86 FYSIOTERAPEUTEN 5/23 other hand, do not target people’s motivation as such, but influence instead through adjusting the choice architecture inherent in the situation, without necessarily influencing the conscious motivation of the patient. Whether techniques are employed to affect behaviour subconsciously or to change the conscious motivations of patients, their use seems to invite certain questions, namely: Whose motivation do they serve? Are nudges and incentives mere instruments designed to affect people’s behaviour in accordance with state-sanctioned health imperatives, or are they ways of helping patients act within their own best interest? How is a physiotherapist’s clinical knowledge of treatment appropriately balanced with other aspects of the lives of patients? Do nudges and incentives promote health at the expense of such balance? If so, is it worth it? Answering these questions once and for all seems impossible as they relate to deeply rooted philosophical and sociological debates regarding the relationship between patient and professional, individual and society. Practical disclaimer Generally, the present paper has not investigated or elaborated on any legal constraints for using nudges or incentives in physiotherapy treatment. Nudges, as defined in this paper, are surely a part of many current physiotherapy practices and must of course be applied in accordance with the obligation to ensure that patients receive professionally sound healthcare. Regarding incentives, there may be differences in the scope of action for privately practising physiotherapists without an agreement with a municipality and physiotherapists working directly or indirectly in the public health services. However, negative incentives in the shape of nonattendance fees that patients must pay if they do not attend their outpatient appointments—including those with physiotherapists—are for instance widely implemented in the public health services in Norway (23). The motivation behind this paper is not to have individual physiotherapists radically change their practices but rather to spark debate about the appropriateness of nudges and incentives in certain situations, and thus to contribute to the development of well-thought-out guidelines for their use that consider other (ethical) aspects than the mere effectiveness of the techniques in eliciting desired behavioural outcomes. Conclusion While there are distinct ethical issues related to the use of nudges and incentives, among them the nontransparent character of many nudges and the potential coercive nature of negative incentives, there is a common moral imperative for physiotherapists to provide and discuss with the public and/or the patients the reasons for employing such techniques. Since both nudges and (at least negative) incentives appear to be prevalent in current physiotherapy practices, and are ripe with potential ethical issues, the need for conceptual and ethical reflections concerning their use is obvious. References 1. Simon HA. Human nature in politics: the dialogue of psychology with political science. Am Polit Sci Rev 1985; 79(2): 293–304. https://doi.org/10.2307/1956650 2. Kahneman D. Thinking, fast and slow. London: Penguin Books, 2012. 3. Blumenthal-Barby JS. Good ethics and bad choices: the relevance of behavioral economics for medical ethics. 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Snakes and ladders: state interventions and the place of liberty in public health policy. J Med Ethics 2016; 42(8): 510–3. https://doi.org/10.1136/ medethics-2016-103502 23. Fystro JR, Feiring E. Mapping out the arguments for and against patient non-attendance fees in healthcare: an analysis of public consultation documents. J Med Ethics 2023; 49: medethics-2022-108856. https://doi.org/10.1136/jme2022-108856 FAGARTIKKEL Hvem sin motivasjon? En konseptuell og etisk analyse av dulter og insentiver i fysioterapibehandling Sammendrag Dulter og insentiver kan brukes – og blir brukt – for å endre og styre atferden til pasienter i fysioterapibehandling. I denne artikkelen undersøker vi først den konseptuelle forskjellen mellom dulter og insentiver. Deretter gjennomfører vi en etisk analyse av disse to teknikkene for å påvirke atferd, hvor vi peker på forskjellige aspekter som kan ha etisk betydning for fysioterapipraksis. Vi konkluderer med at selv om bruken av dulter og insentiver i fysioterapibehandling reiser ulike etiske problemstillinger på grunn av konseptuelle forskjeller mellom dem, eksisterer det et felles moralsk imperativ for fysioterapeuter til å meddele og diskutere grunnene til å bruke dulter og insentiver med offentligheten og/eller pasientene. Nøkkelord: bioetikk, dulting, insentiver, fysioterapi, medisinsk etikk.
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