LAUSR

Digital twinning in medicine refers to the idea of simulating a person’s organs, muscles or perhaps their entire body, in order to arrive more effectively at accurate diagnoses, to make treatment recommendations that reflect chances of success and possible sideeffects, and to better understand the longterm trajectory of an individual’s overall condition. Digital twins, in these ways, build on the recent movement toward personalised medicine, and they undoubtedly present us with exciting opportunities to advance our health. Of course, the opportunities are accompanied by newfound challenges—a common refrain in discussions surrounding emerging technologies. In a recent article, Matthias Braun surveys numerous problems, including the precision of simulations, ownership and consent to the use of digital models, and issues of justice in assuring equitable access to novel medical systems. In particular, he places special emphasis on the notion of representation. According to Braun, proper representation naturally calls for correspondence—namely a precise model offering dynamic, realtime feedback as well as transparency, both for the patient and the practitioner, in terms of the data being employed. While technical challenges remain, these goals are quite clear and relatively uncontroversial. Where a host of questions arise, however, is in the discussion on the interaction between the represented persons and their simulations. Alongside questions regarding ownership of one’s digital twin, Braun raises the concern that ‘giving power to a simulation to act in my name implies the risk of illegitimate replacement’. But what sort of power might we be giving to virtual representations in medical settings? How exactly, if at all, can they ‘act’ in our name? Are we really at risk of being replaced? By further appealing to the dangers of surrogate power, Braun shows how the process of representation can be described as ‘not reversible at will’. This vision should be alarming—namely digital simulations permanently and illegitimately replacing humans—and it begins to stoke fears of science fictionlike scenarios. Still, Braun suggests that it is plausible to take seriously the cases where our digital twins ‘knock at our door’. That is, the models can be made to warn us of imminent disease or injury, and may well provide intervention or lifestyle recommendations. Indeed, considering the rise of personal heart monitors and digital sleep tracking, among other devices, we are already witnessing the introduction of such ‘knocking’ in our everyday lives. It is possible, Braun writes, that the warnings issued by digital twins ‘will change my life completely’ in the sense that they ‘will be exercising power over me and my life’. One may worry, he shows, that the use of digital twins is a threat to our freedom. In my recent work at the Technical University of Munich, I have become closely acquainted with the work practices and some of the thought processes of engineering experts developing technologies like digital twins, telemedicine and robotic assistant systems. Among many rich insights the developers have bestowed on me and my team working to ‘embed ethics’ is the concern for a mismatch between societal perceptions and the reality of emerging technologies. It is thought, for instance, that the hype surrounding artificial intelligence (AI) and robotics far exceeds the actual capabilities of such devices. Similarly, the fears that these technologies will somehow takeover or replace us often distort or overlook the potential benefits to be achieved, if not balanced by sound portrayals of their capacities and the intentions behind their development. Naturally, popular media is a key player in the generation of these sorts of discrepancies, but academic discussions too have a significant role to play. Granted, the consideration of ethical concerns in emerging technology is not a zerosum game. Along with the immediate challenges of development, it is crucial to fully scrutinise the extent of possible longterm effects of powerful tools which we increasingly have at our disposal, particularly in such sensitive domains as healthcare. For that matter, Braun’s thoughtful work helps us in precisely these ways, giving us a glimpse into a world where we let digital twins run amok. What I find important to emphasise is that the prospect of permanent, illegitimate replacement of a person by their digital representative can be seen largely as a rhetorical move aimed at conveying the necessity of consent. Undoubtedly, representation by digital twins—especially for possible medical intervention—demands regular updates with the represented subject. Accordingly, a person must be able to optin, optout, reconfirm or alter their participation based on careful deliberation and informed consultations with compassionate healthcare professionals. Braun notes that ‘there can be good reasons why a person ... modifies the manner of representation, transforms it into another form, interrupts it or even ends it’. Still, it seems that much more attention can and should be given to the details of consent, in order to accompany the illustrations of what might happen without it. Indeed, the passing mention of ‘dynamic consent’ in conclusion pales beside the depiction of technology’s potential power over us. Repeatedly, Braun refers to modes of control and modes of freedom, and conveys that the use of a simulation ‘forces us to think ... about the modes of control required to maintain the direction of interaction in a way that is adaptive to personal modes of freedom’. So, let’s think about it. What sorts of control might best accommodate the use of digital twins? Are any of the various new models of consent developed for datadriven medicine fit for the task? Why, if at all, should we accept dynamic consent over openconsent, broadconsent or metaconsent? 5 And what exactly is a personal mode of freedom? It seems clear that digital twinning in medicine forces us to think carefully about control over digital tools and the details of patient consent. Braun’s exploration helps to raise key questions, even if by raising grave concerns—ultimately showing that there is much work to be accomplished, both to address the challenges posed by digital twins and to assure that our scrutiny is matched by realism and robust proposals for harnessing or perhaps rethinking the opportunities provided by technology. Institute for History and Ethics of Medicine, Technical University of Munich, Munich, Germany