Introduction
Imagine that a group of physicians and administrators at a local nursing home is considering purchasing several social robots (henceforth “carebots”) from Robocorp. Among other things, these carebots will take over menial tasks but also provide companionship and interactive engagement with residents. Administrators point to the safety, economic, and efficiency benefits. However, some staff have raised concerns given the profound impact that this technology may have on the care environment and relationships between caregivers and patients. They worry that such technologies reduce opportunities for caring interactions, compassionate listening, and human touch—all of which are at the core of good care. Should the nursing home purchase and deploy these carebots? How should they decide? If they decide to do so, how can they ensure that this technology is deployed ethically?
Given their potential to significantly alter foundational aspects of human life, discussions regarding the ethics of artificial intelligence (AI) and robotic technology have increased substantially over the past two decades.Footnote 1 As noted in the United Nation’s Resource Guide on AI Strategies:
“AI-based technologies blur the boundary between human subjects and technological objects [and] not only have societal implications […] but they also affect the central categories of ethics: our concepts of agency and responsibility, and our value frameworks.”Footnote 2
Within medicine, a growing literature explores the ethical dimension of how such technologies can be designedFootnote 3 and appliedFootnote 4 in a variety of care contexts like nursingFootnote 5 or eldercare.Footnote 6 Researchers explore how these technologies impact values such as patient autonomy, dignity, welfare, nonmaleficence, privacy, safety, transparency, human capabilities (e.g., bodily integrity, bodily health, control over one’s environment), social isolation, and the care relationship.Footnote 7
Although much of this literature examines the ethics of designing and developing AI and robotics, the majority of medical institutions in the United States must make purchase and deployment decisions about technologies that have already been designed and developed.Footnote 8 Given the frequent amalgamation of AI and robotics systems, we jointly refer to these overlapping technologies as “advanced technologies.”Footnote 9 A central practical problem facing medical institutions is not one of ethical design but of ethical deployment. The purpose of this paper is to develop a practical model by which medical institutions may make ethical deployment decisions about ready-made advanced technologies.
Currently, a variety of governmental, industrial, and scientific organizations have drafted principles and ethics guidelines for developers of AI and robotic technologies.Footnote 10 Although there appears to be some convergence on broad ethical principles (e.g., respect for autonomy, harm prevention, fairness, and explicability),Footnote 11 critics have argued that this apparent agreement at the general level “obscures deep political and normative disagreement.”Footnote 12 Furthermore, the available evidence suggests that such guidelines do not influence the behavior of professionals developing these technologies.Footnote 13
Despite these problems, the continued articulation and evaluation of broad ethical frameworks by the government and industries is important in the ethical development of advanced technologies. Some guidance and regulation are likely better than none. Our proposal is consistent with the continued need for value-sensitive design as well as research on systems and structures that incentivize ethical design in the engineering of advanced technologies.Footnote 14 Nevertheless, we also share the additional practical concern noted by Mark Coeckelbergh in his recent analysis of AI policy guidelines:
[I]t remains a huge challenge to build a bridge between, on the one hand, abstract, high-level ethical and legal principles and, on the other hand, the practices of technology development and use in particular contexts, the technologies, and the voices of those who are part of these practices and work in these contexts. This bridging work is left to the addressees of the proposals. Can and should more be done, at the earlier stage of policymaking? At the very least, more work on the “how” is required alongside the “what”: the methods, procedures, and institutions we need for making AI ethics work in practice. We need to pay more attention to process. Footnote 15
One response might be to argue that concerns about ethical deployment can be addressed through ethical design. It is true that design is a value-laden activity and that design explicitly and implicitly builds in values. However, building in values assumes that a particular set and ranking of values can be applied universally across all contexts in which advanced technology will be applied. As we discuss later in the paper, this is unlikely to be the case.
Taking our cue from Coeckelbergh, we aim to achieve two objectives: (1) Identify shortcomings in current decisionmaking processes regarding the deployment of advanced technologies in medicine; and (2) Develop a decisionmaking process for the ethical deployment of advanced technology in medicine that functions in a wider variety of value contexts. Our slogan is “more process, less principles.” We call our model Participatory Deliberative Conservatism (PDC).
This model has four central features that we believe are necessary for ensuring that deployment decisions and the processes by which they are generated are ethical. First, unlike current generalist approaches, which purport to apply across all domains of human activity, PDC is domain-specific to medicine. Medical practice involves its own unique values, traditions, and goals.Footnote 16 We will argue that an adequate ethical model for the deployment of advanced technology must be sensitive to the unique normative and teleological features of this practice. Second, our model is fundamentally participatory in that, in addition to healthcare workers and administrators, it includes local and lay stakeholders such as patients and caregivers. Third, our model is deliberative. The deliberative element ensures that abstract values and stakeholder concerns are appropriately understood, weighed, and applied in their local concrete contexts. Finally, our approach retains a conservative element since the outcome of this participatory deliberative process is not overriding but constrained by established legal, regulatory, and medical codes of ethics. Although patient values and concerns inform deployment, the moral and legal responsibility for deployment (and its consequences) rests with medical practitioners and administrators.
In the next section, we evaluate prominent ethical models and decisionmaking processes for the deployment of advanced technologies in medicine. We then present our alternative model, PDC, and explain how it overcomes challenges to existing views and has additional practical, moral, and epistemic virtues over its competitors.
Principles and Processes: Two Distinctions
Current approaches to the design, development, and deployment of advanced technologies favor ethical principlism, that is, the idea that a limited set of normative principles and values appropriately governs specific decisions.Footnote 17 Ethical principlism comes in two general forms: generalist and domain-specific. Generalist approaches aim to establish a set of ethical principles that ought to govern decisions about advanced technologies across many distinct domains of practice. Domain-specific approaches aim to establish a set of ethical principles appropriate to specific domains of human practice.
Similarly, the processes by which institutions make decisions about design, development, and deployment can be divided into two broad approaches: top-down proceduralism and bottom-up proceduralism. Although they exist on a continuum, top-down proceduralism favors investing decisionmaking power in those who hold higher positions of formal institutional authority in an organization. Bottom-up proceduralism accords more decisionmaking power to stakeholders affected by the relevant policies and practices regardless of their formal institutional authority. With these distinctions in mind, we briefly sketch the strengths and weaknesses of these common approaches to the ethics of advanced technologies.
Principlist Approaches to the Ethics of Advanced Technologies
Generalist Approaches
The most common approach to addressing the ethics of advanced technologies involves formulating and applying a set of broad ethical principles to guide their design and development.Footnote 18 These principles are intended to apply across all human domains of activity. For example, consider the recent proposal from the European Commission’s Expert Group on AI (AIHLEG). In their Ethical Guidelines for Trustworthy AI, Footnote 19 they argue that AI should respect human autonomy, minimize harm, be fair, and be explicable “throughout the system’s entire life cycle” and that these principles are presented “without a hierarchy.”Footnote 20 These general principles are translated into concrete requirements involving human agency and oversight, technical robustness and safety, privacy, transparency, diversity and fairness, societal/environmental well-being, and accountability. The AIHLEG notes that these concrete requirements will be applied by developers and deployers, with end users requesting that they are properly upheld.
Although generalist principlisms are useful for foregrounding broad ethical values and concerns, they present theoretical and practical challenges. Our point in this section is not that generalist principlisms are irredeemably flawed but rather that current models are incomplete with respect to concrete deployment processes. We outline three challenges with these approaches, many of which have also been variously articulated by other authors: the ambiguity challenge, the ranking challenge, and the tacit exclusion challenge. We discuss each in turn.Footnote 21
The ambiguity challenge arises as a consequence of the abstract nature of the ethical concepts applied to concrete situations by diverse populations. The concept of justice, for example, contains multiple conceptions like distributive, egalitarian, desert-based, social, and equity-based accounts. Within each account, there are further divisions. For example, not all egalitarians agree on the nature of equality or in what respects people ought to be equal. The ambiguity of the concept lends itself to being differently understood by different people and within different contexts.
To illustrate the ambiguity challenge in the context of AI, consider the recommended principles from the Department of Defense (DoD) on the “Ethical Use of Artificial Intelligence by the Department of Defense.” They argue that defense AI should be responsible, equitable, traceable, reliable, and governable.Footnote 22
These resemble other generalist ethical frameworks for AI, but a closer examination reveals how differently the terms are understood in specific cases. Although “equitable” in this context suggests that the DoD should “avoid unintended bias…that would inadvertently cause harm to persons,” they also note that their understanding of this term does not follow the standard concept of “fairness” as it is “cited in the AI community.”Footnote 23 This is because from the perspective of military engagement (within the relevant norms of warfare), “fights should not be fair, as DoD aims to create the conditions to maintain an unfair advantage over any potential adversaries.”Footnote 24 Effective military action may be lethal and involve inflicting deliberate harm on targets or justify deception and deceit in ways that would be wrong in other contexts.
The ambiguity challenge raises further questions about justification: Whose understanding of the principles ought to apply and why? But this is also a practical problem. The practical needs of policymakers require that, if they want a new technology to promote or preserve some set of values, they need to understand those values in a sufficiently precise, naturalistic, and implementable way.Footnote 25 Principlist models, however, offer nonhierarchical sets of abstract principles that admit multiple interpretations. Such approaches can fail to provide clear context-sensitive and therefore action-guiding interpretations of values and principles. Furthermore, even if they could provide context-sensitive action-guiding formulations of values, they do not provide rankings.
The ranking challenge occurs any time two or more values in a nonhierarchical set conflict.Footnote 26 For example, existing generalist models do not provide an account of what would justify prioritizing autonomy above beneficence in one context but beneficence above autonomy in another. Principled resolutions of value conflicts across cases require a metatheory for resolving conflicts, which current models lack. Thus, decisionmakers appealing only to generalist models lack clear methods for determining and justifying normative priorities in particular cases. Critically, both the ranking and ambiguity challenges leave unresolved the important moral and practical questions regarding whose normative interpretations and rankings govern decisions.
Finally, it is unlikely that any concise list can capture all values relevant to all situations. The tacit exclusion challenge occurs when important values are not given their due because they are not specified by a particular generalist model. Proponents of such models might reply that specified values should be considered necessary but not sufficient ethical criteria. Nevertheless, by formulating a limited list of general principles, policymakers risk attending less to unlisted values that may be salient in particular situations. For example, no current generalist model contains the value of caring. However, it would be a mistake not to give caring high priority when considering the effects of deploying carebots in nursing homes. Models that do not explicitly enumerate a value tacitly allow decisionmakers to either omit or diminish the weight of that value—especially if it conflicts with enumerated values.
The exclusion problem also stems from the fact that lists of values have been developed primarily by academics and policymakers who are likely distant from the local contexts in which decisions will be made.Footnote 27 Hence, local and lay values or values relevant only to particular contexts risk being underappreciated in decisions. Furthermore, as we will discuss later, the tacit exclusion problem is amplified when combined with top-down proceduralism.
Our point, once again, is not that generalist principlisms are inherently flawed or that principlists cannot respond to the three challenges but rather that ethical deployment requires that these challenges be addressed. Generalist approaches to the ethics of AI are important for clarifying relevant ethical values and identifying potential stakeholders. They also serve as accessible heuristics for decisionmakers seeking guidance on complex problems. Further, the AIHLEG has developed these broad principles (and concrete considerations) into an operationalized framework for addressing each of the ethical areas of concern (e.g., data privacy) and they continue to seek feedback from users in specific areas of industry or society to clarify this framework. However, they also rightly note that “the implementation of the [guidelines] needs to be adapted” to particular contexts and that “the necessity of an additional sectoral approach, to complement the more general [framework]…should be explored.”Footnote 28 We agree. As we discuss below, there are a variety of reasons to favor a domain-specific approach.
Domain-Specific Approaches to Advanced Technologies
As far back as Aristotle, thinkers and policymakers have recognized that particular domains of human activity have their own goods, which are set by the telos of that practice.Footnote 29 The goods of the art/craft (techne) of shipbuilding, for example, depend on what it is for a ship to be good. Similarly, the goods of medical practice are set by the preservation and promotion of health. Hence, contra the generalist principlist approach to the ethics of advanced technologies, one might advocate for a domain-specific approach.
On this view, the set of normative values that govern the ethical implementation of advanced technologies is fixed by the goals and values internal to a particular domain of practice. Medicine, as a distinct domain of practice with an identifiable telos, appears to be well suited to this approach.Footnote 30 This is evidenced by the fact that domain-specific principlism has come to dominate ethical analysis in medicine.Footnote 31 For our purposes, we will follow the consensus view.
A growing body of research takes a domain-specific approach to the ethical dimensions of introducing advanced technologies into a variety of clinical settings. Some literature examines caregiving broadly,Footnote 32 whereas others focus on specific issues within subdomains like eldercare,Footnote 33 or the potential impact of technology on specific practices like nursing.Footnote 34
This raises an ontological question regarding the nature and scope of different subdomains of medicine and the ways in which they are related. For example, one might argue that psychiatry, surgical oncology, palliative care, and eldercare are substantively distinct and require governance by different ethical norms and values. There are two claims worth noting here. First, these subdomains are similar in that they all aim at the same telos, that is, they all seek to protect and promote health. As such, we should expect that the same broad normative approach governs these activities. Second, these subdomains are different in that they contribute to the telos in distinct ways. For example, following Aristotle’s analogy, although the specific end of sail-making (e.g., to build sturdy sails that capture wind well) or bow-making (e.g., to build sturdy bows that break waves) may be distinct, both are subdomains of shipbuilding because they serve the general telos of shipbuilding (i.e., sturdy, swift ship construction).Footnote 35
A strength of the domain-specific approach is that, unlike the generalist approach, it more clearly specifies the contextual features of the relevant clinical domain and helps illuminate some of the specific goods and values that are inherent in that discipline’s practices.Footnote 36 For example, human contact is vital in many areas of medical practice and is particularly important in some subdomains like long-term eldercare where issues of loneliness may be more salient. As such, introducing robotic technologies into this particular domain may produce distinct challenges and opportunities for achieving a range of relevant goods.Footnote 37 Further, it is possible that introducing new technologies and practices may even alter or displace the nature of the goods that we want to promote.Footnote 38
The key insight of the domain-specific approach is that it is essential to attend to a practice’s specific goals and contextual features when evaluating the permissibility of employing new technologies in medicine. However, when domain-specific approaches are principlist, they inherit the same three challenges as generalist principlism: the ambiguity challenge, the ranking challenge, and the tacit exclusion challenge. Even if we narrow the scope of discussion to subdomains within medicine, the use of abstract ethical concepts may still suffer from problems of ambiguity and variance across contexts. Further, like generalist perspectives, domain-specific approaches require a non-ad hoc basis for ranking relevant values and avoid excluding relevant values of stakeholders impacted by the deployment of advanced technologies.
Two Forms of Proceduralism
In addition to ethical frameworks, decisions regarding the deployment of advanced technology may be addressed with two kinds of procedures that exist on a continuum. At one end, top-down proceduralism rests decisionmaking power in those who occupy the upper echelons of an institution or group’s formal hierarchy, whereas bottom-up proceduralism takes a broader view of stakeholders and derives decisions from those further down a hierarchy.
Top-down proceduralism exemplifies current institutional approaches to decisions regarding the deployment of advanced technologies. The process often begins when a group of physicians or administrators become aware of a new technology. Any decisions regarding deployment must satisfy, at minimum, institutional procurement, safety, quality, and data security oversight committees. These institutional bodies are themselves constrained by federal and state regulatory frameworks. Satisfying these various oversight groups often requires running a pilot study to demonstrate that the technology meets the various institutional requirements and demands.
Medical institutions are driven by innovation and patient outcomes, but as scholars have noted this “needs to be achieved within limited budgets” and “deciding which [technologies] will deliver clinical and cost advantages is fraught with difficulty.”Footnote 39 Given that institutional actors make purchasing decisions, many new medical technologies are developed primarily with narrow institutional values in mind, that is, economic, efficiency, and safety benefits. However, these are obviously not the only values relevant to medicine. Hence, the ethical design and deployment of advanced technologies requires decisionmaking processes that identify and weigh all values relevant to those meaningfully affected by the new technology. As such, relevant stakeholders—including patients or patient groups—must be involved in the decisions about whether to adopt and how to deploy new technology.
Defenders of current practices might reply that hospital administrators and physicians can represent and advocate for patient interests. However, without substantive patient representation in top-down models, it is less likely that patient values and concerns can be accurately identified and ranked. Even if they can, top-down proceduralism raises concerns regarding whether they will receive sufficient weight—especially when they conflict with institutional and physician interests. Insufficient patient representation thus raises both ethical and epistemic concerns, both of which may undermine patient-centered care—the purported lodestar of modern medical practice.
Modern medicine is characterized by a movement toward greater patient-centered care and shared decisionmaking. On this model, healthcare providers are “encouraged to partner with patients to co‐design and deliver personalized care.”Footnote 40 Yet, when it comes to having a voice in the wider technological and institutional structure of the medical environment, patients typically have much less input. This means that the nature of the care environment and the choice architecture in which patients find themselves can emphasize the values and desires of physicians and hospital administrators. Insofar as institutional decisions to deploy technology aim to represent patient values and desires, top-down processes imply that these values and desires are filtered through the (not impartial) imaginations of physicians and administrators. Although they may sometimes converge, a genuine commitment to patient-centered care would include patient populations in decisionmaking to ensure that their contextually situated values and desires are accurately represented.
Relatedly, there is a consensus commitment to shared decisionmaking in medicine, and yet this practice is largely absent in decisions that reshape care and care environments with advanced technology. Fundamental to the shared decisionmaking model is the recognition of epistemic asymmetries between participants and, hence, the value of deliberation among stakeholders. Patients possess important knowledge that physicians lack, and vice versa. Coherent integration of this disparate knowledge requires a deliberative process among interested actors.
We suggest extending the existing commitment to shared decisionmaking to the deployment of advanced technologies in care environments. In short, decisions about whether and how to deploy advanced technology in medical institutions should be the outcome of a deliberative process among diverse stakeholders that include patient groups and/or their advocates, healthcare workers, and administrators. As such, we propose a model that is consistent with the ideals of patient-centered care and shared decisionmaking for decisions to deploy advanced technologies in medicine.
Participatory Deliberative Conservatism
In this section, we present our approach to decisionmaking about the deployment of advanced technologies in medicine. We call it PDC. In what follows, we demonstrate that PDC preserves the strengths of existing frameworks, avoids their shortcomings, and delivers its own moral, practical, and epistemic advantages. Importantly, our example below is only one of many possible instantiations of a decision process that incorporates the relevant elements of PDC. Medical institutions, depending on their size and scope of practice, may develop decision processes that instantiate participatory, deliberative, and conservative elements differently.
To illustrate this model, consider the case with which we began: An assisted living facility is considering introducing carebots. Employing these robots will likely be cheaper (in the long run) and perform certain tasks more efficiently than human nurses. Should this facility purchase these carebots? How should they decide? And if they decide to purchase them, how should they determine the way in which the carebots are deployed?
Step 1: Preliminary Identification of Values and Concerns
The goal of the first step is to generate a list of values and concerns from a small group of primary stakeholders. This is the work of the pilot committee, a group composed of diverse primary stakeholders that include nurses, administrators, caregivers, physicians (from various disciplines), patients, and/or former patients. In addition, the pilot committee should include representatives from the development team of the relevant advanced technologies.Footnote 41 This first step provides an initial account of any practical and normative considerations relevant to whether and how to deploy the new technology. Practical considerations are primarily pragmatic, like whether gloved hands can use a touchscreen on the carebot. Normative concerns involve value-laden features of concrete situations. For example, rather than expressing abstract concerns for privacy, patients might articulate apprehension about whether acarebot’s presence violates their sense of privacy or whether it enhances it.Footnote 42
Since the pilot committee is small, its conclusions risk being unrepresentative of the various stakeholder subgroups. Therefore, through appropriate interview and survey techniques, the pilot committee compiles information from a larger set of each of the primary stakeholder groups.Footnote 43 Possible survey techniques include interviews (structured, semi-structured, and unstructured), focus groups, panel sampling, surveys (telephone, mail-in, kiosk, and online), and other sociological methods. The particular methods employed will be determined by the properties of the issue, the target population, and their environment. Because so much will be context-sensitive, we do not advocate for any particular information-gathering method but rather suggest that the context will determine the methods. For example, methods used to gather information from an unhoused population will be different from those used to gather information from institutionalized populations. Appropriately drawing from larger samples increases the likelihood that the values and concerns relevant to deployment decisions adequately represent those of all stakeholder groups.
Step 2: Deliberation About Values, Concerns, and Ranking
Clinical situations are “saturated with values, obligations, responsibilities, character traits [and] virtues.”Footnote 44 But, in particular situations, concrete normative concerns often represent more general values. The purpose of the second step is for stakeholders to deliberate about their collective contextually understood concerns, identify the underlying values that motivate them, and generate a provisional ordering of these values. Unlike a top-down principlist approach that begins with a list of abstract values to be imposed on the adoption decision, an ordered list of relevant values emerges organically from stakeholders’ deliberations about contextually situated concerns.
For example, in Step 1, nurses may have expressed concerns that carebots will replace valuable face-to-face time with patients. Nurses are articulating a context-specific instantiation of the more general value of caring. The deliberative process allows stakeholders to identify the more general values that underlie their concrete concerns. This accomplishes two important desiderata for decisions about the ethical deployment of advanced technologies.
First, it provides clarity since initially stakeholder concerns are not always clearly articulated, understood, or consistent with other normative concerns. Deliberative processes allow stakeholders to clarify both for themselves and to others the precise nature of their concerns.Footnote 45
Second, the group identifies the underlying general values motivating their particular concerns. Values may be instantiated in multiple ways in concrete situations. When people are committed to a particular instantiation of a value (e.g., not enough face-to-face time) rather than the value that underlies that commitment (e.g., caring), reconciling disagreement can be difficult. However, by focusing deliberation on shared underlying values, deliberators can more easily rank those values and generate conciliatory policies when they understand that the same value may be instantiated in multiple ways. In other words, identifying and focusing on underlying values provides more avenues for conflict resolution.Footnote 46
Step 3: Formulation of Initial Deployment Policy
In Step 3, the pilot committee decides whether to adopt the new technology and, if so, how. Consider again a nursing home’s decision about whether to adopt carebots. In Step 2, the committee may have identified the following set of values: caring, privacy, autonomy, independence, safety, economic cost, and efficiency. The committee must evaluate whether introducing carebots protects and promotes these values better than current arrangements. Such a decision requires evaluating trade-offs between the various values. Importantly, decisions on whether and how to adopt will depend on contextual features and value rankings as they are locally understood.
If the pilot committee decides to implement the new technology, they generate, via a deliberative process, a means of deployment that satisfactorily protects and promotes the values from Step 2. In addition, the committee will develop success criteria, assessment tools by which implementation is measured, and the intervals at which they will be evaluated. The deliberative process is creative in that it generates novel ways of representing in policy the values identified in earlier steps. Stakeholders engage in the deliberative process to discover models of deployment that mutually satisfy diverse stakeholder concerns.
Although the process is participatory, it is not populist. Patient values and concerns from Step 2 are not de facto overriding. The final authority and responsibility regarding deployment (and its consequences) rests on medical practitioners and administrators, not patients. This is because, as we noted, sole reliance on patient preferences to guide policy may lead to practices that undermine important established medical values or legal frameworks, provide only marginal medical benefit, or insufficiently weigh local economic considerations.
Step 3, therefore, involves this model’s conservative element. Since this model is specific to the domain of medicine, it aims to preserve and advance the values intrinsic to medical practice to which medical professionals are bound.Footnote 47 Further, it leverages important epistemic asymmetries between lay people, medical experts, and administrators. For example, patients know best their own medical needs, medical providers have special access to training and medical protocols to satisfy those needs, whereas administrators often have better access to economic and relevant legal/regulatory frameworks.
Step 4: Deployment and Iterative Evaluation of the New Technology
The purpose of Step 4 is to deploy the new technology and perform iterative evaluations of how well it protects and promotes the relevant values and concerns from Steps 2 and 3.Footnote 48 The pilot committee: (1) deploys the new technology according to the previously established goals and values; (2) monitors the deployed technology for unintended consequences; (3) meets regularly to assess and deliberate on how well the new technology achieves the various goals and objectives set out in Step 3; and (4) makes adjustments to the deployment policy commensurate with the assessments.
The Virtues of Deliberative Participatory Conservatism
Practical Virtues: Specifies Meaning of Values in a Local, Contextually Specific Way
Recall that most existing ethical frameworks for advanced technologies face the ambiguity challenge because they are principlist. This challenge arises due to the abstract nature of ethical concepts and how they are variously understood by stakeholders in different contexts. PDC’s participatory and deliberative elements, however, ensure that stakeholder values and concerns are understood and applied in ways that reflect local cultural, economic, and social values and are sensitive to concrete contextual features.
Existing frameworks also face the ranking challenge which occurs any time two or more values in a nonhierarchical set conflict and the model contains no guidance or mechanism for conflict resolution. The PDC model generates rankings when diverse stakeholders engage in a deliberative process (Steps 2–4). We elaborate on the ethical significance of this point below. The point here is that, unlike existing principlist frameworks, PDC provides a non-ad hoc process by which values are ordered and conflicts between them are reconciled.
Moral Virtues: Justification of Values and Value Orderings
There is a tension between the ability to be sensitive to the normative richness of medicine and the practical need to narrow the scope of normative concerns. Approaches that insist on considering all and every normative value are unwieldy and inappropriate for the practical needs of institutional decisionmakers, hence the popularity of principlist models. Approaches that narrow the scope of relevant normative considerations, such as some forms of ethical principlism, risk excluding important values in particular contexts—especially when the relevant values are imposed a priori. Hence, any approach to normative decisionmaking must balance sensitivity to the normative richness of medicine with the practical need for a limited and tractable set of normative concerns.
Any model of normative decisionmaking must justify why some normative considerations are included and others are not. Similarly, it must justify why some of the included values are weighted more heavily than others. PDC provides this justification since the relevant values for each decision emerge as a result of deliberation between those affected by and responsible for the new technology.
Those who experience the direct effects of a new technology ought to have a say in how it is applied to them. Unlike standard institutional approaches to deployment decisions, PDC includes patient voices. Doing so not only serves to justify value rankings but also is consistent with patient-centered care. Administrative/top-down policymaking risks failing to respect the very persons whose medical situation it is. It is their circumstances, their problems, their values, and their lives that are at stake.Footnote 49 Nevertheless, administration and medical professionals need to be included, too, since they also experience and bear responsibility for a new technology’s effects, hence the conservatism in our approach.
The deliberative process serves to balance the otherwise narrow concerns of each constituent group. For example, there is long-standing consternation that if deployment decisions rest primarily with hospital administrators, economic concerns will be overweighted.Footnote 50 Patients and long-term caregivers, therefore, must have a voice. However, sole reliance on patient values and concerns can disregard genuine economic considerations and appropriate medical practice.Footnote 51 After all, as a goal-oriented human practice, medicine already aims at certain goods and values which constrain the values and rankings of this participatory process. Hence, physicians and nurses too must have a voice to ensure that the technology is medically beneficial, conforms with good practice, and does not displace practices containing goods internal to them such as caring, touch, and humanistic interactions. We view this model as analogous to a constitutional democracy. The public subject to laws and policies has a say in what those policies are, but their policy preferences are constrained by a preexisting and more fundamental legal and normative framework.
The deliberative and participatory elements of our model allow it to be sensitive to the local cultural context in which deployment decisions are made. For example, a decision whether or how to deploy carebots for eldercare will look different in rural Thailand compared with New York City. These differences in outcomes are a function of the model’s sensitivity to local economic conditions and social, cultural, religious, and political values. This sensitivity to these broad contextual features enhances the justificatory power of the deliberative outcomes in ways that models without a deliberative process cannot.
Epistemic Virtues: Complexity and Interaction
In addition to these practical and moral virtues, PDC also overcomes numerous epistemological challenges arising in decisions to deploy advanced technologies in medical contexts. One central problem with medical and hospital ecosystems involves their sheer variability and complexity. Even within a single hospital, there will be numerous divisions, each with distinct priorities, specialists, administrative staff, and technological needs. The complexity of gathering and factoring the preceding variables in decisionmaking is amplified when taking into account further contextual features within which they are embedded such as geographic location, specialization and availability of resources, and technology.
It is nothing new for medical institutions to introduce new technologies. For example, a hospital might introduce new bandages with advances in materials science. In these familiar kinds of cases, new introductions often serve as functional equivalents of whatever they are replacing. However, the institutional effects of these sorts of technologies are qualitatively different than those emerging from advanced technologies. The introduction of the latter often comes with unexpected complex downstream effects on institutional structures, values, and human-to-human interactions.
For example, some deployment decisions may require information about practical concerns. This might include hiring technicians and providing relevant training to the staff. Others involve complex relationships between hospital divisions and healthcare workers. Machine learning systems in radiology, for example, may alter staffing and internal communication patterns.Footnote 52 In other cases, introducing a new technology can inadvertently eliminate or displace a good that is internal to a particular medical practice.Footnote 53 For example, suppose a hospital deploys a new technology that allows immobile patients to feed themselves.Footnote 54 In doing so, the technology displaces the nurse who otherwise would have fed the patient. Both cases are functionally equivalent in that the patient gets fed. However, “caring” is inadvertently removed along with the nurse’s displacement. In short, advanced technologies can eliminate or displace goods and values internal to human practices when those technologies eliminate or displace the humans involved in those practices.
The epistemological challenges of introducing advanced technologies into complex human institutions present two challenges for generalist principlist and “top-down” decisionmaking models. The first problem relates to the way principlism can tacitly exclude important values. As we have argued, certain forms of principlism attempt to identify a limited set of values a priori and apply them to situations as they arise; however, following widely held views in clinical ethics, we believe that it is “not possible to know in advance, beyond common themes, just which moral issues are actually presented by any specific situation.”Footnote 55
Unlike generalist principlism, on the PDC model, the relevant values and concerns that inform a particular medical situation are generated (in Step 2) through discussion and deliberation with diverse groups of stakeholders who will have direct experience with the technology’s impacts on the care setting and treatments. The composition of the decisionmaking body influences which values guide deployment policy. People are most acutely aware of the normative concerns that most directly impact their interests and lived experiences. By including a variety of stakeholders, the PDC model answers the question, “which are the values relevant to whether and how we deploy this technology?” For this reason, decision processes which draw from diverse stakeholder perspectives hold epistemic advantages over those that rely primarily on administrators or physicians.
The second problem relates to the epistemic disadvantages of employing top-down decisionmaking when introducing a new advanced technology into a complex and dynamic human practice. Top-down decisionmaking bodies are often deprived of relevant factual information necessary to make good decisions. This problem is analogous to a common critique of centralized economic planning, which is that centralized policymakers are typically epistemically insulated from the complex stream of market information required to accurately coordinate supply and demand.Footnote 56
The PDC model solves this issue in two ways. First, by involving a diverse set of stakeholders, decisionmakers ensure that as much relevant information as possible is available to them at the outset. Excluding diverse stakeholder involvement deprives decisionmakers of rich sources of relevant information.
Second, even if decisionmakers had a full grasp of all relevant information at the time of deployment, introducing advanced technologies into dynamic medical settings may produce unexpected (desirable and undesirable) effects. For example, employing carebots in one context might exacerbate isolation and loneliness but empower residents with more independence and privacy in another.Footnote 57 In short, well-informed deployment policies require regular monitoring over time of all the areas touched by the new technology.
The iterative nature of the PDC’s evaluation process (Step 4) ensures that new information is continuously integrated into the deliberative process. Without more direct epistemic access to these kinds of effects, decisionmakers risk deploying advanced technologies in ways that adversely impact the values and practices involved in good medicine.
Conclusion
In this paper, we have argued that decisionmaking about the ethical deployment of advanced technologies ought to emphasize process over principles. Contemporary models and methods for decisionmaking rely heavily on generalist forms of principlism and top-down decisionmaking. We have argued that these approaches present a variety of practical, moral, and epistemic challenges. In response, we presented a new approach, PDC, which addresses the challenges inherent to existing models and provides practical guidance for medical institutions. The participatory element ensures that a broad set of stakeholder values and concerns influences policy outcomes, whereas the deliberative element ensures the quality of policy outcomes. Finally, the conservative element recognizes the goods and values inherent to the practice of medicine and the legal and moral responsibility of physicians and administrators for the effects of policy decisions.
Importantly, we do not see PDC and domain-specific principlism as necessarily mutually exclusive. Throughout, we have emphasized the idea that, beyond broad themes, the contextual features of deployment decisions severely limit the possibility of knowing a priori stakeholder values and their rankings. However, institutions or decisionmaking bodies may still elect to adopt one of the many possible domain-specific principlisms for guidance. That is, the enumerated principles might be used more as suggestions and reminders rather than systematically deployed top-down. Whether or not institutions elect to adopt a principlist model, ethically sound deployment decisions in concrete situations will nevertheless still require the processes we have outlined throughout the paper.
Acknowledgments
We would like to thank the audience at the Philosophy Research Workshop at California Polytechnic State University (2022) and an anonymous reviewer at the Cambridge Quarterly of Healthcare Ethics for their helpful feedback on earlier drafts on this paper.
Open access
