Lifeboat Foundation: Safeguarding Humanity
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Category: homo sapiens

My sociology of knowledge students read Yuval Harari’s bestselling first book, Sapiens, to think about the right frame of reference for understanding the overall trajectory of the human condition. Homo Deus follows the example of Sapiens, using contemporary events to launch into what nowadays is called ‘big history’ but has been also called ‘deep history’ and ‘long history’. Whatever you call it, the orientation sees the human condition as subject to multiple overlapping rhythms of change which generate the sorts of ‘events’ that are the stuff of history lessons. But Harari’s history is nothing like the version you half remember from school.

In school historical events were explained in terms more or less recognizable to the agents involved. In contrast, Harari reaches for accounts that scientifically update the idea of ‘perennial philosophy’. Aldous Huxley popularized this phrase in his quest to seek common patterns of thought in the great world religions which could be leveraged as a global ethic in the aftermath of the Second World War. Harari similarly leverages bits of genetics, ecology, neuroscience and cognitive science to advance a broadly evolutionary narrative. But unlike Darwin’s version, Harari’s points towards the incipient apotheosis of our species; hence, the book’s title.

This invariably means that events are treated as symptoms if not omens of the shape of things to come. Harari’s central thesis is that whereas in the past we cowered in the face of impersonal natural forces beyond our control, nowadays our biggest enemy is the one that faces us in the mirror, which may or may not be able within our control. Thus, the sort of deity into which we are evolving is one whose superhuman powers may well result in self-destruction. Harari’s attitude towards this prospect is one of slightly awestruck bemusement.

Here Harari equivocates where his predecessors dared to distinguish. Writing with the bracing clarity afforded by the Existentialist horizons of the Cold War, cybernetics founder Norbert Wiener declared that humanity’s survival depends on knowing whether what we don’t know is actually trying to hurt us. If so, then any apparent advance in knowledge will always be illusory. As for Harari, he does not seem to see humanity in some never-ending diabolical chess match against an implacable foe, as in The Seventh Seal. Instead he takes refuge in the so-called law of unintended consequences. So while the shape of our ignorance does indeed shift as our knowledge advances, it does so in ways that keep Harari at a comfortable distance from passing judgement on our long term prognosis.

This semi-detachment makes Homo Deus a suave but perhaps not deep read of the human condition. Consider his choice of religious precedents to illustrate that we may be approaching divinity, a thesis with which I am broadly sympathetic. Instead of the Abrahamic God, Harari tends towards the ancient Greek and Hindu deities, who enjoy both superhuman powers and all too human foibles. The implication is that to enhance the one is by no means to diminish the other. If anything, it may simply make the overall result worse than had both our intellects and our passions been weaker. Such an observation, a familiar pretext for comedy, wears well with those who are inclined to read a book like this only once.

One figure who is conspicuous by his absence from Harari’s theology is Faust, the legendary rogue Christian scholar who epitomized the version of Homo Deus at play a hundred years ago in Oswald Spengler’s The Decline of the West. What distinguishes Faustian failings from those of the Greek and Hindu deities is that Faust’s result from his being neither as clever nor as loving as he thought. The theology at work is transcendental, perhaps even Platonic.

In such a world, Harari’s ironic thesis that future humans might possess virtually perfect intellects yet also retain quite undisciplined appetites is a non-starter. If anything, Faust’s undisciplined appetites point to a fundamental intellectual deficiency that prevents him from exercising a ‘rational will’, which is the mark of a truly supreme being. Faust’s sense of his own superiority simply leads him down a path of ever more frustrated and destructive desire. Only the one true God can put him out of his misery in the end.

In contrast, if there is ‘one true God’ in Harari’s theology, it goes by the name of ‘Efficiency’ and its religion is called ‘Dataism’. Efficiency is familiar as the dimension along which technological progress is made. It amounts to discovering how to do more with less. To recall Marshall McLuhan, the ‘less’ is the ‘medium’ and the ‘more’ is the ‘message’. However, the metaphysics of efficiency matters. Are we talking about spending less money, less time and/or less energy?

It is telling that the sort of efficiency which most animates Harari’s account is the conversion of brain power to computer power. To be sure, computers can outperform humans on an increasing range of specialised tasks. Moreover, computers are getting better at integrating the operations of other technologies, each of which also typically replaces one or more human functions. The result is the so-called Internet of Things. But does this mean that the brain is on the verge of becoming redundant?

Those who say yes, most notably the ‘Singularitarians’ whose spiritual home is Silicon Valley, want to translate the brain’s software into a silicon base that will enable it to survive and expand indefinitely in a cosmic Internet of Things. Let’s suppose that such a translation becomes feasible. The energy requirements of such scaled up silicon platforms might still be prohibitive. For all its liabilities and mysteries, the brain remains the most energy efficient medium for encoding and executing intelligence. Indeed, forward facing ecologists might consider investing in a high-tech agronomy dedicated to cultivating neurons to function as organic computers – ‘Stem Cell 2.0’, if you will.

However, Harari does not see this possible future because he remains captive to Silicon Valley’s version of determinism, which prescribes a migration from carbon to silicon for anything worth preserving indefinitely. It is against this backdrop that he flirts with the idea that a computer-based ‘superintelligence’ might eventually find humans surplus to requirements in a rationally organized world. Like other Singularitarians, Harari approaches the matter in the style of a 1950s B-movie fan who sees the normative universe divided between ‘us’ (the humans) and ‘them’ (the non-humans).

The bravest face to put on this intuition is that computers will transition to superintelligence so soon – ‘exponentially’ as the faithful say — that ‘us vs. them’ becomes an operative organizing principle. More likely and messier for Harari is that this process will be dragged out. And during that time Homo sapiens will divide between those who identify with their emerging machine overlords, who are entitled to human-like rights, and those who cling to the new acceptable face of racism, a ‘carbonist’ ideology which would privilege organic life above any silicon-based translations or hybridizations. Maybe Harari will live long enough to write a sequel to Homo Deus to explain how this battle might pan out.

NOTE ON PUBLICATION: Homo Deus is published in September 2016 by Harvil Secker, an imprint of Penguin Random House. Fuller would like to thank The Literary Review for originally commissioning this review. It will appear in a subsequent edition of the magazine and is published here with permission.

Transhumanists will know that the science fiction author Zoltan Istvan has unilaterally leveraged the movement into a political party contesting the 2016 US presidential election. To be sure, many transhumanists have contested Istvan’s own legitimacy, but there is no denying that he has generated enormous publicity for many key transhumanist ideas. Interestingly, his lead idea is that the state should do everything possible to uphold people’s right to live forever. Of course, he means to live forever in a healthy state, fit of mind and body. Istvan cleverly couches this policy as simply an extension of what voters already expect from medical research and welfare provision. And while he may be correct, the policy is fraught with hazards – especially if, as many transhumanists believe, we are on the verge of revealing the secrets to biological immortality.

In June, Istvan and I debated this matter at Brain Bar Budapest. Let me say, for the record, that I think that we are sufficiently close to this prospect that it is not too early to discuss its political and economic implications.

Two months before my encounter with Istvan, I was on a panel at the Edinburgh Science Festival with the great theorist of radical life extension Aubrey de Grey, where he declared that people who live indefinitely will seem like renovated vintage cars. Whatever else, he is suggesting that they would be frozen in time. He may actually be right about this. But is such a state desirable, given that throughout history radical change has been facilitated generational change? Specifically, two simple facts make the young open to doing things differently: The young have no memory of past practices working to anyone else’s benefit, and they have not had the time to invest in those practices to reap their benefits. Whatever good is to be found in the past is hearsay, as far as the young are concerned, which they are being asked to trust as they enter a world that they know is bound to change.

Questions have been already raised about whether tomorrow’s Methuselahs will wish to procreate at all, given the time available to them to realize dreams that in the past would have been transferred to their offspring. After all, as human life expectancy has increased 50% over the past century, the birth rate has correspondingly dropped. One can only imagine what will happen once ageing can be arrested, if not outright reversed!

So, where will the new ideas of the future come from? The worry here is that society may end up being ruled by people with overlong memories who value stability over change: Think China and Japan. But perhaps the old Soviet Union is the most telling example, as its self-consciously revolutionary image gradually morphed into a ritualistic veneration of the original 1917 revolutionary moment. To these gerontocratic indicators, the recent UK vote to leave the European Union (‘Brexit’) adds a new twist. There were some clear age-related patterns in the outcome: The older the voter, the more likely to vote to leave – and the more likely to vote at all. To be sure, given the closeness of the vote (52% to leave vs. 48% to remain), had the young voted in comparable numbers to their elders, Brexit would have lost.

One might think that the simple solution is to encourage, if not force, the young to vote in larger numbers. However, this does not take into account the liabilities of their elders when it comes to dictating the terms for living in the future. Whatever benefits might accrue to people living longer, the clarity of the memories of such people may not be an unmitigated good, as it might incline them to perpetuate what they regard as the best of their own pasts. One way around this situation is to weight votes inversely to age. In other words, the youngest voters would effectively get the most votes and the oldest voters the least. This would continually force the elders to make their case in terms that their juniors can appreciate. The exercise would serve to destabilize any sense of nostalgia that members of the same generation might experience simply by virtue of having experienced the same events at the same age.

However, two technologically based solutions also come to mind. One is for the elderly to be subject to the strategic memory loss procedure described in the film, The Eternal Sunshine of the Spotless Mind, which might be understood as a the cognitive correlate of an inheritance tax – or even a high-class lobotomy! In other words, the elders would lose their personal attachment to events which would nevertheless remain available in the historical record for more detached scrutiny vis-à-vis their lessons for the future. The other, more drastic solution involves incentivizing the elders to exchange biological for digital immortality. This would enable them to enjoy a virtual existence in perpetuity. They might be resurrected (‘downloaded’) on a regular or simply a need-to-remember basis, depending on prior contractual arrangements. The former might be seen as more ‘religious’, as in a Roman Catholic feast day, and the latter more ‘secular’, as in an ‘on tap’ consultant. But in either virtual form, the elders could retain their attachment to certain past events with impunity while at the same time not inflicting their memories needlessly on present generations.

David Wood, the head of the main UK transhumanist organization, London Futurists, has recently published a summa of anti-ageing arguments, which makes a cumulatively persuasive case for indefinite life extension being within our grasp. But most assuredly, this would create as many social problems as it solves biological ones. Under most direct threat would be the sorts of values historically associated with generational change, namely, those related to new thinking and fresh starts. Of course, as I have suggested, there are ways around this, but they will invariably revive in a new high-tech key classic debates concerning the desirability of brainwashing and suicide.

Human civilization has always been a virtual reality. At the onset of culture, which was propagated through the proto-media of cave painting, the talking drum, music, fetish art making, oral tradition and the like, Homo sapiens began a march into cultural virtual realities, a march that would span the entirety of the human enterprise. We don’t often think of cultures as virtual realities, but there is no more apt descriptor for our widely diverse sociological organizations and interpretations than the metaphor of the “virtual reality.” Indeed, the virtual reality metaphor encompasses the complete human project.

Figure 2

Virtual Reality researchers, Jim Blascovich and Jeremy Bailenson, write in their book Infinite Reality; “[Cave art] is likely the first animation technology”, where it provided an early means of what they refer to as “virtual travel”. You are in the cave, but the media in that cave, the dynamic-drawn, fire-illuminated art, represents the plains and animals outside—a completely different environment, one facing entirely the opposite direction, beyond the mouth of the cave. When surrounded by cave art, alive with movement from flickering torches, you are at once inside the cave itself whilst the media experience surrounding you encourages you to indulge in fantasy, and to mentally simulate an entirely different environment. Blascovich and Bailenson suggest that in terms of the evolution of media technology, this was the very first immersive VR. Both the room and helmet-sized VRs used in the present day are but a sophistication of this original form of media VR tech.

Read entire essay here

I learn useful life lessons from each patient I meet. Some are positive messages, reminding me of the importance of maintaining balance between family, work, and leisure activities, but more frequently I witness examples of the remarkable resilience of the human spirit when facing the reality and risks of a major surgical procedure and a diagnosis of cancer. Rarely, patients and their family members utter remorseful or simply sad remarks when they are faced with a grim prognosis and the emotions associated with an onrushing date with mortality. These comments invariably involve an inventory of regrets in life, including, “I should have spent more time with my kids,” “I wish I had told my father (or mother, brother, sister, child, or some other person) that I loved them before they died,” and “I have spent my entire life working, I never took time for anything else.” I wince when I hear these openly expressed remonstrations, I recognize that I am hearing painful and heartfelt truths. Not a week goes by that I am not reminded that I do not one day want to look back at my life with a long list of regrets, should have dones, and what ifs.

I was blessed to meet a great teacher in the guise of a patient early in my academic career. He came to my clinic in my first year after completing a Fellowship in Surgical Oncology, my first year as an Assistant Professor of Surgery. My patient was a 69 year-old Baptist Minister from a small town in Mississippi. He was referred to me by his medical oncologist who called me and said, “I don’t think there is anything you can do for him, but he needs to hear that from you because he doesn’t believe me.” This tall, imposing man had colon cancer that had metastasized (spread) to his liver. The malignant tumor in his colon was removed the year before I met him, and he had received chemotherapy to treat several large tumors found in his liver. The chemotherapy had not worked and the tumors grew. At the point I met him, the medical oncologist told him he would live no more than 6 months, and because he was an avid fisherman when not preaching or helping others in his community , the doctor suggested that he go out and enjoy his remaining time by getting in as much fishing as possible. I learned two invaluable lessons from this patient and his family. First, never deny or dismiss hope from a patient or their family, even when from a medical perspective the situation seems hopeless and the patient is incurable. Second, quoting the minister directly, “Some doctors think of themselves as gods with a small ‘g’, but not one of you is God”.

When I first walked into the examining room, this man was slouched on the examining table in the perfunctory blue and white, open-backed, always unflattering hospital gown. He made eye contact with me briefly, then looked down to the floor. In that momentary meeting of our eyes, I saw no sparkle, no life, no hope in his eyes. He responded to my initial questions with a monotonic and quiet voice. Several times I had to ask him to repeat an answer because his response was so muted. Mid-way through our first visit, the patient’s wife told me he had been very depressed by his diagnosis of untreatable metastatic colon cancer. She reported, despite his occasional side-long warning glances requesting her silence, that while he was eating well, he was spending most of his time sitting in a chair or laying in bed, and that the active, gregarious man with the quick wit and booming voice she had married was gone.

After I interviewed and examined the Minister I left the room so he could dress and sit in a chair next to his wife. I reviewed the results of the lab tests and CT scans we had performed on him, and then returned to the examining room. I explained to them that I believed it was possible to perform a difficult operation that would remove approximately 80% of his liver. The operation would be risky, it was possible he would require blood transfusions, and as a worst-case scenario the small amount of remaining liver might not be sufficient to perform necessary functions. If I pushed the surgical envelope too far and removed too much normal liver, following the operation he could develop liver failure leading rapidly to his death. I also stated, assuming he survived a major operation and the recovery period, that I could not predict his long-term outcome or survival. I emphasized that even if the operation was successful, it was possible that the cancer would recur in the remaining liver or in some other organ. I even attempted to raise his spirits a bit by injecting some puerile surgical word play when I said, “This operation will leave you with little more than a sliver of liver, but God willing it will be enough!” At the conclusion of my very direct monologue, he looked up from the floor and once again his eyes met mine. I remember blinking several times in surprise at how different his eyes now appeared. With his eyes bright and twinkling he asked, “Are you saying there is hope?” I replied that I believed there was hope, albeit small and impossible to measure, but hope nonetheless. An unforgettable and immediate transformation occurred in his demeanor and as his wife smiled at me and mouthed the words, “He’s back”; he reverted instantaneously to what I would come to learn was his former garrulous self.

The spiritually-resuscitated Minister sat upright, grasped my right hand with both of his hands, and launched into a memorable diatribe. “Never deny someone hope doctor, no matter how hopeless you know the situation to be. Humans need hope, without it comes depression, despair, and death. Why do you think the Jewish defenders at Masada held out against an overwhelming Roman force for so long? Because they had hope, and they had faith. Why do people let you cut them open? Hope. Never deny a human being hope doctor, without it we have no humanity, we are only another animal.” He was a forceful and eloquent speaker. With his Mississippi drawl, he could alternatively be plain spoken or pedantic. He was a well-read and educated man and he loved to display his extensive etymologic armamentarium. Not infrequently after our conversations I would seek out a dictionary to learn the meaning of a word or two. I had no difficulty visualizing him preaching from a pulpit in his Baptist church, like a yo-yo dropping his parishioners to the floor with the fear of eternal damnation, and then pulling them back up into his hands with a message of redemption and salvation.

I walked out of the examination room enthralled and scheduled the operation for the next week. I was amazed by the sudden change I had witnessed in this man’s posture and overall demeanor. As with all who provide care for patients with debilitating and serious medical conditions, I have seen patients lapse into a state of abject, deep despair and complete hopelessness. Like an autumn leaf falling from a tree branch, their spiritual demise leads to a rapid downward spiral of their physical condition. These patients fulfill the expectations of medical practitioners who have told them their survival will be a matter of only weeks or months, in fact I have seen several patients die much more rapidly than I would have predicted when darkness and despair overwhelmed them.

I had the Minister’s “sermon” on my mind throughout his operation. As I expected, the operation was technically difficult. He was a robust, barrel-chested man and had four large tumors in his liver. Two of these were right lobe of the liver only, but the other two extended from the right lobe of his liver into portions of the left lobe of the liver. One of these latter two tumors also extended down to involve two of the three large veins that drain blood from the liver into the large vein, called the inferior vena cava, that carries blood back to the heart. To assure that I had completely removed all of the tumor around these two veins, I removed a portion of the wall of the inferior vena cava and replaced it with a patch from another vein. It was a liver surgery tour-de-force, and at the conclusion of the operation the surgical fellow who performed the operation with me and I quietly congratulated one another on a job well done. Nonetheless, I admit to my own negative sentiments and relative paucity of optimism at the end of the operation. I remarked to the surgical fellow working with me that while the operation had been technically challenging and a great lesson in surgical anatomy, I doubted that we had cured this patient because I was concerned his aggressive cancer would return.

“Never deny someone hope doctor.” If I ever had a crystal ball to predict the future, I obviously dropped it in the mud a long time ago. I was wrong about the Minister. His cancer never returned. He spent only one week in the hospital after his operation and his sliver of liver performed and regenerated beautifully. For the first five years after the operation I saw him every three to six months with lab tests and CT scans to check for return of malignant tumors. For the next six years I saw him only for an annual visit. This man survived and enjoyed life for eleven years after being told that he only had only six months to live. He died as many of us would wish to die, in his sleep from a stroke. He gave his last sermon from the pulpit of his church three days before he died. His cancer never returned to prey upon his mind and hunt down his hope.

After thinking about it, I realize I learned one additional lesson from this patient. He taught me that it was acceptable to express a little clean, righteous anger and then laugh and move on. The Minister and I developed a ritual that was repeated with each of his visits after passage of the initial six months he was told he would live by his medical oncologist. After I reviewed the results of his tests and CT scans and confirmed that all was well and that cancer had not returned, he would smile and say, “Let’s do it!” From the examining room, I would dial the phone number of the medical oncologist in Mississippi who had referred him to me. The Minister admitted to me he was angry that this doctor had needlessly denied him hope. When the medical oncologist came to the phone, I would hand it to the Minister, who would identify himself to the doctor, and then he would say the same exact words, “Hey doc, you want to go fishing?” As a surgeon, I confess I enjoyed witnessing the surgical precision with which the preacher inserted this verbal blade, deftly turning it to maximize the impact of his statement. When I passed the phone to the Minister, he always had an impish, perhaps even devilish grin on his face. Each time after he asked the doctor in Mississippi if he would care to join him for a fishing expedition, he would hand the phone back to me and a look of beatific serenity would come to his face. The ritual was completed when I would take the phone and speak to the doctor in Mississippi. In my first few conversations with this physician, I apologized for my obvious and indecorous breach in professional behavior, but to the credit of this man being regularly taunted by a Baptist Minister who wasn’t entirely forgiving, he would tell me that no apology was necessary and that he believed he deserved and benefited from these brief but poignant verbal reminders. As the years passed, he would be laughing when I put the phone to my ear and tell me that he really enjoyed those calls and that his whole office staff looked forward to this annual event.

Two years before the Minister finally died at the age of 80, the doctor in Mississippi told me that because of this patient, he never answered the question asked to him by patients about their expected longevity with a diagnosis of advanced cancer. Instead, he would inform the patients and their families that he really couldn’t make such a prediction because of marked individual differences in responses to treatment, along with the immeasurable will to live even in individuals no longer receiving treatment for their cancer. Together, he and I learned the importance of leaving no treatment stone unturned; to engage in multidisciplinary management and to consider all options for our patients. Great lessons from a great spiritual teacher, taught to a couple of hard-headed doctors.

“Hey doc, you want to go fishing?”

hope

One of the things I love most about being a Surgical Oncologist is that I see my patients for years after I have treated them. However, my clinic days are inevitably like the opening scenes from the old Wide World of Sports television program that aired on Saturday afternoons on ABC. I remember watching this show on weekends as a child and teenager. The “thrill of victory”, with images of athletes crossing the finish line in first place, equates to those patients who receive good news during their clinic visit. I tell them I am confident I can perform an operation to remove their cancer; or I confirm that their blood tests and scans show that tumors have not recurred after surgery, chemotherapy, and other treatments; or we pass some major chronologic milestone without evidence of cancer rearing its ugly head again (many patients still believe the 5 year anniversary of being cancer-free equates with being “cured”, if only that were always true). In contrast, the “agony of defeat”, forever seared in my memory in the opening scenes of Wide World of Sports with the ski jumper falling off the end of the jump and bouncing hard off the slope, represents the distress and depression felt by patients and their family members when I deliver bad news.

I would never make it as a professional poker player because I can’t bluff when I’m holding a bad hand or keep from grinning when I have a good one. My patients can tell from my face when I walk into the clinic room what the news is going to be. When all of the blood tests and scans reveal no evidence of cancer recurrence, I walk in smiling and immediately tell all gathered in the room that everything looks great and I see no evidence of any cancer. The remainder of the visit becomes a combination of medical checkup and social enterprise. I inquire about the well-being of their children, grandchildren, parents, other friends and relatives I have met, their pets, their gardening, their recent travels, and sundry snippets of their ongoing lives. Patients frequently bring pictures of children and grandchildren, or travel photos of places they have been since their last visit with me. Often I’m asked for medical advice on conditions totally unrelated to their cancers as they get farther and farther away from that diagnosis. My patients also know about tidbits from my life. They ask about the status of soccer teams that I coached, how my son or daughter were doing in college (both graduated and onto successful careers, thank you), and whether I have progressed from owning a Ferrari lanyard to hold and display my medical badge (I’m a fan of Ferrari F1 racing) to actually owning a Ferrari automobile (I do not).

I am told by patients, family members, and members of my patient care team that I am quite solemn when I walk in a clinic room to deliver bad news. No “light-hearted” chatter or discussion of recent family events or outings occurs. The nervous, hopeful smiles on the faces of the patient and the family members in the room quickly fade as I describe what I am seeing on their blood tests and the scans I have reviewed. Friedrich Nietzsche, the pejorative poster boy of pessimism, is credited with the aphorism, “Hope is the worst of evils, for it prolongs the torments of man.” Thankfully, he was not involved in the care of patients with cancer or other chronic illnesses. A particular patient comes to mind when I remember the importance of dealing with both the highs and the lows of talking with cancer patients.

The patient in question was the wife of an Emeritus Professor of Engineering at a prestigious American university. The Professor knew a thing or two about scientific investigation, statistics, and assessments of probability. Mrs. Professor had a large, grapefruit-sized malignant vascular tumor in the center of her liver called an epithelioid hemangioendothelioma. Quite a mouthful of a name for a rare malignant tumor of the liver. Her tumor was in an unfortunate location in the center of the liver and was wrapped around two of the three veins that drain all of the blood out of the liver into a large blood vessel called the inferior vena cava. The tumor was abutting a portion of the third vein. As a hepatobiliary surgical oncologist, I know I must preserve at least one of these veins to allow blood that flows into the liver to flow back out properly. She had seen surgeons at several other hospitals in the United States and was told that the tumor was inoperable and untreatable. If she was lucky, she might live a year, these doctors told my patient and her husband. The Professor contacted me, and I examined Mrs. Professor and evaluated her prior scans, and then obtained some additional high resolution scans to better understand the appearance of her tumor. I realized that her particular tumor had a very thick fibrous capsule surrounding it. I explained to the patient and her husband that it may be possible to remove the tumor, but that it would be challenging. This lady who had been sullen, withdrawn, and tearful every time I had met with them previously suddenly looked up and said, “If there’s any chance, I’m willing to take it!” I preceded the next week to perform an operation that removed the entire left lobe and a portion of the right lobe of her liver and I was able to gently dissect the tumor capsule free from the third hepatic vein. The operation was successful and the patient recovered well over the next several weeks.

The Professor, having lots of time on his hands, sent an acerbic letter to the physicians at the other hospitals, explaining in detail to them his mathematical analysis of the fallacy of their prognosis when considering an individual patient in terms of a statistical mean. He pointedly informed them that it was impossible to predict if any given individual would fall near the mean or several standard errors away from the mean. In plain language, the Professor was indicating that predicting the length of survival of cancer patients is usually based from data on the life-span of a large number of people diagnosed with the same disease. Some people live for a shorter, possibly even much shorter time than the average, while some live for significantly longer periods than the average survival time. Unfortunately, for the next year when I would encounter these various surgeons at national or international surgery or cancer meetings, I would get some frosty glares and very little conversation.

For the next three years, I saw Mrs. Professor every four months and with each visit I would enter the room smiling and pleased to report that all looked well on the blood tests and the scans. Unfortunately, three and a half years after her operation, the nature of the clinic visit changed. The moment I walked in the door of the room the professor said, “Uh oh!” Mrs. Professor immediately looked crest fallen and asked, “What is wrong?”. I sat down and explained to them that there were new small tumors in her liver and in her lungs. She asked how this could be possible since she felt so well, and I countered that small tumors frequently do not cause symptoms or problems that make the patient aware of their presence. I spent almost an hour answering an array of questions from my patient and the Professor, many of which were different ways of asking me to predict the future and her probable longevity. I repeatedly explained that this was a bad prognostic finding, and that her particular tumor was generally quite resistant to chemotherapy. She stated openly that she had no interest in taking chemotherapy or other treatments that would adversely impact the quality of her life. She then looked at me with tears in her eyes and asked, “Does this mean I won’t see you again?” I immediately replied that I would continue to see her on a regular basis throughout her life and that in my opinion part of the job for all of us in oncology is to support and care for our patients through all phases of the disease, even when our treatments have failed to eradicate the malignancy. I also confirmed that I respected her decision to decline chemotherapy treatment, and that I would assist her at any time. The patient smiled wanly, and reported that she was relieved that my colleagues and I would be available to treat any symptoms and help her should she develop any discomfort or other problems.

I continued to see my patient and the Professor every three months for another year. I arranged for consultation visits with physicians from our Palliative Care Service. Approximately fourteen months after I delivered the bad news that her cancer had recurred, the Professor called me and said that she was fading rapidly and they would likely not return. A month later I received a poignant and personal letter. In it, the professor included the obituary from the local newspaper regarding his wife’s death. It chronicled an impressive array of accomplishments and interests enjoyed over the course of a life lived fully. There was also a small hand painted watercolor card from the patient with a note to me. In it, she thanked me for giving her hope at that initial visit when I told her that it may be possible to remove her liver tumor with an operation. She then wrote something that I will never forget, “When I saw the other doctors, I felt rejected, trashed, and discarded. I felt they were dismissing me because they could not remove my cancer. All my hope was killed.” The note went on to thank me for giving her several additional years of life to enjoy traveling with her husband and spending time with friends and activities that were important to her. I make no apology to Friedrich Nietzsche or his acolytes, for I know that the death of hope is a much greater torment for patients than the presence of hope.

They didn’t teach a course on delivering bad news when I was in medical school, surgical residency, or during my surgical oncology fellowship. I often think of this cartoon by New Yorker cartoonist Matthew Diffee:

Bickles

Delivering and receiving bad news is difficult for everyone involved in cancer care (and any other area of Medicine or life, for that matter): the patient, their family members, their friends, the physicians, and the members of the medical and nursing teams. We can’t have Mr. Bickles deliver the bad news for us and then walk away unscathed. There is an emotional toll taken on all of us. We can deliver bad news with compassion and care, and that should be the goal. Patients have the right to know that they are facing a battle with cancer that they will ultimately lose, but that physicians and other medical professionals will fight alongside them and support them and their family members. Supporting the family members of a cancer patient is too often a forgotten or unspoken component in cancer care, but one which requires mindfulness because all members of the family suffer and need support as they watch the disease progress and change their mother, father, son, daughter…whomever. One thing I learned early in my career is that patients may feel they will be abandoned by the medical profession when we can no longer treat or alter the progression of their cancer. Recall the words written by my patient, “I felt rejected, trashed, and discarded. I felt they were dismissing me because they could not remove my cancer.” Regardless of the outcome, I believe we must fight the battle hand in hand with our patients to the end, providing hope tempered with realistic expectations, discussion of possible symptoms and problems, compassion, and reassurance that we are there to help throughout the process.

hope

I learn useful life lessons from each patient I meet. Some are positive messages, reminding me of the importance of maintaining balance between family, work, and leisure activities, but more frequently I witness examples of the remarkable resilience of the human spirit when facing the reality and risks of a major surgical procedure and a diagnosis of cancer. Rarely, patients and their family members utter remorseful or simply sad remarks when they are faced with a grim prognosis and the emotions associated with an onrushing date with mortality. These comments invariably involve an inventory of regrets in life, including, “I should have spent more time with my kids,” “I wish I had told my father (or mother, brother, sister, child, or some other person) that I loved them before they died,” and “I have spent my entire life working, I never took time for anything else.” I wince when I hear these openly expressed remonstrations, I recognize that I am hearing painful and heartfelt truths. Not a week goes by that I am not reminded that I do not one day want to look back at my life with a long list of regrets, should have dones, and what ifs.

I was blessed to meet a great teacher in the guise of a patient early in my academic career. He came to my clinic in my first year after completing a Fellowship in Surgical Oncology, my first year as an Assistant Professor of Surgery. My patient was a 69 year-old Baptist Minister from a small town in Mississippi. He was referred to me by his medical oncologist who called me and said, “I don’t think there is anything you can do for him, but he needs to hear that from you because he doesn’t believe me.” This tall, imposing man had colon cancer that had metastasized (spread) to his liver. The malignant tumor in his colon was removed the year before I met him, and he had received chemotherapy to treat several large tumors found in his liver. The chemotherapy had not worked and the tumors grew. At the point I met him, the medical oncologist told him he would live no more than 6 months, and because he was an avid fisherman when not preaching or helping others in his community , the doctor suggested that he go out and enjoy his remaining time by getting in as much fishing as possible. I learned two invaluable lessons from this patient and his family. First, never deny or dismiss hope from a patient or their family, even when from a medical perspective the situation seems hopeless and the patient is incurable. Second, quoting the minister directly, “Some doctors think of themselves as gods with a small ‘g’, but not one of you is God”.

When I first walked into the examining room, this man was slouched on the examining table in the perfunctory blue and white, open-backed, always unflattering hospital gown. He made eye contact with me briefly, then looked down to the floor. In that momentary meeting of our eyes, I saw no sparkle, no life, no hope in his eyes. He responded to my initial questions with a monotonic and quiet voice. Several times I had to ask him to repeat an answer because his response was so muted. Mid-way through our first visit, the patient’s wife told me he had been very depressed by his diagnosis of untreatable metastatic colon cancer. She reported, despite his occasional side-long warning glances requesting her silence, that while he was eating well, he was spending most of his time sitting in a chair or laying in bed, and that the active, gregarious man with the quick wit and booming voice she had married was gone.

After I interviewed and examined the Minister I left the room so he could dress and sit in a chair next to his wife. I reviewed the results of the lab tests and CT scans we had performed on him, and then returned to the examining room. I explained to them that I believed it was possible to perform a difficult operation that would remove approximately 80% of his liver. The operation would be risky, it was possible he would require blood transfusions, and as a worst-case scenario the small amount of remaining liver might not be sufficient to perform necessary functions. If I pushed the surgical envelope too far and removed too much normal liver, following the operation he could develop liver failure leading rapidly to his death. I also stated, assuming he survived a major operation and the recovery period, that I could not predict his long-term outcome or survival. I emphasized that even if the operation was successful, it was possible that the cancer would recur in the remaining liver or in some other organ. I even attempted to raise his spirits a bit by injecting some puerile surgical word play when I said, “This operation will leave you with little more than a sliver of liver, but God willing it will be enough!” At the conclusion of my very direct monologue, he looked up from the floor and once again his eyes met mine. I remember blinking several times in surprise at how different his eyes now appeared. With his eyes bright and twinkling he asked, “Are you saying there is hope?” I replied that I believed there was hope, albeit small and impossible to measure, but hope nonetheless. An unforgettable and immediate transformation occurred in his demeanor and as his wife smiled at me and mouthed the words, “He’s back”; he reverted instantaneously to what I would come to learn was his former garrulous self.

The spiritually-resuscitated Minister sat upright, grasped my right hand with both of his hands, and launched into a memorable diatribe. “Never deny someone hope doctor, no matter how hopeless you know the situation to be. Humans need hope, without it comes depression, despair, and death. Why do you think the Jewish defenders at Masada held out against an overwhelming Roman force for so long? Because they had hope, and they had faith. Why do people let you cut them open? Hope. Never deny a human being hope doctor, without it we have no humanity, we are only another animal.” He was a forceful and eloquent speaker. With his Mississippi drawl, he could alternatively be plain spoken or pedantic. He was a well-read and educated man and he loved to display his extensive etymologic armamentarium. Not infrequently after our conversations I would seek out a dictionary to learn the meaning of a word or two. I had no difficulty visualizing him preaching from a pulpit in his Baptist church, like a yo-yo dropping his parishioners to the floor with the fear of eternal damnation, and then pulling them back up into his hands with a message of redemption and salvation.

I walked out of the examination room enthralled and scheduled the operation for the next week. I was amazed by the sudden change I had witnessed in this man’s posture and overall demeanor. As with all who provide care for patients with debilitating and serious medical conditions, I have seen patients lapse into a state of abject, deep despair and complete hopelessness. Like an autumn leaf falling from a tree branch, their spiritual demise leads to a rapid downward spiral of their physical condition. These patients fulfill the expectations of medical practitioners who have told them their survival will be a matter of only weeks or months, in fact I have seen several patients die much more rapidly than I would have predicted when darkness and despair overwhelmed them.

I had the Minister’s “sermon” on my mind throughout his operation. As I expected, the operation was technically difficult. He was a robust, barrel-chested man and had four large tumors in his liver. Two of these were right lobe of the liver only, but the other two extended from the right lobe of his liver into portions of the left lobe of the liver. One of these latter two tumors also extended down to involve two of the three large veins that drain blood from the liver into the large vein, called the inferior vena cava, that carries blood back to the heart. To assure that I had completely removed all of the tumor around these two veins, I removed a portion of the wall of the inferior vena cava and replaced it with a patch from another vein. It was a liver surgery tour-de-force, and at the conclusion of the operation the surgical fellow who performed the operation with me and I quietly congratulated one another on a job well done. Nonetheless, I admit to my own negative sentiments and relative paucity of optimism at the end of the operation. I remarked to the surgical fellow working with me that while the operation had been technically challenging and a great lesson in surgical anatomy, I doubted that we had cured this patient because I was concerned his aggressive cancer would return.

“Never deny someone hope doctor.” If I ever had a crystal ball to predict the future, I obviously dropped it in the mud a long time ago. I was wrong about the Minister. His cancer never returned. He spent only one week in the hospital after his operation and his sliver of liver performed and regenerated beautifully. For the first five years after the operation I saw him every three to six months with lab tests and CT scans to check for return of malignant tumors. For the next six years I saw him only for an annual visit. This man survived and enjoyed life for eleven years after being told that he only had only six months to live. He died as many of us would wish to die, in his sleep from a stroke. He gave his last sermon from the pulpit of his church three days before he died. His cancer never returned to prey upon his mind and hunt down his hope.

After thinking about it, I realize I learned one additional lesson from this patient. He taught me that it was acceptable to express a little clean, righteous anger and then laugh and move on. The Minister and I developed a ritual that was repeated with each of his visits after passage of the initial six months he was told he would live by his medical oncologist. After I reviewed the results of his tests and CT scans and confirmed that all was well and that cancer had not returned, he would smile and say, “Let’s do it!” From the examining room, I would dial the phone number of the medical oncologist in Mississippi who had referred him to me. The Minister admitted to me he was angry that this doctor had needlessly denied him hope. When the medical oncologist came to the phone, I would hand it to the Minister, who would identify himself to the doctor, and then he would say the same exact words, “Hey doc, you want to go fishing?” As a surgeon, I confess I enjoyed witnessing the surgical precision with which the preacher inserted this verbal blade, deftly turning it to maximize the impact of his statement. When I passed the phone to the Minister, he always had an impish, perhaps even devilish grin on his face. Each time after he asked the doctor in Mississippi if he would care to join him for a fishing expedition, he would hand the phone back to me and a look of beatific serenity would come to his face. The ritual was completed when I would take the phone and speak to the doctor in Mississippi. In my first few conversations with this physician, I apologized for my obvious and indecorous breach in professional behavior, but to the credit of this man being regularly taunted by a Baptist Minister who wasn’t entirely forgiving, he would tell me that no apology was necessary and that he believed he deserved and benefited from these brief but poignant verbal reminders. As the years passed, he would be laughing when I put the phone to my ear and tell me that he really enjoyed those calls and that his whole office staff looked forward to this annual event.

Two years before the Minister finally died at the age of 80, the doctor in Mississippi told me that because of this patient, he never answered the question asked to him by patients about their expected longevity with a diagnosis of advanced cancer. Instead, he would inform the patients and their families that he really couldn’t make such a prediction because of marked individual differences in responses to treatment, along with the immeasurable will to live even in individuals no longer receiving treatment for their cancer. Together, he and I learned the importance of leaving no treatment stone unturned; to engage in multidisciplinary management and to consider all options for our patients. Great lessons from a great spiritual teacher, taught to a couple of hard-headed doctors.

“Hey doc, you want to go fishing?”

As recently as 50 years ago, psychiatry lacked a scientific foundation, the medical community considered mental illness a disorder of the mind, and mental patients were literally written off as “sick in the head.” A fortunate turn in progress has yielded today’s modern imaging devices, which allow neuroscientists and psychiatrists to examine the brain of an individual suffering from a mental disorder and provide the best treatment options. In a recent interview, Columbia University Psychiatry Chair Dr. Jeffrey Lieberman stated that new research into understanding the mind is growing at an accelerated pace.

(iStock)
(iStock)

Lieberman noted that, just as Galileo couldn’t prove heliocentrism until he had a telescope, psychiatry lacked the technological sophistication, tools, and instruments necessary to get an understanding of the brain until the 1950s. It wasn’t until the advent of psychopharmacology and neuroimaging, he said, that researchers could look inside the so-called black box that is the brain.

“(It began with) the CAT scan, magnetic resonance imaging (MRI) systems, positron emission tomography (PET scans) and then molecular genetics. Most recently, the burgeoning discipline of neuroscience and all of the methods within, beginning with molecular biology and progressing to optogenetics, this capacity has given researchers the ability to deconstruct the brain, understand its integral components, its mechanisms of action and how they underpin mental function and behavior,” Lieberman said. “The momentum that has built is almost like Moore’s law with computer chips, (and) you see this increasing power occurring with exponential sort of growth.”

Specifically, the use of MRIs and PET scans has allowed researchers to study the actual functional activity of different circuits and regions of the brain, Lieberman noted. Further, PET scans provided a look at the chemistry of the brain, which has allowed for the development of more sophisticated pathological theories. These measures, he said, were used to develop treatments while also allowing measurement of the effectiveness of both medication-based therapies and psychotherapies.

As an example, Lieberman cited the use of imaging in the treatment of post-traumatic stress disorder (PTSD). The disorder, a hyperarousal that chronically persists even in the absence of threatening stimulation, is treated through a method called desensitization. Over time, researchers have been able to fine-tune the desensitization therapies and treatments by accessing electronic images of the brain, which can show if there’s been a reduction in the activation of the affected amygdala.

Lieberman noted that despite progress in this area, technology has not replaced interaction with the individual patient; however, as technology continues to evolve, he expects the diagnoses of mental disorders to be refined.

“By the use of different technologies including genetics (and) imaging, including electrophysiological assessments, which are kind of EEG based, what we’ll have is one test that can confirm conditions that were previously defined by clinical description of systems,” Lieberman said. “I think, of all the disciplines that will do this, genetics will be the most informative.”

Just as genetics is currently used to diagnose cancer using anatomy and histology, Lieberman said the expanding field is helping researchers distinguish mental illness in individuals with certain genetic mutations. He expects that in the future, doctors will use “biochips” to routinely screen patients and provide a targeted therapy against the gene or gene product. These chips will have panels of genes known to be potentially associated with the risk for mental illness.

“Someone used the analogy of saying the way we treat depression now is as if you needed to put coolant into your car. Instead of putting it into the radiator, you just dump it on the engine,” he said. “So genetics will probably be the most powerful method to really tailor to the individual and use this technique of precision and personalized medicine.”

Lieberman also sees additional promise in magnetic stimulation, deep brain stimulation through the surgical implanting of electrodes, and optogenetics. Though he has plenty of optimism for these treatments and other potential treatments for mental illness, much of their continued growth may hinge on government policy and budgets. Recent coverage of gun violence in the United States, and a public call for better means by which to screen individuals for mental health inflictions, may be an unfortunate catalyst in moving funding forward in this research arena. A recent article from the UK’s Telegraph discusses Google’s newfound interest in this research, with former US Head of the National Institute of Mental Health now in a position at Google Life Sciences.

“Science, technology and healthcare are doing very well, but when it comes to the governmental process, I think we’re in trouble,” he said. “A welcome development in this regard is President Obama’s Human Brain Initiative, which if you look at the description of it, (is) basically to develop new tools in neurotechnology that can really move forward in a powerful way of being able to measure the function of the brain. Not by single cells or single circuits, but by thousands or tens of thousands of cells and multiple circuits simultaneously. That’s what we need.”

Can an emotional component to artificial intelligence be a benefit?

Robots with passion! Emotional artificial intelligence! These concepts have been in books and movies lately. A recent example of this is the movie Ex Machina. Now, I’m not an AI expert, and cannot speak to the technological challenges of developing an intelligent machine, let alone an emotional one. I do however, know a bit about problem solving, and that does relate to both intelligence and emotions. It is this emotional component of problem solving that leads me to speculate on the potential implications to humanity if powerful AI’s were to have human emotions.

Why the question about emotions? In a roundabout way, it has to do with how we observe and judge intelligence. The popular way to measure intelligence in a computer is the Turing test. If it can fool a person through conversation, into thinking that the computer is a person, then it has human level intelligence. But we know that the Turing test by itself is insufficient to be a true intelligence test. Sounding human during dialog is not the primary method we use to gauge intelligence in other people or in other species. Problem solving seems to be a reliable test of intelligence either through IQ tests that involve problem solving, or through direct real world problem solving.

As an example of problem solving, we judge how intelligent a rat is by how fast it can navigate a maze to get to food. Let’s look at this in regards to the first few steps in problem solving.

Fundamental to any problem solving, is recognizing that a problem exists. In this example, the rat is hungry. It desires to be full. It can observe its current state (hungry) and compare it with its desired state (full) and determine that a problem exists. It is now motivated to take action.

Desire is intimately tied to emotion. Since it is desire that allows the determination of whether or not a problem exists, one can infer that emotions allow for the determination that a problem exists. Emotion is a motivator for action.

Once a problem is determined to exist, it is important to define the problem. In this simple example this step isn’t very complex. The rat desires food, and food is not present. It must find food, but its options for finding food are constrained by the confines of the maze. But the rat may have other things going on. It might be colder than it would prefer. This presents another problem. When confronted with multiple problems, the rat must prioritize which problem to address first. Problem prioritization again is in the realm of desires and emotions. It might be mildly unhappy with the temperature, but very unhappy with its hunger state. In this case one would expect that it will maximize its happiness by solving the food problem before curling up to solve its temperature problem. Emotions are again in play, driving behavior which we see as action.

The next steps in problem solving are to generate and implement a solution to the problem. In our rat example, it will most likely determine if this maze is similar to ones it has seen in the past, and try to run the maze as fast as it can to get to the food. Not a lot of emotion involved in these steps with the possible exception of happiness if it recognizes the maze. However, if we look at problems that people face, emotion is riddled in the process of developing and implementing solutions. In the real world environment, problem solving almost always involves working with other people. This is because they are either the cause of the problem, or are key to the problem’s solution, or both. These people have a great deal of emotions associated with them. Most problems require negation to solve. Negotiation by its nature is charged with emotion. To be effective in problem solving a person has to be able to interpret and understand the wants and desires (emotions) of others. This sounds a lot like empathy.

Now, let’s apply the emotional part of problem solving to artificial intelligence. The problem step of determining whether or not a problem exists doesn’t require emotion if the machine in question is a thermostat or a Roomba. A thermostat doesn’t have its own desired temperature to maintain. Its desired temperature is determined by a human and given to the thermostat. That human’s desires are a based on a combination of learned preferences from personal experience, and hardwired preferences based on millions of years of evolution. The thermostat is simply a tool.

Now the whole point behind an AI, especially an artificial general intelligence, is that it is not a thermostat. It is supposed to be intelligent. It must be able to problem solve in a real world environment that involves people. It has to be able to determine that problems exists and then prioritize those problems, without asking for a human to help it. It has to be able to socially interact with people. It must identify and understand their motivations and emotions in order to develop and implement solutions. It has to be able to make these choices which are based on desires, without the benefit of millions of years of evolution that shaped the desires that we have. If we want it to be able to truly pass for human level intelligence, it seems we’ll have to give it our best preferences and desires to start with.

A machine that cannot chose its goals, cannot change its goals. A machine without that choice, if given the goal of say maximizing pin production, will creatively and industriously attempt to convert the entire planet into pins. Such a machine cannot question instructions that are illegal or unethical. Here lies the dilemma. What is more dangerous, the risk that someone will program an AI that has no choice, to do bad things, or the risk that an AI will decide to do bad things on its own?

No doubt about it, this is a tough call. I’m sure some AIs will be built with minimal or no preferences with the intent that it will be simply a very smart tool. But without giving an AI a set of desires and preferences to start with that are comparable to those of humans, we will be interacting with a truly alien intelligence. I for one, would be happier with an AI that at least felt regret about killing someone, than I would be with an AI that didn’t.

What follows is my position piece for London’s FutureFest 2013, the website for which no longer exists.

Medicine is a very ancient practice. In fact, it is so ancient that it may have become obsolete. Medicine aims to restore the mind and body to their natural state relative to an individual’s stage in the life cycle. The idea has been to live as well as possible but also die well when the time came. The sense of what is ‘natural’ was tied to statistically normal ways of living in particular cultures. Past conceptions of health dictated future medical practice. In this respect, medical practitioners may have been wise but they certainly were not progressive.

However, this began to change in the mid-19th century when the great medical experimenter, Claude Bernard, began to champion the idea that medicine should be about the indefinite delaying, if not outright overcoming, of death. Bernard saw organisms as perpetual motion machines in an endless struggle to bring order to an environment that always threatens to consume them. That ‘order’ consists in sustaining the conditions needed to maintain an organism’s indefinite existence. Toward this end, Bernard enthusiastically used animals as living laboratories for testing his various hypotheses.

Historians identify Bernard’s sensibility with the advent of ‘modern medicine’, an increasingly high-tech and aspirational enterprise, dedicated to extending the full panoply of human capacities indefinitely. On this view, scientific training trumps practitioner experience, radically invasive and reconstructive procedures become the norm, and death on a physician’s watch is taken to be the ultimate failure. Humanity 2.0 takes this way of thinking to the next level, which involves the abolition of medicine itself. But what exactly would that mean – and what would replace it?

The short answer is bioengineering, the leading edge of which is ‘synthetic biology’. The molecular revolution in the life sciences, which began in earnest with the discovery of DNA’s function in 1953, came about when scientists trained in physics and chemistry entered biology. What is sometimes called ‘genomic medicine’ now promises to bring an engineer’s eye to improving the human condition without presuming any limits to what might count as optimal performance. In that case, ‘standards’ do not refer to some natural norm of health, but to features of an organism’s design that enable its parts to be ‘interoperable’ in service of its life processes.

In this brave new ‘post-medical’ world, there is always room for improvement and, in that sense, everyone may be seen as ‘underperforming’ if not outright disabled. The prospect suggests a series of questions for both the individual and society: (1) Which dimensions of the human condition are worth extending – and how far should we go? (2) Can we afford to allow everyone a free choice in the matter, given the likely skew of the risky decisions that people might take? (3) How shall these improvements be implemented? While bioengineering is popularly associated with nano-interventions inside the body, of course similarly targeted interventions can be made outside the body, or indeed many bodies, to produce ‘smart habitats’ that channel and reinforce desirable emergent traits and behaviours that may even leave long-term genetic traces.

However these questions are answered, it is clear that people will be encouraged, if not legally required, to learn more about how their minds and bodies work. At the same time, there will no longer be any pressure to place one’s fate in the hands of a physician, who instead will function as a paid consultant on a need-to-know and take-it-or-leave-it basis. People will take greater responsibility for the regular maintenance and upgrading of their minds and bodies – and society will learn to tolerate the diversity of human conditions that will result from this newfound sense of autonomy.

Among transhumanists, Nick Bostrom is well-known for promoting the idea of ‘existential risks’, potential harms which, were they come to pass, would annihilate the human condition altogether. Their probability may be relatively small, but the expected magnitude of their effects are so great, so Bostrom claims, that it is rational to devote some significant resources to safeguarding against them. (Indeed, there are now institutes for the study of existential risks on both sides of the Atlantic.) Moreover, because existential risks are intimately tied to the advancement of science and technology, their probability is likely to grow in the coming years.

Contrary to expectations, Bostrom is much less concerned with ecological suicide from humanity’s excessive carbon emissions than with the emergence of a superior brand of artificial intelligence – a ‘superintelligence’. This creature would be a human artefact, or at least descended from one. However, its self-programming capacity would have run amok in positive feedback, resulting in a maniacal, even self-destructive mission to rearrange the world in the image of its objectives. Such a superintelligence may appear to be quite ruthless in its dealings with humans, but that would only reflect the obstacles that we place, perhaps unwittingly, in the way of the realization of its objectives. Thus, this being would not conform to the science fiction stereotype of robots deliberately revolting against creators who are now seen as their inferiors.

I must confess that I find this conceptualisation of ‘existential risk’ rather un-transhumanist in spirit. Bostrom treats risk as a threat rather than as an opportunity. His risk horizon is precautionary rather than proactionary: He focuses on preventing the worst consequences rather than considering the prospects that are opened up by whatever radical changes might be inflicted by the superintelligence. This may be because in Bostrom’s key thought experiment, the superintelligence turns out to be the ultimate paper-clip collecting machine that ends up subsuming the entire planet to its task, destroying humanity along the way, almost as an afterthought.

But is this really a good starting point for thinking about existential risk? Much more likely than total human annihilation is that a substantial portion of humanity – but not everyone – is eliminated. (Certainly this captures the worst case scenarios surrounding climate change.) The Cold War remains the gold standard for this line of thought. In the US, the RAND Corporation’s chief analyst, Herman Kahn — the model for Stanley Kubrick’s Dr Strangelove – routinely, if not casually, tossed off scenarios of how, say, a US-USSR nuclear confrontation would serve to increase the tolerance for human biological diversity, due to the resulting proliferation of genetic mutations. Put in more general terms, a severe social disruption provides a unique opportunity for pursuing ideals that might otherwise be thwarted by a ‘business as usual’ policy orientation.

Here it is worth recalling that the Cold War succeeded on its own terms: None of the worst case scenarios were ever realized, even though many people were mentally prepared to make the most of the projected adversities. This is one way to think about how the internet itself arose, courtesy the US Defense Department’s interest in maintaining scientific communications in the face of attack. In other words, rather than trying to prevent every possible catastrophe, the way to deal with ‘unknown unknowns’ is to imagine that some of them have already come to pass and redesign the world accordingly so that you can carry on regardless. Thus, Herman Kahn’s projection of a thermonuclear future provided grounds in the 1960s for the promotion of, say, racially mixed marriages, disability-friendly environments, and the ‘do more with less’ mentality that came to characterize the ecology movement.

Kahn was a true proactionary thinker. For him, the threat of global nuclear war raised Joseph Schumpeter’s idea of ‘creative destruction’ to a higher plane, inspiring social innovations that would be otherwise difficult to achieve by conventional politics. Historians have long noted that modern warfare has promoted spikes in innovation that in times of peace are then subject to diffusion, as the relevant industries redeploy for civilian purposes. We might think of this tendency, in mechanical terms, as system ‘overdesign’ (i.e. preparing for the worst but benefitting even if the worst doesn’t happen) or, more organically, as a vaccine that converts a potential liability into an actual benefit.

In either case, existential risk is regarded in broadly positive terms, specifically as an unprecedented opportunity to extend the range of human capability, even under radically changed circumstances. This sense of ‘antifragility’, as the great ‘black swan’ detector Nicholas Taleb would put it, is the hallmark of our ‘risk intelligence’, the phrase that the British philosopher Dylan Evans has coined for a demonstrated capacity that people have to make step change improvements in their lives in the face of radical uncertainty. From this standpoint, Bostrom’s superintelligence concept severely underestimates the adaptive capacity of human intelligence.

Perhaps the best way to see just how much Bostrom shortchanges humanity is to note that his crucial thought experiment requires a strong ontological distinction between humans and superintelligent artefacts. Where are the cyborgs in this doomsday scenario? Reading Bostrom reminds me that science fiction did indeed make progress in the twentieth century, from the world of Karl Čapek’s Rossum’s Universal Robots in 1920 to the much subtler blending of human and computer futures in the works of William Gibson and others in more recent times.

Bostrom’s superintelligence scenario began to be handled in more sophisticated fashion after the end of the First World War, popularly under the guise of ‘runaway technology’, a topic that received its canonical formulation in Langdon Winner’s 1977 Autonomous Technology: Technics out of Control, a classic in the field of science and technology of studies. Back then the main problem with superintelligent machines was that they would ‘dehumanize’ us, less because they might dominate us but more because we might become like them – perhaps because we feel that we have invested our best qualities in them, very much like Ludwig Feuerbach’s aetiology of the Judaeo-Christian God. Marxists gave the term ‘alienation’ a popular spin to capture this sentiment in the 1960s.

Nowadays, of course, matters have been complicated by the prospect of human and machine identities merging together. This goes beyond simply implanting silicon chips in one’s brain. Rather, it involves the complex migration and enhancement of human selves in cyberspace. (Sherry Turkle has been the premier ethnographer of this process in children.) That such developments are even possible points to a prospect that Bostrom refuses to consider, namely, that to be ‘human’ is to be only contingently located in the body of Homo sapiens. The name of our species – Homo sapiens – already gives away the game, because our distinguishing feature (so claimed Linnaeus) had nothing to do with our physical morphology but with the character of our minds. And might not such a ‘sapient’ mind better exist somewhere other than in the upright ape from which we have descended?

The prospects for transhumanism hang on the answer to this question. Aubrey de Grey’s indefinite life extension project is about Homo sapiens in its normal biological form. In contrast, Ray Kurzweil’s ‘singularity’ talk of uploading our consciousness into indefinitely powerful computers suggests a complete abandonment of the ordinary human body. The lesson taught by Langdon Winner’s historical account is that our primary existential risk does not come from alien annihilation but from what social psychologists call ‘adaptive preference formation’. In other words, we come to want the sort of world that we think is most likely, simply because that offers us the greatest sense of security. Thus, the history of technology is full of cases in which humans have radically changed their lives to adjust to an innovation whose benefits they reckon outweigh the costs, even when both remain fundamentally incalculable. Success in the face such ‘existential risk’ is then largely a matter of whether people – perhaps of the following generation – have made the value shifts necessary to see the changes as positive overall. But of course, it does not follow that those who fail to survive the transition or have acquired their values before this transition would draw a similar conclusion.