Physiotherapy in 2050: Ethical and clinical implications

This post describes a project that I began earlier this week with my 3rd year undergraduate students as part of their Professional Ethics module. The project represents a convergence of a few ideas that have been bouncing around in my head for a couple of years and are now coming together as a result of a proposal that I’m putting together for a book chapter for the Critical Physiotherapy Network. I’m undecided at this point if I’ll develop it into a full research proposal, as I’m currently feeling more inclined to just have fun with it rather than turn it into something that will feel more like work.

The project is premised on the idea that health and medicine – embedded within a broader social construct – will be significantly impacted by rapidly accelerating changes in technology. The question we are looking to explore in the project is: What are the moral, ethical, legal, and clinical implications for physiotherapy practice when the boundaries of medical and health science are significantly shifted as a result of technological advances?

The students will work in small groups that are allocated an area of medicine and health where we are seeing significant change as a result of the integration of advanced technology. Each week in class I will present an idea that is relevant to our Professional Ethics module (for example, the concept of human rights) and then each group will explore that concept within the framework of their topic. So, some might look at how gene therapy could influence how we think about our rights, while others might ask what it even means to be human. I’m not 100% how this is going to play out and will most likely adapt the project as we progress, taking into account student feedback and the challenges we encounter. I can foresee some groups having trouble with certain ethical constructs simply because it may not be applicable to their topic.

Exoskeletons are playing an increasingly important role in neurological rehabilitation.
Exoskeletons playing an increasingly important role in neurological rehabilitation.
The following list and questions aim to stimulate the discussion and to give some idea of what we are looking at (this list is not exhaustive and I’m still playing around with ideas – suggestions are welcome):

  1. Artificial intelligence and algorithmic ethical decision-making. Can computers be ethical? How is ethical reasoning incorporated into machines? How will ethical algorithms impact health, for example, when computers make decisions about organ transplant recipients? Can ethics programmed into machines?
  2. Nanotechnology. As our ability to manipulate our world at the atomic level advances, what changes can we expect to see for physiotherapists and physiotherapy practice? How far can we go with integrating technology into our bodies before we stop being “human”?
  3. Gene therapy. What happens when genetic disorders that provide specialisation areas for physiotherapists are eradicated through gene therapy? What happens when we can “fix” the genetic problems that lead to complications that physiotherapists have traditionally had a significant role in. For example, what will we do when cystic fibrosis is cured? What happens when we have a vaccine for HIV? Or when ALS is little more than an inconvenience?
  4. Robotics. What happens when patients who undergo amputations are fitted with prosthetics that link to the nervous system? When exoskeletons for paralysed patients are common? How much of robotic systems will students need to know about? Will exoskeletons be the new wheelchairs?
  5. Aging. What happens when the aging population no longer ages? How will physiotherapy change as the human lifespan is extended? There is an entire field of physiotherapy devoted to the management of the aging population; what will happen to that? How will palliative care change?
  6. Augmented reality. When we can overlay digital information onto our visual field, what possibilities exist for effective patient management? For education? What happens when that information is integrated with location-based data, so that patient-specific information is presented to us when we are near that patient?
  7. Virtual reality. What will it mean for training when we can build entire hospitals and patient interactions in the virtual world? When we can introduce students to the ICU in their first year? This could be especially useful when we have challenges with finding enough placements for students who need to do clinical rotations.
  8. 3D printing. What happens when we can print any equipment that we need, that is made exactly to the patient’s specifications? How will this affect the cost of equipment distribution to patients? Can 3D printed crutches be recycled? Reused by other patients? What new kinds of equipment can be invented when we are not constrained by the production lines of the companies who traditionally make the tools we use?
  9. Brain-computer interfaces. When patients are able to control computers (and by extension, everything linked to the computer) simply by thinking about it, what does that mean for their roles in the world? What does it mean when someone with a C7 complete spinal cord injury can still be a productive member of society? What does it mean for community re-integration? How will “rehabilitation” change if computer science is a requirement to even understand the tools our patients use?
  10. Quantified self. As we begin to use sensors close to our bodies (inside our phones, watches, etc.) and soon – inside our bodies – we will have access to an unprecedented amount of personal (very personal) data about ourselves. We will be able to use that data to inform decision making about our health and well-being, which will change the patient-therapist relationship. This will most likely have the effect of modifying the power differential between patients and clinicians. How will we deal with that? Are we training students to know what to do with that patient information? To understand how these sensors work?
  11. Processing power. While this is actually something that is linked to every other item in the list, it might warrant it’s own topic purely because everything else depends on the continuous improvements in processing power and parallel reduction in cost.
  12. The internet. I’m not sure about this. While the architecture of the internet itself is unlikely to change much in the next few decades (disregarding the idea that the internet as we know it might be supplanted with something better), who has access to it and how we use it will most certainly change.

An artist's depiction of a nanobot that is smaller than blood cells.
Nanobot smaller than blood cells.
I should state that we will be working under certain assumptions:

  • That the technology will not be uniformly integrated into society and health systems i.e. that wealth disparity or income inequality will directly affect implementation of certain therapies. This will,obviously have ethical and moral implications.
  • That the technology will not be freely available i.e. that corporations will license certain genetic therapies and withhold their use on those who cannot pay the license.
  • That technological progression will continue over time i.e. that regulations will not prevent, for example, further research into stem cell therapy.
  • …we may have to make additional assumptions as we move forward but this is all I can think of now

We’ll probably find that there will be significant overlap in the above topics, since some are specific technologies that will have an influence on other areas. For example, gene therapy and nanotechnology may have an impact on aging; artificial intelligence will impact many areas, as will robotics and computing power. The idea isn’t that these topics are discrete and separate, but that they provide a focus point for discussion and exploration, with the understanding that overlap is inevitable. In fact, overlap is preferable, since it will help us explore relationships between the different areas and to find connections that we maybe were not previously aware of.

Giving patients bad news in virtual spaces where we can control the interaction.
Giving patients bad news in virtual spaces where we can control the interaction.
The activities that the students engage in during this project are informed by the following ideas, which overlap with each other:

  • Authentic learning is a framework for designing learning tasks that lead to deeper engagement by students. Authentic tasks should be complex, collaborative, ill-defined, and completed over long periods.
  • Inquiry-based learning suggests that students should identify challenging questions that are aimed at addressing gaps in their understanding of complex problems. The research that they conduct is a process they go through in order to achieve outcomes, rather than being an end in itself.
  • Project-based learning is the idea that we can use full projects – based in the real world – to discuss and explore the disciplinary content, while simultaneously developing important skills that are necessary for learning in the 21st century.

I should be clear that I’m not really sure what the outcome of this project will be. I obviously have objectives for my students’ learning that relate to the Professional Ethics module but in terms of what we cover, how we cover it, what the final “product” is…these are all still quite fluid. I suppose that, ideally, I would like for us as a group (myself and the students) to explore the various concepts together and to come up with a set of suggestions that might help to guide physiotherapy education (or at least, physiotherapy education as practiced by me) over the next 5-10 years.

Augmented reality has significant potential for education.
Augmented reality has significant potential for education.
So much of physiotherapy practice – and therefore, physiotherapy education – is premised on the idea that what has been important over the last 50 years will continue to be important for the next 50. However, as technology progresses and we see incredible advances in the integration of technology into medicine and health systems, we need to ask if the next 50 years are going to look anything like the last 50. In fact, it almost seems as if the most important skill we can teach our students is how to adapt to a constantly changing world. If this is true, then we may need to radically change what we prioritise in the curriculum, as well as how we teach students to learn. When every fact is instantly available, when algorithms influence clinical decision-making, when amputees are fitted with robotic prosthetics controlled directly via brain-computer interfaces…where does that leave the physiotherapist? This project is a first step (for me) towards at least beginning to think about these kinds of questions.