To begin the creation of the framework, I embark on a conceptual investigation of the concepts of ‘value’ and of ‘care’. By uncovering the values of ethical importance in a care context, the aim is to expose the moral precepts to operationalize in the design of a care robot.
According to the Oxford English Dictionary, values are conceived of as “the principles or standards of a person or society, the personal or societal judgment of what is valuable and important in life” (Simpson and Weiner 1989). Thus, a value is something desirable, something we want to have or to have happen. It follows then that when something is de-valued it loses importance. Values may be intrinsic or inherent to an object, activity or concept, or, things may be valued as a means to an end (Rosati 2009). For example, in the healthcare context, the concept of human dignity is valued on its own whereas the activity of touch in care contexts is valued as a means to preserving the dignity of persons (Gadow 1985). Things of valueFootnote 2 may be valued on a personal level or on a societal/cultural level. Values then may be more of a subjective enterprise (various things valued for an individual) or more of an objective enterprise (universal values such as justice, human dignity, fairness). The latter does not imply that values considered abstract and universal are interpreted in the same way between cultures or time periods but rather that the valuation of things may differ from an individual’s sphere to a more public one. Linked with the concept of ‘good’, a value may be construed as something that is good or brings about a good consequence.
In the VSD literature, Batya Friedman and colleagues, opt for a more open definition of a value to refer to “what a person or group of people consider important in life” (Friedman and Kahn 2003, p. 2). This implies then that all the values are not interpreted in the same way. Nathan et al. illustrate this with the value of privacy and its divergent ways of being interpreted between cultures and therefore protected (2008). Le Dantec et al. reinforce the idea that values may be universal, or generally accepted, but differ in their interpretation. Because of this, Le Dantec et al. suggest a way in which the methodology of VSD may be strengthened, through an uncovering of values in situ or discovering values through experiencing the practice (Le Dantec et al. 2009). This is of course due to the idea that differences exist between designers’ values and users’ values (Nathan et al. 2008). Thus, the scope of values varies depending on the technology, the users, the culture, the time period and the application domain. In the VSD methodology, Friedman selects the values of ethical importance pertaining to computer systems. Given that my framework is intended for use in the design of care robots, the values pertaining to the specific context are of greater ethical significance and relevance.
Defining Care, Care Ethics and Care Values
Care may be one of the most difficult concepts to articulate. This is in part due to the ubiquity of the word but is also largely a consequence of the fact that one is assumed to know what care means given its revered place in many cultures. The work of Warren T. Reich nicely outlines the broad range of meanings and connotations care has embodied going back as early as Ancient Greece (Reich 1995). Regardless, of how one perceives or defines care, care is valued as something above and beyond simple care giving tasks. It has a central role in the history of human kind as a means to signify the value of others. In other words, by caring you bestow value on the care-receiver.
In the verb “to care” one finds that caring may actually be divided into the idea of caring about and caring for. The dimension of caring about in the medical field implies a mental capacity or a subjective state of concern. On the other hand, caring for implies an activity for safeguarding the interests of the patient. In other words, it is a distinction between an attitude, feeling or state of mind versus the exercise of a skill with or without a particular attitude or feeling toward the object upon which this skill is exercised (Jecker et al. 2002). In the field of care ethics, Joan Tronto claims that good care is the result of both a caring attitude in combination with a caring activity (Tronto 1993). In other words, a marriage between the dimensions of caring about and caring for.
The field of care ethics is most often attributed to the Kohlberg-Gilligan debate on moral psychology (Gilligan 1982). Because of this debate, a new way of perceiving the moral dilemma in a given scenario arose; one that shifted the central focus from rights and universally applicable rules to a focus on responsibilities and relationships as central factors. Perhaps the most significant result that came from Gilligan’s work (along with the assistance of other scholars) is the understanding of care ethics as a perspective or orientation from which one begins to theorize rather than a pre-packaged ethical theory. In fact, care ethicists are not striving to arrive at some ready-made theory for application (as in traditional ethical theories) but rather point towards the necessary beliefs or elements that structure the care orientation. These beliefs refer to:
an emphasis of concern and discernment (to notice and worry more about the dangers of interference rather than the dangers of abandonment), habits and proclivities of interpretation (the proclivity to read the moral question presented by a situation in terms of responsibilities rather than rights), and selectivity of skills (to have developed an ease of abstraction more than an attunement to difference) (Little 1998, p. 195).
As Little articulates, “the orientations provide illuminating stances from which to develop ethics of these relationships, not that they constitute those ethics ready-made” (Little 1998, p. 206). This is precisely what my aim is when developing the framework for the ethical analysis and evaluation of care robots—to outline an orientation from which the ethical evaluation may begin by emphasizing certain fundamental components in care.
Aside from a conversation about the concept of care or the care ethics perspective, there is much to say about care values. Alternative to the idea that care in itself is a value—linked with the good life and with a valuation of another—is the idea that beneath the umbrella concept of care comes many other values. These values are given importance for their role in care—their role in giving significance to care, in making care what it is. These values form the buttress for care as an ethical endeavor and create a framework for evaluating care as a practice. It is through the manifestation of these values that one comes to understand what care really is in practice. It is therefore fruitful for the topic of embedding care values, to understand these values and their link with consequences. Thus, to begin from a top-down approach, I look to the values articulated by the governing body of healthcare, namely the World Health Organization (WHO). The WHO framework for people-centered health narrows in on the values in healthcare stemming from the patient’s perspective; patient safety, patient satisfaction, responsiveness to care, human dignity, physical wellbeing and psychological wellbeing (2007). This is not to say that other values like innovation or physician autonomy are not valued but rather from the patient’s perspective, the listed values are the ones with the greatest ethical importance and will thus be used in my evaluation of implementing robots in the care of persons.
Without an understanding of the specific context or the individual characteristics of a patient, these values don’t tell the engineer much concerning how the value may be embedded in a care robot prototype. Therefore, I take the suggestions of Le Dantec et al. to understand the specific interpretation of these values in context, achieved through fieldwork experience in both a hospital and a nursing home.Footnote 3 Interestingly, the interpretation of values as well as their ranking and meaning differed depending on: the type of care (i.e. social vs. physical care), the task (ex. bathing vs. lifting vs. socializing), the care-giver and their style, as well as the care-receiver and their specific needs. For example, in a ward with people suffering from dementia, safety is in terms of not letting patients wonder onto the streets, or preventing patients from hurting both themselves and others. In a ‘typical’ ward of a nursing home, safety is in terms of preventing patients from falling, or assisting in the feeding of patients to prevent chocking. How a value is prioritized is also dependent on the context, personal experiences but also the specific practice. For example, through the practice of lifting, the value of safety is manifest (or interpreted) by ensuring the care-receiver does not fall or is not injured. Here, safety is of paramount importance. In contrast, through the practice of bathing, the value of safety is interpreted in terms of suitable water temperature (not burning or scarring the patient), and proper positioning on the bed or tub to prevent injury. In the practice of bathing, however, while safety is of the utmost importance, other values take precedence. For example, closing the curtain to ensure privacy, verbal communication to calm the care-receiver, and gentle strokes to convey empathy and respect through the practice. These examples make us aware of both the intertwining of care values and the actions of care-givers but also the significance of the therapeutic relationship—all of the values central to the healthcare tradition are observable within the relationship, the actions and interactions between the nurse and the patient.
When wondering about the relationship between technologies and care values, the value of touch helps to shed light. Touch is an important action in care that is valued on its own as well as a means for manifesting other values like respect, trust and intimacy. Touch is the symbol of vulnerability, which invokes bonds and subjectivity (Gadow 1985). Touch acts to mitigate the temptation for objectification. Thus, touch is considered an instrumental value in the healthcare domain, the outcome of which results in the preservation of the value of human dignity. Using the value of touch as an example, we can see how a certain technology might impede its manifestation. Melanie Wilson illustrated how a particular computer system implemented in the field of nursing was rejected as it prevented nurses from “hands on care”—from touch—a cornerstone of the nursing tradition (Wilson 2002). One might suggest that designers of this technology were not aware of the significance of ‘hands-on’ care for nurses even when the nurse’s role is to create a daily care plan.
In short, not only is care a value for what it symbolizes (a valuation of another) and manifests (meeting the needs of another) but it is also valued for the additional elements that make up care; patient safety, patient satisfaction, responsiveness to care, human dignity, physical wellbeing and psychological wellbeing. The list of care values is exhaustive when one considers the significance of the therapeutic relationship and the elements within this conclave (trust, respect, compassion, empathy and touch); however, what is hopefully now evident is the significance of the care relationship in terms of the intertwining of care actions with care values. Meaning, the expression of care values are the result of the actions and interactions between actors. To explain this further, I turn to the concept of a care practice.
To elaborate on the marriage between caring about and caring for, a useful concept is that of a care practice. A care practice is, as care ethicist Joan Tronto describes it, a way to envision a care task or a series of care tasks. A way in which one can grasp the fortitude of each action and interaction between a care-giver and a care-receiver. More importantly, it is a way to envision the holistic nature of care.
The notion of a care practice is complex; it is an alternative to conceiving of care as a principle or as an emotion. To call care a practice implies that it involves both thought and action, that thought and action are interrelated, and that they are directed toward some end (Tronto 1993, p. 108).
Understanding that care tasks are more than just ‘tasks’ but are rich practices in a value-laden milieu that act to bring about the promotion of values, may be one of the most crucial points for designers to grasp. The reason for this has to do with understanding how values are manifest and thus how a design will impact this materialization. To exemplify this shift from task to practice, let me use the practice of lifting. When a patient is lifted by the care-giver, it is a moment in which the patient is at one of their most vulnerable. The patient trusts the care-giver and through this action a bond is formed and/or strengthened which reinforces the relationship between care-giver and the care-receiver. The significance of this is apparent in the actual practice of lifting but comes into play later on in the care process as well. Meaning trust, bonds, and the relationship, are integral components for ensuring that the care-receiver will comply with their treatment plan, will take their medication and be honest about their symptoms. Without trust, these needs of the care-giver are threatened, ultimately threatening the entire care process and the good care of the care-receiver. Thus, conceptualizing care tasks as practices adds a deeper meaning to each ‘task’. It is within a care practice that the values are manifest and given their significance but it is also within practices that the holistic vision of care takes form—each care practice builds from, and on to, another practice linking all practices in the overall care process.
Selecting the Values of Ethical Importance in Care
While many care ethicists make clear the range of values and principles that provide a normative account for care (Vanlaere and Gastmans 2011; Little 1998; Ruddick 1995; Noddings 1984) they fall short of providing a systematic way to visualize and evaluate these principles and values. The vision presented by Joan Tronto allows for a perception of care as a process with stages and corresponding normative moral elements, which provides the most enticing conceptualization for engineers to work with. There are four phases of a care practice for Tronto; caring about (recognizing one is in need and what those needs are), care taking (taking responsibility for the meeting of said needs), care giving (fulfilling an action to meet the needs of an individual), care receiving (recognition of a change in function of the individual in need). These phases have corresponding moral elements as standards to evaluate the care practice from a moral standpoint. These elements are: attentiveness, responsibility, competence, and responsiveness. Attentiveness refers to an attribute or virtue of the care-giver, a certain competence for recognizing needs. Responsibility refers again to an element of the care-giver and their stance or concern for ensuring the care-receiver is pointed in the right direction for care or maintaining an accurate assessment of needs etc. Responsibility is often delegated to a moral agent; however, some responsibilities are delegated to an artifact as technologies are wide spread in healthcare. Here, the concept of mediation (Verbeek 2006) becomes critical in the sense that decision making on the part of nurses and patients is a hybrid affair between the nurse/patient and existing technologies. Competence is once again an attribute of the care-giver and refers to the skills with which the care is given. An unskilled care-giver may be more detrimental than no care at all. Responsiveness refers to an attribute of the care-receiver and their role in the relationship—to guide the care-giver. This element (and the phase of care receiving) is important for remembering the reasons for care in the first place: the care-receiver and their needs. Without this, care is not complete. This recognition also encourages an active stance of the care-receiver rather than a more passive, vulnerable one.
Creating a standardized framework to guide the promotion of these values which applies to any care context, task, care-receiver or care-giver reveals itself to be quite problematic given the range and variety of care values discussed in the former section. In other words, to claim that human dignity, compassion or respect for power are values to be embedded in a care robot offers nothing for the designer in terms of the robot’s capabilities. Moreover, as we have seen, their ranking and prioritization is dependent on the context (i.e. one hospital domain or another vs. a nursing home) and task (ex. lifting vs. bathing). To standardize the creation of care robots there needs to be another avenue besides values alone. In the care ethics literature, alongside values, need too play a central and crucial role in the provision of good care. The needs of the patient mark the starting point of the care process and the process then revolves around a care-giver (or multiple care-givers) taking steps to meet these needs. Understanding the multiple layers of needs, the many ways in which they might be fulfilled, the preferences for one way over another, and the divergent needs between individuals, adds a further complexity to the meeting of needs. If this wasn’t complicated enough, the care-giver has needs too! Needs in terms of resources, skills, responsiveness from the care-receiver to understand when needs have been met as well as their own personal needs.
Given the central role of needs in a care context, what might the relationship be between needs and values? Although many authors have written on the subject, little consensus can be found. I suggest that the values in healthcare are given their importance for their role in meeting needs. This corresponds with Super’s conceptualization of the relationship between needs and values: “values are objectives that one seeks to attain to satisfy a need” (1973, pp. 189–190). Meaning, the value is the goal one strives towards and in so doing, intentionally meets a need. Thus, we begin with needs, and the values represent the abstract ideals which, when manifest, account for the needs of individuals. It follows then that a framework for designing care robots ought to address the meeting of needs. But not so fast, we’ve just shown how multifaceted and intricate needs are for the care-giver and care-receiver. What’s more, according to the field of care ethics, it is neither possible nor advisable to outline a series of needs which pertain to all care-givers, care-receivers or care tasks in every instance/scenario (Tronto 2010). While useful for policy or a universal ethical code, it goes against the vital element in care—that of the individual and their unique, dynamic needs. In other words, care is only thought of as good care when it is personalized (Tronto 1993). There is, however, a solution to this barrier. It is possible to delineate a set of needs for every care practice. To recapitulate, together the phases and the moral elements make up a care practice. The practices are values working together and the vehicle for this is the moral elements. If we assume a care practice ought to proceed according to Tronto’s phases than the needs for every care practice are the corresponding moral elements. It is therefore these elements that ensure the promotion of care values. Consequently, it is these elements—attentiveness, responsibility, competence, responsiveness—that make up the normative portion of the framework.
With this suggestion, there are two assumptions being made; that every care practice will always have the moral elements as needs, independent of the care-giver and care-receiver, and that the values are subsumed within the moral elements. Using the practice of feeding as an example to illustrate the first assumption, I am making the claim that this practice will always require attentiveness, responsibility and competence on the part of the care-giver and will always require a reciprocal interaction between care-receiver and care-giver for determining whether or not the needs have been met, no matter who the care-giver is or who the care-receiver is. In other words, these moral elements are independent of the actors. They are, however, dependent on the context and the specific practice for their interpretation and prioritization. If we were to compare the practice of lifting with the practice of feeding we would see how the element of competence is uniquely interpreted in each practice (skillfully bearing the weight of another without dropping or causing pain vs. skillfully coordinating timing and placement of food and utensils). In terms of context, the practice of lifting in the hospital requires greater efficiency than the practice of lifting in a home setting where time may not be as much of an issue. Thus, although the moral elements must always be present, the context and practice still play a crucial role in their interpretation, prioritization and manner of manifestation.
For the second assumption—that the values are subsumed within the moral elements—one may find that the values are often analogous to a phase or moral element or are expressed through the manner in which an action takes place. The value of patient safety is fulfilled through the competent completion of a practice (the phase being care giving and the moral element being competence). The valued action of touch requires attentiveness on the part of the care-giver for determining when and to what degree touch is considered necessary. The manner in which care practices take place is often tailored to the specific likes of one care-giver or another and again requires attentiveness to those preferences and competence in meeting them. What’s more, paying attention to those unique preferences is a vehicle for establishing trust and allowing for successful reciprocal interaction.
In short, ensuring that the elements are present or strengthened through the design and introduction of a care robot, ultimately results in a manifestation of the core care values. Differences in the prioritization and manifestation of moral elements between practices and/or contexts is something that the care ethicist may draw the attention of the designer to while utilizing the framework throughout the design process. Nevertheless, the designer must first be aware of the necessary elements and their manner of manifestation.