Ethical considerations around
telecare
Andrew Eccles
Issues under discussion
Some background: definitions of telecare and the policy discourse underpinning its application
Ethical frameworks: what is in use, how they are interpreted and other approaches that might be relevant
Scottish Government definition
‘Telecare usually refers to equipment and detectors that provide continuous, automatic and remote
monitoring of care needs emergencies and lifestyle changes’.
Generations:
2 sensor based ‘lifestyle monitoring’ (for
example ‘just checking’) / smart houses
Telecare objectives by 2015
All new homes, public and private, and all refurbished social housing, will be fitted with the capacity for care and health services to be provided interactively via broadband from day one of occupation
Telehealth will be widely recognised by service users and their carers as the route to greater independence and quality of life Independent evaluation will confirm that no care service users
in Scotland who could benefit from telecare services in a home-based setting remain in an institutional environment
Scotland by comparison
Telecare in Scotland: Benchmarking the Present,
Embracing the Future (Scottish Government 2008):
‘Scotland can consider itself in the vanguard of countries progressing to mainstream telecare service provision’
The Telecare Development Programme
Reduce the number of avoidable emergency admissions and readmissions to hospital
Increase the speed of discharge from hospital once clinical need is met
Reduce the use of care homes
Improve the quality of life of users of telecare services
Telecare Development Programme
Extend the range of people assisted by telecare services in Scotland
Achieve efficiencies (cash releasing or time releasing) from the programme investment in telecare
The ethical dimension
‘
[the need to] address an ethical and democratic deficit in this field which has arisen due to aproliferation in research and development of advanced care technologies that has not been accompanied by sufficient consideration of their social context’
The discourse around telecare
Demographic change
Discussion of projections / ‘dependency’ ratios
Key Telecare company and partner of Scottish government: ‘the demographic timebomb’
Tinker (1998) on demographic change: the rates of change are significant but do not constitute the
timebomb that is supposed
Bowling & Dieppe (2005) self evaluation versus
Ethical framework(s) in use
Based on four principles (Beauchamp and Childress, 2002) Beneficence, Non-maleficence, Autonomy, Justice
Ethical interpretation
Sommerville (2003: 283)
‘interpretation of the terms [for example, harm and benefit],
depends in different contexts on a number of variables, including individuals’ perceptions as well as legal and professional
benchmarks’
Interpretations of beneficence: positive
and utility beneficence
Scottish Government
‘we should try to do good to the people we care for’
The Care Services Improvement Partnership
‘involves finding the balance between risk tolerance
Interpretations of non-maleficence
Scottish Government
‘we should try to avoid doing people harm’
The Care Services Improvement Partnership
‘will involve a balance between avoiding harm and respecting decisions, dignity, integrity and
Interpretations of autonomy
Wilmot (1997) ‘the primacy of autonomy’ which obscures the interdependence of human affairs
‘Unwanted autonomy’ in post Griffiths community care
Independence but isolation?
Astrid (2001) framework warns of potential for isolation in the use of technology
Lowe (2009) surveys literature linking isolation to depression and notes potential attendant costs for health care. Will depression be detected? If so, will it be dealt with adequately?
Is a system (for example ‘befrienders’) being
Interpretations of justice
Scottish Government
‘people should be treated fairly and equally’
The Care Services Improvement Partnership
Interpretations of justice
By what measure should people be treated ‘equally’?
A social inclusion angle
Need for telephone landline for telecare monitors to work: excludes ‘pay as you go’ service users
Ideally access needed to broadband to monitor ‘just checking’ system by family members
3rd generation AT will rely more on mobile
Virtue ethics
Recourse to the moral character of
professionals in addition to value bases
across professions (a response to codes of
practice)?
Banks & Docherty (2009)
Whose virtues? Value bases across
An ethic of care
Ethical decisions are contextual, relational and based on
reciprocity in which rule based decisions are insufficient (but nonetheless set the agenda)
Barnes (2006): the way in which care workers go beyond
tasks to develop relationships beyond contractual obligations: care as a moral activity
LMD evaluation
Hanson, Osipovic, Percival (2009, 111) evaluation of Lifestyle Monitoring Devices conclude:
‘In order to make ‘sense of sensors’ alongside the data provided by the devices, one needs rich
Is a ‘checklist’ bio-medical ethical framework
adequate for the needs of different telecare user groups and are assessors sensitive enough (for example to risk) in its interpretation?
If ethics are contextual, then ought the context of
older people and people with disabilities be subject to the same ethical framework? Does the framework
have enough latitude for interpretation for different
Intuitionism
(Driver, 2007) intuitionism as an additional dimension to ethical frameworks
Some other ethical issues
From telemedicine: the desire for human
engagement among some medics and patients
Cultural sensitivity: to what extent is the biomedical framework culturally transferable; for example,
Research with staff using telecare
‘Snapshot’ research approach
Information gathering and piloting across three sites, interviews across further two
Site U Urban
Site R Rural
Findings
Ethical frameworks based on the biomedical four principles at both sites
Generally agreed across both sites that in practice staff will use their ‘professional judgement’ rather than any framework as such
Interprofessional working
Assessment
Health professionals note more unmet need
Consistency of referrals
U and R sites operate different approaches to gatekeeping the assessment process
Site U operate gatekeepers from across disciplines
Social inclusion
Different policies across Sites U and R about underwriting costs of landline installation
OT (U) ‘people used to using computers at work are at an advantage’
SWM (R) Not an issue: ‘you can get pay as
you go Blackberries these days’.
HO (R) [of older people] ‘telecare a non-starter in some cases….they don’t need
Addressing potential isolation
Is the
type
of care an ethical issue?
OT(U) not itself: technology decisions ‘in the best interests of service user’
PM (U) concerns about loss of human relationships if telecare was used inappropriately
SW manager (R), Housing Officer (R): telecare is superior as it is less intrusive
Policy drivers
OT (U) independence, choice
SWM (R) fitting in best with what
people want
HO (R) choice , demographics
Performance indicators
Reduce the Number of Avoidable Emergency Admissions and Readmissions to Hospital
Hospital bed days saved through telecare supported discharge
Reduce the use of care homes
Improve quality of life for users of telecare services
Method of evaluating telecare impact
‘The evaluation relied on Project Managers or other staff working with the telecare users (e.g. those
undertaking telecare assessments) to identify what they thought would otherwise have happened to the client at and subsequent to the time of issue of their
telecare equipment. This information was then used
to estimate the resources that would have been used if the telecare equipment had not been provided’.
Figures drawn from telecare ‘partnerships’
Acknowledged differences in methods of recording
Performance measurement
Scottish Government categories of telecare partnership performance
Criteria underpinning these unclear to Telecare Project Managers
Telecare packages (supplied by Scottish
What happens to fulfilling the performance
indicators if technology is
not employed
– or
if human care services would be more
Scottish Government research with
service users
Independence
Informal carer anxieties quelled
Project managers’ ethics
Girling (2007) discusses the argument (Loughlin,
2002) that in a managerialist world ethical reasoning requires the freedom of critical thought that is simply not available to managers
Draws on Aristotle’s ideas of ‘cleverness’ and
Clarke, S (2006) drawing on Woolgar (2002);
The uptake and use of new technologies depend crucially on local social context
Are the ethical frameworks in use adequate and/or sensitive enough?
Are frameworks understood and employed within a tolerable degree of subjectivity across assessment professions?
Are the policy drivers open to debate and do they allow for local telecare partnerships to pursue local approaches?
Astrid (2000): a social and technological response to meeting the needs of individuals with dementia and their carers. A guide to using technology in dementia care London: Hawker
Barnes, M (2006) Caring and Social Justice Basingstoke: Palgrave MacMillan
Beauchamp, L & Childress, A F (2001) Principles of Biomedical Ethics (5th ed) Oxford: Oxford University Press
Lowe, C (2009)Beyond Telecare – the future of independent living Journal of Assistive Technologies 3(1)
Loughlin, M (2002) Ethics, management and Mythology Abingdon: Radcliffe Medical Press
Hanson J, Osipovic D, Percival J(2009) Making Sense of Sensors in Loader, B Hardly, M & Keeble L (2009) Digital Welfare for the Third Age London Rotledge
Sommerville, J (2003) Juggling law, ethics and intuition: practical
answers to awkward questions Journal of Medical Ethics 29 (281-286)
