“Smart” pills are here and we need to consider the risks

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“Smart” pills are here and we need to consider the risks

Robert Klitzman is a professor of psychiatry and director of the Masters of Bioethics Program at Columbia University. He is author of “The Ethics Police? The Struggle to Make Human Research Safe.” The opinions expressed in this commentary are solely those of the author. View more opinion articles on CNN.

(CNN)In the new Broadway musical “Be More Chill,” the main character is a bullied teenager who doesn’t fit in with the popular kids at his high school.

It isn’t long before he’s introduced to a new drug that’s becoming popular among his classmates. The drug contains a computer chip that balances the competing adolescent voices in his head — full of desires and fears — and tells him what to do, whether it’s how to be cool or how to get a girlfriend.
The play purports to be science fiction. But is it?
Pharmaceutical companies have already released digital “smart” pills containing computer chips. The first digital cancer pill, which was released in January, contains a chip in capsules filled with capecitabine, a cancer chemotherapy that patients need to take several times a day.  When the chip hits the stomach, it emits a signal that a skin patch detects, triggering a message to a computer which allows doctors, patients and families to track medication adherence. Smart pills could also monitor chemical states in the stomach.  Proteus, the pharmaceutical company behind the cancer pill, has already incorporated its chip into 40 other kinds of medications.
These pills can provide important benefits to the overwhelming number of people who have trouble taking their medications as they should.  We doctors hope, at best, for 80% adherence to prescribed medication, yet half of medications for chronic disease aren’t taken as directed while about one-third of patients don’t even fill their prescriptions. What’s more, following a prescription regimen can be particularly tough for patients who are elderly or have cognitive deficits. 
I have told many patients to make sure they take the medications I had prescribed for them, but sometimes I, too, forget to take the ones my doctor has ordered for me, especially when I’m traveling or getting up late on the weekends.
Because this is such a widespread problem, the Food and Drug Administration approved the first digital pill in 2017. It contained aripiprazole, a drug used to treat schizophrenia and bipolar disorder, which many patients avoid taking because it can cause unpleasant side effects.
The United States Defense Advanced Research Projects Agency (DARPA) has also been developing various computer-brain interfaces that have helped patients with strokes and epilepsy by activating or deactivating portions of the brain. By interfacing with the nervous system, the technology allows veterans and other people with amputated limbs to control their prostheses’ movements.
Researchers initially developed these devices in animals, and successfully controlled the brains of birds, mice and cockroaches to make them move in certain ways. These robo-animals could be used to detect explosives or spy on enemies.  Scientists have even created Frankensharks, which have electrodes implanted in their brains that are hooked up to a remote control. These sharks can potentially be steered to spot enemy ship movements.
But with this new technology comes new dangers. Such devices, like all computers, can be hacked or go awry. What if a person’s prosthetic limbs are co-opted and instructed to walk in front of cars, rather than away from them? What if hackers take over these franken-sharks and force them to charge at swimmers?
This is where “Be More Chill” provides a prescient warning against these technological advances. Without disclosing the play’s plot, the pill ends up causing problems and students soon want to turn the computer chips off — but doing so proves difficult.
Questions about who should control these devices in the body and how they might be turned off are also not merely the stuff of science fiction. Recently, I was asked to help consult on a patient with a left ventricular assist device in his heart that maintained his pulse. He asked his doctors to turn the machine off, because it required that he lug around a large, heavy battery at all times. But shutting the battery off would immediately kill him.
“I don’t care,” the patient said. “I’d prefer not to live than have to carry this battery around all the time.”
“The patient walked into the hospital,” a physician involved in the case told me, “but wanted to leave in a coffin.” The doctors refused. The patient said he would go to other hospitals to ask. I hope they agreed with us, but I don’t know.
Smart pills also raise concerns about privacy. I’d welcome a reminder if I forget to take my cholesterol medicine, but I wouldn’t want my family or others knowing about it.  
The advent of these digital pills introduces a myriad of ethical quandaries. Paranoid schizophrenic patients may feel spied on. Courts already mandate that certain patients comply with treatments for tuberculosis and psychiatric disorders in order to be released from prison or gain custody of their children. A court could also order patients to take digital pills. But for patients who suffer debilitating side effects, that demand could be unfair and even dangerous.
As these medical technologies become increasingly widespread, manufacturers and health care providers will need to figure out how to maximize the benefits to patients and minimize the risks. 
Ultimately, in “Be More Chill,” the lead character decides that the drug poses more risks than benefits.
Acknowledging the clashing teenage impulses in his head, he sings, “They scream and shout. I tune them out, then make up my own mind.”
It won’t be long before many of us will have to make up our minds about these smart pills as well. Hearing these concerns in harmony and rhyme can raise our awareness of these increasing conundrums.

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