Lily Frank

This book investigates behaviour change technologies (BCTs) from an ethical perspective, examining the broader societal and philosophical implications of these types of technologies. These technologies-ranging from fitness trackers and smart home systems to digital nudging and persuasive AI-are increasingly shaping our choices, habits, and lifestyles. This book moves beyond nudging and persuasion to explore a broader spectrum of ethical concerns, including autonomy, privacy, trust, responsibility, and social justice. Contributors from leading scholars do not merely critique BCTs but also offer constructive ethical frameworks and ethical analysis for their responsible design and implementation.

The AI Act advances a risk-based approach to the legal regulation of AI systems in the European Union. While we support this development, we argue that adequate AI governance requires paying attention to the broader implications of AI systems on the socio-technical landscape in which they are designed, developed, and used. In addition to risk-based impact assessments, this involves coming to terms with the socially disruptive implications of AI, which should be governed and guided in a dynamic ecosystem of regulation, law, ethics, and evolving human practice. In this paper, we outline a ‘social disruptiveness-based’ approach to AI governance aimed at addressing disruptions by AI that are not easily captured by legal regulation, but that are nonetheless of great societal and ethical concern. We argue that integrating the AI Act risk-based approach with a social disruptiveness-based approach can offer a more nuanced understanding of the dimensions of impact of AI systems on society at large, thus enhancing the governance of AI and other socially disruptive technologies.

In recent years, there has been growing optimism about the potential of conversational agents, such as chatbots and social robots, in mental healthcare. Their scalability offers a promising solution to some of the key limitations of the dominant model of treatment in Western countries. However, while recent experimental research provides grounds for cautious optimism, the integration of conversational agents into mental healthcare raises significant clinical and ethical challenges, particularly concerning the partial or full replacement of human practitioners. Overall, this theoretical paper examines the clinical and ethical implications of deploying conversational agents in mental health services as partial and full replacement of human practitioners. On the one hand, we outline how these agents can circumvent core treatment barriers through stepped care, blended care, and a personalized medicine approach. On the other hand, we argue that the partial and full substitution of human practitioners can have profound consequences for the ethical landscape of mental healthcare, potentially undermining patients’ rights and safety. By making this argument, this work extends prior literature by specifically considering how different levels of implementation of conversational agents in healthcare present both opportunities and risks. We argue for the urgent need to establish regulatory frameworks to ensure that the integration of conversational agents into mental healthcare is both safe and ethically sound.

De Proost & Grey criticize Nickel et al.’s article “Justice and empowerment through digital health: ethical challenges and opportunities,” arguing that it should have embraced relational autonomy and capability approaches. We distinguish two variants of this critique, one saying that a view of digital health empowerment should welcome these approaches, and one saying that a view of digital health empowerment should essentially be defined in terms of these approaches. We are somewhat open to the first variant: relational autonomy and the capability approach are promising ways of spelling out the ethical values behind digital health empowerment, even if they are not completely unproblematic and uncontroversial. However, there are reasons to reject the second variant. A view that leaves the exact normative commitments of digital health empowerment open is persuasive to a wider audience, and more amenable to different constructs of autonomy, capability, and empowerment across disciplines.

In this chapter, we consider ethical and philosophical aspects of trust in the practice of medicine. We focus on trust within the patient-physician relationship, trust and professionalism, and trust in Western (allopathic) institutions of medicine and medical research. Philosophical approaches to trust contain important insights into medicine as an ethical and social practice. In what follows we explain several philosophical approaches and discuss their strengths and weaknesses in this context. We also highlight some relevant empirical work in the section on trust in the institutions of medicine. It is hoped that the approaches discussed here can be extended to nursing and other topics in the philosophy of medicine.

Advocates of moral enhancement through pharmacological, genetic, or other direct interventions sometimes explicitly argue, or assume without argument, that traditional moral education and development is insufficient to bring about moral enhancement. Traditional moral education grounded in a Kohlbergian theory of moral development is indeed unsuitable for that task; however, the psychology of moral development and education has come a long way since then. Recent studies support the view that moral cognition is a higher-order process, unified at a functional level, and that a specific moral faculty does not exist. It is more likely that moral cognition involves a number of different mechanisms, each connected to other cognitive and affective processes. Taking this evidence into account, we propose a novel, empirically informed approach to moral development and education, in children and adults, which is based on a cognitive-affective approach to moral dispositions. This is an interpretative approach that derives from the cognitive-affective personality system (Mischel and Shoda, 1995). This conception individuates moral dispositions by reference to the cognitive and affective processes that realise them. Conceived of in this way, moral dispositions influence an agent's behaviour when they interact with situational factors, such as mood or social context. Understanding moral dispositions in this way lays the groundwork for proposing a range of indirect methods of moral enhancement, techniques that promise similar results as direct interventions whilst posing fewer risks.

This report aims to offer insights into cutting-edge research on digital well-being. Many of these insights come from a 2-day academic-impact event, The Future of Digital Well-Being, hosted by a team of researchers working with the Royal Netherlands Academy of Arts and Sciences (KNAW) in February 2024. Today, achieving and maintaining well-being in the face of online technologies is a multifaceted challenge that we believe requires using theoretical resources of different research disciplines. This report explores diverse perspectives on how digital well-being can be actively cultivated, while also emphasising the importance of considering individual differences, societal contexts, and nuanced cultural factors. We aim to offer a holistic view of the future of digital well-being, one that will inspire the next generation of designers of online tools, as well as policymakers who will regulate these tools. We start by asking what digital well-being is – how we can best define a concept that is used by diverse stakeholders and researchers from many disciplines in various ways. To do this, we explore the classic ethical theories of well-being, showing how they can give us insights into how the term digital well-being is currently deployed. We then move to look at the existing strategies that have been proposed to actively cultivate digital well-being, exploring the business models that threaten digital well-being and the relative advantages of the digital and non-digital solutions that are currently proposed. On the one hand, digital tools – such as Apple’s Screen Time and app blockers such as Opal and Forest – integrate seamlessly with the digital lifestyles of users. They also create precise metrics for digital well-being, which facilitates their solutions to reduce screen time. On the other hand, non-digital solutions, including mindfulness practices, digital detoxes, and digital well-being coaching, offer a new set of tools to reconnect individuals to their natural rhythms and help to actively promote offline activities. We then move to discuss diversity and how various groups of users have strikingly different digital well-being needs. Embracing neurodiversity in digital well-being is crucial as it strongly impacts the users’ experience of online technologies. When designing for diversity, organisations and designers alike need to prioritise customization for people with physical disabilities, mitigate harmful content for users with mental well-being conditions, address gender stereotypes and online harassment, and be designed in ways that recognize the very real risks of online technologies. This report closes by examining cultural differences. We believe that non-Western conceptions of well-being offer rich sources for enhancing digital well-being insofar as these traditions can inform and inspire the designers of future online technologies. We focus on East-Asian and South-Asian traditions, although in further work we recognise it would be useful to investigate conceptions of well-being that are influential in the Gulf region, Africa, and South America. Each of these areas have ethical frameworks that discuss well-being in depth as well as a rich cultural heritage. In conclusion, this report’s insights underscore the imperative of recognizing diversity in digital well-being, both in terms of cultural contexts and disciplinary perspectives. It emphasises the need for culturally responsive design methodologies and the integration of non-Western philosophical perspectives into current digital well-being research. Embracing this diversity, we believe, offers the best chance to create digital environments that prioritise well-being for users and the societies they live in across the world. Ultimately, we believe that it is not only about designing better online products; it’s about shaping a digital landscape that promotes well-being and flourishing for everyone.

Existing ethical guidelines that aim to guide the development of mental health apps tend to overemphasize the role of Western conceptual frameworks. While such frameworks have proved to be a useful first step in introducing ethics to a previously unregulated industry, the rapid global uptake of mental health apps requires thinking more deeply about the diverse populations these apps seek to serve. One way to do this is to introduce more intercultural ethical perspectives into app design and the guidelines that aim to encourage best practices. In addition to this, existing ethical guidelines can also benefit from the ethical scholarship from the feminist and disability traditions, both of which highlight specific ethical considerations for vulnerable users. Rethinking the ethical responsibilities of mental health app designers through the prisms of feminism, disability studies, and intercultural philosophy leads us to a more global and inclusive set of ethical considerations in app design. This white paper explores what existing guidelines for the regulation of mental health apps are missing. It also explores how these guidelines could be improved for users who inhabit an increasingly diverse and globalized world.

Kunstmatige intelligentie (AI) en systemen die met machine learning (ML) werken, kunnen veel onderdelen van het medische besluitvormingsproces ondersteunen of vervangen. Ook zouden ze artsen kunnen helpen bij het omgaan met klinische, morele dilemma’s. AI/ML-beslissingen kunnen zo in de plaats komen van professionele beslissingen. We betogen dat dit belangrijke gevolgen heeft voor de relatie tussen een patiënt en de medische professie als instelling, en dat dit onvermijdelijk zal leiden tot uitholling van het institutionele vertrouwen in de geneeskunde.

In the last few decades, several philosophers have written on the topic of moral revolutions, distinguishing them from other kinds of society-level moral change. This article surveys recent accounts of moral revolutions in moral philosophy. Different authors use quite different criteria to pick out moral revolutions. Features treated as relevant include radicality, depth or fundamentality, pervasiveness, novelty and particular causes. We also characterize the factors that have been proposed to cause moral revolutions, including anomalies in existing moral codes, changing honour codes, art, economic conditions and individuals or groups. Finally, we discuss what accounts of moral revolutions have in common, how they differ and how moral revolutions are distinguished from other kinds of moral change, such as drift and reform.

In this chapter we take stock of some of the complexities of the sprawling field of AI ethics. We consider questions like "what is the proper scope of AI ethics?" And "who counts as an AI ethicist?" At the same time, we flag several potential uses and abuses of AI ethics. These include challenges for the AI ethicist, including what qualifications they should have; the proper place and extent of futuring and speculation in the field; and the dilemmas concerning how we use our public and academic resources.

The proposition that digital innovations can put people in charge of their health has been accompanied by prolific talk of empowerment. In this paper we consider ethical challenges and opportunities of trying to achieve justice and empowerment using digital health initiatives. The language of empowerment can misleadingly suggest that by using technology, people can control their health and take responsibility for health outcomes to a greater degree than is realistic or fair. Also, digital health empowerment often primarily reaches people who already have high technological and health literacy, leaving others behind. We critically investigate whether the concept of health empowerment could be re-engineered to mean something different, namely the process of improving the health literacy and access of those who least possess it, in line with recent proposals for conceptual engineering in the service of justice. We settle on the weaker conclusion that underlying ethical values including justice should be used to interpret the existing concept of empowerment. To conclude, we take a high-level view of various strategies for achieving the ethical value associated with digital health empowerment.

How could ectogestative technology disrupt gender roles, parenting practices, and concepts such as ‘birth’, ‘body’, or ‘parent’? In this chapter, we situate this emerging technology in the context of the history of reproductive technologies and analyse the potential social and conceptual disruptions to which it could contribute. An ectogestative device, better known as ‘artificial womb’, enables the extra-uterine gestation of a human being, or mammal more generally. It is currently developed with the main goal of improving the survival chances of extremely premature neonates. We argue that the intended use of the technology in neonatal intensive care units, as an alternative to current incubators (’partial-ectogestation’), challenges concepts such as ‘birth’, ‘fetus’, and ‘neonate’, and has several ethico-legal implications. We moreover address a more futuristic scenario where the entire embryological and fetal development could happen within an artificial womb (’full-ectogestation’). Such a scenario reveals the disruption of gender roles, parenting practices, and concepts such as ‘mother’, ‘father’, and ‘parent’. Both full- and partial-ectogestation would have implications for engineering and design, law-making, ethics, and philosophical anthropology.

The “attention economy” refers to the tech industry’s business model that treats human attention as a commodifiable resource. The libertarian critique of this model, dominant within tech and philosophical communities, claims that the persuasive technologies of the attention economy infringe on the individual user’s autonomy and therefore the proposed solutions focus on safeguarding personal freedom through expanding individual control. While this push back is important, current societal debates on the ethics of persuasive technologies are informed by a particular understanding of attention, rarely posited explicitly yet assumed as the default. They share the same concept of attention, namely an individualistic and descriptive concept of attention that is a cognitive process, an expendable resource, something that one should control individually. We step away from a negative analysis in terms of external distractions and aim for positive answers, turning to Buddhist ethics to formulate a critique of persuasive technology from a genuinely ethical perspective. Buddhist ethics points at our attention’s inescapable ethical and ontological embeddedness. Attention as practice requires “the right effort” to distinguish desirable and undesirable states, the “right concentration” to stop the flow we are caught in, and the “right mindfulness” to fortify the ability to attend to the present situation and keep in mind a general sense of life’s direction. We offer input for further philosophical inquiry on attention as practice and attention ecology. We put forward comfort/effort and individualism/collectivism as two remaining central tensions in need of further research.

In this chapter we identify three potentially morally problematic behaviours that are common among users of dating and hook-up apps (DHAs) and provide arguments as to why they may or may not be considered (a) in a category of their own, distinct from similar behaviours outside of DHAs; (b) caused or facilitated by affordances and business logic of DHAs; (c) as indeed morally wrong. We also consider ways in which morally problematic behaviours can be anticipated, mitigated, or even prevented by analysis of the ethical and moral dimensions of technologies and their afforded uses. Finally, we offer some possible directions for future work on these topics in particular and on the ethical consequences of DHAs in general.

The power of technology to transform religions, science, and political institutions has often been presented as nothing short of revolutionary. Does technology have a similarly transformative influence on societies’ morality? Scholars have not rigorously investigated the role of technology in moral revolutions, even though existing research on technomoral change suggests that this role may be considerable. In this paper, we explore what the role of technology in moral revolutions, understood as processes of radical group-level moral change, amounts to. We do so by investigating four historical episodes of radical moral change in which technology plays a noteworthy role. Our case-studies illustrate the plurality of mechanisms involved in technomoral revolutions, but also suggest general patterns of technomoral change, such as technology’s capacity to stabilize and destabilize moral systems, and to make morally salient phenomena visible or invisible. We find several leads to expand and refine conceptual tools for analysing moral change, specifically by crystallizing the notions of ‘technomoral niche construction’ and ‘moral payoff mechanisms’. Coming to terms with the role of technology in radical moral change, we argue, enriches our understanding of moral revolutions, and alerts us to the depths of which technology can change our societies in wanted and unwanted ways.

Dating and hookup apps (DHAs) are now widely used and may be transforming our intimate relationships. The apps are beneficial in fostering intimate connections among those who are lonely, who are members of minority or marginalized groups, or who live nomadic lifestyles because of work or recreational travel. However, the wider social and relational changes that DHAs portend are merely beginning to be seriously discussed by academics (Arias et al., 2017). In this chapter, we employ concepts from the philosophy of technology that inform our analysis of these changes. We also collate some of the morally significant impacts of DHAs and present some of the elements of the architecture of DHAs that facilitate them. Although there are many reasons to be concerned about DHAs, we argue that there is room for cautious optimism that DHAs may be vehicles of positive social and moral change.

This paper provides an analysis of the way in which two foundational principles of medical ethics–the trusted doctor and patient autonomy–can be undermined by the use of machine learning (ML) algorithms and addresses its legal significance. This paper can be a guide to both health care providers and other stakeholders about how to anticipate and in some cases mitigate ethical conflicts caused by the use of ML in healthcare. It can also be read as a road map as to what needs to be done to achieve an acceptable level of explainability in an ML algorithm when it is used in a healthcare context.

Addiction appears to be a deeply moralized concept. To understand the entwinement of addiction and morality, we briefly discuss the disease model and its alternatives in order to address the following questions: Is the disease model the only path towards a ‘de-moralized’ discourse of addiction? While it is tempting to think that medical language surrounding addiction provides liberation from the moralized language, evidence suggests that this is not necessarily the case. On the other hand non-disease models of addiction may seem to resuscitate problematic forms of the moralization of addiction, including, invoking blame, shame, and the wholesale rejection of addicts as people who have deep character flaws, while ignoring the complex biological and social context of addiction. This is also not necessarily the case. We argue that a deficit in reasons responsiveness as basis for attribution of moral responsibility can be realized by multiple different causes, disease being one, but it also seems likely that alternative accounts of addiction as developed by Flanagan, Lewis, and Levy, may also involve mechanisms, psychological, social, and neurobiological that can diminish reasons responsiveness. It thus seems to us that nondisease models of addiction do not necessarily involve moralization. Hence, a non-stigmatizing approach to recovery can be realized in ways that are consistent with both the disease model and alternative models of addiction.

Moral bioenhancement, nudge-designed environments, and ambient persuasive technologies may help people behave more consistently with their deeply held moral convictions. Alternatively, they may aid people in overcoming cognitive and affective limitations that prevent them from appreciating a situation’s moral dimensions. Or they may simply make it easier for them to make the morally right choice by helping them to overcome sources of weakness of will. This paper makes two assumptions. First, technologies to improve people’s moral capacities are realizable. Second, such technologies will actually help people get morality right and behave more consistently with whatever the ‘real’ right thing to do turns out to be. The paper then considers whether or not humanity loses anything valuable, particularly opportunities for moral progress, when being moral is made much easier by eliminating difficult moral deliberation and internal moral struggle. Ultimately, the worry that moral struggle has value as a catalyst for moral progress is rejected. Moral progress is understood here as the discovery and application of new values or sensitization to new sources of harm.

Engineering an artificial intelligence to play an advisory role in morally charged decision making will inevitably introduce meta-ethical positions into the design. Some of these positions, by informing the design and operation of the AI, will introduce risks. This paper offers an analysis of these potential risks along the realism/anti-realism dimension in metaethics and reveals that realism poses greater risks, but, on the other hand, anti-realism undermines the motivation for engineering a moral AI in the first place.

It is not clear to what the projects of creating an artificial intelligence (AI) that does ethics, is moral, or makes moral judgments amounts. In this paper we discuss some of the extant metaethical theories and debates in moral philosophy by which such projects should be informed, specifically focusing on the project of creating an AI that makes moral judgments. We argue that the scope and aims of that project depend a great deal on antecedent metaethical commitments. Metaethics, therefore, plays the role of an Archimedean fulcrum in this context, very much like the Archimedean role that it is often taken to take in context of normative ethics (Dworkin 1996; Dreier 2002; Fantl 2006; Ehrenberg 2008).

Upon entering the examination room, Caitlyn encounters a woman sitting alone and in distress. Caitlyn introduces herself as the hospital ethicist and tells the woman, Mrs. Dennis, that her aim is to help her reach a decision about whether to perform an autopsy on her recently deceased husband. Mrs. Dennis begins the encounter by telling the ethicist that she has to decide quickly, but that she is very torn about what to do. Mrs. Dennis adds, “My sons disagree about the autopsy.” As a standardized patient, a specialized actor, the woman playing Mrs. Dennis has already delivered the same opening lines several times to different learners practicing their clinical ethics consultation skills. An SP encounter is a simulated patient encounter used for educational purposes that requires the standardization of verbal and behavioral responses. In the encounter, the simulator, or “patient,” uses a scripted medical history to enable the learner to employ a certain skill, say, the ability to perform a neurological exam. The use of standardized patients in the evaluation of clinical skills has become a staple in medical education. To tackle the challenge of teaching clinical ethics consultation skills, we have incorporated SP encounters into the curriculum of the Bioethics Program of The Union Graduate College and the Icahn School of Medicine at Mount Sinai. SP encounters are incorporated into one of our onsite classes, the Onsite Clinical Ethics Practicum, and they are part of the capstone examination, which all of our graduates must complete successfully. The inclusion of simulated encounters into the curriculum is one way in which we equip our students with the core competencies specified by the American Society for Bioethics and Humanities Task Force for clinical ethicists