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Artificial Intelligence & the Social Role of Medicine Redefined · Health Ethics Podcast

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  Speaker 1: Welcome to Health Ethics, a series of conversations with leading
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  Speaker 1: experts about ethical considerations associated with health and healthcare, both
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  Speaker 1: locally and globally. I am Brian Pilkington, Professor of Bioethics
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  Speaker 1: in the Department of Medical Sciences at the Hackensack Meridan
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  Speaker 1: School of Medicine. This series, like its predecessor, which focused
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  Speaker 1: on the COVID nineteen pandemic, relies on the idea that
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  Speaker 1: challenging ethical issues are best addressed by folks from diverse
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  Speaker 1: backgrounds practically reasoning together, and complements the Health Ethics series
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  Speaker 1: with its panel of leading experts from medicine, nursing, politics, economics,
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  Speaker 1: philosophy and the law. Thank you and enjoy the episode.
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  Speaker 2: Welcome everyone to Health Ethics Podcast. I am Brian Pilkington,
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  Speaker 2: and it is my great pleasure to be speaking with
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  Speaker 2: doctor John Lantos. Doctor Lantos is a pediatrician and bioethicist.
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  Speaker 2: He's spent his career writing about bioethical issues raised by
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  Speaker 2: innovative technologies. He's discussed these on OPRAH Nightline, in The
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  Speaker 2: Wall Street Journal, and of course now on the Health
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  Speaker 2: Ethics Podcast. And he's been an ethics advisor to the
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  Speaker 2: President's Council on Bioethics, the American Academy of Pediatrics, and
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  Speaker 2: the Vatican. He's currently working on a book about the
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  Speaker 2: doctor patient relationships in the era of AI, and it's
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  Speaker 2: the latter that we're really going to focus on today.
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  Speaker 3: So John, thanks so much for joining me.
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  Speaker 4: Hey, thanks for having me. This is great.
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  Speaker 2: Among the host of topics you've written on and you've
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  Speaker 2: been amazingly prolific over your career, is AI and the
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  Speaker 2: role of the physician. As I just mentioned, I had
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  Speaker 2: known your work in pediatric bioethics, but after reading the
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  Speaker 2: recent piece in Jama or an Auras, which I think
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  Speaker 2: is sort of deeply philosophical in lots of ways, I
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  Speaker 2: actually went back and saw that you've been asking these
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  Speaker 2: questions for I think all almost thirty years. It was
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  Speaker 2: nineteen ninety nine that do we still need doctors? Came
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  Speaker 2: out right, and so I think you're the perfect person
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  Speaker 2: to really jump in into these. Now let's focus a
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  Speaker 2: bit on the paper. So in that recent piece in
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  Speaker 2: JAMA you rely on a philosophical conception of an aura
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  Speaker 2: to help distinguish physicians from AI and to push physicians
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  Speaker 2: or at least to ask them to think about their
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  Speaker 2: future in light of the increasingly extensive role AI is
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  Speaker 2: playing in healthcare delivery. So there's the big intro of
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  Speaker 2: the frame for folks who haven't read the paper yet,
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  Speaker 2: help us sort.
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  Speaker 3: Of think through it.
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  Speaker 2: You make a comparison between medicine and art that I
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  Speaker 2: think sort of the backbone of this. So tell us
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  Speaker 2: a little about what got you into thinking about this
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  Speaker 2: and sort of the Benjamin stuff on medicine.
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  Speaker 4: Yeah, a complicated question. I'll see if I can set
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  Speaker 4: up a framework that my guide our discussion for it,
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  Speaker 4: because there's really two important points wrapped up in your
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  Speaker 4: question there. One was what I was thinking about thirty
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  Speaker 4: years ago, when long before AI was anywhere but in
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  Speaker 4: the MIT labs, but primitive AI as we know it now,
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  Speaker 4: but primitive AI now seems primitive was making inroads into medicine.
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  Speaker 4: And one of the things that I focused on in
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  Speaker 4: the book Do We Still Need Doctors? Were devices that
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  Speaker 4: could interpret electric cardiograms. Electric cardiograms were one of reading
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  Speaker 4: electric cardiograms was one of the skills that people thought
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  Speaker 4: you needed a cardiologist for. And when these new devices
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  Speaker 4: that could interpret ekg's came out. There were big questions
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  Speaker 4: about whether we still need the cardiologists to read them,
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  Speaker 4: and people did head to head studies and they found,
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  Speaker 4: as they've found in subsequent studies, that the machines are
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  Speaker 4: better than most doctors, but may not be as good
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  Speaker 4: as the expert of electro physiologists reading cardiograms. Two points
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  Speaker 4: about that one, there aren't expert electrophysiologists in most places
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  Speaker 4: where doctors need to interpret these, and so having a
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  Speaker 4: device that was better than anything available in the moment,
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  Speaker 4: particularly in an emergency room or rural sweating or just
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  Speaker 4: in a primary care doctor's office, was a huge advance
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  Speaker 4: and raised questions about whether this sort of technology where
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  Speaker 4: cardiograms would soon develop for X rays, for rednoscopies, for
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  Speaker 4: all the things that in the subsequent years we've seen
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  Speaker 4: AI developed technologies to do. So. In that book, I
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  Speaker 4: speculated both about devices like that, but also about power
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  Speaker 4: our professionals. So in addition to AI and machines, doctors
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  Speaker 4: were being replaced in many settings by their practitioner's physician
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  Speaker 4: extenders and other non physicians with bar less tramining, who
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  Speaker 4: could again do many and in some cases most of
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  Speaker 4: the things that doctors do do them just as well,
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  Speaker 4: So it seemed like questions were importantly being raised about
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  Speaker 4: what's left that's the special skill and talent of the physician,
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  Speaker 4: and which things might be replaced. That was thirty years ago.
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  Speaker 4: Along comes chat, GPT, Claude, all the rest of the
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  Speaker 4: current crop of large language model generative artificial intelligence products,
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  Speaker 4: and it just takes those same questions and kicks them
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  Speaker 4: up many notches or many degrees of complexity. Oh, second
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  Speaker 4: part of your question recent paper in drama. This concept
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  Speaker 4: of ara comes from a famous essay to the German
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  Speaker 4: philosopher Walter Benjamin, who was talking about art medicine. There
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  Speaker 4: was no AI for medicine, but his concern was whether
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  Speaker 4: in the age of mechanical reproduction, particularly film and photography,
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  Speaker 4: we would still need painters. And if so, what is
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  Speaker 4: that that painters do or what is it that makes
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  Speaker 4: an original work of art special in a way that
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  Speaker 4: a high quality reproduction is not special? And he proposed
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  Speaker 4: this vaguely defined concept of aura. He said, an original
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  Speaker 4: work of art has some ineffable, undefinable, but recognizable and
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  Speaker 4: special quality. It's aura that has to do with its history,
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  Speaker 4: the purposes for which it was built, the specific place
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  Speaker 4: and time in which it is being seen by a
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  Speaker 4: particular observer. That makes the original work of art unique
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  Speaker 4: and special, even if you have a high quality reproduction
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  Speaker 4: that almost nobody can tell the difference about. And he
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  Speaker 4: went on to look at the ways that the technology
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  Speaker 4: might change the way we think about the social function
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  Speaker 4: of our painting exists in one place, in one time
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  Speaker 4: and has an original, but there's no such thing as
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  Speaker 4: an original photograph. You have the negative and then you
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  Speaker 4: can make dozens hundreds of millions of identical, reproducible reproductions
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  Speaker 4: of that work of art. So in the essay and Drama,
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  Speaker 4: I said, it looks like AI is doing for the
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  Speaker 4: doctor patient encounter what photography did for oil painting or
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  Speaker 4: the visual arts. It's taking something that once had an aura,
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  Speaker 4: was thought to be unique, special, located at a particular
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  Speaker 4: place in time, and had it derived its value from
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  Speaker 4: that moment that interaction between two human beings and makes
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  Speaker 4: it infinitely be reproducible. You can consult your LLM doctor
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  Speaker 4: your chatbut anywhere anytime twenty four to seven. The chatbot
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  Speaker 4: is never off duty, it has never moody, It doesn't
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  Speaker 4: need sleep and so will replace many of the functions
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  Speaker 4: of the physician. And in the paper, I asked, what's
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  Speaker 4: left of the area the specialness of the doctor patient incounter.
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  Speaker 2: Yeah, and I think it's helpful to think about it
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  Speaker 2: in terms of the physician patient relationship. And it's because
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  Speaker 2: when I first read the piece, I think you read
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  Speaker 2: it too quickly, and I thought, oh, the ore is
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  Speaker 2: something right, it's the area of the physician.
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  Speaker 3: But is the ore really applicable.
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  Speaker 2: To that, to the interaction, to that of relationship as
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  Speaker 2: opposed to just one of the parties like how are
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  Speaker 2: you thinking about where the auras look?
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  Speaker 4: In Manuman's work, he talks about that about how the
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  Speaker 4: work of art exists in a place and time, but
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  Speaker 4: it's aura comes from the interaction between the viewer seeing
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  Speaker 4: the work of art in that place and time. And
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  Speaker 4: he actually goes back to Neanderthal cave art and early
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  Speaker 4: Greek sculptures and the relationship between art and religion or
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  Speaker 4: these original works of art had a sacred function and
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  Speaker 4: often were placed in temples or we're thought to have
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  Speaker 4: magic the future or somehow thanktify a moment when one
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  Speaker 4: interacted with them, and over the years he talks about
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  Speaker 4: how they lost those functions but then developed a new
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  Speaker 4: kind of oro where they were placed not in temples
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  Speaker 4: but in museums, and people would make pilgrimages to see
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  Speaker 4: the Mona Lisa or billion Celo's David or other particularly
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  Speaker 4: famous and venerable, irreplaceable rs around works of art, where
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  Speaker 4: seeing a reproduction was not thought to have the same magic,
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  Speaker 4: the same power, the same deep meaning as seeing the
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  Speaker 4: regional Michaelangelo sculpted himself.
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  Speaker 2: Yeah, I mean that that's really helpful because I'm thinking about,
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  Speaker 2: you know, the occasional interaction with you know what, you
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  Speaker 2: hop on some l M. Gemini chatch with you whoever
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  Speaker 2: and you ask, you know, I've got this cut, what
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  Speaker 2: do I do or whatever?
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  Speaker 3: The right medical questions. That's different from the kind of
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  Speaker 3: conversation and.
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  Speaker 2: I don't use AI as much as most people, I know,
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  Speaker 2: as much as I probably should, But that's different than
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  Speaker 2: you know, sitting in a physician's office talking about X.
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  Speaker 2: And so that's that's helpful to kind of get the ORAN.
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  Speaker 2: And it brings me back to some early work in
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  Speaker 2: bioethics by Paul Ramsey, and I remember reading for time
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  Speaker 2: patient as person and when he's talking great because he's
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  Speaker 2: really in some research ethics questions. He says something like,
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  Speaker 2: you know, in thinking about the relationship between physicians and patients,
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  Speaker 2: it's such a joint endeavor. I think he calls them
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  Speaker 2: joint adventurers and says that at the end of this process,
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  Speaker 2: both a physician and patient can say I cure. And
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  Speaker 2: I think, well, I get how that works if you
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  Speaker 2: have been you know, a well oiled physician patient relationship.
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  Speaker 3: I don't know if any patient.
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  Speaker 2: Who hops on chat, GPT whatever think that, you know,
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  Speaker 2: the chat, GIPT and the patient are curing together, right.
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  Speaker 3: I'm just going to find information about something.
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  Speaker 2: So I'm trying to sort of better understand because I
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  Speaker 2: think there's something right there. There's something about your arguments
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  Speaker 2: for the ore that seems really attractive.
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  Speaker 3: I just can't. I can't.
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  Speaker 2: I'm not there. I think there's something right, I just
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  Speaker 2: don't know exactly what it is.
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  Speaker 4: In the paper, I borrow the concept of Barbara from
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  Speaker 4: this one hundred year old essay I've altered, you mean,
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  Speaker 4: but use it to highlight a longer trend that I
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  Speaker 4: think set the stage for the current use of a
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  Speaker 4: GUI and medicine and In that longer trend, I go
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  Speaker 4: back to Fuco's work The Birth of the Clinic and
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  Speaker 4: talk about how the rise of modern scientific medicine was,
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  Speaker 4: in large part a movement to shift the focus of
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  Speaker 4: doctor's concerns from the patient's subjective experience and narrative of
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  Speaker 4: their illness and attempt to derive meaning from their suffering,
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  Speaker 4: to what he called the clinical gaze, which seems which
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  Speaker 4: attempts to abstract the patient, get rid of all those
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  Speaker 4: personal meanings in order to arrive at objective truths about
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  Speaker 4: disease that don't require subjective interpretation or understand In the work, Co,
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  Speaker 4: who doesn't necessarily endorse this approach is working as a historian,
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  Speaker 4: unpacked a lot of the work that was being done
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  Speaker 4: in the late eighteenth and early nineteenth century, particularly in Paris,
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  Speaker 4: where many clinical biologists an experimentalists in medicine thoughts to
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  Speaker 4: find measurable, objective findings that can be used to categorize disease.
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  Speaker 4: So it was the rise of oscultation listening to the
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  Speaker 4: lung zunes, It was the rise of microscopy. In particular,
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  Speaker 4: it was the autopsy that correlated the clinical symptoms of
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  Speaker 4: the patient was alive pathological findings seen an autopsy after
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  Speaker 4: they die. In order to achieve this idea of saying,
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  Speaker 4: when you come in, I don't need to talk to
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  Speaker 4: you anymore, I don't need to know your story. All
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  Speaker 4: I need is the objective fact that I can find
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  Speaker 4: by listening through my stethoscope, by measuring your temperature, your heartbeat,
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  Speaker 4: anything else we could measure. And the more objective I
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  Speaker 4: can be, the more scientific practice of medicine will be,
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  Speaker 4: and ultimately the more effective it will be. At the
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  Speaker 4: time in seventeen ninety Paris, they weren't very good at
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  Speaker 4: doing that, but the philosophy developed over the next two
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  Speaker 4: hundred years, and in the paper I suggest that most
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  Speaker 4: of the successes of medicine, modern scientific medicine came from
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  Speaker 4: steadily applying that point of view and making medicine more objective,
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  Speaker 4: less subjective, more dependent on precise measurement, and less narrative
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  Speaker 4: and storytelling, more about path of physiology than about psychology
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  Speaker 4: or the patient's metaphysical or deep understood deep attempts to
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  Speaker 4: understand why they got ill and what illness means in
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  Speaker 4: the larger context of their life. I go through like
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  Speaker 4: the rise of the modern hospital, which moved doctors and
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  Speaker 4: their interactions with the patients from the patient's pome skulls
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  Speaker 4: and couldn't see the patient's families, see whether they lived
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  Speaker 4: on a farm, see what sort of life they add
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  Speaker 4: to a hospital where they could get more of these
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  Speaker 4: objective measurements but obliterate the patient's individuality. Surgery and anesthesia
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  Speaker 4: is another chapter in this long development, where you know,
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  Speaker 4: you effectuate your cure other patients anesthetized and unaware of
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  Speaker 4: what you're doing. The randomized control trial, the global standard
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  Speaker 4: of evidence based medicine seeks to obliterate anything that makes
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  Speaker 4: the individuals unique. Those are seen as confounders rather than
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  Speaker 4: important elements of illness, because we want to abstract what's
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  Speaker 4: common across all people rather than what's unique and individual.
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  Speaker 4: And I suggest that all of these developments led to
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  Speaker 4: what we think of as high quality medicine, evidence based medicine,
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  Speaker 4: and they're all dehumanizing, depersonalizing, and at the stage for
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  Speaker 4: a machine to come in and say, hey, that's what
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  Speaker 4: medicine is. It's just about measuring, predicting, and changing path
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  Speaker 4: of physiology. What do you need a human interaction for
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  Speaker 4: machines can do most of that stuff better.
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  Speaker 2: Yeah, I mean, and the depersonalization point I thought was
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  Speaker 2: very powerful in the essay. I hadn't thought much about
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  Speaker 2: the surgery, which fit really well. And when we teach
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  Speaker 2: surgical ethics here, I mean, I've always thought, oh my gosh,
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  Speaker 2: that's a relationship where I'm always a patrier and I'm
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  Speaker 2: a PhD.
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  Speaker 3: I'm not a doc.
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  Speaker 2: But I think that's where that's an instance where the
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  Speaker 2: relationship would be so important to me because I can't
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  Speaker 2: say anything, and when the surgeon is making particular kinds
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  Speaker 2: of valuating decisions about right where to cut, what to do,
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  Speaker 2: how risky to be, and it risk factors and those
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  Speaker 2: kinds of things, I hadn't thought about it, which was.
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  Speaker 3: A great point.
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  Speaker 2: The Payot's oh and but Brian's not moving, I mean,
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  Speaker 2: you don't have to worry about that in some ways.
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  Speaker 2: So that was a really helpful sort of history of
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  Speaker 2: how we got to the point where we're at just
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  Speaker 2: before AI. When you're on the history, you also make
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  Speaker 2: the comparison to telemedicine, and I thought that was super interesting,
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  Speaker 2: especially sort of coming out of COVID. It seems like
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  Speaker 2: the telemedicines just everywhere and in person, and interactions had
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  Speaker 2: been prized, right, you did whatever you could to get
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  Speaker 2: to the doctor's office.
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  Speaker 3: You didn't miss that appointment.
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  Speaker 2: But you know that the ore that makes patients feel
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  Speaker 2: maybe uniquely human sort of that thing that was Maybe
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  Speaker 2: that's sort of what I find so attractive about the
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  Speaker 2: ore line. I want to know is that something that
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  Speaker 2: patients want? And I'm not looking for a big studies
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  Speaker 2: to be anecdotal across your use.
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  Speaker 4: I mean.
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  Speaker 2: They're increased technologically mediated interactions today. So the and there's
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  Speaker 2: a payment that came out I can find I can
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  Speaker 2: stick in the show notes forks who are interested.
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  Speaker 3: But you know, I.
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  Speaker 2: Message my doc and I say, oh, hey, you know
• 17:55
  Speaker 2: my leg hurts here where it's back, come in, Brian,
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  Speaker 2: or hey, here's the test result.
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  Speaker 3: If AI is responding, it says, oh.
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  Speaker 2: Sorry, like hurts, Brian. I heard the Mets lost yesterday.
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  Speaker 2: I'm so sorry. I know you really care about that,
• 18:07
  Speaker 2: you know, yeah, did you bang it at the gate?
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  Speaker 2: And I'll find the paper. But there's have been there's
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  Speaker 2: research that suggests that it's really patients think AI, at
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  Speaker 2: least in certain context, is more empathetic than human beings,
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  Speaker 2: which I think is just perception. But so now this
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  Speaker 2: is turning into a long mandering question. Is this something
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  Speaker 2: you think patients want? Is the ore of something that
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  Speaker 2: they would go in for? Or is AI a good
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  Speaker 2: enough replacement for a doctor.
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  Speaker 4: I don't think there's a simple bl answer to that one.
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  Speaker 4: I think it is very context dependent, takes dependent. Because
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  Speaker 4: with that, I think there are many things that people
• 18:47
  Speaker 4: now go to doctors for that they will soon go
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  Speaker 4: to AI for. And I feel like nothing is lost,
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  Speaker 4: and in fact, much it is gained because as a
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  Speaker 4: twenty four to seven I remember is that you're a
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  Speaker 4: mass fan and asked a feeling about it. AI reads
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  Speaker 4: all of the medical literature and remembers every bit of
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  Speaker 4: it in ways that doctors cannot. One of the points
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  Speaker 4: I made in the book do we still need doctors
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  Speaker 4: thirty years ago? Was we need doctors the most where
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  Speaker 4: the science is the worst. So the better course to
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  Speaker 4: put it positively, the better the science, the less we
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  Speaker 4: need a doctor. And the example I used in the
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  Speaker 4: book was immunization. They work really well, and they work
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  Speaker 4: well whether I know you, I don't know you, whether
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  Speaker 4: a doctor gives them, a nurse, a pharmacist or a
• 19:42
  Speaker 4: clerk in the grocery store. The science is impact up
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  Speaker 4: our people who will argue with that, of course today,
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  Speaker 4: but that's my belief. Where we need doctors the most
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  Speaker 4: is when the algorithms fail, when it's unclear what the
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  Speaker 4: best thing is for you today, and then a doctrine
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  Speaker 4: and patient I think really need to have that deeply
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  Speaker 4: personal value in form discussion about the uncertainties associated with
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  Speaker 4: various approaches to a disease that maybe can't be precisely diagnosed,
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  Speaker 4: for which no good treatment is clearly the best, and
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  Speaker 4: for which the choices all involve deeply personal values and
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  Speaker 4: risk tradeoffs that for which there's no right answer. The
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  Speaker 4: irony that I pointed out in the book, and that
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  Speaker 4: I think is as true today as it was then,
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  Speaker 4: is we're all going to get to that point. The
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  Speaker 4: algorithms are good for certain diseases. We know which treatments
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  Speaker 4: work in which situations for many things. But the better
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  Speaker 4: treatments work, the more complicated become the diseases for which
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  Speaker 4: there is no longer any good size or treatment. We're
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  Speaker 4: seeing that today in cardiac care, we're seeing that today
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  Speaker 4: in cancer care. Were certainly seeing it in genomics and
• 21:08
  Speaker 4: or diseases had left the algorithms behind, or back to
• 21:13
  Speaker 4: that sort of Paul Ramsey asque mutual exploration of what
• 21:19
  Speaker 4: the appropriate response to an illness suffering an embodied frailty
• 21:24
  Speaker 4: to be.
• 21:25
  Speaker 2: Yeah, I mean, and then reminds me of one of
• 21:27
  Speaker 2: my favorite lines in your Jama piece about sort of
• 21:31
  Speaker 2: I think maybe capture and I'll ask you to expand
• 21:34
  Speaker 2: on it, but I think it captures what you were
• 21:36
  Speaker 2: just laying out. Well, you wrote, artificial intelligence is but
• 21:40
  Speaker 2: the latest development in this long struggle over the soul
• 21:44
  Speaker 2: of medicine, right, which sounds especially weight And you're describing
• 21:48
  Speaker 2: sort of a tension and you've lived this out in
• 21:50
  Speaker 2: historically you pain in the picture well, but attention I
• 21:53
  Speaker 2: think between technological efficiency and human presence, and so can
• 21:58
  Speaker 2: you just say a little bit more about that tension,
• 22:01
  Speaker 2: because as you've framed it, I mean like, O, hey, look,
• 22:03
  Speaker 2: there's some things Brian can go grab good AI. For
• 22:06
  Speaker 2: some things, the really challenging stuff, we don't have an
• 22:08
  Speaker 2: answer valuating questions where I'm going to want to spend
• 22:11
  Speaker 2: time with a physician. Some people have access to these things,
• 22:14
  Speaker 2: some people won't. If I go to AI a lot. Well,
• 22:18
  Speaker 2: I then maybe not want to bother with the physician
• 22:21
  Speaker 2: because I'll conflict.
• 22:22
  Speaker 3: So say more about sort of this fight for the
• 22:25
  Speaker 3: soul of medicine.
• 22:26
  Speaker 4: Yeah, So long before AI and particularly in the last
• 22:36
  Speaker 4: say thirty years, we've seen the rise of so called
• 22:39
  Speaker 4: evidence based medicine. I say so called because I think
• 22:43
  Speaker 4: medicine has always been evidence based, just the quality of
• 22:47
  Speaker 4: the evidence and the way we think about what counts
• 22:50
  Speaker 4: as an explanation. But bribal shamanistic healers we're looking for evidence.
• 22:55
  Speaker 4: It just wasn't the kind of generalizable scientific evidence that
• 22:59
  Speaker 4: we think about. It was much more of a deeply
• 23:01
  Speaker 4: personal understanding of who you were and why your symptoms
• 23:07
  Speaker 4: made sense in the context of what is going on
• 23:10
  Speaker 4: in your life at this moment. Again back to the
• 23:14
  Speaker 4: idea of our in the unique time and place of
• 23:17
  Speaker 4: a particular interact. The rise of evidence based medicine. It
• 23:20
  Speaker 4: followed the logic of randomized controlled trials that was talking
• 23:24
  Speaker 4: about before. I don't want to know your life story.
• 23:27
  Speaker 4: I don't want to know I want to know your symptoms.
• 23:29
  Speaker 4: I want to know your lab values. I want to
• 23:31
  Speaker 4: know what your X ray show. And then I will
• 23:35
  Speaker 4: follow a practice guideline based on the best available evidence.
• 23:40
  Speaker 4: It shows that for people with your objectively measured path
• 23:45
  Speaker 4: of physiology, this form of treatment is the best. So
• 23:49
  Speaker 4: the soul of medicine involved kind of the art of
• 23:52
  Speaker 4: medicine or clinical judgment, clinical judgment that said, Okay, there's
• 23:56
  Speaker 4: a practice guideline, there's all this evidence, but I know
• 24:00
  Speaker 4: I'm a doctor. I'm looking in your eyes. I can
• 24:04
  Speaker 4: see the way you're describing their symptoms, and I think
• 24:08
  Speaker 4: there's something unique and different about you. I'm going to
• 24:12
  Speaker 4: leave the practice guideline behind. I'm going to deviate from
• 24:16
  Speaker 4: evidence based medicine, and I'm going to apply my unique skill,
• 24:20
  Speaker 4: my talent laying on a hand to all the things
• 24:23
  Speaker 4: that used to be the essence of a caring, empathic
• 24:27
  Speaker 4: doctor patient relationship. That becomes harder and harder to do
• 24:31
  Speaker 4: and did before AI because the evidence, the practice guidelines,
• 24:36
  Speaker 4: all these things were agreed upon as the recommended standard
• 24:42
  Speaker 4: of care or particular set of treatments, and doctors were
• 24:47
  Speaker 4: increasingly discouraged from exercising individualized clinical judgment because much of
• 24:54
  Speaker 4: the time their individualized clinical judgment led to worse outcomes
• 24:58
  Speaker 4: than following the pres the evidence based practice guidelines. When
• 25:03
  Speaker 4: that happens, medicine loses something of the soul, something of
• 25:09
  Speaker 4: the idea of an art of medicine, something about individualized,
• 25:13
  Speaker 4: personalized patient care. And AI is going to accelerate that process.
• 25:20
  Speaker 4: Hey lead to better outcomes, certainly will in many cases,
• 25:23
  Speaker 4: but will come at the costs of this deeply personal,
• 25:28
  Speaker 4: trusting doctor patient interaction that people have valued for centuries
• 25:35
  Speaker 4: there a millennium.
• 25:36
  Speaker 2: Yeah, that's I mean, I think you've lived the tension.
• 25:39
  Speaker 3: You've lit up the tension well.
• 25:41
  Speaker 2: And when I hear different folks in this conversation, some
• 25:45
  Speaker 2: folks saying, well, look if the outcomes are better, oh
• 25:47
  Speaker 2: my cards on the table, folks who listen to the podcast. Now,
• 25:49
  Speaker 2: I'm more of a virtues vices guy than a rules
• 25:52
  Speaker 2: are a consequential consequences guy. But you know, I mean,
• 25:56
  Speaker 2: the outcomes are powerful. When I go see a physician,
• 25:59
  Speaker 2: I want thing fixed usually, or if I bring my
• 26:02
  Speaker 2: little kids into a little more complicated but you know,
• 26:04
  Speaker 2: I want them to be better.
• 26:06
  Speaker 3: And so it's nice.
• 26:08
  Speaker 2: They're you know, i'd like my general practitioner, the pediatricians.
• 26:11
  Speaker 3: My daughter.
• 26:12
  Speaker 2: So they're nice, you know, But reflecting on medicine as
• 26:16
  Speaker 2: somebody interesting in ethics. I think the relationship is just
• 26:19
  Speaker 2: tremendously interesting, and we're thinking about this our sou sounds great,
• 26:22
  Speaker 2: but as a patient I want something fixed. And so
• 26:24
  Speaker 2: this gets to another really nice line you have. I
• 26:26
  Speaker 2: think you frame it well and you say when of
• 26:28
  Speaker 2: profession's core competencies, And this brings us back to the
• 26:31
  Speaker 2: ben you mean, stuff become reproducible. The central question is
• 26:35
  Speaker 2: not will it disappear? As someone who teaches at medical schools,
• 26:39
  Speaker 2: I think medical schools should always be around, and you know,
• 26:41
  Speaker 2: physician should always be around. But it's not back to you.
• 26:44
  Speaker 2: It's not whether it will disappear, but how its social
• 26:48
  Speaker 2: role will be redefined.
• 26:50
  Speaker 3: And so.
• 26:52
  Speaker 2: If this is the book, then just you know, push
• 26:54
  Speaker 2: us in the direction and when the book comes out,
• 26:56
  Speaker 2: we'll make sure we post the link to get it.
• 26:59
  Speaker 2: But how are you thinking about defining such a role?
• 27:03
  Speaker 2: Because of as I mean, I imagine the instances where we
• 27:09
  Speaker 2: where patients are most in need of physicians, right where
• 27:11
  Speaker 2: the science is less strong. Those instances, I imagine will
• 27:15
  Speaker 2: become fewer as we know more and as you know
• 27:19
  Speaker 2: the algorithms and the research become more sophisticated. So what
• 27:24
  Speaker 2: do you envision the role of physicians being or the
• 27:26
  Speaker 2: redefinition of the role in the future.
• 27:28
  Speaker 4: Great question difficult to answer at this point, but one
• 27:32
  Speaker 4: of the points I make in the essay again drawing
• 27:35
  Speaker 4: on Venumine, is that his concern was that art might disappear,
• 27:41
  Speaker 4: of visual arts, painting in particular, replaced by mechanical reproduction.
• 27:46
  Speaker 4: He found two things that modified his view on that.
• 27:50
  Speaker 4: One is, painting didn't disappear, but it did completely redefine
• 27:55
  Speaker 4: its social role. So painting used to be either associated
• 28:00
  Speaker 4: with religious iconography. Paintings existed to create enhance a sacred
• 28:06
  Speaker 4: space and generate in us feelings of devotion and reverence
• 28:13
  Speaker 4: for God, or art existed to flatter the bourgeoisie to
• 28:18
  Speaker 4: you know, portrait painting. People would sit, they'd get a
• 28:22
  Speaker 4: flattering picture to put on their wall, the way people
• 28:25
  Speaker 4: now put photographs on their wall. Once photography came along,
• 28:29
  Speaker 4: those functions diminished in importance. But painting didn't go away.
• 28:35
  Speaker 4: It just said, whatever it is we're doing has to change.
• 28:39
  Speaker 4: And so realism gave way to Impressionism and Cubism and
• 28:44
  Speaker 4: surrealism and Dadaism. All these new ideas of what art
• 28:50
  Speaker 4: ought to be and do, and that there's arguably more
• 28:55
  Speaker 4: art and maybe even better art, or a wider variety
• 29:00
  Speaker 4: of interesting ways to think about what counts as beauty
• 29:04
  Speaker 4: in a painting or a museum than there ever were.
• 29:07
  Speaker 4: Art didn't go away. It just looks nothing like it
• 29:10
  Speaker 4: looked one hundred and fifty years ago before the rise
• 29:14
  Speaker 4: of technology. Benymine was writing one hundred years after the
• 29:18
  Speaker 4: development of photography, so this was a long process. The
• 29:22
  Speaker 4: second thing he pointed out and didn't just allow more
• 29:27
  Speaker 4: accurate depictions of reality, It enabled us to explore reality
• 29:33
  Speaker 4: in new ways. Cameras could zoom in, they could zoom out,
• 29:38
  Speaker 4: they could go in slow motion. They could show us
• 29:42
  Speaker 4: things that were there that we had been unable to
• 29:44
  Speaker 4: see it all before. So taking those two things together,
• 29:47
  Speaker 4: I think AI is going to help us understand in
• 29:51
  Speaker 4: new and different ways things that we thought we understood before.
• 29:56
  Speaker 4: For example, rustworthina, empathy, objective perceptions of illness, the meaning
• 30:02
  Speaker 4: of conversation and interaction. When you can do for those
• 30:07
  Speaker 4: with a chat pot what a zoom lens could do
• 30:10
  Speaker 4: for the way we see things, will suddenly see new
• 30:14
  Speaker 4: things and different things. And one of my favorites is empathy.
• 30:18
  Speaker 4: I mean, the studies showing that people perceive AI to
• 30:21
  Speaker 4: be more empathic clearly represent one aspect of empathy. Representational empathy.
• 30:28
  Speaker 4: Chat Bots know the words that generate in somebody who
• 30:32
  Speaker 4: reads those words of feeling that they are cared for.
• 30:35
  Speaker 4: That's one piece of empathy. I don't think it's all
• 30:39
  Speaker 4: of empathy, and so, but it will force us to
• 30:42
  Speaker 4: think about what are the other aspects, how are they important,
• 30:45
  Speaker 4: how are they different? How many will be machine reproducible,
• 30:48
  Speaker 4: and what will be left that's uniquely human, that can
• 30:52
  Speaker 4: be studied, can be deeply understood in new ways, can
• 30:58
  Speaker 4: be taught, and can be developed as if it were
• 31:01
  Speaker 4: a new movement. And are how medicine will reimagine a
• 31:04
  Speaker 4: social rubble. I can't say, but I think if it doesn't,
• 31:08
  Speaker 4: then we doctors are screwed.
• 31:10
  Speaker 3: Yeah, I mean that it's a great answer.
• 31:12
  Speaker 2: It's both tremendously interest I mean, it gives us so
• 31:15
  Speaker 2: many things to think about and even just how patient
• 31:19
  Speaker 2: populations I mean this varies across you know, places and times,
• 31:22
  Speaker 2: but might change.
• 31:23
  Speaker 4: You know.
• 31:23
  Speaker 2: I'm I am much more concerned about privacy and confidentiality
• 31:28
  Speaker 2: than some of my younger colleagues. And I imagine my daughters,
• 31:31
  Speaker 2: who are prettying, we'll grow up with just different kinds
• 31:34
  Speaker 2: of views. And so I'm thinking I teach matterical, I
• 31:36
  Speaker 2: thinks not. I used to teach a lot of philosophy.
• 31:38
  Speaker 2: And when The Matrix came out, that whole film, every philosopher,
• 31:42
  Speaker 2: Oh my gosh, they're doing the things we've been talking
• 31:44
  Speaker 2: about for us. So it's always around and there's a
• 31:47
  Speaker 2: character who sort of knows things are deluded, but sort
• 31:51
  Speaker 2: of is going to intentionally buy into the delusion. And
• 31:54
  Speaker 2: that's where I think the sort of representations of empathy
• 31:58
  Speaker 2: is super interesting. Are there future persons who are going
• 32:01
  Speaker 2: to say, hey, and you know, I still feel good
• 32:04
  Speaker 2: even though I know it's not anyway, there's a time.
• 32:07
  Speaker 2: That's just one of many, many things we could think about.
• 32:09
  Speaker 2: And I said, the answer is great, it's it's unsatisfying.
• 32:13
  Speaker 2: And it reminded me of the first time I read
• 32:15
  Speaker 2: in grad school of Macintire's After Virtue.
• 32:19
  Speaker 3: And so it goes through this long treatise.
• 32:20
  Speaker 2: You get the history and get arguments for you know,
• 32:22
  Speaker 2: we really need to be thinking more about virtue. A
• 32:24
  Speaker 2: character also and then at the end it's like, okay,
• 32:27
  Speaker 2: well what's the answer, and he says something like, well,
• 32:29
  Speaker 2: we're not waiting for a GOODO but for another doubtless
• 32:32
  Speaker 2: very different Saint Benedict. And it reminded me of your analysis.
• 32:35
  Speaker 2: I mean, what that social role that physicians, how they
• 32:39
  Speaker 2: will redefine it.
• 32:40
  Speaker 3: We don't know what it is.
• 32:42
  Speaker 2: And right Magetar's talking about sort of the Benedictine and
• 32:44
  Speaker 2: monk communities and all that, and so I think that's
• 32:46
  Speaker 2: that's a powerful question. And so I'm going to move
• 32:49
  Speaker 2: briefly to an education question. Then I'll get you out
• 32:51
  Speaker 2: on another one, because I see we're closing out on time.
• 32:54
  Speaker 2: Given you know, all of you thought about these kinds
• 32:58
  Speaker 2: of technological advances over thirty plus years or practice everything.
• 33:03
  Speaker 2: I mean, what if it were up to you, how
• 33:07
  Speaker 2: would you shape medical education? So you've got the great
• 33:12
  Speaker 2: work from for Co and the clinical gays that you
• 33:15
  Speaker 2: mentioned Aura, and then you mean, I should medical students
• 33:20
  Speaker 2: study philosophy? I mean, what's the if you could give
• 33:24
  Speaker 2: sort of one bit of advice to medical students or
• 33:26
  Speaker 2: to deans of curriculum, where would you push medical education
• 33:31
  Speaker 2: to help prepare future physicians for a world of new
• 33:34
  Speaker 2: social hole.
• 33:35
  Speaker 4: It's the perfect question to ask, and I'll explain what
• 33:39
  Speaker 4: I mean by then. I think we end to forget
• 33:43
  Speaker 4: a lot of the time, how our current ideas of medicine,
• 33:47
  Speaker 4: of what doctors should do, of what a healthcare system
• 33:50
  Speaker 4: should look like, are deeply culturally embedded and deeply historically
• 33:56
  Speaker 4: determined and therefore contingent. So we have a healthcare system,
• 34:02
  Speaker 4: our non system in the United States, that has all
• 34:06
  Speaker 4: these weird quirks. I mean, the way we do medical
• 34:09
  Speaker 4: education is pretty much the way they developed a curriculum
• 34:14
  Speaker 4: in Germany in the eighteen eighties. It was this idea
• 34:18
  Speaker 4: that doctors should be scientists. We start by doing physics
• 34:22
  Speaker 4: and calculus and biochemistry, and then medical school we do
• 34:28
  Speaker 4: other basic sciences, the physiology, physiology, histology, all this stuff.
• 34:35
  Speaker 4: And this idea that the doctor should be sort of
• 34:38
  Speaker 4: a learned scientist in the model of pastor or you know,
• 34:45
  Speaker 4: the other great nineteenth century people is completely obsolete in
• 34:52
  Speaker 4: terms of what doctors actually do and need to know today,
• 34:56
  Speaker 4: but also remarkably durable in its obsolescence. I've been on
• 35:05
  Speaker 4: curriculum reform committees in medical schools and they say it's
• 35:08
  Speaker 4: easier to move a graveyard than to change the medical
• 35:11
  Speaker 4: school Curriculm doul Ai might be the nudge that will
• 35:16
  Speaker 4: allow a radical reconceptualization of what that would mean, what
• 35:21
  Speaker 4: might it look like. A question would be what do
• 35:26
  Speaker 4: people want in terms of health or a system that
• 35:30
  Speaker 4: can address the many ailment to which humanity is there.
• 35:34
  Speaker 4: Another quirk of the current system is that we have
• 35:38
  Speaker 4: all these different kinds of health professionals, but they don't
• 35:42
  Speaker 4: train together. Though there's no concept that building a functional
• 35:47
  Speaker 4: team that brings together the expertise of physicians versus physical therapists,
• 35:53
  Speaker 4: speech therapists, psychologists, social workers, economists, administrators to develop us
• 36:00
  Speaker 4: system that addresses some defined goal that all could agree with.
• 36:06
  Speaker 4: That just doesn't happen today. Each gets their own siloed education,
• 36:10
  Speaker 4: and then they're thrown into a complicated institution like a
• 36:15
  Speaker 4: hospital or an academic medical center or a primary care clinic,
• 36:19
  Speaker 4: and somehow expected to complement each other and work together.
• 36:23
  Speaker 4: That's completely nuts, and yet that's the system we've ended
• 36:26
  Speaker 4: up with, and we all just take it for granted.
• 36:29
  Speaker 4: Of course, nurses, they're going to go to nursing school. Doctors,
• 36:32
  Speaker 4: you're going to go to doctor school. Mental health is
• 36:35
  Speaker 4: its own themission of social workers, psychologists, MD psychiatrists, all
• 36:41
  Speaker 4: of whom have different kinds of training, and all of
• 36:43
  Speaker 4: them are supposed to work together. What would it look
• 36:45
  Speaker 4: like if we were going to reconceptualize that. I mean,
• 36:48
  Speaker 4: here's the eye in the sky thought experiment, but together
• 36:51
  Speaker 4: a group that includes philosophers, theologian, psychologists, psicians, administrators, and say,
• 36:59
  Speaker 4: how can we work together to build a system that
• 37:02
  Speaker 4: addresses the concerns of people who feel disease, who feel
• 37:08
  Speaker 4: something is wrong in their life and they don't know
• 37:11
  Speaker 4: if it's physical, mental, social, emotional, economic, and redefine what
• 37:18
  Speaker 4: a caring institutionotopyople That could happen probably outside of mainstream medicine.
• 37:24
  Speaker 4: I mean, I think it's starting to happen in a
• 37:27
  Speaker 4: lot of alternative healthcare settings. I think that process will
• 37:31
  Speaker 4: likely accelerate. And the question of whether we can find
• 37:35
  Speaker 4: the administrative skill, the philosophical astuteness, or the willingness to
• 37:42
  Speaker 4: challenge tradition and received wisdoms in ways that allow us
• 37:48
  Speaker 4: to build something truly new and radical that harnesses the
• 37:51
  Speaker 4: energy of all the biomedical technology and now the new
• 37:55
  Speaker 4: energy of artificial intelligence do better than we've done.
• 38:00
  Speaker 3: I mean that is quite a vision.
• 38:01
  Speaker 2: I think it's very attractive, and of course like the
• 38:03
  Speaker 2: additional piece that maybe philosophers will have more jobs too,
• 38:06
  Speaker 2: But it's that's the move because that's what people care
• 38:08
  Speaker 2: about at the end of the day, right, it's responding
• 38:11
  Speaker 2: to the disease.
• 38:13
  Speaker 3: Excellent.
• 38:13
  Speaker 2: Well, John, let me get you out on this one
• 38:15
  Speaker 2: last question for folks who've enjoyed this conversation, where can
• 38:19
  Speaker 2: they hear you next? We'll look out for the book
• 38:22
  Speaker 2: whenever it comes out, but what's next for you? If
• 38:24
  Speaker 2: you're given a talk, an expected paper, a recent paper
• 38:28
  Speaker 2: that's good, where can we point folks to sort of
• 38:31
  Speaker 2: read more and hear more?
• 38:32
  Speaker 4: I mean they could go to my website, John leyntoast
• 38:35
  Speaker 4: dot com. Usually when I've been upcoming talk or an
• 38:39
  Speaker 4: article coming out, I'll post something on there about it.
• 38:42
  Speaker 4: I'm focusing a lot on these questions of medical education,
• 38:46
  Speaker 4: and so I have papers impressed at academic medicine, speaking
• 38:51
  Speaker 4: at an international conference on ethics education next month, and
• 38:57
  Speaker 4: just trying to keep up with a few that's rapidly changing.
• 39:02
  Speaker 4: I know what other people are doing and add a
• 39:05
  Speaker 4: little something where I can well.
• 39:07
  Speaker 3: I really enjoyed the article and it was great to chat.
• 39:10
  Speaker 2: I appreciate the time, and we'll make sure in our
• 39:13
  Speaker 2: show notes that we link to the page and we'll
• 39:15
  Speaker 2: keep an eye out for the book when it comes
• 39:17
  Speaker 2: in for the Academic Medicine article.
• 39:18
  Speaker 3: So John, thanks so much in the time. I really
• 39:20
  Speaker 3: appreciate it.
• 39:21
  Speaker 4: Thanks so much for having me. This was great.
• 39:23
  Speaker 1: Series is a production of the Health Ethics Lab, and
• 39:26
  Speaker 1: I am grateful to colleagues in the Department of Medical Sciences,
• 39:29
  Speaker 1: the IHS Library, and the Hackensack Ready in the School
• 39:31
  Speaker 1: of Medicine for making this collaboration possible. To learn more
• 39:35
  Speaker 1: about our work or to engage with the series content,
• 39:38
  Speaker 1: reach out to me Brian Pilkington at Brian dot Pilkington
• 39:42
  Speaker 1: at HMH and dot org.