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What Autonomy for Telecare? An Externalist ApproachLuca Chiapperino a , Marco Annoni a , Paolo Maugeri a & Giuseppe Schiavone aa European School of Molecular Medicine

Version of record first published: 10 Aug 2012.

To cite this article: Luca Chiapperino, Marco Annoni, Paolo Maugeri & Giuseppe Schiavone (2012): What Autonomy forTelecare? An Externalist Approach, The American Journal of Bioethics, 12:9, 55-57

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Telecare, Surveillance, and the Welfare State

cases mentioned thus far, in which personal rights deserveparticular attention, an assessment from various perspec-tives is recommended.

We argue that this requires a careful analysis of how therelation to technology changes individual self-perception,as well as a close look at the influences this has on thepotential for self–determined decisions. Importantly, con-siderations regarding ethical acceptability are even moreimportant and challenging for persons with mild cognitiveimpairment or dementia. In those cases we do not reliablyknow to what degree they are irritated additionally by im-plemented artifacts and thus how much artifacts might in-crease their suffering.

It is crucial to understand technologically inducedchanges in self-perception, and for this it is helpful to con-sider philosophy of technology to illuminate the ethical di-mensions. Ethical evaluation is notoriously difficult whenaiming at general processes. One can hardly find the ethi-cal borders of technology, especially as technology alwaysdevelops and is part of everyday life. However, technologi-cally induced effects that potentially limit interaction, com-munication, and eventually well-being based on irritationsin self-perception can be evaluated if proper assessment isdone. Sensitive assessment can show how technologies im-pact daily lives of users and can inform researchers, design-ers, users, and policymakers. Future investigations mustshow what really leads to the best possible quality of life

in vulnerable populations when humans and technologybecome more interwoven. �

REFERENCES

Frank, A. W. 1995. The wounded storyteller. Body, illness, and ethics.Chicago, IL: University of Chicago Press.

Ihde, D. 1990. Technology and the lifeworld: From garden to earth.Bloomington: Indiana University Press.

Kruse, A. 2003. Psychological issues of aging independently. InAging independently, eds. K. W. Schaie, H. W. Wahl, H. Mollenkopf,and F. Oswald, 46–61. New York, NY: Springer.

Merleau-Ponty, M. 1945. Phenomenologie de la perception. Paris,France: Gallimard.

Pollack, M. E. 2005. Intelligent technology for an aging population.AI Magazine 26(2): 9–24.

Remmers, H., and M. Hulsken-Giesler. 2011. e-Health technolo-gies in home care nursing. Recent survey results and subsequentethical issues. In Human-centered design of e-health technologies. Con-cepts, methods and applications, ed. M. Ziefle and C. Rocker, 154–178.Hershey, NY: Medical Information Science Reference (IGI Global).

Sorell, T., and H. Draper. 2012. Telecare, surveillance, and the wel-fare state. American Journal of Bioethics 12(9): 36–44.

Verbeek, P.-P. 2005. What things do: Philosophical reflections on technol-ogy, agency, and design. University Park, PA: Penn State UniversityPress.

What Autonomy for Telecare?An Externalist Approach

Luca Chiapperino, European School of Molecular MedicineMarco Annoni, European School of Molecular MedicinePaolo Maugeri, European School of Molecular Medicine

Giuseppe Schiavone, European School of Molecular Medicine

“Telecare, Surveillance and the Welfare State” addresses eth-ical issues arising from the use of sensors and other med-ical technologies for home care. Sorell and Draper (2012)maintain that a technology is “Orwellian” only insofar asit is controlled by a policing authority. Since no such ex-ternal agency is in place, they claim to have successfullydebunked the analogy. We believe their argument countersthe charge, but only under a narrow reading of 1984. Theauthors also claim that the main objection against telecarelies in the danger of deepening users’ isolation. Sorell andDraper fail to appreciate that the two objections share a

The authors acknowledge Fondazione Umberto Veronesi for its financial support. All authors contributed equally to this work.Address correspondence to Luca Chiapperino, Ifom-Ieo Campus, Folsatec, Via Adamello 16, Milano, 20139 Italy. E-mail: luca.chiapperino@ieo.eu

common root. This failure is due to the conception of au-tonomy they entertain. Siding with their recognition thattelecare can hardly promote patients’ independent living,we maintain that autonomy needs not be reduced to “thecapacity for making and carrying out short- and long-termplans” (Sorell and Draper 2012, 36). Although such an inter-nalist conception accounts for autonomous decision mak-ing in standard health care settings (Mental Capacity Act:Great Britain 2005), we believe that telecare monitoring re-quires autonomy to be conceived as control over one’s ex-ternal situation in the absence of severe constraints. If an

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externalist reading of autonomy is taken on board, we sug-gest, a broader conceptual space opens up for rethinkingthe ethics of telecare.

THE ORWELLIAN OBJECTION

Sorell and Draper claim to have defended telecare againstthe charge that it is Orwellian. We argue that their recon-struction is inaccurate and fails to capture worries that amonitoring technology such as telecare may legitimatelybring about. The authors maintain that the core of the Or-wellian objection lies in the possibility that telecare tech-nologies are used for surveillance and policing purposes.They convincingly show that such an authority is absent inthe case at issue. Hence, they conclude, the analogy betweenthe sinister forms of control envisioned in 1984 and telecareis implausible and ultimately misleading. The authors, nev-ertheless, admit that users themselves raise Orwellian-likeobjections (Percival and Hanson 2006). Therefore, one is leftto wonder whether their worries are solely to be referred to amistaken reading of 1984—as the authors seem to imply—orinstead if that is a genuine source of discomfort requiringcareful scrutiny—as we are inclined to believe.

Though this is no place for a thorough exegesis of 1984,we think that Sorell and Draper’s reading of the role of tech-nology in Orwell’s novel is indeed too narrow. As a result,the Orwellian objection for which they provide an answer isonly partially adequate. While they recognize that monitor-ing devices have the potential for direct control and surveil-lance, they fail to account for a subtler, yet equally troubling,feature of telecare technologies. In 1984, telescreens or theThought Police are not to be feared because they are visiblemeans of control and repression only. Rather, what makesthose technologies disquieting is their being a sign of a per-vasive and opaque form of control, fictionally exemplifiedby ever-watching Big Brother. Since Big Brother is every-where, he is nowhere, and therefore he cannot be foughtor resisted. Despite his rarefied nature, Big Brother createsa constraining decisional environment in which people’sopinions and behaviors can be controlled well before theymanifest themselves.

Similarly, Orwellian objections to telecare need not bereduced to dreadful policing aspects but should also in-clude interferences with users’ decisional contexts. Telecarehas more troublesome implications than an exclusive fo-cus on direct monitoring may at first reveal. These implica-tions, in turn, may also have to do with the places in whichmonitoring occurs (Oudshoorn 2012). Sorell and Draperacknowledge that telecare may result in constraints overpeople’s lifestyles and hence give rise to “heteronomousand therefore morally undesirable behaviour” (36).Nonetheless, they quickly dismiss this concern, replyingthat forms of contextual coercion do not fall within the le-gitimate scope of telecare. Again, the acknowledgment thattelecare may indeed prove problematic is discharged on thegrounds that no intended control is being exercised overthe users. We believe that the prompt dismissal of this ob-jection points to the shortcomings of the internalist account

of autonomy the authors subscribe to. To this point we nowturn.

INTERNALIST VERSUS EXTERNALIST CONCEPTIONS

OF AUTONOMY

The notion of autonomy employed in the Sorell and Draperarticle is summarized as follows: “the capacity for makingand carrying out short- and long-term plans” (36). This defi-nition implies that the condition of being autonomous is bestexplained by appealing to the psychology in which agents’preferences and values move to action. Following Oshana(1998), we label this model an “internalist account of auton-omy.” Autonomy, under this interpretation, “is guaranteedas long as nothing occurs to compromise the structural in-tegrity of the agent’s psychology” (Oshana 1998, 84), anddoes not require decision making to occur under contextualconditions over which she or he has control. On an external-ist reading, instead, autonomy would also require a certainlevel of control over the agent’s contextual conditions thatcontribute to self-determination.

The internalist model of autonomy adopted by Sorelland Draper, we argue, does not adequately map onto moralconsiderations relevant to telecare. To be sure, Sorell andDraper acknowledge that telecare technologies raise someserious concerns regarding their isolating potential. As theyput it: “Carers are typically important members of an el-derly’s social network, [thus] the conclusion that telecareis isolating is unavoidable” (36). Though we side with theauthors in recognizing that such an aspect of monitoringtechnology is not devoid of ethical implications, we believethat their notion of autonomy is structurally inadequate todeal with the ethical core of telecare. Indeed, though theseexternal elements might significantly alter the way in whichpeople subjected to telecare decide, they escape the authors’internalist conception of autonomy.

We submit that an externalist account, such as the oneproposed by Oshana (1998), would more suitably describewhat is problematic in telecare contexts and, consequently,may also be relevant on the normative level. This approachcould highlight the fact that, although not suffering fromany psychological impairment, a person who is not in theappropriate and enabling conditions is less likely to expe-rience autonomy. Furthermore, by endorsing such an ex-ternalist point of view, one would more readily recognizethat both the Orwellian and the “isolation” worries stemfrom a unique problematic core; namely, the various anddiverse constraints on individual autonomy that pervasiveand unpersonalized technologies may deploy onto people’sdecisional context.

These concerns, if taken seriously, indicate that some-thing needs to be done to accommodate perceived formsof discomfort. This is not the place to provide a full ac-count as to how this has to be done. Some suggestions can,nevertheless, be given. With an externalist view, respect forautonomy in telecare would point toward redressing users’control over the technology itself so as to weaken potentiallyoppressive contextual features. In practical terms, this could

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imply (i) enhancing users’ control over the use of informa-tion gathered through monitoring practices, (ii) clearly stat-ing the stakeholders directly involved in the surveillance,and (iii) increasing the understanding of how such tech-nologies operate. Taking into account these issues, we sub-mit, would amount to an improved respect for autonomy,thereby defeating residual Orwellian concerns.

CONCLUSION

We have suggested that an externalist model of autonomywould enrich the ethics of telecare. Such an account couldmove the focus of ethical scrutiny from the autonomy ofchoices to the context in which those choices are taken.Agents’ competence as to medically relevant decision mak-ing could be in general considered as the fundamentalsubjective requirement for self-determination. Being an au-tonomous telecare user, however, is also a function of thesocial relationships that affect individual perception of one’sown situation. By contrasting this model with the one pro-posed by Sorell and Draper, we mean to show that the in-ternalist stance the authors endorse is not suited to fullycope with the relational components that a technology liketelecare structurally embeds. On the one hand, it fails toaccount for the contextual coerciveness potentially arisingfrom monitoring practices. On the other, it leads to concep-

tualizing the isolating potential of such technologies as in-dependent from concerns for autonomy. An externalist viewprovides instead more solid grounds to address both objec-tions. Different technologies and medical practices call forrethinking respect for autonomy according to the differentconstraints that their application puts on individual self-determination. Telecare, we argue, is the kind of health caretechnology that urges us to reconsider “respect for auton-omy” as a process involving more than deference to discreteacts of choice. �

REFERENCES

Great Britain. 2005. Mental Capacity Act. London, UK: The StationeryOffice.

Oshana, M. A. L. 1998. Personal autonomy and society. Journal ofSocial Philosophy 29(1): 81–102.

Oudshoorn, N. 2012. How places matter: Telecare technologies andthe changing spatial dimensions of healthcare. Social Studies of Sci-ence 42(1): 121–142.

Percival, J., and J. Hanson. 2006. Big brother or brave new world?Telecare and its implications for older people’s independence andsocial inclusion. Critical Social Policy 26: 888–909.

Sorell, T., and Draper, H. 2012. Telecare, surveillance and the wel-fare state. American Journal of Bioethics 12(9): 36–44.

Using Foucault to Recastthe Telecare Debate

Adrian Guta, University of TorontoMarilou Gagnon, University of Ottawa

Jean Daniel Jacob, University of Ottawa

Sorell and Draper (2012) offer a much-needed engagementwith the bioethical dimensions of new and emerging tele-care technologies. They address the popular critique thatthese technologies are an extension of the “surveillance so-ciety” but refute them. Instead, they argue the dangers oftelecare are to be found in the uptake of these technolo-gies as a way to decrease health care spending—linkingthese advancements with the ongoing erosion of the wel-fare state. The concern is that these technologies will re-place existing forms of health interventions that better meetpatient’s medical and psychosocial needs. We concur withSorell and Draper (2012) that the implications of these tech-nologies require appraisal with consideration for the politi-cal and economic context in which they are developed andused (an important lesson many bioethicists would ben-

Address correspondence to Adrian Guta, University of Toronto, Dalla Lana School of Public Health, 155 College Street, Health ScienceBuilding, 6th floor, Toronto, Ontario M5T 3M7, Canada. E-mail: adrian.guta@mail.utoronto.ca

efit from). However, an attention to these issues invitesa range of alternative theoretical lenses that may lead todifferent conclusions then were reached by the authors.Drawing on the work of Michel Foucault, we intend toproblematize aspects of their analysis. Specifically, we takeissue with their strategically chosen examples of the elderly(occasionally juxtaposed with criminals) to dismiss surveil-lance critiques. We offer an analysis based on “governmen-tality” and “biopower” that considers the ways in whichthese technologies are first introduced in seemingly benignways (where they are “most needed”) and then becomenormalized, standardized, and generally deployed. Draw-ing on debates in the field of HIV, specifically adherence andcriminalization, we show that these technologies do in factpose considerable dangers to some groups of vulnerable

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