Ethics and Persuasive Technology: An Exploratory Study in the Context of Healthy Living Rachel E. Page Christian Kray School of Computing Science School of Computing Science Newcastle University Newcastle University Newcastle upon Tyne, UK Newcastle upon Tyne, UK r.e.page1@ncl.ac.uk c.kray@ncl.ac.uk ABSTRACT and assisting people in living a healthy lifestyle. Particularly in Persuasive Technology has been heralded as a new paradigm to industrialized nations, the latter is rapidly becoming a very change people’s behavior to improve various aspects of everyday pressing issue. In the UK, for example, and estimated 24.2% of life. In combination with mobile and ubiquitous delivery adults are considered to be obese [1], a condition which has been mechanisms, persuasive technology has the potential to reach and shown to cause a number of short and long-term illnesses such as influence people everywhere and at any time. While there are diabetes. Alcohol abuse is a similar problem of comparable clear benefits to be gained from this approach, there are obviously proportion and impact [9]. These two issues are predominantly a ethical considerations that need to be taken into account and that result of misbehavior, and specific persuasive technologies could currently are not well understood. This paper aims to contribute be created to help to correct this behavior and thus to reduce the towards a better understanding of ethics in persuasive technology. number of people affected by these problems. However the use of We present results from a focus group session and an online such technology does also raise some ethical questions, e.g. with survey on the use of persuasive technology in the context of respect to which measures are acceptable in what context, and it is healthy living. The results indicate that the “golden rule of these ethical issues that this paper is investigating. persuasion” [5] might not always be applicable to persuasive Ethics can be defined as “the moral principles governing or technology, that self-initiated persuasion per se may always be influencing conduct” [2], and it is clearly dependent on the acceptable, and that there may be a link between the purpose of cultural context, as moral principles will differ between cultures. persuasion and the means used to persuade. The findings can be (Therefore, the results of the studies are limited to Western used to inform the design of future persuasive interventions. European/British context.) When considering ethical implications of persuasive technology, there are a number of factors that could Categories and Subject Descriptors potentially play an important role in determining whether a H.5.m [Information Systems]: Information interfaces and particular piece of persuasive technology is considered ethical or presentation – miscellaneous. not. These factors include: the user of the persuasive technology; the commissioner behind the persuasive message; the persuasion method used; and the technology being used. One goal we were General Terms pursuing with our research was thus to identify the relative Design, Experimentation, Human Factors. importance and relationships of these factors. In the following, we first briefly summarize related work Keywords before discussing insights gained through a focus group session. Persuasive technology, ethics, healthy living, user studies. We then present the questionnaire study we conducted based on the findings of the focus group, and discuss its results as well as 1. MOTIVATION its implications for the design of persuasive technology. A brief Persuasive technology can be defined as “any interactive summary concludes the paper. computing system designed to change people’s attitudes or behavior” [4], which can be applied in a wide range of scenarios. 2. BACKGROUND Mobile (and ubiquitous) devices are very well suited for the Persuasive technology [3] is a relatively new area in Human- delivery of persuasive content as they can sense contextual factors Computer Interaction, which focuses on using technology (such as of relevance to a specific user (such as location and/or task) and mobile phones, web sites and other means) to change the behavior tailor messages so that they are delivered in the most effective or attitude of people. According to Fogg [3], computers benefit way. Considerable potential has been attributed to this technology from several advantages over humans when persuading others in terms of helping people to change their behavior [10]. such as being able to persist indefinitely or the option to exploit One key area, which could greatly benefit from persuasive the positive image of computers. Fogg also asserts that one has to technology, is healthy living. For example, it could be applied to analyze intentions, methods and outcomes of an instance of areas such as disease management and prevention, improving care persuasive technology in order assess its ethical implications [4]. In our studies we considered these as well as further factors. Copyright is held by the author/owner(s). 1st int. Workshop on Nudge & Influence Through Mobile Devices MobileHCI 2010 September 7-10, 2010, Lisboa, Portugal. . Berdichevsky and Neuenschwander [5] focus directly on the certain area, as teenage girls often are with regards to weight and ethics of persuasive technology. They outline ten principles for body image. We also hoped that the fact of a private company ethical design of persuasive technology, including the so-called being behind it would be picked up by the focus group. golden rule of persuasion. It states that designers of persuasive Scenario B was a website for young adults to monitor their technology should not create any artifact that persuades someone alcohol intake and be persuaded to drink less through social to do or think something that they (the designers) would not want comparisons. The website was provided by the Government to to be persuaded of themselves. One of the goals of the work support people to change their own behavior. Questions driving reported in this paper is to test this golden rule in a specific this scenario were whether website would be perceived as an context (i.e. healthy living). effective way of delivering persuasive content relating to healthy Persuasive technology does not exist in a vacuum, so we need to living, and what subjects would make of the use of social select an application domain. We chose to focus on healthy living comparisons in this context. [6] not only to control the complexity of the user study but also Scenario C was a purpose built embedded device for morbidly because it is a global and growing problem that has been obese adults to change their eating habits by delivering drastic identified as a key future research challenge [7]. Chaterjee and messages such as “Keep eating like that and you’ll be dead soon”. Price [8] provide an overview of specific issues and challenges. It was commissioned by their doctor and paid for by the NHS. The study presented in this paper expands on their work by This scenario was designed to test extreme conditions and their including further persuasive methods and empirically assessing impact on perception of what would be ethically acceptable. It their ethical implications. was also meant to evoke an emotional response to be discussed Our work uses key factors of ethical relevance that were identified and any limits that should be placed upon this kind of technology. in previous work. We extend the list of these factors and study the Scenario D was a text message system, similar to the warnings on ethical acceptability of specific combinations through focus group cigarette packets, which were being sent to a mobile phone at the sessions and a questionnaire-based survey. time when the user was about to have a cigarette. A commercial company was presumed to be behind the messages. Key features 3. FOCUS GROUP SESSIONS of this scenario were the pro-active delivery of persuasion as well as the inclusion of contextual factors into the equation. In order to gain a better understanding of relevant aspects relating to ethics and persuasive technology in the context of healthy Finally, scenario E investigated the use of a game to persuade living, we organized two focus group sessions. We were children to eat more fruit. It encouraged them to ask their parents particularly interested in people’s understanding of persuasive for fruit. The initiators in the scenario were their teachers, who technology, their reaction to different types of persuasive encouraged them to play the game. The main goal of this scenario techniques, and which combination of factors would be perceived was to investigate if manipulating children in this way was as being ethically acceptable. In addition, we wanted to test a set acceptable and whether ‘disguising’ persuasion as a game would of scenarios in order to select the most useful ones for the raise any concerns. subsequent survey study. 3.2 Outcomes and Observations In total, seven students from local universities were recruited The results from the ranking task administered prior to the through word of mouth and via a group set up on a social discussion are summarized in Figure 1. The diagram highlights networking website. We ran two separate focus groups to keep the that except for scenarios A and D there was a very clear ordering, number of participants manageable. Both sessions were recorded where C was rated as being lowest, E rated highest, and B second on video, which was later partially transcribed. After a brief initial highest. While the limited number of scenarios used prevents a discussion about ethics and persuasive technology in general, participants were asked to fill out a brief questionnaire, where they had to rank several scenarios according to how ethically acceptable they were. The scenarios were then discussed within the group on and individual basis first. At the end of the session, we encourage subjects to discussing and comparing all scenarios. In total, we designed five scenarios based on the factors identified in previous work (intent, methods, outcome) but we also included the commissioner of a piece of persuasive technology, the influencer as well as the actual recipient of the persuasive content. By focusing the discussion on five distinct scenarios, we aimed to limit high-level/matter of principle types of discussion, and to probe specific combinations of factors. We also hoped that Figure 1 – Ranking of scenarios according to how ethically concrete examples would provide participants with a better acceptable they were rated, 1=very ethical, 5=very unethical. understanding of what persuasive technology could be in practice. direct analysis with respect to which factors are the key drivers 3.1 Scenarios behind people ranking the scenarios as they did, the ranking Scenario A was a food diary mobile phone application for teenage provides some initial indication that the severity of an outcome girls that provided incentives and motivated the users to follow a may have some considerable impact. Results with respect to the healthy diet. It was created and influenced by a private company. vulnerability of the recipients of persuasion are somewhat We designed this scenario to spark a discussion about using inconclusive (as the two scenarios including children and girls) persuasive technology on a group that may be vulnerable in a are rated quite differently. We were somewhat surprised by the 4.1 Material and Procedure comparatively low ranking of the texting + smoking scenario, Three scenarios from the focus group sessions were adapted for which we believed to be much more acceptable. This might the questionnaire: one scenario related to encouraging people to indicate that the proactive delivery of persuasive content may be exercise more while at a gym, a second one picked up on helping an important factor to consider (which is a key reason why mobile people to quit smoking, and the final one was built around helping devices and ubiquitous environments are considered to be very people to change their eating habits. Instead of fixing the three well suited for persuasive technology). factors mentioned above, we systematically varied them and then From the video material we also transcribed a number of asked participants to rate them on a five point Likert scale. comments that highlighted various aspects and relationships with For each scenario, we asked people to assess the ethical respect to applying persuasive technology in the context of appropriateness of a particular technique for two distinct groups healthy living. For scenario A, one participant remarked that “if of people: healthy people and people who had a condition, which the NHS was behind it and it was backed up by research it would meant that they could greatly benefit from changing their be ok, the problem is the private investor and influencer”, which behavior. For the eating scenario, for example, we asked the same hints at the importance of who is commissioning an instance of questions twice: once for regular people and once for morbidly persuasive technology when assessing it’s ethical acceptability. obese people. Another subject stated that “girls have their mobile phones with them all the time and might receive the incentives all the time, but In terms of initiator we also considered two levels for each it still encourages healthy eating so it’s still a good thing”, which scenario. One always referred to self-persuasion (i.e. the user provides some evidence that context-awareness may be chose to use a piece of persuasive technology to change their considered ethical under certain circumstances. behavior) and the other one was an external entity. In the first scenario, this entity was the gym (a commercial company), in the Most comments about scenario B questioned the effectiveness of second on it was the NHS (National Health Service – a this approach (“people would use this to compete on how much governmental institution), and in the third one the Quick Smoking they could drink, especially groups of guys on a night out”) but Campaign (a not-for-profit organization). were not concerned about the ethical implications it might have (“It is not unethical but unworkable, you wouldn’t check the The final key factor identified during the focus group sessions was website as you were drinking”). the means use to persuade people. We chose five different techniques, four of which are feasible with today’s technology, in Scenario C attracted a lot of discussion, in particular with respect particular using mobile phones, and one that was meant to be an to the ‘shock tactics’ being used. Participants voiced concerns extreme example (electric shocks). The four feasible techniques about the effects of this method on people’s well-being, e.g. were: text messages sent to a users mobile phone, public “people who are obese may have low self esteem and if they use announcements at the location of the user (so that bystanders this it may make them depressed”, “this is controversial because would know about the failure of the user to change their of the messages, if users are repeatedly told they are going to die, behavior), notification of friends on Facebook (so that friends they might give up and eat more anyway”, or “the messages can’t would learn about a user’s performance), and restrictions to the be impersonal and attack people or it will have an effect on their user’s bank account (e.g. restricting the amount of money being psychological well-being.” However, subjects also came back to available to the user depending on their behavior). the question of who commissioned the technology: “The use of this device depends on a persons character and self esteem, it’s ok For each scenario, there were 20 questions, where participants hat if it’s their choice to use it, it’s person specific.”, “It is being given to rate the ethical acceptability of statements describing a specific to them by their doctor so it will be ok, their doctor will check combination of factors in the context of this specific scenario. We their mental stability.” published the survey on a commercial web service and advertised it through a number of mailing lists, web sites and groups on This aspect of who was behind the persuasive message was social networking sites. 72 participants (36 male, 36 female) discussed for scenario D as well: “c company is making money completed the survey. The majority of subjects (61%) fell into the and they could use it to take advantage, if the NHS were behind it, 18-25 years old bracket, with a further 9.7% reporting being it would be ok; if it is promoting other products such as patches, between 26 and 35 years old. Equal numbers (11.1% each) then it is unethical.”, “but some private companies already prompt indicated their age as being between 36 and 45, respectively 46 people not to smoke, it is just another venture.” The discussion and 60. 6.9% reported being over 60 years old. also brought up a general benefit of computer-based persuasion compared to a human trying to persuade someone: “you would get 4.2 Results cross at friends trying to make you stop, it’s a good thing, We analyzed the results according to different dimensions and persistence is good.” factors but due to space (and time) restrictions, not all results of the study can be reported here. In the following paragraphs we 4. SURVEY STUDY summarize some key results that potentially have some Based on the observations and feedback we gathered during the implications for the design of persuasive technology in the future. focus group sessions, we created an online questionnaire to With respect to the initiator/commissioner of an instance of investigate ethical issues pertaining to the use of persuasive persuasive technology, we re-affirmed that if a person decides to technology in the context of healthy living. In order to narrow use persuasive technology, then even drastic measures such as down the number of factors being investigated simultaneously, we electric shocks are considered predominately unethical. Figure 2 chose to focus on the three aspects that were mentioned most summarizes the responses we obtained for the three scenarios. frequently during the focus group sessions: the recipient, the commissioner and the means of delivery. The picture was more diverse when looking at how ethically into the ethics of using persuasive technology to promote healthy acceptable rated various scenarios. We were not able to identify a living. One interesting aspect relates to the golden rule of clear trend across all three scenarios. When analyzing different persuasion [5] – based on our observations, this rule may have to means to deliver persuasive content, we found that they varied be revisited as self-chosen persuasive technology appeared to be considerably in terms of how ethical they were considered to be. perceived as being generally more ethically acceptable Text messages were the least problematic, followed by public irrespective of the means being used. Related to this, there also announcements and Facebook notifications. Interestingly, was a trend to rate more drastic measures (such as electric shocks) Facebook announcement appeared to be rated slightly more more ethically acceptable in cases where there was much at stake unethical than public announcements. The most unethical means (such as persuading people with cardio-related illnesses to were bank account restrictions and electric shocks, with the latter exercise in order to improve their condition). consistently being rated as being unethical or very unethical. There are some lessons designers of future persuasive technology can draw from our studies. We identified three factors that seem to be relevant for people to assess the ethical acceptability of this kind of technology: the recipient, the commissioner, and the means of delivery. It may thus make sense to clearly convey these aspects to users when implementing persuasive technology. We also found evidence that social pressure, such as caused by public announcement or automatic posting on Facebook groups, can be very problematic. Consequently, such techniques need to be carefully analyzed before being implemented. Finally, we specifically included aspects of context adaptation, which are key benefits of persuasive technology built on mobile devices and ubiquitous environments. The focus group sessions hinted at this being perceived as ethically questionable but we did not find a Figure 2. Ethical acceptability of different means to deliver clear trend with respect to this aspect in the survey study. Further persuasion when self-chosen research in this area is therefore needed. The third factor that we had identified during the focus group sessions was the recipient of the persuasive content. For each 6. ACKNOWLEDGEMENTS scenario, we had asked about a healthy and an ill adult. Figure 3 This work reported in this paper was partially supported by the depicts the results we obtained when plotted according to this EU-funded Balance@Home project. dimension. As can be seen from the graph, there are considerable differences in terms what participants deemed to be ethically 7. REFERENCES acceptable depending on whether or not the recipient is healthy or [1] BBC News. 2009. Obesity in Statistics. ill. For example, almost twice as many subjects considered it to be http://news.bbc.co.uk/1/hi/health/7151813.stm, retrieved 10 ethical or very ethical to restrict access to a person’s bank account May 2010. if they were ill (and would thus suffer potentially fatal [2] Def. of ethics, Compact Oxford English Dictionary, 2009. consequences if they did not respond to the persuasive message. [3] Fogg, B.J. 1998. Persuasive Computers: perspectives and research directions. Proc. of CHI 98, ACM, 225-232. [4] Fogg, B.J. 2003. 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