Presented to the IEEE Serious Games and Applications for Health Conference on April 3, 2017, in Perth, Western Australia

1. The Ethics of Serious Games
for Health
SEGAH 2017 Perth, Australia
Dr. Rudy McDaniel, Twitter: @rutang5
University of Central Florida, Orlando, FL
School of Visual Arts and Design and Games Research Lab
http://slideshare.net/rudymcdaniel

2. The Ethics of Echo
• What is the Echo capable of doing?
• What does the Echo actually do?
• Who has access to the Echo?
• Who does the Echo share information
with?
• Can the Echo learn?
• Is the Echo fair?
• Is the Echo loyal?
• Is the Echo trustworthy?

3. http://gizmodo.com/dont-expect-amazons-alexa-to-help-you-in-a-life-or-deat-1788572138

4. Outline
1. My Background
2. Considering Ethics and Games
3. Ethics for SeGAH
4. Applications and Opportunities
5. Ethical Challenges for SeGAH Designers
6. Responsibilities and Recommendations

5. My Background
• Professor of Digital Media at the University
of Central Florida in Orlando, FL
• Background in CS, psychology, and the
humanities
• Researcher of games, gamification, and
digital badges
• Co-editor of Special issue of Cognitive
Technology (2010)
• Published several book chapters and
articles on studying the ethics of games
(2010-2012)
• Co-Chair of SeGAH 2016 in Orlando, FL
(2016)

6. Discover Babylon (2006)
• What are our
ethical obligations
as serious games
designers?
• Accuracy?
• Fun?
• Access?

7. Veritas University (2009)
How do you teach ethical decision making in a games-based medium?

8. What are the correct sorts of interfaces and
scenarios for teaching about ethical decision
making?

9. Definitions
• There is often a
disconnect between
philosophical work
in ethics and the
practical needs of
professional ethics
training.
• How can we use
games to improve
ethical awareness
and empathy?

10. Learning
• What our team
learned from this
design experience is
that ethics is quite
difficult to
operationalize into
game mechanics.
• Creating rich
scenarios with “grey
areas” is an
important design
technique for
considering ethical
scenarios.

11. Assessment
• Evaluating learning of
ethics is perhaps the
most difficult part of
designing games for
teaching about ethics.
• We can assess
knowledge of content,
but will this awareness
transfer into more
ethical behaviors
when they are most
needed?

12. The Knights of Astrus (2010)
• Knights of Astrus was a
student-led
independent study in
which students at UCF
developed an original
game to explore
difficult decisions in an
RPG.
• Many of the decisions
in the game deal with a
problem of scarcity.

13. On Genre
• Different genres of
games afford
different types of
opportunities for
exploring ethics.
• One benefit of the
RPG genre is the
ability to speak to
multiple characters
and learn about
different stakeholder
perspectives and
values.

14. Avatar
• Of critical
importance in
serious game
design is the
relationship of
the real player to
their virtual
avatar.
• How does what I
do as a character
relate to me as a
real person?

15. Practical Ethics
The player must take
advantage of emergency
escape pods (which require 8
humans to deploy and contain
a maximum of 12 seats) to flee
the premises. She can choose
to rescue the other prisoners,
or leave them to their fate. In
addition, to complicate matters
further, one of the prisoners is
elderly and has a stroke just
when the first pod fills to
capacity. Do you choose to give
up your seat to the elderly
prisoner and hope the other
pod fills, or do you leave him
behind to wait and face an
almost certain death?

16. SuperNutrition! (2011)
• A virtue ethics-based approach to
game design asks us to consider this:
what does it mean to be a virtuous
player or a virtuous designer?
• Project developed for Michelle
Obama’s Apps for Healthy Kids
Campaign
• Designed to provide virtual rewards
to young players for developing
healthy habits in the game world
• Students complete exercise and
nutrition-related missions to power
up their own superheroes

17. Digital Badges for Medicine (2016)
• Digital badges can be
used to credential
expertise, to encourage
exploration, or to
reward performance.
• What are the ethical
implications of using
gamification in design?
• How do we design
ethical
badges/achievements?

19. II. Considering Ethics and Games

20. The Ethical Role of the Player
“I started thinking about this topic because, for
the first time, a game made me consider the
nature of my actions by means of game
mechanics and game world design … When
playing Deus Ex I felt that a computer game was
challenging me as a moral being, showing me
new ways of understanding games as well as my
presence and actions as a player.”
(Miguel Sicart, The Ethics of Computer Games,
2011, p. 2).

21. The Ethical Role of the Designer
“Digital games are particularly well-
suited to the practice and development
of ethical thinking, since, for example,
the computationally rich media
platform offers the ability to iterate
and reflect on multiple possibilities and
consequences. Games also provide a
virtually authentic content within
which to practice and experience
ethical dilemmas and decision making”
(Schrier & Gibson, 2010, p. xx).

22. The Heart Cowboy
• Are the gameplay mechanics
truly conducive to the learning
content?
• What is the order of priority:
• Accurate learning content
• Fun / engagement
• Aesthetics / look and feel
• Balance
• Replayability
• Technological efficiency
• Etc.

23. The Conscientious Designer
• Acknowledging that there are common (but
not universal) values, that games and
applications may embody values, and that
careful design can affect these values.
• Considering “problem setting” in addition to
“problem solving”
• The “conscientious designer” takes an “active
role in shaping the social, ethical, and
political values that may be embedded in
games” (Flanagan & Nissenbaum, 2014, p.
12).

24. Where Do We Look?
• According to Sicart (2011), we still
know little to nothing about the
ethics of computer games and lack
clarity on underlying questions:
• Are ethics important to consider in
the game itself, or in the playing of
the game?
• Is there a difference?
• Do game designers have moral
responsibilities?
• How about researchers?

26. http://www.denofgeek.com/us/games/mass-effect/262932/mass-effects-hidden-kirkpicard-morality-system

27. “Kirk and Picard aren’t opposite ends of a morality scale. They’re two swirling entities in the vortex of existence whose
views on right and wrong are just as likely to cohabitate the same molecule as they are to be on polar ends of the
universe. They are fully-fledged characters and choosing one requires you to play a role.
That’s the problem with Mass Effect’s baseline morality. For all its good intentions and great ideas, it doesn’t fulfill its
promise of letting you complete your character creation over the course of the game through organic choices that
eventually lead to natural consequences. Instead, it encourages you to adhere to preset ideas through methods both
mechanical and psychological. It aims high but too often gamifies morality” (Byrd, 2017).

28. So, Then What Are Ethics?
Ethics are the
moral
principles that
govern a
person’s
behavior.

29. III. Ethics of SeGAH

30. Ethics for SeGAH

31. Ethics for SeGAH

32. What Does it Mean,
Ethically, When…
• Our characters are doctors and
patients and caregivers…
• Our core mechanics are
crafted around critical health
procedures…
• Our GUI is filled with
information with potential
privacy concerns…
• Our stories are taken from real
world healthcare scenarios…

33. Factors to Consider
• What is different with games when we cross from commercial
entertainment games into games designed for health?
• Working with private/protected health information
• Moral obligations to present accurate information
• Possibility for virtuous games (e.g., games to motivate healthy
behaviors)
• Stakeholders of games can be more complex
• Medical processes can be increasingly autonomous and
algorithmic rather than mediated by human facilitators
• Potential connections to non-gaming communities with different
backgrounds, expectations, knowledge about games

34. A Sample Case (Smith & Lammers, 2014)
“Wednesday afternoon in the simulation center learners
are practicing their lumbar puncture skills on a partial task
trainer. They practice and are checked off on the skill and
now feel confident to perform a lumbar puncture on a
patient. A month after learning how to perform a lumbar
puncture, a resident had his first opportunity on a “real”
patient. The resident cleaned the site and prepared for
the procedure and noticed it looked and felt different than
what he remembered when he was learning. The resident
was uncertain about what to do. What the learner did
not know was that the task trainer he practiced with had
been used many times, was old and worn but due to
budget cuts and turnover in staff was not replaced”
(Smith & Lammers, 2014, p. 2).

35. The “Four Principles” of Medical Ethics
• Autonomy: “The patient should have autonomy of thought, intention,
and action when making decisions regarding health care procedures.
Therefore, the decision-making process must be free of coercion or
coaxing” (Stanford, online).
• Justice: Benefits must be equitably distributed across all groups of
society
• Beneficence: The procedure is provided with the intent of doing good
for the patient
• Non-maleficence: a procedure does not harm the patient or others in
society
https://web.stanford.edu/class/siw198q/websites/reprotech/New%20Ways%20of%20Making%20Babies/EthicVoc.htm

36. Counterpoint
“The dominant conception of medical ethics being taught in British and
American medical schools is at best pointless and at worst dangerous, or so
it will be argued. Although it is laudable that medical schools have now given
medical ethics a secure place in the curriculum, they go wrong in treating it
like a scientific body of knowledge. Ethics is a unique subject matter precisely
because of its widespread familiarity in all areas of life, and any teaching has
to start from this shared ethical understanding and from the familiar ethical
concepts of ordinary language. Otherwise there is a real risk that spurious
technocratic jargon will be deployed by teacher and student alike in the
futile search for intellectual respectability, culminating in a misplaced sense
of having ‘‘done’’ the ethics module. There are no better examples of such
jargon than ‘‘consequentialism’’, ‘‘deontology’’, and the ‘‘Four Principles’’. At
best, they cannot do the work they were designed to do and, at worst, they
can lead student and practitioner into ignoring their own healthy ethical
intuitions and vocabulary” (Cowley, 2005, p. 739).

37. IV. Applications and Opportunities

38. Growing Opportunities for Health Games
217 medical students surveyed (53%
female). 98% liked the idea of using
technology to enhance healthcare
education and 96% that education should
do better with new tech. 80% believed
that video games can have educational
value and 97% would use multiplayer
simulations if they were fun. There were
significant gender differences in relation to
preferences for game genre, educational
value, and clinical practice expectations
(Kron, Gjerde, Sen, & Fetters, 2010).

39. Virtual Patients (VPs) and Ethical Training
“Six hundred and one students (77%) completed
the feedback form and the general response of
the student to the EVP cases was extremely
positive. For example, the vast majority (85%)
strongly agreed or agreed that EVPs were an
effective way of gaining knowledge about
medical ethics and 85% also thought that using
EVP cases made them more confident to make
ethical decisions. 95.2% also agreed or strongly
agreed that using the EVP cases encouraged
deliberation, debate and interaction” (Hooper
et al., 2012, p. 674).

40. Methods for Teaching Nursing Ethics Education
(Woods, 2005)

41. Nursing Games to Teach Ethics
“The benefits of using the game are
that students gain confidence in their
ability to defend an ethical decision,
are able to see ethical situations from
more than one perspective, and have
an opportunity to clarify values. In
addition, ethical principles and
decision-making models are brought
to life in a fun way”
(Metcalf & Yankou, 2003).

42. V. Ethical Challenges for SeGAH

43. Areas of Opportunity
• Medical curricula designers also should consider including video games as
teaching tools so that our wealth of health care resources can be delivered
safely and effectively” (Kato, 2010, p. 120).
• “…well-educated nurses continue to argue that their ethical contribution to
health care situations is often received in ways that are either dismissive or
condescending” (Woods, 2005, p. 6).
• “…In the twenty-first century, given the vast disparities that persist in
healthcare resources and access to them around the world, we cannot
continue business as usual” (Kolski, 2005, p. 400).
• We need to move away from games that teach ethical terminology and
jargon and move toward teaching scenario-based decision making.

44. https://www.learningnurse.org/games/wg-ethics/game.html#

45. Unique Issues: The Moral Buffer
• Image Credit: http://www.idc.iitb.ac.in/~anirudha/ppts/UI%20Ethics_09%20Apr%202014.pdf

46. VI. Responsibilities and
Recommendations

47. Ethical Opportunities and Responsibilities for
SeGAH Designers
1. Designers can take advantage of the potential for
multiple stakeholder perspectives
2. Designers can experiment with prototypes for more
intuitive interfaces for medical technologies
3. Designers should be aware of the constraints
imposed by simulated interactive experiences and
the opportunities created by them
4. Designers should possess ethical awareness of
systems and potential ethical challenges (e.g., the
moral buffer)
5. Designers should protect sensitive and private health
information

48. The Trust Game (Macer, 2008)
• “Ask students to sit round in a circle facing each other. Explain to students
that this is a serious exercise about trust. Ask students to think of a secret
that they have which they would not want anyone else to know. Ask them
to write this down on a small piece of paper, fold it up and not show it to
anyone. Now ask students to pass their piece of paper with the secret in it
to the person to their left, but not to look at it. Ask each person around
the circle how it feels to have their secret in someone else's hand. Now
ask each person how in turn how it feels to have someone else's secret in
their possession. You can record some of these responses on a flip chart.
Now ask students to give back the pieces of paper with the secret on them
to the person the secret belongs to. Once this is done, tell students that
they can all destroy their pieces of paper and relax! No-one has to share
their secret.”
• “Debrief students by asking them: What does this tell us about
confidentiality? What kind of things might people share with us, which
should be kept confidential? What rules should we have about
confidentiality in different circumstances?”

49. Recommendations from the Literature
• Medical games are unique enough to deserve their own classification
system as we do not yet fully understand that domain space
(Bochennek et al., 2007).
• Ongoing reflection and practice in simulation is critical, leading to
thoughtful practice in the clinical situation (Smith & Lammers, 2014).
• Expedited ethics reviews for medical games are needed, including the
opportunities to approve frameworks rather than full games
(McCallum, 2012)

50. Useful References
• Bochennek, K., Wittekindt, B., Zimmermann, S. Y., & Klingebiel, T. (2007). More than mere games: a review of card and board games for medical education. Medical teacher, 29(9-
10), 941-948.
• Cowley, C. (2005). The dangers of medical ethics. Journal of Medical Ethics, 31(12), 739-742.
• Green, H., & Hannon, C. (2007). Their space: Education for a digital generation.
• Hooper, C. R., Jivram, T., Law, S., Michell, A., & Somasunderam, A. (2012). Using virtual patients to teach medical ethics, medical law and medical professionalism. Medical
teacher, 34(8), 674-675.
• James, C., Davis, K., Flores, A., Francis, J. M., Pettingill, L., Rundle, M., & Gardner, H. (2009). Young people, ethics, and the new digital media: A synthesis from the GoodPlay
Project. MIT Press.
• Kron, F. W., Gjerde, C. L., Sen, A., & Fetters, M. D. (2010). Medical student attitudes toward video games and related new media technologies in medical education. BMC Medical
Education, 10(1), 50.
• Kolski, E. G. (2005). Renegotiating the Grand Bargain: Balancing Prices, Profits, People, and Principles. In M. A. Santoro & T. M. Gorrie (Eds.), Ethics and the Pharmaceutical
Industry (pp. 393-403). New York: Cambridge UP.
• Macer, D. R. (2008). Moral games for teaching bioethics. International Center for Health, Law and Ethics.
• McDaniel, R., & Fiore, S. M. (2010). Applied ethics game design: Some practical guidelines. Ethics and game design: Teaching values through play, 236-254.
• Metcalf, B. L., & Yankou, D. (2003). Using gaming to help nursing students understand ethics. Journal of Nursing Education, 42(5), 212-215.
• McCallum, S. (2012). Gamification and serious games for personalized health. Stud Health Technol Inform, 177(2012), 85-96.
• Schrier, K. (2010). Ethics and Game Design: Teaching Values through Play: Teaching Values through Play: IGI Global.
• Sicart, M. (2011). The ethics of computer games: MIT Press.
• Smith, A. B, Lammers, S. E. (2014, December). The Ethics of Simulation, Defining Excellence in Simulation Programs (pp. 592-596). Philadelphia, PA: Wolters Kluwer.
• White, G. B., & Davis, A. J. (1987). Teaching ethics using games. Journal of Advanced Nursing, 12, 621-624.
• Woods, M. (2005). Nursing ethics education: are we really delivering the good(s)? Nursing Ethics, 12(1), 5-18.

51. • http://gamesresearch.cah.ucf.edu/
• https://www.facebook.com/groups/ucfgames/