1 Where Human Meets Machine
People move through life in blissful ignorance. In many ways, our bodies and lives work like a black box, and we consider it a surprise misfortune when disease or disaster strikes. For better or worse, we stumble through our existence and figure out our strengths and weaknesses through trial and error. But what happens as we start to fill in more and more of the unknowns with insights generated by smart algorithms? We might get remarkable new ways to enhance our strengths, mitigate our weaknesses, and defuse threats to our well-being. But we might also start to limit our choices, blocking off some enriching pathways in life because of a small chance they could lead to disastrous outcomes. If I want to make a risky choice, will I be the only one who has agency over that decision? Can my employer discriminate against me because I decided not to take the safest path? Have I sacrificed an improbable joy for fear of a possible misfortune?
And what happens to us fifteen years from now, when AI-powered technologies permeate so many more facets of everyday lives?
The chimes from Avaâs home artificial intelligence system grew louder as she rolled over and covered her head with the pillow. Despite her better judgment, not to mention the constant reminders from her PAL, sheâd ordered another vodka tonic at last call. She already hated this dayâthe anniversary of her motherâs diagnosis thirty years earlierâbut the hangover throbbing in her temples was making this morning downright painful. The blinds rising and the bedroom lights growing steadily brighter didnât help. âYeah, yeah. Iâm up,â she growled as she steadied herself with a foot on the floor. Slowly, she rose and walked toward the bathroom, her assistant quietly reminding her of what she couldnât put out of her mind this morning no matter how hard she might try: precancer screening today.
So far, the doctors and their machines hadnât seen any need for action. But given her motherâs medical history, Ava knew she carried an elevated risk of breast cancer. Iâm only twenty-nine years old, she thought, I shouldnât have to worry about this yet. Her mother was pregnant with Ava when she got her diagnosis, so it came as a complete shock. Her parents agonized over what to doâabout the cancer and the babyâuntil they found a doctor who made all the difference. In the two decades since, progress in artificial intelligence and biomedical breakthroughs had eliminated many of the worst health-care surprises, and it seemed like medical science conquered a couple new ones in the few years since. Ava was old enough to remember when AI could identify and predict ailments half the time. Now, it hit 90 percent thresholds, and most people trusted the machine to make critical decisions (even if they still wanted a doctor in the room).
Ava snapped back into focus: âWhere are my goddamned keys?â
A patient, disembodied voice reminded her: âYou left your keys and sunglasses on the kitchen counter. Iâll order a car for you.â
She winced. âI gotta change your speech setting,â she said. âYou still sound too much like Connor.â No time now. She headed out the door for the doctorâs office. If she could, she would skip the precautionary checkups, but then sheâd lose her health insurance. So today, she just had to go through the motions and the machines.
Just donât say that word. A couple hours later, seated in the consultation room, the pounding in Avaâs head finally faded. The anxiety didnât. âSorry about the delay,â her doctor said as she breezed in and sat down. âEverything looks fine for now, but weâre starting to see some patterns in your biomarkers. The WellScreen check says about 78 percent of patients with your combination of markers and genetic disposition develop cancer within a decade. Itâs about time we look at some preventative measures.â
The rational part of Avaâs mind expected the news; she always knew how likely it was given her family history. Still, that wordâshe stared blankly for a moment while the jolt of âcancerâ started to ease. The doctor leaned forward and put a hand on Avaâs forearm, and Ava remembered again why she kept coming back to her. âThereâs plenty of time between now and any potential tumors that might come of this,â the doctor said. âWe have a lot of options.â
Ava started to breathe a little easier and tried to convince herself this was a good thing: All the tests and machines caught this long before she ran short on options. The doctor nodded to the screen on the wall, and up popped Avaâs customized patient portal. They waited a few seconds for the health monitor on Avaâs wrist to connect and upload her real-time biodata. There was her ex-boyfriend again, Connorâs voice oddly reassuring this time: âDo you want me to grant the patient portal access to your data?â
The recommendations filled the screen, and the doctor started explaining. âDo you plan to have children? Research shows that pregnancy-related hormones can be a strong defense against the development of some breast cancers. If you have a child in the next ten years, the best models suggest your chances of developing cancers drop to about 13 percent. But given the types of cancers that run in your family, we also have a tailored set of hormone therapies you could choose from. Better, because youâre starting now; it wonât be nearly as harsh as the old hormone drugs your mom dealt with. There are some side effects, but theyâre pretty mild in most patients. On their own, theyâll drop your chances of developing cancer to less than 20 percent. If you do either of thoseâthe child or the hormone therapyâand replace your biological breasts with Lactadyne prosthetics in the next eight years, your chances of breast cancer are essentially nil.â
The doctor noticed Avaâs furrowed brow. âLook, you donât need to decide right now. Take a little time to think about it. You can go through all these options anytime on your portal. Meanwhile, take a couple days to look at this waiver, too. If youâre up for it, we can start collecting data about your home and habits through your health manager and its connection to your refrigerator, toilet, and ActiSensor mattressâthe usual stuff like environmental quality, diet, and exercise. It weirds some people out, but the monitoring can help suggest simple lifestyle changes to improve your odds. Once we get that data, we can adjust some parameters in your daily life and think about how we might change your diet and exercise. Youâre on Blue Star insurance, right? Their Survive ânâ Thrive incentive plan offers some great rewards for people who do environmental and health monitoring. You give up some controlâbut, hey, it is your health weâre talking about, after all.â
The doctor chuckled. Ava shuddered. She didnât much care for any of the options. The whole ride home she wondered how much the diagnosis would sidetrack her dreams. Will my predisposition toward cancer disqualify me from the Antarctica trip? Iâm comfortable, but I donât have piles of moneyâwill the insurance company raise my premiums if I wait a few years before starting preventative therapies? What if my bosses find out? Will they ask me to leave or take a different role? And what about Emily? Should I tell my love, my partner that I might develop cancer unless we adjust our lifestyle? Will she still want to buy the condo on the hill?
Will Emily leave? Ava harbored no illusions about the program the doctor described. Sure, it would keep her clock ticking, but it also meant giving the machine a lot of control over her life, and she would pay a financial and personal price if she didnât comply. As her PAL started describing the program during the ride home, it began to dawn on Ava just how comprehensive this program would be. The insurance company and the doctor would put together a total treatment plan that would consider everything from her emotional well-being to the friends she hung out with. Her girlsâ nights out would never fly, at least not to the heights it did last night. Would she have to rethink her entire social life, her friends, and her schedule to make healthier choices? She might have to change her home environment to maximize the hormonal therapy. She might have to reduce the stress of her job, maybe even change jobs altogether.
Her mind was racing now: Will I have to give up Ayurveda because itâs not scientifically proven to minimize my risk? I could move to Germany, where regulators accept Ayurveda and allow personal AIs to integrate data from Indian and Chinese medicine. Emily loves traveling, but we never thought about living overseasâŚ
âToo much,â she whispered. âItâs too much.â She took a deep breath and massaged her temples. âI canât go home right now, and I sure as hell canât concentrate on work.â Her fingers trembled as she rifled through her purse to find her PAL. She chuckled about the device in her handâwhenever she needed a human touch, she relied on a machine to deliver it.
âAva! Whatâs going on?â
âMom?â she said, her voice cracking.
Avaâs PAL had made the call automatically, a sensor in the earpiece picking up on her anxiety through the minute electromagnetic impulses in her brain and skin. The PAL instantly correlated the best person to call in her current stateâalways Mom or Dad, at least when Dad wasnât gallivanting through some far-off placeâwhich, of course, her PAL also knew to be the case during this time of the year. Ava couldnât even recall whether sheâd acknowledged a prompt to connect the call. Sometimes the PAL would just call automatically, as she had set it to do at especially stressful times.
Normally, the chipper greeting and the background noise that came over her momâs eight-year-old iPhone drove her nuts, like an old vinyl record. Today, it couldnât have been more comforting. âPapa sends his best,â her mother said. âHeâs teaching today in Shanghai. He said he got you the gift of the century. I told him I donât even want to know.â
âHe got the beacon, too?â
âOf course, honey. You havenât delisted either of us yet. And you better not, either. You need your Swarm.â
âYeah, I suppose,â Ava said, trailing off. Every week, Avaâs PAL asked if she wanted to switch her alerts from the Swarm of friends and family to only Emily, who still couldnât understand why Ava wouldnât make the change. Ava tried to explain her relationship with her mom, the peace she got from the idea of multiple loved ones responding whenever she needed a comfort call or a reassuring holo-message. But Ava had substituted Connor for the Swarm back then, and the fact that she wouldnât make the change now really burned at Emily.
Momâs voice snapped Ava back again: âSo, Zut! in Berkeley, then? At least thatâs what my phone says.â
Connorâs disembodied voice piped in: âFifteen minutes until we arrive at Zut!â
Their favorite lunch spot. The restaurant theyâd gone to for years. An easy drive from the city. The fact that Zut! just popped up as her new destination didnât even register with Ava, though she hadnât been there in months. Still, her PAL assigned it a unique rating, based on voice diagnostics and states of mind. Ava still marveled about how often Connorâs voice suggested the perfect place, just like he used to.
When they met at lunch, Ava couldnât stop hugging her mom. There was nothing like the real thing, communing with another body and all its warmth, tenderness, and vulnerability. It didnât matter that her momâs advice was pretty much exactly what Avaâs doctor and AI recommended. The emotional connection and the depth of familial love imbued it with so much more credibility. The AI knew, Ava thought, but mom knows.
âI survived,â her mom said, âand so will you. Your chances are so much better now, and at least you can take a little time to map out a more predictable path. God, Iâll never forget how shocked I felt when the first doctor told us to terminate the pregnancy.â
Tears started to well in Avaâs eyes, but her mom pushed on: âHoney, there was no way I was going to let that happen. No way. When we talked to the second doctor, he realized that was nonnegotiable and looked for alternatives. It helped that he worked at a Catholic hospital, but I think he just understood the emotional side of it, the fact that fighting for something I so desperately wanted, motherhood, probably helped my chances.â Her mom shook her head, sighed, and wiped away a tear. Her eyes bored into Avaâs. âThereâs nothing worse than someone or something telling you that you have no optionsâespecially when they might be wrong. You need to take care of yourself, but you need to live your own life, too.â
Ava looked up at the hills and smiled as she rode toward her film studio. Mom and Dad wonât be around forever, at least not physically, she mused, but something about the song selection during the drive reminded her of how intimately her PAL picked up on the little recordings, notes, conversations, and subtle guidance her parents always provided. Melody Gardotâs âWho Will Comfort Meâ piped in, followed by Con Funk Shunâs âShake and Dance With Me.â Dadâs favorites were ancient, but her PAL correlated her mood with data on her interactions with him and found the exact combination of empathy and pick-me-up she needed. âGo get the day,â the message on her PAL said. She didnât even bother to check if her dad actually sent it, or if her AI just knew to post his favorite exhortation. She smiled again, soaking in the energy of the sunny day.
At the studio, the walk to her desk always prompted a sense of gratitude. She had initially accepted a Wall Street job, opting for the money and the excitement without ever consulting the Career Navigator. Had she never bothered to take her momâs advice and consult her old AI assistant before moving to New York City, who knows how many miserable years she wouldâve spent at that investment bank?
Fortunately, the Navigator homed in on her passion and predisposition for all things living and environmental, despite her best efforts to convince even herself otherwise. Career advisers, with their engrained biases and imperfect data, had told her she was a science ace, so the recommendation seemed to fit. It was definitely better than investment banking, anyway. She embarked on a mission to help mitigate climate change, enrolled in social justice programs, and spent a year as a park ranger in Tanzania. It was a fantastic time, but she never felt fully satisfied by the work. She spent a year debating herself until her AI finally projected a life picture that truly excited her. That beautiful, lifelike hologram of her workânot so different from the studio she stood in todayâeventually took her to NYUâs writing and directing program. The first night out with her classmates, the night she noticed Connor sitting by himself at the end of the bar, she actually kissed her new PAL.
Her job changed dramatically in the years since. AI generated increasingly precise insights about audience consumption patterns, societal mood swings, and political trends. Now the studioâs AI capabilities distilled narratives that guided plot development and created meaning for people in their daily lives. Ava would guide those narratives and enrich them with emotional content, imaginative imagery, and storyboards that spoke to the human mind and spiritâhowever undefinable that still was in 2034.
But not everyone integrated well when the studio, like so many other companies, installed deeper AI systems. Ava had a number of friends who started and aborted careers in different fieldsâaccounting, civil engineering, and pharmacy majors who suddenly discovered their education had not prepared them for the days when machines would conduct analyses, calculations, and highly routine or repetitive tasks. Ava recalled all too well the many long nights of whiskey-induced commiseration with struggling friends. Yet, it had been the same sort of AI insights that set her on the right path.
Ava started flipping through the storyboards for the studioâs next animated feature, occasionally stopping to dictate a few ideas. Each time she felt especially inspired by a change, sheâd reload the entire package and start reviewing the fully revised plotlines from the beginning. Today, though, she just couldnât connect with the stories. Leaning back in her chair, she flipped her PAL to attention mode. Peso, her financial advice AI, immediately beeped in: âHi, Ava. Looks like the markets will rebound tomorrow. Weâre picking up on improving geopolitical, productivity, and climate forecasts for next quarter. I give it a 75 percent probability, and we still have some time to move. Shall I put $2,500 of your savings into the market? Your medical and communication data suggest youâll be cutting back on consumables and travel over the next few months, so maybe put that money to good use in equities?â
âFine,â Ava replied in a resigned tone. It was the right advice, rational and purposeful, no matter how much it rekindled the anxieties from earlier in the day.
âYou sound worried,â her PAL said. âDo you want to speak with Zoe?â
Ah, Zoe, the fin-psych. Fin-psychs hadnât even existed until six or seven years ago. Before financial AIs hit the mainstream, no one needed people to help them process the difficult choices recommended by the machine. There were no more investment advisers, at least not as Ava remembered her parentsâ meetings with them. AI could handle all the synthesis of quantifiable data. What people needed was the emotional intelligence to anchor those decisions and make them palatable. These frail, complex, and emotional animals still needed that support.
âI need the support of a glass of wine,â Ava muttered to herself, gathering her things and heading out of the studio. She walked up the hill toward home. Despite all the support around her, both machine and human, she felt as fragile as ever. This mustâve been what Leo felt like, she thought as she walked past his old apartment. A few years ago, Leo, her old college friend, had locked himself inside, drank a bottle of top-shelf vodka, and overdosed on a fistful of pills. Soon after he got married a decade earlier, he railed against the âAI Gaydarâ app that could identify the sexual preference of a person in a photo with disturbingly high precision. Following the divorce, though, his PALâs relationship advice started to convince him that maybe he wasnât the Latin Lothario heâd always been conditioned to believe he was. If he ever admitted his sexual ambiguity to himself as his depression set in, he never accepted it.
Neither did Connor. He left Ava the day after Leoâs wake, unable or unwilling to deal with the loss of a friend and the same sort of ambiguity her PAL expressed about her choice of partners. It had said her sexuality wasnât as clear cut and simple as either of them thought. She told herself and Connor that she didnât fit a typical mold, whatever that was. And as she was coming to grips with her fuller identity, they fought in ways they never had before. She stopped knowing how to act around him, whether to argue with him or suppress her feelings about their relationship. After Leoâs suicide, it didnât matter. Connor left for Canada, hurt and heartbroken. A year later Emily entered Avaâs life.
Ava smiled at the thought of her.
âI need to change my Swarm settings,â she told herself as she walked into the condo she shared with Emily. âAnd I need to change this goddamned voice.â
Her PAL asked about both, but she turned it off and poured herself glass of wine instead. She dr...