Issues, Impacts and Insights Column: Whats

New in Healthcare Robotics?

Source:
OJNI Volume 18, Number 3
October 01, 2014
Recently, I stumbled on a fascinating New York Times op ed piece that highlighted 10
robotic technologies that could have a big impact on healthcare delivery. The field of
robotics has long interested me because roboticists have had to essentially reverse-
engineer living animals in order to design robots. As a result, the field has had
substantial impact on what we know about how animals get around in the world; and
some scientists have moved away from the computer model of the brain to a more
holistic understanding. This new paradigm has proved to be very useful to roboticists
and psychologists alike (Effken & Shaw, 1992). Because of my fascination with robotics-
and the multiple sciences that underlie it-I decided to check further into what's been
going on in the field. Here I address two questions: (1) What's new in health robotics?
(2) What are the ethical and social issues related to health robots--will they be friends
or foes?

What's new in health robotics?

Robots are already being used in hospitals to restock pharmacies and fill prescriptions,
as well as to deliver supplies to nursing units (e.g., Pyxis' HelpMate) and food to
patients. Robots are at least as accurate as humans at selecting and delivering "the
goods." The use of robotic surgery is increasing rapidly because the robot's "hand" can
reach into smaller spaces with finer control than a surgeon's-assuming the surgeon
using it is highly trained. Others are under development. For example, IRobiQ is a
table-top robot designed to monitor drug interactions (Datta, Yang, Tiwari, &
MacDonald, 2012). Initial testing with four patients showed that its effective use
depends on knowing all of a patient's medications (a perpetual challenge for human
caregivers) and on having very cooperative patients.
Robotic home assistants are getting increased attention from designers due, in part, to
the military's many battlefield-incurred disabilities, as well as the growing number of
elders with restricted mobility or self-care ability. Robots can move about and retrieve
objects (Graf, Hans, & Schraft, 2004; Jain & Kemp, 2010; Martens, Prenzei, & Graser,
2007), but typically on flat surfaces only. Designers have also mounted a robotic arm
on a wheelchair (Tsui, Yanco, Kontak, & Beliveau, 2010). A more advanced human
support robot (HSR) was designed to help people with arm or leg mobility issues live
independently (Hashimoto, Saito, Yamamoto, & Akida, 2013). HSR can be controlled by
voice, phone, or laptop. Primarily a grasping or fetching device, HSR moves on small
wheels. Its telescopic body allows it to cover a range of heights. Its weight is sufficient
to let it manage fairly heavy loads without tipping over. For caregivers, who can control
it remotely, the device can open and close curtains, or provide a visual check of the
patient's status.
Robots such as these required building in technologies that plan tasks and movements,
recognize objects, environments, and speech, as well as enable safe, autonomous
navigation through cluttered environments. The first two experimental subjects with
mobility issues who tested HSR used it to pick up towels and paper money from the
floor, retrieve a bottle of soda from the refrigerator, insert a straw and hold it for them
to take a drink. Both subjects reported that the device was hard to learn to use, and
both had ideas about how they would like to use it in the future if enhancements could
be made. Developers intend to add to the robot's task repertoire, simplify its operation,
and create centralized hubs from which nurses or others could monitor and control
robots caring for patients in multiple homes.
Japanese designers have built robots to help paralyzed patients balance or walk. The
balance robot is actually a two-wheeled game in which patients balance on the robot
and shift their weight to control actors in sports games. The "Walk Assist" robot
attaches to a paralyzed leg and detects muscle movement of the hip joint through
sensors on the foot or thigh. Initially, the robot helps move the leg, but as the patient
becomes more able to walk on his own, the robotic assistance is reduced. The robot
monitors joint angles, which provides a more accurate way to monitor the patient's
progress (Aronson, 2014). In May, Toyota announced a trial arrangement with 20
Japanese hospitals that would let them lease the robots (Toyota to trial lease robots to
hospitals that assist in walking rehabilitation, 2014).
Robotic nursing assistants are also a target of designers' efforts, particularly in Japan,
because of the rapidly aging population. A prototype "nursing assistant" named Cody is
"learning" to bathe patients (Chen & Kemp, 2010; King, Chen, Jain, & Kemp, 2010). So
far, the "bath" involves only repetitive rubbing to remove dirt from a particular spot on
the patient's skin. Cody can be moved easily if a human leads him by his "hand."
Clearly, a lot of work remains to make Cody practical. As well, Pearl, a so-called
"nursebot" visits hospitalized elderly patients, reminding them about medications,
providing information, taking messages, and guiding them about (Montemerlo, Pineau,
Roy, Thrun, & Verma, 2002).
Robotic therapy too is promising. A robot called "Cosmobot" is being used, not only to
make rehabilitation therapy more interesting for developmentally challenged children,
but also to collect data about their progress (Brisben, Safos, Lockard, Vice & Lathan,
2005). To see how this works, take a look at this Cosmobot video. PARO looks like an
adorable baby seal, but provides "robotic" animal therapy for elderly patients with
dementia. PARO requires less care by staff and is very well accepted by patients. PARO
can sense touch, light, sound, temperature, and posture; and can show various
emotions (e.g., happiness, surprise, or anger). PARO will repeat actions that produce
petting and avoid actions that have resulted in its being hit by a human. You'll get a
good idea about how PARO functions in various sites from the videos on this website. In
a pilot study involving 18 dementia patients, PARO produced higher pleasure scores
than an interactive reading group (Moyle, Cooke, Beattie, Jones, Klein, et al., 2013).
I'm not surprised by the results because while attending a robotics seminar in Japan
several years ago, I saw some equally cute robots that we all wanted to cuddle!
Efforts are ongoing to make robots' facial expressions more "human-like." One
Canadian team (Santos, de Castro Maia, Goubran & Petriu, 2013) mapped human facial
expressions onto a standard 3-D model then mapped the 3-D version onto an android
robotic face by deforming its elastic "skin." Based on the photos I saw, the 3-D model
appears relatively lifelike, but the android face is much less so. It will take a lot more
work to create a robot whose face can show the range of expressions that human faces
can.
Friends or Foes? Social and Ethical Implications
Caregivers experienced in using multi-sensory stimulation (either in the form of real or
artificial pets such as PARO) for dementia patients in nursing homes were asked about
the use of robots, compared to real pets and the potential need for guidelines for using
such robots. Caregivers noted that, unlike a live pet, a furry robot would always be
ready for cuddling. Caregivers felt guidelines (for either real or robotic pets) were
needed on how to manage patient responses such as anger or sadness, as well as
families' viewing its use with their loved ones as humiliating or degrading (Heerink,
Albo-Canals, Valenti-Soler, & Martinez-Martin, 2013). Bekey (2012) suggests that in
the case of interactive "nursebots" like Pearl, patients may become attached and feel a
personal loss if the robot is removed. When patients act out in frustration or anger, the
robot may not respond appropriately. Finally, because robots can only respond to one
patient's request at a time, this can cause problems if robots are shared (Bekey, 2012).
In another study, residents were more positive than home care staff about the use of
robots, suggesting that the robots could assist with turning appliances on and off,
lifting, cleaning, medication reminders, phoning, and monitoring location and even fall
detection. Residents preferred a wheeled, silver colored robot a little over one meter
tall with a screen on the body (Broadbent, Tamagawa, Kerse, Knock, Patience, &
MacDonald, 2009). The same researchers found no age differences between middle-
aged and elderly patients in interacting with a robot, Charles, who took their blood
pressures. However, more males than females found Charles acceptable. Patients did
suggest that Charles should interact more with them and have a better voice (Kuo,
Rabindran, Broadbent, Lee, Kerse, Stafford, et al., 2009). In another study, severely
demented patients recognized that a metal android, AIBO, was a robot, but interacted
with it readily. When AIBO was clothed, the patients were more likely to treat it as
either an infant or dog (Tamura, Yonemitsu, Itoh, Oikawa, Kawakami, & Higashi, 2004).
Dressed or not, the patients interacted with AIBO by looking at it, caring for it, or
talking to it. Research has shown that humans typically respond to dolls and robots with
growing acceptance as they become more human-like, but only up to a certain level of
realism, when distrust sets in. At about 90 percent accuracy, trust returns and
acceptance peaks (Bekey, 2012).
To "live" safely in humans' homes, robots must become much more aware of their
environments and human responses. One robot, Mitsubishi's Wakamaru, moves easily
on wheels, albeit only on flat surfaces, recognizes 10,000 words, makes phone calls,
recognizes and responds appropriately to 10 faces, and communicates through either
speech or gestures (Shiotani, Kemmotsu, Oonishi, Tomonaka, Asano, & Hiura, 2006).
As robots become even more human-like, interactive and ubiquitous, Bekey (2012)
cautions that we may encounter some unexpected (even bizarre) social and ethical
issues such as:

Loss of privacy for the human inhabitants if the robots are permitted free access
to all rooms in a home.
Ability of the robots to recognize commands that may lead to unethical behaviors
(e.g., to steal a neighbor's camera or cell phone).
Rights and responsibilities of the robots (e.g., should they be treated with
respect, as if they were human?)
 Emotional relationships (e.g., how should a robot relate to human anger, say,
when the robot drops a dish of food on the floor?) In other words, is it ethical to
yell at a robot? Can and should robots be punished for misbehavior? If so, how?
How should a robot react to multiple instructions from different humans (e.g.,
when a child calls for it to come and play while the mother calls for it to come
and wash the dishes)?
Can the robot's computer be accessed by hackers, so it may stake out and send
pictures from the home to potential burglars? (Bekey, 2012; 29).

Bekey (2012) warned that interactive robots, as we have described them here, are
social creatures, so we need to start thinking about the impact of their interactions, not
only with humans, but also with each other if they begin to work as teams. Certainly,
more research is needed to understand the impact of their emotions-or lack thereof-
when working with a nurse or a patient.

Wrapping Up
We have encountered robots in movies for many years. Who can forget the affection we
felt for Star Wars' R2-D2 and C-3PO and the anxiety HAL provoked in 2001: A Space
Odyssey? Today robots are quickly becoming more fact than fiction-even in healthcare.
As nurses, we need to learn more about them, how they can help, and what ethical and
social issues may need resolution as they are implemented more widely. Nurses are
well positioned to identify situations where robots could be useful and, when
implemented, ensure that the robots are managed intelligently and ethically to provide
more efficient and safe care. Nurse informaticists should consider adding robotics to
their skill sets and/or contributing their analysis and implementation skills to robot
design teams. I've provided only a glimpse of the possibilities health robots offer as well
as some of the social and ethical implications their introduction might entail. Despite
the cautions raised, in my view, the future of robots in healthcare is very bright indeed.

References
Toyota to trial lease robots to hospitals that assist in walking rehabilitation. (2014). The
Asahi Shimbun, May 28, 2014. Retrieved July 29, 2014,
from http://ajw.asahi.com/article/business/AJ201405280050
Aronson, L. (2014). The future of robot care givers. New York Times, July 19, 2014.
Bekey, G. A. (2012). Current trends in robotics: Technology and ethics. In P. Lin,
K . Abney, & G. A . Bekey (Eds.), Robot ethics: The ethical and social implications of
robotics. Cambridge, MA: MIT Press.