Grandma and Her Robot

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As early as 1985, in A Robot in Every Home, futurist Mike Higgins predicted that “pet robots” would ultimately provide companionship for the elderly. He was right.

“Service robots,” like the vacuum cleaner Roomba (on sale at Costco for $299), perform instrumental tasks. By contrast, “social/emotional robots” target the experiential aspects of our lives. Earlier this year the journal GeroPsych devoted an entire issue to the use of social/emotional robots in the aging global population.

The most widely used social/emotional robot is Paro, developed in Japan over a 12 year period by Dr. Takanori Shibata at the Japanese National Institute of Advanced Industrial Science and Technology.  Paro, modeled on a baby harp seal, is cute and cuddly. It has internal sensors, responds to its name, and apparently can adapt to the preferences of the person interacting with it. The company website features videos of nursing home residents holding and petting Paro. A man, who is said to have been non-communicative, is shown singing to Paro.

Paro has been used with elderly patients with dementia in Japan and Europe since 2003. It’s slowly being disseminated in the US since the FDA approved it as a “Type 2 Medical Device” in 2009.  Here’s how the Vinson Hall Retirement Community, which was a pilot site for Paro prior to FDA approval, describes the role Paro plays in its program:

Vinson Hall Retirement Community was one of the first Continuing Care Retirement Communities in the United States to include Paro as an ongoing part of our therapy program – with positive results. Paro has been in our community since March 2008, and we have a robot that resides in each of our residences.

In our award winning residence for the memory impaired, The Sylvestery, Paro is used to ease anxiety and calm residents with dementia, Alzheimer’s and other cognition disorders. In our independent and assisted living residences, Paro is used quite differently. It is a great interactive tool to initiate conversation and socialization in group settings.

A search for “Paro” in Google elicits many videos and popular press articles that present Paro in a very positive light. But according to Lori Marino (quoted here), a neuroscientist at Emory University, “the work done in this area has generally been of low scientific quality, making it very difficult to reliably interpret results. Many reports in the literature are observational or, when prospective, involve very small numbers of patients or lack critical control conditions. As a result, most suffer from . . . inability to identify which components . . . are causally related to any observed short-term changes.”

Some distinguished leaders in geriatric care and technology, like Dr. Bill Thomas, founder of the Green House Project, and Professor Sherry Turkle, director of the MIT Initiative on Technology and the Self, are deeply concerned about technologies like Paro. At the practical level they fear it will replace contact with and care from real human beings. At the intrinsic level, they fear that technologies like Paro will undermine the dignity of elderly persons and the respect accorded to them by others.

I have no doubt that Paro can be a source of comfort to elderly patients with dementia. When I worked at the Massachusetts Mental Health Center during the summer after my first year of medical school I heard about an experiment that would never get by an institutional review board today. Subjects from a population seeking psychotherapy were given the option of speaking to a tape recorder and were told that a therapist, whom they would never meet, would listen to what they said. That was it. No therapist listened to the tapes. No one did. But when the subjects were asked about their “treatment” a remarkable number reported benefit, and felt cared for by their nonexistent “therapist.”

If a creaky, box-like tape recorder can have a “therapeutic” impact, a cuddly, responsive baby harp seal robot certainly can.

Empirical observation is key for the ethical assessment of Paro. Some caretakers report that Paro in a group increases interaction among nursing home residents. This could reduce isolation. And it would be possible to study the impact of using Paro on the amount of human attention a person receives. It’s theoretically possible that if a person with dementia developed new positive behaviors, that would elicit better attention from humans. The point to make is that the ethical assessment of Paro shouldn’t be made simply on theoretical grounds.

But even if the empirical findings are positive, they wouldn’t “refute” the concerns that have been raised about infantalization and loss of dignity. My own conclusion is that we should continue to pilot technologies like Paro and carefully study the effects on patients and the care they receive. Institutions like the Green House model will reject use of Paro. Others will be open to trying out new technologies. In the same way that proxy decision-makers are asked about other aspects of care, they should be asked about Paro and other technologies. If they feel the technology is inconsistent with the values previously held by the person with dementia whose care they are overseeing, Paro will stay on the shelf.

6 Responses to “Grandma and Her Robot”

  1. Carol Eblen

    Interesting! and, of course, a new market for the medical device manufacturers! What if they could get Medicare to approve and pay for “Paro” after trials prove that there is great benefit for isolated patients? Even with the tax on medical devices, wouldn’t this be a windfall? I wonder how long we, as a nation, can keep storing these unfortunate, mostly elderly patients in these for-profit boxes called Nursing Homes at great expense and pain to the families and to government.

    Forgive me! I am cynical — I am 86 — and when I go into Nursing Homes and into locked units where patients have to be protected because of their incompetency —dementia and Alzheimer’s, etc… it all seems so futile and hopeless.

    Always, I think that if these patients knew when they were competent that they would be reduced to “mad little children” who are locked away and would have no control over their daily lives or even “hope” to get better (because even hope is dead for the patient who is seriously senile or in late stage Alzheimer’s) I think that they would not want to end their lives this way and would believe that they would have been “better off dead.”

    Saying that, I am generally not in favor of advanced directives that can be misused to shorten the lives of the elderly/disabled but I would not be opposed to advanced directives that would allow me to leave this world if and when I was declared under some due process procedure to be seriously senile or diagnosed with advanced Alzheimer’s.

    If the Courts can declare that abortion is legal up until the time the brain is developed to a certain point —maybe they will some day in the future use this same reasoning (that we are human because of our brain) to permit this kind of advanced directive to be made when patients are in their right mind.

    See where this article took me, Jim!

  2. Carol Levine

    I wrote a “review” of the movie “Robot and Frank” for Bioethics Forum last year.
    Frank (Frank Langella) reluctantly accepts the robot his son forces on him but then it becomes his accomplice in crime and a kind of friend. (Frank is a retired cat burglar). More seriously, I also worry about the expectation that technology can replace human contact, but no one seems to have a problem with providing animals for emotional comfort. (Except people like my late, fastidious mother who would have been appalled if anyone suggested that she get a pet or move to a place with lots of animals.)

    Carol Eblen, I understand your reaction to nursing homes, but the facts are that nursing home placement is decreasing, not increasing. And at that only about 1 million people are in nursing homes. Most older people live in the community, with family care being their only source of support. Nursing homes are now two kinds of places: short-term rehab programs (paid for by Medicare) and long-stay residences (mostly paid by Medicaid at lower rates.)

  3. Jim Sabin

    Dear Carol

    I would think of you as a “feisty 86 year old,” not as “cynical.” You raise several valuable points.

    A propos your thougts about advance care planning, you might be interested in a program of that name (at that develops teaching videos to assist individuals and families in the planning process. As you speculate, when people better understand what late stage dementia is like, they tend to opt for comfort care, not life prolongation.

    A propos Paro – if research supports the promise of it and similar technologies, it will, as you say, create an economic opportunity for device manufacturers. But Medicare is not likely to pay for devices like Paro even if they’re helpful. Visits from family and friends would probably be even more helpful, but Medicare does not pay for “social support.” If Paro were paid for, Medicare payment for pets would be next!

    I’m glad the post triggered a wide range of thoughts for you. That’s what we hope for from Over65.



  4. Jim Sabin

    Dear Carol Levine

    Your comment arrived while I was responding to Carol Eblen. Thank you for the link to your wonderful review of a movie I hadn’t heard of. It sounds as if a Paro on every elderly lap could have been a scene in the film. The idea of replacing human contact with cuddly robots is horrifying. But it’s at least imaginable that devices of that kind could be a useful supplement to human contact.

    A propos of the dismay your mother would have felt about live animal pets – that’s one of the advertising pitches the manufacturer of Paro makes – namely, that Paro doesn’t pose the hygienic concerns that living animals do!



  5. Ellen Cahn

    Although it would require human supervision, I think live animals including a cat option(for those who are not allergic) are a tremendous source of comfort to residents. People who do not have advanced dementia probably have fond memories of family pets. If I had to choose a nursing home for myself, access to animals would be much more important than food or decor.

  6. James Sabin

    Dear Ellen
    The old saying that a dog (or cat) is a person’s best friend has a lot of wisdom to it. For folks of any age who are ambulatory, a dog provides a prod for getting outside and walking, which themselves are “therapeutic” activities. And for those who are isolated, the attachment and affection dog’s develop for their owners can be very affirming. Those who love cats (I’m not one of them – cats make me sneeze and have watery eyes) get their own versions of pleasure from them. In 2012 there were 69 million dogs and 74 million cats in the US. That proves your point!