Abstract
Background
The robotic nurse introduces ontological and ethical issues that have not yet been adequately addressed in nursing research and practice. Despite this technology growing, we found that ‘roboethics’ is a new discourse for addressing ethical issues in artificial intelligence (AI) robot technology. From an anticipatory standpoint, we are writing this Perspectives piece based on relevant evidence to prompt discussion and highlight some concerns about the issues of AI technology, robotic nurses and potential ethical issues arising from those technologies to amplify the discourse surrounding roboethics. Throughout this Perspective, the term ‘robotic nurse(s)’ does not refer to a specific type of robot that has been created. Instead, it refers more generally to the robot as a new entity that is created by humans to do traditionally human work, both presently and in the future, and is equipped with many possible kinds of AI or similar advanced technologies that strive to achieve the same level of functionality and independence of thought as humans. In this Perspective, we will briefly address the following: (1) artificial intelligence and advanced robot technology; (2) nurses, AI robots and caring in nursing practice and (3) ethical issues in robotics nurse technology, nurses’ role and roboethics, before concluding and recommending future directions.
Artificial intelligence and advanced robot technology
Over the last few decades, robot technology has grown rapidly. The development of robots mirrors that of humans: unconsciously, humans create robots that mimic their species. Simultaneously occurring with robotics development, the world population of humans has increased, reaching 8.1 billion (Worldometer, 2023). This phenomenon is a paradox; eventually, adding machinery to an already-overpopulated world may hurt humans by eliminating some of the traditional human roles, such as labour-oriented work in industry and caring for patients in healthcare settings.
The term ‘robot’ comes from the Czech word ‘robota’, which is a biosynthetic machine used for forced labour (Hamet and Tremblay, 2017). There are many, varied reasons why robots are important; they can help humans and may increase utility value under certain conditions. Consider, for example, social robots, which are being used in long-term care homes because they can interact with residents (Buchanan et al., 2021) and can do some task-oriented roles such as cleaning and housekeeping.
The role of robots philosophically suggests the notion of technological utopianism. This view explains that technology is not just a mechanical tool, but a necessary means towards reaching a ‘perfect’ society (Segal, 1986). This claim may not be just theoretical after all. Technological developments suggest that it is only a matter of time before some of our fantasies of today become tomorrow’s reality.
In 2017, Forbes published a groundbreaking paper, the title of which indicates its controversial theme: ‘Prepare Yourselves, Robots Will Soon Replace Doctors in Healthcare’ (Stark, 2017). This paper alarmed healthcare providers around the world. According to the author, the robot population will become a ‘threat’ to the existence of healthcare providers and their relationship with patients. Moreover, AI has become an exciting topic in terms of robot creation. AI, which is the concept of utilising computers to simulate intelligent behaviour with minimal human interaction, is widely regarded to have begun with the advent of robots (Hamet and Tremblay, 2017). AI is generally accepted as using robots with intelligence to learn specific patterns, like children who learn new things and use their new knowledge in various situations. In other words, AI plays a role in increasing learning capacity and providing decision-support systems in robots (Noorbakhsh-Sabet et al., 2019).
Nurses, AI robots and caring in nursing practice
The issue of AI robots with decision-support systems deserves more attention from the public, mainly as it concerns the existence of human nurses. In healthcare practice, a nurse is a healthcare professional, providing maximal interaction with patients, and caring is a fundamental aspect of creating a relationship that manifests dignity (Stokes and Palmer, 2020). Referred to as the philosophical theory of nursing from a nursing theorist, caring as a central concept in nursing has been defined by Boykin and Schoenhofer’s (1993: 25) Theory of Human Caring as ‘the intentional and authentic presence of the nurse with another who is recognised as a person living caring and growing in caring’ (McCance et al., 1999). In its application, that definition implies that the nurse’s caring amplifies direct emotional contact with patients as a unique response so that trust will emerge between them.
Nonetheless, cultivating trust between nurse and patient for better care is complex. It also cannot be taken lightly, especially if we suppose that robotic nurses with no human values could establish the trust that human nurses traditionally develop with patients. It is risky and may adversely affect the patient’s dignity in the healthcare system. Therefore, given the prospect of robot assistance, we should address the vital role of caring in nursing. This is necessary due to the robotic nurse’s ability to work precisely on certain things, drastically reducing the possibility of human error. A simple calculation presumes robotic nurses will bring economic value, because they can perform human-like functions, that are undoubtedly more efficient than human performance, with minimal operational and maintenance costs.
Furthermore, particular concerns have been raised regarding the interaction between people and robots, with some apprehension that humans may lose their jobs if robots become the primary preference to replace human vocation in the future (Klein and Schlömer, 2018). In other words, the employment of robotic assistants could reduce the amount of physical work that nurses perform (Eckberg, 1998), which may increase productivity, but at the same time, potentially contribute to higher unemployment (Boyer and Farzaneh, 2021).
Ethical issues in robotic nurse technology, nurses’ roles and roboethics
Recently, the terms ‘robotic nurse’ and ‘robot nurse’ have been used by some popular media, which indirectly suggests the existence of nurse robots. We must admit that those robots can practically fill gaps in human nursing and do tasks like staffing needs in healthcare (Ortiz, 2022) and supporting emotional care, particularly in isolated patients (Barandy, 2021). But regardless of those increasing in popularity, we must realise that enclosing the robotic nurses’ role in traditional patient–human nurse care is not easy. A study showed that nurses acknowledge robots’ assistance in their work while still raising concerns about disrupting patient relationships (Lee et al., 2018). Robot assistants may potentially devalue nurses’ positions, impacting caring as a core value of nursing (Eckberg, 1998) while threatening the essence of a nurse’s role, including their professional identity (Franke et al., 2021). As a result, nurses’ hesitancy towards robotic technology and its ethical implications may always exist. Therefore, in terms of planning for clinical application, contemporary ethical issues that arise regarding robotic nurses are insufficiently acknowledged and addressed, and ultimately need more attention (Fuji et al., 2014).
In recent decades, the discourse of roboethics has emerged while sparking controversy and debate worldwide regarding its neologism. As we reach an era with more complex and intelligent robots, roboethics will become increasingly relevant (Fourtané, 2019), and it raises fundamental ethical questions about the moral dilemmas generated by robot application development (Maddahi et al., 2021). Roboethics is concerned with how AI robots will be developed by being able to learn and potentially make ethical decisions through their own calculation. Some experts have claimed that robots cannot be moral agents and were not designed to have decision-making capabilities (Fourtané, 2019). However, one could imagine the robotic nurse being equipped with decision-making ability through AI. Robotic nurses would have the capacity to calculate threats and opportunities before they act, and this authority could potentially be quite terrifying because, in certain situations, specific commands can be interpreted by the robotic nurse as giving authority to act; however, in other conditions, these commands could be interpreted as a threat for them, so that robotic nurses would behave unpredictably, which could potentially harm patients. In this situation, the autonomy of robotic nurses raises an ethical concern and triggers nurses’ responsibility for patients’ protection, safety and dignity (Bulfin et al., 2019).
Conclusion and future directions
In conclusion, we might ask whether robotic nurses could effectively replace human nurses. It is a fundamental question that nursing experts face, and it requires in-depth discussion and careful steps for future implementation. Fundamentally, although the pursuit of improving robotic nurses continues, at the policy level, we suggest that nursing and healthcare policymakers address the ethical and social issues of using robotic nurses particularly in nursing and healthcare practice, including discussing alternative solutions to fill in the nursing staffing needs gap and its relation with demanding robotics nurse assistants in nursing care, for example, internationally educated nurses (Kurup et al., 2023; Salma et al., 2012). At the academic level, we suggest embedding the discourse of roboethics in recent nursing ethics or bioethics-related nursing curricula to increase the interest and awareness of ethical issues in robotic nurses and nursing. At the level of practice, we suggest conducting a deeper ethical study with an anticipatory approach as essential to distinguish between robotic nurse advancement and potential ethical dilemmas in nursing and healthcare practice, including how caring and human dignity can be maintained. This is because caring comprises an innate moral imperative that exists as part of being human, and this caring supports the human dignity of both the nurses and the patients (Stokes and Palmer, 2020). Through that, we hope nurses can become aware of potential ethical issues that might arise from clinical applications concerning the use of robotic nurses (Betriana et al., 2020). Finally, this Perspective does not aim to underestimate the development and progress of robotic nurses’ technology. Instead, it provides insights with a forecasting approach based on the recent developments in robotic nurses so that we can be more tactical with the advanced technology we have created ourselves, which ultimately will help both healthcare providers and their patients.