Sahana: Hi everyone! Welcome to In Limbo Conversations. Today, we have with us Nancy Jecker. Nancy Jecker is a Professor of Bioethics and Philosophy at the Department of Bioethics and Humanities in the University of Washington School of Medicine. For more details about her research, please check the links mentioned in the video description. Thank you so much for joining me today.
Nancy: Thank you.
Sahana: Today, we're going to be talking to Nancy about two themes- first is about midlife bias, it's manifestation during the pandemic and ways to tackle it; and second, more specifically, about sociable robots for older adults during the global pandemic.
So, starting with the first theme- Recently, her book titled “Ending Midlife Bias” was published where she argues that we can observe a midlife bias when we ethically analyze our ways of looking at the world. To start with, could you please tell us what midlife bias is and why do you feel- what do you feel is the source of such a bias? Why is autonomy usually valued more than other values, which are equally significant at other stages in our life?
Nancy: That's a great question. Thank you very much for inviting me to speak and to share ideas on this important topic. So, midlife bias is a term I coined to refer to applying values that are central during midlife, to all life stages. The underlying idea is that different values matter more to us at different stages of our lives and they should matter more given the conditions of human development during early life - caring, trust and nurturing ought to figure more prominently due to the vulnerabilities and needs that characterize infancy and childhood. In midlife, in young adulthood, the capacity to be more independent, to develop greater physical and emotional independence makes autonomy and self-determination a really salient value.Things start to shift again during later life when we face statistically much higher risk for chronic disease and disability which makes maintaining our capabilities in the face of loss a primary consideration and there's more of a focus on keeping our dignity intact, because it comes under threat. That's what I mean by midlife bias, and the general idea is to contextualize values to different life stages and to avoid the common mistake of using the midpoint of life. This notion of autonomy and independence figures very prominently, especially in the U.S. and many other western nations, using that as a way to make judgments about what we ought to do with all the different stages of our lives.
Sahana: You pointed out in the book that privileging midlife bias raises fundamental problems of fairness and also that it suggests larger gaps in the ethical principles and theories at hand- could you please share a bit more about it? What do you feel are the shortcomings of having this midlife bias?
Nancy: Yeah, so, why worry about it? Well it has really important practical effects and in the book I focus primarily on effects in healthcare. So, in healthcare settings, it shapes decision making on behalf of people who are not in midlife, where other values are more appropriate. For example, I talk in the book about pediatrics, and applied to pediatrics, the principle of autonomy generates what I call a “Prep-School Model.” So we focus on picturing children as future adults, as future autonomous agents and we see our job as delivering them safe to adulthood and sort of transforming children into adults.
When you're talking about an infant, is autonomy really the central value? Or is it nurturing, care and tenderness? And you're talking about someone in later life, perhaps who's care-dependent, perhaps who suffers from cognitive deficits, is it really the case that the most important thing is their self-determination? It's not that those values go away, they're just not focal values, they're not the most important values and they shouldn't be the overarching basis for our decisions on behalf of people at all stages of life.
Drawing on a prep school model, then, we focus on how to protect children's future rights to be autonomous rather than thinking about the goods that are intrinsic to childhood; and when we apply the notion of autonomy- this mid-life bias- to later life which is the primary focus of my book, that generates what I call a “Hang-in-There Model.” So, we picture later -life as holding on and we see our job as helping the old stay young and privileging mid-life values. For example, when we're making decisions on behalf of people in later-life, we use tools like advanced directives and we base our decisions on what someone wanted at a prior time, often a midlife moment, and generalize that to what's best for a present person - even if they are in later life, maybe lack autonomy or suffer from advanced dementia. We're still trying to extend this notion of autonomy rather than thinking about their present interests and well-being, so it produces all kinds of sort of strange effects. When you're talking about an infant, is autonomy really the central value? Or is it sort of nurturing and care and tenderness? And you're talking about someone in later life, perhaps who's care dependent, perhaps who suffers from cognitive deficits, is it really the case that the most important thing is their self-determination? It's not that those values go away, they're just not focal values, they're not the most important values and they shouldn't be the overarching basis for our decisions on behalf of people at all stages of life. We also tend, I think, to devalue people at different ages- so if we use a yardstick of midlife to think about children, they seem deficient - their reasoning is impaired, it's not developed, they're immature, they're not capable of moral virtues. Older people seem past their prime - they seem a shadow of their former self, so we don't value the dignity of individuals at each stage of life if we judge them by this mid-life yardstick.
Sahana: Okay. That makes sense. So, I wanted to specifically see the case of old age houses and nursing homes where we saw a range of ethical issues arise during the pandemic. So there was a time- still is, I think- where elderly people were left to take care of themselves without nurses around and I think there are reports of thousands of people losing their lives. So I remember the New York Times calling nursing homes “death pits” at some point. Could you tell me about such a crisis in old age homes and nursing homes? Could it be related to mid-life biases, like when things were being decided on how to deal with the pandemic?
Nancy: That's a great question! I think midlife bias certainly underlies in many places the devaluing of later life and the lack of investment, especially public investment in long-term care facilities, serving primarily older clientele in skilled nursing nursing facilities. We haven't invested in these facilities and we know- well, it's well documented before the pandemic even hit- we knew, for example, in the US, there was a major study that the government accounting office did documenting major deficiencies and things like infection prevention and control in nursing homes and long-term care facilities. Something like 82 percent of facilities that were surveyed showed deficits and the staff that work in long-term care facilities are underpaid and they are often working multiple jobs. So they're spreading infection from one long-term care facility to another because they don't have a living wage and they have to work in multiple jobs at the same time. I think that reflects the values of society, the view that older adults are burdens somehow rather than individuals that have rights and who deserve to be treated with respect and dignity. So the idea is “This is a burden, we don't want to put our investments there.” and we devalue the caring labor that nursing home staff make, we underpay people and we don't staff enough, and people in the US, I think in many parts of the world, have to pay out of pocket for long-term care facilities and they can't afford it; so there are informal networks that get set up. There are all kinds of problems with a lack of investment in long-term care and it will only increase as societies age, because we know that as people get older, they face increased risk of chronic disease and disability, so they'll need help with simple activities of daily living. And with changing roles of women - women having opportunities more similar to what men have, to work outside the home for education - we can't rely on female family members to serve as unpaid caregivers and perform that labor. So, we need to, as a society, invest in and value older adults and to see that that is a responsibility and a requirement. I think it's a reflection of a broader problem with long-term care, and with increased longevity comes increased care dependence and we need systems around the world that address this. There are a few places such as Japan where they do have publicly funded long-term care and they have made an investment but as societies age, it gets more and more of a strain to do it, becomes more and more of a challenge - but it's a challenge that we need to meet, because we owe it to older adults, right?
...midlife bias certainly underlies, in many places, the devaluing of later life and the lack of investment, especially public investment in long-term care facilities, serving primarily older clientele in skilled nursing nursing facilities...this reflects the values of society, the view that older adults are burdens somehow rather than individuals that have rights and who deserve to be treated with respect and dignity...we need to, as a society, invest in and value older adults and to see that that is a responsibility and a requirement...
Sahana: So, relating from that, when we are creating public policies to deal with the health crisis like the current one, what kind of policies do you think could address the mid-life bias? What are the policies which would be sensitive to later life stages? Do you feel there are any instances in the current pandemic which would sort of give us an idea of where such sensitive treatment has been there?
Nancy: That's a great question! I'm going to answer it in very broad terms. I can't think of any examples where I'd say that it's gone well. I think, broadly speaking, we need to shift from focusing on autonomy and self-determination during later life to focusing on respecting dignity and helping older adults to live dignified lives. A dignified life's approach underscores, you know what I call, reasonable efforts- making reasonable efforts to safeguard central human capabilities and I mean, the central things that we can do and be as human beings- so be healthy, have bodily integrity, just be able to use our bodies to carry out our desires and goals, exercise our senses, our imagination, our thoughts, express our emotions, affiliate with others, you know relate to nature, play, recreate, have some control over our immediate environment- these are simple things that we can do and the central things that we can do and be that are under threat when people face chronic disease and disability. People need support with activities of daily living, and respect for dignity demands that we make reasonable efforts to support people, at least at a minimal level. And that relates to what we're just talking about - long-term care facilities and that sort of support, as individuals become care-dependent in later life, increasingly at risk of that. So, I think a dignity-guided approach is what should govern policies for older adults.
A dignified life's approach underscores, you know what I call, reasonable efforts- making reasonable efforts to safeguard central human capabilities and the central things that we can do and be as human beings- be healthy, have bodily integrity, be able to use our bodies to carry out our desires and goals, exercise our senses, our imagination, our thoughts, express our emotions, affiliate with others, relate to nature, play, recreate, have some control over our immediate environment- these are simple things that we can do and be that are under threat when people face chronic disease and disability.
Sahana: Okay- this marks the end of the first segment of our conversation about mid-life bias. In the second segment, we will be looking at sociable robots. You published a paper titled “You have got a friend in me! Sociable robots for older adults in an age of global pandemics”- I think it was in July and we have linked the paper in the video description as well. So in this paper, you talk about the proposal of sociable robots as companions for older adults who are facing social isolation and loneliness due to physical distancing, especially during the lockdown. So you have talked about the idea of sociable robots, especially how modern public health strategies could leverage robot designs to create robots that are lifelike. Could you tell me how you came upon this idea of sociable robots? I'm really excited to know- how do you imagine sociable robots, like futuristically, especially when we are dealing with pandemics like this in the future as well?
Nancy: Good question! Yeah- before the pandemic, in the US, the National Academies of Sciences, Engineering and Medicine had come out with this big report that had summarized four decades of research showing how serious a problem social isolation, loneliness is. It's not just that we miss other people or we feel lonely, it really is a threat to health. It’s not debated: social isolation and loneliness predict all causes of mortality and the risk to health rivals clinical risk factors like obesity and smoking. In the US, it's associated with not only threats to physical health but psychological, cognitive health and death. It's a serious problem and it becomes even worse during a pandemic like the Covid 19 pandemic. Because during infectious outbreaks, (there are) mandates to self-isolate for long stretches with - in this case, the situation we're currently in - with no endpoint in sight yet. But in this need to contain disease-spread and keep people safe, social isolation and loneliness spike. So, what's a safe way, when we can't see our family or our friends or when we're already socially isolated and don't have interactions and opportunities to affiliate with others? What's a safe way to protect this feeling of loneliness, but also the real threats to health that go along with that?
What I propose in the paper that you mentioned is that there's an important role for social robots that's been overlooked. And just to share with your audience what I mean by a social/sociable robot - it's really an artificial agent, often powered by artificial intelligence that has some emotional intelligence, can learn about us as unique individuals, often embodied with human or animal-like features and it interacts with us and it learns social norms and behaviour attached to whatever role it's playing. And so it gives us an opportunity to interact safely and afford social interactions and help to compensate for the losses that occur during an infectious disease outbreak and to maintain health and well-being during a pandemic like Covid 19. Sociable robots can be sanitized and they can afford a safe, infection-free form of social relationships and I think they're only getting better. Not only are they getting more emotionally intelligent but the morphology, the way that they're designed - they've been these hard metallic surfaces but increasingly there's a lot of great research that's being done on soft robotics, and this research is modelling robots on objects in nature that are soft and will allow us to touch a soft surface to hug and pat and you know have the sorts of interactions that we would have with a friend. I think it's an important avenue to help not just during a pandemic but in societies where populations are rapidly aging. Social isolation and loneliness are larger problems, as that National Academies Report that I mentioned documented. So especially during pandemics, but beyond pandemics, we have a serious challenge with social isolation and loneliness.
...sociable robots give us an opportunity to interact safely and afford social interactions and help to compensate for the losses that occur during an infectious disease outbreak and to maintain health and well-being during a pandemic like Covid 19....Sociable robots can be sanitized and they can afford a safe, infection-free form of social relationships and I think they're only getting better....
Sahana: Right- so, I was hoping I could talk to you about one objection to the idea of sociable robots. It is not even an objection I guess, it is just a challenging thought. So there is a prejudice in favor of human likeness, you know, like there's a certain resistance to the possibility that robots or any machine could be capable of emotions or pairing a relationship with us. You have dealt with this point in many of the objections in your paper. On one hand, this means that people could be leaving out potential support systems but on the other hand, there are limitations to the sociality of these robots and some users could be emotionally destabilized when they lose the robot, say, due to technical errors or decisions which are beyond the person's control- like the company that handles the robots decides to shut them down. So, how do you usually weigh and evaluate all of these points when we are thinking about sociable robots?
Nancy: Well, I mean, part of my answer is just to say that you're right - about that there are risks. There are risks in human relationships as well. Relationships end, people die, people move, people you know.. And we're sad and we miss them and we can't, you know, what's the- what's the comparison? Is it some gold standard in the sky? What are the real alternatives for older adults who are alone? The alternative may not be a loving human relationship- it might be social isolation and loneliness during a pandemic, and outside the pandemic situation. So I think we need to compare sociable robots to live options and I think it's hard to make the case that social robots are going to take the place of human beings, especially during a pandemic when people are isolating. But even outside of that, more and more older adults live alone, and it's not the case that a sociable robot would be taking the place of anyone. There is a yuck factor I think- like “Oh we can't do this, we can't, you know it's perverse to interact with robots, they don't have (if you come from a Judeo-Christian society) they don't have consciousness, they don't have a soul, you know, they don't feel anything..they don't care..it's not going to be a human human relationship..it's going to be a robot-human relationship and it's going to look different.” But I think the issue is not whether we're going to have social robots- we do already and they're going to grow in their significance- the question is “How are we going to do it well? How are we going to preserve and promote the values of social interactions and affiliation that we value?” And I think the pandemic is really an opportunity to think hard about what is important to us in our social interactions and how we want to design these artificial agents to interact with us in ways that we feel good about and that will value, that will be meaningful to us. So those are great questions and I'm excited to see you know what happens in the future because I think they are coming and I hope that we do a good job with it, yeah.
I think the issue is not whether we're going to have social robots- we do already and they're going to grow in their significance- the question really is “How are we going to do it well? How are we going to preserve and promote the values of social interactions and affiliation that we value?” And I think the pandemic is really an opportunity to think hard about what is important to us in our social interactions and how we want to design these artificial agents to interact with us in ways that we feel good about and that will value, that will be meaningful to us.
Sahana: Those were all the questions I wanted to ask you Nancy. Thank you so much for doing this with me! It's been really great talking to you.
Nancy: Thank you very much! It's been a pleasure.