Science, Ethics … and the Future ?

UNIVERSITY OF WASHINGTON SCHOOL OF MEDICINE

Richard M. Satava, MD FACS

Professor of Surgery

University of Washington School of Medicine and Program Manager, Advanced Biomedical Technologies Defense Advanced Research Projects Agency (DARPA) and Special Assistant, Advance Medical Technologies US Army Medical Research and Materiel Command idea

City 04 Toronto, CANADA

June 17, 2004

Alan Kay

“The way to predict the future . . .

. . . is to invent it ” fund

RMS

Air Force 1 - refit

Unofficial Administration request

Virtual Surgery for the Future??

Figure 4 Scott Fisher wearing one of the first head mounted displays at the NASA Ames Research Center virtual reality laboratory – ca 1985. (Courtesy of Dr. Scott Fisher, PhD, Telepresence Research, Inc., Palo Alto, CA)

Not quite ready for Prime Time !!

Current Visions

“The Future is here … . . . it’s the Information Age”

Critical Basic Concept

The new technologies are emerging from Information Age discoveries to

FUNDAMENTALLY

change our approach in all areas of medicine

. . .

EXAMPLES

This is a revolution

Holomer

Total body-scan for total diagnosis

From visible human to

Virtual Soldier

Multi-modal total body scan on every trauma patient in 15 seconds Satava March, 2004

“TriCorder”

Point-of-care noninvasive therapy

Courtesy Larry Crum, Univ Washinton Applied Physics Lab

HIFU

High Intensity Focused Ultrasound for Non-invasive Acoustic hemostasis

“ . . .is aware of everything (patient) . . .” The LSTAT

Courtesy of Integreated Medical Systems, Signal Hill, CA Total Patient Awareness • Defibrillator • Ventilator • Suction • Monitoring • Blood Chemistry Analysis • 3-Channel Fluid/Drug Infusion •Data Storage and Transmission • On-board Battery • On-board Oxygen • Accepts Off-Board Power and Oxygen

LSTAT Deployment to Kosovo - March 2000

212th MASH Deployed with LSTAT - Combat Support Hospital

Courtesy of Integreated Medical Systems, Signal Hill, CA

Intuitive Surgical, Inc. system Fred Moll, Intuitive Surgical, Menlo Park, CA

Remote telesurgery

“Operation Lindberg” First remote and trans-Atlantic Telesurgery procedure ROUTINE telesurgery from Hamilton to North Bay 300 mile distant Prof. Jacques Marescaux, IRCAD Dr. Mehran Anvari, MD McMaster Univ, Toronto CANADA

Why robotics, imaging and modeling & simulation

• Healthcare is the only industry without a computer representation of its “product” •A robot is not a machine . . .

it is an information system with arms . . .

• A CT scanner is not an imaging system it is an information system with eyes . . .

thus

• An operating room is an information system with . . .

“Penelope” – robotic scrub nurse Michael Treat MD, Columbia Univ, NYC. 2003

The Operating Room of the Future

Creative Thinking

How can I think OUTSIDE of the box When I don’t know where the edges are?

OR S

Am I still inside?

Disruptive Visions

“The Future is not what it used to be”

….Yogi Berra

The Information Age is NOT the Future The Information Age is the Present ...

There is something else out there

. . . . . .

SATAVA 7 July, 1999 DARPA

The Future of Science

Information is critical but not sole-sufficient Science is moving toward interdisciplinary fields Science must encompass all dimensions (or domains) Must alsoinclude time and information ? BioIntelligence Age SATAVA 7 July, 1999 DARPA

Clayton M Christensen

BIO INTELLIGENCE AGE

CONSUMER ACCEPTANCE 2000 BC 0 1500 TIME (year) 1800 1900 2000 AD

Satava 29 July 99

The BioIntelligence Age

BIOLOGIC Biosensors Biomaterials Biomimetic PHYSICAL FUTURE Genomics Bioinformatics Biocomputation Robotics HPCC/WWW MEMS/Nano INFORMATION

Satava 2 Feb 1999

Global Concepts

?? BioIntelligence Age (what are the implications) The entire world is becoming “smarter” - embedded intelligence RF-ID, “smart dust” Networking provides distributed intelligence (informatics, telecom) The next wave will be Bio…..X

mimicking or incorporating biologic processes Understanding biologic processes is a cornerstone (4 1/2 Billion yrs) 7 SATAVA 7 July, 1999 DARPA

Antenna IC circuit Connector Chip substrate

RF-ID

Radio-Frequency Identification Courtesy David Brock, Auto-ID and MIT, Boston, Mass

University of Montana, 1999

University of Wisconson, 1999

Capsule camera for gastrointestinal endoscopy Courtesy Paul Swain, London, England

“BrainGate” John Donohue, Brown University, 2001 Richard Andersen, CalTech, 2003 Greg Kovacs. Stanford University, 1990

Brain Machine Interface – Controlling motion with thoughts Recorded activity for intended movement to a briefly flashed target.

TARGET PLAN MOVEMENT Time

Courtesy Richard Andersen, Cal Tech, Pasadena, CA

Thoughts into Action

Direct brain implant control of robot arm Miguel Nicholai, Duke University, 2002 Satava March, 2000

Smart prostheses

Neurosurgical MEMS for Monitoring of Spinal Fusion

Spinal Instrumentation Antenna Electronics Module Strain Gauge

Courtesy: E.C. Benzel, L.A. Ferrara, A.J. Fleischman, S.Roy

Pressure Sensor

Tissue Engineering

Artificial Ear

Liver Scaffolding

J. Vacanti, MD MGH March, 2000 Artificial Blood Vessel

Courtesy of J. Vacanti, MD MGH March, 2000

Orb spider - web Spinnerette of spider Cross section of synthetic fiber Spider silk protein as biomaterial -BioSteel Nexia Biotechnologies, Montreal Canada

Femtosecond Laser

(1 x 10 –15 sec) Los Alamos National Labs, Los Alamos NM Cold Spring Harbor Laboratory, Long Island, NY Time of Flight Spectroscopy Cellular opto-poration

Courtesy Dr. Ralph Merkel, Center for Biologic Nanotechnology, Univ Michigan, Ann Arbor, MI

4 m Spatial/temporal control of structure, function, morphology over multiple length scales Eisenstadt DARPA Feb. 2000

Bacteria with flagella – Biology’s nanomotor

*Courtesy: Richard Smalley, Director, Center for Nanoscience Technology at RICE UNIVERSITY

Research in hibernation suspended animation hypometabolic states resuscitation reperfusion Relative size of subjects Alaska Black Bear Artic Ground Squirrel

Suspended Animation

Institute of Arctic Biology’s Toolik Field Station, Alaska's North Slope Brian M. Barnes, Institute of Arctic Biology , University of Alaska Fairbanks 11/02

active hibernating heart rate 300 3 (beats/min) resp. rate 150 <1 (breaths/min) body temp. 37 o C -2 o C gene function ongoing transcription and translation suppressed metabolic rate 0.5 0.01 (2%) (mlO 2 /g/h)

The Moral Dilemma

Technology is Neutral - it is neither good or evil It is up to us to breathe the moral and ethical life into these technologies And then apply them with empathy and compassion for each and every person

.

Saturday, 28 December, 2002, 14:28 GMT

Demands grow for human clone ban

Advocates argue cloning can help infertile couples

“These technologies . . . are raising new moral and ethical morasses for us.” Dr Ian Gibson

British legislator

There are growing demands for a ban on human cloning after claims that a girl born on Thursday is an exact genetic replica of her mother.

Clonaid scientist Brigitte Boisselier said four more clones will be born soon.

French President Chirac has called on all countries to rally behind a Franco-German proposal for a global ban on human cloning which has been submitted to the United Nations.

US President George W Bush says the process is "deeply troubling".

Scientists remain sceptical of the success claimed by the Clonaid company, which is linked to a sect that believes aliens created humans by cloning 25,000 years ago.

But legislators in Britain and elsewhere say there has to be discussion and introduction of rules for the practice of scientific methods which could produce a cloned baby, even if Clonaid's claims are untrue.

“The practice is contrary to human dignity and is criminal”

French President Jacques Chirac Clonaid scientist Brigitte Boisselier said a baby girl - nicknamed Eve was born in the US after the genetic material from a woman's skin cell was fused with one of her eggs. Dr Boisselier said four other women were due to give birth to baby clones in the coming weeks one in Europe, another in North America and two in Asia.

Chinese Cloning Control Required

Tuesday 16 April, 2002, 10:41 GMT 11:41 UK Strict ethical guidelines are needed in China to calm public fears about new cell technologies such as cloning, the country's leading scientist said. Professor Ching-Li Hu, the former deputy director of the World Health Organization, was speaking at the Seventh Human Genome Meeting in Shanghai. His call follows recent reports that Chinese scientists are making fast progress in these research fields.

One group in the Central South University in Changsa is said to be producing human

embryo clones, while another team from the Sun Yat-sen University of Medical Sciences in Guangzhou is reported to have fused human and rabbit cells to make tissues for research.

Human embryos cloned

February 12, 2004

South Korean team demonstrates cloning efficiency for humans similar to pigs, cattle | Thersa Tamkins

After outlandish claims, a few media circuses, and some near misses by legitimate researchers,

a team of South Korean researchers reports the production of cloned human embryos

. The findings, were released Wednesday (

Science

, DOI:10.1126 /science.1094515, February 12, 2004).Wook Suk Hwang and Shin Yong Moon of Seoul National University used somatic cell nuclear transfer to produce 30 human blastocysts and a single embryonic stem cell line; SCNT-hES 1. Using 242 oocytes and cumulus cells from 16 unpaid donors, the group achieved a cloning efficiency of 19 to 29%, on par with that seen in cattle (25%) and pigs (26%).

Jeffery Steinberg, MD Fertility Institutes of Los Angeles

Five "designer babies" created for stem cells

1.

Gregory Stock

Five healthy babies have been born to provide stem cells for siblings with serious non-heritable conditions. This is the first time

"savoir siblings"

have been created to treat children whose condition is not genetic, says the medical team.The five babies were born after a technique called preimplantation genetic diagnosis (PGD) was used to test embryos for a tissue type match to the ailing siblings, reports the team, led by Anver Kuliev at the Reproductive Genetics Institute in Chicago, US.The aim in these cases was to provide stem cells for transplantation to children who are suffering from leukaemia and a rare condition called Diamond-Blackfan anaemia (DBA)."It's a big step, because it gives people another option," says Mohammed Taranissi, at the Assisted Reproduction and Gynaecology Centre, London, UK, one of the team. "Before that the only option was to look in the siblings and immediate family to see if you had a match or alternatively to just keep trying [to have a baby which matches]."He told New Scientist that people trying to conceive a child naturally as a tissue match for a sick sibling had only a one in five chance. This Genetically “designed” child match for the sibling."If you do it this way, the chance of finding a match is 98 per cent." 1997

'Unlawful and unethical'

However, the use of this technology to provide a "designer baby" to treat an ill sibling is highly controversial.A UK couple involved in this study travelled to the US for treatment after the UK's Human Fertilisation and Embryology Authority (HFEA) ruled that they could not create a tissue-matched sibling as a stem cell donor to their son.In-vitro fertilisation (IVF) and tissue-typing was used in the US to give the Whitakers a perfectly matched baby boy to help their son Verlinsky Y, Rechitsky S, Sharapova T, Morris R, Taranissi M and Kuliev A. Preimplantation HLA Testing. JAMA (2004) 29: 2079

Gaak Intelligent “Living Robot” Uses genetic algorithms to “learn” TECHNOLOGY NEWS

"Thinking" robot in escape bid

Scientists running a pioneering experiment with robots which think for themselves have caught one trying to flee the centre where it "lives".

The small unit, called Gaak, is one of 12 taking part in a "survival of the fittest" test at the Magna science centre in Rotherham, South Yorkshire, which has been running since March.

Gaak made its bid for freedom after it had been taken out of the arena where hundreds of visitors watch the machines learning how to repair themselves after doing daily battle.

Professor Noel Sharkey said he turned his back on the drone, but when he returned 15 minutes later he found it had forced its way out of the small make-shift paddock it was being kept in.

He later found it had travelled down an access slope, through the front door of the centre and was eventually discovered at the main entrance to the car park when a visitor nearly flattened it with his car.

Courtesy Professor Noel Sharkey, Sheffield Unversity, London

Humans vs Machine Humans 4.0

X 10 19 Red Storm 3.5

X 10 15 cps cps Moore’ s Law “computer power doubles every 18 months” Do the Math !!

Who is smarter now??

WHEN COMPUTERS EXCEED HUMAN INTELLIGENCE The Age of Spiritual Machines Ray Kurzweil

ROBOT

Hans Moravec Will Machines become “smarter than humans?

Extending Longevity

A strain of mice that have lived . . .

. . . more than three normal lifespans Should humans live 200 years?

April 14, 2004

Life extension

Life extension consists of attempts to extend human life beyond the natural lifespan. So far none has been proven successful in humans.

Several aging mechanisms are known, and anti aging therapies aim to correct one or more of these: Dr. Leonard Hayflick discovered that mammalian cells divide only a fixed number of times. This "Hayflick limit" was later proven to be caused by telomeres on the ends of chromosomes that shorten with each cell-division.

When the telomeres are gone, the DNA can no longer be copied, and cell division ceases.

In 2001, experimenters at Geron Corp. lengthened the telomeres of senescent mammalian cells by introducing telomerase to them.

They then became youthful cells. Sex and some stem cells regenerate the telomeres by two mechanisms: Telomerase, and ALT (alternative lengthening of telomeres). At least one form of progeria (atypical accelerated aging) is caused by premature telomeric shortening. In 2001, research showed that naturally occurring stem cells must sometimes extend their telomeres, because some stem cells in middle-aged humans had anomalously long telomeres.

CAN I REPLACE MY B O D Y ?

Artificial organs Smart Prostheses Genetic engineering Regeneration If I replace 95% of my body . . .

. . . Am I still “human”?

What does it mean to be human ?

Photograph taken at Hell, Norway 32km from Trondheim, Norway When will this be accomplished?

Sector

Technology Business Society Healthcare

TIME

Differing responses to scientific discovery by various sectors

Moral and Ethical Issues

Raised by Technological Success Summary Should we do research in areas we may not be able to control? (eg, genetics, cloning, nanobots, intelligent machines?) Will prolonging life through technology result in more disease in the overall population Can we change medicine from treatment to prevention of disease In defeating diseases, will technology change a human into a combination of man and machine - what does it mean to be “human” How will we decide who gets the technology, especially in 3rd World 6 SATAVA 7 July, 1999 DARPA

The Ultimate Ethical Question?

For the first time in history, there walks upon this planet, a species so powerful, that it can control its own evolution, at its own time of choosing …

…

homo sapiens.

Who will be the next “created” species?

Do Robots Dream ?