Fostering reflection on the ethical dimension of personal health monitoring in the armed forces

Abstract

This dissertation examines the ethical dimension of personal health monitoring (PHM) within the Netherlands Armed Forces and explores how ethical awareness and critical reflection can be fostered to support its responsible development, use, and evaluation. PHM refers to devices or systems carried by individuals that continuously collect health-related data. In military settings, PHM may support health protection, injury prevention, casualty detection, and operational readiness. However, PHM raises ethical questions concerning its intended benefits and broader consequences for individuals, organisations, and society. Within the Netherlands Armed Forces, perspectives on these questions, levels of ethical awareness, and moral responsibilities remain unclear. Strengthening ethical awareness may support critical reflection, help identify moral blind spots, and enable more informed and responsible decision-making. A qualitative research approach combined a scoping review, two case studies, and participatory research. The scoping review showed that research on the ethics of military PHM remains limited. Existing studies predominantly adopt a utilitarian perspective, emphasising anticipated benefits while giving little attention to adverse effects, threats to moral values, and conflicts between individual and organisational interests. The literature also highlights value-based considerations related to privacy, security, trust, and autonomy, and responsibilities regarding data protection and governance. The review argues that the focus on positive outcomes may introduce bias and obscure drawbacks, including overreliance on PHM data. The case studies showed that security, privacy, hierarchy, readiness, trust, and autonomy are central values shaping stakeholder perspectives. Readiness and trust are key drivers for PHM adoption. Trust operates between individuals, between personnel and the organisation, and in relation to technology. However, strong trust, reinforced by military hierarchy and collective goals, may limit critical reflection and contribute to moral blind spots. These may obscure tensions between values and lead to morally questionable practices. Concerns include limited autonomy due to the potentially involuntary nature of PHM and individuals’ restricted ability to act upon their data, as well as inconsistent implementation resulting from differing interpretations of legislation. Stakeholders identified few moral dilemmas, potentially reflecting low perceived concern or the presence of moral blind spots. Based on these findings, the PHM Value Radar was developed through co-creation workshops. This digital ethics support tool centres on trust, autonomy, safety, privacy, readiness, responsible use, hierarchy, and legal frameworks. Through a six-step process, it aims to stimulate awareness and critical reflection, help identify moral blind spots, and strengthen moral competence, thereby supporting informed decision-making. The dissertation further discusses organisational routines, implicit biases, high levels of organisational trust, and the normalisation of technology as potential contributors to moral blind spots. As PHM becomes routinised, its ethical dimension may become less visible. Another concern is the quantification of soldiers, through which measurable data may be prioritised over subjective experiences, potentially affecting well-being and interpersonal relationships. The dissertation concludes by recommending the integration of ethical reflection throughout all phases of PHM, the inclusion of diverse stakeholder perspectives, and attention to the risks associated with high levels of trust and routinisation. The PHM Value Radar offers a practical, pluralistic ethical framework for supporting this process.