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Social Science & Medicine 67 (2008) 128–136

Contents lists available at ScienceDirect

Social Science & Medicine

journal homepage: www.elsevier.com/locate/socscimed

The two facets of electronic care surveillance: An exploration

of the views of older people who live with monitoring devices
Anna Essén *
School of Business, Stockholm University, Kraftriket Bldg 2, 3, & 15, Stockholm 106 91, Sweden

a r t i c l e i n f o a b s t r a c t

Article history: Scholars are increasingly questioning the notion that electronic surveillance merely
Available online 8 April 2008 constrains individuals’ liberty and privacy. However, illustrations of alternative perspec-
tives are few and there is a need for empirical research exploring the actual experience
of surveilled subjects. This study, carried out in Sweden, seeks to offer a nuanced account
Keywords: of how senior citizens experience electronic care surveillance in relation to their privacy. It
Sweden
is based on in-depth interviews with 17 seniors who have participated in a telemonitoring
Telehealth
project and who have experience of being continuously activity monitored in their own
Technology
Surveillance homes. The findings suggest that senior citizens can perceive electronic care surveillance
Privacy as freeing and as protecting their privacy, as it enables them to continue living in their
Elderly care own home rather than moving to a nursing home. One individual, however, experienced
a privacy violation and the surveillance service was interrupted at her request. This illus-
trates the importance of built-in possibilities for subjects to exit such services. In general,
the study highlights that e-surveillance can be not only constraining but also enabling.
Hence, it supports the view of the dual nature of surveillance. The study also illustrates
the agency of the surveilled subject, extending the argument that various agents actually
participate in the construction of surveillance practices. It analyzes the indirect role and
responsibility of the surveilled subject, and thereby questions the traditional roles ascribed
to the agents and targets of surveillance.
! 2008 Elsevier Ltd. All rights reserved.

Introduction (Bentham, 1969; Foucault, 1977), which inspire one-sided

Academics have worried about the threats to privacy
associated with electronic surveillance (e-surveillance) for
decades (e.g. Davies, 1992; Flaherty, 1989; Floridi, 2006;
Garson, 1988; Goodwin, 1991; Lyon, 2001, 2002; Lyon &
Zureik, 1996; Mason, 1986; Ogura, 2006; Parenti, 2001;
Solove, 2006; Weckert, 2001). However, as noted by a large
number of scholars (e.g. Lyon, 2006, 2007; Haggerty, 2006;
Haggerty & Ericson, 2000; Hier, 2003; Rössler, 2005;
Solove, 2001; Vaz & Bruno, 2003; Wood, 2003), the extant
surveillance literature is overly dominated by the Big
Brother (Orwell, 1949) and Panopticon metaphors
* Corresponding author. Tel.: þ46 73 971 76 87.
E-mail address: aes@fek.su.se
and dystopic views on surveillance. To paraphrase Lianos
(2003), contemporary e-surveillance studies routinely refer
to the erosion of privacy and liberties by sinister and total-
itarian forces, which ‘‘is damaging as it is superficial and
analytically unfounded, and it pre-empts the feelings and
opinions of the public, usually with great inaccuracy’’
(Lianos, 2003: 414). Similarly, Haggerty and Ericson
(2000) argue that ‘‘far from the negative connotations
that tend to be attached to surveillance, many surveillance
practices today are not only supported but encouraged by
those who serve as the primary targets of data gathering
systems’’ (pp. 401). Indeed, the widespread assumption in
the surveillance literature that subjects are surveilled
against their will is now being questioned (Lyon, 2007;
Pecora, 2002). Few studies have actually explored the

0277-9536/$ – see front matter ! 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2008.03.005
 Author's personal copy
A. Essén / Social Science & Medicine 67 (2008) 128–136
experience of surveilled subjects (Haggerty, 2006; Lyon,
2006). In general, the contemporary surveillance literature
tends to analyze surveillance technology in isolation, as
given and as inevitably producing certain effects in
a predictable fashion (Ball, 2002; Haggerty, 2006; Haggerty
& Ericson 2000; Hier, 2003). It therefore fails to give
balanced accounts of how users interact with surveillance
technologies in practice.
Recently, studies taking the locality and particularity of
e-surveillance applications and the agency of surveilled
subjects into account have however emerged (Dubbeld,
2006; Fotel & Thomsen, 2004; Koskela, 2006). Drawing on
insights from the field of science and technology (e.g. Bijker,
Hughes, & Pinch, 1989; Latour, 1987), these studies high-
light that the operation of surveillance technology is by
no means given, but rather contingent on the user-context.
It is also argued that e-surveillance should not only be
understood as constraining but also as enabling (Bogard,
2006; Lyon, 2007). These insights have however not been
used to explore the relation between e-surveillance and
privacy. In general, this perspective is underdeveloped
and more research is asked for, in particular as regards the
view of the surveilled subject (e.g. Lyon, 2006, 2007).
Given these weaknesses in the surveillance literature,
the present paper attempts to provide a nuanced account
of individual subjects’ experience of electronic care
surveillance in relation to their privacy. Care surveillance
has received little attention in the surveillance literature
(Dubbeld, 2006; Lyon, 2001, 2006, 2007; Vaz & Bruno,
2003; Wood, 2003). As noted by Vaz and Bruno (2003),
this neglect may partly be due to the challenge related
to studying e-care surveillance in a critical fashion.
Surveillance and control are integral parts of care and it
is difficult to separate these elements. Nevertheless, elec-
tronic care surveillance technologies such as in-home tel-
emonitoring are emerging and authors have underlined
the pertinence of taking the issue of privacy into account
when evaluating such technologies (Bauer, 2002; Hensel,
Demiris, & Courtney, 2006; Von Tigerstrom, 2000).
Responding to these calls, the paper uses empirical data
from the Swedish elderly care setting, exploring how
care takers perceive that being continuously activity
monitored in their own home affects their privacy. As
this is a fairly unexplored area, the paper also asks
more broadly how we can understand e-surveillance
and privacy in this context.
The findings highlight that electronic care surveillance
can be perceived as enabling by surveilled subjects. The
majority of the seniors in this study feel that electronic
care surveillance can indirectly protect their privacy by
enabling them to continue living in their own homes rather
than moving to a nursing home. In general, care surveillance
makes the majority of the seniors interviewed feel cared for
and safe rather than constrained. What makes them feel safe
is however the fact that certain familiar care workers watch
over them. The technology merely becomes a link between
themselves and the care workers. The study also highlights
the importance of built-in possibilities for subjects to exit
from the service. One individual experienced a privacy
violation and felt constrained when monitored. The surveil-
lance service was interrupted at her request.
129
The article begins with a definition of privacy. Next,
widespread assumptions in the surveillance literature are
problematized in relation to care surveillance and privacy.
Alternative perspectives are outlined. Findings from the
in-depth interviews with 17 seniors follow. The article
ends with discussion, conclusions, implications and limita-
tions, which suggest further research avenues.
Defining privacy
There has been a debate regarding whether or not
a ‘‘right to privacy’’ exists and even if there is a unified con-
cept of privacy (cf. Schoeman, 1984). Warren and Brandeis
(1890) defined privacy as the right to be let alone. This
definition has since been extended and includes various
multi-dimensional conceptualizations (cf. e.g. Altman,
1976; DeCew, 1997; Gavison, 1995; Inness, 1992; Westin,
1967). Rössler (2005) recently provided a comprehensive
definition, outlining three interrelated aspects of ‘‘the
private sphere’’: (1) informational privacy (protection
against unwanted access to personal information about
us); (2) decisional privacy (protection against unwanted
interference in our decisions); and (3) local (physical) pri-
vacy (protection against the unwanted admission of other
people to personal spaces or areas).
Empirical studies of patients’ perception of privacy
focus on hospital or nursing home settings (e.g.
Damschroder et al., 2007; Parrott, Burgoon, Burgoon, &
LePoire, 1989). This literature suggests that hospital
patients experience a loss of privacy when they cannot
withdraw or find a personal, private space, e.g. when they
have to share room with other patients (Barron, 1990;
Marini, 1999; Mattiasson & Hemberg, 1998; Woogara,
2005). What also emerges from this literature is that
patients experience privacy violations if they have to
witness other patients’ problems (Sidenvall, Fjellstrom, &
Ek, 1994). This aspect of privacy, which has been neglected
in the surveillance literature, is in this paper referred to as
freedom from observing and reacting to others.
What emerges from the privacy and care literature is
that patients primarily desire privacy in relation to other
patients rather than in relation to care professionals. It
seems reasonable to assume that patients are relatively
inclined to willingly disclose personal, health-related infor-
mation to care personnel if they believe that this is relevant
for the care services to be provided. I will return to this
point below.
Care surveillance as a potential privacy harm
As noted above, much of the surveillance literature
builds on the concept of the Panopticon society (Bentham
1969; Boyne 2000; Foucault, 1977), suggesting that e-
surveillance can violate individuals’ privacy by intruding
on their informational and decisional privacy (e.g. Gandy,
1993; Lyon & Zureik, 1996; Floridi, 2006; Michelfelder,
2001; Nagel, 1998; Rössler, 2005; Solove, 2006; Udo,
2001). It is argued that the harm of surveillance is that, if
unsure about whether one is watched or not, one must
constantly present oneself as though one were being
observed. The result is inhibition and self-censorship, i.e.
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130 A. Essén / Social Science & Medicine 67 (2008) 128–136
a loss of autonomy in terms of the authenticity of one’s
behavior, which is turned into behavior ‘‘as if’’.
This view provides significant insights. However, it
highlights certain aspects of surveillance while ignoring
others. Importantly, studies bringing this view of surveil-
lance to the fore build on certain presumptions. For one,
elites with malign intentions to discipline and exert social
control are the assumed agents of surveillance. Second,
the intention to control is understood as an ambition to
constrain the behavior of the targets of surveillance. Third,
the targets of surveillance are depicted as passive victims.
And fourth, the surveillance technology itself is viewed as
the source of negative effects (cf. Bogard, 2006; Dubbeld,
2006; Haggerty, 2006; Lyon, 2007). I will argue below
that these four assumptions are not easily generalized to
the care surveillance setting.
What makes care surveillance a complex subject of
study is the intertwined relation between control and
care (Dubbeld, 2006; Lyon, 2006; Vaz & Bruno, 2003). The
work of Lianos (2003) can provide some clarification
here. Lianos (2003) highlights that institutional control is
integral to specific surveillance activities, but that ‘‘It would
be reductive and unjustified to see such activities as relat-
ing exclusively or principally to control’’. He gives an exam-
ple: ‘‘One could look at a CCTV system which monitors the
traffic on a road network; is this dispositif about repressive
surveillance (traffic offences), detective surveillance (stolen
vehicles).accident prevention or the improvement of
access times for emergency services.?’’ (pp. 415). He
answers that the system is about everything at once. This
is indeed applicable to the care surveillance setting. The
intention behind care surveillance includes but cannot be
reduced to a malign ambition to control (cf. Lyon, 2007).
In this respect, the general definitions of e-surveillance
do not quite capture the meaning of care surveillance.
E-surveillance is often referred to as the systematic obser-
vation and recording of acts of compliance and deviance
in order to manage or influence behaviors by means of
information technology (Clarke, 1988; Lyon, 2001). Dictio-
naries further define surveillance as: ‘‘to watch over; super-
vision or superintendence; close observation of a person or
group. especially one under suspicion e.g. a prisoner, or
the like (usually by the police)’’ (Dictionary.com, 2007).
While the first definition says little about the intention
behind surveillance, the latter highlights that surveillance
is associated with observation of ‘‘suspected’’ individuals
and is understood as something that is done for the sake
of others rather than the surveilled.
Can we not watch over others because we care about
them, then? Of course, we can suggest this is so (cf. Lyon,
2007). Consider the meaning of care: dictionary definitions
of care include ‘‘Watchful oversight; charge or supervision;
to be concerned; have thought or regard; to make provision
or look out for someone in need.providing treatment for
or attending to; have a special preference for; to have incli-
nation, liking, fondness or affection for.’’ (Dictionary.com,
2007). Major caring constructs in the nursing literature are
compassion, empathy, nurturance, succorance, comfort and
support (Cloyes, 2002; Jecker & Self, 1991; Kreuter, 1957;
Lavoie, De Koninck, & Blondeau, 2006; Leininger, 1977).
Hence, care is, just like any type of surveillance, associated
with supervision and ‘‘watching over’’. However, care
also refers to the concern about and feelings directed to
a person – a person in need. An act of care is generally
thought of as performed ‘‘for one’s own sake’’, i.e. to main-
tain or improve the surveilled subjects’ health or safety.
Hence, in studies of care surveillance it is important to con-
sider that care surveillance includes but cannot be reduced
to an ambition to control. It can also incorporate an inten-
tion to maintain or improve the patients’ health.
Let us return to Lianos (2003): he also maintains that
institutional control is often perceived as beneficial ‘‘and
sometimes even liberating as much as constraining’’ (pp.
415). Others have recognized the dual function of surveil-
lance (Lyon, 1994, 2001, cf. Giddens, 1984). For example,
Bogard (2006) refers to surveillance both as capture
(fixing a flow, surveillance as determination) and as flight
(releasing a flow, surveillance as resistance). Bogard
(2006) argues that to surveil means to guard and he
writes: ‘‘guardianship is not a simple constraint, but an
art of control that makes it safe for something to move
freely.’’ (Bogard, 2006: 98). From this view, surveillance
practices can in a sense be viewed as freeing. Drawing on
these arguments, this paper assumes that care surveil-
lance can be perceived as both enabling and constraining
from the viewpoint of individuals.
Finally, the surveillance literature tends to discuss the
effects of surveillance technologies without considering
that the consequences of a certain technology are by no
means given (Ball, 2002; Dubbeld, 2006). The present
paper assumes that while a certain technology facilitates
certain behaviors and impedes others, there are also oppor-
tunities for people to choose how to use and not use the
technology (Berg, 1997; Bijker et al. 1989; Latour, 1987;
Oudshoorn & Pinch, 2003). This perspective makes clear
that users are not necessarily victims passively subjugated
to technological domination or disciplinary surveillance. It
allows for a consideration of the potential resistance from
users (Ball, 2002, 2006; Dubbeld, 2006; Wood, 2003).
In summary, scholars have begun to suggest alternatives
to the dystopic and deterministic principles traditionally
applied in the surveillance literature. There are, however,
no empirical studies illustrating how these principles
work in relation to privacy, in actual empirical settings
and from the perspective of the surveilled subject.
This paper seeks to address this gap in the literature by
exploring individuals’ experience of being surveilled in
relation to their sense of privacy. Privacy here is defined
as (1) the freedom to escape being observed or accessed
when desired. This implies protection from unwanted
access to personal information about us, i.e. informational
privacy; unwanted interference in our decisions, i.e.
decisional privacy; and unwanted admission of others to
personal spaces or areas, i.e. local/physical privacy (Rössler,
2005). Privacy also refers to (2) the freedom to escape
observing and reacting to others (Sidenvall, Fjellstrom, &
Ek, 1994). The question of concern is: how do individuals
experience care surveillance as enabling and/or constrain-
ing in relation to their privacy? The premise is that
a surveillance technology needs to be understood in
relation to how it is used and not used in the actual context,
i.e. how the care surveillance practice is constructed. The
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A. Essén / Social Science & Medicine 67 (2008) 128–136
surveilled subjects are viewed as participating in this
construction.
Method
The purpose of this paper is to understand not only if,
but also why seniors feel that electronic care surveillance
(telemonitoring) does or does not violate their privacy.
The paper further attempts to illicit not only expected,
but also unexpected, privacy issues arising from the
viewpoint of senior citizens. Hence, an open-ended,
in-depth interview approach was deemed appropriate. As
noted by McRobb and Rogerson (2004), quantitative instru-
ments may be too blunt and may obscure more than they
reveal, as our understanding of consumers’ privacy concep-
tions is as yet limited.
Research setting
In 2006, a public long-term care provider in the munic-
ipality of Heby, Sweden, decided to introduce a new tele-
monitoring service in their community. The new e-service
was seen as a potential replacement to traditional manual
alarms that were currently in use. The monitoring service
requires that the user wear a monitoring device on the
wrist. Sensors embedded in the monitoring device contin-
uously collect ‘‘activity data’’ about the user. This data is
transmitted to the care center. Care personnel can access
the data, which is presented in graphical format as activity
curves on a computer screen. The activity curves provide
information about the user’s sleeping patterns (e.g. how
many sleeping interruptions and sleeping periods per day
and night, how many times the user gets out of bed during
the night), when the user leaves the house and takes off the
wrist worn unit, among other things. The activity curves
can be analyzed over time in order to detect changing activ-
ity patterns, which can indicate emerging health problems.
During the first two days of use, the monitoring system reg-
isters each user’s ‘‘normal’’ activity pattern. Thereafter, au-
tomatic alarms are generated when the sensors detect that
the user’s activity diverges from her/his normal pattern, e.g.
in cases where the activity level is unusually low due to the
senior having fallen and turned unconscious. Users can also
activate alarms manually by pushing a button on the
device, just like with ‘‘traditional’’ pendant safety alarms.
The alarms are also transmitted to the care center. The
Heby managers decided to provide the new service to 20
seniors, as a first step, before expanding the use of the
new monitoring technology. Two social workers recruited
20 seniors who were (1) living alone in their own home;
(2) vulnerable and exposed to health risks in their home
and therefore provided with manual safety alarms; and
(3) capable of being interviewed. Three of the seniors could
not use the devices due to allergies, etc. The seniors were
informed about the monitoring service via letters and
were given the opportunity to ask further questions in fol-
low up telephone calls. They were told that that their activ-
ity level would be monitored, that automatic alarms could
be triggered if there would be a radical change in activity
level and that this was performed to ensure their safety.
131
It’s worth noting that the personnel did not see any rad-
ical health problems on basis of the surveillance data during
the study period, but rather that the seniors were sometimes
not wearing their alarms and that they were not sleeping
well. The personnel were ‘‘discrete’’ when acting on this
kind of information. They did not say ‘‘we have seen on
the data that you did not sleep well’’ for example. They tried
to embed questions and reminders, e.g. about to wear
alarms in their regular conversations with the seniors.
Data generation
This study is based on in-depth interviews with 17 of the
seniors (68–96 years old, 9 female and 8 male) who accepted
the use of the monitoring service. This purposeful sampling
strategy can be called extreme case sampling, i.e. selecting
cases that are information rich because they are special in
some way (Alvesson & Sköldberg, 1994). At the time of the
interviews (September 2006), the 17 seniors had been mon-
itored for 6–7 months. The seniors were somewhat familiar
with the interviewer (author) who had visited all the seniors
to perform interviews once before, and who had chatted
with the seniors at least twice on the phone. The interviews
lasted 90–120 min, were performed face-to-face and within
the homes of the seniors. Interviews were very informal,
unstructured, including open-ended questions in order to
allow for unexpected issues to emerge (Patton, 2004). The
interviewer (author) began by asking the seniors how they
experienced the new monitoring alarms, discussing this at
a general level for a while before bringing the issue of
privacy explicitly to the fore. Interviews typically proceeded
with a discussion about privacy and privacy threats. Other
topics were also covered, as this study is part of a larger
research program. Interviews were recorded, transcribed
and translated (Swedish to English) by the author. Notes
were taken on nonverbal cues, such as general appearance,
anxiety, etc. (Patton, 2004).
Data analysis
The content analysis was performed in several steps.
First, all transcripts and observational notes were read
through to obtain a sense of the whole. Meaning units,
a word, a sentence or a whole paragraph that answered
questions of why and how the seniors perceived or did
not perceive privacy violations, were marked. As privacy
perceptions are often covert and expressed ‘‘between the
lines’’ (Bates, 1964), the author tried to be sensitive to
observational notes on nonverbal cues. The meaning units
were condensed into a description of their manifest con-
tent and an interpretation of their latent content. Themes,
i.e. threads of meaning running through the descriptions
and interpretations (Baxter, 1991) were abstracted. The
transcripts were thereafter compared with the aim of
detecting patterns across participants (Moustakas, 1994).
Next, the themes were compared and analyzed based on
the assumptions presented in the theoretical framework.
Hence, a combined inductive and deductive approach was
used (Alvesson & Sköldberg, 1994). In order to improve
the credibility of the interpretation, the author presented
the themes to peer scholars at research seminars
 Author's personal copy
132 A. Essén / Social Science & Medicine 67 (2008) 128–136
(Leininger, 1994). The thematization as presented in this
paper is a result of an iterative process of culling the empir-
ical data, modifying the sub-themes and refining the
theoretical framework. The themes are presented below,
illuminated by extracts and quotations. The names are
pseudonyms.
The Stockholm University Ethics committee gave
approval to the study.
Empirical findings
The interviews suggested that the seniors had divergent
experiences of the new monitoring alarms. Two contrasting
perspectives are presented below.
Care surveillance as enabling – feeling cared for
The majority of the seniors (16 out of 17) expressed
positive views about being surveilled. Interviews suggest
that these seniors believe that the monitoring service
serves their own interest to get help in case of accidents.
For example, Kurt says:
I think it’s great that they do this for us.they must be
very expensive, these new alarms.they told me it
would be safer than the old one [which does not include
any monitoring functionality].so I feel safe. It must be
safer; it is newer so it should be better, more reliable.
And I mean, in this way they can keep a track of me
even when they are not here, which is good because
I’m alone here in my house.
Further, Sonja maintains that:
It is good that they know, it is good thing to be
surveilled! I mean the more they know, the better
they can understand my problems .I really trust
them, the girls. Very reliable girls.You know, they are
like my friends.of course I want them to see if some-
thing is wrong, I might not be able to press the button
and if I am lying on the floor dying .
And Ingrid states that ‘‘.It is a safety thing. you never
know when you will fall. When you least expect it.’’
When asked what he would say if his GP would want to
access the information, Bror says:
Of course he could do that!.I only see him when some-
thing is VERY wrong.and that is not very often so he
does not keep much track of me.I’m glad if he takes
the time to think about my condition! But I have to con-
fess that I am also glad if I don’t have to go to the doctor.
These seniors clearly want care personnel to know as
much as possible about them and they appreciate that
the care providers are interested in gathering data about
them; they see it as a privilege. The seniors also appreciate
it if the care personnel exert influence on their behavior or
intervene, on basis of the surveillance data. For example
Lilly explains:
they can see if I wear the new alarm, and that’s good,
because I tended to forget to wear the old alarm. They
remind me if they see that I’m not wearing the new
alarm. They do it in a nice way of course. Now I always
use the alarm, and that’s good. .And my children
think its great.
The seniors also believed that being surveilled contrib-
utes (in combination with other home-help services) to
them being able to stay safely in their own homes instead
of moving to nursing homes. Henning maintains that:
Sometimes I can feel a bit lonely here living alone. I
think, what if something would happen to me? I mean,
no one knows what’s going on here. I think they have
bought these things [surveillance devices] for this
reason, they cannot call me every minute, but I guess
they can get some information now.and of course
that’s important if I am to remain here in my own house
[as opposed to being moved to a nursing home]. I really
hope I can live here until I die.so that’s good because its
nice if someone else knows if I’m OK or not OK. Of course,
my kids call me now and then, but they may not be lucky
enough to call at the right time so to speak
Further, Ulf says: ‘‘I think we need more things like this,
like this new thing, so that they can keep an eye on us at
home rather than moving us to nursing homes.’’. Privacy
concerns make many of the seniors reluctant to move to
a nursing home. They mention two aspects of privacy in
this context. First, they express a desire for freedom to
escape being observed and intruded on by others:
It is important that you can go home, leave others when
you feel tired.and I like to do just whatever I feel like.
without anyone looking at me. here [in my own home]
I can walk around in my two day old socks sometimes, if
they are not dirty.I try to not wash too often. (Elov).
If I would move to a nursing home they would see me
walking up during the night. .I wouldn’t want to
meet anyone when I get up during the night when I
cannot sleep. Maybe they would force me to take
sleeping pills then! (Anna).
Second, the seniors underline the importance of privacy
in terms of being able to escape observing and being close
to others. In other words, the seniors are not only
concerned about others watching them, but also about
themselves being forced to watch others, illustrated by
the following quotes:
I don’t want company by those I don’t know.I wouldn’t
like to sit with other oldies when I eat.I don’t want to
see them eat with trembling hands.listen to their
memories.it would make me feel older I think
(Lennart).
Last time I was hospitalized it really struck me that there
is nothing worse than being forced to watch people that
cannot manage themselves. And I had to sit next to
some of them who had really bad breaths due to heavy
medication I believe.[.] .and I like the peace and
quiet in my own home.being by myself is not too
bad. I like being by myself too, you see.even if it is
lonely (Bror).
I don’t want to sit and stare at others sitting in their
chairs like me.meeting people in the mornings in the
corridor.hearing them speaking on the phone with
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A. Essén / Social Science & Medicine 67 (2008) 128–136
their children.seems crowded.It’s easier to spend the
days here, where I know what to do. Thanks to my daily
routines the days pass rather quickly. (Bo).
The seniors consider surveillance to be a service that can
help them avoid moving to a nursing home and thereby
escape such intrusions.
The seniors who viewed surveillance as a positive
service did not mention any feelings of ‘‘being watched’’
or feeling intruded on due to the monitoring services spon-
taneously. When asked specifically if they have ever felt
uncomfortable by being monitored, they clearly rejected
this idea. They seem surprised at this question. For exam-
ple, Bror says: ‘‘.I never think about it!.I really don’t.I
hardly feel it. I never take it off.’’ Other seniors expressed
similar views, illustrated by the following quotes: ‘‘. [gig-
gles]. I never think about it!!! .Actually never.’’ (Jim);
‘‘.No, I haven’t thought about it at all. I don’t go around
reflecting on what the alarm does.it feels very natural for
me to wear it.[.] who cares if they see when I get up in
the night and go to the toilet.they’ve seen me naked.’’
(Elov). ‘‘.On the contrary, no! I feel safer now.’’ (Sonja).
These seniors understand that information about them
is collected and transferred to the care providers. They
also know that care providers can see if they are wearing
the alarm or not and that automatic alarms can be
triggered. But none of them completely understand what
the sensors monitor, or how the technology analyzes this
information. They believe they have received sufficient
information, however. Consider Lilly for example. She was
obviously not very knowledgeable about the data collected
about her. I started explaining a bit more in detail how the
new technology operates to her. She seemed very uninter-
ested, even uncomfortable, and says: ‘‘That I do not under-
stand.’’. When I ask Lilly if she wishes she had received
more information about how the technology works, she
says no: ‘‘Oh I think I’ve been sufficiently informed. I don’t
need to know everything about that apparatus .that’s their
job, the girls.and I trust them so.’’. This is typical. Indeed,
the seniors trust the care providers and are happy to dele-
gate the task of understanding the new technology to them.
It is however important to note that while the seniors know
little about the workings of the technology, they do not feel
that they have no control over the service. The seniors do
not feel that the alarms are forced upon them, or that
they have no possibility to exit this service. On the contrary,
they feel that they can interrupt the monitoring service at
any time, as illustrated by the following quotes:
I believe I can get my old alarm back any time, sure. I’d
just tell them if that was the case. (Bror).
You bet I could let them have this new alarm back.I
think it’s much more expensive than the old alarm.
And it’s modern technology. So I wouldn’t trade it
against the old alarm! (Linnea).
Care surveillance as constraining – feeling
as if under suspicion
One of the interviewed seniors, Siv, experienced a pri-
vacy violation. Siv claimed her personal space right from
133
the start. She agreed to meet me when I called her to
book an interview, but with a reluctant tone of voice.
When I arrive, she opens the door with her dog Toy in
her arms. ‘‘You better not touch me, Toy might get mad
then’’, she says and smiles nervously. Siv is anxious, and
suffers from an apparent lack of self-esteem. She worries
about her health a lot. She is frank about this: ‘‘I am
a very anxious person.always have been.I worry about
everything.anything.the smallest things.’’. Siv says –
before I have asked – that she wishes to get her old alarm
back. ‘‘I don’t like it, the new alarm. I don’t like being
surveilled. I want my old alarm back.[.].it doesn’t matter
who looks at the information. The fact that someone can look
is enough.’’. Siv explains her dislike with feelings of being
observed. She thinks that her sleeping pattern is sensitive
information. She says ‘‘I don’t want people to know when I
take a nap.when Toy [her dog] and I are lazy.that’s only
between him and I.they know enough about me. I want to
spare them my strange habits.’’. It is also clear that being
monitored influences Siv’s decisions: ‘‘It hits me, when I
lay down late in the mornings that this is monitored.also,
at times when I can’t sleep and get up in the middle of the
night I sometimes think that this might be seen.which makes
me reluctant to do so!’’
Siv cannot see that the monitoring service adds
anything beyond the service she already receives. The com-
munity care personnel deliver food to her at noon, and
conduct a check up visit in the evenings. She says:
They check on me twice a day already, I think this is
enough.I mean, it is different at a hospital, but in my
own home I don’t want people to watch me all the
time.It feels a bit strange, this idea, to monitor people
in their own homes. Your home is your own place; they
can’t start turning it into a technicality. You have to let
people alone in their own homes. No, that’s going too far.
During my visit, a home-helper came by to give Siv her
old alarm back, which made her happy.
Discussion
This study explored senior care takers’ experience of
being e-surveilled in relation to their privacy. The majority
of the seniors in this study (16 out of 17) have a positive
experience of being surveilled. This has to do with how
the care surveillance technology was used and not used
in the particular setting studied but also with the specificity
of care surveillance. This paper initially argued that care
surveillance includes but cannot be reduced to an ambition
to control. It can also be understood as incorporating an
intention to provide for individuals in need. This view of
surveillance resonates with the view of e-surveillance
expressed by the positive seniors in this study. These
seniors are aware of their frailty and they feel that they
need to be watched over in one way or another. Hence,
these seniors do not experience any violation of their infor-
mation privacy (Rössler, 2005) when monitored because
they do not want to hide the information collected from
care personnel. The seniors further appreciate that care
personnel can acquire digital information about and
influence their behavior. They view it as a benefit to be
 Author's personal copy
134 A. Essén / Social Science & Medicine 67 (2008) 128–136
reminded to behave in certain ways as this can enhance
their own safety. In other words, they do not perceive
that e-care surveillance intrudes on their decisional privacy
(Rössler, 2005). Interviews make clear that the seniors do
desire to physically withdraw from care personnel. They
do not however perceive any local/physical privacy
(Rössler, 2005) invasion due to the monitoring service as
they feel that they are ‘‘let alone’’ (Warren & Brandeis,
1890), even if they are electronically monitored. Indeed,
the monitoring service can indirectly protect informational,
decisional and local privacy from the viewpoint of these
seniors. It strengthens their possibilities to continue living
in their own homes rather than moving to nursing homes,
where they expect significant threats to their privacy, both
in terms of a reduction in the freedom to escape being
observed but also in terms of a declined freedom to escape
being exposed to information about other care takers.
These latter points highlight that surveillance can be
liberating rather than constraining.
In general, these seniors’ reported experience of care sur-
veillance involves the thought of ‘‘a friendly eye in the sky’’
(Solove, 2001) rather than of a ‘‘Big Brother’’ watching
(Orwell, 1949). It is however important to note that the con-
ceived thought of ‘‘friendly eye’’ is not anonymous. The se-
niors rather think of certain care workers, who deliver
other services to them, as being ‘‘the watchers on the other
side’’. Being surveilled by the care personnel who they trust
makes the seniors feel safe. Indeed, it makes them feel more
cared for. The seniors do not reflect much about the surveil-
lance technology itself, it withdraws and merely becomes
a link between themselves and the care workers. This sug-
gests that the technological artifact is far from central in sur-
veillance practices. What is important to consider is rather
how the surveillance service is introduced to the subjects
in the actual setting. An important aspect in this context
was the opportunity for seniors to exit the surveillance ser-
vice. As we discussed above, one of the seniors used this pos-
sibility and opted out of the service. This woman was more
concerned about her public appearance than the others
and she had a lower threshold regarding the amount of
data she was willing to disclose to the care personnel. The
possibility that someone may look at the data collected
about her, and the possibility that her data may not look
‘‘normal’’ bothered this woman. Indeed, e-monitoring in-
trudes on her informational privacy and it threatens her de-
cisional privacy (Rössler, 2005) as the fact that she is
monitored influences – or at least crosses her mind when
making – decisions about how to behave. E-surveillance fur-
ther invades on her local/physical privacy as she perceived
the surveillance service as a physical intrusion in her
home. This woman was however not forced to continue
and the monitoring was interrupted at her request. This il-
lustrates that surveilled subjects can exert resistance.
Hence, the widespread assumption that malign inten-
tions lie behind surveillance practices is not quite valid in
the care surveillance context. The care surveillance practice
studied here involves control but this is not perceived as
constraining by the majority of the surveilled seniors. On
the contrary, the seniors appreciate the fact that the care
providers collect information about and intervene in their
health. They feel that someone else takes responsibility
for their well-being and this makes them feel free rather
than constrained.
Conclusion
This study suggests that care surveillance practices can
be constructed in ways that make the surveilled subjects
feel cared for and liberated. It thereby challenges the wide-
spread deterministic view of e-surveillance as involving the
destruction of privacy and liberty by sinister forces (see
further e.g. Dubbeld, 2006; Haggerty, 2006; Hier, Walby,
& Greenberg, 2006). The majority of the seniors in this
study viewed care surveillance as a means to protect their
privacy in terms of freedom to escape being observed and
observing others face-to-face, as they compare being
e-surveilled to moving to a nursing home. (cf. Rössler,
2005; Lyon, 2001, 2002). Hence, the study illustrates the
dual side of surveillance in relation to privacy, arguing
that surveillance is not necessarily constraining but can
also be enabling (Bogard, 2006; Lyon, 2001, 2006, 2007).
It is however important to note that one senior in this study
perceived the care surveillance service as constraining. The
experience of being surveilled is subjective and it should be
expected to vary across individuals. Of importance here is
a built-in possibility for individuals to exert resistance.
One could argue that the care surveillance practice stud-
ied here involves an element of seduction (see Bauman,
1992; Hier, 2003; Rössler, 2005). The majority of the seniors
studied here are indeed attracted by the rewards they asso-
ciate with being surveilled (individualized care) and rather
uncritically accept the surveillance service. However, de-
scribing the subjects as victims seduced and manipulated
by the care providers would be to oversimplify the situa-
tion and would merely reproduce the view of the surveilled
subject as passive and subject to totalizing powers. We can
learn more by broadening the perspective and analyze the
surveilled’s indirect participation and responsibility for the
development of surveillance practices of the kind studied
here. As noted above, the seniors studied here wish to
age in their own homes, rather than at institutions. This
is partly because of their desire for privacy in terms of
freedom to withdraw physically from others. In general,
citizens’ wish to ‘‘age in place’’ due to the independence
and freedom this entails, has contributed to the emergence
of various in-home care surveillance technologies (e.g. Bar-
low & Venables, 2004). These technologies also emerge as
a result of the governmental desire to reduce costs of nurs-
ing homes and the technology providers’ strive to make
profit. Against this background, the care surveillance
practice studied here may be considered as predicated on
and in the service of a certain type of liberty, namely the
freedom to age in one’s own home and manage everyday
life without being constantly intruded on. This suggests
that surveillance can cultivate and protect certain types of
freedom desired by care consumers in today’s society
(Lyon, 2002; Rose, 1999 cf. Nock, 1993).
Limitations
The findings reported here concern elderly care, which
is a very specific setting. The senior citizens in this context
 Author's personal copy
A. Essén / Social Science & Medicine 67 (2008) 128–136
are generally frail and aware of their need to be ‘‘checked
on’’ regularly. The rural Swedish community studied is
further characterized by a low turnover of care personnel
and satisfied senior citizens. Also, the seniors in this study
are grateful for being provided with new, modern and
expensive monitoring alarms and participating in a devel-
opment project. This may lead to overly positive attitudes.
There is also the risk of the senior citizens seeking to please
the home-helpers and the interviewer by expressing
positive views. The author tried to reduce this risk by estab-
lishing a relationship with the seniors and by creating an
open and informal atmosphere during interviews.
Research suggestions
This study challenges the argument that e-surveillance de-
humanizes activities (e.g. Los, 2006; Ogura, 2006) by showing
that care surveillance can make individuals feel cared for
rather than ‘‘reduced to digital data’’. In the case studied,
e-surveillance complemented rather than substituted face-
to-face visits. More research is warranted about how e-
surveillance can be integrated with face-to-face services in
order to avoid de-humanizing practices.
While the enabling capacity of e-surveillance deserves
more attention in general, so does its constraining poten-
tial. We need critical studies of surveillance practices
rooted in good intentions – at what point do they develop
into unacceptable forms of control? This issue is relevant
considering the development toward IT-based preventive
health assessment in healthcare systems internationally.
Rising wage costs and reducing costs of technology will cre-
ate more instances of e-surveillance. Indeed, Armstrong’s
(1995) argument that we are heading toward ‘‘surveillance
medicine’’ is highly pertinent. Further, this study high-
lighted the agency of the surveilled individuals in terms
of their possibility to exit surveillance services. The alterna-
tives provided to such individuals warrant further research.
Will their resistance imply that they are excluded from
certain benefits?
This study further opens up avenues for research
problematizing the border between the targets and agents
of e-surveillance. As noted by Lyon (2007), people today
increasingly desire public services that require surveillance.
We need to study at multiple levels who initiates e-surveil-
lance practices?
Finally, this paper highlights that privacy does not only
refer to the possibility to limit what others know about us.
Privacy also refers to the possibility to limit what informa-
tion we are exposed to. Further research about how this
privacy aspect, concerning the information flow from the
external environment to us, operates is relevant consider-
ing the vast amount of health information and advice that
is transferred to consumers in today’s society.
Acknowledgements
I want to acknowledge the support and constructive
advice provided by three anonymous reviewers and the
Editorial team of Social Science & Medicine. I also owe
thanks to Ali Yakhlef, Torkild Thanem and Solveig
Wikström at the Department of Business Administration,
135
Stockholm University, for critical but useful comments on
how to improve the paper.
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