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Social Science & Medicine 67 (2008) 128–136

Contents lists available at ScienceDirect

Social Science & Medicine


journal homepage: www.elsevier.com/locate/socscimed

The two facets of electronic care surveillance: An exploration


of the views of older people who live with monitoring devices
Anna Essén *
School of Business, Stockholm University, Kraftriket Bldg 2, 3, & 15, Stockholm 106 91, Sweden

a r t i c l e i n f o a b s t r a c t

Article history: Scholars are increasingly questioning the notion that electronic surveillance merely
Available online 8 April 2008 constrains individuals’ liberty and privacy. However, illustrations of alternative perspec-
tives are few and there is a need for empirical research exploring the actual experience
of surveilled subjects. This study, carried out in Sweden, seeks to offer a nuanced account
Keywords: of how senior citizens experience electronic care surveillance in relation to their privacy. It
Sweden
is based on in-depth interviews with 17 seniors who have participated in a telemonitoring
Telehealth
project and who have experience of being continuously activity monitored in their own
Technology
Surveillance homes. The findings suggest that senior citizens can perceive electronic care surveillance
Privacy as freeing and as protecting their privacy, as it enables them to continue living in their
Elderly care own home rather than moving to a nursing home. One individual, however, experienced
a privacy violation and the surveillance service was interrupted at her request. This illus-
trates the importance of built-in possibilities for subjects to exit such services. In general,
the study highlights that e-surveillance can be not only constraining but also enabling.
Hence, it supports the view of the dual nature of surveillance. The study also illustrates
the agency of the surveilled subject, extending the argument that various agents actually
participate in the construction of surveillance practices. It analyzes the indirect role and
responsibility of the surveilled subject, and thereby questions the traditional roles ascribed
to the agents and targets of surveillance.
! 2008 Elsevier Ltd. All rights reserved.

Introduction (Bentham, 1969; Foucault, 1977), which inspire one-sided


and dystopic views on surveillance. To paraphrase Lianos
Academics have worried about the threats to privacy (2003), contemporary e-surveillance studies routinely refer
associated with electronic surveillance (e-surveillance) for to the erosion of privacy and liberties by sinister and total-
decades (e.g. Davies, 1992; Flaherty, 1989; Floridi, 2006; itarian forces, which ‘‘is damaging as it is superficial and
Garson, 1988; Goodwin, 1991; Lyon, 2001, 2002; Lyon & analytically unfounded, and it pre-empts the feelings and
Zureik, 1996; Mason, 1986; Ogura, 2006; Parenti, 2001; opinions of the public, usually with great inaccuracy’’
Solove, 2006; Weckert, 2001). However, as noted by a large (Lianos, 2003: 414). Similarly, Haggerty and Ericson
number of scholars (e.g. Lyon, 2006, 2007; Haggerty, 2006; (2000) argue that ‘‘far from the negative connotations
Haggerty & Ericson, 2000; Hier, 2003; Rössler, 2005; that tend to be attached to surveillance, many surveillance
Solove, 2001; Vaz & Bruno, 2003; Wood, 2003), the extant practices today are not only supported but encouraged by
surveillance literature is overly dominated by the Big those who serve as the primary targets of data gathering
Brother (Orwell, 1949) and Panopticon metaphors systems’’ (pp. 401). Indeed, the widespread assumption in
the surveillance literature that subjects are surveilled
* Corresponding author. Tel.: þ46 73 971 76 87. against their will is now being questioned (Lyon, 2007;
E-mail address: aes@fek.su.se Pecora, 2002). Few studies have actually explored the

0277-9536/$ – see front matter ! 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2008.03.005
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A. Essén / Social Science & Medicine 67 (2008) 128–136 129

experience of surveilled subjects (Haggerty, 2006; Lyon, The article begins with a definition of privacy. Next,
2006). In general, the contemporary surveillance literature widespread assumptions in the surveillance literature are
tends to analyze surveillance technology in isolation, as problematized in relation to care surveillance and privacy.
given and as inevitably producing certain effects in Alternative perspectives are outlined. Findings from the
a predictable fashion (Ball, 2002; Haggerty, 2006; Haggerty in-depth interviews with 17 seniors follow. The article
& Ericson 2000; Hier, 2003). It therefore fails to give ends with discussion, conclusions, implications and limita-
balanced accounts of how users interact with surveillance tions, which suggest further research avenues.
technologies in practice.
Recently, studies taking the locality and particularity of Defining privacy
e-surveillance applications and the agency of surveilled
subjects into account have however emerged (Dubbeld, There has been a debate regarding whether or not
2006; Fotel & Thomsen, 2004; Koskela, 2006). Drawing on a ‘‘right to privacy’’ exists and even if there is a unified con-
insights from the field of science and technology (e.g. Bijker, cept of privacy (cf. Schoeman, 1984). Warren and Brandeis
Hughes, & Pinch, 1989; Latour, 1987), these studies high- (1890) defined privacy as the right to be let alone. This
light that the operation of surveillance technology is by definition has since been extended and includes various
no means given, but rather contingent on the user-context. multi-dimensional conceptualizations (cf. e.g. Altman,
It is also argued that e-surveillance should not only be 1976; DeCew, 1997; Gavison, 1995; Inness, 1992; Westin,
understood as constraining but also as enabling (Bogard, 1967). Rössler (2005) recently provided a comprehensive
2006; Lyon, 2007). These insights have however not been definition, outlining three interrelated aspects of ‘‘the
used to explore the relation between e-surveillance and private sphere’’: (1) informational privacy (protection
privacy. In general, this perspective is underdeveloped against unwanted access to personal information about
and more research is asked for, in particular as regards the us); (2) decisional privacy (protection against unwanted
view of the surveilled subject (e.g. Lyon, 2006, 2007). interference in our decisions); and (3) local (physical) pri-
Given these weaknesses in the surveillance literature, vacy (protection against the unwanted admission of other
the present paper attempts to provide a nuanced account people to personal spaces or areas).
of individual subjects’ experience of electronic care Empirical studies of patients’ perception of privacy
surveillance in relation to their privacy. Care surveillance focus on hospital or nursing home settings (e.g.
has received little attention in the surveillance literature Damschroder et al., 2007; Parrott, Burgoon, Burgoon, &
(Dubbeld, 2006; Lyon, 2001, 2006, 2007; Vaz & Bruno, LePoire, 1989). This literature suggests that hospital
2003; Wood, 2003). As noted by Vaz and Bruno (2003), patients experience a loss of privacy when they cannot
this neglect may partly be due to the challenge related withdraw or find a personal, private space, e.g. when they
to studying e-care surveillance in a critical fashion. have to share room with other patients (Barron, 1990;
Surveillance and control are integral parts of care and it Marini, 1999; Mattiasson & Hemberg, 1998; Woogara,
is difficult to separate these elements. Nevertheless, elec- 2005). What also emerges from this literature is that
tronic care surveillance technologies such as in-home tel- patients experience privacy violations if they have to
emonitoring are emerging and authors have underlined witness other patients’ problems (Sidenvall, Fjellstrom, &
the pertinence of taking the issue of privacy into account Ek, 1994). This aspect of privacy, which has been neglected
when evaluating such technologies (Bauer, 2002; Hensel, in the surveillance literature, is in this paper referred to as
Demiris, & Courtney, 2006; Von Tigerstrom, 2000). freedom from observing and reacting to others.
Responding to these calls, the paper uses empirical data What emerges from the privacy and care literature is
from the Swedish elderly care setting, exploring how that patients primarily desire privacy in relation to other
care takers perceive that being continuously activity patients rather than in relation to care professionals. It
monitored in their own home affects their privacy. As seems reasonable to assume that patients are relatively
this is a fairly unexplored area, the paper also asks inclined to willingly disclose personal, health-related infor-
more broadly how we can understand e-surveillance mation to care personnel if they believe that this is relevant
and privacy in this context. for the care services to be provided. I will return to this
The findings highlight that electronic care surveillance point below.
can be perceived as enabling by surveilled subjects. The
majority of the seniors in this study feel that electronic Care surveillance as a potential privacy harm
care surveillance can indirectly protect their privacy by
enabling them to continue living in their own homes rather As noted above, much of the surveillance literature
than moving to a nursing home. In general, care surveillance builds on the concept of the Panopticon society (Bentham
makes the majority of the seniors interviewed feel cared for 1969; Boyne 2000; Foucault, 1977), suggesting that e-
and safe rather than constrained. What makes them feel safe surveillance can violate individuals’ privacy by intruding
is however the fact that certain familiar care workers watch on their informational and decisional privacy (e.g. Gandy,
over them. The technology merely becomes a link between 1993; Lyon & Zureik, 1996; Floridi, 2006; Michelfelder,
themselves and the care workers. The study also highlights 2001; Nagel, 1998; Rössler, 2005; Solove, 2006; Udo,
the importance of built-in possibilities for subjects to exit 2001). It is argued that the harm of surveillance is that, if
from the service. One individual experienced a privacy unsure about whether one is watched or not, one must
violation and felt constrained when monitored. The surveil- constantly present oneself as though one were being
lance service was interrupted at her request. observed. The result is inhibition and self-censorship, i.e.
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130 A. Essén / Social Science & Medicine 67 (2008) 128–136

a loss of autonomy in terms of the authenticity of one’s with supervision and ‘‘watching over’’. However, care
behavior, which is turned into behavior ‘‘as if’’. also refers to the concern about and feelings directed to
This view provides significant insights. However, it a person – a person in need. An act of care is generally
highlights certain aspects of surveillance while ignoring thought of as performed ‘‘for one’s own sake’’, i.e. to main-
others. Importantly, studies bringing this view of surveil- tain or improve the surveilled subjects’ health or safety.
lance to the fore build on certain presumptions. For one, Hence, in studies of care surveillance it is important to con-
elites with malign intentions to discipline and exert social sider that care surveillance includes but cannot be reduced
control are the assumed agents of surveillance. Second, to an ambition to control. It can also incorporate an inten-
the intention to control is understood as an ambition to tion to maintain or improve the patients’ health.
constrain the behavior of the targets of surveillance. Third, Let us return to Lianos (2003): he also maintains that
the targets of surveillance are depicted as passive victims. institutional control is often perceived as beneficial ‘‘and
And fourth, the surveillance technology itself is viewed as sometimes even liberating as much as constraining’’ (pp.
the source of negative effects (cf. Bogard, 2006; Dubbeld, 415). Others have recognized the dual function of surveil-
2006; Haggerty, 2006; Lyon, 2007). I will argue below lance (Lyon, 1994, 2001, cf. Giddens, 1984). For example,
that these four assumptions are not easily generalized to Bogard (2006) refers to surveillance both as capture
the care surveillance setting. (fixing a flow, surveillance as determination) and as flight
What makes care surveillance a complex subject of (releasing a flow, surveillance as resistance). Bogard
study is the intertwined relation between control and (2006) argues that to surveil means to guard and he
care (Dubbeld, 2006; Lyon, 2006; Vaz & Bruno, 2003). The writes: ‘‘guardianship is not a simple constraint, but an
work of Lianos (2003) can provide some clarification art of control that makes it safe for something to move
here. Lianos (2003) highlights that institutional control is freely.’’ (Bogard, 2006: 98). From this view, surveillance
integral to specific surveillance activities, but that ‘‘It would practices can in a sense be viewed as freeing. Drawing on
be reductive and unjustified to see such activities as relat- these arguments, this paper assumes that care surveil-
ing exclusively or principally to control’’. He gives an exam- lance can be perceived as both enabling and constraining
ple: ‘‘One could look at a CCTV system which monitors the from the viewpoint of individuals.
traffic on a road network; is this dispositif about repressive Finally, the surveillance literature tends to discuss the
surveillance (traffic offences), detective surveillance (stolen effects of surveillance technologies without considering
vehicles).accident prevention or the improvement of that the consequences of a certain technology are by no
access times for emergency services.?’’ (pp. 415). He means given (Ball, 2002; Dubbeld, 2006). The present
answers that the system is about everything at once. This paper assumes that while a certain technology facilitates
is indeed applicable to the care surveillance setting. The certain behaviors and impedes others, there are also oppor-
intention behind care surveillance includes but cannot be tunities for people to choose how to use and not use the
reduced to a malign ambition to control (cf. Lyon, 2007). technology (Berg, 1997; Bijker et al. 1989; Latour, 1987;
In this respect, the general definitions of e-surveillance Oudshoorn & Pinch, 2003). This perspective makes clear
do not quite capture the meaning of care surveillance. that users are not necessarily victims passively subjugated
E-surveillance is often referred to as the systematic obser- to technological domination or disciplinary surveillance. It
vation and recording of acts of compliance and deviance allows for a consideration of the potential resistance from
in order to manage or influence behaviors by means of users (Ball, 2002, 2006; Dubbeld, 2006; Wood, 2003).
information technology (Clarke, 1988; Lyon, 2001). Dictio- In summary, scholars have begun to suggest alternatives
naries further define surveillance as: ‘‘to watch over; super- to the dystopic and deterministic principles traditionally
vision or superintendence; close observation of a person or applied in the surveillance literature. There are, however,
group. especially one under suspicion e.g. a prisoner, or no empirical studies illustrating how these principles
the like (usually by the police)’’ (Dictionary.com, 2007). work in relation to privacy, in actual empirical settings
While the first definition says little about the intention and from the perspective of the surveilled subject.
behind surveillance, the latter highlights that surveillance This paper seeks to address this gap in the literature by
is associated with observation of ‘‘suspected’’ individuals exploring individuals’ experience of being surveilled in
and is understood as something that is done for the sake relation to their sense of privacy. Privacy here is defined
of others rather than the surveilled. as (1) the freedom to escape being observed or accessed
Can we not watch over others because we care about when desired. This implies protection from unwanted
them, then? Of course, we can suggest this is so (cf. Lyon, access to personal information about us, i.e. informational
2007). Consider the meaning of care: dictionary definitions privacy; unwanted interference in our decisions, i.e.
of care include ‘‘Watchful oversight; charge or supervision; decisional privacy; and unwanted admission of others to
to be concerned; have thought or regard; to make provision personal spaces or areas, i.e. local/physical privacy (Rössler,
or look out for someone in need.providing treatment for 2005). Privacy also refers to (2) the freedom to escape
or attending to; have a special preference for; to have incli- observing and reacting to others (Sidenvall, Fjellstrom, &
nation, liking, fondness or affection for.’’ (Dictionary.com, Ek, 1994). The question of concern is: how do individuals
2007). Major caring constructs in the nursing literature are experience care surveillance as enabling and/or constrain-
compassion, empathy, nurturance, succorance, comfort and ing in relation to their privacy? The premise is that
support (Cloyes, 2002; Jecker & Self, 1991; Kreuter, 1957; a surveillance technology needs to be understood in
Lavoie, De Koninck, & Blondeau, 2006; Leininger, 1977). relation to how it is used and not used in the actual context,
Hence, care is, just like any type of surveillance, associated i.e. how the care surveillance practice is constructed. The
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A. Essén / Social Science & Medicine 67 (2008) 128–136 131

surveilled subjects are viewed as participating in this It’s worth noting that the personnel did not see any rad-
construction. ical health problems on basis of the surveillance data during
the study period, but rather that the seniors were sometimes
Method not wearing their alarms and that they were not sleeping
well. The personnel were ‘‘discrete’’ when acting on this
The purpose of this paper is to understand not only if, kind of information. They did not say ‘‘we have seen on
but also why seniors feel that electronic care surveillance the data that you did not sleep well’’ for example. They tried
(telemonitoring) does or does not violate their privacy. to embed questions and reminders, e.g. about to wear
The paper further attempts to illicit not only expected, alarms in their regular conversations with the seniors.
but also unexpected, privacy issues arising from the
viewpoint of senior citizens. Hence, an open-ended, Data generation
in-depth interview approach was deemed appropriate. As
noted by McRobb and Rogerson (2004), quantitative instru- This study is based on in-depth interviews with 17 of the
ments may be too blunt and may obscure more than they seniors (68–96 years old, 9 female and 8 male) who accepted
reveal, as our understanding of consumers’ privacy concep- the use of the monitoring service. This purposeful sampling
tions is as yet limited. strategy can be called extreme case sampling, i.e. selecting
cases that are information rich because they are special in
some way (Alvesson & Sköldberg, 1994). At the time of the
Research setting interviews (September 2006), the 17 seniors had been mon-
itored for 6–7 months. The seniors were somewhat familiar
In 2006, a public long-term care provider in the munic- with the interviewer (author) who had visited all the seniors
ipality of Heby, Sweden, decided to introduce a new tele- to perform interviews once before, and who had chatted
monitoring service in their community. The new e-service with the seniors at least twice on the phone. The interviews
was seen as a potential replacement to traditional manual lasted 90–120 min, were performed face-to-face and within
alarms that were currently in use. The monitoring service the homes of the seniors. Interviews were very informal,
requires that the user wear a monitoring device on the unstructured, including open-ended questions in order to
wrist. Sensors embedded in the monitoring device contin- allow for unexpected issues to emerge (Patton, 2004). The
uously collect ‘‘activity data’’ about the user. This data is interviewer (author) began by asking the seniors how they
transmitted to the care center. Care personnel can access experienced the new monitoring alarms, discussing this at
the data, which is presented in graphical format as activity a general level for a while before bringing the issue of
curves on a computer screen. The activity curves provide privacy explicitly to the fore. Interviews typically proceeded
information about the user’s sleeping patterns (e.g. how with a discussion about privacy and privacy threats. Other
many sleeping interruptions and sleeping periods per day topics were also covered, as this study is part of a larger
and night, how many times the user gets out of bed during research program. Interviews were recorded, transcribed
the night), when the user leaves the house and takes off the and translated (Swedish to English) by the author. Notes
wrist worn unit, among other things. The activity curves were taken on nonverbal cues, such as general appearance,
can be analyzed over time in order to detect changing activ- anxiety, etc. (Patton, 2004).
ity patterns, which can indicate emerging health problems.
During the first two days of use, the monitoring system reg- Data analysis
isters each user’s ‘‘normal’’ activity pattern. Thereafter, au-
tomatic alarms are generated when the sensors detect that The content analysis was performed in several steps.
the user’s activity diverges from her/his normal pattern, e.g. First, all transcripts and observational notes were read
in cases where the activity level is unusually low due to the through to obtain a sense of the whole. Meaning units,
senior having fallen and turned unconscious. Users can also a word, a sentence or a whole paragraph that answered
activate alarms manually by pushing a button on the questions of why and how the seniors perceived or did
device, just like with ‘‘traditional’’ pendant safety alarms. not perceive privacy violations, were marked. As privacy
The alarms are also transmitted to the care center. The perceptions are often covert and expressed ‘‘between the
Heby managers decided to provide the new service to 20 lines’’ (Bates, 1964), the author tried to be sensitive to
seniors, as a first step, before expanding the use of the observational notes on nonverbal cues. The meaning units
new monitoring technology. Two social workers recruited were condensed into a description of their manifest con-
20 seniors who were (1) living alone in their own home; tent and an interpretation of their latent content. Themes,
(2) vulnerable and exposed to health risks in their home i.e. threads of meaning running through the descriptions
and therefore provided with manual safety alarms; and and interpretations (Baxter, 1991) were abstracted. The
(3) capable of being interviewed. Three of the seniors could transcripts were thereafter compared with the aim of
not use the devices due to allergies, etc. The seniors were detecting patterns across participants (Moustakas, 1994).
informed about the monitoring service via letters and Next, the themes were compared and analyzed based on
were given the opportunity to ask further questions in fol- the assumptions presented in the theoretical framework.
low up telephone calls. They were told that that their activ- Hence, a combined inductive and deductive approach was
ity level would be monitored, that automatic alarms could used (Alvesson & Sköldberg, 1994). In order to improve
be triggered if there would be a radical change in activity the credibility of the interpretation, the author presented
level and that this was performed to ensure their safety. the themes to peer scholars at research seminars
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132 A. Essén / Social Science & Medicine 67 (2008) 128–136

(Leininger, 1994). The thematization as presented in this alarm. They do it in a nice way of course. Now I always
paper is a result of an iterative process of culling the empir- use the alarm, and that’s good. .And my children
ical data, modifying the sub-themes and refining the think its great.
theoretical framework. The themes are presented below,
The seniors also believed that being surveilled contrib-
illuminated by extracts and quotations. The names are
utes (in combination with other home-help services) to
pseudonyms.
them being able to stay safely in their own homes instead
The Stockholm University Ethics committee gave
of moving to nursing homes. Henning maintains that:
approval to the study.
Sometimes I can feel a bit lonely here living alone. I
Empirical findings think, what if something would happen to me? I mean,
no one knows what’s going on here. I think they have
The interviews suggested that the seniors had divergent bought these things [surveillance devices] for this
experiences of the new monitoring alarms. Two contrasting reason, they cannot call me every minute, but I guess
perspectives are presented below. they can get some information now.and of course
that’s important if I am to remain here in my own house
[as opposed to being moved to a nursing home]. I really
Care surveillance as enabling – feeling cared for
hope I can live here until I die.so that’s good because its
nice if someone else knows if I’m OK or not OK. Of course,
The majority of the seniors (16 out of 17) expressed
my kids call me now and then, but they may not be lucky
positive views about being surveilled. Interviews suggest
enough to call at the right time so to speak
that these seniors believe that the monitoring service
serves their own interest to get help in case of accidents. Further, Ulf says: ‘‘I think we need more things like this,
For example, Kurt says: like this new thing, so that they can keep an eye on us at
home rather than moving us to nursing homes.’’. Privacy
I think it’s great that they do this for us.they must be
concerns make many of the seniors reluctant to move to
very expensive, these new alarms.they told me it
a nursing home. They mention two aspects of privacy in
would be safer than the old one [which does not include
this context. First, they express a desire for freedom to
any monitoring functionality].so I feel safe. It must be
escape being observed and intruded on by others:
safer; it is newer so it should be better, more reliable.
And I mean, in this way they can keep a track of me It is important that you can go home, leave others when
even when they are not here, which is good because you feel tired.and I like to do just whatever I feel like.
I’m alone here in my house. without anyone looking at me. here [in my own home]
I can walk around in my two day old socks sometimes, if
Further, Sonja maintains that:
they are not dirty.I try to not wash too often. (Elov).
It is good that they know, it is good thing to be If I would move to a nursing home they would see me
surveilled! I mean the more they know, the better walking up during the night. .I wouldn’t want to
they can understand my problems .I really trust meet anyone when I get up during the night when I
them, the girls. Very reliable girls.You know, they are cannot sleep. Maybe they would force me to take
like my friends.of course I want them to see if some- sleeping pills then! (Anna).
thing is wrong, I might not be able to press the button
Second, the seniors underline the importance of privacy
and if I am lying on the floor dying .
in terms of being able to escape observing and being close
And Ingrid states that ‘‘.It is a safety thing. you never to others. In other words, the seniors are not only
know when you will fall. When you least expect it.’’ concerned about others watching them, but also about
When asked what he would say if his GP would want to themselves being forced to watch others, illustrated by
access the information, Bror says: the following quotes:
Of course he could do that!.I only see him when some- I don’t want company by those I don’t know.I wouldn’t
thing is VERY wrong.and that is not very often so he like to sit with other oldies when I eat.I don’t want to
does not keep much track of me.I’m glad if he takes see them eat with trembling hands.listen to their
the time to think about my condition! But I have to con- memories.it would make me feel older I think
fess that I am also glad if I don’t have to go to the doctor. (Lennart).
Last time I was hospitalized it really struck me that there
These seniors clearly want care personnel to know as
is nothing worse than being forced to watch people that
much as possible about them and they appreciate that
cannot manage themselves. And I had to sit next to
the care providers are interested in gathering data about
some of them who had really bad breaths due to heavy
them; they see it as a privilege. The seniors also appreciate
medication I believe.[.] .and I like the peace and
it if the care personnel exert influence on their behavior or
quiet in my own home.being by myself is not too
intervene, on basis of the surveillance data. For example
bad. I like being by myself too, you see.even if it is
Lilly explains:
lonely (Bror).
they can see if I wear the new alarm, and that’s good, I don’t want to sit and stare at others sitting in their
because I tended to forget to wear the old alarm. They chairs like me.meeting people in the mornings in the
remind me if they see that I’m not wearing the new corridor.hearing them speaking on the phone with
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A. Essén / Social Science & Medicine 67 (2008) 128–136 133

their children.seems crowded.It’s easier to spend the the start. She agreed to meet me when I called her to
days here, where I know what to do. Thanks to my daily book an interview, but with a reluctant tone of voice.
routines the days pass rather quickly. (Bo). When I arrive, she opens the door with her dog Toy in
her arms. ‘‘You better not touch me, Toy might get mad
The seniors consider surveillance to be a service that can
then’’, she says and smiles nervously. Siv is anxious, and
help them avoid moving to a nursing home and thereby
suffers from an apparent lack of self-esteem. She worries
escape such intrusions.
about her health a lot. She is frank about this: ‘‘I am
The seniors who viewed surveillance as a positive
a very anxious person.always have been.I worry about
service did not mention any feelings of ‘‘being watched’’
everything.anything.the smallest things.’’. Siv says –
or feeling intruded on due to the monitoring services spon-
before I have asked – that she wishes to get her old alarm
taneously. When asked specifically if they have ever felt
back. ‘‘I don’t like it, the new alarm. I don’t like being
uncomfortable by being monitored, they clearly rejected
surveilled. I want my old alarm back.[.].it doesn’t matter
this idea. They seem surprised at this question. For exam-
who looks at the information. The fact that someone can look
ple, Bror says: ‘‘.I never think about it!.I really don’t.I
is enough.’’. Siv explains her dislike with feelings of being
hardly feel it. I never take it off.’’ Other seniors expressed
observed. She thinks that her sleeping pattern is sensitive
similar views, illustrated by the following quotes: ‘‘. [gig-
information. She says ‘‘I don’t want people to know when I
gles]. I never think about it!!! .Actually never.’’ (Jim);
take a nap.when Toy [her dog] and I are lazy.that’s only
‘‘.No, I haven’t thought about it at all. I don’t go around
between him and I.they know enough about me. I want to
reflecting on what the alarm does.it feels very natural for
spare them my strange habits.’’. It is also clear that being
me to wear it.[.] who cares if they see when I get up in
monitored influences Siv’s decisions: ‘‘It hits me, when I
the night and go to the toilet.they’ve seen me naked.’’
lay down late in the mornings that this is monitored.also,
(Elov). ‘‘.On the contrary, no! I feel safer now.’’ (Sonja).
at times when I can’t sleep and get up in the middle of the
These seniors understand that information about them
night I sometimes think that this might be seen.which makes
is collected and transferred to the care providers. They
me reluctant to do so!’’
also know that care providers can see if they are wearing
Siv cannot see that the monitoring service adds
the alarm or not and that automatic alarms can be
anything beyond the service she already receives. The com-
triggered. But none of them completely understand what
munity care personnel deliver food to her at noon, and
the sensors monitor, or how the technology analyzes this
conduct a check up visit in the evenings. She says:
information. They believe they have received sufficient
information, however. Consider Lilly for example. She was They check on me twice a day already, I think this is
obviously not very knowledgeable about the data collected enough.I mean, it is different at a hospital, but in my
about her. I started explaining a bit more in detail how the own home I don’t want people to watch me all the
new technology operates to her. She seemed very uninter- time.It feels a bit strange, this idea, to monitor people
ested, even uncomfortable, and says: ‘‘That I do not under- in their own homes. Your home is your own place; they
stand.’’. When I ask Lilly if she wishes she had received can’t start turning it into a technicality. You have to let
more information about how the technology works, she people alone in their own homes. No, that’s going too far.
says no: ‘‘Oh I think I’ve been sufficiently informed. I don’t
During my visit, a home-helper came by to give Siv her
need to know everything about that apparatus .that’s their
old alarm back, which made her happy.
job, the girls.and I trust them so.’’. This is typical. Indeed,
the seniors trust the care providers and are happy to dele-
Discussion
gate the task of understanding the new technology to them.
It is however important to note that while the seniors know
This study explored senior care takers’ experience of
little about the workings of the technology, they do not feel
being e-surveilled in relation to their privacy. The majority
that they have no control over the service. The seniors do
of the seniors in this study (16 out of 17) have a positive
not feel that the alarms are forced upon them, or that
experience of being surveilled. This has to do with how
they have no possibility to exit this service. On the contrary,
the care surveillance technology was used and not used
they feel that they can interrupt the monitoring service at
in the particular setting studied but also with the specificity
any time, as illustrated by the following quotes:
of care surveillance. This paper initially argued that care
I believe I can get my old alarm back any time, sure. I’d surveillance includes but cannot be reduced to an ambition
just tell them if that was the case. (Bror). to control. It can also be understood as incorporating an
You bet I could let them have this new alarm back.I intention to provide for individuals in need. This view of
think it’s much more expensive than the old alarm. surveillance resonates with the view of e-surveillance
And it’s modern technology. So I wouldn’t trade it expressed by the positive seniors in this study. These
against the old alarm! (Linnea). seniors are aware of their frailty and they feel that they
need to be watched over in one way or another. Hence,
these seniors do not experience any violation of their infor-
Care surveillance as constraining – feeling mation privacy (Rössler, 2005) when monitored because
as if under suspicion they do not want to hide the information collected from
care personnel. The seniors further appreciate that care
One of the interviewed seniors, Siv, experienced a pri- personnel can acquire digital information about and
vacy violation. Siv claimed her personal space right from influence their behavior. They view it as a benefit to be
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134 A. Essén / Social Science & Medicine 67 (2008) 128–136

reminded to behave in certain ways as this can enhance for their well-being and this makes them feel free rather
their own safety. In other words, they do not perceive than constrained.
that e-care surveillance intrudes on their decisional privacy
(Rössler, 2005). Interviews make clear that the seniors do Conclusion
desire to physically withdraw from care personnel. They
do not however perceive any local/physical privacy This study suggests that care surveillance practices can
(Rössler, 2005) invasion due to the monitoring service as be constructed in ways that make the surveilled subjects
they feel that they are ‘‘let alone’’ (Warren & Brandeis, feel cared for and liberated. It thereby challenges the wide-
1890), even if they are electronically monitored. Indeed, spread deterministic view of e-surveillance as involving the
the monitoring service can indirectly protect informational, destruction of privacy and liberty by sinister forces (see
decisional and local privacy from the viewpoint of these further e.g. Dubbeld, 2006; Haggerty, 2006; Hier, Walby,
seniors. It strengthens their possibilities to continue living & Greenberg, 2006). The majority of the seniors in this
in their own homes rather than moving to nursing homes, study viewed care surveillance as a means to protect their
where they expect significant threats to their privacy, both privacy in terms of freedom to escape being observed and
in terms of a reduction in the freedom to escape being observing others face-to-face, as they compare being
observed but also in terms of a declined freedom to escape e-surveilled to moving to a nursing home. (cf. Rössler,
being exposed to information about other care takers. 2005; Lyon, 2001, 2002). Hence, the study illustrates the
These latter points highlight that surveillance can be dual side of surveillance in relation to privacy, arguing
liberating rather than constraining. that surveillance is not necessarily constraining but can
In general, these seniors’ reported experience of care sur- also be enabling (Bogard, 2006; Lyon, 2001, 2006, 2007).
veillance involves the thought of ‘‘a friendly eye in the sky’’ It is however important to note that one senior in this study
(Solove, 2001) rather than of a ‘‘Big Brother’’ watching perceived the care surveillance service as constraining. The
(Orwell, 1949). It is however important to note that the con- experience of being surveilled is subjective and it should be
ceived thought of ‘‘friendly eye’’ is not anonymous. The se- expected to vary across individuals. Of importance here is
niors rather think of certain care workers, who deliver a built-in possibility for individuals to exert resistance.
other services to them, as being ‘‘the watchers on the other One could argue that the care surveillance practice stud-
side’’. Being surveilled by the care personnel who they trust ied here involves an element of seduction (see Bauman,
makes the seniors feel safe. Indeed, it makes them feel more 1992; Hier, 2003; Rössler, 2005). The majority of the seniors
cared for. The seniors do not reflect much about the surveil- studied here are indeed attracted by the rewards they asso-
lance technology itself, it withdraws and merely becomes ciate with being surveilled (individualized care) and rather
a link between themselves and the care workers. This sug- uncritically accept the surveillance service. However, de-
gests that the technological artifact is far from central in sur- scribing the subjects as victims seduced and manipulated
veillance practices. What is important to consider is rather by the care providers would be to oversimplify the situa-
how the surveillance service is introduced to the subjects tion and would merely reproduce the view of the surveilled
in the actual setting. An important aspect in this context subject as passive and subject to totalizing powers. We can
was the opportunity for seniors to exit the surveillance ser- learn more by broadening the perspective and analyze the
vice. As we discussed above, one of the seniors used this pos- surveilled’s indirect participation and responsibility for the
sibility and opted out of the service. This woman was more development of surveillance practices of the kind studied
concerned about her public appearance than the others here. As noted above, the seniors studied here wish to
and she had a lower threshold regarding the amount of age in their own homes, rather than at institutions. This
data she was willing to disclose to the care personnel. The is partly because of their desire for privacy in terms of
possibility that someone may look at the data collected freedom to withdraw physically from others. In general,
about her, and the possibility that her data may not look citizens’ wish to ‘‘age in place’’ due to the independence
‘‘normal’’ bothered this woman. Indeed, e-monitoring in- and freedom this entails, has contributed to the emergence
trudes on her informational privacy and it threatens her de- of various in-home care surveillance technologies (e.g. Bar-
cisional privacy (Rössler, 2005) as the fact that she is low & Venables, 2004). These technologies also emerge as
monitored influences – or at least crosses her mind when a result of the governmental desire to reduce costs of nurs-
making – decisions about how to behave. E-surveillance fur- ing homes and the technology providers’ strive to make
ther invades on her local/physical privacy as she perceived profit. Against this background, the care surveillance
the surveillance service as a physical intrusion in her practice studied here may be considered as predicated on
home. This woman was however not forced to continue and in the service of a certain type of liberty, namely the
and the monitoring was interrupted at her request. This il- freedom to age in one’s own home and manage everyday
lustrates that surveilled subjects can exert resistance. life without being constantly intruded on. This suggests
Hence, the widespread assumption that malign inten- that surveillance can cultivate and protect certain types of
tions lie behind surveillance practices is not quite valid in freedom desired by care consumers in today’s society
the care surveillance context. The care surveillance practice (Lyon, 2002; Rose, 1999 cf. Nock, 1993).
studied here involves control but this is not perceived as
constraining by the majority of the surveilled seniors. On Limitations
the contrary, the seniors appreciate the fact that the care
providers collect information about and intervene in their The findings reported here concern elderly care, which
health. They feel that someone else takes responsibility is a very specific setting. The senior citizens in this context
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A. Essén / Social Science & Medicine 67 (2008) 128–136 135

are generally frail and aware of their need to be ‘‘checked Stockholm University, for critical but useful comments on
on’’ regularly. The rural Swedish community studied is how to improve the paper.
further characterized by a low turnover of care personnel
and satisfied senior citizens. Also, the seniors in this study
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