© 2016 Journal of International and Advanced Japanese Studies
Vol. 8, February 2016, pp. 17–33
Master’s and Doctoral Program in International and Advanced
Japanese Studies
Graduate School of Humanities and Social Sciences,
University of Tsukuba

ArticleRobotic Systems in Healthcare with Particular Reference
to Innovation in the ‘Fourth Industrial Revolution’— An Ethical Challenge for Management —Martin POHL
University of Tsukuba, Faculty of Humanities and Social Sciences, Associate Professor
The use of robotic systems is undergoing an evolution; they will become part of daily life in many ﬁelds,
including the healthcare sector. Examples of operational robotic systems suggest huge growth potential.
The ‘Fourth Industrial Revolution’ based on the Internet of Things (IoT) and ‘Everything-as-a-Service’(XaaS) will provide the platform for innovations.
Macro-trends in the healthcare sector in Japan, for example, suggest that in many ﬁelds of healthcare,
new robotic systems may be developed and implemented in the near or mid-term future. For these trends
to be accepted by stakeholders, ethical standards have to be developed for robotic systems in thehealthcare sector. From the viewpoint of management, acting in accordance with ethical principles will
make success of a new product likely and as such prove investment successful.
Keywords: Robotic System, Healthcare, Innovation, Fourth Industrial Revolution, Internet of Things, Ethics,
Management

Introduction
Robotic systems play an increasingly crucial role not only in traditional industrial production, but also inservice industries such as health. From a medical point of view, current robotic systems make surgeries safer.
From a business point of view, the Gartner Consulting Group determined that initial robotic systems such as‘mobile health monitoring’ are on the edge of proﬁtability, whereas other ﬁelds, such as ‘biochips’, based on
robot technology are still in an early stage of development.
Robotic systems in healthcare are like any other product and service only successful if they add bothﬁnancial and social-ethical value. So the core question is whether robotic systems add monetary and/or social
value to healthcare. As a hypothesis it is expected that in fact robotic systems can do so. For example, ﬁrst,
robotic systems can reduce labor costs. Second, robotic systems can increase the independence and social
participation of vulnerable people. Third, robotic systems can increase the quality of care. Fourth, robotic
systems can perform activities that cannot be done by humans.
To prove these statements, the research will be based on three steps. At ﬁrst the macro-trends in the Japanese
health sector will be analyzed. In the second step applications of existing and prototype robotic systems will becollected based on information on the internet and by contacting selected enterprises, to develop anunderstanding of current robot-technology in the market or close to the market. Based on this, the collection ofrobotic systems can be categorized to focus management thoughts. As a third step the paper will conclude by17

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developing the spectrum of a scenario embedded in ethics, and how robots in the mid-term-future may be a
blessing for human beings.
The methodology used in this paper is based on three analytical approaches. First, to cover the major macrotrends surrounding robotic systems in healthcare a PESTEL Analysis will be undertaken. This analysis is ananalytical concept to identify the major trends and inﬂuencing factors, which affect a market or an industry.
Results of the literature research will be included. Second, a Situation Analysis will analyze the existing market
ﬁelds for robotic systems. In other words this will determine what kind of robotic systems exist in the market or
close to the market. This includes prototypes and robotic systems in operation. For doing so a search of theliterature and other documents including medical and management material will be undertaken related to theoverall topic of this research. Third, with Ethical Analysis the results from two approaches will be set in an
ethical context. Therefore an early consideration of trends management may react proactively at an early stage.
For common understanding of ideas in this paper, ‘Robotic Systems’, ‘Fourth Industrial Revolution’, ‘Internetof Things’ (IoT), ‘Everything-as-a-Service’ (XaaS) must be deﬁned.
What is a ‘Robotic System’? “The word ‘robot’ (Czech translated as “work”) was created in 1920 by the Czech
artist Josef Čapek for his play: R.U.R: Rossum’s Universal Robots. Before the creation of this word thesemachines were called ‘automat’ or ‘semi-automat’. The word ‘robot’ itself went through many metamorphoseswith the result that a general accepted deﬁnition does not exist. It is generally agreed that a robotic system is amachine with a degree of autonomous function.”1
The ‘Japanese Industrial Standard Association’ deﬁnes a robotic system as “a mechanical system which has
ﬂexible [autonomous] motion [and intelligent] functions analogous to …living organisms, or combines suchmotion to the human will. In this context, intelligent functions mean the ability to perform at least one of thefollowing: judgment, recognition, adaptation or learning.”2
What are robotics systems in healthcare? The Butter et. al. deﬁnition for the European Commission states“Robotics for medicine and healthcare is considered the domain of systems able to perform coordinatedmechatronic actions (force or movement exertions) on the basis of processing of information acquired throughsensor technology, with the aim to support the functioning of impaired individuals, rehabilitation of patientsand also to support individuals in prevention programs”.3 However, a clear distinction for a robotic system inhealthcare is not given. Some robots used in healthcare are categorized as ‘service robots’, however, somehealthcare related robotic systems such as those used in logistics do not fall into that criteria either.
The ‘Fourth Industrial Revolution’4 can be characterized as a new level of organization and control
instrument of the entire value-added chain consisting of the life-cycle of products. This cycle is increasingly
adapting itself to individual customer oriented wishes and begins from an idea, development and production,delivery to the customer and up to recycling including the services needed.
Condition is the availability of all relevant information data, in real time by interlinking all parts of the valueadded chain and the ability, to optimize the production process at all times by using the data. By combining
humans, objects and systems, dynamic, real-time and self-organizing value-added chain networks are created.
They can be optimized towards different criteria such as cost, availability and use of resources.5
The Instrument of the ‘Fourth Industrial Revolution’ is the ‘Internet of Things’ (IoT). It is the network of
1 POHL, Martin: A Comparison of Websites by Robot Manufacturers in Germany and Japan: The Ethical
Relationship Between ‘Robot’ and ‘Human Body’ as a Management Challenge (2015) p.28

2 SHENKAR, Oded: The Robot Masters: How Japan Has Won the Race to the Robotized Work Place (1991) p.145
3 BUTTER, Maurits, et al: Robotics for Healthcare (2008) p.12
4 The ‘Fourth Industrial Revolution’ is known in Germany as “Industrie 4.0”. See POHL, Martin: “Industry 4.0” – An
Evolution at the Beginning of the 21st Century (2015) Unpublished Slide Presentation
5 PLATTFORM INDUSTRIE 4.0 (Ed.): Industrie 4.0. White Paper FuE Themen (2015) p.3

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physical objects or ‘things’ imbedded with sensors and software. Its connectivity enables objects to exchange
data with the operator, other connected devices or the manufacturer.6 Grounded on the IoT, businesses will
establish global networks that incorporate their facilities in the shape of ‘Cyber-Physical Systems’ (CPS), a
system of collaborating computational elements controlling physical entities. These facilities are capable ofautonomously exchanging information, releasing actions and controlling each other independently.7 This will
enable the production of robotic systems for individual customers, such as health nanobots for an individual
patient.
The IoT enables the ‘Everything-as-a-Service’ (XaaS): Products and services systems are no longer separate
from each other. Innovation is designing new businesses where products, services and interfaces are seen as
interconnected parts. “Each product system is interlinked to a service system, and every system is dependent on
products that grant value to customers. (Every product and service has an interface. Its touch points) deﬁne theway customers collaborate with services and physical products”.8
1. PESTEL Analysis: Macro-Trends in Healthcare in JapanPESTEL Analysis is used as a strategic tool for understanding potential directions for business positions. It
includes six ﬁelds: political, economic, social, technical, environmental and legal factors. In principle, thechallenges of industrialized countries related to robots in healthcare are not very different therefore thefollowing PESTEL Analysis will focus on health provision from a Japanese perspective. Conclusions related torobotic systems for healthcare are drawn after the analyses.
Political Analysis:
As a general guideline government support is a condition for the operation of healthcare systems, regarding
ﬁnancing and regulating quality, cost effectiveness, safety, and patient focus. Governments are also actively
responsible for innovation in the healthcare sector as they launch research programs and support medical
research institutes. In Japan also, the main political target of the Japanese government is maintaining a costeffective health system while providing access to healthcare for the entire population. Both cost and revenue areunder permanent observation of the Ministry of Health, Labor and Welfare. Examples of reducing expenditure
are the limitation of cost for new pharmaceutical products – and after being on the market – the annual
decrease of remuneration for these products by the health insurance system, the long and bureaucratic
procedure for permitting new health products in the list of products being refunded by health insurance,competition of health insurance funds under strict guidelines of the government such as a strict contribution
corridor for insured while offering equal scope in services. In addition, prevention of diseases plays animportant role.
On the contribution side, health insurance via contributions of the insured covers about half of the cost.
About one-third comprises government health expenditure and the rest out of pocket payments.9 The outlook of
the Japanese health system is characterized by an aging society causing increasing cost and a national debt
which is among the highest in the world. As a consequence, tight cost control in the Japanese health system will
also be a main target of Japanese politics in the future.10 Costs may increase or decrease depending on efﬁciency
and effective investment in emerging technologies, including robotic systems at its forefront.
6 MELZER, Rudolf J.: Mit Industrie 4.0 könnte Europa der Anschluss gelingen (2014) p.27
7 WAHLSTER, Wolfgang: Neue Fabrikwelten: Industrie 4.0 (2013) p.12
8 FELL, Mark: Roadmap for the Emerging “Internet of Things” (2014) p.30; CAGAN, Jonathan; VOGEL, Craig M.:
Creating Breakthrough Products (2013) pp.258-261

9 WHO and MHLW (Ed.): Health Service Delivery Proﬁle Japan 2012 (2012) p.3; MOSSIALOS, Elias et. al. (Ed.):International Proﬁles of Health Care Systems 2014 (2015) p.83

10 JONES, Randall S.: Health Care Reform in Japan (2009) p.6
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Economic Analysis:
From a macroeconomic point of view, the Japanese economy has stagnated since the burst of the ﬁnancial
bubble in 1990. Japan is an important player in global trade however the outlook for the global economy isuncertain and depends on multiple factors. Japan’s public debt –as already mentioned– is the highest amongindustrialized countries based on GDP. A value added tax increase from 8% to 10% is planned for the near
future to cover the expected increase in cost of social insurances including health due to the aging of society,among other factors. The total health expenditure in Japan amounts to about 10.3% of the GDP.11
There is a shortage of health related human resources, physicians, but in particular nursing staff.12 In
contrast to other industrial countries foreign health workers barely play a role. The Japanese education systemprovides enough health workers, however, many of them leave the health sector after some years to move toindustries with better working conditions such as higher pay and settled working hours. The competition withthe growing nursing sector for the elderly in care houses and the difﬁculties faced by the public authorities inproviding further money will likely deteriorate this situation in coming years. Among other factors, robotic
systems may play a role in this context.
Social Analysis:
In Japan, as in other industrial countries, macro level socio-cultural factors include rising expectations about
health. These expectations arise out of sociological and cultural processes. Patient empowerment and virtual
exchange of communication has become another criterion. Micro-level socio-cultural factors include patient
safety and labor conditions in the health sector. Not only the relatively low payment of nursing, staff but thestressful working conditions cause absenteeism and long-term incapacity to work.13
Based on this global development, Japan’s healthcare system is under pressure. Furthermore, this pressure iscaused by a phenomenon called “double aging”: an increasing demand due to the growing number of elderly
people based on a baby boom after World War II and better medical procedures. At the same time, the younger
age groups are decreasing as is the population in Japan as a whole. While the number of people receiving
allowances out of the social security systems is increasing, the people contributing to the systems are
decreasing. The rural-urban migration is ongoing, and while metropolitan areas are still growing, parts ofJapan are graying rapidly making it difﬁcult to keep traditional healthcare delivery at a reasonable level.
Demographic factors in healthcare are related with epidemiological factors. The difference in life expectancy
between women and men is decreasing. Chronic diseases will likely increase. In Japan, the top three of causes ofdeath in 2010 were cancer (30%), heart disease (16%), and cerebrovascular disease (10%). Aspiration
pneumonia is an emerging health issue due to the aging population.14 Expectation of people includes having ahigh quality of life including the absence of disease until old age. Japanese have the longest healthy lives.15 Alsoin this context robotic systems may ﬁnd their place.
Technological Analysis:
The acceptance of new technologies is an important factor for the successful implementation of a new device
and “how society has discussed ethical, social, environmental issues and the way end users have been informed
about the new technology and how they got accustomed to the new technology.”16 Beyond that technologicaldevelopments are the driving forces for social change.
In the context of robotic systems innovations may have many different background sources.17 What all these
11 OECD (Ed.): OECD Health Statistics 2014 – How does Japan compare? (2014) p.3
12 WHO and MHLW (Ed.): Health Service Delivery Proﬁle Japan 2012 (2012) p.4
13 BUTTER, Maurits, et al: Robotics for Healthcare (2008) p.24
14 WHO and MHLW (Ed.): Health Service Delivery Proﬁle Japan 2012 (2012) p.1
15 NHK WORLD NEWS (Ed.) Study: Japanese have the Longest Healthy Lives (2015) online
16 BUTTER, Maurits, et al: Robotics for Healthcare (2008) p.24
17 Peter Drucker points out as innovation sources: (i) The unexpected, (ii) The incongruity, (iii) Innovation based on
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sources have in common is the product planned for the market goes through several stages starting from theoriginal idea to later mass product. Crucial in the health market, the product has to meet legal criteria toproceed from one stage to another, especially, and including Japan, patient trials,18 and in certain cases theapproval of an ethical review committee. As such, pure science including the academic sector is no longer theruling model. Valorisation of output and promotion of innovation is part of their ofﬁcial mission.
Beyond that, technological trends and developments including health related robotic systems are drivers forchange in society.
Legal Analysis:
Not only in regard to health related robotic systems but also here laws and regulations frequently pose a
problem to freedom of research and innovation. When overdone, it may also hinder technological and economic
progress.
Obviously, robotic systems are different from other devices due to its degree of autonomy. In the case ofhealthcare, robotic systems operate close to humans who are often in a helpless situation. Obviously stricter
guidelines as per non-health related robotic systems are desirable. However, too strict guidelines will question
the approval of robotic systems as a whole.
There are more questions to think about.
・The historically developed legal methodology for medicine and medical interventions will likely becumbersome for robotic systems therefore a new approach should be developed. If not, legal questions may
become a major obstacle to innovation in that ﬁeld in the future.
・Data security, including privacy of data is important – data may be transferred on a global level.
・Access to the still expensive robot systems causes legal questions regarding regulation if it cannot becovered by public health insurance.
Last but not least there is the question of liability – a complex matter.19 Responsibility for malfunctions ofrobot systems could be taken by:20
・The person being impacted (why get physically in touch with the robotic system?)・The patient as end user (why believe in a robotic system?)・The medical doctor (did he/she really understand the system?)・The government regulatory authority (giving permission for use of the robotic system too early?)・The testing agency (is the testing of the robotic system adequate?)
・The producer (release of the robotic system without enough experience in the market?)・The researchers (error in academic thought?)
・The programmers and designers (immature programming or design?)
・The robotic system itself (if running on self-improvement software based on artiﬁcial intelligence?)
If the robotic system is set into the ‘internet of things’ further responsibilities may occur:
・The service enabler (error in programming? Wrong understanding of product-lifecycle?)
・The service provider (technical instability or wrong priority of data-ﬂow?)
Environmental Analysis:
Environmental factors include ecological and environmental aspects of robots in health such as sustainable
development, considerate use of natural resources such as rare earth, and consumption of energy. Recycling is
process need, (iv) Changes in industry structure or market structure, (v) Demographics, (vi) Changes in perception,mood, and meaning, (vii) New knowledge, both scientiﬁc and nonscientiﬁc. In: DRUCKER, Peter Ferdinand:Innovation and Entrepreneurship (1985) pp.37-129
18 BAST, Uwe: Das neue Medizinproduktgesetz (2007) Unpublished Slide Presentation
19 Neue Züricher Zeitung (Ed.): Innovation im Gesundheitswesen. Roboter nur als Hilfen, nicht als Begleiter erwünscht(2012) online
20 BUTTER, Maurits, et al: Robotics for Healthcare (2008) p.29

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another aspect which should be considered. As background, in industrial countries, in total the healthcare
sector is accountable for about one tenth of the ﬂow of materials, waste production and energy usage, all thefactors mentioned before should be considered when designing, using and disposing of (health) robotic systems
before robots play a larger role in the health industry.
The factors explained before in the PESTEL Analysis may give different stakeholders important directions
which will be explained below. Companies involved in production of health robotic systems have to consider all
factors to satisfy the cross-relationships of their customers. Major stakeholders are: Producers of robotic
systems, companies producing healthcare services, health professionals, non-professional users, the government,
and science.21
Companies Producing Robotic Systems:
・Due to technical and social innovations new business ﬁelds will occur.
・Privacy of data is becoming more and more important.
・Both, operational efﬁciency and effectiveness will be increasingly important for robotic systems related tothe health sector.
・The lack of health workers, both caregivers and physicians, will necessitate use of more technicalequipment and at its forefront will be robotic health systems.
Companies Producing Healthcare Services:
・Pressure on prices – due to government intervention, national and international competition – result in
more competition among care services.
・As a result of demography, the demand for healthcare will continue to increase.
・Though pressure for keeping patients as out-patients is still limited in Japan, the trend of treating
outpatients for disease will increase. Robotic systems may support this process.
Health Professionals:
・Pressure on performance transparency will increase.
・The use of robotic systems will demand new skills.
Non-Professional Users:
・An increasing percentage of the population will get in touch with robotic health systems. ‘Digital Natives’learn to use robotic systems during childhood though the systems should be easy to use.
Government:
・Cost for health will increase resulting in cost-saving measures. Payment systems by health insurance tothe health sector could be focused on using robotic systems balancing quality care and costs.
・Providing research money for R&D to develop robotic systems in health will considerably inﬂuence which
systems will be developed in the near future.
・Regulations for robotic systems are crucial, based on ethical criteria to be developed.
Science:
・The speed of technical development is constantly increasing.
・Cooperation between science and industry is increasingly important.
・Technology and other ﬁelds in science will merge with the development of robotic systems.
・Science depends on ﬁnancial transfers from government and private enterprise.
Based on the PESTEL Analysis stakeholders may set their existing healthcare robotic systems to develop amanagement strategy for developing their robotic systems in healthcare. As the next step the existing market
ﬁelds of robots has to be analyzed to determine the existence of the kind of robots in the market or close to themarket.
21 BECKER, Heidrun et. al. (Ed.): Robotik in Betreuung und Gesundheitsversorgung (2013) pp.105-112
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2. Situation Analysis: Applications of Robots in Healthcare
When thinking about using robotic systems in healthcare an elementary starting thought is: What are people
good at and what are robots good at? Only if robotic systems have advantages over human abilities or have abetter relationship with work-cost structure22 can their use be justiﬁed.
People have their strengths in sensing, doing complex work, in judgment and in learning ability. Robots oftoday’s technical standard may be physically very strong, good at doing sustained work, they may do repeat
work and may work in ﬁelds which people do not like to do. Though robotic systems may gradually improve inhuman strengths, this will take time and cannot be predicted. Humans and robots have speed, precision workand ﬂexibility in common.23 Obviously, robotic systems are a promising ﬁeld, though the speed of development
and implementation into the market is diverse. It takes time until robots can do work better than humans andthe learning curve from ﬁeld to ﬁeld is very different.
From a current perspective it is necessary to determine where the advantages of robots in health can beapplied. There are different ways of categorizing robotic systems in health. The most common approaches are
based either on the medical treatment chain or on the ﬁelds of application.
(1) Robotic Systems Categorized by Medical Treatment Chain
When applying this to the medical treatment chain, basically ﬁve groups of robotic systems can be
determined. (i) It is useful to begin with prevention by having a target of no treatment. If there is the risk of adisease, the next step is diagnosis (robotic systems in preventive therapies and diagnosis). If the diagnosis
results in a disease, two possibilities may occur: (ii) a surgery (robotic systems for medical interventions) plus(iii) professional care (robotic systems for professional care) in the hospital (iv) and/or rehabilitation treatment(robotic systems for rehabilitation treatment) outside the hospital. At the end of the chain are (v) activities related
to daily living (robotic systems for assistance in life).24 These ﬁve groups require more detailed reﬂection.25
With the robots in preventive therapies and diagnosis as business ﬁelds the connection of diagnostic
functionalities to robots already used and diagnostic robots can be underlined. Robotized analysis of motion andcoordination as well as intelligent ﬁtness systems belongs to the ﬁrst group. Tele-diagnostic and monitoring
robotic systems as well as smart medical capsules belong to the second group.

Toyota developed the ‘Balance Training Assist’. “The robot acts as a twowheeled balancing game. The machine displays one of three sports games on amonitor and requires the patient to make moves in the game by shifting his/herweight on the robot.”27
26
22 The economic impact of robotic systems on patient health may be calculated in terms of improvements in quality oflife. Disability-adjusted life-years (DALY) estimate the burden of disease by accounting for years of life lost as wellas patients’ decreased quality of life. On the other hand, quality-adjusted life-years (QALY) express the gain of years
based on treatment, here with IoT applications. If the DALY for a disease is ten years, a 10-percent reduction would
result in the gain of one QALY. The value of QALY in years can be set in context using GDP per capita of an
economy. In: McKINSEY GLOBAL INSTITUTE: The Internet of Things: Mapping the Value Beyond the Hype(2015) p.42
23 TANAKA, Hirofumi: Strategy of Medicaroid KK (2015) Unpublished Slide Presentation
24 BUTTER, Maurits, et al: Robotics for Healthcare (2008) pp.36-37
25 BUTTER, Maurits, et al: Robotics for Healthcare (2008) pp.37-38
26 McNICKLE, Michelle: 10 Medical Robots That Could Change Healthcare (2012) p.11

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Robots for medical interventions allow the accomplishment of tasks that physicians themselves cannot
achieve due to the precision, endurance and repeatability of robots. Furthermore, robots can work in a verysmall contained space inside the human body. In the following ﬁelds the use of robots is becoming increasingly
popular:・“Robot assisted micro surgery,・Robot precision surgery,・Robotic devices for minimal invasive surgery,28・Medical micro- and nanobots,・Remote surgery,・Robotized assistance for small medical interventions,・Robotized surgery assistance.”29

30

The nanobot ‘Steerable Surgeons’ “is made of ﬂat nickel
parts assembled to make a 3-D tool that can be used during
retinal surgeries, in drug therapy and for ocular disease. Its
power sources are external electromagnetic coils, and it uses
magnetic ﬁeld gradients as a steering mechanism.”31

Though robots supporting professional care are mainly focused on the aging society they overlap with thehealth categorization. Products in this ﬁeld are robotized aid for nurses, robotized patient monitoring systems,
robotized physical tasks in care provision32 and robotized paramedic tasks.33

34‘Cody’ is a ‘human-scale‘ mobile manipulator. The “healthcare
robotics’ nursing assistant uses a direct physical interface (DPI)
that lets a nurse have direct control over the movement of therobot. … Using the DPI, the nurse is able to lead and position
Cody by making direct contact with its ‘body’. When the user
grabs and moves either of the robot’s end effectors - or the blackrubber balls attached to the robot - Cody responds.”35

Both in clinics as well as at home robots for rehabilitation treatment may support, not replace the therapist.
Robotics in physical therapy can be divided into muscle sustaining therapies and motor-coordination therapies.
Robot assisted therapies for cognitive and mental diseases are frequently based on role playing concepts.36

27 Ibid. See also: TOYOTA Deutschland (Ed.): Toyota entwickelt Roboter für Pﬂege- und Gesundheitswesen (2011)
online28 An early example is the ‘da Vinci Surgical System’. SCUTTI, Susan: Innovation ? Medical Robots are not just the
Future of Health Care, but Part of the Present (2015) Slideshow p.2

29 BUTTER, Maurits, et al: Robotics for Healthcare (2008) p.55
30 McNICKLE, Michelle: 10 Medical Robots That Could Change Healthcare (2012) p.8
31 Ibid
32 PLUTA, Werner: Cody wäscht bettlägerige Patienten (2010) online
33 STEEVES, Rich: Robots Invade Your Pharmacy (2013) online
34 McNICKLE, Michelle: 10 Medical Robots That Could Change Healthcare (2012) p.6
35 Ibid36 SCUTTI, Susan: Innovation – Medical Robots are not just the Future of Health Care, but Part of the Present (2015)
Slideshow p.4

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A ‘HAL’ hybrid assistive limb is a “cyborg-type robot, by which a wearer‘sbodily functions can be improved, supported and enhanced.”38 “Major causes oflower limb disabilities are disorders of the cerebral and nervous muscularsystem. In those cases, the brain cannot use ordinary neural pathways andcannot order to move the legs. The Hybrid Assistive Limb for medical use the‘Lower Limb Model’ – moves the wearer’s legs in accordance with the wearer’s
intention.”39 It can teach the brain how to move the legs.
37
With the robotic systems for assistance in life as commercial ﬁelds: ﬁrst applications may help users with
devices for improving their lives by focusing on their daily activities, second on mobility of disabled people, andthird intelligent prosthetics may replace parts of the body.40

The electric wheelchair ‘Friend’ is equipped with a computer, arobot-arm and sensors such as a camera, connected with the robotarm. With a joystick operated by the chin a disabled person may use
the robotic system. Reading of books including turning of pages ispossible.42
41(2) Robotic Systems Categorized on Fields of Application
As mentioned before, another way to categorize robotic systems is by ﬁelds of application. One group may
include robotic systems such as training devices and aids for mobility and independence. A second group may
be telepresence and assistant robotic systems. And a third group may be social-interactive robotic systems.43
Robotic systems such as training devices and aids for mobility and independence
These robotic systems help with (re-)learning human needs such as moving a wheel-chair, moving a hand or
foot. Three sub-groups of robotic systems may be characterized: passive guidance, supporting of an active
movement and bimanual guidance, where the movement of one healthy part of the body is transferred toanother, sick part. The devices allow long-term intensive therapies and permit accuracy when exercising. Theymay give motivation when therapists are not available, though they do not have the sensitivity and experienceof therapists. These robotic systems can be ﬁxed directly with the body (orthosis) or ﬁxed with the body
(exoskeleton). Other aids may be robotic ‘smart’ wheelchairs.44 Some products are already on the market, though
they are still expensive. Research on the efﬁciency of these systems is still limited. A breakthrough will bedependent on ﬁnancing such as by the public assurance system.

37 CYBERDYNE Inc. (Ed.): HAL for Medical Use (2015) online
38 CYBERDYNE Inc. (Ed.): What’s HAL. The World’s First Cyborg Robot HAL (2015) online
39 CYBERDYNE Inc. (Ed.): HAL for Medical Use (2015) online
40 SILVERSTEIN, Ed: Low-Cost Robohand Provides Miracle for Five-Year-Old Boy, Others Can Beneﬁt from Device(2013) online

41 DPA (Ed.): Roboter hilft Behinderten beim Arbeiten (2012) online
42 Ibid
43 BECKER, Heidrun; RÜEGSEGGER, Adrian: Robotik in Betreuung und Gesundheitsversorgung (2013) p.62-63
44 STEEVES, Rich: Robotic Wheelchair Can Smoothly Traverse Even the Bumpiest Terrain (2012) online
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‘Bestic’ “is a small robotic arm with a spoon on the end. The arm can beeasily maneuvered, and a user can independently control the spoon’s
movement on a plate by choosing what and when to eat.”46
45

Telepresence and assistant robotic systems
Telepresence robotic systems are remote-controlled, mobile robots. They can replace the physical presence of acare person. These robots can be used for example in rural areas.

The ‘RP-VITA’ is an independent telemedicine assistant system that allows
physicians to care for patients remotely. “The system features mapping andobstacle detection, as well as avoidance technology and an iPad user interface
for control and interaction. The robot can also interface with diagnostic devices
and electronic medical records (EMR) systems.”48
47‘AnyBots’ “provides a type of immersive telepresence, meaning instead of
focusing merely on audio and video communications, the ‘AnyBots’ robot allows
for movement controlled by a remote. … ‘AnyBots’ can turn on sensors at thecontrol of not the person in the room, but the person who wants to do thecommunication.”50
49
Assistant robotic systems support humans in their everyday work such as routine work or physical andpsychologically demanding work. These robots can be divided into the subgroups of robots supporting carestaff, for example cleaning of the ﬂoor or distribution of food.51 The other group of robotic systems is designed
to help sick people at home. They allow people to live in their homes and may support relatives in providing
assistance. They may remind people about taking medicine, communicate with nursing staff and collect data
regarding diseases.52 Depending on their function, the robots have different designs, such as the shape ofanimals, humans or a fanciful shape.

45 McNICKLE, Michelle: 10 Medical Robots That Could Change Healthcare (2012) p.5
46 Ibid
47 McNICKLE, Michelle: 10 Medical Robots That Could Change Healthcare (2012) p.4
48 Ibid
49 McNICKLE, Michelle: 10 Medical Robots That Could Change Healthcare (2012) p.9
50 Ibid
51 MALSEKI, Debra Ann: Health Care Robotics (2014) online
52 SCUTTI, Susan: Innovation – Medical Robots are not just the Future of Health Care, but Part of the Present (2015)
Slideshow p.3

26

Martin POHL, Robotic Systems in Healthcare53

The ‘Swisslog RoboCourier’ “is an autonomous mobile robot. The tool
dispatches and delivers specimens, medications and supplies throughout thehospital. Once the robot is carrying what needs to be delivered, a person
identiﬁes the destination and the robot selects the most efﬁcient route to deliver
the materials. … The robot uses laser detection to ensure precise and safe
navigation, while voice-activated messages alert staff of the robot’s presence.
The robot also stops and waits until trafﬁc is clear, and it can signal doors toautomatically open so it can move through.”54

There is little research on the analysis of acceptance of telepresence and assistant robotic systems such as therelations between the robot and patients and care staff. One risk could be a feeling of safety that is notjustiﬁed.55
Social-interactive robotic systems
Social robots are virtual social actors produced to form an illusion of a ‘real’ social interaction. In contrast to
artiﬁcial or mediated items social robots are physically tangible and real since they are embodied.56
Social robotic systems evoke social behavior based on human behavior in forming emotional bonds. They
can distinguish between objects and social agents in their environment with whom they are in touch. Theyshow social intelligence. Most of the social robotic systems are designed as toys. Humanoid robots which canwalk on two legs can be characterized into:
・Utilitarian humanoid robots: They interact as embodied ‘beings’ providing guidance in shops, serving foodin hospital etc.
・Affective humanoid robots: They are created to interact with human on an emotional level – either on theinternet or in mostly private homes. Humans can enter into an individual relationship.

‘CosmoBot’ is used “to enhance the therapy of developmentally disabled children
between 5 and 12 years old. The robot can make therapy more interesting forchildren and allows for better success when achieving long-term therapy goals: …
the robot collects data on a child’s performance. This allows therapists to evaluate
how successful the therapy is.” 58
57
Though, it must be questioned if a relationship between human and robotic system is really a social
interaction. Context and action are interrelated however robots cannot set communication into a context.
Artiﬁcial intelligence is based on planning models, in other words, the mind is ﬁxed before action takes place.
This may contradict with the interpretations of humans, which may cause communication problems.59 Crucially,
the control of communication is within the competence of the individual human being.
53 McNICKLE, Michelle: 10 Medical Robots That Could Change Healthcare (2012) p.10
54 Ibid
55 A list of existing research studies can be found in BECKER, Heidrun et. al. (Ed.): Robotik in Betreuung undGesundheitsversorgung (2013) p.48 and p.51

56 LILL, Felix: Unheimliche Helfer. Eine neue Generation von Robotern soll den Alltag verändern. Eindrücke von der
Mensch-Roboter-Konferenz in Tokio (2013) online

57 McNICKLE, Michelle: 10 Medical Robots That Could Change Healthcare (2012) p.7
58 Ibid
59 BECKER, Heidrun et. al. (Ed.): Robotik in Betreuung und Gesundheitsversorgung (2013) p.60
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(3) Robotic Systems in the Context of the “Internet of Things”
Health robotic systems within context of the Internet of Things (IoT) are in a very early stage of production,
so it is too early to talk of a speciﬁc category. Furthermore, the robotic systems in this context being developedin future may be included in the previous two groups of categorization. The existing systems focus mainly on
improving health and wellness. Internet-connected devices used in medical facilities may have a health-related
relationship; however, they may be closer to factory settings. In principle three groups of devices may be
determined:
・Wearables: The devices available presently designed to carry or wear are mainly focused on diabetes,
chronic heart failure, and chronic obstructive pulmonary disease. Most of them represent an early stage ofa robotic system: they have sensors and transmit information; however, most of them are not able to fulﬁllcoordinated mechatronic actions.
・Intelligent implantables, injectables and ingestibles: The devices available today are mainly prototypes, suchas nanobots that recognize early stage cancer or can clear arteries.
・Non-wearable measurement devices: These “devices gather and transmit health data from the human bodyperiodically but are not attached continuously.”60 Not all of them are robots.
For all three groups it can be stated, that “using IoT technology for more continuous and consistentmonitoring of patients with chronic diseases can help patients to avoid medical crises, hospitalizations andcomplications.”61
In brief there are a lot of robotic systems: starting from training devices and assisting preventive therapies up
to robots which can do surgeries or who appear as humanoid robots. Many of the robotic systems are still
prototypes and as such knowledge about their helpfulness is limited. The difference in technical complexity
among the robotic systems is large.
3. Ethical Analysis: The Bottleneck for Robotic Systems in the Market
Ethical issues in the arena of public discussion usually arise only when stakeholder groups have differing
opinions about what is appropriate and what is inappropriate within the context of new developments. Robotic
systems for major healthcare issues have not been discussed, though there are severe emerging issues. The
ethical thoughts in this paper concentrate on three topics: ﬁrst communication between human and robotic
systems in general, second the operational level of robotic systems in healthcare and on third the IoT as crucialpart of the health related robotic systems of the future.
Communication between human and robotic systems: Only humans understand the meaning ofcommunication and only in robotic system ﬁelds is programmed communication possible. Furthermore, only
humans can understand meanings out of context. Humans use energy to establish and maintain humanrelations with other humans and animals and receive in return emotional support such as friendship. This ispart of human existence. Also for communication with robots humans have to use energy. But what is thereturn? Can the mechanical smile of a robot be appreciated in a similar way as the smile of a human? Can it beargued that this depends on the context, such as a lonely person in a hospital, or a culture, such as the openminded Japanese culture. Or, at its core: is it ethically appropriate to develop and sell robotic systems forhumans who have no other opportunity to develop emotional bonds?62 In that sense the interaction between
human and robotic systems may convert society with the result that both human beings and the individual may

60 McKINSEY GLOBAL INSTITUTE (Ed.): The Internet of Things: Mapping the Value Beyond the Hype (2015) p.38
61 McKINSEY GLOBAL INSTITUTE (Ed.): The Internet of Things: Mapping the Value Beyond the Hype (2015) p.39
62 BECKER, Heidrun et. al.(Ed.): Robotik in Betreuung und Gesundheitsversorgung (2013) p.62
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Martin POHL, Robotic Systems in Healthcare

have to be re-deﬁned.
On an operational level of robotic systems in healthcare two questions appear: Do health related robotic
systems violate ethical values? And if such robotic systems act by themselves: do they do that in an ethicalway?
Related to the ﬁrst question, basic values in the health sector are ﬁrst: no damage, second: autonomy, third:
care, fourth: righteousness. From the point of view of ethics, this discipline has to think about the newdevelopments and evaluate, if there is a violation against these ethical principles. From the viewpoint ofmanagement, a violation of these principles will make a success of a new product very unlikely and as such theinvestment a management failure. What could be the ethical demands?63
・Dehumanising: The care of sick people by robots may be called inhuman, especially, if the care has been
undertaken by human before. On the other hand, robotic systems may be companions for sick people.
・Social Poverty: The care by robots of sick people may be considered an exclusion by society in an
increasingly health orientated society. There is a positive correlation between social poverty and mortality.
・Experimenting with Sick People: The use of robotic systems may give the impression, that sick people may
be used as test subjects. Though, people having no chance to survive based on present know-how may
beneﬁt from experiments.
・Exploitation of Human Emotions: Robots with communication abilities may use human emotions for
doubtful purposes.
・Redeﬁnition of Human: If applying robotic systems in healthcare, humans might be presented with thesituation where they are surrounded by robotic systems that simulate human behavior, while themselves
being dependent on robotic systems.
・Risk of Developing a Dual-Use Technology: Technologies developed for the health sector may be used formilitary purposes.
・Human Enhancement Technologies: Technologies developed for health diseases may be used to increaseabilities of healthy people. This may cause questions about the deﬁnition of future humans. Touching the
ethical dividing line between healing and enhancement may impact the deﬁnitions of illness and health.
・Affordability: Robotic systems will be only successful if they can be used by a large percentage of the
population. This does not only apply if only wealthy people have access, but an ethical boundary may becrossed when the gap is widened between what can be done and what is actually done.
In relation to the second question: ‘Are robotic systems able to act ethically themselves?’ The answer seems tobe from today’s point of understanding evident. It is questionable that robots may be taught ethical behavior as
such. Since robots are developed for a speciﬁc purpose, considering ethical questions must be within thecontext of the purpose.
Since more and more robotic systems will be related to the ‘Fourth Industrial Revolution’ thinking of ethics is
crucial in this context. At this early stage it is particularly important to focus on the governance of the IoT.
Various stakeholders in the value chain may obtain power: Power over ﬁrst network standards, second products
and their distribution, and third network trafﬁc.64
Power Over Network Standards
Both, how and what a robotic system can communicate, may be part of closed standards and may create thechance of controlling IoT networks. Closed standards struggle with two main problems. First, they re-create“problems that the internet has already solved: how to assign network names to devices, how to route messages
between networks, how to manage the ﬂow of trafﬁc, and how to secure communication.”65 Second, it is not in

63 Ibid p.84-85
64 FELL, Mark: Roadmap for the Emerging “Internet of Things” (2014) pp.52-56
65 FELL, Mark: Roadmap for the Emerging “Internet of Things” (2014) p.52
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the interest of the customer, such as a hospital, that wants to buy products from different makers which speak
the same technical language. Though, in contradiction to the customers’ desire, it can be expected that in thenear future many companies will try to develop closed standards.
Power Over Products
Manufacturers traditionally use “the power of distribution systems and intellectual property rights to control
the supply of their products. … (This causes new interdependencies, such as) an IoT-based product may need to
employ a third party product. … (However,) even if both products are present in a market, one of them may
refuse to cooperate.” 66Power over Network Trafﬁc
Network operators “can block or slow down trafﬁc on their broadband networks based on individual users or
the type of trafﬁc those users are accessing or by the type of service that is sending the content. … (Beyond
network neutrality) consumers need to be able to afford to pay for their IoT data use. Many devices, also in
robotic systems related health sector, will be mobile and as such prone to roaming fees. New business models
for data usage have to be developed,”67 going as far as treating the IoT network as a public utility - health may
be a good starting ﬁeld for development in this direction.
The thoughts on ethics show that there are many open questions applicable for the arena of public
discussion. Finding ethical agreements – is a condition for the success of robotic systems in the healthcare
sectors – at least within societies where the robotic systems are supposed to be implemented. In the following
outlook an approach for a result-orientated outcome will be introduced.
4. Summary and Outlook
This paper states that robotic systems in healthcare will be like any other product and service, that is be
successful only if they add both ﬁnancial and social-ethical value. The core question is, can robotic systems add
monetary and/or social value to healthcare? A positive answer is sine qua non for the development of any
robotic system – and due to that also the thoughts of this text.
Following the research question and the hypothesis of this paper, the ideas are proof that not only the macrotrends are favorable, but on the operational level robotic systems can add value to healthcare. This has alreadybeen achieved for robotic systems currently in the market. Due to the large number of different kinds of robotic
systems, each system fulﬁlls a different task. Overlapping between tasks is frequent, and so are the monetaryand non-monetary values these robotic systems produce. A robotic system may reduce labor-cost and perform
activities that cannot be done by humans. But a robotic system may also increase the cost for human resources
or capital commitment while increasing the quality of care. A challenge in this context is that monetarytransfers can be measured whereas intangible factors such as quality of life are difﬁcult to evaluate and transfer
into monetary units. Finding solutions for this has to be the subject of future research.
Whereas technical and management challenges towards new robotic systems are on track – though indifferent stages – the discussion about ethics is in a very early stage, though the potential for conﬂict within thecontext of robotic systems is signiﬁcant. Whereas many ethical demands towards robotic systems in healthcare
are identiﬁed as such, public discussions remain fragmented. Since in the very near future more and more
health related robotic systems will be part of the ’Internet of Things’ (IoT), ﬁnding a consensus based on a
public discussion is time sensitive for successful ongoing development. Beyond the general ethical discussion on
the IoT the health sector has its own ethical context since it is embedded into the context of monetary needs,
reﬂecting modern management, but at the same time in the Hippocratic oath. From an international perspective,
66 FELL, Mark: Roadmap for the Emerging “Internet of Things” (2014) pp.52-53
67 FELL, Mark: Roadmap for the Emerging “Internet of Things” (2014) pp.55-56
30

Martin POHL, Robotic Systems in Healthcarecomparisons in terms of ethics, business practices including managed innovation, healthcare practices andreﬂection among different countries being selected, are multidimensional and discrete topics of research. Future
work may shed light on them.
The thoughts on ethics indicate: How can these conﬂicts be socially and economically better and effectively
solved based on ethic values? Stakeholders in robotic systems may seek to: First reconcile their underlying
interests, second to ﬁnd who is right, third to state who is more powerful.68 But what does ‘better’ and ‘effective’suggest, when following this structure? To minimize the cost of disputes is equivalent with reducing transaction
cost. Another way of evaluating different approaches is by the parties’ mutual satisfaction with the results.
Satisfaction does not only depend on the perceived fairness of the resolution, but also on the perceived fairnessof the dispute resolution procedure. A third criterion is the long-term effect on the parties’ relationship. It may
affect the abilities of parties to work together on a day-to-day basis. The fourth criterion is whether a particularapproach produces durable resolutions.69
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