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Between human and not human care

The era we are living is called post-contemporary, and philosopher Francesca Ferrando goes beyond this definition, calling it a posthumanism age [1]. It means that we overcome the anthropocentric humanistic approach, encompassing, and even being threatened by the technological crafts of Artificial Intelligence. Posthuman relationships [2] are already here in some places, like Japan, United States, United Kingdom, China and other Western countries and evoke a future in which humans could be dependent not on each other, but robots or other non-human entities.

Man is, by nature, a social animal; an individual who is unsocial naturally and not accidentally is either beneath our notice or more than human. Society is something that precedes the individual. Anyone who either cannot lead the common life or is so self-sufficient as not to need to, and therefore does not partake of society, is either a beast or a god, quoting Aristotle’s Politics, and his words are at the basis of our Western culture. Are his words still valid? Do we need other human beings, or can we rely on Intelligent machines?

Considering Western countries from a demographic point of view, they are significantly ageing, with fragmented families, a considerable amount of lonely people and an essential need for caregiving. Our society is too much pushing the biomedical model rather than the biosocial, psycho and spiritual model, in which the importance of human touch and bonding is paradigmatic. In a few words, we could say that there is a risk towards too much chronic illness taken care by robots and too few vitalities coming out from human relationship in this social paradigm for the elderly – but even more than this, also in our civil society.

Caregiving is a mix of actions and emotions: older people, ill people, as well as everybody who lives a vulnerable situation may recover through this combined approach of facts of care and empathy.

Human touch, human contact is the most crucial thing for child development: hugging is the first thing that allows bonding and a safe growing up of children. When we are ill, we somewhat regress to that time of seeking bonding, the belonging to our people, to our clan, to other human beings, or living beings.

In this article, we will examine two fields of application of robotics: the first one as caregivers, the second one as doctors.

The word robot comes from the Czech robotnik and means forced working, from robota, forced labor, compulsory service. Are they only living in Asimov’s science fiction book? No, they are already with us.

Globally, the number of people 60 and older is expected to skyrocket from 962 million in 2017 to 2.1 billion in 2050, according to the United Nations. At the same time, countless people regularly use technology such as smartphones, Google Home, to enhance their lives.

In an article [3], Laura Petrecca from the AARP (American Association of Retired People) states that The iPal’s elder-focused software is still being developed, but it may soon be able to remind you to take medicine and provide entertaining content, mind-stimulating puzzles and more. Once on the market, it would join other socially assistive robots such as the aforementioned Mabu and Intuition Robotics’ ElliQ, both of which are already coaching and educating older US adults to good health.

Commenting on iPal, William Dale, MD, geriatrician and Palliative Medicine specialist at City of Hope National Medical Center in Southern California, affirms he does see much promises in this technology: he can envision device helping with tasks such as reminding patients to take medicines, to eat or go for a walk. According to him, “socially assistive” robots can be useful, in particular, if patients are in the early stages of physical or cognitive decline. He adds yet that people also need empathy and kindness coming from other humans: The social benefits of that are hard to replace… There are some things that require human judgement, stressing that there are limits to what any device driven by algorithms can do.

Another therapeutic robot comes from Japan and is named Paro, a “fake” seal, an advanced interactive robot. It allows the benefits of animal and pet therapy, to be administered to patients in environments such as hospitals and extended care facilities where live animals present treatment or logistical difficulties. Paro has five kinds of sensors; tactile, light, audition temperature a posture sensor with which it can perceive people and its environment. Paro can recognize light and dark, the direction of voice and words such as its name, greetings and praise: it works in the Japanese context, as the result of a historical process in which robots were consciously designed to evoke positive feelings [4]. We might think about it as challenging to be exported in our culture; however, it was exported.

Although looking like an oddity, Paro has reached the UK [5] where it is employed for caring people with dementia. With its artificial intelligence, the robot seal can “learn” and remember its name, can learn the behaviour that results in a pleasing stroking response and repeat it. Clinically it does work, which is why Sheffield Health and Social Care NHS Foundation Trust and the University of Sheffield evaluated the effectiveness of the robotic seal in a dementia care setting in a joint project.

“Socially assistive” robots could replace the hard job of being a caregiver, that can be tedious, ghastly intimate and physically and emotionally exhausting. Caregiving time seems to be never-ending: the lives of caregivers, mostly low-income or unpaid women, are dramatically changed, together with the erosion of their self-realization. Caregivers’ experiences are eroded by wanted or unwanted symbiosis with the elder or with the patient. An empathetic human caregiver is preferable to a robot, but maybe, due to an excessive burnout of caregivers, caregiving robots might be better than an unreliable or abusive person or than a caregiver who totally gave his/herself and eventually developed compassion fatigue.

There is a philosophical stream called Extropy, originated by Max More in The principles of Extropy [6]: this is an evolving framework of values and standards for continuously improving the human condition. Extropians believe that advances in science and technology will someday let people live indefinitely. An extropian may wish to contribute to this goal, by doing research and development or by volunteering to test new technology. Extropian thinking places a strong emphasis on rational thinking and on practical optimism. According to More, these principles do not specify particular beliefs, technologies, or policies. Extropians share an optimistic view of the future, expecting considerable advances in computational power, life extension, nanotechnology and the eventual realization of indefinite lifespans, and the recovery, thanks to future advances in biomedical technology or mind uploading, of those whose bodies/brains have been preserved by means of cryonics. The name Extropy is invented on the principle of the opposition to Entropy, the eventual increase of chaos and energetic waste. This paradigm is also called transhumanism, very different from posthumanism, since in the former case there is a continuous interchange between human and technology to give meaning to lives, in a world where every individual life is interconnected through technology not only to the present but also to our future.

Now, I ask the reader to try to think and feel What it would be like to be assisted by a caregiver robot?, Which could be the minimal requirements to allow a robot to be our caregiver? What do we think about pet therapy with Paro? What it would be like to receive violent human caregiving?, and last but not least, Would we define all this phenomenon extropian or dystopian [7]? Not everybody could have access to the newest robot application, and this would create further inequalities.

Let’s now wondering whether robotics is such a threat to the medical profession that doctors can be replaced by intelligent robots.

Researchers at the John Radcliffe Hospital in Oxford, England, developed an Artificial Intelligence (AI) diagnostic system that’s more accurate than doctors at diagnosing heart disease, at least in 80 per cent of the time. At Harvard University, researchers created a “smart” microscope that can detect potentially lethal blood infections: the AI-assisted tool was trained on a series of 100,000 images from 25,000 slides treated with dye to make the bacteria more visible. The AI system can already sort those bacteria with a 95 per cent accuracy rate. A study from Showa University in Yokohama, Japan revealed that a new computer-aided endoscopic system could show signs of potentially cancerous growths in the colon with 94 per cent sensitivity, 79 per cent specificity, and 86 per cent accuracy [8] [9].

In some cases, researchers are also finding that AI can outperform human physicians in diagnostic challenges that require a quick judgment call, such as determining if a lesion is cancerous.  In one study, published in December 2017 in JAMA, deep learning algorithms [10] were able to diagnose better metastatic breast cancer than human radiologists. While human radiologists may do well when having limited time to review cases, in the real world (especially in high-volume, quick-turnaround environments like emergency rooms) a rapid diagnosis could make the difference between life and death for patients. However, this is not so new since technology has always been an aid in helping doctors to formulate a diagnosis. The question is, With which words shall doctors communicate information about the diagnosis? With their words, chosen with wisdom and empathy, or also this will be taken over by the robot to have less defensive problems?

Let’ s move to surgery: surgical robots are an extension of the human surgeon, who controls the device from a nearby console. One of the more ambitious procedures claimed to be a world-first took place in Montreal in 2010. It was the first in-tandem performance of both a surgical robot as well as a robot anesthesiologist, Mc Sleepy; data gathered on the procedure reflect the impressive performance of these robotic doctors.

In 2015 MIT performed a retrospective analysis of FDA data to assess the safety of robotic surgery. The report noted that the vast majority of procedures were successful and did not involve any problems. However, the number of events of complication in more complex surgical areas like cardiothoracic surgery were “significantly higher” than in fields like gynaecology and general surgery. It means that for doctors as surgeons a future career is guaranteed for very complicated procedures, but in terms of sustainability, for secure operations, despite patients could scream and search for the human touch, from an economic and even safety point of view, the Dr Knife robot is here [11].

Very recent news tells about an academic program between Hunimed, the faculty of Medicine at Humanitas University and the Politecnico, the Faculty of Engineering [12]: the aim is the creation of a hybrid, the Doctor-Engineer. This merge could be very beneficial to make sure that doctors can contribute to creating their robot: up to date, this is left to a co-creation process carried out by doctors, biomedical engineers and IT experts. Here, a new competence is created – and this is my thought – unbalanced towards technical skills. I would have been preferring much more to see the rise of a new course in Medicine joined with Philosophy to create a new hybrid, that is the philosopher-doctor. Alternatively, Humanist-Doctor, skilled also with robotic knowledge. Since we know that Extropy will go on, creating new Paros to treat the increasing loneliness of our civil society, and new robot as intelligent emotionless caregivers with the possibility to diagnose our health, I think that human thoughts, feelings and words are desired and have to be preserved in this technocratic world. An investment in creating the engineer-doctor is worth for survival of the “doctor species”; given the way that most of the faculty of Medicines teach the taking care and the care through algorithms, this adventure is tactic, but I cannot state how much strategic it will be on the long run.

The quantum leap would have been represented by letting the robots doing their job, always improving under the AI experts, including doctors, philosophers, economists, anthropologists, psychologists, and nurses, caregivers, patients, and individuals in a real multidisciplinary work team. Human careers could avoid the threat of losing “their job” by focusing more on existential issues, communications, emotions, words, gesture: that is, the Humanities for Health.

Just in few faculties of Medicine and Nursing, Communication, Bioethics, and Medical Humanities are mandatory subjects for students. I think that, on the one hand, the case of Mr Quintana informed of his imminent death by a robot, and on the other hand, the beautiful therapeutics effects when competent people in Medical Humanities use the right words and emotions, bring the evidence that a balance between Technology and Humanities can no longer be postponed.

A robot can learn fast to do a pleasant shower to older people, cook a nice meal; today, it can operate middle-complexity patients and tomorrow more difficult ones. Still, we are waiting for that robot able to create poems, or artistic masterpieces, without copying them from something already seen and memorized. It is the beauty of our brain interconnections, the pleasure of a caress at the touch, the scent of a walk after the rain: if robots will be more natural and creative than a human being one day, if Extropian can make it, I would be the first to say Chapeau.

[1] Francesca Ferrando, 2013. Posthumanism, Transhumanism, Antihumanism, Metahumanism, and New Materialisms: Differences and Relations. In Existenz: An International Journal in Philosophy, Religion, Politics, and the Arts, vol. 8 n. 2, pp. 26-32.

[2] For an in-depth analysis of posthuman relations, please consult: https://robotics.leeds.ac.uk/research/medical-robotics/medical-humanities/

[3] Full article available at https://www.aarp.org/caregiving/home-care/info-2018/new-wave-of-caregiving-technology.html

[4] For further analysis of robots and humanoids in Japanese culture, see Yulia Frumer, 2018. Cognition and emotions in Japanese humanoids robotics.

[5] Full news available at https://www.brighton.ac.uk/research-and-enterprise/groups/healthcare-practice-and-rehabilitation/research-projects/the-paro-project.aspx

[6] For further details on Extropy, please consult: https://web.archive.org/web/20131015142449/http:/extropy.org/principles.htm

[7] Dystopia is an imagined state or society where there is great suffering or injustice.

[8] Yuichi Mori et al, 2017. Computer-aided diagnosis for colonoscopy. In Endoscopy 49:8

[9] Erwin Loh, 2018. Medicine and the rise of the robots: a qualitative review of recent advances of artificial intelligence in health. In BMJ Leader 2:59-63

[10] Babak Ehteshami Bejnordi et al, 2017. Diagnostic Assessment of Deep Learning Algorithms for Detection of Lymph Node Metastases in Women With Breast Cancer. Jama 318(22):2199-2210.

[11] For further details and information, please consult: https://futurism.com/ai-medicine-doctor

[12] For the full article please visit https://www.ilsole24ore.com/art/a-milano-nasce-medico-ingegnere-doppia-laurea-politecnico-e-humanitas-AC2r3YN

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Epidemiologist and counselor – 30 years of professional life in health care. Classic humanistic background, including the study of Latin and ancient Greek, followed by scientific academic studies, chemistry and pharmacology. First years of career, in private international environment. I worked in medical research, moved to health care organization, getting academic specialization in Epidemiology. Later, in consultancy and health care education. Counselor with transactional analysis orientation. Currently, director of Innovation in Health Care Area of Fondazione ISTUD, an independent not for profit Italian Business School with an humanistic approach acknowledged by the Italian Ministry of Researech.. Active member of the board of Italian Society of Narrative Medicine, tenured professor of Narrative Medicine at Hunimed, Milan, and in 2016, referee for World Health Organization for “Narrative Method in Public Health.” Writer of the book; “Narrative medicine: Bridging the gap between Evidence Based care and Medical Humanities,” edited with Springer and of international publications on narrative medicine in scientific journals. Last book “The Languages of care in narrative medicine: words, space and sounds in the healthcare ecosystem”. Lecturer in different international contexts from Academy to Public and Private Foundations.

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