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January 24, 2020

Ethical and Legal Aspects of Ambient Intelligence in Hospitals

Author Affiliations
  • 1The Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics, Harvard Law School, Cambridge, Massachusetts
  • 2Department of Biomedical Data Science, and the Clinical Excellence Research Center, Stanford University, Stanford, California
  • 3Harvard Law School, Cambridge, Massachusetts
JAMA. 2020;323(7):601-602. doi:10.1001/jama.2019.21699

Ambient intelligence in hospitals is an emerging form of technology characterized by a constant awareness of activity in designated physical spaces and of the use of that awareness to assist health care workers such as physicians and nurses in delivering quality care. Recently, advances in artificial intelligence (AI) and, in particular, computer vision, the domain of AI focused on machine interpretation of visual data, have propelled broad classes of ambient intelligence applications based on continuous video capture.

One important goal is for computer vision-driven ambient intelligence to serve as a constant and fatigue-free observer at the patient bedside, monitoring for deviations from intended bedside practices, such as reliable hand hygiene and central line insertions.1 While early studies took place in single patient rooms,2 more recent work has demonstrated ambient intelligence systems that can detect patient mobilization activities across 7 rooms in an ICU ward3 and detect hand hygiene activity across 2 wards in 2 hospitals.4

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    1 Comment for this article
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    Surveillance is the Bigger Issue
    Myron Pulier, MD | Rutgers New Jersey Medical School
    Selecting "ambient intelligence" for the title obscures the surveillance issue with a euphemism. Ignoring the context outside hospital walls, and ignoring the impact on the patient, on patient care and on professionalism severely constricts the applicability of this discussion. Absent religious or moral values or tradition, ethics rests on utilitarian considerations... so what is the balance of benefit against cost... and benefit for whom? This article did not address what patients and clinicians, at least, consider the bottom line utility for health care, namely clinical outcome.

    The discussion mentions serving "legitimate business interests" and bringing negligent hand washers to
    task but this hardly matches the potential harms that are not addressed. For example, routine surveillance in hospitals may normalize routine surveillance in other environments... something that many governments have eagerly instituted to stabilize their rule well before even audio technology became available.

    More specific negatives within a hospital inhere in a surveillance programme. General surveillance diverts scarce funds from actual patient care, further clutters patients' rooms, adds maintenance and administrative functions and functionaries, exposes sensitive information to outside contractors and consultants and ties up and demoralizes healthcare workers in petty hearings where they have to explain their necessary, optional, minor, harmless, misinterpreted or imagined deviations. It indicates disrespect for professionalism, adding to the healthcare system's burnout burden.

    Now, in addition to "educating" patients about their treatment, risks, rights, payment issues, obligations, proxy and do-not-code options, in addition to making patients sign multiple acknowledgements and waivers and having them repeat their birthdate over and over, now patients have to deal with opting-in or -out of this and that aspect of being surveilled in this and that location after supposedly absorbing an explanation about the local facility's methods of deidentification and reidentification of its images and videos. Yet another way to make patients serve the system.

    Can visitors insist that the spy cams be turned off while they with the patient, and then check to see if indeed their conversations with the patient have not been recorded, that the patient's complaints about some doctor(s) and nurse(s) and technician(s) and aide(s) and chaplain(s) and about their spouses and previous visitor(s) are private? Can a patient feel free to snore in an unsightly manner or masturbate in private... after all, it's hard enough for an inpatient to sleep and eat.

    With these and as yet unanticipated downsides to surveillance, an ethical approach demands prioritizing scientific assessment, measuring costs and benefits, especially in terms of clinical outcome before debating other, theoretical and relatively minor up- and downsides. If the clinical effect size is too small to matter, or too small to detect amidst all the other influences, then there is no ethical justification for deploying surveillance, with or without any contribution from artificial intelligence. Empowering and protecting administrators, creating jobs for technicians and generating fuel for prosecution and defense are hardly what the larger society considers the purpose of health care. Absent actual advantage to patients there is no point to further ethical argument.
    CONFLICT OF INTEREST: None Reported
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