A futurist’s view
With smart dust, surgical robots, transgenic replacement organs and a 150-year life span now conceivable, Richard Satava says now is the time to face the ethical challenges that technology will bring to medicine.
Every few months Richard M. Satava, M.D., visits colleagues at a lab at MIT where there's a coffee cup with his name on it. The cup also has embedded in it something called "smart dust," an electronic medium so small that it is barely noticeable as it receives and transmits information. When Satava places his cup in a coffee machine at the lab, the cup's smart dust tells the machine's smart dust how he likes his coffee, right down to the cream and sugar.
For Satava, a faculty member in the Department of Surgery from 1998 until last July, when he moved to the University of Washington, this smart dust has implications and applications far beyond the frivolity of getting his coffee right. [Satava came to Yale from DARPA, the Defense Advanced Research Projects Agency, which was established in 1958 in response to the Soviet Union's launching of Sputnik.] It is one of many technologies that offer the promise of longer, healthier lives. These technologies sit on the cusp of biology, engineering, nanotechnology and other sciences. They will revolutionize, he believes, not only medicine but also society. Some of these technologies are already in use; others soon will be. Society's task is not only to understand how to harness them but also to address how they will change what it means to be human.
Associate Editor John Curtis met with Satava before his departure last summer for Seattle to discuss the "biointelligence age" and its implications.
You have described modern society as having entered "the biointelligence age." What does this mean?
The biointelligence age is marked by the intersection of technologies to do things you can't do with a single technology. It has become obvious that one of the most important things about the future of science and research is that the major disruptive technologies that are going forward are going to be coming from interdisciplinary research.
What are disruptive technologies?
Mobile communication is an example. We've gone from a telephone to a cell phone, and we've gone from dumb stuff to smart stuff. It may be in the not-too-distant future that there won't be any phones in any homes. Why do you need a phone at home if you've got one on your watch everywhere you go?
And so what used to be only a scientific research tool, as you saw with the Internet, became something that intruded in virtually every person's life. That's a disruptive change. Those technologies that are disruptive are no longer coming out of information or engineering alone, but from the intersection of two technologies. And you have enormous potential: disruptive technologies will displace other previously successful technologies. So that's the origin of the biointelligence age.
We had the agricultural age, the industrial age and the information age. If we look at our technologies, what we're seeing is that they're getting smaller and smaller in scale. And they're becoming smarter and smarter. So things like microsensors are going to be virtually everywhere. They're like a smart bar code. They interact, you can program them and they can tell you about themselves without having to be scanned.
Where would these microsensors be?
Virtually everywhere. This was coming out of Xerox Park Research Lab and the University of California, Berkeley, under the program Smart Dust. These particles are so tiny—they're the size of the head of a pin or smaller—but they're entire intelligence systems that have sensors on them that can sense the environment and store information. You can't see them without a microscope; that's why they're called dust.
They communicate with each other. So the environment is going to be smart instead of dumb. They're going to be in the food you eat, the clothes you wear, embedded in your body, absolutely everywhere. For example, when you came into this room, this desk would know it was you and rearrange itself for you.
Have you been able to buy anything lately that doesn't have a bar code on it? Probably not. But it's dumb. In the future, it will be smart. You plant the field and you spray it with the fertilizers and insecticides and smart dust—maybe a thousand different sensors per millimeter—and as the food comes up the smart dust gets incorporated into the plants. And the plants talk to the harvester: "Pick me. I'm ready. Don't pick me. I'm not ready." It goes into the store. You've got a little handheld and you talk to the artichokes. "How ripe are you? How much do you weigh?" A world that used to be dumb and unconnected now gets connected, and that information gets shared.
How is this going to be applied to medicine?
We will have sensors throughout our bodies. So, as doctors, we'll be able to continuously monitor the health of individuals.
At DARPA we came up with something that got called the millennium toilet. The only place that we could monitor somebody and give a physical examination every single day would be in the bathroom. Everybody has to do their morning hygiene. What today is a dumb bathroom would become a smart one. When you brush your teeth, your toothbrush takes your blood pressure and looks for cavities. When you look in the mirror there is a little camera that looks at your eyes to check your diabetes or hardening of the arteries or any of the thousands of diseases that we can pick up by looking at your eyes. When you go to the toilet, it would check what's in there. If, for example, Grandma was supposed to be taking her digitalis and she's got Alzheimer's disease and can't remember, the toilet would know. Because there is supposed to be a certain level of the byproduct, and if it's not there that means she didn't take her medicine. So she can be reminded. So we would postulate that in the future we would be able to make the room a smart room and it would actually be kind of an aid for you.
How do you envision technology affecting surgery?
Eventually the majority of surgery will be done by computers, but we're talking a minimum of 50 to 100 years from now. You can do a total body scan of the patient; this is called the holographic medical electronic representation, or HOMER. You can plan the operation on the HOMER. You'll have the opportunity to do it on the computer two or three different times and edit them together and get the perfect operation. And when you have got the perfect operation, the robot will do it faster, quicker, more efficiently and more precisely than you could. It's possible that you could just send the operation file somewhere, to India, and let the robot in India do it. You don't have to be there once you've programmed it exactly to the patient's specifications.
The robots, I think, have turned out to be the key, one of the major innovating components of the future of surgery. The important issue here is that the robot is not a machine. The robot is an information system. It sends bits and bytes back and forth and works in the information world. Most of the people I have talked to are thinking of them as nothing more than extensions of your arm. And that unfortunately is a very narrow vision of what they are.
You can give the surgeon X-ray vision because you can overlay where the blood vessels are inside of the organ. When you look at the liver, you can see all the bile ducts and all the arteries and the veins, which aren't visible to the naked eye. And then you can use that same data afterwards, when they finish the operation. And so we will know exactly what you have done with your surgery and how good your outcomes are. In addition to that, taking the analogy of the aviation industry, the robot is also a recorder. Every time I make a motion, it sends a signal to the arm to move in a specific way. All you do is tap into that and send it to the black box behind the surgeon. It's just like the black box behind the pilot when he flies the airplane. So we will have continuous recording and we'll be able to use that system to monitor how good the surgeon actually is. And this will help surgeons to improve the quality of their surgery.
A few years ago you were testing "smart shirts" on climbers on Mt. Everest. These shirts could monitor vital signs and transmit them to base camp. Where does that technology stand now?
About 18 months ago a company was set up for this, and this spring they're supposed to come out with the first commercial version that anybody can buy. And by that I mean you or your doctor can go to the store and order one of these shirts and you put it on, and it will begin taking your vital signs.
How much will they cost?
The probable production cost is somewhere between $50 and $75, so you should be able to buy the shirt for $100 or $200. Not very expensive. And it's washable, you can use it for a long period of time and then you connect it to a little transmitter that sends the information on for analysis.
Who would want to wear one of these?
Oh, there are many, many people, whether they be the people who have a chronic disease like asthma, congestive heart failure or heart arrhythmia. There is a whole host of people that you can monitor various vital signs on. I think it would be super to put them on every high school or college athlete and be able to see how well they're performing. Every year we lose half a dozen young strong kids playing sports because they had some kind of unknown abnormality. And these can pick them up. There is a whole slew of different diseases that we know about that if we would screen for them we could prevent these deaths.
Any technology has potential for misuse as well. Can you protect the confidentiality of the massive amounts of medical information that would be gathered and stored electronically?
I always tell this little story and it has to do with the security of the medical record. When I was in the military in California, we were able to arrange it so that the people would come to their family practitioners in the morning. If they had something wrong and needed a surgeon, we'd see them that same afternoon. And so what would happen is they would have seen the doctor in the morning and then gone shopping or gotten lunch or something, and they'd come back and see us. And every Saturday from the grocery, from the commissary over at the PX, from the department store, they would come with shopping carts full of medical records that people had left sitting on the checkout counter. Now I ask you, is electronic security better than people bringing back shopping baskets full of these medical records? It's not an issue really of whether or not it's secure. It's clearly, in my view, much more secure than anything we have today. But it's not perfect, and yet 95 percent of security breaches are from people on the inside misusing legitimate access to the information. The hackers that you read about in the newspaper account for less than 5 percent of all the losses of security of information. It's not a technical issue. Security is absolutely a regulatory issue or a human behavioral issue.
What ethical issues do these new technologies pose?
The ethical issues that the new technologies are raising are far beyond anything that most people are addressing at this time. Security of medical records pales in comparison to the implications of the new technologies that are coming. Human cloning is one of them. There will be a human clone in 12 months. End of story. There is no question about that. And the reason is that there are two very reputable, very talented scientific groups offshore that have decided for reasons of their own that it is ethical to clone a human being. One of the groups has 200 families that have tried every single known method of creating their own child and have not been able to. Should we deny these families the opportunity to have children if we have the technology to give it to them? I don't know. On the other hand we don't want a version of Brave New World, where the gammas do all the physical work and the betas do all the clerical work and the alphas do all the management.
And that's brought to the forefront that there are many technologies that are accelerating so rapidly and we have not even looked at the potential behind them. When they come on the scene, we're going to be completely unprepared.
We need to look at a number of the issues in advanced technologies, no matter how hypothetical. There is research on apoptosis and telomerase, which we believe are the keys to longevity. There is no known human that has ever lived more than 120 years that's been documented scientifically.
Now you can control when a cell lives or dies, and you can make them live longer. They have allowed some rats to live the equivalent of three to five life spans. That is similar to living 360 years instead of a maximum possible 120. What happens if we just double a human's average life span so everybody now lives 150 years? What is the implication of that? Am I going to have one career for 130 years or 150 years? When do I retire? Do I ever? How do we feed all the additional people? We are on the threshold right now. Who is looking at the implications of longevity?
A number of researchers are looking at salamanders and flat worms and beginning to find genes for regeneration. In these animals, if you cut off a leg they will grow a new one. Scientists at MIT and Massachusetts General Hospital have been growing synthetic organs made with stem cells and a vascular substrate. We now have a world with synthetic organs. What does that mean? It means a lot of things. Transplant is not going to be a problem. More important for me as a surgeon, right now I know about 20 different operations I do for different stomach problems. If you have an ulcer I do this procedure, if you have a cancer I do another procedure, if you're bleeding I do still a different procedure. In the future, if you have something wrong with your stomach, regardless of what the problem is, the stomach will be removed and replaced with one grown with your own stem cells. And, since I will do the same operation over and over, instead of many different ones, it will be possible for me to perfect the technique to provide you with a much better outcome.
Why should I repair an organ? The only reason for repairing now is that we cannot replace entire organs on everyone every time. What we will have in the not-too-distant future, approximately 10 to 20 years from now, is patients will have all these replaceable parts.
This prompts a very fundamental ethical question: what does it mean to be human? If I am all pieces of metal and artificial organs, am I still human?
This is just one of the many enormous ethical problems that technology is going to put on our plate. And the challenge is, are we courageous enough at this time to face them, or are we just going to scorn them out of ignorance? People say, "Well, that just cannot happen—that's just Star Trek." And then Dolly appears on the scene and we're unprepared for the question of human cloning. So I think we have had a warning, and it's time to look at these technologies and say, "Yes, they sound futuristic, but since we can't predict the future, it is incumbent upon us to look at them and be more prepared than we have been in the past." YM