Robotic Surgery: An Ethical Dilemma?

Our local hospital has a "da Vinci Xi Surgical System", you can learn more about it here: There are only 10 units doing surgery as of July 2014. This is the future, today. I have been hammering the healthcare system with my series of posts on "Patient Dignity" (a.k.a. patient modesty). When I saw the "da Vinci Xi" (pictured below), I was thinking that this is a good thing! But, I was thinking in terms of "Patient Dignity" (same gender care, draped properly, no unnecessary people in the room, etc. Then I realized that this is a piece of advertising.

Of course it looks good, that is what it is designed to do. Just look at "11 Ways Advertisers Make Food Look Delicious" (on mentalfloss.com). So I decided to put aside the issue of "Patient Dignity" in regards to robotic surgery. I have to assume less people in the room is a good thing for the dignity of the patient.

But there is a pitfall: How many on the hospital staff are going to want to see this "wonder of medicine" in action? How many people will be "popping in?" Will they broadcast live video, rebroadcast it, and do this in an "Operating Theater?" Who will get to see it, medically licensed professionals only? Will the manufacturer want video of it in action for promotional pieces, will medical schools want video for educational reasons? Will the corporation that owns the hospital want video for promos?

What say will the patient have in spectators permitted and the procedure being videoed or not? This circus of spectators reminds me of the 1889 oil painting by Thomas Eakins, "The Clinic of Dr. Agnew."

Can the hospital ethically say:

"We need to film your procedure to further learning of medical students, if you refuse we cannot schedule you for robotic surgery, you must have traditional surgery. Based on the principle of utilitarianism (John Stuart Mill), spectators and video taping cures you, promotes learning, and we received this unit at a discount by providing the manufacturer with video of procedures, otherwise it would not be here."

I believe that robotic surgery is the same as any surgery in regards to patient dignity. So I will leave that issue for my series on "Patient Dignity." So other than the issue of patient dignity, there are no other ethical issues, and it is a good thing. Maybe not...

There are pros and cons to robotic surgery, and specifically to the "da Vinci Xi." I will list the pros and cons to both robotic surgery and specifically the "da Vinci Xi" together:

Pros:

• For the patient, there's usually less blood loss, a shorter hospital stay and less reliance on postoperative pain medication. There's also the cosmetic benefit of no big scars: As in laparoscopic surgery, the instruments enter the body through small incisions.
• For surgeons, the procedures can be less tiring. They don't have to bend over an operating table, they can sit in front of a screen with a magnified, full-color 3-D view of the surgical field. For maneuvering in very tight spaces, the enhanced screen image makes it much easier to see. 
• Overall costs to patients: A robotic procedure may mean less need for pricey items like blood transfusions and post-op pain meds. Patients may also spend less time in the hospital and have a lower chance of readmission for complications.
• Robot hands don’t shake and they can twist and rotate in more directions than human hands. 
• By 2009, 85% of the 85,000 U.S. men who had prostate-cancer surgery to have their prostates removed by the da Vinci system (Source: Intuitive Surgical Inc. of Sunnyvale, California).
• The robotic arm can make finer, more precise movements, with greater accuracy than the human hand.
• A map of the organ or structure, developed from radiology images, with landmarks or surgical points highlighted, can be superimposed over the realtime endoscopic video.
• The endoscope allows the surgeon a better view of the organ or structure.

Cons:

• Da Vinci robots were approved by the U.S. Food and Drug Administration (FDA) in 2000. Since its approval, there have been 4,600 adverse events reported to the FDA, which amounts to an average of one problem per day by June 2013.
• Robotic surgery complication rates may be no better than those of traditional laparoscopic surgery, according to an article published in the Journal of the American Medical Association (JAMA).
• Cost: A study published last year by surgeons at Brigham and Women's Hospital in Boston showed these average total patient costs for different types of hysterectomies: $49,526 for a robotic procedure, $43,622 for abdominal, $28,312 for laparoscopic and $31,934 for vaginal.
• More chance of nonessential people (non-medical personnel, students, medical personnel not directly involved in the care) wanting to see the technology in action. 
• More chance of the procedure being filmed.
• No expert consensus on how much training is needed. A 2010 New England Journal of Medicine essay by a doctor and a health policy analyst said surgeons must do at least 150 procedures to become adept.
• Machines break, power can go out, computers can freeze; even though there is redundancy built in, things can still go wrong.

Here are some facts about Robotic surgery:

• The term "robotic surgery" refers to "robotic assisted surgery." A surgeon sits at a computer console in the operating room, directing the long robot arms with hand controls. The arms are tipped with tiny surgical instruments and one has a video camera that lets the surgeon view the operation on the computer screen.
• The world’s first surgical robot was the ‘Heartthrob’, which was developed and used for the first time in Vancouver, BC, Canada in 1983.
• Robotic surgery devices generally include 3 critical tools which include a robotic arm, endoscope and monitor, and a tele manipulator which enables the doctor to simulate their hand movements with the movements of the robotic arm.
• Major advances aided by surgical robots have been remote surgery, minimally invasive surgery, and unmanned surgery. 
• The surgical robots that have been developed for use include Da Vinci Surgical System, ZEUS Robotic Surgical System, and the AESOP Robotic System.
• Robotic surgery gained popularity first among prostate surgeons, who like its precision in working with delicate male organs.
• The U.S. Food & Drug Administration (FDA) web page about robotic surgery can be found here:

The "da Vinci Xi" at first glance reminded me of Number "Johnny" 5, from the 1986 movie "Short Circuit." It can be scary to look at to some people. Some patients may feel dehumanized being treated by a robot.

This also reminded me of a theory that science fiction predicts future technologies.  Studies have shown that cultures with rich collection of science fiction prose, have greater technological advances. These include ancient cultures to modern day cultures. Here are some sources of this theory:

• Thomas Clareson: "Science Fiction Criticism" (Kent, OH, 1972) 
• Roy C. Amara and Gerald R. Salancik; "Forecasting: From Conjectural Art Toward Science" The Futurist (April 1969)
• Albert Somit: "Political Science and the Study of the Future" (Hinsdale, 11., 1974)
• Dennis Livingston; "Science Fiction as a Source of Forecast Material," Futures, I (March 1969)

Proof of this comes from the 1960's television series "Star Trek." The communicators predict cell phones. Motorola's "StarTAC" cell phone not had an uncanny resemblance to the Star Trek communicator, but the name closely resembled the title "Star Trek." There are also flatscreen television, the tricorder (see the iphone in medicine here:), and laser pointers.

I think the most realistic look into the future of medical robots comes from the movie "Star Wars Episode III: Revenge of the Sith"(2005)  and "Prometheus" (2012), part of the movie "Alien" (1979) franchise.

In "Star Wars Episode III: revenge of the Sith," Darth Vader then engages Obi-Wan Kenobi in a lightsaber duel which ends when Obi-Wan severs Vader's legs and remaining organic arm mid-air. Vader then slides too close to a lava flow and sustains life-threatening third-degree burns. Darth Vader is saved by medical droids (robotic surgery) who treat his injuries and reconstructed his body with the cybernetic limbs and the black armor. Also note the use of cybernetic limbs.

The second vision of robotic surgery coves from "Prometheus." I believe that this is a more realistic view of what is to come. The medical droids in "Star Wars" were totally autonomous and to some extent "self aware." (See reference of self awareness here:) The term "droid" is "Star Wars" nomenclature and short for android;  a robot with a human appearance.

The surgical robot in "Prometheus" is called the "Medical Pod 720i." The definition of "pod" is self-contained unit on an aircraft, spacecraft, vehicle, or vessel, having a particular function. The "Medical Pod 720i"is semi-autonomous. It needs to be directed by a human being, when there is a conflict (machine doesn't know what to do), then a person has to resolve the conflict with in the machine's capabilities.

Essentially the "Star Wars" droids direct the examination, diagnosis, decision on treatment/procedure, and treatment the medical condition. They can be overridden by humans. In "Prometheus" the person directs the "Medical Pod." The human can examine or request an examination. The machine can suggest a diagnosis and treatment, but the person must ultimately decide the diagnosis and treatment. The person also direct the treatment or procedure. Here is a YouTube video of the "Medical Pod 720i" from  the movie "Prometheus" in action:

This is how I see the evolution of robotic surgery:

1. The surgical instrument: the first extension of the human hand being.
2. Power assisted mechanical surgical instruments (surgical drill).
3. Mechanical laparoscopic surgical instruments.
4. X-Rays, MRI, CTs, laparoscopic video, etc.; advances in imaging.
5. Energy surgical instruments (surgical laser).
6. Powered laparoscopic surgical instruments (da Vinci Xi).
7. Powered laparoscopic surgical instruments with advanced imaging. 
8. Hands free powered laparoscopic surgical instruments. 
9. Computerized diagnosis and treatment recommendations.
10. Hands free powered laparoscopic surgical instruments with advanced imaging. 
11. Hands free powered laparoscopic surgical instruments with advanced imaging, body mapping, and organ recognition. 
12. Hands free powered laparoscopic surgical instruments with advanced imaging, body mapping, organ recognition, and preprogrammed procedures ("Medical Pod 720i").
13. Autonomous medical robots ( "Star Wars" medical droids).

Ethically it comes down to the doctor's diagnosis and recommendations, patients' choice, full disclosure, patient dignity, and "NO STRINGS ATTACHED." 

By doctor's diagnosis and recommendations, I mean the doctor diagnosis the disease and ONLY recommends the course of treatment. This includes if the patient is a candidate for robotic surgery, if there is a less invasive technique, or if "hands on" surgery is the best route. The best example of  "hands on" surgery that I can think of is plastic surgery which is just as much art as science.

At this point the patient chooses which treatment. A patient may prefer "hands on" surgery. It must be the patient's choice. When I say full disclosure, I do not mean the fine print on page 18 of the admission form that the patient signs at 5AM when being admitted on the day of surgery. This is beyond the risks, this is about who will be in the room, who is necessary to be in the room. There should be NO "maybe's, only "in the event of's."

Patient dignity has special considerations in robotic surgery due the the "wow factor" of the technology. It should not be broadcast world wide on pay-per-view. It should not be done at Madison Square Garden. If the unit records video from the endoscope, the patient should have full disclosure as to what happens with that video, and full control as to who is allowed to view it.

No strings means "NO STRINGS AT ALL!" Ethically, strings are the same as coercion. If a patient wants no spectators, students, or recordings, they CANNOT be denied robotic surgery. Saying "the unit automatically records video and we can't do nothing about it" is a STRING! Pre-negotiated contracts with third parties (such as the manufacturer) for things that are in the realm  of patient control are STRINGS! A discount to the hospital from the manufacturer for a video of all procedures is a STRING (and coercion).

The conditions (other than direct health related) on receiving robotic surgery should be no different than that of receiving laparoscopic surgery.

Me, I welcome robotic surgery, and at my insistence, it will NOT be a spectator sport for me.

Thank you for reading.