Little arrangements that matter. Rethinking autonomy-enabling innovations for later life
Introduction
In active ageing policy, autonomy has become the driving force behind most services, technologies and policies within a context of increasing long-term care needs. Strengthening the freedom of any individual to determine their own life as they age, and fighting against ageist discriminatory prejudices and paternalistic/disabling practices have been played out as means of enhancing social participation in active ageing policies. In the last 30 years this “push for autonomy” has been incorporated, not without criticism [2], into local and national policies [3] and deployed to transform enclosed care-delivery settings, such as nursing homes or hospitals, into far more sustainable home-based and self-managed health and social care services.
In this scenario, innovations in technology are playing key roles [4]. In the current landscape of pervasive technologies for supporting active ageing,1 telecare is seen as a cost-saving and autonomy-enabling solution [6], contributing as it does to delay, or simply replace, the psychological and social burden of moving to a next-of-kin house, and the economic cost of nursing home and hospital admissions. Telecare enables ageing in place: a desirable situation for users, who can then control their own lives as they age and participate meaningfully in the community.
Given this push for greater autonomy in active ageing policies, it is necessary to understand what “keeping control of one's life as you age” means [7], how it is performed and in what sense technological innovation enables or disables older people to do so [8]. These are the main questions I will reflect upon in this contribution to the debate. I will attempt to do so following the insights we can draw from the picture above (Fig. 1), which Gratiane de Moustier took of Odile, an 82 year old woman living on her own in a small Alsace village. The collection from which the picture originates, Aging at Home: The Story of Odile, beautifully and very realistically illustrates Odile's daily struggle to continue with the most mundane routines. Through these portraits, we get a sensuous and very touching insight of what living an “ageing yet autonomous life” means, materially and pragmatically, and what difference technologies such as telecare could make. Indeed, when Gratiane suggests Odile might access a care service to ease her day-to-day life, Odile's reply reveals the main concern of this paper: “If old people had their habits removed they would be left with nothing” [1]. On this Gratiane adds: “The very notion of her independence being tampered with leaves her with an uneasy air of discomfort. The high priority she places on what others may view as menial tasks often leaves Odile under pressure and in a panic, continually searching for her next task. Odile's continual striving to maintain, what in her view resembles her own meaningful and necessary independence, is a continual drain on her fragile frame” [1].
This picture is an invitation to take Odile's unyielding disposition seriously and reflect upon the mundane “arrangements” on which an “ageing yet autonomous life” depends. Particularly important are the materials these arrangements consist of, the practices in which they are embedded and, especially, the required care these arrangements need to keep them functional and meaningful. These are the aspects I believe worth considering if we hope to produce a nuanced account of what might be considered an autonomy-enabling innovation.
To accomplish this, I have divided this article into different sections.
In the following section of the paper, I reviewed the Science and Technology Studies (STS) and critical feminist work on “the idea of a technological fix” and “the ideal of autonomy” that inform current telecare endeavours. Although this contribution is aligned with and inspired by some of these studies, I propose a slightly different approach. Drawing on STS-inspired literature on infrastructures, disability studies and care studies, I set out the notion of arrangement as a symmetrical and ecological interpretative key to render visible the diversity of “ageing yet autonomous lives”, and of practical ways of configuring them.
Following a brief description of the study conducted within a social alarm service in Catalonia in 2008 and 2009, and the data to be used on the installation and user-adoption of the service, I undertake an analysis of some ethnographic instances of friction with the service reported by users. The implementation of the social alarm service is taken to be a “breaching experiment” [9], displaying at least three different groups of arrangements that configure the “ageing yet autonomous” lives of the informants. The spatial, care and subjective configurations these arrangements enact are analysed at the end of this section.
This leads to the final sections where I put the ethnographic insights in dialogue with current debates on the material and pragmatic production of autonomy and the role of innovation in this endeavour. Here I set out an approach to what might be considered “an ageing yet autonomous life” and “an autonomy-enabling innovation” that prioritises the bounded but inalienable undertaking of caring about the mundane arrangements that sustain us.
Section snippets
Reviewing critical appraisals of autonomy promotion and telecare solutions
I align myself with those voices that exhort us to not be swayed by hyperbolic enthusiasm for autonomy in active ageing policies and technological innovation, and insist on the necessity to reflect more carefully and critically about what enables and disables the push for autonomy in this context [2].
Conceptual tools
Questioning both the idea of a “technological fix” and autonomy usually conveyed in telecare endeavours is necessary to undertake a more critical and nuanced reflection on the effects of autonomy-enabling innovations on the daily lives of older people. However, reporting evidence on how autonomy is always inextricably interdependent and pointing at the complexities telecare systems enact in practice, should not be taken as “matters of fact”, generating a wholesale rejection of telecare as an
Method
This paper is based on data collected in an ethnographic study of the installation and user-adoption of a social alarm service in Catalonia in 2008 and 2009. The service is intended to provide social and health aid in the case of emergency. Installation is simple: a terminal connected to the telephone line dials the call centre automatically, or whenever the user presses the button of the terminal or the pendant he/she should wear. On receiving the call, operators evaluate the situation using a
Ethnographic excerpts of friction
The installation is a highly complex procedure, during which different types of friction might arise [37]. Usually the user has authorised the installation, even if in a reluctant response to family pressure. But the installation often becomes an appraisal, with users figuring out during the process whether they would actually need the service. Therefore, this may be a moment of confrontation, hesitation, rejection and doubt in which other arrangements come to the fore for a somehow intimate
Identifying arrangements
As most of these ethnographic instances are framed within the conflictive encounter between users and the telecare service, our attention is drawn to something that may otherwise go unnoticed: telecare must be arranged, which implies something more than the simple placing of a piece of machinery in the home of an older person. It is a complex process, which entails the creation of technical, social and legal entanglements with arrangements that already operate in the day-to-day routine of our
Arranging spaces, care and subjectivities
As Langstrup [30] and Thygesen and Moser [28] have shown, arrangements have place-making effects, and enact different conceptions of care and subjective configurations. In this section I briefly describe different enactments of these three elements that emerge through the arrangements described.
Reconsidering what counts as autonomy in later life
As our breaching-experiment with the invasive social alarm has shown, an “autonomous yet ageing life” is constructed by different arrangements and therefore defined in multiple ways. It can emerge out of a plurality of possible spatial configurations, modes of carework organisation and forms of subjectivity. Depending on the arrangements, the “ageing yet autonomous life” is enacted in various ways, but there is no autonomy without arrangements. Or as Latour has phrased it: “We can substitute an
Rethinking what counts as autonomy-enabling innovations
This endless activity of creating, connecting and balancing arrangements is very much in line with the policies and technologies of habilitation that Michel Callon [31] has identified in the social model of disability. Policies and technologies of habilitation, in contrast to the meaning Winance gave to this word,6 are not
Concluding remarks
Living an ageing yet autonomous life is a fragile and arduous endeavour. The arrangements on which we all rely are various and variable but need to be cared for; this is what the installation of a telecare systems, quite crudely at times, brought to the fore. Introducing a new device, regardless of how usable, well fitted in the real context and meaningful for the user it might be, challenges existing arrangements and makes the already intense work of adjusting them even more laborious. As our
Acknowledgements
This work is the result of the EU FP7 project EFORTT (pn. 217787) and the Spanish I+D project EXPDEM (SO201129749-C0202). I would like to acknowledge the wise and fruitful comments on previous versions of the paper made by Mike Michael and Niels Van Dijk, the inspiring meetings with David Pontille, Jerome Dênis, Geraldine Fitzpatrick and Orla O'Donovan, and the generous and really helpful feedbacks of the reviewers. Finally, I want to thank Gratiane de Moustier for giving permission to use
Daniel López Gómez is an Assistant Professor at the Department of Psychology and Education at the Universitat Oberta de Catalunya and is working on ageing, technology and innovation. His main research interests are the biopolitical and technoscientific construction of later life and the rise of quantified-self subjectivities.
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Daniel López Gómez is an Assistant Professor at the Department of Psychology and Education at the Universitat Oberta de Catalunya and is working on ageing, technology and innovation. His main research interests are the biopolitical and technoscientific construction of later life and the rise of quantified-self subjectivities.