vox--2020-12-08--You can buy a robot to keep your lonely grandparents company. Should you?

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Should you ?
Mabel LeRuzic , age 90 , lives alone — but not really .
“ He ’ s my baby , ” she tells me over Zoom , holding up a puppy to the camera .
“ Huh , Lucky ?
Yes !
Say hello !
” Lucky barks again , and the sound is convincing , as if it ’ s coming from a real dog .
He ’ s got a tail that wags , eyes that open @ @ @ @ @ @ @ turns to face you when you talk .
Under his synthetic golden fur , he has sensors that respond to your touch and a heartbeat you can feel .
LeRuzic , who lives in a rural area outside Albany , is fully aware that her pet is a robot .
But ever since she got him in March , he ’ s made her feel less lonely , she says .
She enjoys watching TV with him , brushing his fur with a little hairbrush , and tucking him in each night in @ @ @ @ @ @ @ of a box and towel .
She hugs him and coos into his floppy ear , “ I love you !
Yes , I do !
” She ’ s not the only one embracing robots these days .
Even before Covid-19 came around , robots like these were being introduced in nursing homes and other settings where lonely people are in need of companionship — especially in aging societies like Japan , Denmark , and Italy .
Now , the pandemic has provided the ultimate use case for them .
This spring @ @ @ @ @ @ @ LeRuzic , received robotic pets through the Association on Aging in New York , an advocacy organization .
Another 375 people received them through the Florida Department of Elder Affairs .
Retirement communities and senior services departments in Alabama , Pennsylvania , and several other states have begun buying robots for older adults .
Robots designed to play social roles come in many forms .
Some seem like little more than advanced mechanical toys , but they have the added capacity to sense their environment and respond to it .
Many of these @ @ @ @ @ @ @ are especially popular — that issue comforting little barks and meows .
Other robots have more humanoid features and talk to you like a person would .
ElliQ will greet you with a friendly “ Hi , it ’ s a pleasure to meet you ” and tell you jokes ; SanTO will read to you from the Bible and bless you ; Pepper will play music and have a full-on dance party with you .
Companies have also designed robots to help with the physical tasks of caregiving .
You can get @ @ @ @ @ @ @ feed you , Sanyo ’ s electric bathtub robot to wash you , and Riken ’ s RIBA robot to lift you out of bed and into a chair .
These robots have been around for years , and they work surprisingly well .
There ’ s a decent body of research suggesting that interacting with social robots can improve people ’ s well-being , although the effects vary depending on the individual person , their cultural context , and the type of robot .
The most well-studied robot , Paro , comes @ @ @ @ @ @ @ seal .
It ’ s adorable , but the US has recognized it as more than just that , classifying it as a medical device .
It coos and moves , and its built-in sensors enable it to recognize certain words and feel how it ’ s being touched — whether it ’ s being stroked or hit , say .
It learns to behave in the way the user prefers , remembering the actions that earned it a stroke and trying to repeat those .
In older adults , notably those with @ @ @ @ @ @ @ depression , agitation , blood pressure , and even the need for some medications .
Social robots come with other benefits .
Unlike human caregivers , robotic ones never get impatient or frustrated .
They ’ ll never forget a pill or a doctor ’ s appointment .
And they won ’ t abuse or defraud anyone , which is a real problem among people who care for elders , including family members .
During the pandemic , when we ’ re all forced to socially distance from other human beings , robots @ @ @ @ @ @ @ can roll right up to seniors and keep them company without any risk of giving them the coronavirus .
It ’ s no wonder they ’ re being touted as a fix for the isolation of older people and others who are at high risk of severe Covid-19 .
But the rise of social robots has also brought with it some thorny questions .
Some bioethicists are all in favor of them — like Nancy Jecker at the University of Washington , who published a paper in July arguing for increased robot use @ @ @ @ @ @ @ grounds that they can alleviate loneliness , itself an epidemic that ’ s seriously harmful to human health .
Others are not so sure .
Although there ’ s a strong case to be made for using robots in a pandemic , the rise of robot caregiving during the coronavirus crisis raises the possibility of robots becoming the new normal even in non-pandemic times .
Many robots are already commercially available , and some are cheap enough that middle-class consumers can easily snag them online ( LeRuzic ’ s dog costs $ 130 @ @ @ @ @ @ @ robots are not yet as widely used in the US as they are in Japan , we ’ ve all been inching toward a future where they ’ re ubiquitous , and the pandemic has accelerated that timeline .
That has some people worried .
“ We know that we already underinvest in human care , ” Shannon Vallor , a philosopher of technology at the University of Edinburgh , told me .
“ We have very good reasons , in the pandemic context , to prefer a robot option .
The problem @ @ @ @ @ @ @ threat has abated ?
We might get in this mindset where we ’ ve normalized the substitution of human care with machine care .
And I do worry about that.
” That substitution brings up a whole host of moral risks , which have to do with violating seniors ’ dignity , privacy , freedom , and much more .
But , as Vallor pointed out , “ If someone wants to be given the answer to ‘ Are social robots good for us ?
’ — that question is at the wrong @ @ @ @ @ @ @ be ‘ When are robots good for us ?
And how can they be bad for us ?
’ ” The ethics of care in a future with robots Replacing or supplementing human caregivers with robots could be detrimental to the person being cared for .
There are a few different ways that could happen .
For one thing , human contact is already in danger of becoming a luxury good as we create robots to more cheaply do the work of people .
Getting robots to take on more and more caregiving @ @ @ @ @ @ @ of human contact even further .
“ It might be convenient to have an automated spoon feeding a frail elderly person , but this would remove an opportunity for detailed and caring human interaction , ” the robot ethics experts Amanda Sharkey and Noel Sharkey noted in their paper “ Granny and the Robots.
” As companies urge us to let their robots care for our parents and grandparents , we might feel like we don ’ t need to visit them as much , figuring they ’ ve already got the company @ @ @ @ @ @ @ mistake .
For many older adults , interacting with a robot would feel less emotionally satisfying than interacting with a person because of the sense that whatever the robot says or does is not “ authentic , ” not based on real thoughts and feelings .
But for those who have no one or very few people to interact with , contact with a robot is probably better than no contact at all .
And if we use them wisely , robots can improve quality of life .
Take LeRuzic and her dog @ @ @ @ @ @ @ visit less often now that they know she ’ s got a robot , she said no .
In fact , Lucky has given her and her granddaughter Brandie an extra way to connect , because Brandie also got a new puppy ( a real one ) in March .
“ We ’ ve found a lot in common , ” she told me .
“ Except one of us doesn ’ t have to deal with vet bills !
” Some particularly well-designed robots , like Paro , have also been shown @ @ @ @ @ @ @ residents and between seniors and their kids .
It gives them something positive to focus on and talk about together .
Another common worry is that robots may violate human dignity because it can be demeaning and objectifying to have a machine wash or move you , as if you ’ re a lump of dead matter .
But Filippo Santoni de Sio , a tech ethics professor at Delft University of Technology in the Netherlands , emphasized that individual tastes differ .
“ It depends , ” he told me .
“ @ @ @ @ @ @ @ more dignifying to be assisted by a machine that does not understand what ’ s going on .
Some may not like anyone to see them naked or assist them with washing.
” The question should be ‘ When are robots good for us ?
And how can they be bad for us ?
’ Then there are concerns about violating the privacy and personal liberty of seniors .
Some robots marketed for elder care come with built-in cameras that essentially allow people to spy on their parents or grandparents , or nurses @ @ @ @ @ @ @ as 2002 , robots designed to look like teddy bears were being used in Japanese retirement homes , where they ’ d watch over residents and alert staff whenever someone left their bed .
You might argue this is for the seniors ’ own good because it will prevent them from getting hurt .
But such constant monitoring seems ethically problematic , especially when you consider that the senior may forget the robot in their room is watching — and reporting on — their every move .
There may be ways to solve @ @ @ @ @ @ @ design with an eye to safeguarding privacy and freedom .
For example , they can program a robot so it needs to get the senior ’ s permission before entering a room or before lifting them out of bed .
The difference between liberation from care and liberation to care There ’ s also another factor to wonder — and worry — about : Can getting robots to do the work of caregiving also be detrimental to the would-be caregivers ?
Vallor lays out the case for this claim in an important 2011 @ @ @ @ @ @ @ She argues that the experience of caregiving helps build our moral character , allowing us to cultivate virtues like empathy , patience , and understanding .
So outsourcing that work wouldn ’ t just mean abdicating our duty to nurture others ; it would also mean cheating ourselves out of a valuable opportunity to grow .
“ If the availability of robot care seduces us into abandoning caregiving practices before we have had sufficient opportunities to cultivate the virtues of empathy and reciprocity , among others , ” Vallor writes , “ the @ @ @ @ @ @ @ society , could be quite devastating.
” She ’ s careful to note , though , that caring for someone else doesn ’ t automatically make you into a better person .
If you don ’ t have enough resources and support at your disposal , you can end up burned out , bitter , and possibly less empathetic than you were before .
So Vallor continues : “ On the other hand , if carebots provide forms of limited support that draw us further into caregiving practices , able to feel more @ @ @ @ @ @ @ fear that we will be crushed by unbearable burdens , then the moral effect on the character of caregivers could be remarkably positive.
” Again , robots aren ’ t inherently good or bad ; it depends on how you use them .
If you generally feel good about caring for a senior except for a couple of tasks that are too physically or emotionally difficult — say , lifting him up and taking him to the bathroom — then having a robot to help you with those specific tasks might actually make @ @ @ @ @ @ @ , and care better , the rest of the time .
As Vallor says , there ’ s a big difference between liberation from care and liberation to care .
We don ’ t want the former because caregiving can actually help us grow as moral beings .
But we do want the latter , and if a robot gives us that by making caregiving more sustainable , that ’ s a win .
What if people come to prefer robots over other people ?
There ’ s another concern we haven ’ @ @ @ @ @ @ @ provide company that the senior finds not inferior , but actually superior , to human company .
After all , a robot has no wants or needs of its own .
It doesn ’ t judge .
It ’ s infinitely forgiving .
You can glimpse this sentiment in the words of Deanna Dezern , an 80-year-old woman in Florida living with an ElliQ robot .
“ I ’ m in quarantine with my best friend , ” she said .
“ She won ’ t have her feelings hurt and she doesn @ @ @ @ @ @ @ puts up with my moods , and that ’ s the best friend anybody can have.
” Dezern might be happy with this arrangement ( at least so long as the pandemic lasts ) , and the preferences of seniors themselves are obviously crucial .
But some philosophers have raised concerns about whether this setup risks degrading our humanity over the long term .
The prospect of people coming to prefer robots over fellow people is problematic if you think human-to-human connection is an essential part of what it means to live a @ @ @ @ @ @ @ ’ needs and moods are part of what makes life meaningful .
“ If we had technologies that drew us into a bubble of self-absorption in which we drew further and further away from one another , I don ’ t think that ’ s something we can regard as good , even if that ’ s what people choose , ” Vallor says .
“ Because you then have a world in which people no longer have any desire to care for one another .
And I think the ability to live @ @ @ @ @ @ @ a universal good .
Caring is part of how you grow as a human.
” Yes , individual autonomy is important .
But not everything an individual chooses is necessarily what ’ s good for them .
“ In society , we always have to recognize the danger of being overly paternalistic and saying , ‘ You don ’ t know what ’ s good for you so we ’ ll choose for you , ’ but we also have to avoid the other extreme , the naive libertarian view that suggests that @ @ @ @ @ @ @ is leaving everything up to individual whims , ” Vallor says .
“ We need to find that intelligent balance in the middle where we give people a range of ways to live well.
” Santoni de Sio , for his part , says that if a senior has the ability to choose freely , and chooses to spend time with robots instead of people , that ’ s a legitimate choice .
But the choice has to be authentically free — not just the result of market forces ( like tech companies @ @ @ @ @ @ @ ) or other economic and social pressures .
“ We should not buy a simplistic and superficial understanding of what it means to have free choice or to be in control of our lives , ” he says .
“ There ’ s this narrative that says technology is enhancing our freedom because it ’ s giving us choices .
But is this real freedom ?
Or a shallow version of it that hides the closing of opportunities ?
The big philosophical task we have in front of us is redefining freedom and @ @ @ @ @ @ @ ” So , bottom line : Should you buy your grandma a robot ?
If you take anything away from this discussion , take away the fact that there ’ s no single answer to this question .
The more productive question is : Under what specific conditions would a robot enhance care , and under what conditions would it degrade care ?
During a pandemic , there ’ s a strong case to be made for using social robots .
The benefits they can provide in terms of alleviating loneliness seem to @ @ @ @ @ @ @ fully embrace robots now , deeming them a fine substitute during a pandemic , how will we make sure they ’ re not used to disguise ethical gaps in our behavior post-pandemic ?
Several tech ethicists say we need to set robust standards for care in the environments where we ’ re morally obligated to provide it .
Just as nursing homes have standards around physical safety and cleanliness , maybe they should have legal restrictions on how long seniors can be left without human contact , with only robots to care for @ @ @ @ @ @ @ an inspector reviews facilities on an annual basis and has the power to pull their certification if they ’ re not providing the requisite level of human contact .
“ Then , even after the pandemic , we could say , ‘ We see that this facility has just carried on with roboticized , automated care when there ’ s no longer a public health necessity for that , and this falls short of the standards , ’ ” she told me .
But the idea of developing standards around robot care leads @ @ @ @ @ @ @ determine the right standards ?
Santoni de Sio lays out a framework called the “ nature-of-activities approach ” to help answer this .
He distinguishes between a goal-oriented activity , where the activity is a means to achieving some external aim , and a practice-oriented activity , where the performance of the activity is itself the aim .
In reality , an activity is always a mix of the two , but usually one element predominates .
Commuting to work is mostly goal-oriented ; watching a play is mostly practice-oriented .
In the @ @ @ @ @ @ @ that reminding an elderly person to take their medication or collecting a urine sample for testing is mostly goal-oriented , so for that type of activity , it ’ s okay to substitute a robot for a nurse .
By contrast , watching a movie with the senior or listening to their stories is mostly practice-oriented .
You doing the activity with them — your very presence — is the point .
So it matters that you , the human being , be there .
There ’ s some intuitive appeal to this @ @ @ @ @ @ @ the robot , while the broader process of showing up emotionally to listen , laugh , and cry remains our human responsibility .
And it echoes a claim we often hear about artificial intelligence and the future of work : that we ’ ll just automate the dull and repetitive tasks but leave the work that calls on our highest cognitive and emotional faculties .
Vallor says that sounds good on the surface — until you look at what it actually does to people .
“ You ’ re making them turn their @ @ @ @ @ @ @ for many hours instead of having those moments of decompression where they do something mindless to recharge , ” she says .
“ You can not divide up the world such that they are performing intense emotional and relational labor for periods that the human body is just not capable of sustaining , while you have the robots do all the things that sometimes humans do to get a break.
” This point suggests we can ’ t rely on any one conceptual distinction to take the nuance out of the problem .
@ @ @ @ @ @ @ human connection can be automated and which can not , we should ask ourselves several questions .
Is it goal-oriented or practice-oriented ?
Is it liberating us from care or liberating us to care ?
And who benefits — truly , authentically benefits — from bringing robots into the social and caregiving realm ?

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Mabel LeRuzic, age 90, lives alone — but not really.
“He’s my baby,” she tells me over Zoom, holding up a puppy to the camera. “Huh, Lucky? Yes! Say hello!”
Lucky barks at me.
I laugh and say, “Who’s a good robot?”
Lucky barks again, and the sound is convincing, as if it’s coming from a real dog. He’s got a tail that wags, eyes that open and close, and a head that turns to face you when you talk. Under his synthetic golden fur, he has sensors that respond to your touch and a heartbeat you can feel.
LeRuzic, who lives in a rural area outside Albany, is fully aware that her pet is a robot. But ever since she got him in March, he’s made her feel less lonely, she says. She enjoys watching TV with him, brushing his fur with a little hairbrush, and tucking him in each night in a bed she’s made out of a box and towel.
She hugs him and coos into his floppy ear, “I love you! Yes, I do!”
She’s not the only one embracing robots these days.
Even before Covid-19 came around, robots like these were being introduced in nursing homes and other settings where lonely people are in need of companionship — especially in aging societies like Japan, Denmark, and Italy. Now, the pandemic has provided the ultimate use case for them.
This spring, more than 1,100 seniors, including LeRuzic, received robotic pets through the Association on Aging in New York, an advocacy organization. Another 375 people received them through the Florida Department of Elder Affairs. Retirement communities and senior services departments in Alabama, Pennsylvania, and several other states have begun buying robots for older adults.
Robots designed to play social roles come in many forms. Some seem like little more than advanced mechanical toys, but they have the added capacity to sense their environment and respond to it. Many of these mimic cute animals — dogs and cats are especially popular — that issue comforting little barks and meows. Other robots have more humanoid features and talk to you like a person would. ElliQ will greet you with a friendly “Hi, it’s a pleasure to meet you” and tell you jokes; SanTO will read to you from the Bible and bless you; Pepper will play music and have a full-on dance party with you.
Companies have also designed robots to help with the physical tasks of caregiving. You can get Secom’s My Spoon robot to feed you, Sanyo’s electric bathtub robot to wash you, and Riken’s RIBA robot to lift you out of bed and into a chair. These robots have been around for years, and they work surprisingly well.
There’s a decent body of research suggesting that interacting with social robots can improve people’s well-being, although the effects vary depending on the individual person, their cultural context, and the type of robot.
The most well-studied robot, Paro, comes in the form of a baby harp seal. It’s adorable, but the US has recognized it as more than just that, classifying it as a medical device. It coos and moves, and its built-in sensors enable it to recognize certain words and feel how it’s being touched — whether it’s being stroked or hit, say. It learns to behave in the way the user prefers, remembering the actions that earned it a stroke and trying to repeat those. In older adults, notably those with dementia, Paro can reduce loneliness, depression, agitation, blood pressure, and even the need for some medications.
Social robots come with other benefits. Unlike human caregivers, robotic ones never get impatient or frustrated. They’ll never forget a pill or a doctor’s appointment. And they won’t abuse or defraud anyone, which is a real problem among people who care for elders, including family members.
During the pandemic, when we’re all forced to socially distance from other human beings, robots come with another major advantage: They can roll right up to seniors and keep them company without any risk of giving them the coronavirus. It’s no wonder they’re being touted as a fix for the isolation of older people and others who are at high risk of severe Covid-19.
But the rise of social robots has also brought with it some thorny questions. Some bioethicists are all in favor of them — like Nancy Jecker at the University of Washington, who published a paper in July arguing for increased robot use during and after the pandemic on the grounds that they can alleviate loneliness, itself an epidemic that’s seriously harmful to human health.
Others are not so sure. Although there’s a strong case to be made for using robots in a pandemic, the rise of robot caregiving during the coronavirus crisis raises the possibility of robots becoming the new normal even in non-pandemic times. Many robots are already commercially available, and some are cheap enough that middle-class consumers can easily snag them online (LeRuzic’s dog costs $130, for example). Although social robots are not yet as widely used in the US as they are in Japan, we’ve all been inching toward a future where they’re ubiquitous, and the pandemic has accelerated that timeline.
That has some people worried. “We know that we already underinvest in human care,” Shannon Vallor, a philosopher of technology at the University of Edinburgh, told me. “We have very good reasons, in the pandemic context, to prefer a robot option. The problem is, what happens when the pandemic threat has abated? We might get in this mindset where we’ve normalized the substitution of human care with machine care. And I do worry about that.”
That substitution brings up a whole host of moral risks, which have to do with violating seniors’ dignity, privacy, freedom, and much more.
But, as Vallor pointed out, “If someone wants to be given the answer to ‘Are social robots good for us?’ — that question is at the wrong level of granularity. The question should be ‘When are robots good for us? And how can they be bad for us?’”
The ethics of care in a future with robots
Replacing or supplementing human caregivers with robots could be detrimental to the person being cared for. There are a few different ways that could happen.
For one thing, human contact is already in danger of becoming a luxury good as we create robots to more cheaply do the work of people. Getting robots to take on more and more caregiving duties could mean reducing seniors’ level of human contact even further.
“It might be convenient to have an automated spoon feeding a frail elderly person, but this would remove an opportunity for detailed and caring human interaction,” the robot ethics experts Amanda Sharkey and Noel Sharkey noted in their paper “Granny and the Robots.”
As companies urge us to let their robots care for our parents and grandparents, we might feel like we don’t need to visit them as much, figuring they’ve already got the company they need. That would be a mistake. For many older adults, interacting with a robot would feel less emotionally satisfying than interacting with a person because of the sense that whatever the robot says or does is not “authentic,” not based on real thoughts and feelings.
But for those who have no one or very few people to interact with, contact with a robot is probably better than no contact at all. And if we use them wisely, robots can improve quality of life. Take LeRuzic and her dog. When I asked if her grandchildren visit less often now that they know she’s got a robot, she said no. In fact, Lucky has given her and her granddaughter Brandie an extra way to connect, because Brandie also got a new puppy (a real one) in March. “We’ve found a lot in common,” she told me. “Except one of us doesn’t have to deal with vet bills!”
Some particularly well-designed robots, like Paro, have also been shown to increase human-to-human interaction among nursing home residents and between seniors and their kids. It gives them something positive to focus on and talk about together.
Another common worry is that robots may violate human dignity because it can be demeaning and objectifying to have a machine wash or move you, as if you’re a lump of dead matter. But Filippo Santoni de Sio, a tech ethics professor at Delft University of Technology in the Netherlands, emphasized that individual tastes differ.
“It depends,” he told me. “For some people, it’s more dignifying to be assisted by a machine that does not understand what’s going on. Some may not like anyone to see them naked or assist them with washing.”
The question should be ‘When are robots good for us? And how can they be bad for us?’
Then there are concerns about violating the privacy and personal liberty of seniors. Some robots marketed for elder care come with built-in cameras that essentially allow people to spy on their parents or grandparents, or nurses to surveil their charges. As early as 2002, robots designed to look like teddy bears were being used in Japanese retirement homes, where they’d watch over residents and alert staff whenever someone left their bed.
You might argue this is for the seniors’ own good because it will prevent them from getting hurt. But such constant monitoring seems ethically problematic, especially when you consider that the senior may forget the robot in their room is watching — and reporting on — their every move.
There may be ways to solve these problems, though, if roboticists design with an eye to safeguarding privacy and freedom. For example, they can program a robot so it needs to get the senior’s permission before entering a room or before lifting them out of bed.
The difference between liberation from care and liberation to care
There’s also another factor to wonder — and worry — about: Can getting robots to do the work of caregiving also be detrimental to the would-be caregivers?
Vallor lays out the case for this claim in an important 2011 paper, “Carebots and Caregivers.” She argues that the experience of caregiving helps build our moral character, allowing us to cultivate virtues like empathy, patience, and understanding. So outsourcing that work wouldn’t just mean abdicating our duty to nurture others; it would also mean cheating ourselves out of a valuable opportunity to grow.
“If the availability of robot care seduces us into abandoning caregiving practices before we have had sufficient opportunities to cultivate the virtues of empathy and reciprocity, among others,” Vallor writes, “the impact upon our moral character, and society, could be quite devastating.”
She’s careful to note, though, that caring for someone else doesn’t automatically make you into a better person. If you don’t have enough resources and support at your disposal, you can end up burned out, bitter, and possibly less empathetic than you were before.
So Vallor continues: “On the other hand, if carebots provide forms of limited support that draw us further into caregiving practices, able to feel more and give more, freed from the fear that we will be crushed by unbearable burdens, then the moral effect on the character of caregivers could be remarkably positive.”
Again, robots aren’t inherently good or bad; it depends on how you use them. If you generally feel good about caring for a senior except for a couple of tasks that are too physically or emotionally difficult — say, lifting him up and taking him to the bathroom — then having a robot to help you with those specific tasks might actually make it easier for you to care more, and care better, the rest of the time.
As Vallor says, there’s a big difference between liberation from care and liberation to care. We don’t want the former because caregiving can actually help us grow as moral beings. But we do want the latter, and if a robot gives us that by making caregiving more sustainable, that’s a win.
What if people come to prefer robots over other people?
There’s another concern we haven’t considered yet: A robot might provide company that the senior finds not inferior, but actually superior, to human company. After all, a robot has no wants or needs of its own. It doesn’t judge. It’s infinitely forgiving.
You can glimpse this sentiment in the words of Deanna Dezern, an 80-year-old woman in Florida living with an ElliQ robot. “I’m in quarantine with my best friend,” she said. “She won’t have her feelings hurt and she doesn’t get moody, and she puts up with my moods, and that’s the best friend anybody can have.”
Dezern might be happy with this arrangement (at least so long as the pandemic lasts), and the preferences of seniors themselves are obviously crucial. But some philosophers have raised concerns about whether this setup risks degrading our humanity over the long term. The prospect of people coming to prefer robots over fellow people is problematic if you think human-to-human connection is an essential part of what it means to live a flourishing life, not least because others’ needs and moods are part of what makes life meaningful.
“If we had technologies that drew us into a bubble of self-absorption in which we drew further and further away from one another, I don’t think that’s something we can regard as good, even if that’s what people choose,” Vallor says. “Because you then have a world in which people no longer have any desire to care for one another. And I think the ability to live a caring life is pretty close to a universal good. Caring is part of how you grow as a human.”
Yes, individual autonomy is important. But not everything an individual chooses is necessarily what’s good for them.
“In society, we always have to recognize the danger of being overly paternalistic and saying, ‘You don’t know what’s good for you so we’ll choose for you,’ but we also have to avoid the other extreme, the naive libertarian view that suggests that the way you run a flourishing society is leaving everything up to individual whims,” Vallor says. “We need to find that intelligent balance in the middle where we give people a range of ways to live well.”
Santoni de Sio, for his part, says that if a senior has the ability to choose freely, and chooses to spend time with robots instead of people, that’s a legitimate choice. But the choice has to be authentically free — not just the result of market forces (like tech companies pushing us to adopt addictively entertaining robots) or other economic and social pressures.
“We should not buy a simplistic and superficial understanding of what it means to have free choice or to be in control of our lives,” he says. “There’s this narrative that says technology is enhancing our freedom because it’s giving us choices. But is this real freedom? Or a shallow version of it that hides the closing of opportunities? The big philosophical task we have in front of us is redefining freedom and control in the age of Big Tech.”
So, bottom line: Should you buy your grandma a robot?
If you take anything away from this discussion, take away the fact that there’s no single answer to this question. The more productive question is: Under what specific conditions would a robot enhance care, and under what conditions would it degrade care?
During a pandemic, there’s a strong case to be made for using social robots. The benefits they can provide in terms of alleviating loneliness seem to outweigh the risks.
But if we fully embrace robots now, deeming them a fine substitute during a pandemic, how will we make sure they’re not used to disguise ethical gaps in our behavior post-pandemic?
Several tech ethicists say we need to set robust standards for care in the environments where we’re morally obligated to provide it. Just as nursing homes have standards around physical safety and cleanliness, maybe they should have legal restrictions on how long seniors can be left without human contact, with only robots to care for them.
Vallor imagines a future where an inspector reviews facilities on an annual basis and has the power to pull their certification if they’re not providing the requisite level of human contact. “Then, even after the pandemic, we could say, ‘We see that this facility has just carried on with roboticized, automated care when there’s no longer a public health necessity for that, and this falls short of the standards,’” she told me.
But the idea of developing standards around robot care leads to the question: How do we determine the right standards?
Santoni de Sio lays out a framework called the “nature-of-activities approach” to help answer this. He distinguishes between a goal-oriented activity, where the activity is a means to achieving some external aim, and a practice-oriented activity, where the performance of the activity is itself the aim. In reality, an activity is always a mix of the two, but usually one element predominates. Commuting to work is mostly goal-oriented; watching a play is mostly practice-oriented.
In the caregiving context, most people would say that reminding an elderly person to take their medication or collecting a urine sample for testing is mostly goal-oriented, so for that type of activity, it’s okay to substitute a robot for a nurse. By contrast, watching a movie with the senior or listening to their stories is mostly practice-oriented. You doing the activity with them — your very presence — is the point. So it matters that you, the human being, be there.
There’s some intuitive appeal to this division — certain discrete tasks go to the robot, while the broader process of showing up emotionally to listen, laugh, and cry remains our human responsibility. And it echoes a claim we often hear about artificial intelligence and the future of work: that we’ll just automate the dull and repetitive tasks but leave the work that calls on our highest cognitive and emotional faculties.
Vallor says that sounds good on the surface — until you look at what it actually does to people. “You’re making them turn their cognitive and emotional faculties up to 11 for many hours instead of having those moments of decompression where they do something mindless to recharge,” she says. “You cannot divide up the world such that they are performing intense emotional and relational labor for periods that the human body is just not capable of sustaining, while you have the robots do all the things that sometimes humans do to get a break.”
This point suggests we can’t rely on any one conceptual distinction to take the nuance out of the problem. Instead, when deciding which aspects of human connection can be automated and which cannot, we should ask ourselves several questions. Is it goal-oriented or practice-oriented? Is it liberating us from care or liberating us to care? And who benefits — truly, authentically benefits — from bringing robots into the social and caregiving realm?
Reporting for this article was supported by Public Theologies of Technology and Presence, a journalism and research initiative based at the Institute of Buddhist Studies and funded by the Henry Luce Foundation.


vox--2020-12-09--How to keep the smart speaker you got for the holidays and still keep some of your privacy, too

Smart speakers — Amazon ’ s Echo , Google ’ s Nest , Apple ’ s HomePod and the like — are in approximately one-third of American homes , a number that ’ s sure to increase once all the cyber Monday deals have been shipped and Christmas presents have been unwrapped .
But the people receiving ( or giving ) these digital personal assistants may not realize all the potential privacy pitfalls that come with them — or know what they can do to protect themselves from always-on listening and data collection devices .
Smart speakers and their virtual @ @ @ @ @ @ @ they collect a ton of data about their users by design .
They listen for your commands , record your requests , and those recordings may be stored and accessed by other human ears .
They can be used to build or contribute to a more comprehensive profile of their users , and their manufacturers are constantly coming up with new and unforeseen ways to use the data they collect .
That doesn ’ t mean they don ’ t make for good and useful gifts , just that you should fully consider @ @ @ @ @ @ @ open your ( or your Uncle Fred ’ s ) home to one .
Smart speakers are more popular than ever , and users don ’ t always know what they ’ re getting into Market intelligence firm IDC estimates that about 18 million smart speakers will be shipped in America in the fourth quarter of 2020 alone .
Roughly 80 percent of those will be made by Amazon or Google , and most of the others made by third parties that incorporate Amazon ’ s Alexa and Google ’ s Assistant .
@ @ @ @ @ @ @ a fraction of the market share , but if you count devices with Apple ’ s Siri voice assistant then you ’ ve got pretty much every iPhone and iPad out there , too . )
“ Smart speakers are likely to be a hot item for the holidays this year , ” Adam Wright , senior analyst for IDC , told Recode .
“ Vendors like Apple , Amazon , and Google have released new devices and ramped up their marketing efforts , and they are heavily discounting these devices for the @ @ @ @ @ @ @ .
Moreover , the pandemic is serving as a boost for sales of these devices as consumers shift their spending priorities from other areas and look to these devices for entertainment and to stay connected with friends and family.
” Smart home devices make lives easier for their users in many ways .
Depending on the smart home tech you own and what you connect to your speaker , it can play your favorite songs , answer your questions , tell you the weather , turn on your lights , control your thermostat @ @ @ @ @ @ @ on your door , among other things — and all cued by verbal command issued from your couch .
That ’ s great for everyone , from people who have mobility issues to people who have always dreamed of living in a computer house that is at their beck and call .
While smart speakers on their own are affordable for most people , getting all the bell and whistles — a video display , smart bulbs and plugs , security cameras and systems , thermostats , and the like — can bump @ @ @ @ @ @ @ ’ s another cost , too : privacy .
You may not be comfortable putting microphones that connect to some of the largest companies in the world — and the biggest collectors of personal data — in your home .
And you might rightfully be concerned about what these devices are listening to and recording .
“ If you have received one of these things as a gift , and you ’ re super paranoid , it ’ s probably going to be a very nice paperweight , ” David Choffnes , an @ @ @ @ @ @ @ University who studies smart speakers , told Recode .
Studies have shown that most smart speaker owners don ’ t know that their devices are storing their recordings or that they might be reviewed by humans , and are concerned about how much data their devices collect about them ( apparently not so concerned that they don ’ t continue to use them , however ) .
But you do have some privacy options , and you might as well know what they are before you turn your new digital assistant on , @ @ @ @ @ @ @ loved one to very nice paperweight status .
How to know ( and control ) who ’ s listening to you and when First of all : Yes , smart speakers are listening to you .
In order to work , they have to .
When you say a verbal cue — Hey Google , or Alexa , or Siri — the devices wake up , record your request , and send it to their servers , translate it into computer speak , and send a response back to you , all of @ @ @ @ @ @ @ constantly refining and improving their voice recognition algorithms , but they aren ’ t perfect and the speakers make mistakes .
They may not understand what you say or they may activate accidentally .
So human beings are contracted to listen to a small sample of recordings to see where device algorithms are getting things wrong .
And that means someone out there might hear your request to play “ Despacito ” — or , if the device was activated accidentally , whatever you happened to say without knowing you were being recorded @ @ @ @ @ @ @ that you both can be identified by the listener and that you ’ ll say something embarrassing or somehow incriminating are exceedingly small .
But there have also been isolated instances where Alexa recordings were turned over to law enforcement for use in investigations , or accidentally sent to random people .
You may also want to consider who else in your home your device might overhear — your kids or ( assuming the pandemic ever ends ) visiting friends , for instance — and if they ’ re comfortable having Amazon listening @ @ @ @ @ @ @ , Google , and Apple all give users the option not to have their recordings reviewed by human ears , and you can delete whatever they ’ ve recorded .
( More details on how to do this can be found here , or you can check the privacy policies of those devices . )
Some devices also allow you to disable their microphones and , if applicable , cameras .
That will , of course , defeat the purpose of having these devices in the first place , but it ’ s @ @ @ @ @ @ @ temporarily if you ’ re engaged in an activity you don ’ t want someone else to potentially see or hear .
Along those lines , you may want to avoid placing , say , a camera in sensitive areas and trusting that your device has taken proper security precautions or has your best privacy interests at heart .
When Amazon ’ s Ring cameras were hacked , strangers could see inside children ’ s bedrooms .
Ring also has partnerships with hundreds of police departments across the country and its app was @ @ @ @ @ @ @ user information to Facebook , among other companies .
Your data may be used in other ways , but you can minimize your exposure Another privacy control you should consider : how the devices collect and use your data in other ways .
Google says it “ may use ” your interactions with Google Assistant to target ads to you , for instance .
You ’ ll have to check your privacy settings and turn off ad personalization to prevent this , and trust that a company built on data collection and targeted @ @ @ @ @ @ @ , Amazon hasn ’ t been shy about its plans to create a virtual assistant that runs many aspects of its users ’ lives — which it would have to know and learn a lot about its user to be able to do .
You may be giving data to a company to be used for some future purpose you can ’ t yet imagine , let alone control .
“ The thing that actually worries me a little bit more these days is just because they ’ re not sending [ your @ @ @ @ @ @ @ doesn ’ t mean that they ’ re not doing something with your data , ” Choffnes said .
“ The question I have is more what are the secondary purposes they might use that data for ?
” One possible example of this is Amazon ’ s Sidewalk , a somewhat mysterious free feature coming to Echos , Rings , and any other device under its Sidewalk Bridge umbrella .
Sidewalk uses Bluetooth and radio frequencies to connect all of your devices to each other and to any other Sidewalk Bridge devices @ @ @ @ @ @ @ s Echo , for instance — turning your smart home into a smart neighborhood .
It will extend the range of your own devices beyond your home wifi , and keep you connected through your neighbor ’ s wifi if yours goes down .
It also means Amazon is getting an uninterrupted and expanded feed of your data .
Amazon says this could allow people to use security cameras that exceed their home wifi range or locate lost pets ( assuming they ’ re outfitted with a Sidewalk-enabled tracking device ) .
But @ @ @ @ @ @ @ about the service beyond basic details and privacy whitepaper meant to assure concerned users that , while their data might be traveling through their neighbors ’ devices , their neighbors can ’ t see or access any of it .
Another major concern among privacy advocates is that Sidewalk is opt-out , with a notice going out to Echo users — tens of millions of them — to let them know that their devices would be added to the Sidewalk network unless they went into the privacy settings on their Alexa and Ring @ @ @ @ @ @ @ didn ’ t respond to Recode ’ s questions as to why it placed the burden of choice to use Sidewalk on its customers , rather than creating a service so immediately useful to them that the majority would happily opt into it .
“ It ’ s an interesting thing they built , ” Choffnes said .
“ But if you can ’ t provide a compelling reason for everybody to opt in — and then your solution to that is to make it opt out — that ’ s a red @ @ @ @ @ @ @ after you peel off the wrapping paper on your brand new virtual assistant and before you decide to turn it on — or toss it — take a look at how much data you might be giving away and how it may be used , how to prevent some of that exposure , and , finally , if the service it provides is worth what Amazon , Google , and other companies may learn about you .
Open Sourced is made possible by Omidyar Network .
All Open Sourced content is editorially independent @ @ @ @ @ @

Smart speakers — Amazon’s Echo, Google’s Nest, Apple’s HomePod, and the like — are in approximately one-third of American homes, a number that’s sure to increase once all the cyber Monday deals have been shipped and Christmas presents have been unwrapped. But the people receiving (or giving) these digital personal assistants may not realize all the potential privacy pitfalls that come with them — or know what they can do to protect themselves from always-on listening and data collection devices.
Smart speakers and their virtual assistants are nice to have, but they collect a ton of data about their users by design. They listen for your commands, record your requests, and those recordings may be stored and accessed by other human ears. They can be used to build or contribute to a more comprehensive profile of their users, and their manufacturers are constantly coming up with new and unforeseen ways to use the data they collect. That doesn’t mean they don’t make for good and useful gifts, just that you should fully consider your privacy options before you decide to open your (or your Uncle Fred’s) home to one.
Smart speakers are more popular than ever, and users don’t always know what they’re getting into
Market intelligence firm IDC estimates that about 18 million smart speakers will be shipped in America in the fourth quarter of 2020 alone. Roughly 80 percent of those will be made by Amazon or Google, and most of the others made by third parties that incorporate Amazon’s Alexa and Google’s Assistant. (Apple’s HomePod has only a fraction of the market share, but if you count devices with Apple’s Siri voice assistant then you’ve got pretty much every iPhone and iPad out there, too.)
“Smart speakers are likely to be a hot item for the holidays this year,” Adam Wright, senior analyst for IDC, told Recode. “Vendors like Apple, Amazon, and Google have released new devices and ramped up their marketing efforts, and they are heavily discounting these devices for the holidays, making them highly visible and affordable. Moreover, the pandemic is serving as a boost for sales of these devices as consumers shift their spending priorities from other areas and look to these devices for entertainment and to stay connected with friends and family.”
Smart home devices make lives easier for their users in many ways. Depending on the smart home tech you own and what you connect to your speaker, it can play your favorite songs, answer your questions, tell you the weather, turn on your lights, control your thermostat, and announce who’s knocking on your door, among other things — and all cued by verbal commands issued from your couch.
That’s great for everyone, from people who have mobility issues to people who have always dreamed of living in a computer house that is at their beck and call. While smart speakers on their own are affordable for most people, getting all the bell and whistles — a video display, smart bulbs and plugs, security cameras and systems, thermostats, and the like — can bump the price tag up considerably.
There’s another cost, too: privacy. You may not be comfortable putting microphones that connect to some of the largest companies in the world — and the biggest collectors of personal data — in your home. And you might rightfully be concerned about what these devices are listening to and recording.
“If you have received one of these things as a gift, and you’re super paranoid, it’s probably going to be a very nice paperweight,” David Choffnes, an associate professor in computer science at Northeastern University who studies smart speakers, told Recode.
Studies have shown that most smart speaker owners don’t know that their devices are storing their recordings or that they might be reviewed by humans, and are concerned about how much data their devices collect about them (apparently not so concerned that they don’t continue to use them, however). But you do have some privacy options, and you might as well know what they are before you turn on your new digital assistant, or relegate the gift from a well-meaning loved one to very nice paperweight status.
How to know (and control) who’s listening to you and when
First of all: Yes, smart speakers are listening to you. In order to work, they have to. When you say a verbal cue — Hey Google, or Alexa, or Siri — the devices wake up, record your request, and send it to their servers, translate it into computer speak, and send a response back to you, all of which happens almost instantaneously. Developers are constantly refining and improving their voice recognition algorithms, but they aren’t perfect and the speakers make mistakes. They may not understand what you say or they may activate accidentally. So human beings are contracted to listen to a small sample of recordings to see where device algorithms are getting things wrong.
And that means someone out there might hear your request to play “Despacito” — or, if the device was activated accidentally, whatever you happened to say without knowing you were being recorded at all. Now, the chances that you can be identified by the listener and that you’ll say something embarrassing or somehow incriminating are exceedingly small. But there have also been isolated instances where Alexa recordings were turned over to law enforcement for use in investigations, or accidentally sent to random people. You may also want to consider who else in your home your device might overhear — your kids or (assuming the pandemic ever ends) visiting friends, for instance — and if they’re comfortable having Amazon listening in on whatever they say.
Amazon, Google, and Apple all give users the option not to have their recordings reviewed by human ears, and you can delete whatever they’ve recorded. (More details on how to do this can be found here, or you can check the privacy policies of those devices.) Some devices also allow you to disable their microphones and, if applicable, cameras. That will, of course, defeat the purpose of having these devices in the first place, but it’s not a bad idea to do it temporarily if you’re engaged in an activity you don’t want someone else to potentially see or hear.
Along those lines, you may want to avoid placing, say, a camera in sensitive areas and trusting that your device has taken proper security precautions or has your best privacy interests at heart. When Amazon’s Ring cameras were hacked, strangers could see inside children’s bedrooms. (Ring says that in this instance its systems and network were not hacked directly. The company told Recode that bad actors obtained Ring users’ login credentials through hacks of other companies and then used those credentials to gain access to Ring accounts. The company now has mandatory two-factor authentication on its products.) Ring also has partnerships with hundreds of police departments across the country, and its app was found to include multiple trackers that sent user information to Facebook, among other companies.
Your data may be used in other ways, but you can minimize your exposure
Another privacy control you should consider: how the devices collect and use your data in other ways. Google says it “may use” your interactions with Google Assistant to target ads to you, for instance. You’ll have to check your privacy settings and turn off ad personalization to prevent this, and trust that a company built on data collection and targeted ads is respecting your choice. Meanwhile, Amazon hasn’t been shy about its plans to create a virtual assistant that runs many aspects of its users’ lives — so it would have to know and learn a lot about its user to be able to do. You may be giving data to a company to be used for some future purpose you can’t yet imagine, let alone control.
“The thing that actually worries me a little bit more these days is just because they’re not sending [your recordings] to humans to interpret, doesn’t mean that they’re not doing something with your data,” Choffnes said. “The question I have is more what are the secondary purposes they might use that data for?”
One possible example of this is Amazon’s Sidewalk, a somewhat mysterious free feature coming to Echos, Rings, and any other device under its Sidewalk Bridge umbrella. Sidewalk uses Bluetooth and radio frequencies to connect all of your devices to each other and to any other Sidewalk Bridge devices in the vicinity — your neighbor’s Echo, for instance — turning your smart home into a smart neighborhood. It will extend the range of your own devices beyond your home wifi, and keep you connected through your neighbor’s wifi if yours goes down. It also means Amazon is getting an uninterrupted and expanded feed of your data. Amazon says this could allow people to use security cameras that exceed their home wifi range or locate lost pets (assuming they’re outfitted with a Sidewalk-enabled tracking device).
But Amazon hasn’t told us much about the service beyond basic details and a privacy white paper meant to assure concerned users that, while their data might be traveling through their neighbors’ devices, their neighbors can’t see or access any of it.
Another major concern among privacy advocates is that Sidewalk is opt-out, with a notice going out to Echo users — tens of millions of them — to let them know that their devices would be added to the Sidewalk network unless they went into the privacy settings on their Alexa and Ring apps to turn it off. Amazon didn’t respond to Recode’s questions as to why it placed the burden of choice to use Sidewalk on its customers, rather than creating a service so immediately useful to them that the majority would happily opt into it.
“It’s an interesting thing they built,” Choffnes said. “But if you can’t provide a compelling reason for everybody to opt in — and then your solution to that is to make it opt out — that’s a red flag, right?”
So, after you peel off the wrapping paper on your brand new virtual assistant and before you decide to turn it on — or toss it — take a look at how much data you might be giving away and how it may be used, how to prevent some of that exposure, and, finally, if the service it provides is worth what Amazon, Google, and other companies may learn about you.
Updated December 11, 2020, 6:45 pm ET: Added comment from Ring.
Open Sourced is made possible by Omidyar Network. All Open Sourced content is editorially independent and produced by our journalists.


vox--2020-12-09--Steroids are a powerful Covid-19 treatment. We need to learn to use them better.

The Covid-19 pandemic has infected more than 68 million individuals worldwide and killed 1.5 million people , including more than 285,000 Americans .
And many hospitals are now running short on beds for the sickest patients .
Approximately one in 25 people with Covid-19 need hospitalization , and about 9 percent of hospitalized Covid-19 patients end up having acute respiratory distress syndrome ( ARDS ) .
Hospital care does not guarantee survival , with Covid-19 killing about 2.1 percent of people who get it in the US .
We don ’ t always know why the SARS-CoV-2 virus that causes @ @ @ @ @ @ @ horribly than others .
But one thing many of these severe patients have in common is an overly active immune response .
This intense immune reaction to the virus often has features of cytokine storm syndrome ( CSS ) .
And , fortunately , we have drugs to treat this sort of immune response generally , including one President Trump took while he was sick with Covid-19 , dexamethasone .
But these drugs must be given at the right time to Covid-19 patients specifically experiencing CSS , not simply all patients with severe @ @ @ @ @ @ @ .
In short , we must optimize the drugs we already have .
And there is still a lot we need to learn about how these sorts of treatments work in the case of Covid-19 .
What we know about cytokine storms in Covid-19 Cytokine storm syndrome is an umbrella term for a variety of hyper-inflammatory reactions to various insults and triggers .
It can be brought on by other viruses , such as influenza and Epstein-Barr virus , as well as blood cell-related malignancies such as lymphoma and leukemia .
The diagnosis @ @ @ @ @ @ @ no single agreed-upon set of criteria for deciding if someone has CSS without their already having another related underlying condition .
Pinpointing it in people with Covid-19 is even trickier , in part because levels of key blood markers are not as high as the levels seen in patients with CSS in other contexts .
Additionally , severe lung inflammation is generally a late development in CSS , but it ’ s early in Covid-19 .
Nevertheless , like other CSS patients , those with severe Covid-19 often develop multi-organ dysfunction syndrome in @ @ @ @ @ @ @ primarily by excessive immune system activation and/or blood clotting , rather than by the virus itself .
These patients also have other overlaps with general CSS cases , including fever , liver dysfunction , low blood counts ( particularly low lymphocyte counts ) , and very elevated markers of inflammation .
We still don ’ t know , however , exactly how Covid-19 triggers this hyper-inflammation .
It only occurs in a subset of infected individuals , and there may be genetic risk factors .
For other cytokine storm syndromes , 30-40 percent @ @ @ @ @ @ @ that alter the immune response to infection .
Time and further research will tell if something similar occurs with Covid-19 .
Since the pandemic began , we have also learned more about the timeline of how these severe cases often go .
And this can help determine how best to treat people .
For symptomatic individuals , infection with Covid-19 comes in phases , with the early days ( the first week ) dominated by viral replication leading into features of a flu-like illness ( such as fever , cough , diarrhea ) @ @ @ @ @ @ @ adults with symptomatic infection , shortness of breath with low blood oxygen levels may develop five to 10 days after the onset of symptoms .
And things can deteriorate rapidly from there .
Hospitalized patients requiring oxygen support can quickly ( often within hours ) progress to requiring ICU management for ARDS , low blood pressure , and subsequent multi-organ dysfunction .
Confirmed predictors of patients at risk of developing more severe complications include being older than 60 , obesity , underlying cardiovascular disease , and/or a history of asthma or other chronic @ @ @ @ @ @ @ identified several blood test abnormalities at the time of early symptom onset that are predictive of a patient developing more severe complications later .
But these sorts of tests are not routinely done .
And it still doesn ’ t tell doctors exactly how best to treat these individuals who end up getting life-threateningly ill. Antiviral drugs don ’ t help cytokine storms , but we are learning how some other drugs can We do have some ways to attack the virus itself .
Antiviral approaches are likely to be most beneficial early @ @ @ @ @ @ @ first present and the virus is still infectious .
But even then they haven ’ t by any means been a cure-all .
At present , remdesivir , a nucleotide analog that has received emergency use authorization from the FDA , has been demonstrated to somewhat shorten hospital stays but has not been shown to improve survival .
Other treatments hyped by the current administration , including hydroxychloroquine , have not proven to be effective .
Because none of the antiviral approaches have thus far been proven to increase survival rates or prevent @ @ @ @ @ @ @ syndrome , we need treatments for patients fighting CCS in order to save more lives .
The most accessible and comprehensive anti-inflammatory approach to treating Covid-19 associated CSS involves the use of glucocorticoids ( anti-inflammatory steroids ) .
These include prednisone , methylprednisolone , and dexamethasone , the steroid given to President Trump .
Many hospitals have adopted dexamethasone as the standard of care for hospitalized patients with Covid-19 pneumonia .
These steroids not only inhibit cytokine production but also broadly tamp down many other aspects of the immune response , which makes @ @ @ @ @ @ @ but also tricky to use — especially in the case of an infection .
As immunosuppressants , these drugs are associated with a vast array of side effects , including secondary infections .
The use of glucocorticoids to treat previous fatal coronavirus epidemics , SARS and MERS , reported mixed results .
There was even concern that the use of glucocorticoids may increase mortality , so the World Health Organization strongly discouraged their use early on during the SARS-CoV-2 pandemic .
Nevertheless , out of desperation , clinicians overwhelmed by the pandemic resorted @ @ @ @ @ @ @ numbers of Covid-19 deaths .
So far , several retrospective analyses have reported lower Covid-19 mortality in glucocorticoid-treated patients compared to control groups .
A September meta-analysis done by the World Health Organization also concluded that glucocorticoids do save lives for some hospitalized Covid-19 patients , reducing all-cause mortality over four weeks from 40 percent to 32 percent .
A randomized placebo-controlled trial of 2,104 hospitalized Covid-19 patients , published in July , reported a statistically significant decrease in mortality with modest doses of dexamethasone for those on ventilators , from about 41 @ @ @ @ @ @ @ 29 percent in those receiving the steroid .
Those not requiring oxygen , and perhaps not experiencing CSS , trended toward worse outcomes ( 14 percent in the control group died versus almost 18 percent of those receiving the treatment ) .
Similarly , a recent study reported that patients with notable markers of inflammation improved with glucocorticoids , but those with lower levels fared worse .
These studies underscore the importance of careful patient selection for these treatments , namely that they should be used specifically to treat CSS in Covid-19 patients @ @ @ @ @ @ @ Covid-19 .
Initiating glucocorticoids as early as possible in CSS patients who will benefit , but avoiding needlessly immunosuppressing other patients who will not benefit from ( and may be harmed by ) them is a challenging needle to thread .
Looking for biomarkers for hyper-inflammation during hospitalization could help clinicians determine which patients are the best candidates for treatment with these potentially life-saving drugs .
Ideally , more targeted anti-inflammatories would be best to deploy in an effort to further lower Covid-19 mortality rates .
We have a few leads , documented @ @ @ @ @ @ @ in Covid-19 CSS patients , but the research is ongoing .
More recent — but lower quality — studies suggest that we might have luck using less risky , targeted immunomodulatory and immunosuppressive therapies , which have documented success treating non-Covid-19 CSS .
Many of these treatments — including Tocilizumab ( IL-6 blockade ) , IL-1 blockade , and emapalumab — have had mixed results and are still under investigation .
Currently , for example , IL-6 blockade is not looking promising .
While we all eagerly await the availability of safe and @ @ @ @ @ @ @ and subsequent Covid-19 , we need to optimize antiviral treatments and therapies directed against the associated CSS when it develops .
New iterations of antiviral approaches will hopefully decrease the development of hyper-inflammation .
But until these arrive , glucocorticoids and/or anti-cytokine approaches will likely be necessary to save lives .
With glucocorticoids already being readily available globally and relatively inexpensive , they may be our best therapeutic option for treating Covid-19 CSS worldwide for now .
Randy Q. Cron , MD , PhD , is a professor of pediatrics and medicine and @ @ @ @ @ @ @ at the University of Alabama at Birmingham .
In November 2019 , he published Cytokine Storm Syndrome , the first dedicated textbook on cytokine storms .
W. Winn Chatham , MD , is a professor of medicine , clinical immunology , and rheumatology ; senior scientist at the Comprehensive Arthritis , Musculoskeletal , Bone and Autoimmunity Center ( CAMBAC ) ; and director of Rheumatology Clinical Services at the University of Alabama at Birmingham .
Scott W. Canna , MD , is an assistant professor of pediatrics and immunology at the University of @ @ @ @ @ @ @ the Richard King Mellon Foundation Institute for Pediatric Research with expertise on auto-inflammation and cytokine storm disorders .

The Covid-19 pandemic has infected more than 68 million individuals worldwide and killed 1.5 million people, including more than 285,000 Americans. And many hospitals are now running short on beds for the sickest patients.
Approximately one in 25 people with Covid-19 need hospitalization, and about 9 percent of hospitalized Covid-19 patients end up having acute respiratory distress syndrome (ARDS). Hospital care does not guarantee survival, with Covid-19 killing about 2.1 percent of people who get it in the US.
We don’t always know why the SARS-CoV-2 virus that causes Covid-19 ravages some people so much more horribly than others. But one thing many of these severe patients have in common is an overly active immune response.
This intense immune reaction to the virus often has features of cytokine storm syndrome (CSS). And, fortunately, we have drugs to treat this sort of immune response generally, including one President Trump took while he was sick with Covid-19, dexamethasone.
But these drugs must be given at the right time to Covid-19 patients specifically experiencing CSS, not simply all patients with severe Covid-19, to get the best outcomes. In short, we must optimize the drugs we already have. And there is still a lot we need to learn about how these sorts of treatments work in the case of Covid-19.
What we know about cytokine storms in Covid-19
Cytokine storm syndrome is an umbrella term for a variety of hyper-inflammatory reactions to various insults and triggers. It can be brought on by other viruses, such as influenza and Epstein-Barr virus, as well as blood cell-related malignancies such as lymphoma and leukemia.
The diagnosis of CSS is complicated. There is no single agreed-upon set of criteria for deciding if someone has CSS without their already having another related underlying condition.
Pinpointing it in people with Covid-19 is even trickier, in part because levels of key blood markers are not as high as the levels seen in patients with CSS in other contexts. Additionally, severe lung inflammation is generally a late development in CSS, but it’s early in Covid-19.
Nevertheless, like other CSS patients, those with severe Covid-19 often develop multi-organ dysfunction syndrome in which organ damage appears to be caused primarily by excessive immune system activation and/or blood clotting, rather than by the virus itself.
These patients also have other overlaps with general CSS cases, including fever, liver dysfunction, low blood counts (particularly low lymphocyte counts), and very elevated markers of inflammation.
We still don’t know, however, exactly how Covid-19 triggers this hyper-inflammation. It only occurs in a subset of infected individuals, and there may be genetic risk factors. For other cytokine storm syndromes, 30 to 40 percent of patients do harbor mutations in genes that alter the immune response to infection. Time and further research will tell if something similar occurs with Covid-19.
Since the pandemic began, we have also learned more about the timeline of how these severe cases often go. And this can help determine how best to treat people.
For symptomatic individuals, infection with Covid-19 comes in phases, with the early days (the first week) dominated by viral replication leading into features of a flu-like illness (such as fever, cough, or diarrhea). In up to 20 percent of adults with symptomatic infection, shortness of breath with low blood oxygen levels may develop five to 10 days after the onset of symptoms.
And things can deteriorate rapidly from there. Hospitalized patients requiring oxygen support can quickly (often within hours) progress to requiring ICU management for ARDS, low blood pressure, and subsequent multi-organ dysfunction.
Confirmed predictors of patients at risk of developing more severe complications include being older than 60 and having obesity, underlying cardiovascular disease, and/or a history of asthma or other chronic respiratory disease. Recent studies have also identified several blood test abnormalities at the time of early symptom onset that are predictive of a patient developing more severe complications later.
But these sorts of tests are not routinely done. And it still doesn’t tell doctors exactly how best to treat these individuals who end up getting life-threateningly ill.
Antiviral drugs don’t help cytokine storms, but we are learning how some other drugs can
We do have some ways to attack the virus itself. Antiviral approaches are likely to be most beneficial early in the disease course when symptoms are first present and the virus is still infectious. But even then they haven’t by any means been a cure-all.
At present, remdesivir, a nucleotide analog that has received emergency use authorization from the Food and Drug Administration, has been demonstrated to somewhat shorten hospital stays but has not been shown to improve survival. Other treatments hyped by the current administration, including hydroxychloroquine, have not proven to be effective.
Because none of the antiviral approaches have thus far been proven to increase survival rates or prevent the development of ARDS or multi-organ dysfunction syndrome, we need treatments for patients fighting CCS in order to save more lives.
The most accessible and comprehensive anti-inflammatory approach to treating Covid-19 associated CSS involves the use of glucocorticoids (anti-inflammatory steroids). These include prednisone, methylprednisolone, and dexamethasone, the steroid given to President Trump. Many hospitals have adopted dexamethasone as the standard of care for hospitalized patients with Covid-19 pneumonia.
These steroids not only inhibit cytokine production but also broadly tamp down many other aspects of the immune response, which makes them helpful in reducing harmful inflammation but also tricky to use — especially in the case of an infection.
As immunosuppressants, these drugs are associated with a vast array of side effects, including secondary infections. The use of glucocorticoids to treat previous fatal coronavirus epidemics, SARS and MERS, reported mixed results. There was even concern that the use of glucocorticoids may increase mortality, so the World Health Organization strongly discouraged their use early on during the SARS-CoV-2 pandemic.
Nevertheless, out of desperation, clinicians overwhelmed by the pandemic resorted to these drugs to lower the massive numbers of Covid-19 deaths.
So far, several retrospective analyses have reported lower Covid-19 mortality in glucocorticoid-treated patients compared to control groups. A September meta-analysis done by the World Health Organization also concluded that glucocorticoids do save lives for some hospitalized Covid-19 patients, reducing all-cause mortality over four weeks from 40 percent to 32 percent.
A randomized placebo-controlled trial of 2,104 hospitalized Covid-19 patients, published in July, reported a statistically significant decrease in mortality with modest doses of dexamethasone for those on ventilators, from about 41 percent in the control group to about 29 percent in those receiving the steroid.
Those not requiring oxygen, and perhaps not experiencing CSS, trended toward worse outcomes (14 percent in the control group died versus almost 18 percent of those receiving the treatment). Similarly, a recent study reported that patients with notable markers of inflammation improved with glucocorticoids, but those with lower levels fared worse.
These studies underscore the importance of careful patient selection for these treatments, namely that they should be used specifically to treat CSS in Covid-19 patients, not simply all patients with severe Covid-19. Initiating glucocorticoids as early as possible in CSS patients who will benefit, but avoiding needlessly immunosuppressing other patients who will not benefit from (and may be harmed by) them is a challenging needle to thread. Looking for biomarkers for hyper-inflammation during hospitalization could help clinicians determine which patients are the best candidates for treatment with these potentially lifesaving drugs.
Ideally, more targeted anti-inflammatories would be best to deploy in an effort to further lower Covid-19 mortality rates. We have a few leads, documented in high-quality studies of specifically anti-cytokine treatments in Covid-19 CSS patients, but the research is ongoing.
More recent — but lower-quality — studies suggest that we might have luck using less risky, targeted immunomodulatory and immunosuppressive therapies, which have documented success treating non-Covid-19 CSS. Many of these treatments — including Tocilizumab (IL-6 blockade), IL-1 blockade, and emapalumab — have had mixed results and are still under investigation. Currently, for example, IL-6 blockade is not looking promising.
While we all eagerly await the availability of safe and effective vaccines to prevent infection with SARS-CoV-2 and subsequent Covid-19, we need to optimize antiviral treatments and therapies directed against the associated CSS when it develops. New iterations of antiviral approaches will hopefully decrease the development of hyper-inflammation.
But until these arrive, glucocorticoids and/or anti-cytokine approaches will likely be necessary to save lives. With glucocorticoids already being readily available globally and relatively inexpensive, they may be our best therapeutic option for treating Covid-19 CSS worldwide for now.
Randy Q. Cron, MD, PhD, is a professor of pediatrics and medicine and director of the Division of Pediatric Rheumatology at the University of Alabama at Birmingham. In November 2019, he published Cytokine Storm Syndrome, the first dedicated textbook on cytokine storms.
W. Winn Chatham, MD, is a professor of medicine, clinical immunology, and rheumatology; senior scientist at the Comprehensive Arthritis, Musculoskeletal, Bone and Autoimmunity Center (CAMBAC); and director of Rheumatology Clinical Services at the University of Alabama at Birmingham.
Scott W. Canna, MD, is an assistant professor of pediatrics and immunology at the University of Pittsburgh. He is a scholar of the Richard King Mellon Foundation Institute for Pediatric Research with expertise on auto-inflammation and cytokine storm disorders.


vox--2020-12-09--A less miserable winter

A less miserable winter

Winter is never the easiest time .
It ’ s cold .
It ’ s dark .
It ’ s icy and snowy and windy .
It puts the “ season ” in “ seasonal affective disorder.
” And this winter , the end of 2020 and the beginning of 2021 , is extra complicated .
The end of the pandemic might be in sight , but we ’ re not there yet , not by a long shot .
So we know that we won ’ t have all the things to look forward to that we once had @ @ @ @ @ @ @ friends , bundling up for a night out at a restaurant or bar , the relief of running on a treadmill at the gym while the streets outside are slick and dangerous .
It ’ s going to be rough ; some might even call it miserable .
We ’ d like to help you make it less miserable .
Vox has brought together some of our coziest minds — and tapped the experts — to help you figure out how to navigate this winter .
Join us as we roll out tips @ @ @ @ @ @ @ ( indoor ) hobby , how to bake magical bread , and how to keep your houseplants from calling it quits .
We ’ ll be checking with people who know how to deal with small-space living and long , dark winters .
We hope it ’ ll help make things less terrible — maybe even a little joyful .
How to keep your houseplants ( and yourself ) less miserable this winter , by Umair Irfan A Scandinavian local explains how to make it through winter , by Melinda Fakuade How to @ @ @ @ @ @ @ Alanna Okun How do you handle a tiny living space ?
We asked a Below Deck crew member , by Alex Abad-Santos

Winter is never the easiest time. It’s cold. It’s dark. It’s icy and snowy and windy. It puts the “season” in “seasonal affective disorder.”
And this winter, the end of 2020 and the beginning of 2021, is extra complicated. The end of the pandemic might be in sight, but we’re not there yet, not by a long shot. So we know that we won’t have all the things to look forward to that we once had: gatherings at home with family and friends, bundling up for a night out at a restaurant or bar, the relief of running on a treadmill at the gym while the streets outside are slick and dangerous. It’s going to be rough; some might even call it miserable.
We’d like to help you make it less miserable. Vox has brought together some of our coziest minds — and tapped the experts — to help you figure out how to navigate this winter. Join us as we roll out tips on how to pick up a new (indoor) hobby, how to bake magical bread, and how to keep your houseplants from calling it quits. We’ll be checking with people who know how to deal with small-space living and long, dark winters. We hope it’ll help make things less terrible — maybe even a little joyful.
How to keep your houseplants (and yourself) less miserable this winter, by Umair Irfan
A Scandinavian local explains how to make it through winter, by Melinda Fakuade
How to get a hobby this winter, by Alanna Okun
How do you handle a tiny living space? We asked a Below Deck crew member, by Alex Abad-Santos
A patio expert explains how to make winter socializing tolerable, by Alex Abad-Santos
This sourdough recipe takes all day. That’s what makes it great, by Brian Resnick
How to find fitness motivation after this trainwreck of a year, by Alex Abad-Santos