AI & SOCIETY https://doi.org/10.1007/s00146-021-01330-w OPEN FORUM Caring in the in‑between: a proposal to introduce responsible AI and robotics to healthcare Núria Vallès‑Peris1 · Miquel Domènech1 Received: 26 June 2021 / Accepted: 24 November 2021 © The Author(s) 2021 Abstract In the scenario of growing polarization of promises and dangers that surround artificial intelligence (AI), how to introduce responsible AI and robotics in healthcare? In this paper, we develop an ethical–political approach to introduce democratic mechanisms to technological development, what we call “Caring in the In-Between”. Focusing on the multiple possibilities for action that emerge in the realm of uncertainty, we propose an ethical and responsible framework focused on care actions in between fears and hopes. Using the theoretical perspective of Science and Technology Studies and empirical research, “Caring in the In-Between” is based on three movements: the first is a change of focus from the world of promises and dangers to the world of uncertainties; the second is a conceptual shift from assuming a relationship with robotics based on a Human–Robot Interaction to another focused on the network in which the robot is embedded (the “Robot Embedded in a Network”); and the last is an ethical shift from a general normative framework to a discussion on the context of use. Based on these suggestions, “Caring in the In-Between” implies institutional challenges, as well as new practices in healthcare systems. It is articulated around three simultaneous processes, each of them related to practical actions in the “in-between” dimensions considered: monitoring relations and caring processes, through public engagement and institutional changes; including concerns and priorities of stakeholders, with the organization of participatory processes and alternative forms of representation; and making fears and hopes commensurable, through the choice of progressive and reversible actions. Keywords Ethics of care · Science and technology studies · Robot embedded in a network (REN) · Measured action · Care robots 1 Introduction the theoretical approach of Science and Technology Stud- ies (STS), we propose a set of actions in these in-between In the landscape of imaginaries that surround artificial intel- spaces to introduce responsible AI and robotics to health- ligence (AI) and robotics in healthcare, there is a prominent care. However, we do not propose any kind of action, but debate regarding utopian and dystopian scenarios, whereby actions based on the ethics of care. We do so by exploring social and ethical discussions are polarized between the a particular case that could exemplify some of the common promises and the dangers of AI. This paper is grounded in a dynamics of medical AI, namely that of care robots in a realm that is far removed from the so-called ‘abyss’ between children’s hospital (i.e., socially assistive robots). utopias and dystopias, and is instead situated in the terrain that lies between the fears and hopes, and where the multiple 1.1 The narrative of promises and dangers in AI possibilities are experienced (de Sousa Santos 2016). Using There is an increasing narrative in public and academic domains that assumes that the solution to the main clinical, * Núria Vallès‑Peris nuria.valles@uab.cat economic, and general well-being problems that healthcare systems are facing around the world will come from AI Miquel Domènech miquel.domenech@uab.cat (Morley et al. 2020; Topol 2019). Medical AI offers plenty of promise: early diagnosis using image analysis in radiol- 1 Barcelona Science and Technology Studies Group (STS‑B), ogy, pathology, and dermatology, with excellent diagnostic Department of Social Psychology, Universitat Autònoma de speed and accuracy when working in parallel with medical Barcelona, Barcelona, Spain 13 Vol.:(0123456789) AI & SOCIETY experts; personalized treatments that optimize the care tra- debate focuses only on a utopian or dystopian development jectory of chronically ill patients; precision therapies for of robotics, some issues are exaggerated, while the identi- complex illnesses; reduction of medical errors; and greater fication of contexts, situations and controversies regarding enrolment for clinical trials (Miller and Brown 2018). Lead- artefacts that do not respond to this promised future remains ing healthcare and computer scientists have argued that AI unclear. At the same time, it is difficult to identify problems will help healthcare systems achieve greater efficiency in and generate an ethical debate around some robots that are two ways: on the one hand by improving the timeframe already in use (that do not integrate the complex functionali- and accuracy of patient diagnosis and treatment and, when ties and capabilities expected of highly intelligent autono- possible, helping with early prevention; and, on the other mous robots). hand, streamlining the workload, using staff more efficiently As a proposal to go beyond this scenario of promises/ (Kerasidou 2020). Robotics is considered to be a specific dangers, we develop an approach to introduce responsible sub-category of medical AI (Shoham et al 2018). In the time AI and robotics to healthcare based on three movements: of so-called New Robotics, a new family of robots devoted (a) the first is a change of focus from the world of promises to healthcare applications has become particularly prolific and dangers to the world of uncertainties; (b) the second is (Schaal 2007). This new era of robotics enables safe robot a conceptual shift from assuming a relationship with robot- interactions with humans, easy programming and adjustment ics based on a Human–Robot Interaction (HRI) to another to particular needs, and the possibility for robots to func- focused on the network in which the robot is embedded (the tion as mobile, interactive information systems in hospitals, “Robot Embedded in a Network-REN”); and the last is (c) nursing homes and other healthcare settings. Due to their an ethical shift from a general normative framework to a capacity to interact with humans, these robots open up an discussion on the context of use, from the logic of the eth- interesting scenario for working on the emotional and social ics of care. Based on these suggestions, we define a new dimensions of health. ethical–political proposal for introducing responsible AI and The impetus of AI and robotics science, and the deep robotics, what we call “Caring in the In-Between”. learning subtype in particular, facilitated by the use of In order to develop our proposal, this paper is organized so-called big data, along with highly enhanced comput- in seven sections. The one that follows contextualizes our ing power and cloud storage, enables greater automation research on care robots; we then develop the three move- in a variety of sectors. However, although automation has ments on which we base our proposal: in Sect. 3 we focus on a long-standing impact on employment, productivity and the movement from the world of promises and dangers to the the economic performance of companies and nations, the world of uncertainties, in Sect. 4 we explore the movement introduction of AI systems to healthcare environments has from HRI to a REN relation and, in Sect. 5 we explain the had an unprecedented impact on the automation of care. movement from an general ethical framework to the context (Vallès-Peris and Domènech 2020; Sampath and Khargon- of use, from the ethics of care; in Sect. 6 we outline our ekar 2018). Thus, along with the narrative on the promises ethical–political proposal to introduce responsible robotics of AI, these innovative technologies are also the source of and AI to healthcare and; finally, we summarize the main many of the uncertainties of our time. conclusions. The field is certainly high on promise and relatively low on data and proof. Moreover, many problems have been associated directly to AI and robotics, such as social bias, 2 Empirical research on care robots privacy and security, and lack of transparency (Topol 2019). in a children’s hospital The possibility of machines performing activities that are traditionally associated with the exclusively human condi- Our proposal for responsible AI and robotics is based on a tion -such as abstract problem-solving, perceptual recog- series of empirical studies that we carried out on the intro- nition, social interaction and natural language (Vallor and duction of care robots to a children’s hospital in Barcelona. Bekey 2017)-generates many dangers. These dangers relate In children’s health settings, robots for care are typically to a hypothetical scenario of future AI functionalities, rather considered to be those that are used in specific therapeu- than real, current ones, and are associated with the “sup- tic interventions, e.g., with autistic children (Heerink et al posed” possibility of humans being replaced by technologi- 2016) or in rehabilitation processes (Meyer-Heim and van cal systems or of care for dependent and ill persons becom- Hedel 2013). Care robots are also those involved in the ing "dehumanised" (Vallès-Peris et al. 2021a). extensive line of research and application of robots to reduce Although it is undeniable that the development of AI and pain and anxiety when children are subjected to some type robotics is exponentially real, there is a gap between the ethi- of intervention (Crossman et al 2018) or simply to make cal concerns around its supposed functionalities and the real hospital stays more pleasant (Díaz-Boladeras et al 2016). In possibilities of contemporary AI (Hagendorff 2020). If the engineering and computer science, the care robots to which 13 AI & SOCIETY we refer in this paper are usually included in the field of so- implementation of these artefacts. The fact that our study called “socially assistive robotics”. In general terms, this was carried out on robots used with hospitalised children field is focused on providing artificially intelligent robotic meant we could identify particularly sensitive issues and systems to aid end-users with special physical or cognitive highly delicate situations more easily. needs in their daily activities (Pareto Boada et al. 2021). We analysed the collected data using qualitative tech- Since 2015, we have been involved in the research being niques, i.e. thematic analysis for the interviews and focus done by a children’s hospital in Barcelona to design and groups (Clarke and Braun 2014) and thick description for the introduce care robots. As social scientists, our work together participatory process (Ponterotto 2006). However, the goal with an interdisciplinary team of physicians, nurses and of this paper is not to present the analysis and results of these engineers involved identifying the ethical and social implica- three research projects, but to build a responsible approach tions of introducing such robots to the hospital. Throughout to AI and robotics that embraces the practices and concerns the process, we conducted three empirical research projects of the different groups of actors identified in those projects. that shared the common objective of exploring the fears and hopes of the different actors that, in one way or another, established or would have to establish a relationship with a 3 From the world of promises and dangers robot for care. to the world of uncertainties Some details of these research projects are the following: As explained in the introduction, the social and ethical – A participatory process with children to design a robot debates surrounding AI and robotics are often articulated for care for a children’s hospital. For three months, we around utopian or dystopian scenarios (Shatzer 2013), or conducted a participatory process in a school with 60 focused on the identification of risks and benefits (Verbeek six-year-old children. Children were organized into two 2006), which contributes to a growing polarization of prom- large groups of 30, and 12 sessions were held with each ises and dangers. As sociologist de Sousa Santos (2016) group (24 sessions in total). The participatory process warns, in our technologically modified world, fear and hope employed design-thinking techniques. are collapsing in the face of the growing polarization of hope – A Vision-Assessment process to identify the risks and without fear (the health innovation sector and markets with benefits associated with future visions of robots for care exponential benefits) and fear without hope (anyone who among the different categories of people involved in care believes that technological progress cannot be stopped and at a children’s hospital. We organized: three focus groups that we will need to adapt to whatever changes may come with nurses, with a total of 22 people; three focus groups about). In this situation, uncertainties become abysmal, and with hospital volunteers, also with 22 people taking part; leave no room for action. one focus group with the relatives of hospitalized chil- Inspired by Spinoza's notions, de Sousa Santos (2016) dren—after previously holding a workshop with them on examines the unequal epistemological and experiential dis- robotic technologies in care—with 10 people participat- tribution of fear and hope. In addition to the idea of abysmal ing; and three interviews with physicians who were heads uncertainties, uncertainty is also the experience of the pos- of units at a children’s hospital. sibilities that arise from the multiple relationships that can – A set of interviews with roboticists to identify their con- exist between fear and hope. Since the relationships between cerns regarding robots for care. Eleven face-to-face semi- different groups and actors are different, the types of uncer- structured interviews were conducted with roboticists tainty are also different. Fear and hope are not equally dis- working in the field of care robots. tributed among all social groups or historical epochs. In rela- tion to technologies, fear and hope are defined by parameters The framework of reference for the various participants that tend to benefit social groups that have greater access to and the fieldwork carried out during the investigations, scientific knowledge and technology. For these groups, the was the robots that were being implemented in that hospi- belief in scientific progress and innovation is strong enough tal (already introduced or in pilot/prospective phases): pet to neutralise any fear regarding the limitations of current robots used to reduce anxiety in pre-operative and diagnostic knowledge. For those who have less access to scientific and tests, as well as to make the hospital stay more pleasant for technological knowledge, this is experienced as inferiority children with long admissions; therapy robots for children that generates uncertainty. For them, uncertainty is gener- with autism and; tele-communication robotic systems, for ated by their place in a world that is defined and legislated diagnostic visits by doctors or to facilitate communication by powerful and alien knowledge that affects them and over with their school in the case of hospitalised children. This which they have little or no control. This knowledge is pro- does not mean that our proposal refers only to this type of duced about them and eventually against them, but never robot, but that our proposal is nurtured by a study of the with them (de Sousa Santos 2016). 13 AI & SOCIETY In the dreamscape of promises and dangers that surround introduction of these technologies to healthcare is situated medical AI, we defend the need for ethical and social discus- in the realm of uncertainty that lies between fears and hopes. sion to move away from a speculative scenario that consid- In these contexts of the uncertain impact of technologies, ers an abyss between utopias and dystopias. In contrast, we Callon et al (2009) call for precaution with regard to the situate ourselves in the terrain that lies in between fears and potential harm, impact or causal relation of a technological hopes, where multiple possibilities arise (de Sousa Santos innovation. The action that may better represent precaution 2016). In this terrain, uncertainty is situated and negoti- is the so-called “measured action”, meaning a progressive ated, embedded in the actors that participate in healthcare action motivated by feedback and constant debate that con- relations. So, in order to develop more responsible AI in siders the consequences of that action. “Measured action healthcare, which is particularly addressed at social needs implies an active, open, contingent and revisable approach, and guaranteeing individual and collective well-being, we exactly the opposite of a clear final decision. And then, this propose a focus on care (caring as action) in the spaces in approach rests on a deepening of knowledge, but not only between that are opened by a particular artifact (i.e. robots of the knowledge provided by the scientific disciplines of for care in paediatric hospitals). isolated research. The proportionality of actions for soci- The literature on ethics and robots primarily addresses ety, acceptability and economic cost also have their place in the interests of what the community focused on study in deliberation” (Callon et al. 2009: 210). this field considers important, while the opinions of other This position leads us away from the realm of abysmal stakeholders, such as robotics researchers, health profession- uncertainties between utopian promises and dystopian dan- als and patients, are not directly discussed. In the public gers. This is uncertainty about desired futures, about what debate, questions about whether humans are replaceable by a care robot is, about the risk of introducing such devices robots or whether robots should have rights seem to take to children’s care, and so on. In our proposal, uncertainty precedence over the current and more real challenges that and precaution are the most relevant characteristics of AI could arise from their use in specific applications (van der and robotics, and are thus a privileged space for responsi- Plat et al. 2010). This “a priori” philosophical approach has ble introduction of these technologies to healthcare. This some limitations (Stahl and Coeckelbergh 2016), including idea is grounded on an STS theoretical background and on the difficulty of establishing a normative framework to guide a particular way of understanding robots, as well as on the and orient everyday problems that may arise in hospitals or centrality of the ethics of care when considering responsible other health settings when care robots are introduced. technologies. In the following sections, we develop each of Our proposal to go beyond a discussion centred on the these issues. promises of AI is based on an analysis of how fears and hopes are articulated and negotiated with different actors. While looking into the controversies that the several actors 4 From human–robot interaction (HRI) involved in care processes with robots have to deal with, to a robot embedded in a network (REN) we came to study the practices and values of the different actors that participate in healthcare relations in a children’s Care robots are used to perform a number of specific tasks- hospital. Callon et al (2009) maintain that the controversies such as facilitating the relationship between patients and over the use of certain technologies create uncertainty and places outside the hospital, reducing distress in pre-operative bring about unforeseen concerns. Instead of simply seeking care, and modifying the ways that healthcare staff perform consensus or general principles, if we wish to enrich the certain actions—such as measuring vital signs, perform- debate around technologies, it is important to call attention ing detailed interventions, etc. When thinking about and to the importance of collective discussion of the matter. As designing a robot’s agency in medical settings, as well as observed by Epstein (1995), the participation of non-special- its ability to interact with children, it is relevant to take into ists in the development of knowledge that actually concerns account how artefacts or devices are embedded in a network them may lead to problems being formulated and research of caring relationships that involves several actors(López- results being disseminated and implemented in a different Gómez 2015). Children’s well-being is not only defined by way. Following this view, what we try do here with regard to the robot’s ability to interact with them, but also by its ability care robots is to reflect the importance of collective discus- to interact with the whole social system of care relationships. sion of the controversies surrounding medical AI to thereby However, in engineering and the related ethical debates, the enrich the formulation of problems and propose alternative relationship between children and AI robots is often concep- frameworks. tualized by the notion of Children-Robot Interaction (CHRI), Given that the level of innovation in robotics and AI is which is the children’s equivalent of Human–Robot Interac- accelerating and surpassing our capacity to anticipate its tion (HRI), and which describes two isolated entities inter- consequences and influences on our lives, the responsible acting with each other: a human and a robot. 13 AI & SOCIETY Most STS approaches, such as the Actor Network Theory settings, for example, by monitoring vital signs and thus and social constructivism of technology, postulate a more preventing certain situations in critical paediatric patients, or less open ontological universe in which it is difficult to or by personalizing and adjusting therapies with autistic establish rigid boundaries between the social, the human, children. However, some studies have warned us that the the natural and the technological (Karakayali 2015). With introduction of telemedicine devices (technologies that are the abandonment of the notions of nature and society as often built into AI robots) has changed healthcare practices separate entities, a new entity emerges: a heterogene- and knowledge (Mort et al 2003). The heterogeneity of care, ous network (Callon and Latour 1992). In this view, any as well as robot heterogeneity, implies that the practices and technological innovation is explained by its relational and values of care are transformed when new nodes are intro- contextual nature, i.e. how it makes sense in its network duced to healthcare networks. When a robot is introduced to of relationships (Domènech and Tirado 2009). Therefore, a a network of care relations in a hospital, it and the network technological innovation is not only an artefact, but a whole are transformed. Technologies enable certain relationships network of devices, processes and actors (Latour 1999). between human beings and the world that would not oth- From this perspective, care robots are a conglomerate of erwise be possible. However, technologies are not neutral material, social and semiotic relations in which technical, intermediaries, but active mediators that contribute to the scientific, political, economic, social and ethical considera- formation of human perceptions and interpretations of real- tions are intimately entwined within a single actor (Latour ity (Verbeek 2006). Robots mediate the way we understand 1999). This idea of heterogeneity can be accompanied by and practice care processes, just as the robot is reconstructed relational materialism, according to which the elements do from the assemblage of social relations in which it partici- not exist for reason of any essence but are constituted from pates (Law and Mol 1995). the networks of which they are part. This approach could be Following the idea that, in the use of technologies, forms carried to its logical conclusion by assuming that objects, of mediation are performed that are pre-inscribed in the entities or actors are nodes in a network. These nodes are artefact—what Peter-Paul Verbeek (2006) called the mate- also constituted interactively, and do not exist outside their rialized morality—, we analysed how children performed interactions. Artefacts, people, institutions, protocols… eve- when designing a robot for care (Vallès-Peris et al. 2018). rything is an effect or a product (Law and Mol 1995). Children’s representations of well-being in healthcare set- Some authors use the concept of interpretive flexibility to tings typically include the presence of their relatives or other classify robots for care. According to this concept, a robot people. Their representation of themselves alone while hos- could be classified by its context of use, the function for pitalized or sick is a sad one, while that of being surrounded which it is used, and the user (Howcroft et al 2004). This by relatives, siblings or medical personnel is a happy one. notion highlights the impossibility of separating the defini- Prospective interactions with a robot that produce a feeling tion of technical problems from the socio-economic frame- of well-being are imagined in a network with other people. work to which they are associated (Bijker 2009). Therefore, In the same manner, assessment of a robot made by those a robot can be called a care robot when it is used in a hospi- responsible for care in a hospital (in this case, the focus tal to reduce children’s anxiety in preoperative spaces, but groups of nurses and volunteers who evaluated the risks and the same robot can also be classified as an entertainment benefits of a dinosaur-shaped robot introduced to the hos- robot when it is used by engineering students to compete in pital in a pilot phase) is based on the robot’s capacity to be international robot soccer leagues. Likewise, a robot that is integrated into the relationship network that accompanies used by nursing staff to lift patients with little or no mobility the child during his or her hospitalization. can be classified as a robot for care, but when it is used by Going beyond the conceptualization of human–robot workers in a factory to lift heavy objects, it can be consid- relationships in a binary model represented by the HRI, ered an industrial robot (van Wynsberghe 2015). the interest of the Robot Embedded in a Network approach When technologies are used, they always help to shape (REN) lies in the uncertainties and controversies that appear the context in which they fulfil their function. They help to in daily care in children’s hospitals, such as: how tasks are shape human actions and perceptions, and create new prac- distributed between nurses and robots, for example, if the tices and ways of living. Latour (1999) calls this phenom- nurse is accompanied by a robot that takes the patient's vital enon “technological mediation”: technologies mediate the signs; how a hospital integrates the psychology staff’s opin- experiences and practices of their users. Such mediations ions when deciding whether to take part in a pilot program have at least as much moral relevance as technological risks to introduce this type of device to therapies for children with and disaster prevention (Ihde 1999; Verbeek 2006). Tech- autism; how nurses take advantage of the presence of a robot nologies help to shape the quality of our lives and, more to entertain a child when trying to insert an IV (intravenous importantly, they help to shape our moral actions and deci- line); how parents and doctors can assess whether it is nec- sions. Robots for care can help medical staff in healthcare essary to collect facial expression data to monitor a child 13 AI & SOCIETY when in the ICU, etc. Knowing how to manage and solve identifying prevailing care issues in technological develop- these uncertainties requires alternative ethical frameworks ment, what power relations the artefacts generate and what that go beyond “big” philosophical issues about robotics for relations they contribute to. care; issues that, in turn, are based on “hypothetical” devel- Care experiences and practices can be identified, opments of robots for care, not on “real” functionalities and researched and understood concretely and empirically. tasks that they can perform nowadays. However, “care” is ambivalent in its meaning and ontol- ogy (Puig de la Bellacasa 2017). Assuming this complex- ity and diversity in its understanding, Fisher and Tronto 5 From an ethical general framework (1990) propose it should be viewed from a heterogeneous to the context of use, using the ethics perspective, inseparable from the economic, political, sym- of care bolic and material considerations that shape it. For them, care includes: the practices of care, what is usually consid- This conceptualization of technological innovation raises ered domestic work; the affections and emotional meaning questions about the traditional ethical approach to AI while involved in care; and the organisational and political concep- delving deeper into the relational theory in bioethics that tion that involves managing and regulating everything that includes a more-than-human-approach (Lupton 2020). Rela- sustains care relationships. In STS focused on health tech- tional theory reshapes the notion of autonomy, emphasizing nologies, this perspective has been included in the notion of the patients’ social and contextual circumstances, highlight- “empirical ethics of care” (Vallès-Peris 2021a), from which ing that people are always part of social networks and all the analysis of care relationships implies rejecting the logic ethical considerations have to take such networks of relation- according to which there is prior and true knowledge about ships into account (Sherwin and Stockdale 2017). Deborah how care should be provided. Thus, the empirical ethics of Lupton (2020) proposes consideration of the role of techno- care revolve around the idea that it is located in the prac- logical artefacts in such networks for a better understanding tices of people who, with the help of processes, protocols, of digital health and bioethical considerations. In her view, routines or machines, act to achieve good care (Willems and this more-than-human analysis highlights the complexities Pols 2010). involved when robots for care or other digital health tech- From the idea of heterogeneity, the emergence of any nologies are introduced to medical settings (Lupton 2020). artefact has to do with the diverse biases, values or politi- In this same line of thought, we situate ethical and social cal and economic relations existing during its creation and controversies around care robotics in the network made up design process, conditions that are inscribed in that artefact by a diverse range of actors: technology designers, health- (Bijker 2009; Callon 1998). Hence, the creation and design care professionals, relatives, patients and robots. Our focus of care robots cannot be disassociated from the neoliberal would not be on AI technologies, but on identifying the rel- logic in which we live, from the low social and political evant variables that shape healthcare relationships when AI value attributed to care, nor from the sexual division of labor technologies are introduced. that organizes care in an unequal way between women and To develop an ethical framework, together with the STS men (Tronto 2018). It is in a similar vein that Maibaum et al. tradition, we use the notion of the ethics of care. From the (2021) propose that robotics should be approached from its different approaches to this field, our proposal is based on political reality. It is commonplace to say that we are living the perspective developed by Joan C. Tronto that seeks to a care crisis, which has to do with the pressure caused by understand care from political philosophy. The starting point the lack of nurses, teachers, carers and domestic staff, aggra- of Tronto’s approach is that the core definition of the human vated by demographic change and the ageing of the popu- is its relational involvement with others, in a network of rela- lation (Vallès-Peris et al. 2021b). In the neoliberal model, tionships in which each individual has to reconcile different the solution to the so-called care crisis is articulated by the forms of care responsibilities (Vallès-Peris and Domènech market: after years of state downsizing promoted precisely 2020). In these relationships, the morality of care is bound by this neoliberal model, the solution proposed is that the to concrete situations rather than being abstract and based on market should be set up to meet human needs (Tronto 2018). principles (Cockburn 2005). From these bases, analysis of In this context, the growth of robotics in the field of care processes provides us with a useful guide for thinking healthcare cannot be separated from its powerful economic about how we perform a particular care task and its ethical impact on the technological innovation market. Despite dimensions (Tronto 1998). Likewise, and in line with the the fact that the care crisis is one of the arguments that are idea that not all collectives face uncertainty under the same most often used to explain the need to develop care robotics conditions, the perspective of the ethics of care engages with (Maibaum et al. 2021), the issue of care tends to be vir- those who have difficulties voicing their concerns (Puig de la tually absent from the debates surrounding it—although Bellacasa 2011). In medical AI and robotics, this also means there are some exceptional proposals, such as those by van 13 AI & SOCIETY Wynsberghe (2013). This issue can be seen, for example, in of different actors involved in healthcare relations in a hos- the scarce attention given to the tensions that might arise pital (patients, relatives, medical staff, volunteers, protocols, between commercial or business interests and issues linked units, tests, etc.) that the problems and the rules to solve to the needs and organization of care, in the various guide- such problems emerge. Thus, the point of reference of our lines and regulatory mechanisms for AI systems, including research is not the robot, but the relationships in which it robots (Hagendorff 2020). participates. There is no prominent actor in analysis of and From this approach, it is understood that the ethical reflection on ethical and social controversies, but rather debate surrounding AI and robotics cannot focus solely on various actors that are involved in healthcare relations in a major philosophical issues, but must also consider aspects children’s hospital. linked to healthcare management and everyday practices. It is in the collective network of care relations in a par- Thus, in the case of care robots, the interest should not ticular environment where we situate research on social and only lie in questions such as whether it is appropriate to ethical issues on medical AI, approaching the topic from replace humans with robots (Sharkey 2008), whether it is a notion close to the empirical ethics of care in which the- desirable to establish affective bonds (Sharkey and Sharkey ory around “good care” is localized in practices, and not 2012; Sparrow and Sparrow 2006), or liability in the event just underlying them or guiding actions (Willems and Pols of harm or damage (Matsuzaki and Lindemann 2016). The 2010). Consequently, the results of this type of approach debate from the ethics of care also looks at identifying the are not prescriptive solutions. They do not give answers to practices, fears and hopes that shape care relationships when questions such as whether or not to install a robot with a robots are introduced to specific contexts and situations. For webcam in order to monitor paediatric patients in the ICU example, how a nurse in a pediatric ward gets the children at all times but to offer suggestive proposals in relation to in the different rooms to go out into the corridor to feed the specific problems. Continuing with the example, what are pet robot; or how it might be decided at a meeting that from the arguments for and against installing a webcam, what now on, therapies with autistic children will use robots that are the views of relatives, patients, medical staff, innovation have been donated by a large robotics company. departments, etc., and how can we tweak the robot to fit From a REN approach, we turn away from the standard routines, needs and concerns in this context? (Vallès-Peris discussion about utopian or dystopian scenarios based on and Domènech 2020). the risks and benefits of promised care robots, an approach that seems addressed at building trust and anticipation of objections and reticence (Nordmann and Rip 2009). The 6 Caring in the in‑between possibilities for mediation with regard to care robots are con- figured by the technical elements of a concrete AI device in The heuristics of research on ethical and social issues around its interaction with a network of healthcare relations. Thus, care robots, from the three defined movements, could be it is in that network of social relations that the robot medi- summarized in three assumptions: (1) if a robot is a network ates; specific mediations with a particular device within a of actors and processes making up an assembly, then the particular social context (Feng and Feenberg 2008). Andrew identification of such actors and processes, as well as knowl- Feenberg (1999) illustrates this idea in his instrumentaliza- edge of their relations and forms of negotiation, becomes the tion theory. The technical dispositions of a robot for care starting point of any ethical reflection. (2) Since the robot is determine the conditions of the robot’s functional possibili- not only the artefact, but is inscribed within a full network ties in the network, and these have to do with its design and of care, the ethical implications are specific to each context production history. However, these features are reoriented of application, to the way in which the robot changes or when they are integrated into a given environment. Robots modifies the articulation of specific care relationships. (3) have their (instrumental) rationality, but when they enter a Therefore, a responsible framework guiding the introduction children’s hospital, what they are and the mediations they of robots to hospitals or other healthcare settings must be make possible depend on their use in that hospital, and in particularly linked to these contexts and their ethical prin- a particular Care Unit with specific protocols and actors ciples and values. (Feenberg 2010). As explained in the previous sections, if our conception Next to the door to the operating theatre, a mother strokes of robots from the ethics of care assumes heterogeneity, the a robot pet that her child was holding 10 min before and that focus of ethics shifts to the healthcare relationships that are calms her down while her child is being operated, it is then interactively constituted when a robot for care is introduced, when the robot becomes a robot for care for the mother. and debates on how to introduce responsible robots come to In that situation, controversies and ethical discussions arise revolve around REN. From a REN perspective, the focus of about, for example, the dangers of establishing emotional the analysis is on the network of care relationships in which ties with artificial objects. It is in the specific daily practices the robot participates, not on the specific functionalities or 13 AI & SOCIETY characteristics of a robot taken as an isolated entity, nor in We adapt the measured action proposed from the ethics the dyadic interaction between individual entities. The net- of care to discuss care robots and thereby define a responsi- work of relationships between multiple agents (the robot, ble framework for introducing these technologies based on the child, family members, hospital protocols, healthcare “caring in the in-between”. The primary argument regard- staff, etc.) constitutes the only framework for discussion. It ing the ethics of care is that in order for interdependent is within this framework of particular and specific everyday living to be conceivable, care is the common element that practices, imaginaries, narratives, etc., that the problems and makes the relationships we establish between our lives and rules for solving these problems emerge. our environment possible. Thus, if we take care seriously, it From this approach, for example, it is possible to analyze represents a necessary ethical and political proposition for how the introduction of certain robotic devices can change thinking about the technologies that surround us. This idea the care relationship between the hospital and the patient, or problematises a deontological approach according to which how the diagnosis or treatment skills of healthcare staff are ethical standards can only be realised through the declaration transformed (Vallès-Peris et al. 2021a). Focusing attention of principles. These principles describe moral aspirations, on REN, we can identify those elements that are considered but do not make it possible to think critically or to develop necessary to ensure that the introduction of a robot does not transformative practices (Tronto and Kohlen 2018). Thus, undermine the ethical values that shape medical practice and responsible robotics, from its conceptualisation as REN, care relationships in a particular context. So, it will not be requires institutional changes to the framework in which the same to introduce a robot to make a remote diagnostic robotic care is organised, managed and practised. From the visit to a child in hospital, while the doctor is elsewhere, as integration of measured action and the ethics of care, car- it will be to perform the same visit while the patient is at ing in the in-between is defined as a triadic process or rela- home. Similarly, it will not be the same when the same robot tionship: (a) between the nodes, in the threads of the web; is used in the hospital to make a follow-up visit to a pediatric actions as movements of care relations and care processes patient admitted to the trauma unit, as it is to a patient admit- in which healthcare technologies participate; (b) between ted to the mental health unit. the different actors in a network; actions as an exercise of listening to the voices and different concerns of all the actors involved in healthcare settings and integrating their formula- 6.1 An ethical–political proposal to ensure tions of problems and solutions into the ethical debate; and responsible introduction of AI and robotics (c) between fears and hopes, in the realm of uncertainty; to healthcare actions as a tool for overcoming the polarization between the promises and the dangers of medical AI, thus offering Focusing on the multiple possibilities for action that emerge an alternative to abysmal uncertainty. in the realm of uncertainty, we propose an ethical and This proposal focuses on the possibilities for mediation responsible framework focused on care actions in between inscribed in the robot, configured by the design of a specific fears and hopes. From this idea, we take the notion of meas- AI device in its interaction with a network of healthcare ured action from an ethics of care. According to Callon et al relations. Thus, broadening and complexifying the process (2009), measured action occurs through three interrelated of responsible development of care robots, caring in the in- dimensions: (1) a surveillance system: precaution is only between is a complement to other proposals that focus on the possible when formalised socio-technical devices are used to design process of the artefacts that also integrate the ethics collect information and thereby enable us to move from sur- of care -such as the Care Centered Value-Sensitive Design veillance to alarm; (2) the deepening of knowledge, through proposed by van Wynsberghe (2013). From these bases, car- the exploration and identification of excesses. Precaution ing in the in-between is a proposal of responsible robotics requires a preliminary assessment of the associated risks that implies institutional challenges, as well as new practices and dangers in order to evaluate their severity and (3) the in healthcare systems. It is articulated around three simul- choice of temporary measures to be taken, which must be taneous processes, each of them related to practical actions adapted to each of the situations to which they are applied, in one of the in-between dimensions considered: monitor- guaranteeing their follow-up and update according to the ing relations and caring processes; considering stakeholders’ constant polemics that arise. In each of these three dimen- opinions; and making fears and hopes commensurable. Each sions, there may be specific actors, with particular modes of of these processes could be defined as: action and different levels of responsibility. Measured action replaces clear and forceful decisions with a series of “small” • Monitoring relations and caring processes The creation decisions in each of the three dimensions. Small decisions of local public health systems to monitor the design and represent gradual advances, but none of them entails irrevo- introduction of medical AI technologies. This implies the cable commitments. creation of follow-up and assessment procedures to also 13 AI & SOCIETY be applied to pilot or experimental projects. Care is car- each hospital or healthcare setting. Such feedback loops ried out by “all the hospital”, by the networks of material, will ensure that the introduction of AI devices is in line semiotic and social fluxes that occur every day among with care procedures in a specific hospital or healthcare all the actors in which technologies participate. If care setting and integrates the concerns of all the different relations and care practices are placed at the centre of the actors involved. Undoubtedly, the introduction of forms debate, and the whole hospital is in charge of giving care, of feed-back loops also implies slowing down the pro- then we need to put mechanisms in place that encompass cesses of designing and implementing AI systems in hospitals and other healthcare settings, mechanisms that healthcare. We understand that a slowdown is necessary ensure that the introduction of these devices responds to as a prerequisite for radically integrating responsiveness medical and care values and priorities and not, for exam- into the design of healthcare technologies. ple, to commercial or prestige interests. This process of monitoring relations and care processes particularly From this perspective, then, the responsibility to intro- needs public entities to ensure that the introduction of duce robotic and AI devices in accordance with ethical cri- AI and robotic systems to healthcare settings responds to teria and societal needs and priorities does not only refer to collective health and well-being needs; and to guarantee the technical design process of such devices, nor is it lim- that market or innovation interests in AI and robotics are ited to establishing strong legal frameworks to regulate their not detrimental to the ethical and social criteria govern- use. The development of robotics and AI in consideration of ing public health systems. ethical and social concerns requires public engagement and • Considering stakeholders’ opinions The development institutional changes to health systems on the path towards of inclusiveness and public participation strategies to more responsible technologies. Monitoring relations and establish a prioritisation strategy for the development of caring processes, considering the opinions of stakeholders IA in health, as well as to identify the main concerns and making fears and hopes commensurable are, as a whole, around its introduction. In view of this need, multiple a way to introduce democratic mechanisms to technological strategies are traditionally developed from STS and what development. And, it is no doubt impossible to talk about is known as the “participatory turn” in science and tech- responsible AI and robotics if technology and democracy do nology (hybrid forums, citizen conferences, etc.). The not go together. It is also impossible to talk about democracy idea of heterogeneity is central to these types of propos- in AI and robotics if care is not integrated as a central ethi- als, using diverse mechanisms to integrate the knowl- cal and political proposition in all processes and relations edge and expertise of multiple actors (engineers, medical involved in the development of healthcare technologies, practitioners, formal and informal caregivers, patients or what we call “caring in the in-between”. relatives). But it is not enough to speak of heterogeneous assemblies, because in these assemblies not all the agents involved are the same, nor do they participate in the same 7 Conclusions way, nor are uncertainties distributed equally. Different groups are not equal in their capacity to impose their Just as a single technology cannot undertake all care or cure logic and some groups represent more than others the alone, studies of AI and robotics in healthcare cannot be dominant economic-instrumental interpretation of care focused only on a particular device. In this paper, we develop inscribed in technology (Hergesell and Maibaum 2018). an approach grounded on the uncertainty surrounding AI The limitations of participatory processes to address and robotics, on the heterogeneity and mediations that the these inequalities are well-known, so there is a need to robot makes possible (what we call the REN approach) and develop complementary strategies to allow for alternative on the ethical and social debate regarding its context of use. forms of inclusion and representation in matters related Within this framework, we propose a method for responsible to the introduction of AI and robotics systems to health- introduction of AI and robotics based on an ethical–political care. In this sense, we propose the need to explore sys- proposal called “Caring in the In-Between.” This proposal tematic methods to integrate informal and spontaneous for action looks into the eyes of uncertainties to collectively popular movements and expression of the population’s discuss ways to design and use technological devices in fears and hopes (also viewed as potential patients, rela- healthcare settings, while respecting the values that guide tives, and caregivers of the health system). public health practice and its networks of care. Using the • Making fears and hopes commensurable The choice of ethics of care and the notion of measured action developed progressive, small actions to “keep under control” the from the STS, we propose responsible AI and robotics by effects or consequences of a development, small actions focusing on the mediations of concrete devices in their inter- based on progressive feedback loops with monitoring action with a network of healthcare relations. 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