United States statistics continue to indicate that the human donor heart pool does not and will not meet the great demand for hearts. For those patients unresponsive to maximal medical therapy (approximately 60,000 patients per year), cardiac transplantation is currently their best hope for increased survival. To address the need for additional end-stage congestive heart failure (CHF) therapy options, three medical device manufacturers have developed implantable left ventricular assist devices (LVAD) which act as a pump for hemodynamic (...) support of the patient’s diseased heart. Although LVADs have been shown to improve patient disease state prior to organ transplantation. LVADs do nothing to increase the pool of human donor hearts, and they negatively impact the United Network for Organ Sharing (UNOS) waiting list by increasing the size of the waiting pool. This paper identifies and explores the ethical challenges presented by the use of LVADs as a bridging technology for heart transplant candidates. Although LVADs raise some ethical concerns, these concerns are outweighed by the proven medical efficacy of these devices. Thus, this technology should continue to be used and further developed. (shrink)

In the last decades, new technologies have improved the survival of patients affected by chronic illnesses. Among them, left ventricular assist device has represented a viable solution for patients with advanced heart failure. Even though the LVAD prolongs life expectancy, patients’ vulnerability generally increases during follow up and patients’ request for the device withdrawal might occur. Such a request raises some ethical concerns in that it directly hastens the patient’s death. Hence, in order to assess the (...) ethical acceptability of LVAD withdrawal, we analyse and examine an ethical argument, widely adopted in the literature, that we call the “descriptive approach”, which consists in giving a definition of life-sustaining treatment to evaluate the ethical acceptability of treatment withdrawal. Focusing attention on LVAD, we show criticisms of this perspective. Finally, we assess every patient’s request of LVAD withdrawal through a prescriptive approach, which finds its roots in the criterion of proportionality. (shrink)

Destination therapy is the permanent implantation of a left ventricular assist device in patients with end-stage, severe heart failure who are ineligible for heart transplantation. DT improves both the quality of life and prognosis of patients with end-stage heart failure. However, there are also downsides to DT such as life-threatening complications and the potential for the patient to live beyond their desired length of life following such major complications. Because of deeply ingrained cultural and religious beliefs regarding (...) death and the sanctity of life, Japanese society may not be ready to make changes needed to enable patients to have LVADs deactivated under certain circumstances to avoid needless suffering. Western ethical views that permit LVAD deactivation based mainly on respect for autonomy and dignity have not been accepted thus far in Japan and are unlikely to be accepted, given the current Japanese culture and traditional values. Some healthcare professionals might regard patients as ineligible for DT unless they have prepared advance directives. If this were to happen, the right to prepare an advance directive would instead become an obligation to do so. Furthermore, patient selection for DT poses another ethical issue. Given the predominant sanctity of life principle and lack of cost-consciousness regarding medical expenses, medically appropriate exclusion criteria would be ignored and DT could be applied to various patients, including very old patients, the demented, or even patients in persistent vegetative states, through on-site judgment. There is an urgent need for Japan to establish and enact a basic act for patient rights. The act should include: respect for a patient’s right to self-determination; the right to refuse unwanted treatment; the right to prepare legally binding advance directives; the right to decline to prepare such directives; and access to nationally insured healthcare. It should enable those concerned with patient care involving DT to seek ethical advice from ethics committees. Furthermore, it should state that healthcare professionals involved in the discontinuation of life support in a proper manner are immune to any legal action and that they have the right to conscientiously object to LVAD deactivation. (shrink)

Background Destination therapy is the permanent implantation of a left ventricular assist device in patients with end-stage, severe heart failure who are ineligible for heart transplantation. DT improves both the quality of life and prognosis of patients with end-stage heart failure. However, there are also downsides to DT such as life-threatening complications and the potential for the patient to live beyond their desired length of life following such major complications. Because of deeply ingrained cultural and religious beliefs (...) regarding death and the sanctity of life, Japanese society may not be ready to make changes needed to enable patients to have LVADs deactivated under certain circumstances to avoid needless suffering. Main text Western ethical views that permit LVAD deactivation based mainly on respect for autonomy and dignity have not been accepted thus far in Japan and are unlikely to be accepted, given the current Japanese culture and traditional values. Some healthcare professionals might regard patients as ineligible for DT unless they have prepared advance directives. If this were to happen, the right to prepare an advance directive would instead become an obligation to do so. Furthermore, patient selection for DT poses another ethical issue. Given the predominant sanctity of life principle and lack of cost-consciousness regarding medical expenses, medically appropriate exclusion criteria would be ignored and DT could be applied to various patients, including very old patients, the demented, or even patients in persistent vegetative states, through on-site judgment. Conclusion There is an urgent need for Japan to establish and enact a basic act for patient rights. The act should include: respect for a patient’s right to self-determination; the right to refuse unwanted treatment; the right to prepare legally binding advance directives; the right to decline to prepare such directives; and access to nationally insured healthcare. It should enable those concerned with patient care involving DT to seek ethical advice from ethics committees. Furthermore, it should state that healthcare professionals involved in the discontinuation of life support in a proper manner are immune to any legal action and that they have the right to conscientiously object to LVAD deactivation. (shrink)

The left ventricular assist device was originally designed to be surgically implanted as a bridge to transplantation for patients with chronic end-stage heart failure. On the basis of the REMATCH trial, the US Food and Drug Administration and the US Centers for Medicare & Medicaid Services approved permanent implantation of the left ventricular assist device as a destination therapy in Medicare beneficiaries who are not candidates for heart transplantation. The use of the left (...) class='Hi'>ventricular assist device as a destination therapy raises certain ethical challenges. Left ventricular assist devices can prolong the survival of average recipients compared with optimal medical management of chronic end-stage heart failure. However, the overall quality of life can be adversely affected in some recipients because of serious infections, neurologic complications, and device malfunction. Left ventricular assist devices alter end-of-life trajectories. The caregivers of recipients may experience significant burden (e.g., poor physical health, depression, anxiety, and posttraumatic stress disorder) from destination therapy with left ventricular assist devices. There are also social and financial ramifications for recipients and their families. We advocate early utilization of a palliative care approach and outline prerequisite conditions so that consenting for the use of a left ventricular assist device as a destination therapy is a well informed process. These conditions include: (1) direct participation of a multidisciplinary care team, including palliative care specialists, (2) a concise plan of care for anticipated device-related complications, (3) careful surveillance and counseling for caregiver burden, (4) advance-care planning for anticipated end-of-life trajectories and timing of device deactivation, and (5) a plan to address the long-term financial burden on patients, families, and caregivers. Short-term mechanical circulatory devices (e.g. percutaneous cardiopulmonary bypass, percutaneous ventricular assist devices, etc.) can be initiated in emergency situations as a bridge to permanent implantation of ventricular assist devices in chronic end-stage heart failure. In the absence of first-person (patient) consent, presumed consent or surrogate consent should be used cautiously for the initiation of short-term mechanical circulatory devices in emergency situations as a bridge to permanent implantation of left ventricular assist devices. Future clinical studies of destination therapy with left ventricular assist devices should include measures of recipients' quality of end-of-life care and caregivers' burden. (shrink)

Background Pediatric critical care physician attitudes about withdrawal of ventricular assist devices and extracorporeal membrane oxygenation in cases of medical futility are poorly defined. Our aim was to define current attitudes regarding the withdrawal of these devices. Methods IRB-approved, cross-sectional observational survey conducted among pediatric critical care attending physicians and fellow physicians in the United States between 2016 and 2017. Data was collected anonymously and statistically analyzed. Results A total of 158 physicians responded with 67% being attending physicians. (...) Compared to a VAD, a higher percentage had taken care of a patient on ECMO where the device was turned off because care was believed to be futile, including currently. Nearly all reported that it can be ethically permissible to withdraw support from a patient with a VAD and on ECMO, but varied opinions existed as to who should ultimately make this decision if the patient/their family disagrees. More respondents agreed that a patient/their family should agree to withdrawal of VAD or ECMO support prior to initiation if futility is later determined and that protocols should be created for VAD and ECMO withdrawal. Conclusion Most pediatric critical care physicians felt that it can be ethically permissible to withdraw VAD and ECMO support. Our study indicates that pediatric VAD and ECMO withdrawal protocols are desired, but further investigation is needed to determine how to best design protocols that would incorporate multiple stakeholders. (shrink)

Background Bioethics and law distinguish between the practices of "physician-assisted death" and "allowing the patient to die." Discussion Advances in biotechnology have allowed medical devices to be used as destination therapy that are designed for the permanent support of cardiac function and/or respiration after irreversible loss of these spontaneous vital functions. For permanent support of cardiac function, single ventricle or biventricular mechanical assist devices and total artificial hearts are implanted in the body. Mechanical ventilators extrinsic to the body are (...) used for permanent support of respiration. Clinical studies have shown that destination therapy with ventricular assist devices improves patient survival compared to medical management, but at the cost of a substantial alteration in end-of-life trajectories. The moral and legal assessment of the appropriateness and permissibility of complying with a patient's request to electively discontinue destination therapy in a life-terminating act in non-futile situations has generated controversy. Some argue that complying with this request is ethically justified because patients have the right to request withdrawal of unwanted treatment and be allowed to die of preexisting disease. Other commentators reject the argument that acceding to an elective request for death by discontinuing destination therapy is 'allowing a patient to die' because of serious flaws in interpreting the intention, causation, and moral responsibility of the ensuing death. Summary Destination therapy with cardiac and/or ventilatory medical devices replaces native physiological functions and successfully treats a preexisting disease. We posit that discontinuing cardiac and/or ventilatory support at the request of a patient or surrogate can be viewed as allowing the patient to die if--and only if--concurrent lethal pathophysiological conditions are present that are unrelated to those functions already supported by medical devices in destination therapy. In all other cases, compliance with a patient's request constitutes physician-assisted death because of the pathophysiology induced by the turning off of these medical devices, as well as the intention, causation, and moral responsibility of the ensuing death. The distinction between allowing the patient to die and physician-assisted death is pivotal to the moral and legal status of elective requests for death by discontinuing destination cardiac and/or ventilatory medical devices in patients who are not imminently dying. This distinction also represents essential information that must be disclosed to patients and surrogates in advance of consent to this type of therapy. (shrink)

BackgroundBioethics and law distinguish between the practices of "physician-assisted death" and "allowing the patient to die."DiscussionAdvances in biotechnology have allowed medical devices to be used as destination therapy that are designed for the permanent support of cardiac function and/or respiration after irreversible loss of these spontaneous vital functions. For permanent support of cardiac function, single ventricle or biventricular mechanical assist devices and total artificial hearts are implanted in the body. Mechanical ventilators extrinsic to the body are used for permanent (...) support of respiration. Clinical studies have shown that destination therapy with ventricular assist devices improves patient survival compared to medical management, but at the cost of a substantial alteration in end-of-life trajectories. The moral and legal assessment of the appropriateness and permissibility of complying with a patient's request to electively discontinue destination therapy in a life-terminating act in non-futile situations has generated controversy. Some argue that complying with this request is ethically justified because patients have the right to request withdrawal of unwanted treatment and be allowed to die of preexisting disease. Other commentators reject the argument that acceding to an elective request for death by discontinuing destination therapy is 'allowing a patient to die' because of serious flaws in interpreting the intention, causation, and moral responsibility of the ensuing death.SummaryDestination therapy with cardiac and/or ventilatory medical devices replaces native physiological functions and successfully treats a preexisting disease. We posit that discontinuing cardiac and/or ventilatory support at the request of a patient or surrogate can be viewed as allowing the patient to die if--and only if--concurrent lethal pathophysiological conditions are present that are unrelated to those functions already supported by medical devices in destination therapy. In all other cases, compliance with a patient's request constitutes physician-assisted death because of the pathophysiology induced by the turning off of these medical devices, as well as the intention, causation, and moral responsibility of the ensuing death. The distinction between allowing the patient to die and physician-assisted death is pivotal to the moral and legal status of elective requests for death by discontinuing destination cardiac and/or ventilatory medical devices in patients who are not imminently dying. This distinction also represents essential information that must be disclosed to patients and surrogates in advance of consent to this type of therapy. (shrink)

Both the doctor and the patient have rights to terminate an implantable cardioverter-defibrillator device for reasons of futility or autonomyImplantable devices have a long history in medicine with artificial hips being implanted since 1925, pacemakers since 1957, Starr-Edwards heart valve since 1961, artificial hearts since 1982 and ventricular assist devices since 1991. The ethics of deactivation or removal of these devices were not an issue until the use of implantable cardioverter defibrillator device, as the ICD can (...) produce considerable distress from defibrillation shocks in end-of-life patients. However, development of a clear ethics for ICD is critical as the massive technological advances in implantable heart failure devices will soon produce an epidemic of patients with implanted devices and end-of-life diseases. Should one turn off a biventricular pacer at the request of a patient who is having recurrent disabling heart failure? Should one turn off an AbioCor artificial heart in a patient who developed a severe disabling stroke from the device? Who has the right to turn off the device? Does the doctor have the right to turn it off, against the patient’s wishes, for reasons of futility? Does the patient have the right to turn it off, against the doctor’s wishes, and if so, for what reasons?In this issue of the Journal of Medical Ethics, England et al1 argue that the classification of an implantable device determines the rights of device deactivation. At the one end of the spectrum, there are semi-implanted devices like an intra-aortic balloon pump or a ventilator, where the doctor has the right to turn off the supportive therapy by commission on grounds …. (shrink)

Artificial devices that functionally replace internal organs are likely to be more common in the future. They are becoming more and more technologically feasible, increases in chronic diseases that can compromise various organs are anticipated, and donor organs will remain necessarily limited. More people in the future may have bodies that are partly nonorganic. How might artificial organs affect how we experience and conceptualize our bodies and how we understand the relation of the body to the experiencing, acting subject, or (...) self? Here, I focus on artificial heart devices (AHDs), including total artificial hearts (TAHs) and ventricular assist devices (VADs). While other devices, such as pacemakers and implantable cardiac defibrillators, assist the heart, I focus on devices that replace rather than assist organic function. AHDs, I argue, may have two opposing effects. On the one hand, having an AHD could alter experience, seemingly confirming that selves are shaped by the specifics of embodiment. On the other hand, AHDs are likely to encourage people to regard bodies as machines that are separable from the self. AHDs thus both confirm and undermine a body-self dualism. People with these devices may come to regard their bodies as machinelike even while having an artificial part alters their subjective experience. (shrink)

Socially assistive devices such as care robots or companions have been advocated as a promising tool in elderly care in Western healthcare systems. Ethical debates indicate various challenges. An important part of the ethical evaluation is to understand how users interact with these devices and how interaction influences users’ perceptions and their ability to express themselves. In this review, we report and critically appraise findings of non-comparative empirical studies with regard to these effects from an ethical perspective.Electronic databases and other (...) sources were queried using a comprehensive search strategy generating 9851 records. Studies were screened independently by two authors. Methodological quality of studies was assessed. For 22 reports on 21 datasets using a non-comparative design a narrative synthesis was performed.Data shows positive findings in regard to attitudes and emotional reactions of users. Varying perception of a social relation and social presence are the most commonly observed traits of interaction. Users struggle with understanding technical complexities while functionality of the devices is limited. This leads to a behavioral alignment of users towards the requirements of the devices to be able to make use of them.This evidence adds to three important ethical debates on the use of socially assistive devices in healthcare in regard to (1) reliability of existing empirical evidence to inform normative judgements, (2) ethical significance of the social presence of devices and (3) user autonomy in regard to behavioral alignment. (shrink)

Assistive Device Art derives from the integration of Assistive Technology and Art, involving the mediation of sensorimotor functions and perception from both, psychophysical methods and conceptual mechanics of sensory embodiment. This paper describes the concept of ADA and its origins by observing the phenomena that surround the aesthetics of prosthesis-related art. It also analyzes one case study, the Echolocation Headphones, relating its provenience and performance to this new conceptual and psychophysical approach of tool design. This ADA tool is designed (...) to aid human echolocation. They facilitate the experience of sonic vision, as a way of reflecting and learning about the construct of our spatial perception. Echolocation Headphones are a pair of opaque goggles which disable the participant’s vision. This device emits a focused sound beam which activates the space with directional acoustic reflection, giving the user the ability to navigate and perceive space through audition. The directional properties of parametric sound provide the participant a focal echo, similar to the focal point of vision. This study analyzes the effectiveness of this wearable sensory extension for aiding auditory spatial location in three experiments; optimal sound type and distance for object location, perceptual resolution by just noticeable difference, and goal-directed spatial navigation for open pathway detection, all conducted at the Virtual Reality Lab of the University of Tsukuba, Japan. The Echolocation Headphones have been designed for a diverse participant base. They have both the potential to aid auditory spatial perception for the visually impaired and to train sighted individuals in gaining human echolocation abilities. Furthermore, this Assistive Device artwork instigates participants to contemplate on the plasticity of their sensorimotor architecture. (shrink)

The purpose of this article is to investigate how cultural meanings associated with the left ventricular assist device inform acceptance and experience of this innovative technology when it is used as a destination therapy. We conducted open-ended, semistructured interviews with family caregivers and patients who had undergone LVAD-DT procedures at six U.S. hospitals. A grounded theory approach was used for the analysis. Thirty-nine patients and 42 caregivers participated. Participants described a sense of obligation to undergo the procedure (...) because of its promise for salvation. However, once the device was implanted, patients described being placed into a liminal state of being neither sick nor healthy, with no culturally scripted role. Consideration of end-of-life decisions was complicated by the uncertainties about how patients with LVADs die. Pre-implantation communications among patient, family, and clinicians should take into account the impact of the technology on meaning, identity, and patient experience. (shrink)

This paper addresses a dichotomy in the attitudes of some clinicians and bioethicists regarding whether there is a moral difference between deactivating a cardiac pacemaker in a highly dependent patient at the end of life, as opposed to standard cases of withdrawal of treatment. Although many clinicians hold that there is a difference, some bioethicists maintain that the two sorts of cases are morally equivalent. The author explores one potential morally significant point of difference between pacemakers and certain other life-sustaining (...) treatments: specifically, that the former are biofixtures, which become part of the patient in a way that the latter do not. The concept of the pacemaker as biofixture grants pacemakers a unique moral status that gives reason to treat a pacemaker the same as other parts of the patient that are necessary to sustain life. The author employs this biofixture analysis to affirm the intuition that deactivating a pacemaker in a highly dependent patient at the end of life is, in moral terms, more analogous to active euthanasia than it is to standard cases of withdrawal of treatment. The paper concludes with consideration of potential implications for further implantable medical technologies, such as ventricular assist devices and total artificial hearts. (shrink)

This article deals with the euthanasia debate in light of new life-sustaining technologies such as the left ventricular assist device (LVAD). The question arises: does the switching off of a LVAD by a doctor upon the request of a patient amount to active or passive euthanasia, i.e. to ‘killing’ or to ‘letting die’? The answer hinges on whether the device is to be regarded as a proper part of the patient's body or as something external. We (...) usually regard the switching off of an internal device as killing, whereas the deactivation of an external device is seen as ‘letting die’. The case is notoriously difficult to decide for hybrid devices such as LVADs, which are partly inside and partly outside the patient's body. Additionally, on a methodological level, I will argue that the ‘ontological’ arguments from analogy given for both sides are problematic. Given the impasse facing the ontological arguments, complementary phenomenological arguments deserve closer inspection. In particular, we should consider whether phenomenologically the LVAD is perceived as a body part or as an external device. I will support the thesis that the deactivation of a LVAD is to be regarded as passive euthanasia if the device is not perceived by the patient as a part of the body proper. (shrink)

Rapid advancements in artificial intelligence and machine learning (AI/ML) in healthcare raise pressing questions about how much users should trust AI/ML systems, particularly for high stakes clinical decision-making. Ensuring that user trust is properly calibrated to a tool’s computational capacities and limitations has both practical and ethical implications, given that overtrust or undertrust can influence over-reliance or under-reliance on algorithmic tools, with significant implications for patient safety and health outcomes. It is, thus, important to better understand how variability in trust (...) criteria across stakeholders, settings, tools and use cases may influence approaches to using AI/ML tools in real settings. As part of a 5-year, multi-institutional Agency for Health Care Research and Quality-funded study, we identify trust criteria for a survival prediction algorithm intended to support clinical decision-making for left ventricular assist device therapy, using semistructured interviews (n=40) with patients and physicians, analysed via thematic analysis. Findings suggest that physicians and patients share similar empirical considerations for trust, which were primarilyepistemicin nature, focused on accuracy and validity of AI/ML estimates. Trust evaluations considered the nature, integrity and relevance of training data rather than the computational nature of algorithms themselves, suggesting a need to distinguish ‘source’ from ‘functional’ explainability. To a lesser extent, trust criteria were also relational (endorsement from others) and sometimes based on personal beliefs and experience. We discuss implications for promoting appropriate and responsible trust calibration for clinical decision-making use AI/ML. (shrink)

Mrs. Duong had coronary artery disease, ischemic cardiomyopathy, and mildly altered mental status when her case was presented before an advanced heart therapy medical review board. She was accepted for left ventricular assist device placement pending additional insight into her cognitive state. Before the LVAD could be implanted, however, Mrs. Duong went into cardiogenic shock, and her heart failure team placed an intra‐aortic balloon pump in her subclavian artery. Within two weeks, Mrs. Duong became IABP dependent and (...) deconditioned. The attending deemed her as lacking capacity to make complex medical decisions, and the medical review board officially declined her for LVAD placement. The heart failure and CICU teams feel that Mrs. Duong is not being helped by the care they are giving her. They recommend terminal weaning of the IABP and initiation of comfort care. Her family disagrees, pointing to activities like continued eating and interacting with family. At an impasse after yet another family meeting, the attending for the heart failure team asks the clinical ethics consultant, “Do we have to replace the balloon pump when it fails?”. (shrink)

Unlike critically ill neonates, care of children with complex cardiac disease increasingly involves use of invasive technologies—such as ventricular assist devices (VAD)—or emergent surgical proced...

BackgroundSocially assistive devices (care robots, companions, smart screen assistants) have been advocated as a promising tool in elderly care in Western healthcare systems. Ethical debates indicate various challenges. One of the most prevalent arguments in the debate is the double-benefit argument claiming that socially assistive devices may not only provide benefits for autonomy and well-being of their users but might also be more efficient than other caring practices and might help to mitigate scarce resources in healthcare. Against this background, we (...) used a subset of comparative empirical studies from a comprehensive systematic review on effects and perceptions of human-machine interaction with socially assistive devices to gather and appraise all available evidence supporting this argument from the empirical side.MethodsElectronic databases and additional sources were queried using a comprehensive search strategy which generated 9851 records. Studies were screened independently by two authors. Methodological quality of studies was assessed. For 39 reports using a comparative study design, a narrative synthesis was performed.ResultsThe data shows positive evidential support to claim that some socially assistive devices (Paro) might be able to contribute to the well-being and autonomy of their users. However, results also indicate that these positive findings may be heavily dependent on the context of use and the population. In addition, we found evidence that socially assistive devices can have negative effects on certain populations. Evidence regarding the claim of efficiency is scarce. Existing results indicate that socially assistive devices can be more effective than standard of care but are far less effective than plush toys or placebo devices.DiscussionWe suggest using the double-benefit argument with great caution as it is not supported by the currently available evidence. The occurrence of potentially negative effects of socially assistive devices requires more research and indicates a more complex ethical calculus than suggested by the double-benefit argument. (shrink)

In contemporary global knowledge based society there are scorching needs for new knowledge and unprecedented vision of future development. Author is focuses attention to new possibilities of fostering creative abilities and gaining new socio-economic knowledge by the assistance of ICT, Internet and mainly by using products and services of computational intelligence. His method used is prevailingly new knowledge creation by experimentation in virtual laboratories. In using conventional methods, he combines inductive and deductive methods as set up for developing mental models (...) from up to down and bottom to up. Because in socio-economic branches it is very difficult and even almost wholly impossible to do experiments in objective reality the experimentation by the assistance of computational intelligence is promising advance in gaining new socioeconomic knowledge in contemporary complex world. Using such new approaches, methods and tools is the main scientific aim of the author. He uses convictive demonstration of successful using these unprecedented possibilities in gaining deeper knowledge about complex evolutionary phenomena. The distinction of such knowledge is against conventional one is consisting in very deep understanding of complex socio-economic dynamics. Using meant knowledge acquisition approaches is promising in quality and in abiding knowledge and skill of single individuals but the extraordinary progress of creative knowledge based society fostered by using them in advanced webs is useful for whole society. (shrink)

Music is the carrier through which human beings express their emotions. It can clean up their hearts and seek emotional resonance. The combination of music and artificial intelligence, when music meets artificial intelligence, the mathematical logic part of data and algorithm replaces the image thinking, resulting in automatic music production. The basic principle of music creation is to use artificial intelligence technology to conduct in-depth training on a large number of songs, and then build a database. Then, within a certain (...) period of time, extract a segment from several songs, and then decompose it to form a new melody. The automatic music production is the collision of music and technology. With the flying of code and notes, it creates a different kind of beauty. Music culture is a new field of music application. With its refreshing audio-visual effect, it has made people have a new understanding of music and has become a hot topic in current mass cultural activities. The sound quality characteristics of music culture programs determine the characteristics of simple, fast and efficient design. However, the current audio and video design still stays in the traditional audio and video form design, with low design efficiency, long cycle, high cost and high requirements for designers. In view of the fact that the traditional audio and video design mode in China's music and cultural programs cannot meet the needs of performance programs at present, this paper proposes a design scheme of audio and visual effects of music and cultural programs with intelligent devices as the core, and develops a complete set of audio and visual effects aided design system on this basis. (shrink)

This article discusses how technological official aids influence sporting competitions in terms of fairness and flow. It addresses the main arguments against technological official aids used to assist refereeing in binary referee situations. First, I argue that the criticism directed at the use of ball tracking devices (‘reconstructed track devices’) is mainly unjustified and that these devices provide the opportunity to make refereeing in certain types of sport fairer. In this regard, I also argue that empirical findings about referees’ (...) decision-making and potential biases must be considered when deciding how technological official aids influence the fairness of sporting competitions. Then I attempt to refute the argument that no situations are more decisive than others in sports with no fixed breaks, such as football. Finally, I scrutinise the argument that human fallibility in refereeing is somehow valuable in itself. Consequently, this article concludes that there are no convincing arguments against the use of technological official aids in binary referee situations. (shrink)

Atrial fibrillation is the most common cardiac arrhythmia in clinical practice. It often starts with asymptomatic and short episodes, which are difficult to detect without the assistance of automatic monitoring tools. The vast majority of methods proposed for this purpose are based on quantifying the irregular ventricular response during the arrhythmia. However, although AF totally alters the atrial activity reflected on the electrocardiogram, replacing stable P-waves by chaotic and time-variant fibrillatory waves, this information has still not been explored for (...) automated screening of AF. Hence, a pioneering AF detector based on quantifying the variability over time of the AA morphological pattern is here proposed. Results from two public reference databases have proven that the proposed method outperforms current state-of-the-art algorithms, reporting accuracy higher than 90%. A less false positive rate in the presence of other arrhythmias different from AF was also noticed. Finally, the combination of this algorithm with the classical analysis of RR series variability also yielded a promising trade-off between AF accuracy and detection delay. Indeed, this combination provided similar accuracy than RR-based methods, but with a significantly shorter delay of 10 beats. (shrink)

This paper uses Actor Network Theory to examine two cases of device‐mediated educational change, one involving a computer‐assisted interactive video module that provided a half‐hour of instruction for a university course, the other an assistive communication device that proved a supposedly retarded pre‐school child to be intelligent. The paper explores how device construction instigated by middle‐level organizational workers can ramify into organizational change, and extends Actor Network theory by augmenting some of its conceptual tools. I argue that (...) the organizational change processes initiated by work on the devices played out in non‐linear ways across the decades‐long careers of their makers, and that to understand them we not only have to look across such extended time frames, but must also consider how agency and identity positions emerge and shift over time through the mediation of devices. (shrink)

This paper uses Actor Network Theory to examine two cases of device-mediated educational change, one involving a computer-assisted interactive video module that provided a half-hour of instruction for a university course, the other an assistive communication device that proved a supposedly retarded pre-school child to be intelligent. The paper explores how device construction instigated by middle-level organizational workers can ramify into organizational change, and extends Actor Network theory by augmenting some of its conceptual tools. I argue that (...) the organizational change processes initiated by work on the devices played out in non-linear ways across the decades-long careers of their makers, and that to understand them we not only have to look across such extended time frames, but must also consider how agency and identity positions emerge and shift over time through the mediation of devices. (shrink)

A growing number of consumer technology companies are aiming to convince older people that humanoid robots make helpful tools to support aging-in-place. As hybrid devices, socially assistive robots (SARs) are situated between health monitoring tools, familiar digital assistants, security aids, and more advanced AI-powered devices. Consequently, they implicate older people’s privacy in complex ways. Such devices are marketed to perform functions common to smart speakers (e.g., Amazon Echo) and smart home platforms (e.g., Google Home), while other functions are more specific (...) to older people, including health and safety monitoring and serving as companions to mitigate loneliness. Privacy is a key value central to debates about the ethics of using SARs in aged care, yet there has been very little interchange between these debates and the robust theoretical discussion in the legal literature about the future of privacy and AI governance. Drawing on two qualitative studies of older people’s views on consumer SARs, the paper contributes novel findings about older people’s thinking on privacy and data governance at the intersection of their experiences with present day digital technologies and projections for future AI systems, and places their views in dialogue with debates about the future of privacy protection and AI governance. (shrink)

The rapid advancement of artificial intelligence systems has generated a means whereby assistive bionic prosthetics can become both more effective and practical for the patients who rely upon the use of such machines in their daily lives. However, de lege lata remains relatively unspoken as to the legal status of patients whose devices contain self-learning CIS that can interface directly with the peripheral nervous system. As a means to reconcile for this lack of legal foresight, this article approaches the topic (...) of CIS-nervous system interaction and the impacts it may have on the legal definition of “persons” under the law. While other literature of this nature centres upon notions of transhumanism or self-enhancement, the approach herein approached is designed to focus solely upon the legal nature of independent CIS actions when operating alongside human subjects. To this end, it is hoped that further discussion on the topic can be garnered outside of transhumanist discourse to expedite legal consideration for how these emerging relationships ought to be received by law-generating bodies internationally. (shrink)

Over recent years, brain-computer interface (BCI) has emerged as an alternative communication system between the human brain and an output device. Deciphered intents, after detecting electrical signals from the human scalp, are translated into control commands used to operate external devices, computer displays and virtual objects in the real-time. BCI provides an augmentative communication by creating a muscle-free channel between the brain and the output devices, primarily for subjects having neuromotor disorders, or trauma to nervous system, notably spinal cord (...) injuries (SCI), and subjects with unaffected sensorimotor functions but disarticulated or amputated residual limbs. This review identifies the potentials of electroencephalography (EEG) based BCI applications for locomotion and mobility rehabilitation. Patients could benefit from its advancements such as wearable lower-limb (LL) exoskeletons, orthosis, prosthesis, wheelchairs, and assistive-robot devices. The EEG communication signals employed by the aforementioned applications that also provide feasibility for future development in the field are sensorimotor rhythms (SMR), event-related potentials (ERP) and visual evoked potentials (VEP). The review is an effort to progress the development of user’s mental task related to LL for BCI reliability and confidence measures. As a novel contribution, the reviewed BCI control paradigms for wearable LL and assistive-robots are presented by a general control framework fitting in hierarchical layers. It reflects informatic interactions, between the user, the BCI operator, the shared controller, the robotic device and the environment. Each sub layer of the BCI operator is discussed in detail, highlighting the feature extraction, classification and execution methods employed by the various systems. All applications’ key features and their interaction with the environment are reviewed for the EEG-based activity mode recognition, and presented in form of a table. It is suggested to structure EEG-BCI controlled LL assistive devices within the presented framework, for future generation of intent-basedmultifunctional controllers. Despite the development of controllers, for BCI-based wearable or assistive devices that can seamlessly integrate user intent, practical challenges associated with such systems exist and have been discerned, which can be constructive for future developments in the field. (shrink)

The loss or absence of vision is probably one of the most incapacitating events that can befall a human being. The importance of vision for humans is also reflected in brain anatomy as approximately one third of the human brain is devoted to vision. It is therefore unsurprising that throughout history many attempts have been undertaken to develop devices aiming at substituting for a missing visual capacity. In this review, we present two concepts that have been prevalent over the last (...) two decades. The first concept is sensory substitution, which refers to the use of another sensory modality to perform a task that is normally primarily sub-served by the lost sense. The second concept is cross-modal plasticity, which occurs when loss of input in one sensory modality leads to reorganization in brain representation of other sensory modalities. Both phenomena are training-dependent. We also briefly describe the history of blindness from ancient times to modernity, and then proceed to address themeansthat have been used to help blind individuals, with an emphasis on modern technologies, invasive (various type of surgical implants) and non-invasive devices. With the advent of brain imaging, it has become possible to peer into the neural substrates of sensory substitution and highlight the magnitude of the plastic processes that lead to a rewired brain. Finally, we will address the important question of the value and practicality of the available technologies and future directions. (shrink)

Introduction Cholbi, Michael (et al.) Pages 1-10 -/- Assisted Dying and the Proper Role of Patient Autonomy Bullock, Emma C. Pages 11-25 -/- Preventing Assistance to Die: Assessing Indirect Paternalism Regarding Voluntary Active Euthanasia and Assisted Suicide Schramme, Thomas Pages 27-40 -/- Autonomy, Interests, Justice and Active Medical Euthanasia Savulescu, Julian Pages 41-58 -/- Mental Illness, Lack of Autonomy, and Physician-Assisted Death Varelius, Jukka Pages 59-77 -/- Euthanasia for Mental Suffering Raus, Kasper (et al.) Pages 79-96 -/- Assisted Dying for (...) Individuals with Dementia: Challenges for Translating Ethical Positions into Law Downie, Jocelyn (et al.) Pages 97-123 -/- Clinical Ethics Consultation and Physician Assisted Suicide Adams, David M. Pages 125-147 -/- License to Kill: A New Model for Excusing Medically Assisted Dying? Huxtable, Richard (et al.) Pages 149-168 -/- Medically Enabled Suicides Cholbi, Michael Pages 169-184 -/- Saving Lives with Assisted Suicide and Euthanasia: Organ Donation After Assisted Dying Shaw, David M. Pages 185-192 -/- Implanted Medical Devices and End-of-Life Decisions Gill, Michael B. Pages 193-215 -/- Everyday Attitudes About Euthanasia and the Slippery Slope Argument Feltz, Adam Pages 217-237 -/- “You Got Me Into This…”: Procreative Responsibility and Its Implications for Suicide and Euthanasia Weinberg, Rivka Pages 239-252 . (shrink)

The time is near where ‘therapeutic’ bodily assistive devices, developed to mimic species-typical body structures in order to enable normative body functioning, will allow the wearer to outperform the species-typical body in various functions. Although such devices are developed for people that are seen to exhibit sub species-typical abilities, many ‘therapeutic enhancements’ might also be desired and used by people that exhibit species-typical body abilities. This paper presents the views of members of the World Federation of the Deaf on potential (...) beyond species-typical abilities enabling therapeutic assistive devices (i.e. related to hearing). Survey respondents showed support for the development and uptake of beyond normal hearing enabling devices. The views of survey respondents as clients affect hearing-enabling professions (such as audiologist and speech pathologists). The paper analyzes what guidance code of ethics of hearing enabling professions give in regards to beyond normal hearing enabling devices. This paper suggests that people labeled impaired and the professions that serve them should more involved in the enhancement discourse. (shrink)

Medical technologies and assistive devices such as ventilators and power wheelchairs are designed to sustain life and/or improve functionality but they can also contribute to stigmatization and social exclusion. In this paper, drawing from a study of ten men with Duchenne muscular dystrophy, we explore the complex social processes that mediate the lives of persons who are dependent on multiple medical and assistive technologies. In doing so we consider the embodied and emplaced nature of disability and how life is lived (...) through bodies coupled with technologies and experienced as 'techno-body-subjects in situ'. Normative implications for theory and research, including bioethics research, are discussed. (shrink)

Medical technologies and assistive devices such as ventilators and power wheelchairs are designed to sustain life and/or improve functionality but they can also contribute to stigmatization and social exclusion. In this paper, drawing from a study of ten men with Duchenne muscular dystrophy, we explore the complex social processes that mediate the lives of persons who are dependent on multiple medical and assistive technologies. In doing so we consider the embodied and emplaced nature of disability and how life is lived (...) through bodies coupled with technologies and experienced as ‘techno-body-subjects in situ’. Normative implications for theory and research, including bioethics research, are discussed. (shrink)

Mobile devices with health apps, direct-to-consumer genetic testing, crowd-sourced information, and other data sources have enabled research by new classes of researchers. Independent researchers, citizen scientists, patient-directed researchers, self-experimenters, and others are not covered by federal research regulations because they are not recipients of federal financial assistance or conducting research in anticipation of a submission to the FDA for approval of a new drug or medical device. This article addresses the difficult policy challenge of promoting the welfare and interests (...) of research participants, as well as the public, in the absence of regulatory requirements and without discouraging independent, innovative scientific inquiry. The article recommends a series of measures, including education, consultation, transparency, self-governance, and regulation to strike the appropriate balance. (shrink)

The present study investigated the impacts of mobile assisted vocabulary learning via digital flashcards. The data were collected from 44 adult English as Foreign Language learners in three intact classes in a private language teaching institute in Iran, randomly assigned to experimental and control learning conditions. The experimental group used a freely available DF application to learn items from a recently developed corpus-based word list for high-frequency vocabulary in English. The treatment was implemented as out-of-the-classroom learning activities where the EFL (...) learners used DFs to augment their vocabulary knowledge, and their learning gains were compared to the control group that received regular English language education. The participants’ vocabulary knowledge was tested in pre-, post-, and delayed post-tests, and the findings indicated that using DFs for outside the classroom vocabulary learning contributed significantly to short- and long-term improvements in the knowledge of high-frequency words. The study provided empirical evidence for the affordances of mobile assisted vocabulary learning for learning a considerable proportion of core vocabulary and has some implications for addressing the vocabulary learning needs of EFL learners. (shrink)

Purpose This paper aims to show how the production of meaning is a matter of people interacting with technologies, throughout their appropriation and in co-performances. The researchers rely on the case of household-based voice assistants that endorse speaking as a primary mode of interaction with technologies. By analyzing the ethical significance of voice assistants as co-producers of moral meaning intervening in the material and socio-cultural space of the home, the paper invites their informed and critical use as a form of (...) empowerment while acknowledging their productive role in human values. Design/methodology/approach This paper presents an empirically informed philosophical analysis. Using the conceptual frameworks of technological appropriation and human–technological performances, while drawing on the interviews with voice assistants’ users and literature studies, this paper unravels the meaning-making processes in relation to these technologies in the household use. It additionally draws on a Wittgensteinian perspective to attend to the productive role of language and link to wider cultural meanings. Findings By combining two approaches, appropriation and technoperformances, and analyzing the themes of privacy, power and knowledge, the paper shows how voice assistants help to shape a specific moral subject: embodied in space and made as it performatively responds to the device and makes sense of it together with others. Originality/value The researchers show how through making sense of technologies in appropriation and performatively responding to them, people can change and intervene in the power structures that technologies suggest. (shrink)

Personal AI assistants are now nearly ubiquitous. Every leading smartphone operating system comes with a personal AI assistant that promises to help you with basic cognitive tasks: searching, planning, messaging, scheduling and so on. Usage of such devices is effectively a form of algorithmic outsourcing: getting a smart algorithm to do something on your behalf. Many have expressed concerns about this algorithmic outsourcing. They claim that it is dehumanising, leads to cognitive degeneration, and robs us of our freedom and autonomy. (...) Some people have a more subtle view, arguing that it is problematic in those cases where its use may degrade important interpersonal virtues. In this article, I assess these objections to the use of AI assistants. I will argue that the ethics of their use is complex. There are no quick fixes or knockdown objections to the practice, but there are some legitimate concerns. By carefully analysing and evaluating the objections that have been lodged to date, we can begin to articulate an ethics of personal AI use that navigates those concerns. In the process, we can locate some paradoxes in our thinking about outsourcing and technological dependence, and we can think more clearly about what it means to live a good life in the age of smart machines. (shrink)

Much of the research on the delivery of advice by professionals such as physicians, health workers and counsellors, both on the telephone and in face-to-face interaction more generally, has focused on the theme of client resistance and the consequent need for professionals to adopt particular formats to assist in the uptake of the advice. In this article we consider one setting, Kid’s Helpline, the national Australian counselling service for children and young people, where there is an institutional mandate not (...) to give explicit advice in accordance with the values of self-direction and empowerment. The article examines one practice, the use of script proposals by counsellors, which appears to offer a way of providing support which is consistent with these values. Script proposals entail the counsellors packaging their advice as something that the caller might say — at some future time — to a third party such as a friend, teacher, parent or partner, and involve the counsellor adopting the speaking position of the caller in what appears as a rehearsal of a forthcoming strip of interaction. Although the core feature of a script proposal is the counsellor’s use of direct reported speech, they appear to be delivered not so much as exact words to be followed, but as the type of conversation that the client needs to have with the third party. Script proposals, in short, provide models of what to say as well as alluding to how these could be emulated by the client. In their design, script proposals invariably incorporate one or more of the most common rhetorical formats for maximizing the persuasive force of an utterance such as a three-part list or a contrastive pair. Script proposals, moreover, stand in a complex relation to the prior talk and one of their functions appears to be to summarize, respecify or expand upon the client’s own ideas or suggestions for problem solving that have emerged in these preceding sequences. (shrink)

Persons with aphasia suffer from a loss of communication ability as a consequence of a brain injury. A small strand of research indicates effec- tiveness of dialogic interventions for communication development for persons with aphasia, but a vast amount of research studies shows its effectiveness for other target groups. In this paper, we describe the main parts of the hitherto technological development of an application named Dialogica that is (i) aimed at facilitating increased communicative participation in dialogic settings for persons (...) with aphasia and other communication disorders, (ii) based on comput- er game technology as well as on theory in dialogic education and argumenta- tion theory, and (iii) designed for mobile devices with larger screens. (shrink)

This paper aims to critique the phenomenon of advanced patient autonomy and choice in healthcare within the specific context of self-testing devices. A growing number of self-testing medical devices are currently available for home use. The premise underpinning many of these devices is that they assist individuals to be more autonomous in the assessment and management of their health. Increased patient autonomy is assumed to be a good thing. We take issue with this assumption and argue that self-testing provides (...) a specific example how increased patient autonomy and choice within healthcare might not best serve the patient population. We propose that current interpretations of autonomy in healthcare are based on negative accounts of liberty to the detriment of a more relational understanding. We also propose that Kantian philosophy is often applied to the healthcare arena in an inappropriate manner. We draw on the philosophical literature and examples from the self-testing process to support these claims. We conclude by offering an alternative account of autonomy based on the interrelated concepts of relationality, care and responsibility. (shrink)

The times are progressing and the demand for opera performance talents is gradually increasing. In the new media environment as well as the technological environment, the teaching of opera performance in colleges and universities has ushered in the challenges of the new era, and the teaching staff of colleges and universities need to continuously improve their abilities. This paper explores the use of intelligent devices to explore the professional curriculum and teaching research in the new media environment.

In this paper, I argue that AI-powered voice assistants, just as all technologies, actively mediate our interpretative structures, including values. I show this by explaining the productive role of technologies in the way people make sense of themselves and those around them. More specifically, I rely on the hermeneutics of Gadamer and the material hermeneutics of Ihde to develop a hermeneutic lemniscate as a principle of technologically mediated sense-making. The lemniscate principle links people, technologies and the sociocultural world in the (...) joint production of meaning and explicates the feedback channels between the three counterparts. When people make sense of technologies, they necessarily engage their moral histories to comprehend new technologies and fit them in daily practices. As such, the lemniscate principle offers a chance to explore the moral dynamics taking place during technological appropriation. Using digital voice assistants as an example, I show how these AI-guided devices mediate our moral inclinations, decisions and even our values, while in parallel suggesting how to use and design them in an informed and critical way. (shrink)

Four years ago, I tried assigning blogs as homework to ensure that students came to class prepared for seminar discussions. From the start, it was clear that blogging was having a good effect, but I needed to make many refinements before I was satisfied that I was squeezing the greatest benefit from this device. In this paper, I summarize and explain the fully developed method on which I eventually settled. I first explain what I’m hoping will happen to students (...) over the semester. Then, I list some guiding principles that have pushed me in certain directions as I refined the method. Next, I give a step-by-step account of how the method works, from the syllabus to the classroom. Finally, I consider drawbacks, advantages, and an important objection. (shrink)