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Asian Bioethics Review

, Volume 10, Issue 2, pp 143–155 | Cite as

Ethical Perspectives of Japanese Engineers on Ambient Assisted Living Technologies: Semi-structured Interview

  • Jungen Koimizu
  • Minori Kokado
  • Kazuto Kato
Original Paper

Abstract

Ambient assisted living (AAL) technologies are expected to solve a significant number of problems related to elderly care. However, in Japan, limited discourse on the ethical issues concerning their application is hindering the spread of AAL technologies. Against this background, this study explores the ethical perspectives of AAL technology engineers in Japanese companies and the circumstances influencing their perspectives. A qualitative study using semi-structured interviews was conducted. Nineteen Japanese AAL-technology companies were contacted, and nine of them and their engineers responded to the interviews. The contents of the interviews were analyzed with thematic analysis which showed that the engineers had ethical concerns about their products as follows: (1) safety and related conflicts, (2) acceptance of the technology, (3) dependence on the technology, (4) accident liability, (5) fair access to the technologies, and (6) privacy. In relation to these issues, they identified as company employees with regard to the following: responding to social needs, having many users, and cost reduction. They also mentioned being influenced by the Japanese national program for AAL-technology promotion. The engineers experienced dilemmas between the various stakeholders’ interests and they hoped that ethical guidelines for developing AAL technologies would resolve such dilemmas. In conclusion, Japanese AAL-technology engineers tackle ethical issues with regard to the application of their products. The engineers hope for the establishment of guidelines for the ethically responsible development of AAL technologies. The guidelines need to be established and implemented in an interactive manner, in order to avoid their being reduced to a bureaucratic formality.

Keywords

Ambient assisted living technology Robot ethics Ethics in elderly care Engineering ethics 

Introduction

As population aging advances, innovative technologies for elderly care practice are currently the focus of international attention. Ambient assisted living technologies (AAL technologies) are innovative technologies which allow the care-recipient to live in their preferred environment maintaining their health (Novitzky et al. 2015). AAL technologies are expected to help meet the demand for elderly care work which will continue to increase in the coming decades. However, ethical issues which arise with the broader use of AAL technologies need to be considered (Ienca et al. 2017). Previous literature has discussed various ethical issues regarding AAL technologies for the elderly, including privacy, cost, safety, independence, autonomy, user involvement, and acceptance (Ienca et al. 2017; Novitzky et al. 2015).

According to the literature review by Novitzky et al. (2015), different stakeholders contribute to the ethical goals and issues in relation to the development and spread of AAL technologies. Such stakeholders can be classified as cared-for individuals with dementia, caregivers, researchers, engineers, designers, and technicians. With such a variety of stakeholders involved, it may come as no surprise to find that some of the ethical goals in relation to AAL technologies conflict with one another (Hofmann 2013). Indeed, among the stakeholders, both the person being cared-for and the caregiver are positioned as users of the AAL technologies from which they both benefit. However, they might have different perspectives from each other on the ethical goals surrounding the use of AAL technologies (van Kemenade et al. 2015; Sponselee et al. 2008; Zajicek 2001).

An important group of stakeholders involved are the technology developers, such as researchers, engineers, and designers. These stakeholders shape the ethical goals through the design of AAL technologies and thereby also contribute to ethical problems that may arise (Ienca et al. 2017; Friedman et al. 2002). Therefore, investigation into the ethical goals of the AAL technology developers and the ethical issues considered by them could contribute to our understanding of the ethical implications of these technologies.

In Japan, the attitude towards the use of AAL technologies is positive: 60% of the public and 80% of care professionals have expressed approval (The Cabinet of Japan 2013; Nursing Plaza 2014). Nevertheless, Japanese people, especially care professionals, have also expressed concern about the ethical issues related to the use of AAL technologies. Such issues include safety, reduction of human contact, erosion of autonomy, and dependence on robots (Nursing Plaza 2014; PESTI 2015), and they are shared with the international community (Novitzky et al. 2015; Ienca et al. 2017). In contrast to the amount of research conducted with the public and with care professionals, it has been noted that Japanese engineers have not had much opportunity to deliberate on these ethical issues and are often perplexed by them (Yamauchi 2011, 2013).

Policies have been made to address some of the issues. For instance, the Japanese national project (RDNCP: Robotic Devices for Nursing Care Project 2013), which started in 2013, has attempted to promote development of AAL technologies in a way that avoids risks in safety and independence of the elderly (Okawa and Yamada 2013). When technologies are being developed, this project provides the AAL technology developers with monetary support for developing the technologies and also evaluates the safety and efficacy of their products. The RDNCP also assesses any unfavorable influence of the technologies on the elderly, such as reduction of human contact and dependence on the technologies, but the focus seems to have been on the issues of efficacy, non-maleficence, and safety (Okawa and Yamada 2013). The project required the engineers to correct their products in order to avoid such influences, particularly problems in safety.

Under such circumstances, it is worth considering what Japanese engineers think about the ethical goals and issues in relation to AAL technologies. Additionally, this study aims to explore possible measures for increasing the ethically responsible use of AAL technologies. In this article, a descriptive approach is employed to survey the ethical perspectives of Japanese engineers as significant stakeholders in the development of AAL technologies for elderly care. This study also describes how the ethical perspectives of some engineers are shaped by their being employees of companies which aim to profit from the spread of AAL technologies.

Methods

In order to acquire detailed engineers’ perspectives on ethical issues concerning AAL technologies, and to understand the experiences which influenced their perspectives, a qualitative research approach using semi-structured interviews was employed.

Recruitment

Contact with the engineers was mediated through their respective employers. The candidate companies willing to support this study were requested to recommend suitable employees as interviewees. The selection criteria of candidate companies were based on the requirements that they had to (1) be participants of the Japanese national project for AAL-technology development (RDNCP), (2) have already released AAL-technology products for sale, and (3) have published information about their products on their websites as of April 2016. Here, engineers who had finished developing AAL technology with RDNCP were selected so that it was possible to explore how the engineers felt about the ethical issues raised by other stakeholders throughout the whole development process.

Nineteen Japanese companies that fulfilled the criteria were contacted, and nine of them agreed to participate in the study. The characteristics of products developed by the companies which participated in the survey were five mobility assistance products, two automated toilets, one mobility actuation technology for rehabilitation, and one companion robot for conversation. These companies recommended their employees who could be invited to participate in the study. These employees were then contacted by email, and informed consent was obtained from those who were willing to participate in the study as interviewees. The interviewees were between 28 and 55 years old, and were composed of eight males and one female. Please refer to the Table 1 (below) on the profile of the interviewees. The survey was conducted in Japan, from September 2016 to February 2017.
Table 1

The ethical issues in relation to AAL technologies mentioned by the interviewees

Function of the product

Movement actuation

Conversation partner

Interviewee

A

B

C

D

E

F

G

H

I

Issues mentioned

 Conflicts over appropriate safety levels

+

+

+

+

+

+

+

+

+

 Acceptance of the technology

+

+

+

+

+

+

+

+

+

 Dependence on the technology

+

+

+

+

+

 Legal liability for accidents

+

+

+

 Fair access to the technologies

+

 Privacy

+

+ indicates the topics mentioned by the interviewee; − indicates the topics not mentioned by the interviewee

Data Collection

Background Survey

Before the interview, interviewees were requested, by email, to answer a questionnaire about their background. This background survey included questions relating to their experience with elderly care and on their views regarding the development of AAL technologies in order to assess their possible influence. The responses revealed that none of them have cared for elderly relatives and only two of them have experience in care training. However, all of them were responsible for dealing with RDNCP queries and making relevant changes based on those queries.

Interview

One-to-one, semi-structured interviews were conducted to explore the interviewees’ understandings and experiences of the ethical issues involved in the development of AAL technologies. The interview was based on an interview guide which included questions on their struggles regarding the development of the products, their feelings about the national project, and their thoughts on ethical issues surrounding AAL technologies in general (i.e., not limited to their own products).

Data Management and Analysis

The first case was positioned as a pilot study to validate the interview guide, recorded by handwritten notes. The other interviews were audio-recorded with a digital device and transcribed verbatim, and were also recorded as handwritten notes. All scripts and notes were included as data, for analysis. As the interview guide did not need revision through the all interviews, the notes in the pilot study also included as data. Thematic analysis was conducted on the data and coded based on a hybrid approach (Fereday and Muir-Cochrane 2006). Codes were generated inductively at first and then re-organized deductively following approaches which were used in previous research. The systematic reviews of Novitzky et al. and Ienca et al. were employed as reference for applicable terms and the concepts (Novitzky et al. 2015; Ienca et al. 2017). Consistency of the codes to the contexts was checked iteratively. Data saturation (Fusch and Ness 2015) was reached after interviews with the nine participants. Both the interviews and the data analysis were conducted in Japanese.

Results

Findings

Overview

The ethical concerns communicated by the engineers can be grouped into six categories: (1) conflicts over appropriate safety levels, (2) acceptance of the technologies, (3) dependence on the technologies, (4) legal liability for accidents, (5) fair access to the technologies, and (6) privacy. Furthermore, their experiences seem to have been influenced by their being employees of commercial companies; those influences were expressed in terms of (1) wanting their products to respond to social needs, (2) developing them for a wide range of users, and (3) cost reduction. Their responses were also affected by the RDNCP and from feedback provided by the various stakeholders. In addition, they envisaged that the number of queries raised could be reduced or answered through the development of clear ethical guidelines for AAL technologies. It was mentioned that, for such guidelines to work meaningfully, they should be developed and implemented interactively with developers and users.

Ethical Goals and Issues of AAL Technologies that Engineers were Concerned with

  1. 1.

    Conflicts over appropriate safety levels

    All interviewees referred to product safety as being an essential condition in that they must not cause harm to the humans they care for and the humans involved in the care. Despite this, safety was not one-dimensional. This was evident when some of them spoke of the dilemma between safety concerns and the benefits to elderly users of the products. For instance, during clinical trials, some caregivers stopped using the product because they felt that the elderly user was too weak to use it and they were afraid of causing injury. Although this decision was made by the care professionals to ensure the safety of the elderly user, it might also deprive them of significant benefits the products might give. Indeed, one engineer who observed such cases suggested that the attitudes of care professionals were over-prioritizing safety. He said:

    I understand why a care work manager would put safety on top priority…However, the patient was quite eager to use the robot in spite of the judgment made by the manager, and they rose to the challenge to use it. Then, after a month, his/her joint motion improved so that he/she handled the robot perfectly and stood up without anyone’s support… So, I feel somewhat suspicious about the over-prioritization of safety at the expense of everything else. (Engineer developing mobile assistance technology, male)

    Engineers also mentioned a conflict of interest between safety and their employment in commercial enterprises. Hence, when they needed to ensure the safety of the product, sometimes additional functions were required, but this in turn raised the price of the product. Consequently, maximizing safety would conflict with creating an affordable product.
    Similarly, while the engineers felt naturally responsible for safety, they also had felt restricted by the RDNCP which placed a strong emphasis on safety. This resulted in the engineers designing products to suit the users’ needs, but sometimes the RDNCP then directed them to change the design to meet the program’s safety requirement. In such cases, the engineers expressed discomfort in being caught between the interests of users and policy requirements. This engineer noted:

    [Because the product creates quite a strong force,] the evaluation committee in the national project said that this product had safety problems although we designed it in response to the users’ needs. (Engineer developing mobility actuation technology, male)

     
  2. 2.

    Acceptance of the technology

    The engineers assumed that society expected their technologies to improve independent living for the elderly and decrease the care burden of caregivers. Therefore, they believed that their products needed to be accepted by both the elderly and their caregivers.

    To this end, the engineers approached users in various ways, such as by inviting them to exhibitions and preliminary trials of prototypes, in order to involve the users in the development of the products. They needed to understand which specific functions would be required in order to increase the probability that their products would be truly accepted in the users’ daily lives. For instance, one of the engineers mentioned that they needed to understand the relationship between the users and real life tools, through dialog with the users, in order to gain an accurate picture of the usefulness of the tools in daily life:

    Actually, this usage might be possible by doing simple laboratory work. However, it is impossible in real life, because the users’ behavior in real life is completely different from that in the laboratory. (Engineer developing automated toilet, male)

    Additionally, engineers were concerned that some elderly users might consider the machines strange and that they might feel as though they are being treated as a mere object being manipulated by a machine. She explained:

    Elderly people are often uncomfortable dealing with robots and other cutting-edge technology, and, when using robots, some older people feel like they are being watched or stared at in a strange way… Many elderly people have an image of robots as cold-hearted and unfriendly, and this impression may extend to care robots as well. (Engineer developing mobile assistance technology, female)

    To mitigate this effect, some engineers attempted to conceal the mechanical structures completely under an outer coat and others tried to mimic the appearance of other, more familiar, care equipment in order to make the product appear less robotic.

    Encouraging the elderly and the caregivers to accept the technologies was also important to commercial companies because a wide range of users would result in higher profits. However, a wide range of users leads to a wide range of opinions, and the engineers considered such a range unfeasible to attend to because of the costs that would be involved.

     
  3. 3.

    Dependence on the technology

    Known as disuse syndrome (Bortz 2009), extended bed rest or not using extremities for other reasons can cause a loss of healthy functioning. The interviewees mentioned the risk of disuse syndrome as an ethical issue in the use of AAL technologies, as such technologies might substitute some of the actions required for daily living (ADL). Accordingly, some engineers were concerned that prolonged overuse of such products might deprive the elderly person of the chance of, or motivation to, use his or her body more fully. If this occurs, the elderly user would become dependent on the technologies, resulting in disuse syndrome. Moreover, the engineers reported that some elderly users became attached to the products and sometimes became emotionally dependent on them, especially in the case of companion robots, as evidenced by the observation that such users seemed to be confused and restless when separated from their AAL technologies.

    As a result of concerns regarding dependence, the interviewees expressed a need to find an appropriate balance between the long-term benefits and the immediate need for support regarding technology-assisted elderly care. The users tended to want to save physical energy by using the technologies, even though this might result in disuse syndrome in the long-term, as this participant observed:

    The purpose of the technology is to aid in the independent living of the elderly, and so we have to ask ourselves how much support is appropriate… In the case of our automated toilet, ... this action (for picking up the waste) may be burdensome for the elderly. Of course we can get rid of this task with technology, but it’s better not to—precisely because we want the user to do it (as exercise). (Engineer developing automated toilet, male)

    The interviewees mentioned that the RDNCP geared them towards appreciating the issues surrounding dependency. It accomplished this by having them consider the possibilities of harm if the products make the elderly user dependent on them. The following remark suggests that an engineer’s awareness of the issues related to dependency seemed to be enhanced by the project:

    Being comfortable reduces the activity of the elderly. This product has such capabilities, and it is the biggest problem with the product. The personnel of the national project told us so. (Engineer developing automated toilet, male)

     
  4. 4.

    Legal liability for accidents

    If products place too heavy a load on the user’s body or fail to activate the programmed monitoring functions, they could cause injury. Some engineers were concerned about legal liability in such cases. These kinds of concern were not limited to supporting machines which directly touch the body of the elderly user and use powerful motors. Even in the case of monitoring technologies which would not come into direct contact with the user, errors in the function could cause physical harm. The engineers were sensitive about who would be liable for accidents because the law tend to favor injured users. Due to this, some engineers expressed that they sometimes decided against adding innovative functions to their products because they could not entirely eliminate the possibility of a malfunction.

     
  5. 5.

    Fair access to the technologies

    One engineer expressed the view that the products should be covered by the national long-term care insurance so as to allow for purchase at a reduced cost. The engineer offered three reasons for this: Firstly, the users would wish to keep their own costs down; secondly, so that the companies could meet their goal of acquiring as many users as possible by lowering the price; and finally because everyone should have an equal opportunity to access the new technologies.

     
  6. 6.

    Privacy

    Only one of the interviewees mentioned that monitoring technologies might not be so readily accepted by elderly users because of privacy issues. He observed:

    I suppose that the person being monitored would feel uncomfortable being closely watched (Engineer developing automated toilet, male)

     

Necessity of Making Guidelines for the Development of the Technologies

Regarding the evaluation process in the RDNCP, a number of interviewees claimed that the responsibility of considering the risks of the technology, including ethical issues, lay with the developers. Despite this, they struggled with conducting such an evaluation of their product because it required exploring unfamiliar fields in order to solve conflicting issues that arose. One interviewee offered this explanation:

We needed to start with understanding the meaning of “activity” and “participation” for the field of elderly care. We had a lot of questions of them… The documents for the evaluation only presented us with a blank table but didn’t include how we should respond to the questions. (Engineer developing mobile assistance technology, male)

In order to cope with the conflicting ethical issues, the interviewees said that ethical guidelines on the development of AAL technologies are needed. The guidelines should provide a set of criteria for certification and also the logic behind how to consider the more abstract ethical issues. This is because, once they had become aware of the wide variety of elderly care users, they realized that the issues would not be resolved through simple application. Concrete criteria (such as terminology for diseases, conditions, or symptoms) must be in place to enable the selection of appropriate users. Currently, the RDNCP directed the developers to specify the target users of their products by the users’ diseases or symptoms. The interviewers were perplexed by this requirement of the national project, and one of them made this observation:

It was quite difficult for us to draw the dividing line. It was especially difficult to clarify the line between those who can use the product and those who cannot…We need a set of questions for judging whether we can apply the product to the patient, [not a list of diseases or symptoms that should be excluded.] (Engineer developing mobile assistance technology, male)

In relation to the implementation of such ethical guidelines, an interviewee mentioned the necessity of interactivity. He has been involved in research board certification and clinical trial processes in Denmark. He questioned the way in which ethical review is conducted in Japan and pointed out that the Japanese review process seemed to be merely a bureaucratic formality because it only involved checking documents. In contrast, the process which he saw in Denmark had been developed to build trust between developers and the care recipients through one-on-one interaction during the clinical trials. He suggested that ethical review might not actually protect the care recipients if the review process is purely procedural. Interactivity between the developers and the care recipients was seen as essential to the process. He explained as follows:

I feel there is a tendency [in Japan] to over-estimate the skill of the ethics boards to ensure the wellness of the trial participants… In the case of Denmark, beyond the board certification, the researchers actually made the participants relaxed. Beginning with chat, they tried to create an environment where the participants could say what they felt without hesitation… During the trial, they frequently asked the participants their feelings… I felt this was much more important than the formality of board certification in the aspect of ensuring wellness and safety of the participants. (Engineer developing mobile assistance technology, male)

Discussion

Ethical Issues from the Perspective of Engineers

This is the first study to investigate the perspectives held by Japanese AAL technology engineers with regard to the ethical issues in the development and use of their products. The results seem to suggest that, as employees, engineers are concerned about the development of their products both as designers and researchers. They are aware of the ethical issues in the development and use of AAL technologies and experience a similar range of dilemmas to those reported in the international literature (Ienca et al. 2017; Novitzky et al. 2015) in spite of there being a limited amount of Japanese literature with which the engineers could formulate their ideas.

Furthermore, this study builds on previous discourse on the ethically responsible development of AAL technologies, in that it presents a fresh insight into what some of the ethical issues and concerns engineers are. These perspectives seem to be informed by their being employees of for-profit companies, and by policies and legislation. In particular, the former (i.e., their interests as business people) influences their thoughts on the acceptance of technologies and on user involvement. As mentioned by all of the interviewees, these themes seem important to employees, as they are required to respond to social needs and to tailor their products so that they are accepted by many users.

In tandem, policies on AAL technology in relation to manufacturing seem to influence engineering perspectives on safety and dependence. For example, the RDNCP has affected the interviewees’ perspectives on safety and dependence.

While policy and commercial interests might have contributed to the engineers being aware of certain ethical issues, their thoughts on fair distribution of the technology and on privacy were barely mentioned. Previous literature has shown that privacy is an important ethical issue relating to AAL technologies (Novitzky et al. 2015) and that engineers need to take this issue into careful consideration (Kosta et al. 2010). However, the interviewees did not follow this trend. This might simply be because only a few of the interviewees were developers of monitoring or companion technologies, both of which tend to provoke privacy concerns. Alternatively, it might be an effect of their cultural background (i.e., Japanese) which tends to be less sensitive towards privacy issues (Luther and Radovic 2012). Likewise, issues surrounding the fair distribution of technology were scarcely mentioned, possibly because such issues are too far beyond the scope of engineering responsibilities. Even being involved in the RDNCP, which focuses on efficacy and non-maleficence (Okawa and Yamada 2013), did not result in the interviewees being more aware of the issues concerning fairness and privacy.

Dilemmas and the Necessity of Guidelines

Discussing their concerns, the interviewees seem to describe experiences in which they face three dilemmas. Firstly, they faced a conflict between social needs and users’ desires, with a growing emphasis on the use of AAL technologies to improve independent living of the elderly care recipient who, in turn, become over dependent on machines as result of long-term use. However, the users (especially the care recipients) were keen to use the technology for their immediate convenience regardless of any potential long-term harm.

Secondly, when approaching the gap between perspectives of the elderly and their caregivers, the interviewees reported difficulty in balancing what elderly users want with safety concerns. The interviewees feel that an overemphasis on safety could lead to over-protection as evidenced when caregivers refrained from using the technology because they have misguidedly prioritized safety, depriving an elderly person of the chance to be independent. This observation is supported by previous research which has posited that over-protectionism and paternalism (Martin et al. 2010) are causes of ethical issues with caregivers (Novitzky et al. 2015).

Thirdly, the engineers encounter a dilemma between user’s needs and restrictive policies; even innovative technologies produced through user involvement might not rule out regulatory obstacles later on because of safety or other issues. In order to overcome these dilemmas, some of the interviewees were looking to having a set of guidelines at their disposal for when they are developing products. This study maintains the necessity of such guidelines in order to address the ethical issues that the interviewees have highlighted. In fact, in the UK, British Standards Institution (BSI) published a set of guidelines regarding ethical problems in relation to robotic products (BSI 2016). Japanese society will need a similar set of guidelines as an accessible reference for engineers to use when they need to consider the various opinions and concerns among a wide range of stakeholders.

This brings us to consider how guidelines for ethically responsible innovation of AAL technology should be established. Balancing people’s interests in relation to AAL technologies is known to be challenging because it is still ambiguous who benefits from the technology and who is responsible for implementation (Hofmann 2013). Indeed, this research shows that engineers might not be aware of issues that fall outside of their frame of reference, such as ensuring fair access to the technology. For this reason, any guidelines that have been established by a limited range of stakeholders might fail to consider the interests of all the stakeholders. Therefore, in order to circumvent this when establishing the guidelines for ethically responsible innovation of AAL technology, the discussion needs to involve the developers, the users (including both the elderly users and their caregivers), and the policymakers.

The need for comprehensive stakeholders’ involvement in creating the guidelines should also be apparent in the application of the guidelines which, as the interviewees mentioned, should be implemented in an interactive manner. Failure to do so might result in the engineers solely interacting with paperwork rather than with the other stakeholders, and this might create a bureaucratic system far removed from the “real life” ethical issues it aims to address. In summary, substantial stakeholders’ involvement that is inclusive and balanced needs interactive dialogs (Dawkins 2014), as one of the interviewees also mentioned.

Methodological Limitations

This study has methodological limitations resulting from the selection of interviewees as they were likely to be influenced by the RDNCP and the mediation of their respective companies. As the RDNCP possibly enhanced the engineers’ awareness of particular ethical issues, this study might be biased towards over-estimating the engineers’ ethical awareness.

During the first step of the recruitment process, the companies to which the interviewees belonged were contacted and they recommended the interviewees. The interviews were conducted in quiet compartments, and the interviewees appeared to answer the questions frankly. Nevertheless, they might have felt some pressure to provide company-biased responses because the interviews were carried out on company premises which might have nudged them towards presenting positive responses in relation to their products.

In order to assess these biases, it would be useful to include engineers who research and develop AAL technologies in academic settings, as they might be less influenced by the RDNCP and by their employers.

Conclusion

This study investigated the ethical issues surrounding the development and use of AAL technologies from the point of view of some Japanese engineers. In coping with these issues, many of the engineers feel caught between the interests of the elderly users and their caregivers and are worried that the conflict of interests might undermine the well-being of the elderly users.

This study reveals the factors that influence the interviewees’ ethical perspectives regarding their technologies and also gives us an insight into how we might develop and implement ethical guidelines for the development of AAL technologies. The interviewees’ perspectives are influenced by their interests as employees and by policies such as those set out in the RDNCP. To avoid being caught between stakeholders’ interests and policy requirements, engineers require guidance on ethically responsible development of AAL technologies. The guidelines should be established in a way that involves all relevant stakeholders: the engineers, the users (including the elderly and their caregivers), and policymakers. Furthermore, the guidelines need to be implemented in an interactive manner, in order to avoid their becoming a bureaucratic formality that would have little real-life, positive impact on the stakeholders.

Notes

Acknowledgements

The authors would like to thank all companies and interviewees involved in the survey. We also thank Joshua Wittig and Elizabeth Wade for language editing.

Authors’ Contributions

JK designed the study in consultation with MK and KK. MK contributed to design of the study and analysis of data. JK carried out the interviews and wrote the initial draft of the manuscript. MK and KK critically examined the results and reviewed the manuscript. All authors approved the final version of the manuscript.

Compliance with Ethical Standards

Ethics Approval

This study was approved by the institutional review board of Osaka University Hospital (no. 16081-2, approved on July 5, 2016). Informed consent for research participation and publication of results in academic papers was obtained from all interviewees.

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Copyright information

© National University of Singapore and Springer Nature Singapore Pte Ltd. 2018

Authors and Affiliations

  1. 1.Biomedical Ethics and Public Policy, Graduate Schools of MedicineOsaka UniversitySuitaJapan

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