Richard M. Satava, MD
Each generation of surgeons inherits the moral and ethical foundations from the preceding generation and must practice the art and science of surgery based on these principles. While the foundations remain unchanged, the applications become more complex and the decisions more difficult as advancing technology provides greater opportunities to save lives and relieve pain and suffering. Until the past 50 years, the technology did not exist to treat many diseases, surgery was relatively straightforward, and all a surgeon’s effort was directed at stopping the advance of a disease or correcting a congenital defect. Sometimes social issues related to advanced surgical technology, such as implementing an unproven technology or itinerant surgery, would arise. With each of the new dilemmas, the foundations have continued to suffice, although the solutions have become more complex. More importantly, the ethical dilemmas have dramatically increased in scope; rather than revolving only around an individual patient or the conduct of medical practice, the impact of the technologies have driven the ethical implications to the new dimensions of global health, population imperatives, and impact of the evolution of the human species per se.
Laparoscopic surgery was a turning point, because it is less about a new technology and more about providing surgical practice with a new method or approach to surgery. Concurrent social changes, such as the need to more fully disclose all aspects to the patient to obtain informed consent, self-improvement through life-long learning to ensure the highest quality of service for the patient, and evaluating the best approach (open or minimally invasive) based on both surgeon and patient factors, have extended the difficulty of decisions. These ethical challenges, however, have remained relatively similar in nature to those engendered during the traditional training of surgeons and remain fixed upon what is important for the individual patient or the practice of medicine.
The new, advanced surgical technologies are generating circumstances that extend well beyond previous experience and affect choices at a much more profound level. Without question, old dilemmas, such as the issues of genetically correcting a congenital defect or itinerant surgery using telesurgery, will acquire a new mantel. However, moral questions that had been considered mere fantasy or speculation (“unthinkable” dilemmas) have become the conundrum for serious debate. No longer are surgeons constrained to deciding what is best for a patient, but now surgeons will need to engage in discussions about extraordinary issues like creating new life, providing a person with capabilities beyond what is natural, integrating human with machine, extending life well beyond a normal life span, and, most of all, what it means to be human. Previous reflections have started by considering a new technology and examining the known or potential ethical challenges;1 the following will focus on the category of ethical dilemmas, because many of the new technologies will pose or contribute to the same or similar moral crises.
LIFELONG LEARNING, SELF-ASSESSMENT, AND QUALITY OF CARE
Although these current buzz words have arisen acutely because of the rapidity of the introduction of laparoscopic surgery and the reports about medical errors,2 they will continue to plague the conscience of all surgeons. Finding the time to learn new techniques and train to a level of proficiency before offering the new procedure to the patient was rarely discussed before laparoscopic surgery came about. Because the introduction of new technology was slow, the standards of practice changed gradually; the ‘apprenticeship model’ of training conceded that the blessing of the mentor (or Department Chair) guaranteed competence and the surgeon was the person deciding upon the introduction of the new technique. With laparoscopic surgery, that all changed. Suddenly, patients were demanding new procedures, and the surgeon was faced with either providing the procedure (whether trained on not) or losing the patient. The majority of surgeons were experienced and well established in their surgical practice, with little opportunity to learn laparoscopy, so weekend courses and short proctoring were the only choices, leaving patients to suffer the brunt of the learning curve. Surgeons had no objective measures to determine whether they were ready to perform the procedure and no outcomes (other than the gross outcomes of morbidity or mortality) to determine their proficiency. Surgical simulation, both curricula and simulators, as well as objective assessment methodology for competency had not appeared. Physicians who embrace emerging technologies will face these same challenges, and modest progress has already been made. Yet in robotic or telesurgery, no standards or guidelines exist, no courses have been conducted at national meetings (as have been with laparoscopic surgery), and no determination has been made as to long term outcomes for both safety and efficacy. This is quite surprising because the first robotic cholecystectomy was performed over 12 years ago.3 And the first telesurgery was performed more than 9 years ago.4 However, the experience from laparoscopic surgery should suffice for some of these issues, and lessons learned from robotic, computer-assisted, and other information-dependent surgical techniques may transfer well to other similar new technologies.
Now that simulation has become a required part of surgical skills training, and quality assurance procedures have been validated and routinely instituted, a number of interesting issues have arisen. With the institution of check lists, does there need to be repercussions if the check list is not performed? Even there is no harm to the patient? Since pre-op warm-up on a simulator has been validated to improve performance, will it become mandatory to warm up before an operation? And if not, will the surgeon either be prevented from operating until (s)he goes back to warm up, or will they be penalized at a later time? If team training has not been completed, will the surgeon be prevented from operating?
ORGAN REPLACEMENT AND REGENERATION
Currently, transplantation is a common, though difficult surgical technique, regardless of the organ. Artificial prostheses are likewise quite complicated. However, neither of these technologies poses great ethical issues except for the availability of organs. The latest dilemma has been that of living donors, such as in nephrectomy or partial liver donation. This has been made even more of an issue because laparoscopic nephrectomy minimizes the discomfort to the donor to a much more acceptable level. Although the agonizing decision about who is to receive a donated organ persists during the shortage of donor organs, the issue of illicit payment for organ donation also must be addressed.
Recent significant success has been achieved in growing artificial organs from stem cells. It is likely that such technology will come to clinical application within the decade. Because the organs are derived from the patient’s own cells, it is likely that rejection will be a minimal problem or no problem at all. What about all the transplant surgeons who deal daily with the ravages of organ rejection–with rejection no longer posing a problem, will every surgeon become a transplant surgeon? In surgical practice today, numerous operations are available for every organ system (at least 32 different procedures can be performed on the stomach alone), depending upon the disease. In the future, a surgeon may have only 1 operation for any organ system—remove the old, diseased organ and replace it with a new, healthy, patient-specific organ. With a surgeon’s repertoire returning to 1 operation per organ system, will a resurgence of the general surgeon occur? Will surgeons become more inclined to operate more frequently and perhaps sooner, knowing that they will replace a damaged organ or tissue with a new healthy one?
Other more seminal research in the area of tissue regeneration will raise issues further in the future. It may become possible to regenerate a lost part or whole organ, with surgeons being responsible for implanting stem cells or operating on a cellular basis to change genetic material to induce regeneration. If this were the case, would surgeons be tempted to regenerate more than is required or to generate tissue with properties beyond normal human potential? Just as plastic surgeons provide cosmetic surgery to enhance self-image, confidence, and other factors for social and behavioral remediation or advantages, will future surgeons enhance musculoskeletal, intellectual, or other functions to a select few who can afford to possess physical, intellectual, or other capabilities beyond limitations imposed by nature and create a significant advantage in all areas?
In a similar manner, prostheses are becoming “intelligent,” embedded with sensors and feedback control. As with the generation of new tissue, will such devices impart substantial advantages to those who can afford to possess them? Other prostheses are being implemented, such as brain implants,5 resulting in direct control of devices (eg, limbs, robots, and others) by thought alone. This will be a boon for the severely handicapped; however, it also raises the specter of direct communication, downloading to the Internet, and other such scenarios. Patients may be asking for any number of implants to give them advantages over others. A surgeon will be tasked with legitimately providing substitutes for lost function or providing significant advantage to a very limited number of persons. Will it be ethical to enhance a person beyond his or her own natural capabilities? Who will decide whether a person can have a new prosthetic device, especially if the person is otherwise healthy? Will the technology be so expensive that only the affluent can afford these advantages, giving rise to a new caste system?
GENETICALLY ENGINEERING OUR CHILDREN
Impressive success has been achieved in discovering the genetic defect that causes certain hereditary diseases, such as von Wildebrandt disease, and genetically engineering cures. In his book, Redesigning Humans–Our Inevitable Genetic Future, Gregory Stock6 makes a convincing argument that the technology exists today in the Human Genome Project to begin modifying the genetic code to create the properties we would choose for our children, from repairing genetic defects to improving physical or mental capabilities. Although it clearly is morally and ethically acceptable to repair a genetic defect of a child (or fetus) to return normalcy, is it ethical to willfully change the genetic structure in the hopes of providing capabilities beyond “normal” human performance, such as being able to “hear” ultrasound the way bats can or see in the infrared regions as certain nocturnal mammals can? What ethical issues are involved should the modification go wrong? As indicated above, will genetic engineering give rise to a small number of people with exceptional advantages over all others? Will researchers be tempted to engineer for seemingly trivial reasons?
The human brain computes at approximately 4 x 1019 computations per seconds (cps).7 The fastest supercomputer, ASIC Red at Sandia National Labs, computes at 35 teraflops/sec (3.5 x 1016 cps)–or just 1000 times slower than the human brain. With computer power continuing to double every 18 months (referred to as “Moore’s Law”), it is expected that computers will be as fast as the human brain in less than 20 years. In addition, Professor Noel Sharkey of Sheffield University in London8 has been designing small, simple robots and has been programming them with “rules” instead of traditional programming language. After 6 months, one of the robots “escaped” from the laboratory and was finally caught as it was leaving the parking lot. Although the robot had never “seen” stairways, an open door, or hallways, did this robot exhibit “intelligence”? As computers become more powerful and programming begins adding intelligence, will the machines become more intelligent than humans? Will humans increase their own intelligence by incorporating a ‘computer’ with their brain? Will humans be able to recognize a different intelligence, and will we communicate with these new entities? Or perhaps we will become so dependent upon the machines that we cannot turn them off. Will the machines remember we created them, or will they even care? If they are intelligent, should they be given certain “rights,” or will it be ethical to unplug (“kill”) an intelligent system?
A number of approaches to prolonging life are available. Some of them deal with the mechanisms of apoptosis. Another approach is to block the enzyme telomerase, which is believed to cause aging by shortening the telomere region of a chromosome during cell division. Although the average age of an individual in a modern society is now exceeding 75 years, to date no human has lived beyond 120 years old. However, a strain of mice has been genetically engineered by blocking the telomerase enzyme to live the equivalent of 5 lifespans.9 If this technology is applied to humans, even if it only doubles lifespan, what are the consequences of the average person living 150 to 200 years? Should we continue to attempt to prolong life, when so many people are starving? Who will be able to afford the benefits of a prolonged life? Will everyone have multiple careers? And what justification exists to extend a human life span beyond the “natural” limit?
WHAT DOES IT MEAN TO BE HUMAN?
Many of the above technologies will be implemented in the next 2-3 decades, including multiples of these in the same person. If patients get more and more replacement parts in the form of tissue engineering, regeneration, or intelligent prostheses, will they continue to be “human”? What if a person is more than 95% synthetic parts, and no longer possesses the biologic body he or she was born with? Is that person still “human”? With artificial brain chips, will a person be able to directly connect to the Internet or download information? (The argument that no rational person would willingly add mechanical or electronic parts to his or her body can easily be countered simply by observing our teenage children with their fascination with body piercing and other practices.) Will a person ‘live’ forever if they download their memories, etc. into a computer? The fundamental question is, as asked by Francis Fukyama in his book The Post-human Future,10 are we moving to a new “species” of humans beyond homo sapiens, perhaps a combination of human and synthetic parts or a man-machine?
These are but a few of the ethical dilemmas likely to emerge in the next 2-3 decades–that is, during the career of the students and residents we are training today. Although some of the challenges mentioned are not strictly surgical, all physicians have a moral obligation as stewards of our patients’ rights to accept the responsibility of addressing any technology that will impact so profoundly upon the health, welfare, and future of our patients. What was previously considered pure fantasy and science fiction is rapidly becoming scientific fact. In 1957, commercial airlines were using propellers and few people had ever heard about rockets. Yet, later that same year, the first satellite Sputnik was launched; 2 years later (1959), Yuri Gagarin was the first human orbiting around the earth; and within a decade, a human was walking on the moon! With the exponential growth of technology, many of the above possibilities will come true, with the corresponding moral and ethical challenges. Five years ago, the announcement of Dolly the cloned sheep shook the scientific world; a call was made for a ban on human cloning. Yet today, a number of human clones exist, and none of the ethical issues has been resolved. History has again proven that science will not wait, and therefore the question becomes whether today’s students will be prepared to solve the consequences of “unthinkable” science. Human cloning is just the beginning–a warning shot across the bow–and all the scientific, medical, and social communities have responded in a crisis mode, but we are no closer to a solution on human cloning. The consequences of the above types of revolutionary technologies will take decades to solve, in the quiet and deliberate light of reasoned debate, not in the crisis mode that has been the response to human cloning. It is essential that we begin now to identify the likely disruptive technologies and to address the issues to have a rational and measured response to their introduction. More importantly, we must begin introducing courses on biomedical ethics to students, to engage with professional biomedical ethical societies, and to present sessions on the ethical challenges to the specialties during the annual meetings and conferences. The need is urgent, because, for the first time in history, a species exists on this planet–homo sapiens–that is capable of determining its own evolution at its own pace, without waiting for thousands of years for serendipitous changes by nature.
1. Satava RM. Laparoscopic surgery, robots, and surgical simulation: Moral and ethical issues. Seminar Laparosc Surg. 2002;9(4):230-238.
2. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999:12.
3. Himpens J, Leman G, Cardiere GB. Telesurgical laparoscopic cholecystectomy. Surg Endosc. 1998;12:1091.
4. Marescaux J, Leroy J, Gagner M, Rubino F, Mutter D, Vix M, Butner SE, Smith MK. Transatlantic robot-assisted telesurgery. Nature. 2001;413:379-380.
5. Serruya MD, Hatsopolous NG, Paninski L, Fellows MR, Donoghue JP. Brain-machine interface: Instant neural control of a movement signal. Nature. 2002;416:141-142.
6. Stock G. Redesigning Humans: Our Inevitable Genetic Future. New York, NY: Houghton Mifflin Company; 2002.
7. Kurzweil R. The Age of Spiritual Machines. New York, NY: Penguin Group (USA); 2000.
8. Higgens D. Robot on the run. The Age. 2002. Available at: http://www.theage.com/au/articles/2002/06/20/1023864460978.html.
9. Cohen-Tannoudji M, Babinet C. Beyond ‘knock-out’ mice: new perspectives for the programmed modification of the mammalian genome. Mol Hum Reprod. 1998;4(10):929-938.
10. Fukyama F. Our Post-human Future: Consequence of the Biotechnology Revolution. New York, NY: Farrar, Straus, and Giroux; 2002.
The opinions or assertions contained herein are the private views of the authors and are not to be construed as official, or as reflecting the views of the Department of the Army, Department of the Navy, the Advanced Research Projects Agency, or the Department of Defense.