84 FYSIOTERAPEUTEN 5/23 FAGARTIKKEL How is a physiotherapist’s clinical knowledge of treatment appropriately balanced with other aspects of the lives of patients? economics (12), various conceptual types of nudges exist. Consequently, there are various ethical considerations associated with the different types of nudges. However, in what follows, our focus is on raising some general ethical issues associated with leveraging insights into cognitive biases to influence other people’s behaviour in predictable ways. What are incentives? In contrast to nudges, incentives appeal to the conscious and reasoning processes of the human mind. Most basically, an incentive is a proposed transaction, where a price has been put on a particular behaviour (13, 14). An incentive entails that a person is offered an extrinsic benefit for behaving in a particular way, and that the person is free to take the offer or leave it (15). The extrinsic benefit may be both monetary and nonmonetary. For example, a physiotherapist offering discounts on service prices if patients attend a series of group exercises, or a physiotherapist offering t-shirts to patients who adhere to an exercise programme both count as incentives. Accordingly, an incentive functions in the sense that it gives extrinsic reasons to perform a particular action or behave in a particular way, meaning reasons unrelated to the values ascribed to the particular behaviour itself (16, p. 113; 17, pp. 75–6). Like nudges, incentives are generally considered noncoercive and ‘soft’ interventions, where the intended receiver can freely choose to accept the incentive and comply with the requirements for receiving it, or instead refuse the offer and not end up worse off than before the offer was made (16, pp. 77–8). However, proponents of nudging might see incentives as more intrusive interventions, as they consist of changing people’s economic conditions, which, by definition, nudges do not do (note that ‘economic’ here may be interpreted narrowly as alluding to money, as some do (9, p. 125), or more broadly as including every form of utility calculation in human reasoning, concerning money or not (18)). In contrast to nudges that work through changing the choice architecture, incentives add more options to the situation without altering the other options already available or the environment surrounding them, which might be considered a desirable feature of employing incentives (16, p. 42). Since techniques such as nudges and incentives are employed in many physiotherapy clinics, and since we firmly believe it is necessary to discuss the appropriateness of employing such means of promoting certain behaviours, we now turn to an ethical analysis of these concepts. Ethical analysis The purpose of the following analysis is to point at (some) ethical aspects that may have importance for the use of nudges and incentives in physiotherapy practice. Such aspects include the concepts of transparency, manipulation, coercion and motivation. By highlighting these ethical aspects, we hope to help practitioners in considering why and how they apply nudges or incentives in treatment situations, and in determining when they might (not) be appropriate. Transparency As a basic principle, fellow humans should be treated as our equals, and thus as competent grown-ups capable of making informed and appropriate decisions. Making such decisions relies on having a proper understanding of the choice situation (19). Notably, nudges are a type of nonargumentative influence that bypasses the realm of reasoning to instead leverage cognitive biases, which is to say that many nudges are not transparent for the patient (3, pp. 118–22). As such, the patient might be deprived of the opportunity for partaking in processes of making informed choices as they do not know that they are being influenced by specific techniques designed to affect their behaviour in a certain direction. Nudges in the shape of the framing of a choice, or in how the order of the alternatives in a choice set are arranged, are examples of nontransparent influence, whereas nudges in the shape of defaults may be understood as recommendations and therefore influence the patient more transparently (11, pp. 93–4). If, for instance, a physiotherapist organising an exercise class asks participants to give notice if they do not show up rather than if they do show up, because she believes changing the default makes more participants show up, this constitutes a kind of nudging that is easier to see through. In contrast to nudges that might be more or less transparent, incentives work by extending offers of benefits to patients and are thus transparent by their very nature. It is worth noting that while nudges are generally viewed as less problematic than incentives, when it comes to transparency, the asymmetry favours incentives over at least some types of nudges. While the above deals with a side of transparency we might call transparency of the means (the nudging itself), another aspect is the transparency of the reasons for employing such means, i.e. the ends being promoted (3, p. 121). That it is clear to patients what is being done to affect their behaviour, does not necessarily entail that it is clear to them why it is being done. It is conceivable that a physiotherapist employs a nudge or an incentive that is transparent for the patient, but that the reasons for doing so are hidden. It is our understanding, that it is generally rather trans-
RkJQdWJsaXNoZXIy MTQ3Mzgy