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{{Paper
|id=Vol-3069/longpaper03
|storemode=property
|title=Towards Ethical and Sustainable Technology-Supported Ageing at Home in Finland – KATI Programme
|pdfUrl=https://ceur-ws.org/Vol-3069/FP_03.pdf
|volume=Vol-3069
|authors=Heidi Anttila,Marketta Niemelä,Minna Anttila,Satu Pekkarinen,Jaana Hallamaa,Jani Koskinen
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==Towards Ethical and Sustainable Technology-Supported Ageing at Home in Finland – KATI Programme==
https://ceur-ws.org/Vol-3069/FP_03.pdf
Proceedings of the Conference on Technology Ethics 2021 - Tethics 2021
Towards Ethical and Sustainable Technology-Supported
Ageing at Home in Finland – KATI Programme
Full paper
Heidi Anttila1, Marketta Niemelä2, Minna Anttila1, Satu Pekkarinen3, Jaana Hallamaa4
and Jani Koskinen5
1 Finnish Institute for Health and Welfare, Helsinki, Finland
2 VTT Technical Research Centre of Finland Ltd, Tampere, Finland
3 LUT University, Lahti, Finland
4 University of Helsinki, Helsinki, Finland
5 University of Turku, Turku, Finland
1
heidi.anttila@thl.fi
Abstract. 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.
Keywords: ageing, home, technology, AI, ethics
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1 Introduction
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
(Technology Advisory Board 2021) underlines the better utilization of technology as
the most promising solution for the sustainability challenge created by the ageing
population. There is an urgent need to apply new technologies, data and artificial
intelligence (AI), and digitalization of services to prevent diseases, support ageing at
home as long as possible and increase the effectiveness of early-phase care.
Finland is not alone but the sustainable provision of elderly care is a topic of debate
in most welfare states (Essink 2012). The debate mainly relates to quality and
affordability of care.
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 (e.g. Kapadia et al. 2015; Malanowski 2008; Peine et al. 2015). Implementing
these technologies entails a range of challenges, including a lack of suitable
technologies and immature existing ones (Pekkarinen, Melkas & Hyypiä 2019).
However, to a great extent, the challenges are related not only to the technologies alone
but to their integration into the user contexts, such as the services in which they are
used. In particular, the ethical aspects of the wide technology integration into care
services should be of interest. The major ethical issues concern, for instance, a sense of
autonomy, human dignity, informed consent – particularly in the case of cognitive
impairment, data management issues, affordability and distributive justice (potential
socio-economic disparities) and impacts of technology use on human contact and
empathy (see e.g. Wangmo et al. 2019; Niemelä et al. 2021).
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
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Proceedings of the Conference on Technology Ethics 2021 - Tethics 2021
knowledge to ensure the sustainable, ethical and systematic adoption of technologies in
the ageing society.
2 A national programme to support well-being, ageing and care
at home with new technologies (KATI programme)
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 (Ministry of Social Affairs and
Health 2020). The programme itself is a coordinating activity that steers six regional
projects across seven regions in Finland (Figure 1) to reform the services of living at
home and home care with technology. The project consortia include municipalities or
associations of municipalities, actors from both the third and private sectors, and
universities as partners. The projects follow their own regional plans for technology
deployments under and in collaboration with the coordination body from the Finnish
Institute for Health and Welfare (THL). The Technical Research Centre of Finland Ltd
(VTT) participates as an expert of technology solutions.
Fig. 1. The regional KATI projects on a map of Finland. The number in the circle refers to the
population coverage of the project in the county.
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The regional projects carry out pilots and deployments of various technology
devices, applications, services and systems. The projects also use technology to collect
health-related data to be used in care services to support independent and safe living at
home. The projects co-develop by engaging the users in piloting and adopting
technologies together with independent older adults, homecare customers, family
members and care professionals. Moreover, the projects educate and train homecare
professionals for technology use; develop new care work roles, procurement processes,
support services and registries for devices and application; and produce health
technology assessments by using the national Digi-HTA criteria and procedure
(Haverinen et al. 2019). Overall, the programme encourages the projects to co-develop
with the stakeholders, involve end users in the early phases to plan the deployment and
use of technology solutions, and ensure the solutions’ ethics. The vision of the KATI
programme is illustrated below (Figure 2).
Fig. 2. The KATI programme vision.
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
(Ministry of Social Affairs and Health 2020), which supports good health and
functional capacity of older people. In addition, KATI is part of the national welfare
development strategies and implements home living measures of the Well-being and
Health AI and Robotics Programme (THL 2020). In total, the programme and projects
have a budget of approximately 10 million euros.
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3 Technology solutions and ethical concerns in the KATI
regional projects
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.
Table 1. Technology solutions to be adopted in the KATI projects
Solution category Examples
Remote health measurements Measurements of vital signs or weight at home are
(attached to the older person) automatically transferred to care information systems
Monitoring technologies Sleep, activity and nutrition monitoring
Wearable safety solution with GPS localization; medicine-
Safety-increasing solutions dispensing robot and medicine reminder; monitoring
falling or risk of falling
Solutions supporting social
Virtual peer groups and coffee groups, social robot
activity
Technologies installed in the Home condition measurements: temperature, humidity,
apartment lights; safety monitoring system at home
Electronic homecare optimizing system; home and remote
Technologies for care
rehabilitation solutions, exoskeletons, virtual homecare or
professionals
consultation visits, Virtual Reality–based training
Data from devices, applications and services at home are
IoT and integration platforms collected in a platform to be further analysed by care
professional or AI
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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).
Table 2. Ethical worries raised in the KATI projects
Ethical worry Ethical values at stake
When must there be a physical homecare visit and when is a An issue of expert knowledge
remote visit sufficient? A professional can judge that remote vs (recognition of) patient’s
care is enough, but the relatives or the client are against it. (perceived) needs
There are unclear cases.
Wide 24-hour monitoring strives for safe, independent living Many values ranging from
for the client. Homecare workers as well as relatives should surveillance to rights of access
have access to the data. What kind of ethical issues concern to data
privacy?
In remote care, e.g. remote care phone application for the An issue of autonomy and the
homecare worker who has the phone in her pocket: How can a possibility of meaningful
client with memory loss give consent for data viewing and consent
sharing?
Data are widely collected in information systems and can also Right for data protection and
be viewed for other purposes (secondary use). How do security
customers and relatives experience the monitoring and
(extensive) utilization of data?
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:
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Case 1. The client’s relative refuses to implement and pay for a drug reminder.
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 technology-
related 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 Approaches of ethics and sustainability
4.1 The older person’s health as ‘homelike being-in-the-world’
The World Health Organization (2021) has defined health as ‘a state of complete
physical, mental, and social well-being and not merely the absence of disease or
infirmity.’ This definition from 1946 is over 70 years old, but it seems we are still failing
to achieve the spirit of that definition, which is to see human beings as complete
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individuals and not to look at only the biomedical state or let the disease define the
people. Therefore, there is a need for other viewpoints that respect patients as
individuals with their own needs, desires, fears and backgrounds.
For this, we derive the definition of health from Svenaeus (2001), who presents it
as ‘a homelike being-in-the-world’, a concept based on Heidegger’s being-in-the-world
in his magnum opus, Being and Time (Heidegger 1929). Svenaeus’ view of being
focuses on the medical context and gives rich insight from the phenomenology of health
and hermeneutics of medicine. Svenaeus’ idea is that that we should focus not only on
medical problems per se but should instead shift focus towards individuals’ experiences
of their own life and their meaningfulness (see Svenaeus 2001). From this viewpoint,
as a premise, the individual is healthy if they are homelike with their life and can pursue
meaningful and personal goals. In the sense of health as homelike being-in-the-world,
some diseases do not necessarily mean that the patient is not healthy – they may just
have some medical condition, such as diabetes, that needs to be noted and taken care
of, if needed. Thus, this definition of health is a good approach for promoting different
roles in health care so that peoples’ needs are taken into account instead of their being
treated as mere patients. Koskinen (2010) shows that health, when seen as homelike
being-in-the-world, is compatible with patient-centredness and patient empowerment –
issues at the core of the KATI programme.
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. Mingers and Walsham (2010) noted that discourse ethics can be seen as a
practical ethical approach for developing the information services. Likewise, Stahl
(2012) supports this idea that discourse ethics – based on Habermasian rational
discourse – provides a mechanism to consider different moral views and intuitions.
Discourse ethics (Habermas 1992) is based on rational discourse, which is presented in
communicative action theory (Habermas 1984, 1987) and further developed in his
work, Between Facts and Norms (Habermas 1996).
Rational discourse is based on the view that all stakeholders can participate in
discourse and that discourse itself is rational (Habermas 1996). All arguments in
rational discourse are evaluated in terms of how convincing and plausible they are.
Arguments can be based on logic, ethics or another justified basis. A crucial aspect of
rational discourse is that no strategic games are allowed: they must be rejected. A
strategic game is a way of influencing others where some participant is trying to end up
with an outcome by using an action other than a better argument, and this is not allowed.
These strategic actions can be bargaining, hidden agendas or use of authority over
others (James 2003).
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4.2 Seeking resources for ethically sound AI systems and services
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 (Mittelstadt 2019, 501; Jobin, Ienca & Vayena 2019). Two things are
common to the ethics documents: first, they share the aim to support the ethical design
of AI, and second, they presuppose that it is possible to formulate AI ethics that will
serve as the theoretical basis for deducing morally sound practical solutions for AI
(Morley et al. 2019).
Evidence from the AI ethics endeavours is rather depressing. Studies show that
attempts to secure ethical sustainability has not been effective (Hagendorff 2020, 118).
Both theoretical and practical reasons suggest that the approach to tackle the moral
problems should be wider than the present conceptions of AI ethics.
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 (Boddington 2017, 93).
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 (see
Reiman & Oedewald 2008, 39–47 and Hollnagel 2014 about the development).
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).
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4.3 Technology implementation in elderly care transition – the socio-technical
transition framework
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 (Bugge, Coenen, Marques & Morgan 2017; Smith, Voss & Grin
2010), it is a fruitful approach in studying processes taking place in the digitalization
of the elderly care sector. The introduction of technologies into society and the
development of technological innovations require a deep transition that entails the
simultaneous development of technologies, service operations and people’s practices
and mindsets (e.g. Geels 2002, 2005; Truffer & Coenen 2012).
The multi-level perspective of socio-technical transitions tackles transitions as co-
evolutionary 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
(Pekkarinen et al. 2020). In other words, elderly care is perceived as a socio-technical
system consisting of services, technologies, science, infrastructures, user preferences
and cultural meanings as well as ethical values (see Geels 2002).
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 (Geels & Schot, 2007). The destabilization of the regime
creates windows of opportunity for niche innovations, which are emerging social or
technical innovations that differ radically from the products and practices in the
prevailing socio-technical system and regime (Kemp et al. 1998; Geels 2018).
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’ (Geels 2005). Examples of niches
in social and health care and elderly care include service robots, various monitoring
devices, technology for self-diagnosis and novel service configurations or care-work
practices (Pekkarinen et al. 2020). The selection of new technologies and innovative
practices is more than mere adoption. Users must also integrate novelties into their
practices, organizations and routines (Geels 2002), and niches frequently collide with
the regime because of existing practices’ inertia and lock-ins. More than the ‘singular
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disruption’ of niches, the question is about ‘system reconfiguration’ (Markard &
Truffer 2006; Geels 2018). A wider breakthrough is followed by a stabilization and
new types of structuring. These dynamics and interplay at different levels reinforce
each other and lead to system changes and transitions (Geels & Kemp 2007).
5 Discussion
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 technology-
supported ageing and care of older people at home – will be ethical and sustainable.
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