By Stacey Kusterbeck
The cutting-edge field of telesurgery holds promise for improved patient outcomes, but there also are significant ethical considerations.1 When considering ethical issues with telesurgery, “it is important to exactly define what is being discussed,” says Peter Angelos, MD, PhD, FACS, director of the MacLean Center for Clinical Medical Ethics and a professor of surgery and surgical ethics at the University of Chicago. In most circumstances, telesurgery refers to a surgeon using robotic technology to operate on a patient from a distance. “Currently, such approaches are largely limited to laparoscopic procedures where surgeons can readily use an operating robot on the patient. Such cases are only a small portion of all the operations done,” notes Angelos. When using an operating robot to operate on a patient remotely, there must always be a knowledgeable provider at the bedside to prepare the patient, obtain the appropriate access to the inside of the patient, and set up the robot in the patient. “There are multiple ethical issues with such cases,” observes Angelos.
Telesurgery may give patients access to surgical specialists who would not otherwise have that access. “We know that disparities in access to care are a central ethical issue. And telesurgery has the potential to mitigate some of these disparities,” acknowledges Angelos. However, Angelos says there is a need to pay close attention to these items, for patients to obtain care via telesurgery in an ethical manner:
• There still must be robust informed consent processes. “The patient must have the opportunity to have questions answered,” underscores Angelos.
• It is essential that there be mechanisms for the patient (who may be in a remote location) to get postoperative care. This is especially important if there is a complication.
• The remote surgeon still must take full responsibility for the operation and what happens to the patient. “It is not acceptable to expect that a far distance reduces the operating surgeon’s individual responsibility to the patient,” emphasizes Angelos.
Potentially, telesurgery can provide high-quality surgery to patients in remote, medically underserved areas. “In rural areas or remote locations like Antarctica, it potentially eliminates long-distance travel from surgeons who might have scheduling conflicts otherwise,” says Douglas W. Hanto, MD, PhD, MBE, co-chair of the Surgical Ethics Working Group at Harvard Medical School’s Center for Bioethics.
One central ethical concern involves informed consent, which usually is done with the surgeon in person. “Informed consent establishes a personal relationship between the patient and surgeon that can be helpful in postoperative recovery and healing,” notes Hanto. Upon undergoing general anesthesia, patients put themselves in the hands of the surgeon to do the right thing when they are asleep. “That can be a little bit more difficult when you are not meeting the surgeon in person and you don’t establish a personal relationship with them. There is an idea that if the surgeon is not physically present, the patient doesn’t develop that same emotional connection with the surgeon,” explains Hanto.
When obtaining consent for telesurgery, surgeons need to be clear on these specifics, says Hanto:
• how the procedure will be done;
• what kind of safeguards exist should something go wrong and the remote surgeon is hundreds of miles away;
• how complications would be dealt with;
• whether there are backup systems in place to make sure that the patient has a good outcome.
“The idea of the patient putting their life in the hands of the surgeon is really an important aspect of surgery and requires close attention to make the patient feel they are getting the best possible care,” stresses Hanto.
Telesurgery patients are having a procedure by a team that is not capable of performing the procedure on their own. Since the procedure is normally done in a larger center where the remote surgeon is located, patients may question whether they should have confidence in the local team. “Particularly if something goes wrong and they have to intervene, patients want to know: ‘Am I in the best hands?’ That’s a really critical aspect,” says Hanto.
According to the American College of Surgeons’ itinerant surgery policy, surgeons cannot perform surgery at a rural hospital, leave, and not be readily accessible to take care of that patient should complications arise.2 “That’s going to be a very important consideration with telesurgery, in terms of who is taking care of the patient after surgery,” says Hanto. Patients should know if local surgeons will take care of the patient with complications, or if the patient would be transferred to a larger center, and if so, what the risks are in terms of patient outcomes.
Surgeons have an ethical obligation to make sure that, to the best of their ability, patients understand the benefits and risks of any surgical procedure. “For telesurgery in particular, I think it’s even more critical. But it’s something that people are really aware of and are thinking about,” says Hanto.
If the patient feels they do not have access to a larger center, they might feel coerced or like they do not have a choice in the matter. In such cases, telesurgery would appear to be the patient’s only option. “That’s why the informed consent has to be really transparent and very open,” says Hanto.
Another major ethical concern is data security and data privacy. “You are going to be transmitting patient images and sensitive information over the internet,” notes Hanto. There is always the concern for cyberattacks, with outside entities potentially accessing the procedure at the time, or accessing recorded videos of the procedure later. Another concern is the possibility of technical issues with delays of transmission due to unstable connections. If the information coming from the patient does not get immediately transmitted to the remote surgeon, it could result in some problems during the procedure. “There are going to be some technical challenges, and the need for expertise at both ends — for the surgeon who is operating the robot, and also for the surgeon at the institution where the patient is,” says Hanto.
There also is the potential risk of the process of telesurgery dehumanizing the patient. “There is some concern that the patient is being taken care of by robots with the help of the surgeons. That is something that people do have to be a little concerned about. It depersonalizes it a bit,” says Hanto.
There also are concerns about inequity, according to Hanto. Patients must participate in teleconsults with surgeons prior to the surgery. However, some groups of individuals — older patients or lower socioeconomic status or rural patients — do not have the same access to technology that others have.
Misleading marketing campaigns are another ethical concern. “We are all influenced by advertising, whether it’s for a vacation spot or a new pill that will cure whatever is ailing you. It’s also very true with robotics,” says Hanto. Patients have been led to believe —- in some cases correctly, and in other cases incorrectly — that a robotics procedure is better. There is also the potential for financial conflicts of interest. “Obviously, the device companies have a big stake in this, and would love to see a greater expansion in the use of robotics. It is also true for surgeons involved with these robotic companies, who have to be very careful that if they apply this in new ways, that they are not being influenced by their own financial considerations,” warns Hanto.
The overarching ethical question is whether telesurgery is going to benefit the patient. “The history of robotic surgery has been, to some extent, to use a robot not because it’s going to benefit the patient, but because we can,” says Hanto. Both companies and hospitals have made robotic surgery the center of marketing campaigns. The concern is that the general public will get an overly positive view of the benefits of telesurgery, with potential risks downplayed.
“Certainly today, robotic surgery is used where there is unquestionable proven benefit. But it has also been used in some circumstances when it hasn’t necessarily been shown to provide patient benefit — and it’s a pretty expensive alternative to other means of treatment,” says Hanto. “We need to be sure we are not using this expensive technology for something other than clear patient benefit.”
- Patel V, Saikali S, Moschovas MC, et al. Technical and ethical considerations in telesurgery. J Robot Surg 2024;18:40.
- American College of Surgeons. Statements on Principles. April 12, 2016. https://www.facs.org/about-acs/statements/statements-on-principles/#iie
