The latter of the abovementioned advantages, the usefulness of practical wisdom or *phronesis,* is ftting for a practice like engineering that is both a) inescapably normative and b) supposed to provide practical and acceptable solutions in ever-changing circumstances. These characteristics parallel Aristotle's characterisation of practical wisdom as not only concerned with human goods (NE VI.5) but also not "concerned with universals only – it must also recognise the particulars; for it is practical, and practise is concerned with particulars" (VI.7). This positions practical wisdom as a virtue of careful deliberation about the good that is paramount in exercising virtue more generally (VI.13). Nevertheless, to deliberate well about proper action in a world of particulars is not straightforward because practical wisdom will run up against practical and epistemic limits, i.e., deliberation about practical action is often made more diffcult by uncertainty, something the COVID-19 pandemic has proven time and time again. That is, many rapid technological developments were considered while knowledge of their effects or the situation into which they were to be implemented was incomplete, e.g., contact tracing apps, new vaccine technologies, testing kits, and new anti-viral drugs. The complex and ongoing deliberations that these prompted are emblematic of the fact that as the consequences of our technological interventions (and/or our appreciation of them) have come to extend farther in time, space and our lives, uncertainties have likewise grown despite signifcant efforts to map them better. Unsurprisingly, then, virtue ethicists have explicitly argued for the need to account for uncertainty in virtue ethics as well as the need for virtue ethics in light of uncertainties brought about by rapid (socio-)technological change. In "Seven Traits for the Future" (MacIntyre, 1979), MacIntyre grapples with the question of what traits would be desirable to promote in our society going forward. Interestingly, the virtue that tops his list is the "Ability to Live with Uncertainty". In line with the above, MacIntyre points out that "there are necessary limits to our predictions about the future of technology […] The answer is clear: we will have to design people with all those traits [...] necessary for living in an unpredictable environment, people with an ability to live with a large lack of certainty about their future" (p. 5). A more developed account of the need for virtues in light of the uncertainty in an increasingly technological world is provided by Shannon Vallor (2016), who makes the case that the unpredictability of technological development and its consequences brings about a state of 'acute technosocial opacity',

which in turn requires that we develop the proper 'technomoral virtues' if we are to deal with that opacity well. From her list of twelve technomoral virtues, some stand out as specifcally conducive to dealing with the uncertainty involved in our technological future, i.e., those of *humility, courage, fexibility, perspective* and, of course, *technomoral wisdom* (the latter being structurally similar to *phronesis* in more general virtue ethics). The central conclusion from these accounts is clear: deliberating about proper action when we are uncertain about future consequences and normative changes requires appropriately virtuous and wise deliberators. The extremely polarised and uncharitable nature of many societal discussions about COVIDrelated technological interventions would also seem to indicate a need for more of such virtuous deliberators.

Suppose this is true for society at large. In that case, it should be at least as important for those who have the power to steer the very technological developments that bring about a signifcant share of the uncertainties we are discussing. As such, it most certainly applies to *engineers*. Some of those who have argued for a role for virtue ethics in engineering (discussed in the previous section) have also made the link with uncertainty explicit. Sand (2018), while discussing the virtues of innovators more broadly, recognises that even responsible innovation processes have signifcant, unpredictable effects on society (dealing in so-called 'wicked problems). Countering the critique that a virtue-ethical approach would be unable to provide an answer to the question of what innovators should do in such a context, he points out that a) that is equally a problem for deontological and consequentialist approaches in those circumstances, and b) virtues could nevertheless provide "guidance and orientation for becoming a more creditable person and avoiding making moral mistakes. Certain dispositions and capacities help to assess risks properly and, thereby, enhance good decision making" (p. 84). Sand's focus on risk is not coincidental. Innovation generally, and engineering projects specifcally, are characterised by the impossibility "to predict absolutely accurately what their consequences will be" (Ross & Athanassoulis, 2010 p. 148). This leads to situations of *risk*, which "involve, of necessity, uncertainty; therefore, the outcomes of one's actions will be uncertain" (Ross & Athanassoulis, 2012 p. 838). This central feature of engineering practice puts a "peculiar ethical burden" on engineers: "the assessment, management, and communication of risk—the very real possibility that engineered projects and products could detract from the material well-being of some people, rather than enhancing the material well-being of all." (Schmidt, 2014 p. 998). As such, we should expect engineers to be well-equipped to deal with such situations, which, according to Ross and Athanassoulis (2012), is enhanced by having virtuous dispositions, including *phronesis*. As such, virtue ethics' focus on the engineer's moral character and their responsiveness to relevant contextual features can help them deal with uncertainty in the form of risks (Athanassoulis & Ross, 2010). However, as Sand's reference to 'wicked problems' already indicates, technical risks are only one instantiation of uncertainty engineers may be confronted in their work. In what follows, we present different types of uncertainty, including normative ones, that engineers may encounter when designing the very technologies that will shape our future and ideally help others fourish. In so doing, we hope to show that uncertainty in engineering is more multifaceted than a singular focus on risk would disclose.

### *9.3.1 Broadening the Scope of Engineering Uncertainty*

In a technical sense, uncertainty represents the lack of probabilistic knowledge for a given event (Doorn & Hansson, 2011). Engineering's preoccupation with risk rather straightforwardly fts this 'technical' sense of uncertainty. However, scholarship in the philosophy/ethics of technology and engineering has gone further in defning types of uncertainties that engineers may encounter and capture the complexity of what is unknown. In this section, we present four types of uncertainty from recent publications from these felds. In each type, uncertainty represents a situation that may hamper engineering decision-making, i.e. design decisions in which the potential risks of new technologies play a defning role.

A frst type of uncertainty identifed in the engineering ethics literature is *scenario uncertainty* (van de Poel & Robaey, 2017). This type of uncertainty captures the lack of full knowledge about a situation, where different potential ways forward (scenarios) can be imagined based on the available information. Still, we lack the knowledge to reasonably predict how likely these scenarios are to unfold. We often lack complete knowledge for many innovations, but there are some benchmark or a history of use that provide reasonable expectations of a way forward. In scenario uncertainty, this is not the case. Moreover, it is not only that we do not know which scenarios will be likely to happen but -because the form of our knowledge or the lack thereof has normative consequences- also which ones would be more or less desirable. Thus, this type of uncertainty will have normative implications and relate to *epistemic normative uncertainty* (Taebi et al., 2020).

Another type of uncertainty, also related to epistemic normative uncertainty, is *ignorance*: a situation where there is simply no knowledge of some potential consequences of a technological intervention (van de Poel & Robaey, 2017). Here, we don't even know what scenarios we don't know.

There are two more types of uncertainties we include in our analysis. In these, the normative aspects of engineering applications take centre stage. The third type of uncertainty identifed in the literature mentioned above is *indeterminacy***,** the situation in which causal chains are uncertain, and different actions of different agents could lead to different outcomes that might be unforeseen (van de Poel & Robaey, 2017). This type of uncertainty also evokes *evolutionary normative uncertainty* where, as technology and moral norms co-evolve (Taebi et al., 2020), it is unclear how to normatively assess a technological innovation because of unpredictable moral change. A fourth and fnal type of uncertainty is *normative ambiguity* representing a disagreement about values and norms (van de Poel & Robaey, 2017). Normative ambiguity can be further specifed as *theoretical normative uncertainty*, where different ethical theories will justify different ways of dealing with a problem (Taebi et al., 2020), or *conceptual normative uncertainty* where the norms themselves allow for different interpretations or prioritizations (Taebi et al., 2020).

Even from this condensed summary, it is clear that uncertainty has many forms and, importantly, includes *normative* unknowns. In light of this, if virtues are supposedly effective at helping engineers deal with uncertainty, and the exercise of virtue aims at the practical and the good, it stands to reason that virtue may be helpful for both epistemic and normative uncertainties. However, whether and to what extent this is the case remains to be seen. As such, this chapter aims to evaluate the usefulness of engineering virtues when faced with various forms of uncertainty in engineering. Before it can do so, however, we must frst consider what engineering virtues might be applicable in the frst place.

### *9.3.2 What Are the Engineering Virtues?*

Above, we said that this chapter does not aim to make a case for virtue ethics in engineering anew. Likewise, it does not aim to develop a new list of most important engineering virtues, nor is this necessary given the impressive array of engineering virtues presented by others. Table 9.1 offers an extensive overview of engineering virtues as proposed by those making a case for virtue ethics in engineering; virtues that we take as inspiration in analysing the uncertainty scenarios below.

This table structures the overview of engineering virtues differently from how one would fnd them in the sources from which they were extracted. The presentation of these virtues, their character, and their connection to other virtues and to engineering varied widely across those sources. Thus, the virtues in Table 9.1 have been brought together under a new structure. However, because of these varied foundations, and because we are not taking a strong position on the nature of virtue, Table 9.1's virtue categories should be read heuristically.

For example, it follows the general distinction between moral and intellectual virtues. However, it also has an 'in-between' category that contains virtues that do not neatly fall in either of those two. For example, whether humility is a moral or an intellectual virtue may depend on whether we have outcomes – or motivations based understanding of virtue (Wilson, 2017) and/or the context in which it is acted upon (Bommarito, 2018). Likewise, the virtue of anticipation has been linked to both moral responsibility as well as intellectual virtue in engineering (Steen et al., 2021; Stone et al., 2020). It has even been argued that some virtues can be hybrid, simultaneously moral and intellectual (e.g., hermeneutic justice, see Fricker, 2007). Answering the question of which of these possibilities fts which virtue in the category is beyond the ambitions of this chapter. However, it indicates that exercising these virtues may exhibit both moral and intellectual excellence.

Next, Table 9.1 distinguishes between 'fundamental human virtues relevant for engineering' and 'specifcally engineering virtues'. This is simply to indicate that the former would be expected of virtuous persons generally but are also important for the virtuous engineer, while the latter are specifc to the practice of engineering.

**Table 9.1** Overview of previously recognised virtues relevant for engineering

*Sources***:** [1] Bowen (2014), [2] Crawford-Brown (1997), [3] Harris (2008), [4] Pritchard (2001), [5] Sand (2018), [6] Schmidt (2014), [7] Steen et al. (2021), [8] Van de Poel and Royakkers (2011), [9] Frigo et al. (2021)

This specifcity also prompted a redesignation to 'social' and 'technical' virtues, indicating the community-orientedness of the former and the partially practical rather than solely intellectual nature of the latter. Such a division is to be expected for engineers since their being persons and being engineers is not distinct. It is

important for engineers to fnd "continuity and coherence in both professional and personal life. [They] are human persons always and only sometimes engineers" (Bowen, 2014 p. 25).

Interestingly, it would seem that the specifc virtue characterisation of the practice of engineering has generally focused on the 'technical' rather than the 'social' virtues, with the moral virtues for engineers being left less specifc to the practice. While this is likely partly due to the cognitive nature of engineering work, its practical and normative orientation could be a reason to explore this imbalance further.

Lastly, the central position of practical wisdom in the table is no coincidence. Not only is it one of the virtues most often cited, but when it is, it is given a central, regulative role in the exercise of the engineering virtues as well as in appropriate, context-sensitive engineering judgement (Frigo et al., 2021; Schmidt, 2014; Steen et al., 2021). This, of course, runs parallel to the role that practical wisdom plays in virtue ethics more generally.

Armed with the different types of uncertainty and a list of engineering virtues, the latter's usefulness in dealing with the former can now be investigated. In the next section, we do so by sketching several scenarios based on real situations and technological innovations in which hypothetical engineering professionals face diffcult decisions under different conditions of uncertainty.

### **9.4 Applying the Virtues to Cases of Uncertainty in Engineering**

In this section, we present real events and persons to provide a context for discussion. Our subsequent analysis develops *hypothetical* agent-centred considerations grounded in those real events. This allows us to discuss the role of virtues in decision-making by engineers in situations burdened by different types of uncertainty. Each case exemplifes a particular uncertainty situation. However, few reallife cases are likely to be so ideal-typical as to present only one type of uncertainty. Although that does not make their application in our analysis less salient for the purposes of the chapter, we recognise that they do not tell the whole story. Another observation about the cases we present is that they all capture potentially undesirable situations. We acknowledge that uncertainties need not always be about undesirable situations, and in this analysis, we will see that all cases can present desirable and undesirable uncertainties.

Moreover, the cases presented below are all from the life sciences, where the application of recent scientifc fndings allow translating them to useful engineering applications. The technologies presented thereby add a layer of uncertainty because of their relation to new knowledge not always resulting from traditional science but also of techno-science (Bensaude-Vincent et al., 2011). This allows examining situations where uncertainty is not only an epistemic endeavour but also a moral one. Finally, the cases presented are engineering applications that result from various

forms of bio-engineering that relate directly to the pandemic, like mRNA vaccines, or that could come play a role in mitigating effects of the pandemic, like mechanical wombs, and synthetic milk.

### *9.4.1 Situations of Scenario Uncertainty and Ignorance*

#### **<IP_ADDRESS> The mRNA COVID Vaccines**

Recently developed COVID-19 vaccines have raised many questions on their potential side effects. Receiving emergency approval by local regulatory bodies, recommendations on their use for specifc age groups changed as they were rolled out. The main discourse concerning administering vaccines under emergency approval has been that benefts outweigh the risks of the disease itself. This consequentialist claim was made from a general public health perspective. However, for vulnerable populations, like pregnant people, children, or people with certain existing conditions, the risks and benefts of the vaccines had not been researched when they were frst rolled out.

One event that represents **scenario uncertainty**, in particular, is the June 2021 citizen petition on the assessment of mRNA vaccines, led by Dr. Linda Wastila, professor and Parke-Davis Chair in Geriatric Pharmacotherapy at the University of Maryland. Leading the Coalition Advocating for Adequately Licensed Medicines (CAALM) comprised of scientists, clinicians, and patients advocates, their citizen petition to the Food and Drug Administration (FDA) asked for more caution in the full approval of mRNA COVID vaccines (BMJ Opinion, 8 June 2021b). The petition raises eight points of consideration to the Food and Drug Administration. We highlight three of these here: CAALM asks the FDA to provide evidence that the new vaccines will actually beneft vulnerable groups, to research biodistribution of mRNA vaccines, and to further investigate all severe reactions following vaccination. Following the 23 August 2021, FDA decision to grant full approval to the mRNA COVID-19 vaccine by Pfzer, another member of CAALM, Peter Doshi, senior editor of the BMJ, reiterated the need for the 2-year requirement in phase 3 clinical trials in order to "have the science right" (BMJ Opinion 23 August 2021a).

This citizen petition essentially demands less scenario uncertainty by defning specifc areas of concern that need further investigation. Reducing scenario uncertainty, in turn, allows reducing **epistemic normative uncertainty**. To make the right choices about vaccine rollout and considering further measures like mandatory vaccination, we need to know the likelihood of different scenarios.

For certain groups of the population, like pregnant people, this goes even further than a situation of scenario uncertainty but rather of **ignorance**. Pregnant people are excluded from medical clinical trials (Smith et al., 2020), understandably so, given the potentially devastating side effects on their future child. In this sense, they are protected, but in the face of the urgency of the COVID-19 pandemic, pregnant people are also at specifcally high risks (Wastnedge et al., 2021). Until governments emitted recommendations on vaccination during pregnancy,1 pregnant people could, in certain cases, elect to receive vaccines. While not all vaccines are safe to administer during pregnancy, like those containing live viral material, mRNA vaccines have the advantage of not containing live virus material and thus presented the option of being administered to pregnant people. One can only imagine the heightened sense of **epistemic normative uncertainty** for this particular population group, with it possibly impacting future generations.

### **<IP_ADDRESS> What Virtues to Consider for Scenario Uncertainty and Ignorance?**

Normally, in drug development, stage-gate models are used to "fail early and fail often", to ensure that whatever drug is produced at the end has higher safety standards (Hjorth et al., 2017). Now, we enter a hypothetical scenario of a vaccine developer: typically, this would be a scientist working on applying knowledge from biochemistry, pharmacology, molecular life science, immunology and so on to the end of making an effective vaccine. For this discussion, our hypothetical scientist engineers a new vaccine and is acutely aware of the concerns raised in the CAALM citizen petition to the FDA. We could even imagine this scientist being pregnant, thus embodying the two types of uncertainties and experiencing the urgency of developing vaccines to fght the pandemic and protect vulnerable groups.

Considering the list of virtues presented above, here are some we could consider relevant and why we think so. Here, the virtue of *justice* seems particularly relevant when making design choices in terms of access to the new vaccines. Here, as MacIntyre points out, we face the challenge of multiple meanings of justice, where he suggests considering the issue of desert (MacIntyre, 1981, p.249). One interpretation we can offer here is that everyone deserves access to health, so this could mean designing vaccines to beneft all groups of the population. This might come at the cost of other internal engineering goods, like effciency, or run into other challenges like clinical trials regulations. Typically, engineering solutions do not, at frst, focus on justice though they can certainly contribute to it. A *just* engineer would aim to realise the normative goal of engineering; whether it is in her ability and power to do something about it is another question.

Here, general virtues of *integrity, honesty and perseverance* can support the *just* engineer. Aiming to act as a just engineer might prove frustrating, and especially in an urgent and business context where outcomes are needed fast. So having virtues of *integrity, honesty and perseverance* can help her remain *just* in such a highpressure environment. Finally, virtues of *open-mindedness, originality, and thoroughness* can help realise the goal of a *just* engineer, for they help engineer safe and accessible vaccines for all.

<sup>1</sup>France and Ireland recommended vaccination from week 16 of pregnancy, whereas Germany recommended waiting for week 20 in certain Länder, and 13 in others, and the Netherlands advised taking it throughout the entire pregnancy.

Looking at specifc engineering virtues, *inclusion* and *responsiveness* are a specifcation of the virtue of justice, accompanied by virtue of *anticipation*, and the virtues of *sensitivity to 'tight coupling' and 'complex interaction'*. We present these as specifcations as it is not clear what the exercise of these engineering virtues would amount to without the virtue of justice. For instance, one could excel at anticipating and yet not mobilise it towards justice or human fourishing.

So far, we've discussed scenario uncertainty and ignorance as the same thing. Does ignorance call for different dispositions than scenario uncertainty? With this specifc technological intervention, being a just engineer will likely be paramount in either case. Lacking information, conceptions of justice and moral dispositions become increasingly important. As an analogy, consider Rawl's veil of ignorance. A lack of knowledge prompts an increased need for moral virtues of *compassion, empathy and care* (and, arguably, in the case of technology development, *imaginativeness and creativity*).

In this frst analysis of relevant virtues in cases of scenario uncertainty and ignorance, it seems that an engineer apt to deal with these situations is a *just* engineer. The other virtues come to support the exercise of justice as a virtue but could be different, depending on the context and type of scenario uncertainty.

### *9.4.2 Situations of Indeterminacy*

### **<IP_ADDRESS> The Mechanical Womb**

In March 2021, a New York Times article heralded the success of mechanical womb research giving birth to thousands of mice embryos (Kolata, 2021). While this article underlines the scientifc advantages of studying the development of mice through a mechanical womb, e.g., by pausing development, it also points to potential future applications to human embryos. Needless to say, one can imagine many applications of a mechanical womb for people who struggle with infertility (Berglund, 2021), new avenues to replace problematic issues of surrogacy (Abecassis, 2016), and for increasing chances of survival of preterm babies (Werner and Mercurio, 2021). At the moment, laws prohibit any research on embryos older than 14 days.

In the New York Times article, one of the scientists interviewed on the matter, Dr. Tesar, not involved in the development of the mechanical womb, is quoted saying: "[e]ven assuming they could [grow human embryos], whether that is appropriate is a question for ethicists, regulators and society." In the enthusiasm of this technoscientifc achievement, it seems that scientists interviewed in this New York Times piece defer moral judgement and potential future use to other agents in society.

Questions of **indeterminacy** arise at several levels. In this case, we can expect an entanglement of causal events, different decisions of different stakeholders, and changing norms and values concerning this. Here, we list just a few of the indeterminate issues in relation to the mechanical womb (cf. Verbeek, 2008):

These questions capture potential **evolutionary normative uncertainty.** Of course, we might change our moral views on many of these issues, but we just don't know what kind of possibilities the mechanical womb will afford, even within a pandemic situation like ours. For example, pregnant people with COVID-19 are more at risk of pre-term births than their healthy counterparts (Villar et al., 2021). Recent news reports in the Netherlands indicated an alarming number of unvaccinated pregnant people needing emergency C-sections as early as 24 weeks of gestation (NOS, 2021). Despite the fact that the mechanical womb is still under development, one can readily imagine a use case for it in similar circumstances, with all the normative uncertainties that brings.

#### **<IP_ADDRESS> What Virtues to Consider for Indeterminacy?**

Let us now imagine our bioengineer, with a background in developmental biology, or training in obstetrics, designing a carefully balanced environment meant to support the development of a human being.

Bioengineers' choices impact the integrity of the life of children, but also on the relationships to their parents, and potentially on the future of labour for pregnancy care. Decisions on the use of technology will impact technical choices and vice versa. It will require understanding the impact that technical limitations might have on the fundamental questions listed above. This is typically beyond the purview of a designer, as the focus is on optimising technology to help grow healthy babies.

In order to capture the range of effects on different agents, an important set of virtues here are *compassion, empathy and care*. Indeed, designing the mechanical womb is not just a matter of optimisation, but rather a matter of what should this technology afford for our human identities and integrity. With this comes a requirement for intellectual *carefulness*, in order to verify assumptions on these various relationships and inquire on how such a development changes things for a complex set of people, also in the future. Some engineering virtues can further specify how to be careful: for instance, *cooperativeness* with healthcare providers, patient organisations, surrogacy advocates, and various types of prospective parents. Furthermore, in order to be able to be cooperative, virtues of *inclusion and responsiveness*, as well as the virtues of *perspective,* will help give depth to cooperativeness by inviting speaking to a broad range of stakeholders and engaging with relevant moral issues at stake. Another possible engineering virtue that would help support this endeavour is *seeing the 'big picture' as well as the details of smaller domains*.

Therefore, a compassionate, empathetic, and caring engineer could make design choices that accompany indeterminate situations, where norms are bound to evolve.

### *9.4.3 Situations of Normative Ambiguity*

#### **<IP_ADDRESS> Synthetic Maternal Milk**

There is certainly a lot of debate on the 'right' way to nourish a newborn with global health recommendations focussing on maternal milk, and in the cases where breastfeeding is not an option due to health or socio-economic factors, formula from cow milk is presented as the next best alternative. A new development in synthetic maternal milk might signifcantly change these discussions, creating new opportunities for personalized nutrition. Just like the mechanical womb, the case of synthetic maternal milk could also serve as an helpful alternative for mothers infected with COVID-19 to provide superior nutrition to their children while lowering chances of infection.

An in-depth portrait of Dr. Leila Strickland (Kleeman, 2020), founder of Biomilq, a synthetically produced maternal milk, questions how such a development in precision fermentation could disrupt what we understand as a good way to feed the next generations of newborns and even further prevent breastfeeding in public which is a taboo in many western countries (Hauck et al., 2021). If 'breast is best', how will synthetic breast milk change how people perceive the need for breastmilk, or what kind of added price tag will this put on parents who already pay a premium for formula milk derived from cow milk?

Here we can see various layers of **normative ambiguity** that can be captured at an individual but also societal level. From a public health perspective, an innovation like Biomilq presents several advantages: it is more environmentally friendly as it reduces reliance on dairy farming and refects parents' preferences in diets as it would be customizable. In the beginning, it would probably be a luxury product using a biopsy from the feeding parent. Still, its production could become available at an attractive price point for consumers in the long run. This is a consequentialist perspective on the matter, often preferred in public health recommendations (Markmann et al., 2015). However, synthetic maternal milk could steer parents away from either formula, or breastfeeding. This can hide a host of problems concerning health and justice. For instance, the designers of Biomilq recognise that

synthetic milk will never be equivalent to breast milk due to the adaptive nature of breastmilk: becoming more diluted on warmer days, containing antibodies when a child is sick. Another issue is justice. If synthetic maternal milk is superior to formula, how will parents without means have access to this better option? These two issues point to a rights-based approach to health, where the right to health of a child and the right to access healthy food might be put at risk or might create new demands on the health system. Which of these theories will help us deal with these developments? It is hard to say and rather likely that these different reasoning will create conficts on the issue of feeding children. This is what *theoretical normative uncertainty* captures. Within this, there will likely be *conceptual normative uncertainty* as to how parents and doctors, hospitals, or even international organisations like the World Health Organization see what as healthy or just.

### **<IP_ADDRESS> What Virtues to Consider for Normative Ambiguity?**

Let us now consider the role of a bioengineer, active in precision fermentation and developing synthetic maternal milk. Looking at the personal story of Dr. Strickland and the account of experiencing emotional stress that comes from not being able to breastfeed, an act linked to being a good parent, providing the best nutrition for a child's health, is a laudable motivation. At the same time, the social disruption potential of such an innovation can change many norms of what is desirable for a child's health, from a public and individual perspective, and what is acceptable in public places in terms of breastfeeding.

In order to be able to think about others, whom a disruptive innovation rather do disservice, our bioengineer might have to exercise *benefcence next to justice*. For example, is it a good invention if it's only good for a portion of parents? This could be further specifed as cultivating *appropriate ambition* for an invention and exercising the virtue of *humility* in order to evaluate design choices beyond their own goal. This also calls for the intellectual virtue of *carefulness*. Here this could be understood as being careful to make synthetic milk that is good for children but also being careful about wider issues. A common idea of potentially disruptive innovation is 'break things and move fast' where exactly in these cases, carefulness would be advised.

These fundamental virtues can be further specifed in terms of engineering virtues. For instance, to think of benefcence and appropriate ambitions, engineers can develop *techno-social sensitivity* and practise *inclusion and responsiveness* to recalibrate these ambitions and notions of the good for others. This also requires the exercise of *anticipation* of effects or *seeing the big picture as well as the details of smaller domains*. Our engineer needs to be open to criticism and correction for this recalibration of ambitions and notions of the good.

Therefore, a benefcent engineer would be equipped to deal with theoretical and conceptual normative ambiguity by virtue of thinking of the good beyond her own experience.

### *9.4.4 The Regulative Role of Phronesis in Situations of Uncertainty*

The cases described above highlight the interaction of different virtues that support the ultimate exercise of fundamental moral virtues. Depending on how authors classify them, these various types of virtues are human virtues, more specifc to engineering, moral/social, intellectual/technical, or somewhere in between. This is the main fnding from analysing these cases: types of uncertainties do not necessarily require more knowledge of the truth, but more ways of relating to various issues at stake: for instance, the health of unborn children, parents who struggle with infertility, and parents who want to feed their children with the best possible options. Our interpretative analysis did not make the role of practical wisdom explicit, so we would like to return to it here. In order to navigate between different virtues and be able to know which ones could help support the exercise of other virtues: this demands practical wisdom to be regulative of the various types of virtues (see summary Table 9.2).

In the cases presented, we suggest that some of these virtues are the most relevant virtues and that these are supported by other fundamental human virtues that

**Table 9.2** Summary of relevant virtues for life science engineering in different situations of uncertainty

can then be further specifed into engineering virtues. This is consistent with Aristotle's account where moral virtues and practical wisdom depend on each other in order to achieve human goods (NE VI.13). This analysis from relevant virtues to virtue specifcation is evaluative and interpretative and might not yield the same conclusions in every case of either type of uncertainty. Rather it underlines the necessity of practical wisdom in recognising which virtues to practise when and which virtues to acquire.

Therefore, the deliberate exercise of practical wisdom is primordial to making design choices, as these choices will require the exercise of various virtues, as our cases illustrate. It is not suffcient to be inclusive if the exercise of justice does not accompany this or to be open to criticism if not for the exercise of benefcence. This confrms the important role of practical wisdom in situations of uncertainty (Frigo et al., 2021).

### **9.5 Conclusion: Virtues for Designing under Uncertainty**

To conclude this chapter, we fnd that moral virtues are paramount to making good design decisions in situations of uncertainty, like many presented by the COVID-19 pandemic. For the cases we evaluate, we conclude that: situations of scenario uncertainty and ignorance call for a just engineer. Situations of indeterminacy call for a compassionate, empathetic and caring engineer. Finally, situations of normative ambiguity call for a benefcent engineer. Because of the nature of the situations described, we found that the most relevant virtues were, in fact, moral virtues. In addition, we fnd that these will require the exercise of many other virtues of different kinds. Our analysis also indicates that without a central moral virtue and without practical wisdom, there is perhaps no guarantee of goodness in the exercise of other, more technical virtues.

Our analysis reinforces existing scholarship on virtue ethics and engineering and highlights the need for virtues-based approaches therein, with a specifc focus on engineering ethics education. New approaches are needed to *complement* the idea that uncertainties can either be avoided or eliminated through more knowledge. Engineering education could also embrace different situations of uncertainties in order to give space for the cultivation of other virtues; or, as MacIntyre writes, we should have the ability to live with uncertainty.

There are further avenues for research that we have not touched upon in this chapter. First, we have not discussed vices corresponding to the virtues we present. Doing so could bring to light virtue conficts and present a more complete account of designing under uncertainty. Second, we have not explored poietic virtues (Poznic & Fisher, 2021) as it would require a more sustained interaction with empirical material to add to this discussion than this chapter would allow. Nevertheless, doing so would present additional opportunities to deepen philosophers' and ethicists'

empirical engagement with design situations under uncertainty. Third, empirical research could broaden the array of design cases and possibly relevant virtues for engineers, which could, in turn, broaden and/or confrm our idea that some virtues lend themselves better to specifc types of uncertainties.

We would like to end this chapter by once more stressing the importance of experience and education for shaping responsible engineers. That is, if we want virtuous engineers ready to tackle an uncertain future, we need to think about how to cultivate the necessary virtues through engineering education in pandemic times and beyond.

**Acknowledgements** This work is part of the research programme "Virtues for Innovation in Practice (VIPs): A Virtue Ethics Account of Responsibility for Biotechnology" with project number VI. Veni.191F.010, fnanced by the Dutch Research Council (NWO). ZR is also a research fellow in the Ethics of Socially Disruptive Technologies programme.

### **References**

Fricker, M. (2007). *Epistemic injustice: Ethics and the power of knowing*. Oxford University Press.

**Open Access** This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

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### **Chapter 10 Confronting Ableism in a Post-COVID World: Designing for World-Familiarity Through Acts of Defamiliarization**

**Janna van Grunsven and Wijnand IJsselsteijn**

### **10.1 Introduction**

The COVID-19 pandemic has brought about a dramatic change in how we interact with others in our everyday activities. Two-dimensional screens and online platforms have profoundly mediated how we work, learn, stay in touch with friends and family, and connect with health care providers and therapists. For many, the pervasive digitalization of our social and practical lives has signifed a substantial loss, with the pandemic underscoring that in-person interactions play a key if not constitutive role in well-being. At the same time, a signifcant number of people have experienced the digitalization of our social and practical lives not as detrimental but precisely as conducive to their overall well-being. In particular, many disabled people and disability rights activists have celebrated the increased accessibility to practical and social spaces enabled by the pandemic-induced embracing of online communication platforms and other digital technologies.1 In the words of Ashley Shew:

J. van Grunsven (\*)

<sup>1</sup>We will use identity-frst as opposed to people-frst language in this paper. In doing so, we are following Elizabeth Ladau's (2015) argument that by "intentionally separate[ing] a person from their disability … it … implies that 'disability' or 'disabled' are negative, derogatory words. In other words, disability is something society believes a person should try to dissociate from if they want to be considered a whole person. This makes it seem as though being disabled is something of which you should be ashamed. PFL [people-frst language] essentially buys into the stigma it claims to be fghting."

Delft University of Technology, Delft, Netherlands e-mail<EMAIL_ADDRESS>
W. IJsselsteijn Eindhoven University of Technology, Eindhoven, Netherlands e-mail<EMAIL_ADDRESS>
M. J. Dennis et al. (eds.), *Values for a Post-Pandemic Future*, Philosophy of Engineering and Technology 40, https://doi.org/10.1007/978-3-031-08424-9\_10

Many accommodations demanded under COVID-19 were implemented within weeks …. These are all things that disabled and chronically ill people have wanted for a very long time. I hope that when we've fattened the curve and saved as many people as possible, we don't return to a world in which disabled people are ignored (especially when COVID-19 will probably produce more of us). (Shew, 2020a)

Not wanting to return to the 'old normal,' Shew suggests, that a new post-COVID world should retain many of the now widely implemented technology-enabled forms of access that have beneftted so many disabled and chronically ill people.2 Yet, as Shew readily acknowledges, we must be cautious about the role of digital technologies in a post-COVID world, and the idea that these technologies straightforwardly promote access. For one thing, disability is often co-opted by technology developers in order to illustrate the alleged societal benefts of their products, raising the concern that the genuine access-enabling potential of digital technologies for disabled people can play into a more problematic "screens everywhere" temptation that is "representative of today's dominant approach to technology design" (IJsselsteijn et al., 2020, p. 37). Furthermore, as Shew explicitly warns, although many digital technologies may have made it easier for disabled and chronically ill people to access a range of spaces and resources, *ableist* biases that (de)value some bodies and minds over others are rampant in tech-development. Without combating these biases – biases that "shape how and what we design" (Shew, 2020b) – the return to the 'old normal' that Shew warns against seems all but inevitable.3

Our aim in this chapter is to take Shew's call for technology-supported access *and* her warning against technology's ableist tendencies seriously. Starting from the premise that promoting accessibility and resisting ableism in technology development are morally imperative, our paper discusses two distinct conceptions of accessibility, paired with two conceptions of how access thus understood can be promoted through technology development. The frst conception builds off the notion of *affordances*, taken from the feld of ecological psychology (Gibson, 1979). Using the pandemic as an illustrative case, we show (Sect. 10.3) that an affordance-based notion of access underscores the link between a person's sense of well-being and their habitual sensorimotor embeddedness in a world that they experience as a space of familiarity – a space in which they know their way around and are able to respond effortlessly to the many perceived possibilities for action that the world affords (Van

<sup>2</sup>This is not to say that these communication technologies were not available prior to COVID, but rather that everyone is now forced to resort to them. Arguably, this has created a level playing feld of sorts, where quite unlike people's access to physical meeting spaces, and the unequal distribution of social and physical affordances embedded therein, interactants meet in virtual spaces that allow them similar affordance to the other. Of course, due to the video-centric nature of digital communication platforms this point only goes so far.

<sup>3</sup>Shew refers not just to technological accommodations but also to a widespread increase in fexibility when it comes to scheduling, deadlines, etc. A more fexible (and critical) approach to productivity and the organization of time, she argues, is something we all beneft from. This signifes another dimension of how we design daily life that could beneft from the experience and knowledge of disabled persons.

Grunsven, 2020). In Sect. 10.4, we will present *Warm Technology* (IJsselsteijn et al., 2020) as a paradigmatic example of a design-approach aimed at designing for world-familiarity – thus supporting accessibility in one sense of the word. The second conception of accessibility comes from the feld of Crip Technoscience (Hamraie & Fritsch, 2019) and underscores technology's potential to create access not by promoting world-familiarity but precisely by creating friction and disruption within habitual practices and ways of perceiving the world – particularly when those practices are ableist. Though these two perspectives may appear to be in confict with one another our goal is to defend the importance of both. Promoting accessibility, we suggest, involves a readiness to oscillate between two normative imperatives: (1) recognizing how human well-being depends on world-familiarity, which, in turn, can be materialized through design and (2) recognizing how worldfamiliarity can harbor pernicious biases that can be called into question through material gestures of *defamiliarization* (Bell et al., 2005) with Crip Technoscience providing an important framework for such defamiliarization. By presenting these two perspectives as mutually required in efforts to design for accessibility, and, furthermore, by framing the pandemic as an event that has placed us, en masse, in a defamiliarized position capable of attuning us to the normative signifcance of world-familiarity, we hope to better enable technologists and laypersons alike to refectively evaluate if and how a technological innovation may (or may not) be access-promoting, such that it can contribute to a more just post-COVID world.

### **10.2 Why We Must Foreground and Finetune the Notion of Accessibility in HCI**

As mentioned in the introduction, our proposal starts from the premise that promoting accessibility (and resisting ableism) is a moral imperative in technology development. Our focus is on digital technologies and the space of human-computer-interaction. We frst want to briefy elaborate on this premise, before delving into the specifcs of our proposal.

First, one might question the need to foreground and fnetune the notion of accessibility in the feld of human-computer-interaction. After all, this feld has been emphatically concerned, at least prima facie, with developing participatory and inclusive design methods that place the needs of digital technology-users at center stage. As Cynthia Bennett notes, "accessibility was one of the most popular keywords describing publications at the 2019 CHI Conference on Human-Computer Interaction" (2020). At the same time, she adds that "despite increased momentum, perspectives from the people with disabilities accessible designs purportedly beneft are under-represented, and these absences may negatively impact people with disabilities and the feld of professional design" (2020). There is a need, then, to meaningfully claim and cash-out the notion of accessibility for the feld.

Still, one might ask, why focus specifcally on *accessibility*, as opposed to, say, inclusivity? We believe accessibility is the right value-concept to foreground for several reasons. Firstly, the notion of *inclusivity* (and of *being included*) can evoke associations of disabled people *being invited* or *brought into* some pre-existing space by those who are in a position of power to extend such an invitation (typically the non-disabled technology experts within that space). While communal belonging is arguably a moral good, we wager that it matters how this belonging is achieved in a procedural sense. The notion that one needs to be included into a space by others, for instance in virtue of design-choices made by non-disabled 'experts,' may (implicitly or explicitly) diminish the degree of agency one is credited with. IJsselsteijn et al. (2020) worry that "this starting point can lead to an inherent disempowerment, and an implicit lack of respect in data collection practices towards [the relevant stakeholders] and in the resulting designs made for them" (p. 40). This is particularly problematic in the context of designs intended for disabled users, given the pervasive tendency (both by tech-developers and society at large) to view disabled people as somehow less agential than non-disabled people and merely as the passive users of technology (Shew, 2020b). This tendency in fact discredits a long history of disabled people actively modifying ("tinkering with" or "hacking") the artefacts they rely on in navigating the environment so as to gain *access* to a world that is by and large designed for non-disabled people. Before non-disabled people started to consider the importance of 'including' marginalized disabled people into 'their' spaces, disabled people were in fact already actively creating and claiming access to those spaces – while simultaneously critiquing and challenging the ableist value-system contouring those spaces (Hamraie & Fritsch, 2019).

Second, then, the notion of accessibility is signifcant because it underscores the environment's constitutive role in the experience of disability and the work involved in making the material and digital built environment more hospitable to all. The notion of inclusivity, with its connotation of 'bringing people in' may leave unquestioned the normative status of the world that technology designers and developers are attempting to include people into. As Shew discusses, a paradigmatic example of an innovation refective of this perspective is the exoskeleton, which is designed with the purpose of providing *some* paralyzed wheelchair users with the required abilities that would enable them to quite literally step into a world organized around walking. The idea that this world is better and more desirable is itself left unquestioned. Shew has coined the term *technoableism* to capture this phenomenon, which "describe[s] a rhetoric of disability that at once talks about empowering disabled people through technologies while at the same time reinforcing ableist tropes about what body-minds are good to have [in this case body-minds that are upright and ambulant] and who counts as worthy. Technoableists usually think they have the good of disabled people in mind. They do not see how their work reinscribes ableist tropes and ideas on disabled bodies and minds" (Shew, 2020b, p. 43). The notion of accessibility, we wager, reminds us of the idea (also central to the social model of disability) that what disabled people very often need – and indeed very often already bring about through their own active hacking and tinkering – is not necessarily a change to their individual body-minds such that they can participate in 'our' world, but precisely a change to the wider social and material environment. Combatting ableism, then, crucially involves promoting changes in the environment that increase accessibility.4 As we will suggest in a moment, an affordance-based approach offers resources for feshing out this idea; making perspicuous how, in our thriving as agents, we rely upon an embodied habitual familiarity with the possibilities for action afforded by the material and digital built environments in which we are embedded.

Of course, in a straightforward sense 'inclusivity' and 'accessibility' are simply concepts that allow for a range of interpretations. Indeed, as Hamraie and Fritsch (2019) note, the notion of access can also be developed in assimilatory directions. However, they highlight that "the etymology of the word *access* reveals two frictional meanings: access as "an opportunity enabling contact," as well as "a kind of attack," adding that "Taking access as a kind of attack reveals access-making as a site of political friction and contestation" (Hamraie & Fritsch, 2019, p. 10). Following this idea, our fnal reason for focusing on accessibility is that it encourages us to consider how digital technologies may be designed so as to promote accessibility in this critical friction-creating sense.

In sum, what we will be arguing in the remainder of this chapter, is that promoting accessibility through technology design involves an oscillation between (1) appreciating and designing for accessibility understood as world-familiarity and (2) turning to mechanisms of defamiliarization to critically refect on the habits, biases, and assumptions that are always an ineluctable part of one's world-familiarity.

### **10.3 An Affordance-Based Take on Accessibility: Lessons from the Pandemic**

The idea that worlds, in virtue of how they are designed and built, can be more (or less) accessible to some people than to others can be further deepened via the notion of *affordances*. Affordances, a term coined by ecological psychologist J.J. Gibson, captures the idea that living beings perceive their environment in terms of the practical possibilities for action it affords them as embodied embedded beings (Gibson, 1979; see also Van Grunsven, 2015; Rietveld & Kiverstein, 2014; Dreyfus, 2007). For instance, a chair is built for sitting and a living being whose needs, embodied sensorimotor skills, and socio-cultural practices make sitting desirable, possible, and meaningful will typically directly perceive a chair as *affording*-*to-be-sat-on*. When, as affordance-responsive beings, our embodied sensorimotor skills are attuned to the artefacts that surround us, we typically know our way about in the

<sup>4</sup>Crucially, as Shew (2020b) notes, increased accessibility through changes in the wider social and material environment isn't just what disabled people need. Whereas the exoskeleton is only capable of (potentially) beneftting some wheelchair users, public ramps – as opposed to steps – beneft many people with limited mobility, including people with various disabilities, many aging adults, parents with young children, people who are temporarily injured etc.

world without requiring much effort or refection. To borrow an example from Van Grunsven (2020), when you enter a crowded subway car you typically do not have to thematize the number of passengers around you to take up an appropriate distance from them, nor do you have to pay attention to the shape of the subway pole in order to be able to grab it and maintain your balance. You effortlessly and habitually negotiate these social and practical affordances. If you had to focus on how to shape your hand in order to grip the subway pole appropriately; how to maintain your balance while the train was in motion; how to maintain an appropriate distance from the other passengers on the train, you would have a hard time directing your thematic attention to other, arguably more meaningful, activities (having a conversation with a friend; reading a book; rehearsing an important conversation with your boss that you plan to have later that day, listening to your favorite music or podcast, etc.).

The effortless pre-refective embeddedness in practical environments described here depends on a close-coupled match between an agent's embodied sensorimotor skills on the one hand and the material environment on the other hand. Accessibility, we propose, can be understood in terms of this match between the affordances available in a given environment and the embodied skills and capacities that enable situated agents to perceive these affordances as familiar features of a world in which they habitually know their way around. Crucially, this means that not everybody enjoys equal access to the world understood as a space of familiar affordances. Stair cases, door-handles, public bathroom, bicycles, cars, tablets, smart phones, key boards, screens – all these artefacts and features of the technological built environment are designed for certain types of embodied minds (often young adult, neurotypical, able-bodied, and digitally literate) who possess certain (sensorimotor) skills, capabilities and preferences. When this is forgotten or ignored in technology development, seemingly innocuous choices made at the level of design effectively legislate who has access to the world as a space of familiarity.

Many of the habitual fow-like interactions with the environment that people (especially able-bodied people) are typically able to take for granted in the course of everyday living have been disrupted as a result of the pandemic; particularly in its early stages when the world seemed to transform overnight from a place of familiarity into a defamiliarized space. As Van Grunsven has noted:

Many of the most basic features of our practical environment (door-handles, elevators, public transportation, cash, produce, our mail) seem to warrant a new form of engagement. … The transformation of social affordances—both in the private sphere and the public domain—has been even more dramatic. Strangers on the street largely afford to-be-shunned or avoided. … many of us no longer dwell in public spaces the way we used to—we no longer casually grab the subway pole and rely on our habitual know-how to take up an appropriate distance to others. Moving about in public space is now more often than not an effortful endeavor (Van Grunsven, 2020).

By defamiliarizing the familiar, dislodging many of us from our habitual taken-forgranted access to a world of familiarity, the COVID-19 pandemic has (in principle) created the conditions for an appreciation of how our sense of agency and over-all well-being depend on a fuent, close-coupled match between our embodied

sensorimotor skills on the one hand and our practical socio-technological environment on the other hand:

If the unrefective activities that tend to support our more labor-intensive thematic forms of world-directedness now warrant thematic directedness themselves, this creates the condition for a specifc kind of fatigue stemming from excessive self-monitoring and of reorienting oneself in a world that has lost some of its immediate action-guiding signifcance. Flow-like engagements are continuously interrupted by attitudes of distrust towards and detachment from the familiar. To put this in terms familiar to psychologists, the loss of world-familiarity brought about by the pandemic can be understood as a distinct source of *ego-depletion* (Van Grunsven, 2020).

A pandemic-enabled awareness of how our functioning and thriving as agents depends on a close-coupled match between our embodied sensorimotor skills on the one hand and the sociomaterial environment on the other hand can be utilized to design for world-familiarity; serving as an experiential resource that non-disabled technology designers can tap into to understand the normative signifcance of being embedded in a world-familiarity and the strenuousness that might go along with having to navigate an environment whose affordances resist effortless coupling with one's embodied skills and capacities. That said, we acknowledge that while many may have experienced the kind of loss of world-familiarity described here, that this experience of loss was not distributed equally. While, as discussed in the introduction, many disabled people and disability rights activists have welcomed the digitally-enabled forms of access that the pandemic world has embraced en masse, disabled people have still been among those bearing the brunt of the pandemic and the effects of various COVID-prevention measures (c.f., Wright, 2020). That worldfamiliarity is not an evenly distributed phenomenon makes it all the more important to introduce it as an explicit goal for technology development and design. In the next section we turn to Warm Technology as one example of what a design approach to promoting world-familiarity might look like.

### **10.4 Warm Technology: Designing to Support Fragile World-Familiarity**

An alternative approach to technology design, termed Warm Technology (IJsselsteijn et al., 2020) has recently been formulated in the context of designing for and with people with dementia. Since loss of world familiarity is central to the phenomenology of dementia, the case of designing for dementia using the Warm Technology approach helps underscore the potential as well as the normative signifcance of using technology to support world-familiarity and, relatedly, well-being. Furthermore, refection on how world-familiarity for people with dementia can be supported through digital technologies is particularly urgent during these pandemic times. As social distancing measures have had a particularly devastating impact on people with dementia, it is tempting to turn to digital technologies as quick technological fxes for this pressing social problem (Cheung & Peri, 2021). Our worry is that the pandemic could motivate the development and adoption of digital interventions that fail to incorporate a robust refection on how exactly digital technologies must be designed such that they genuinely support people in fnding or retaining meaningful access to social and practices spaces. To make our case we take a closer look at how Warm Technology approaches the design for people with dementia.

Dementia is not a single disease.  Central to the dementia experience is a loss of world familiarity, which comes in different guises. Dementia, as it progresses, is associated with a loss of temporal and spatial awareness, loss of episodic and semantic memory, loss of cognitive planning and control functions (e.g., not being able to coordinate one's behavior, such as cooking a meal, or making an appointment), loss of language abilities, and loss of sensory-motor functions and skilled behaviors. The familiar slowly becomes strange and confusing. One may get lost on well-traveled routes to and from home, or disoriented in familiar places such as a shopping mall or local park. One may forget words, and names of familiar objects, activities or events. Everyday appliances, such as a remote control or mobile phone, become increasingly opaque and inaccessible. Daily chores, rituals and habits become complex and disorganized. People that were once intimately familiar become mixed up with others or altogether hard to recognize. The trusted may become suspect. Attempts at sense-making – to integrate experiences over time and to form a coherent foundation of one's identity and understanding of the present moment – become unanchored from reality, transforming into a gap-riddled and incoherent patchwork of distorted memories, perceptual hallucinations, and confabulation. Eventually, one may lose all sense of understanding, of self-effcacy, of control over one's environment, and one's own body and mind. This is frequently aggravated by a necessary, sometimes forced, move to a care residence, with its dramatic shift in both physical and social contexts – moving from familiar surroundings to deeply unfamiliar ones. All this may result in feelings of alienation, apprehension, confusion, frustration, loneliness, anxiety, or apathy. These processes do not happen overnight – people live with dementia for years while enjoying a relatively good quality of life. Also, there are signifcant variations depending on the type and stage of dementia, individual differences, and availability of psychosocial and physical support. Even with progression of the disease, many worthwhile experiences are retained to quite advanced stages of dementia, including appreciation of music, of social company, and affective social touch.

In recent years, the health care technology space has witnessed the development of a wide gamut of digital technological interventions aimed at ameliorating some of the challenges caused by dementia. As we fagged earlier, we can expect that this trend will only accelerate as a result of the pandemic's ubiquitous social distancing measures. Some see this this as a welcome "technology evolution in dementia practice," arguing that "health policy makers, service providers and clinicians should take hold of these innovative opportunities and support the technological transformation of dementia practice in the coming years" (Cheung & Peri, 2021). But the proof is in the pudding and will depend on the types of digital interventions pursued and the manner in which these interventions are designed. Typically, technological interventions used in dementia care settings include ambient assisted living, telecare systems, social robots, and internet of things technologies. The *Warm Technology* approach has emerged as a critical reaction to many of these developments. The underlying problem is that these standard 'cold technology' approaches tend to prioritize what is technologically possible instead of what makes sense from the viewpoint of the lived experiences of people with dementia, whose world-familiarity is increasingly fragile yet crucial to their well-being.

When designing Warm Technology for and with people with dementia, the importance of world familiarity is foregrounded in different ways. First, Warm Technology recognizes the diversity of needs, abilities and resources of people living with dementia. With or without dementia, older adults represent a growing and highly diverse group. Old age is not a uniform stage of life for everyone aged over 65, as some developmental models suggest, rather it is a rich, multiform, non-linear, culturally contextualized and deeply personal process. Furthermore, there is growing cultural and ethnic variation amongst seniors in Western countries. Some are tech-savvy or may have had professional careers that involved tech. Many are well-educated, well-traveled, and in relatively good health. Although clearly the dementia experience will play a role in one's personal identity, experience and outlook on life, it does not defne a person. As IJsselsteijn et al. (2020) write: "design efforts to support people living with dementia should not focus on the support, substitution or amelioration of functional decline, but on better ways of affrming old age – enabling people to remain open and attached to the world and to other people, and, as Lynne Segal (2013) so beautifully put it, 'staying alive to life itself'" (p. 33). Technologies designed from a defciency-frst instead of person-frst perspective tend to translate into interventions such as large red alarm buttons to be worn as a necklace, tracking devices enabling care-takers to monitor the whereabouts of wandering individuals with dementia, or mobility support ('walkers') designed as medical devices. Such interventions, which, promote a medicalized view of the individual tend to be experienced as stigmatizing and alienating. As Don Norman, himself in his mid-80s at the time of this writing, lamented in a critical essay on technology designed for seniors:

Despite our increasing numbers the world seems to be designed against the elderly. Everyday household goods require knives and pliers to open. Containers with screw tops require more strength than my wife or I can muster. (We solve this by using a plumber's wrench to turn the caps.) Companies insist on printing critical instructions in tiny fonts with very low contrast. Labels cannot be read without fashlights and magnifying lenses. And when companies do design things specifcally for the elderly, they tend to be ugly devices that shout out to the world "I'm old and can't function!" We can do better. (Norman, 2019).

Second, and relatedly, when designing for world familiarity, Warm Technology puts the person's lived experience at center stage, connecting to their personal and family history, their cultural background and upbringing, their local context and community, as well as diversity in literacy and skillsets, technological or otherwise. Familiarity with technology may differ substantially, in part because it will depend on the dominant technology of people's formative years (i.e., one's technology generation – Docampo Rama et al., 2001). In terms of technology design, this may imply referencing familiar form factors and interaction metaphors from the formative years of the elderly person. A recent example of this is the StayTuned radio – a communication system designed by Marjolein Wintermans – den Haan (Wintermans et al., 2017). This 'radio' combines the WhatsApp messaging application with a familiar 60s radio exterior, allowing people to scroll through recorded voice messages of their loved ones using a simple turning knob on a familiar radio interface.

Third, Warm Technology acknowledges the importance of rich multimodal sensory experiences when interacting with the world. Instead of populating the environment with hidden sensors and actuators, touch-screens, virtual agents, or robotic devices, Warm Technology means designing for everyday interactions using everyday objects. This preserves the important affordances of objects and their intuitive relation to the dexterous and perceptual skillsets of a person – easy to recognize and to make sense of. In general, it also implies a preference in designing strong-specifc, tangible systems over weak-general, virtual ones – typically steering clear from complicated, multi-layered, multi-purpose ('integrated') systems. In short, Warm Technology focuses on the affordances of familiar objects, and thereby adds to the world familiarity of designed technology interfaces.

Thus, Warm Technology is marked by two key constitutive elements. First, it is born from an emancipatory view of living with dementia. It is to de-emphasize disease and defciency, and instead focus on the unique identity of the person, on the myriad of ways in which the person inhabits their world as a place of familiarity.

The second essential ingredient of Warm Technology, directly following from the frst, is to work closely with people with dementia as part of the design process. Many innovations to date have been designed based on the possibilities of technology (a tech-push approach), or based on inputs from people *around* the person with dementia – for example, family members, informal carers or care professionals. Important and valuable as these perspectives are in their own right, they cannot substitute for the frst-person perspective of the person with dementia. Research has shown that different needs, wishes, and requirements emerge depending on the perspective of those involved. The active and continued involvement of people with dementia is of key importance to the design of Warm Technology. In this context participatory practices are proposed and are needed (Suijkerbuijk et al., 2019).

At the same time though, we need to acknowledge that here too, a fundamental tension exists, as noted earlier, of "bringing people in" on the designer's terms. That is, people with dementia are invited to take part in the design process, at the initiative of the designer, and within the value system and implicit assumptions of the design team. This means that the timing of inputs, their nature and expressive bandwidth are, at least in part, enabled and constrained within the design process that is determined by the designer. This observation falls within a larger discourse in research methodology literature on the relation between the researcher(s) and the researched. The privileged position of the researcher in relation to research participants has been a recurrent theme, and perceived asymmetry is both an object of ethical as well as methodological concern.5

### **10.5 On the Importance of Instilling Mechanisms of Defamiliarization in Technology Design**

In the previous section we saw that IJsselsteijn et al. (2020) argue for genuine participation of people with dementia in the design of warm technologies, such that the technological interventions designed for and with them align with their particular sensorimotor skills and personal histories, thus meaningfully contributing to their precariously maintained world-familiarity. Similarly, Shew stresses the importance of placing the perspectives and needs of disabled people at center stage: "Instead of imagining the desires of disabled people … why don't technologists simply ask disabled people what kinds of technological applications we want and need?" (Shew, 2020b, p. 47) Yet, as both Shew and IJsselsteijn et al. recognize, 'simply asking' people isn't as simple as it seems. This is because the types of questions asked, the types of answers given and the importance and meaning attributed to those questions and answers are in part motivated and circumscribed by the wider value systems within which we are embedded. Since ableism is one of such value systems "that all of us participate in, including individual disabled people," cocreation initiatives seem important but not suffcient in technology design efforts to combat ableism and to promote accessibility (Shew, 2020b, p. 46). Bell et al. (2005) argue, for instance, that there is a limit to "user-centered design techniques" when it comes to subverting entrenched pernicious value-systems, because of the emphasis placed on the "current needs and desires" of users. Focusing not on ableism but on patriarchy qua value-system, they maintain that:

Gender assumptions about labor may be built into technology and reinforce stereotypes about who in the home should do what …. Designers have an opportunity to alter these built-in gender assumptions and thereby support different patterns of behavior. This strategy runs counter to user-centered design techniques because it proposes to design not for users' current needs and desires, but to shape alternative needs, desires, and behaviors through design (Bell et al., 2005, p. 168).

The specifc strategy focused on shaping "alternative needs, desires, and behaviors" that Bell et al. are referring to is one of *defamiliarization*, which, compels designers "to examine *their automated perceptions of that which is so familiar* that it seems natural and so unquestionable (Bell et al., 2005, p. 151, our italics). By recontextualizing and reframing "the affordances" of familiar everyday use-objects, such as "door handles, faucets, fling cabinets," we can make them "strange" and

<sup>5</sup>This is not to say, however, that the researched do not bring their own agenda to the research situation.

"defamiliarize[e] the familiar" (Bell et al., 2005, p. 153, referring specifcally to Donald Norman's *The Psychology of Things*).

Bell et al. focus on literary, textual, ethnographic techniques of defamiliarization capable of offering "a lens to help us see our own design practices in a new light" (p. 154). Thus, they propose that defamiliarization is "available as a strategy to anyone with access to a pen and paper, or more likely, a keyboard and a monitor. Defamiliarization is not tremendously diffcult to achieve and most of us have done it before. It is essentially a rich description which renders strange the familiar" (p. 169–70).6 This can bring into view the pernicious dimensions of our habitual ways of inhabiting our world of familiarity.

Alongside these ethnographic techniques, we have already presented the pandemic as an event that has viscerally exposed most of us to the experience of defamiliarization. To capitalize on this experience as a resource for access-promotion, we furthermore want to highlight the powerful mechanisms for defamiliarization that have been forged by disability activists themselves, contributing to the feld of Crip Technoscience. Crip refers to the "anti-assimilationist position that disability is a desirable part of the world, and "technoscience," refers to "the co-production of science, technology, and political life," i.e. the ways in which our scientifc and technological endeavors both form and are formed by shared conceptions of the good life and communal membership (Hamraie & Fritsch, 2019, p. 2). As we mentioned in Sect. 10.2, Crip Technoscience proposes to understand "access as friction" or "as a kind of attack" which "reveals access-making as a site of political friction and contestation" (Hamraie & Fritsch, 2019, p. 10). Furthermore, it foregrounds the long history of disabled agents of access-making, where disabled people have actively hacked, altered, tinkered with sociomaterial environments catered towards 'able-bodied' world-familiarity to not only make these environments more conducive to disabled forms of inhabiting the world, but also to explicate and critique entrenched habitual and often ableist ways of experiencing the world, promoting "practices of critique, alteration, and reinvention of our material-discursive world" (Hamraie & Fritsch, 2019, p. 1).

For instance, Collin Kennedy's act of "protesting hospital parking prices by flling the pay-slot on a parking meter with spray foam," defamiliarizes habitual takenfor-granted capitalistic norms of effciency dictating what constitutes as a normal pace for moving through the world (Hamraie & Fritsch, 2019, p. 12). For another powerful example that illustrates this form of critical access-promotion through Crip Technoscientifc acts of defamiliarization, consider "Deep Sea Diving … in a

<sup>6</sup>Many qualitative traditions attempt to minimize the distance between researcher and research participant. A particular example, from design research with elderly communities, is the development of the cultural probe method as a way to rebalance this negotiation, and to subvert the roles of the designers and those "to be designed for". Cultural probes are themselves designed to allow for more agency on the part of the participant – more expressive and creative ability, choice and freedom whether, when and in what ways to partake (See Gaver et al., 1999). Here too, defamiliarization techniques could play an important role, in particular to uncover value systems and default implicit assumptions in how to design for and with people living with dementia.

Wheelchair" – a TED talk in which artist and disability rights activist Sue Austin presents the various ways in which she has altered her wheelchair in order to claim her visibility in social space by challenging people's implicit habitual ways of seeing what wheelchairs afford. Seeking for new narratives to reclaim her identity, Austin purposely "transform[s] perceptions by revisiting the familiar." Among other things, Austin turns her wheelchair (or power chair, as she prefers) into a deep sea diving device. As viewers of Austin's work watch her explore the ocean's corals in her under-water power-chair, arms spread wide, she wagers that

In that moment of them seeing an object they have no frame of reference for or so transcends the frames of reference they have with the wheelchair they have to think in a completely new way. …. For me this means that they are seeing the value of difference, the joy it brings, when instead of focusing on loss or limitation, we see and discover the power and joy of seeing the world from exciting new perspectives. For me the wheelchair becomes a vehicle of transformation. … Because nobody's seen or heard of an underwater wheelchair before … creating this spectacle is about creating new ways of seeing, being and knowing. (Austin, 2012)

Though ableism as a pernicious value-system has been materialized into the world through a wide range of technological artefacts and sociotechnical systems, it is also through the tweaking of artefacts and the disruption of sociotechnical systems that entrenched ways of seeing disabled people and perceiving our everyday world of familiarity can be called into question and new unfamiliar ways of imagining the world can open up. We wager that the mechanisms of defamiliarization offered by the feld of Crip Technoscience, positioned as forms of access promotion, provide a powerful resource for technology developers and designers who follow the premise of our argument, namely that promoting accessibility (and resisting ableism) is a moral imperative in technology development. Finally, a commitment to Crip Technoscience's mechanisms of defamiliarization can be reinforced by tapping into what we have presented as an important phenomenological feature of the pandemic; namely the sense in which the pandemic can be understood as a mass-scale event of defamiliarization, confronting many of us with the intimate but often taken-forgranted link between well-being and having access to a world of familiarity.

### **10.6 Conclusion**

In his commencement speech 'This is Water", David Foster Wallace offers the following anecdote:

There are these two young fsh swimming along, and they happen to meet an older fsh swimming the other way, who nods at them and says, "Morning, boys, how's the water?" And the two young fsh swim on for a bit, and then eventually one of them looks over at the other and goes, "What the hell is water?" … The immediate point of the fsh story is that the most obvious, ubiquitous, important realities are often the ones that are the hardest to see and talk about (2005, p. 2).

Wallace calls on us to develop "simple awareness — awareness of what is so real and essential, so hidden in plain sight all around us, that we have to keep reminding ourselves, over and over: "This is water, this is water." It is unimaginably hard to do this … day in and day out" (2005, p. 8). This diffculty applies to everyone, including those of us who live our lives as technology developers and who, in this capacity, "are the unacknowledged legislators of our technological age" (Winner, 1990, p. 59).

What Wallace calls water, we have called world-familiarity and we have argued that inhabiting the world as a place of familiarity plays an integral role in our thriving as agents – the pandemic, which has pervasively disrupted people's worldfamiliarity, has underscored as much. Of course, many disabled and chronically ill people have always been aware of this as they confront a world that is, for the most part, neither designed for them nor by them. That world-familiarity is deeply central to well-being is recognized in the Warm Technology approach, which aims to promote accessibility through technology development. However, because worldfamiliarity turns on the habitual, because, in Wallace's words "it is unimaginably hard" "to keep reminding ourselves …' This is water," designing for worldfamiliarity demands acts of defamiliarization, through which we critically examine whose world-familiarity we are in fact designing for to. As such, we have suggested that promoting accessibility involves a readiness to oscillate between two normative imperatives: (1) recognizing how human well-being depends on world-familiarity, which, in turn, can be materialized through design and (2) recognizing how worldfamiliarity can harbor pernicious biases that can be called into question through material gestures of *defamiliarization* (Bell et al., 2005). While the pandemic itself has offered many, if not all, of us a visceral experience of defamiliarization that can serve as a reminder in endeavors of access-promoting technological interventions, we also need tangible mechanisms and frameworks that can guide such projects. As such, we have presented Crip Technoscience as an important resource for defamiliarization – a resource that doesn't frame disabled people as waiting to be included in 'our' world of familiarity, but that actively disrupts some of 'our world's' basic organizing biases, assumptions and value-commitments.

By presenting these two perspectives as mutually required in efforts to design for accessibility, we hope to better enable technologists and laypersons alike to refectively evaluate if and how a technological innovation may (or may not) be accesspromoting, such that it can contribute to a more just post-COVID world; a world where we can all not merely survive, but thrive as precarious embodied worlddependent beings.

**Acknowledgments** This work is part of the research programme Ethics of Socially Disruptive Technologies, which is funded by the Gravitation programme of the Dutch Ministry of Education, Culture, and Science and the Netherlands Organization for Scientifc Research (NWO grant number 024.004.031).

### **References**

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### **Chapter 11 Understanding Risks and Moral Emotions in the Context of COVID-19 Policy Making: The Case of the Netherlands**

**Sabine Roeser**

### **11.1 Introduction**

A Chinese colleague said in early March 2020: "My Chinese friends and I are very concerned. We have seen what happened in China. This is not just any virus. We don't understand that Western countries do not take stricter measures." In the beginning of the COVID-19 pandemic, many people in Western countries, including politicians, took pride in publicly stating that they were not worried about the Sars-Cov-2 virus. For example, Dutch prime minister Mark Rutte insisted to shake hands with a journalist when asked about safety measures concerning social distancing. In various respects, the Netherlands were late in introducing measures that were already urgently recommend by the WHO (NOS, 2021d). Likewise, some virologists assured the public that COVID-19 was nothing more than just another fu virus from which they could not get sick because only people with vulnerable health conditions were susceptible. Potential worries were explained away. For example, in February 2020, in pieces for major news outlets, psychologists Paul Slovic and Daniel Kahneman as well as legal scholar Cass Sunstein claimed that supposedly exaggerated reactions to the COVID-19 virus could be elucidated by an opposition between reason and emotions. They argued that people's perception of risk is driven by 'irrational' emotions based on which people close themselves off from scientifc facts (Fisher, 2020; Sunstein, 2020). Slovic and Sunstein stated that worries about COVID-19 could be readily explained via this framework. A few weeks later, almost the whole world went into lockdown, but it was already too late to stop this supposedly harmless virus, the pandemic was a fact, and the rest is history.

If these experts and politicians were wrong in their initial assessment of the virus, could they also be wrong about their dismissal of emotional responses that

S. Roeser (\*)

Delft University of Technology, Delft, Netherlands e-mail<EMAIL_ADDRESS>
<sup>©</sup> The Author(s) 2022

M. J. Dennis et al. (eds.), *Values for a Post-Pandemic Future*, Philosophy of Engineering and Technology 40, https://doi.org/10.1007/978-3-031-08424-9\_11

did highlight concerns about the virus at an early stage? And could we learn important lessons from this, leading to more appreciation of emotions and underlying ethical values and concerns? This is the idea I will pursue in this chapter.

### **11.2 COVID-19 and Emotions**

In his initial speeches about COVID-19 policy, Dutch Prime Minister Mark Rutte repeatedly emphasized the importance of listening exclusively to medical-scientifc experts, particularly the virologists and modellers of the National Institute for Environmental Studies (RIVM) and the Outbreak Management Team (OMT). He explicitly said that we should not listen to historians and lawyers, for example, and that we should not "philosophize". Closing the schools in mid-March 2020 wouldn't have been scientifcally necessary, but here people have "voted with their feet" (NOS, 2020). Interestingly, a few weeks later, Rutte mentioned that he had been pondering on "dilemmas". However, he still explicitly stated that he would only listen to medical and virological advice, thereby dismissing possible expertise on addressing dilemmas, such as from philosophers and social scientists.

Notably, many people were (and still are) worried because of the impact that policies may have on public health, the economy, and the way of life people are used to. Some are concerned whether it is responsible to send their children to school or to go outside without a mask. Others are angry because they perceive the measures as too strict and because their income is at stake. Until vaccines were available in early 2021, many older people in care homes languished in loneliness during various lockdowns because their loved ones were not allowed to visit. The question is how policy makers and politicians should deal with such emotions and worries, and how philosophical research may shed light on this. In this chapter, I will argue that emotions such as empathy and compassion, as well as resentment and concern, can help to make critical moral dilemmas explicit and thereby contribute to taking moral considerations into account when policy decisions are made about virus-restriction measures.

Obviously, it is crucial to uncover the relevant scientifc facts to make important decisions on dealing with a pandemic. But I will argue in this chapter that addressing the COVID-19 crisis and making decisions about trade-offs between different risks is not just a matter of gathering scientifc information and listening to scientists, as crucial as that is. Scientifc information is *necessary* to make assessments and policy decisions in such a crisis situation, but not *suffcient*. We also have to take into account societal and ethical considerations, which requires explicit ethical refection and attending to emotions. This argument is grounded in my philosophical approach, according to which emotions can play an important role in ethical refection (e.g. Roeser, 2011, 2018).

My ideas go against the dominant scientifc and political approaches to risk and emotion. As mentioned above, scholars such as Paul Slovic (2010), Cass Sunstein (2005) and Nobel Prize winner Daniel Kahneman (2011) think that all kinds of misunderstandings about risks and statistics can be explained by a contradiction between reason and emotion, so-called 'Dual Process Theory' (DPT). According to DPT, we process information via two distinct systems, "system 1" versus "system 2". System 1 is said to be based on emotion and intuition, and while fast, it is unreliable. System 2 is based on rationality and analytical thinking. System 2 is slower but much more reliable than system 1. According to Kahneman, Slovic, Sunstein, and other psychologists and decision theorists, all kinds of misunderstandings about risks and statistics can supposedly be explained by this: people respond emotionally in their risk perceptions (system 1) and therefore close themselves off to scientifc facts (which require system 2 processes).

However, many emotion researchers from psychology and philosophy reject the reason-emotion dichotomy that underlies Dual Process Theory. Instead, they have developed so-called cognitive theories of emotions. The renowned Dutch psychologist Nico Frijda (Frijda, 1986) considered emotions crucial for our appraisals and actions. Philosophers Robert Solomon (1993), Martha Nussbaum (2001) and Bob Roberts (2003) have argued for the importance of emotions for our moral thinking. The neuropsychologist Antonio Damasio (1994) has shown that people who seize to have emotions due to specifc brain damage can no longer make practical and moral decisions. These ideas give us a very different and much richer understanding of emotions: emotions are not by defnition at odds with rationality as dualistic views of emotion and rationality, such as DPT, entail. Rather, emotions can be an important source of moral refection and deliberation (Roeser, 2011; Furtak, 2018). Emotions can point to what morally matters. Of course, emotions can also be misguided, but that holds for all our sources of insight. Instead of dismissing emotions, we should see them as an important source of ethical refection in the context of risks. Emotions can draw attention to important ethical considerations that are frequently overlooked in quantitative, STEM-based approaches to assessing risks. Emotions such as sympathy, compassion, care, and feelings of responsibility can highlight ethical concerns such as justice, fairness, and autonomy. In my previous work, I have argued that these ideas can shed a different light on the role of emotions in decision making about risks, primarily in the context of technological risks (Roeser, 2018). In the remainder of this chapter, I will apply these insights to decision making about COVID-19.

### **11.3 COVID-19, Risks, Uncertainty, Complexity, and Ethics**

The dominant approaches to decision making about risk view emotions as a source of irrationality. A standard approach to decision making about risks is, therefore, to rely solely on scientifc expertise. This is what I would call the "technocratic approach"; quantitative information is guiding, public concerns are dismissed as irrelevant. A common alternative strategy is what I call the "populist approach"; here, the public's will is seen as leading. Even if the public's will is attributed to supposedly irrational emotions, it is still followed, either for seemingly democratic

or pragmatic (instrumental) reasons to avoid public opposition (cf. e.g. Loewenstein et al., 2001, De Hollander & Hanemaaijer, 2003). However, both approaches fall short because they do not take emotions and underlying values seriously. In neither approach is there a genuine dialogue and deliberation about the values that are at stake (Roeser, 2018). Technocratic risk approaches rely solely on descriptive information and consequentialist methods such as risk-cost-beneft analysis. But such approaches contain implicit and often problematic value judgments. Only net impacts at a high level of aggregation are considered, and often only a limited type of impact, such as the number of deaths. For example, issues such as justice, fairness and autonomy are usually overlooked in such approaches, as are long-term consequences for health and (psychological) well-being (cf. Roeser, 2006; Asveld & Roeser, 2009). Let us begin by zooming in on the ethical intricacies of decision making under risk and uncertainty. After this, in the following section, I will argue that policy measures to combat COVID-19 are intrinsically value-laden. I will then proceed to explore how emotions can contribute to highlighting these ethical issues.

As mentioned above, at various crucial moments, the Dutch government explicitly stated that they would follow the technocratic approach by directly acting on the advice of the STEM-based RIVM and OMT. It can be argued that it is not the task of such STEM-based policy organizations to include ethical considerations in their recommendations. STEM-based approaches are limited to discerning the facts relating to the transition of COVID-19. However, this means that there is an important, unaccounted for 'is-ought gap'1 between descriptive STEM data and policy decisions, which also have important normative dimensions. One could solve this by having the following separate steps: frst, gather the descriptive information, and then have an intermediate step of ethics evaluation before policymakers make decisions based on both steps. However, things are even more complicated: descriptive research also involves normative assumptions, e.g. concerning how to measure, assess and compare data, specifcally in the context of risk and uncertainty (Roeser et al., 2012). To account for these issues, even STEM-based councils should include social science experts (to account for the impact and role of society) as well as ethicists to point out implicit ethical and other normative assumptions, highlight ethical dilemmas, and provide for explication of ethical considerations to make these transparent and object of critical deliberation by policymakers and societal stakeholders. This is the case with various governmental advisory boards in the Netherlands, e.g. at the COGEM (committee on genetic modifcation), as well as the Dutch Health Council, which also provides advice concerning e.g. COVID vaccinations. Ethicists have also been involved in the development of COVID-19 track-and-trace apps. Despite this, ethicists have not yet been involved in decision making on the policy measures, even though these measures include many pressing ethical considerations. This means that these ethical considerations have either been ignored, not made explicit, or dealt with haphazardly without consulting ethics experts' relevant

<sup>1</sup>The 'is-ought gap' refers to the issue that one cannot derive a normative conclusion ('ought') from solely descriptive information ('is') (cf. Hume, 1975 [1739–40], Moore, 1988 [1903], Prichard, 1912 etc. for diverging analyses of the implications of this gap).

expertise. This is not to say that ethicists should have the fnal word on such vital issues. Still, they could play an important role in explicating ethical considerations and highlighting potentially ethically problematic decisions. I will illustrate this in what follows by discussing various aspects of Dutch COVID-19 policies.

There are methodological issues of risk, uncertainty, and complexity that give rise to ethical issues. The measures policy makers implement directly impact the development of the pandemic. Furthermore, numerous actors are involved, and the virus may develop in unforeseen ways, with scientifc knowledge lagging behind. This can lead to complex interaction effects, high uncertainty, and a lack of predictability. As pointed out by the critical 'Red Team', COVID-19 should be seen as a case of complexity, requiring different decision-making approaches than conventional, more predictive types of risk. The Red Team was an interdisciplinary team of Dutch scientists (from STEM as well as the social sciences) that criticized the approach of the Dutch government to deal with the pandemic. In 2020, the Red Team strongly infuenced Dutch public opinion via social media, as well as being consulted at certain stages of the pandemic by the government. However, they were silent for most of 2021. They recently announced that they had decided to stop working altogether, as their advice was largely ignored and was fundamentally at odds with the strategy of the Dutch government. The Red Team advised to keep infection rates low via early lockdown measures and tracking and tracing. In direct contrast, the Dutch government has from the beginning followed a strategy that primarily steers at preventing the health care sector from getting overburdened, in the meantime being reluctant to employ safety measures.

In recent reports, it has been argued that the initial Dutch, UK, and Swedish approaches to strive for so-called heard immunity were irresponsible, infeasible from the start, and eventually led to thousands of unnecessary deaths. Interestingly, the Dutch government later denied having had such a strategy. Instead, they claimed that they only wanted to achieve herd immunity as a side effect, not as a goal in itself. However, publicly available information such as press communications from the early days of the pandemic as well as internal documentation clearly shows that this was the initial strategy in the Netherlands (cf. NOS, 2021a, b, c). Such wavering communications obviously do not contribute to public trust, which is already a delicate issue given the controversies about different COVID-measures and the various other scandals that the Dutch government and political institutions are currently involved in.2

Ethical decision-making about risks presents us with different challenges than ethical decision-making about options where the outcomes are easily predictable or

<sup>2</sup>The Dutch government fell in January 2021 due to the so-called 'toeslagenaffaire', i.e. a more than 15 year long systematic tax scandal based on racist and other biases, with widespread consequences for numerous people, and continuously growing evidence of the failure of the rule of law. Since then, various other scandals have emerged that would presumably have led to the falling of the government, if it hadn't stepped down already. Despite elections in March 2021, as of December 2021, the date of fnalizing the writing of this chapter, there is still no new government, and the most likely new government is a continuation of the previous coalition.

even fxed, as argued by the Swedish risk ethicist Sven Ove Hansson (2009). Hansson has argued that there is a signifcant ethical difference between so-called "type-1" errors and "type-2" errors, i.e. false positives versus false negatives. In scientifc research, we aim to prevent false positives, that is, false claims that something is the case. But in the context of, for example, policy making about health risks, we want to avoid false negatives, that is, false claims that people are safe while they are at risk. This is based on an ethical consideration, namely that it is prudent to be cautious when dealing with health effects for human beings, in other words that we would rather be safe than sorry. In the context of a pandemic, this can support following the precautionary principle: we don't know how the contagion curve will play out, so it is better to intervene early and be extremely cautious, rather than reach a point where it's too late to prevent disastrous consequences.

For example, the Dutch RIVM had to adjust previous information: initially, it said that Sars-Cov-19 would not be a dangerous virus, not much more than the normal fu. Furthermore, the RIVM initially stated that Sars-Cov-19 could only be spread by people who have symptoms, and therefore not by children as they hardly get sick from COVID-19; they furthermore maintained that aerosols do not play an important role in the spreading of this virus, and that face masks are unnecessary. We now know that all of these claims are wrong. Interestingly, the RIVM and OMT maintained these claims for many months, even in the light of countervailing evidence from other countries, as well as the WHO. Presumably, the OMT and RIVM held on to very high scientifc standards concerning suffcient evidence about these matters: as long as it is not entirely clear that these hypotheses are true, they are rejected in order to avoid false positives. As was discussed above, while these are important standards in the context of scientifc research, they may not be suitable in the context of public health measures where prevention can also be an important concern, and these standards may not be responsive enough in an urgent crisis. In the words of World Health Organization health emergencies programme executive director Dr. Mike Ryan from 14 March 2020 [sic]:

Perfection is the enemy of the good when it comes to emergency management. Speed trumps perfection, and the problem in society we have at the moment is everyone is afraid of making a mistake – everyone is afraid of the consequence of error. But the greatest error is not to move. The greatest error is to be paralyzed by the fear of failure (WHO, 2020).

A precautionary approach could have involved a 'what if' exercise at an earlier stage: let's assume the worst and start planning how to deal with this situation. Communicating the diffculties of dealing with uncertain information and complex developments can also help, much more than downplaying these diffculties and claiming certainty. Downplaying uncertainty can easily backfre when things turn out differently (cf. Van Asselt & Vos, 2006), as this will lead to distrust. Striving for certainty cannot always be a priority in situations that are intrinsically uncertain and highly complex, while stakes are high and urgent decision making is needed. As I will discuss in Sect. 11.5, emotions such as compassion and care can highlight important ethical considerations, such as precaution. But frst in the following section I will zoom in in more detail on the value-ladenness of COVID-19 policy measures.

### **11.4 The Value-Ladenness of COVID-19 Policy Measures**

The previous discussion highlights that decision-making about possible COVID-19 precautions and their intended positive and negative effects requires ethical refection. I will now zoom in in more detail on various policy options, by highlighting that they involve important values that need to be deliberated on. In Sect. 11.5 I will then argue that emotions can play an important role in such a deliberation.

In schematic terms, the following COVID-19 strategies can be distinguished. Each comes with underlying assumptions about values and ethical implications:

In the early stages of the pandemic, different countries chose various strategies. They also switched or mixed aspects of these strategies, depending on developments of the pandemic as well as on other societal factors. This is because the development of the pandemic does not just rely on virological issues; it also depends on socio-political and behavioural issues. This means that it requires insight of impacts of behaviour and strategies, as well as refection on the signifcant ethical implications of these strategies, by explicating underlying values.

It is crucial to explicitly face the question of how to evaluate different scenarios on how to respond to the COVID-19 crisis. This involves considering available alternatives and their respective advantages and disadvantages, each of which requires ethical refection. Which values are at stake? How can we assess, compare, and weigh them? Values such as the inconvenience and drastic consequences of social distancing must be weighed against values such as protecting public health and containing a pandemic promptly. This relates to the ethical question as to how to balance direct versus indirect health effects. An example of direct health effects is the need to protect people who are vulnerable to infections. An example of indirect health effects is the need to mitigate the consequences of lockdowns for those who are disproportionally vulnerable to them (e.g. children, young people, people working in the hospitality and cultural sectors).

In any case, those most vulnerable in society will be disproportionally most exposed to the risks of a pandemic. People without health insurance, a steady income, and proper housing are more exposed, for example. These people have fewer means available to ameliorate the impacts of exposure to the virus or lockdown measures than wealthy people and citizens of affuent countries with wellfunctioning and accessible public health services. The social disruption of a lockdown, for example, is much more profound in a society that does not have a robust social safety net. In a society with such facilities, people whose jobs are at risk due to social distancing policies have better protection, and society's implications will be less disastrous. Finally, the existing political and socio-economic infrastructure in a society is based on ethical considerations. These contextual features need to be considered when ethically evaluating scenarios on how to deal with this and future pandemics.

Furthermore, is increasing herd immunity ethically acceptable if it means that some people will end up in intensive care units when they would not have gotten sick under stricter measures? Given the (specifcally in the early stages of the pandemic) uncertain knowledge surrounding the possible immunity against the SARS-Cov-2 virus, can it be ethically defended to make such an assumption? How to deal with 'triage', that is, how to compare the need for ICU treatment of different patients? In the Netherlands, Covid-19 patients with urgent health care needs are prioritized above other patients who are waiting for non-emergency surgery, and COVID-19 patients stay signifcantly longer in ICU units than other patients. This means that increasing hospitalization of COVID-19 patients has signifcant health effects for people with other, less urgent but also eventually life-threatening conditions.

Fundamental and diffcult, if not impossible to answer, ethical questions such as 'what is the value of a human life?' are at stake here. Do we opt for a consequentialist approach to assign a monetary value to human lives, while also allowing human lives to be traded off against each other and other monetized considerations? Or are human lives of intrinsic value, meaning that they cannot be put into a simple equation? The latter seems to be a rhetorical question. From an emotional point of view, we experience the life of a loved one, for example, as infnitely valuable. Deontological approaches in ethics seem to ft better with this insight because they say that we should not use people merely as a means. On the other hand, it is evident that government policies need to balance deontological and consequentialist considerations.

Furthermore, there are ethical questions related to civil liberties, freedom of choice and privacy. Several countries have adopted measures requiring COVID-19 passes, showing that citizens are 'safe' if they have been: (1) fully vaccinated, (2) recovered from COVID-19, or (3) recently tested negative. The privacy of citizens is preserved to a signifcant degree by not needing to show which of the three criteria they meet. Others see this as a disproportionally restrictive measure, which is unsuited for a liberal society. However, respecting people's freedom of choice here comes at the price that vulnerable people – e.g. those who have immune defciencies and therefore have no or limited choice – are less protected. Even though freedom of choice is of vital importance in a liberal society, we always have to make concessions and trade-offs between individual liberties and societal concerns, i.e. the

liberty, safety, and health of other people. Safety measures may provide a reasonable trade-off, such as wearing masks and COVID passes.

A crucial issue is that between distributive and procedural justice. While from a distributive justice perspective, it seems fair to have such preventive measures, from a procedural point of view it is essential to have fair means of decision-making that are also experienced as such. Politicians could convey more explicitly that in their decisions, they also take into count ethical and societal concerns and engage with the views of societal stakeholders before making – often complicated – decisions that require trading off or balancing important values. Doing this may have the effect of showing the public the complex value trade-offs that are required in a public health crisis. Such transparency can help the public to see that the decision making was complicated but fair. Making the diffcult moral dilemmas and trade-offs explicit as well as reminding people of the responsibilities towards others that come with individual liberties, and appealing to solidarity, can make an important contribution in public deliberation and support for measures. However, these important moral arguments have only rarely been made explicitly by politicians in the Netherlands and other countries.

### **11.5 The Importance of Emotions**

In the previous sections, I have discussed the ethical intricacies of risk assessments and the value-ladenness of COVID-policy measures. The technocratic approach that politicians have primarily used does not suffce to address these issues, but neither would a populist approach be a solution. As mentioned above, populist approaches merely follow the dominant view in society at a particular moment, rather than explicitly addressing the concerns and values at stake. This avoids the problematic ethical deliberations that are sorely needed. Emotions such as compassion, feelings of responsibility, and care can help highlight these ethical aspects. More generally, emotions such as sympathy, empathy, and indignation can play an important role in alerting us to ethically relevant aspects of risks. These and other emotions are at stake within the public at large. Addressing these emotions in explicit ethical deliberation would mean that ethical concerns of the public could be seriously addressed, rather than waved off as in the technocratic approach, or superfcially followed without further refection as in the populist approach, leading to wavering and inconsistent policies.

When thinking about COVID-19 measures, the emotions of diverse stakeholders could therefore play an essential role in highlighting ethical issues and doing justice to important values. The emotions in society can be an essential source of moral insights; indeed, some of the ethical considerations I have mentioned have also been raised by concerned citizens. But, of course, emotions can also be misleading, like all our sources of insight. Emotions can unnecessarily infate risks, letting them appear overly frightening. At the same time, emotions can make us overlook latent dangers. Intense emotions can magnify our own suffering and thereby ignore the suffering of others (Steinert & Roeser, 2020). This means that emotions must be critically assessed based on scientifc information and ethical refection. But emotions themselves can also play an important role in the latter. Elsewhere, I call this 'emotional deliberation' (Roeser & Pesch, 2016, Roeser, 2018). Furthermore, people's emotions and ethical evaluations can diverge. But rather than eschewing deliberation about these emotions and values, we should engage with them. Such diverging emotions and values can highlight different horns of the complex dilemmas we face. For example, should we require vaccination, e.g. for people working in the care professions or teaching settings or even for all occupations where people interact with each other? Or should we respect people's free choice? But what if that comes at a high price for other members of society, such as people with immune conditions, or those whose medical treatment is getting postponed because of overfull hospitals, or because, say, of secondary health effects due to lockdowns? These are intricate ethical dilemmas, and different stakeholders in society have different views on the best ways to address these. There are, by defnition, no easy solutions to moral dilemmas. Instead, they require deliberation, exchange of viewpoints, arguments and experiences to hopefully come to solutions that are acceptable to a broad range of stakeholders. For example, emotions such as a sense of responsibility and concern for others can contribute to putting one's suffering in perspective and being open to policy options that can contribute to the well-being of others. Furthermore, compassion can help understand the suffering of an individual victim, which can disappear in a cold, consequentialist calculation. Opening up deliberation to such concerns can also overcome seemingly unavoidable trade-offs and open new perspectives, by learning from each other and encouraging creative solutions. This can help devise innovative strategies that do justice to public health, economic resilience, and an ecologically sustainable society at the same time.

One might worry that including ethical deliberation and emotional concerns would delay decision making when quick responses are needed. However, there can be explicit ethical deliberation under time pressure, as well as more extensive ethical deliberation, involving stakeholders etc., when preparing strategies in advance. Emotions can actually contribute to a sense of urgency. I will discuss these issues in more detail in the following section.

### **11.6 COVID-19 Risks, Imagination and Feeling a Sense of Urgency**

Emotions, such as a sense of responsibility and empathy, can encourage us to imagine the implications of alternative action options. Works of art and documentaries can facilitate this and contribute to a sense of urgency that currently seems to be lacking in policy approaches to the COVID-19 pandemic, such as in the Netherlands.

It is striking that aside from the warnings of virologists, artists have also warned of the real possibilities of a severe pandemic. There are many examples of this, but John Suits' 2016 flm, *Pandemic*, maps this out in depth. Despite these warnings from the arts and sciences, policy makers around the globe seem to be continuously improvising about how to respond to the current pandemic. One would imagine that every government should have a range of scenarios available with concrete and adaptive plans for a situation like this. Furthermore, on the level of international politics, strategies for dealing with such a situation should have been prepared in advance, e.g. in the context of the WHO. But presumably, other issues were perceived as more urgent, and as we have seen, the Dutch authorities have frequently put recommendations from the WHO concerning COVID-19 aside.

This happened at various stages of the pandemic, not only in the beginning but for example also in the early autumn 2020, when infection rates in the Netherlands started to increase, presumably due to international travel during summer vacations, schools reopening, and seasonal effects. While some other countries were already taking more precautionary measures, the Netherlands waited until the numbers were so high that harsh lockdown measures were eventually unavoidable, in the meantime implying hospitalizations, severe illness and death as well as overburdening the health sector, which had been trimmed down over the last decades in the light of effciency considerations. Dutch ICU patients had to be admitted to German hospitals at several stages due to Germany's signifcantly larger ICU capacity. A lack of preparedness also surrounded the early stages of the Dutch vaccination strategy. In autumn 2020, the world was getting unexpected good news: much earlier than hoped for, several vaccines proved to be effective and could be available on a large scale within a few months. Dutch newsreaders could learn on a daily basis how the UK, Israel, Germany, and other countries were preparing their vaccination strategies. They didn't hear much about the Dutch strategies until late December 2020. It was then announced that the vaccination would start in early January 2021, weeks later than the countries mentioned above. The Dutch health minister, Hugo de Jonge, justifed this by saying that the Dutch needed more time because they would do things 'thoroughly', implying a less thorough approach by the other countries. Yet, the frst weeks of vaccinating were dominated by news about chaotic and ineffcient bureaucracy, and multiple changes in strategy, while other countries were making quick progress. Eventually, the Netherlands caught up and now has one of the highest vaccination rates in the world. But a lot of time seems to have been wasted in the early weeks and months. More timely preparations could have alleviated COVID-19 numbers and accompanying direct and indirect health burdens, not to mention the sense of despair that many people felt during that time.

At the time of writing this article (autumn 2021) we see a similar situation in the Netherlands as 1 year before. Despite high vaccination rates, infection rates are rapidly rising, presumably due to the much more infectious Delta-variant in combination with seasonal effects and the loosening of measures when infections rates still were low. While there is a lot of societal concern about this, politicians are slowly and only hesitantly responding, again primarily relying on STEM-based advice by the modellers of the RIVM and the medical and virological experts of the OMT, without consulting social scientists and ethicists. This is despite the fact that there is a growing public tension, for example, an opposition between those who are vaccinated and those who are not, and different views in societies on whether more safety measures are needed or not. This is an issue for which the expertise of social scientists and ethicists could be of crucial importance. Yet, these experts are not systematically consulted by the government or policymakers, except consultation of ethicists for specifc medical policy advice concerning vaccination or triage in hospitals and concerning some issues, behavioural scientists at the RIVM and OMT. But, as argued above, all aspects of COVID-policies have signifcant ethical and societal dimensions, thereby requiring systematically involving the expertise of ethicists and social scientists concerning the overall policy measures.

Emotionally charged human capacities, such as imagination, can play an important role in experiencing urgency, as well as in moral deliberation and in developing and thinking about future scenarios. As mentioned above, the work of artists, flmmakers, and writers can play an essential role in such future scenario thinking. Artworks can appeal to the imagination, make abstract problems more concrete and facilitate ethical deliberation on the implications of such future scenarios (Roeser, 2018). Artworks such as (science fction) novels and flms in which the consequences of a pandemic are described can appeal to the imagination, make abstract problems tangible and thereby facilitate ethical deliberation about the implications of such future scenarios. If policy makers can heed the warnings of artists (such as *Pandemic*, for example), then the arts may have potential to help catalyse future pandemic-prevention strategies, taking into account the implications for public health, as well as for the economy and well-being of different population groups.

### **11.7 Conclusion**

The current COVID-19 crisis highlights that decision-making about risks always requires scientifc knowledge to be accompanied by societal and ethical considerations. My approach to emotions in the context of risk offers an alternative to the technocratic or populist approaches used to combat COVID-19. Emotions are a rich and valuable resource that is wrongly rejected in decision-making about risk and uncertainty. The current approach should be enriched, focusing on citizens' concerns, involving ethical refection on different choices and policy options. Emotions such as compassion, feelings of responsibility, and concern can help us refect on the ethical implications of the diffcult decisions we face. In the current situation and coming years, we will need all the sources of insight we have at our disposal to meet the enormous challenges of the COVID-19 crisis as well as possible future pandemics. So indeed, we need to consider the insights of virologists and medical experts. Still, we also need expertise from ethicists, social scientists, and the arts and humanities to take social and ethical considerations into account. In order to take on the severe challenges of this situation, we need to draw on our rich human capacities: scientifc knowledge, insights from social sciences, arts and humanities, and emotional capacities. Rather than dismissing emotions, we should embrace them as a vital resource. Emotions such as compassion and feelings of responsibility and care can help us to refect on the ethical implications of the hard choices we face. They can play an essential role in motivating actions of solidarity and courage that can hopefully contribute to solutions to the ongoing as well as future pandemics.

**Acknowledgements** I would like to thank Matthew Dennis and the other editors for their very helpful comments on an earlier version of this chapter. The chapter incorporates updated and signifcantly expanded passages from a Dutch article: Sabine Roeser (2020), 'Corona, risico's en morele emoties', Tijdschrift voor Bioethiek 27:3 pp. 7–9 (reprinted at the blog 'bijnaderinzien'). Available at: https://nvbioethiek.fles.wordpress.com/2020/07/podium-20-3-naar-een-moreleagenda-na-de-coronacrisis.pdf

### **References**

Roeser, S. (2018). *Risk, technology, and moral emotions*. Routledge.

**Open Access** This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

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### **Chapter 12 How to Balance Individual and Collective Values After COVID-19? Ethical Refections on Crowd Management at Dutch Train Stations**

**Andrej Dameski, Andreas Spahn, Caspar A. S. Pouw, Alessandro Corbetta, Federico Toschi, and Gunter Bombaerts**

### **12.1 Introduction**