In several industrialized countries, healthcare and social services are challenged by the growing and aging population. An increased number of older adults leads to an increased need of help and support in daily life. A shortage of younger people who can care for the aging population, especially in remote areas, necessitates better and more effective health care systems and technologies. eHealth can be a complement to traditional health and social services. For a sustainable and long-term plan for the person in need of support, it is important to reason about values affected when implementing and using eHealth as support at home. Implementation should, therefore, always be done based on the individual’s needs. This chapter focuses on ethical aspects when implementing eHealth solutions as support for older adults at home.
Key Terms: eHealth, older adults, ethics
The future increase in the population of people over 80 years leads to increased need of help and support in daily life (Rechel et al., 2013). Simultaneously, urbanization leads to increased number of working age people in cities and a decreased number of those individuals in remote areas (Eurostat, 2016). This future demographic prediction necessitates better and more effective health care systems and technologies, in order to meet older adults’ needs and enable them to age-in-place, particularly in rural areas. eHealth gives possibilities and can be a complement to traditional health and social services. There is not one single definition of eHealth but according to World Health Organization (WHO, 2018), eHealth is the use of information and communication technologies (ICT) for health. This can include ICT tools and applications, such as video/tele technology, robots, alarms and security systems, surveillance, etc. all with the common aim to support older adults to live at home as long as possible. The concepts of assistive or welfare technology are also commonly used (cf. Michel & Franco, 2014). In order to achieve the best outcome, such eHealth services have to be developed through active work in collaboration with different actors (Kernisan, 2016). An awareness of not being the single solution to people’s feelings of security at home is also an important consideration, as are feelings of being healthy and having someone to rely on (Petersson et al., 2012). The process of development and implementation of eHealth should therefore include thoughtful reasoning regarding values and ethical aspects of such services. This paper focuses on potential ethical aspects of implementing eHealth solutions as support for older adults at home.
A systematic literature review was conducted to identify relevant literature (cf. Smith et al., 2011). Suitable search terms were identified through a pilot search in several databases, which resulted in search terms e-Health, technique, ethics, and older adults. Studies published between 2003 and 2016 were included and after limitation to reviews, fourteen studies from international journals were included in the analysis.
The results reveal several ethical aspects of importance when developing and implementing eHealth solutions to support older adults at home. First, dignity has to be respected which means the person’s right to their own life and integrity, autonomy, and informed consent. In order to promote dignity, aspects such as independence, participation, security and safety, beneficence, equity, and justice have to be taken into consideration.
Second, access to different eHealth solutions is an important potential ethical issue, independent of where you live, your economic situation, or your knowledge. Everyone should have access to the service if it can cater to his or her needs (Magnuson & Hanson, 2003; McLean, 2011).
A third important aspect to take into consideration is contextual and cultural differences in experiences with using technology (Hofman, 2013; Korhonen et al., 2015). This means that questions about for whom and for what purpose the solutions are developed are important, as well as the importance of asking older adults what they want (cf. Hofmann, 2013; Lauriks et al., 2007; Magnuson & Hanson, 2003; McLean, 2011).
Fourth, values, such as autonomy and independence, are important in relation to support from technology at home and eHealth solutions can promote the sense of independence, but technological solutions may also inadvertently promote the opposite (Dahler et al., 2016). If the focus is on activity, there is a risk of exclusion of people with disabilities as for example frail older adults. Instead, promoting independence and autonomy should be based on the older adults’ own free will to choose what, how, when and with whom they want to do whatever they want, including support from eHealth solutions. This perspective increases the older adults’ empowerment and can facilitate the will to use technology at home (cf. McLean, 2011; Novitsky et al., 2015; Swijsen, et al., 2011). A wish to stay at home as long as possible has shown to increase the acceptance for eHealth solutions. Cultural values and differences can, however, affect this (Peek et al., 2014), which is why it is important to evaluate what independence means for each person (McLean, 2011).
eHealth solutions can decrease the burden on family members, but it can also increase the dependence on the technology (Dahler et al., 2016; Hofman, 2013; Korhonen et al., 2015). From a participatory perspective, older adults should be a part of the development of eHealth solutions (Bjering et al., 2014; Novitsky et al., 2015; Piau et al., 2014; Swijsen et al., 2011; Topo, 2009). Although this can sometimes be problematic, the older adult should be a part of the implementation process (cf. Dahler et al., 2016), as well as their family members, as their opinions have great importance in the acceptance (or rejection) of the technology (Dahler et al., 2016; Novitsky et al., 2015; Peek et al., 2014; Piau et al., 2014).
Finally, Fischer et al. (2014) showed that if the technology is beneficial for the older adults’ feeling of security and safety, they may be willing to forgo their privacy. According to Swijsen et al. (2011), the fear of violence on one’s privacy and integrity was small, as long as there was a balance between the need of surveillance and preserving the integrity of their autonomy. However, it is important to ensure confidentiality regarding information of the older adults and storage of data (Hofmann, 2013; Magnuson & Hanson, 2003). To be able to control the technology by themselves might protect the older adults from intrusion (Mordini et al., 2009), but it could be a problem for those elders with cognitive disabilities (Novitsky et al., 2015).
During the planning, implementation and post-implementation stages of utilizing eHealth, it is important to bear in mind the ethical aspects related to eHealth solutions for support at home for older adults. This is irrespective where the older adult lives, even though organizational and infrastructural conditions affect peoples’ equal possibilities to be part of different eHealth solutions. Furthermore, older adults are not a homogenous group, but have different needs based on living, cultural and socioeconomic conditions, as well as level of frailty. eHealth solutions should be used as a complement to health- and social services, but cannot alone support independence, activity, and social interaction. Hence, eHealth cannot completely replace the physical contact with healthcare personnel and other caregivers. In addition, one has to keep in mind that not only individual disabilities may be limiting, but also factors in the environment where older adults live, such as lack of proper infrastructure, may be challenges as well. According to WHO (2016), a lack of funding has been shown to be the biggest barrier for eHealth solutions, as the cost for the society can increase in the initial face of the implementation. In order to be equally available for everyone, development of the solutions is important, as well as of equipment and connectivity. Schrader et al. (2016) showed that low levels of ICT literacy is a barrier for engagement in eHealth as support in daily life for people in remote areas. For a successful implementation of eHealth solutions, the primary focus should be on changing working methods for the healthcare personnel and the need to involve the user (i.e. older adult), instead of focusing solely on the technological solutions.
RemoAge website: http://remoage.eu/
Lecturers to listen: https://www.youtube.com/results?search_query=remoage
Lecturers of the concept of Aging-in-place: https://www.youtube.com/results?search_query=aging+in+place
Casey, M., P. S., Heaney, D., L., ÓLaighin, G., Matero, M., S., U., Alrutz, K., Eadie, F., &
Glynn, L. G. (2013). Implementing transnational telemedicine solutions: A connected health project in rural and remote areas of six Northern Periphery countries. European Journal of General Practice, 19, 52–58.
Bjering, H., Curry, J., Maeder, A. (2014). Gerontechnology: The importance of user participation in ICT development for older adults. Investing in E-Health: People, Knowledge and Technology for a Healthy Future.
Dahler, A.M., Rasmussen, D.M., & Andersen, P.T. (2016). Meanings and experiences of assistive technologies in everyday lives of older citizens: a meta-interpretive review. Disability and Rehabilitation.
Eurostat. (2016). Urban Europe. Statistics on cities, towns and suburbs. European Untion.
Fischer, S.H., David, D., Crotty, B.H., Dierks, M., & Safran, C. (2014). Acceptance and use of health information technology by community-dwelling elders. International Journal of Medical Informatics, 83, 624-635.
Hofmann, B. (2013). Ethical challenges with welfare technology: A review of the literature. Science and Engineering Ethics, 19, 389-406.
Kernisan, L. (2016). Promises and pitfalls: Technology and the future of delivering eldercare. Journal of the American Society on Aging, 40.
Korhonen, E-S., Nordman, T., & Eriksson, K. (2015). Technology and its ethics in nursing and caring journals: An intergrative review. Nursing Ethics, 22, 561-576.’
Lauriks, S., Reinersmann, A., Van der Roest, H.G., Meiland, F.J.M., Davies, R.J., Meolaert, F., Mulvenna, M.D., Nugent, C.D., & Dröes, R.M. (2007). Reviewof ICT-based services for identified unmet needs in people with dementia. Ageing Research Reviews, 6, 223-246.
Magnusson, L., & Hanson, E.J. (2003). Ethical issues arising from a research, technology and developement project to support frail older people and their family carers at home. Health and Social Care in the Community, 11, 431-439.
McLean, A. (2011). Ethical frontiers of ICT and older users: cultural, pragmatic and ethical issues. Ethics & Information Technology, 13, 313-326.
Michel, J-P., & Franco, A. (2014). Geriatricians and technology, JAMDA, 15, 860-862.
Mordini, E., Wright, D., Wadhwa, K., De Hert, P., Mantovani, E., Thestrup, J., Van Steendam, G., D’Amico, A., & Vater, I. (2009). Senior citizens and the ethics of e-inclusion. Ethics & Information Technology, 11, 203-220.
Novitzky, P., Smeaton, A.F., Chen, C., Irving, K., Jacquemard, T., O’Brolcháin, F., O’Mathúna, D., & Gordijn, B. (2015). A review of contemporary work on ethics of ambient assisted living technologies for people with dementia. Science Engineering Ethics, 21, 707-765.
Piau, A., Campo, E., Rumeau, P., Vellas, B., & Nourhashemi, F. (2014). Aging society and gerontechnology: A solution for an independent living. The Journal of Nutrition, Health & Aging, 18, 97-112.
Peek, S.T.M., Wouters, E.J.M., van Hoof, J., Luijkx, K.G., Boeije, H.R., & Vrihoefj, H.J.M. (2014). Factors influencing acceptance of technology for aging in place: A systematic review. International Journal of Medical Informatics, 83, 235-248.
Petersson, I., Lilja, M., & Borell, M. (2012). To feel safe in everyday life at home – a study of older adults after home modification. Ageing and Society, 32, 791-811. Doi: 10.1017/S0144686X11000614
Rechel, B., Grundy, E., Robine, J.M., Cylus, J., Mackenbach, J.P., Knai, C., & McKee, M. (2013). Ageing in the European Union. The Lancet, 381(9874), 1312-1322.
Schrader, G., Bidargaddi, N., Harris, M., Newman, L., Lynn, S., Peterson, L., & Battersby, M. (2014). An eHealth Intervention for Patients in Rural Areas: Preliminary Findings From a Pilot Feasibility Study. JMIR Research Protocols, 3(2):e27. Doi: 10.2196/resprot.2861.
Smith, V., Devane, D., Begley, C.M., & Clarke, M. (2011). Methodology in conducting a systematic review of systematic reviews of healthcare interventions. BMC Medical Research Methodology, 11:15.
Topo, P. (2009). Technology studies to meet the needs of people with dementia and their caregivers. A literature review. Journal of Applied Gerontology, 28, 5-37.
World Health Organization. eHealth at WHO. [Online]. 2018. Available from: http://www.who.int/ehealth/about/en/.
World Health Organization. Global diffusion of eHealth: Making universal health coverage achievable [Online]. 2016. Available from: http://apps.who.int/iris/bitstream/handle/10665/252529/9789241511780-eng.pdf;jsessionid=E98EB393DA64D61E0C2B4A42688C5F7C?sequence=1.
Zwijsen, S.A., Niemeijer, A.R., & Hertogh, C.M.P.M. (2011). Ethics of using assistive technology in the care for community-dwelling elderly people: An overview of the literature. Aging & Mental Health, 15, 419-427.