# How Emergency Medicine Solves the Alignment Problem

[Emergency medical technicians](https://en.wikipedia.org/wiki/Emergency_medical_technician) (EMTs) are not licensed to practice medicine. An EMT license instead grants the authority to perform a [specific set of interventions](https://www.ems.gov/national-ems-scope-of-practice-model/), in [specific situations](https://en.wikipedia.org/wiki/Indication_(medicine)), on behalf of a [medical director](https://en.wikipedia.org/wiki/Emergency_medical_technician#Medical_direction). The field of [emergency medical services](https://en.wikipedia.org/wiki/Emergency_medical_services) (EMS) faces many [principal-agent problems](https://en.wikipedia.org/wiki/Principal%E2%80%93agent_problem) that are analogous to the principal-agent problem of designing an intelligent system to act autonomously on your behalf. And many of the solutions EMS uses can be adapted for AI alignment.

Separate Policy Search From Policy Implementation
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If you were to [look inside](https://www.lesswrong.com/tag/gears-level) an [agent](https://en.wikipedia.org/wiki/Rational_agent), you would find one piece responsible for considering which policy to implement, and another piece responsible for carrying it out. In EMS, these concerns are separated to different systems. There are several enormous bureaucracies dedicated to defining the statutes, regulations, certification requirements, licensing requirements, and protocols which EMTs must follow. An EMT isn't responsible for gathering data, evaluating the effectiveness of different interventions, and deciding what intervention is appropriate for a given situation. An EMT is responsible for learning the rules they must follow, and following them.

A medical protocol is basically an if-then set of rules for deciding what intervention to perform, if any. If you happen to live in Berkeley California, here are the [EMS documents for Alameda County](https://ems.acgov.org/Documents/Documents.page). If you click through to the [2024 Alameda County EMS Field Manual](https://ems.acgov.org/ems-assets/docs/Clinical/Field%20Protocols/2024%20FM/ALCO_FM_2024%20-%20Final%20Book.pdf), under Field Assessment & Treatment Protocols, you'll find a 186 page book describing what actions EMS providers are to take in different situations.

As a programmer, seeing all these flowcharts is extremely satisfying. A flowchart is the [first step towards automation](https://blog.danslimmon.com/2019/07/15/do-nothing-scripting-the-key-to-gradual-automation/). And in fact many aspects of emergency medicine have already been automated. An [automated external defibrillator](https://en.wikipedia.org/wiki/Automated_external_defibrillator) (AED) measures a patient's heart rhythm and automatically evaluates whether they meet the indications for defibrillation. A typical AED has two buttons on it: "On/Off" and "Everyone is clear, go ahead and shock." A [ventilator](https://en.wikipedia.org/wiki/Ventilator) ventilates a patient that isn't breathing adequately, according to parameters set by an EMS provider.

A [network router](https://en.wikipedia.org/wiki/Router_(computing)) isn't a consequentialist agent. It isn't handed a criteria for evaluating the consequences of different ways it could route each packet, and then empowered to choose a policy which optimizes the consequences of its actions. It is instead what I'll suggestively call a [mechanism](https://en.wikipedia.org/wiki/Mechanism_design), a system deployed by an intelligent agent, designed to follow a specific policy which enforces a predictable regularity on the environment. If that policy were to be deficient in some way, such as [having a flaw in its user interface code](https://techcrunch.com/2023/10/19/hackers-exploit-zero-day-to-compromise-tens-of-thousands-of-cisco-devices/) that allows an adversary to remotely obtain complete control over the router, it's up to the manufacturer and not the router itself to address that deficiency.

Similarly, EMS providers are not given a directive of "pick interventions which maximize the expected quality-adjusted life years of your patients." They are instead given books that go into 186 pages of detail describing *exactly* which interventions are appropriate in which circumstances. As the medical establishment gathers more data, as technology advances, and as evidence that another off-policy intervention is more effective, the protocols are amended accordingly.

Define a Scope of Practice
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A provider's [scope of practice](https://www.ems.gov/national-ems-scope-of-practice-model/) defines what interventions they are legally allowed to perform. An EMT has a fixed list of interventions which are ever appropriate to perform autonomously. They can tell you quickly and decisively whether an intervention is in their [scope of practice](https://en.wikipedia.org/wiki/Basic_Life_Support), because being able to answer those questions is a big part of their training and [certification process](https://www.nremt.org/). A paramedic has more training, has been certified as being able to safely perform more interventions and knowing when to perform them, and has a correspondingly [larger scope of practice](https://en.wikipedia.org/wiki/Advanced_life_support).

A household thermostat isn't empowered to start small uncontrolled fires in its owner's home, even though that would help raise the temperature of the space. We deliberately limit the space of actions that our devices can perform autonomously, as part of our overall goal of being able to safely deploy autonomous systems.

Define Indications and Contraindications
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Every intervention in a scope of practice has [indications](https://en.wikipedia.org/wiki/Indication_(medicine)) associated with it. Many also have [contraindications](https://en.wikipedia.org/wiki/Contraindication) associated with them. An indication indicates that an intervention should be performed. A contraindication indicates that an intervention should not be performed. A patient that is unresponsive, not breathing, and has no detectable pulse meets the [Alameda County indications](https://ems.acgov.org/ems-assets/docs/Clinical/Field%20Protocols/2024%20FM/ALCO_FM_2024%20-%20Final%20Book.pdf) for performing cardiopulmonary resuscitation (CPR). A family member standing in front of the patient, with a valid Do Not Resuscitate (DNR) order is a contraindication for performing CPR. In order for an intervention to be appropriate for a situation, all of that intervention's indications need to present, and all of that intervention's contraindications need to be absent.

Indications and contraindications are a modular and flexible model for specifying what actions are appropriate to take in a well-understood domain of action. If this, then that. In such domains, autonomous systems should be designed to implement a policy which predictably only leads to acceptable outcomes. But what should an autonomous system do when [outside of the domain that it was designed for](https://en.wikipedia.org/wiki/Generalization_(learning))?

Let Your System Ask You What to Do
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EMTs perform medical interventions on behalf of a medical director. Directives from a medical director can come in two forms: offline and online. Offline medical directives are also called standing orders. Those 186 pages of "here's what interventions to perform under different circumstances" are offline medical directives. They can be implemented autonomously, without checking in with anyone else.

In contrast, online medical direction involves a medical director (or an authorized representative) telling an EMS provider what intervention to perform. This can include interventions which the provider does not have the authority to perform autonomously. One amazing fact about EMS protocols is that they can direct a provider to seek online medical direction. "I only have 186 pages to describe what to do in literally any situation, and so I'm going to cover a lot of them, but if you find yourself in a situation that isn't covered go ahead and call me and I'll tell you what to do."

This is another great example of the [do-nothing pattern](https://blog.danslimmon.com/2019/07/15/do-nothing-scripting-the-key-to-gradual-automation/) of gradual automation/delegation. We start out doing everything ourselves. Eventually we have enough experience that we can write down a flowchart for a task. We can then automate or delegate parts of that task. And the flowchart can say things like "if this happens, you are outside of the domain where I know what to tell you to do in advance. Go ahead and call me and I'll [give you direction on how to proceed](https://en.wikipedia.org/wiki/Exception_handling)."

Of course, the flowchart also needs to specify what to do if the director can't be reached. In particular, the system should continue to only take actions which it is authorized to perform autonomously, and only in situations where those actions were defined to be appropriate. In EMS, online medical direction is often helpful, but providers can always fall back on their training and offline medical direction if necessary.

Implement Oversight
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A [patient care report](https://www.ems.gov/issues/using-ems-data/collecting-good-data/) (PCR) records information about an interaction between a patient and an EMS provider. This includes information about the patient including their name, contact information, signs and symptoms. And it also records what interventions, if any, the EMS provider performed. This documentation can be used for all sorts of important purposes. Often, a patient needing emergency medical attention is taken to a hospital. The PCR becomes part of their medical records, and helps the providers there understand what's been happening with this patient and what treatments they have already received.

The data from many PCRs can be aggregated to measure the effectiveness of different interventions. This information can be used to improve decisions about how protocols should be updated, what equipment should be present in hospitals and ambulances, and sometimes even what interventions should be in a given scope of practice. This is one form of oversight.

It is often emphasized to EMS providers that a good PCR can also mean the difference between being liable or not liable in court. EMS providers are held to a [standard of care](https://en.wikipedia.org/wiki/Standard_of_care#Medical_standard_of_care), and they can face liability for performing an inappropriate intervention, or failing to perform an appropriate one. And a PCR is a provider's documentation of what was going on with a patient, and what interventions they performed. This is another form of oversight.

An EMS provider is also expected to actually follow the directions of their medical director, and is held accountable for failure to do so. This "following my directions" property is one we also want our autonomous systems to have. We call an autonomous system [corrigible](https://www.lesswrong.com/tag/corrigibility) if it follows valid instructions from authorized parties, and doesn't resist being turned off or reprogrammed. Network routers and thermostats are corrigible. [Goal-directed agents](https://en.wikipedia.org/wiki/The_Sorcerer%27s_Apprentice) are generally not corrigible, because you generally can't accomplish your goal if you're turned off or reprogrammed.

Increasing Automation and Alignment in EMS
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Interestingly, solving the Alignment Problem is also the centerpiece of the [EMS Agenda 2050](https://www.ems.gov/issues/planning-for-the-future-ems-agenda-2050/). The tagline is "A People-Centered Vision for the Future." And it's about how the design of the EMS system can be better aligned with the people it serves. 

![](https://39669.cdn.cke-cs.com/rQvD3VnunXZu34m86e5f/images/bb887efba0147feb08951f4b9ad37407b26df05af63fdf57.png)

It envisions a world where providers can perform safer and more effective interventions. Where more artificially intelligent and robotic systems are deployed as part of EMS. Where access to care, quality of care, and outcomes are not determined by age, socioeconomic status, gender, ethnicity, geography or other social determinants. Where new technologies, system designs, educational programs, and other aspects of EMS are continuously evaluated and improved.

The principles guiding the EMS Agenda 2050 were selected as part of designing an system for providing emergency medical care. But those same principles can be applied to the design of other systems, including software systems. And to institutions that design software systems. Wouldn't you like your software to be inherently safe and effective, integrated and seamless, reliable, scalable, and efficient? Wouldn't you like the institutions designing your software to be adaptable and innovative, to consider factors like sustainability and the equitable distribution of access and benefits?

This sequence is about how to approach the problem of delegating decision-making to software systems, which are empowered in some circumstances to act autonomously on your behalf. EMS has been doing an impressive job solving an analogous delegation problem, and many practices from EMS can be readily applied to software development.