The field of surgery has clearly experienced a revolution in recent decades thanks to the advent of robotic surgery. Surgical procedures involving a robot surgeon are characterised as enabling greater precision, flexibility and control when compared to traditional methods.
Nowadays, robot surgeons are actively used across a range of surgical procedures. This includes applications in cardiac surgery, such as mitral valve repair and tumor removal; gastrointestinal surgery for colectomies and gastric bypass operations; gynecologic surgery involving hysterectomies and endometriosis resection; and urologic surgery for cystectomies and radical prostatectomies, among others.
Overall, robot surgeons offer benefits such as lower risks of infection and scarring, reduced blood loss and faster patient recovery, while also enhancing precision and speed with smaller incisions. Furthermore, they contribute to minimising case-to-case variations and lower the risk of tremors or other unintended movements. Currently, there are projects in place, such as FAROS, whose primary goal is to improve functional precision by integrating physical intelligence, the most fundamental form of intelligence, which is inherent in our brain and body’s network of mental, emotional and physical patterns, into surgical robotic systems. This project aims to achieve surgeon-like autonomous behaviour by: (i) using non-visual sensors to capture diverse aspects of the surgical task; (ii) developing functional models connecting unconventional sensor signals to functional parameters; (iii) implementing functional controllers through reinforcement learning to embody physical intelligence; and (iv) enabling autonomous robot actions that optimise functional performance and address knowledge gaps.
The existing robot surgeons currently in use serve as an extension of the human surgeon’s hand, operating under their control and not fully autonomously. For example, the da Vinci system allows surgeons to perform precise procedures, with their hand movements at the console being directly translated into actions by the instruments, mimicking the dexterity of the human hand.
Studies show that the popularity of robotic surgery is on the rise across various fields, experiencing an annual growth of approximately 15%, with global volume having reached USD 1.24 million in 2020.
Although recent trends reveal the increasing rise of robot surgeons, it is crucial to examine the numerous ethical challenges associated with robotic surgery, from both a roboethics and a biomedical ethics perspective. Ethics can be considered as the “science of conduct”, as it includes the fundamental ground rules by which society functions as a whole. Given the capabilities of surgical robots, it is paramount to address the related ethical considerations and potential societal impacts.
When considering robots capable of performing surgeries, it is important to reflect on the concerns raised from a roboethics perspective. Roboethics, also known as machine ethics, constitutes an innovative interdisciplinary research field that merges applied ethics principles with robotics. More specifically, it examines and seeks to govern the ethical implications and impacts of robotic technology, particularly of intelligent and autonomous robots in our society. As per these definitions, roboethics is not merely about the ethics of robots; rather, it also encompasses the human ethics of those involved in designing, manufacturing and using robots.
Firstly, there are implications regarding liability and responsibility. In the event of an error or malfunction during a robotic surgery operation, accountability is often unclear given the involvement of multiple stakeholders in the development and utilisation of the robotic system.
In addition, the safety and effectiveness of robotic surgery give rise to concerns. Stakeholders bear moral and ethical responsibilities to ensure the technology’s safety, efficiency and the implementation of effective measures to mitigate the risk of harm to patients.
Furthermore, the use of robot surgeons introduces privacy and confidentiality risks. Since these systems collect and store sensitive patient information, stakeholders have an ethical duty to protect patients and uphold their privacy rights.
Considering the impact from the perspective of human dignity is also essential. There are ethical obligations to uphold a person’s dignity and ensure that the use of robot surgeons is humane and compassionate. Moreover, it is important to consider the challenges raised within the biomedical ethics field, taking into account its foundational principles, specifically those of autonomy, non-maleficence, beneficence and justice.
In addition, the AI Act encompasses several important principles, such as, (i) human agency and oversight, (ii) technical robustness and safety, (iii) privacy and governance, (iv) transparency, (v) diversity, non-discrimination and fairness, (vi) social and environmental well-being and finally, (vii) accountability.
The principle of respect for autonomy encompasses both positive and negative aspects. The positive aspect refers to the duty to provide respectful treatment by disclosing information and taking actions that promote autonomous decision-making. The negative aspect involves the obligation to refrain from imposing controlling constraints on the autonomous actions of others. In order to facilitate informed choices, it is crucial to provide patients with all necessary information. When a robot surgeon is used in an operation, the human surgeon should address any misunderstandings or apprehensions the patient may have in relation to the robot’s capabilities or the surgeon’s own proficiency in using the robot surgeon. Consequently, building a transparent and open doctor-patient relationship is crucial for patients to autonomously make decisions and provide informed consent for the procedure.
The principle of non-maleficence requires abstaining from causing harm to others. In medical ethics, this principle is frequentlysynonymous with the well-known saying “Primum non nocere” or “Above all (or first) do no harm”, which means that doctors should avoid causing harm to their patients. In the context of surgical procedures, it is crucial to evaluate and communicate potential risks to patients. However, the increasing autonomy of robots in surgeries poses a dilemma, as it remains uncertain who is responsible for fulfilling these obligations and determining fault if they are not met.
In relation to the principle of beneficence, it extends beyond respecting individual autonomy and preventing harm, encompassing proactive measures to improve well-being. These actions surpass the principle of non-maleficence, as they involve not only abstaining from harmful acts but also engaging in positive actions to assist others. All medical and healthcare professions, as well as their institutional settings, inherently operate with an underlying commitment to beneficence: prioritising the well-being of patients, rather than just avoiding injury. When considering the specific case of robotic surgery, surgeons should, therefore, prioritise the well-being of patients and assess whether undergoing such a procedure would be in their best interest. Lastly, the principle of justice involves the fair and impartial distribution of healthcare resources. From an ethical standpoint, the use of robot surgeons raises concerns about potential disparities in resource allocation. The anticipated high cost of new technologies, especially robotic treatments, may not be fully or partially covered by public insurance in various healthcare systems. Consequently, many patients may find themselves unable to afford these treatments, thus being deprived of the associated benefits. Moreover, the scarcity of this technology in most hospitals, particularly in the public sector, further exacerbates this issue. The substantial expenses involved in purchasing and maintaining a robot surgeon contributes to the limited accessibility of robotic surgery, even for those who might have the financial means to afford it.
There are also ethical concerns linked to the informed consent process, which should be more understandable than that used for conventional surgery. Informed consent refers to the process of providing patients with essential information to enable them to autonomously make informed decisions about treatments and interventions. Three crucial aspects should be observed in obtaining appropriate informed consent: the patient’s decision-making capability, adequate information provision and absence of coercion. Moreover, it is imperative that patients are provided with thorough details regarding the risks of treatment and contingency plans in case of failure. Additionally, patients should understand the pros and cons of employing robotic surgery, the surgeon’s expertise, technique and familiarity with the technology, and also the reliability of the equipment.
Moreover, these ethical considerations are significantly influenced by the doctor-patient relationship. In this scenario, the patient-doctor dynamic deviates from the traditional model, as the surgeon’s role is only partial, potentially introducing trust-related challenges. Unlike human surgeons, robots operate within predetermined protocols and lack the capability of clinical judgment, potentially resulting in a deficit of empathy and emotional connection between the patient and the medical professional. Nevertheless, it remains the surgeon’s responsibility to engage in discussion about treatment options and define how a robot will be used. In conclusion, it is crucial that robot surgeons are employed in an ethically responsible way with the ultimate objective of better protecting people. Additionally, it is essential that ethical concerns are considered during the development of robot surgeons. Moreover, the legal significance of ethical considerations related to robotic surgery holds considerable weight, given the potential impact on patients’ rights. Finally, incorporating ethical considerations can be instrumental in guaranteeing the responsible, safe and legally compliant use of robot surgeons.