Environmental Cognitive Remediation in Schizophrenia: Ethical Implications of "Smart Home" Technology

Article excerpt

Objective: In light of the advent of new technologies, we proposed to reexamine certain challenges posed by cognitive remediation and social reintegration (that is, deinstitutionalization) of patients with severe and persistent mental disorders.

Method: We reviewed literature on cognition, remediation, smart homes, as well as on objects and utilities, using medical and computer science electronic library and Internet searches.

Results: These technologies provide solutions for disabled persons with respect to care delivery, workload reduction, and socialization. Examples include home support, video conferencing, remote monitoring of medical parameters through sensors, teledetection of critical situations (for example, a fall or malaise), measures of daily living activities, and help with tasks of daily living. One of the key concepts unifying all these technologies is the health-smart home. We present the notion of the health-smart home in general and then examine it more specifically in relation to schizophrenia.

Conclusion: Management of people with schizophrenia with cognitive deficits who are being rehabilitated in the community can be improved with the use of technology; however, such technology has ethical ramifications.

(Can J Psychiatry 2005;50:281-291)

Clinical Implications

* Cognitive deficits in schizophrenia can lead to the introduction and maintenance of a true handicap.

* New technologies, applied to the field of health, could serve as a cognitive prosthesis.

* Smart homes are an illustration of a possible environmental modification that would facilitate rehabilitation and community adaptation.


* Altering the environment in a fashion suitable for persons with cognitive handicaps is not a common approach.

* There are significant ethical concerns related to smart homes, including issues of individual freedom, personal autonomy, informed consent, and confidentiality.

* There is limited literature evaluating the outcome and impact on the quality of life of persons using smart equipment.

Key Words: schizophrenia, dementia, cognition, mental disorder, rehabilitation, cybernetics, ethics, smart home, cognitive remediation

The cognitive remediation and social reintegration (that is, deinstitutionalization) of patients with severe and persistent mental disorders present challenges that psychiatry has been trying to meet for many years. Nowadays, the unprecedented development in communication and information technologies has redefined the terms of these challenges. Recent studies have attested to the flexibility, effectiveness, and growing affordability of these technologies (1-3). This article aims to demonstrate the potential these technologies may have with respect to research and the efforts made by psychiatric institutions that provide cognitive remediation to persons with schizophrenia. Our second objective is to start a debate on an unresolved matter: what are the ethical implications of new technologies in teaching cognitive skills and monitoring safety in schizophrenia patients?

Community care today has, in many respects, become a necessity, provided that acceptable conditions of safety and autonomy are met. A lower birth rate and a higher life expectancy together go a long way toward explaining the growing need for medical care for dependent seniors. As the number of dependent seniors increases, so do economic and sociomedical issues (for example, overloaded health facilities, higher health costs, desire for quality of life [QoL], and quality care). When a senior person is no longer capable of independent living, home living has always been the preferred choice over institutionalization. The advent of innovative technologies has today revived issues related to community care in terms of means and safety (4,5). At the technical level, adapting these technologies to the conditions specific to schizophrenia poses a priori difficulties that depend on a creative interaction between psychiatrists and technologists. …


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