Use of Robotic Media as Persuasive Technology and Its Ethical Implications... Ryuji YAMAZAKI et al.

REVIEW ARTICLE

Use of Robotic Media as Persuasive Technology and
Its Ethical Implications in Care Settings
Ryuji YAMAZAKI1, Shuichi NISHIO2, Hiroshi ISHIGURO2,3, and Hiroko KASE1
1 Waseda University; 2 Advanced Telecommunications Research Institute International; 3 Osaka University
E-mail: rys@aoni.waseda.jp (Correspondence: Ryuji Yamazaki)

Abstract
Communication support for older adults has become a growing need; as well, assistive technologies
such as robotic media are expected to facilitate social interactions in both verbal and nonverbal ways.
Focusing on dementia care, we consider two studies exploring the potential of robotic media that
could promote changes in subjectivity in older adults with Behavioral and Psychological Symptomsof Dementia (BPSD). Further, we investigate the conditions that might facilitate such media’s use
in therapeutic improvement. Using case studies in dementia care, we investigate the potential andconditions that allow robotic media to mediate changes in human subjects. The case studies indicatethat those with dementia become more open and prosocial, thanks in part to robotic intervention, byusing suitable conversational topics to catalyze case study patients’ reactions more efficiently. The
two studies under review also mention the requirement of considering both the positive and negative
aspects of using robotic media. With social robots being developed as persuasive agents, users
sometimes have difficulty controlling the information flow, and thus when personal data is dealt with,ethical concerns arise. The ethical implication is that persuasive technology puts human autonomy atrisk. Finally, we discuss the ethical implications and the effects on emotions and behaviors by applying
persuasive robotic media in care settings.
Keywords: BPSD, communication, mediation, prosocial, reminiscence, persuasion, autonomy,
freedom, ethics, feedback.

1. Introduction
As the aging of our society rapidly advances, theratio of those with dementia increases along with
the need for care systems that can support older
adults with dementia, in a home or residential
setting. Just as social media can promote people’sinteraction, especially among the young, robotic
media technology may be able to help overcome
the digital divide that disadvantages present
older adults, including those with dementia.
Further, technology that can affect sociability
and behavior via persuasion is on the rise. Let us
consider the use of such technology, its effects,
and related issues in different approaches to using
robotic media in dementia care.
In dementia care in residential or homesettings, there is typically a severe lack ofstaff, so much so that the isolation of people
with dementia has become a social issue. In
such a situation, it is difficult for older adults
with dementia to have dialogue opportunities
and communicative stimulation in daily life.
Several ways of using media technology havebeen proposed, but only a limited amount ofresearch has explored the inf luence of social
robotic media, including persuasive technology.
The discomfort caused by media design thatclosely replicates the human form, such as
androids and humanoid robots, is known as theuncanny valley. However, once we interact withrobots, the discomfort is usually overcome. In
fact, field studies with teleoperated androids
have revealed that such robots create a sense ofaffinity, especially in older adults with dementia,
and can promote positive attitudes while evoking
imagination. By making use of such technology,
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Journal of Philosophy and Ethics in Health Care and Medicine, No. 12, December 2018

it is important to investigate its effects on
lessening symptoms of dementia such as agitation
and apathy.
On the basis of the studies considered inthis paper, we investigate the effects and related
issues while considering how robotic media
affect the sociability and behavior of older adults
in their relationships. Further, a pilot study showsthat by providing topics related to a patient’s
personal history, positive effects could emerge
in older adults with dementia. Consequently, it
is expected that media technology incorporatingsuch inf luential information could reduce thesymptoms associated with dementia. Therefore,
we need to investigate ways to enhance robotic
operation systems as well as ways to make useof memory and personal information to promotedialogue using media technology, rather than aface-to-face encounter.
The purpose of this study is to investigate
the nature of inductive media technology andsubjectivity changes in older adults with dementia
through the intervention of media technology.
These investigations were made based on casestudies on older adults’ sociability, mediated byrobots.
In the following sections, we first describe
current research on welfare technology, social
robotics, and persuasive technologies. Next, we
explain previous studies conducted in Denmark,and then in sections 3 and 4, we present two fieldstudies in Japan. In section 5, we discuss theimplications of our experimental results as wellas ethical issues, and conclude with summary
remarks.

2. Related work
With the increasing population of older adults, therobotic approach to dementia care has become ahot topic, due primarily to staff shortages in careservices, with people’s demand for aging-in-placesolutions, and the need for new technologicalapproaches. Such technologies as Information
and Communication Technology (ICT) andpersuasive media technology could play a keyrole in assisting older adults and providing thetools for improved treatment settings.

46

2.1 A robotic approach to care for older
adultsA s a c o m m u n i c a t io n a i d , r e m i n i s c e n c einter vention has proven itself effective bytriggering long-term memory to evoke emotional
responses and facilitate conversation witholder adults with dementia. Studies such as
the CIRCA computer reminiscence program[1] and the net worked interaction therapy
based on Web technology [2] have shown theimpor tance of conversation among people
with dementia and those surrounding them toreduce various behavioral and psychologicalsymptoms associated with dementia (BPSD)
such as agitation, depression and aggression [3].
Telecommunication media have the potential
to relieve such symptoms while improving
relationships and social interaction.
The challenge of developing effective media
comes from trying to satisfy both the verbal andnonverbal communicative needs of older adults.
The Giraff robot is one of the video conferencing
technologies that has been developed to enhanceinteraction [4]. It is remotely controlled and canprovide limited physical interaction by tilting
its head, while audio and video communication
is provided to make it look friendly for older
users. Other robots made for non-verbal tactileinteraction have therapeutic and stress-reducing
effects, such as the zoomorphic Paro the Seal,
which was designed as a companion robot todecrease loneliness [5]. Telephone or videoconferencing systems such as Skype lack tactileinteraction, whereas huggable communication
media such as Telenoid and Hugvie, promote
non-verbal and verbal interactions. The huggablecom mu n icat ion med iu m Hug v ie prov ides
opportunities for tactile interaction and has theeffect of reducing anxiety [6, 7]. With a humanlike shape, it enables users to feel a humanpresence, as well as talking and listening to the
Hugvie medium. Telenoid, a similar but moreadvanced version that can be teleoperated,
inspired Hugvie’s minimalistic human design [8,9]. With the advantage of multiple modalities,
robotic media technology is expected to improvemental health and behavior, i.e., to provide wellbeing for older adults with dementia.

Use of Robotic Media as Persuasive Technology and Its Ethical Implications... Ryuji YAMAZAKI et al.

2.2 Persuasive technologies
With the intent to change our attitudes andbehaviors, researchers applying communicative
robotic tech nolog y to assist patients withde me nt ia a r e st r iv i ng t o a d d p e r s u a sivecom mu n icat ive feat u res. As descr ibed i n
psychology literature, persuasion is “an attempt
to shape, reinforce or change behaviors, feelingsor thoughts about an issue, object or action”[10]. A key point in the definition is that true
persuasion requires an intent to change attitudes
or behaviors, i.e., intentionality. If in creating,
distributing, or adopting a technology lies theintent to change attitudes or behaviors, the related
technology inherits this intent from its humandevelopers. Stated another way, a technology ispersuasive in the sense that it mirrors the intent
of its manufacturer. Methods of persuasion areplenty, and they are encountered in our daily
use of technologies such as computers, mobile
phones and videogames. Algorithms are often
incorporated to achieve a developer’s goal, forinstance, advertisements based on user behavior
or even in-app purchasing. Along with the useof technology, two types of human interaction,either through or with computing systems, havebeen examined as two separate issues. First, forcomputer-mediated communication, technology
is used as an auxiliary mediator between two
or more users, not as the terminus of a user’s
action [11]. Second, human interaction with
but not through computing systems lies in thefield of captology, “Computers as Persuasive
Te ch n olog y ” [10], wh ich u n d e rl i n e s t h epersuading relationship between the users and thesystems themselves.
Our focus here is on people interacting withmedia and the power of technological persuasion
to affect social interaction and to apply social
norms to behavior. Social dynamics is one of
the main features of persuasive technology [12],and it reflects the relations between people andcomputing systems in a similar way to people
following unwritten implicit rules, i.e., norms
in interactions with each other. An example
of attempting to shape attitudes in a specificway can be seen, for example, in digital toys
for children such as the goods and charactersthat express emotions and ask users to respondwith corresponding feelings.1 By using suchtoys, children learn and adapt their behavior
accordingly in their interactions with humans
as well. In this context, we expect human-likerobots to have the same effect through “ambientpersuasion” as the persuasive and intelligent
computing systems capable of directly interactingwith users in their everyday life.

3. Reactions from users and nonusers
Based on a case study on the acceptabilityof a teleoperated robot conducted in Japan,
a field study was conducted at a care facility
in Denmark, where assistive technologies areembraced and institutional care is being replacedwith care housing [14, 15]. The pur pose of
the research in Denmark was to explore andcompare reactions toward an android robot as acommunication medium for older adults and toinvestigate whether its design technology was
acceptable across cultures for supporting their
quality of life. Denmark has an advanced welfare
system, and welfare technologies are currently
incorporated in it and continue to be developed.
Social robots such as Paro and telepresence
robots have been produced to support older
adults in keeping their social connections andwell-being; accordingly, the acceptability of
teleoperated androids for seniors needs to beinvestigated. We started an experiment with
the Telenoid ® (Figure 1), 2 a 50-cm and 3-kg
minimalistic human-designed teleoperated robot
with the ability to let the operator move its head
and arms while talking [15]. It was developed by
Osaka University and ATR’s Hiroshi Ishiguro
Laboratories.
Figure 1: Older adult interacting with Telenoid

A participant who was aggressive gradually started
showing prosocial behaviors.

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Journal of Philosophy and Ethics in Health Care and Medicine, No. 12, December 2018

3.1 User reactions
A two-day trial was conducted with two maleparticipants who were living alone in houses
attached to care facilities: a healthy 92-yearold (participant K) and a 75-year-old with mild
Alzheimer’s (participant L). In both cases, we
set Telenoid up where they could relax andreceive visitors. A connected room was used to
set up the operating system for tele-operation by
the researchers, nursing students, and a friendof the participants. In the individual homes,
Telenoid encouraged positive responses andbehaviors from both participants K and L, whowillingly maintained conversations in a naturalmanner with Telenoid, from the beginning.
We observed that their attitudes toward it wereconsistently positive and they both engaged wellwith Telenoid. Participant K did so by being
talkative, while participant L included non-verbal
communications such as hugging.
3.2 Public opinion
Since android robots require operators such as
volunteers and family members, it is necessary
to capt u re positive public opi nion on theacceptability of implementing a robot, but
integrating android robots to eldercare settings
has already met resistance from non-users.
Anxiety over the replacement of humans withrobots has been expressed as concern about
surrendering human relations to machines. For
example, one report describes the strange sightof seniors interacting with the Telenoid robot,
as did Participants K and L. The report quoted
disdainful comments on a TV station’s website
about its feature story on Telenoid’s visit to anolder adult’s home [16]. “Nothing, absolutely
nothing, will ever replace real and present
compassionate touches and care. How sad that
we have come to this point, where such a debate
can possibly take place,” wrote one user [16].
According to an expert in information andmedia studies, it would be strange to deny such
togetherness just because it does not follow thecurrent social norms, adding that technology
constantly creates new ways for us to be together,using Facebook as an example. Moreover, anotherexpert in ethics said, “When people talk on thephone, they also lose a degree of emotional
feelings, expression of respect, and so on. You48

could easily reduce human emotions using
robots. Relational Technology can therefore
lead to curtailment of human emotions” [16].
Even if emotional involvement is reduced, it
has ambiguous aspects and can be seen both
negatively and positively [17]; therefore, botht y pes of effects require investigation. We
should also explore the advantages of mediatedcommunication, which could be attractive
even when the option of interaction in physicalproximity is available [18]. Therefore, we suggest
long-term studies using android robots while
keeping pitfalls such as novelty effects in mind.

4. Field study 1
We explored how the sociability of older adults
with BPSD could be affected by use of robots,
as described. For this purpose, we introduced
Telenoid to a care facility for older residents
with dementia, and we investigated changes inthe subjects over time. As the initial state of alongitudinal study, the experiment was conductedintermittently for two months to minimize
the novelty effect on the results. This study,
discussed below, showed positive and prosocialchanges [19-21].
4.1 Method
A field experiment was conducted at a carefacility where Telenoid was introduced ten times,
intermittently, for about two months (averageinterval, 6.6 days) to two female participants
with Alzheimer’s and BPSD, an 88-year-old(participant A) and a 93-year-old (participant B).
We conducted a quantitative and qualitative study
that collected narrative and behavioral data of thesubjects during conversations. While interacting,the volunteer teleoperator spoke through Telenoid
to the participants and replied with nodding andhugging them. A mock-up resembling Telenoid,
which neither talks nor moves, was used fromday 2 to 5 for comparison. The residents’behaviors were observed, classified, coded, andanalyzed, based on ten-minute video recordings
from each day. We divided reactions into positive(prosocial or altruistic behavior) and negative,
verbal and non-verbal (Table 1). Prior to theexperiment, we received approval from the Ethics
Committee at Advanced Telecommunications
Research Institute International.

Use of Robotic Media as Persuasive Technology and Its Ethical Implications... Ryuji YAMAZAKI et al.

over time to be more communicative, and theprospect of verifying the android’s effects onsenior citizens in further longitudinal studies is
promising.
From both participants, continuous andvarious reactions were shown. Positive reactions
were shown by saying “It is smiling.” or “It iscute.” and, as time passed, participants started
showing various ways of engagement (Tables
1, 2). At first, participant A was almost asleep
and paid little attention to the robot next to her.
However, in the adaption process, she gradually
started speaking to the robot positively (Figure2, 3). Participant B showed strong reactions fromthe beginning and increased her behavior bytalking to other people around the robot and paid
more attention to the robot, by taking care of it.

4.2 Results
The study shows that the older adult residents
developed prosocial behaviors and increasingly
positive attitudes toward Telenoid. Participant
A, who was aggressive due to dementia, started
to calm down and gradually increased herinteraction, verbally and non-verbally, with
Telenoid, in showing prosocial behaviors suchas stroking its head and attempting to give foodto it (Figure 1). On the other hand, participant B,
who tended to remain isolated and in her room,
showed a strong attachment to Telenoid from the
beginning, started to come out to see it, and then
expanded the various ways of interaction, such as
by sharing the conversation with other residents.
Telenoid encouraged the older adult participants

Change in frequency of speech of participant A

ChangeinChangefrequencyof speech
ofofparticipant
Figure 2:
in frequencyof speech

Table 1: Classification of participants’ speech㻞㻜㻜contents
Category

Positive(mainly,
altruistic
behavior)㻲㼞㼑㼝㼡㼑㼚㼏㼥㻌

PraiseAffection
CaringRequestDaily events in life, telling㻢㻣㻲㼞㼑㼝㼡㼑㼚㼏㼥㻌

Speechparticipant A㻝㻤㻜
Example㻝㻢㻜㻝㻠㻜 grinning, “Good“Pretty eyes”,
boy/girl” 㻝㻞㻜㻝㻜㻜“Pretty child”, “Come to me”,
㻤㻜“You are thebest for me”
㻢㻜Singing songs,
㻠㻜 sharing drinks,
Defending 㻞㻜㻜Singing together,inviting to go㻝 㻞 㻟 㻠 㻡
out to play

㻤

㻰㼍㼥㻌

Introduction others about Telenoid
Resistance
Negative

Discomfort from its stare, “Toosmart”

㻞㻜㻜
㻝㻤㻜
㻝㻢㻜
㻝㻠㻜
㻝㻞㻜
㻝㻜㻜
㻤㻜
㻥 㻝㻜
㻢㻜
㻠㻜
㻞㻜
㻜

㻼㼛㼟㼕㼠㼕㼢㼑
㼟㼜㼑㼑㼏㼔
㻺㼑㼓㼍㼠㼕㼢㼑
㼟㼜㼑㼑㼏㼔

㻼㼛㼟㼕㼠㼕㼢㼑
㼟㼜㼑㼑㼏㼔

㻭㼘㼘㻌㼟㼜㼑㼑㼏㼔㻺㼑㼓㼍㼠㼕㼢㼑
㼟㼜㼑㼑㼏㼔

㻭㼘㼘㻌㼟㼜㼑㼑㼏㼔3

㻝 㻞 㻟 㻠 㻡 㻢 㻣 㻤 㻥 㻝㻜
Heaviness When holding and hugging
Changein frequency
of non-verbal behavior of 㻰㼍㼥㻌
“Get away”,“Turn away”
Bad temper
speech content, e.g., “You are the best forparticipant APositiveme” gradually increased (A mock-up was used fromday 2 to 5 for comparison).
Ta b l e 2: Cl a s si f ic at㻠㻡i on of p a r t icip ant s’behaviors㻠㻜Figure 3: Change in frequency of non-verbal
behavior of participant A
SpeechCategory 㻟㻡
ExampleBeckoning,
looking
intoeyes
Approach 㻟㻜㻠㻡Positive㻠㻜Support㻝㻜
Showing by pointing, pointingat㻡 something to give㻜Holdinga cup to share drinks,
㻝 the
㻞 robot’s㻟㻠directions
㻡㻢changing
to avoid other residents 㻰㼍㼥㻌Resistance

Surprised by fast motions orvibration of the robot

Heaviness

Looking for a person who canhold it instead
Making a gesture of clutching

Bad temper a care staff member who wastrying to hand over Telenoid㻼㼛㼟㼕㼠㼕㼢㼑
㼎㼑㼔㼍㼢㼕㼛㼞

㻟㻡

Synchroniza- 㻝㻡
Nodding, imitating its motions
tion
Instruction

Negative

Rubbing, kissing, lifting the
㻞㻡
robot
㻞㻜

㻣

㻤

㻲㼞㼑㼝㼡㼑㼚㼏㼥㻌Touch㻲㼞㼑㼝㼡㼑㼚㼏㼥㻌

Change in frequency of non-verbal behavior
participant A㻥㻺㼑㼓㼍㼠㼕㼢㼑
㼎㼑㼔㼍㼢㼕㼛㼞

㻟㻜㻞㻡㻼㼛㼟㼕㼠㼕㼢
㼎㼑㼔㼍㼢㼕㼛㻞㻜㻝㻡㻝㻜㻺㼑㼓㼍㼠㼕㼢
㼎㼑㼔㼍㼢㼕㼛

㻝㻜
㻡
㻜
㻝

㻞

㻟

㻠

4

㻡

㻢

㻣

㻤

㻥

㻝㻜

㻰㼍㼥㻌

Positive behavior, e.g., kissing gradually increased (Amock-up was used from day 2 to 5 for comparison).
49

Journal of Philosophy and Ethics in Health Care and Medicine, No. 12, December 2018

She was pleased to tears with having the robot
visit her, and she welcomed it from the beginningby saying, “It is good you came, to see such an
old person like me. You look nice.” Comparedwith participant A, participant B engaged withthe robot positively from the beginning and kept
this engagement, even with the mock-up, to someextent. In the comparison between Telenoid andthe mock-up, when Telenoid moved, especiallywhen responsive movements increased, theparticipants became more positively engaged. We
also investigated whether there was a difference
on average between the mock-up and Telenoid,
concerning the amount of positive utterancesand behaviors. In the case of participant A
communicating with Telenoid, utterances were
6.5 times greater, while behavior was 4.7 times
greater. For participant B, utterances were 1.8
times greater, while behavior was 1.3 times
greater. In all cases, the frequency was higher
with Telenoid than with the mock-up. Thissuggests Telenoid’s utterances and movements
are effective in extracting stronger reactions fromolder adults with dementia.

work for older adults with dementia: C1) No
sound, C2) Radio, non-interactive, C3) Daily
conversation, and C4) Reminiscence work. Theinteractions were recorded, and later transcribed,
to count the duration of concentration andnumber of utterances (words and particles).
Behaviors and utterances directed only to Hugvie
were counted in the duration of concentration.
Prior to the experiment, we had received approval
from the facility’s administrator, all participants,
and the participants’ family members, based on
the approval for the experiment from the Ethics
Committee at Waseda University.
Figure 4: Older adults using Hugvie

5. Field study 2
In this study we investigated whether there
were conditions that could affect emotions andbehavior in older adults with dementia [22] byintroducing the huggable communication medium
Hugvie ® developed by Osaka University and
ATR’s Hiroshi Ishiguro Laboratories.3
5.1 Method
A field experiment was conducted at a longterm care facility for older adults with dementia.
The experiment included f ive par ticipants(three females and two males), all diagnosed
with dementia (M=89.8 years, SD=6.85) with atendency to show some BPSD. Their conversation
partner was a male in his 20s who had received
basic information and life histories about all
participants in advance. Hugvie (Figure 4), a
600-g, 75-cm pillow-phone in a minimalistic
human form designed to enable the feeling ofpresence while talking with it and hugging it,
was introduced to participants individually, forup to 15 minutes per session. This was done toinvestigate how the following Conditions (‘Cs’)
50

Participants were given the medium with four conditions, i.e., (1)No sound, (2) Radio, non-interactive, (3) Daily conversation, and(4) Reminiscence work.

5.2 Results
We observed and compared the duration ofconcentration and the number of utterances. Asan overall result, under condition 4 (reminiscencewo r k), t h e f ive p a r t ic ip a nt s m a i nt a i n e dconcentration in interacting with the medium fora duration of 2.23 times longer than condition 2(radio, non-interactive) and 2.88 times longer thancondition 3 (daily conversation) (Figure 5). The
maximum duration was more than 10 minutes.
In condition 4, the number of results was 2.11
times larger than in condition 2 and 1.69 times
larger than in condition 3 (Figure 6). Further, one
participant kept talking negatively in condition
3, but in condition 4, she changed her mood andkept talking positively.

Use of Robotic Media as Persuasive Technology and Its Ethical Implications... Ryuji YAMAZAKI et al.

Figure 5: Total duration of concentration on
Hugvie by all participants in each condition(‘C’ in figure) Concentration duration
1600

1380

1400

1000

Sseconds

seconds

1200

800
600

480

620

400

105

200
0

C1C1
C1

C2
C2
C2

C3
C3
C3

C4
C4

C4

Reminiscence work (C4) provided the most prolonged
concentration.

Figure 6: Total number of utterances by allparticipants in each condition (‘C’ in figure)and particles

Number of words
and particles
Amount of woords

Utterances

600

553

In the results of field study 1, changes were foundin participants with dementia toward prosocial
behavior. This result can be seen as an example ofchanges in human subjectivity via robotic media.
In most cases, the Telenoid robot was perceived
as a small child, but as observed in relation withthe mock-up, passivity is not the only factor
that promotes change. Through interaction withrobotic media, we need to consider how best to
motivate older adults with dementia, to engage
them and help them change their behaviors.
In field study 2, we inferred that there ispotential for efficiently gaining the attention ofolder adults through mediation. In this section,
we discuss the implication of these studies,including ethical issues.
6.1 Promotive factors for voluntariness

500
400

328

300

262

200
100
0

6. Discussion

12
C1
C1
C1

C2
C2
C2

C3
C3
C3

C4
C4
C4

Reminiscence work (C4) provided the most utterances.

Although the overall results showed that
reminiscence work prolonged interaction, theindividual results imply that there are morenuances. Two of the participants did not show
reactions in the four conditions. One kept
ref using to hold Hugvie, and another was
almost always sleeping on that day. Concerning
condition 3 (daily conversation), participant 3
did not speak so much, but paid more attention
to Hugvie, whereas participant 4 spoke morehere than under the other conditions. Undercondition 2 (radio, non-interactive), participant 5
talked almost the same amount as in condition 4(reminiscence work). In condition 1 (no sound),the participants barely showed any reaction witheither concentration or utterances.

Eve n tod ay, whe re t ele com mu n icat ion ishighly developed, devices for older adults withdementia are limited. It will be important todevelop robotic media, such as Telenoid, that candiminish the barrier of the digital divide. The
idea that robots can provoke or promote people’s
capability, i.e., extract their will, can be seenin the development of Babyloid, which cannot
do anything but be taken care of. It is expectedthat older adults can take the role of caregiverto such baby-like robots, thus giving them asense of self-esteem. However, there might bea limit to the ability to extract willingness fromolder adults, by using thoroughly passive robots
without vocal capability, even for those who
cannot recognize a telephone. As seen in our
experiment with telecommunication, when thatbarrier is removed, it is possible for people withdementia to increase their willingness to talk. In
fact, rather than a mock-up robot that cannot doanything, participants more vigorously reacted to
the Telenoid, which can initiate a conversation,and so they became more willing to talk. Thoughparticipants took care of the mock-up and talked
to it by saying, for instance, “You must be cold;
let him wear some clothes.” the use of Telenoid
could more effectively extract speaking fromparticipants with dementia and increase their
willingness to communicate. The participants,
once they could talk with Telenoid, started
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Journal of Philosophy and Ethics in Health Care and Medicine, No. 12, December 2018

stroking and patting its head and enthusiasticallyconversed by saying, for instance, “You becameso smart; I am happy.” and showed pleasure in
seeing its growth. Although the weight of therobot did not change, a participant said, “Youbecame heavier.” and was pleased. Once theoperator asked, “Please raise me higher andhigher.” The patient raised the robot higher
and started holding it. In the beginning, shefrequently complained that she could not hold it
because of its weight, but she changed her mind
and came to accept its request easily and engaged
more willingly. By not only being passive but
exchanging in words and explicitly transmitting
intentions, such as asking questions, we think wemay be able to enhance the willingness of older
adults to take care of others without avoiding
or diminishing their willingness. Therefore, weneed to investigate appropriate ways of talking tothem.
6.2 Enhancement of freedom by persuasion
The overall result of field study 2 indicates
it is possible to prolong conversation andcommunication for older adults with dementia
by shifting to suitable conversational topics, thus
helping subjects recall memories. The study also
indicates that topics triggering personal memories
could change subjects’ moods and improve
communication for older adults, even at remotesites. Individual results pointing toward different
approaches, other than reminiscence work, might
be more suitable to promote interaction for somepeople. One-way communication, for instance,
seems sufficient for some, so it is necessary toinvestigate which conditions are most suitablefor each person, in order to create, facilitate andimprove verbal and non-verbal communication indementia care. For example, compatibility could
be related to the types or severity of dementia
or personality. Concerning compatibility, we
also need to think about ways in which obtained
memories and personal information could be
used to encourage communication or persuade
older adults through robotic teleoperation systems
in order to further benefit them.
Applying suitable dialogue strategies withthe use of persuasive technology might provide
ways to direct older adults. In another field study,
an older adult who initially complained about
the weight of Telenoid eventually started to lift52

it and follow its instructions. Another individualalso changed her attitude toward the robot overa short-term period and started helping it, uponrequest. These examples suggest that we might
be able to lead others to follow the robot’s
instructions too. A way to explore the benefitsof persuasion through technology is to guideolder adults in promoting diet and health. As an
example, robots can observe and help an older
adult if he or she does not want to take daily
medication. Using technology to persuade people
is not new: We encounter it in our surroundings
as an extra layer of environmental intelligencesuch as a car’s eco-meter, where human behavior
is guided in a specific direction in an unobtrusive
manner. Some technologies even force people
to act in a specific way such as a speed bump.
It is still uncertain to what extent robotic media
can change or manipulate human behavior. It
is important to investigate if, how, and to what
extent people follow robots’ instructions.
A robot can effectively collect and convey
personal information with instant recall andstorage and has the ability to adjust its expression,voice, and gender, while continuously acting as
an active listener, thus enabling it to incorporate
interactive techniques necessary for psychologicalmanipulation that seem to convince throughanthropomor phism [23]. By making robots
persuasive, users may have difficulty controlling
their own information flow by themselves. With
this in mind, we also need to further discuss
the ethical implications around the emotionaland behavioral persuasion of older adults
when it comes to persuasive technology. Whendeveloping teleoperation systems and artificial
intelligence, as a way to benefit older adults, weneed to investigate effective ways to collect andutilize memories or personal information, thus
encouraging communication through robotic
teleoperation systems. A support system is also
required for older adults who face the possibilityof not only giving away their information to
robots, but also being led involuntarily and thus
losing autonomy. Ethical concerns are raised
when personal data are dealt with, but this goes
further than privacy implications. The ethicalimplication is that robotic media as persuasive
technology pose a risk of undermining humanautonomy. We need to consider autonomy and theunintended side-effects of robotic persuasion.

Use of Robotic Media as Persuasive Technology and Its Ethical Implications... Ryuji YAMAZAKI et al.

6.2.1 Two approaches to enhancing
freedom
The notion of autonomy is problematic in relation
to technology. So what kind of freedom canolder adults have while being led by technology?
As Berlin states, there is a distinction between“negative freedom” in the absence of limits andconstraints and “positive freedom” indicating
hu ma n autonomy [24]. Tech nolog ies t hat
interfere with positive freedom do not simply
externally constrain our actions, but also involve
themselves internally in our intentions. Thisimplies another type of liberty, i.e., “relational
freedom” as coined by Verbeek, that shapes our
subjectivity while interacting with technology,
allowing us to adjust the influence of technology
accordingly [25]. Older adults have a certain
relational freedom in determining how their will
and behaviors are being changed, while receiving
the influence of media technology. As suggested
by Verbeek, based on Foucault’s thoughts
on freedom as an alternative to the notion ofautonomy concerning older adults’ freedom, weneed to take acknowledge and accept that any
form of mediation must be critically examinedwhen it dominates users, without a way to modify
its impact.
The so-called “golden rule” of persuasive
technology proposed by Berdichevsky and
Neuenschwander goes along the lines of “neverseek to persuade others to what you cannot
accept yourself” [26]. Its support is the Rawlsian
idea that you can only agree to be treated inways that you would consent to from behind the“veil of ignorance” [27]. There are approaches
to respecting the user’s own will from theBelmont report and research ethics [28, 29]. In
the report, three ethical principles are presented,
where Informed Consent is one applicationembracing the principle of Respect for Persons,by letting people opt in or out of research activity
by stressing information, comprehension, andvoluntariness. Voluntariness is a key componentof Informed Consent, and it protects against
coercion or unjustifiable pressure. So other thanthe explanatory approach, which simply follows
the users’ will, we propose to adopt a feedback
approach to change the users’ will by convincing
them of greater advantages when providing theminformation. Letting persuasive technology help

us instead of seeing it as a threat to autonomy orrelational freedom can in some cases support ourcapacity for self-government, thus enhancing ourfreedom under the influence of technology.
For i n st a nce, a n app for weig ht loss
or quit ting smoking may encou rage one’s
self-discipline and support one in a task by
providing ideas and letting the person track
his or her progress. One might even conclude
that persuasive technology does not affectour freedom, since we are free to choose andvoluntarily change according to its demands, so it
does not deny us the right to autonomy. But, due
to the characteristics of technological methodsof persuasion, there are important ways freedom
can be limited. One is when users cannot avoid
attempts at persuasion by technology and mustendure it, for instance, use of a neuro-implant
device to impart electrical signals directly tosomeone’s brain, which could result in changing
his or her behavior in uninhibited ways. Second,
it is always an empirical question whether
persuasive or manipulative methods are employedin practice.
To enhance users’ freedom and thus allow
them to adjust the inf luence of technology,
we can develop, for example, research ethics
to balance the risks and benefits of research
activities related to the individual, while also
assuming that the good of society sometimes
requires tradeoffs. For example, data breach andprivacy loss could create risks an organization
faces in improving the quality of therapy. As fordata access and review, one might accidentally
give out information that in retrospect could
be deemed unwanted; therefore, subjects – ortheir assigned surrogates – need the freedom
to review and amend personal records. There
are therapeutic robot design options that giveindividuals the ability to understand and manage
their information portfolio. It is important toboth maximize the user’s benefit and enable
researchers to access resources such as datasharing, based on Informed Consent. These
capabilities should be incorporated in the designand deployment of therapeutic robots, by making
use of robotic modalities, for instance, vocal
systems in daily usage. Explanatory and feedback
approaches, along with media design, need to befurther investigated in parallel with conditions
and methods for deploying persuasion. Also,
53

Journal of Philosophy and Ethics in Health Care and Medicine, No. 12, December 2018

as Berdichevsky and Neuenschwander pointedout [26], cultural context could play a role in
the impact of technology and thus needs to beinvestigated in relation to care settings.
6.2.2 On-site ethical issues and theprospect for improvement
In on-site dementia care, there are cases in whichpeople with dementia have difficulty refusing
private information flow, especially when theylose the ability to control it by themselves or
become passive towards care staff, due to thepower balance of providing care and being
taken care of. For individualized care, private
information of older adults can be collectedby the staff, even without approval. Privacy
regulations are lacking in dementia care, forexample, the assessment regarding to what extent
the information of older adults should be allowed
to be collected, creating ethical dilemmas forcare staff challenged with individualizing careand respecting the patient’s will, particularly
when patients cannot express their thoughts andfeelings.
Self-determination is deemed to be theprinciple that gives people the opportunity
to make decisions based on their own choice,without coercion. Care staff are required tocontrive ways to encourage self-determinationof people with dementia, but they also face anethical dilemma when a decision is made by aperson with dementia, for instance, to go backhome from a care facility, while the staff cannot

provide such an opportunity.
A lt hou g h s eve r a l e t h ic a l i s s u e s a nd
dilemmas arise on site, many of them appear
when the older adult’s ability to convey their willis disturbed or distorted in interaction with carestaff, mainly due to dementia (Figure 7). Becauseof impaired judgment and deterioration of shortterm memory, it takes time for people withdementia to decide a matter, and they sometimes
also have difficulty in articulating their decision.
For instance, a person with dementia might justwander away when he or she would like to havea glass of water or use a toilet, and in such acase, it is hard for the staff to figure out what theperson wants, possibly resulting in a situation
where patient self-determination is not respected(step 1 to 2 in Figure 7). Likewise, a dilemma
occurs when staff members have a certain bias
in interpreting the will of older adults (step 2 to
3 in Figure 7); for example, the staff members
may interpret an old lady’s wandering behavior
as seeking a role to take on and ask her help
to clean a room, but afterward her family tells
the staff that she favors paper-related work, notphysical work [30]. The same situation can occur,even if the interpretation seems to be correct, forinstance, an older adult decided to go back home,
but the staff ignores the decision, without any
consideration for what he wants (step 3 to 4, inFigure 7). Temporarily, he may be able to go backhome by arrangement, or he may just be looking
for a place where he can feel at ease. In any
case, it will be important for the staff to not only
observe behaviors of older adults with dementia

Communication
process for or against self-determination
Figure 7: Communication process for or against self-determination
Principle: Respecting the person’s will (as it is)

Person with dementia
1) Will / Decision

Persuasion /Feedback

Caretaker

2) Expression3) Interpretation

4) Response

Wandering

Biased view

Neglect

Example of pitfall

Data collection and analysis through interactions in daily life

In the process of encouraging self-determination of people with dementia, ethical dilemmas
occur, e.g., from step 1) will/ decision of older adults to step 4) responses from caretakers.
54

Use of Robotic Media as Persuasive Technology and Its Ethical Implications... Ryuji YAMAZAKI et al.

but also to utilize records or data of their daily
behaviors to have a better understanding. For
this purpose, robotic media are suitable for datacollection and analysis through interactions indaily life, and at the same time our feedback
approach will be required.
Even in other types of ethical issues, datacollection and utilization will be important; forexample, if opinions of family members andcaretakers are opposed to each other, collected
infor mation for mak ing decisions will be
required. Also, a balance of sharing versus not
sharing information in a team could depend on
the beneficence patients can receive by making
use of their data. So, it will be worth considering,
if it could be beneficial for patients to share
their information with their team, for example,
family members and even a hired third-party. In
this way, we can argue in favor of the feedback
approach to change the will of media users byconvincing them of greater advantages such as
joy and emotional well-being of an older adultpatient with dementia, when providing otherswith a patient’s information, instead of simply
following the user’s original will, using the
explanatory approach. Thus, a key factor going
forward would be to build an effective systemof utilizing information so that robotic media
users can be convinced of greater advantages
by providing information, when the system of
preventing the misusage of data may conflict.
Considering the advantages of informationsharing, while balancing privacy concerns, wemight need to look at other factors and previous
established care systems, such as considering
cultural background.
6.2.3 Retrieving the freedom of
encountering with others
Considering the closed nature of residential
dementia care sites, we can discuss an implicit
assumption among group home managers inJapan that private space appears to cover theentire care site as their home, even when social
services are provided [21]. Philosopher Hannah
Arendt was astute to note that the privationof privacy lies in the absence of others and its
nature, barely transformed [31]. Because caresites are enclosed spheres of privacy within whichsocial services are applied, lack of transparency

occurs, resulting in residential older adults being
inadvertently deprived of being seen and heard
by others. Against such dangers of hiding andconfining older adults, possibly resulting in
accidents, neglect or even abuse, we can thenadvocate for their right to be carefully watched
over, by presenting a paradoxical viewpoint
to show that an effective system of utilizing
information would help older adults regain thefreedom to encounter others.4
Managing technological knowledge may
provide a chance for caretakers to responddeliberatively to a call for taking care of older
adults with dementia. 5 Such a chance can berealized, by making use of robotic modalities,
sensors, and connected systems and providing
caretakers a way to ensure some greater access,even if only remotely, thus avoiding some of the
problems of the closed nature of care service. The
ethics of information and the use of persuasive
technology for older adults with dementia
requires a more extended dialog ue among
citizens and a more detailed analysis of the
stakeholders’ professional and moral positions.

7. Conclusion
Communication support for social interaction
among older adults in dementia care is expected
to be facilitated by assistive robot technology,
so we explored two studies involving robotic
media with the purpose of investigating theinfluential nature of robotic media and the effects
on human subjects. These studies indicatedthat those with dementia would change their
behavior, becoming open and prosocial throughrobotic mediation; further, by using suitable
conversational topics, subjects’ reactions could
be extracted more easily. Those results indicatethat there is potential for leading older adults ina specific direction. With further developmentof robotic persuasive technology, we can expect
older adults’ subjectivity to be led by suchtechnologies in daily activities, sometimes eveninvoluntarily. Regarding ethical implications,
we pursued ways to enhance autonomy anddiscussed the freedom to adjust our relationshipto technology. As protection against coercion,
we considered the principle of voluntariness asa basic ethical element in Informed Consent.
An explanatory approach to voluntary freedom
55

Journal of Philosophy and Ethics in Health Care and Medicine, No. 12, December 2018

is to pursue a way to respect the user’s will
as it is; however, there is a limit to rationality,
when asking questions to those with dementia.
While still using that approach, we can also
follow the feedback approach by balancing risk
versus benefit. Hypothetically, with emotional
appeal, those with dementia may satisfactorilychange their will, when provided with enoughinformation or appropriate mediation, thus being
convinced of greater advantages by providing
personal infor mation. In other words, thelikelihood of users of providing highly personal
information might increase when obtaining
usable and beneficial feedback from seemingly
trustworthy robotic media. With the lack of data
as a limitation of the current study, we need toinvestigate such a hypothesis through empirical
study. Questions, however, arise: What ways caneffectively let users of persuasive technology
acknowledge the merits of disclosure? Will theusers start to talk more by acknowledging andaccepting the merits of providing information?
The robotic persuasive tech nologies open
a new interdisciplinary area of research on
human subjectivity. More research is needed
to clarify the conditions in which older adults
with dementia can feel the freedom to modify
the impact of technological mediation. Further,
we should consider what kind of democratic
procedures should be developed for applying
persuasion through robotic media technology.

2

3

4

5

Acknowledgements
This work was partially supported by JST CREST
and JSPS KAKENHI Grant Numbers 16K16480.
This paper is also a part of the outcome of research
performed under a Waseda University Grant forSpecial Research Projects (Project number: 2018K308) and the Japanese Council of Senior Citizens
Welfare Service.

Endnotes
1 Microsoft’s ActiMates characters for children
are examples of attempting to shape attitudes
in a specific way and ask users to respond withcorresponding feelings. ActiMates were a seriesof i nteractive toys such as Telet ubbies and
56

D.W. introduced in the late 1990s, marketed as
educational tools, and designed to use implicit rules
or norms, such as social dynamics to persuadechildren to interact with the characters. At thattime, digital “creatures” like Furby, an owl-likecreature, came along, dazzling children with theirsociability. Social robots found ways to express
their love and started presenting themselves as
having feelings and needs. As Turkle describes
their adaptation, children were brought to the belief
that the machines were alive enough to care and be
cared for [13].
Telenoid was developed by Osaka University
and Hiroshi Ishiguro Laboratories at Advanced
Te l e c o m m u n i c a t i o n s R e s e a r c h I n s t i t u t eInternational (ATR) in Japan.
The huggable communication medium Hugvie wasdeveloped by Osaka University and ATR’s Hiroshi
Ishiguro Laboratories.
As for the freedom of encountering with others,
Nancy, J.-L. offers a valuable insight for redefining
freedom and regarding it, not as the ideal or
the rights held by subjects, but the fact in therelationship between self and others [32].
From the perspective of knowledge management,in reference to Aristotle’s distinction of three typesof knowledge, we can further develop arguments
for t he a mbig u it y of te c h nē i n m a k i ng it s
combination not only with epistēmē, but also withphronēsis, the ability to judge, sometimes called
insight, as a deliberative kind of action-oriented
knowledge, which guides people to the common
good in its performative enactment and functionsin the presence of others, including robotic media[33].

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