What ethical issues parallel assistive technology use with older adults?

What ethical issues arise with assistive technology use within older adult populations?

“We need to get away from thinking that old age is about declining health and sickness and focus on well-being and technological solutions”.

ANDREW SIXSMITH, SFU News

Assistive technology can be perceived as an asset or a problem for vulnerable populations. Questions that surround the bigger question of “Is assistive technology good or bed?” can help us clarify limits and our reasoning related to technology use. In this sixth and final module, we will explore this question, the debate over who needs this technology, concepts of privacy and accountability, and aging theory, to answer the focused question “What ethical issues arise with assistive technology use within older adult populations?”

Who really needs this technology?

There are many populations that can be influenced by assistive technology (AT). But who needs it the most? The chart below tries to answer this question and brings our attention to a number of vulnerable populations.

 

(Mattison et al., 2017c)
 (Mattison et al., 2017a)

It can be surmised from this chart that older adult populations with mental health and aging issues are priority groups that require AT tools to improve their subjective experiences of aging. Segal et al. (2018) implies that assistive technology is essential to older adult lifestyles because a baseline level of functional status is necessary for independent community living. It is implied that individuals who fail to meet this baseline on their own (e.g. those experiencing functional decline) require an “adaptation of person- environment” (Segal et al., 2018, p. 397). Corrigan (n.d.) details how assistive technologies connect to aging and disability within our environment. Corrigan (n.d.) highlights the fact that older adults, and those with mental health issues, are amongst the most in need for assistive devices that reduce functional decline, and that this need increases with age. 

As the chart indicates, assistive technology can help improve the lived experience in many social, physical and economic ways (e.g. it can ease transitions of residence from autonomous living to assisted living within an institution, and provide caretakers peace of mind; by acting as a substitute carer. However, if this is true, and if AT can positively impact enrich the lives of the vulnerable, why do we hear so little about geriatric technology a.k.a. gerotechnology (Holstein et al., 2011)? I believe there are many reasons, including elements associated with access and economic disparities. It is the thought of these disparities and inequity that makes me consider the solutions to these inequities. If all populations cannot access AT equally, I wonder, “who should financially support assistive technology integration a.k.a. “foot the bill”?”

 (Mattison et al., 2017b)

Are we financially responsible for assistive care?

Segal et al. (2018) stresses that there is a “persistent relationship between health and socioeconomic status”(p. 120). Older adults may have financial difficulties as their health declines. Segal et al. (2018) goes on to link chronic financial strains to social and mental well being, and to depressive symptoms and physical illness. I believe the ethical issue of financial responsibility and accountability arises with the topic of chronic financial strain.  We must ask “are these technologies accessible to everyone or only those with significant resources? I think that  they are not, and that financial support could be a solution to strains that hinder optimal health. I posit that financial supports can help an older adult maintain their socioeconomic status, and that cost effective treatments and therapies that prevent health decline should be funded (at least in part) by society.

Some may argue that community funding for hearing aids, and other valuable ATs is impractical. The debate of who should be responsible for these technologies financially brings up the Canadian healthcare system, which we contribute to with our taxes. Review of our current system suggests that Canadians believe that we should be responsible for some AT (with OHIP coverage of hearing and vision tools, as well as psychiatric therapies and other treatments). With an aging population, adapting our system to our population is a rational action. Shifts in thinking towards a view that enhancing healthcare with AT is a utilitarian act (as it will benefit the greatest amount of people) may justify its consideration in financial policies of the future.  

Corrigan (n.d) surmised that financial support for vulnerable populations is needed to better society, and that older adults with and without mental illness can better benefit from access assistive technologies, with public funding support.

Government programs are currently providing this support, and steps have been made to improve access to assistive technology. The Assistive Devices Program is a provincial resource that will pay 75% of the cost of many types of assistive technology (Government of Ontario, 2020, July 16). This link will direct you to information on how to get help with payment for towards these technologies -> (Government of Canada, 2007).

However, it is important to mention that while equipment and supplies are more accessible with government initiatives like this, older adults with and without mental health issues may not be aware of these initiatives. Amending programs like the Ontario Assistive Devices Program so that mental in addition to physical disabilities are considered, could be a step in the direction of equitable care for all (Registered Nurses’ Association of Ontario, 2017).

Efforts must also be made to promote these resources of financial support through communities by mail, word of mouth, television and presentations; because many of these older adults do not use the internet (Government of Ontario, 2020, July 16). Better access to resources will maximize access to treatments and mental wellness (Government of Ontario, 2020, July 16).

World Health Organization [WHO] (2015) states that society is accountable to the aging population, and that it should minimize inequities that maximize functional ability and supportive environments. This implies that there should be financial support for the elderly relating to assistive technology support, and that it would be a violation of non maleficence to act in a way that does not maximize the functional abilities of elders with and without mental illness issues.

With the concept of maximizing accessibility in mind, I posit the question, what gaps are there with access to digital technology, beyond the limitation of funding, in our greying population?

(clipdealer.com, 2020a)

Safety versus Invasion of Privacy

The question surrounding whether the inclusion of AT will “enhance the liberty and safety” of older adults with mental illnesses (e.g. dementia) or restrict it (Sallinen et al., 2020), is an important inquiry that surrounds the ethical issues of freedom, privacy and safety (Jotterand et al., 2019). Age related changes may call into question whether or not an AT is appropriate for the older adults, and if elements of the individual experience will be threatened (e.g. with fraud and financial abuse) (Sriram et al., 2020). I believe that this can be a reality, but that freedom, privacy and safety can also be improved with assistive technology (Jotterand et al., 2019).

For example, a caregiver that is also the child of an older adult may be violating their parent’s privacy with the implementation of a high-tech security system into the home of their parent. This system could have camera technology that allows the carer to see and hear everything that happens with in the home. The intervention may have come with good intentions (a desire to keep their parents safe and healthy), but the ability to see all of the individual’s actions and movements throughout the day may be an invasion of privacy.

In contrast, the implementation of this system could be an act that maintains privacy in addition to the elders safety, if the AT is implemented with a person-centered approach (Sriram et al., 2020). If the older adult gets to control which rooms or times of day they can be observed, it could contribute to feelings of improved safety and security at home (Yusif et al., 2016), and to perceived senses of privacy, independence and life enjoyment (Holstein et al., 2011).

(clipdealer.com, 2020b)

I think it all comes down to the individuals role within their own care. I think safety, privacy and Freedom can be maintained if the older adult is involved in an intervention with assistive technology that allows for autonomous decision making.

Course readings state that that person centered care solutions could promote social inclusion and these positive outcomes (Bryant 2012). Security systems that include the older adult in their care, can also be an opportunity for the caregiver to place that older adult into a central role within their care. Assistive technology can be a means to inclusion. Associated outcomes of perceived competence and independence may subsequently empower seniors to drive their health and achieve personal goals (e.g. to perform morning ADL’s independently).

(clipdealer.com, n.d.)

Robots in Care

When we think about technologies connections to these concepts, we must also ask ourselves what the consequences would be if technologies replaced humans in elderly care; as assistive technology can be integrated into practice with robot assistants (Boucher, 2019). Ethical concerns that surround robot- elder interactions involve concepts of deception, respect and authenticity (Check out this podcast clip to hear about what society is saying about AT in elder care (Boucher, 2019).

(Boucher, 2019)

Benefits and consequences of social robots can be weighed to determine if the inclusion of this technologies is ethical, and if AT replacements are ethically justified. Sætra (2020) states that robots will improve the quality of eldercare. I agree. I believe that the quality of care includes the ability to meet care needs (e.g. opportunities that encourage independence) which assistive technology allows for.

Talk about the use of a social robot as a means of deception connects assistive technology once to the concept of cognitive capacity. The older adult with dementia may not have the capacity to understand that a robot is not a real animal or person, and care of this individual could be seen as unjust. Full deception is a term that has been used to identify this type of care. We must ask ourselves, even if the individual receives perceived feelings of joy and comfort from the fake carer, is it right to lie to an individual with a cognitive deficit or mental illness (Sætra, 2020)?

Whether or not the AT can provide authentic care is also a ethical issue that should be considered. Theory suggests that that care can satisfies the authentic (the potential self) and/or the empirical self (the clinical manifestation of the individual). It is important to think about how the AT affects that authentic and empirical selves. Is the person with dementia is being cared for by an assistive device that would bring happiness to the person, even if they did not suffer with illness disability (Sætra, 2020)?

Further, if the subjective experience is one of pleasure and happiness, are social robots then acting as agents of good with actions of beneficence? Ethical implications of these acts of nonmalificence could include the denial of an older adult’s potential happiness, therefore we must carefully analyse social robots like Tombot (mentioned in Module 1), to determine if they are socially responsible innovations of healthcare (Sætra, 2020).

One last ethical consideration is AT use within the context of the current COVID pandemic.

The elderly are experiencing social isolation like never before, and social robots may not be enough. The pandemic has made quality care is more complex. It brings up the question of how social robots impact patient care.  Some argue that robot care is “undignified and disrespectful” (Sætra, 2020). Others argue that inclusion of these robots in care is an example of respectful action towards the elderly (Sætra, 2020). The addition of robot assistants could satisfy a need for companionship in a time of social restrictions with family and friends (Sætra, 2020). What do you think?

(shutterstock, n.d.)

Theory

With a greying population our care needs are increasing, as is the need to stay active within our communities. The activity theory (a psychosocial theory of aging) posits that new activities should replace the old (Wadensten, 2006). The theory posits that society should encourage activity in older adults with and without mental illness (Wadensten, 2006). It would agree that assistive technology, whether in the form of robot assistants or hearing aids is necessary for successful aging and for life enrichment (if the technology enabled the older adult to participate in life activities to a greater extent (Wadensten, 2006). Enriched communities can consequently increase capacities of adaptation and resilience to changes of activity throughout the lifespan (World Health Organization [WHO], 2015).  Aging theory reflects the World Health organization belief that technologies stimulation of behaviors, will improve older adults connection with their community (WHO, 2015).

Policies

So if technologies provide older adults with the ability to engage in activities that improve their quality of life, should we change current aging-related tech policies to promote these improvements? Yes, I believe we should. I think we must work to integrate policies about technologies and technology education directed at older adults. New device updates may require educational training or easy to use tutorials to entice  to older adults and caregivers to adapt these new applications and programs into their daily routines. This idea makes me consider if there is space for a new kind of health care worker that works to ensure relevant health literacy. Perhaps coordinated care plans of the future could include sessions of technology education with a new type of digital health information specialist. This addition of digital education could improve health literacy, and could encourage more effective patient centered care.

Ethics and values matter in public policy development. Regulations may reinforce medicalization, and effective inclusive practices that could improve society and older adults quality of life (Holstein et al., 2011). I believe that law reform is needed, because assistive technology is not being used to its full potential with vulnerable populations. More collaboration is also needed to address limited mental health services, with policies that carve out the need for assistive devices in mental health care (like the ones I’ve mentioned in the earlier modules).

Conclusion

If we put all of our learnings from these modules together, it is easy to see that there are many ways to integrate technology into the lives of our aging population. Ethical issues related to assistive technology (privacy, safety, financial responsibility and deception) must be explored to develop a better comprehension of how AT can influence the lives of older adults with and without mental health issues.

These blog modules have allowed me to be more self-aware of my own gaps in knowledge about assistive technologies, and to draw connections between practical interventions and academic literature. I have also been able to link aging theory to issues that surround AT devices that will improve lives globally.

Community and industry policies can be inclusive of vulnerable populations with effort, and investment in policy change will lead to better holistic care for all. We can shape technological advances to improve the lives of older adults with and without mental illness and hopefully this module has been a step towards that. I hope that I have encouraged you to question technologies role in society and within aging, and that your learning has changed your mindset and beliefs about AT use. Spread the word about assistive technology and about third act technology, so that we can continue to educate future generations about aging and health.

Thank you for Reading.

All the Best,

Katie

References

Boucher, P. (2019). What if technologies replaced humans in elderly care? [Science and Technology Podcast]. European Parliamentary Research Service Blog. https://www.youtube.com/watch?v=myYe0Y1RxFI&feature=youtu.be

Bryant, C., Bei, B., Gilson, K., Komiti, A., Jackson, H., & Judd, F. (2012). The relationship between attitudes to aging and physical and mental health in older adults. International psychogeriatrics, 24(10), 1674–1683. https://doi.org/10.1017/S1041610212000774

clipdealer.com. (2020a). Elderly couple at home. Stay home concept from COVID-19 coronavirus prevention [Online image]. https://en.clipdealer.com/vector/media/A:143932440

clipdealer.com. (2020b). Relatives call grandparents [Online image]. https://en.clipdealer.com/vector/media/A:143932440

clipdealer.com (n.d.). Senior couple watching tv news during covid-19 [Online image] https://en.clipdealer.com/vector/media/A:152233563

Corrigan, P. D. (n.d.). Double Trouble: The stigma of mental illness and of aging [PowerPoint slides]. National Council on Aging. https://www.ncoa.org/wp-content/uploads/PRC-HAN-Oct-1-Webinar-Overcoming-Stigma2.pdf

Government of Canada. (2007). Seniors and aging – Assistive devices. https://www.canada.ca/en/health-canada/services/healthy-living/your-health/lifestyles/seniors-aging-assistive-devices.html

Government of Ontario. (2020, July 16). Assistive Devices Program. https://www.ontario.ca/page/assistive-devices-program?_ga=2.100592860.370261105.1498230646-1288996817.1488815350

Holstein, M. B., Waymack, M., & Parks, J. A. (2010). Ethics, aging, and society: The critical turn. Springer publishing company.

Jotterand, F., Ienca, M., Wangmo, T., & Elger, B. (2019). Intelligent Assistive Technologies for Dementia: Clinical, Ethical, Social, and Regulatory Implications. Oxford University Press

Mattison, C. A., Wilson, M. G., Wang, R. H., & Waddell, K. (2017a). Demographic and social changes are increasing the need for assistive technologies [Online image]. McMaster Health Forum.https://www.mcmasterforum.org/docs/default-source/product-documents/evidence-briefs/asst-tech-eb.pdf?sfvrsn=8

Mattison, C. A., Wilson, M. G., Wang, R. H., & Waddell, K. (2017b). Factors contributing to the challenge of enhancing equitable access to assistive technologies [Online image]. McMaster Health Forum. https://www.mcmasterforum.org/docs/default-source/product-documents/evidence-briefs/asst-tech-eb.pdf?sfvrsn=8

Mattison, C. A., Wilson, M. G., Wang, R. H., & Waddell, K. (2017c). Who needs assistive technology? [Online image]. McMaster Health Forum. https://www.mcmasterforum.org/docs/default-source/product-documents/evidence-briefs/asst-tech-eb.pdf?sfvrsn=8

Registered Nurses’ Association of Ontario. (2017). Amending the Ontario Assistive Devices Program to include mental as well as physical disabilities. https://rnao.ca/policy/letters/OntarioAssistiveDevicesProgram

Segal, D., Qualls, S., & Smyer, M. (2018). Aging and mental health (3rd ed.). Wiley-Blackwell

Sriram, V., Jenkinson, C., & Peters, M. (2020). Carers’ experience of using assistive technology for dementia care at home: a qualitative study. BMJ Open,(10)3. https://doi.org/10.1136/bmjopen-2019-034460

Sætra H. S. (2020). The foundations of a policy for the use of social robots in care. Technology in Society63, 101383. https://doi.org/10.1016/j.techsoc.2020.101383

Sallinen, M., Hentonen, O., & Teeri, S. (2020). Ethical dilemmas related to the use of safety technology in service house environments. Scandinavian Journal of Caring Sciences34(1), 199–205. https://doi.org/10.1111/scs.12721

Shutterstock. (n.d.). Couple in wheelchairs with laptops [Online image]. https://epthinktank.eu/2019/10/18/what-if-technologies-replaced-humans-in-elderly-care-science-and-technology-podcast/

Wadensten, B. (2006). An analysis of psychosocial theories of ageing and their relevance to practical gerontological nursing in Sweden. Scandinavian Journal of Caring Sciences, 20(3). 347-354. https://doi.org/10.1111/j.1471-6712.2006.00414

World Health Organization. (2015). World report on ageing and health. https://apps.who.int/iris/bitstream/handle/10665/186463/9789240694811_eng.pdf;jsessionid=FC07827C532795963E8C63041C2676EB?sequence=1

Yusif, S., Soar, J., & Hafeez-Baig, A. (2016). Older people, assistive technologies, and the barriers to adoption: A systematic review. International Journal of Medical Informatics, (94), 112-116. https://doi.org/10.1016/j.ijmedinf.2016.07.004

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