Can you trust a robot surgeon?

Surgical robots have been around for a while, but how autonomous are they, what can they do, and should we trust them? Graihagh Jackson spoke to Hutan Ashrafian - surgeon and lecturer at Imperial College London...

Hutan - Robots have been around in surgery and in health care for over 30 years. But they’ve had a particular rise in fame over the past ten years because they offer so many good things that we like in surgery such as increased precision, better outcomes, smaller incisions, shorter hospital stays, and quicker recoveries. They are used in nearly every organ system that we have today and, typically, they’re used to take away cancers, or reconstruct parts of the body by connecting two blood vessels together. They’re very fabulous and, as you said, they can be used for injections in the eye because they’re very precise. But they also have this capability of acting as platforms for all sorts of new novel technology such as being able operate from inside the body rather than outside the body. Or using some of the new devices that we have at Imperial College such as the eye knife, which is an electrical scalpel whose smoke can detect cancer.

Graihagh - That’s absolutely incredible and I want to ask you more about that. But what you’re talking about here, the eye knife, that’s all still very much in the domain of human control - you control it when you're doing surgery. What about the autonomy, the robot doing and thinking for itself?

Hutan - At the moment, safety tends to be the strongest paradigm in modern surgery and all the robots we tend to use are using the master/slave system. That means the surgeon is the master and the robot is the slave so that it’s essentially an extension of the human mind to make decisions. The human mind makes the decisions and the robot performs the action and in that sense the robots are not at all autonomous. There are robots that help guide people and you can have augmented reality where you can overlay images in your robotic field, but currently no robots are autonomous.

Graihagh - What needs to happen next for say a robot to take out your appendix?

Hutan - We need to know, with good evidence, that an autonomous robot would be safe. If this an autonomous robot with a human level of consciousness, can it make decisions and can those decisions be trusted? At the moment we don’t have that evidence, and we don’t have that technology so we can’t go down that road. But there is potential, as strong AI tends to become stronger literally every day, we might be able to use robots that have a level of autonomy in our day to day operations.

Graihagh - Is that just a case of coding algorithms? I know we’ve got more than three laws that enable robots means they can’t hurt you or me.

Hutan - There’s up to six classical laws that were started off by Isaac Asimov, but people have modified them - I did one of them myself. But the issue is that although there are these laws, we need to make sure that if a robot has autonomy and has a human level of consciousness, then it will act in the human best interest. Potentially that may happen one day, although it’s not currently there yet.

Graihagh - Why would we want something like this? You’ve spent years training to do the work you do, why would a robot be better than you?

Hutan - The robot might have increased precision, might have better access to parts of the body. But the reality is the robot can be manufactured and automated and there are up to 5 billion people worldwide that don’t have access to quality surgical care or anesthesia. This could fulfill and complete that void to ensure that everyone worldwide could have surgical care at a very high level. There is a downside, and the downside might be that if we do have robots that have a level of autonomy and decision making that is independent, how can we trust them? Can we necessarily trust them? And will patients trust them to operate on them because this is a new device? Whereas before you’d have the doctor/patient relationship - now you have the doctor/patient/robot relationship.

Graihagh - Would you trust a robot to take out your appendix?

Hutan - If the evidence was available and it was successful then yes, I would be happy for it, although I would say 20/30 years.

Graihagh - It’s still a long way off then?

Hutan - Yeah. I would say a long way off.

Graihagh - So presumably there are some risk associated with this?

Hutan - Once clear risk is diseases are unpredictable by their very nature. So although we can have robots that have been programmed in a particular way to look for particular diseases in a particular context, sometimes diseases don’t present themselves in a standard fashion. The way we’ve been trained is to think out of the box and to be able to assess patients from multiple angles and multiple facets of their health care. A robot, at the moment, doesn’t have that ability and therefore might miss something.

Chris - One of the things that surgeons say to me is that it’s the feel which really matters and actually getting your hands dirty (metaphorically) is 90% of the experience. Now if you’re operating a robot you don’t get that same visceral (excuse the pun) interaction with the tissue. Do you think that this is a good substitute?

Hutan - The feel effect that people talk about is very important for a trainee surgeon, particularly in open surgery, but the evidence suggests that for some operations in some parts of the body, although you don’t get that tactility, in some settings it doesn’t seem to have caused any difference in outcomes. Whereas in other operations in other settings it does seem to be a critical factor. So it really depends on the organ system that is being talked about, but for a trainee surgeon clearly that’s an important step. It might be one for a robotic surgeon on their learning curve and most of the current robotic platforms in use today tend to have a 3D visualisation scheme to try and offer the surgeon a depth-of-vision that can offer them something that would reflect what they see in real life in an open surgery so that they can have better outcomes.