents with the resources they need to make the best decisions possible for their families without economic concerns is the right decision for the future of humanity.

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