Fundamentally, we believe that we won’t be able to help people improve their health unless we are trusted and trustworthy, and that being ethical will underpin this trust. This belief is based on three rationales that explain the importance of ethics in what we do.
Why ethics is important to us
Firstly, ethics is intrinsic to issues of health and healthy behaviours, especially when providing advice and recommendations on what to do. Even as we ensure that our recommendations are as evidenced-based as possible, there will be occasions where it will not be obvious what the ‘right’ answer is.
This is not because the evidence is wrong, but because people can have competing priorities, for instance, when deciding whether to recommend activities that favour long-term health (e.g. get some exercise after work), with those that might have more short-term benefits (e.g. go home and watch your favourite show after work).
While there may be options that combine the best of both options (watching a show while you exercise), or it can be argued that over time such choices can be evened out, there will be occasions where Koa Health will have to choose which recommendation to favour, when and why, and we must understand the ethical values that support such a position.
Secondly, to be able to help people effectively, we need to be able to access large amounts of data. This richness of data is necessarily highly personal and sensitive because unless this is the case, we cannot create highly personalised support we aim to provide.
In order to access such personal data, we need to earn people’s trust. Being ethical and doing the right thing significantly contribute to earning this level of trust.
Last, but not least, we know that people are increasingly demanding that technology is developed and deployed in an ethical and trustworthy manner. We have heard this firsthand from the clinicians that we work with, for example, insisting on the explainability of our predictive algorithms.
We can also infer this from general trends on trust. For instance, a survey by Rock Health in 2018 found that only 11% of people would be willing to share their health data with a technology company.
On defining health
Koa Health’s goal is to improve people’s health. So how do we define health? We follow the World Health Organisation’s definition of health: a state of complete physical, mental, and social wellbeing, and not merely the absence of disease or infirmity1.
Clearly this definition goes beyond merely looking at life expectancy, requiring us to think about general wellbeing as well as symptoms and conditions.
To provide an overall sense of a person’s health, there are a number of measures such as Quality Adjusted Life Year, (QALY) or Disability Adjusted Life Year (DALY). Koa Health is still exploring which of these is the most appropriate to use.
This does not mean that we are not measuring health status for our users, instead we are focused on measures that relate to the specific challenges that our apps are currently addressing, e.g., measures for stress, depression, anxiety, etc.
The role of happiness
In terms of wellbeing, emerging evidence from across cognitive science is that people optimise for happiness. To that end, happiness is considered to be a mental feedback signal that some behaviour or experience is good, and should be repeated, with sadness as the converse.
Happiness can be broken down into two parts: pleasure and purpose2. Improving health status often fits more into the purpose part, although it doesn’t have to be without pleasure, in fact when people find ways to enjoy healthy behaviours, they may be easier to maintain.
At Koa Health, we’d include a third element as a key part of happiness: control over our own affairs is also a crucial aspect of happiness, i.e. a part of what humans optimise for.
Health and society
In addition, we must also account for the fact that no one exists as an island; for each of us our health and happiness hugely affects and is affected by those around us. However, the reality is that our ability to understand what those people who are not our customers are doing, and how they may impact the health of our customers, is very limited. As a result we have chosen to focus on societal harms in general, and the impact that they may have on our customers’ health.
To frame our understanding of societal level harms we have turned to the Universal Declaration of Human Rights and the European Convention for Human Rights. Our view is that there are many rights that are not relevant to our work, such as the right to life and liberty, the right to a fair trial, etc. Instead, we believe that there are two core harms that we should pay attention to: undermining privacy (UDHR art 12 and ECHR art 8) – through the level of data we collect; and discriminating against people based on gender, race, etc (UDHR art 7 and ECHR art 14) – because our products could make recommendations that are biased against one or more groups, creating a less effective service and undermining equality.
Taken together, health status, pleasure, purpose, and control, provide a rich picture of what it means to support individuals to improve their health, much more so than relying solely on traditional measures of health status; and avoiding societal harms allows us to account for the broader context within which all of us live our lives.
The relationship between ethics and trust
However, achieving all of these factors is not the same as being ethical or trusted, so we must turn to defining these terms3:
Ethics — the study of what is morally4 right and wrong, or a set of beliefs about what is morally right and wrong.
Trust — to believe that someone is good and honest and will not harm you, or that something is safe, and reliable.
Ethics is thus intimately connected to, but not sufficient for trust, since it does not speak to reliability and safety. It is interesting to note that trust in an object or tool is related to safety and reliability, but not necessarily to being good or honest. As such we usually don’t ascribe ethics to things.
But the fact that this is changing for tools that deploy automated decision-making appears to reflect the fact that such tools are entering a domain that has previously been the preserve of humans. In effect, this is what is driving the need to consider ethical dimensions in how these tools are developed and deployed.
To understand how to pull together these threads of meeting our goal, and being ethical and trusted, we have drawn on the ethical frameworks developed by a wide-range of organisations (see the appendix), for an overview of the frameworks that we have considered).
Our own ethical principles have resulted from this analysis and cover both ethics and trust. However, we continue to describe them as an ethical framework in line with common practice.
Further reading on ethics at Koa Health
1 Preamble to the Constitution of WHO as adopted by the International Health Conference, New York, 19 June – 22 July 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of WHO, no. 2, p. 100) and entered into force on 7 April 1948
2 Dolan, P. (2015). Happiness by design. London: Penguin.
3 Definitions from the Cambridge English Dictionary.
4 For completeness, the definition of morals is: relating to the standards of good or bad behaviour, fairness, honesty, etc. that each person believes in, rather than to laws.
For further information about our approach to ethics, consult the appendix.