The population of Finland is ageing with greater demand for health and social care; homecare workers are over-burdened with keeping up with this change whilst ageing themselves. Technology is seen as one of the most promising solutions to tackling these challenges. In the national KATI programme, six regional projects will implement technology solutions and adopt new technology-based practices in a coordinated manner to support the ageing of older people at home as well as the homecare professionals and services. In this article, we give an overview of the variety of technology solutions being implemented and the first ethical questions that have been raised by the projects in the early phase. Thereafter, we highlight three different theoretical approaches that support the ethical and sustainable technology implementation advanced by the programme. The approaches 1) emphasize the holistic perspective on the health of the older person and the method of discourse ethics to seek for consensus about the technology solutions, 2) learn from safety research and the change theory for better ethical design of AI systems, and 3) analyse the technology implementations and the programme from a systemic perspective within the framework of socio-technological transition. Our expectation is that the approaches will provide theoretical tools and heuristics that can be used to ensure that the ultimate goal of the KATI programme, a national, continuing collaborative model of technology-supported ageing and care of older people at home, will be ethical and sustainable.
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Finland is one of the fastest ageing countries in the world. Although ageing people are
healthier compared to earlier decades, the Finnish workforce, care professionals among
them, are getting older. People are expected to work longer and retire later, but
simultaneously, there is a lack of care workers. The economy is facing challenges due
to increasing service needs and the weakening dependency ratio. Among earlier
governmental strategies and programmes, the recent technology policy report
Finland is not alone but the sustainable provision of elderly care is a topic of debate
in most welfare states
Digitalization and the implementation of technologies in elderly care are expected
to play an increasing role in meeting the anticipated sustainability gap in elderly care
services
This article introduces a governmental programme called ‘Smart Ageing and Care at Home’ (‘KATI’ for the Finnish Acronym) to systematically and purposefully advance the implementation of new technologies and digital services for well-being, ageing and care of older people at home in Finland. The programme steers six regional projects that implement new technologies in services supporting ageing at home and home care. The projects themselves already raised some ethical questions in their early phases. The programme aims to bring these into the public discussion.
The programme is supported by an Ethical Advisory Board of expert members that bring different ethical and scientific approaches to ensure the ethical and sustainable technology implementation advanced by the programme. The approaches concern the holistic perspective on the health of the older person and the importance of engaging older persons and professionals in the development, the challenges in the current design of ethically sound AI systems and services, and the changing practices of ageing at home and care services as socio-technical transition. In the discussion, we analyse how these approaches support developing the KATI programme towards a continuing national-level practice of collaboration, learning and sharing of experiences and knowledge to ensure the sustainable, ethical and systematic adoption of technologies in the ageing society. 2
The main goal of the KATI programme is to advance and support the integration of
new technologies into care services for older adults as well as independent living in
Finland. Utilizing technologies is embedded in the quality recommendation to improve
the well-being of older people and renew services
All projects participate in impact assessment coordinated by THL and VTT. The impact assessment of technology systems will be done in a multi-perspective way. The focus will be on well-being at home, care professionals and work, costs, processes and infrastructure to utilize technology, technology aspects such as feasibility, integrability and scalability, business and innovation, and ethics.
The KATI programme is funded by The Ministry of Social Affairs and Health for
the years 2020–2023. It is part of the Horizontal National Programme on Ageing 2030
The KATI projects were launched in February 2020. The overview of the technology solutions that are being implemented by the KATI projects has been collected in two phases. In online discussions with the KATI projects in the latter phase, we also enquired if the project had ethical worries in mind related to the technologies. The ethical concerns we raise in this chapter are based on this project input and do not systematically cover all ethical concerns related to the technologies in KATI.
First, in February–March 2020, we arranged a survey for the regions to collect information about the technologies they were planning to pilot, adopt or strengthen in their KATI project. The survey data were collected as an Excel table from each region (the local project coordinator). The table also included questions about expected pilots, level of usage, integration into other systems, scalability and support services related to each single technology mentioned by the region.
The aggregated data include dozens of different technology solutions. The most popular solutions are various monitoring (e.g. sleep, activity, falling, nutrition) and remote health measurements, Internet of Things (IoT) and integration platforms with data collected at home, and AI analytics. In Table 1, we have categorized the technologies into seven groups. Second, in May 2020, we arranged online meetings with each project to discuss the first months of the project and elaborate on plans for piloting and implementations. In this phase, we found that the projects were starting the implementations somewhat slower than we initially expected, and many pilots and implementations were scheduled for the next autumn or even the next year. Nevertheless, we collected information about the plans related to pilots, purchases, support and training services and expected impacts and challenges of the technologies and their use. We also asked the projects whether they have already identified ethical questions related to the technologies. The projects named four types of worries that they perceived as being ethical (Table 2). When must there be a physical homecare visit and when is a remote visit sufficient? A professional can judge that remote care is enough, but the relatives or the client are against it.
There are unclear cases.
Wide 24-hour monitoring strives for safe, independent living for the client. Homecare workers as well as relatives should have access to the data. What kind of ethical issues concern privacy? In remote care, e.g. remote care phone application for the homecare worker who has the phone in her pocket: How can a client with memory loss give consent for data viewing and sharing? Data are widely collected in information systems and can also be viewed for other purposes (secondary use). How do customers and relatives experience the monitoring and (extensive) utilization of data? Ethical values at stake An issue of expert knowledge vs (recognition of) patient’s (perceived) needs Many values ranging from surveillance to rights of access to data An issue of autonomy and the possibility of meaningful consent Right for data protection and security
Based on the data and discussions with the project, it is obvious that homecare services with physical visits at the older client’s home are strongly shifting towards various technology-enabled remote homecare and health services, to the extent that technology-based remote care will be provided as the default service. Thus, we also present two case descriptions that highlight challenges in the negotiations of remote care, as raised by one KATI project:
The client has a mild memory disorder. The home services attempted to get her a medicine reminder because she is still coping relatively well with her daily activities. Her only problem is remembering to take medication, which she sometimes forgets. The client still carries out other tasks independently, except for banking matters. The client agreed to try the medication reminder. However, her sister refused to implement it, arguing that the nurse would no longer visit the client daily. The home services suggested that instead of a daily visit, three visits a week should be sufficient after implementing the drug reminder, as the visits served no other purpose than to monitor medication intake. The sister and the client were also informed that if the medicine is not taken, the home care will receive an alert, in which case the customer will be either called or visited. The sister refused to implement a drug reminder for the client and will not pay a monthly fee of €35 for the drug reminder.
Case 2. Check-up visits according to the client’s wishes. When returning from the hospital department, the client wishes to have a check-up visit, even if there is no need for home care. The client and relatives want to check that everything is fine. According to the criteria, check-up visits are not possible without a real need. In this situation, a video connection to the customer may be offered. If the client does not agree to this or does not want a remote connection, he or she will not be provided with a homecare service. This easily creates a problem for the caregiver because they want to be ‘good caregivers’. At the same time, a strong commitment from the caregiver is required for the given criteria. This applies to all other caretakers; they promise check-up visits even if there is no justification other than the client’s wish. As a caregiver, it is often difficult to refuse a client’s request.
To summarize, the KATI projects will pilot and implement dozens of various technology solutions to support home care and independent living of older adults. Monitoring and remote care applications are emphasized (and not, for instance, physical robots). It seems that the many single devices, applications and systems adopted will also be integrated into IoT and integration platforms that combine different health data collected at the client’s home. The platforms may also utilize AI to automatically analyse the data and raise (non-critical) alerts. These involve many ethical questions. The KATI projects themselves have provided some technologyrelated worries that they perceive as ethical in nature, and it is clear that a more systematic ethical review needs to be done on the technologies. In this paper, we start by discussing three theoretical approaches that we have initially focused on in order to understand and tackle the ethical concerns. 4 4.1
The World
For this, we derive the definition of health from
However, to be able to create health technologies that support health as homelike being-in-the-world, we need to bring the citizens and different professionals together to ensure that all needed insight is brought to the table. To be able to find consensus about what kind of technology supporting smart ageing and care at home would be needed, we need open communication between all stakeholders. Without proper communication, some viewpoints will override others, and usually, the weakest part is bypassed, which is ethically problematic.
As an approach to prevent this, we propose to utilize discourse ethics in the KATI
project.
Rational discourse is based on the view that all stakeholders can participate in
discourse and that discourse itself is rational
Along with the great expectation attached to the design and use of AI systems, there are
still worries over the negative impacts of the ongoing development. To prevent and
mitigate the ills, several suggestions for how to design ethically sound AI systems have
been formulated. The existing AI ethical codes cover a variety of approaches from high
profile declarations to normative rules of thumb for users and practical checklists for
designers
Evidence from the AI ethics endeavours is rather depressing. Studies show that
attempts to secure ethical sustainability has not been effective
One of the reasons why the current ethical approaches have not been successful is
that they do not pay enough attention to the specific features of AI. Typically in AI,
the products and outcomes are not just single devices or services but sets of programs
and applications within larger, often extremely complex systems. It is not possible to
extract AI from the rest of the system. Most of the development and applications are
carried out as commercial enterprises within the market economy. AI is a general
means that is applicable to almost any human activity, which provides innumerable
possibilities to employ it. Such features of AI have moral relevance, and they should
receive due attention in formulations of AI ethics
To better account for the specific features of AI systems, we need a wider variety of
resources than just the traditional ethical apparatus characteristic of the current AI
ethics codes. During the past century, safety research has developed into a rigorous
academic study that is tightly connected to the empirical reality of hazards and risks.
There are several useful conceptions within safety studies that could help detrimental
chains of events from taking place, even when implementing AI into elderly care
The aim of AI design and development is to change people’s lives for the better and to positively impact the targeted issues. Recent studies on the factors involved in bringing about change and making a desired impact also offer tools for improving the ethical quality of AI. The theory of change and the Impact Management Project offer methods for organizations and companies to better keep track of the change they intend to bring about and the actual effects of their work on reality. Both approaches have their starting point in the complexities of the current world, where it is often difficult to plan and follow straightforward strategies. In favourable circumstances and with the right kinds of measures, the desired change emerges (Weiss 1995; Theory of Change). 4.3
A central question is how innovations – both technologies and related innovative
practices – contribute to broader societal changes in an ethically and socially
sustainable way. This is also an issue to be considered in the KATI programme. To
respond to this question, systemic views that highlight the relationships of technical,
human and social aspects are needed. One of these systemic frameworks is the
framework of socio-technological transition. Because this approach highlights the
interdependence and mutual adjustments between technological, social, political and
cultural dimensions
The multi-level perspective of socio-technical transitions tackles transitions as
coevolutionary processes on three interrelated conceptual levels: the socio-technical
landscape, the socio-technical regime and bottom-level niches. The socio-technical
regime can be seen as the way services are currently organized regarding
infrastructures, service structures and products (using both high and low technology).
It also includes mindset-related issues, such as people’s preferences about the products
and services they use and consume and related ethical values, the market, public sector
and policy views, and the responses of such actors to people’s wishes and requirements
Established socio-technical regimes are resistant to change, but transitions take place
when changes at the landscape level, such as population ageing, exert pressure on the
regime and make it unstable
The various technologies and technology-based practices created and implemented
in the KATI programme projects can be viewed as these niches. It may be difficult for
new technologies to gain ground if they face a mismatch between the existing regime
and the landscape. Until external circumstances are right, for example, the regime is
destabilized, creating a window for opportunity for these radical novelties. This is why
the niche innovations are called ‘seeds for change’
When adopting new technologies to support ageing and care services at home, the care professionals will need to tackle various ethical issues, of which we gave examples in Section 3. The KATI programme will raise these into public discussion in order to support the regional projects to find acceptable and sustainable solutions, whether based on technology or on the renewing practices of care. In addition, we described three approaches to ethical and sustainable technology implementation into elderly care. First, we introduced a concept of homelike being-in-the-world as a patient-centred and participatory approach and how the utilization of discourse ethics can be used to support open communication and understanding between all stakeholders. Second, we highlighted the theory of change and the Impact Management Project, which offers methods for homecare organizations to better keep track of the change they intend to bring about and the actual effects of their work on the patients. And third, we discussed the framework of socio-technological transition and how bringing several new technologies into home care is an evolving ‘system configuration’ where single solutions are seeds for a larger socio-technical change.
The homecare services would benefit from adding these perspectives in their practical care ethics in several ways. Every single worry that care professionals identify in their everyday work should be collected and discussed. This gives information about possible risks and lack of safety and tackling these at early phase increase care ethics for each single client situation. Taking the wider perspective and applying the method of Discourse Ethics could help to discuss and solve concrete problematic cases. For instance, in the two case examples from the KATI projects, the rules and care principles of the homecare are not understood either by the relatives, the client or the homecare workers. We argue, however, that using the presented principles and methods even these problems could be solved. This may require wide discussion from several angles and change of viewpoints of all participants.
Nevertheless, the approaches should work best on the programme level to support its development and national coordinating activities towards the sustainable technology-supported aging at home. For example, the KATI programme itself can be seen as a ‘window of opportunity’ for innovative niche technologies and practices to at least be experimented with, if not adopted, in the prevailing homecare service system, thus expectedly contributing to a wide-scale systemic change. The approaches provide theoretical tools and heuristics that can be used to ensure that the ultimate goal of the KATI programme – a national, continuing collaborative model of technologysupported ageing and care of older people at home – will be ethical and sustainable.
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