Digitalization, health, and ageing

The use of digital technologies in health care has increased rapidly in recent decades and ranges from wellness apps via artificial intelligence and Big Data technologies to care robots. At the same time, there is a strong demographic shift in most European countries, with a growing number of individuals entering their older years. Population ageing generates new needs in healthcare sectors as they are confronted with an increasing demand for services for older adults. Digitalization, especially driven by advancements in data analytics and algorithm-based technologies, promises to deliver innovative solutions to address the complex healthcare requirements of an ageing demographic. Technologies for older adults, for example, digital technologies for communication, assistive robots for care or rehabilitation, and technologies for ageing at home, promise opportunities for more efficient, cost-effective, and patient-centred care for older adults. At the same time, there are a lot of questions regarding the ethical and social aspects in the context of digitalization and ageing. Exemplarily, what does “ageing at home” or “ageing well” mean in the context of digital technologies? How are autonomy, empowerment, and vulnerability related to digital technologies for older individuals? To what extent is ageism perpetuated in technology? What would be a just distribution of resources for digital health care, and how can we ensure access to digital health care for older adults? Despite these many questions, a debate is currently lacking that brings together the ethical and social aspects of digitalization in health care for older individuals. In this special issue, we will delve into the multifaceted relationship between digitalization and health care in the context of ageing, shedding light on the impact of technology on the way we understand and address the health and well-being of older adults.

We present five contributions here that examine these and other key questions raised by the convergence of digitalization, health care, and ageing. The issues were discussed at the DiGesA research retreat, hosted by the Institute of Ethics and History of Medicine, University of Tübingen, in 2023. This retreat brought together scientists and experts from different disciplines to explore the ethical, legal, and social issues related to digitization, health, and older age and helped to crystallize the key points at issue.

The special issue opens with an article on the paradox of ageing in the digital age by Joan Albreda Llorca and Pablo García-Barranquero. Emphasizing the importance of societal values and understandings of ageing, the authors draw on Rowe and Kahn's concept of “successful ageing” and critically analyses the relationships between digitization and societal perceptions of ageing. It is suggested that if ageing is associated with unproductivity and obsolescence, the rapid pace of digital change may cause biologically and chronologically young individuals to feel obsolete and “old.” The article suggests that this phenomenon is rooted in the institutionalization of ageing stages, where life is divided into phases, such as education, productivity, and retirement. Furthermore, the ever-changing and complex skill requirements are interpreted as potentially rendering people obsolete in the labor market at a younger age, which is linked to the acceleration of digitalization. In this context, the authors emphasize the need to understand ageing also from a societal perspective, taking into account rapid technological change and its impact on perceptions of productivity and obsolescence. This broadens the discourse on ageing and highlights the importance of structural factors in experiencing and understanding growing older in the digital age. Thus, Joan Albreda Llorca and Pablo García-Barranquero argue for a re-evaluation of how we perceive and structure ageing in society.

As new digital technologies enter the healthcare sector, it is crucial to collect data on patients' experiences with them. In order to provide patient-centred and value-based care, the input by patients is necessary. Yet, the data reported back from patients or, as Nina Roxburgh writes in her article, patient-reported measures may also reproduce biases related to the use of healthcare resources. If older adults are under-represented in the use of a particular healthcare intervention, they will also, in all likelihood, be under-represented in the data reported back. Ageism may contribute to such biases, both ageism, on the one hand, of those who potentially provide digital technologies and, on the other, of those older adults who might use them if, for instance, a belief that older adults cannot adapt to new technologies is internalized.

Alexandra Kapeller critically analyses the notion of empowerment in the context of self-testing apps for health and medical conditions. These self-testing apps target ill individuals who are not yet engaged with the healthcare system. They indicate the potential presence of a disease but do not provide a diagnosis. By offering test results outside the traditional healthcare systems and delivering health information, these apps are marketed as empowering. Kapeller questions, however, whether empowerment might be the right term to describe what these mHealth apps can realize. She points out that relevant conceptualizations of empowerment foreground either internal states or external conditions. However, both match self-testing apps without conceptual problems. By using theory from critical phenomenology, Kapeller, thus, develops an understanding of empowerment that includes both the internal and external processes of empowerment: an understanding of empowerment as an interplay between them. Instead of abandoning the concept of empowerment or accepting that self-testing apps are not empowering, Kapeller drafts a phenomenological reformulation of empowerment that can account for what self-testing apps could offer.

Michiel De Proost, Seppe Segers, and Heidi Mertes also focus on a specific health technology: hearing technologies for older adults. They discuss these “hearables” especially as disruptive innovations, their potential moral impact and consequences for medical ethics. The authors explore the field of moral arguments—for and against—of so-called “disruptive” hearables in ageing societies and identify four areas where moral problems could arise: prevention, empowerment, access, and the intersection of ageism and ableism. After discussing the most common arguments related to those problems, De Proost, Segers, and Mertes propose an ethics agenda for hearables, emphasizing the need for professional hearing-care services, a variety of available products, alternative solutions, and empirical reflections. In the end, they do not advocate for or against hearables but initiate a broader discussion on the ethics of disruptive hearables. To that extent, they draw attention to ethical issues of wearables in the context of ageing societies and provide further questions on how these technological devices may affect conceptions of normality, disability, and “good ageing.”

Socially assistive robots represent one of the main technologies in the care of older adults currently in development or which have already been applied. PARO, an interactive therapeutic resembling a baby seal, has been one of the most common examples of this kind of technology for a long time. The technology has rapidly evolved in recent years, and robots are seen as a potential solution to the shortage of care workers, taking over tasks such as lifting patients. Gastmans et al. provide a brief overview of the ethical issues discussed so far. Their main contributions to the corresponding debate are seven considerations from a Christian anthropology. The problem of trusting robots and the possible deception of patients by the resemblance between robots and humans, for instance, could benefit from a reflection of what makes humans special. One of the main focuses is the bodily existence of humans, their “incarnation” as entities integrating physical, social, and sociological aspects. From this results a unique and also “inaccessible human experience,” which cannot be achieved by robots.

The contributions collected in this special issue present thoughtful perspectives on how healthcare systems, digitalization, and ageing can be brought together and will stimulate further debate on these topics. We hope that the reflections discussed here will help patients or users of the technologies, healthcare workers, policymakers, and researchers to engage constructively with these complex and challenging issues.