Emily Brindley
RECENT ADVANCES IN UPPER-LIMB PROSTHESES AND THE SHORTCOMINGS OF PROPRIOCEPTIVE FEEDBACK TECHNOLOGY
Emily Brindley ()
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Emily Brindley
INTRODUCTION: CURRENT PROSTHESIS TECHNOLOGY AND THE PROGRESS STILL TO BE MADE
In the past decade, the technology of prosthetic limbs has made great advancements. The U.S. Defense Advanced Research Projects Agency (DARPA) has been focusing funding on projects designed to advance prostheses technology [1], a worthwhile endeavor as it aims not for empty advancements, but for positive changes in the lives of amputees.
This funding is targeted specifically toward upper limb prosthetics research and development as upper limb prostheses remain woefully short of the capabilities of flesh and blood limbs [1]. Because of the devastation that can and typically does accompany upper limb loss, the continuing development of prosthesis technology is an absolutely necessary and worthy endeavor. Recent advancements in prosthesis technology include myoelectric, or electromyogram, control as well as the specialization of terminal devices. Despite these advances, prosthetic technology remains largely incapable of providing proprioceptive feedback [3], a shortcoming that must be accounted for if prostheses are to undergo continued advancement.
BACKGROUND INFORMATION ON PROPRIOCEPTIVE FEEDBACK TECHNOLOGY IN CURRENT PROSTHESES
The most prominent drawback of modern prosthetic limbs is their lack of proprioceptive feedback, which limits the movement and capability of the artificial limb. Currently, the only reliable sensory feedback is visual, which necessitates increased and unnatural attention to the artificial limb and considerably restricts the capability to execute precise motions.
One possible solution to the proprioception problem is “directly interfacing…afferent peripheral nerves using signals derived from the prosthesis” [6]. This method, though, has not yet left the hypothetical stages of development, as researchers are still attempting to understand how the brain processes sensory input and adapts to new stimuli [6].
The development of proprioceptive feedback technology has the potential to entirely alter the lives of amputees, allowing them to participate in physically stringent activities and to be self-sufficient in their daily lives. Continued research and development is necessary if prostheses will ever be able to truly replace native limbs.
ETHICAL DILEMMA
As stated above, current proprioceptive feedback technology has not left the hypothetical stages. However, imagine that a company has recently made a significant breakthrough and has developed a method of interfacing the nerve system with the mechanical prosthesis. Only short-term testing has been conducted on this interfacing method, and it is suspected that the materials that must be used in this new technology will cause neural and brain damage during long-term use. Despite this, the company wishes to send the technology on to mass testing and, as soon as possible, to place the technology on the market for public use. The potential dangers of the interfacing technology would be hidden from the public and, by the time problems begin to manifest themselves, the company hopes to have a solution prepared. As a key member of the technology development team, I have the power to announce the dangers of the interfacing method; though doing so would almost certainly cost me my job. My other option is to allow the technology onto the market while working on a solution to the future problem, knowing that in the mean time many amputees would find happiness in the regained use of their lost limb.
CONSULTATION OF ENGINEERING CODES OF ETHICS
In order to decide how to proceed in this situation, consultation of the engineering ethics codes is essential. First, consider the overarching engineering code which applies to all engineering fields; the National Society of Professional Engineers (NSPE) provides several guidelines on matters of deception and public endangerment. In scenarios where the safety of others hangs in the balance, the NSPE states that this safety should be held “paramount” to all other concerns, and that the proper authorities should be notified if an individual is unable to control the situation on his own [7]. Following these guidelines, it is clear that the new proprioceptive feedback technology should not be permitted on the market, as it risks the safety of anyone who uses it. However, the potential benefits of the technology must also be considered. Allowing the interfacing method to be put into use would greatly improve the quality of life of many amputees, with no guarantee that problems will arise in the future. The safety of patients must be weighed with their happiness in order to properly evaluate this issue.
In addition to safety guidelines, the NSPE discusses the presentation of information and research. Engineers should “issue public statements only in an objective and truthful manner,” and should include “all relevant and pertinent information” within the report [7]. This code of ethics specifically denounces deception in engineering, which would be necessarily included in allowing the public to have access to the new interfacing method. Because the potential dangers of the technology are known (or at least highly suspected), withholding this information conflicts directly with the engineering code of ethics. Again, however, such omission could be justified by reasoning that these dangers are a long way off, and a solution to any issue could be found before the repercussions become irreversible. Such reasoning is not entirely sound, as the exact nature of the potential dangers is not known, and therefore there is no guarantee that they can be reversed or even prevented.
As this scenario is entirely within the field of bioengineering, consulting the Bioengineering Code of Ethics is also advised. The Biomedical Engineering Society addresses the ethical responsibilities of bioengineers; their code states that bioengineers have a responsibility not only to public safety, but also that “responsibility to...patients…[is] their primary concern” [8]. In addition, bioengineers are responsible for “accurately and clearly” presenting all research information [8], which would include addressing all potential dangers with newly developed technologies. Supreme to all of these specific responsibilities, bioengineers should be committed to “increasing the prestige and honor of the biomedical engineering profession” [8], which necessitates honesty in reports and candor where health risks are concerned. These guidelines leave little room for misleading the public about the new interfacing method.
It is possible, however, to justify breaking these ethical guidelines for the greater good of the patients, who would receive the technology more quickly. The code of ethics does state that bioengineers must “consider the larger consequences of their work” [8], which could be interpreted as a permission to blur the other guidelines for the greater good. Specific to this scenario, it may be reasoned that the greater good would be served by allowing access to this technology now with the intent to solve any problems retroactively, as these problems are not of immediate concern. Though the bioengineering code of ethics decries deception and endangerment of the public, it also encourages a commitment to the big picture, which may at times permit the previously denounced behavior.
CONSULTATION OF ADDITIONAL ETHICS RESOURCES
Though the ethics codes point toward legalistic, rigidly correct behavior, some scholars have been calling for a shift in the way engineers approach ethics. The rule-based ethics of the past, called preventive ethics, focuses on the avoidance of “professional misconduct and harm to the public” [9]. However, many are calling for the adoption of aspirational ethics, which concerns itself much more with the “promotion of human well-being” [9]. Applying this perspective change to this situation, it may be reasonable to allow the new interfacing method onto the market, as this would enhance the wellbeing of amputees in the short-term. The underlying assumption is that there would be sufficient time to find a solution to any future problems, though this assumption may be incorrect. If a worst-case scenario is considered instead of assuming that a solution will be found, the opposite conclusion is reached. That is, if a solution to the potential damage cannot be found, then patients using the new technology in the long-term will ultimately suffer more from the use of the technology than they would have suffered without it. Assessing this situation with regard to the wellbeing of the public results in opposite conclusions depending on whether or not a solution to potential issues can be found.
If I were to subscribe to the concept that deception is permissible where it may serve the greater good (an “ends justify the means” perspective), I must then establish whether or not deception is permissible in this specific situation. This situation certainly does involve deception, even though it includes the deliberate omission of a truth instead of the assertion of a falsehood. Deception is the “intentional attempt” to lead someone to false conclusions, which can be done “with or without asserting something” [10].
I must now determine if this deception is a morally allowable act. A consequentialist view of lying and deceit asserts that “an action is right if it has the best consequences” [10]. Using this definition, I might argue that the best consequences would include keeping my job and allowing my company to become successful. However, looking at the big picture, it is clear that the potential long-term consequences of patient harm and even death are larger detriments than the positive outcomes are beneficial. Though neither outcome is ideal, the best consequences occur when patients are kept out of `harm’s way. For this reason, even the consequentialist, non-legalistic perspective struggles to justify putting a dangerous product on the market for public access.
ADDITIONAL RESOURCES AND ADDITIONAL CONSIDERATIONS
At this point of reasoning through the scenario, multiple ethical resources have been consulted and the situation has been viewed from the perspective of its consequences on others. Though all of the possible impacts on the “greater good” have been considered, there is one relatively un-discussed effect of taking or not taking action. As much as I would like to imagine that I would only be concerned with what is morally right, the reality is that if I were placed in this situation, I would also be concerned with what would happen to me if I were to denounce the actions of my company. More than likely, taking action in this way would cost me my job. Depending on my own situation and the state of the economy, this may be a considerable concern. Though at this point I have fairly well reasoned that the only moral behavior is to notify the public of my company’s intentions, fear for my own welfare would likely lessen my resolve on the matter. “Retaliation against the whistleblower” is a reasonable and expected outcome in these types of situations [11]. However, after considering the magnitude of the harm that could be done to many people by this new interfacing method, the tendency towards self-preservation must be weighed with moral obligation and the wellbeing of others.
Once I have made my decision, a course of action or non-action must be established. If the decision is for non-action, then I must evaluate whether or not I can live with this choice. Erma Bombeck once declared that guilt is “the gift that keeps on giving.” If allowing the unsafe technology onto the market causes me any initial discomfort, that guilt is only going to multiply with time. From a purely self-serving standpoint, I must consider the effects upon myself that this ongoing guilt will have. Will I be able to forgive myself if people come to harm from this technology? Will I regret this decision in the future, when I have my job but not my good conscience? The answers to these questions may be enough to spur me to action.
In the case of taking action against my company, I must remember to go about it carefully and deliberately. Nothing will be achieved if I call out my company correctly, but with inadequate proof to back up my claims. With appropriate documentation and evidence, it is possible even that I may retain my job while simultaneously preventing my company’s dishonest conduct [11]. Though this end result is less likely, in any case I must approach the whistleblowing delicately, calmly, and with great attention to detail.
ETHICAL DILEMMA THOUGHT PROCESS
My thought process in order to come to a conclusion in this situation would begin with consideration of the danger to those who use the interfacing method. Simply knowing that lives may be lost in the future would likely be enough for me to take action, though I would also wish to first consider the situation from all angles. Firstly, I would consider the outcomes of both options: whistleblowing and remaining silent. I would weigh the pros and cons of each scenario, attempting to be as objective and unbiased as possible. Secondly, having already begun to think that staying silent would be morally wrong, I would consult several codes of ethics to determine what was expected of me in such a context. These ethics codes would undoubtedly confirm my previous suspicion that silence would be immoral, and at this point I would have arrived at my conclusion nearly unshakably. However, in order to entirely confirm this conclusion, and also to provide me with sufficient courage to follow through with my intentions, I would read through several articles on deception and truth telling, as well as consider some common adages about lying and guilt. At this point, I would have chosen definitely to take action against my dishonest company, and, with the additional confidence from my research, I would proceed to document the misconduct to the best of my ability and to report it to the appropriate authorities.