The false promise of health apps

“I spent five years working on this thesis, and it really was a matter of aiming at a moving target. That’s what is difficult about philosophy of technology. You choose a technology to focus on, but before you know it your examples are outdated and technologies have already changed. You try to keep up with current events and look ahead, but philosophy also requires reflection, distance and tranquility.

My dissertation is about technologies that aim to allow users to live a healthier live. This could be physical health (lose weight, exercise more, eat more slowly) or mental health (apps that make you think about something positive at regular intervals or make you do mindfulness exercises). Or a combination, such as an app that helps people with Alzheimer’s remember to take their medicines.

Friction

Persuasive technology is widely used in healthcare. This fits in with a broader trend of preventive health care and personalized medicine. But it also raises ethical questions. You don’t want persuasion to turn into manipulation or coercion. That is why it is important that the user understands how the technology works. This is at odds with the idea of many designers: it works because the user doesn’t exactly know how it works.

The debate about persuasive technology has been going on for over ten years. I noticed that in the ethical discussion the assumption tends to be that the users of such technologies are strong, autonomous individuals. That’s where friction arises. Because why would people use such technology? Because they need help with something. Isn’t that an extra moral argument to keep an eye on the users of this technology? I missed reflection on vulnerability in the literature.

I started to delve into the question: what exactly is vulnerability? The term ‘vulnerability’ is frequently used in everyday language and in scientific literature, but it is also a catch-all term. Nobody knows exactly what you mean by ‘vulnerable people’. I wanted to get a grasp on that, but I was reluctant to use vulnerability as a label and label groups of people as vulnerable.

“It’s possible to enter an unhealthy weight goal in the MyFitnessPal app.”

There are roughly two schools of thought in the literature on vulnerability. The first one posits that vulnerability is part of the human condition. Everyone is vulnerable. I think that’s right, while at the same time this isn’t a very useful definition. The second school says that ‘vulnerable people’ have certain characteristics that make them less capable of protecting their own interests and needs. This definition makes it possible to offer extra help, but you do risk stigmatizing people with certain characteristics.

Feminist philosophers Catriona Mackenzie, Wendy Rogers, and Susan Dodds try to combine both views of vulnerability. They distinguish between different sources of vulnerability. These sources can be personal, for example you are hard of hearing or deaf. But whether this bothers you, and to what extent, depends on your social and cultural context. If a lesbian woman finds herself in a context in which homosexuality is not accepted, her sexual orientation is a source of vulnerability.

Bulimia

Such an analysis of vulnerability offers a framework to take another look at health apps. How do they work? Do they counteract vulnerability, or can they trigger or increase different sources of vulnerability? In my dissertation I describe the MyFitnessPal app for example. This diet app allows you to track how many calories you take in and how much you exercise. The app is widely used by young women who want to lose weight.

You could say: this technology is trying to help people with maintaining a healthier lifestyle. There is nothing wrong with that. But such an app can also pose a threat to people with an inherent vulnerability. Research shows that the app is widely used by people with eating disorders.

I tried to imagine how MyFitnessPal would be used by a young woman with bulimia. In the app you can enter the daily amount of calories you want to eat. When you reach your goal, you will be rewarded with trophies, badges and virtual prizes. A ranking shows you how well you are doing compared to other people. What’s misleading is that it’s possible to enter an unhealthy goal. MyFitnessPal may work for people with a healthy relationship to diet and exercise, but it’s often used by people who are already unhappy about their bodies. Their vulnerability is not removed with such an app, but rather reinforced.”