Andrew Eccles

Ethical considerations around the implementation of telecare technologies

The use of assistive technology in social care, through a program of telecare, has become a prominent feature of policy development in some advanced industrial societies. This article looks at developments in Scotland, where ambitious targets for the application of telecare technologies are underway. The focus here is on telecare for older people. The paper starts by examining the discourse around demographic change and fiscal pressures to explore an increased use of technology. The paper then examines ethical issues raised by this telecare program and argues that the frameworks in use, while important, are limited in scope. It thus considers wider ethical frames of reference and looks at policy imperatives—such as interprofessional working and a performance driven culture—that may make ethical considerations more difficult to realize in practice.

Single Shared Assessment: The Limits to ‘Quick Fix’ Implementation

Joint working between health and social services has been a key focus of policy in recent years, albeit ‐ underneath the protocols and partnership agreements ‐ integrated processes have developed unevenly. A single shared assessment tool has been one of the concrete expressions of policy on the ground. This paper explores the implementation of the shared assessment process in Scotland. It discusses the broader policy agenda, before exploring the introduction of the shared assessment tool in a large urban authority. Based primarily on interviews with front‐line staff in health and social work and managers charged with delivering shared assessment, the paper suggests a lack of engagement on issues such as working cultures and equity of workloads, while some of the main reasons behind the implementation of shared assessment, such as overcoming duplication, have not generally materialised for staff. Overall, single shared assessment has been driven by process rather than by engagement with wider ideas about joint working, which has led to uneven and at times unwilling implementation.

Assistive Technologies: Ethical Practice, Ethical Research, and Quality of Life

Much has been written about the benefits, for example, greater independence, autonomy, and dignity, which can derive from the use of assistive technologies with older people (Loader, Hardey, & Keeble, 2009; McCreadie & Tinker, 2005; Poser & Moser, 2009). These benefits have been well researched, clearly expressed in the literature, and remain uncontested here. Apart from benefits to individuals and carers, assistive technologies can release funds for other applications, and where this is in care settings funded through public expenditure, the cost savings that might arise from their application may afford the opportunity for more effective targeting of taxpayer’s resources. As the Audit Commission (guardian of public expenditure in the UK) noted, the use of technology represents the unusual possibility of providing cost savings at the same time as better service provision (Audit Commission, 2004). The merits then are evident. But there is a need also to be alert to the ethical questions that arise as a concomitant to the use of new technologies and to address what Mort, Roberts, and Milligan (2009) have argued is an “ethical and democratic deficit in this field which has arisen due to a proliferation in research and development of advanced care technologies that has not been accompanied by sufficient consideration of their social context” (p. 85). This chapter will raise these ethical issues, alight on the potential deficits, and highlight some of the policy and practical issues that might warrant further inquiry. It does so by addressing three key areas. First, it considers ethical approaches commonly in use and their limitations for application in the field of assistive technologies. Second, it explores the ethical issues that arise around the design and execution of research with users of assistive technologies. Third, it raises the question of whether or not assistive technologies contribute to a better quality of life (QoL) for recipients, not least because QoL is explicitly included as an intended policy outcome of the deployment of such technologies (Scottish Government, 2009; Telecare Services, 2010). The chapter draws its examples primarily from the experience of the UK (and its devolved polities), where the policy objectives of governments for extending the use of assistive technologies are particularly ambitious. We are mindful of the methodological pitfalls of cross-national applicability, but the discussion should have broader resonance, as ethical approaches and practices come to terms with a technologically fast-changing world. Our use of the term assistive technologies embraces the definition of any item, piece of equipment, product, or system, whether acquired commercially off the shelf, modified, or customized, that is used to increase, maintain, or improve the functional capabilities of individuals with disabilities (Technology-Related Assistance for Individuals with Disabilities Act, 1988 P.L.100/407); more practicably, as Cowan and Turner Smith (cited in McCreadie & Tinker, 2005) note, it refers to any device or system that allows an individual to perform a task that they would otherwise be unable to do or increases the ease and safety with which the task can be performed. We note in particular that some of the more interesting ethical challenges have arrived with the advent of telecare sensor-based technologies, which open up important issues around privacy, autonomy, and the potential for replacement of human care through remote monitoring.

Telecare technologies and isolation: some ethical issues

Telecare technologies involve the remote monitoring of patients who have health, rehabilitation or social needs. These technologies, although deployed unevenly in developed countries, represent a shift in the ways in which care is practiced. Research on the consequences of this shift away from more traditional ‘hands-on’ care has focused primarily on quantitative measurement (for example cost savings) with less attention paid to how recipients themselves experience these new care practices. This paper discusses two aspects of telecare technologies which are under researched; the potential for isolation which may arise as a result of the use of these technologies, and the ethical issues raised by this. The primary locus of the discussion is the United Kingdom, where a major public policy shift towards telecare is under way and where telecare research has been particularly well funded by government. The discussion concludes that isolation raises the potential for loneliness – which is increasingly recognised as a significant factor in overall health and well-being – and is not being sufficiently considered, in part because the ethical frameworks in use do not adequately address the issue of loneliness itself, given their bio-medical, rather than relational focus.