IEEE Technology and Society Magazine - June 2015 - 53

over the settings of their medical devices in order to
avoid, whenever reasonably possible, situations where
technology is functioning in a mode other than one corresponding to the patient's (user's) moral preferences.
Placing undue burdens on the patient (user) that might
discourage her from modifying settings, or might prevent or delay the changes from being communicated to
the proxy (artifact/device), threaten to subject her to a
paternalistic relationship with respect to her device.
Handing over more direct control of device settings to users carries an additional benefit, in that it
requires user consent to be more properly informed.
Whenever a device functions in a proxy decision-making mode of operation, the user surrenders some
moral authority to the device. If a user does so unsuspectingly, say because the device was set in a default
mode of operation not fully explained to him, then the
informed consent requirements of the proxy relationship might not have been satisfied. This is particularly problematic in cases where the user, if properly
informed, would have set the device otherwise from
the defaults. Such defaults are always somewhat problematic, given that a basic requirement of all autonomous decisions is that they be informed. Thus, if
engineers design devices such that they require certain
modes of operation to be explicitly activated by the
user, the chances of satisfying the moral requirement
of fully informed consent increase in the use context.
Users will need to be educated as to which design features have ethical implications in the use context, and
will need to make explicit choices about them.
In the case of the ICDs or other medical technologies,
one might object to the notion of handing over too much
control of device settings to the patient on grounds of
patient safety. This might be especially so in cases where
liability concerns are at issue. Jane's situation (being
unable to directly deactivate her ICD) might be the result
of detailed discussions in consultation with lawyers, ethicists, healthcare professionals, patients, and other relevant parties, intended to strike an appropriate balance
between safety, security, patients' autonomy (the ease
with which they are able to change the settings on their
ICDs), and making sure they don't do so accidentally,
hastily, while incapacitated, or worse yet unknowingly.
It can also be argued, however, that objections
based primarily on patient safety are overly paternalistic. The patient safety objection runs the risk of assuming incorrectly that patients are prone to accidents,
hasty judgments, incapacitation of some sort, or other
failures that can only be avoided by placing an expert
in between the patient, whose life is at stake, and the
switch the throwing of which would place the patient
at risk against better judgment. After all, paternalism
in healthcare stems in part from the notion that the
june 2015

∕

patient is less capable than some other person of making good decisions with respect to her own care, and
so must be protected. To be sure, devices must be
designed to safeguard against accidental harms. Whether or not devices ought to be designed to safeguard
against the deliberate, rational, competent actions of
those on behalf of who the devices are properly acting
is another matter altogether. On the balance, placing
gatekeepers in between the patient and certain settings

The presence of a switch allowing
the ICD to be either active or
inactive is an ethical
design requirement.

on his device could be as ethically problematic as placing the same gatekeepers between a patient and his
human moral proxy.

Beyond Medical Devices
My argument has focused so far on a single medical
technology: the ICD. However, we find proxy relationships instantiated by nonmedical technologies. Whenever a technology, medical or otherwise, instantiates
a moral proxy relationship in the use context, we can
evaluate its design using a proxy analysis.
Self-driving cars (SDCs) provide an excellent example
for thinking about how non-medical technologies can
function as moral proxies. Perhaps the best-known
example of an SDC is the one under development at
Google [17]. Google's SDC uses a series of sensors, digital maps, databases, and software to solve the extremely complex problem of driving [18]. To date, Google's
SDCs have logged hundreds of thousands of kilometers
driving autonomously in regular traffic, with only the
occasional need for human intervention [18]. In 2011
the state of Nevada authorized the licensing of SDCs
for the state's roads [19]. Florida and California passed
similar laws [20]. According to Google, their SDCs are
safe: "there hasn't been a single accident under computer control" [20]. Many major auto manufacturers are
developing SDCs, while almost every auto manufacturer
is implementing semi-autonomous features such as
parallel parking and collision avoidance systems. It is
expected that SDCs will be on the market within the
next decade, and some predict the SDC will dominate
the roads by 2040 [21], [22].

IEEE Technology and Society Magazine

Table of Contents for the Digital Edition of IEEE Technology and Society Magazine - June 2015