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Satava
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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.
A Yale Medicine interview
Illustrations by Bob Fortier
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
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