Draft Note These are draft slides to be

Draft Note These are draft slides to be updated within one week of presentation to better reflect the direction the presentation may have taken in line with audience participation or Q&A. Not all images have image descriptions. This is an issue of energy resources on my part rather than deliberate or ignorant exclusion, and will be fixed within one week of presentation for accessibility. If you’re hoping to share these, please contact me at c. dalrymple. fraser@mail. utoronto. ca so I can send you a more representative and accessible version first!

Exclusion & Healthism in Population-level Health Nudging Practices C. Dalrymple-Fraser (they/them) Ph. D Candidate, Vanier Scholar, University of Toronto c. dalrymple. fraser@mail. utoronto. ca @socdf — http: //cdf. so/media Prepared for the 2018 Canadian Bioethics Society Meeting Halifax, NS, Canada

Access Check-In Prioritize your wellbeing: we will be discussing content that can be distressing (health exclusions, ableism, eating disorders, calorie counts, etc), and I cannot foresee what may be distressing to you. Feel free to leave, move around, zone out: This space is ours for the moment; use it as you need to. Digital Slides: scan this QR code or visit cdf. so/media for digital versions of these slides Ask me to slow down, rephrase: English is my dominant language and I sometimes use phrases or idioms that are unclear, or speak too quickly. Take photos: You’re welcome to take pictures of me, but try to avoid identifiable photos of others without consent. Can tag me on twitter with @socdf or Instagram with @so. cdf

Silencing and Exclusion Generally: my research focuses on questions like: • Who are practices and conversations designed for? • Who gets to join or access a practice or conversation? • Who gets to be seen/heard in those practices and conversations? • How do practices shape our abilities to act or be together? • And how can we change these answers? Today: Not (only? ) a research talk, but (more) a translation project on perceived exclusions in nudging practices.

Silencing and Exclusion Who gets access to academic and professional conferences? Non-member conference registration: Mean rent, 1 -BRM apartment in Halifax: $966. 00 (after tax) $881. 00 (source: CMHC) See also: Saba Fatima “Walking the Talk of Inclusivity: Prohibitive Costs of Bioethics & Humanities Conferences” (Talk delivered at ASBH 2017, and posted in blog format at IJFAB Blog (26/10/17)

Nudging Health Nudging Practices: Undertake to improve patient or population health via social, political, and private interventions to “choice architectures” to influence (but not force) decision-making: nudges. Central questions in nudging literature: • What evidence do we need to enact nudging practices or policies? • How do we identify/evaluate success criteria, measure outcomes? • Under what circumstances do we require or forego consent? Today: Who are nudges centred around? Who do they presuppose?

Nudging Two examples for discussion: (1) Ontario Healthy Menu Choices Act 2015 (2) Take the stairs initiatives;

Ontario Healthy Choices Menu Act 2015 Requires regulated food service premises that sell food to gen public (with more than 20 premises in Ontario) to display calorie counts on menus, with specification as to formatting. Apparent exemptions: • Food prepared for inpatients of a hospital, private hospital, psychiatric facility, or residents of a long-term care home or retirement home. (2. 2. 2 -3) • Premises that operate for less than 60 days per calendar year, or are located in a school or private school, or correctional institution, or child care centre. (5. 1 -4)

Ontario Healthy Choices Menu Act 2015 Discussion during three readings of Bill 45 (Making Healthier Choices Act 2015, of which Healthy Choices Menu Act was one schedule): • Limited discussion of calorie counts • Largely support offered through narrated self-experiences • Concerns about focus on calories and not sodium, sugars, carbs, fats • “Certainly no negatives” (consequences focus on for business owners) • “Make the healthy choice” becomes “Make the right choice” • Only five explicit mentions of eating disorders (that I found through reading) over more than twelve hours of discussion in Bill readings (and no responses to those comments)

Take the Stairs Initiatives Nudges incentivizing the use of stairs rather than escalators or elevators, usually through postering on elevators, images and statements on closed stair risers, architectural manipulations. General focuses: • “Healthier” option • Calorie burning statistics • “Environmental” option

Take the Stairs Initiatives Johnna S Keller: “The Politics of Stairs” Architectural designs for “preferred” or “irresistible” staircases visually deprioritize or obscure more accessible options. Often motivated by health or environmental concerns. (Keller’s presentation available from Sustaining Access wordpress)

“Today is the day we take the stairs” Who belongs to “we”?

Healthism Crawford (1980): “[Healthism] situates the problem of health and disease at the level of the individual […] health as a primary–often the primary– focus for the definition and the achievement of well-being” Turini (2015): “the role played by health promotion as a moral imperative” Generally: framing and moralizing health in terms of individual choices and behaviours for population nudging tends to rely on normative assumptions or ideals of a “normate” body in its target populations

Healthism Healthy and environmental choices framed explicitly or implicitly as “right” choices ↔ a moral failing not to engage in those activities. Risks perpetuating food and eating stigma or shame, and perception of disability as necessarily deficient, social or environmental drain, and motivates framings of individual responsibility for disability, weight, etc.

Main suggestion Just health nudging practices must explicitly attend to individual and sociomaterial differences that arise in populations, including relational and sociomaterial constraints on choices. A more just and inclusive population health nudging practice will be grounded in initiatives that seek to improve access and disrupt inequalities and stigmas that may be otherwise perpetuated by those nudging practices.

Wela'lioq Miigwetch Merci Thank You

Notes to Acknowledgements This presentation is not my own: Nothing in this talk is new. These criticisms aren’t unique. In fact, the reason I am giving it is exactly because it isn’t new. These things have been said over and over without reception, uptake, or change. I owe debts of gratitude to my friends, peers, teachers, elders, for engaging in conversation and being and feeling with these questions, and to all those on who are sharing their own stories and surviving and resisting. I am grateful to know and grow with you. This event is visible, public (to a degree), and may be archived. I have elected not to include references to those tweets, posts, stories, that people have shared on their own personal web accounts, or in conversation with me, unless explicitly published as public, as a matter of consent and as a matter of potential harm reduction (the internet can be a cruel place to excluded peoples). The references in the preceding slides are, as such, not always representative of the experiences and thoughts of those most affected by these issues, and their uncritical use may risk upholding a status quo of ‘visibility’. I have not closely vetted all their authors or venues for their views or language. I share them based on accessibility for those seeking to read more, and with the explicit cautions of this slide. If you want to know more, and I think we should always strive to, it can be easy to respectfully search social media with keyterms for first person experiences and narratives.

Further Acknowledgements Places and Spaces • The land we gather on, currently known as Halifax, is the traditional land of the Mi’kmaq peoples, and the Wabanaki Confederacy, and a site of the Peace and Friendship Treaty. What is currently known as Toronto or Tkaronto is the land of the Huron-Wendat and Petun First Nations, the Seneca, the Mississaugas of the New Credit First Nation. • Indigenous peoples all across Turtle Island, who are so often disproportionately the subjects and victims of exclusions, of silencing, of having their languages and names and knowledges discounted and appropriated, and of other harms and violences including those of our medical practices and Western conceptualizations of what is ethical or moral. • The staff and workers who ensure that this space is clean and operational, who provided space and food and drink today, who helped us to travel and meet together in person or online, and those who work or suffer globally for our privileges of meeting today and using the resources we do. • The organizers and participants in this conference, for my co-panelists, for those following online via Twitter, for coming together and sharing your thoughts, perspectives, experiences, and everything you are, for building up and (re)shaping this community, and the invitation to join you in doing so. • The baristas and friends who let me haunch over their desks and tables trying to craft these slides, and the friends and study buddies who kept me company and shared reflections on these works in progress. You know who you are. Thank you.