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Robotic Surgery Training in Residency: Good or Bad?

“First Law: A robot may not injure a human being or, through omission, allow a human being to come to harm; Second Law: A robot must obey the orders given by human beings except where such orders would conflict with the First Law; Third Law: A robot must protect its existence as long as such protection does not conflict with the First and/or Second Law.” –Isaac Asimov, Eu, Robô

The rapid introduction of revolutionary technologies like minimally invasive robotic-assisted surgeries will exponentially increase complexity in medicine, law, education and ethics. Ethics studies human conduct, moral assessments, the concepts of good and bad, right and wrong, justice and injustice. Roboethics deals with the code of conduct that robotic engineers must implement in the artificial intelligence of a robot. Through this kind of ethics, roboticists must guarantee that autonomous systems will exhibit ethically acceptable behavior in situations in which robots interact with patients.

The first law of roboethics will accord with the ethical principle of non-maleficence, which requires that physicians’ actions do not intentionally cause harm. There are two main concerns for the training of residents when it comes to non-maleficence. One is whether training in robotic surgery does harm to the patients. The second is whether a lack of training in robotic surgery allows a patient to come to harm through omission. Omitting robotic training from graduate medical education will be ethically acceptable if we consider a robot as simply another surgical tool, or if we consider it as neither better nor worse than the tools of traditional surgical procedures. However, if robotic surgery allows more patients to have complex minimally invasive surgeries with improved post-surgical outcomes, then the omission of such training would be unethical to the population of patients that the trainee would serve in the future. Additionally, lack of formal training could lead to legal issues such as malpractice. The science fiction writer Isaac Asimov noted that increasing dependency on surgical robots would lead to a reduction in surgeons’ knowledge and motor skills. Consequently, this would violate the principle of ‘first, do no harm,’ since patients would be treated by inadequate surgeons. Also, working with surgical robots could have a negative impact on residents’ surgical skills. Their manual skills will be replaced by a new set of skills related to the control of robot-using procedures.

The second law considers that robots should be designed using processes that assure their safety and security. Nowadays, surgical tools have become increasingly more complex and prone to malfunction. This is certainly the case with complex robotic surgery systems. All robotic systems are directly manned by qualified technicians, so why is there any reason for concern? Communication among the patient operating arms, camera, and surgeon console is critical for the success of the operation, as well as patient safety. Failure of this loop at any of these critical points could cause harm to the patient. The responsibility for preventing such harm resides with the surgeon who controls the robot. Therefore, the surgeon must report malfunctioning robotic systems to the relevant authority figures. Failure to do so is a lapse of the surgeon’s ethical duty. It is the surgeon’s responsibility to ensure safety and non-maleficence during the implementation of a robotic practice by participating in sufficient training and maintaining a low threshold for conversion to an open surgical approach. If the robot did not obey the command due to a program error or a technical failure during training that caused patient harm, the question is, should the resident take full responsibility for such an event?

The third law says that the promotion of robots leads to conflicts of interest. Robotic surgery has become a big business for manufacturers and hospitals during the COVID-19 pandemic. Many countries have invested millions of dollars to establish and advertise robotic systems during the past two years. It has been suggested that such robotic investments may pressure trainee surgeons to downplay issues with accuracy or other problems associated with medical robots. By shifting the resident teaching time from conventional surgeries to robotic surgeries, there will be a huge financial burden on patients, but we cannot assure the cost can be justified by better outcomes.

The only robotic-assisted surgeries approved today are those that can directly be controlled by surgeons. However, there is no standardized practice. Currently, there are no widely accepted training programs or requirements for certifications that need to be completed before a surgeon can perform robotic-assisted surgery. Only time, experience, and health informatics will tell you the future direction of robotics. However, the ethical and educational principles behind successful surgical training will endure the robotic technology of today as well as the next surgical trend. The primary ethical obligation of the physician is to the patient alone; as always, the utmost consideration must be the safety of the patient, rather than the type of tools utilized for the surgery.

Image credit: Public domain.

Diluksha Prasad, MBBS Diluksha Prasad, MBBS (1 Posts)

Resident Physician Contributing Author

General Sir John Kotelawala Defence University Hospital

Hettiarachchige Diluksha Prasad Jayawardana, MBBS is a physician in orthopedic surgery at General Sir John Kotelawala Defence University Hospital, Sri Lanka.