IEEE Technology and Society Magazine - June 2015 - 52

being that an artifact's settings can also put it in a mode
of operation that confounds a patient's preferences.
Returning to Jane's stubborn ICD, we can say that
while it is in a mode of operation Jane has not explicitly
endorsed (whether or not it corresponds to or confounds
Jane's end-of-life preferences) it is acting paternalistically. We can say this because "paternalism" is meant
to describe a particular kind of relationship, and in
the case of ICDs there exists just that kind of relationship between a patient and her ICD when the ICD is
set without a patient's explicit endorsement. The ICD is
capable of intervening in Jane's life and providing material answers to moral questions: it functions as a powerful moral proxy. So long as the ICD is functioning in a
mode of operation Jane explicitly endorses, it is acting in
Jane's best interests, and the proxy relationship between
Jane and her ICD respects Jane's autonomy. When the
ICD is functioning without Jane's explicit consent, it
acts very much like a healthcare professional poised to
assume proxy decision-making authority and impose

An internal cardiac defibrillator
can all but eliminate the need
for humans in the critical path
to medical intervention.

upon Jane its own answer to what is in Jane's best interests, despite her expressed interests to the contrary. In
this latter case, the relationship between Jane and her
ICD can accurately be described as paternalistic.
Thus, there exists a complex moral relationship
between designers, artifacts, and users. Designers can
embed into artifacts moral norms that offer material
answers to moral questions. An activated ICD attempts
resuscitation, making it both a technology that promotes
resuscitation as a valuable means of extending life,
and a technology that answers, Resuscitate! Yes, shock
the heart! By designing a switch into the ICD (a setting
for selecting between modes of operation), designers
make the ICD a technology that acknowledges and problematizes the instability of end-of-life decision-making in
healthcare. From a purely technical perspective, designers need not have included the switch (it would require
further research to determine if designers considered the
switch a practical or ethical requirement, or both). From
a moral perspective, it is essential to provide a switch.
However, the presence of a switch raises an important

question about who gets to "set" it and how - who
ultimately gets to tell the proxy which way to decide. By
designing the ICD in such a way that a patient does not
have direct access to the switch, designers embedded
another moral norm into the artifact; one that suggests
a patient ought not to have direct access to the switch.
Each design decision regarding the switch - its presence
and who gets access to it - changes the nature of the
moral relationship between the artifact and the user.
Further analysis of the presence and nature of an
ICD's on/off setting clarifies some ethical aspects of
design that engineers should acknowledge in their relationship with artifacts and users. Using the proxy model
as a framework for analysis underscores how artifacts
can function as deeply moral participants in our lives,
as proxies capable of both respecting and usurping our
autonomy in surprising ways. A switch, it turns out, is
much more than an efficient way of turning things on
and off. Without the ability to change the ICD's setting,
it would be difficult for the ICD to satisfy the ethical
requirement for ongoing consent since the "always on"
state of the ICD would eliminate the possibility of changing one's mind. Without the switch it would be difficult
to determine in an ongoing manner whose decision is
delegated to the ICD: on whose behalf would the proxy
currently be acting, the designer's or the patient's?
Add the switch, and suddenly you gain traction on
some of the problems associated with paternalistic technological moral proxies. First, you can delegate different
healthcare preferences to the proxy, enabling the possibility of ongoing consent. You also then have a mechanism for delegating explicit healthcare preferences to
the artifact. More than the mere presence of the artifact
indicating a preference, the setting indicates which preference is the current selection among whatever options
are available (resuscitation or no resuscitation in the case
of the ICD). Third, the presence of a switch forces one to
answer the question, whom ought to have access to it?
Whenever the relationship between designers, artifacts,
and patients is one in which moral proxies are instantiated in the use context via the artifact, the relationship
ought to be such that the patient's autonomy is reasonably maximized. Artifacts should not be designed to
function in a mode that would subject a patient to a problematic paternalistic relationship. It follows that patients
ought to have reasonable access to the settings that put
their technologies into modes of operation that provide
material answers to moral questions.
How can we apply these three points to a rudimentary design analysis of ICDs? We can say that beyond
any practical requirements it might also satisfy, the
presence of a switch allowing the ICD to be either active
or inactive is an ethical design requirement. We can
also say that patients ought to have more direct control

IEEE Technology and Society Magazine

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june 2015

Table of Contents for the Digital Edition of IEEE Technology and Society Magazine - June 2015