A more sceptical assessment of the potential for wearable technologies to support their users autonomy over health is provided by a broader notion of autonomy, referred to as a substantive–relational account (Mackenzie 2008; Owens and Cribb 2013). From this broader view, a focus on processes of cognitive deliberation appears to be relatively narrow in scope: procedural accounts only tell us part of the story about what autonomy is, why it is important and how it can and should be promoted. While they may provide important details about how people have arrived at a particular decision, procedural accounts tell us little about what people can actually do to enact that decision. We have argued elsewhere that it is important to understand autonomy in terms of the opportunities people have for free and meaningful action (Owens and Cribb 2013). Indeed, it is people’s capacity to act and achieve the goals they have decided upon that is often considered morally and politically salient about autonomy, and we noted above that it is a promise of supporting action towards health and fitness goals that provides a major selling point of these devices.
The substantive–relational account of autonomy we have in mind has been derived from scholarship in feminist ethics, notably writings about relational autonomy (Mackenzie 2008; Mackenzie and Stoljar 2000). These relational accounts were partly developed out of a concern to facilitate ‘real-world’ understanding of the practices of autonomous decision-making by paying close attention to the ways in which a person’s circumstances may influence their deliberative processes. In particular, relational accounts of autonomy pay attention to the ways in which a person’s deliberative processes will be subject to the myriad influences of socialisation. While there is no definitive account of relational autonomy—i.e. it is a label that permits a variety of interpretations—its proponents have stressed the need to recognise the social embeddedness of persons and the causal role that structural circumstances have on people’s capacity to engage in processes of autonomous deliberation (Westlund 2009). It is possible to refer to a spectrum of positions derived from the literature on relational autonomy. For instance, so-called procedural–relational accounts of autonomy acknowledge the importance of socialisation on decision-making but retain the view that autonomy is essentially a cognitive process bound up with deliberation, albeit one that must be made answerable to ‘public reasoning’ (Ben-Ishai 2012; Benson 2000). For the purposes of our argument, we set such intermediate positions aside and concentrate on those perspectives that depart more radically from procedural accounts of autonomy.
Substantive–relational accounts of autonomy broaden the notion of autonomy beyond processes of cognitive deliberation to include the possibilities for autonomous action (Mackenzie 2008; Oshana 2006). Such accounts consider a narrow focus on procedures of autonomous deliberation as a necessary but insufficient condition for any account of autonomy that can usefully be applied to evaluate real-life situations, behaviours and practices. Accordingly, substantive–relational accounts extend the concept of autonomy beyond the cognitive domain and into the realm of material and social structures and relationships. They suggest that attention to the impact that a person’s structural circumstances should not end with consideration of their capacity for autonomous deliberation, rather it should also include the substantive opportunities they have to enact the decisions they have made and actually achieve their intended goals.
It is important to note that shifting attention from autonomous deliberation to autonomous action involves altering the conceptual focus of the idea of autonomy, from deciding to acting. This is significant because acting appears to be a far more complicated activity than deciding: action involves engaging with the myriad types of antecedent material and social structures that shape the potential actions available to a person, as well as considering how the consequences of these actions will affect their future opportunities. For example, while procedural accounts may consider a person who weighs up the information from their wearable device and then freely decides to take up a new diet or exercise regime to be autonomous on the basis that they have engaged in independent cognitive processes of deliberation, a substantive–relational account would ask additional questions about whether they are in a position to successfully enact their decision. For example, if the person lacks the money, time, space and/or confidence required to cook healthier food or go to the gym regularly, the substantive–relational account could conclude that the person lacked the capacity for autonomous action.
Substantive–relational accounts of autonomy therefore suggest we must pay attention to more than just the cognitive processes by which decisions are made: we must consider the conditions, contents and consequences of a person’s decisions, the circumstances in which these decisions are made and the implications these decisions have for their intended actions. A person’s capacity for autonomous action is therefore shaped by the variety, quality and quantity of opportunities that their material and social environment makes available to them, as well as by the extent to which they are willing and able to exploit these opportunities. On this basis, promoting a person’s substantive–relational autonomy involves providing them with supportive circumstances and relationships that confer on them genuine opportunities to enact their decisions.
This shift to a substantive–relational view of autonomy is significant for our consideration of health promoting wearable technologies because there are good reasons to be sceptical about any claims that providers of these technologies make about them offering people genuine opportunities to meet the health and fitness goals they set for themselves. Health promoting wearable technologies may enable people to improve their health by supplying information and encouragement, but they do little to change a person’s capacity to act in the world and to positively enhance their opportunities for achieving better health. Given that people’s opportunities to achieve better health in practice are always mediated by their wider material and social circumstances, then those people who are relatively well-positioned may already enjoy circumstances that enable them to act on the information or prompt provided by their device (e.g. if they are wealthy, confident, have positive and supportive familial and clinical relationships, have access to required goods, commodities and facilities, etc.). However, for those people in less-advantageous social positions (particularly those affected by oppressive conditions linked to isolation, exclusion, poverty, deprivation or discrimination), simply being informed or encouraged that a particular form of action will help them to meet their health and fitness goals may not make much, if any, difference.
Providing people with genuine opportunities to act on the information and encouragement provided by their devices (and to exercise autonomous action over their health) will often require attending to the adverse material and social circumstances that constrain their potential actions. This argument is borne out by the extensive literature that provides evidence of the causal role that material, economic and social factors have in creating patterns of health inequalities across society (Dorling 2013; Marmot 2010, 2015; Marmot and Wilkinson 2005; Pickett and Wilkinson 2015). These social epidemiological studies clearly demonstrate that the social determinants of health—the conditions in which people are born, grow, live, work and age, and the ways in which these conditions are affected by the relative distribution of money, resources, power, recognition and status—create patterns of unequal health across society. As Marmot explains, ‘the lower a person’s social position, the worse his or her health’ (2010: p. 9). Personal autonomy over health, understood in substantive–relational terms as the genuine opportunities or capabilities people have to act to sustain and/or improve their health, is substantially shaped by these social determinants (Abel and Frohlich 2010; Owens and Cribb 2013; Prah Ruger 2010; Sen 1992;).
Wearable technologies are, of course, narrowly concerned with measuring, analysing and displaying the biomedical data of their users, and not with the wider structural contexts that shape their health and fitness. As Lupton explains,
‘many digitized health promotion strategies focus on individual responsibility for health and fail to recognise the social, cultural and political dimensions of digital technology use’. (2014: p. 1)
Without engaging with the broader structural conditions that cause patterns of unequal health status, there seems to be little reason to expect that health promoting wearable technologies will do anything other than reproduce, reinforce or even widen entrenched patterns of health inequalities. Moreover, this recognition that opportunities for autonomous action over health are socially mediated is important for understanding associated concerns that health promoting wearable technologies may generate forms of anxiety for their users, particularly if they find themselves unable to act to in line with the information or advice provided. For relatively advantaged people who may only lack the will power or motivation to improve their health, a wearable device may provide the positive and supporting presence they need. But for people living in adverse material and social circumstances, the presence of a device that informs them that they have a potential health risk or fitness problem that they are unable to fix may be a significant cause of concern and frustration. For these people, an inability to act in accordance with the information and prompts provided and to achieve their health and fitness goals may lead to the development of anxiety, stigma and a form of self-victim blaming (Crawford 1977). By providing a constant stream of information about alarming biomedical data, unhealthy habits and the seemingly unobtainable targets they are failing to meet, such technologies may erode their users’ (perhaps fragile) sense of control over their health, not to mention their feelings of self-esteem and well-being.
The doubts we have rehearsed here resonate with some published professional concerns and empirical literature. As Spence, a GP from Glasgow, suggests,
‘We must reflect on what we might lose here, rather than what we might gain. Will apps simply empower patients to overdiagnosis and anxiety?’ (Husain and Spence 2015: p. 2)
A further concern relates to studies which have indicated that there is a lack of evidence demonstrating that wearable technologies actually do enable people to improve their health in practice. For example, following randomised control trials conducted with young adults seeking to reduce obesity, Jakicic and colleagues claimed that ‘devices that monitor and provide feedback on physical activity may not offer an advantage over standard behavioral weight loss approaches’ (2016: p 1161). Similarly, Spence has questioned the efficacy of wearable devices to deliver improvements in health. He describes apps and devices as ‘untested’, ‘unscientific’ and ‘likely useless’ (Husain and Spence 2015: p. 2). Moreover, he raises concerns that promises that these devices will enable their users to achieve better health may end up being an illusion:
‘death and disease is a lottery outside our control. So when the “undeserving” sick get sick, they feel cheated. These new technologies will serve only to fuel this anger and resentment further’. (Husain and Spence 2015: pp. 2–3)
It may be suggested that highlighting health promoting wearable technologies’ limits when it comes to supporting autonomous action is unnecessary: Is it not just unreasonable to expect wearable technologies to be able to make the deep structural changes required for gains in substantive–relational autonomy? Perhaps so, however, we would argue it is important to highlight these limits because, as we have seen, the rhetoric that presents wearable technologies characterises them as devices that will support autonomous action by enabling their users to do more, to be more and to actually achieve their health and fitness goals. It is precisely the distinction between procedural and substantive–relational autonomy that helps to critically unpick this rhetoric.