Table 1 Data extraction

Austin, M. S

2020

Wearables: Useful Sentinels of Our Health?

Homeland Security Affairs

Journal article

The United States of America

Personal view

Determining whether wearables are technologically capable of providing accurate early warnings of COVID-19 symptoms, how policies and procedures could leverage early warnings to protect workforce members, and what legal or political challenges those policies may encounter

Qualitative

N/A

N/A

N/A

Military

1. Utilitarian considerations

2. Value-based considerations

· Financial motivation (1)

· Health benefits (1)

· Organisational benefits (1)

· Data ownership (2)

· Privacy (2)

· Security (2)

· Voluntariness (2)

· In fact, should COVID-19 detection become a lesser priority for policy makers in future years, the BCT benefits and quantification of performance markers (HRV and sleep performance) may prove to be a beneficial primary utilization of wearables for personnel conducting extensive physical training and/or risk analysis as part of operational missions

· An additional area of concern, the global positioning system (GPS) mapping functions of some wearables can present security vulnerabilities, inadvertently charting military location or operations information

· While the desire to monitor the entirety of the military workforce may tempt policymakers to enact mandatory use of wearable devices, the use of a voluntary program may prove to be a more politically expedient course of action

Bovens, D. et al

2023

Personal health monitoring in the armed forces—scouting the ethical dimension: A case study in the Netherlands Armed Forces during the Covid-19 pandemic

BMC Medical ethics

Journal article

The Netherlands

Primary research

Obtaining insights into the experiences and related values of different stakeholders regarding an existing form of personal health monitoring

Qualitative

Interviews

Army Reserve Personnel, developers of PHM, policy advisors

12

Military

1. Utilitarian considerations

2. Value-based considerations

3. Regulatory responsibilities

· Health benefits (1)

· Autonomy (2)

· Conflict of interest (2)

· Data ownership (2)

· Hierarchy (2)

· Informed consent (2)

· Responsibility (2)

· Security (2)

· Trust (2)

· Voluntariness (2)

· Vulnerable population (2)

· Task government (3)

· As illustrated by two respondents, this value (security) demonstrates a common understanding for both users and stakeholders about preserving security of data, thereby setting a norm

· Several respondents value their trust in relation to privacy as soldiers differently than as civilians. As soldiers, they have a potential inclination to give up privacy more easily. This is considered necessary for the organisation to operate and, on the other hand, also seems related to the context in which soldiers operate

· This insight leads to the moral question what a military organisation, considering the context (e.g. deployment or peacekeeping activity), might desire from its soldiers, knowing that soldiers are willing to compromise on certain individual interests to serve the organisation

· Furthermore, in light of the ongoing ethical debate about security, privacy, data ownership and data increasingly being seen as a human right, armed forces should closely consider who actually owns a soldiers PHM data, and who can access it and under what circumstances

· We argue that a moral responsible use of PHM, in the light of this paradox, needs ethics support to uncover and address these potentially hidden ethical aspects

Bratt, S et al

2017

Translation in personal crises: Opportunities for wearables design

14th International Conference on Information Systems for Crisis Response and Management

Conference paper

The United States of America

Primary research

Exploring design opportunities for sensor devices to aid veterans in translation work of managing personal crises

Qualitative

Interviews

Veterans

14

Military

1. Utilitarian considerations

2. Value-based considerations

· Health benefits (1)

· Quality of care (1)

· Acceptability (2)

· Involvement of users (2)

· Privacy (2)

· A wearable has the potential to effectively circumvent the stigma we found in our study associated with mental health issues through the widespread use of wearable devices because of its inconspicuousness

· The design criteria put forth in this paper is contingent on the input, feedback, and opinions of users, and the veteran user should control the ICTs’ design to the greatest extent possible

· When it comes to veterans in transition, especially in design involving quantified self, the body–a site of privacy and identity–is the primary source of data generation and collection. For example, issues of privacy were forefront in our informant data

Casselman, J. et al

2017

Wearable healthcare: Lessons from the past and a peek into the future

Telematics and Informatics

Journal article

The United States of America

Secondary research

SWOT examination of the wearable healthcare industry

Qualitative

Product and literature review

N/A

N/A

Civilian and military

1. Utilitarian considerations

2. Value-based considerations

3. Regulatory responsibilities

· Health benefits (1)

· Organisational benefits (1)

· Confidentiality (2)

· Privacy (2)

· Safety (2)

· Security (2)

· Approval by authority (3)

· Task government (3)

· Task industry (3)

· wearables could be used in the training of military and law enforcement personnel to track their vitals, reduce injury, and help them control their stress

· Security concerns remain the most significant barrier to the growth of wearable healthcare devices because of the potentially disastrous effects of a security breach on patient safety

· Data security is always a concern for any networked technology. Striking a balance between data availability and confidentiality has been a challenge for the information technology (IT) community since before the advent of the Internet

· Data security and privacy will continue to pose challenges for developers, but industry standards and governmental regulations can help ensure control measures are built in and enforced

Davison, C. B. et al

2020

Privacy and security considerations of the IOT: approaching privacy by design

Issues in Information Systems

Journal article

The United States of America

Secondary research

Provide awareness of IoT privacy and security issues within the IoT and advocate for a holistic approach to address these issues

Qualitative

Literature review

N/A

N/A

Civilian and military

2. Value-based considerations

· Privacy (2)

· Safety (2)

· Security (2)

· Trust (2)

· As the IoT increases in size and scope, privacy and security become more important

· As the US military moves toward the Internet of Battlefield Things (IoBT) and smart, sensorized environments, privacy and the perception of privacy may degrade

· Privacy and situational awareness in the IoBT are often at odds

· PbD [privacy by design] is crucial in decreasing privacy risk and increasing trust

Elhoseny, M. et al

2021

Security and Privacy Issues in Medical Internet of Things: Overview, Countermeasures, Challenges and Future Directions

Sustainability

Journal article

Egypt

Secondary research

Review of the security and privacy aspects of the MIoT and providing further research opportunities

Qualitative

Literature review

N/A

N/A

Civilian

2. Value-based considerations

3. Regulatory responsibilities

· Privacy (2)

· Security (2)

· Trust (2)

· Task government (3)

· the security and privacy of the data obtained from MIoT devices, which are either stored in the cloud or in remote servers or obtained during the transmission to the cloud or remote servers, are becoming a major unresolved concern in healthcare, where less attention is paid by the industry and the academic community

· It is no doubt that MIoT security and privacy play a vital role in modern ubiquitous healthcare, as most healthcare organizations do not devote the adequate time and necessary resources to safeguard security and privacy

· the successful development and deployment of MIoT must take security and privacy both as core considerations. If not, the lack of sufficient MIoT security and privacy would not only jeopardize the privacy of patients but may also jeopardize the lives of patients

· What the authors have understood is that effective security needs to be built-in, not patched. It has to be an integral part of the pervasive MIoT ecosystem

Karkazis, K. & Fishman, J. R

2017

Tracking U.S. Professional Athletes: The Ethics of Biometric Technologies

The American Journal of Bioethics

Journal article

The United States of America

Primary research

Start deeper discussion of the adoption of biometric technologies in professional sports by examining five areas of ethical concern

Qualitative

Literature review and interviews

Developers and users of biometric technolo-gies

Unknown

Professional sport

1. Utilitarian considerations

2. Value-based considerations

3. Regulatory responsibilities

· Health benefits (1)

· Organisational benefits (1)

· Accountability (2)

· Autonomy (2)

· Confidentiality (2)

· Conflict of interest (2)

· Contextuality (2)

· Data governance (2)

· Data ownership (2)

· Data validity (2)

· Informed consent (2)

· Interpretation (2)

· Privacy (2)

· Purposeful (2)

· Security (2)

· Trust (2)

· Validity (2)

· Vulnerability (2)

· Clear policies needed (3)

· Protection of user (3)

· Regulation (3)

· Liability (3)

· However, these same biometric data come with the risk of compromising players’ privacy and autonomy, as well as the confidentiality of their data. Moreover, they also have the potential to disadvantage players in contract negotiations and to harm, and even cut short, athletic careers

· The collection and storage of biometric data by employers and third parties raises risks of exploitation, coercion, and employee discrimination when these data are used in hiring and firing decision making

· In sport, team physicians, for example, are obligated both to provide care to the individual athlete and to act in the team’s interest. This involves deciding, for example, whether an athlete should return to play, which may not be in an athlete’s best interest, but could benefit the team

· Trust can only be developed when players feel like they are being heard, respected, and treated fairly. With biometric data, some feel that the data are able to speak for themselves, thereby bypassing the need to listen to the “subjective” feelings (of fatigue, readiness, behaviors) of players themselves. As these measures become quantified and objectified, there is a greater risk of using them to the exclusion of players’ own assessments. This could lead to an erosion of trust in the relationships between players and team representatives, lending suspicion to the intentions of team representatives and the technologies themselves

· We see a number of critical areas for immediate deliberation, most especially the development of a sound data governance program, which would include a governing body or council, a defined set of procedures, and a plan to execute those procedures

Kim, R. H. & Patel, M. S

2018

Barriers and Opportunities for Using Wearable Devices to Increase Physical Activity Among Veterans: Pilot Study

JMIR Formative Research

Journal article

The United States of America

Primary research

Evaluate veterans’ perceptions of and experiences with wearable devices and identify the potential barriers and opportunities to using such devices to increase physical activity levels in this population

Qualitative

Interviews

Veterans

16

Military

1. Utilitarian considerations

2. Value-based considerations

· Health benefits (1)

· Privacy (2)

· “People might not be comfortable with the idea of someone else tracking their behavior.”

· if programs are well designed, these devices could play a meaningful role in helping veterans change their physical activity behavior

Kröger, J. et al

2019

What does your gaze reveal about you? On the privacy implications of eye tracking

14th IFIP International Summer School on Privacy and Identity Management

Conference paper

Germany

Secondary research

Provision of structured overview and classification of sensitive pieces of information that can be disclosed by analysing a person's eye activities

Qualitative

Review

N/A

N/A

Civilian

2. Value-based considerations

3. Regulatory responsibilities

· Privacy (2)

· Transparency (2)

· Protection of user (3)

· Task government (3)

· Task industry (3)

· The many beneficial uses and enormous potentials of the rising technology have to be acknowledged and should be embraced. However, a more ubiquitous use of eye tracking will also raise serious privacy concerns – not only because gaze data may be collected and shared in non-transparent ways, but also because such data can unexpectedly contain a wealth of sensitive information about a user

· In our view, the vast possibilities of continuously advancing inference methods are clearly beyond the understanding of the ordinary consumer. Therefore, we consider it to be primarily the responsibility of technical experts, technology companies, and governmental agencies to inform consumers about potential consequences and protect them against such covert invasions of privacy. Also, since it is unlikely that companies will voluntarily refrain from using or selling personal information that can be extracted from already collected data, there should be strong regulatory incentives and controls

Leightley, D. & Murphy, D

2022

Personalised digital technology for mental health in the armed forces: The potential, the hype and the dangers

BMJ Military Health

Journal article

The United Kingdom

Personal view

Exploring the potential use of personalised digital technology for mental health, the hype surrounding it and the dangers

Qualitative

N/A

N/A

N/A

Military

1. Utilitarian considerations

2. Value-based considerations

3. Regulatory responsibilities

· Access to care (1)

· Organisational benefits (1)

· Quality of care (1)

· Acceptability (2)

· Data ownership (2)

· Evidence based (2)

· Purposeful (2)

· Trust (2)

· Standards (3)

· While the benefits on the use of digital technology are clear, it is vital that the technology is shown to be acceptable and underpinned by scientific evidence

· Technology should not be used for the sake of it, and any technology which is used should be designed and developed following rigorous standards

· By focusing on the individual, we attempt to address the disorder before it occurs. Technology engages the patient in healthcare decision- making, improves our healthcare systems and ensures our armed forces are supported. Each person has their own health risks, lifestyle choices and goals for their health, and recent advances in the analysis of big data can allow us to better understand the individualised needs of patients. Therefore, personalising care to the individual is critical for engagement, along with the delivery of holistic support, management and intervention

Metzger, M.J. et al

2021

What can fitness apps teach us about group privacy?

Research Anthology on Privatizing and Securing Data

Chapter in book

The United States of America

Primary research

Evaluate and discuss the differences and implications of individual vs group privacy

Mixed-methods

Review & Experiment

Partici-pants from Amazon Mechanical Turk

260

Civilian and military

2. Value-based considerations

3. Regulatory responsibilities

· Acceptability (2)

· Accountability (2)

· Autonomy (2)

· Informed consent (2)

· Privacy (2)

· Responsibility (2)

· Transparency (2)

· Clear policies needed (3)

· Code of conduct (3)

· Lawsuits (3)

· Organisation rules (3)

· Protection of user (3)

· Task government (3)

· Task industry (3)

· These scenarios raise questions about the collective's right not to be discovered in the first place because the action of clustering imposes an unwanted or unwarranted identity on people

· While anonymization of individual-level privacy may protect "their privacy" (i.e., the privacy of individual group members) it does not protect "its privacy" (i.e., the privacy of the group as a whole)

· This raises an important question of whether algorithmically-identified but not self-aware (i.e. passive) groups can have a legitimate claim to privacy

· algorithmically-determined groups may indeed produce group privacy concerns for people, and thus warrant claims to group privacy rights

· Advances in big data mining and inference algorithms make the degree to which people are aware of privacy risks from group inference technologies a pressing issue. Such awareness is important because it is a precondition for attempts to manage group privacy risks with appropriate measures

· the results indicate that group privacy concern is greater when group privacy threats are highlighted, and this effect is independent of threats to personal privacy

· Participants’ support for government oversight showed a different pattern, such that threats to group privacy salient significantly increased attitudes in favor of government regulation, but threats to personal privacy did not

· Recognize that privacy goes beyond single individuals and extends to groups

· Develop and then adhere to codes of ethical professional conduct that emphasize responsible data use

· another challenge when developing software tools for privacy protection is how to balance users’ individual or group privacy with the self-interests of companies whose revenue stream depends on inferring groups and their memberships

· efforts are needed to expand information literacy about inference algorithms and their risks to individuals and groups

Authors

Year of publication

Title of article

Journal

Publication type

Country study conducted in

Type of evidence source

Aim of article

Methodology

Methods

Population

Sample size

Context

Ethical Dimension

Subcategories

*The number corresponds to the ethical dimension to which the subcategory belongs

Examples from the article illustrating ethical dimension

Mohammadian, M. et al

2022

Factors affecting the use of smart wearables in veterans

Iranian Journal of War and Public Health

Journal article

Iran

Primary research

Investigate the factors affecting the use of smart wearables for veterans

Qualitative

Interviews

Veterans, trustees, and manufacturers related to smart wearables

10

Military

1. Utilitarian considerations

2. Value-based considerations

· Benefits society (1)

· Financial motivation (1)

· Acceptability (2)

· Non-explicit ethical concerns (2)

· Privacy (2)

· Security (2)

· Trust (2)

· These technologies can help reduce hospital and nursing costs and provide care for the needy. Therefore, investing in the production of smart textiles is a dual-purpose process, which is both an approach for economic prosperity and support for the well-being and health of society

· In this research, in examining the attitude of veterans, the factors that can be effective in their use of technological products such as smart wearables include things such as paying attention to religious issues, acceptance of defects due to self-sacrifice, belief in technology, product trust, influence from other veterans, risk aversion, and bias

· Attention to security and ethical considerations is a significant obstacle to providing smart medical services. The main concern in health care includes data protection, prevention of errors related to information, conversation records, and location tracking, which can adversely affect users' privacy. Paying attention to the veteran's physical security, data security, and security for old age are the things that have been mentioned in the current research

Murdock, R. C. et al

2018

Soldier safety and performance through wearable devices

2018 Micro- and Nanotechnology (MNT) Sensors, Systems, and Applications X Conference

Conference paper

The United States of America

Secondary research

Discusses a

couple of the use cases for wearable technologies within military environments

Qualitative

Review

N/A

N/A

Military

1. Utilitarian considerations

· Access to care (1)

· Financial motivation (1)

· Health benefits (1)

· Organisational benefits (1)

· For the military, being able to fuse all of the data streams, using wearable sensors and/or other data sources, into actionable recommendations as to reduce overtraining, increase readiness, and reduce injuries

· Military operators perform at an elite level, and can benefit from technologies that can allow them to perform at an even higher level from personalized training, tracking, and recovery

· These technologies can significantly enhance the safety of military operations, the effectiveness of disaster relief, and improve provision of health care in remote areas with limited infrastructure

Ng, A. et al

2018

Veterans' Perspectives on Fitbit Use in Treatment for Post-Traumatic Stress Disorder: An Interview Study

JMIR Mental Health

Journal article

The United States of America

Primary research

Gain understanding of patients’ motivations to use or not to use wearables devices

Qualitative

Interviews

Veterans

13

Military

1. Utilitarian considerations

2. Value-based considerations

3. Regulatory responsibilities

· Health benefits (1)

· Social effects (1)

· Meaningful data (2)

· Non-explicit ethical concerns (2)

· Privacy (2)

· Purposeful (2)

· Transparency (2)

· Trust (2)

· Clear policies needed (3)

· The veterans were not given any formal training on how to use the Fitbit or interpret the data, and this inability to derive meaning from the data discouraged some participants from using the Fitbit

· Fitbits may reduce the burden from manual tracking, but if veterans do not understand or trust the data, it could be difficult for them to be motivated to use it

· Veterans may be hesitant to disclose information to clinicians to avoid feeling “judged” by someone who has not experienced war

· There has to be clear policies in place to handle issues such as privacy and sharing of data. This is particularly important when dealing with wearable devices that continually collect data about the individual

· However, the use of such data and devices in clinical practice and clinical research does raise a host of ethical questions. Yet, dealing with these questions is likely a necessity given the increased attempts toward using this data in the health space

Roy, M. et al

2020

Security and privacy issues in wireless sensor and body area networks

Handbook of Computer Networks and Cyber Security: Principles and Paradigms

Chapter in book

India

Secondary research

Reviewing the security and privacy issues of WSN and WBAN

Qualitative

Review

N/A

N/A

Civilian

1. Utilitarian considerations

2. Value-based considerations

3. Regulatory responsibilities

· Quality of care (1)

· Acceptability (2)

· Autonomy (2)

· Data governance (2)

· Informed consent (2)

· Privacy (2)

· Security (2)

· Task government (3)

· Both WSN and WBAN deal with sensitive information related to physical phenomena or human health, hence privacy is a prime aspect that regulates the acceptability of such system by the people. Health related data are always private in nature and hence sending data out from a patient through wireless media in case of WBAN applications imposes serious threats to privacy of an individual

· Some of the major aspects to be addressed before deployment of WBAN applications in order to guarantee privacy are where the health data should be stored, who can view the patient’s medical record, who will be responsible for maintaining these data in case any emergency arises, and so on. Most importantly, it is to be taken into account that whether the data are obtained with the consent of the person or without it due to the requirement by the system so that the misuse of this private information could be prevented

· The second issue that definitely will become more important in near future is lack of cohesive policy sets to protect the patient's privacy

Shore, J. H. et al

2014

Review of mobile health technology for military mental health

Military Medicine

Journal article

The United States of America

Secondary research

Identifying high-priority mHealth technology development considerations for military mental health

Qualitative

Review

N/A

N/A

Military

1. Utilitarian considerations

2. Value-based considerations

3. Regulatory responsibilities

· Access to care (1)

· Quality of care (1)

· Acceptability (2)

· Availability (2)

· Data management (2)

· Evidence based (2)

· Informed consent (2)

· Non-explicit ethical concerns (2)

· Privacy (2)

· Safety (2)

· Security (2)

· Approval by authority (3)

· These unique capabilities provide new ways for mHealth to help provide access to care and improve quality of care through enhancing communication, improving compliance, enriching the available health care data, and encouraging patient engagement

· Protection of records and information is particularly important given the existing stigma toward mental health in civilian and military populations

· Measures need to be taken to ensure providers and health care systems are not overwhelmed by increased data management (including triage, filtering, and storage) and patient communication demands

· mHealth developers should make every effort to ensure that users are fully informed and aware of the capabilities, risks, and limitations of a particular application or technology

Sipila, E. et al

2021

Technology-related Challenges in Smart Clothing-Viewpoints from Ideation Workshops

9th IEEE International Conference on Serious Games and Applications for Health

Conference paper

Finland

Primary research

Discovering future users and applications of smart clothes

Qualitative

Ideation workshops

(Future) Experts in the field of engineering, education, social services and health care

50

Civilian

2. Value-based considerations

3. Regulatory responsibilities

· Autonomy (2)

· Data governance (2)

· Informed consent (2)

· Privacy (2)

· Purposeful (2)

· Security (2)

· Task industry (3)

· Task government (3)

· “Ethics” was found to be the biggest challenge in smart clothing. Even though the technology itself would be good and helpful in many ways, several ethical issues exist related to the technology and to how it is used

· Wearable technology indeed has raised multiple ethical questions, such as privacy and security challenges. It is important to identify and understand these problems from the user’s viewpoint

· Thus, even though smart clothes could collect real-time data on various issues, we must carefully consider if we really need it. Does the continuous data provide some advantage to the user or is it perhaps a source of stress?

· The strict regulation process is good and necessary, yet it also increases the product’s development costs, possibly leading to a more expensive product and a longer time to market

Stacey, M. J. et al

2018

Physiological monitoring for healthy military personnel

Journal of the Royal Army Medical Corps

Journal article

The United Kingdom

Personal view

Addressing issues around real-time monitoring of military populations

Qualitative

N/A

N/A

N/A

Military

1. Utilitarian considerations

2. Value-based considerations

· Health benefits (1)

· Organisational benefits (1)

· Autonomy (2)

· Data ownership (2)

· Interpretation (2)

· Justice (2)

· Purposeful (2)

· Quality of data (2)

· Reliability of data (2)

· Validity (2)

· Vulnerability (2)

· The most direct beneficiaries would be individual personnel, empowered by information about their own physical and training status

· Wearable technology represents an appealing and potentially hugely beneficial enhancement to the equipment currently used by UK military personnel, which could improve healthcare across a number of domains

· These include the freedom to achieve peak physical performance, which may on occasion fall a hair’s breadth from physiological failure

· …it is vital to understand the consequences of producing data that may influence perceptions of occupational suitability

· Other challenging issues that may be of relevance in military settings include the scope for false reassurance

· Just because technology exists, however, does not mean we are mandated to use it. Rather, we must define the questions we wish to answer. Hypothesis-driven research must determine if the wearable technology in question can answer our specific questions and whether it benefits the wearer or, ultimately, the mission

Authors

Year of publication

Title of article

Journal

Publication type

Country study conducted in

Type of evidence source

Aim of article

Methodology

Methods

Population

Sample size

Context

Ethical Dimension

Subcategories

*The number corresponds to the ethical dimension to which the subcategory belongs

Examples from the article illustrating ethical dimension

Winslow, B. & Mills, E

2023

Future of service member monitoring: the intersection of biology, wearables and artificial intelligence

BMJ Military Health

Journal article

The United States of America

Personal view

Addressing the monitoring of (physical and mental) health in the military at the intersection of biology, wearables and artificial intelligence

Qualitative

N/A

N/A

N/A

Military

1. Utilitarian considerations

2. Value-based considerations

3. Regulatory responsibilities

· Organisational benefits (1)

· Quality of care (1)

· Health benefits (1)

· Accountability (2)

· Benchmark (2)

· Explainability (2)

· Fairness (2)

· Human centred (2)

· Informed consent (2)

· Privacy (2)

· Security (2)

· Transparency (2)

· Standards (3)

· Efforts should be made to ensure that underlying datasets used to develop algorithms are diverse and unbiased and consider individual human differences, demands, values, expectations and preferences rather than algorithmic capabilities

· All applications should be private and transparent, and support individual consent, accountability and fairness

· Methods for system verification, validation and certification should be standardised, and cybersecurity safeguards should be central to all systems

· Wearable technology is central to the future of service member modernisation, in which real- time physiological data will be persistently monitored to evaluate individual physical and mental health, maintain safety and optimise performance