3.2. An applicable Matrix?
I introduced the Matrix to the participants through the case of the GPS system. First, they were asked if they had any initial reactions. The clearest and unequivocal response to the Matrix was that the suggested approach did not provide an easily accessible overview of the GPS system because of the high level of specifications. The additional outcomes of the discussions might be separated along two strands: One pragmatic strand where the display of information and the applied case is considered, and a different strand where the Matrix is seen as an RRI-tool (see Wickson and Forsberg above). I will commence with the latter strand.
When it comes to the how the Ethical HTA Matrix is related to RRI, several of the respondents gave the impression that it opened up for reflection on problems, mutual learning and value analysis. What characterized all meetings with municipal decision-makers was extensive discussions regarding the red and orange colors in the well-being column for the stakeholder category Health system. They all expressed that the economic effects of introducing assistive technologies are real and substantial, but that there are methodological difficulties in asserting or quantifying these effects due to expected gains in other sectors in addition to those in the home-based services. Most interviewees agreed that even if this latter factor is taken into account, systematic knowledge concerning economic gains is scarce.
One could note an ambivalence regarding care workers and health professionals’ roles in innovation processes. Some informants saw their primary role as adapting to the needs of the health system and the users, whereas others regarded their contribution as constitutive of any municipal innovation process. A third view was to rethink the whole organization of the services based on the introduction of assistive technologies. I would venture that there might be different models for innovation underlying these conceptualizations of health professionals as stakeholders. The first approach connotes a view on the care workers as in a principal/agent relation [96
], whereas the second moves towards the opposite outlier where one departs from the local experiences and professional values of care workers and health professionals in order to arrive at innovations [97
]. The third approach seems managerial with a solid belief in planning and structuring to facilitate for innovations [98
There is a conflict in the literature between a view on assessments as in need of proper resources and a view suggesting that assessment frameworks should be cost-minimizing [99
]. This tension could also be found among the interviewees with some highlighting that complexity is a value in itself and one needs to dedicate the proper resources, and others who expressed that municipalities need facile and simple procedures throughout an assessment or procurement process. A different line of comment addressed that what is needed is a closer examination of the localized understanding and a systematization of existing practical knowledge. This line of thinking seems to suggest an additional place for bottom-up approaches or ethnographic studies. The latter might be difficult to reconcile with the procedural thinking in the Ethical HTA Matrix since it emphasizes rich context and local cultures [101
] whereas the former approach has been used in several instances [24
Contrary to the usual practice of using an Ethical Matrix, I have chosen to display what I refer to as Critical factors for the realization of potential values. This dimension addresses the non-use of assistive technologies and barriers to use of assistive technologies (see e.g., Scherer [102
]) and the point raised by Hofmann, Droste, Oortwijn, Cleemput and Sacchini [22
] regarding the morally relevant challenges of assessing ex ante
. They expressed that a link between the different levels of critical factors and the realizations of the relevant values is a valuable contribution.
Regarding mutual learning, nearly all the respondents recognized the different stakeholder groups and saw them as relevant with the exception of the climate/ecosystem. The exception to this was a position where only the health system and the user ought to count. The climate and the ecosystem were not in themselves considered irrelevant, but more out of scope of what decision-makers in assistive technologies might influence. Decisions on these matters are taken at a political level and implemented as general procurement rules, and form part of the calls for tender.
Several informants raised the issue of uncertainty and knowledge as central. However, there were differences in opinion on what counted as knowledge. In the matrix, I relied on published sources whereas some informants added that they had much knowledge—and this lead to a discussion on what counts as knowledge in assessments. Some municipalities conduct a range of studies by themselves, and there is a significant amount of information-sharing concerning assistive technologies between municipalities.
A related discussion to the status of knowledge were the views on who should count as the most relevant stakeholders. In this regard, the technology developers expressed interests in all stakeholder groups but with a clear orientation towards users and next of kin. On the opposite side of the spectrum, an informant from the municipalities said regarding the technology developers, “Finally, they are experiencing our power” whereas a different municipal interviewee saw co-production of services with the technology developers as crucial in fitting solutions to the actual context. The technology developers’ orientation towards users and next of kin seems to make sense since these categories constitute their end-target group and it fits their rationale. However, the divergent orientations towards technology developers as a stakeholder group indicates either that large parts of the customization of the solutions takes place in the municipalities or that these municipalities are able to make very specific orders from the technology providers. Regardless which interpretation is correct, there is a peril of little feedback from the municipalities to the technology firms. However, in the opposite case with a large degree of cooperation, this feedback would seem to be secured. These differences were raised directly in the interview with one view held that the technology firms for too long have played a strong part in the implementation of assistive technologies. Whereas a different view was to see the long relation with select technology developers as the municipality’s strongest asset in successful implementation and seeing other municipalities as not allocating adequate budgets to transform an “off-the-shelf” device to a functional assistive technology in cooperation with the technology developer. It is of interest to further research to investigate what separates the municipalities emphasizing contracts and those that emphasize collaboration as a means to successful implementation of assistive technologies.
Analysis of values created the main discussions, especially the column dignity in the matrix-produced reflections. I experienced that the informants accepted the division into utilitarian and fairness concerns easily, but the line regarding dignity was more problematic and more valuable at the same time. The problematic aspects consisted of different conceptions of dignity among the interviewees, but also among those working with assistive technologies, according to the informants. Several informants expressed that the column dignity had content that was at the core of their efforts in the health services, and likewise one technology developer said that this form of documentation of how an assistive technology might affect quality of life is central to their planning and sales as a technology firm. Dignity expressed the types of change that several of their customers sought.
When discussing the Health system as a stakeholder, one informant said that what mattered in this time of technological hype was to be frugal. Since frugality is one central concept in the recent proposal for Responsible Innovation in Health [18
], I pursued this theme and asked why she used the word frugal
and what she meant by it. She replied that one has the responsibility to ensure that patients and users receive proper care, something that cannot be left uniquely to technologists and that when spending large amounts of public money, one has the responsibility to ensure that these funds are spent well. I raised the theme if one should replace the heading welfare with the heading frugality
in the overall Matrix, but she said that while it made sense for the stakeholder of the Health system, it did not apply well to the other stakeholders.
Regarding the case and display of information, one interviewee expressed skepticism if this GPS system was a valuable case to study as an example since GPS localization currently was not seen as only unproblematic—contrary to the situation 5 or 10 years ago—but also highly desirable by everyone. In all the interviews, I had different discussions regarding specific interpretations of the content of the cells, but no one expressed that any of content was erroneous even though some were surprised or suspicious to the content of one or two cells. Displaying the knowledge status for an intervention with assistive technologies was conceived as valuable, both as providing the specific state of affairs and as a general approach. Several informants engaged in discussion if I had presented the right critical factors and of the internal links between the critical factors as well as their sequence and placement in the matrix.
In addition, we had discussions concerning the layout and the presentation. In general, the interviewees agreed that one should attempt at diminishing finer nuances and limit the presentation of the potential consequences as certain, uncertain, and ignorance. The weighing should likewise consist of the categories very important, important, and unimportant. I will not pursue the issues of layout and graphics further in this paper.
3.3. Places for Responsibility
As mentioned above, the general view was that it is too complex—at least at first sight. However, the Matrix contained elements the informants found useful, and, in addition, they mentioned concrete places for using the matrix in the working and innovation processes in the municipalities as well as potential for dialogues within the municipalities and between those implementing assistive technologies and those external to the process, such as policy-makers and firms.
Some informants expressed that one potential place in the municipal innovation chains was to employ the Matrix with health professionals or care workers in order to discuss their own experiences with existing solutions under testing or prior to deployment. One informant had recently been involved in a project where care workers filled in diaries or logs to document how a new assistive technology was used in homes. This exercise garnered an impressive amount of information regarding both the home-dwellers and the care workers interactions with the devices and with the elderly, and also regarded the organization of the services. However, what they lacked was a method that could structure what affected welfare, dignity, justice and fairness when they all discussed their individual experiences as a collective. The informants mentioned the utility of structuring discussions with care workers, however, they did this in earlier phases in order to structure concerns, thoughts and interests over novel solutions. Such dialogues are necessary and useful, but they have a tendency to be dominated by a few central themes to the detriment of less acute problems that may be of lower significance to some, but that does not mean that the themes are irrelevant. In addition, a possible use could be to investigate the relations between and experiences or views of different categories of health professionals or care workers in the home-based services.
All informants who took the perspective of using a matrix as a structure for dialogue between care workers also raised the theme of facilitation. They expressed concern that facilitating would need to be based on some specific skill set. However, this is not different from other situations where one wishes to use input from employees in developing the workplace.
A different perspective was to see the potential value of the Ethical HTA Matrix as a planning and documentation tool to prepare for the introduction of an assistive technology and structure the discussion with technology suppliers as well as mapping potential pitfalls. A similar, albeit somewhat different approach, was to apply the matrix as an intermediate mapping tool before setting out on a gain’s analysis and risk management as it provided a (too large) overview over the values at stake for the relevant stakeholders. One informant said that such work was often done more or less intuitively while the risk management and the analysis of gains had a rigorous structure. In such a use, the Matrix could be applied at an early stage in order to filter and select desired effects and to concentrate on some specific gains.
Even though several informants drew a picture where politicians set unrealistic goals or goals that would lead to a near-future impasse because of obsolete technological products, they did not mention that the Matrix held a potential to be applied at a political level or as a dialogue instrument between themselves as experts and politicians.
3.4. The Processes of Filling in the Matrix
As will be further developed in the next section, the systematic approach to the documentation of knowledge triggered interest for all informants except one. As mentioned above, there clearly exists sources of knowledge concerning the assistive technologies internally in companies and in municipalities to which outsiders do not have access. Questions are related to the creation of the presented matrix related to the literature searches, the amount of sources, the validation process, the workload, and the possible validity of the findings. However, some informants said that the main challenge in assistive technologies is not so much how to systematize what is known, but rather to bring the practical experiences with assistive technologies from the care workers to the decision-makers, and then to act on this knowledge in order to create improved services.
I emphasized that the content in the Matrix built substantively upon the Socratic approach [22
], and that these were the questions guiding the search for the central value topics. However, this step was not commented upon by any of the informants. Not even those who saw it as a useful way of structuring information in planning and implementation processes.
When I presented the validation phase—obtaining knowledge from the different stakeholders of how they rated the different values—there was surprisingly little reaction to the process, but as accounted for above, the results with font sizes and positive or negative impacts triggered discussions.