Intraoperative application of mixed and augmented reality for digital surgery: a systematic review of ethical issues

Introduction: Head-mounted displays (HMDs) that superimpose holograms onto patients are of particular surgical interest as they are believed to dramatically change surgical procedures by including safety warning and allowing real-time offsite consultations. Although there are promising benefits of mixed and augmented reality (MR/AR) technologies in surgery, they also raise new ethical concerns. The aim of this systematic review is to determine the full spectrum of ethical issues that is raised for surgeons in the intraoperative application of MR/AR technology.

Methods: Five bibliographic databases were searched for publications on the use of MR/AR, HMDs and other devices, their intraoperative application in surgery, and ethical issues. We applied qualitative content analysis to the n = 50 articles included. Firstly, we coded the material with deductive categories derived from ethical frameworks for surgical innovations, complications and research. Secondly, clinical aspects with ethical relevance were inductively coded as ethical issues within the main categories. Thirdly, we pooled the ethical issues into themes and sub-themes. We report our findings according to the reporting guideline RESERVE.

Results: We found n = 143 ethical issues across ten main themes, namely patient-physician relationship, informed consent, professionalism, research and innovation, legal and regulatory issues, functioning equipment and optimal operating conditions, allocation of resources, minimizing harm, good communication skills and the ability to exercise sound judgement. The five most prevalent ethical issues are "Need for continuous research and innovation", "Ensuring improvement of the learning curve", "MR/AR enables new maneuvers for surgeons", "Ensuring improvement of comfort, ergonomics, and usability of devices," and "Not withholding MR/AR if it performs better".

Conclusions: Recognizing the evidence-based limitations of the intraoperative MR/AR application is of paramount importance to avoid ethical issues, but clinical trials in surgery pose particular ethical risks for patients. Regarding the digital surgeon, long-term impact on human workforce, potentially harmful "negative training," i.e., acquiring inappropriate behaviors, and the fear of surveillance need further attention. MR/AR technologies offer not only challenges but significant advantages, promoting a more equitable distribution of surgical expertise and optimizing healthcare. Aligned with the core principle of social justice, these technologies enable surgeons to collaborate globally, improving training conditions and addressing enduring global healthcare inequalities.