Artificial intelligence (AI) is driving rapid and widespread change in surgical practice.
Cholecystectomies have been performed autonomously by AI-trained robotic systems without direct human intervention. Similar to this advancement in complete automation, AI also is enhancing remote care through telesurgery, enabling surgeons to perform robotic-assisted prostatectomies with the surgeon and patient in different countries. The idea that a surgeon may not be physically in contact with the patient during an operation is no longer extraordinary.
This rapid AI evolution in key areas of surgery has fundamentally reshaped the surgeon-patient relationship. Robotic procedures are routinely performed across multiple specialties, including cardiac, abdominal, and pelvic surgery.
While the transition from open surgery to minimally invasive laparoscopic techniques began in the late 1990s and early 2000s,1 robotic surgery soon followed, evolving from a novel innovation into a widely available and increasingly ubiquitous platform. More than 12 million procedures have been performed by more than 60,000 surgeons using the da Vinci system.2
These advances offer significant promise—but they also demand careful evaluation.
Surgeon-Patient Relationship at Risk
Technological change has the potential to alter core tenets of the surgeon-patient relationship. Historically, surgeons evaluated patients in person, obtained a history, performed a physical examination, ordered diagnostic tests, and explained diagnoses and treatment plans to the patient. Surgeons met patients preoperatively, performed the operation, communicated outcomes to patients and their families, and provided postoperative care. This continuity fosters trust, confidence, and accountability.
This care model is increasingly being challenged. Greater reliance on electronic health records (EHRs), robotics, shift-based care, and multiple surgeons interacting with the same patient has introduced both physical and conceptual distance.
The risk is that the surgeon-patient relationship may shift from one grounded in trust and continuity to one that is more transactional. These concerns are magnified with remote or autonomous AI-guided robotic surgery. In the event of an adverse outcome, inadequate or imprecise explanations of complex, novel technologies can quickly erode trust and damage the surgeon-patient relationship.
Ethical Foundations in the AI Era
Ethics remains central to surgical practice. The foundational principles of beneficence, nonmaleficence, and justice remain unchanged:
- Beneficence: Acting in the patient’s best interest
- Nonmaleficence: “First, do no harm”
- Justice: Ensuring fair and equitable care
These principles take on heightened importance as AI-driven and remote surgery expand. Patients must understand:
- What procedure is being performed
- Who—or what—is performing the operation
- Expected outcomes
- Potential risks and complications
- Who is accountable if something goes wrong
Failure to clearly communicate these elements, particularly when new technologies are involved, undermines trust and threatens the ethical foundation of surgical care.
Accelerating Pace of Change
The integration of EHRs, AI, and shift-based surgical care has transformed clinical practice. These changes have improved efficiency and access to information but have also contributed to fragmentation.
Patients increasingly turn to online sources rather than their surgeon for information and reassurance. While these individuals seek trusted guidance from someone with experience, judgment, and time, this is a role that has been historically filled by the surgeon.
Unfortunately, the expectation of receiving evidence-based guidance from a trusted clinician is no longer guaranteed, especially if the information is coming from an unsubstantiated online source. With optimal patient care potentially at risk, it is worth asking how and why these changes have evolved—and what will they mean over the next 20–30 years.
Cars Without Drivers, Surgery Without Surgeons?
Other industries offer instructive parallels. The shift from horse-drawn carriages to automobiles required infrastructure, regulation, education, licensure, and legal accountability. The transition forced a clear assignment of responsibility for safety, establishing who would be held accountable for passengers and others on the road. Public safety depends on clearly defined standards and responsibilities.
Today, driverless cars raise new questions about accountability when no human operator is directly responsible for the operation of a vehicle. Careful thought and regulations should be in place to standardize this transportation modality because with driverless cars, by their very definition, there is no driver responsible for the safety of the passengers and other vehicles on the road.
Aviation provides an even stronger example of the importance of standards. Once plagued by accidents, aviation became one of the safest industries in the world through rigorous standardization, training, certification, and global coordination. Safety has become the unifying principle of this industry.
Surgery stands at a similar inflection point. As AI becomes more integrated into operative care, comparable standards, safeguards, and accountability structures are essential.
AI as a Transformative Force
AI is already integrated into multiple aspects of surgical care. It can assist with clinical documentation, analyze imaging and data, support decision-making using large datasets, facilitate informed consent discussions, and enhance intraoperative precision and safety.
In 2025, robotic systems were trained using surgical video data. As stated earlier, a robotic system autonomously performed a cholecystectomy.3 More recently, a surgeon in London successfully performed a robotic-assisted prostatectomy on a patient in Gibraltar—more than 1,000 miles away—with negligible latency.4
While this telesurgery approach expands healthcare access to specialists for remote populations, it also raises critical questions. How are intraoperative complications managed from such distance? Who is accountable across state or national borders?
One could imagine significant concerns raised in the event of an intraoperative catastrophe. In the US, performing operative procedures in different states would require state-specific licenses. These safety and accountability-related considerations are even more profound if the surgeon and patient are located in different countries. Liability becomes more complex if a procedure is performed autonomously without real-time human supervision.
Six Levels of Robotic Medical Autonomy
Yang and colleagues describe six levels of robotic medical autonomy:5
- Level 0: No autonomy—Human operator performs all functions.
- Level 1: Robot assistance—Human retains continuous control.
- Level 2: Task autonomy—Human has discrete control with specific tasks given to robot.
- Level 3: Conditional autonomy—Human selects autonomous strategy performed by robot.
- Level 4: High autonomy—Robot makes decisions under supervision of a human.
- Level 5: Full autonomy—Procedure performed by robot with no human supervision required.
Robot-assisted surgery has reached Level 4 (high autonomy). Level 5 (full autonomy) remains experimental. Transitioning between these levels requires rigorous oversight to ensure patient safety. The surgical community must proactively develop policies and regulations to protect patient safety as autonomous AI technologies evolve.
Surgery from the Patient’s Perspective
As a surgeon with many decades of experience, I had a different perspective when I was a patient undergoing major surgery. Of course, I selected a surgeon who had successfully performed a great number of the procedures I would have.
The surgeon’s technical excellence is important but so are communication, trust, and personal connection. The reassurance provided by direct interaction with the surgeon before and after surgery is irreplaceable. The surgeon’s preoperative explanation of why the procedure would be helpful was critical. Seeing the surgeon immediately before and after the surgery was very comforting. Being able to ask questions during the surgeon’s morning rounds and receive clear, precise answers was very reassuring.
However, the modern era of AI-generated, non-human answers to questions degrades the trust, comfort, and confidence in the surgeon-patient relationship. This is a fundamental change in the way surgery has been practiced, and we need to be very thoughtful as to whether this is the path that we want to go down. It would be difficult to return to the original surgeon-patient relationship once this road is taken.
Accountability, Risk, and Cybersecurity
AI-driven systems can enhance safety by identifying critical operative steps and avoiding known hazards. However, not all cases are routine. If harm occurs, responsibility becomes ambiguous. Is the surgeon accountable? The hospital? The manufacturer? The programmer? These questions must be addressed proactively rather than after an adverse event.
Cybersecurity presents an additional risk. Cyberattacks have already disrupted EHRs, billing systems, and medical equipment. Safeguards to identify and prevent such threats must be integral to AI-enabled surgical platforms.
Cost, Incentives, and Unintended Consequences
Robotic surgery offers potential benefits for patients, including shorter hospital stays and faster recovery. However, these systems carry substantial costs, often exceeding $1 million per unit, with significant annual maintenance fees.
Robotic surgery also is associated with financial incentives for surgeons. A recent report found an association between industry payments to surgeons and increased use of robotic-assisted surgery. In addition, the study found an association between higher industry payments and increased use of surgical robots. The authors of an article examining this topic suggest that surgeon-industry financial relationships may be an important contributor to the increase in robotic-assisted surgery.6
On the plus side, AI systems track every movement of the robot and operative time, enabling efficiency analysis and skill refinement. The benefit is that the most efficient and effective movements can be learned by and taught to surgeon operators. Yet postoperative complications and long-term outcomes are not captured. On the minus side, efficiency metrics may incentivize speed over safety. From the patient’s perspective, optimal outcomes—not faster operating times—are paramount.
Governance
We have seen how quickly new technology can transform human life. Take cell phones, for example. In a relatively short period of time, 10–20 years, cell phones swept onto the scene and radically changed global behavior.
Widespread adoption of new technology often comes with unforeseen consequences. The same is true with AI. Medicine must avoid a reactive approach. AI and its applications in medicine and surgery have evolved exponentially in a short period of time. The benefits of AI to the profession are significant, but clear guardrails and oversight are needed to monitor and thoughtfully address its ethical, clinical, legal, and personal impact.
It is time for a comprehensive evaluation of AI’s impact on medicine and surgery. We should remember the lessons of history, specifically what transpired in the early part of the 20th century.
Improvements in surgical safety advanced through leadership and collaboration, notably through efforts led by the ACS and Joint Commission. These organizations created standards that fundamentally improved care, which are built on objective criteria that guide the practice of medicine in healthcare facilities today. A comparable effort is needed to establish guidelines and safeguards that will allow patients to benefit from the extraordinary advancements of AI while ensuring their safety.
