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5 Questions for: David Paydarfar

Ahead of his SXSW appearance, the chair of neurology at Dell Med describes what’s possible when brains and computers meet

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David Paydarfar

Paralyzed people now can control prosthetic limbs and wheelchairs with their brains. People with neuromuscular disorders or brain injuries now can communicate or make art. Advances in brain-computer interface are making the previously impossible possible. From patients to athletes to artists, these advances are changing lives and how we engage the world but also present new ethical and legal questions.

On Friday, March 8, 2024, David Paydarfar, chair of the Department of Neurology at UT’s Dell Medical School, will participate on a panel at UT’s Hook ‘Em House at SXSW exploring health care advances in brain-computer interfaces. The other panelists will be Amanda Pustilnik, professor of law, University of Maryland, and Matt Angle, CEO of Paradromics. The session will be moderated by Kavita Patel, physician, policy research, venture partner of Healthcare, NEA. We spoke to Paydarfar on March 1.

1. What would most people be surprised to learn now can be done with a brain-computer interface?

Most people are familiar with the use of prosthetic devices like the iPhone. It’s a kind of brain-computer interface, but I have to use my brain to tell my hand what to do with it. I think what’s really shocking is that we now, for the first time, can decode these signals that look kind of random in our head, to take the hand out of the process. I’m a neurologist and a computationally oriented neuroscientist. Just the idea that you can decode these signals and then recode them to do something with a robotic arm, a cursor or directly with your iPhone, an artificial larynx, a wheelchair or an exoskeleton — from just a purely technological point of view, that’s really amazing.

If I want to throw a baseball at a target, I command all these motor neurons in my spinal cord that lead to all these muscles, and there’s a signaling code that flows through the brain that helps me hit the target. Using machine learning, we can decode this information and command not my arm but an artificial arm. Same for speech and a speech producer. In a nutshell, it’s research that’s the embodiment of hope for people who have lost these functions.  

2. How does the advance of this technology affect you as a clinician?

Unfortunately, I’ve seen way too many patients where, just in front of my eyes, as a clinician, there’s such despair. There was a kid with Duchenne’s dystrophy I took care of from his late teens through adulthood to death. This despair of just no hope, it’s just going down. Yeah, we all hope for miracles, right? But as a scientist, as a clinician, I can with precision predict when this person is going to die. It’s just so depressing. I don’t really want to make these predictions. And then to watch my own patients and their families in the despair of loss of agency. What is it to be human? It’s the ability to communicate, to move, to think, to interact and having agency over all these cardinal functions. Those are like neurological vital signs. There have been so many times a patient of mine has said, “I’m ready to go. I don’t want to live anymore.”

Now, suddenly this technology is coming. Wow! Oh my God! Finally all those NIH dollars and everything we’ve been doing as academicians — it was like a moonshot to another galaxy, and now, we can actually see it could happen. The part that’s really exciting for us is that UT, for a variety of reasons, is perfectly positioned for this. It’s really perfectly positioned.

UT, for a variety of reasons, is perfectly positioned for this."

David Paydarfar

3. Why is that?

It’s perfectly positioned because UT Austin historically has been a quantitative sciences campus. In all the colleges, there’s a strong commitment to quantification in measurement and computation. TACC (Texas Advanced Computing Center) is not just one department, it’s for the whole University. And there’s not just one department that’s incredibly strong in quantitative science, it’s just across the campus. When I was recruited to Austin, I wasn’t really sure why I was being recruited, because I was not on the circuit looking for chair jobs. Clay Johnston (founding dean) said point blank, “I’m recruiting you because your background is in physics and engineering, and we need somebody here at the med school to bridge with the Cockrell School of Engineering, with physics, the College of Natural Sciences, all the departments that are quantitatively oriented. It’s also in liberal arts: you’ve got folks in psychology, in the neurosciences, who are incredibly advanced at quantitative methods for behavior. Feelings, emotions — those can be quantified too. They can be measured, they can be encoded, decoded.

The biggest Achilles’ heel UT Austin has had historically has been the lack of a medical school and the lack of a medical center. The medical school thing has been solved. Having a dedicated, research-oriented, focused medical center is now being solved with the UT Austin Medical Center being planned over the next few years. I view that as being transformative. The ability to take a clinic and a hospital and make it a laboratory for discovery at alleviating suffering in people in a safe and ethical way, it just means so much to patients and their families to contribute to that. If we can’t help them, then they want to be able to help others in the future. Having a research option for people really helps them with their legacy. I’ve seen that desire from patients my entire career.

4. What’s an example of an ethical question these advances present?

I’m not an ethicist, but as a practicing physician and scientist, when I invent something or develop some new idea or treatment, in the back of my mind I’m thinking that eventually it needs to be valuable for all of society, for all people. So equity is really important. Another way to say it is: disease doesn’t care whether you’re rich or poor. Since my villain, as a clinician and a scientist, is disease, I’m thinking about how I can make the biggest impact on people who are afflicted by this disease. If I have to worry, well this is only for people who can pay out of pocket, it’s not as exciting to me. 

Disease doesn't care whether you're rich or poor."

David Paydarfar

Having said that, we have to be open to the fact that this could evolve. When I was in college, it was announced that in England there was this amazing breakthrough making dialysis possible. The size of the dialysis machine was bigger than my office, and it cost millions of dollars. And people thought, well who’s going to benefit from that! But over the years, the price point has come down, and the size has come down. And now — this is not on the market yet — there is an artificial kidney that’s a chip, an organ on a chip that can be implanted. They’re taking human kidney cells, implanting them on a chip, and then programming it to be your kidney. It’s like, OK! Now we’re talking! But we wouldn’t have gotten here if we hadn’t invented the big dialysis machine, which was crazy and not practical and maybe it was good for the Queen of England or something! But the job of industry and government and people like me is to be thinking about how to bring these things down price-point-wise. Now dialysis has value for all of society, and Medicare and insurance will pay for it.

There’s also the ethical question of, if you can decode the brain, what’s going to prevent somebody else from decoding your brain? If an MR scanner can read what my thoughts are, one day is there going to be some technology that’s going to read our thoughts? This gets to a somewhat science-fiction ethical question, but it’s worth talking about: if that were to happen 50 years from now, what would we do? It’s a legitimate question. But at the moment, the biggest policy ethics question is the equity question.

5. What led you to this area of study? Is there a personal connection or was it simply where the academic and research road led you?

It’s a mixture of personal witness of tragedy and background. I was not planning on going to medical school. I was very much in the field of physics, and I became interested in the physics of life. What is life? Does it violate the laws of physics? How do you explain self-organizing things that become intelligent? You can imagine an 18-year-old who has a lot of crazy thoughts. It just kind of went wild. Finally, I decided I’m interested not only in what is life, but what is death? What is disease? As a physics and math person, I think in symbols and like to do computer programming. So what is death and how does life unravel and become inanimate again? What is disease? What are disease dynamics? What’s the overall mathematical model? 

Of course, the brain is the least understood part of the body, so for a kid who wants to study weird stuff, the brain is the ultimate. I applied to medical school because I wanted to learn about disease. They said, “Well, do you want to be a doctor?” and I said, “Oh, I never really thought of that!” Eventually I fell in love with taking care of patients, but there’s still a fascination with how the brain computes. What can a neuron, one cell, compute? How the heck—I mean, this brain is using less than 20 watts of energy, and I can play chess, and if an alarm goes off I would realize something was wrong, and do other things.

I don’t build brain-machine interfaces myself, but I work with José Milan, Elizabeth Tyler-Kabara, a  very imminent neurosurgeon who works on brain-machine interfaces, and Matt Willsey, whom we just recruited from Stanford to work at the Mulva Center for Neurosciences; he’s a neurosurgeon who’s also an engineer. I have committed myself to recruiting and working with people who are really dedicated to making this happen.