Design and Use of Assistive Technology

Meeko Mitsuko K. Oishi • Ian M. Mitchell

H. F. Machiel Van der Loos
Editors

Design and Use of Assistive

Technology

Social, Technical, Ethical, and Economic

Challenges

Foreword by Maja J. Matarić

123
Editors
Meeko Mitsuko K. Oishi H. F. Machiel Van der Loos
University of British Columbia University of British Columbia
Electrical and Computer Department of Mechanical Engineering
Engineering 6250 Applied Science Lane
2332 Main Mall Vancouver, BC V6T 1Z4
Vancouver, BC V6T 1Z4 Canada
Canada [email protected]
[email protected]

Ian M. Mitchell
University of British Columbia
Department of Computer Science
201-2366 Main Mall
Vancouver, BC V6T 1Z4
Canada
[email protected]

ISBN 978-1-4419-7030-5 e-ISBN 978-1-4419-7031-2

DOI 10.1007/978-1-4419-7031-2
Springer New York Dordrecht Heidelberg London

Library of Congress Control Number: 2010935719

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Foreword

The not too distant future will feature assistive technology as an integral
part of people’s lives. This future is ensured by the disquieting speed at
which the need for that technology is growing. With the aging population
trends in developed countries and the growing rates of developmental and
other disorders and conditions in children, large sectors of the population are
in need of one-on-one, dedicated, and individualized care. At the same time,
our species’ ever-increasing lifespan means such care is needed for increasingly
longer periods, beyond convalescence and into long-term rehabilitation and
life-long support. Given population demographics, there simply will not be
enough human labor available to provide this needed care. The resulting “care
gap” presents a niche for human-centered technology. What does it take to
create such technology?
The challenges of safe, ethical, culturally-appropriate, engaging, accessi-
ble, and affordable assistive technology are many, and constitute the moti-
vating forces of the growing interdisciplinary research trend reflected in this
book. If we are to make progress toward addressing these challenges, we must
create a culture that sustains an active interaction between the technology
developers and the intended user communities, by bringing them much closer
together than they have been or have needed to be so far. The two commu-
nities must inform each other; the collaboration must be bidirectional. In an
effective collaboration, users direct research to make it relevant to real-world
needs, and researchers disseminate technologies and training through service
models. To succeed, we must also address the complex ethical issues of tech-
nology acceptance, dependence, access, and safety throughout the process,
not after the technology is developed. Finally, the foundation for making all
this possible must rest on a funding structure that provides support for the
full cycle of collaborative, interdisciplinary, and community-centered devel-
opment, testing, evaluation, and iterative improvement.
The future is in sight but we are not yet there. This book and related
work aid in outlining the steps that will bring us closer to what will be a true

v
vi Foreword

paradigm shift in technology-aided medicine and health. In the words of a

participant in one of our assistive technology studies, “The sooner we can do
this, the better!”

University of Southern California Maja J. Matarić

May 2010
Preface

Assistive technologies have the potential to significantly improve the lives

of people with disabilities, by enabling independence and facilitating social
connections. However, these same technologies can be a barrier to indepen-
dence and social connectedness if they are poorly designed, do not effectively
incorporate user requirements, or are inappropriate for the task at hand.
Effective assistive technologies depend not only on “good” engineering de-
sign (sometimes a challenge in and of itself), but also on the extent to which
the technology has been integrated with clinical needs, user requirements,
ethical concerns, and the social context of the technology’s use. In fact, poor,
ineffective, or inappropriate design is a key cause of device abandonment.
The gaps between engineering design, clinical evaluation, and actual use rep-
resent an inherently multidisciplinary challenge that must be forcefully and
creatively addressed if assistive technologies are to better succeed in enhanc-
ing people’s lives. In a workshop held July 22–24, 2009 at the University
of British Columbia, “Removing barriers and enabling individuals: Ethics,
design, and use of assistive technology” (http://www.removingbarriers.
pwias.ubc.ca), clinicians and researchers from computer science, engineer-
ing, ethics, medicine, and rehabilitation sciences gathered specifically to ad-
dress this increasingly expensive issue.
This book is a result of presentations and discussions that took place
over the course of the 3-day joint Peter Wall Institute for Advanced Studies
(PWIAS)/Institute for Computing, Information, and Cognitive Systems
(ICICS) Exploratory Workshop. The workshop was unique in its interdisci-
plinary focus and opportunities for multidisciplinary, small-group discussion.
The workshop focused on four different topics: evaluation, sensing, network-
ing, and mobility, and four different cross-cutting themes: novelty, customiza-
tion, privacy, and user perspective. Workshop participants were encouraged
to go beyond mere anecdote to identification of current problems and po-
tential improvements in the entire cycle of design, evaluation, knowledge
transfer, and actual use of assistive technologies. Three key recommendations
were identified: (1) The user’s experience must be fully – not just partially,

vii
viii Preface

anecdotally or vicariously – integrated into both engineering design and clin-

ical evaluation. (2) Academic outreach via service models should be widely
adopted to create customized assistive technology solutions for clients as the
experience simultaneously educates the embedded researcher and students in
real-world situations. (3) Knowledge transfer should be enabled through the
creation and enforcement of regulations and standards to increase quality
and reduce cost, the implementation of mechanisms to pool risk and limit
liability, and the financial support to small businesses to capitalize on the
inherent advantages of agile, niche companies.
The purpose of this book is to assess some of the major hurdles in bringing
assistive technologies out of the lab and into everyday use and to provide
guidelines and recommendations to improve their design and use. Some of
the most difficult problems in creating effective assistive technology are (a)
the inherent heterogeneity of the user population, (b) privacy concerns in
data gathering and analysis, (c) knowledge transfer of novel technologies, and
(d) incorporation of user perspective into the design process. It is our belief
that true solutions to these issues can only arise through a multidisciplinary
approach.
We have gathered in this book a set of papers that demonstrate how pro-
cess improvements in assistive technology deployment have the potential to
empower businesses, researchers, and nonprofit organizations to create and
bring to market new devices, such that they incorporate ethical, social, and
clinical concerns by design. Contributors to the book are leading researchers
in their fields, and their contributions are inherently broad in scope and ac-
cessible to researchers from a wide range of disciplines. We provide a critical
assessment of hurdles in assistive technology that are relevant for researchers
in engineering, computer science, rehabilitation sciences, and ethics. The book
is organized according to the main outcomes of the workshop: regarding the
user’s experience, research and academic outreach, and development and com-
mercialization.
We begin with a discussion of the issues that inherently frame how assistive
technology is conceived of, designed, used, and perceived. In Chap. 1, Silvers
identifies key ways in which ethics of assistive technology differ from seem-
ingly similar issues in engineering ethics and medical ethics. Miller Polgar
provides an alternative framework in Chap. 2 in which to consider the role
and assumed neutrality of assistive technology, both as a barrier and as an
enabler. Even the words commonly used to describe “assistive” technology
have implicit assumptions about perception of and identification as an in-
dividual with a disability. Ladner makes a case for “accessible” technology
in Chap. 3. In Chap. 4, Cook and Adams focus on how technology can en-
able play for children with disabilities. In Chap. 5, Cook, Miller Polgar, and
Livingston discuss need-based and task-based assistive technology design and
evaluation as a means to prevent device abandonment. They employ the hu-
man activity assistive technology (HAAT) model to evaluate both successful
and failed technologies.
Preface ix

The second part of the book focuses on models of the research pipeline
and the role of academic outreach in improving how assistive technology is
designed, evaluated, and used. Simpson discusses in Chap. 6 common barriers
in the typical research pipeline. Livingston discusses in Chap. 7 how commu-
nity service in academia can not only enable improved technology design and
use, but is also a means to create a new workforce of engineers and technolo-
gists cognizant of accessibility issues, irrespective of whether the technology
they design is truly “assistive.” Matsuoka and Lewis provide a case study
in Chap. 8 of the creation of a non-profit organization, spun off from work
done originally in academia, to create highly-customized assistive technolo-
gies. Lastly, Danielson, Longstaff, Ahmad, Van der Loos, Mitchell, and Oishi
discuss in Chap. 9 the results of a recent survey in the ethics of assistive
technology that highlights some of the unique challenges in the research,
development, evaluation, implementation, and use of assistive technologies.
The last section of the book discusses some of the most difficult aspects
of improving assistive technologies – the broader legal and economic con-
text that influences the development and commercialization of assistive tech-
nologies. In Chap. 10, Birch evaluates the current regulations and standards
(as well as those in process but not yet implemented) and argues that en-
forcement of regulations and standards is required to provide truly universal
access. Borisoff draws upon his personal experience as an entrepreneur, to dis-
cuss in Chap. 11 some of the unique challenges and opportunities in assistive
technologies due to the small market for AT products.
We are pleased to acknowledge financial support from the Peter Wall Insti-
tute for Advanced Studies at the University of British Columbia (UBC), the
UBC Institute for Computing, Information and Cognitive Systems, and the
British Columbia Disabilities Health Research Network. The workshop would
not have been possible without guidance and support from our Advisory
Committee, a multidisciplinary team of leading researchers at UBC focused
on the ethics, design, and use of assistive technologies. In addition, we are
grateful to Dr. Dianne Newell, the Director of PWIAS, for her continued
interest and support, and to her staff for their assistance.

University of British Columbia at Vancouver Meeko M.K. Oishi

May 2010 Ian M. Mitchell
H.F. Machiel Van der Loos
Acknowledgments

UBC Advisory Committee

Elizabeth Croft, Ph.D.

Mechanical Engineering, Faculty of Applied Science
Peter Danielson, Ph.D.
Applied Ethics, W. Maurice Young Centre for Applied Ethics
Judy Illes, Ph.D.
Neuroscience, Faculty of Medicine
Alan Mackworth, Ph.D.
Computer Science, Faculty of Science
William C. Miller, O.T., Ph.D
Occupational Science and Occupational Therapy, Faculty of Medicine
Bonita Sawatzky, Ph.D.
Orthopedics, Faculty of Medicine

xi
xii Acknowledgments

PWIAS-ICICS Exploratory Workshop Participants

Mark Ansermino, M.D.

Gary Birch, O.C., Ph.D., P. Eng.
Jean-Sébastien Blouin, Ph.D.
Jaimie F. Borisoff, Ph.D.
Anna Cavender
Albert M. Cook, Ph.D., P. Eng.
Susan Crawford
Peter Danielson, Ph.D.
Kirsty Dickinson
Antony Hodgson, Ph.D., P. Eng.
Thomas Huryn
Judy Illes, Ph.D.
Chandrika Jayant
Philippe Kruchten, Ph.D., P. Eng.
Richard Ladner, Ph.D.
Linda Lanyon, Ph.D.
Nigel J. Livingston, Ph.D.
Holly Longstaff
Alan M. Mackworth, Ph.D.
Yoky Matsuoka, Ph.D.
Johanne Mattie, M.A.Sc.
William C. Miller, Ph.D., O.T.
Ian M. Mitchell, Ph.D.
Meeko M.K. Oishi, Ph.D.
Wayne Pogue
Jan Miller Polgar, Ph.D., O.T.
Bonita Sawatzky, Ph.D.
Richard Simpson, Ph.D., O.T.
Chris Speropoulos
H.F. Machiel Van der Loos, Ph.D.
Rongrong Wang
Contents

Part I The User’s Experience

1 Better Than New! Ethics for Assistive Technologists . . . . . . 3

Anita Silvers
1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.2 Fear of Technology and Disability Discrimination . . . . . . . . . . 4
1.3 Sources of Assistive Technology Ethics . . . . . . . . . . . . . . . . . . . 6
1.3.1 Engineering Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.3.2 Medical Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.3.3 At the Intersect of Medical and Engineering Ethics . 9
1.4 The Standard of Normality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.5 Justice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.6 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
1.7 Afterword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2 The Myth of Neutral Technology . . . . . . . . . . . . . . . . . . . . . . . . . 17
Jan Miller Polgar
2.1 Source of the Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2.2 Key Ideas Related to Meaning and Assistive Technology . . . 19
2.2.1 Assistive Technology as a Tool . . . . . . . . . . . . . . . . . . . 19
2.2.2 Assistive Technology as a Visible Sign of Disability . 20
2.3 Implications for AT Design and Selection . . . . . . . . . . . . . . . . . 21
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

3 Accessible Technology and Models of Disability . . . . . . . . . . . 25

Richard E. Ladner
3.1 What is Assistive Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
3.2 Models of Disability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
3.3 Accessible Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
3.4 Concepts from Human–Computer Interaction . . . . . . . . . . . . . 28

xiii
xiv Contents

3.5 New Directions in Accessible Technology . . . . . . . . . . . . . . . . . 29

3.6 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

4 The Importance of Play:

AT for Children with Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . 33
Albert M. Cook and Kim Adams
4.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
4.2 Robot Applications for Children . . . . . . . . . . . . . . . . . . . . . . . . 34
4.3 Robots and Cognitive Development in Children . . . . . . . . . . . 34
4.4 Robot Use by Very Young Typically Developing Children . . 36
4.5 Integrating Communication and Robotic Manipulation . . . . . 37
4.6 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
5 Need- and Task-Based Design and Evaluation . . . . . . . . . . . . 41
Albert M. Cook, Jan Miller Polgar, and Nigel J. Livingston
5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
5.2 Assistive Technology Abandonment . . . . . . . . . . . . . . . . . . . . . . 42
5.3 HAAT Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
5.3.1 Human . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
5.3.2 Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
5.3.3 Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
5.3.4 Assistive Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
5.4 Case Stories: Applying the HAAT Model . . . . . . . . . . . . . . . . . 44
5.4.1 Successful Projects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
5.4.2 When Projects Don’t Go So Well... . . . . . . . . . . . . . . . 46
5.5 Discussion and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Part II Research and Academic Outreach

6 Challenges to Effective Evaluation of Assistive Technology 51

Richard Simpson
6.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
6.2 Evaluating Technology in the Lab . . . . . . . . . . . . . . . . . . . . . . . 52
6.3 Evaluating Technology in the Clinic . . . . . . . . . . . . . . . . . . . . . 53
6.4 Evaluating Technology in the World . . . . . . . . . . . . . . . . . . . . . 54
6.5 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
7 Community Service in University Curricula . . . . . . . . . . . . . . . 57
Nigel J. Livingston
7.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
7.2 The Need and Opportunity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
7.3 The CanAssist Model and History . . . . . . . . . . . . . . . . . . . . . . . 59
Contents xv

7.4 The University Commitment: Engaging Faculty, Students,

and the Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
7.5 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

8 Providing Innovative Engineering Solutions

Between Academia and Industry . . . . . . . . . . . . . . . . . . . . . . . . . 65
Brian E. Lewis and Yoky Matsuoka
8.1 The Niche Between Academic and Commercial Approaches . 65
8.2 History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
8.3 Project Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
8.3.1 Absence of Existing Solutions . . . . . . . . . . . . . . . . . . . 68
8.3.2 Potential for Direct and Ancillary Benefit . . . . . . . . . 68
8.4 Example Projects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
8.4.1 Umbrella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
8.4.2 Orthotic Exoskeleton . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
8.5 Logistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
8.5.1 Identifying and Recruiting Volunteers . . . . . . . . . . . . . 70
8.5.2 Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
8.5.3 Liability Management . . . . . . . . . . . . . . . . . . . . . . . . . . 71
8.5.4 Intellectual Property Issues . . . . . . . . . . . . . . . . . . . . . . 72
8.6 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
9 Case Study: An Assistive Technology Ethics Survey . . . . . . 75
Peter A. Danielson, Holly Longstaff, Rana Ahmad, H.F. Machiel
Van der Loos, Ian M. Mitchell, and Meeko M.K. Oishi
9.1 Survey Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
9.2 Survey Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
9.3 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
9.3.1 Aggregated Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
9.3.2 Self-Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
9.4 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
9.4.1 Survey Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
9.4.2 Survey Content . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
9.5 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Appendix 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Appendix 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Appendix 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
xvi Contents

Part III Development and Commercialization

10 The Fast Pace of New Emerging Information

and Communication Technologies: The Need
for Regulations and Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Gary E. Birch
10.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
10.2 Examples of ICT: A Barrier or an Enabler . . . . . . . . . . . . . . . . 98
10.3 Three Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
10.4 The Need for Regulations and Standards . . . . . . . . . . . . . . . . . 100
10.5 Concluding Remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
11 Small Markets in Assistive Technology: Obstacles
and Opportunities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Jaimie F. Borisoff
11.1 Small Market Obstacles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
11.1.1 Obstacles Beyond AT . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
11.1.2 AT-Specific Obstacles . . . . . . . . . . . . . . . . . . . . . . . . . . 108
11.2 Small Market Opportunities . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
11.3 New Opportunities in Small Market Innovation . . . . . . . . . . . 111
11.4 Afterword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
List of Contributors

Kim Adams, Ph.D., P. Eng.

Faculty of Rehabilitation Medicine, University of Alberta, Edmonton,
AB, Canada, and Glenrose Rehabilitation Hospital, 10230-111 Avenue,
Edmonton, AB, T5G OB7, Canada, e-mail: [email protected]
Rana Ahmad
Philosphy, University of British Columbia, Vancouver, BC, V6T 1Z4,
Canada, e-mail: [email protected]
Gary Birch, O.C., Ph.D., P. Eng.
Neil Squire Society, 220-2250 Boundary Road, Burnaby, BC, V5M 3Z3,
Canada, e-mail: [email protected]
Jaimie F. Borisoff, Ph.D.
Instinct Mobility Inc., and Brain Interface Lab, Neil Squire Society,
International Collaboration on Repair Discoveries, 818 West 10th Avenue,
Vancouver, BC, V5Z 1M9, Canada, e-mail: [email protected]
Albert M. Cook, Ph.D.
Speech Pathology & Audiology, Faculty of Rehabilitation Medicine,
University of Alberta, Corbett Hall, Edmonton, AB, T6G 2G4, Canada,
e-mail: [email protected]
Peter A. Danielson, Ph.D.
W. Maurice Young Centre for Applied Ethics, University of British
Columbia, 227-6356 Agricultural Road, Vancouver, BC, V6T 1Z2, Canada,
e-mail: [email protected]
Richard E. Ladner, Ph.D.
Computer Science & Engineering, University of Washington, Box 352350,
Seattle, WA 98104, USA, e-mail: [email protected]
Brian E. Lewis, J.D.
Rosen Lewis PLLC, 615 Second Avenue, Suite 760, Seattle, WA, 98104,
USA, e-mail: [email protected]
xvii
xviii List of Contributors

Nigel J. Livingston, Ph.D.

CanAssist, University of Victoria, PO Box 1700, STN CSC, Victoria,
BC, V8W 2Y2, Canada, e-mail: [email protected]
Holly Longstaff
Interdisciplinary Studies, University of British Columbia, 164-1855 West
Mall, Vancouver, BC, V6T 1Z2, Canada, e-mail: longstaf@interchange.
ubc.ca
Yoky Matsuoka, Ph.D.
Computer Science & Engineering, University of Washington, Box 352350,
Seattle, WA 98195, and YokyWorks Foundation, 6513 132nd Ave. NE #385,
Kirkland, WA 98033, e-mail: [email protected]
Ian M. Mitchell, Ph.D.
Dept. Computer Science, University of British Columbia, 201-2366 Main
Mall, Vancouver, BC, V6T 1Z4, Canada, e-mail: [email protected]
Meeko M. K. Oishi, Ph.D.
Electrical and Computer Engineering, University of British Columbia,
2332 Main Mall, Vancouver, BC, V6T 1Z4, Canada,
e-mail: [email protected]
Jan Miller Polgar, Ph.D., O.T. Reg. (Ont.) FCAOT,
School of Occupational Therapy, Elborn College, 1201 Western Road,
The University of Western Ontario, London, ON, N6G 1H1, Canada,
e-mail: [email protected]
Anita Silvers, Ph.D.
Philosophy, College of Humanities, San Francisco State University, 1600
Holloway Avenue, San Francisco, CA, 94132, e-mail: [email protected]
Richard Simpson, Ph.D., O.T.
School of Health & Rehabilitation Science, University of Pittsburgh, 4020
Forbes Tower, Pittsburgh, PA, 15260, e-mail: [email protected]
H.F. Machiel Van der Loos, Ph.D.
Dept. Mechanical Engineering, University of British Columbia, 6250 Applied
Science Lane, Vancouver, BC, V6T 1Z4, Canada, e-mail: [email protected]
Acronyms and Abbreviations

AAC Augmentative and Alternative Communication

ACM Association for Computing Machinery
ADA Americans with Disabilities Act
ANSI American National Standards Institute
ASL American Sign Language
ASSETS ACM SIGACCESS Conference on Computers
and Accessibility
AT Assistive Technology
CAE Centre for Applied Ethics
CAOT Canadian Association of Occupational Therapists
CAPTCHA Completely Automated Public Turing test to tell Computers
and Humans Apart
CHI International Conference on Human Factors in Computing
Systems
CRTC Canadian Radio–television and Telecommunications
Commission
DHRN British Columbia Disabilities Health Research Network
DSS DriveSafe System
EADL Electronic Aid to Daily Living
EATS Efficiency of Assistive Technology and Services
EMG Electromyography
E&J Everest and Jennings, Inc.
FCAOT Fellow of the Canadian Association of Occupational
Therapists
FCC US Federal Communications Commission
FDA US Food and Drug Administration
G3ict Global Initiative for Inclusive Information and Communica-
tion Technologies
GPS Global Positioning System
HAAT Human Activity Assistive Technology
HAC Hearing Aid Compatibility

xix
xx Acronyms and Abbreviations

HCI Human–Computer Interaction

ICICS UBC Institute for Computing, Information, & Cognitive
Systems
ICRA IEEE International Conference on Robotics and Automation
ICT Information and Communication Technologies
IDEA US Individuals with Disabilities Education Act
IEEE Institute for Electrical and Electronics Engineers
IEP Individualized Education Plan
IRD Interactive Robotic Device
IROMEC Interactive Robotic social Mediators as Companions
ISAAC International Society for Augmentative and Alternative
Communication
MBA Master of Business Administration
MPT Matching Person and Technology Assessment
NASA US National Association for Space and Aeronautics
O.C. Order of Canada
OCR Optical Character Recognition
OT Occupational Therapist
O&M Orientation and mobility
PIADS Psychosocial Impact of Assistive Devices Scale
PWIAS UBC Peter Wall Institute for Advanced Studies
P.Eng. Professional Engineer
QUEST Québec User Evaluation of Satisfaction with Assistive
Technology
RESNA Rehabilitation Engineering and Assistive Technology Society
of North America
SIGACCESS Special Interest Group on Accessible Computing
SGD Speech Generating Device
STEM Science, Technology, Engineering, and Mathematics
TADNSW Technical Aid to the Disabled of New South Wales
UBC University of British Columbia
UIST User Interface Software and Technology
UN United Nations
UVATT University of Victoria Assistive Technology Team
VA US Dept. of Veterans Affairs
WCAG Web Content Accessibility Guidelines
WSP Wireless Service Provider
W3C World Wide Web Consortium
 Part I
The User’s Experience
Chapter 1
Better Than New! Ethics for Assistive
Technologists

Anita Silvers

Abstract What are the fundamental values that should guide the practice
of assistive technologists? This essay examines two sources that appear to
inform current understandings of the ethics of assistive technology: medical
ethics and engineering ethics. From medical ethics comes the notion that
assistive technology should aim to restore its users to normal functioning,
making them like new. Engineering ethics, on the other hand, recommends
enhancing users’ functionality, even if functioning is not achieved in a species
typical way. From this engineering perspective, it is permissible and even
desirable for assistive technology to make its users function even better than
new. Thus enhancing functionality is a central value in assistive technology.
Professionals in the field have the ability, and the responsibility as well, to
address and counter societal suspicion of artificially enhanced functioning
achieved through technology. Consequently, assistive technology professionals
should fight against discrimination that excludes people with disabilities,
whose functioning depends on prostheses and other products of technology,
from the mainstream of social life.

1.1 Introduction

As is common at the commencement of a new profession, the ethics of as-

sistive technology is a somewhat discordant conjunction drawn from other
practices – in this case, from engineering ethics and also from medical ethics.
The emphasis in the current approach is on doing no harm, prompted by fa-
miliar fears about the propensity of new technologies to trigger unfortunate
results [5]. This kind of “hand-me-down” approach to shaping the aspirations,

Anita Silvers
San Francisco State University, San Francisco, CA, USA, [email protected]

M.M.K. Oishi et al. (eds.), Design and Use of Assistive Technology: Social, 3
Technical, Ethical, and Economic Challenges, DOI 10.1007/978-1-4419-7031-2 1,

c Springer Science+Business Media, LLC 2010
4 Anita Silvers

as well the conduct, of assistive technologists may have the effect of delaying
the maturation of the field, not to mention disrespecting the autonomy of
and deferring justice for disabled people.
The unreflective importation of the values of rehabilitation, which aims
to repair or restore people, making them as normal as possible and ideally
“like new,” is problematic. This is an understandable but unworthy goal for
assistive technologists, whose ethics should be grounded in more innovative
ideas about how people function and society may progress. In what follows
I explain the current sources of assistive technology ethics. Then I argue
that functioning “better than new” is as good a goal for assistive technology
as functioning “like new.” From this it follows that the goal of functioning
“other than like new” is appropriate and acceptable in developing assistive
technology. Assistive technologists should give the value of “functioning as
well as possible” precedence over the value of “functioning normally” and
should not be concerned if the outcome is to give assistive technology users
functional advantage in some respects.

1.2 Fear of Technology and Disability Discrimination

The repugnant intervention of humans who impose technology to corrupt na-

ture’s design, or attempt to override naturally imposed limitations by trying
to control and improve the effects of natural processes, has been a powerfully
influential cultural theme at least since the Romantic movement of the nine-
teenth century. The stories of the creation by Frankenstein of an artificial
man, and of Hyde by Jekyl, are well-known progenitors of an enormous num-
ber of works in the romantic genre. Romanticism privileges nature and its
products (regardless of inadequate, unfair or destructive natural processes)
over what humans craft.
While this way of looking at the world dominates our understanding of
the human condition, the idea of the natural usually has been elided with
the standard of the normal. And the identification of normality in humans
usually is reduced to species typicality, so what is typical of humans is equated
with what is normal for us. Thinking in the “romanticist” style thus has
caused enormous harm to individuals who function atypically or anomalously
by making unusual people seem “abnormal” and consequently dangerously
deviant, rather than merely different. Individuals evaluated as abnormal are
too easily supposed to disrupt, threaten or burden the personal or social lives
of normal ones.
Individuals with disabilities often are ostracized because they are imagined
to be less functional and therefore weaker than other people. But a contrary
rationale becomes operative when assistive technology enters the picture.
Societal suspicion of artificially enhanced functioning achieved through tech-
nology sometimes prompts the exclusion of disabled individuals who rely on
1 Better Than New! Ethics for Assistive Technologists 5

prosthetics to participate in the mainstream of social life. Examples of such

prejudice are numerous, from denying blind law students use of common
screen reading technology to take the bar exam1 to excluding a competi-
tor with lower limb prostheses from the Olympic games. A third example,
more widespread, is anxiety about danger to pedestrians, which is directed
at wheelchair users.
In general, it is not unusual for prosthetics that enable people with disabil-
ities to function independently and competitively to be condemned prospec-
tively for their supposed potential for social destabilization. In the first case
mentioned above, the California Bar Association was comfortable with the ap-
plicant using a screen reader but the company marketing the bar exam feared
that the screen reading software would steal the exam questions (which are
reused for several exams).2 The National Conference of Bar Examiners, the
vendor for part of the exam, objected to the use of standard screen reading
technology, claiming (among other reasons) that the bar exam items could
be stolen, but this expression of fear did not prevail. In the second case, the
International Association of Athletics Federations objected on the ground
that the lower limb prosthetics user did not exert as much below-the-knee
effort as runners on flesh feet,3 but was overruled by the Court of Arbitra-
tion for Sport, which found no evidence that the prosthetics user expended
less energy overall because of his artificial running feet. (I will return to the
third case – conflict over safety between wheelchair using person and walking
people – in the Afterword.)
A commonly expressed fear is that using technology might catapult a for-
merly disadvantaged person to advantaged status, altering who is positioned
where on the social playing field. Both of the cases referenced above have this
dimension. In the first case, the vendor of the national segment of the exam
also objected to the plaintiff’s using a screen reading program, claiming that
all blind bar exam takers might request this accommodation.4 In the second
case, track officials speculated that permitting an individual with a disability
to compete on manufactured racing feet would open the way to track com-
petitors being allowed many other kinds of assistive devices, including skates.

1 See [16] for the latest US court decision permitting use of screen reading technology.
2Apparently, the company did not think the human reader it proposed to hire long distance
would be as larcenously inclined.
3 In early commentary, international track officials invoked a range of speculative claims
about the destabilizing effects of allowing a double amputee using manufactured feet to
compete. These included fears that he would harm other runners by falling over on them
and that other athletes would have their legs amputated so as to be fitted with artificial
racing feet. I have addressed these exaggerations and the prejudices leading to them in [13].
4 Why the specter of a blind test taker independently using screen reading programs, rather

than depending on human readers of uncertain quality plus Braille, was presented by the
vendor as a harm remains obscure, except for the suggestion that allowing screen reading
programs would give more blind individuals access to bar exams and thus to legal careers.
6 Anita Silvers

In general, allowing disabled individuals the same opportunity to participate

as others when their functioning involves technology reduces the underclass
of deficient individuals, leaving normal people a smaller number to whom
they can feel superior.
There, thus, is a widespread social habit of rejecting individuals with dis-
abilities based on their intimate ties with the products of technology. Assis-
tive technology professionals ought to be aware of this familiar reaction, and
most are. They also ought to understand this prejudice for what it is and be
committed to facing and dealing with it. Unfortunately, the sources available
from which to draw guidance in professional ethics for assistive technology
do not prepare them to do so.

1.3 Sources of Assistive Technology Ethics

1.3.1 Engineering Ethics

Codes of engineering ethics5 began to be developed early in the twentieth

century, coincident with engineers organizing as a profession sufficiently re-
sponsible to regulate itself. Unlike medical ethics, where individual patients
are regarded as the primary beneficiaries, engineers are held first of all to pro-
mote the public or general good. They must protect public health, safety and
welfare, sometimes against the interests of employers, to whom they have an
obligation of loyalty. Harm caused by structural failure sometimes, although
not always, arises from design or construction failure to which ethical fail-
ures, such as conflict of interest or bribery or deflection of responsibility or
absence of respect for other humans, have contributed.
As the twentieth century drew to a close, engineers found themselves work-
ing with structures of kinds unimaginable to their predecessors at the begin-
ning of the century – not only in electrical engineering but most prominently
in bioengineering. Because the structures bioengineers create enable individ-
ual humans to achieve biological functioning, albeit through mechanical or
electrical means, for bioengineers, including designers of assistive technology,
the ethics of bioengineering resides at the intersect of medical and engineering
ethics.
For example, contrary to some prevailing practice, the medical devices they
design should be tested on human subjects, with the risk-benefit standards
and safeguards common to human subject research, such that subjects:

5 For examples of engineering codes of ethics and discussions of ethical dilemmas specific
to engineering, see the excellent website of the National Academy of Engineering, On-
line Ethics Center for Engineering and Research [4]. See also the Code of Ethics of the
Rehabilitation Engineering and Assistive Technology Society of North America [6].
1 Better Than New! Ethics for Assistive Technologists 7

1. Are honestly informed about risks

2. Are potentially benefited from the research, either personally or by bring-
ing about a more general good that gratifies them
3. Are competent to weigh personal risks and benefits
4. Are specially protected from exploitation if they belong to historically
vulnerable groups, and people with disabilities belong to one or more such
vulnerable groups.
These safeguards should be extrapolated to use contexts, as users may be
supposed to be exposed to some of the same risks (in order to achieve the
same personal benefits) as the test subjects. Currently, some assistive tech-
nology items are not submitted to human subjects testing, which is standard
for prescription drugs.6 Their evaluation is more like that of bridges and lap-
tops, a combination of construction and product standards with marketing
research. Further, prospective users often are not accorded the opportunity
to be informed of the potential risks and benefits of using each assistive or
prosthetic device, and to consent, other than to be warned about (mis)uses
of devices in attempts to defend against product liability.

1.3.2 Medical Ethics

Many assistive and prosthetic devices are acquired through medical prescrip-
tion. As engineers move into designing devices that are distributed in this way,

6 See [17] for an easily understood description of the distinction between FDA require-
ments for Class 3 devices (usually invasive, such as implantable defibrillators) and Class 2
devices such as wheelchairs and communication devices. A review of FDA procedures by
the Institute of Medicine is due in Spring 2011.
For an account of lack of testing in, as an example, wheelchair design, and production
see [2]. Cooper writes here:

“Unfortunately, neither the VA nor FDA, or any other US-based agency made the
standards a requirement. This has resulted in a virtual flea market for testing, as
manufacturers and distributors pick and choose which tests to apply, create their
own tests, or even choose to ignore the issue altogether. In the end, wheelchair users,
their families, and their caregivers pay the price.”

See also Alberta Floyd, Individually and as Administrator of the Estate of Jacqueline
Ann Adams, Deceased, et al., Plaintiffs, v. Pride Mobility Products Corp., Defendant.
No. 1:05-CV-00389, United States District Court For The Southern District Of Ohio,
Western Division, 2007 US Dist. Lexis 91287 as an example of court assessments of the
nondispositive role of compliance with RESNA and ANSI standards in regard to wheelchair
design safety issues.
See also [15], a policy document that urges expansion of research on and manufacture
of assistive technology products but does not address testing.
Of course, the research of university-based assistive technology researchers and develop-
ers is monitored by institutional research and human subjects committees, but universities
are not central players in marketing assistive technology products.
8 Anita Silvers

the ethical status of end-users of their products becomes more complex.7 This
is due not to technology users being exceptional or idiosyncratic but because
of conflict in the current characterization of service receivers in the health
care system.
On the one hand, the traditional portrayal of patients in medicine has
been as unknowledgeable dependents who ought to be compliant with the
expert decisions of physicians for their own good. On the other hand, courts
adjudicating cases in which patients have not been benefitted but instead
harmed, and legislators enacting statutes to prevent more such cases, have
conceived of patients as autonomous agents who typically are competent
to consent to risk for the sake of benefit (or to refrain from consenting)
if only they are given appropriate information. The medical professionals’
obligation to obtain patients’ informed consent is grounded in this recently
expanded notion of the doctor–patient relationship as like a contract between
two individuals with equivalently respectable agency.
The development of codes or schemes of, or philosophical approaches to,
professional ethics in medicine and related fields – endeavors that conduct
medical research on human subjects or provide therapeutic or other health
care services to them – became of increasing concern during the last half of
the twentieth century. This effort responded to a deepening erosion of trust
in medical professionals, fueled at least in part by the 1946–1947 trial of
the Nazi doctors who sterilized, euthanized, and experimented on patients.
Revelations about scandalous conduct toward patients entrusted to physi-
cians’ care exacerbated the evaporation of confidence in physicians giving
the individual patients’ good priority over other values that may drive them.
Investigations at Tuskegee, Willowbrook, and other venues revealed that the
health of patients whose welfare was placed in the hands of physicians had
instead been sacrificed by those same physicians, who invoked the value of
advancing scientific knowledge to defend their actions.
Restraints on professionals in whom the well-being of vulnerable patients
was vested needed to be inherent in the healthcare professions themselves,
or else the state would intervene in the forms of regulative legislation or
restrictive case law. Codes of professional ethics partly staved off regulation
through law. Nevertheless, this was a time of unprecedented statutory and
judicial action aimed at protecting patients by emphasizing their right to
determine whether to accept medical interventions.
Being subject to regulatory law, and to civil rights protections for pa-
tients, altered the conceptual framework of medicine. In the courts at least,
if not as clearly and consistently in the clinic, patients no longer were con-
ceptualized as passive and clueless beings dependent on the benevolence of
healthcare professionals but were thought of, instead, as (usually) competent
choosers with the right to control what is done to their bodies and their minds.

7 The descriptions in this section are familiar ones in the literature of medical ethics. For

expanded discussion of them, see such standard textbooks as [1, 14, 7].
1 Better Than New! Ethics for Assistive Technologists 9

In recent years, therefore, the status of the patient in relation to the physician
or other health care professional has come to resemble that of the client in
relation to the engineer: a competent chooser.

1.3.3 At the Intersect of Medical and Engineering

Ethics

A first step for developing assistive technology ethics is to consider what

engineering and medical ethics might have in common. Both center on direc-
tives to avert the kinds of harm that professionals in the field have special
opportunity, occasion or opening to do. But engineering and medical ethics
presume very different notions of who or what must be protected from harm.
Engineering ethics aims to defend the general public welfare against harm
caused by inadequate engineers. But medical ethics is focused on protecting
individual patients from being harmed by feckless physicians.
Engineering ethics does not evidence similar worry about obligations to
dependent individuals. Rather, individuals to whom ethical obligation is owed
are cast mainly in the role of independent employers or clients. Clients are
presumed autonomous in the sense of their being sufficiently powerful to con-
trol or manage their own fates. They are owed the loyalty of the marketplace
– that is, compliance with their wishes by those whom they compensate for
doing so. Engineering ethics does conceive of the employers’ good as poten-
tially in conflict with the public good, and ethical sensitivity and response to
such conflict is a central issue for engineering ethics.
Medical ethics does not usually conceive of, and thus is not centrally con-
cerned about, conflicts between the patients’ good and the public good. The
main exceptions are (1) where medical resources are so scarce as to require
rationing and some kinds of patients are thought to seek or need more than
a fair share, so as to deprive other equally deserving recipients if the wants
of the most needy (who may also be the most ill) are satisfied or (2) where
an individual’s health state poses a danger to others. If anything, in the lit-
erature of medical ethics individual recipients of services – that is, patients
– are much more likely to be portrayed as endangered by an indifferent or
hostile public that denies or delays treatment for them.
Thus, the characterization of recipients of medical services contrasts
markedly with the characterization of those who use engineering services.
To exercise their autonomy, patients control only the choice of whether to
consent or not to the decisions of professionals with knowledge and power of
a higher order than their own. Medical ethics even further discounts disabled
people’s views about their own good, dismissing those who are not inclined to
risk whatever functionality they possess to pursue therapies to return them to
normality. It is well-known that surveys of people with disabilities find them
rating their quality of life higher than expected, but until recently bioethicists
10 Anita Silvers

have dismissed such reports as products of denial or self-delusion. They have

been prompted in doing so by a medical value system that finds it hard to
imagine patients enjoying a high quality of life unless they are cured.
Engineering ethics equally has discounted disabled people’s views about
their own good, but for a different reason. Disabled people have been viewed
not as employers or clients, but instead as being subject to the decisions of
the real purchasers, namely, physicians or other therapeutic or rehabilita-
tion professionals, family members, or insurance systems. Engineering ethics
has tended to adopt these nondisabled people’s attitudes toward the dis-
abled and for this reason has not granted primacy to disabled people’s self-
determination based on their own ideas of the good for themselves.

1.4 The Standard of Normality

Both systems – medical and engineering – presume that the aim of their
efforts is to restore the disabled person as closely as possible to normality,
understood as species typicality. For medicine, species typical or normal func-
tioning is a component of health [10]. So for medicine, restoration to normal
functioning is therapeutic, or at least rehabilitative. Moreover, the closer to
normal functioning a person can achieve, the more comfortable the fit with
the usual ways of doing things and the less trouble for everyone else who
interacts with that person. Returning differently functioning individuals to
species typicality therefore may seem to contribute to the general welfare,
which aligns with the value engineering ethics places on preserving the pub-
lic good. Therefore, or at least so it may have seemed, the aims of medical
engineering’s clients appear consistent with engineers’ commitment to the
general good.
Adopting species typical functioning as a standard has both benefits and
costs. The impaired individual who can be made as good as new escapes the
social disadvantages aimed at disability, and society escapes the issues around
providing disabled people with special care. Society benefits insofar as one-
size-fits-all social arrangements meant only for the species typical may be
simpler to organize than practices allowing all to participate. Inclusive prac-
tice must be flexible and nuanced in order to respond to people’s differences.
Further, to the extent that everyone functions alike, resentment from nondis-
abled people about special accommodations privileging disabled people, and
from disabled people about ordinary social arrangements privileging nondis-
abled people, disappears.
On the other hand, efforts to make disabled people as good as new also
have costs, both to society and to the subjects themselves. When normality is
the standard that social arrangements expect participants to meet, disabled
people feel themselves under great pressure to become as normal as possible,
1 Better Than New! Ethics for Assistive Technologists 11

and their families are similarly pressured to get them medical resources so
they can be so. Concomitantly, questions of justice about the state’s obli-
gation to provide these resources arise. If the state condones public practice
that advantages the normal, then should not the state offer those unfortunate
enough to depart from normality the opportunity to attain that state?
Yet being offered such opportunity may not be purely beneficial. The same
social pressure to be normal may induce people with disabilities to hide their
incapacities, even when doing so is dangerous, and to incline them or their
families to consent unnecessarily to risky or damaging medical procedures
in pursuit of normality. For example, the history of the imposition of dys-
functional prostheses on children with phocomelia is well-known. Among the
harms done to these children was the amputation of usable appendages in or-
der to fit more normal looking, but nonfunctional, prostheses [12]. In general,
at least some medical interventions aimed at making people more like new fail
to do so and also result in reducing their capacity for adaptive functioning.
Further, disabled individuals who fail rehabilitation may suffer loss of self-
esteem, viewing themselves as lacking value because they have not reached
their long-sought goal of normality. Their trying to do so extracts many kinds
of costs, not only psychological damage but also the suffering of educational
and career delays because of time spent away from school or work. These
considerations all suggest that for many individuals with disabilities the toll
taken by engagement with professionals who place too high a value on nor-
mality may be unjustly great.

1.5 Justice

Theories of distributive justice are meant to guide decisions about who is

owed what resources, and for which purposes, by society as represented by
the state. But theories of participatory justice, which determine who counts as
a full citizen or subject of justice, come first. In democratic theory, answering
this latter question precedes determinations about what kind of political and
economic system we should adopt. This is because answers to the questions
about the organization of the state, priorities for distribution of resources by
the state, citizens’ obligations to provide resources to the state, and citizens’
entitlements to receive resources from the state all depend on who is thought
to merit full considerability in deliberations about the political shape of the
state. If we think that moral and political considerability as subjects of justice
is deserved only by military males who are native speakers of our language
– indeed, who speak it with our provincial accent, as the ancient Greeks
did – or only by property-owning white males, as the US once did, then
basic principles of justice may be very different than if we have to give equal
weight to consideration by very different kinds of people – men and women,
12 Anita Silvers

native speakers or those who express themselves in a foreign tongue, people

of diverse racial heritages and different ethnic identities, and individuals with
those physical or intellectual or emotional anomalies labeled “disabilities.”
The democratic trend in North America for the past half-century has been
to increase the inclusiveness of participation of diverse kinds of people in
social and political practices and, by doing so, to improve equitable oppor-
tunity for them. Congress and state legislatures in the US (and courts in
Canada) are altering how people with disabilities are conceptualized, decree-
ing that individuals do not become noncitizens just because they function
atypically and prohibiting social arrangements that treat them as outcasts,
denying them opportunity. The UN Convention on the Rights of People with
Disabilities is evidence of how widely this trend has spread. As of this writing,
144 nations have become parties to the Convention.8
What does full social participation for people with disabilities involve?
First, people’s different functional modes must be equally embraced, which
means abandoning the standard of normality that privileges typical ways of
functioning over unusual ones.9 While medical professionals aim at restoring
patients to functional modes and functional capacity typical of the human
species or a familiar subset of humans, engineers prosper professionally by
developing a wide repertoire of different functional solutions and offering their
clients whichever best suits the situation. Typicality in mode of functioning is
not necessarily a value when it comes to designing technology that performs
effectively in atypical conditions, and especially in straitened or deprived
circumstances.
What follows from this first point is the necessity of civic and commercial
organizations flexibly responding to diversely functional people rather than
serving only those with species-typical functionality. Building accessibility
into technological advances is an especially important requirement of justice.
The adverse effect of the telephone’s invention on employment of people who
are deaf is a well-known example of injustice resulting from technological
change. Deaf people were evicted from the workplace by the change from a
mainly visual to a mainly aural mode of business communication.
The recent shift back from aural to visual communication, as emailing
replaced telephoning and face-to-face speech, threatened a similar result for
people who are blind. This was not a technological problem, as the develop-
ment of voice output of electronic texts followed fairly soon after the means
for sending and receiving such texts were widely marketed. There are vari-
ous accounts of how, in a relatively short time, normal business software was
made accessible so that screen reading software works well.10

8 See the webpage of the Convention’s Secretariat [9] for the latest information on global

activity to achieve equitable social opportunity for people with disabilities.

9 The ethical imperative that promotes this goal is discussed in [11].
10 For two sides of the story, see [8] on the American Federation of the Blind webpage,
and [3] on the Microsoft webpage.
1 Better Than New! Ethics for Assistive Technologists 13

What is clear is that the adoption of state policies prohibiting purchasing

of inaccessible programs and the arrival on the market of accessible com-
mercial programs were contiguous. A political commitment to participatory
justice prompted just distribution of technological skills and knowledge so
that the needed resources were deployed to create products usable by people
with different modes of functioning, not just by typically functioning people.
Microsoft, for example, now claims “increasing momentum toward the goal
of making computers accessible and useful to all people.”11

1.6 Conclusion

In this chapter, I have drawn attention to an unresolved discordance between

medical and engineering values that can conflict the practice of assistive tech-
nology. The difference lies in engineering placing a higher value on innovative
outcomes, even if these (and perhaps especially if these) alter familiar modes
of functionality. I recommend giving engineering values about functionality
more preeminence in the practice of assistive technology, and medical values
about functionality (at least to the extent that these overvalue “normality”)
somewhat less.
Assistive technologists have a responsibility beyond designing and dis-
tributing prostheses, that is, internal or external devices substituting for or
supplementing species-typical physical or cognitive human equipment to en-
able effective, even if atypical, functioning. Humans are toolmakers, and hu-
man society has advanced through the enhancement of functioning that we
achieve by using tools. This perspective on people’s social participation too
often is obscured by romantic prejudices condemning technology as unnatural
or unfair.
A common experience for individuals with disabilities when provided with
effective assistive technology is to enjoy an enormously expanding vista of op-
portunity for social participation – from the ability to visit a grocery store at
will to the ability to earn a higher education degree – so much so that they feel
functionally better than new. But technological progress in enhancing func-
tion must be matched by social and political progress in reconceptualizing the
relationship between human biology and human technology. Who better than
assistive technologists to cultivate public appreciation of the functional inti-
macy that effectual assistive engineering achieves between disabled people’s
bodies and their adaptive equipment? Thus, it is not merely permissibly ethi-
cal, but professionally obligatory, for assistive technologists to advance justice
by promoting progressive ideas and combating cultural prejudices against the
prosthetic uses of tools.

11 Compare the narratives at the sites above for two versions of Microsoft’s alacrity in
pursuing the goal of responsiveness to diversely functioning people. (See footnote 10)
14 Anita Silvers

1.7 Afterword

The intersection of the law with medicine in the last decades of the twentieth
century reshaped the conceptualization of patients, characterizing receivers
of medical care as competent choosers due the respect of deciding their good
for themselves. This idea is of individuals who retain the status of full so-
cial participants, regardless of their being ill or impaired. The intersection of
engineering with medicine has the potential to induce a similar conceptual
transformation. Assistive technologists should be in the lead in this move-
ment.
Disabled people who use technology to function come to experience their
devices as parts of themselves. Their standpoint in this regard differs from
that common to nondisabled people. I illustrate with a personal observation,
relating an incident that occurred as I returned to my home city from the
site of the workshop that prompted this book.
While I waited with my mobility scooter in the queue to go through US
customs, another traveler came up behind me pushing a luggage-loaded large
and heavy cart – right into my scooter. As I swung my seat around on the now
immobilized scooter to see a back wheel severed from the axle and lying on its
side, the perpetrator laughingly said that she had been looking back over her
shoulder for a friend and so had not noticed me, and then proceeded on to her
plane – leaving me to deal with mobility as impaired by her irresponsibility
as if she had broken my leg, and wondering why the workshop I had just
attended had facilitated discussion about the ethical obligation of protecting
walking people from injury by wheelchair users, but not about the equally
harmful reverse.
Justice for all equally calls for affording engineering’s emendations to hu-
man functioning the same status as medical interventions. One is as human
an enterprise as the other, for disabled people who use assistive technology
are as human as nondisabled people who do not.

References

[1] Beauchamp T, Childress J (2008) Principles of Biomedical Ethics.

Oxford University Press, New York
[2] Cooper R (2006) Wheelchair standards: It’s all about quality assurance
and evidence-based practice. Journal of Spinal Cord Medicine 29(2):
93–94, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1929010
[3] Microsoft Accessibility (2010) History of Microsoft’s commitment to ac-
cessibility, http://www.microsoft.com/enable/microsoft/history.
aspx
[4] National Academy of Engineering (2003) Online ethics center for engi-
neering and research, http://www.onlineethics.org/
1 Better Than New! Ethics for Assistive Technologists 15

[5] Rauhala M, Topo P (2003) Independent living, technology, and ethics.

Technology and Disability 15(3):205–214
[6] Rehabilitation Engineering and Assistive Technology Society of North
America (2010) Code of ethics, http://resna.org/certifications/
certification-professional-standards-board
[7] Rhodes R, Francis L, Silvers A (eds) (2007) The Blackwell Guide to
Medical Ethics. Wiley-Blackwell, Oxford
[8] Schroeder P (2000) A brief history of Microsoft and accessi-
bility. AccessWorld 1(4), http://www.afb.org/AFBPress/pub.asp?
DocID=aw010402
[9] Secretariat for the Convention on the Rights of Persons with Disabilities
(2008) Promoting the rights of persons with disabilities, http://www.
un.org/disabilities
[10] Silvers A (2001) No basis for justice: Equal opportunity, normal function-
ing, and the distribution of healthcare. American Journal of Bioethics
1(2):35–36
[11] Silvers A (2001) Prescribing multi-functionalism to achieve equality in a
world of difference. Health Ethics Today 12(1), http://www.phen.ab.
ca/materials/het/het12-01a.asp
[12] Silvers A (2003) On the possibility and desirability of constructing
a neutral conception of disability. Theoretical Medicine and Bioethics
24(6):471–487
[13] Silvers A (2008) The right not to be normal is the essence of freedom.
Journal of Evolution and Technology 18(1):79–85, http://jetpress.
org/v18/silvers.htm
[14] Steinbock B, London AJ, Arras J (eds) (2008) Ethical Issues in Modern
Medicine: Contemporary Readings in Bioethics. McGraw-Hill, New York
[15] Vaughn, Chairperson J (2006) Over the horizon: Potential impact of
emerging trends in information and communication technology on dis-
ability policy and practice. Washington, DC, http://www.ncd.gov/
newsroom/publications/2006/emerging_trends.htm
[16] Williams CJ (2010) Blind UCLA graduate can use computer-
assisted reading tools during state bar exam. Los Angeles Times,
http://articles.latimes.com/2010/feb/05/local/la-me-blind-
bar6-2010feb06
[17] Woolston C (2010) The healthy skeptic: Be wary of products touting
FDA certification. Los Angeles Times p 1, http://articles.latimes.
com/2010/mar/01/health/la-he-0301-skeptic-20100301, Health
section, Features desk, Part E
Chapter 2
The Myth of Neutral Technology

Jan Miller Polgar

Abstract The meaning that assistive technology (AT) holds for the user is
a key determinant of whether the device will be used or abandoned. Two
concepts, stigma and liminality (existing in a state of transition), are used
to frame users’ perceptions of the assistive technology they use, as generated
through research projects investigating aspects of assistive technology use.
Implications of the meaning of AT to the design and selection process are
described. Assistive technology that is seen as a tool, as just another way of
achieving a desired activity is much more likely to be assimilated into the
user’s daily life. Technology perceived in this manner enables people to share
activities with others and augment their personal abilities. Alternately, tech-
nology can be seen as a visible sign of disability, reinforcing stigma associated
with a disability and the perception of the AT user as existing somewhere be-
tween health and illness. Individuals with this view of technology may avoid
or resist use of technology, resulting in avoidance of meaningful activities and
both social and physical isolation. These findings support the conclusion that
technology is not neutral. Inclusion of users in both the design and selection
process and understanding the meaning that AT use holds are integral to
the development of assistive technology that achieves the desired outcome of
enabling participation in daily life.
Meaning is at least as powerful an influence as skill in determining whether a device
will be incorporated by an individual as a useful tool or discarded as excess baggage
[9].

Assistive technology (AT) can augment or replace function in many in-

dividuals with disabilities, enabling them to participate in daily activities
in their communities. The functionality of AT can be very appealing to

Jan Miller Polgar

School of Occupational Therapy, University of Western Ontario, London, ON, Canada,
[email protected]

M.M.K. Oishi et al. (eds.), Design and Use of Assistive Technology: Social, 17
Technical, Ethical, and Economic Challenges, DOI 10.1007/978-1-4419-7031-2 2,

c Springer Science+Business Media, LLC 2010
18 Jan Miller Polgar

designers, researchers and prescribers, with the potential to create ever more
complex technology to address physical, cognitive, or sensory impairment
without the necessary consideration of the influence of technology on the
user’s self-perception. Focus on device functionality may limit understanding
that the technology holds meaning to the consumer and significant others,
in other words, that technology is not neutral. Meaning is often a factor in
whether technology will be used or put into the closet. This chapter will ex-
plore various meanings that users ascribe to AT and the implications of these
meanings to the design, recommendation, selection and evaluation processes.
Two related constructs will guide this exploration: stigma and liminality.
Stigma was described by Goffman [2] as possession of an external charac-
teristic that discredits the individual. The presence of a physical impairment
becomes the source of a spoiled identity. He discusses the concept of “spread”
where the discrediting attribute attains a “master” status so that it defines
the individual, and all other personal accomplishments or attributes are ig-
nored. Stigma is context dependent; environments of various physical, social,
or institutional elements either reinforce or limit the perception of stigma.
Liminality is an anthropological term that conveys the notion of transition
and is often used to characterize the period of development of moving from
childhood to adolescence. It frequently involves a change of status, social
isolation, and/or physical removal of an individual. Liminality for a person
with disabilities has been described by Murphy [7] as feeling distant from
society, although not specifically excluded from it; as being between health
and illness. Murphy’s 1990 book The Body Silent describes his transition
from full participation in society as an academic anthropologist to living
with the physical abilities that resulted from a spinal cord tumor that caused
increasing paralysis. His account ably describes the experience of being and
becoming a person who has a disability [10].
These two constructs, stigma and liminality, are used to frame the dis-
cussion of the meaning of assistive technology for individuals who use it,
including the consumer and their families or other caregivers. They will be
applied to the following ideas to give context to results of various research
projects that included a component of the meaning that individuals ascribe
to the technology they use and to promote awareness in AT designers and
prescribers of why a device that is anticipated to be of benefit to the user in
their daily life is not embraced or is even discarded.

2.1 Source of the Data

The following ideas come from various research projects: a qualitative explo-
ration of how persons with disabilities chose to complete daily activities, a
phenomenological study of the lived experience of using AT when assisting
2 The Myth of Neutral Technology 19

a significant other, and design projects that involved consumers (broadly

understood) at all stages of the process as well as from the literature [6, 5].
This work, in part, derives from concern about the rate of abandonment of
AT and the associated costs – monetary, time, and social participation – to
the consumer, others in their social sphere, and society.

2.2 Key Ideas Related to Meaning and Assistive

Technology

Not surprisingly, the meaning of technology conveys both positive and nega-
tive/enabler and barrier notions. Two broad perceptions of technology will be
discussed to illustrate the meaning that AT can hold for consumers: assistive
technology as a tool and assistive technology as a visible sign of disability.

2.2.1 Assistive Technology as a Tool

Some assistive technology users, mostly those who are experienced users, view
their technology as a means to complete an activity. The meaning ascribed
to the AT was no different than any other tool or technology used in daily
life. For example, participants in a project exploring how individuals chose
to complete daily activities talked about sharing opinions on the best chair
components for their sport along with wheelchair maintenance and modifi-
cation activities. These discussions had the flavor of cyclists discussing the
latest cycling technologies. The AT was simply a tool that enabled them to
compete in a sport they loved.
Participants in both qualitative studies indicated that assistive technol-
ogy facilitated their ability to engage in desired activities. Participants in
one study indicated that access to AT was a primary factor in enabling a
significant other to return home, as seen in the following quote [6]:
“[lift] helps him and me together to do it [daily care]... Without [the lift] I would
not be able to handle [husband].”

For many participants in these studies, the technology had faded into the
background of their lives. They did not speak of the challenges posed by the
technology but did describe the constraints imposed by the environment that
was not accessible due to their use of the technology.
Assistive technology can provide a means to share activities. While the
decision to obtain a powered wheelchair is not made lightly, it can provide
independent mobility that results in a couple being able to walk side by side as
they go about daily tasks rather than one partner being dependent on the
20 Jan Miller Polgar

other to propel the chair. Technology levels the playing field, a point often
made in reference to computer access technology. As one study participant
indicated [5]:
“We are all given the exact same abilities in the digital environment ... And when
you are online, nobody knows you have a disability so it [the disability] never really
comes into it—it has a very big appeal to me.”

When technology is viewed as a tool, as something that is a necessary and

integrated part of daily life, it becomes an enabler of activity. However, far
too often, technology is seen as a reminder that the user cannot participate
in their community as they wish.

2.2.2 Assistive Technology as a Visible Sign

of Disability

When assistive technology is perceived to signal to others that the user is

disabled, it can become a barrier to participation in daily activities or be
abandoned. The technology reinforces a discrediting attribute and enhances
the perception of stigma. The technology becomes the focus of attention
rather than the person using the technology. The influence of the technol-
ogy on others’ perceptions is seen in the following quote by a 22-year-old
university student [5]:
“People see the chair and make certain perceptions and there’s certain understanding
of what it means to be disabled.”

Some people will avoid the use of technology and either not go to certain
community locations or, if they do so, will limit what they do because they
do not want to be seen as someone with a disability. The following quote
from a 25-year-old social worker illustrates this point [5]:
“the other night...I chose to like suck it up and walk the best I could without my
cane, because I would rather them not see me like that.”

Similar ideas were expressed by people who refused to use a white cane or a
powered wheelchair because of the image of disability these devices conveyed.
AT can be seen as a source of isolation in a number of ways. It can
physically isolate the user as in the experience of a woman who reported
that she and her husband were located in a back corner of a restaurant, out
of sight of other patrons or when people who use wheelchairs are relegated
to specific areas of a theatre or stadium that are accessible, but that do
not necessarily allow them to sit with their companions. Technology such as
augmentative and alternative communication devices or wheelchairs, by the
nature of their design and use, are an actual physical barrier between the user
and others in their environment, reinforcing a state of liminality.
2 The Myth of Neutral Technology 21

More troubling than the physical barrier is that AT can be socially

isolating. A common comment, reflected in the notion of wheelchairs as
portable seclusion huts [8], is that the technology distances the user from
others in their environment. This physical barrier then becomes a psycho-
logical barrier. People who use technology frequently report experiences such
as service providers speaking to their companions rather than themselves in
social circumstances, such as when they are making purchases.

2.3 Implications for AT Design and Selection

The collective results of these projects reinforce the notion that assistive
technology is not neutral. It carries a meaning to the user, others in their
social sphere and the community at large. When that meaning is a positive
one, AT is more likely to be incorporated into daily life. These key themes and
the feedback obtained during the design process have important implications
for AT design and selection. They suggest that technology that reduces the
impact of stigma and that enables the user to participate and thus feel less
isolated will be more acceptable and useful to the consumer.
Successful technology fades into the background of daily life. It becomes
just another way of completing a desired activity. Feedback provided by
children, parents and formal caregivers on design and function of AT in the
development of three types of seating projects [1, 4] revealed considerable
consistency across projects on perceptions of features that defined a desirable
device. Many consumers wanted a device that was aesthetically pleasing, was
simple to use and easy to maintain. Flexibility of use for different activities
and in different environments was another key feature.
The design and appearance of the device carry meaning for the individ-
ual and should not be overlooked in the development or recommendation
processes. Color of the device may not seem like an important feature over
others such as the ability to tilt a wheelchair seat or adjust a guardrail on
a bed. However, materials used to make a device and attention paid to the
aesthetics can result in a device that blends into the user’s environment, or
not. A device that looks similar to those available on the consumer market
reinforces the perception that the user is healthy and potentially reduces
isolation (ideas related to liminality).
The meaning of technology is a particularly important consideration for
older adults, who form an increasingly larger proportion of our population.
Many older adults want to remain in their own homes and will incorporate
technology that does not make them feel vulnerable and allows them to feel
more secure, safe and less of a perceived burden. Johnson, Davenport and
Mann [3] explored the perceptions of older adults of different smart technol-
ogy used in the Gator House at University of Florida. They asked seniors
whether they felt that the devices present in the house were useful to them
22 Jan Miller Polgar

at this time in their life. Technology that conveyed a sense of security was
more readily accepted than that which was seen as surveillance. For example,
people typically indicated that sensors that would detect a fall were probably
something that would be useful but not at that point in their life; in other
words, the more invasive technology was less acceptable.
The collective results of all of these projects lead to one critical conclusion:
the individuals seeking devices are the experts in their own lives. The individ-
ual designing or recommending a device retains expertise related to AT and
a professional responsibility to the client, but does not know what is best for
the user. It remains important to ask questions about what technology means
to the user. The most carefully designed and prescribed technology is of no
value if the intended user leaves it in the closet. Technology that is recom-
mended without input from the consumer is in danger of being abandoned,
at a cost to the user, their community, and society.

References

[1] Fong Lee D, Ryan S, Polgar J, Leibel G (2002) Consumer based ap-
proaches used in the development of an adaptive toileting system for
children with positioning problems. Physical and Occupational Therapy
in Pediatrics 22(1):5–24
[2] Goffman E (1963) Stigma: Notes on the management of spoiled identity.
Simon and Schuster, New York
[3] Johnson J, Davenport R, Mann W (2007) Consumer feedback on smart
home applications. Topics in Geriatric Rehabilitation 23(1):60–72
[4] Miller Polgar J, Ryan S, Coiffe M, Barber A (2003) Development of a
toileting system for adolescents with severe positioning problems: Feed-
back from consumers. In: 26th International Conference on Technology
and Disability: Research, Design, Practice and Policy (RESNA), Atlanta,
GA
[5] Miller Polgar J, Winter S, Howard S, Maheux K, Nunn J (2009) The
meaning of assistive technology use. In: Proceedings of the 25th Inter-
national Seating Symposium, Orlando, FL, p 75
[6] Morgan-Webb S (2005) Understanding the informal caregiver’s expe-
rience with the use of assistive devices. Master’s thesis, Occupational
Therapy, University of Western Ontario
[7] Murphy R (1990) The body silent. W. W. Norton, New York
[8] Scheer J (1984) They act like it was contagious. In: Hey S, Kiger G,
Seiden J (eds) Social aspects of chronic illness, impairment, and disabil-
ity, Willamette University, Salem, OR
2 The Myth of Neutral Technology 23

[9] Spencer C (1998) Tools or baggage? Alternative meanings to assistive

technology. In: Gray DB, Quantrano L, Lieberman ML (eds) Designing
and using assistive technology: The human perspective, vol 2, Paul H.
Brookes, MD, pp 89–98
[10] Wilcock A (2006) An occupational perspective on health, 2nd edn.
SLACK, Thorofare, NJ
Chapter 3
Accessible Technology and Models
of Disability

Richard E. Ladner

Abstract In this chapter, we discuss assistive technology from the view of

the consumer. Consumers of assistive technology follow the social model of
disability, that is, persons with disabilities are part of the diversity of life,
not necessarily in need of cure or special assistance. Their identity does not
revolve around being a patient or client, but focuses on their human desires to
work, play, and associate with others. The social model of disability dictates
an empowering approach to assistive technology research and development
where consumers are given the power to configure and even create technology
to suit their own needs and desires. The technology that comes from this
approach is called accessible technology, rather than assistive technology,
emphasizing its role in making human activities more accessible.

3.1 What is Assistive Technology

“Assistive technology” is really a redundant term because, in some sense, all

technology is assistive, making tasks possible or easier to do. Automobiles,
trains, busses, and airplanes are assistive technologies because they make
getting from one location to another easier to do. Telephones assist us to talk
to people over a distance. Computers are very general devices that assist us
with many tasks. In some sense, the whole purpose of technology is to make
tasks possible or easier to do. Nonetheless, the moniker “assistive technology”
has come to mean specialized technology for persons with disabilities. Hear-
ing aids are commonly called assistive listening devices, yet eye-glasses and
contact lenses are not typically called assistive technology. Correctable vision
is not considered to be a disability. Why is it that persons with disabilities
have assistive technology, while the rest of us just have technology?

Richard E. Ladner
Computer Science, University of Washington, Seattle, WA, [email protected]

M.M.K. Oishi et al. (eds.), Design and Use of Assistive Technology: Social, 25
Technical, Ethical, and Economic Challenges, DOI 10.1007/978-1-4419-7031-2 3,

c Springer Science+Business Media, LLC 2010
26 Richard E. Ladner

It is helpful to see what terms are used by advocacy groups of persons

with disabilities. The National Federation of the Blind just uses the term
“technology” on its web site for technology that is useful to its members, such
as screen readers, Braille printers, Braille notetakers, and talking phones.
Similarly, the American Council of the Blind talks about “products,” not
“assistive technology products”. The National Association of the Deaf just
uses the term “technology” on its web site for technology that is useful to its
members such as captioning, video phones, and video relay services. However,
they do use “assistive listening technology” for devices that enhance hearing.
The Alexander Graham Bell Association for Deaf and Hard of Hearing talks
about hearing aids and cochlear implants, but does not use the term “assistive
technology” on its web site. Why do many people with disabilities not use
the term “assistive technology” when talking about the technology that they
use?
I believe that the two questions in the previous paragraphs are answered
by understanding how people with disabilities view themselves and their re-
lationship to technology; that is, their identity as users of technology. First,
as I pointed out earlier, the addition of “assistive” does not add anything
to “technology” that one uses every day on a routine basis. All technology
is assistive, by definition. Second, and more important, the term “assistive”
when used with “technology” emphasizes a person’s need for extra assistance.
It has the ring of paternalism, a view that people with disabilities need lots
of extra help, are dependent and are not capable human beings.

3.2 Models of Disability

There have been a number of attempts to define different perspectives on

or models of disability [1]. The following are five models of disability that
are found in western society through which we can understand better the
relationship between people with disabilities and technology.
Medical Model: People with disabilities are patients who need treatment
and cure or partial cure. Generally, treatment is very expensive and may
require continual monitoring over a lifetime. Some assistive technologies can
be prescribed by doctors or other medical professionals. In such cases, the
technologies may be paid for by medical insurance.
Rehabilitation Model: People with disabilities are clients who need assis-
tance and assistive technology for employment and everyday life. Job related
assistive technology may be paid for by employers, but technology for every-
day living is usually paid for by the client.
Special Education Model: Children with disabilities have the need for
special education, which may differ substantially from education programs
that other children receive. Technology may be provided to some children with
3 Accessible Technology and Models of Disability 27

disabilities to further their education. In the United States the Individuals

with Disabilities Education Act (IDEA) provides for access to public edu-
cation for all children regardless of disability. Under this act a student may
have an Individualized Education Plan (IEP) whereby the student may not
be expected to achieve as much as other children without a disability.
Legal Model: People with disabilities are citizens who have rights and re-
sponsibilities like other citizens. Accessibility to public buildings and spaces,
voting, computers, television, and telephone are some of those rights. These
rights are ensured by many laws in the United States including the Rehabil-
itation Act and the Americans with Disabilities Act (ADA). Often assistive
technology related to legal access is provided free of charge.
Social Model: People with disabilities are part of the diversity of life, not
necessarily in need of treatment, cure, or special assistance. They do need
access – often through technology – to partake in many activities of life, but
they do not need to be taken care of or have decisions made for them by
others. Technology developed in the social model is typically paid for by the
individual with the disability or is free, if mandated by law. Closed captioned
television is an example of free technology mandated by law.
Naturally, these five descriptions of models of disability are oversimpli-
fied, but they do help delineate overlapping approaches to disability. Each
of the models has a work force that provides the services and products as-
sociated with the model. Medical professionals provide medical procedures
and services. Rehabilitation professionals provide services like job training
and assistive technology training. Special education professionals teach in
the classroom and provide out-of-class training. Disability lawyers and other
legal professionals provide legal assistance when needed, for example, to file
a law suit. The social model workforce includes developers and sustainers of
technology whose goal is technology at no or low cost to consumers. There
are also certain workforces that cut across all five models. For example, sign
language interpreters and real-time captioners are needed by deaf people in
many situations including medical, educational, work place, legal, and social.

3.3 Accessible Technology

These models of disability provide a framework for thinking about the re-
lationship between people with disabilities and the technology they use.
The medical model tends to focus on prostheses, devices that restore lost
function. For example, the cochlear implant is a surgically implanted device
that stimulates the auditory nerve system and may partially restore hearing.
Joint replacement surgery may restore someone’s ability to walk. Research
on retinal implants may partially restore vision someday. The rehabilitation
model tends to focus on assistive technology that does not necessarily restore
28 Richard E. Ladner

lost function, but permits alternative approaches to achieving goals. For

example, a motorized wheelchair does not allow someone to walk, but pro-
vides an alternative to walking for someone desiring to go from one location
to another. A video phone does not restore hearing, but instead allows a deaf
person to talk at a distance to another person in sign language.
In the social model, the term “accessible technology” seems to fit bet-
ter than “assistive technology” because it focuses on alternative approaches
to achieving goals rather than the paternalistic notion of needing assistance.
Given the prevalence of the medical and rehabilitation models one should not
expect a sudden change in language use. The term “assistive technology” will
continue to be used for many years to come. However, for those of us working
in accessible computing research – which is not currently dominated by the
medical and rehabilitation point of view – the term “accessible technology”
is very attractive. The term leans towards the legal and social models, and
away from the paternalistic medical and rehabilitation models. The term “as-
sistive technology” has come to mean special purpose devices, but given that
computers are general purpose devices that can provide multiple accessibility
solutions the term “accessible technology” might be more appropriate.

3.4 Concepts from Human–Computer Interaction

Human–computer interaction (HCI) is one research area where there is sig-

nificant interest in accessible technology. At the premier HCI conference, the
International Conference on Human Factors in Computing Systems (CHI),
32/277 (12%) papers mentioned the term “disability” in 2009. The ACM
SIGACCESS Conference on Computers and Accessibility (ASSETS) started
in 1994 and focuses exclusively on accessible technology. The interest among
HCI researchers in accessibility solutions for people with disabilities is rooted
in the researchers’ innate desire to solve interesting problems that are related
to computers and human beings. Some of the most interesting problems come
from the space where the humans have some disability.
One concept from HCI is usability, meaning how easy it is to learn, config-
ure, and use an interface. It is possible for an interface to be accessible but not
especially usable. Examples are early audio CAPTCHAs1 that permit blind
users to prove that they are human by listening to a distorted message and
then entering the message into a text box. These audio CAPTCHAs allowed
blind users to access sites that only permit human access, but they are ex-
tremely difficult to use. Another important concept in HCI is human centered
design, which means involving users in each iterative design cycle from con-
cept to prototype to final design. Human centered design generally leads to
1 A CAPTCHA is a challenge response test often used by web site servers to determine
whether the entity trying to access the site is a human or another computer. The most
commonly used CAPTCHAs are images of distorted characters.
3 Accessible Technology and Models of Disability 29

more usable interfaces. The same principle can be applied to the design of
accessible technology by involving disabled users in the design process. The
concept of universal design means designing interfaces in a way that they can
be used by the vast majority of people regardless of disability. For webpage
design this might mean making sure that the design is usable by a blind
person with a screen reader, without necessarily modifying its visual appear-
ance. Fortunately, there are standards for such designs in the web content
accessibility guidelines (WCAG) offered by the W3C [6].
It is doubtful that one interface can be truly universal, so another approach
to accessibility is to design for user empowerment, which means to design to
enable people to solve their own accessibility problems whenever possible.
A simple example is found in modern screen readers where the user can
adjust the speed of the speech. Many blind people use a very high speed
which is incomprehensible to an average listener. In screen readers, a design
goal is not the most natural speech, but speech that can be understood at
a speed adjustable by the user. Designing for user empowerment is a non-
paternalistic approach to interface design. In a sense, it encompasses both
human centered design and universal design. It would be difficult to design
for user empowerment without involving users in the design cycle. Universal
design includes solutions that allow for easily set individual configurations;
for example, most computer keyboard trays have adjustable height.
The most powerful form of user empowerment is providing the education
and environment to people that will enable them to solve their own accessi-
bility problems. The famous adage, “Give a man a fish; you have fed him for
today. Teach a man to fish; and you have fed him for a lifetime,” applies to
accessible technology. The highest level of user empowerment is the inclusion
of people with disabilities as designers and creators of the technology.

3.5 New Directions in Accessible Technology

There are many new research directions in accessible technology that take
the non-paternalistic approach of the social model of disability, and in this
last section I will mention a few. The first is the SUPPLE++ project, which
automatically generates appropriate user interfaces for users with varying
motor and vision abilities [4]. The beauty of this system is how easy it is
for a user to configure the interface: A user can perform a few simple tasks,
which are recorded and analyzed to determine which interface would work
best for that person.
The second is WebAnywhere, an open source web-based screen reader [2].
WebAnywhere is a free screen reading web service that allows audio access
to the web from almost any computer, even those with highly circumscribed
capabilities such as those found in public places like libraries and internet
cafes. Because it is open source, contributors from around the world, disabled
30 Richard E. Ladner

or not, can add value to the service by adding new features, such as multiple
languages. The development of open source software for accessibility fits the
social model of disability.
The third is the ASL-STEM Forum, which enables people to upload def-
initions and their signs for topics in science, technology, engineering, and
mathematics (STEM) [3]. Because deaf students are so thinly spread at hun-
dreds of colleges and universities it is very difficult to develop a uniform
vocabulary of signs in technical fields. The forum will enable students, their
sign language interpreters, and deaf professionals to share vocabulary and
discuss among themselves what signs they would like to use. The forum is a
form of community empowerment whereby deaf students can solve their own
accessibility problems collectively.
Finally, I will mention the MobileAccessibility Project [5], which is a
relatively new project at the University of Washington and University of
Rochester. Modern smart phones have multiple sensors (camera, microphone,
GPS, compass, accelerometer), network capability (WiFi, Bluetooth, cellular
data network, cellular voice network), alternative input (keyboard, touchpad,
buttons, speech), and output (screen, sound, speech, vibration). With appro-
priate programming these devices could solve multiple accessibility problems,
that is, smart phones can become multi-function accessibility devices. As an
example, smart phones (KNFB Reader Mobile, TestScout) can already do
optical character recognition (OCR) so that blind people can take pictures
of pages of text, convert them to digital text, and then listen to them using
text-to-speech technology. My vision for the future is that a blind person can
buy a standard smart phone and data plan, and then download any needed
accessibility applications. Blind designers and computer programmers will be
part of the development community that builds these new applications.

3.6 Conclusion

People with disabilities, including those who become disabled as a result of

aging, are all part of the rich fabric of human life. Modern medicine’s ability
to save lives creates even more people with disabilities before old age sets in.
Typically, people with long-term disabilities are not looking for cures or lead-
ing lives of desperation. People who are newly disabled go through a number
of stages of grief that eventually turn into some form of acceptance of their
disabilities. In either case, people with disabilities are simply social human
beings who want to work, play, and associate with friends. Technology en-
ables these people to have more access to what they want and need in life.
Designing technology for user empowerment fits this social model of disabil-
ity. “Accessible technology” is a better term than “assistive technology” for
technology targeted to people with disabilities who view themselves in the
social model of disability.
3 Accessible Technology and Models of Disability 31

Acknowledgment Thanks to Anna Cavender for several helpful comments on a draft of

this chapter.

References

[1] Albrecht GL, Bury M, Seelman KD (ed) (2001) Handbook of Disability

Studies. Sage publications, California
[2] Bigham JP, Prince CM, Ladner RE (2008) WebAnywhere: a screen reader
on-the-go. In: Proceedings of the international cross-disciplinary Confer-
ence on Web Accessibility (W4A 2008), pp 73–82, http://webanywhere.
cs.washington.edu
[3] Cavender A, Otero D, Bigham JP, Ladner RE (2010) ASL-STEM Forum:
Enabling Sign Language to Grow Through Online Collaboration. In: 28th
ACM Conference on Human Factors in Computing Systems (CHI 2010),
Atlanta, GA, pp 2075–2078, http://aslstem.cs.washington.edu
[4] Gajos KZ, Wobbrock JO, Weld DS (2007) Automatically generating
user interfaces adapted to users’ motor and vision capabilities. In: 20th
Annual ACM symposium on User Interface Software and Technology
(UIST 2007), pp 231–240, http://www.eecs.harvard.edu/~kgajos/
research/supple/
[5] MobileAccessibility (2008) Bridge to the world for blind, low-vision,
and deaf-blind people. Computer Science and Engineering, University
of Washington, Seattle, http://mobileaccessibility.cs.washington.
edu
[6] W3C (2008) Web Content Accessibility Guidelines (WCAG) 2.0, http://
www.w3.org/TR/WCAG20/
Chapter 4
The Importance of Play:
AT for Children with Disabilities

Albert M. Cook and Kim Adams

Abstract The potential of robots as assistive tools for play activities has
been demonstrated through a number of studies. Children with motor impair-
ments can use robots to manipulate objects and engage in play in activities
that parallel those of their typically developing peers. This participation cre-
ates opportunities to learn cognitive, social, motor, and linguistic skills. By
comparing disabled children’s performance with that of typically developing
children, robot use can also provide a proxy measure of cognitive abilities.

4.1 Background

During typical development, play activities provide an opportunity for chil-

dren to learn cognitive, social, motor, and linguistic skills through the ma-
nipulation of objects. Physical impairments make it difficult for a child who
has disabilities to independently manipulate objects in a play context [16].
Assistive technologies have been used to enable play by adapting battery
powered toys to be controlled by a single switch activated by a gross mo-
tor movement. This engages children and provides a sense of control, but
the repetitive action of the toy causes the child to lose interest. There are
also simple electronic aids to daily living (EADLs) that allow an appliance
such as a food mixer to be plugged in and controlled with a single gross
movement on one switch. This allows a child to participate in activities with
other children. For example a child with fair fine motor control could open a

Albert M. Cook
Speech Pathology and Audiology, Faculty of Rehabilitation Medicine,
University of Alberta, AB, Canada, [email protected]
Kim Adams
Glenrose Rehabilitation Hospital, and Faculty of Rehabilitation Medicine,
University of Alberta,
AB, Canada, [email protected]
M.M.K. Oishi et al. (eds.), Design and Use of Assistive Technology: Social, 33
Technical, Ethical, and Economic Challenges, DOI 10.1007/978-1-4419-7031-2 4,

c Springer Science+Business Media, LLC 2010
34 Albert M. Cook and Kim Adams

package of pudding and pour it into a blender. Another child might add milk
and a child with very limited motor control could mix the ingredients using
the EADL.
One challenge with many EADL or switch-controlled toy situations is
that a child who is using augmentative communication must choose be-
tween controlling the toy or EADL, or controlling her communication device.
Anderson [4] overcame this choice problem by having children control infrared
toys from their communication device and reported that this approach offers
“highly motivating activities for use in the development of language” (p. 7).
Although this approach solves the problem of integrating play and communi-
cation, infrared toys will always perform the same function, becoming boring
after a while.

4.2 Robot Applications for Children

Robots have a potential learning advantage over toys or appliances since

robots can be reprogrammed to perform a variety of functions and thus
keep the interest of the child. They can also present increasing challenges.
Young children with disabilities can control robots for manipulation of three-
dimensional objects in play and school activities. Children with disabilities
may also be able to carry out the robot programming on a computer to engage
in problem solving.
Robots have been used successfully in a number of studies to allow children
with disabilities to participate in play and engage in school-based activi-
ties. School activities aided by robots include manipulative tasks using a
robot [12], pick and place academic activities [15, 14], drawing [21], science
lab activities [11], and science and art [10, 17]. Robots have also been used
to facilitate play [5, 13]. In many of these projects, the focus is on the impor-
tance of play in child development and the ability of robotics to enable play
by children who have disabilities. The IROMEC project team has developed
a set of play scenarios that serve to set the context for users to be involved in
the design process of appropriate robotics activities and hardware. They have
identified four types of play: sensory motor play, symbolic play, constructive
play, and games with rules [20], and have developed a flexible modular mobile
robot to accommodate multiple users and play scenarios [18].

4.3 Robots and Cognitive Development in Children

Many standardized tests of cognitive ability require speech or fine motor

control, which can make it difficult to ascertain the developmental level of
children who have motor disorders and complex communication needs. Due to
4 The Importance of Play: AT for Children with Disabilities 35

Fig. 4.1 Lego robots and adapted controller

these limitations, children with severe disabilities may be perceived as being

more developmentally delayed than they actually are. Robots give children
an opportunity to manipulate items and choose how to interact with their
environment. Because these tasks often require problem solving, they can
also provide a method for children to demonstrate their understanding of
cognitive concepts.
Robots have been used to demonstrate previously unmeasured cognitive
skills. Robot-based tool use was demonstrated by disabled and typically-
developing children greater than 8 months in mental age by using a robot
to bring an object closer to them [6]. Children aged 6–14 years who had se-
vere cerebral palsy performed a structured play task to uncover a hidden
toy by activating one or more switches [7]. The majority of the partic-
ipants could not be evaluated through standard cognitive measures, but
teachers noticed differences in overall responsiveness, amount of vocalization,
and interest (i.e., increased attention to tasks) for children who used the
robotic arm.
Ten children with varying physical and cognitive disabilities participated
in a study using the Lego MindStorms robot [8]. Two robots were built and
used in this project, and are shown in Fig. 4.1: the robot arm (left image in the
figure) and the roverbot car (centre image). Each robot could be programmed
to perform different actions. The child used from one to four switches con-
nected to a modified remote control (right image) designed and built for this
project. The child could play back a movement (e.g., a dancing robot) with
one switch press or control the robot to move in four directions (left, right,
forward, back) using four switches.
The study’s hypothesis was that children with cognitive disabilities will use
a robot to interact with objects in a manner that is consistent with typical
developmental levels for non-disabled children.
The children fell into three groups with respect to their cognitive level and
skills attained with the robots:
1. Severe physical and cognitive disabilities: These children had limited con-
trol or understanding of the robot. They controlled the robot with a single
switch to bring toys to them, or to move it across their field of vision.
36 Albert M. Cook and Kim Adams

2. Multiple physical and cognitive disabilities: This group had greater, but
still limited, control over their surrounding environment. They were able to
use one switch to control the robot in tasks such as fetching a toy or taking
toys to play partners. They took turns with the researcher. This group’s
verbal skills improved, their willingness to interact with others increased,
and their ability to concentrate on new tasks was apparent throughout the
sessions.
3. Greater physical and cognitive abilities: These children controlled the
robots using multiple switches. This group could drive the robot through
an obstacle course, create stories, use the robot to take specific items
to others, and use the arm to sort and play games with other students.
Their socialization skills increased, and they became more outgoing and
vocal. Their parents were pleased as they noticed changes in the home
environment.
Children in groups 2 and 3 demonstrated discovery using the robots in
symbolic and imaginative play. All of the children were able to demonstrate a
range of cognitive skills, even though many of them were judged non-testable
on standardized tests. The hypothesis was proven true, and a hierarchy of
cognitive skills represented by robot tasks was developed.

4.4 Robot Use by Very Young Typically

Developing Children

If robot-based tasks are to be used as a proxy measure of cognitive develop-

ment, it is important to know how typically developing young children are
able to use the robot. Few studies have addressed robot use with very young
children. A recent study involved typically developing children aged 3, 4 and
5 years [19]. They used a Lego robot to complete tasks based on the cogni-
tive concepts of causality, negation, binary logic, and sequencing. All of these
tasks are related to the use of electronic assistive technologies and the use of
robots for exploration and discovery.
Of the cognitive skills, causality was understood by all of the participants,
negation (the concept that releasing a switch was an action) and binary logic
(left and right) task were understood by the 4-and 5-year-olds. The 3-year-
olds had more difficulty with negation and none were able to consistently
use a two-step sequence to accomplish a task. Most of the 4-and 5-year-olds
accomplished the two-step sequence successfully. This study confirmed that
robot-related tasks were dependent on developmental level. This provides
the basis for using simple robot tasks to probe cognitive understanding and
developmental level in children who have disabilities.
4 The Importance of Play: AT for Children with Disabilities 37

4.5 Integrating Communication and Robotic

Manipulation

As described above, children who use augmentative communication devices

(often called speech generating devices or SGDs) may have difficulty in in-
tegrating the control of play objects with the control of the SGD. Just as
Anderson [4] integrated SGDs and infrared controlled toys, infrared robots
like the Lego roverbot can be controlled via the SGD [3]. Many SGDs have the
capability to learn infrared commands. Robotic control is important because
much of play and selected portions of the academic curriculum involve ma-
nipulation of real objects. Controlling robots through SGDs allows children
to talk while they play, similar to how typically developing children do it.
Professional experts [9] and children with and without disabilities per-
formed usability testing with an integrated communication and robotic play
platform. The robot could be used to either play back stored programs or
in direct teleoperated mode. Teleoperation was possible for the experts and
older children (5-year-olds). Younger children (3-year-olds) relied on the play-
back of pre-programmed movement using a single switch. Children were also
given the option of directing another person to do the manipulation in a
play task or to do it directly with the robot. Children preferred to do activ-
ities using the robot rather than directing another person. All children used
the built-in communication functions to spontaneously talk while using the
system during play.
A commercially available communication device was used by a 12-year-old
girl who has Cerebral Palsy to control Lego robots for academic activities
[3, 2, 1]. This study established the feasibility of controlling Lego robots via
an SGD for social studies, math, and robot programming activities. With
systems such as these, children can demonstrate and develop manipulative,
communicative, and cognitive skills in an integrated way.

4.6 Summary

Small robots can provide interesting and engaging opportunities for children
with disabilities to engage in play. They can also allow access to learning
activities involving manipulation. The ways in which children use robots re-
veals a great deal about their cognitive skills and problem solving abilities.
When combined with use of augmentative communication devices, robots
provide a powerful active component to play and academic activities that is
not possible with the communication device alone.
38 Albert M. Cook and Kim Adams

References

[1] Adams K, Cook A (2009) Using an augmentative and alternative

communication device to program and control Lego robots. In: RESNA
Annual Conference, New Orleans, LA
[2] Adams K, Yantha J, Cook A (2008) Lego robot control via a speech gen-
erating communication device for operational and communicative goals.
In: International Society for Augmentative and Alternative Communi-
cation – 13th Biennial ISAAC Conference, Montreal, QC
[3] Adams K, Yantha J, Cook A (2008) Lego robot control via a speech
generating communication device for play and educational activities. In:
RESNA Annual Conference, Washington, DC
[4] Anderson A (2002) Learning language using infrared toys. In: 23rd An-
nual Southeast Augmentative Communication, Birmingham, AL
[5] Andreopoulos A, Tsotsos J (2007) A framework for door localization
and door opening using a robotic wheelchair for people living with mo-
bility impairments. In: Proceedings of the Robotics Science and Sys-
tems (RSS) Manipulation Workshop: Sensing and Adapting to the Real
World, Atlanta, GA
[6] Cook A, Hoseit P, Ka M, Lee R, Zenteno-Sanchez C (1998) Using a
robotic arm system to facilitate learning in very young disabled children.
IEEE Transactions on Biomedical Engineering 32(2):132–137
[7] Cook A, Bentz B, Harbottle N, Lynch C, Miller B (2005) School-based
use of a robotic arm system by children with disabilities. IEEE Transac-
tions on Neural Systems and Rehabilitation Engineering 13(4):452–460
[8] Cook A, Adams K, Volden J, Harbottle N, Harbottle C (2010) Using
Lego robots to estimate cognitive ability in children who have severe
physical disabilities. Disability and Rehabilitation: Assistive Technology
(in press)
[9] Corrigan M, Adams K, Cook A (2007) Development of an interface
for integration of communication and robotic play. In: RESNA Annual
Conference, Phoenix, AZ
[10] Eberhardt S, Osborne J, Rahman T (2000) Classroom evaluation of the
arlyn arm robotic workstation. Assistive Technology 12(2):132–143
[11] Howell R, Hay K (1989) Software-based access and control of robotic ma-
nipulators for severely physically disabled students. Journal of Artificial
Intelligence in Education 1(1):53–72
[12] Karlan G, Nof S, Widmer N, McEwen I, Nail B (1988) Preliminary
clinical evaluation of a prototype interactive robotic device (IRD-1). In:
Proceedings of the International Conference on Agents and Artificial
Intelligence, Montreal, QC
[13] Kronreif G, Kornfeld M, Prazak B, Mina S, Frst M (2007) Robot assis-
tance in playful environment user trials and results. In: Proceedings of
the IEEE International Conference on Robotics and Automation, Rome,
Italy
4 The Importance of Play: AT for Children with Disabilities 39

[14] Kwee H, Quaedackers J, van de Bool E, Theeuwen L, Speth L (1999)

POCUS project: Adapting the control of the Manus manipulator for per-
sons with cerebral palsy. In: Proceedings of the International Conference
on Rehabilitation Robotics (ICORR), Palo Alto, CA
[15] Kwee H, Quaedackers J, van de Bool E, Theeuwen L, Speth L (2002)
Adapting the control of the Manus manipulator for persons with cerebral
palsy: An exploratory study. Technology and Disability 14(1):31–42
[16] Musselwhite C, Wagner D, Cervantes O (2008) AAC authors: Writ-
ing beginning books for young readers. In: 13th Biennial Conference
of International Society for Augmentative and Alternative Communica-
tion, Montreal, QC
[17] Nof S, Karlan G, Widmer N (1988) Development of a prototype in-
teractive robotic device for use by multiply handicapped children. In:
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Intelligence, Montreal, QC
[18] Patrizia M, Claudio M, Leonardo G, Alessandro P (2009) A robotic
toy for children with special needs: From requirement to design. In:
Proceedings of the 11th International IEEE Conference on Rehabilita-
tion Robotics, Kyoto, Japan, pp 918–923
[19] Poletz L, Encarnao P, Adams K, Cook A (2009) Robot skills of preschool
children. In: RESNA Annual Conference, New Orleans, LA
[20] Robins B, Ferrari E, Dautenhaun K (2008) Developing scenarios for
robot assisted play. In: Proceedings of the 17th Annual Interna-
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pp 180–186
[21] Smith J, Topping M (1996) The introduction of a robotic aid to drawing
into a school for physically handicapped children: A case study. British
Journal of Occupational Therapy 59(12):565–569
Chapter 5
Need- and Task-Based Design
and Evaluation

Albert M. Cook, Jan Miller Polgar, and Nigel J. Livingston

Abstract Unfortunately, device abandonment (by clients or caregivers) is a

pervasive problem in the provision of assistive technology. This is not nec-
essarily the result of poor design of the technology, but rather a failure to
account for other factors or determinants. This issue can be successfully ad-
dressed by employing the human activity assistive technology (HAAT) model
when considering potential solutions for clients. The model conceptualizes the
consumer, their activities, environment, and assistive technology as an inte-
grated system in which changing one element affects all other elements in the
system. The model can be applied in the design, selection, and evaluation of
technology for use by an individual, or as a conceptual model for exploring
the influence of assistive technology on participation in daily activities. In
this chapter, examples and explanations are given for both “successful” and
“failed” technologies with specific reference to the HAAT model.

5.1 Introduction

Well-intentioned but poorly designed assistive technology (AT) is a pervasive

problem, and a contributing factor to device abandonment. By focusing on
specific needs and specific tasks, AT design can be made much more efficient,
and evaluation much more effective.

Albert M. Cook
Audiology and Speech Pathology, Faculty of Rehabilitation Medicine,
University of Alberta, AB, Canada, [email protected]
Jan Miller Polgar
School of Occupational Therapy, University of Western Ontario, London, ON, Canada,
[email protected]
Nigel J. Livingston
CanAssist, University of Victoria, Victoria, BC, Canada, [email protected]

M.M.K. Oishi et al. (eds.), Design and Use of Assistive Technology: Social, 41
Technical, Ethical, and Economic Challenges, DOI 10.1007/978-1-4419-7031-2 5,

c Springer Science+Business Media, LLC 2010
42 Albert M. Cook, Jan Miller Polgar, Nigel J. Livingston

5.2 Assistive Technology Abandonment

Technology abandonment occurs when a consumer stops using a device even

though the need for which the device was obtained still exists. The underlying
factors of device abandonment are important to consider. A survey of more
than 200 users of assistive technologies identified four factors significantly
related to the abandonment of assistive technologies: (1) failure of providers
to take consumers’ opinions into account, (2) easy device procurement, (3)
poor device performance, and (4) changes in consumers’ needs or priorities
[4]. Another factor is the personal meaning attributed to assistive devices by
the user [3].
Psychosocial and cultural variables can be primary factors in determin-
ing the meaning individuals assigned to AT. In particular, expectations of
how the device would function and the social costs of using the device (i.e.,
cost/benefit of device use) determined whether a person integrated AT into
his or her life or not. Personal characteristics related to mood, self-esteem,
self-determination, motivation, and psychosocial characteristics related to
friend and family support are also significant predictors of device use [5].

5.3 HAAT Model

The human activity assistive technology (HAAT) model conceptualizes the

consumer, their activities, environment, and assistive technology as an inte-
grated system in which changing one element affects all other elements in the
system [2]. It can be applied in the design, selection and evaluation of tech-
nology for use by an individual, or as a conceptual model for exploring the
influence of assistive technology on participation in daily activities.
The HAAT model has four elements: the activity, the human, the environ-
ment (context), and the assistive technology.

5.3.1 Human

The Human element considers all aspects that relate to the person, and is one
of the most complex elements of the HAAT model. In considering potential
assistive technologies, a consumer’s cognitive, physical, and emotional skills
and abilities as they relate to participation in daily activities and use of
technology, are involved. Further, the consumer’s experience with technology,
whether they are an expert or a novice in its use, is also an important part
of the human element.
5 Need- and Task-Based Design and Evaluation 43

5.3.2 Activity

Activity involves all those daily tasks in which a person wants or needs
to engage. Often, these are conceptualized as self-care, productivity (work,
education, volunteer activities), and leisure [6]. When considering the selec-
tion of assistive technology, it is important to determine which activities a
person wants or needs to pursue, where these occur, and when they occur
(e.g., time of day, frequency of occurrence).

5.3.3 Context

Context refers to different aspects of the environment that affect the person,
the activities in which they engage, and their use of assistive technology.
The conceptualization of the context involves four elements: physical, social,
cultural, and institutional.
The physical environment includes both the natural and built environ-
ments as well as physical parameters (such as temperature and light) that
affect the function and integrity of the assistive technology.
The social element of the context refers to other people and their in-
teractions in the AT user’s environment, and social conventions that affect
technology use. The social environment can be conceptualized as a series
of concentric rings representing increasingly distant relationships to the in-
dividual at the centre [1]. The first ring, the one closest to the individual,
consists of family and close friends. The farthest ring consists of individuals
or groups with whom the person has infrequent interaction, or whose actions
affect the life of the person indirectly. The environments in which a person
lives, works (or learns), plays and engages in community activities like shop-
ping also form the social context. Here, the expectations of others and their
attitudes and understanding of assistive technology affect whether it can be
used successfully.
The cultural environment includes all those attitudes, beliefs, values, and
practices that are shared by members of a broader group. Where a social
group includes individuals who interact with each other with some frequency,
a cultural group shares many values, but members may be geographically
distant and unknown to each other. Cultural values such as independence and
emphasis on physical abilities may discourage a person from using assistive
technology that is seen as drawing attention to the user’s lack of independence
or physical skill.
Finally, the institutional element of the context refers to formal rules, pro-
cedures, policies, regulations, and legislation that affect daily life. Examples
include the policies and procedures required to obtain funding for an assistive
device or legislation related to accessibility of the physical environment and
services to individuals with a wide range of disabilities.
44 Albert M. Cook, Jan Miller Polgar, Nigel J. Livingston

5.3.4 Assistive Technology

The last element of the model is the assistive technology, specifically, the
device and its interface with the user. Various features of the technology are
considered in this element. These include the input required by the person
when using the device, the interface between the device, the person and the
environment, the device processor and the output of the device. Cook and
Polgar [2] define hard and soft technologies, which refer to the actual device,
in the first instance and the education, training, and other support needed
to use the technology in the latter instance.
The design of an assistive technology system involves consideration of each
of these elements, through a formal or informal evaluation. Cook and Pol-
gar [2] describe a process to guide the design which involves starting at the
activities that the individual wishes to perform when using the AT. The hu-
man skills and abilities, attitudes toward AT, and level of experience are
considered next. The environments in which the activities are performed are
identified as well as the need to transport the technology among environ-
ments. Once all of these elements and their interaction are considered, then
selection of the actual device is considered. This process underscores the im-
portance of assessing the needs and abilities of the person and the influence
of the environment prior to determining which device is most useful.

5.4 Case Stories: Applying the HAAT Model

CanAssist is a program based at the University of Victoria (BC, Canada)

that is dedicated to developing and providing technologies and services that
increase the quality of life and independence of those with disabilities. In an
approach consistent with the HAAT model framework, all projects under-
taken by CanAssist are in direct response to requests – either directly from
the individual with special needs or from a family member, caregiver, or
health care-professional acting on their behalf. Before a project proceeds, the
client coordinator talks with or preferably meets with the prospective user
(and/or representative) to clearly understand the user’s needs and the con-
text of the request. The questions in Table 5.1: illustrate this data collection
process.
The first question in Table 5.1: identifies the HAAT model activity to be
performed. Questions 2 and 3 define the HAAT model context, as well as
obtain information about the soft technology supports available. Question 4
begins to consider the assistive technology, especially the relationship between
new and existing devices.
Once the information in Table 5.1: has been collected, a decision is made
as to whether to proceed with the project. At this point, the critical questions
focus on the potential assistive technology in the context of the HAAT model,
5 Need- and Task-Based Design and Evaluation 45

Table 5.1: Initial questions used to define a need

1. What is the exact nature of the task that needs to be accomplished?

2. Will the device be used in the home, school, or work setting?
3. What supports will be in place for that individual?
4. What other devices are in use, and will the new device in any way compromise the
use of other devices?

and the existence of supporting soft technologies to ensure success. The pri-
mary determinant is whether the project is technically feasible. Additionally,
CanAssist is focused on supplying devices when none exist commercially, so
it is crucial to determine whether a solution already exists commercially. If a
suitable device already exists, the client is directed to the source; if not, then
a team will be assembled to develop the new device.
The client is a member of the design team, and is consulted on a continuous
basis during the development of the device and after its delivery. To avoid the
pitfalls associated with device abandonment, it is paramount that the client’s
expectations for performance and usefulness of the device are realistic and
agreed upon by all parties.

5.4.1 Successful Projects

Keeping Marion connected at 92: Marion is 92 and has mild dementia.

She lives in a care facility. CanAssist was approached by her daughter to
develop an easy-to-use system by which she and her mother could regularly
communicate (Marion is not able to use a regular phone). Thus, the activity
is leisure and the activity output is communication. The context of use is
primarily Marion’s care facility.
In considering the development of the assistive technology component, the
CanAssist team recognized that a broad constituency of users might have
similar needs. The team’s approach was to create a simple program based on
Skype, a software application that lets people make free phone calls over the
Internet. The new program, called CanConnect, simplifies the standard Skype
user interface. CanConnect makes Skype accessible to people who have never
used computers or are intimidated by them, and to people who are unable
to use a regular mouse or keyboard. One benefit of using Skype is that it
includes both audio and visual connections between the two parties.
To use CanConnect, Marion views a small gallery of photos, which are
displayed on a computer screen. Using a touch-screen computer monitor, she
simply touches the image of her daughter to establish audio and video con-
tact with her. Other options for making audio and video contact include
using an EMG headband, a webcam, or an eye tracking system. Marion
46 Albert M. Cook, Jan Miller Polgar, Nigel J. Livingston

uses CanConnect to have conversations with her daughter. Since its original
development and customization for Marion, the CanConnect program has
been distributed to many hundreds of users across Canada and internationally.

5.4.2 When Projects Don’t Go So Well...

There are many factors that can lead to unsuccessful outcomes. Surprisingly,
few of these are due to the technology not working as designed. In this sec-
tion, we present several examples of how factors beyond the technology can
affect success or failure of an approach. Often project failures arise from a
lack of effective communication between the user (or the user’s caregiver)
and the design team, or from changed circumstances over the duration of the
project. Sometimes the project can be rectified relatively easily (e.g., chang-
ing a mounting or the color of a device to make it more appealing or less
obtrusive), but in some cases it is better to accept that mistakes have been
made and that no further investment should be made in the project.
Sophie and the slippers: In some cases, needs are determined by focusing
on the wrong person. Consider Sophie, who has Angelman Syndrome, char-
acterized by profound developmental delay, a lack of speech, and ataxia of
gait. Sophie’s parents wanted a device that would encourage her to put on
her slippers by herself with the expectation that once she did, she would also
put on her shoes. This was considered to be a critical step in teaching So-
phie to become more independent. Sophie loves music and dogs, so CanAssist
modified a pair of slippers (featuring a large dog’s head on the toes) so that
when Sophie put both feet in the slippers her favorite song would play. (Each
slipper is equipped with a pressure sensor, a radio receiver, and a transmitter,
and a small MP3 player is embedded in one of the slippers.) Unfortunately,
Sophie refused to put on the slippers and would insist that her parents acti-
vate her slippers themselves. The assistive technology worked flawlessly, the
need was clear, and the reinforcement was matched to the client. Further, the
way the reinforcement was built into the desired item was clever. So what
went wrong? The critical element was that Sophie never participated directly
in the design – rather, her parents decided that the slippers would be a good
approach. The motivational component of the HAAT model’s human element
was not addressed. If Sophie had been brought into the process sooner, with
a careful evaluation of why she did not put her slippers on, another approach
might have been chosen.
Carol and the video camera: In some cases, a key person can wield con-
trol over the situation. Consider Carol, who has cerebral palsy. She was one of
ten high school children with special needs who were each given an adapted
video camera system. The camera system included control panels with large,
easy to use buttons that control functions such as recording, zooming in and
5 Need- and Task-Based Design and Evaluation 47

out, taking still photos, and turning the system on and off. Initially, Carol was
extremely enthusiastic and produced wonderful images and footage with her
system. Unfortunately, after a few months, the entire system was returned
(and has since been given to another enthusiastic user). Under further ex-
amination, we found that Carol’s original caregiver had moved on to a new
position, and the replacement caregiver had a strong aversion to technology.
The new caregiver was not able to provide Carol with the support and encour-
agement she needed to operate the system. Thus, when the soft technologies
changed, the hard technologies could not be used. Carol’s video camera il-
lustrates the importance of having available the necessary soft technology
supports.

5.5 Discussion and Conclusions

Obtaining a successful assistive technology outcome often hinges not on the

technology itself, but rather on other factors incorporated into the HAAT
model. The three case studies illustrate three factors that influence a suc-
cessful outcome. Marion used the technology because it allowed her to con-
tinue with an activity (communication with her family) that was important
to her. Sophie’s slippers were not used because no one determined whether
she wanted them, or the reason why she refused to use them. Carol was pre-
vented from continuing with an activity she enjoyed because the environment
no longer supported the use of her technology.
Soft technologies often determine success or failure of an assistive tech-
nology system. Focus on user needs and continued involvement of the user
in the development process for custom assistive technologies is essential to
avoid device abandonment. CanAssist maintains a very high success rate by
paying attention to these critical factors, and by directly addressing the need
for which the assistive technology should be designed.

References

[1] Blackstone S (2003) Social networks. Augmentative Communication News

15(1):1–16, http://www.augcominc.com/index.cfm/acn.htm
[2] Cook AM, Polgar JM (2008) Cook and Hussey’s Assistive Technologies:
Principles and Practice, 3rd edn. Elsevier, MO
[3] Louise-Bender Pape T, Kim J, Weiner B (2002) The shaping of individual
meanings assigned to assistive technology: A review of personal factors.
Disability and Rehabilitation 24(1–3):5–20
[4] Phillips B, Zhao H (1993) Predictors of assistive technology abandonment.
Assistive Technology 5(1):36–45
48 Albert M. Cook, Jan Miller Polgar, Nigel J. Livingston

[5] Scherer MJ, Sax C, Vanbiervliet A, Cushman L, Scherer J (2005)

Predictors of assistive technology use: The importance of personal and
psychosocial factors. Disability and Rehabilitation 27(21):1321–1331
[6] Townsend E, Stanton S, Law M, Polatajko M, Baptiste S, Thompson-
Franson T, Kramer C, Swedlove F, Brintnell S, Campanile L (eds)
(2002) Enabling Occupation: An Occupational Therapy Perspec-
tive. Canadian Association of Occupational Therapists, Ottawa, ON,
http://www.caot.ca
 Part II
Research and Academic Outreach
Chapter 6
Challenges to Effective Evaluation
of Assistive Technology

Richard Simpson

Abstract Evaluation in the context of assistive technology can take sev-

eral forms. Engineers evaluate the devices and technologies they develop.
Clinicians perform clinical evaluations to decide which device(s) are most ap-
propriate for their client. Finally, researchers hope to evaluate the long-term
outcomes of assistive technology interventions. Evaluating a new assistive
technology in the lab can be complicated by small user populations and the
lack of universally accepted performance measures. The obstacles to effective
clinical evaluations include the wide variety of devices that can meet each
client’s needs and the limited time and resources available to clinicians and
their clients. Evaluating assistive technology outcomes is a relatively new
pursuit, with many open questions.

6.1 Introduction

Evaluation is a critical aspect of the research and development process. The

scientific method rests on the ability to measure the results of actions or
interventions. Similarly, the development process is almost always depicted
as a repeating cycle of implementation and evaluation. There are at least
three different kinds of evaluation in regards to assistive technology (AT).
Scientists and engineers evaluate the devices and technologies they develop
as part of the research and development process. Clinicians perform clinical
evaluations of a client’s needs and abilities to decide which device(s) are most
appropriate for their client. Finally, there is the idea (though rarely put into
practice) of evaluating the long-term outcomes once a client has received AT.

Richard Simpson
Rehabilitation Sciences, University of Pittsburgh, PA, USA, [email protected]

M.M.K. Oishi et al. (eds.), Design and Use of Assistive Technology: Social, 51
Technical, Ethical, and Economic Challenges, DOI 10.1007/978-1-4419-7031-2 6,

c Springer Science+Business Media, LLC 2010
52 Richard Simpson

6.2 Evaluating Technology in the Lab

Evaluating a new AT in the lab can be a challenge for even the most rigorous
scientist with the best of intentions. Depending on the target user population,
identifying a sufficient number of potential users who are able to travel to the
lab to trial devices can be difficult. An alternative is to utilize single-subject
or “small N” experimental designs, but these are difficult to generalize.
As an example, consider the DriveSafe System (DSS) [15]. The target
user population for the DSS includes individuals who have both mobility
impairments and visual impairments. This population is small to begin with
and, almost by definition, has difficulty traveling to a lab. We were only able
to successfully recruit two individuals from this population to test out the
DSS. One approach we took to augment our testing with potential users was
to use blindfolded able-bodied individuals as subjects.
Unfortunately, able-bodied subjects lack the orientation and mobility
(O&M) skills of individuals who are actually visually impaired. A second
approach was to blindfold actual O&M specialists, which was more realistic,
but not even O&M specialists have the navigation skills of someone who is
truly blind. A third approach we pursued was to use ambulatory blind individ-
uals. These participants had the appropriate navigation skills, but they were
unable to give us much insight into the needs of visually-impaired wheelchair
users. In all three cases, we were able to recruit enough participants to per-
form group statistical analyses, at the expense of a realistic appraisal of the
system’s performance with the target user group.
A significant obstacle to accurately evaluating some technologies is the
need for lots of training. Some technologies are inherently difficult to master,
especially in cases where using a different technology outside of the lab in
between training sessions can interfere with retention of skills taught during
training. Even with regular use, some technologies can take months to mas-
ter. For example, operating an augmentative and alternative communication
(AAC) device with a sophisticated language encoding scheme like Semantic
Compaction [1] is akin to learning a new language.
In the case of the DSS, some participants were given several hours of
training prior to initiating data collection. Participants needed to learn how
to operate a powered wheelchair that occasionally refused to travel in the
indicated direction because of perceived obstacles. Then, participants needed
to learn how to do this blindfolded.
A final obstacle to evaluating AT in the lab is the decision of what to
measure. Investigators often emphasize speed at the expense of other valid
measures like accuracy, comfort, or workload. When evaluating the DSS, for
example, we knew the DSS was likely to cause participants to take longer to
complete navigation tasks because the DSS slows down the wheelchair in the
presence of obstacles. A participant completing a navigation task without the
DSS could drive straight from the start point to the goal, if he or she chose,
completing the navigation task in the shortest time possible at the expense of
6 Challenges to Effective Evaluation of Assistive Technology 53

incurring multiple collisions. Our approach was to measure and report task
completion time, collisions, and cognitive workload (measured through the
NASA Task Load Index [4]) without trying to choose a single indicator upon
which to base comparisons.
An alternative to evaluating AT in the lab is to evaluate AT “in the field”
or “in the real world.” Testing AT in unconstrained environments is appeal-
ing because that is how we ultimately hope it will be used, but there are
challenges, as well. For example, there may be only one existing prototype
of the device being tested, which makes field trials much less efficient than
laboratory trials. In addition, real world environments are (by definition) less
controlled than laboratories, making it difficult to replicate conditions across
subjects. Field trials can also take much longer to generate data. For exam-
ple, an entire day in a wheelchair user’s life may feature much less driving
than a single hour in a laboratory.

6.3 Evaluating Technology in the Clinic

Choosing the most appropriate AT is a collaborative decision-making process

involving the consumer, clinician(s), and third-party payers. The challenges
involved in a successful AT intervention include:
1. Evaluating and documenting client’s goals, needs, and abilities [5].
2. Choosing the most appropriate AT to address these difficulties.
3. Configuring the technology to the user’s needs.
4. Training the user in appropriate use of the system [10, 12, 14].
5. Providing continuous follow-up to ensure that the interface remains well-
suited to the user [2, 9, 16, 14, 7].
The consequences of failing to successfully meet any one of these challenges
include wasted human and material resources spent in the intervention pro-
cess, unnecessary obstacles placed in the individual’s path toward personal
goals, and technology abandonment [9, 11].
Perhaps the greatest obstacle to effective clinical evaluation is the number
of devices that are available. The fact that there are numerous mobility de-
vices, communication devices, computer access devices, and other AT, each
of which offers multiple configuration options, can be both a blessing and a
curse. The existence of multiple products increases the odds that there exists
at least one product that is well-suited for each consumer’s specific needs.
On the other hand, the variety of products and configuration options can
be difficult to navigate when time (for both the clinician and the client) is
constrained.
Clinicians are limited in the amount of time they can devote to a single
client. Devices that can be trialled more efficiently may be emphasized over
devices that require a lot of time for set-up in the clinic. Similarly, clients
54 Richard Simpson

have a limited amount of time to devote to pursuing AT. Clients may have
difficulty making repeated trips to a clinic to try out multiple devices and
external deadlines, like school, training programs, or returning to work can
intrude to force a decision. Consequently, a device that has an extended
learning curve often loses out to a device that is easy to use quickly, even if
the more complicated device might be a better choice in the long run.
A final obstacle to effectively evaluating a client’s needs and abilities in
the clinic is that both will change over time. A client’s needs will change
as job responsibilities, schoolwork, or personal interests evolve over time. A
client’s abilities can change due to the progression of their medical condition
or changes in medication, but can also change as their familiarity with their
AT increases.

6.4 Evaluating Technology in the World

Once a client has received an AT (or multiple AT), measuring the outcome
of the entire AT intervention is extremely difficult. The discipline of AT
Outcomes Measurement is still quite new and many fundamental questions
remain unanswered, including:
• When do we measure? Immediately after the technology is received may
be too early. The client may not have had adequate time to integrate the
technology into his or her life. Do we wait until the technology has been in
use for a while? Maybe, but how long? And, if we do, how do we isolate the
AT intervention from everything else that has happened in the intervening
time?
• What do we measure? Measures of performance can’t be compared across
device categories (e.g., mobility devices and communication devices). Even
within a single device category, comparing performance measures across
clients with different clinical goals (e.g., maximizing text entry rate vs.
minimizing pain) may be fruitless. Measures of quality or satisfaction, on
the other hand, can be difficult to define.
• How do we measure? Objective measures are attractive because they lend
themselves to statistical analysis, but objective measures for inherently
subjective concepts (e.g., quality of life) are not always readily available.
Subjective measures, on the other hand, raise issues such as inter-rater
reliability.
• Whom do we measure? The challenges presented by measuring AT out-
comes are exacerbated by the diversity and (relative) scarcity of AT
users. Identifying enough AT users to accommodate all of the potentially
confounding variables, and isolating a control group of similar non-AT
users, can be extremely difficult.
6 Challenges to Effective Evaluation of Assistive Technology 55

Several AT outcomes instruments have been developed, including the

efficiency of assistive technology and services (EATS) [8], matching person
and technology assessment (MPT) [13], psychosocial impact of assistive de-
vices scale (PIADS) [6], and the Québec User Evaluation of Satisfaction with
Assistive Technology (QUEST) [3]. However, none of these instruments mea-
sure the interaction of concurrent interventions or isolates the impact of an
individual AT when multiple technologies are adopted at the same time.

6.5 Conclusions

There are challenges to evaluating assistive technology at all stages of product

development and service delivery. Some of these obstacles are unavoidable
when designing technology for a small, heterogeneous population with diverse
needs. Others, however, may be overcome through advances in technique or
technology.

References

[1] Baker B (1982) Minspeak. Byte 7:186–202

[2] Batavia AJ, Dillard D, Phillips B (1990) How to avoid technology aban-
donment. Washington, DC
[3] Demeres L, Weiss-Lambrou R, Ska B (1996) Development of the Québec
user evaluation of satisfaction with assistive technology (QUEST). As-
sistive Technology 8(1):3–13
[4] Hart SG, Staveland LE (1988) Development of NASA-TLX (Task Load
Index): Results of empirical and theoretical research. In: Hancock PA,
Meshkati N (eds) Human Mental Workload, chap 7, pp 139–183. Elsevier,
Amsterdam
[5] Hazell G, Colven D (2001) ACE centre telesupport for loan equipment.
Oxford
[6] Jutai J, Day H (2002) Psychosocial impact of assistive devices scale
(PIADS). Technology and Disability 14(3):107–111
[7] Lysley A, Colven D, Donegan M (1999) Catchnet final report. Oxford
[8] Persson J (1997) An overview of the EATS project: Effectiveness of assis-
tive technology and services. In: Anogianakis G, Bühler C, Soede M (eds)
Advancement of Assistive Technology, pp 48–52. IOS Press, Amsterdam
[9] Phillips B, Zhao H (1993) Predictors of assistive technology abandon-
ment. Assistive Technology 5(1):36–45
[10] Raskind M (1993) Assistive technology and adults with learning disabil-
ities: A blueprint for exploration and advancement. Learning Disability
Quarterly 16(3):185–196
56 Richard Simpson

[11] Riemer-Reiss M, Wacker R (1999) Assistive technology use and abandon-

ment among college students with disabilities. International Electronic
Journal for Leadership in Learning 3(23), http://www.ucalgary.ca/
iejll/riemer-reiss_wacker
[12] Scherer MJ (1993) What we know about women’s technology use, avoid-
ance, and abandonment. Women and Therapy 14(3–4):117–129
[13] Scherer MJ, Craddock G (2002) Matching person and technology (MPT)
assessment process. Technology and Disability 14(3):125–131
[14] Scherer MJ, Galvin JC (1996) An outcome perspective of quality
pathways to most appropriate technology. In: Scherer MJ, Galvin JC
(eds) Evaluating, Selecting and Using Appropriate Assistive Technol-
ogy, chap 1, pp 1–26. Aspen Publishers, Gaithersburg, MD
[15] Sharma VK (2008) Design and evaluation of a distributed shared control,
navigation assistance system for power wheelchairs. PhD thesis, Depart-
ment of Bioengineering, University of Pittsburgh, Pittsburgh, PA
[16] Tewey BP, Barnicle K, Perr A (1994) The wrong stuff. Mainstream
19(2):19–23
Chapter 7
Community Service in University
Curricula

Nigel J. Livingston

Abstract CanAssist is a university-based program at the University of

Victoria that is dedicated to developing and providing services and technolo-
gies to those with disabilities. All of CanAssist’s activities are in response
to requests from the community. The program has engaged many thousands
of students (from a broad range of disciplines), faculty and staff, as well as
many hundreds of community volunteers. The CanAssist model extends the
traditional mandate of universities, to undertake research and education, by
adding a third core pillar of activity – community service. This additional
task is highly augmentative in that it creates outstanding new research av-
enues and provides students with a myriad of extraordinarily challenging and
rewarding experiential learning opportunities.

7.1 Introduction

This paper provides an overview of CanAssist, a program dedicated to em-

powering those with disabilities, removing barriers to their full inclusion in
society, and creating tools that will provide them with greater autonomy and
independence.
A critical component of the CanAssist model is the extension of the tra-
ditional mandate of universities, to undertake research and education, by
adding a third core pillar of activity – community service. This additional
task, rather than reducing a university’s capacity to fulfill its traditional
role, is highly augmentative in that it creates outstanding new research av-
enues and provides students with a myriad of extraordinarily challenging
and rewarding experiential learning opportunities. Beyond this, by directly

Nigel J. Livingston
CanAssist, University of Victoria, Victoria, BC, Canada, [email protected]

M.M.K. Oishi et al. (eds.), Design and Use of Assistive Technology: Social, 57
Technical, Ethical, and Economic Challenges, DOI 10.1007/978-1-4419-7031-2 7,

c Springer Science+Business Media, LLC 2010
58 Nigel J. Livingston

addressing a key societal need, universities can further demonstrate their

importance and relevance to society as a whole.
Another key element of the CanAssist model is the engagement of commu-
nity. That is, CanAssist enables true partnerships between the university and
the community at large, utilizing and leveraging the considerable combined
resources of both. These partnerships encompass government at all levels –
municipal, provincial and federal – and include business and industry, em-
ployers, charities, foundations and public sector agencies, as well as private
individuals.
CanAssist is unique in being an interdisciplinary, university-based, service
organization that develops and delivers technologies and services across the
entire disability and age spectrum. To our knowledge, there are not any other
similar organizations in North America.

7.2 The Need and Opportunity

Almost one in seven Canadians – roughly 4.4 million people – live with a
disability. As Canada’s population ages the proportion of people with dis-
abilities will likely rise dramatically. Many of these Canadians face enormous
challenges and barriers that not only make it difficult for them to accom-
plish the basic tasks of daily living but also severely limit their ability to
participate in society.
Many of those with disabilities lack personalized equipment and technol-
ogy that might allow them to better address the physical and/or cognitive
challenges or limitations presented by their condition. Further, people with
disabilities live in a world where too often little or no consideration is given to
their special needs [3]. For example, consider the growing trend of miniatur-
ization of devices (i.e., cell phones, digital and video cameras, MP3 players,
etc.), while those devices are simultaneously becoming more feature laden.
This combination makes operation of increasingly tiny and complex devices
difficult for those who are lacking in dexterity, sight impaired, or facing cog-
nitive challenges. Similarly, computer interfaces designed only for use with a
regular keyboard and mouse (with attendant pull-down menus) as primary
input devices are often not accessible to many people with disabilities. Thus,
rather than benefiting from the wonderful opportunities offered by the Inter-
net, many people with special needs are marginalized and excluded.
The fundamental issue behind inaccessible technology is the lack of eco-
nomic incentives for the majority of manufacturers (e.g., of consumer elec-
tronic products) to address the needs of those with disabilities. Manufacturers
often assume that the market is too small to warrant attention. Manufactur-
ers who target, for example, a demographic of young successful professionals,
may consider the production of fully accessible devices to be inconsistent with
their brand or the image they wish to project [2]. Even those manufacturers
7 Community Service in University Curricula 59

who specialize in assistive technologies devote their attention to devices that

have relatively large markets (wheelchairs, lifts, walkers, etc.) with the re-
sult that there is a paucity of companies that design technologies or devices
that can be tailored to individual needs, and address some of the most basic
needs of disabled people.
Apart from these “physical” barriers, a major impediment to disabled peo-
ple being able to participate in society comes from a general lack of knowledge
or understanding of disability issues. All too frequently, the able-bodied un-
derestimate the contributions to society that people with a disability can,
and more importantly, want to make. This assumption does not necessarily
stem from a lack of good will but from inaccurate or ill-informed perceptions.
Indeed, these pervasive misconceptions have been shown to extend to the
workplace. Potential employers, for example, tend to focus on the perceived
risks and necessary accommodations in hiring those with disabilities, and do
not appreciate the benefits that might accrue from having such motivated
individuals working for them.
There is no doubt that perceptions can change through direct experience.
Therefore, any program that can provide opportunities for extensive interac-
tion between those with disabilities and those who will take a leadership role
in shaping society has the potential to be truly transformative.

7.3 The CanAssist Model and History

CanAssist was founded just over 10 years ago at the University of Victoria
in BC, Canada (originally, as the University of Victoria Assistive Technology
Team (UVATT)). The original concept was to harness resources both within
the university and in the greater community to address the unmet techno-
logical needs of those with disabilities. CanAssist was conceptualized as an
organization that, given the extensive expertise and facilities available, would
develop highly customized devices on an individualized basis to improve the
quality of life of users. From the onset, a key imperative was that CanAssist
would be a service-based organization, in that projects would only be un-
dertaken in response to requests from the community. However, in delivering
its services, CanAssist would utilize both educational and research resources
and methods. This still holds true.
CanAssist started with a single project in 1999. For the first 5 years, all of
its activities were undertaken on a volunteer basis by university staff, faculty,
and members of the community. However, in order to provide reliable ser-
vice and preserve continuity, permanent staff were eventually hired. Through
donations from corporations and other philanthropists, CanAssist was able to
hire seven full-time staff in 2005. Today, CanAssist has over 30 staff members
(excluding faculty), including 17 engineers and computer scientists. In 2007,
the university Senate and Board of Governors gave formal recognition to
60 Nigel J. Livingston

CanAssist and appointed a full-time director. In addition, CanAssist has

been given dedicated space (approximately 6,000 square feet) that includes
laboratories, machine and fabrication shops and testing rooms.
CanAssist now receives approximately 200 requests a year for assistance.
The majority come from individuals and families, although a significant num-
ber come from professional care givers and health care agencies. We develop
over 40 new technologies a year, ranging from ball launchers (allowing dis-
abled users to “throw” a ball for their dog) to electromyographic (EMG)
based binary switches for software that allows users to easily browse the web
without use of a mouse. Two particularly successful CanAssist technologies
are the iPod adapter, PodWiz (Fig. 7.1), and an adjustable umbrella holder
(Fig. 7.2).

Fig. 7.1 CanAssist’s PodWiz iPod adapter has been provided to many hundreds of users
with acute special needs. It allows them to control the music player with a wide variety
of input devices including a single button switch (shown in the photo). The PodWiz also
provides voice prompts, eliminating the need for users to read the iPod’s display

One key ingredient to CanAssist’s success is direct and regular contact

with its clients. In fact, our philosophy is that our clients are valuable team
members and their input is critical to the successful design of any device.
Another core tenet of the program is to engage students in CanAssist as
widely as possible. One of the main anticipated benefits is that students,
through their exposure to disability issues and the knowledge gained by hav-
ing direct contact with disabled individuals, will be highly motivated to pro-
mote and exercise inclusion when in a position to do so. Of course, at the
same time, students are provided with a unique, intellectually challenging and
deeply rewarding experience that can only reinforce their feelings of good cit-
izenship.
A third, and perhaps most critical element of the CanAssist model, is
the engagement and partnership with community. This extends from the
recruitment of individuals as volunteers to the forging of partnerships with
community agencies, government, and industry.
7 Community Service in University Curricula 61

Fig. 7.2 CanAssist’s adjustable umbrella holder is designed to be mounted on a walker

or wheelchair to provide users protection from the sun or rain. Its design has gone through
a number of iterations, primarily to reduce the cost of production and its weight

Through (a) the efforts of its regular full-time staff, (b) the recruitment
of university faculty, staff, and students from virtually every discipline on
campus, as well as community volunteers (typically, but not exclusively re-
tirees), and (c) access to infrastructure support and facilities (e.g., machine
shops, sophisticated laboratories, and equipment), CanAssist has become a
significant resource for the disability community. It has been able to take on
projects that are well beyond the scope of other agencies, either because of
the technical challenges and/or the perceived lack of opportunity to recoup
project costs.
While CanAssist is extraordinarily cost effective, program funding is a crit-
ical issue. We believe that through having multiple, diversified revenue sources
(beyond infrastructural and direct support from the university) CanAssist
can be sustainable. These sources include:
1. Service contracts with public and private sector agencies.
2. Funding from government (provincial and national).
3. Revenues accrued through the commercialization of technologies or deliv-
ery of other services.
4. Grants from traditional research funding agencies (e.g., provincial or fed-
eral agencies supporting scientific, medical, and engineering research).
5. Grants from philanthropic groups and organizations, corporate sponsors,
and donations from individuals.
6. Social financing.
To date, CanAssist has not had a policy of charging individuals or families
for its services. Rather, beneficiaries of the program who have some financial
62 Nigel J. Livingston

capacity are encouraged to make a donation should they see fit. In some cases,
the cost of developing a specific customized technology can be very high. It
might require, for example, the full time attention of two senior engineers for
6 months. It is not realistic to institute a charge directed at recouping a major
portion of the cost of such a project. So within the program as a whole, there
must be a means of subsidizing the more complex and challenging projects.
We also recognize, that over the long term, to be sustainable, we must
secure revenues from some of our lower cost technologies, particularly those
that might secure a relatively large market. There are a number of options
to do so. One approach under consideration is to set up a small scale man-
ufacturing facility that will employ people with disabilities in a number of
facets of its operation (for example, in the processing of orders, production,
packaging, inventory control). The benefits would be twofold: (1) accrued
revenues would offset some of the costs associated with the development of
individualized technologies and (2) meaningful and rewarding work would be
provided to individuals, who by virtue of their challenges, have limited job
opportunities.
Other opportunities to generate revenues will come about through the
development of technologies that could be utilized in other arenas and
markets (e.g., medical technology). This is particularly true of devices or
products that could be adopted by general users, simply through the incor-
poration of good universal design features. For example, our CanConnect
program, which allows calls to be made over the internet by simply touch-
ing an onscreen photo or icon, could appeal to a wide range of users who
are not necessarily comfortable using a much more complicated computer
interface [1].

7.4 The University Commitment: Engaging Faculty,

Students, and the Community

In order for the CanAssist model to be adopted elsewhere, it is critical that

universities make a fundamental commitment to the idea that community ser-
vice should become an entrenched, recognized, and valued activity alongside
research and education. Certainly, some work needs to be done to persuade
administrators that more emphasis should be placed on community service
when evaluating faculty, particularly with respect to determining tenure and
promotion.
One key ingredient to the success of the CanAssist program is that even
though its focus is on community service, it utilizes research and education to
achieve its goals. Thus, there are numerous opportunities to involve faculty,
whether through the supervision of students or through direct participation in
projects and core research. Faculty involvement is not just limited to those in
engineering, science or medical disciplines. For example, there are tremendous
7 Community Service in University Curricula 63

opportunities for those in the social sciences and in education to evaluate the
benefits that accrue from the provision of assistive technologies from social
or economic perspectives.
The CanAssist program provides a myriad of opportunities to engage stu-
dents across all disciples, either through courses and practicums for which
they can receive credit, or through the provision of volunteer projects. Thus,
whole classes that undertake design courses (e.g., in mechanical engineering,
computer science, and mechatronics) have been recruited to assist in the de-
sign of customized devices. In the process, students are introduced to the
individuals who will receive the technology and their caregivers, thus giving
a much better insight into the challenges faced by those with disabilities. Re-
cently, commerce students and MBA students have been engaged in projects
to investigate licensing and marketing of specific technologies.
Additionally, students are recruited for co-op work terms, honors projects
and graduate studies. Students have the opportunity to work with individual
clients on a one-on-one basis (mentoring the client and teaching them how
to use a particular device) or as part of an interdisciplinary team.
We believe that local communities will continue to embrace opportunities
to partner with the universities to address the needs of disabled people. Apart
from the establishment of institutional partnerships and collaborations, a key
element of community engagement is the recruitment of volunteers (many of
these are retirees with a wide range of experience and background, includ-
ing retired engineers, physicians, academics, machinists, seamstresses, and
health care providers) to work in every facet of CanAssist activities, such
as administrative tasks, research and development, and fundraising. We be-
lieve that with a well coordinated and professionally run program, volunteer
contributions could account for up to 20% of a centre’s activities.

7.5 Conclusion

CanAssist has engaged more than 3,000 students, over 200 faculty and staff,
and approximately 200 community volunteers in its activities. In the process,
it has developed over 150 novel technologies and provided direct assistance
to many hundreds of clients. Thousands of others have benefited through the
widespread distribution of software and computer programs. CanAssist has
been able to flourish because the university has recognized that community
service brings tremendous benefits not only to the community but also to the
university itself, by creating outstanding experiential learning opportunities
for students and also a myriad of research opportunities.
64 Nigel J. Livingston

References

[1] CanAssist (2008) CanConnect. http://www.canassist.ca/CanConnect

[2] Goodman J, Langdon P, Clarkson P (2006) Providing strategic user in-
formation for designers: Methods and initial findings. In: Clarkson P,
Langdon P, Robinson P (eds) Designing Accessible Technology, pp 41–51.
Springer, London
[3] Lewis T, Langdon P, Clarkson P (2006) Investigating the role of ex-
perience in the use of consumer products. In: Clarkson P, Langdon P,
Robinson P (eds) Designing Accessible Technology, pp 189–198. Springer,
London
Chapter 8
Providing Innovative Engineering
Solutions Between Academia
and Industry

Brian E. Lewis and Yoky Matsuoka

Abstract Academic research is an invaluable development engine for creating

assistive technology. Commercial enterprises are critical for making academ-
ically developed technology available to individuals provided that there are
sufficient numbers of people with substantially similar technology needs. Un-
fortunately, there is little incentive for academic research organizations to
optimize user interface, fit, finish, or function attributes associated with the
assistive technology that they develop. The rate at which technology is be-
ing created that could be used to help people with disabilities is staggering.
However, disturbingly little of that technology is being harnessed to provide
actual benefit to the disabled community because the adaptation of that tech-
nology is viewed as too customized or the market size too small to justify
commercialization. In this paper, the authors focus on the use of uniquely
created non-profit organizations, such as YokyWorks Foundation, to bridge
the gap between academic research and traditional commercial enterprises.

8.1 The Niche Between Academic and Commercial

Approaches

There are many people with disabilities who could participate more fully in
life, achieve more of their potential, and live more satisfying lives through
technological assistance. Consider, for example, a college student with a C6
spinal cord injury who could not control his hands and fingers [5]. He had a
brilliant mind, but his injury prevented him from writing, typing, grabbing

Brian E. Lewis
RosenLewis PLLC, Seattle, WA, USA, [email protected]
Yoky Matsuoka
Computer Science, University of Washington, Seattle, WA, and YokyWorks Foundation,
Kirkland, WA, [email protected]

M.M.K. Oishi et al. (eds.), Design and Use of Assistive Technology: Social, 65
Technical, Ethical, and Economic Challenges, DOI 10.1007/978-1-4419-7031-2 8,

c Springer Science+Business Media, LLC 2010
66 Brian E. Lewis and Yoky Matsuoka

objects, and using his hands. He feared that effects of his injury would
preclude meaningful employment. Moreover, he longed for the previously sim-
ple ability to eat food on his own without assistance. There was no medical or
engineering intervention available on the market that could solve his problem.
Active academic research projects focus on understanding how human
hands work [1] and how to augment these movements using technology
[11, 4, 3]. However, development of such knowledge and technology is typically
targeted toward solving research challenges and lacks design attributes that
would make the technology practical for a daily user. In research, there is no
incentive to build an easy-to-use device because investing time and resources
reducing the weight or enhancing the design of a system does not address
the fundamental research challenge of proving whether such a system is fea-
sible, nor does it enhance the published output associated with that research.
Sadly, for people suffering from these challenges, the technology developed
through such academic efforts only proceeds through functional optimization
if there is a market: a market is typically defined by the money that can be
generated with developing a solution. In most cases, technologies for people
with disabilities do not have a sufficient market because (1) the population is
too small, (2) individual differences are too large, and (3) insurance does not
cover devices that are life-enabling but not necessary for survival. YokyWorks
Foundation [12] was created, staffed, funded, and organized to successfully
solve problems such as these, that fall in the gap between academic research
and commercial products.

8.2 History

YokyWorks grew from outreach projects undertaken at Carnegie Mellon Uni-

versity, personally funded and supported on a volunteer basis by students
with a desire to have a positive impact on someone’s life. The initial successes
created referrals and inspired the team to search for existing organizations
serving this niche. Looking for similarly situated organizations identified a
void surrounded by three well established pillars: academia, commercial ven-
tures, and philanthropic organizations.
Academic research institutions were perceived to focus on long horizon
development efforts, and commercial enterprises on profitable and near term
development efforts. Neither commercial nor academic enterprises are par-
ticularly well suited for near term research with highly uncertain commer-
cial value. The challenge in developing individually oriented solutions using
volunteers in an academic setting is multifold. Academic research projects
often have long or uncertain development cycles, which is fundamentally
inconsistent with the immediate needs that YokyWorks sought to address.
YokyWorks sought to conduct much of the design, development and test-
ing work using independent volunteers. Similarly, the commercial enterprise
8 Providing Innovative Engineering Solutions 67

model does not work well for short term projects with a highly uncertain
upside. Funding for commercial ventures typically requires either a short cer-
tain pathway to a return on investment or the potential for a large return on
that investment. Because of the constraints inherent in both academic and
commercial enterprises, the YokyWorks team needed to find an innovative
approach.
Several non-profit organizations provide extraordinary benefit to people
with disabilities. The Tetra Society of North America [9] has supported a
large number of projects that help disabled people with specific challenges.
Tetra typically focuses their efforts on direct adaptation of existing commer-
cial devices tailored to the unique needs of a specific individual. Similar to
Tetra is an organization in the United Kingdom called Remap [7] which cre-
ates unique pieces of special equipment tailor-made by volunteers and given
at no cost to disabled individuals. In Australia, the Technical Aid to the Dis-
abled of New South Wales (TADNSW) [8] also creates one of a kind solutions
for disabled people in that region. In Canada, CanAssist [10], a university af-
filiated service organization, creates customized solutions for people with dis-
abilities, and is described in Chap. 7 of this book. The Neil Squire Society [6],
a nonprofit organization in Canada, offers personal consultation, adaptation,
and worksite modification to existing technologies as part of its mission to
facilitate social and economic independence for people with disabilities. Yoky-
Works saw the opportunity to tackle more challenging development closer to
the academic research space with the potential to help more than the single
individual initially being served.
YokyWorks’ challenge was to blend some of the best attributes of academic
and commercial structures with the benefits of non-profit structures. Histori-
cally, non-profit organizations have been used to provide services to people in
need, but it is far less common for non-profit organizations to develop goods
that benefit many people in need. The YokyWorks model does not work as
a commercial enterprise because no sincere assurance could be made to an
investor that there would ever be a return on investment. Compounding this
was YokyWorks’ objective to tap into the good will of volunteers to provide
much of the brainpower behind the organization. Similarly, the YokyWorks
model does not work in an academic setting because results needed to be
achieved near term and were directed to people with immediate needs. Con-
sequently, YokyWorks sought to use a non-profit model that incorporated
certain elements of both commercial and academic enterprises.

8.3 Project Criteria

YokyWorks faces a problem common to both commercial and non-profit

enterprises: It has more need than resources. The organization lacks the
resources to help every person who requests assistance. The challenge for
68 Brian E. Lewis and Yoky Matsuoka

the organization is creating a repeatable analytic paradigm that efficiently

sifts through the volume of requests to produce the most fruitful projects.
YokyWorks seeks projects that meet two objectives: (1) there is no existing
commercial solution and (2) providing a solution for this person might also
provide a solution for other people. These objectives are explored in more
detail below.

8.3.1 Absence of Existing Solutions

While YokyWorks is fundamentally in the business of engineering solutions

to problems where no commercial solution exists, the organization has been
surprised at the number of applicants for whom a solution is on the market.
The most frequent reason YokyWorks turns projects away is that a solu-
tion already exists. Other non-profit organizations assist clients in finding
appropriate existing assistive technology. Unfortunately, prospective clients
are often unaware of these organizations and lack the familiarity to be able
to search for these devices on their own. Accordingly, the first step for every
project is to find a team member to look at the state of the art used to solve
challenges similar to the one being evaluated. This effort amounts to looking
for a null set in a diversely populated universe, and, as such, lacks complete
certainty. Despite the lack of certainty, after a reasonable effort, it is possible
for YokyWorks to conclude that no existing solution adequately addresses
the challenge faced and that the case merits further evaluation.

8.3.2 Potential for Direct and Ancillary Benefit

YokyWorks is in an unusual niche. The organizational goal is to find projects

that both benefit a specific individual and hold the potential to assist many
additional people with a similar challenge. Simply, the organization wants to
provide the greatest benefit from each dollar of funds it spends on research
and development. Finding projects that can benefit a large number of people
may seem incongruous with developing unique engineering solutions. If there
are an enormous number of people with the same need, an existing com-
mercial solution becomes a virtual certainty. Despite the apparent conflict
between finding problems for which no solution exists and finding problems
that could benefit many people, the organization has found several promising
candidates.
8 Providing Innovative Engineering Solutions 69

8.4 Example Projects

8.4.1 Umbrella

One of the projects that led to the formation of YokyWorks involved a boy
in a wheelchair with a fairly simple problem. It often rained where he went
to school, and to cross campus involved using an umbrella. Commercially
available umbrella holders for wheelchairs held the umbrella directly above
the individual. This solution initially seems reasonable. Unfortunately, the
student often found himself soaked and uncomfortable by the time he arrived
at class. The gestalt moment in the project came with the fairly obvious
realization that while we perceive rain to fall “down,” the angle of incidence
between rain and an individual after factoring in wind and velocity of travel is
almost never straight down. The team developed a readily adjustable system
that allowed the umbrella to be positioned on a wide variety of angles with
different radial orientations. This enabled the student to quickly adapt the
umbrella to the prevailing wind direction and velocity relative to his own
direction and rate of travel. In the end, he spent far fewer days focusing on
his physical discomfort in class, and more time learning.

8.4.2 Orthotic Exoskeleton

The opening remarks of this paper described the motivation for developing
an exoskeletal pneumatically actuated assistive grip device. What the person
suffering from vertebral injury needed was a simple power enhancing device
for his hand without the level of sophistication of typical research exoskeletal
devices. Our team designed a simple device that enables index/thumb pinch-
ing motion with a biceps EMG control (Fig. 8.1). The student was then able
to grab different objects with his own volition without relying on the assis-
tant, and could eat some soft food that he longed to eat on his own. We are
proud that this project has both benefitted the individual, and lead to aca-
demic publications. Two undergraduate students who worked on this project
have successfully written a conference and a journal paper [5, 2]. While this
project was more research targeted than a typical YokyWorks project, it is a
great example of the level of sophistication in engineering that YokyWorks
focuses on.
YokyWorks is actively pursuing development of several innovative projects
including a communication device for children with cerebral palsy and other
movement disorders, and devices that make writing and eating easier for
people with Parkinson’s Disease.
70 Brian E. Lewis and Yoky Matsuoka

Fig. 8.1 Orthotic exoskeleton system devised to assist a person with spinal cord injury

8.5 Logistics

To build a successful foundation, YokyWorks has developed mechanisms for

identifying and recruiting volunteers, managing teams of disparately located
volunteers, funding development efforts, managing liability issues, and assur-
ing intellectual property rights to sustain the organization.

8.5.1 Identifying and Recruiting Volunteers

One of the pleasant surprises while putting together YokyWorks was that
a large perceived potential hurdle was easier to solve than expected. This is
not to say that finding volunteers, identifying the particular skill sets required
and keeping those individuals engaged over the course of a project is not chal-
lenging. It was anticipated that finding qualified people to perform testing,
evaluation, engineering, and project management work on a volunteer basis
could prove an insurmountable obstacle – these were busy professionals that
had every reason to expect compensation for their services. The challenge was
to identify skilled people interested in philanthropically providing service to
people with disabilities through application of their unique skills.
In addition to finding a pool of skilled volunteers, there is the challenge
of assigning from this pool people with the appropriate skill set to work
on a particular project. It is clear that the skill sets of the people working
on a problem will have an enormous impact on the nature of the solutions
pursued. A physical therapist may be more inclined to pursue rehabilitative
solutions while a mechanical engineer may look for augmentative solutions.
Thus, developing a project team requires some early stage brainstorming of
probable solutions, conceiving the largest technical roadblocks to achieving
those solutions, and identifying the skill sets needed to address those chal-
lenges. Because each new project requires a unique combination of skills,
8 Providing Innovative Engineering Solutions 71

YokyWorks is constantly looking for people that can bring their skills to bear
on potential challenges, and keeping those people engaged until a project that
matches those skills arrives.

8.5.2 Funding

YokyWorks uses four approaches to funding its work: Seeking grants, ac-
cepting donations, managing expenses, and (at some point in the future)
developing passive revenue sources. The principal near term sources of fund-
ing for the organization include a combination of grants and donations. The
organization has consciously avoided the traditional funding source of com-
mercial investors to avoid the concomitant requirement that the organization
provide those investors a financial return on their investment. Grant funding
is used where feasible and is expected to be a long term funding source for
the organization. Private donor funding has been critical to launching the
organization. Organizing the entity as a non-profit assists in the fundraising
challenge by providing significant tax incentives to donors.
YokyWorks’ volunteers make an invaluable contribution to meeting the
funding needs of the organization. These volunteers contribute to funding by
attacking and reducing the expense side of the business. It is perhaps obvious,
but still worth stating: The lower the organization’s expenses, the less time
and energy must be invested in raising money for the organization and the
greater the number of projects the organization can undertake.
It is conceivable that at some time in the future a third funding source
may arise if the devices YokyWorks develops benefit enough people. People
who benefit from YokyWorks devices may be willing to financially support
the organization either directly or indirectly. That support may take the form
of purchasing an industrially hardened embodiment of a YokyWorks device
or making a direct donation to YokyWorks.

8.5.3 Liability Management

YokyWorks creates devices that people use in the real world under harsh
and unpredictable conditions. The solutions we develop and test are often
prototypes that have not been industrially hardened. These devices are faced
with situations and factors that our team of volunteers could not possibly
have imagined during design, and we design for some pretty amazing envi-
ronmental conditions. For example, one YokyWorks project is developing a
device to assist an individual whose ability to walk is severely compromised
because he contracted poliomyelitis (polio) as a youth. Using the device, this
72 Brian E. Lewis and Yoky Matsuoka

person will seek to race across 151 miles of the Sahara Desert over 6 days
in the Marathon Des Sables under his own power. YokyWorks’ devices may
be designed to give a person a wider range of motion, travel, and speed. The
user may not be practiced in controlling such motion. In short, liability may
arise from any number of sources.
Unfortunately, lawsuits are prevalent in the United States, so it is worth
undertaking cost effective prophylactic strategies to minimize the risk and im-
pact of potential litigation. Most of these practices are common in the indus-
try. We use a non-profit corporation to shield individual volunteers and others
supporting our work from personal liability, we use individualized statements
of risk for each client tailored to the reasonably foreseeable risks, and we use
volunteer agreements to make sure our relationship with volunteers is clear
and well understood.

8.5.4 Intellectual Property Issues

YokyWorks is focused on solving technical problems for which no solution

exists. If a project matures to produce a solution, that solution addresses one
individual’s problem. If the project is well selected, that solution may benefit
other similarly situated individuals. Inherent in the YokyWorks model is the
notion that the projects will produce new know-how and inventions. Because
the people contributing to these inventions may come from universities or
corporations there are commonly restrictions on creating patents that are
not owned by the university or corporations.
Unfortunately, simply being a non-profit does not shield YokyWorks from
such claims. Fortunately, many such claims are legally prohibited because
states like Washington and California prevent claims by employers against
work that is not related directly to the employer’s business at the time of the
invention, or inventions that cannot be shown to demonstrably result from
work performed by the volunteer for the employer.
YokyWorks is still a young organization and it is unclear how it will lever-
age its intellectual property to effect the greatest good for the largest number
of beneficiaries. Alternatives include putting specific devices into production
or licensing the technology to people expert in manufacturing and marketing
these services.

8.6 Conclusion

Blending the research and grant funding skills of academia, the team man-
agement and building skills common to for-profit enterprises, and the donors
and volunteers that support non-profit companies has enabled YokyWorks to
8 Providing Innovative Engineering Solutions 73

rapidly develop unique engineering solutions for people facing challenges in

life. The organization is eager to grow and expand and take on as many new
engineering challenges as possible.

Acknowledgements The authors gratefully acknowledge the contribution of our

volunteers, donors, and clients who have trusted us to confront the challenges they face.

References

[1] Bradberry T, Gentili R, Contreras-Vidal (2010) Reconstructing

three-dimensional hand movements from noninvasive electroen-
cephalographic signals. Journal of Neuroscience 30(9):3432–3437,
doi:10.1523/jneurosci.6107-09.2010
[2] DiCicco M, Lucas L, Matsuoka Y (2004) Comparison of control strategies
for an EMG controlled orthotic exoskeleton for the hand. In: Proceed-
ings of the IEEE International Conference on Robotics and Automation
(ICRA), New Orleans, LA, pp 1622–1627
[3] Ehrsson HH, Rosen B, Stockselius S, Ragn C, Khler P, Lundborg G
(2008) Upper limb amputees can be induced to experience a rubber
hand as their own. Brain 131(12):3343–3352, doi:10.1093/brain/awn297
[4] Kipke DR, Shain W, Buzsaki G, Fetz E, Henderson J, Hetke J,
Schalk G (2008) Advanced neurotechnologies for chronic neural inter-
faces: New horizons and clinical opportunities. Journal of Neuroscience
28(46):11830–11838
[5] Lucas L, DiCicco M, Matsuoka Y (2004) An EMG-controlled hand ex-
oskeleton for natural pinching. Journal of Robotics and Mechatronics
16(5):482–488
[6] Neil Squire Society (2010) We use technology, knoweldge, and pas-
sion to empower Canadians with physical disabilities. http://www.
neilsquire.ca
[7] Remap (2009) Custom made equipment for people with disabilities.
http://www.remap.org.uk
[8] Technical Aid to the Disabled (2009) New South Wales. http://www.
technicalaidnsw.org.au
[9] Tetra Society of North America (2009) http://www.tetrasociety.org
[10] University of Victoria (2008) CanAssist. http://www.canassist.ca
[11] Velliste M, Perel S, Spalding M, Whitford A, Schwartz A (1998) Cor-
tical control of a prosthetic arm for self-feeding. Nature 453:1098–1101,
doi:10.1038/nature06996
[12] YokyWorks Foundation (2010) Engineering for the human experience.
http://www.yokyworks.org
Chapter 9
Case Study: An Assistive Technology
Ethics Survey

Peter A. Danielson, Holly Longstaff, Rana Ahmad, H.F. Machiel Van der
Loos, Ian M. Mitchell, and Meeko M.K. Oishi

Abstract This chapter describes the online N-Reasons Ethics and Assistive
Technology survey (AT) designed to address key ethical issues in assistive
technologies. The survey was used to foster deliberation and focus discussions
in a multidisciplinary workshop on assistive technologies. The survey focused
on each of the four workshop topics (evaluation, sensing, networking, and
mobility). This chapter thus begins with an overview of the survey design in
Sect. 9.1 followed by the process that was used to establish survey content
in Sect. 9.2. The results for the survey are presented in Sect. 9.3 followed by
brief conclusions in Sect. 9.4.
A survey on the ethics of assistive technologies was commissioned to
identify debatable issues that could facilitate discussion about assistive tech-
nologies in a multidisciplinary setting. The survey was designed by a multidis-
ciplinary group of researchers in assistive technology prior to the workshop.
All workshop participants completed the survey, as well as members of the
general public. The results of the survey provided data about which issues
were non-controversial, and which issues were far less clear.

Peter A. Danielson, Holly Longstaff, and Rana Ahmad

Applied Ethics, University of British Columbia, Vancouver, BC, Canada,
[email protected], [email protected], [email protected]
H.F. Machiel Van der Loos
Dept. Mechanical Engineering, University of British Columbia, 6250 Applied Science Lane,
Vancouver, BC, V6T 1Z4, Canada, [email protected]
Ian M. Mitchell
Dept. Computer Science, University of British Columbia, 201-2366 Main Mall, Vancouver,
BC, V6T 1Z4, Canada, [email protected]
Meeko M.K. Oishi
Electrical and Computer Engineering, University of British Columbia, 2332 Main Mall,
Vancouver, BC, V6T 1Z4, Canada, [email protected]

M.M.K. Oishi et al. (eds.), Design and Use of Assistive Technology: Social, 75
Technical, Ethical, and Economic Challenges, DOI 10.1007/978-1-4419-7031-2 9,

c Springer Science+Business Media, LLC 2010
76 P.A. Danielson et al.

9.1 Survey Design

The Ethics and Assistive Technology survey (AT) addressed key ethical issues
in assistive technologies and employed the N-Reasons experimental online
survey platform developed by the Norms Evolving in Response to Dilemmas
(NERD) research team led by Peter Danielson at the University of British
Columbia’s Centre for Applied Ethics. This novel platform provides a means
of engaging both the general public and experts in various ethically challeng-
ing issues and debates in two formats: (1) reason-based responses (described
in greater detail below) and (2) the more conventional survey question for-
mats (e.g., multiple choice, ranking) [1, 8, 2, 9, 6]. To date, the NERD research
group has launched N-Reasons surveys on a wide variety of topics including
research ethics, stem cell research, and robot ethics [9, 7, 5, 4].
The AT survey consists of five scenarios accompanied by one or more
questions related to the various issues that each scenario involves. A total of
14 questions are posed, each with the option to answer “Yes,” “Neutral” or
“No.” Participants must select one of these responses and provide a reason,
explanation or elaboration to move forward through the survey. The innova-
tive feature of the N-Reasons platform is the opportunity participants have
to vote for other participants’ reasons instead of (or in addition to) provid-
ing their own (see Fig. 9.1). The goal is to generate richer and more varied
alternatives based on user-supplied contributions. The number of reasons the
user chooses from (e.g., the “choice problem”) is kept to a reasonable num-
ber by limiting content in three ways. First, by encouraging participants to
use existing reasons rather than generating their own, the number of over-
all reasons is minimized and therefore more likely to result in identifiable
trends or patterns. Second, running vote tallies for each reason are provided,
which allows participants to factor in the valuation of the available reasons by
other participants (e.g., no sums for decisions are displayed in order to make
the reasons, as opposed to the “Yes”/“Neutral”/“No” decision, salient.) The
display ranking method used in the survey gives some weight to recent con-
tributions in order to mitigate the primacy effect; this method is discussed in
more detail in [4] and shown in Fig. 9.1 below, where the third reason from
the top (with a vote of 1.0) is displayed above one with 2.0 votes. Finally,
each participant can vote for multiple reasons so that there is no need to
generate conjoint reason responses: “I agree with R#101 and R#111.”
The NERD research group generally designs each new survey with a back-
ground empirical investigation. For this survey, we explored the effect of
identifying reasons by either their author’s pseudonym or merely by a gener-
ated number that represents the reason anonymously. The participants were
divided into two groups with cohort 0 viewing only numbers (N = 45) and
cohort 1 viewing pseudonyms (N = 50); see Fig. 9.1. All participants viewed
the same reasons; only the author’s identifier (appended to each reason, as
shown in Fig. 9.1) was varied.
9 Case Study: An Assistive Technology Ethics Survey 77

Fig. 9.1 N-Reasons survey visual presentation (from Cohort 0, who views reason numbers,
the number listed at the end of each reason). For each reason, the first number indicates
display rank (equal to the number of other reasons this reason was preferred over, minus the
number of other reasons preferred over it), the second number indicates weighted number
of votes (fractions arise due to split votes), and the third number represents the total
number of votes.
78 P.A. Danielson et al.

Fig. 9.1 (continued) N-Reasons survey visual presentation (from Cohort 0, who views
reason numbers, the number listed at the end of each reason). For each reason, the first
number indicates display rank (equal to the number of other reasons this reason was
preferred over, minus the number of other reasons preferred over it), the second number
indicates weighted number of votes (fractions arise due to split votes), and the third number
represents the total number of votes
9 Case Study: An Assistive Technology Ethics Survey 79

9.2 Survey Questions

Four topics were selected by a multidisciplinary working group in assistive

technology at UBC prior to the workshop. They represent a set of topics con-
sidered not only highly relevant to assistive technology, but also intractable
without multidisciplinary collaboration. The survey questions were designed
to address each of the four workshop topics:
• Evaluation: How and why are assistive technologies being used, and
what sensor technologies could provide accurate data to assess usage?
• Sensing: What ethical and privacy concerns might be raised by the vast
amounts of personal data that computer-controlled assistive technologies
can easily collect, and how might technologies incorporate features to ad-
dress those concerns?
• Networking: How do assistive technologies impact the sense of self,
agency, sense of privacy, and/or quality of life of users and the people in
their social circles (family, friends, caregivers, others)?
• Safety and Mobility: How, if at all, can technological innovations
improve or mitigate some of the ethical concerns surrounding powered
wheelchairs and their potential for harm to the wheelchair user as well as
to others in the environment?
Participants of the workshop were then asked to propose key issues and so-
lutions to these particularly difficult problems.
To generate the survey questions, the NERD research group solicited input
from the expert participants (the Advisory Committee to the PWIAS-ICICS
workshop): each expert was asked to contribute scenario-based questions that
they felt ought to be asked of the general public and which, in their opinion,
represented key issues. After some initial feedback, the Advisory Committee
was presented with an additional opportunity to comment on or revise the
scenarios and questions. These revisions were then compiled and edited by the
NERD research team to produce the final set of questions, which comprised
the AT Survey. In addition, a fifth scenario regarding athletic performance
was added, given the timeliness of the workshop with the 2010 Vancouver
Olympics.
The AT survey was formally launched to the general public 3 weeks prior
to the workshop. The twin objectives of the survey were to identify (1) key
ethical issues in assistive technologies and (2) the most significant topics in
each of the workshop theme areas. The survey scenarios and questions are
presented in Appendix 1.

9.3 Results

A total of 95 people participated in the survey, including both the

general public as well as researchers involved with the workshop. Of the
80 P.A. Danielson et al.

95 participants, 76 completed all questions in the survey (N = 35 from co-

hort 0, N = 41 from cohort 1). Survey results can be found online [3]; results
for two of the five scenarios are reproduced in Appendix 2.

9.3.1 Aggregated Results

The survey produced clear qualitative outputs. While participants could

choose from an often rich menu of reasons to support their decisions, their
votes aggregate to a set of social decisions on the “Yes,” “Neutral,” and “No”
options. Figure 9.2 summarizes these results.
This level of aggregation allows us to characterize the answers to various
questions in different ways. First, in questions 2A, 2B, 2C, 3A, and 4B the
“Yes” answer is a clear majority choice. In contrast to these clear decisions,
while question 1C has a bare majority “Yes,” nearly as many voted “No”
and no one voted “Neutral.” We can characterize 1C as the most contro-
versial question. In contrast, question 4C has a similar “Yes” vote but with
far fewer “No” votes. Questions 1A, 1B, 2D, 2E, and 4A all had a plural-
ity of “Neutral” votes, and question 3B was almost evenly divided between
“Neutral” and “No” votes. Question 5 was also quite controversial. Both
Questions 1A and 5, two of the most most controversial questions, are pre-
sented in full in Appendix 2.
These rough characterizations based on aggregative votes should be qual-
ified in two ways. First, they can be refined by considering the additional
information provided by the reasons participants voted for. For example,
some “Neutral” reasons protest the formulation of the question. Second, while
we can characterize these distributions of answers as social decisions in the
clearest cases (like the majority “Yes” and “No” cases noted) this is less
clear in the plurality cases. Announcing a decision rule in advance would
strengthen these characterizations and move our device from survey to social
decision procedure.
Evaluation Scenario: This scenario focused on obligations between a uni-
versity and a student with a disability. Most survey participants stated that
they would require additional information to determine the appropriate level
of accommodation a university should provide to a student with a disability
(1A, 1B). While most survey participants agreed that an occupational ther-
apist should not consider cost to the university in deciding what assistive
device the student needs, some survey participants disagreed (1C). However,
despite disagreement, the most popular “Yes” and “No” responses both held
in common that the occupational therapist’s primary obligation is to the
student.
Sensing Scenario: Survey participants most clearly agreed that in group
homes, surveillance of residents always requires their approval (2A), and that
9 Case Study: An Assistive Technology Ethics Survey 81

100 No
90 Neutral
Yes
80

70

60
Votes

50

40

30

20

10

0
1A 1B 1C 2A 2B 2C 2D 2E 3A 3B 4A 4B 4C 5
Question

Fig. 9.2 Survey decisions by question. “No” is the top dark shaded bar, “Neutral” is the
middle lightly shaded bar, and “Yes” is the lower dark shaded bar

in considering privacy of residents, raw data is more sensitive than data that
has been read by machines and encoded into high-level characterizations (2B).
Survey participants largely agreed that approval should also be required for
in-home monitoring, as an integral part of respecting another person’s au-
tonomy (2C). The last two questions (regarding group homes) produced a
variety of responses. For care facilities with residents who do not want to
be monitored, the most popular response was that residents should not be
removed, but rather accommodated as much as possible (2D). In considering
whether monitoring of residents in bathrooms and bedrooms is acceptable,
the most popular reason was “Neutral,” depending on the type of sensors
being used, on the degree of data encoding and manipulation prior to hu-
man analysis of the data, and on security measures put in place to prevent
violations of privacy (2E).
Networking Scenario: Survey participants agreed that social inclusion
should be a design factor (3A), along with other relevant design factors (e.g.,
cost, environmental impact, maintenance) (3B).
Mobility Scenario: This scenario focused on a powered wheelchair user liv-
ing in a group home. Survey participants expressed a wide variety of opinions
in assessing whether the occupational therapist should be able to reduce the
wheelchair’s maximum speed (4A); the most popular response was “Neutral”
due to a lack of information. However, an unambiguous majority of survey
participants believed that the user should be able to set the wheelchair’s
maximum speed (4B), with many responses citing the need for autonomy
and personal choice of risk level. Many survey participants agreed that the
group home should be able to set and enforce speed limits on their property;
others pointed out the necessity of increasing wheelchair speed outside of the
facility (4C).
82 P.A. Danielson et al.

Enhancement Scenario: While the majority of respondents believed that

Oscar Pistorius should not be able to compete with able-bodied athletes, the
reasons behind “Yes,” “No,” and “Neutral” responses varied widely (5). Rea-
sons included the biomechanics of sprinting, comparison with other assistive
devices, visibility of the prostheses, passivity of the device, Pistorius’ skill,
perceptions of fairness, and Pistorius’ ability to inspire and attract viewers.

9.3.2 Self-Documentation

The survey is “self-documenting,” meaning that both the quantitative and

qualitative results are generated by the survey itself, thereby making the anal-
ysis both rapid and accurate. Immediate results can be obtained and updated
as more users complete the survey. The results of both the Evaluation scenario
and the Enhancement scenario can be found in Appendix 2 and the results
from all 14 questions can be retrieved directly from the yourviews website [3].

9.4 Discussion

9.4.1 Survey Design

Each of the NERD surveys is an experiment in a broad sense, dependent on

having enough voluntary participants. In a stronger sense, however, NERD
also experiments on new methods in most surveys, aiming to improve our
platform incrementally. In this survey, we added voting for multiple reasons as
well as the modified popularity display ranking described above. We evaluate
each of these innovations as a success. There were no complaints about the
voting (as there had been in an earlier single vote survey) and our display
method does mitigate the primacy effect as intended [4].
Finally, NERD conducted an experiment in the stronger sense of a ran-
dom partition by dividing the population into two cohorts showing reasons
identified by authors’ pseudonyms or only by reason numbers. A preliminary
analysis of these data suggests two small effects: first, those respondents who
saw authors’ pseudonyms contributed more reasons; second, they contributed
more votes of “Yes” and less of “No,” while neutral votes remained about
the same. We are presently conducting further experiments on ways of linking
authors and reasons, which we hope will help explain these differences.

9.4.2 Survey Content

Some questions produced clear agreement (2A, 2B, 3A, 4B), while others
did not. One particularly useful element of the survey was the exploration
9 Case Study: An Assistive Technology Ethics Survey 83

of the respondents’ reasons behind the simple “Yes,” “No,” “Neutral” vote.
Agreement in assessment (“Yes,” “No,” “Neutral”) was not necessarily syn-
onymous with agreement in reasons. In some questions, participants agreed
on the reason, yet came to different conclusions. In addition, in some ques-
tions with a high percentage of “Neutral” responses, many respondents stated
that the question did not address the proper issue. This was still quite infor-
mative, since respondents often provided their own assessment of the relevant
issue. Consider Question 1C, which falls into both of these categories:
Suppose the University has in place an evaluation system in which a certified oc-
cupational therapist assesses the student’s capabilities. Based on this assessment
the needs of the student are determined and a recommendation is made to provide
assistance. Should the occupational therapist consider the cost to the school when
identifying assistance required for the student?

Question 1C elicited a variety of responses, including the following:

No because the OT should make recommendations based on what is required of the
student regardless of cost, but then someone OTHER than the OT should make a
final decision that does take cost into consideration.
Yes because the OT should make recommendations based on what is required of the
student regardless of cost, but in high cost cases, also outline what can be achieved
with a lower cost option and what limitations this places on the student. Then an
informed decision can be made.

In this case, the reasons behind “No” and “Yes” revealed that the respondents
believed that the question missed the relevant issue. While the question had
been designed to elicit a prioritization of the student’s or the school’s needs,
the issue of who ultimately made the informed decision was found to be more
pertinent. Without the additional information provided in the reasons, “Yes”
and “No” have far less meaning.
The results of the survey were incorporated into “seed” questions to facili-
tate roundtable, small-group, interdisciplinary discussions in (a) Evaluation,
(b) Sensing, (c) Networking, and (d) Safety and Mobility. Some of the ques-
tions with high “Neutral” responses were useful in honing issues for discussion
that would be of the most multidisciplinary interest. Some of the questions
that did not have high “Neutral” responses, and were particularly divisive
(5), were used as “icebreakers.” Ultimately, workshop participants were given
the leeway, as was found useful in the survey, to pose and answer questions
they believed were most relevant. The initial list of questions identified for
each discussion session is listed in Appendix 3.

9.5 Conclusion

The AT Survey was successful in generating both qualitative and quantita-

tive results in response to the issues associated with assistive technologies
and which formed much of the discussion during the workshop. Rather than
merely producing one type of data or another, the survey has provided a more
comprehensive set of data upon which further analysis can be performed.
84 P.A. Danielson et al.

It is possible to see from this approach that the issues involved are complex
and include several factors to consider. In general, there were a number of
neutral responses in all but two of the questions (1C and 4B), which are
difficult to interpret in standard surveys; however, given the structure of
the N-Reasons platform, it is possible to more clearly understand what the
participants were concerned with and why they chose such a response. Ad-
ditionally, the survey addressed those subjects that the experts engaged in
this field felt were the most important and relevant to other researchers and
the general public.

Acknowledgements This research was partially funded by the Peter Wall Institute for
Advanced Research and Genome Canada through the offices of Genome British Columbia.
Thanks to the NERD team, especially Robin Avery for programming the N-Reasons plat-
form, and our participants for their enthusiastic support.

Appendix 1: Ethics and Assistive Technology Survey

• Evaluation Scenario: The University has purchased voice recognition

software for students who have disabilities that make it difficult or painful
to type. Jane is a student with this kind of disability and has been provided
with the software but does not use it. She instead asks to be accommodated
with a typist to whom she can dictate.
1A. The software the University purchased was chosen for its accuracy and
performance but also for its high degree of customization. Jane has tried
to learn the software once or twice but she quickly gave up, finding it too
difficult to learn. Do you think that the University has an obligation to
accommodate Jane with a typist in this case?
1B. There is a one-time cost associated with the software license which the
University assumes will pay off over time. The cost of a typist is ongoing
and dependent on a variety of factors such as the typist’s availability and
changing rate of pay. Do you think that Jane should be accommodated
with a typist in this case?
1C. Suppose the University has in place an evaluation system in which a cer-
tified occupational therapist assesses the student’s capabilities. Based
on this assessment the needs of the student are determined and a rec-
ommendation is made to provide assistance. Should the occupational
therapist consider the cost to the school when identifying assistance
required for the student?
• Sensing Scenario: Barbara has decided that she needs to provide greater
supervision for her frail mother who is showing early signs of dementia.
Barbara’s mother does not want to leave her home, but has had a series
of incidents that leave Barbara questioning whether her mother might
9 Case Study: An Assistive Technology Ethics Survey 85

inadvertently do herself harm (e.g., leaving the stove on, leaving food
unrefrigerated). Barbara has a few choices in how she plans to cope with
this situation. One option is to outfit her mother’s home with sensors,
which might include cameras that provide a live video feed and infrared
sensors that detect (in real time) whether or not a person has entered a
room. If her mother falls, for example, Barbara would be notified via email
on her Blackberry. Alternatively, Barbara could move her mother into a
full-time care facility. The reputable facility she has in mind has recently
begun to monitor its patients and staff for potential acts of violence or
aggression. Hence, all residents must agree to be monitored in all common
areas in order to live in the facility.
2A. Should residential facilities be subject to ethical guidelines for this type
of surveillance of their residents, to ensure the residents’ approval, at
some level, of the intrusion on their privacy?
2B. If personal data collected from assistive technologies is encoded and read
only by machines instead of people, is it less sensitive? For example, real-
time data (like video) would not be stored. Instead, only higher-level
information would be extracted from it (e.g., a time-stamped event such
as “subject went to living room”).
2C. Should Barbara ask for her mother’s permission to install sensors in her
home?
2D. Does the care facility have the right to remove current residents (who
moved into the facility before monitoring was implemented) if they are
unwilling to be monitored?
2E. Is it acceptable for the care facility to monitor residents in their bed-
rooms and bathrooms?
• Networking Scenario: A university is built on the side of a steep hill.
The university is deciding how to design access routes between buildings.
One option is to build a series of long ramped paths, which can be used
by everyone. The other is to build a staircase that goes up the middle of
the hill for non-wheelchair users and a series of lifts which could only be
operated with a key, and which could fit only a single wheelchair user and
nobody else at one time.
3A. Should the social interactions of people using the potential access route
be incorporated into the design of the university? In this case, should the
design of the university aim to keep wheelchair users and non-wheelchair
users on the same route?
3B. Should the university take into account the long term increased energy
and maintenance costs associated with keeping wheelchair users and
non-wheelchair users on the same route?
• Safety and Mobility Scenario: Peter is a 30-year-old intelligent man
who has cerebral palsy with severe spasticity, which renders him unable
to walk. He has limited fine motor control of one arm. In the past, he has
86 P.A. Danielson et al.

tried a mouth switch and a head switch on a power wheelchair, as well as

a standard joystick. However, therapists are reluctant to give him a power
chair because he lives in a busy area of the city. Their fear is that he will
either drive into a building or a person, or drive off the sidewalk and hurt
himself. Currently, when he leaves the group home where he lives, he must
be accompanied by an assistant who pushes him in a manual wheelchair.
Peter has just been informed that a wheelchair manufacturing company is
developing a prototype of a new power wheelchair that is maneuverable,
accessible to a variety of user inputs (e.g., sip and puff, joystick), and has
some safety features built in (e.g., bumpers to protect walls, furniture, etc.
in soft collisions). Due to damage and liability concerns, the manufacturer
is also planning to add a speed control function (accessible by a key code
only) that determines the maximum possible speed.
4A. Peter’s occupational therapist has recommended he try the new pro-
totype wheelchair that includes safety features. The chair is outfitted
with a “black-box” that continuously records maximum speed, average
speed, and number of collisions. After a 30-day probationary period,
the therapist evaluates Peter’s driving record. Based on the black-box
data, the therapist decides that Peter can continue to use the powered
wheelchair, but that the wheelchair’s maximum allowable speed will be
set to half its previous value. Is this fair?
4B. Should Peter be given the key code to his own wheelchair?
4C. Assume that Peter will not have access to codes on his wheelchair.
Does his group home have the right to dictate that only wheelchairs
with speed control functionality can be used in the facility?
• Enhancement Scenario: “Despite having both lower legs amputated as
a child, South African runner Oscar Pistorius dreamed of one day com-
peting in the Olympic Games. That dream was dashed in early 2008 when
the International Association of Athletics Federations ruled him ineligible,
claiming his carbon-fibre prosthetics gave him an unfair advantage over
able-bodied competitors. Pistorius appealed to the Court of Arbitration
for Sport, which overturned the decision just in time for the Beijing Games.
Unfortunately, the athlete known as Blade Runner fell seven-tenths of a
second short of the Olympic qualifying time in the 400 m.” [10]
5. Should Oscar Pistorius be allowed to compete with able-bodied
athletes?

Appendix 2: Results of Question 1A and Question 5

Question 1A: The university has purchased voice recognition software for
students who have disabilities that make it difficult or painful to type. Jane is
9 Case Study: An Assistive Technology Ethics Survey 87

a student with this kind of disability and has been provided with the software
but does not use it. She instead asks to be accommodated with a typist to
whom she can dictate (Fig. 9.3).
The software the university purchased was chosen for its accuracy and
performance but also for its high degree of customization. Jane has tried to
learn the software once or twice but she quickly gave up, finding it too difficult
to learn. Do you think that the university has an obligation to accommodate
Jane with a typist in this case? (Table 9.1)

Fig. 9.3 Responses for Question 1A

Table 9.1: Participant reasons generated by Question 1A

Score Reason

191 (28.5/95) Neutral because not enough information is provided about Jane’s diffi-
culty with the software or the university’s efforts to help her use it ef-
fectively. I don’t want to waste time speculating on either, I prefer fuller
information in the question. I don’t think the university should accommo-
date someone who has not made an honest effort to participate, but there
is no way of telling that.
42 (17.8/95) Yes because Jane should be given a typist in the interim with encourage-
ment to try modifying the software to improve success. In the long run
she could be more independent if she found something that worked for her
beyond a typist.
−3 (13.0/95) No because more can be done to make the software usable for Jane. E.g.,
the university could offer a customization session. The typist approach
will likely be very expensive long-term, and the most cost-effective option
should be used (taking into account all costs, not just financial ones –
Jane’s frustration should be counted as a cost).
−9 (10.5/95) Neutral because I am not sure how well the software performs. If it is well
designed in terms of usability and demonstrates robust voice recognition
then Jane should be strongly encouraged to persevere and not be given a
typist unless she really has made a lot of effort.
−45 (7.0/95) Neutral because Jane should be given a typist in the interim with encour-
agement to try modifying the software to improve success. In the long run
she could be more independent if she found something that worked for her
beyond a typist.

(continued)
88 P.A. Danielson et al.

Table 9.1: (continued)

Score Reason

6 (6.7/95) No because Jane has not made a good-faith effort to use the software. She
will be more productive in the long term if she can do inputting into the
computer without having to schedule a typist each time.
−69 (5.3/95) Yes because this may be a difference between US and Canadian law. Under
US law, the university must provide an effective accommodation for Jane,
and as everyone who has used voice recognition software knows, it does not
work well in some contexts, especially for someone who does not articulate
uniformly. The reason given above does not state what more can be done,
other than a customization session which will not be effective if Jane does
not articulate uniformly.
8 (3.5/95) Yes because accommodations cannot be “one size fits all.” The technology
the university is offering may not be suitable for Jane. If there is another
viable or realistic alternative, such as a typist, it should be considered.
−9 (2.3/95) Neutral because there is not enough information to tell if voice recogni-
tion software is appropriate for her, or if other technology would be more
appropriate, a typist should be provided until a complete assessment is
completed, voice recognition does not work for all individuals.
−69 (2.0/95) Yes because not all people are comfortable using computers and the soft-
ware might not be adaptable to all.
−12 (2.0/95) No because first they should provide training. If this does not work, they
should provide the typist.
25 (1.5/95) Neutral because it is hard to tell the degree of disability from the scenario.
Is Jane having a short term upper hand impairment? Is she in wheelchair
with paralysis with decreased muscle strength in her hands? It is unclear
whether the university conducted an assessment prior to giving Jane the
equipment to check if it would be suitable for her. I am assuming that the
university does not have a high number of students similar to Jane’s needs,
if indeed an assessment was not done, and Jane’s disability is a chronic and
debilitating one, the university ought to provide Jane with a typist while
they fix the software issue.
−74 (1.0/95) Yes because with the current state of technology, even the most advanced
speech recognition software cannot adequately address Jane’s needs. Con-
tribution to software development is not Jane’s responsibility.
15 (1.0/95) Yes because I work with LD students and have an LD myself.
14 (0.8/95) No because where do you draw the line in “assistance”? This could be an
expensive precedent to set. Also, I personally have been unable to work
due to a injury to my arm (I cannot type); my employers were not obli-
gated to purchase me software to assist me and this is my livelihood, but
I understand the cost factors involved if this were required.
−40 (0.5/95) No because the software is designed for people with this disability.

Question 5: “Despite having both lower legs amputated as a child, South

African runner Oscar Pistorius dreamed of one day competing in the Olympic
Games. That dream was dashed in early 2008 when the International Asso-
ciation of Athletics Federations ruled him ineligible, claiming his carbon-
fibre prosthetics gave him an unfair advantage over able-bodied competitors.
Pistorius appealed to the Court of Arbitration for Sport, which overturned
9 Case Study: An Assistive Technology Ethics Survey 89

the decision just in time for the Beijing Games (Fig. 9.4). Unfortunately, the
athlete known as Blade Runner fell seven-tenths of a second short of the
Olympic qualifying time in the 400 m.” [10] (Table 9.2)
Should Oscar Pistorius be allowed to compete with able-bodied athletes?

Fig. 9.4 Responses for Question 5

Table 9.2: Participant reasons generated by Question 5

Score Reason

239 (23.0/76) No because with prosthetics, the biomechanics of sprinting are significantly
different than without prosthetics. A 400 m with prosthetics is a different
sport than a 400 m without.
119 (13.0/76) No because although I’m sympathetic to Pistorius’ goals, there’s no prin-
cipled way to draw a line between Pistorius’ blades and other assistive
devices that would clearly give an unfair advantage.
113 (12.3/76) Neutral because it is not clear whether Pistorius’ prothesis is an “external
device or piece of equipment” like a spring loaded shoe or whether it is an
integral part of his body. Would an athlete with an artificial internal hip
or knee joint be restricted from participating? Is it because the prosthesis
is external and visible that we are considering discriminating against Pis-
torius? Wouldn’t we want the most current technology in an internal knee
joint for an athlete? Why not in an external prosthesis also? Or, do we
view the prosthesis as we would a wheelchair which is a clear advantage
for some running events over natural runners, i.e., it is an external device
that is not part of the person? This is the reason given above for a Yes
answer (acook), but its indeterminacy really supports a neutral stance.
−23 (9.0/76) Yes because there is as yet no evidence that the prosthetics give him an
unfair advantage. This is obviously a grey area – few would argue that
he shouldn’t be allowed to compete with no prosthetic at all, but most
argue that he shouldn’t be allowed to compete if his prosthetics were fuel-
powered. A fully passive prosthetic is roughly equivalent to the introduction
of the clap skate in speed skating – some skaters were faster with the
clap skate than the conventional, but the top athletes were initially faster
with the conventional skate. It would be very difficult to design a passive
prosthetic which would confer any significant advantage over an intact
athlete.

(continued)
90 P.A. Danielson et al.

Table 9.2: (continued)

Score Reason

−26 (4.8/76) Neutral because I do not know enough about the speeds achievable with
the prosthetic limbs compared to able bodied athletes. I assume they do
not infer an advantage and so should be allowed. However, if the prosthetic
limbs, on average, increase performance then their user becomes a different
class of athlete and should compete in a separate competition.
33 (4.0/76) Neutral because in the same way that there are restrictions on swim
suit designs, racket designs, there also has to be restrictions and rules for
prosthetic design used in competition so it is not a greater advantage to
have a prosthetic limb.
−26 (3.0/76) Yes because we are speaking about a game. But then all able-bodied run-
ners should be allowed to use carbon-fiber prosthetics, to be fair.
−53 (2.5/76) Yes because agree with john. Also, perhaps Pistorius is a black swan com-
pared to his peers. Now if all amputee runners began to post times better
than olympics runners, then this would clearly be a different class. But the
reality is that they are not even close and Pistorius just happens to be that
good.
−73 (2.5/76) No because even a passive prosthetic can provide an unfair advantage over
other athletes. Where do we draw the line between Pistorius’ blades and a
bicycle fitted for amputated legs? What about spring-loaded shoes on able-
bodied athletes? Should those be allowed? It seems that the best response
at this point is to disallow all prosthetics which could potentially offer
performance enhancements. One significant consequence of saying “no”
here is questioning where the line of prosthetic enhancement ends (e.g.,
shoes).
−51 (2.0/76) Yes because it is not clear whether Pistorius’ prothesis is an “external de-
vice or piece of equipment” like a spring loaded shoe or whether it is an
integral part of his body. Would an athlete with an artificial internal hip
or knee joint be restricted from participating? Is it because the prosthesis
is external and visible that we are considering discriminating agains Pis-
torius? Wouldn’t we want the most current technology in an internal knee
joint for an athlete? Why not in an external prosthesis also? Or, do we
view the prosthesis as we would a wheelchair which is clear advantage for
some running events over natural runners, i.e., it is an external device that
is not part of the person?
−6 (2.0/76) Yes because it’s inspiring for other amputees and it would attract a large
viewing audience. Fairness is all relative, and we actually make the rules
so that the competition is interesting. Clearly, the blades do give an ad-
vantage to Oscar (I’m very familiar with this technology) and eventually
prostheses or exoskeletons will enable Oscar and other athletes with physi-
cal “disabilities” to outperform their intact counterparts. As this happens,
the Olympic committee will have to be creative in coming up with new
rules that meet the spectators’ expectations that the competition be both
“fair” and all-inclusive. Perhaps separate categories could be created, each
having their own technology-based rules. It may be that NASCAR could
serve as a model for some future Olympic events.
9 (2.0/76) Neutral because I do not know enough about the issue.
31 (1.5/76) Neutral because if he can qualify with the devices he should be allowed.

(continued)
9 Case Study: An Assistive Technology Ethics Survey 91

Table 9.2: (continued)

Score Reason

−36 (1.3/76) Neutral because the restriction should be based on how much the artifi-
cial parts enhance the performance of an athlete for a specific event. It’s
an inexact scientific assignment. It’s clear that as science advances super
mechanical parts will become available and no one argues athletes fitted
with such parts should be allowed to compete.
−53 (1.0/76) No because the right judges in such cases are those sponsoring the com-
petition.
−43 (1.0/76) Yes because the Court Of Arbitration For Sport is the supreme sports
court. (CAS said the IAAF failed to prove that Pistorius’ running blades
give him an advantage.)
−36 (1.0/76) No because his goal was to demonstrate that the accident did not affect
his ability to run. He does not need to compete with professional athletes
in order to do this.
−17 (0.5/76) No because no maybe he should try olympics for the disabled.

Appendix 3: Small-Group Discussion Questions

in the PWIAS-ICICS Workshop

• Evaluation
1. What devices, methods, and protocols can assist researchers and clin-
icians in measuring how, when, and under what circumstances AT is
being used? Should users make these determinations?
2. What devices could be designed and implemented to bypass self-
reporting? What best-practices might prevent violations of privacy if
self-reporting is eliminated?
3. What novel devices and methods for collecting data can be used to
evaluate the impact of AT? What do we mean by impact?
4. What novel devices, algorithms, and methods could non-intrusively de-
tect/predict abandonment?
5. How does device novelty affect its knowledge translation? Where in
the pipeline from academic research to end-user use does knowledge
translation fail, and why?
6. When is AT appropriate? What user circumstances determine if AT
should be used? When a device is abandoned, what determines whether
a replacement device is required?
• Sensing
1. How does a user’s specific circumstance (type of disability, social net-
work, use of AT) influence what type of data should be gathered?
2. What level of security is required for user data? What privacy standards
should be enforced? What are potential consequences of breaches?
3. How much user benefit is required to overcome a loss in privacy (e.g.,
utility of Google mail often outweighs privacy concerns)?
92 P.A. Danielson et al.

4. How much control should users have over their sensor data? Why are
specific types of sensor data more acceptable from a user’s point of view
than others?
5. Ubiquitous sensing technologies may require additional computing, stor-
age, and communications infrastructure. How could this burden be mit-
igated to prevent potential derailment of new AT?
6. Ubiquitous sensing may be a deterrent for some people, but if designed
well, could be desirable (e.g., an iPhone-based application for route
finding via wheeled mobility). When is such technology desirable, or
detracting, from the user’s point of view?
• Networking
1. How does level of customization of AT affect a user’s sense of agency?
Are “generic” technologies less beneficial/useful?
2. How should concerns about agency impact technology design and use?
3. How can AT be designed to physically prevent or deter violations of a
user’s privacy or personal space?
4. Novelty and a steep learning curve can be significant barriers to the
adoption of AT. How does switching to a new type of AT impact a
user’s sense of self?
5. How can novel technologies be designed to integrate seamlessly into the
physical and social environments of the users and their surroundings?
6. To what end can sophisticated technologies be made user-friendly for
people who are unfamiliar with computers, etc. (e.g., the elderly)?
7. What best-practices can ensure that devices are made from a need-based
pull, as opposed to a technology-push?
• Safety and Mobility
1. What design practices can make AT more easily and reliably customiz-
able to individual users?
2. What factors determine when mobility AT is warranted for a specific
individual?
3. Under what circumstances should information recorded about the safety
of a person’s previous mobility behaviors be used to restrict or enhance
the future capabilities of their mobility AT?
4. What best-practices in device and algorithm design could make mobility
AT more robust to obsolescence? Given the high cost of mobility AT,
what technologies would be required to make mobility AT modular and
upgradeable?
5. What infrastructure should be developed to enable people who use mo-
bility AT (e.g., Segways that may not be operated on sidewalks, powered
wheelchair restrictions in group homes)?
6. How much control should group home residents have over their powered
mobility AT? What other mechanisms could assure safe driving without
sacrificing user autonomy?
9 Case Study: An Assistive Technology Ethics Survey 93

References

[1] Ahmad R, Bailey J, Bornik Z, Danielson P, Dowlatabadi H, Levy E,

Longstaff H (2006) A web-based instrument to model social norms:
NERD design and results. Integrated Assessment 6(2):9–36
[2] Ahmad R, Bailey J, Danielson P (2008) Analysis of an innovative survey
platform: comparison of the public’s responses to human health and
salmon genomics surveys. Public Understanding of Science Prepublished
doi:10.1177/0963662508091806
[3] Centre for Applied Ethics (2010) Assistive technology survey results.
http://www.yourviews.ubc.ca/en/AT_Survey_Results
[4] Danielson P (2009) N-Reasons: Computer mediated ethical decision sup-
port for public participation. In: Public and Emerging Technologies:
Theorizing Participation, Banff, Canada
[5] Danielson P (2009) Survey on ethics and assistive technologies:
N-reasons design and preliminary results. Presentation at the Peter Wall
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abling individuals: Ethics, design, and use of assistive technology”
[6] Danielson P (2010) A collaborative platform for experiments in ethics
and technology. In: van de Poel I, Goldberg D (eds) Philosophy and
Engineering: An Emerging Agenda, Philosphy of Science, vol 2, Springer
[7] Danielson P (2010) Designing a machine for learning about the ethics
of robotics: The N-Reasons platform. Ethics and Information Technol-
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s10676-009-9214-x
[8] Danielson P, Ahmad R, Bornik Z, Dowlatabadi H, Levy E (2007) Deep,
cheap, and improvable: Dynamic democratic norms and the ethics of
biotechnology. In: Ethics and the Life Sciences, Journal of Philosphical
Research, Charlottesville, VA, pp 315–326
[9] Ormandy E, Schuppli C, Weary D (2008) Changing patterns in the use
of research animals versus public attitudes: Potential conflict. Poster at
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[10] Ripley S (2009) See you in court! Most memorable legal battles in sports.
http://slam.canoe.ca/Slam/Top10/2009/05/24/9553531-sun.html
 Part III
Development and Commercialization
Chapter 10
The Fast Pace of New Emerging
Information and Communication
Technologies: The Need
for Regulations and Standards

Gary E. Birch

Abstract Information and communication technologies (ICT) are directly or

indirectly a form of assistive technology. Indeed, many forms of new emerging
ICT have the potential to provide opportunities for persons with disabilities
to obtain inclusion in the mainstream of society to an extent never before
accomplished. However, due to the rapid and ubiquitous insertion of these
technologies into our society and given that most of these technologies are not
accessible to persons with disabilities they are forming new barriers rather
than opening up new opportunities. New strategies need to be adopted to deal
with this trend and, particularly in the relatively near term, it is argued that
the most important strategy is the development of enforceable regulations and
standards that impact the accessibility of these new emerging technologies.

10.1 Introduction

Many emerging information and communication technologies (ICTs) have

significant potential to enable persons with disabilities and promote their
inclusion in mainstream society. This is in part due to the ever-increasing
power of these devices to accomplish various technological tasks. The most
significant factor, however, is that these new technologies are being incorpo-
rated into the mainstream of our society almost ubiquitously, including in
areas such as employment, recreation, and various forms of service delivery.
Combined with the fact that these technologies are changing at a very rapid
pace, this lays the foundation for a perfect storm of inaccessibility for per-
sons with disabilities. As new technologies come onto the market, they are
not inherently accessible for a large majority of persons with disabilities and
therefore become barriers rather than tools that allow them to take part in

Gary E. Birch
The Neil Squire Society, Burnaby, BC, Canada, [email protected]

M.M.K. Oishi et al. (eds.), Design and Use of Assistive Technology: Social, 97
Technical, Ethical, and Economic Challenges, DOI 10.1007/978-1-4419-7031-2 10,

c Springer Science+Business Media, LLC 2010
98 Gary E. Birch

society like their able-bodied counterparts. The old paradigm of developing

retrofit solutions to access mainstream ICT is failing persons with disabilities
because in the current paradigm these “fixes” cannot keep up. This points to
the need to invent new strategies to deal with today’s unprecedented pace of
new ICT introduction.
The need for this issue to be addressed is becoming better recognized
both within the community of persons with disabilities and in the worldwide
stakeholders community. Perhaps the best recent example is contained in the
Convention on the Rights of Persons with Disabilities [13]. This convention,
among many other important issues, specifically calls for the accessibility of
information and communication technologies and related services (see, e.g.,
Articles 9 and 21). As of July 2009, 62 countries have ratified this convention.
Currently, Canada recently ratified and the US is in the process of working
towards ratifying this convention [12].
In this chapter, a few examples that demonstrate the accessibility barriers
that are caused by mainstream ICT are given and three possible strategic ar-
eas that could work to solve this emerging problem are outlined. One of these
strategies is the development of regulations and standards. This area will be
discussed in greater detail with an attempt to make the case that appropri-
ate technologies for people with disabilities will only be reliably available,
at least in the relative near term (next 5–10 years), with regulation and the
enforcement of standards that effectively mandate their deployment.

10.2 Examples of ICT: A Barrier or an Enabler

As discussed above, as emerging ICTs become generally available in our soci-

ety, the trend also opens up the potential for persons with disabilities to take
part in a wider range of activities. A few years ago, the Neil Squire Society [1]
held a number of focus groups with persons with mobility and vision impair-
ments to gain their input on public ICTs and ensuing challenges, barriers and
potential wireless solutions. Among the outcomes was the general consensus
that wireless technologies had promising potential to enhance inclusion. The
top three services that were identified during this process were banking, retail
(electronic payment) and transit.
There were many examples related to transit and banking including issues
related to accessing automated transit ticket systems or banking machines.
The proliferation of public services using automated dispensing machines
(kiosks for banking, buying transit tickets, getting information, etc.) is re-
vealing common barriers to persons with disabilities; however, if the machines
are improved, the services can be transformed into opportunities for enhanced
accessibility. For a detailed discussion on the use and accessibility of these
technologies, see Ripat et al. [10].
10 The Fast Pace of New Emerging ICTs 99

Given the interest in electronic payment (often referred to as e-commerce)

by persons with disabilities as an enabler if it were accessible, and its grow-
ing use and deployment [6], the Neil Squire Society recently carried out a
large study on the accessibility of mobile payment systems with the blind,
the hard-of-hearing, the deaf, and persons with mobility impairment [5]. The
study highlights 12 key accessibility issues that affect the four different trans-
action methods that were studied (for more details on how these were selected,
see Lew et al. [5]). A few examples of the barriers encountered were: voice
menu systems that did not allow sufficient time for users with mobility im-
pairments; voice menu systems that did not have a text-based alternative to
allow access for deaf users; and web-based systems that did not adhere to all
the Web Content Accessibility Guidelines [7], which made them largely un-
usable by the blind. For a video overview of some examples, including those
noted above, of persons with severe mobility impairments using existing and
potential emerging ICTs and related services see the website in [8].

10.3 Three Strategies

There are at least three main strategic approaches to improve accessibility

of emerging ICTs: (1) working with industry, (2) developing government reg-
ulations and related standards, and (3) educating students who will design
future ICTs.
1. Work with industry The not-for-profit sector that has specific domain
expertise with persons with disabilities and technology needs to engage with
industry to help them better understand the design challenges and potential
solutions. The key is to help companies better understand their role, whether
it be from a business case point of view or from the requirement to meet regu-
lations, or both. Despite the fact that around the world there are a number of
not-for-profit organizations that are attempting to engage with industry, the
relationships have generally been very difficult, with only a few examples of
what most would consider minor successes. Neufeldt et al. explores these chal-
lenges in greater detail [9]. Some of the ways that the not-for-profit sector can
engage with industry are: consumer focus group facilitation; needs determina-
tion studies; usability and accessibility evaluations; sophisticated simulation
studies; device development and adaptation; accessible design consultation;
usability guideline and standards development; and demonstrations of proof-
of-concept solutions in real and/or simulated environments. Given that most
not-for-profit organizations do not have the capacity to do this for free, in-
dustry needs to understand the benefit for them to support these kinds of
engagements and therefore retain these not-for-profits on a fee-for-service ba-
sis. Currently, few industries have been ready to seriously entertain a business
case to do this work, although with the growing aging demographics there
100 Gary E. Birch

are signs that some industries are starting to consider this in their business
planning. To date, most industries that have considered some form of inclu-
sive design have been more motivated to do so by the existence or threat of
regulation requiring them to do so.
2. Engage proactively in the development of government regulations
and related standards The work by Stienstra et al. [11] is but one exam-
ple of research that has pointed out the importance of establishing govern-
ment enforceable regulations and their related standards. See also G3ict, the
Global Initiative for Inclusive Information and Communication Technologies
[4], which is a flagship advocacy initiative of the United Nations Global Al-
liance for ICT and Development. Initiated in December 2006 by the Wireless
Internet Institute, G3ict is a public-private partnership dedicated to facilitat-
ing the implementation around the world of the Digital Accessibility Agenda
defined by the Convention on the Rights of Persons with Disabilities. This
initiative strongly supports the implementation of appropriate government
policy with heavy emphasis on the coordinated development of standards
regarding accessibility of ICT. This initiative involves government, industry
and nongovernment organizations. Stienstra et al. [11] also provide examples
of various pieces of legislation from around the world (primarily the US, Aus-
tralia, and the UK) that in some way regulate accessibility of ICT. Some of
the most commonly cited relevant pieces of legislation in the US are: Section
501 of the Rehabilitation Act [18] and Section 255 of the Federal Communi-
cations Commission (FCC) Communications Act [17] (both currently under
review) [15].
3. Education of students Ensuring that our postsecondary students, pri-
marily engineers, computer scientists, and industrial designers, who will be
involved in the design of new technologies, are taught the principles of inclu-
sive design is a long-term approach, but one that may pay off as a sustainable
solution to the production of accessible ICT in the consumer mass market.
Ideally these students should not just be taught the theory but also have the
opportunity to complete projects that directly involve persons with disabili-
ties and their access challenges with ICT. The students will then carry these
experiences into their workplaces with the grounded realization that inclu-
sive design results in a much broader range of people being able to use the
technology, thereby increasing a company’s market share for a given product
while also helping to contribute to equal access for all.

10.4 The Need for Regulations and Standards

Due to the lack of voluntary uptake by industry as noted above, regulations

and standards will play the key role in providing substantial accessibility
of emerging ICTs in the near-term, over the next 5–10 years. For instance,
10 The Fast Pace of New Emerging ICTs 101

officials in the EU acknowledge that there is a clear correlation between the

existence of legislation and the actual level of progress on accessible ICT [3].
The EU has been exploring a general legislative approach, but there is not yet
a clear consensus on possible specific EU legislation dedicated to accessible
ICT, including elements such as scope, standards, compliance mechanisms,
and links to existing legislation [3].
In Canada, as another example, there are no regulations related to the
accessibility of ICT. However, the Canadian Radio-television and Telecom-
munications Commission (CRTC) recently held hearings on accessibility re-
lated to both communication and broadcast technologies in Canada. These
hearings covered a range of issues, and the CRTC made several rulings and
recommendations as a result [2]. An example of one of the directives that re-
lates to wireless handheld technologies by Wireless Service Providers (WSPs)
is [2]:
Accordingly, the Commission requests that, by 21 October 2009, all WSPs offer and
maintain in their inventories at least one type of wireless mobile handset that will
provide access to wireless service by persons who are blind and/or have moderate-
to-severe mobility or cognitive disabilities.

It is illustrative that regulators are starting to pressure industry more to

produce accessible ICT. While time will tell, this ruling (which is currently a
“request”), could be one of the more progressive pieces of regulation to make
industry take into account inclusive design. If industry does not respond to
this “request”, then the real test will be whether the CRTC will create an
updated directive that requires companies to offer accessible technologies.
This type of requirement (with sanctions) will produce more procurement
demand (and in this case, new demand in areas such as access for persons
with severe mobility impairment that have not yet seen specific regulation)
by the WSPs on the manufacturers of handsets. The handset manufacturers
will be forced to start producing at least some of their products in a format
that is accessible and/or is easily made accessible for the targeted consumers.
The US currently has what is perhaps one of the best examples of reg-
ulation driving the deployment of mass market inclusive technology: the
FCC’s change to the Hearing Aid Compatibility Act of 1998 (HAC Act)
[16]. The change, introduced in 2003, required wireless handset manufactur-
ers and WSPs to make a substantial part of their inventory compatible with
hearing aids. Through a ramping-up process starting in 2008 and finishing
in 2011, the change has resulted in the almost universal availability of cel-
lular telephones that are hearing aid compatible in the US, and because of
the large ripple effect of the US market, these wireless telephones are also
available in many other jurisdictions as well. Now a person with a hearing
disability who uses a hearing aid can simply buy the phone, on a level playing
field with a hearing person, and have a piece of technology that works right
out of the box. This is the ideal case, that regulation can bring about in the
relative near-term: universally accessible or easily adaptable ICT for persons
with disabilities.
102 Gary E. Birch

As noted in the Introduction, the UN Convention may play a big role

in getting jurisdictions in many parts of the world to establish appropriate
regulations. In particular, the Optional Protocol to the UN convention will
increase pressure on countries that ratify the Optional Protocol to establish
mechanisms to ensure the accessibility of ICT. As quoted from the Convention
[14]:
The Committee on the Rights of Persons with Disabilities is a body of independent
experts tasked with reviewing States’ implementation of the Convention. The Com-
mittee periodically examines reports, prepared by States, on the steps they have
taken to implement the Convention. For those States that are party to the Optional
Protocol, the Committee also has authority to receive complaints from individuals
of alleged breaches of their rights and to undertake inquiries in the event of grave
or systematic violations of the Convention.

Therefore, in countries that sign on to the Optional Protocol, there will

exist a robust regulatory mechanism that will allow individuals to lodge com-
plaints to this international body. Hopefully, just the fact that countries know
that they will potentially be held to account will encourage the establishment
of effective local standards and regulations in a timely fashion. As more and
more countries establish these types of regulations, there will be a resul-
tant demand on the manufacturers of ICT to bring us closer to the ideal,
as illustrated above in the example of the hearing aid compatible cell phone
handsets, in which persons with disabilities can easily access mainstream tech-
nology that is designed to be accessible or easily adaptable for their personal
access needs.

10.5 Concluding Remarks

The potential for greatly enhanced inclusion for persons with disabilities us-
ing emerging ICTs is clear, but unfortunately the new barriers they present
are also clear. Students better educated in accessible design of ICT and not-
for-profit companies that represent persons with disabilities working with the
ICT industry are long-term strategies that can help change these new barriers
into enablers. More importantly, in the shorter term over the next 5–10 years,
the implementation of more regulations and standards governing the acces-
sibility of ICT is required. Governments and the general public that produce
the empowering political will must act now, or more persons with disabilities
will become further marginalized in this ever-increasing and faster-evolving
information age.
10 The Fast Pace of New Emerging ICTs 103

References

[1] Birch G (2006) Findings from research conducted by the disability and
information technologies (Dis-IT) research alliance – Retail and public
services. In: Hard-Wiring Inclusion: A Conference about Building an
Accessible ICT World, Winnipeg, Manitoba, pp 73–82. http://www.
dis-it.ca/2006si/2006-10-26.php#research
[2] Canadian Radio-television and Telecommunications Commission (2009)
Broadcasting and telecom regulatory policy CRTC 2009-430: Accessibil-
ity of telecommunications and broadcasting services. http://www.crtc.
gc.ca/eng/archive/2009/2009-430.htm
[3] Commission of the European Communities (2008) Towards an accessi-
ble information society. Communication to the European Parliament,
the Council, the European Economic and Social Committee and the
Committee of the Regions. http://eur-lex.europa.eu/LexUriServ/
LexUriServ.do?uri=COM:2008:0804:FIN:EN:PDF
[4] G3ict (2010) Global initiative for inclusive information and communica-
tion technologies. http://www.g3ict.com
[5] Lew H, Leland D, Birch G (2009) Evaluation of mobile payment systems
for people with disabilities. Research report, Neil Squire Society. http://
www.neilsquire.ca/
[6] Lin KJ (2008) E-Commerce Technology: Back to a Prominent Future.
IEEE Internet Computing 12(1):60–65, doi:10.1109/MIC.2008.10
[7] Mobile Web Initiative (2010) The web on the move. http://www.w3.
org/Mobile/
[8] Neil Squire Society (2009) Wireless technologies for people with
disabilities. http://www.youtube.com/watch?v=JrJA7glzIBA&
feature=related
[9] Neufeldt A, Watzke J, Birch G (2007) Engaging the business/industrial
sector in accessibility research: Lessons in bridge building. The Informa-
tion Society, An International Journal 23(3):169–181
[10] Ripat J, Watzke J, Birch G (2005) Public information and communi-
cation technologies: Improving access or crating new barrier? OT Now
pp 21–24, CAOT Publications Ace
[11] Stienstra D, Watzke J, Birch G (2007) A three-way dance: The global
public good and accessibility in information technologies. The Informa-
tion Society, An International Journal 23(3):149–158
[12] United Nations (2008) Ratification of the convention on the
rights of persons with disabilities. http://treaties.un.org/Pages/
src-TREATY-id-IV~15-chapter-4-lang-en-PageView.aspx
[13] United Nations (2010) Convention on the rights of persons with disabilities.
http://www.un.org/disabilities/convention/conventionfull.
shtml
104 Gary E. Birch

[14] United Nations: Secretariat for the Convention on the Rights of Per-
sons with Disabilities (2010) Frequently asked questions regarding the
convention on the rights of persons with disabilities. http://www0.un.
org/disabilities/default.asp?id=151#sqc8
[15] US Access Board (2008) Update of the 508 standards and the telecom-
munications act guidelines. http://www.access-board.gov/sec508/
update-index.htm
[16] US Federal Communications Commission, Consumer and Governmental
Affairs Bureau (2008) Hearing aid compatibility for wireless telephones.
http://www.fcc.gov/cgb/consumerfacts/hac_wireless.html
[17] US Federal Communications Commission, Consumer and Governmen-
tal Affairs Bureau (2008) Section 255: Telecommunications access
for people with disabilities. http://www.fcc.gov/cgb/consumerfacts/
section255.html
[18] US General Services Administration (1998) Section 508. http://www.
section508.gov/index.cfm?FuseAction=Content&ID=17
Chapter 11
Small Markets in Assistive Technology:
Obstacles and Opportunities

Jaimie F. Borisoff

Abstract While the inherently small market for assistive technology (AT)
can be a significant hurdle in the development of AT solutions, small mar-
kets can also provide opportunities to foster technology innovation under the
right circumstances. Focusing on the wheelchair industry, I summarize the
numerous obstacles that small companies face in trying to address small AT
markets, as well as the range of opportunities available to assist small com-
panies in their efforts to impact the quality of life of those with disabilities.
Indeed, small market AT may be a perfect fit for the growing field of “small
batch” manufacturing in combination with motivated individuals suddenly
empowered by a host of new technologies. I close with a brief discussion of
future possibilities for AT in small markets.

Assistive technology (AT) has seen great progress over the past half century,
creating significant positive impact to overall quality of life for many people.
However, that most obvious form of AT, the wheelchair, provides some muted
historical perspective [4]:
The wheelchair has, for most of its history, been a design that segregated instead of
integrated.

An almost complete lack of innovation over several decades contributed to this

situation. One reason for the disappointing performance by the wheelchair
industry was the monopoly enjoyed by Everest and Jennings Inc. (E & J),
which had up to 90% of the manual wheelchair market share until 1978 [9].
Perhaps the simple lack of competition never created the forces necessary
for innovation in wheelchair technology. A US Government antitrust suit was

Jaimie F. Borisoff
Instinct Mobility Inc., and Brain Interface Lab, Neil Squire Society, International Collab-
oration on Repair Discoveries, 818 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada,
e-mail: [email protected]

M.M.K. Oishi et al. (eds.), Design and Use of Assistive Technology: Social, 105
Technical, Ethical, and Economic Challenges, DOI 10.1007/978-1-4419-7031-2 11,

c Springer Science+Business Media, LLC 2010
106 Jaimie F. Borisoff

finally successful in limiting the market dominance of E & J: by 1983, the mar-
ket had expanded to comprise over 50 wheelchair manufacturers [9]. Twenty
years after the antitrust suit, the number of wheelchair manufacturers had
ballooned to over 170 companies [6]. The early wheelchair industry seemed
to be simply one very large market served by the ubiquitous steel folding
wheelchair manufactured by E & J. In reality, once the barrier to industry
participation was reduced, the wheelchair industry matured into a collection
of many small markets, often completely independent from each other. Small
companies that were effective at creating innovative products also created
their own opportunities in niche markets within the overall marketplace.
Today, several areas in AT, including the wheelchair industry, have main-
stream companies with billion dollar revenues, large scale manufacturing re-
sources, and international sales and distribution channels. However, much of
AT serves customers with an extremely wide variety of disabilities, often en-
compassing unique needs that necessitate specific innovations and solutions
that are only deliverable with small market economics.
This chapter first summarizes the obstacles that individuals, academia,
and small companies face in trying to address small AT markets. Then,
I present a range of opportunities available in small markets. Lastly, I dis-
cuss the brewing revolution in “small batch” manufacturing, which has the
near-term potential to provide specific AT solutions in small markets. This
seemingly perfect fit can address the specific needs and interests of individuals
suddenly empowered with a host of new tools and services.

11.1 Small Market Obstacles

Small markets in any industry (including AT) present many obstacles to

sustainable business growth. Unfortunately, there are also several obstacles
that are more specific to AT and the medical device industry – these will be
summarized following a brief discussion of the most widely applicable issues.

11.1.1 Obstacles Beyond AT

In some manner, almost all obstacles related to small markets involve money
and resources. Bringing new products to market is simply an expensive propo-
sition, both for start-up companies as well as for established companies adding
to existing product lines. Introducing new products into a small market fur-
ther emphasizes these cost issues.
A start-up company will find it difficult to raise money for its ideas that ad-
dress a small market. A rule of thumb for pursuing venture capital is whether
it is possible in the short-term (e.g., less than 5 years) to attain $100 million
in annual revenue. Many successful AT companies that have been operating
11 Small Markets in Assistive Technology 107

for decades have sales only in the low tens of millions of dollars. It is not
uncommon for AT companies to have sales that are even smaller. Of the
approximately 170 wheelchair manufacturers operating in the United States
as of 2003, only five companies had sales in excess of $100 million, although
the industry total reported revenue was $1.3 billion [6]. Thus the majority
of established AT companies could not attract venture capital. Furthermore,
starting up without adequate resources is one of the most detrimental factors
in the long term success of new companies [3].
Similarly, an established company operating in small markets is faced with
limited revenues and little free operating cash. Cash flow is the key resource
for pursuing new product innovation – an endeavor often seemingly at odds
with maintaining a profitable small business. As well, all companies operating
in small markets must prioritize their employees, who are a prized resource.
Often a lack of cash results in a lack of people with the expertise and time
to mount a thorough and viable product development stream.
Some areas of product development and innovation that need ample cash
and resources include:
• People and software for product design.
• Prototype development and design iteration.
• Intellectual property analysis and protection.
• Market testing and feedback.
• Manufacturing considerations.
Small market operations shape all of these issues. Are the people with rele-
vant experience available for design? Does the company possess prototyping
capabilities in-house or does the company need to source more expensive
solutions? Do the projected revenues support patenting costs? If so, which
geographical markets are realistic for a small company to successfully deliver
the product to the end users? Does the company need to hire outside firms for
market testing, and if so, how difficult will it be to gather enough customers
for proper evaluation? Academic researchers face a similar problem when ad-
dressing specific medical problems (essentially a small market). For example,
researchers in spinal cord injury have difficulty running clinical trials without
expensive multi-centre collaborations across North America.
Manufacturing issues also comprise many of the obstacles in small market
operations due to the inherently low volumes involved. Manufacturing a new
product requires new tooling, processes, and training for the supplier. These
costs are somewhat (though not entirely) fixed regardless of volume size, thus
putting a greater burden on companies with only low volume sales projec-
tions. In addition, excess inventory in stocked parts and finished product for
higher volume manufacturing incurs a non-negligible expense. The alterna-
tive to this expense is for the company to absorb a higher per-unit item cost
by running an operation with minimal inventory. However, this strategy may
incur further costs by increasing customer delivery times and also has the
disadvantages associated with back-ordered products.
108 Jaimie F. Borisoff

Sales and distribution is a great challenge for companies in small markets.

Mainstream products in large markets typically use large-scale distribution
channels (e.g., nation-wide drugstore chains for simple crutches and canes).
A company selling a product in a large market can usually target sales chan-
nels, each with many outlets, all handled by a single representative. On the
other hand, a company selling a product in a small market must establish
relationships with distinct retail outlets in each geographical region – this is
a considerably more expensive and time-intensive process than is required in
larger markets.

11.1.2 AT-Specific Obstacles

Issues related more specifically to the AT industry include (1) additional

people in the supply chain, (2) education and training, (3) regulatory issues,
and (4) sales support and ongoing servicing and maintenance.
The supply chain of many businesses (e.g., bicycles) includes the manufac-
turer, distributor, retailer, and customer. The AT industry (e.g., wheelchairs)
also includes the clinician or prescriber as well as the funder. The process of
purchasing an AT device often takes several months and includes many people
besides the customer: a clinician and/or therapist, a funding agency repre-
sentative, a dealer salesperson, and possibly a manufacturer’s representative.
A company introducing a new product into this group must educate and
train many people to promote product sales effectively. The more innovative
and different that product is, the more difficult the educational effort will be.
Furthermore, industry professionals often act conservatively when faced with
new products, preferring to recommend established companies and products
until the newer products have been proven over time. This pattern exacer-
bates two difficulties for small market companies: long periods of time with
low revenues and the burden of sales education. Low revenues make it dif-
ficult to support the sales and education efforts. The burden of education
is even greater when an innovative product must break into a market com-
prised of united force (e.g., many competitors all selling the same type of
competing product) – a difficult situation for any company. Even if the com-
pany successfully completes the hard work of proving an innovative product
and establishing its market niche, it is entirely possible that larger competi-
tors may then enter the maturing niche market with significantly reduced
risk. The payoff of the innovating company’s efforts could be claimed by its
mainstream competitors.
Most AT devices are developed and funded based on medical necessity.
Since medical devices typically fall under the jurisdiction of the FDA or its
equivalent, most AT devices are required to pass a regulatory hurdle, another
expensive and often time-intensive requirement. In the case of wheelchairs,
11 Small Markets in Assistive Technology 109

FDA approval typically requires certification to RESNA standards [5]. Some

jurisdictions make this more cumbersome by using their own rules and pro-
cesses to certify a new device. A small market AT company needs to prior-
itize these jurisdictions to focus on the ones in which they have established
strength (e.g., through sales channels and relationships with clinicians). Nav-
igating the regulatory process requires money, people, and product samples,
all of which can be scarce commodities in small market companies.
Devices considered AT are usually more complex than mainstream prod-
ucts. Consider, for example, a powered wheelchair with custom seating as
opposed to a mountain bike. AT products require ongoing support and ser-
vicing that often only specialists can perform. Funding agencies often insist
on long term support contracts with retailers, an additional burden for small
manufacturers with unique products.
Finally, demographics may play a transformative role in the AT industry
in the coming years. Similar to many small businesses, the founders of many
AT companies are nearing retirement. If in-house heirs are not forthcoming,
will the pool of outside investors commit to make significant acquisitions
and continue supplying much needed products to these niche markets? The
nature of these poorly understood businesses, often with marginal growth
prospects, may force many products out of the market. Hopefully, these ob-
stacles will create opportunities elsewhere for other small innovative compa-
nies to prosper.

11.2 Small Market Opportunities

The above obstacles notwithstanding, small markets in the AT industry also

offer opportunities to small, nimble, and innovative enterprises.
Necessity often drives the development of new innovations, and there are
certainly examples of this in AT. Even the founder of the early monopo-
listic Everest and Jennings wheelchair company used a wheelchair. Highly
motivated people who clearly understand the problem will hopefully develop
better products. User-driven design is often paramount in small market inno-
vations, and seen not only in companies (e.g., Marilyn Hamilton of Quickie
Wheelchairs), but also in academia and in non-profit organizations. For in-
stance, The Tetra Society and CanAssist are staffed by engineers and techni-
cians able to create solutions to many problems. However, the effort is only
undertaken once an end-user has identified a problem and initiated a solution.
Sophisticated customers thus contribute to the innovation process. Resulting
solutions are then made available to others when possible and contribute to
the overall technology pool of available AT solutions. There are rarely issues
surrounding intellectual property or proprietary technology that prevent dis-
semination of new AT solutions developed in this manner. Big businesses are
simply unable to easily contribute to the overall community innovation effort
in this way.
110 Jaimie F. Borisoff

Similarly, other people involved in the supply chain are often motivated to
better understand the nuances of niche markets. It is possible to find amazing
sales people and therapists with years of experience and understanding within
a particular small market. Such people are a valuable source of evaluation and
feedback for small market innovators and usually come at little or no charge.
A therapist, for example, benefits from the availability of better solutions for
the therapist’s clients.
From an economic standpoint, small markets often offer less competition.
Thus, a slow, inexpensive route to commercialization does not carry the same
predatory risks from big companies since the eventual payoff is not enticing
to them. It is also possible to innovate and commercialize a new product
without patent protection in a marketplace with less competition. Innovators
can fly “under the radar” much more easily in small markets.
A successful new product in larger markets may eventually become the
victim of its own success. As a new market matures and becomes mainstream,
the innovative company may be overwhelmed by larger competitors. However,
the nature of most small AT markets ensures that this will not happen –
usually, mainstream growth is simply not possible due to the small population
size of the target consumers.
Large companies can be at a disadvantage due to their size, especially when
developing and introducing new products to big markets. A large company
has an extensive supply chain and ongoing commitments for its own existing
products. Huge inventories of parts and investment in manufacturing can lead
to products that are long overdue for a facelift. Thus, a large company in a
large market may not be able to be responsive to newly identified problems
or product features coveted by customers.
A small market company has two advantages in this case. First, the com-
pany can introduce products without potentially cannibalizing its own exist-
ing product lines. Second, low volume manufacturing enables quick redesign
of specific parts, or even termination of a product in order to introduce a
completely new one.
Larger companies may hesitate to innovate because of the possibility of
confusing customers and partners. This is especially the case in AT, with
numerous people involved with purchasing a product. New, complementary
products, or products with new features too similar to existing products,
create too many messages about the best solution for a particular problem.
Creating more products for the same market may lead to lower volumes for
each product – rendering a large company without its normal advantages
over those used to operating in small volume markets.
Other revenue and cost advantages that are sometimes present in small
AT markets are found in product pricing and marketing efforts. Innovative
products in small AT markets may command higher margins, hence the payoff
for low volumes is a higher per-unit profit. Regarding cost, it may be easier
to introduce a small-market AT product because of the ease of publicizing in
the restricted avenues for a particular niche. Therapists and customers have
11 Small Markets in Assistive Technology 111

familiar sources of information for new products in their particular niche. The
Internet makes publicizing new products even easier, with online communities
dedicated to particular disabilities.
Fundraising groups dedicated to specific disabilities are often quite focused
and effective at raising money for research, or at providing specific AT solu-
tions. For example, the Christopher and Dana Reeve Foundation, the Rick
Hansen Institute, and the National Federation of the Blind have lobbied gov-
ernments and raised funds for research and technology transfer. Companies
looking to innovate in these areas may benefit from such organizations, with
or without traditional partnerships with academia. Targeted grants are some-
times available for specific research into small market AT solutions, including
joint industry-university funding. There is also regulatory assistance available
in certain circumstances, for example, through the FDA’s Humanitarian De-
vice Exemption. Thus, non-traditional resources are often available to help
innovators make an impact in small AT markets. Hopefully, these mechanisms
create enough incentive to further technology innovation.

11.3 New Opportunities in Small Market Innovation

The term assistive technology may be redundant, perhaps better described

as simply technology for individuals with a disability (see Ladner [8, 7] for
more on this issue of redundancy and individual empowerment). Rick Hanson,
Terry Fox, and other individuals have helped raise international awareness of
the capabilities of persons with disabilities. We are moving to a “social model”
of disability and away from a “medical” or “rehabilitation” model. That is,
people with disabilities (and an aging population) are part of the diversity of
life, not necessarily in need of treatment and cure. But people with disabilities
do need full access to all facets of community, with complete dignity and
integrity when at all possible. User-driven AT design for small markets is
closely related to issues of individual empowerment within this social model.
It is possible that technology innovation may greatly support the efforts of
individuals to create their own novel solutions for their own specific wants
and needs, thus further encouraging small market innovation efforts.
As described in Sect. 11.2, user-driven design is a powerful innovation force.
Computers and the Internet have now opened up countless new opportuni-
ties for individual users of almost anything. This is most obvious in terms
of software and information. As Chris Anderson of Wired Magazine [1, 2]
explains, new opportunities abound for small scale manufacturing and prod-
uct development, a perfect fit for AT innovations. This is an application of
the “long tail” of stuff [2], with do-it-yourself manufacturing, crowdsourcing,
and micro-factories. A small market innovator with very little money can use
open-source design tools to design a novel device. Factories around the world,
and particularly in China, now accept small batch and prototype orders from
112 Jaimie F. Borisoff

anyone via the Internet. In a matter of days, the innovator’s AT solution

arrives via post for evaluation and design iteration. Post your design to your
community and let them help create the ideal solution. If the solution works
for one individual, chances are that it will work for others.
What does the future hold for technology innovations for persons with a
disability? Who knows? But a safe bet would be that an individual with a
disability is behind the innovation effort.

11.4 Afterword

The author of this chapter has been involved with spinal cord injury and
assistive technology research for over 10 years and is a wheelchair user. He
recently started his own small business to bring novel wheelchair technology
to the marketplace. This real-world experience, in combination with discus-
sions with several colleagues who have backgrounds in the AT industry (see
Acknowledgments), shaped much of the commentary in this chapter.

Acknowledgements The following individuals have each contributed AT innovations to

the marketplace: Murray Slagerman of Ki Mobility LLC, Dr. Arthur Prochazka of the
University of Alberta, Dr. Mark Richter of Max Mobility LLC, and Harry Lew of the Neil
Squire Society. I would like to thank them for their very helpful comments on this chapter.

References

[1] Anderson C (2008) The long tail. Hyperion, New York

[2] Anderson C (2010) In the next industrial revolution, atoms are the new
bits. Wired Magazine. http://www.wired.com/magazine/2010/01/ff_
newrevolution/
[3] Baldwin J, Gray T, Johnson J, Proctor J, Rafiquzzaman M, Sabourin
D (1997) Failing concerns: Business bankruptcy in Canada. Tech. Rep.
61-525-XPE, Statistics Canada, Micro-Economic Analysis Division,
Ottawa, ON
[4] Cooper R (1998) Wheelchair selection and configuration. Demos Medical
Publishing, New York
[5] Cooper R (2006) Wheelchair standards: It’s all about quality assurance
and evidence-based practice. Journal of Spinal Cord Medicine 29(2):93–94
[6] Cooper RA, Cooper R, Boninger M (2008) Trends and issues in wheelchair
technologies. Assistive Technology 20(2):61–72
[7] Ladner R (2010) Personal communication
11 Small Markets in Assistive Technology 113

[8] Ladner R (2010) Accessible technology and models of disability. In: Oishi
M, Mitchell IM, Van der Loos H (eds) Design and Use of Assistive Tech-
nology, pp 23–29. Springer, Berlin
[9] Shepard DS, Karen SL (1984) The market for wheelchairs: Innovations
and federal policy. Health Technology Case Study 30, Congress of the
United States, Office of Technology Assessment, Washington, DC
Index

A cognitive disability
abandonment, 41, 57 measures of, 33
academia cognitive skill
faculty involvement, 57, 65 measures of, 33
origin of start-up companies, 51, 65 community service, 57
student involvement, 57, 65, 97 competition
accessibility, 97 with large companies, 105
accessible technology, 25 context, 41
aging population, 41, 57 customization, 57, 105
American Federation of the Blind, 3, 25
ASL-STEM forum, 25 D
assistive technology design for user empowerment, 25, 41
abandonment of, 17 discrimination, 3
aesthetics, 17, 57
as a sign of disability, 17 E
as a tool, 17 education
need for the qualifier “assistive”, of technologists, 57, 65, 97
see accessible technology 25 to promote inclusive design, 57
neutrality of, 17 enhancement, 3
perceptions of, 3, 17, 25 entrepreneurs, 65, 105
augmentative communication ethics
controlling toy, 33 assistive technology, 3, 75
engineering, 3
medical, 3
B
survey, 75
ball launcher, 57
evaluation, 75
clinical, 51
C laboratory, 51
CanAssist, 41, 57, 105 measurement, 51
CanConnect, 57 unconstrained environment, 51
children with disabilities, 33, 41, 57
client, see user F
see user 41 funding
as a team membersee user difficulty in obtaining, 51, 57, 65, 105
participation 57 for non-profit organizations, 57, 65, 105
cognitive ability for small companies, 105
measures of, 33 traditional models in academia, 57

115
116 Index

H P
HAAT model, 41, 57 Peter Wall Institute for Advanced Studies,
human centered design, 25 75
human-computer interaction (HCI), 25, 33, physical manipulation, 33
41, 65 Pistorius, Oscar, 3, 75
prosthetics, 3
I
R
industry incentive, 57, 65, 97
regulation, 105
information and communication technolo-
enforcement, 97
gies, 3, 97
Remap, 65
see CanConnect 57
robots
intellectual property, 65, 105
to enable play, 33

J S
justice, 3 screen readers, 3
sensing, 75
L service-based model, 57
legislation SGD,
FCC Act, 97 see speech generating device 33
Hearing Aid Compatibility Act, 97 small companies
Optional Protocol of the UN Convention, flexibility, 105
97 manufacturing, 105
Rehabilitation Act, 97 small markets, 57, 65, 105
liability, 65 social participation, 3, 17, 41, 97
liminality, 17 speech generating device,
see augmentative communication 33
M standards
mainstream products, AT versus, 105 enforcement, 97
manufacturing for information and communication
cost feasibility, 57, 65, 105 technologies (ICTs), 97
prototypes, 57, 65, 105 for Web Content Accessibility
small batch, 105 Guidelines, 25
marginalization, 97 RESNA, 3, 105
Microsoft, 3 stigma, 17
MobileAccessibility, 25 student involvement, 97
mobility, 3, 75 SUPPLE++, 25
models of disability
T
legal, 3, 25
Technical Aid to the Disabled of New
medical, 3, 25
South Wales, 65
rehabilitation, 3, 25
technology
social, 25
fear of, 3
special education, 25 miniaturization of, 97
perceptions of, 17
N quickly emerging, 97
networking, 75 with complex features, 41, 57, 97
niche market, 105 Tetra Society of North America, 65, 105
non-profit organizations, 57, 65, 97 toy
normality, 3 controlled, 33
infrared, 33
O LEGO, 33
obsolescence, 105 robot, 33
optical character recognition (OCR), 25 speech generating device, 33
orthotic exoskeleton gripper, 65 switch controlled, 33
Index 117

U recruiting, 65
umbrella holder, 57, 65 role, 57
UN Convention on the Rights of People
with Disabilities, 3, 97 W
usability, 25 Web Content Accessibility Guidelines
user (WCAG), 25, 97
as a team member, 75 WebAnywhere, 25
inclusion, 41 wheelchairs
involvement, 75 as portable seclusion huts, 17
need, 57
physical isolation, 17
needs, 51, 75
powered, 51
participation, 41, 57
safety, 75, 97
perspective, 41
social isolation, 17
training, 51
user with visual impairment, 51
V
venture capital, 105 Y
volunteer YokyWorks, 65