that it would have been unethical to withdraw the equipment at that time and they draw attention to the risk of people becoming dependent on equipment which is subsequently withdrawn. video - phoning, like monitoring for safety purposes, may be perceived as an invasion of a person ’ s privacy. whilst someone is sitting in front of the screen talking to someone, anyone who walks past may be captured on screen against their will or without their knowledge. in families with children and teenagers, it is unlikely that every one of them would have been asked to consent to the installation of such equipment. there may also be visitors who are unaware that their image is being recorded. some people are very susceptible about their image and would be disturbed if they realised that they had been filmed in their pyjamas, without make - up, wearing curlers or having just woken up etc. the person using the video - phone should also have a certain degree of privacy. for this reason, it would be good to have the video - phone in a separate room or private area but not all households have this option. having an open - line video - phone system, which is permanently switched on, opens up the possibility of professional carers or relatives using this system to ensure from a distance that the person with dementia remains in the home. this could be interpreted as a form of non - maleficence but it could also be considered as a form of restraint in that the person may feel compelled to comply ( magnusson and hanson, 2003 ). it could be argued that certain activities are inappropriate for elderly people and that encouraging people with dementia to participate is demeaning and fails to respect their dignity, particularly when it concerns activities that they would not, in the opinion of others, have done prior to having dementia. this is based on three assumptions : 1. that there are activities which are appropriate for certain age groups and others that are not 2. that people ’ s likes and dislikes do not change over time, and 3. that if they do change, after a person has developed dementia, they should not be considered as valid. each assumption could be challenged. people with dementia are constantly adapting to new situations and the experience of having dementia may result in a different outlook on life and even changing interests. it would be a mistake to consider every change as being linked to damage to the brain ( kitwood, 1993 ). possibilities to engage in activities may arise which were simply not previously envisaged but which nevertheless prove rewarding. moreover, the social and leisure activities of elderly people


consider every change as being linked to damage to the brain ( kitwood, 1993 ). possibilities to engage in activities may arise which were simply not previously envisaged but which nevertheless prove rewarding. moreover, the social and leisure activities of elderly people have already changed considerably in the last few decades, perhaps due to older people being physically fitter, having fewer family and professional responsibilities, greater purchasing power and better mobility than in the past ( fobker and grotz, 2003 ). some concerns about dignity may be valid and care must be taken to ensure that people are not being pressurised to take part in activities which they personally find demeaning or of no interest. however, attention must also be paid to ensuring that a person ’ s autonomy is respected and his / her current wishes respected. as lawrence ( 2007, p. 555 ) points out, “ caring transforms family relationships, and carers may fight to protect and preserve their own image of the person with dementia, with the risk of losing contact with his [ sic ] present needs and identity. ” socially assistive robotics ( sar ) is an area of at which is still very much in its early stages, particularly for use with people with dementia. most of the information in this section is taken from the writings of sherry turkle ( 2007 ) and feil - seifer, skinner and mataric ( 2007 ). please see the references section for full details. there are different kinds of sar systems such as companion robots which provide a focus of attention ( e. g. in the form of a soft toy / animal which responds to touch or sound ), or non - contact assistive robots which provide support in social interaction with little or no physical contact. a companion robot that has received a lot of attention in the media recently is “ paro ” the baby harp seal developed by dr takanori shibata. the producers of this robot divide companion robots into four categories : - familiar animals such as dogs and cats - non - familiar animals such as seals, penguins and whales - new characters and artificial animals and consider paro as being in the third category ( national institute of advanced industrial science and technology ( niast ), 2010 ). according to feil - seifer et al. ( 2007 ), the use of companion robots has led to reduced stress levels and increased social interaction amongst residents in nursing homes. robots can also be given a kind of personality, e. g. serious or playful. this may affect how people with dementia react towards them and feel about


of companion robots has led to reduced stress levels and increased social interaction amongst residents in nursing homes. robots can also be given a kind of personality, e. g. serious or playful. this may affect how people with dementia react towards them and feel about them. sars can have varying degrees of human - like appearance or qualities or with companion robots, varying degrees of similarity to living creatures. turkle ( 2007 ) claims that this may create social side effects with ethical ramifications. a person may become attached to the robot but may have to share it with other people, the robot may break down or the person may be moved to another unit or home and have to part with it. he / she may come to consider the robot as “ real ” and become disappointed by it. in an exploratory study into the psychological effects of domestic at, cesta et al. ( 2007 ) found a clear preference by elderly people for the “ no - face ” version of a prototype assistive robot and that the “ no - face ” version resulted in deeper psychological attachment. the designer of paro ( the baby harp seal robot ) experimented with companion robots representing animals with which people were more familiar such as cats. they found that the initial reaction was very positive but that people soon started to make comparisons between the robot and real cats and were soon disappointed that the robots did not feel the same or react the same as cats they had known. they did not tend to do this with the seal which is an animal that most people are not familiar with, but found it very cute and developed an emotional attachment to it ( niast, 2010 ). evidence that attachment is not limited to lifelike creatures was provided by a study into children ’ s use of “ furbies ” ( please see image ). the children had formed such close emotional bonds to their furbies that when the creatures broke, most children did not want a brand new replacement but rather the old one mending or “ cured ” ( turkle, 2004 ). these findings cannot be generalised to people with dementia but provide useful insight into the human capacity to attach to inanimate objects. another concern linked to the use of sars is their authenticity or rather lack of it. some people may feel that there is something uncanny about a computer which seems to show concern or exhibit caring behaviour, whereas others might appreciate this or simply have no problems with it. in the 1970s a famous computer programme known as “ eliza ” was developed which was capable of mirroring input and providing supportive feedback. for


which seems to show concern or exhibit caring behaviour, whereas others might appreciate this or simply have no problems with it. in the 1970s a famous computer programme known as “ eliza ” was developed which was capable of mirroring input and providing supportive feedback. for example, to the statement “ my mother is making me angry, ” the computer might respond “ tell me more about your family. ” on the basis of observation of students interacting with eliza, turkle ( 2007 ) suggests that they were not pretending to be chatting with a human but actually enjoying talking to a machine. a more recent example is the tamagotchi and similar devices / creatures which promote a desire to nurture and the illusion of reciprocation ( turkle, 2007 ). some sars can be programmed to make eye contact based on detection of where a voice is coming from. sars are different to traditional teddy bears and dolls in that they are active, demand attention, require nurturing behaviour and / or react to the user ’ s behaviour. the use of sars by people with dementia is probably fairly limited at the moment. ethical questions may nevertheless arise such as whether it is right to give sars of this kind to people whose ability to interact with humans is declining, who might at some point be unable to understand that something is not “ alive ” and who may be feeling isolated. however, one could also argue that anything that makes a person feel cared for, wanted, of interest to someone / thing else and drawn into interaction can only be a good thing. although sars are not human, programmed reactions towards the behaviour and movement of the user may affect users ’ sense of privacy in that people may feel that they are not alone ( which can also be positive ) or that they are being watched. if the user can control privacy levels, such problems can easily be overcome. sars may also increase the level of privacy by side - stepping the need for human assistance for tasks which are potentially embarrassing or private ( e. g. going to the toilet or getting washed ). this may also serve to protect the user ’ s dignity. autonomy and safety sars could be used to carry out certain tasks on behalf of the user or to provide a sufficient level of support to enable the person to complete the task him / herself. this should promote the autonomy of the user. cesta et al. ( 2007 ) divided the possible tasks of a domestic robot into two categories : on - demand interaction ( in which the user takes the initiative and might ask the robot : have i


. this should promote the autonomy of the user. cesta et al. ( 2007 ) divided the possible tasks of a domestic robot into two categories : on - demand interaction ( in which the user takes the initiative and might ask the robot : have i taken my pills today, have i already had lunch or where are my keys? ) or proactive interaction ( in which the robot may detect certain programmed danger and warning scenarios such as the person lying on the kitchen floor, and take the appropriate action ). however, the degree of autonomy granted to the robot must be appropriate and carefully monitored, with the user retaining as much control as possible and if necessary, constant monitoring from carers or healthcare professionals ( e. g. in the case of sars dispensing medication ) ( feil - seifer et al., 2007 ). in the case of sars designed to promote social interaction, a certain degree of autonomy of the robot is perhaps needed. as people with dementia may at some point experience difficulties with mobility, vision and coordination, it is essential that sars are stable and not likely to provoke accidents ( e. g. through their colour, size, shape, movement or sound ). in all cases, users need to feel safe using the robot and positive about it. people should avoid patronising those using various forms of assistive technology. dignity, truth - telling and confusion as people may feel more or less at ease interacting with sars, the interaction promoted and required by the sar may suit some people more than others. it could even be problematic if people realise that they are dependent on the sar but feel ridiculous using it. it may remind them of the human contact that is not available to them. some may be confused by the robot, not understanding how it works, what to do to make it work or what triggers its actions. as some people with dementia suffer from confusion and delusions, the use of sars may lead to fears about intrusion in their home. it must be clear to them that they can get rid of the sar if they don ’ t like it and have access to alternative support for their needs. some of the ethical issues linked to doll therapy could be applicable to the use of companion robots. for example, it could be argued that the person with dementia who comes to believe that the device is living is being deceived. a counter argument would be that not correcting the person with dementia concerning this belief provides them with the opportunity to participate in a rewarding and meaningful activity, and to adopt a


who comes to believe that the device is living is being deceived. a counter argument would be that not correcting the person with dementia concerning this belief provides them with the opportunity to participate in a rewarding and meaningful activity, and to adopt a nurturing role ( andrew, 2006 ). such deception linked to good intentions is what marzanski ( 2000 ) would call “ justifiable benevolent deception ”. whether it is actually justifiable is a matter for debate. however, it must also be borne in mind that a person ( adult or child ) who actsas ifan object is alive, does not necessarily believe that this is the case. detectors and monitors fitted to everyday equipment and stand - alone devices various devices and systems can be installed in people ’ s homes which result in a safer environment for people with dementia as well as peace of mind for them and their carers ( provided that the devices and systems function properly and can be easily used ). such at can therefore promote autonomy and safety. blackman et al. ( 2003 ) suggest that despite attempts to create a safe environment where people have quality of life, there is a risk of the home starting to feel like a prison. they emphasise that supporting independence ( e. g. through the use of at ) is no guarantee against exclusion and criticize disabling environments, adding that in some cases a person ’ s impairment may be removed by a suitable adaptation of the environment. buildings are now being constructed which incorporate as standard features various forms of at such as cooker monitors ( to detect gas, smoke and rings which have been left on ), pictorial object locators, water level and temperature gauges, pressure sensors, automatically activated lighting and a range of other monitoring devices. such buildings are sometimes called smart homes. at can be active ( involving some purposive action on the part of the user ) or passive ( responding automatically to the behaviour of the user or to other conditions such as smoke, rising heat or water level ). in the case of active at, it is more likely that the person with dementia will be aware of it and have some degree of choice regarding its use once installed, whereas with passive at, the user does not have the same degree of control, save uninstalling the equipment ( not an easy task for many people ) or getting rid of it. different kinds of safety devices therefore have the potential to increase autonomy and safety but autonomy also involves the ability to choose and this may be affected by the type of at used. when


( not an easy task for many people ) or getting rid of it. different kinds of safety devices therefore have the potential to increase autonomy and safety but autonomy also involves the ability to choose and this may be affected by the type of at used. when a person moves into residential care where such technology is used, it is possible that he / she will not be aware of the various devices used and will only find out later. in such cases, he / she would not have consented to its use as it was pre - existent and may be unhappy about its use. there are also numerous stand - alone devices which may contribute towards self - esteem, autonomy, safety and wellbeing ( as mentioned earlier depending on the devices, the people involved and the situation ) such as picture telephones, digital pens, calendar clocks and medicine dispensers. some of these devices may enable people with dementia to maintain social contact with family, friends and the outside world thereby helping avoid social exclusion and helping ensure recognition of their personhood. in the case of people who do not live alone, the extent to which certain devices are visible to others may affect their sense of pride and dignity. if too obvious, the people for whom they are intended may feel incompetent and embarrassed, especially if people visit and ask what they are for. if such devices were installed on a large scale as standard features, this would be less likely. some devices, such as movement sensor light switches, may be confusing if the person with dementia has forgotten either how they work or having consented to their installation. whilst certain devices may be experienced as contributing towards autonomy and thus reassuring, for some people, they may serve as a reminder of their own loss of capacity, loss of personal control over their lives and disability ( gitlin et al., 1998 ). in some cases, elderly people may rely heavily on the at device or system to the extent that they trust it more than they trust their own judgement. if the device then malfunctions and gives out faulty information ( e. g. regarding taking medication ), they would be less likely to detect the error and this makes them vulnerable ( ho et al., 2005 ). apart from the need to take this into account during the design of various forms of at, regular review and maintenance of at is needed. providers of at also have an obligation to ensure that it is safe and reliable, particularly when used by people who may not have the capacity to check this themselves. as some devices for use in the home


, regular review and maintenance of at is needed. providers of at also have an obligation to ensure that it is safe and reliable, particularly when used by people who may not have the capacity to check this themselves. as some devices for use in the home are fairly expensive, their use raises concerns about equity. clearly, people with a higher income will have more opportunity to obtain them although some devices may be financed to some extent by the state. this will differ, however, from one country to the next and may be dependent on certain conditions such as whether one lives alone, the severity of one ’ s condition and one ’ s level of income. finally, service providers may be hostile towards the introduction of at in the home as they may feel that it is a threat, seeing it as an alternative to the personal service they provide in the home ( magnusson and hanson, 2003 ). there is possible agreement from carers and people with dementia that at should not replace human contact but on the other hand, decisions about this are most probably influenced by economic concerns and as stated earlier, it is the quality of human contact that is important, not the quantity. monitors and alarms linked to the person and his / her activities balancing discretion with transparency enuresis monitors may be a source of shame, particularly if they are visible to others or known about. however, they may also promote dignity by preventing accidents from happening in the long run due to careful analysis of the times that accidents tend to occur. such monitoring may lead to the provision of timely support. preventing enuresis may reduce embarrassment and the need to depend on others for hygiene needs and changing sheets, thereby also promoting autonomy. as with most forms of at, the visibility and invasiveness of the system may be disturbing to some people, especially those who do not need to use it. for example, it may be necessary to install a computer in the living room or monitors around the house or there may be visible wires and buttons. certain equipment, such as hoisting devices, may be very obvious and cumbersome ( check if this is the case ). when obtaining consent for the installation of assistive technologies, cohabitants should therefore also be consulted as installation may represent an invasion of their privacy. finally, whilst it is important to make at unobtrusive when fitted in people ’ s homes, there is an argument in favour of making sure that it can be seen, especially in the case of equipment designed for monitoring purposes. being able to see the equipment, to see when it is


unobtrusive when fitted in people ’ s homes, there is an argument in favour of making sure that it can be seen, especially in the case of equipment designed for monitoring purposes. being able to see the equipment, to see when it is switched on and to control it ( to the extent that the user has the necessary capacity ) has implications for consent, autonomy and management of privacy issues. privacy and autonomy at for the monitoring of falls ( or to signal distress ) can be active or passive. some systems require the person to press a button ( e. g. on a pendant or phone ), whereas others react to the detection of sudden impact or prolonged immobility. those which do not require purposive action may involve some degree of invasion of privacy in that they may record and transmit information to other people about the user ’ s activity. some may even involve video monitoring. systems which are more intrusive may nevertheless be most appropriate for certain individuals and permit greater autonomy. whilst various forms of at may promote autonomy and provide safety, concerns are often expressed that at should not be used to replace human contact. indeed, one study found that the use of at was in some cases dependent on a carer being present to remind the person to use it ( cahill et al., 2007 ). on the other hand, people with dementia have also expressed satisfaction about not having to rely on other people so in some cases, an advantage to at could be that it enables people to express their independence. talking about a night and day calendar, one person commented : “ it ’ s the best thing i ’ ve ever got, i don ’ t have to ask deirdre ( caregiver ) what day it is. it gives me a sense of …. independence. i don ’ t have to be running to deirdre. ” ( quoted in cahill et al., 2007, p. 137 ) autonomy and safety the use of televideo monitoring for the self - administration of medication by people in the early stages of dementia helps promote autonomy but also has implications for safety. people using the technology may fail to respond to it or simply be out of the house when it is activated. this is not unusual as people in the mild stages of dementia, for whom the technology is mainly intended, may be leading fairly active lives and be less bound to the home than those in the later stages ( smith et al., 2007 ). they may also inadvertently switch off the monitor or camera. such technology therefore has the


the technology is mainly intended, may be leading fairly active lives and be less bound to the home than those in the later stages ( smith et al., 2007 ). they may also inadvertently switch off the monitor or camera. such technology therefore has the advantage of promoting autonomy but may result in a false sense of security, which must be borne in mind when trying to balance the two principles. in a small - scale qualitative study in which 8 people using such a system were interviewed, it was found that some people appreciated the personal contact with the caller / operator which shows that technology can sometimes be combined with additional human contact rather than merely replacing it ( smith et al., 2007 ). determining who is granted access to the control of the at is an important factor in the ethical use of at. provided that it would be safe to do so and that the person understands the consequences of doing so, the person using the at should be able to switch it on and off, if and when required, as otherwise his / her continued consent to its use cannot be guaranteed. at can be used as a memory aid to enable people to carry out tasks which would otherwise be difficult or impossible to accomplish on their own due to difficulties remembering what to do, which items are needed for the task or which order to carry out each stage of the task. for example, a video prompt for every step needed to prepare a cup of tea or coffee can be used, based on a recording made in the person ’ s own kitchen ( davies et al., 2010 ). this may enhance self - esteem and promote autonomy and wellbeing. however, the various capacities of people with dementia deteriorate over time. consequently, there may come a time when the device no longer promotes autonomy but rather represents a risk for the person ’ s safety ( e. g. through scalding or electrocution ). similarly, with a computer - based device which gives a reminder consisting of a symbol and text that a door has been left open ( e. g. a door of the house or the fridge ), it will only work if the person with dementia understands the symbol or text message and goes to close the door when the message is shown. if others with an interest in the safety of the person with dementia presume that the device is working, they may have a false sense of security and an alternative, perhaps more effective, approach would not be tried. awareness of dementia and regular assessment of the person with dementia and the appropriateness of various at solutions are therefore


al. ( 2005 ) investigated, by means of a randomized controlled trial, the use of pressure detectors to alert staff that elderly people in a convalescent hospital at risk of falling had moved from their bed or chair ( i. e. so that they could be assisted by staff if necessary which would be preferable to using restraint ). for one group of residents trunk restraint, bedrails and chair boards were used and for another group bed - chair pressure sensors were in addition made available to staff. no significant differences were detected in the number of falls, mobility, transferability or the amount of time that residents had to endure physical restraint. the researchers conclude that staff had only used the pressure sensors selectively as an additional means of safety. this suggests that at may have the potential to serve as an alternative to the use of physical restraint ( which can rarely if ever be justified on ethical or safety grounds ) but that adequate training and explanation must be provided. movement sensors / detectors can also provide information at a distance that the person has not moved ( i. e. that s / he has not remained immobile for a lengthy period of time ) which could in some cases be an indication of a fall or problem. however, rather than providing a sense of security, such devices may in certain cases serve as a means of control or of imposing a daily rhythm on a person that is not his / her own. for example, a person may want to sleep or lie down for several hours during the day but fear triggering the alarm and so refrain from doing so. movement sensors / detectors may be perceived as an invasion of a person ’ s privacy. a senior citizen who had been trying out movement detector surveillance equipment complained about this and about the way she felt controlled : “ i don ’ t want people to know when i take a nap … when toy [ her dog ] and i are lazy … that ’ s only between him and i … they know enough about me. i want to spare them my strange habits … “ … at times when i can ’ t sleep and get up in the middle of the night i sometimes think that this might be seen … which makes me reluctant to do so! ” ( essen, 2008, p. 133 ) while ( 2006, p. 362 ) sums up the issue of privacy and control as follows : “ older people, like everyone else, are entitled to vary their daily routine without consultation and it should not result in the arrival of a rapid response care team to whom they have to justify their lie - in.


issue of privacy and control as follows : “ older people, like everyone else, are entitled to vary their daily routine without consultation and it should not result in the arrival of a rapid response care team to whom they have to justify their lie - in. ” ” some devices can be used to monitor the behaviour of the user via their use of equipment ( e. g. recording how many times he or she opens the fridge door or measuring the weight of the fridge ), which might help determine eating habits and whether food is being eaten, hoarded or thrown away ( van hoof and kort, 2009 ). whilst the person with dementia may be aware of the use of such devices and have agreed to their use, they may nevertheless feel embarrassed or humiliated if they perceive this as infantilisation or unwelcome surveillance. it is therefore necessary to ensure that these devices are as discreet as possible and that their use is kept confidential ( particularly in nursing homes where people live in community with other people whom they do not necessarily know very well ). the intrusion of people ’ s privacy can be limited by the type of equipment used. movement detectors, such as the “ just checking ” devices described by price ( 2007 ) can be used on a temporary basis in order to find out how a person behaves in his / her home in order to devise an appropriate care package. the devices are small, wireless and do not record any visual image. access to the resulting chart can be controlled by a password protected website. privacy, dignity and personhood electronic surveillance, which could include closed circuit television ( cctv ) and video surveillance, takes monitoring a step further in that it adds the visual image of the person being monitored. cctv is used extensively in the uk in the public domain but in some countries much less or hardly at all. in the private sphere of a person ’ s home or living space, video surveillance could be considered an invasion of a person ’ s privacy, involve a lack of respect, and constitute a threat to their dignity and personhood ( in treating them like objects ). there could also be a risk of voyeurism and using video recordings for criminal purposes. the royal college of nursing ( 2004 ) and the mental welfare commission for scotland ( 2005 ) have suggested that electronic surveillance should be considered as a form of restraint. on the other hand, essen ( 2008 ), who interviewed 17 seniors found that some perceived electronic surveillance as protecting their privacy as it enabled them to carry on living in their own homes instead of having to move


should be considered as a form of restraint. on the other hand, essen ( 2008 ), who interviewed 17 seniors found that some perceived electronic surveillance as protecting their privacy as it enabled them to carry on living in their own homes instead of having to move into residential care. saventedt et al. ( 2006 ) distinguish between the use of technology for plain surveillance or support, quoting one of their interviewees who stated : “ it is very important that the person who controls the older person via the electronic device has some kind of connection with them and understands their problems. it cannot be just anybody because then it changes from support of older people to surveillance. ” ( p. 20 ) it is therefore necessary to consider who should have access to video recordings, but also how and for how long recordings should be stored and the justification for using such devices. should, for example, male carers have access to video recordings of female residents in nursing homes or residential care ( or female carers of male residents )? this may be particularly relevant for people from certain cultural or religious backgrounds. in cases where special attire is required in public places ( e. g. the burkha or the sikh turban ), the boundaries between the private and the public sphere may need to be clarified, especially in residential care settings ( bearing in mind the way that each person interprets religious or cultural obligations ). for some people with dementia, concerns over the use of surveillance equipment may be dependent to some extent on who is observing them ( robinson et al., 2007 ). also, there should be limits as to where electronic surveillance can be used ( e. g. not in the wc or the bathroom ). however, the use of at must be considered on an individual basis as taking the example of the bathroom, the use of video surveillance might give the person more freedom, direct privacy and autonomy whilst they take a bath or shower than they would have if someone needed to be physically present. on the other hand, perhaps an alternative, less intrusive form of at could be used which would provide a sufficient level of protection ( e. g. from falls, scalding or overflows ), enhance self - esteem and promote autonomy. the home or a person ’ s own room, in the case of communal living, is a very personal and private domain and people can usually decide whom they want to invite in. as with home care in general, but especially in the case of surveillance technology or tracking devices involving the intervention of other people, the same degree


communal living, is a very personal and private domain and people can usually decide whom they want to invite in. as with home care in general, but especially in the case of surveillance technology or tracking devices involving the intervention of other people, the same degree of privacy cannot be ensured. people may feel uneasy or even threatened by this invasion of their personal space and in the case of same - sex relationships, this may result in an undesired “ outing ”. heterosexual couples might also prefer to keep their relationship private ( e. g. due to ageist attitudes towards sexuality or tensions within the family ). beneficence / maleficence and justification surveillance equipment may be considered as contributing towards beneficence and maleficence. electronic video equipment, for example, can be used by people with dementia to identify visitors, protect against intruders and perhaps even reduce the likelihood of abuse or substandard care. some relatives ( or even people with dementia ) arrange for video cameras ( also known as “ granny cams ” ) to be installed in the rooms of people with dementia living in residential care as a means to protect them against abuse ( bharucha et al., 2006 ). provided that the person with dementia has consented to this and is currently aware of and in agreement with the use of the equipment, the resulting loss of privacy should not be problematic. however, it should be possible for the person to switch off the camera ( or ask for it to be switched off if s / he cannot manage this alone ) should s / he want a moment ’ s privacy ( e. g. if s / he has an intimate relationship ). the issue of privacy is also relevant to visitors who may feel uneasy about being observed. on the other hand, it has been suggested that the use of such equipment could make it even more difficult to attract and retain good staff due to the invasion of their privacy and fears about wrongful allegations ( bharucha et al., 2006 ). another argument is that constant monitoring might damage the personal bonds between people with dementia and professional carers ( newsmax. com, 2001 ). nevertheless, with regard to the principle of justice, if some residents are able to have such surveillance and others not, and if such surveillance is effective, this could increase the likelihood of the abuse or inferior care of those residents who do not have it. tracking and tagging devices the main types of tracking and tagging devices are as follows : - the direct tracking of a person by means of global positioning systems


could increase the likelihood of the abuse or inferior care of those residents who do not have it. tracking and tagging devices the main types of tracking and tagging devices are as follows : - the direct tracking of a person by means of global positioning systems ( known as gps ) which locates a person by satellite ( due to an ankle or wrist device, a pendent or a mobile phone ) and then transmits details of his / her location via a mobile phone network to a mobile phone, computer or call centre. - tagging which involves the person with dementia wearing a special device ( e. g. on the ankle or wrist ) which emits a signal if the person leaves a designated area such as his / her home or garden. this can be combined with a numeric paging device which alerts the carer. - access control systems ( equipment which recognises a chip card and acts on the environment accordingly by locking or unlocking doors, blocking elevators and recording access to certain areas ). - the identification of a trail of locations which indicates where a person has been ( known as breadcrumbing ) - the use of infrared technology to detect immobility within the home or that a person has not returned home by a certain time or has left the house at an unusual time such as in the middle of the night. uses, benefits and practical problems tracking and tagging devices may contribute towards privacy, freedom and autonomy as they may enable people to go somewhere on their own ( e. g. for a walk, to the shops or to visit someone ) in the secure knowledge that if they get lost, it will be easier for others to find them. this also means that they are not dependent on someone else being available to accompany them and can choose when and where they would like to go. in some cases, a “ geofence ” may be erected ( a virtual perimeter ) which limits the freedom of people wearing a tag by emitting a signal if a person goes beyond a certain preset limit. however, this may still be a better alternative to a locked door policy ( bail, 2003 ). studies have shown that people with dementia who get lost are more likely to be permanently admitted to a care home than those who do not, so tracking devices may partly contribute towards the ability to lead an autonomous life ( balestreri et al., 2000 ; mcshane and skelt, 2009 ; phillips and diwan, 2003 ). as the devices can also provide protection by ensuring that a person can be quickly found


ability to lead an autonomous life ( balestreri et al., 2000 ; mcshane and skelt, 2009 ; phillips and diwan, 2003 ). as the devices can also provide protection by ensuring that a person can be quickly found if they get lost, this can provide reassurance for carers ( even if it is never actually necessary to track a particular person ). the above - mentioned benefits may be jeopardized by a number of factors. such devices need batteries. carers therefore need to remember to charge the batteries as if they run out, the person with dementia may be at greater risk. the devices should be fairly small and unobtrusive but this means that they can be easily misplaced. with regard to the actual technology used, there are sometimes problems with the accuracy of gps readings as well as of those of the “ geofence ” ( an additional function which sets a virtual perimeter ). these problems can result in a false sense of security for both carers and people with dementia. in the context of residential care, this false sense of security may lead to reduced staffing levels ( welsh et al., 2003 ). also, the setting of boundaries reflects the unequal power relationship between staff and residents and in the home setting may lead to a change in power relations between couples and between other members of the family and the person with dementia. finally, if tracking and tagging devices are used in settings where there is a shortage of staff or where available staff have a tendency to remain separated from residents and simply watch the recordings or wait for a signal that someone has crossed a barrier in order to react, the people with dementia using this type of at may come to associate breaching the boundaries available to them with obtaining some kind of human contact ( mental welfare commission for scotland, 2006 ). this would clearly be counter - productive as it could encourage “ wandering ” and create tension between residents and staff. conflict between autonomy and liberty, and safety / security as part of his theory of human motivation, maslow ( 1943 ) formulated a hierarchy of needs in which each set of needs must be met before attending to the next set of needs. he claimed that people are preoccupied with ensuring that their basic physiological needs are met before turning their attention to their safety needs and only after that to higher order needs such as love and affection, and self - esteem. under self - esteem, maslow included, amongst other things, the need for confidence in the face of the world, independence and freedom. the use of


and only after that to higher order needs such as love and affection, and self - esteem. under self - esteem, maslow included, amongst other things, the need for confidence in the face of the world, independence and freedom. the use of tracking and tagging involves a conflict between safety / security and autonomy and liberty. whilst most people are probably in favour of balancing respect for a person ’ s rights with the perceived need to protect him / her, different groups of people ( e. g. relatives and professional carers ) may have different opinions on this issue. opinions may also differ between people from different cultures ( landau et al., 2009 ). in a few studies, carers have been reported to have a positive view of tracking and tagging devices but at the same time to be in favour of a greater degree of freedom and respect for the autonomy of the person with dementia ( melillo and futrell, 1998 ; nicolle, 1998 ; robinson et al., 2007 ), although a french study found that 50 % of carers were in favour of a substantial amount of surveillance of the person with dementia and 50 % against ( rialle et al., 2008 ). health and social care professionals tend to be very much concerned about protecting all their patients and residents from harm and may be influenced by concerns about litigation ( robinson et al., 2007 ). these concerns may lead to dilemmas for nurses and day centre staff dealing with people with dementia whose freedom of movement cannot legally be restricted ( i. e. they are voluntary patients or attend a day care centre on a voluntary basis ). a recent study comparing the attitudes of informal carers and professional carers towards the use of gps and radio frequency identification ( rfid ) to track people with dementia highlighted the different attitudes of various groups of people ( landau et al., 2009 ). through a statistical analysis procedure known as factor analysis, five factors reflecting types of attitude were identified, namely use for the sake of the patients ’ safety, use for caregivers ’ peace of mind, respect elders ’ autonomy, support restricted use and oppose use. the highest scores were obtained for the factor “ use for the sake of the caregivers ’ peace of mind ” and the lowest score for the factor reflecting objection to the use of the device. respondents who were older had significantly higher scores for concerns about the caregivers ’ peace of mind and the patients ’ safety but lower scores for respect for the person ’ s autonomy. no gender differences were found. when the scores of


of the device. respondents who were older had significantly higher scores for concerns about the caregivers ’ peace of mind and the patients ’ safety but lower scores for respect for the person ’ s autonomy. no gender differences were found. when the scores of the two groups were compared it was found that informal carers of community dwelling people with dementia were significantly more in favour of the use of tracking for their own peace of mind and for the safety of the person. professional carers obtained significantly higher scores for the restricted use of tracking ( e. g. in severe cases when there was no suitable alternative ) but informal carers were significantly more opposed to its use in general. this last finding contradicts the finding of some of the previously mentioned studies. based on the scores of the informal carers, landau et al. ( 2009 ) conclude that support for the use of tracking is mainly based on a desire for their own peace of mind ( which is similar to the findings of robinson et al., 2009 and landau et al., 2010 ). on the basis of a literature review, robinson et al. ( 2007 ) concluded that it was not possible to draw conclusions about the perspectives of people with dementia on the use of at to manage “ wandering ” as studies focused on carers ’ views. in their qualitative study, carried out in 2006, which involved a focus group discussion with 6 people with dementia, the participants spoke about the benefits of walking and getting out which included getting some fresh air, independence, relieving tension, keeping fit and enjoyment. none of them described this as wandering. risk can be considered in relation to oneself, to another person or to a larger group of people. for example, if a person leaves a ring on the cooker switched on, he / she may later burn him / herself, someone else might burn themselves or if something inflammable is put on the ring, the whole kitchen might burn down, thereby endangering the lives of other people. there may be differences in the perceptions of risk of people with dementia, carers and professionals, although most probably consider safety an important issue for people with dementia and some may believe in the necessity to aim for total safety. however, it could be argued that a total absence of risk is impossible and not even desirable. the mental welfare commission for scotland ( 2006 ) suggests that life is never risk - free and that some degree of risk taking is an essential part of good care. people may be more protective of others, than they would be of themselves


not even desirable. the mental welfare commission for scotland ( 2006 ) suggests that life is never risk - free and that some degree of risk taking is an essential part of good care. people may be more protective of others, than they would be of themselves ( nuffield council on bioethics, 2009 ), particularly in cases where the person being “ protected ” is considered in some way vulnerable. historically, risk was considered as something that could be either good or bad, resulting in loss or gain, but lupton ( 1999 ) claims that it has been transformed into something that is entirely negative. kemshall ( 2000 ) claims that in the context of social and healthcare, which is guided by a managerial discourse, risk is viewed as something that is objective and measurable, and hence can be acted upon although frontline staff might sometimes find the official policy of an organisation inappropriate or unhelpful for specific cases. others argue that it is socially constructed and value - laden ( lupton, 2005 ). it must be borne in mind that everyone is different and that people have different perceptions of danger and different assessments of the level of risk they are willing to take. an example of this, not linked to dementia, is smoking which has been proven to be damaging to health but many people with full mental capacity consciously continue smoking and believe it is their right to do so. imposing one ’ s perception of risk onto someone else deprives them of their autonomy and freedom, and in some cases may affect their wellbeing. a person ’ s position regarding the relative importance of safety and autonomy may depend on whether they are personally responsible for the safety and wellbeing of the person with dementia ( landau et al., 2010 ) : “ when the patients are in the community and the family caregivers feel they have the ultimate responsibility for the patients ’ wellbeing, the family caregivers favor the need for safety more than the right to autonomy and privacy. in the study by robinson et al. ( 2007 ), family caregivers claimed that dementia patients in nursing homes were overprotected. thus, professionals prefer autonomy more than safety when patients are in the community, but safety more than autonomy when under their care in nursing homes. ” ( landau et al., 2010, p. 415 ) however, landau et al. ( 2007 ) also point out that many people with dementia in nursing homes are there because their relatives feel that they are no longer able to assure their safety within the community so the characteristics of the two groups


p. 415 ) however, landau et al. ( 2007 ) also point out that many people with dementia in nursing homes are there because their relatives feel that they are no longer able to assure their safety within the community so the characteristics of the two groups may in some cases be different. it is also important to consider the definition of “ lost ”. what constitutes lost might not be the same thing for the person with dementia and his / her carer and this may lead to conflict or to a breach of the person with dementia ’ s privacy and right to freedom ( hughes, 2008 ). however, there is a risk of erring on the side of safety and of the automatic presumption that the carer knows best which in some cases would be paternalistic and based on stereotypes of people with dementia lacking capacity and awareness. according to martin et al. ( 2010 ), paternalism aims to protect people from themselves and involves an assumption that their safety is more important than their liberty. any potential dangers linked to the use of the device itself must also be considered and communicated to the person or people responsible for consenting to its use. undesired reactions to the use of implanted rfid tags in animals have been reported such as adverse tissue reaction, migration of the device, electromagnetic interference and even tumours, and as foster and jaeger ( 2008 ) point out, few humans have been implanted with such devices so data on possible risks are not yet available. allocation of responsibilities systems designed to monitor or track people and their movements generally involve more than just technological devices as their use is dependent on people who are responsible for the information they provide and aware of the necessity to respect confidentiality. this raises various questions such as who is and should be responsible, how should their behaviour be monitored and controlled and what is the hierarchy of responsibilities? this is not usually inherent in the design as it could be organised in a number of different ways. it also raises the issue of justice mentioned earlier in that it may be presumed that some members of society, such as women, are more available than others. moreover, informal carers are not always able or willing to take on the responsibility of looking for the person if and when s / he gets lost ( mcshane et al., 1998 ). their consent to becoming involved in the functioning of the system cannot be presumed. an interesting argument reported by heeg et al. ( 2005 ) against informing people with dementia that a tagging device had been implanted in their shoes was to avoid triggering memories of


consent to becoming involved in the functioning of the system cannot be presumed. an interesting argument reported by heeg et al. ( 2005 ) against informing people with dementia that a tagging device had been implanted in their shoes was to avoid triggering memories of psychiatry in the third reich. in the reported case, carers were informed and their consent obtained. this raises the issue of the use of devices which might be perceived as restricting liberty of movement with people with prior experience of deprivation of liberty, humiliation and stigmatization ( e. g. through war, incarceration, serious bullying or membership of certain groups ). there may also be a perceived injustice of being deprived of liberty as expressed by an elderly veteran ( in connection with physical restraint ) who stated, “ i have done nothing to deserve this. to think you fought a war – now i am a pow ” ( sullivan - marx, 1995, reproduced in dawkins, 1998, p. 25 ). these examples also emphasise the importance of bearing in mind the personal history and cultural issues associated with each person. concern has been expressed about tagging and tracking devices failing to respect a person ’ s privacy ( dawkins, 1998 ; department of health, 2001 ). two aspects of privacy have been identified : 1. the freedom to escape being observed or accessed when desired, 2. the freedom to escape observing and reacting to others ( essen, 2008 ; sidenvall, fjellstrom and ek, 1994 ). this could include avoiding the undesired access by other people to one ’ s own personal space ( rossler, 2005 ). clearly, tracking devices may prevent people from getting away from others and from having a moment ’ s privacy, but at the same time may prevent others from encroaching on one ’ s personal space. however, in communal living situations, this possible advantage would only occur if there were some prior agreement as to what constitutes one ’ s personal space and would have to be balanced against other people ’ s right to freedom of movement. dignity and personhood the use of tagging has been likened to assault, an attack on civil liberties and a form of restraint ( cassidy, 1994 ; hughes and campbell, 2003 ), particularly when used on a person who is incapable of consent, but some argue that it is nevertheless preferable to physical or chemical restraint which is dehumanising and risky ( bail, 2003 ; wrigglesworth, 1996 ). however, as physical or chemical restraint is rarely justifiable, this is not


some argue that it is nevertheless preferable to physical or chemical restraint which is dehumanising and risky ( bail, 2003 ; wrigglesworth, 1996 ). however, as physical or chemical restraint is rarely justifiable, this is not a convincing argument to override ethical concerns about the use of tagging. moreover, as pointed out by hughes ( 2003 ), straitjackets were initially considered more humane than shackles but this doesn ’ t make either acceptable. even when walking about is considered by others as problematic, there are perhaps other solutions such as modifying the environment or looking for reasons why the person is walking about ( stokes, 2002 ). arguing against the use of restraint for people with mental illness, dawkins states his opinion that “ people have unconditional worth and dignity that supports a strong argument for the maintenance of autonomy, even in the event of possible harm from an injury ” ( dawkins, 1998, p. 26 ). such an argument could be applied to the use of at which may involve a restriction of liberty ( in order to protect ) or alternatively increased liberty and autonomy ( perhaps also involving a slight risk ), but each situation could be seen from different perspectives depending on the actors involved. according to cahill ( 2003 ), tagging should have no place in dementia care as it removes personhood. o ’ neill ( 2003 ) states, “ tagging should be reserved for babies, convicted criminals and animals. ” others would argue that tagging and tracking technology is suitable for use in dementia care provided that it is applied in a way that respects personhood and maintains functional capacity ( college of occupational therapists, 2005 – in plastow, 2006 ; mcshane et al., 1994 ). however, people with dementia may still feel that the use of such devices implies that they are irresponsible and in need of constant surveillance ( landau et al., 2009 ). in an earlier study which involved a survey of family and professional carers, only 18 % reported concern that the use of tracking or tagging devices would result in a loss of dignity ( nicolle, 1998 in robinson et al. 2007 ). however, this is a fairly old study and perceptions may have changed [ also need to obtain details of the study to see how representative it was ]. according to interpersonal theories of personhood, personhood is maintained through genuine contact, and lack of human contact may lead to social withdrawal, the objectification of the person with dementia and non - respect of the person


see how representative it was ]. according to interpersonal theories of personhood, personhood is maintained through genuine contact, and lack of human contact may lead to social withdrawal, the objectification of the person with dementia and non - respect of the person ’ s dignity. consequently, if at devices led to reductions in staff or reduced levels of interaction with residents in nursing homes, this could adversely affect dignity and personhood ( although clearly it is the quality of the contact rather than its quantity that is important ). people who acquire disabilities later life may find the use of at shameful and stigmatizing ( bjørneby et al., 1999 ; brickfield, 1984 ; haggblom kronlofand sonn, 1999 ; luborsky, 1993 and zimmer and chappell, 1999 ). particular concerns have been expressed about the possible stigmatizing impact of tagging on people with dementia. dementia, like a number of other health conditions, is already unfortunately considered a stigma by many people and experienced as such. the use of at may, in some cases, draw attention to the fact that a person has dementia. in the context of health - related conditions, stigma has been described as follows : “ stigma is typically a social process, experienced or anticipated, characterized by exclusion, rejection, blame, or devaluation that results from experience or reasonable anticipation of an adverse social judgment about a person or group. the judgment is based on an enduring feature of identity conferred by a health problem or health - related condition, and the judgment is in some essential way medically unwarranted. in addition to its application to the persons or group, the discriminatory social judgment may also be applied to the disease or designated health problem itself with repercussions in social and health policy. other forms of stigma which results from adverse social judgments about enduring features of identity apart from health - related conditions ( e. g. race, ethnicity, sexual preferences ) may also affect health ; these are also matters of interest that concern questions of health - related stigma. ” ( weiss and ramakrishna, 2004, p. 13 ) however, the term stigma does not only refer to the complex social phenomenon described above but also to specific attributes which, due to the meanings attached to them, are considered discrediting and lead to stigmatization ( goffman, 1963 ; jones et al., 1984 ). the attribute ( an enduring feature of identity ; sometimes but not necessarily a physical or visible mark ) serves to


to them, are considered discrediting and lead to stigmatization ( goffman, 1963 ; jones et al., 1984 ). the attribute ( an enduring feature of identity ; sometimes but not necessarily a physical or visible mark ) serves to identify those people who belong to the out - group ( i. e. “ them ” not “ us ” ). in the case of electronic tagging or even tracking, having the electronic device on one ’ s person can serve as a stigma. tagging has been used for newborn infants, criminals, failed asylum seekers and animals ( o ’ neill, 2003 ; carvel, 2005 ; corsi, 2008 ), as well as to prevent the theft of clothes in stores ( counsel and care, 1993 ). marr ( 1989 ) and welsh et al. ( 2003 ) suggest that the same stigma linked to the tagging of people within the penal system could be extended to people with dementia. an additional link to criminality can be found in the origins of the term “ stigma ” which date back to ancient greece where people were physically marked by burning or cutting as a visible sign to others that there was something bad or unusual about their moral status ( goffman, 1963 ). it was a sign of disgrace and / or a signal to other members of society that the bearer was in some way flawed or deviant, a kind of lesser person. in most cases, this kind of treatment was reserved for slaves, criminals or traitors. the marking of human beings in this way involves an element of dehumanisation and objectification. consequently, the electronic tagging of people with dementia can be stigmatizing as the devices serve as a sign to other people of a potentially discrediting difference and also due to the association with criminality. if the device is obtrusive, the person wearing or carrying it may feel infantilised or incompetent, or it may draw attention to their medical condition. even if the tagging device cannot be seen, the consequences of wearing it may become apparent if ever the alarm is activated as a result of crossing a virtual geographical barrier. this is similar to the use of chair and sensor pads in communal settings where the signal may result in a person being regarded with shock or disapproval and being labelled as “ the one making all the noise ” ( morgan, 2003 ). the issue of visibility / concealability fits in with goffman ’ s distinction between being discredited on the basis of a stigma and being discreditable.


labelled as “ the one making all the noise ” ( morgan, 2003 ). the issue of visibility / concealability fits in with goffman ’ s distinction between being discredited on the basis of a stigma and being discreditable. the former describes the situation whereby the stigma is known about ( e. g. everyone can see the device and knows what it is ) whereas with the latter, the stigma is not immediately apparent ( or at least the person does not think that it is ) but risks becoming apparent ( e. g. by crossing a boundary and hearing an alarm or being brought back ). according to corsi ( 2008 ), an implantable chip is marketed in the united states for use with people with chronic diseases including alzheimer ’ s disease. niemeijer and hertogh ( 2008 ) suggest that the use of implantable radio frequency identification technology ( rfid ) may actually be less stigmatizing to the wearer than a bracelet as it is not visible. however, the person with the implanted chip is likely to eventually forget that he / she has it and from that point on would not be aware that he / she was being tracked ( ). in germany, 23 % of about 1000 respondents taking part in a survey organised by a lobby group bikom stated that they would be willing to have a chip inserted under their skin “ for certain benefits ” but 72 % were completely opposed to having any electronics in their body ( the local, 2010 ). however, the actual stigma ( in the sense of the identifying mark ) is rarely the real root of the problem as it depends on the meanings attributed to it. not everyone interprets tagging and tracking in the same way and some people may be in favour of using such devices for themselves for various reasons and even express this in advance directives. moreover, meanings are culturally constructed and can therefore change. the meanings that people attribute to electronic tagging have not been systematically evaluated but there have been a couple of small - scale qualitative studies which involved asking people about their perceptions of tagging. in a small - scale telephone survey of carers and a feasibility study involving 24 people with dementia, when asked what tagging reminded them of, several said the tagging of criminals ( hughes and campbell, 2003 ). a couple of other people made references to being on a lead and wearing a cow - bell. further information is needed to determine how people with dementia feel about electronic surveillance, tracking and tagging, and also to see how this relates to


2003 ). a couple of other people made references to being on a lead and wearing a cow - bell. further information is needed to determine how people with dementia feel about electronic surveillance, tracking and tagging, and also to see how this relates to the views of carers and healthcare professionals. if electronic tagging becomes more common for different groups of people ( e. g. people with dementia and infants ), if its use and design is discussed with all actors concerned and if it is presented in a positive light by the media, negative associations with criminality might gradually be reduced. “ universal design ” ( mace, 1985 ), sometimes referred to as “ inclusive design ”, involves trying to design products and environments which can be used by “ all people, to the greatest extent possible, without the need for adaptation or specialised design ” ( connell et al., 1997 ). perry, beyer and holm ( 2009 ) suggest that designing at according to the principle of universal design and paying attention to the way things look will reduce the likelihood of the item or system being stigmatizing. this might be possible in some cases but it may prove difficult to design certain devices which could be used by older users whilst remaining attractive to younger or more experienced users ( hawthorn, 2003 ). wallace et al. ( 2010 ) question whether universal design is always appropriate and even desirable. mace ( 1998 ) criticized the lack of attention paid to aesthetics in the design of at but this is perhaps gradually changing. with regard to disability, this might include ramp access to buildings ( not as an alternative but as the only access ) or large, easy to grip utensils with attractive handles which could be mass produced and not marketed as utensils for disabled people. the choice of at could still be tailored to the individual needs of anyone using them. access control systems and breadcrumbing with access control systems, access to designated areas is controlled automatically. if a person has a chip card which grants access to a particular area, it will be detected and the door unlocked or the lift activated. the equipment can also be used to record the access of each person carrying the chip card. margo - cattin and nygard ( 2006 ) suggest that such technology promotes privacy, protection of property and a sense of security in that residents realize that access to their private living space is strictly controlled. they also point out that the automatic locking and unlocking mechanisms of doors may help individual residents find their way to their own rooms by limiting the number of wrong options, thereby promoting autonomy and leading


realize that access to their private living space is strictly controlled. they also point out that the automatic locking and unlocking mechanisms of doors may help individual residents find their way to their own rooms by limiting the number of wrong options, thereby promoting autonomy and leading to a sense of accomplishment. one possible drawback to the access control systems is that it would become clear that different residents had different levels of access to specific areas other than their living space, such as balconies, gardens and kitchens. this could be used as a form of social control or punishment. even if used fairly and with respect, some residents could feel awkward about being publicly denied access to certain areas, especially if they do not understand the reasons for the restriction, and this would not promote their wellbeing. this requires sensitive management of this type of at so as to minimize the possibility of upsetting residents and maximise potential benefits to residents of such technology linked to freedom of movement, autonomy and wellbeing. finally, “ breadcrumbing ” and the use of infrared technology could be interpreted as an invasion of personal privacy if the person is not aware of its use. non - authorized use of such equipment would amount to spying on someone. care must also be taken to ensure that the person fully understands what they are agreeing to. the devices should be explained in terms that are easy to understand bearing in mind that potential users might not have a particularly good understanding of technical matters but not over - simplified so as to hide the full extent of the possible functions and the implications of using the device. also, it should be possible for the person with dementia to know in advance whom to ask for the device to be removed and how much this would cost. - in chapter 3 we have examined the ethical issues linked to the use of assistive technology for and by people with dementia. we have drawn attention to the positive impact that at can have on people ’ s lives as well as some potential dangers or drawbacks which can hopefully be avoided or minimised through increased awareness and communication as well as through careful planning and monitoring. in the next section, we will provide practical guidelines on the ethical use of at by and for people with dementia. the german state from 1933 to 1945 prisoner of war last updated : monday 23 april 2012


healthcare and decision - making in dementia act no. 576 / 2004 coll. of 21 october 2004 on healthcare, health - related services and on the amendment and supplementing of certain laws ( hereafter referred to as the act of health care ) seems to be the main law governing patients ’ rights and decision making in the context of health care. unless otherwise stated, the references in this report on healthcare and decision making in the slovak republic will be to the relevant sections and paragraphs in the act on health care. consent to medical treatment informed consent must be given prior to the provision of healthcare ( § 4. 4 ). it should be given by person to whom the healthcare is to be provided or by a legal representative if that person lacks the capacity to give informed consent. patients with incapacity should participate in the decision - making process to the greatest extent possible ( as determined by their level of capacity ) ( § 6. 5 ) details of the informed consent including a statement made by patients ’ with incapacity should be recorded in the medical file. consent in the case of emergency emergency care can be provided without informed consent if it is impossible to obtain in time and if such consent could be presumed. inpatient care can be provided without informed consent if the person is a danger to him / herself or to his / her environment due to a mental illness or if he / she has symptoms of a mental defect or if there is a risk of serious deterioration of the person ’ s state of health ( § 6. 8 ). the right to refuse treatment if a legal representative refuses treatment for a patient who is unable to give informed consent, and doctors are of the opinion that such treatment is in the patient ’ s best interests, they must submit an application to the relevant court to override the legal representative ’ s refusal. whilst this is being decided, only life - saving treatment can be provided ( § 6. 6 ). the right to withdraw consent any person who gave valid informed consent can freely withdraw it at any time ( § 6. 7 ). consent to innovative treatment and participation in clinical teaching consent to participation in clinical teaching is perhaps what is meant by § 11. 8 ( e ) which states that every person has the right to decide whether to take part in education. consent to blood donation a blood donation ( for the purposes of transfusion and the preparation of medications for transfusion ) can only be made by a person who is over 18 years of age ( § 39. 1 ) and fully capable of executing legal acts specified in


blood donation a blood donation ( for the purposes of transfusion and the preparation of medications for transfusion ) can only be made by a person who is over 18 years of age ( § 39. 1 ) and fully capable of executing legal acts specified in § 39. 2. consent to the donation of organs and / or human tissue paragraphy 11. 8 ( f ) grants people the right to refuse the removal and transfer of organs, tissue or cells after death. chapter 2 of part 4 of the act on health care deals with the removal, conservation and transfer of organs, tissue and cells. living donors must be fully capable of executing legal acts and have given written informed consent. a person who is incapable of giving informed consent can become a donor provided that informed consent is given by his / her legal representative subject to the following conditions : - the removal relates to regenerative tissue. - a suitable donor capable of giving informed consent is not available. - the potential recipient is a brother or a sister of the donor. - the donation has a life - saving potential for the recipient ( § 36. 2 - d ). with regard to the removal of organs, tissue and cells after a person ’ s death, this is permitted unless before dying the person made a written declaration disapproving of such an intervention. for people who are unable to object to such removal of organs, tissue and cells, their legal representative may make a written declaration on their behalf during their lifetime ( § 37. 2 ). disapproval can be withdrawn at any time. statements of disapproval must have a certified signature and be sent to the registry of persons declaring their disapproval with the post - mortem removal of their organs, tissue and cells, which is maintained by the ministry of health. consent to biomedical research according to § 11. 8 ( e ), every person is entitled to decide whether or not to take part in educational or biomedical research. chapter 1 of part 4 of the act on health care is dedicated to the issue of biomedical research. such research cannot be carried out on a person who has been involuntarily interned. otherwise, the following provisions apply ( § 32 ) : “ ( 1 ) medical indication based research with participation of a person incapable of giving an informed approval can be performed only in case that ( a ) the research with comparable effectiveness cannot be performed with the participation of a person capable to give an informed approval, ( b ) the person was informed about this research and about his / her rights and legal measures for their protection in a way adequate to


a ) the research with comparable effectiveness cannot be performed with the participation of a person capable to give an informed approval, ( b ) the person was informed about this research and about his / her rights and legal measures for their protection in a way adequate to his / her health condition and mental abilities, ( c ) the person does not express evident disapproval with his / her participation in this research in a way adequate to his / her abilities to express disapproval regarding his / her physical and mental condition. ( 2 ) research without medical indication with participation of the person incapable of giving an informed approval can be exceptionally performed in the case that, besides conditions as per subsection 1, the following conditions are met : ( a ) the objective of the research is to achieve results bringing benefit for other persons in the same or similar condition, suffering from the same or similar illness or handicap, b ) the research represents for the participant only 1. a risk that according to the current state of scientific knowledge constitutes only low and short - term negative influence on the health condition of the research participant ( hereinafter “ minor risk ” ) or 2. a burden with only a low and short - term inconvenience ( hereinafter “ minor burden ” ). ( 3 ) bio - medical research with the participation of a person incapable of giving an informed approval can only be performed on the basis of an informed approval of the legal representative of the future research participant. ” according to defloor et al. ( 2008 ), there is no legislation in the slovak republic covering previously expressed wishes. access to information / diagnosis the right to be informed doctors must provide information on the purpose, nature, impact and risks of healthcare provision, as well as on proposed alternative provisions and on the risks of rejecting healthcare. this information must be provided to the patient or another designated person. it should be given to the legal representative or tutor of people with incapacity. the information should be provided in a way that is comprehensible and appropriate to the person ’ s intellectual level and health condition. the person should be given enough time to be able to give informed consent ( § 6. 1 - 6. 2 ). access to medical records part 3 of the act on health care deals with medical records. medical records may be in written or electronic form. anyone handling medical records is obliged to ensure that they are treated with confidentiality and to protect them against loss or abuse. the patient ( or his / her legal representative in the case of incapacity ) has the right to


written or electronic form. anyone handling medical records is obliged to ensure that they are treated with confidentiality and to protect them against loss or abuse. the patient ( or his / her legal representative in the case of incapacity ) has the right to examine his / her medical record and to make excerpts or copies. doctors can refuse access to medical records to patients receiving psychiatric care if they believe that this would negatively affect their treatment. according to paragraph 25. 1, the patient, his / her legal representative and / or a person previously appointed by means of a power of attorney are entitled to access the patient ’ s medical file ( to the extent determined by the power of attorney for the latter ). the right to designate another person to be informed on one ’ s behalf according to § 6. 1 - a, information must be provided to the patient or moreover to another person determined by the patient. the doctor ’ s right to withhold information paragraph 25. 3 of the act on health care refers to the right to withhold access to the medical file but only in the domain of psychiatry or in the domain of clinical psychology and only if this would negatively affect the patient ’ s treatment the right to refuse information whoever has the right to be informed also has the right to refuse to be informed. a written record of such refusal must be made ( § 6. 3 ). confidentiality / disclosure of information to other people patients have the right to confidentiality with regard to all information regarding their health condition and circumstances related to their health condition. attending physicians and other healthcare professionals must have access to medical files to the extent that this is necessary ( § 22. 3 ) and so must an inspector doctor from a pertinent health insurance, the surveillance authority, a court advisor in the case of criminal proceedings, a health insurance company inspecting the provision of healthcare linked to insurance, and professional organisations inspecting medical profession performance ( § 25. 1 ). end - of - life care and issues according to § 11. 8 - h of the act on health care, every person is entitled to palliative care, as well as a humane, ethical and dignified approach from healthcare professionals ( § 11. 8 - i ). there is no legislation directly concerning euthanasia in the slovak republic. however, the ethical code of the slovak chamber of physicians prohibits it. this code is, in the form of an appendix, part of act no. 219 / 2002 coll. on profession of physician, the slovak chamber of physicians, profession of dentist, the slovak chamber


code of the slovak chamber of physicians prohibits it. this code is, in the form of an appendix, part of act no. 219 / 2002 coll. on profession of physician, the slovak chamber of physicians, profession of dentist, the slovak chamber of dentists and amending and supplementing certain other acts ( council of europe, 2003 ). assisted suicide is considered a serious criminal act according to § 230 of the penal law no. 141 / 1961 ( as later amended ) ( council of europe, 2003 ). non assistance to a person in danger paragraph 11 ( 11 ) of the hhs states that every person is obliged to provide or mediate necessary help to anyone in danger of death or anyone showing severe health damage unless one ’ s own life or health would be severely endangered by such help. other legal provisions can be found in the penal law ( law no. 141 / 1961 as later amended ). under this law ( paragraph § 219 ), euthanasia would be considered as the taking of an innocent human life ( i. e. as murder ) and / or as not providing necessary professional ( life - saving ) help, thereby failing to honour important professional obligations on the part of the physician or other health professional ( § 224 ) ( council of europe, 2003 ). defloor, s et al. ( 2008 ), patient rights in the eu – slovakia : european ethical - legal papers n°14, leuven steering committee on bioethics ( 2003 ), results of questionnaire, council of europe : http : / / www. coe. int / t / e / legal _ affairs / legal _ co - operation / bioethics / activities / euthanasia / answers % 2520euthanasia % 2520questionnaire % 2520e % 252015jan03. asp # topofpage last updated : mercredi 27 avril 2011


50 years ago may 15, 1951 : communist forces launch a spring offensive against united nations troops in korea. the effort fizzles out within a week. 75 years ago may 9, 1926 : floyd bennett and richard e. byrd make the first flight over the north pole. may 10, 1926 : u. s. marines are dispatched to suppress a rebellion in nicaragua. after a brief withdrawal, they will return in august and stay until 1933. 125 years ago may 10, 1876 : in philadelphia, president ulysses s. grant opens the centennial exposition, which celebrates 100 years of progress since american independence. june 6, 1876 : mark twain ’ s novel tom sawyer is published in england. it will not appear in america for another six months. june 25, 1876 : at the battle of the little bighorn, gen. george a. custer and more than 260 others, most of them members of the 7th u. s. cavalry, are killed by sioux and cheyenne warriors led by sitting bull and crazy horse. 150 years ago may 1851 : william cooper nell publishes services of colored americans in the wars of 1776 and 1812, one of the earliest books about african - american history. may 15, 1851 : the inaugural erie railroad train from new york city arrives at dunkirk, new york, connecting the atlantic and the great lakes by rail. june 5, 1851 : the first installment of harriet beecher stowe ’ s uncle tom ’ s cabin, the most influential antislavery novel ever written, is published in a washington newspaper. 225 years ago may 2, 1776 : king louis xvi of france secretly agrees to send $ 200, 000 worth of arms and ammunition to american colonists rebelling against britain, france ’ s age - old enemy. within a year, the assistance will total more than a million dollars. june 7, 1776 : in the continental congress, richard henry lee of virginia introduces a resolution calling for the colonies to declare their independence. on june 11, the congress appoints a committee to draw up a declaration. 325 years ago may 10, 1676 : gov. william berkeley of virginia proclaims nathaniel bacon, who is leading an armed force against hostile indians, to be a rebel.


no coal fired power stations. no suv ’ s. and they are warning the planet ' s atmosphere could have similar levels of the greenhouse gas within hundreds of years. an international team led by german scientists and involving university of queensland environmental geologist dr kevin welsh has found tropical palms grew on the coast of antarctica 52 million years ago. at that warm period in the earth ' s history, there was twice as much co2 in the atmosphere as there is now and winter temperatures of 10c meant antarctica ' s 4km thick ice sheet didn ' t exist. fancy that, no ice in antarctica 52 million years ago. below is what i wrote on the same subject for menzies house on 24th july 2011 : global warming. rising sea levels. massive volcanic activity around the world. widespread climate change. it ’ s not a scene from the hollywood disaster film, the day after tomorrow, but the earth as it appeared during the mid - to late - cretaceous geological period, 145 million to 65 million years ago, when the largest dinosaurs such as tyrannosaurus rex ruled the planet. our planet during the late cretaceous period was very different than it is today. not only were dinosaurs like t - rex present, but the climate was extremely warm and global sea levels were significantly higher than they are today. this was a time when there were no glaciers in either the arctic or antarctic. late cretaceous atmospheric carbon dioxide levels were two to four times higher than today, which resulted in a greenhouse climate with tropical sea - surface temperatures rising to more than 34 degrees celsius, 3 to 7 degrees celsius warmer than today. calderia and rampino concluded in their 1991 paper - the mid - cretaceous super plume, carbon dioxide, and global warming - that carbon dioxide emissions resulting from super ‐ plume tectonics could have produced atmospheric carbon dioxide levels from 3. 7 to 14. 7 times the modern pre ‐ industrial value of 285 ppm. carbon dioxide levels today are around 390 ppm. according to calderia and rampino, temperature sensitivity to carbon dioxide increases used in the weathering ‐ rate formulations, would have caused global warming of from 2. 8 to 7. 7°c over today ' s global mean temperature. further supporting calderia and rampino ’ s 1991 paper is john tarduno and his collaborators 1998 paper - evidence for extreme climatic warmth from late cretaceous arctic vertebrates. in 1996, tarduno ’ s expedition team literally stumbled across a unique fossil find : vertebrate remains from fish, turtles and champsosaurs. the


his collaborators 1998 paper - evidence for extreme climatic warmth from late cretaceous arctic vertebrates. in 1996, tarduno ’ s expedition team literally stumbled across a unique fossil find : vertebrate remains from fish, turtles and champsosaurs. the fossils indicate that at least once in earth ' s history, high amounts of the greenhouse gas warmed earth to much higher temperatures than usual. the highlight of the expedition find are bones that belonged to an eight - foot champsosaur, a now - extinct crocodile - like beast with a long snout and razor - sharp teeth. the reptiles, which were tied to their freshwater environment on axel heiberg island, needed an extended warm period each summer to survive and reproduce. based on the numbers and sizes of the animals found, the tarduno ’ s team estimated that the annual mean temperature in the arctic during the late cretaceous period, from about 92 million to 86 million years ago, was about 14 degrees celsius. that means it was rarely if ever freezing during the winter, and summer temperatures consistently reached between 27 and 32°c. the arctic today is defined as being the area where the average temperature for the warmest month ( july ) is minus 10°c. the fossils of the champsosaur are a record of what was happening in the arctic just as extreme volcanism on earth was winding down. most of the volcanic activity didn ' t resemble spectacular eruptions like mt. pinatubo. instead, the eruptions were " basaltic " – billions of tons of lava oozed out, and carbon dioxide floated skyward. besides huge amounts of lava in the arctic, where hardened lava rock today measures more than a kilometre thick in some places, magma oozed from volcanoes in the caribbean, in the pacific ocean northeast of australia, in the indian ocean, off the coasts of madagascar and brazil, in south africa and in the southwestern united states. understanding how our past atmosphere, land and ocean system interacted while in this global greenhouse mode is very relevant if we want to understand the fate of our future climate. it also further illustrates that we live on a dynamic planet who ' s climate is always changing over the millennia. whilst no one denies that the world ’ s industrialisation has increased considerably the output of greenhouse gases, to ascribe the current phase of our ever changing climate to one single variable ( carbon dioxide ) or, more specifically, to a very small proportion of one variable ( i. e. human produced carbon dioxide ) is not science, for it requires us to


two weeks ago at our master gardener training class dr. jim jacobi, an auburn pathologist, discussed the many diseases – viral and bacterial, etc. that can afflict our beloved plants. one of those that really caught my attention was rose rosette disease. this is not a new disease but due to the widespread use of knockout roses in landscapes the plant pathologists are seeing a huge rise in outbreaks of this disease. knockout roses appear to be very susceptible to this disease. it is spread by a mite on wild roses but the mites are finding our knockouts and having a field day. symptoms of rrd are witches broom on the rose stem, red pigmentation of new growth, and excessive thorns. before you completely panic, new growth on all knockouts is red but when you have rrd the growth stays red. up in north alabama hundreds of roses were taken out of a park. there is no chemical to treat this disease. the only way to rid your garden of it is to get rid of the rose – root and all. then throw it away, do not compost it. the disease is in the branches so good hygiene is really essential when you prune your roses. clippers should be cleaned with chlorox. pay careful attention to the next sentence. if you are concerned you may have rrd in your garden, do not start tearing your hair and roses out. please take a sample down to the great folks at our calhoun county extension office and let them send the sample to the pathology lab. here is a link to a very informative article : publication 450 - 620. rose rosette disease. chuan hong, extension plant pathologist, hampton roads agricultural research and extension center... our master gardener intern class recently had a soils class with auburn professor, dr. charles mitchell. good soil is the backbone of a garden, whether that garden contains vegetables or flowers or whether the soil supports a beautiful stand of grass. when we talk about soil we are not talking about dirt ( which is soil with all the nutrients and other good stuff removed ) but about the soil. soils can vary from one neighborhood to another and even from one house to another. since some plants thrive in a more acid soil ( like azaleas and gardenias ) and others thrive in lower acid soils ( lilac ), it is important to know more about the soil you have in your garden. thus, the first thing all master gardeners ( as well as any extension agent ) will recommend when asked most plant questions,


thrive in lower acid soils ( lilac ), it is important to know more about the soil you have in your garden. thus, the first thing all master gardeners ( as well as any extension agent ) will recommend when asked most plant questions, especially as the question relates to fertilizer, is that the homeowner do a soil test. it is very easy, relatively inexpensive, and the best thing you can do for your yard and soil and even for the environment. a soil test costs way less than a bag of fertilizer. phosphorous in fertilizers can end up in the groundwater eventually polluting our waterways. too much of the wrong kind of fertilizer can even hamper the health of your grass or your plants or your vegetables. if someone comes in and wants to fertilize your lawn without a soil test, just say no. be an educated consumer. get a soil test first. soil test kits may be obtained from your county extension office. feb. 18, monday, 12 : 30 to 2 : 30 p. m, calhoun county beautification board tree give - away at golden springs ( fred ' s dept. store ) feb. 21, thursday, 3 : 30 p. m., arbor day celebration at jsu international house feb. 22, friday, 3 p, m to 5 p. m., tree give - away on the jacksonville square april 20, saturday, 8 a. m. until noon, master gardener tree amigos 4 - h plant sale, cane creek community gardens at mcclellan april 24, lunch and learn ( 4th wednesday of each month thru september ), noon to 1 p. m. cane creek community gardens, mcclellan. first program is " batty about bats " and vicky smith from a to z animals is bringing bats for her presentation. may 3, friday, noon to 3 p. m. and saturday may 4th, 9 until 2 p. m., master gardener 4h tree amigos volunteers and the anniston museum of natural history volunteers plant sale at the longleaf botanical gardens jacksonville garden club plant sale, date tba someone said to me the other day that he guessed it was hard to make the garden inviting this time of the year. the winter garden does not have to be boring ; it can be just as beautiful as the summer garden. camellias, daffodils, mahonias, pansies, berries, bark, and even the form of bare branches can make the winter landscape as


monday, march 23, 2009 one of the most fulfilling parts of an aquarist ’ s work is raising baby fish and invertebrates to adulthood. here at the aquarium of the pacific, we have successfully bred and raised many different species of animals. as you may know, the aquarium of the pacific was the first in the world to breed and raise weedy seadragons, sharing some of the offspring with other public aquariums to help protect this species. our aquarists have also been culturing and raising west coast sea nettles for several years – a process which takes many months, as the sea jellies go through many different stages of life which all have very different needs. some of these sea jellies are shared with other aquariums as well. by sharing offspring with other aquariums, we reduce our impact on natural populations and still give you the opportunity to see these amazing animals up close. i have the privilege of working in the southern california / baja gallery. recently another public aquarium gave us a small herd of pacific seahorses ( before you start laughing, a group of seahorses really is called a herd! ). we are raising the little guys and gals now and hope to someday have them on display. in the meantime, i thought i ’ d share a little about the pacific seahorse with you to tide you over ( pun intended ). the scientific or proper name of the pacific seahorse is hippocampus ingens. this is the only seahorse on the eastern side of the pacific ocean and it ’ s possible to find them here in southern california! their range goes as far south as peru, but several have been collected as far north as san diego bay. baby pacific seahorses are pelagic, which means after birth they float around in the ocean currents along with the fields of plankton, which they eat voraciously. before that, the father carries the babies in his brood pouch ( around his stomach area ) for up to 6 weeks. pacific seahorse dads carry quite a few babies, an average of around 200 each pregnancy! once they are released from the father ’ s brood pouch, the parents are done parenting. we should all be so lucky to have a parenting job that easy, eh? just kidding! once the young get a little older and develop stronger muscles, they stop traveling with the ocean currents. they ’ ll settle down amongst the corals and sea grasses along the sea floor. there they can grow to be as much as 19 - 20 cm


once the young get a little older and develop stronger muscles, they stop traveling with the ocean currents. they ’ ll settle down amongst the corals and sea grasses along the sea floor. there they can grow to be as much as 19 - 20 cm or 8 inches tall. that makes them one of the largest seahorses in the world, and they ’ re right here in southern california! so, if you are wandering the shores around san diego and happen to come across a seahorse, here ’ s what you ’ re looking for to determine if it ’ s a pacific seahorse ( hippocampus ingens ). first of all, if it ’ s here, it ’ s a 99 % chance it ’ s a pacific seahorse cause again, that ’ s the only seahorse naturally found on the eastern side of the pacific ocean! however, here ’ s some more info, so you can have an idea of what you ’ re looking for. the pacific seahorse comes in a variety of colors ranging from yellows, oranges, and pinks, to browns and blacks. they will more than likely be living amongst coral or sea grasses that are a similar color. this keeps them safer from predators. they ’ ll likely range between 5 and 7 inches tall ( 13 - 19 cm ). one last note, if you do see a pacific seahorse meandering around out there, take a picture if you have an underwater camera! either way, try and remember approximately where it is you found it and report it to project seahorse. you can find this non - profit group online, they are attempting to catalog and document the lives and locations of seahorses worldwide. their research could help understand and protect seahorses for future generations. it ’ s very exciting to know that such exotic looking creatures live so close to us. hopefully, some of you get the opportunity to see them in their natural environment! have something to say? leave a comment! all blogs and comments represent the views of the individual authors and not necessarily those of the aquarium.


may, the month of mary may is the month of mary, the mother of god and the mother of the faithful affirmation of mary ’ s maternal role toward christians is one of the main focal points in chapter 8 of the second vatican council ’ s constitution of the church, a chapter which names mary as the “ mother of all human beings, ” or “ mother of the faithful. ” the development of the doctrine of mary ’ s spiritual motherhood was gradual ; earlier testimonies from irenaeus, ambrose, augustine, and others were present but sparse. it was in the high middle ages that real theological development on the idea of mary ’ s motherhood began to occur. more and more, the scriptural passage of mary at calvary ( john 19 : 25 - 27 ) came to be seen as the pericope expressing mary ’ s spiritual motherhood toward the disciples of jesus : “ so the soldiers did this. but standing by the cross of jesus were his mother, and his mother ' s sister, mary the wife of clopas, and mary magdalene. when jesus saw his mother, and the disciple whom he loved standing near, he said to his mother, “ woman, behold, your son! ” then he said to the disciple, “ behold, your mother! ” and from that hour the disciple took her to his own home. ” ( john 19 : 25 - 27 ) the broader implications of this passage were realized gradually, by theologians, who came in time to understand its significance in expressing the presence and action of mary in our lives. it was found that the best and universal expression of this presence was in the analogy of motherhood, which in this case is a spiritual motherhood, with all that such a mother / child relationship means for both mary and us. from the dictionary of mary : when we call mary “ our mother, ” we grasp instinctively the essential meaning of the title, since it evokes memories of a human experience that is universal and runs deep. but when it comes to explaining clearly and precisely the content of the title, the matter is not so simple. primarily, this is due to the wealth of content, including as it does practically all aspects of mary ' s activity toward us. furthermore, mary is our “ mother ” in a way that is necessarily analogical. theologians are well aware of what this imports, namely certain limitations that have to be remembered, and a transcendence that also must be kept in mind. the limitations come from the obvious fact that as far as