This article examines the gamification of health applications designed to help patients manage chronic pain. Through description of one such program and in-depth interviewing, I describe why gamified pain applications are appealing to patients living with chronic pain. Individuals living with chronic pain are especially disposed to try novel pain management technologies due to the in-control and out-of-control paradox of pain (Leder, 2016). These applications are seductive not only due to this embodied phenomenon, but also because gamification taps into the (...) logic of proactive self-management that is tantamount to an era of biomedicalization, wherein subjects are incentivized to take control of their own health in the face of austerity budgets. However, pain also limits the user’s ability to adopt an immersive, lusory attitude. Thus, the speculative promises of gamified health technologies are just that – speculative, and their immersive potential should not be overstated. (shrink)

Value capture occurs when an agent’s values are rich and subtle; they enter a social environment that presents simplified — typically quantified — versions of those values; and those simplified articulations come to dominate their practical reasoning. Examples include becoming motivated by FitBit’s step counts, Twitter Likes and Re-tweets, citation rates, ranked lists of best schools, and Grade Point Averages. We are vulnerable to value capture because of the competitive advantage that such crisp and clear expressions of value have in (...) our private reasoning and our public justification. There is, however, a price. In value capture, we take a central component of our autonomy — our ongoing deliberation over the exact articulation of our values — and we outsource it. And the metrics to which we outsource usually engineered for the interests of some external force, like a large-scale institution’s interest in cross-contextual comprehensibility and quick aggregability. That outsourcing cuts off one of the key benefits to personal deliberation. In value capture, we no longer adjust our values and their articulations in light of own rich experience of the world. Our values should often be carefully tailored to our particular selves or our small-scale communities, but in value capture, we buy our values off the rack. In some cases – like decreasing CO2 emissions – the costs of non-tailored values are outweighed by the benefit of precise collective coordination. In other cases, like in our aesthetic lives, they are not. This suggests that we should want different values suited to different scales. We should want value federalism. Some values are perhaps best pursued at the largest-scale level, others at smaller scales. The problem occurs when we exhibit an excess preference for the largest-scale values – when we consistently let the universal metrics swamp our quieter interests. (shrink)

Trust and trustworthiness are essential for good healthcare, especially in mental healthcare. New technologies, such as mobile health apps, can affect trust relationships. In mental health, some apps need the trust of their users for therapeutic efficacy and explicitly ask for it, for example, through an avatar. Suppose an artificial character in an app delivers healthcare. In that case, the following questions arise: Whom does the user direct their trust to? Whether and when can an avatar be considered trustworthy? Our (...) study aims to analyze different dimensions of trustworthiness in the context of mobile health app use. We integrate O'Neill's account of autonomy, trust, and trustworthiness into a model of trustworthiness as a relational concept with four relata: B is trustworthy with respect to A regarding the performance of Z because of C. Together with O'Neill's criteria of trustworthiness (honesty, competence, and reliability), this four-sided model is used to analyze different dimensions of trustworthiness in an exemplary case of mobile health app use. Our example focuses on an app that uses an avatar and is intended to treat sleep difficulties. The conceptual analysis shows that interpreting trust and trustworthiness in health app use is multi-layered and involves a net of interwoven universal obligations. At the same time, O'Neill's approach to autonomy, trust, and trustworthiness offers a normative account to structure and analyze these complex relations of trust and trustworthiness using mobile health apps. (shrink)

AI systems have often been found to contain gender biases. As a result of these gender biases, AI routinely fails to adequately recognize the needs, rights, and accomplishments of women. In this article, we use Axel Honneth’s theory of recognition to argue that AI’s gender biases are not only an ethical problem because they can lead to discrimination, but also because they resemble forms of misrecognition that can hurt women’s self-development and self-worth. Furthermore, we argue that Honneth’s theory of recognition (...) offers a fruitful framework for improving our understanding of the psychological and normative implications of gender bias in modern technologies. Moreover, our Honnethian analysis of gender bias in AI shows that the goal of responsible AI requires us to address these issues not only through technical interventions, but also through a change in how we grant and deny recognition to each other. (shrink)

Background: The concept of digital twins has great potential for transforming the existing health care system by making it more personalized. As a convergence of health care, artificial intelligence, and information and communication technologies, personalized health care services that are developed under the concept of digital twins raise a myriad of ethical issues. Although some of the ethical issues are known to researchers working on digital health and personalized medicine, currently, there is no comprehensive review that maps the major ethical (...) risks of digital twins for personalized health care services. Objective: This study aims to fill the research gap by identifying the major ethical risks of digital twins for personalized health care services. We first propose a working definition for digital twins for personalized health care services to facilitate future discussions on the ethical issues related to these emerging digital health services. We then develop a process-oriented ethical map to identify the major ethical risks in each of the different data processing phases. Methods: We resorted to the literature on eHealth, personalized medicine, precision medicine, and information engineering to identify potential issues and developed a process-oriented ethical map to structure the inquiry in a more systematic way. The ethical map allows us to see how each of the major ethical concerns emerges during the process of transforming raw data into valuable information. Developers of a digital twin for personalized health care service may use this map to identify ethical risks during the development stage in a more systematic way and can proactively address them. Results: This paper provides a working definition of digital twins for personalized health care services by identifying 3 features that distinguish the new application from other eHealth services. On the basis of the working definition, this paper further layouts 10 major operational problems and the corresponding ethical risks. Conclusions: It is challenging to address all the major ethical risks that a digital twin for a personalized health care service might encounter proactively without a conceptual map at hand. The process-oriented ethical map we propose here can assist the developers of digital twins for personalized health care services in analyzing ethical risks in a more systematic manner. (shrink)

This paper engages in what might be called anticipatory virtue epistemology, as it anticipates some virtue epistemological risks related to a near-future version of brain-computer interface technology that Michael Lynch (2014) calls 'neuromedia.' I analyze how neuromedia is poised to negatively affect the intellectual character of agents, focusing specifically on the virtue of intellectual perseverance, which involves a disposition to mentally persist in the face of challenges towards the realization of one’s intellectual goals. First, I present and motivate what I (...) call ‘the cognitive offloading argument’, which holds that excessive cognitive offloading of the sort incentivized by a device like neuromedia threatens to undermine intellectual virtue development from the standpoint of the theory of virtue responsibilism. Then, I examine the cognitive offloading argument as it applies to the virtue of intellectual perseverance, arguing that neuromedia may increase cognitive efficiency at the cost of intellectual perseverance. If used in an epistemically responsible manner, however, cognitive offloading devices may not undermine intellectual perseverance but instead allow us to persevere with respect to intellectual goals that we find more valuable by freeing us from different kinds of menial intellectual labor. (shrink)

In this review, I analyse how ‘behaviour-based personalisation’ in insurance – that is, insurers’ increased interest in tracking and manipulating insureds’ behaviour with, for instance, wearable devices – has been approached in recent social scientific literature. In the review, I focus on two streams of literature, critical data studies and the sociology of insurance, discussing the new insurance schemes that utilise sensor-generated and digital data. The aim of this review is to compare these two approaches and to analyse what kinds (...) of understandings, methodologies and theoretical perspectives they apply to so-called ‘behaviour-based insurance’. The critical data studies literature emphasises the exploitative aspects of these new technologies and mobilises behaviour-based insurance to exemplify the negative outcomes of digital health. Scholars from the field of the sociology of insurance empirically analyse the practices of behavioural-based personalisation and study how regulating and ‘doing’ insurance affect attempts to personalise it. I highlight the importance of approaching insurance as a specific financial technology and argue that more research is needed to understand the practices of developing behaviour-based insurance schemes and the insureds’ experiences. (shrink)

Persuasive design draws on our basic psychological makeup to build products that make our engagement with them habitual. It uses variable rewards, creates Fear of Missing Out, and leverages social approval to incrementally increase and maintain user engagement. Social media and networking platforms, video games, and slot machines are all examples of persuasive technologies. Recent attention has focused on the dangers of PD: It can deceptively prod users into forming habits that help the company’s bottom line but not the user’s (...) wellbeing. But PD is not inherently immoral. We can take advantage of our psychological biases to make beneficial changes in ways that enhance our agency rather than limit it. Knowing that a tool is persuasively designed is a consideration in favor of using it when we are trying to break bad habits, such as smoking. How are we to conceptually distinguish between ethical and unethical uses of PD? In this paper, I argue that unethical uses of PD betray or erode our trust. Annette Baier offers a moral test for trust: If gaining knowledge about what other parties do with our trust in them would lead us to stop trusting, then that trusting relationship is immoral. I apply this test to the case of PD. Using trust as a litmus test for ferreting out unethical PD has several advantages, one of which is that it reveals how the harm of unethical PD extends beyond the individual to her wider social network. I close the paper by investigating these cascading effects. (shrink)

The development of personal technologies has recently shifted from devices that seek to capture user attention to those that aim to improve user well-being. Digital wellness technologies use the same attractive qualities of other persuasive apps to motivate users towards behaviors that are personally and socially valuable, such as exercise, wealth-management, and meaningful communication. While these aims are certainly an improvement over the market-driven motivations of earlier technologies, they retain their predecessors’ focus on influencing user behavior as a primary metric (...) of success. Digital wellness technologies are still persuasive technologies, and they do not evade concerns over whether their influence on users is ethically justified. In this paper, we describe several ethical frameworks with which to assess the justification of digital wellness technologies’ influence on users. We propose that while some technologies help users to complete tasks and satisfy immediate preferences, other technologies encourage users to reflect on the values underlying their habits and teach them to evaluate their lives’ competing demands. While the former approach to digital wellness technology is not unethical, we propose that the latter approach is more likely to lead to skillful user engagement with technology. (shrink)

This article highlights the limitations of the tendency to frame health- and wellbeing-related digital tools (mHealth technologies) as empowering devices, especially as they play an increasingly important role in the National Health Service (NHS) in the UK. It argues that mHealth technologies should instead be framed as digital companions. This shift from empowerment to companionship is advocated by showing the conceptual, ethical, and methodological issues challenging the narrative of empowerment, and by arguing that such challenges, as well as the risk (...) of medical paternalism, can be overcome by focusing on the potential for mHealth tools to mediate the relationship between recipients of clinical advice and givers of clinical advice, in ways that allow for contextual flexibility in the balance between patiency and agency. The article concludes by stressing that reframing the narrative cannot be the only means for avoiding harm caused to the NHS as a healthcare system by the introduction of mHealth tools. Future discussion will be needed on the overarching role of responsible design. (shrink)

Interactions between an intelligent software agent and a human user are ubiquitous in everyday situations such as access to information, entertainment, and purchases. In such interactions, the ISA mediates the user’s access to the content, or controls some other aspect of the user experience, and is not designed to be neutral about outcomes of user choices. Like human users, ISAs are driven by goals, make autonomous decisions, and can learn from experience. Using ideas from bounded rationality, we frame these interactions (...) as instances of an ISA whose reward depends on actions performed by the user. Such agents benefit by steering the user’s behaviour towards outcomes that maximise the ISA’s utility, which may or may not be aligned with that of the user. Video games, news recommendation aggregation engines, and fitness trackers can all be instances of this general case. Our analysis facilitates distinguishing various subcases of interaction, as well as second-order effects that might include the possibility for adaptive interfaces to induce behavioural addiction, and/or change in user belief. We present these types of interaction within a conceptual framework, and review current examples of persuasive technologies and the issues that arise from their use. We argue that the nature of the feedback commonly used by learning agents to update their models and subsequent decisions could steer the behaviour of human users away from what benefits them, and in a direction that can undermine autonomy and cause further disparity between actions and goals as exemplified by addictive and compulsive behaviour. We discuss some of the ethical, social and legal implications of this technology and argue that it can sometimes exploit and reinforce weaknesses in human beings. (shrink)

Mobile health is rapidly being implemented and changing our ways of doing, understanding and organising healthcare. mHealth includes wearable devices as well as apps that track fitness, offer wellness programmes or provide tools to manage chronic conditions. According to industry and policy makers, these systems offer efficient and cost-effective solutions for disease prevention and self-management. While this development raises many ethically relevant questions, so far mHealth has received only little attention in medical ethics. This paper provides an overview of bioethical (...) issues raised by mHealth and aims to draw scholarly attention to the ethical significance of its promises and challenges. We show that the overly positive promises of mHealth need to be nuanced and their desirability critically assessed. Finally, we offer suggestions to bioethicists to engage with this emerging trend in healthcare to develop mHealth to its best potential in a morally sound way. (shrink)

Mobile health devices pose novel questions at the intersection of philosophy and technology. Many such applications not only collect sensitive data, but also aim at persuading users to change their lifestyle for the better. A major concern is that persuasion is paternalistic as it intentionally aims at changing the agent’s actions, chipping away at their autonomy. This worry roots in the philosophical conviction that perhaps the most salient feature of living autonomous lives is displayed via agency as opposed to patiency—our (...) lives go well in virtue of what we do, rather than what happens to us. Being persuaded by a device telling us how to conduct our lives seemingly renders the agent passive, an inert recipient of technological commands. This agential bias, however, has led to a marginalization of patiential characteristics that are just as much part of our lives as are agential characteristics. To appreciate the inherent interlocking of acting and being acted upon, it is vital to acknowledge that agency and patiency are correlates, not mutually exclusive opposites. Furthermore, it is unclear whether an action can only count as agential so long as its causes are internal. Drawing on the extended mind and extended will framework, I argue that mHealth applications merely serve as volitional aids to the agent’s internal cognition. Autonomously set goals can be achieved more effectively via technology. To be persuaded by an mHealth device does not mainly—let alone exclusively—emphasize patiency; on the contrary, it can be an effective tool for technologically enhancing agency. (shrink)

Problem Self-tracking—and of course also health-related self-tracking—has an influence on those who use it. This influence can (but does not necessarily have to) pose a threat to the autonomy of people tracking themselves. Argumentation Self-tracking can easily come into conflict with one of the three conditions for autonomy defined by Beauchamp, Faden, and Childress: voluntariness. Based on a distinction between different forms of manipulative influence—mildly controlling and substantially controlling—I will argue that health-related self-tracking often has a mildly controlling influence but (...) that it can also turn into a substantially controlling manipulative influence and even become coercive. Conclusion Substantially manipulative self-tracking and self-tracking that involves coercion is a violation of the condition of voluntariness set for autonomy. This risk of violating autonomy must be taken into account when assessing health-related self-tracking. (shrink)

In this article, we address the case of self-tracking as a practice in which two meaningful backgrounds (physical world and technological infrastructure) play an important role as the spatial dimension of human practices. Using a (post)phenomenological approach, we show how quantification multiplies backgrounds, while at the same time generating data about the user. As a result, we can no longer speak of a unified background of human activity, but of multiple dimensions of this background, which, additionally, is perceived as having (...) no pivotal role in the process, often being hidden, situated beyond human consciousness, or taken for granted. Consequently, the phenomenological experience of the background turns into a hermeneutic practice focused on the interpretation of representations and descriptions. By adopting a (post)phenomenological approach, we show the problems and limitations of quantification of human activities occurring in self-tracking and the theoretical problems associated with the scheme of human-technology relations. (shrink)

Mobile health (mHealth) technologies for self-monitoring health-relevant parameters such as heart frequency, sleeping patterns or exercise regimes aim at fostering healthy behavior change and increasing the individual users to promote and maintain their health. We argue that this aspect of mHealth supports healthism, the increasing shift from institutional responsibility for public health toward individual engagement in maintaining health as well as mitigating health risks. Moreover, this healthist paradigm leads to a shift from understanding health as the absence of illness to (...) regarding health as the performance of certain rituals in order to project healthiness. By drawing from the analogy between healthiness and traditional virtues, we evaluate the promises made by proponents of mHealth technologies for self-monitoring. We argue that the implementation and use of mHealth risk entrenching existing inequalities and, more particularly, tend to exclude populations situated at the losing end of those inequalities from participating in the quasi-virtue of healthiness. Consequently, the implementation and use of mHealth technologies not only present challenges for social justice but also undermine their primary societal goal—to promote public health. Finally, we offer several suggestions on how to realize the potential benefit of mHealth. (shrink)

This paper presents a literature review on the ethics of self-tracking technologies which are utilized by users to monitor parameters related to their activity and bodily parameters. By examining a total of 65 works extracted through a systematic database search and backwards snowballing, the authors of this review discuss three categories of opportunities and ten categories of concerns currently associated with self-tracking. The former include empowerment and well-being, contribution to health goals, and solidarity. The latter are social harms, privacy and (...) surveillance, ownership control and commodification of data, autonomy, data-facilitated harm, datafication and interpretability of data, negative impact on relation to self and others, shortcomings of design, negative impact on health perception, and regulation and enforcement of rules. The review concludes with a critical analysis of the existing literature and an overview of a future research agenda that could complement the current work on ethics of self-tracking. (shrink)

As the rising costs of lifestyle-related diseases place increasing strain on public healthcare systems, the individual’s role in disease may be proposed as a healthcare rationing criterion. Literature thus far has largely focused on retrospective responsibility in healthcare. The concept of prospective responsibility, in the form of a lifestyle contract, warrants further investigation. The responsibilisation in healthcare debate also needs to take into account innovative developments in mobile health technology, such as wearable biometric devices and mobile apps, which may change (...) how we hold others accountable for their lifestyles. Little is known about public attitudes towards lifestyle contracts and the use of mobile health technology to hold people responsible in the context of healthcare. This paper has two components. Firstly, it details empirical findings from a survey of 81 members of the United Kingdom general public on public attitudes towards individual responsibility and rationing healthcare, prospective and retrospective responsibility, and the acceptability of lifestyle contracts in the context of mobile health technology. Secondly, we draw on the empirical findings and propose a model of prospective intention-based lifestyle contracts, which is both more aligned with public intuitions and less ethically objectionable than more traditional, retrospective models of responsibility in healthcare. (shrink)

In this paper, I discuss the formation of habits with the help of self-tracking technologies. Although devices like Fitbit smart bands come with promises of empowerment through the means of increased control over users’ habits, existing literature does not provide conclusive findings about the validity of such claims. I contribute to the ongoing debate by relying on John Dewey’s pragmatist philosophy and its notion of intelligent habit. I demonstrate that from a pragmatist standpoint, habits that are the most likely to (...) accomplish users’ goals contribute to their flourishing need to be reflective (accompanied by adequate deliberation) and flexible (adaptable to the changing circumstances). On this basis I highlight some ethical-epistemic issues surrounding self-tracking technologies that inhibit the formation of habits desirable from a Deweyan standpoint. These include a lack of reflection on the part of the developers, difficulties for users to deliberate and consciously shape the habits developed by their devices, and dependence upon self-tracking tools that makes it difficult to adapt habits to individual needs and circumstances. I conclude the paper by discussing self-tracking’s general impact on flourishing, as well as placing my arguments in the context of the diversity of self-tracking practices and identifying how users attempt to alleviate the shortcomings of the technology and make it more suitable to their goals and needs. (shrink)

Consumer-targeted sleep tracking applications (STA) that run on mobile devices (e.g., smartphones) promise to be useful tools for the individual user. Assisted by built-in and/or external sensors, these apps can analyze sleep data and generate assessment reports for the user on their sleep duration and quality. However, STA also raise ethical questions, for example, on the autonomy of the sleeping person, or potential effects on third parties. Nevertheless, a specific ethical analysis of the use of these technologies is still missing (...) so far. The aim of the current analysis is to identify the characteristics of sleep tracking apps and to explore the specific ethical aspects associated with this form of self-tracking. Firstly, the field of mobile health applications was screened for STA to explore their typical functions and target user groups. Secondly, an ethical analysis was conducted focusing on the three ethical dimensions: (1) medicalization, (2) vulnerability, and (3) relationality. The analysis indicates that these three normative dimensions are decisive for assessing STA and that the ethical profile of this technology varies greatly depending on the respective user group. As the three dimensions medicalization, vulnerability, and relationality play a distinguishing role in the use of STA, they should be especially addressed in responsible development and implementation of STA. In addition, the analysis helps to evaluate the use of STA, in terms of different risks for specific user groups, the sensitive contexts of usage, and potential interference with the intimacy of third parties. (shrink)

Technology corporations and the emerging digital health market are exerting increasing influence over the public healthcare agendas forming around the application of mobile medical devices. By promising quick and cost-effective technological solutions to complex healthcare problems, they are attracting the interest of funders, researchers, and policymakers. They are also shaping the public facing discourse, advancing an overwhelmingly positive narrative predicting the benefits of wearable medical devices to include personalised medicine, improved efficiency and quality of care, the empowering of under-resourced communities, (...) and delivery of health services previously unavailable to the citizens of developing countries. Typically techno-optimist in their description, the key barriers to this impending inflection point in healthcare are identified as technical issues such as short battery life and a lack of data protection. However, this tech innovation narrative is consistent with problematic ethical, social, and political assumptions that have practical and normative effects, and risk, one, undermining the real clinical potential of wearable devices and, two, designing social inequality and injustice into our mobile health interventions in global healthcare. I argue that the foundational assumptions dealing with the just distribution of healthcare ‘goods’, the individual as part of society, and the political framing of future healthcare policy devalue equity and despite what they promise cannot meet the distinctive needs of individuals and groups that do not conform to a standardised concept of care-receiver. (shrink)

This paper explores and rehabilitates the value of decisional privacy as a conceptual tool, complementary to informational privacy, for critiquing personalized choice architectures employed by self-tracking technologies. Self-tracking technologies are promoted and used as a means to self-improvement. Based on large aggregates of personal data and the data of other users, self-tracking technologies offer personalized feedback that nudges the user into behavioral change. The real-time personalization of choice architectures requires continuous surveillance and is a very powerful technology, recently coined as (...) “hypernudging.” While users celebrate the increased personalization of their coaching devices, “hypernudging” technologies raise concerns about manipulation. This paper addresses that intuition by claiming that decisional privacy is at stake. It thus counters the trend to solely focus on informational privacy when evaluating information and communication technologies. It proposes that decisional privacy and informational privacy are often part of a mutually reinforcing dynamic. Hypernudging is used as a key example to illustrate that the two dimensions should not be treated separately. Hypernudging self-tracking technologies compromise autonomy because they violate informational and decisional privacy. In order to effectively judge whether technologies that use hypernudges empower users, we need both privacy dimensions as conceptual tools. (shrink)

This paper consists of two parts. In the first part, I will introduce a philosophical toolbox that I call ‘conceptual scaffolding,’ which helps to reflect holistically on phenomena and concepts. I situate this framework within the landscape of conceptual analysis and conceptual engineering, exemplified by the debate about the concept of disease. Within the framework of conceptual scaffolding, I develop the main idea of the paper, which is ‘the binocular model of plural medicine’, a holistic framework for analyzing medical concepts (...) and phenomena. In the second part, I demonstrate the use and value of the binocular model by analyzing, through the lenses of the model, the phenomenon of health wearable devices and their effects on the concept of diagnosis. (shrink)