Military Human Augmentation: Still Some Way Off

 The publication of Human Augmentation – The Dawn of a New Paradigm by the Defence Concepts and Doctrine Centre (DCDC) in 2021 demonstrated the importance of this topic within UK defence.¹ Human Augmentation (HA) is also referenced in the recent Defence Command Paper (Defence’s response to a more contested and volatile world)³ relative perceived effort,⁴ reduction in muscle EMG activity,⁵ cognitive function,⁶ and metabolic activity⁷ inter alia. In addition, translation of these outcome measures to military utility is not yet convincing. Another fundamental challenge with exoskeletons for military applications is power requirement. The reported improvements in physical performance in tethered systems described in these studies need to be viewed with scepticism as they will be reduced significantly once the systems carry their own power supply. Finally, there is evidence that while performance in one domain (lifting / carrying) may be augmented, this comes at the cost of reduced performance in another (walking).⁸

Remote sensing and measurement has been explored as a means to prevent injury and assure the health of our fighting force. Several remote sensing systems have reached an advanced technology readiness level and have shown promise in the field.⁹ However, there are several key problems that range from technological challenges (e.g. signal noise, calibration, drift, attachment-related artefact, etc) to the lack of causal evidence in the literature to link injuries or illness states with particular measurable parameters.¹⁰ This last problem is a fundamental barrier to this technology finding a military utility. We are currently at the stage of discovering what we can measure, but to be useful we need to know what we should measure.

This problem of lack of fundamental knowledge is profound in the more invasive areas of HA. Much of the means by which HA can be delivered remains entirely theoretical. For example, the specific genetic modifications of the human genome to improve muscle strength or prevent MSK injury are not known. Our literature search has not revealed any human research in these areas, meaning that deficits in understanding are unlikely to be resolved soon. If the HA technology is to transform our fighting force within a generation then significant investment in basic human research is required now.

The scientific problems discussed above are not the only difficulties in this area. Key ethical, legal, societal, and economic problems will need to be overcome for HA to deliver meaningful performance gains. Ethical issues are discussed clearly in the original paper (1) and relate to permanence, harm, societal acceptance, military proportionality, and fairness. Another ethical problem that has not been discussed in the literature is the question of whether HA is a medical therapy. HA intended to mitigate traumatic injury may be argued to be analogous to preventative medicine such as vaccination and may be considered within the remit of our current understanding of healthcare and medical ethics. However, HA that has no preventative medical application has no current medical analogy and cannot be considered part of healthcare as we currently understand it.

Multiple unanswered legal questions will need to be answered before HA can be used in practice (table 2). However, the UK government has no legislative agenda to clarify the law surrounding this area so these questions are likely to remain unanswered for now.

The safety of end users (and those around them) must be central to HA. Invasive procedures related to HA would necessarily carry risks but augmentation technology may also subsequently malfunction, leading to harm for the user. Further, any HA that has electromagnetic signature may be used to locate and target users and HA technology with any degree of connectivity may be hacked to cause harm to the user or others.

The biggest barrier to the development of HA technology in this field is economics. Given the primitive stage of readiness of HA, as demonstrated by the literature review, huge investment will be required to develop, manufacture, market, distribute, implement, dispose of, and assure it. All of these costs will have to be met by the customer (i.e. the military) who will additionally be responsible for the whole-life costs of the technology and who will likely hold the liability if things go wrong. The economic argument for augmenting humans for military purposes is further undermined by the rise in the use of uncrewed systems to deliver military effect. While few military commentators would envisage a battlespace devoid of humans, it is undeniable that the use of uncrewed systems of all levels of size, costs, and complexity is currently increasing enormously¹¹ and is likely to continue to do so. These systems can be mass produced, are less likely to cause costly harm to operators, and are not subject to any of the potentially expensive risks of HA technologies. Their cost per unit of military effect delivered is therefore many orders of magnitudes smaller than achieving the same goals through the use of HA.

The final argument against HA is the lack of clear strategic advantage that it would afford. It is certainly attractive to planners to envisage an augmented force that may carry heavier loads over longer distances for example, while being resistant to MSKI and having a higher survivability in the case of battlefield injury. The tactical advantages of these effects are obvious but the strategic impact is much less clear. It is challenging to see how the strategic situation of any of recent conflicts (Iraq, Afghanistan, or Ukraine) would have changed if HA was used by one side or another. Indeed, in the “information age of systems”, social or cognitive augmentation may deliver greater strategic effect than physical augmentation ever would.

There is nothing inherently wrong with exploring HA and the authors are not arguing that it could never deliver strategic effect or military utility. However, we have concluded from our review of the literature that the gaps in knowledge, the existing alternatives to achieve the same goals, and the unanswered ethical, legal, and safety questions surrounding this technology mean that we are still many years away from realising the vision laid out in recent strategic documents. The primary task for the military now is to define the requirements more clearly and look at the whole range of means to achieve those requirements. Subsequently, a coherent research strategy can be developed to fill the gaps in our knowledge and define what role HA can and should play in meeting them. 

Kirsty Milne and Neil Eisenstein

Neil Eisenstein and Kirsty Milne are both Regular Army orthopaedic surgeons,  with a specialist interest in major trauma and surgical innovation. Their interest in Human Augmentation is driven by curiosity about by the potential role surgeons will have in delivering a capability and the legal and ethical frameworks surrounding this.

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1.            The Development C, Centre D. Human Augmentation – The Dawn of a New Paradigm. Available from: https://assets.publishing.service.gov.uk/media/609d23c6e90e07357baa8388/Human_Augmentation_SIP_access2.pdf
3. Defence’s response to a more contested and volatile world [Internet]. 2023. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1171269/Defence_Command_Paper_2023_Defence_s_response_to_a_more_contested_and_volatile_world.pdf[/note] as a means through which UK defence will “transform the force through science, innovation and technology”. As military clinicians with an interest in this area, the authors have reviewed the current state of readiness of HA technology and its ability to deliver this transformational change. The results demonstrated a major gulf between the vision presented and reality. Furthermore, we argue that the alternatives to HA and the obstructions to its development and implementation have not been fully explored. The purpose of this analysis is to examine these alternatives and objections in more detail.

   Augmentation is not, in itself, a purpose. It is a tool used to achieve definable desirable outcomes; which in this case are improvements in physical performance. If one divides physical performance into sub-domains (Table 1), it becomes clear that there are existing means to deliver improvements in each domain. These can be implemented today, without huge investment, and with minimal ethical or legal challenge. So the first question to be answered by proponents of this area is “why use augmentation when alternatives exist”?

    

   Physical Performance Domain	Non Augmentation Means of Delivering Domain Tasks
   1. Movement and manual tasks within the operating environment: covering ground (improved distance or speed), load carriage, weapon system carriage and operation, augmentation for occupational tasks (e.g. operating machinery).	●      Vehicle use / mounting ●      Physical conditioning ●      Reducing / rationalising weight to be carried ●      Smoking cessation ●      Dietary optimisation ●      Use of uncrewed / autonomous systems
   2. Non-battle injury prevention and rehabilitation: Non-battle MSKI injury prevention, prosthetic enhancement, return to fitness after injury, reduced long term morbidity after injury.	●      Physical Conditioning ●      Injury prevention training and protocols ●      Smoking cessation ●      Safer working practices ●      Automation
   3. Enemy threat resilience: resilience to combat trauma, remote physiological monitoring of injured soldiers to enable improved decision-making regarding medical provision and evacuation.	●      Personal protective equipment (body armour, helmet, eye protection, hearing protection) ●      Adaptive tactics, techniques, procedures to counter enemy threats ●      Use of autonomous / remote weapon systems to remove the human from the threat environment ●      Forward medical provision, casevac, medevac ●      Autonomous / uncrewed systems to facilitate rapid evacuation in non-permissive environments ●      Novel medical practices (e.g. pharmacological pre-treatment)
   4. Environmental threat resilience: ability to tolerate threats such as heat, cold, CBRN, UV radiation, altitude, plant/animal threats, endemic diseases.	●      Environmental PPE (e.g. appropriate clothing state, CBRN PPE, UV protection) ●      Vaccination against weaponised and endemic biological threats ●      Heat acclimatisation where appropriate ●      Adaptive tactics, techniques, and procedures suitable to environmental threats ●      Use of autonomous / remote weapon systems to remove the human from the environmental threat environment
   5. Physical demands of warfighting: Resilience to fatigue. Requirements for water, nutrition, oxygen, sleep.	●      Altitude acclimatisation where appropriate or use of supplemental oxygen ●      Conditioning to function with limited sleep ●      Pharmacological intervention to manage sleep requirements ●      Careful management of water and food resources ●      Force multiplication using technology to reduce the requirements for human physical effort in the combat environment

   Our review of the literature revealed two areas of HA with substantially advanced technology readiness: exoskeletons and remote sensing. The more invasive areas of HA such as genetic manipulation, implantable technologies, or permanent tissue replacement / augmentation were almost entirely absent from the human literature. The paucity of in-human research in these advanced technologies means they are still many years, if not decades, away from being ready to deliver military effect, if they are capable of doing so at all.

   Even in the areas with the richest evidence-base, we found multiple knowledge gaps and flaws in the use-case arguments. For example, one of the key problems in the exoskeleton literature is the heterogeneity of outcome measures, which makes comparison of the systems impossible. These measures include oxygen consumption,²Gregorczyk KN, Hasselquist L, Schiffman JM, Bensel CK, Obusek JP, Gutekunst DJ. Effects of a lower-body exoskeleton device on metabolic cost and gait biomechanics during load carriage. Ergonomics. 2010 Oct 1;53(10):1263–75.

4. Junius K, Lefeber N, Swinnen E, Vanderborght B, Lefeber D. Metabolic Effects Induced by a Kinematically Compatible Hip Exoskeleton During STS. IEEE Trans Biomed Eng. 2018 Jun;65(6):1399–409.
5. Sado F, Yap HJ, Ghazilla RAR, Ahmad N. Exoskeleton robot control for synchronous walking assistance in repetitive manual handling works based on dual unscented Kalman filter. PLOS ONE. 2018 Jul 12;13(7):e0200193.
6. Bridger RS, Ashford AI, Wattie S, Dobson K, Fisher I, Pisula PJ. Sustained attention when squatting with and without an exoskeleton for the lower limbs. Int J Ind Ergon. 2018 Jul 1;66:230–9.

7. Kim J, Lee G, Heimgartner R, Arumukhom Revi D, Karavas N, Nathanson D, et al. Reducing the metabolic rate of walking and running with a versatile, portable exosuit. Science. 2019 Aug 16;365(6454):668–72.

8. Poliero T, Lazzaroni M, Toxiri S, Di Natali C, Caldwell DG, Ortiz J. Applicability of an Active Back-Support Exoskeleton to Carrying Activities. Front Robot AI [Internet]. 2020 Dec 9 [cited 2024 Apr 3];7. Available from: https://www.frontiersin.org/articles/10.3389/frobt.2020.579963
9. Smith M, Withnall R, Anastasova S, Gil-Rosa B, Blackadder-Coward J, Taylor N. Developing a multimodal biosensor for remote physiological monitoring. BMJ Mil Health. 2023 Apr;169(2):170–5.

10. 10.      Preatoni E, Bergamini E, Fantozzi S, Giraud LI, Orejel Bustos AS, Vannozzi G, et al. The Use of Wearable Sensors for Preventing, Assessing, and Informing Recovery from Sport-Related Musculoskeletal Injuries: A Systematic Scoping Review. Sensors. 2022 Jan;22(9):3225.

11. 11.  Jordan J. The future of unmanned combat aerial vehicles: An analysis using the Three Horizons framework. Futures. 2021 Dec 1;134:102848.