Healthy and Happy? An Ethical Investigation of Emotion Recognition and Regulation Technologies (ERR) within Ambient Assisted Living (AAL).

Ambient Assisted Living (AAL) refers to technologies that track daily activities of persons in need of care to enhance their autonomy and minimise their need for assistance. New technological developments show an increasing effort to integrate automated emotion recognition and regulation (ERR) into AAL systems. These technologies aim to recognise emotions via different sensors and, eventually, to regulate emotions defined as "negative" via different forms of intervention. Although these technologies are already implemented in other areas, AAL stands out by its tendency to enable an inconspicuous 24-hour surveillance in the private living space of users who rely on the technology to maintain a certain degree of independence in their daily activities. The combination of both technologies represents a new dimension of emotion recognition in a potentially vulnerable group of users. Our paper aims to provide an ethical contextualisation of the novel combination of both technologies. We discuss different concepts of emotions, namely Basic Emotion Theory (BET) and the Circumplex Model of Affect (CMA), that form the basis of ERR and provide an overview over the current technological developments in AAL. We highlight four ethical issues that specifically arise in the context of ERR in AAL systems, namely concerns regarding (1) the reductionist view of emotions, (2) solutionism as an underlying assumption of these technologies, (3) the privacy and autonomy of users and their emotions, (4) the tendency of machine learning techniques to normalise and generalise human behaviour and emotional reactions.

Liquid Health. Medicine in the age of surveillance capitalism.

Digital health technologies transform practices, roles, and relationships in medicine. New possibilities for a ubiquitous and constant data collection and the processing of data in real-time enable more personalized health services. These technologies might also allow users to actively participate in health practices, thus potentially changing the role of patients from passive receivers of healthcare to active agents. The crucial driving force of this transformation is the implementation of data-intensive surveillance and monitoring as well as self-monitoring technologies. Some commentators use terms like revolution, democratization, and empowerment to describe the aforementioned transformation process in medicine. The public debate as well as most of the ethical discourse on digital health tends to focus on the technologies themselves, mostly ignoring the economic framework of their design and implementation. Analyzing the transformation process connected to digital health technologies needs an epistemic lens that also considers said economic framework, which I argue is surveillance capitalism. This paper introduces the concept of liquid health as such an epistemic lens. Liquid health is based on Zygmunt Bauman's framing of modernity as a process of liquefaction that dissolves traditional norms and standards, roles, and relations. By using liquid health as an epistemic lens, I aim to show how digital health technologies reshape concepts of health and illness, change the scope of the medical domain, and liquify roles and relationships that surround health and healthcare. The basic hypothesis is that although digital health technologies can lead to personalization of treatment and empowerment of users, their economic framework of surveillance capitalism may undermine these very goals. Using liquid health as a concept allows us to better understand and describe practices of health and healthcare that are shaped by digital technologies and the specific economic practices they are inseparably attached to.

[Support of treatment safety by nursing personnel when dealing with emergency situations in long-term care facilities : Results of a qualitative empirical study]. / Unterstützung der Handlungssicherheit von Pflegefachpersonen im Umgang mit Notfallsituationen in Pflegeheimen : Ergebnisse einer qualitativ-empirischen Studie.

A significant number of emergency responses and hospitalizations of nursing home residents are considered avoidable and result in an unnecessary burden or health risk for residents. One cause of these unnecessary emergency responses lies in the lack of confidence of nursing personnel in their own actions and decisions. The goal of the NOVELLE project is to develop recommendations for action for certain emergency situations that enable nursing personnel to make operationalized decisions and empower them to take confident action. The challenges for nursing professionals to act with confidence in emergency situations were collated and assessed through a qualitative interview study. The results of this study are presented.

Adiaphorisation and the digital nursing gaze: Liquid surveillance in long-term care.

The nursing gaze, that is the specific ways of observing the patient in nursing practice, has been the object of ethical debates for decades. It has been argued that the specific feature of observing patients in nursing is the stereoscopic vision that allows nurses to see the patient at the same time as a subject and a body. However, with the increased use of technology in nursing and the focus on quantifiable biomedical data, some commentators see a shift from the view of the patient as subject to the patient as body, which results in a de-humanisation and objectification of patients. The new digital technologies in patient monitoring and surveillance add a further dimension to this topic. It is yet unclear how digital technologies affect the nursing gaze, and with it, nursing practice. Furthermore, the ethical implications of the digitally enhanced nursing gaze have yet to be analysed. It is the purpose of this study to make a first step in this direction. By focusing on digitally enhanced monitoring technologies in long-term care, these technologies are interpreted as liquid surveillance, an approach introduced by Zygmunt Bauman. The Baumanian concept of adiaphorisation, that is the detachment of social action from moral evaluation, is used as normative framework of the analysis. The analysis shows that the tendency to remove surveillance practices from moral evaluation by framing them as enablers of an active, healthy life and as tools for caring for the vulnerable, the stereoscopic vision of the nursing gaze is undermined.

Lost in translation? Conceptions of privacy and independence in the technical development of AI-based AAL.

AAL encompasses smart home technologies that are installed in the personal living environment in order to support older, disabled, as well as chronically ill people with the goal of delaying or reducing their need for nursing care in a care facility. Artificial intelligence (AI) is seen as an important tool for assisting the target group in their daily lives. A literature search and qualitative content analysis of 255 articles from computer science and engineering was conducted to explore the usage of ethical concepts. From an ethical point of view, the concept of independence and self-determination on the one hand and the possible loss of privacy on the other hand are widely discussed in the context of AAL. These concepts are adopted by the technical discourse in the sense that independence, self-determination and privacy are recognized as important values. Nevertheless, our research shows that these concepts have different usages and meanings in the ethical and the technical discourses. In the paper, we aim to map the different meanings of independence, self-determination and privacy as they can be found in the context of technological research on AI-based AAL systems. It investigates the interpretation of these ethical and social concepts which technicians try to build into AAL systems. In a second step, these interpretations are contextualized with concepts from the ethical discourse on AI-based assistive technologies.

A typology of nurses' interaction with relatives in emergency situations.

BACKGROUND: In nursing homes, residents' relatives represent important sources of support for nurses. However, in the heightened stress of emergency situations, interaction between nurses and relatives can raise ethical challenges. RESEARCH OBJECTIVES: The present analysis aimed at elaborating a typology of nurses' experience of ethical support and challenges in their interaction with relatives in emergency situations. RESEARCH DESIGN: Thirty-three semi-structured interviews and six focus groups were conducted with nurses from different nursing homes in Germany. Data were analysed according to Mayring's method of qualitative content analysis. PARTICIPANTS AND RESEARCH CONTEXT: Participants were licensed nurses working in nursing homes. ETHICAL CONSIDERATIONS: Ethical approval was granted by Ostfalia University of Applied Sciences (02.07.2020) and the Ethics Committee of Hannover Medical School (Nr. 8866_BO_K_2020; 27.01.2020). Interviewees were anonymised and focus group were pseudonymised during transcription. All participants provided written consent. FINDINGS/RESULTS: In emergency situations, relatives can represent important sources of support for nurses. However, they may also give rise to different challenges, relating to four ethical conflicts: (1) the challenge of meeting the information needs of relatives while providing appropriate care to all residents; (2) the challenge of managing relatives' demands for hospitalisation when hospitalisation is not deemed necessary by nurses; (3) the challenge of managing relatives' demands for lifesaving treatment when such treatment contradicts the will of the resident; and (4) the challenge of attempting to initiate hospitalisation when relatives oppose this course of action. Several external factors make these conflicts especially challenging for nurses: fear of legal consequences, a low staffing ratio, and a lack of qualified nursing staff. CONCLUSIONS: Conflict between nurses and relatives typically revolves around hospitalisation and the initiation of lifesaving treatment. Whether nurses perceive interaction with relatives as supportive or conflictual essentially depends on the quality of the relationship, which may be negatively influenced by a number of external factors.

Equity in AgeTech for Ageing Well in Technology-Driven Places: The Role of Social Determinants in Designing AI-based Assistive Technologies.

AgeTech involves the use of emerging technologies to support the health, well-being and independent living of older adults. In this paper we focus on how AgeTech based on artificial intelligence (AI) may better support older adults to remain in their own living environment for longer, provide social connectedness, support wellbeing and mental health, and enable social participation. In order to assess and better understand the positive as well as negative outcomes of AI-based AgeTech, a critical analysis of ethical design, digital equity, and policy pathways is required. A crucial question is how AI-based AgeTech may drive practical, equitable, and inclusive multilevel solutions to support healthy, active ageing.In our paper, we aim to show that a focus on equity is key for AI-based AgeTech if it is to realize its full potential. We propose that equity should not just be an extra benefit or minimum requirement, but the explicit aim of designing AI-based health tech. This means that social determinants that affect the use of or access to these technologies have to be addressed. We will explore how complexity management as a crucial element of AI-based AgeTech may potentially create and exacerbate social inequities by marginalising or ignoring social determinants. We identify bias, standardization, and access as main ethical issues in this context and subsequently, make recommendations as to how inequities that stem form AI-based AgeTech can be addressed.

"Democratizing" artificial intelligence in medicine and healthcare: Mapping the uses of an elusive term.

Introduction: "Democratizing" artificial intelligence (AI) in medicine and healthcare is a vague term that encompasses various meanings, issues, and visions. This article maps the ways this term is used in discourses on AI in medicine and healthcare and uses this map for a normative reflection on how to direct AI in medicine and healthcare towards desirable futures. Methods: We searched peer-reviewed articles from Scopus, Google Scholar, and PubMed along with grey literature using search terms "democrat*", "artificial intelligence" and "machine learning". We approached both as documents and analyzed them qualitatively, asking: What is the object of democratization? What should be democratized, and why? Who is the demos who is said to benefit from democratization? And what kind of theories of democracy are (tacitly) tied to specific uses of the term? Results: We identified four clusters of visions of democratizing AI in healthcare and medicine: 1) democratizing medicine and healthcare through AI, 2) multiplying the producers and users of AI, 3) enabling access to and oversight of data, and 4) making AI an object of democratic governance. Discussion: The envisioned democratization in most visions mainly focuses on patients as consumers and relies on or limits itself to free market-solutions. Democratization in this context requires defining and envisioning a set of social goods, and deliberative processes and modes of participation to ensure that those affected by AI in healthcare have a say on its development and use.

Nurses' perspectives on the role of relatives in emergency situations in nursing homes: a qualitative study from Germany.

BACKGROUND: In nursing homes, emergencies often result in unnecessary hospital transfers, which may negatively affect residents' health. Emergency management in nursing homes is complicated by structural conditions, uncertainties and difficulties communicating with the treating healthcare professionals. The present study investigated the role played by relatives in this emergency management, as perceived by nursing staff. METHODS: Within the context of a larger multi-method, interdisciplinary research project, we conducted six focus group discussions and 33 semi-structured interviews with nurses at nursing homes in northern Germany between September 2020 and April 2021. Discussions and interviews focused on emergency management in nursing homes, and were recorded, transcribed and analysed using qualitative content analysis, according to Mayring. RESULTS: Nurses reported that relatives were actively involved in emergency management in the nursing homes. Relatives were informed when there was an emergency situation, and they participated in decision making around the resident's care. Nurses sometimes perceived the involvement of relatives as challenging, due to a lack of time or staff, the opposing views of relatives and/or uncertain communication structures; however, they were willing to involve relatives according to the relatives' preferences. The role played by relatives was seen to range from that of an active supporter to that of a troublemaker. On the one hand, relatives were reported to support nurses in emergency management (i.e. by identifying residents' preferences and advocating for residents' interests). On the other hand, relatives were often perceived by the nurses as overstrained and unprepared in emergency situations, leading them to override residents' wishes, question the emergency plan and put pressure on the nurses' decision making. CONCLUSIONS: Nurses perceive the roles played by relatives in emergency situations in nursing homes as relatively supportive or, alternatively, demanding and troublesome. The timely involvement of relatives in emergency planning, the establishment of clear agreements with general practitioners and the development of trusting relationships between nursing staff and relatives may improve emergency management for nurses.

iHealth: The ethics of artificial intelligence and big data in mental healthcare.

The concept of intelligent health (iHealth) in mental healthcare integrates artificial intelligence (AI) and Big Data analytics. This article is an attempt to outline ethical aspects linked to iHealth by focussing on three crucial elements that have been defined in the literature: self-monitoring, ecological momentary assessment (EMA), and data mining. The material for the analysis was obtained by a database search. Studies and reviews providing outcome data for each of the three elements were analyzed. An ethical framing of the results was conducted that shows the chances and challenges of iHealth. The synergy between self-monitoring, EMA, and data mining might enable the prevention of mental illness, the prediction of its onset, the personalization of treatment, and the participation of patients in the treatment process. Challenges arise when it comes to the autonomy of users, privacy and data security of users, and potential bias.

[Digital interventions for refugees. Challenges, opportunities, and perspectives of agency]. / Digitale Interventionen für Geflüchtete. Herausforderungen, Chancen und die Perspektive der agency.

DEFINITION OF THE PROBLEM: Refugees show a high prevalence of mental health burden. Catering to the need for mental health services is made difficult by access barriers. These barriers consist of structural factors as well as culturally different attitudes towards mental health, mental illness, and therapeutic interventions. One option to overcome these access barriers and to provide mental healthcare services in an appropriate manner is seen in digital interventions. In the form of interactive websites or smartphone apps, these interventions have proven to be effective in mental healthcare. There are also promising examples of successful use of these technologies with refugees. However, the ethical aspects of digital interventions for refugees have scarcely been studied yet. ARGUMENTS: Aim of this paper is to tackle this research desiderate. The instrument of the ethical analysis to be conducted is the concept of agency. According to the concept of agency, persons have to be seen as actors capable of acting based on their own resources and competencies. Agency is the guiding principle here for analyzing the opportunities and risks of digital interventions for refugees. In addition, I will attempt to point out prospects for an agency-based application of digital interventions. CONCLUSION: The ethical analysis could be used as the blueprint for developing therapeutic concepts that contribute to the improvement of mental healthcare services for refugees from an ethical perspective.

Guardians of humanity? The challenges of nursing practice in the digital age.

Digital technologies have become a crucial factor in nursing. Given the fact that many tasks could also be done by robots or AI systems, the place for the nurse in this scenario is unclear. In what way and to what extent will the implementation of ever more sophisticated technology affect nursing practice? It is the aim of this paper to analyse the potential challenges of nursing practice in the digital age. The analysis is conducted through the lens of new materialism, a set of theoretical models that understand the relationship between humans and technology as dynamic and performative. According to this view, there is no prefixed essence of technology. Rather, the meaning of technology is enacted in concrete practice. The analysis shows that in past debates on technology use in nursing, the nurses' role has been defined as guardians of humanity, defending the patient against the dehumanizing effects of technology. This role has been transferred to the digital age, where it is the duty of nurses to cushion the negative effects of digital technology. As an alternative to this outdated role, nurses should be included in processes of technology design and policymaking. Enabling nursing professionals to shape the circumstances of a digitally enhanced holistic practice may empower their status within the healthcare system and also benefit the patient by contributing to a more person-centred care.

[Impotence and belief in witchcraft: a medical treatise by the Ulm town physician Wolfgang Reichart (1486-1547)]. / Impotenz und Hexenglauben: Ein medizinischer Traktat des Ulmer Stadtarztes Wolfgang Reichart (1486­1547).

BACKGROUND: The belief in witchcraft influenced medical thinking and action in the 16th century. In a hitherto unknown treatise on impotence, the Ulmian town physician Wolfgang Reichart (1486-1547) has rationally explained it by using medical concepts. MATERIALS AND METHODS: The treatise was transcribed, translated, and analyzed in terms of its sources, structure, and content. The results were compared with the concept of Johann Weyer (1515-1588). RESULTS: Reichart explains his patient's impotence as an acquired disease involving demons. Since demons act only naturally on the human body, the disease is naturally curable. The basis of the therapy is a medieval pathophysiological concept that combined ancient elements. CONCLUSIONS: Reichart's therapy differs from that of contemporary physicians because he treats the patient himself and does not send him to a theologian. Unlike Weyer, he offers a detailed pathophysiological concept in order to explain impotence medically.

E-mental health applications for depression: an evidence-based ethical analysis.

E-mental health applications (apps) are an increasingly important factor for the treatment of depression. To assess the risks and benefits for patients, an in-depth ethical analysis is necessary. The objective of this paper is to determine the ethical implications of app-based treatment for depression. An evidence-based ethical analysis was conducted. The material was meta-reviews and randomized control studies (RCTs) on app-based treatment. Based on the empirical data, an ethical analysis was conducted using the 3-ACES-approach by Thornicroft and Tansella. Apps may empower autonomy, offer an uninterrupted series of contacts over a period of time, show evidence-based benefits for patients with subclinical and mild-to-moderate-symptoms, are easily accessible, may be used for coordinating information and services within an episode of care, and are on the whole cost-effective. Their risks are that they are not suitable for the whole range of severity of mental illnesses and patient characteristics, show severe deficits in the data privacy policy, and a big variability in quality standards. The use of apps in depression treatment can be beneficial for patients as long as (1) the usefulness of an app-based treatment is assessed for each individual patient, (2) apps are chosen according to symptom severity as well as characteristics like the patient's level of self-reliance, their e-literacy, and their openness vis-à-vis apps, (3) manufacturers improve their privacy policies and the quality of apps.

The disruptive power of Artificial Intelligence. Ethical aspects of gerontechnology in elderly care.

Gerontechnology based on Artificial Intelligence (AI) is expected to fulfill the promise of the so-called 4p-medicine and enable a predictive, personalized, preventive, and participatory elderly care. Although empirical evidence shows positive health outcomes, commentators are concerned that AI-based gerontechnology could bring along the disruption of elderly care. A systematic conceptualization of these concerns is lacking. In this paper, such a conceptualization is suggested by analyzing the risks of AI in elderly care as "4d-risks": the depersonalization of care through algorithm-based standardization, the discrimination of minority groups through generalization, the dehumanization of the care relationship through automatization, and the disciplination of users through monitoring and surveillance. Based on the 4d-model, strategies for a patient-centered AI in elderly care are outlined. Whether AI-based gerontechnology will actualize the 4p-perspective or bring about the 4d-scenario depends on whether joint efforts of users, caregivers, care providers, engineers, and policy makers will be made.

[Who Benefits from the App? Internet- and Mobile-Based Interventions (IMIs) and the Tension between Autonomy and Patient Well-Being]. / Wem nützt die App? Internet- und mobilgestützte Interventionen (IMIs) im Spannungsfeld von Autonomie und Patientenwohl.

OBJECTIVE: The use of internet- and mobile-based interventions (IMIs) is often considered as empowerment of patients and improvement of accessibility of mental health services. Risks for specific patient groups are seldom discussed. Aim of the study is to identify patient groups that do not benefit from IMIs given the tension between autonomy and patient well-being. METHODS: The ethical analysis is based on available empirical evidence (randomized control trials - RCTs, reviews) as well as ethical papers. Methodological background is the tension between patient autonomy and patient well-being, which is crucial to the therapeutic alliance. On this foundation, patient groups are identified that do not benefit from IMIs in terms of empowerment or accessibility. RESULTS: The evidence-based ethical analysis shows that patients with certain disorders or high symptom severity, patients with low level of education or a lack of technical skills, and patients with a migrant background do often not benefit from IMIs. Risks of IMIs are a lack of individualization of interventions given individual treatment needs, symptom deterioration, higher dropout-rate, and insufficient identification of emergency situations. DISCUSSION: Overemphasizing autonomy may compromize patient well-being in certain patient groups. This may lead to a situation where those patient groups whose inclusion into mental health service should be facilitated by IMIs might not be reached. These access barriers should be considered when designing IMIs, so that multimorbid marginalized groups are not forgotten in the necessary digitalization of the health market. CONCLUSION: The application of IMIs depends on the individual resources of the patient. Should IMIs be further implemented within the German mental healthcare system, it is imperative that the patient well-being of those patient groups that do not benefit from IMIs is guaranteed. In addition, an early focus on marginalized groups may and the implementation of low-level access to counselling and treatment may provide chances for said groups.

The Pathophysiology and Therapy of Erectile Dysfunction in a Newly Discovered Treatise by Wolfgang Reichart (1486-circa 1547).

BACKGROUND: A newly-found treatise by Wolfgang Reichart (1486-circa 1547), town physician of Ulm, challenges the contemporary view that bewitchment as a cause of impotence defies any natural explanation. OBJECTIVE: To understand the pathophysiological concept and therapy of erectile dysfunction in Reichart's treatise by examination of his sources and previous concepts. METHODS: Source analysis of Reichart's treatise by comparison of the pathophysiological concepts and therapy of erectile dysfunction with original texts of the Corpus Hippocraticum (5th-3rd century BC) and Constantinus Africanus (11th century). RESULTS: By using rational thinking and medical knowledge mainly drawn from antiquity, especially Constantinus Africanus, Reichart shows that a supposed supernatural cause for impotence can be explained by reason and natural means. Reichart's treatise changes the view of bewitchment as cause of impotence. He makes eclectical use of previous concepts to explain his patient's condition. From the Middle Ages on, bewitchment was accepted as a cause for erectile dysfunction. Usually, physicians of that time accepted this etiology and advised a treatment based on theological concepts. Reichart challenges this view by emphasizing reason and medical knowledge as crucial for treating the patient, rejecting supernatural treatment approaches. CONCLUSIONS: In the 16th century, a type of rational thinking and medical knowledge emerges, which puts supernatural explanations into question and aims at treating patients with natural means. The analysis of Reichart's treatise is a much-needed contribution to understanding the historic development of pathophysiological concepts of and therapeutic measures for impotence, which is yet underresearched.

Saving whom? The ethical challenges of harvesting tissue from savior siblings.

PURPOSE OF THE STUDY: To discuss the ethical challenges for the therapeutic team when dealing with a young savior sibling as a potential tissue donor. BASIC PROCEDURES: Savior siblings are children that are created to serve a sibling as a donor of umbilical cord blood, bone marrow, or peripheral blood from which hematopoietic stem cells are derived. These cells are used for hematopoietic stem cell therapy, which is the only curative treatment for certain hemoglobinopathies. We used a case including a 19-year-old thalassemia patient and his two and a half year old sister from our practice as ethics consultants. Our methodological basis is the principlism approach by Beauchamp and Childress, consisting of four principles: autonomy, non-maleficence, beneficence, and justice. MAIN FINDINGS: We found that the main conflict arises between the autonomy of the savior sibling as well as the non-maleficence regarding her and the beneficence of the thalassemia patient. PRINCIPAL CONCLUSIONS: Decision-making is complex when decisions within the family are concerned, especially when non-competent young children are involved. The therapeutic team does not only have to recognize the principal vulnerability of children but also the different scales of vulnerability depending on their age.