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Successful adoption and sustained use of smart home technology can support the aging in place of older adults with frailty. However, the expansion of this technology has been limited, particularly by a lack of ethical considerations surrounding its application. This can ultimately prevent older adults and members of their support ecosystems from benefiting from the technology. This paper has 2 aims in the effort to facilitate adoption and sustained use: to assert that proactive and ongoing analysis and management of ethical concerns are crucial to the successful development, evaluation, and implementation of smart homes for older adults with frailty and to present recommendations to create a framework, resources, and tools to manage ethical concerns with the collaboration of older adults; members of their support ecosystems; and the research, technical development, clinical, and industry communities. To support our assertion, we reviewed intersecting concepts from bioethics, specifically principlism and ethics of care, and from technology ethics that are salient to smart homes in the management of frailty in older adults. We focused on 6 conceptual domains that can lead to ethical tensions and of which proper analysis is essential: privacy and security, individual and relational autonomy, informed consent and supported decision-making, social inclusion and isolation, stigma and discrimination, and equity of access. To facilitate the proactive and ongoing analysis and management of ethical concerns, we recommended collaboration to develop a framework with 4 proposed elements: a set of conceptual domains as discussed in this paper, along with a tool consisting of reflective questions to guide ethical deliberation throughout the project phases; resources comprising strategies and guidance for the planning and reporting of ethical analysis throughout the project phases; training resources to support leadership, literacy, and competency in project teams for the analysis and management of ethical concerns; and training resources for older adults with frailty, their support ecosystems, and the public to support their awareness and participation in teams and ethical analysis processes. Older adults with frailty require nuanced consideration when incorporating technology into their care because of their complex health and social status and vulnerability. Smart homes may have a greater likelihood of accommodating users and their contexts with committed and comprehensive analysis, anticipation, and management of ethical concerns that reflect the unique circumstances of these users. Smart home technology may then achieve its desired individual, societal, and economic outcomes and serve as a solution to support health; well-being; and responsible, high-quality care.
Population aging, along with chronic disease and disability among older adults, are increasing challenges for supporting a high quality of life and sustaining services in health and social care systems. The COVID-19 pandemic has highlighted the many limitations of multiple health systems worldwide whose delivery models struggled to keep up with service demands. With widespread calls for physical distancing to limit COVID-19 transmission, the existing social isolation of older adults [
This viewpoint paper has 2 aims in the effort to facilitate the adoption and sustained use of smart home technology: (1) to assert that proactive and ongoing analysis and management of ethical concerns are crucial to the successful development, evaluation, and implementation of smart homes for older adults with frailty and (2) to present recommendations to create a framework, resources, and tools to manage ethical concerns with the collaboration of older adults; members of their support ecosystems; and the research, technical development, clinical, and industry communities.
The paper is structured as follows. We begin by explaining the nature of frailty and the importance of addressing it. We discuss smart home technology and its potential to support older adults with frailty. Our work summarizes key anthropological concepts that are relevant to smart homes when managing frailty in older adults and how these concepts can lead to ethical concerns. Thus, we discuss the rationale for proactive and ongoing analysis and management of these ethical concerns from development to sustained use. Finally, we present recommendations and opportunities for collective action to create and implement a framework, resources, and tools.
Approximately 32 million Europeans [
Research suggests that frailty may be viewed as progressive alterations in an older adult’s intrinsic capacities (ie, motor skills, cognition, and sensory functions), suggesting reversibility through strengthening of these altered capacities with health and social interventions (eg, physical and cognitive rehabilitation and participation in valued social and community activities) [
Smart homes may be interventions to address pressing concerns about supporting the high quality of life of older adults, relieve stressors on informal supports, and mitigate the challenges of health and social system sustainability with population aging. Users of smart homes may include older adults and members of their support ecosystems (ie, family or friends in caregiving roles, physicians, therapists, social workers, nurses, and home support workers) [
Smart home technology may assist with daily activities in various ways. Broad functions may include home environment or appliance automation (eg, thermostat control and stove shutoff), health or activity tracking for self-management purposes, monitoring and alerting for safety or emergency situations, and supporting social connectedness [
Despite innumerable smart home projects at various phases of development and implementation worldwide, the vast majority are not realized into commercial products and services, and mainstream technology on the market has not been widely adopted by older adults [
Ethical challenges and the need for deliberation arise when anthropological concepts such as values conflict with other values that are considered equally important. Applied ethics is the field that examines real-world applications of this deliberation and action. We bring together concepts from often-siloed fields of bioethics, such as principlism and ethics of care, and technology ethics to highlight ethical challenges to be deliberated with respect to smart home technology.
Principlism by Beauchamp and Childress [
Although ethics of care, or care ethics, may be positioned as an alternative to the rationalist principle-oriented perspective of principlism [
In details, according to the revised version of the 4-phase model of care by Tronto [
There is currently no dominant or unified approach to technology ethics. Ethical issues, implications, and decision-making practices arising from the design, use, and spread of different technologies are much-discussed topics in different fields and referred to using various terms (eg, technoethics, ethics of technology, computer ethics, AI ethics, and machine ethics). Consistent across these fields is the need to examine ethical, social, and legal implications, and there is often an orientation toward supporting citizens’ rights [
Concepts in technology ethics are numerous and often include those of bioethics. Friedman and Kahn [
Bioethics and technology ethics concepts are salient but intersecting. Examining these concepts in relation to smart homes for use by older adults and in the management of frailty can lead to ethical challenges. We describe in depth 6 key conceptual domains that need to be analyzed for smart homes but that can lead to ethical tensions.
Privacy and security concerns are multidimensional and often interrelated. There are 2 dimensions of privacy that warrant examination: privacy of personal information (ie, identity) and physical privacy (ie, related to one’s body and the activities and routines being carried out in different spaces) [
Information privacy and security are linked as maintaining privacy necessitates the security of information. Ethical concerns relate to the vast amount of sensitive information (eg, personal, medical, physiological, behavioral, and locations) that may be collected from users, how and for what purposes the information may be used, and who has and should have access to the information (eg, family, friends, health care providers, insurers, and manufacturers). Furthermore, the loss of private and confidential information to crime or unauthorized or wrongful access and use may lead to safety concerns and loss of the feeling of security [
Privacy concerns are commonly voiced by older adults when considering smart homes and their adoption [
Issues of privacy loss may be mediated by perceptions of the smart home technology’s usefulness. If the functions or services provided by the technology are perceived to be beneficial, older adults may elect to disregard some privacy concerns [
An important dimension of autonomy involves older adults’ relationships with others in their support ecosystems, as underscored in care ethics. Individual autonomy is the right of individual older adults to make choices about their lives and act freely without external influences [
Some research has identified that caregivers perceive the benefits of technology use more than older adults who feel they may do without technological support [
Beyond autonomy in care relationships with other people, ethical concerns have been raised regarding relationships with technology in the management of health and social needs. Concerns have been identified over the loss of individual autonomy with technology use in circumstances where it is perceived to control what older adults do or provide too much assistance [
Respecting the autonomy of older adults and their support ecosystems individually and within relationships may necessitate the adoption of the tenets of care ethics and the application of a support ecosystem–centered approach. Information about and experience with using smart home systems needs to be personalized to support their collective goals and informed decision-making about use. Notably, older adults with cognitive impairments may require additional considerations for making their needs known and support in shared decision-making [
Informed consent may only occur when people have knowledge and understanding of technology, their intended purposes and uses, and the potential benefits and harms the technology may create for them and their situations. A lack of awareness, familiarity, knowledge, and skills associated with smart home technology undermines consent capacity. This may have implications for adoption and use, the selection of options or features to maximize benefits and minimize risks during use, and consent to terms of service or data use [
Requirements for informed consent become more complex and unfeasible with the addition of AI to smart home technology because of limitations in the transparency and traceability of algorithmic decisions [
Informed consent by older adults also depends on the availability of high-quality information. The proliferation of misinformation creates challenges in disentangling information and finding information from trustworthy and reliable sources. Unscrupulous or unknowledgeable individuals may also sell products or services targeted at older adults that overemphasize benefits and minimize potential harms. Considering older adults’ tendency to select options that minimize losses in novel circumstances, how or by whom information is presented may be more important than what is presented. Older adults, especially those with cognitive impairments or who are socially isolated, may be particularly vulnerable to mistreatment related to the trustworthiness of information.
Without accessible information or appropriate learning opportunities that are oriented to enhance understanding by older adults who may be unfamiliar with technology or have cognitive limitations, informed consent and decision-making may not be possible. The information offered to older adults may be overly simplistic (ie, merely asking for agreement to use a service) or complicated (ie, detailing specifics of terms of service) [
Commonly discussed functions of smart homes are to enhance social connectedness, support, and inclusion; reduce isolation through remote communication with caregivers or health care providers; and offer ready access to assistance in emergency situations. Given the anticipated shortage of health care providers and working-age caregivers and changes in family living arrangements, with younger generations living further away from senior family members, care from a distance through technology is increasingly the reality [
Considering care ethics, relationships and experiences of empathy and responsiveness to needs are critical. As such, technology serves as an augmentative tool and one of several elements of personalized care. Overreliance on technology-based care, whereby technology is applied as a substitute for in-person interactions, may have detrimental effects in situations involving older adults with frailty. Nevertheless, a possibility may be that some older adults wish to include technology in their health management to limit social contact, preserve private time, or protect privacy [
Stigma and discrimination are concerns that may vary across sociocultural contexts and result in considerable harm. These concerns are pertinent to older adults’ adoption and use of smart home technology and are important in the development and implementation of potentially beneficial technology. Stigma may be defined as “a set of negative and often unfair beliefs that a society or group of people have about something” [
Discrimination is “the practice of unfairly treating a person or a group differently from other people or groups of people” [
Equity of access to beneficial support that may enable health and well-being is a concern of justice. Being equitable may involve “treating people or distributing resources differently, when people are in different situations and unequal treatment or distribution creates an equal outcome” [
Government policy makers have also considered the topic critical in policy actions to ensure the health and well-being of citizens and the sustainability of funding to support care systems. In managing resources and spending priorities, there is a need for consideration and evaluation of the cost-effectiveness of smart home implementation for older adults with frailty and the intended goals [
Consideration of ethical issues and ethical practices is increasingly viewed as core in development, evaluation, and implementation activities for assistive and rehabilitation technology, which includes smart homes [
The success of smart home technology will ultimately be adoption, sustained use that facilitates health and well-being outcomes of older adults and caregivers, and increased sustainability of health and social care systems. The concepts within the 6 domains presented have been shown in research to influence adoption and use of smart homes. Smart homes may have a greater likelihood of success with committed proactive and comprehensive analysis, anticipation, and management of ethical concerns. For users with frailty, these processes need especially to reflect and accommodate their unique circumstances throughout the course of projects. Older adults with frailty may require more nuanced consideration with regard to technology use owing to their heightened vulnerability resulting from limitations in physical and cognitive abilities, experiences of mental health concerns and isolation, and reliance on others. Frailty is a complex condition necessitating management through an interdisciplinary clinical approach alongside older adults and their caregivers. This scenario leads to greater complexity in ethical analysis. Development and implementation may be enhanced through ethically aligned practices that place users and their contexts and usability goals at the center of activities such that outputs are usable and accessible by users in various living situations and market and funding systems. We emphasize ongoing analysis and management as the conditions and information related to previous decisions may change over time. A mindset that embraces potential unknowns and promotes reevaluation and course correction if circumstances change may enable better outcomes.
A lack of consideration and mitigation of ethical issues may result in several negative outcomes. Unfavorable perceptions from the public regarding technology and its potential uses and benefits may lead to the rejection of technology-based solutions or the removal of public resources for future research and development. This may result in the loss of opportunities for future implementation to benefit users. Errors or differences in understanding or expectations with AI and other technologies may result in inappropriate policies and legislation and again halt potentially important progress [
To facilitate proactive and ongoing analysis and management of ethical concerns, we recommend collaboration among all stakeholders. This includes older adults; members of their support ecosystems; and the research, technical development, clinical, and industry communities in the field of smart home technology. This collaboration may be achieved through their inclusion in workshops and project teams. It is essential to cocreate a framework and associated resources and tools to support its implementation. The framework may include 4 elements to be discussed and elaborated on (
A set of conceptual domains, such as those discussed in this paper, along with a tool consisting of reflective questions to guide the ethical deliberation of these domains
Systematic and standardized consideration of these domains across stages of a project from conception, development, evaluation, and implementation to sustained use is recommended as part of a comprehensive strategy. Reflective questions, potentially applying a Socratic approach for analyzing ethical implications [
Resources comprising strategies and guidance for the planning and reporting of ethical analysis throughout project phases
These resources may outline detailed strategies and guidance to be used at the start of and throughout projects to reflect on, anticipate, identify, define, deliberate, and mitigate real and potential ethical issues before and if they arise. New methods, guidelines, and checklists to support planning and reporting to enable transparency of ethical analyses during development, evaluation, and implementation processes, especially as they relate to decisions made throughout project phases, may need to be developed.
Training resources to support leadership, literacy, and competency in teams for the analysis and management of ethical concerns
Leadership, collective team responsibility, and a culture that values the analysis and management of ethical concerns need to be promoted. Cross-disciplinary knowledge and skill development for researchers and practitioners in the clinical and technical sciences, industry members, and others may be essential to support literacy and competency in ethical analysis and management as part of smart home development, evaluation, and implementation. Contributing to the collaborative process, team members also need to develop knowledge and skills to meaningfully engage with older adults, their support ecosystems, and the public to fully include them in teams.
Training resources for older adults with frailty, their support ecosystems, and the public to support their awareness and participation in teams and ethical analysis processes
These stakeholders are essential team members and prospective users of smart homes, and therefore, commitment and strategies to ensure their full inclusion are critical. Raising awareness of smart homes and their potential benefits and harms and enhancing knowledge and skills regarding ethics and ethical analysis are important to support critical and realistic assessment of technology for adoption, use, and provision of feedback to developers or providers. For older adults and their support ecosystems, knowledge and skill development may focus on strategies to communicate and advocate for their needs. Resources on technology and ethical analysis need to be easy to understand to promote knowledge exchange and learning.
Successful adoption and sustained use of smart homes in the management of frailty in older adults have thus far been limited. Older adults with frailty require nuanced consideration when incorporating technology into their care because of their complex health and social status and vulnerability. Unmitigated ethical concerns are important factors restricting older adults and their support ecosystems from benefiting from the use of smart home technology. Applying a proactive and ongoing ethics analysis and management approach from development, evaluation, and implementation to sustained use is important for success. We recommend the development of a framework along with educational resources and analysis tools, cocreated by older adults, members of their support ecosystems, and other stakeholders, to support the implementation of this approach. Within this framework, consideration of a range of conceptual domains derived from bioethics and technology ethics is key: (1) privacy and security, (2) individual and relational autonomy, (3) informed consent and supported decision-making, (4) social inclusion and isolation, (5) stigma and discrimination, and (6) equity of access. Smart homes may have a greater likelihood of accommodating users and their contexts with committed and comprehensive analysis, anticipation, and management of ethical concerns that reflect the unique circumstances of these users. Smart home technology use may then achieve its desired individual, societal, and economic outcomes and serve as a solution to support health; well-being; and responsible, high-quality care.
artificial intelligence
Funding was provided by the French National Research Agency–Establishment of European or International Scientific Networks grant ANR-196MRS3-0025-01 to RA, Besançon, France. The funding body had no role in the conception or writing of this manuscript. NB is supported by a career research award from the Fonds de recherche du Québec – Santé. The authors thank the Smart CommuniCare Consortium for discussions related to this topic.
RHW conceived and designed the work and drafted and substantively revised the manuscript. TT, NB, MC, and RA conceived and substantively revised the work. All authors read and approved the final manuscript.
None declared.