THEOF CUTTING EDGE ROBOTIC SURGERY Juliette Hoedemakers - s1423592 1 November 2015 New Media (2015-1A) Creative Technology University Twente, Enschede 3194 words ABSTRACT A very promising and currently emerging technology is robotic surgery. However, due to rapid advances in this field and the development of many different surgical robot prototypes, many ethical questions might arise too. The use robotically assisted surgical systems in medical care has some (obvious) advantages like enhanced precision for the surgeon, less risk for trauma to the patient and reduced costs for society, but there will be unwanted and unpredictable side effects too and these have to be taken into consideration. What are the ethics of robotic surgery? It is clear that this is a difficult question to answer. Even though the future of robotic surgery is bright and the use of robots in clinical environments will definitely expand enormously the next decades, there are also threats such as safety and technical problems, investments and marketing and the reduced training opportunities for upcoming surgeons. TABLE OF CONTENTS 1. BACKGROUND P. 01 2. METHOD P.03 3. SUMMARY P.07 4. CONCLUSION P.10 5. IDEAS FOR FURTHER INVESTIGATION P.11 6. REFERENCES P.12 BACKGROUND Technological developments in the Robotic and Artificial Intelligence sector are growing very rapidly and they are incredibly fascinating. Nowadays, mechanical robots are an indispensable part of major manufacturing industries. Robots in combination with smart software have taken over many of the tasks that require speed, endurance and high precision. Due to their success they have been able to replace a lot of human labour. Advanced operating systems are able to work almost autonomous and we are implementing more and more artificial intelligence (AI) in everyday software. The way this new technology has conquered the world and quickly has been implemented in various applications is truly amazing.. This is fascinating because it proves that humans have the ability to do more than they have ever imagined themselves, especially compared to what man thought was possible a century ago. As time passes more and more discoveries are made and further achievements seem almost endless. The first telesurgical laparoscopic cholecystectomy was performed with success in March 1997 by Cadière [1]. Ever since, minimally invasive robot-assisted surgery is more alive than ever and will continue to grow exponentially. In 2000 the use of the da Vinci Surgical System for performing robotically assisted surgery has been legally acceded. The da Vinci Surgical System (Intuitive Surgical Inc. Sunnyvale, California) is a telesurgery system that consists of a high-tech cart which has 3 robotic operative arms that are remotely controlled by the surgeon. The operation team engages and observes the operation on a video-endoscopic unit (Figure 1). [2] Figure 1: Representation of the da Vinci Surgical System 1 There are a few serious limitations in relation to traditional laparoscopy, which include the inability to perform high-precision sutures, flat vision, unnatural positions for the surgeon and limited ability to move [3]. The statute of legally implementing robotic surgery can help vanquish all the restrictions in connection with conventional procedures. Not only could this improve the efficiency of the operation but also increase the number of patients. This sounds like a great addition to the different utensils that are available to surgeons but many issues are still not properly defined or resolved. Many concerns have risen regarding to the clinical practicality, the duration and level of mastery of the robotic tools and the safety. Some studies claim that there are circumstances where robotic surgery is not any safer than other types of surgery but it is more costly [4]. There are also reports and studies showing that robotic surgery is not advanced enough and can even be more dangerous than regular surgery [5]. These issues have a profound legal and financial entanglement and since the telerobotic industry is still changing and developing every day, there will be no exact solution to settle the safety and cost dispute. However it is still valuable and profitable to discuss research and define whether there is an ethical breach of trust. Some have claimed that commercial interests impel this new upcoming surgery [6]. To summarize it is of interest to look at all the traditional facets of medical ethics like the duty to present the best available care, informed consent, corporate marketing and the trust relationship between the patient and the surgeon. These issues increase as future robotic systems gain more sovereignty in surgical procedures. 2 METHOD To gather information and gain knowledge about any scientific topic, it is very important to first study the topic to a certain extent. This research strategy is very important in order to prevent deviating too far from the research question itself and to avoid losing time due to inefficient searching. To detect and trace articles for “What are the ethics of robotic surgery?” a list of relevant keywords has been constructed: ROBOTIC / SURGERY / ETHIC / MORAL / ETHICS / LEGAL / ISSUES / ASSISTED / ASSIST / INVASIVE / ARTIFICIAL / INTELLIGENCE / PROBLEM / ROBOT / SURGEON / DOCTOR / AUTOMATIC / INTELLIGENT / MEDICAL / MEDIC / MACHINE / AUTOMATION / PROCEDURE / PROCEDURES / COMPUTER / CAPEBILITY / OPEN / TECHNICAL / TELEMEDICINE / DEVELOPMENT / TOOLS / REPLACE / SYSTEM / TELESURGERY However most search terms were formed with only a selection of the keywords shown above or with a sentence formed with some of these keywords. TOTAL OF RESULTS IN: SCOPUS IEEE XPLORE GOOGLE SCHOLAR GOOGLE Ethics of robotic 84 surgery 5 24,700 144,00 Ethical robot medical 14 29 22,500 425,000 Legal issues in telemedicine 5 16 31,600 438,000 Robots surgery ethical dilemma 1 3,354 8,230 251,00 Robotic surgery moral 7 4 18,800 233,000 Figure 2: Table of search results 3 When researching scientific subjects it is very convenient to also explore papers written by predecessors. To find these papers I used search engines like “Scopus”, “IEEE Xplore”, Google and “Google Scholar”. The first search was a direct search to find out about the ethics of robotic surgery. Since this search is very specific and paper tittles can include other words, other searches were also made. The most results came up for “ Legal Issues in Telemedicine”, however the results were very general and not specific to the ethical and moral roles in robotic surgery. Adding a few key words or changing “robot” to “robotic” also made a difference and narrowed down the search results. After cross analysing the search results and clicking on relevant tittles a promising selection of 10 prime articles were selected: LIST OF 10 RELEVANT ARTICLES: 1. Ethical trust in the context of robot assisted surgery http://doc.gold.ac.uk/aisb50/AISB50-S17/AISB50-S17-Sullins-Paper.pdf 2. Ethical Reflections on Health Care Robotics http://people.na.infn.it/~tamburrini/pub/Datteri_Tamburrini_Ethics%20and%20Robotics. pdf 3. The ethical controversy of a faulty design: Surgical Robotics http://www.pitt.edu/~ewm15/EthicsFinal.docx 4. Carry on Automat(r)on: Legal and Ethical Issues relating to Healthcare Robots http://www.scl.org/site.aspx?i=ed32369 5. Ethical Dilemmas in lapararoscopic, robotic and advanced surgical technology http://laparoscopy.blogs.com/prevention_management_3/2010/10/ethical-dilemmas-in-laparoscopic-robotic-and-advanced-surgical-technology.html 6. Ethics, robotics and medicine development http://www.researchgate.net/publication/210361386_Ethics_robotics_and_medicine_development 7. Legal and Ethical Issues in Telemedicine and Robotics http://papers.ssrn.com/sol3/papers.cfm?abstract_id=944833 8. Telesurgery and Robotic Surgery: Ethical and Legal Aspect http://www.omicsonline.org/open-access/telesurgery-and-robotic-surgery-ethical-and-legal-aspect-2376-0214-1000355.pdf 9. Robotic technology in surgery: Past, present, and future http://www.sciencedirect.com/science/article/pii/S0002961004003757 10. Robotics in general surgery: Personal Experience in a Large Community Hospital http://archsurg.jamanetwork.com/article.aspx?articleid=395121&resultclick=1 4 After collecting 10 articles it’s time to narrow it down. The best 3 articles have to be selected which will then be encapsulated in the next chapter “SUMMARY”. In order to narrow down the selection to 3 final articles it is important to create a rating system that evaluates the relevance in relation to the research question. To do this in an organized way it is simple to make a rating matrix. Each article will be rated and aided by a three-step scale. An article can be rewarded stars. Each star is worth a point which will indicate which article is the most useful. The articles will get either 0 stars, ✪ one star, or ✪ ✪ two stars. The most important criteria are: RELEVANCE: Does it answer your research question? ** : Yes, the research question is answered * : A partial answer was given 0 : The research question was not answered USEFULNESS: Is the article technological and specific? ** : Yes it is specific * : There is a mix between technological and general information 0: The information given is very general with very little depth COHERENCE: Does this article contain information that overlaps with other articles? ** : Yes, covers the same information * : Some articles overlap 0: Information is not covered by any other articles PEER-REVIEWED: Is the article peer-reviewed? ** : Yes, the article is peer-reviewed 0 : No, The article is not peer-reviewed 5 ARTICLE NUMBERS RELEVANCE USEFULNESS COHERENCE PEERREVIEWED TOTAL 1 ** ** * ** 7 2 * * * ** 5 3 * 0 ** ** 5 4 ** * 0 ** 5 5 ** * * ** 6 6 * * 0 ** 4 7 ** * * ** 6 8 * 0 * ** 4 9 * ** ** ** 7 10 ** ** ** ** 8 Figure 3: Matrix of article selection As seen from the matrix above, the 3 articles that are the most suitable are articles 1,9 and 10. Article 7 and 5 are also very relevant but are lacking in usefulness and coherence. 6 SUMMARY 1.Ethical trust in the context of robot assisted surgery Robot assisted surgery is part of the area of modern medical care so there is much overlap of ethical concerns in the existing literature of medical ethics. It is important to be aware of how technologies of telemedicine affect ethical choices made within surgery. Ethical trust is the primal question in this research since there is an asymmetry in what the patient knows about their medical situation and what the surgeon believes is the best treatment to quell the medical complication. A great deal of effort is put into maintaining a sociological trustworthiness so that people feel confident putting their lives into the hands of care. Another point is professionalism in surgery since it is also important to take into account that robotic aid will shrink the potential of other new upcoming medical professionals to develop the skills that are necessary for their job since robotic surgical devices may even replace humans entirely or reduce the role that humans play in the present. The medical practice of surgery has very tight links to technology, sciences and social practices. Therefore this kind of system is often cited as “technoscience”. Should the medical industry place more or less trust in the technology of robotic surgery? This depends on how robotic technoloscience has modified the original relationship between the patient and the surgeon. When examining this situation it is crucial to not reduce the patient to an object where surgery is performed on. There needs to be an assorted system where humans are treated with care after and before surgery so that the distant telesurgery can establish ethical trust and consent between the surgeon and their patients. Obviously marketing also plays a role since the hospital now features expensive robotic equipment that they want to use. This does not mean robotic surgery isn’t the most beneficial decision to make but it could mean that some patients are misled. Robotic surgery has the potential to be very beneficial but also completely change the medical industry as we know it since more autonomous machines will be implemented and the profession of surgery isn’t as open to new practitioners as nowadays. These issues need to all be taken in consideration when moving forwards. 9. Robotic technology in surgery: Past, present, and future Almost 20 years has passed since the introduction of robots in the operating room. Since those 20 years a lot of progression has been made when it comes to integrating robotic technologies with surgical instrumentation. “However, to build on past success and to fully leverage the potential of surgical robotics in the future, it is essential to maximize a shared understanding and communication among surgeons, engineers, entrepreneurs and healthcare administrators.” This paper emphasizes the importance of collaboration between all of these different sectors and discusses future prospects for innovation. There are many advantages tied to robotic surgery and as they continue to evolve in the long term the costs will be outweighed. Robots will continue to become smaller, easier to use and less expensive. 7 Something else very important to keep in mind with the development of telerobotics is the “Three Rules of Robotics”[7]: “1. A robot may not injure a human being, or, through inaction, allow one to come to harm. 2. A robot must obey all orders given to it from humans, except where such others would contradict the First Law. 3. A robot must protect its own existence, except when to do so would contradict the First Law or the Second Law. “ These rules provide a fair rational ethical framework for the expansion of robots applied to the surgical industry. Furthermore it is also to keep track of all the advantages and disadvantages that telerobotics can bring to the work floor. Surgeons and robots both have their advantages, disadvantages and limitations (Figure 4.) Another important thing to define is the different roles robots can have in the operation room: “1. Passive role: The role of the robot is limited in scope, or its involvement is largely low risk 2. Restricted role: The robot is responsible for more invasive tasks with higher risk, but is still restricted from essential portions of the procedure 3. Active role: The robot is intimately involved in the procedure and carries high responsibility and risk. “ Figure 4: Table of advantages and drawbacks for surgeons and robots 8 The last classification that proposes the expanding active role of robots is inaccurate since these have been limited due to the lack of artificial intelligence. It is also significant to remember that such an active-role robot will need to be intensively supervised and require human interaction, which will be draining for the surgeon. Next to that it is also self-evident that completely autonomous robots will only be allowed to be involved in low risk surgery (Passive Role). There are only a few truly active robotic instruments available in the medical sector (Figure 5.) Figure 5: Current robotic tools in relation to their role All together it is best to think of medical robotic technology like something that is still very much in the making. It is surprising how much is already possible but the technology is still only yet in its infancy. It’s natural to be cautious for the surprises this new technology will bring in the feature and we should be ready to recognize them. According to this article the rise medical robots needs to be embraced since they have a lot of functionality and utilities in store for us that are currently beyond our dreams. 10. Robotics in general surgery: Personal Experience in a Large Community Hospital The Department of General Surgery, Misericordia Hopistal, Grosseto, Italy has made a study of robot-assisted surgery using the da Vinci Surgical System. 193 patients (74 males and 119 females ranging from 16-91 years old) underwent a minimally invasive robotic procedure (Figure 6) between October 2000 and November 2002. The perioperative morbidity rate was 9.3% (18/193 patients) and 6 patients (3.1%) required a reoperation. The perioperative morbidity rate was 1.5% (3/193 patients.)[8] Figure 6: Person experience with single robotic procedures The initial experience at the hospital advocates that robotic surgery can be attainable in clinical setting. Daily use is safe and can be managed for minimally invasive surgery but the cost-benefit ratio needs to be assessed. 9 CONCLUSION Article 9 “Robotic technology in surgery: Past, present, and future” provided the most general information. This information is crucial since it is important to obtain background information. This improves the understanding of the subject and gives a base in case some interested readers might not have a background in robotic surgery. The paper was quite lightly and optimistically written and shed light on the many possibilities and great things that can be achieved with the development of technology. The paper was more popularly written so that it is accessible for a more general public. Article 10 “Robotics in general surgery: Personal Experience in a Large Community Hospital” is an actual study that offers a lot of data that can help exterminate speculations since it involves testing. This scientific support keeps the research realistic and fact-driven. These facts help depict the current situation more clearly. Article 1 “Ethical trust in the context of robot assisted surgery” provided the most information and research regarding the research question. The information was concentrated on the doubts and where to draw the ethical line between patient and surgeon. This more cautious approach creates awareness for the dangers and the importance to also research the most negative outcomes that robotic technology in surgery can bring. The combination of the above articles answered my research question since they circumscribe the current situation, what the exact current ethical dilemmas are and what can be obtained in the future. The reliability of these results can vary. The most reliable paper was Article 10 since it is a fact based paper which was peer reviewed. This is the opposite from Article 9 that is more opinion based. 10 IDEAS FOR FURTHER INVESTIGATION To discuss this paper in relation to further investigation, there are a few things worth mentioning. The discussion of the ethics within robotic technology for surgery is endless and needs to be strictly organized since it touches so many different disciplines. Since technology is developing so quickly some of the information can sadly quickly get outdated. It is important to look at the most recent studies and tests and form solutions to problems from there. It is true that robotic surgery could be capable of many wonderful and helpful things but it is of uttermost importance to not get blindsided by the less vital things. The safety of the patient and surgeon should always come first. In this scenario prevention of errors would be a solution to most problems. Another crucial point is that most of the negativity regarding this topic should not be ignored, but needs to be nuanced, since it is based on trust and most papers are unfortunately still biased. 11 REFERENCES [1]J. Himpens, G. Leman and G. Cadiere, ‘Telesurgical laparoscopic cholecystectomy’, Surgical Endoscopy, vol. 12, no. 8, pp. 1091-1091, 1998. [2] da Vinci Surgery, ‘Fact Sheet for da Vinci® Surgery’, 2013. [Online]. Available: http:// drwebbobgyn.com/documents/davinci-fact-sheet.pdf. [Accessed: 01- Nov- 2015]. [3]P. Giulianotti, ‘Robotics in General Surgery’, Arch Surg, vol. 138, no. 7, p. 777, 2003. [4] W. Boggs, MD. ‘Robotic Colectomy No Better, but More Expensive,’ Reuters Health Information, reported on Medscape News. December 26, (2013), [Online] Available: http:// www.medscape.com/viewarticle/818302 [Accessed 17- Oct -2015]. [5]J. Carreyrou, ‘Surgical Robot Examined in Injuries’, WSJ, 2015. [Online]. Available: http:// www.wsj.com/articles/SB10001424052702304703104575173952145907526. [Accessed: 01- Nov- 2015]. [6] M.B Schiavone,., E.C. Kuo,. R.W.,Naumann, W.M.,Burke, S. N. Lewin, A. I. Neugut, et al. The commercialization of robotic surgery: Unsubstantiated marketing of gynaecologic surgery by hospitals. American Journal of Obstetrics and Gynecology,207, 174.e1– 174.e17. (2012). [7]I. Asimov, The complete robot. Garden City, N.Y.: Doubleday, 1982. [8.]P. Giulianotti, ‘Robotics in General Surgery’, Arch Surg, vol. 138, no. 7, p. 777, 2003. 12