IEEE Technology and Society Magazine - June 2015 - 51
fail in their duties when they make characteristically
human decisions, when bias, emotions, rational failings (among other factors) prevent them from deciding exactly what the patient would want if she could
express her own preferences. Considered this way,
ideal moral proxies make no decisions at all: the ideal
proxy acts merely as a conduit for communicating the
precise wishes of the patient given the current circumstances. It could be that well-designed ICDs and other
technological artifacts are capable of approximating
ideal moral proxies better than humans.
Second, casting the ICD as a moral proxy in an
evaluative framework does not commit one to any
strong ontological claims about the inner mental lives
of artifacts. When it comes to sophisticated automation technologies - robots and the like - some have
argued that the combined effects of their embodiment
and behavior require us to place them in an ontological category of their own, "somewhere between object
and agent" [9]. I have elsewhere adopted the ontological middle ground and argued that it helps us to more
completely and accurately characterize what it is that
sophisticated automation technologies accomplish in
the use context [10]. But in constructing an ethically
informed design framework (which I turn to shortly) I
can just as easily remain agnostic on the ontological
point. In a design context it is just as effective to treat
the artifact as if it is a moral proxy, if that will enable
an appreciation among engineers, designers, and policymakers, of the fact that automation technologies are
capable of impacting users, positively or negatively,
along characteristically moral lines. In other words, this
possibility of treating the artifact as if it is a moral proxy
enables a more accurate ethical analysis of tecnology,
while rendering the objection misplaced.
Autonomy and Paternalism by Design
Patients have not always been considered the most
appropriate authority for making decisions about their
own healthcare [5], [13]-[15]. Prior to the latter part of the
twentieth century, physicians commonly made deeply
personal healthcare decisions on behalf of the patient,
a practice now termed paternalism. The paternalistic
healthcare model saw physicians and other health care
professionals assuming proxy decision-making power
on behalf of patients, who were told what was the "best"
healthcare decision given their situation. Indeed, physicians commonly lied to patients as a matter of principle
[15], and intervened in patients' care in direct opposition
to the patients' expressed preferences [13].
Paternalism stands in contrast to today's accepted standards of practice. Today, healthcare professionals are seen as having an ethical responsibility
to provide an appropriate set of healthcare options
june 2015
∕
for the patient to choose from, and to reasonably counsel patients on the benefits and risks of each option so
that the patient can make a free and informed, in other
words an autonomous, decision regarding her own care
[11]. Healthcare professionals often have in mind one
option that stands out as most appropriate, but it is ultimately the patient's responsibility to select healthcare
preferences from among the various options presented
to him. Intended to respect a patient's autonomy, this
model of free and informed consent (informed consent hereinafter) has become the ethical standard by
which healthcare decision-making is judged. For consent to be informed, the patient must first be capable
of understanding the implications, the consent must be
given voluntarily (free from undue pressure or coercion),
the decision must be based on having a (reasonably)
full set of options to choose from, and consent must
be ongoing (it can change at any time) [16]. (Though
informed consent practices and requirements differ
slightly between Canada and the U.S., they are similar
enough for the purposes of this argument.) Paternalistic
relationships are problematic in large part because they
act to undermine each of the conditions of informed
consent, seriously undermining patient autonomy.
Where does technology fit into the pictures of paternalism and autonomy outlined above? We have already
seen how an ICD functions as moral proxy: healthcare
decisions are delegated via the artifact's design and settings. Activated, the decision to attempt resuscitation,
and the resuscitation attempt are delegated to the ICD.
Once deactivated, the ICD both declines resuscitation
attempts and respects a DNR decision by not attempting resuscitation. Delegation happens both at the level
of the decision and of the intervention. At both levels,
some technological correlate is required: to delegate
the decision a setting (switch) is required to put the artifact into a particular mode of operation, while delegation of the resuscitation attempt requires more complex
functionality (involving electrical leads, algorithms,
power sources, and the like) to carry out the operations.
From a moral perspective, the settings designed into
a technology can be made to do most of the heavy lifting.
When technology functions as a moral proxy, the settings
that define its mode of operation can reify particular
moral decisions; the settings provide the proxy answers
to the moral question raised in a use context. As such,
an artifact's settings can put it in a mode of operation
that corresponds to a patient's preferences, the corollary
IEEE Technology and Society Magazine
51
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