近年来，随着人工智能技术的迅速发展，自主手术机器人在手术操作、智能计算和决策方面的能力显著增强，提高了医疗服务质量和患者治疗效果，但其带来的潜在威胁和高风险也促使专家和立法机构采取措施。未来，随着自主手术机器人逐步替代医生，传统医学伦理学并不足以应对与回答其涉及的超越当前时空范围的伦理挑战。从“以人为主，以机器人为辅”到“以机器人为主，以人为辅”的变革，不仅对医患关系和医生角色产生影响，也为未来患者的生存状态带来了新的挑战，进而对如何负责任地应用该技术提出要求。

因此，本研究引入汉斯·约纳斯的责任伦理，将其关于对未来负责的道德意识、非人类中心主义立场以及重视未知风险以保护人类存在的核心理念融入当代医学伦理学。约纳斯的责任伦理强调了预防生存性风险的重要性，突出生存原则和非相互性（互惠性）责任原则，利用人类对死亡的恐惧来限制对人类生存条件的不利影响，为自主手术机器人伦理问题提供了切实而深刻的指导框架。

针对自主手术机器人自主能力程度的不同，并根据机器人是否替代医生，可将其分为机器人完全替代医生和机器人部分替代医生（人机合作）两种情况，以区分远期的极端情况与当前的事实情况。本文通过思想实验的方法设计假设条件，推演出在自主手术机器人完全替代外科医生的情况下可能产生的技术控制权问题，得出自主手术机器人与“杀手机器人”在本质上具有一致性，这将强化技术决定论的立场，从而对人类可持续存在产生根本性的负面影响。虽然在极端环境下自主手术机器人有适用性的情况，但约纳斯责任伦理提示我们，完全替代医生的广泛性应受到很大限制。然而，自主手术机器人凭借其独特的高精度手臂功能，尤其是其机器学习能力，使得部分替代医生不仅在理论上受到期待，而且在现实中也成为可能。这种机器部分替代外科医生的人机合作形式得到了支持。医生与机器人在决策方面的相互依赖改变了传统的人机合作情形，使得“人机融合体”成为医者群体的新成员，使医患交往模式在术中阶段以一种新的形态存在，从传统的“单主动”转变为“多主动”模式。就医生的责任而言，患方角度看没有变化，仍然是医生承担完全主动的责任，但这种新形态的医患关系中“人机融合体”的出现，使医生的责任理念和承担责任的方式有新的变化，对医患交往也提出新的要求。约纳斯的责任理论提示我们，应以“关系安全”作为患者与“人机融合体”关系的首要原则，以保障这种医患关系的新形态不影响患者的生命安全。在“人机融合体”内部增加医生对机器人的主导性的非相互性责任，而不是同时要求机器人对医生负责。

但是，若仅基于约纳斯将生命有机体视为责任主体的前提，就自主手术机器人的责任范畴以及人机融合体的责任归属困境而言，当前的责任伦理解释尚显不足。本文通过反思平衡与规范性策略，尝试构建针对自主手术机器人替代医生的综合伦理分析框架。该框架包括三个层级的伦理原则，其中生存原则被确定为第一原则；适度手术目标、恐惧张力、机器人与外科医生互不替代、人与人机融合体的安全关系，以及承认人机融合体作为责任主体之一作为第二序列的伦理原则；第三序列伦理原则是根据第二序列原则的具体情况进行拓展的行动指南。该框架考虑到“人机融合体”作为新医者的场景化问题，提供了优先次序分明的伦理原则，具有一定的灵活性，但也存在一定的局限，需要进一步研究。

In recent years, with the rapid development of artificial intelligence technology, the capabilities of autonomous surgical robots in terms of surgical operation, intelligent computation and decision-making have been significantly enhanced, improving the quality of healthcare services and patient outcomes, but the potential threats and high risks they pose have also prompted experts and legislatures to take measures. In the future, as autonomous surgical robots gradually replace physicians, they will involve many serious ethical challenges that transcend the current spatial and temporal scopes, and for which traditional medical ethics remains inadequate. The shift from "human-dominant, robot-assisted" to "robot-dominant, human-assisted" has a fundamental impact on the doctor-patient relationship and the role of the physician, posing new challenges to the survival of patients and the responsible application of the technology. The challenge is how to apply this technology responsibly.

Therefore, this study introduces Hans Jonas's ethics of responsibility, which incorporates his core concepts of a moral sense of responsibility for the future, a non-anthropocentric stance, and an emphasis on unknown risks to protect human existence into contemporary medical ethics. Jonas's ethics of responsibility emphasizes the importance of preventing existential risks, highlights the principle of survival and the principle of non-reciprocal responsibility, and exploits the human fear of death to limit adverse impacts on the human condition, providing a practical and insightful framework for guiding ethical issues in autonomous surgical robotics.

For the different degree of autonomy capability of autonomous surgical robots and according to whether the robot replaces the doctor or not, it can be categorized into two scenarios: the robot completely replaces the doctor and the robot partially replaces the doctor (human-robot cooperation), in order to differentiate between the extreme scenario of the far future and the factual scenario of the present. In this paper, we design hypothetical conditions by means of thought experiments to deduce the technological control issues that may arise in the case of autonomous surgical robots completely replacing surgeons, and conclude that autonomous surgical robots are essentially the same as "killer robots", which will strengthen the technological determinism position, and thus have a fundamental negative impact on the sustainable existence of human beings. This would reinforce the position of technological determinism and thus have a fundamental negative impact on the sustainability of human existence. While there are cases where autonomous surgical robots are applicable in extreme environments, the Jonas Ethics of Responsibility suggests that the breadth of complete substitution of physicians should be very limited. However, autonomous surgical robots, due to their unique arm capabilities that far exceed surgeon accuracy, and especially their machine learning capabilities, make partial replacement of physicians not only theoretically desirable, but also support a scenario where partial replacement of a surgeon by a machine is realistically feasible, i.e., where the reality of human-machine cooperation becomes possible. The interdependence of doctors and robots in decision-making changes the traditional human-robot cooperation scenario, making the "human-machine fusion" a new member of the community of doctors, and allowing the doctor-patient relationship to take on a new form at some point. The traditional fully active-passive patient-physician model in surgery remains unchanged from the patient's point of view, with the doctor still taking full responsibility, but the emergence of the "human-machine fusion" in this new form of patient-physician relationship has led to new changes in the concept of the doctor's responsibility and the way in which the doctor assumes responsibility, and puts new demands on the patient-physician interaction. The emergence of the "human-machine fusion" in this new form of doctor-patient relationship has led to new changes in the concept of responsibility and the way doctors assume responsibility, and has put forward new requirements for doctor-patient interaction. Jonas's theory of responsibility suggests that we should take "relational safety" as the primary principle of the relationship between patients and the "human-machine fusion" in order to ensure that this new form of doctor-patient relationship does not affect the safety of patients' lives. Within the "human-machine fusion", the doctor's dominant, non-reciprocal responsibility towards the robot will be increased, instead of requiring the robot to be responsible for the doctor at the same time.

However, based only on Jonas's premise that living organisms are responsible subjects, current ethical explanations of responsibility are insufficient in terms of the scope of responsibility of autonomous surgical robots and the dilemma of attributing responsibility to "human-machine fusion". By reflecting on balancing and normative strategies, this paper attempts to construct a comprehensive ethical analysis framework for autonomous surgical robots replacing surgeons, which consists of three tiers of ethical principles, in which the principle of survival is identified as the first principle, the goal of proportionality in surgery, fear tension, non-replacement of the robot and the surgeon from each other, the safe relationship between the human and the "human-machine fusion", and the recognition of the "human-machine fusion" as one of the responsible subjects as the second tier of ethical principles. The third tier of ethical principles is a guide for action that expands on the specifics of the second tier. The framework provides prioritized ethical principles that take into account the contextualization of the "human-machine fusion" as a new healer, and has some flexibility, but also has some limitations that require further study.

第一章 引论 5
1.1 研究背景 5
1.2 研究问题 7
1.3 研究意义 8
1.4 文献综述 9
1.4.1 国外研究综述 9
1.4.2 国内研究综述 22
1.5 研究方法 25
1.6 研究思路与章节安排 26
1.6.1 研究思路 26
1.6.2 章节安排 26
第二章 自主手术机器人对医学伦理学的挑战 29
2.1 自主手术机器人技术概述 29
2.1.1 自主手术机器人的概念 29
2.1.2 自主手术机器人的自主范畴 32
2.1.3 手术机器人的自主性改变了传统人机主从关系 34
2.2 自主手术机器人技术的危险性力量 36
2.2.1 机器操控生命：从加工“物”到加工“人” 36
2.2.2 机器越界：从替代一般工作到替代“专业” 38
2.3 自主手术机器人对医学伦理学提出新需求 39
2.3.1 谨慎应对自主手术机器人的不确定性 39
2.3.2 关注技术后果的不显见风险 40
2.3.3 扩展适用于医生责任变动的伦理关切范围 41
2.4 传统医学伦理学的责任研究范式被挑战 43
2.4.1 伦理关切范畴的近距离化 43
2.4.2 研究对象的人类中心化 44
2.4.3 对未知风险的敏感度不足 44
2.5 走向责任伦理 46
第三章 汉斯·约纳斯的责任伦理理论 49
3.1 责任伦理：一种概念与理论 49
3.2 责任伦理的产生：科技时代的需求 51
3.2.1 作为未来伦理的责任伦理是如何产生的 51
3.2.2 过去的人类行为对应过去的伦理学 53
3.2.3 生命有机体作为责任主体的前提 54
3.3 责任伦理的内容 55
3.3.1 责任命令：一种生存原则 56
3.3.2 实质责任而非形式责任 56
3.3.3 自然责任而非契约责任 57
3.3.4 “非相互性责任”而非“相互性责任” 58
3.3.5 责任伦理的特征 58
3.4 责任伦理的基本方法：恐惧启迪法 60
3.4.1 恐惧作为一种德性 60
3.4.2 发展预测科学成为一种伦理要求 61
3.5 责任伦理的实践：负责任创新与医生责任 62
3.5.1 形而上与形而下的结合 62
3.5.2 预防危险的优先性：关于“医生－人类责任” 64
3.5.3 给予未来患者道德地位 65
3.6 责任伦理对自主手术机器人问题的适用性 65
3.6.1 兼顾近距离个体责任与远距离物种责任 66
3.6.2 契合人工智能的高风险特征 67
3.6.3 责任原理辅助责任种类的选择 67
3.7 小结 68
第四章 自主手术机器人完全替代医生 69
4.1 完全替代的概念与思想实验 69
4.1.1 完全替代的概念 69
4.1.2 完全替代的思想实验 70
4.2 自主手术机器人与杀手机器人的比较和分析 71
4.2.1 致命性工具的非道德属性 72
4.2.2 机器合理性决策的困难 73
4.2.3 技术控制权 74
4.3 约纳斯对完全替代的可能性回应 75
4.3.1 违背了“责任命令” 75
4.3.2 人类放弃了责任 76
4.3.3 强化了技术决定论 77
4.3.4 机器人匮乏对风险的恐惧 78
4.4 机器能够完全替代人类的特殊情形 78
4.5小结 79
第五章 自主手术机器人部分替代医生 81
5.1 部分替代：医生与自主手术机器人的融合性合作 81
5.1.1 部分替代的概念 82
5.1.2 部分替代的不可替代性：“人机融合体”的手术时代 82
5.1.3 部分替代与人机关系问题 84
5.2 医患关系的新形态：人机融合体与患者的关系 85
5.2.1 医患关系的概念与本质 85
5.2.2 术中医患交往模式的转变：从“单主动”到“多主动” 86
5.3 医患关系新形态提出的伦理需求 88
5.3.1 建立预知风险的前端责任 88
5.3.2 创新手术的告知义务 90
5.3.3 发展适用于人机融合体的新型责任 91
5.3.4 重视人机关系与患者安全的密切关联 91
5.4约纳斯对部分替代的可能性回应 92
5.4.1 人机关系安全存在隐患 93
5.4.2 人机融合体的责任地位不明晰 95
5.5 小结 97
第六章 负责任应用自主手术机器人的伦理框架探讨 99
6.1 当前人工智能伦理框架对自主手术机器人适用性不足 100
6.2 责任伦理应对自主手术机器人责任鸿沟问题的不足 101
6.2.1 责任伦理立场中责任过大 101
6.2.2 人机融合体的归责困境 102
6.3 应对责任鸿沟的策略探讨 103
6.3.1 针对责任过大的规范性策略：增加责任分类与次序 103
6.3.2 人机融合体作为责任主体之一的反思平衡策略 104
6.4 自主手术机器人的伦理框架探索 107
6.4.1 自主手术机器人的责任范式：个体性责任+人类责任 108
6.4.2 人的生存作为第一原则 111
6.4.3 人机融合手术安全发展的第二序列原则 112
6.4.4 何种责任：非相互性的责任 116
6.4.5 自主手术机器人伦理框架的灵活性解释 117
6.5 小结 119
结论与展望 121
参考文献 125
致谢 137
北京大学学位论文原创性声明和使用授权说明 139

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