wow-inequalities/02-data/intermediate/wos_sample/5f7d2e2dd4359f6bd0fad2e99693e8c5-gould-carol-c./info.yaml

abstract: 'The concept of solidarity has recently come to prominence in the

  healthcare literature. When understood descriptively, it usefully

  supplements other conceptions like reciprocity (e.g., between healthcare

  providers and their patients), patient-centered medicine, or care

  ethics. In the context of health insurance (especially in Europe), an

  appeal to solidarity effectively addresses the problem of the motivation

  for taking seriously the medical needs of compatriots by emphasizing

  shared vulnerabilities and needs. If understood more broadly as human

  solidarity, the notion proposes attention to the health of distant

  others, as a condition of their dignity. And taken normatively, it fills

  in some of the requirements of the abstract norms of justice and

  equality by advocating `standing with'' or aiding fellow community

  members or possibly also distant others in regard to their medical

  needs. Solidarity may be understood be required either for its own sake,

  when taken as a separate norm, or as a way to realize the demands of

  justice and equal treatment in matters of health. The current focus on

  solidarity in the healthcare literature is useful and important, in my

  view. Yet, to my mind, the understanding of it tends to be unduly

  restricted. For one thing, the literature has most often focused on

  solidarity within nation-states, as a relation among compatriots that

  supports universal healthcare. The notion is also seen as having import

  for contemporary developments like large health databases, biobanks,

  personalized medicine, and organ donation. A few authors extend

  solidarity more widely, particularly in interpreting the Universal

  Declaration on Bioethics and Human Rights, with its reference to

  solidarity in Article 13 and its implication in some other articles.

  Yet, these various uses of the conception of solidarity in healthcare

  have thus far tended to either disregard or even to actively eschew its

  traditional meanings of labor solidarity or social movement solidarity,

  or indeed, any use of the term that posits an `other'' against which

  solidarity might be practiced (although it is generally recognized that

  the concept is bounded and particular). I suggest that the neglect of

  some important historical (and contemporary) senses of solidarity-and

  especially social movement solidarity-leads to a blind spot in the

  current bioethical theories. An alternative reading of solidarity in

  healthcare drawing on social movement and labor contexts would highlight

  a crucial dimension of contemporary healthcare provision, namely,

  structural injustice. Systemic forms of injustice militate against

  adequate healthcare for all, and suggest the need for solidaristic

  action to struggle against and to remedy existing entrenched

  inequalities. Omitting an account of structural injustice and even of

  justice itself from the core meaning of solidarity leads, I argue, to a

  rather weak and too easy sense of what solidarity requires, and is ill

  suited to serve as an adequate normative guide for improving healthcare

  in the present. This is the case most obviously in regard to healthcare

  in the United States with its unequal health system, but I suggest it

  applies more generally and even in Europe, and certainly if we take the

  obligations of solidarity to extend transnationally. While traditional

  notions of solidarity within existing communities and nation-states

  remain significant, I believe that an adequate conception of solidarity

  needs to show how it is connected to justice.

  It also needs to extend transnationally, given our increasingly

  interconnected world, which raises difficult questions of the relation

  between national and transnational solidarities, and the justifications

  we can give for prioritizing the health and healthcare of those closer

  to us. In this essay, I will begin by briefly indicating how the

  existing approaches to solidarity in healthcare, despite their trenchant

  analyses of many of its features and applications, remain abstract and

  without sufficient critical import by not directly considering the

  impact of structural injustices. I will then attempt to sketch how an

  understanding of institutional barriers to equal treatment, along with

  the commitment to achieving justice concretely, need to inform not only

  our application of solidarity in practice but also our understanding of

  the core meaning of solidarity itself. I will not be able to address

  here the complex question of the priority that is often given to the

  needs of those close to us and the related question of negotiating our

  obligations to engage in national vs. transnational solidarity efforts,

  but I have taken this up in other work. In a series of books and

  articles, Barbara Prainsack and Alena Buyx have taken the lead in

  calling attention to the relevance of the concept of solidarity for

  bioethics. They have articulated a general conception and sketched

  several potential implications for healthcare and bioethics more widely.

  They advance the following definition: `Solidarity is an enacted

  commitment to carry ``costs{''''} (financial, social, emotional, or

  otherwise) to assist others with whom a person or persons recognize

  similarity in a relevant respect.'' Prainsack and Buyx usefully develop

  the notion of solidarity as a practice and see it as operating within

  three domains: the interpersonal, the group, and the

  administrative/legal. Their conception is largely descriptive, although

  it has some normative preconditions, and involves what they call

  axiological/axiomatic normativity of some sort. The difficulty of this

  latter phrase aside, Prainsack and Buyx seem willing to countenance

  morally negative expressions of solidarity (e.g., among members of a

  gang or even a terror group) in the interest of preserving the analytic

  utility of the concept. Moreover, they sharply distinguish solidarity

  from justice, regarding the latter as deontic and thus as not part of

  the concept of solidarity itself. But given their attention to the

  context of the practice of solidarity, they expect that norms like

  justice would be brought to bear, presumably to qualify the practice of

  solidarity. Since Prainsack and Buyx''s approach is perhaps the most

  highly developed conception of solidarity in the bioethics literature,

  it can serve as a useful foil for elaborating my own account, drawing on

  and extending my previous work on this theme. The main strength of their

  approach, it seems to me, lies in its aptness for understanding

  solidarity as a group practice, and especially within nation-states.

  Indeed, their view, with its emphasis on bearing costs to assist others

  within a group, seems to line up primarily with what has been called a

  `civic solidarity'' conception, one that has been prominent in connection

  with European welfare states. The idea that solidarity can come to be

  entrenched administratively and legally also points to the dominance of

  that European model in their understanding (though their conception is

  supplemented with what they call interpersonal solidarity).

  Importantly, these authors'' emphasis on solidarity as a practice

  helpfully ties solidarity to action. They suggest that this action

  orientation serves to distinguish solidarity from empathy or other

  sentiments. However, the centrality in their account of bearing `costs''

  with the aim of assisting others brings the model close to the Christian

  tradition of solidarity with its emphasis on relieving suffering and

  aiding the poor. Their perspective likewise focuses on individual

  activity in aiding others, rather than on collective action. (The term

  `costs'', however, has financial connotations that do not sit altogether

  easily with this religious perspective.) The Christian tradition of

  solidarity can be distinguished (at least in its older forms) from the

  alternative socialist tradition of labor union solidarity, where

  solidarity is aimed at promoting shared interests and overcoming

  domination and exploitation with the aim of achieving justice. In this

  article, I will suggest that this latter understanding of solidarity

  introduces an important normative aspect of the concept of solidarity,

  one that is largely lacking in Prainsack and Buyx''s account. Although

  Prainsack and Buyx are at pains to differentiate between solidarity and

  charity (which is indeed an important distinction), I find their

  argument on this point unconvincing. They claim that charity is marked

  by assistance for others who are perceived as `different'' from oneself,

  rather than as being `similar in a relevant respect.'' The problem is

  that this distinction could be seen as having a question-begging aspect,

  inasmuch as the authors seem to posit by definition that in cases where

  people choose to donate to charities for people with a similar condition

  to their own (e.g., a particular illness), they are in fact acting in

  solidarity rather than charity. At the very least, more argument would

  be needed to establish the difference in question. Indeed, the issue of

  what is perceived as `similar'' and what counts as `a relevant respect,''

  remains rather vague in their account. Clearly, perceptions of

  similarity and difference are notably various and variable. Can the

  perception of similarity with another in a relevant respect always be

  explained in a way that itself makes no reference to the solidarity that

  is supposed to follow from it, as it would have to be to avoid

  circularity? Is it, for example, the abstract status of being a fellow

  citizen that generates solidarity or does our tie to these others

  already presuppose pre-existing solidarities, e.g., as being members of

  our nation? The account would need to explicitly address questions such

  as these and also explicate what counts as `similar in a relevant

  respect'' to concretize this notion and give it real utility. In my own

  view, as developed elsewhere and as will become clear below, the

  distinction of solidarity from charity turns rather on the connection

  that solidarity bears to justice, and to the overcoming of domination

  and exploitation. It can also be seen to involve reciprocity in a sense

  to be indicated, which charity does not. Indeed, Prainsack and Buyx

  sharply distinguish between solidarity and reciprocity, taking the

  latter in the narrow sense of what I have elsewhere called instrumental

  reciprocity or `tit for tat'' reciprocity.

  In my view, reciprocity is a fundamental social relation that in fact

  takes several forms besides such instrumental ones, and I believe that

  reciprocity remains important for properly understanding solidarity.

  This potential for reciprocity helps to distinguish solidarity from

  charity, since charity evidently does not presuppose reciprocation from

  the needy or those aided. The reciprocity that applies to solidarity

  actions can be seen in the notion of mutual aid, which has been part of

  traditional understandings of labor and social movement solidarity. The

  mutuality involved here is itself a developed form of reciprocity, but

  one characterized not instrumentally in the manner of Prainsack and

  Buyx. Rather, reciprocity and the solidarity that incorporates it are

  here seen as aiming at improving the situation of the other, at least

  partly for its own sake, and not only for the subsequent return of

  benefit that could be expected from doing so. Although they do not

  explicitly tie solidarity to the overcoming of domination and

  exploitation, Prainsack and Buyx do helpfully take note of the dangers

  for healthcare posed by commercial interests, as well as entrenched

  inequalities. This is evident, for example, in their account of the

  problems that afflict the use of large databases and biobanks, as well

  as the perils that attend some proposed uses of personalized medicine.

  But these problematic dimensions of contemporary life are treated more

  as background conditions rather than as structural and institutional

  features against which solidarity actions with others need to struggle.

  Moreover, we can observe that the prevalence of commercial interests in

  regard to health databases can undercut the very possibilities for

  solidarity that these authors seek, by deterring people from

  contributing their information to them from fear of such commercial use.

  This lends an additional practical motivation to taking these structural

  background conditions seriously, if solidarity is to be encouraged.

  Certainly, these authors are right to highlight forms of solidarity that

  may arise in pursuit of common aims or shared goals, as within a

  political community (often taken as national). But I would suggest that

  solidarity is also centrally a process aimed at overcoming forms of

  domination and structural injustice, where people share an interest in

  doing so. This struggle against domination can sometimes itself take an

  instrumental form. But when it involves normative solidarity, it is

  properly understood as motivated by a shared interest in justice rather

  than simply the pursuit of benefits. As I have suggested, the classic

  account of solidarity in this sense is that of labor movement

  solidarity, but similar notions have characterized a range of social

  movements, e.g., in Latin America and elsewhere, whether aimed at

  agrarian reform or at overcoming authoritarian rule, where they take the

  form also of democratic movements. I propose that these examples, with

  the processive and critical notion of solidarity they imply, have

  implications for an adequate conception of solidarity for healthcare and

  for its applications there. Before turning to this socially critical

  notion of solidarity, we can note a drawback in the standard reading

  that takes solidarity as a unitary notion within a single group or

  community like the nation-state. Insofar as the group is limited to

  compatriots, or to members of smaller pre-existing groups, it evidently

  does not address the needs or vulnerabilities of others situated outside

  these groups'' borders.

  Although there may be unitary groups or communities that are

  transnational, within which traditional forms of solidarity can be

  found, increasingly we see that cross-border or transnational

  relationships take a networked form and involve relations to

  `outsiders''. What sorts of solidarities are possible there both

  generally and in the context of healthcare? Some bioethicists have

  recently addressed this issue by introducing a notion of human

  solidarity or global solidarity. In the analysis given by Gunson, the

  notion of solidarity held to be suitable for global contexts and seen as

  underlying the Universal Declaration on Bioethics and Human Rights is

  explicitly understood as `weak solidarity,'' namely, `the willingness to

  take the perspective of others seriously.'' It does not add the

  requirement `to act in support of it,'' which he holds is characteristic

  of `strong solidarity,'' such as is involved in political solidarities or

  in social movements to counter exploitation or achieve justice. Gunson

  explicates weak solidarity as involving listening to others and `caring

  for others,'' but not necessarily as including efforts at reducing

  inequalities, or even a specific concern with those. He sees the

  Universal Declaration on Bioethics and Human Rights as appealing to a

  notion of human dignity, but seems to think that weak solidarity is

  sufficient to respect and uphold that dignity. I would suggest that the

  appropriate sense of dignity is the robust and demanding one that we

  find explicitly enunciated in the Universal Declaration of Human Rights,

  where dignity is taken in an egalitarian sense, and is held to imply

  certain labor rights, along with health itself as a human right. A

  related notion of dignity is likewise appealed to numerous times in the

  Universal Declaration on Bioethics and Human Rights, which also includes

  a specific reference to solidarity, as a goal of international

  cooperation, along with demands on governments for meeting health

  research and healthcare needs. But this Declaration could usefully go

  further to specify some of the practices that would help to realize

  these aims, and I suggest that strong, rather than weak, forms of

  solidarity would be required in order to fulfill them, and not merely

  the caring for and aiding others that Gunson and also Prainsack and Buyx

  emphasize in their accounts. We can distinguish two main senses of

  solidarity, as already adumbrated, each of which has import for

  healthcare and the structural injustice that may constrain it. One sense

  is unitary solidarity, often taken as pertaining to the relations among

  citizens within a state, but applying as well to the relations among

  members of smaller pre-existing groups. The second is what I call

  networking solidarity, evident when groups (often, though not

  necessarily, transnational), or sometimes also individuals, link up to

  work on projects aimed at overcoming oppression or exploitation. The

  first form of solidarity-unitary group solidarity-is often illustrated

  with the motto of the three musketeers: `One for all and all for one,''

  but that is a rather specific and highly demanding version of it.

  Nonetheless, it has the advantage of calling attention to solidarity as

  involving a clear awareness of a `we'' or `us''. Although some sense of a

  `we'' can be discerned in both forms of solidarity analyzed here, it

  applies to each type somewhat differently, as we shall see.

  In contrast, the individualist approach to solidarity advanced by

  Prainsack and Buyx tends to diminish the role of shared or collective

  activity, although it helpfully includes a notion of identification with

  an other who in their view are aided because they are regarded as

  `similar in some respect.'' In the account that I have developed, the

  first sense of solidarity pertains to relations among co-participants in

  an ongoing group, oriented to shared goals. Not all of the participants

  necessarily share all the goals of the group though they are generally

  committed to the main ones and to the group''s persistence and viability

  as a whole. Note that solidarity here may not always require a

  pre-existing shared identity or culture (although it often does), but

  may emerge from the constitution of an ongoing `we'' in the context of

  collective or group agency. The shared goals of the group are not

  aggregative, that is, a sum of each individual''s similar goals, but

  arise in common endeavors (normally including a multiplicity of

  overlapping subordinate goals), where the overarching goals are at least

  partly constitutive of the group itself. The various aims and goals are

  not always explicitly reflected on and are often embedded or

  institutionalized in the practices of the group. While such a conception

  of solidarity is often thought to be merely descriptive, I see it (as

  will be the case for the second sense as well) as grounded in a social

  ontology of what I have called individuals-in-relations, and as having

  normative dimensions. In this first case of group solidarity, as an

  instance of what I have elsewhere called `common activities,'' the norms

  go beyond the commitments involved in the constitution of any group

  whatever, and extend to the recognition (though often only implicit) of

  the fundamentally equal status of the individuals who constitute the

  group as agents. In virtue of this equality, I have argued elsewhere

  that the members should be granted equal rights to participate in

  processes of affirming and revising the goals of the group and should

  also have some say in how the various shared goals are carried out. This

  follows from an understanding of justice as what I have termed `equal

  positive freedom,'' or prima facie equal rights to the conditions of

  self-development, where such social contexts of activity are among these

  necessary conditions for individuals. In virtue of their equal agency,

  no individual has a right to dominate others in determining these common

  activities, that is, they have equal rights of co-determination of them.

  In this perspective, solidarity can be seen as an integral part of a set

  of norms that encompasses justice, as requiring the equal freedom of

  these relational individuals to develop themselves over time, and the

  norm of democracy, going beyond its traditional meanings of voting and

  majority rule to include equal rights of participation in co-determining

  group ends. In this account, which emphasizes people''s interdependence

  and their embodied nature, the sort of mutual support involved in group

  solidarity emerges as a crucial condition for the self-transformative

  activity of individuals and for the persistence of the group itself. We

  can say then that the requirement to realize justice along with a broad

  range of human rights through solidaristic activity arises from people''s

  interdependence and from the fact that their free development as agents

  requires a set of conditions, both material and social.

  Justice calls for the protection of the traditionally recognized

  negative liberties, but goes beyond it to require the availability of

  conditions that support people''s self-developing activity (both as

  individuals and as collectives) over time, that is, their positive

  freedom. Crucial among these conditions are health and healthcare, as

  well as education and other central social needs. Given the individuals''

  fundamental equality as agents, with both individual dignity and shared

  needs, the norm of justice as requiring action to realize equality not

  only qualifies any potential group solidarity, as it does on the

  Prainsack and Buyx account, but is properly a core aspect of solidarity

  itself as a normative practice. From this perspective, the solidarities

  that obtain within a group not only help to realize justice concretely,

  but also can be said to constitute `the other side of justice'' (in

  Habermas''s phrase). Solidarity actions not only reflect people''s

  pre-existing feelings of connection to each other, but also can function

  in practice to solidify their understanding of shared neediness and

  their interdependence in meeting these needs and pursuing shared goals.

  The interdependence involved in common endeavors like political

  communities, together with the equal vulnerability of members of such

  communities, involves forms of reciprocity and gives rise to the

  requirement of mutual aid that is characteristic of solidarity. Further,

  the conditions for the realization of both individual freedom and of the

  shared goals of the group can in fact be seen to require the absence of

  domination and exploitation, that is, the overcoming of these one-sided

  forms of recognition not only in interpersonal relations, but also as

  they are entrenched in structural or institutional forms. Included here

  are types of economic functioning that systematically disadvantage large

  groups of people, along with other forms of institutional discrimination

  on the basis of race or gender, or other minority characteristics.

  Although existing solidarity groups are not always fully aware of the

  relevance to them of overcoming such injustices, I believe that such

  demands of justice are in fact integral to solidarity as a norm and not

  external to it, as on the empirically oriented account advanced by

  Prainsack and Buyx. Moreover, we can see that ongoing (and not merely

  pre-given) solidaristic social action within a collectivity and

  community is needed as a way to more fully achieve justice within it.

  These interrelations between solidarity and justice are even more

  evident in the second sense of solidarity, which I have called

  networking solidarities. This second form is most often found in social

  movements. Conceptually it arises primarily from classic notions of

  labor solidarity, which I have suggested can be extended to these

  movements and can even characterize the relations that are increasingly

  evident among civil society associations, e.g., NGOs. Networking

  solidarity is a form particularly apt for capturing constructive

  relations of support toward distantly situated others, but it can also

  apply within, as well as across, borders. This form of solidarity is

  generally aimed at overcoming forms of domination and exploitation, but

  may also include networking to help alleviate suffering.

  As a relation among groups (or sometimes even among individuals), I have

  elsewhere argued that it manifests a type of social empathy or the

  understanding of another group''s situation and perspective, but such

  solidarity does not consist in sentiment per se. Rather, it necessarily

  involves action or a readiness to take action on behalf of, and in

  support of, others. Here, too, there is generally a commitment to a

  common cause, and when properly understood, I think, a commitment to

  justice. Although this form of solidarity in practice has tended to

  involve better-off people working to help those who are less advantaged,

  we can find a form of reciprocity implicit even here, in particular, an

  expectation of reciprocal action and mutual aid were it needed. More

  direct reciprocity is evident in traditional labor union solidarity, as

  well as in some social movements, where the solidarity actions are among

  people perceived to be similarly situated. In these various cases of

  networking solidarity, I have argued that normatively solidarity

  requires deference to the needs and goals of others as they themselves

  understand them. And ideally, solidarity movements should embody

  democratic modes of decision making among the participants, given their

  equal status as members, and their shared commitment to the overarching

  goals of their movement. Although there are some fully shared goals that

  motivate these forms of networking solidarity, especially inasmuch as

  they often take a project-oriented form, different subgroups act to

  realize these goals in ways they themselves determine, and they liaise

  or link up with each other to decide how each group can best participate

  and contribute. As groups or associations of their own, they tend to

  have their own sets of goals and plans unrelated to these solidarity

  actions. But they take themselves to be part of the larger movement or

  set of associations, aimed at overcoming forms of domination or

  suffering. Moreover, they often make use of online forms of networking

  and social media to coordinate their efforts with each other, and they

  offer each other mutual support and encouragement. Although the groups

  or individuals linking up in these networks can in some sense be

  regarded as themselves constituting a superordinate group, and thus from

  an abstract perspective as not being essentially different from the

  first form of group solidarity, the latter is unitary and understood by

  the members as a single group, most often pre-existing, while the former

  involves loose relations among groups (or sometimes also individuals)

  undertaken for the purpose of a given project or aim. In practice, then,

  we can regard these two forms of solidarity as distinct, and see them as

  manifested in two different types of social phenomena. The `we'' in the

  case of networking solidarity is constructed serially and diversely by

  its member groups (or individuals), and is oriented to a particular

  cause. Nonetheless, insofar as they take overcoming domination,

  oppression, or exploitation as their aim, they are at least partly

  defined by an egalitarian commitment to justice, and the `we'' should

  remain open to others similarly committed. It must be granted that labor

  solidarity and most social movement solidarity have often involved

  shared interests and an antagonistic relation to others regarded as

  exploitative or authoritarian. Indeed, the first sense of solidarity, as

  group solidarity, admits of a similar antagonistic relation to

  outsiders, e.g., in the case of hostility toward other nation-states.

  Nonetheless, we can see how normatively each of these forms of

  solidarity has the potential to develop in ways that are more inclusive

  rather than exclusive. In the national case this is possible if borders

  are not understood to reflect unitary shared identities but come to be

  regarded as contingent and indeed as porous, or at least much more so

  than at present. Likewise, labor and social movement solidarity are in

  principle open to all those who wish to join in their efforts to work

  toward social (and indeed global) justice, even though it must be

  admitted that in practice those benefiting from exploitation are

  unlikely to join in. The connection of solidarity to social and global

  justice suggests the need to theorize more fully how structural or

  systemic forms of injustice set the frame and motivation for many

  solidarity movements and can serve to orient their practices. The notion

  of structural injustice is perhaps most relevant to networking

  solidarities, especially where they explicitly aim at establishing

  justice and therefore would have to address such institutional forms of

  injustice. But this notion can also apply to unitary solidarity groups,

  if they seek to adequately meet the basic needs and respect the human

  rights of their members, who are affected by these forms of injustice.

  That structures or systems may operate so as to consistently produce

  injustices has been a prime insight in Marxist theories, which highlight

  the way the capitalist economic system exploits workers, apart from the

  specific intentions of individuals, who often do not aim at such

  exploitation. While classical liberal theories tend to put great weight

  on individual action and intention, the Marxist emphasis on structure

  and on the functioning of the capitalist system focuses us on the

  underlying ways in which corporations operate in accordance with the

  requirement to increase profits by way of the exploitation of labor.

  Marxist theory also brings to the forefront the notion of

  objectification. This refers to the significance of the embodiment of

  intentions and plans in artifacts and on the need to be recognized by

  others if people are to understand themselves. That is, it introduces

  elements of externality required for self-transformation, whether

  individual or cultural. In such an approach, not only the social, but

  the material, environment for human action can in various ways reflect

  existing class and other salient group differences. This environment for

  action also generates steady expectations and encourages certain modes

  of comportment in people who tend to operate in accordance with

  prevailing social practices and rules. At the same time, people have the

  capacity to change these practices and rules over time, though often

  only through collective choices and action. (This point may not always

  be duly appreciated in theories of structural injustice themselves.)

  More contemporary analyses of the structural factors that contribute to

  injustice, as found for example in the work of Anthony Giddens and Iris

  Young, cast light on how individuals can reproduce problematic practices

  through their choices within these structural constraints. While Giddens

  focused on processes of what he called structuration, Young highlighted

  consumer choices and other social practices that serve to produce and

  reproduce injustices, in a certain sense unwittingly, for example, by

  impacting sweatshop workers at a distance or by limiting access to the

  existing housing stock.

  According to Young:Structural injustices are harms that come to people

  as a result of structural processes in which many people participate.

  These participants may well be aware that their actions contribute to

  the processes that produce the outcomes, but for many it is not possible

  to trace the specific causal relation between their particular actions

  and some particular part of the outcome. This emphasis on structure,

  Young argues, turns our attention to `how the institutions of a society

  work together to produce outcomes that support or minimize the threat of

  domination,'' where these outcomes largely depend on the social

  positioning that conditions people''s diverse life prospects. In later

  work, Young''s emphasis turns more to the ways that practices that

  connect people to each other implicate them in these processes of social

  and structural reproduction. On her view, the connections in which

  people stand give rise to what she calls a `forward looking'' sense of

  political responsibility, and evoke the need to stand in solidarity with

  others. Leaving aside the difficult issue of responsibility, we can

  observe that focusing primarily on the amorphous practices of social

  life can lead us away from understanding the workings of contemporary

  political economy and its detrimental effects on those who lack the

  power to take any part in determining its direction. I have also

  criticized a view that would simply characterize everyone-whether

  workers or top executives-as implicated in these processes and

  practices, seeing these groups as distinguished only by degree. Rather,

  some have substantial control over the processes to which others are

  subjected. But for the purpose of the analysis here, we can take

  structural or systemic injustice to refer both to the operation of the

  formal political-economic institutions of capitalism (along with racism

  and patriarchy), and to the more informal practices and rules of social

  life, which also contribute to the production and reproduction of

  inequalities. How, then, are these structures and the injustices they

  produce connected to solidarity, as analyzed here? Without attempting a

  thorough account, we can observe that capitalist economic institutions

  have in fact disrupted earlier forms of solidarity, such as those

  characteristic of pre-capitalist political economies, marked by what

  Durkheim called mechanical solidarity. At the same time, new forms of

  solidarity have been created, e.g., through the division of labor (as

  described in Durkheim''s term organic solidarity). In political contexts

  as well, older solidarities within local communities have tended to give

  way to national, or even transnational, forms. Yet, of greater relevance

  for us here are the ways in which political economic institutions, with

  the inequalities and forms of domination and exploitation they may

  generate, frame and motivate new solidarity movements to address these

  injustices. Recognizing how institutions and practices function in ways

  that assign differential power to various groups in society is essential

  if justice is to be constructed through solidaristic action. Even where

  solidarity actions aim only at relieving suffering and do not directly

  attempt to eliminate oppression or explanation, some understanding of

  the social and institutional context of those to be aided is needed if

  the solidarity actions are to be effective.

  For example, efforts to address the aftermath of hurricanes and also to

  mitigate them going forward call for attention to the social conditions

  that lead impoverished or minority groups to be disproportionately

  affected by such natural events-by reason of where they live, or the

  ways they lack protection against excessive damage from these natural

  events. In such situations, empathy with the situation of others, and

  even specific action to assist them, however important they may be, are

  insufficient unless they are coupled with an understanding of the

  impacts of the structural features of political economy and the

  injustices to which the operations of these institutions give rise. This

  is even more evidently the case where solidarity movements aim directly

  at overcoming oppression and exploitation, e.g., ending sweatshop labor.

  In such cases, effective action must not only support workers

  individually or remedy their specific situation but requires a socially

  critical analysis of the prevailing context that gives rise to the

  exploitation in the first place, which may also provide indications of

  how to address it. We can grant that solidaristic practices, whether in

  healthcare or other contexts, may well have their own utility as an

  expression of our sociality and our enjoyment of acting in common, and

  in this sense solidarity can even be said to have some value apart from

  its functioning to help in constructing justice. But the argument here

  is that these practices can be truly effective in meeting their aims

  only if they go well beyond charity and also beyond practices that

  simply `incur costs to assist others recognized as similar'' (in the

  Prainsack/Buyx formulation). If they are to conduce toward justice,

  these solidarity practices and movements need to address the ways that

  social, economic, and political institutions systematically function to

  deny some groups of people the basic means of life, and give rise to

  pervasive inequalities in people''s opportunities for self-development

  and for participating in processes of collective self-determination.

  This is the case most clearly for what I have called networking

  solidarities, but it can apply to solidarity within more unitary

  contexts like nation-states to the degree that the bonds involved (e.g.,

  among citizens) are not merely pre-existing but affirmed and reinvented

  over time. Even more demandingly, at a normative level, we can say that

  solidaristic action needs to take seriously the requirement for deep

  social transformation in the direction of social, and indeed global,

  justice. In this way, as I have argued elsewhere, although solidarity

  remains particularistic in its orientation to specific problems and

  specific groups or individuals, it can keep in view the demands of

  universal human dignity. And solidarity movements can verify that their

  particular goals contribute (in however limited a way) to the broader

  goal of egalitarian social transformation. Thus, dispositions to

  empathy, deference, and mutual aid remain important components of

  solidaristic social action, but a critical analysis of the social

  context and concretely taking action oriented to alleviating structural

  injustices are needed as well. In addition, since the institutional

  context, with its given power relations, frames the various solidarity

  movements, sometimes the prevailing power formations are replicated

  within these movements themselves.

  I suggest that this calls for groups and agents to be self-reflective

  about these effects of the structural context in which they function,

  and to be on guard about the dangers of their own possible complicity in

  its replication and perpetuation. An important proviso should be

  mentioned before returning to the case of healthcare and considering the

  impact of the notions of solidarity analyzed here. That is, although

  solidarity has here been related to justice, with the concomitant need

  to analyze and address the structural injustices that frame solidarity

  action, there is no implication that solidarity movements or other

  solidarity activities are sufficient for achieving the institutional

  changes that justice requires. For that, democratic legislation and

  various political and economic transformations are also needed. But

  solidarity, whether binding the members of a nation-state, or

  interpreted in newer networking forms, are one important way of

  constructing the conditions for these transformations, or even, in some

  cases of prefiguring more just relations within the social relations of

  solidarity themselves. There is no question that the new focus on

  solidarity holds considerable import for healthcare, as Prainsack and

  Buyx have effectively argued. But the issue for us is what further

  benefit would result from incorporating solidarity''s connection to

  justice, holding in view the significance of countering structural or

  systemic injustices. Given the vast range and specifics of healthcare

  and the social and economic factors conducive to health, I will focus on

  only a few of the most obvious implications for the practice of

  healthcare and for the potentially solidaristic activities of

  practitioners. We can ask: what difference would it make if we take

  seriously the need to address the differential structural power of the

  individuals and groups involved in healthcare, whether as practitioners

  or those served by them? And what is the scope and nature of the

  solidarity thus required? I will suggest in this final section that

  understanding solidarity in relation to structural injustice can not

  only shed new light on the sorts of examples that Prainsack and Buyx

  consider, but also, more importantly perhaps, highlight an entirely

  different range of examples of healthcare solidarity from the ones those

  authors consider. It takes us beyond such cases as the readiness to

  assist others through participating in healthcare databases or biobanks

  to cases of active participation in social movements aimed at improving

  healthcare nationally or transnationally, or, more defensively, to

  protesting structural injustices that lead to the wrongful denial of

  healthcare or to deep inequalities in its allocation. An obvious case of

  structural injustice in healthcare is provided by the deficiencies

  evident in the U.S. health insurance system (or lack of a system).

  Europeans have long recognized the centrality of solidarity with fellow

  citizens needed to undergird a willingness to contribute through taxes

  to a universal healthcare system. The types of provision in fact vary

  considerably, from socialized medicine as in the UK to state-funded

  support for private insurance provision, as in the Netherlands, along

  with dual systems mixing public and private support. But the

  universality at which these systems aim reflects the recognition of

  people''s shared vulnerabilities in matters of health, and even an

  understanding that healthcare is a human right required by justice.

  There is also the acknowledgement that systematic or structural

  provision (or at least a guarantee) of healthcare is required in order

  to realize the universality at stake here. It is perhaps worth

  mentioning that despite their achievements, structural injustices do

  nonetheless persist in many of the European systems themselves. This is

  particularly the case where there are two tiers of provision such that

  private insurance is needed in order to gain superior care that (ideally

  at least) should be available to all. (Granted that in some European

  countries the public providers may actually be superior to private ones

  in some respects.) The lack of universal healthcare in the United States

  is evidently primarily due to the existence of structural injustice,

  rather than simply reflecting an absence of solidarity among

  compatriots. To state the obvious: the U.S. private insurance

  industry-and especially its leading large for-profit companies-is

  immensely powerful and, currently at least, enormously profitable. As

  part of the dominion of capitalist economic forms, these private firms

  also have inordinate influence over politics, as do the large drug

  companies. The activities of these companies exemplify the role of the

  `power of money'' that is widely prevalent in U.S. politics and society,

  which in turn circumscribes the possibilities for public policy and law.

  Corporate lobbying and campaign contributions from corporations and the

  wealthy notably undercut political equality in the United States and can

  also prevent attention to the basic tasks involved in meeting human

  needs in equitable ways. Beyond this, it can be argued that the

  systematic differences between people''s starting positions, depending on

  their class and race, in large measure fall out of existing economic

  functioning, particularly given the resistance of the powerful to the

  redistributions that would be needed for genuinely equal opportunities.

  Moreover, these differential and deleterious starting positions conduce

  to worse health outcomes for children affected by them, and for many

  adults over the course of their lives. In view of this systemic

  injustice, the sort of solidarity needed, then, is not only an empathic

  identification with other citizens (or better, with all members of the

  political community, including non-citizens). Rather, for meaningful

  change, attention also needs to be paid to the structural barriers to

  equal and universal healthcare. Although improvements and reforms can

  probably be made even without fundamental changes in these background

  structural economic and political conditions, realizing the goal of

  genuinely equal treatment would require transforming those basic

  economic structures themselves. And this in turn calls for social

  movements aimed at these transformations. In the case of the United

  States, some healthcare workers in fact have taken the lead in

  solidarity actions to preserve the existing limited forms of health

  insurance against efforts to strip vulnerable people of their coverage

  altogether. This represents an example of a type of solidarity action in

  the service of justice. Needless to say, much more needs to be done to

  develop a fully critical solidarity movement of the sort required.

  Indeed, some healthcare worker groups-notably National Nurses United and

  Physicians for Universal Healthcare-have taken the lead in spearheading

  the movement for Medicare for All, going considerably beyond the efforts

  to prevent repeal of the Affordable Care Act.

  They originally argued for a public option when that healthcare law was

  under development, and have gone on to organize healthcare consumers in

  various locales across the United States, including rural areas and

  those with large industries, to press for systemic changes in health

  insurance and in healthcare delivery, such as through establishing

  non-profit community health centers. In both domestic contexts and more

  global ones, connecting solidarity to structural injustice has been

  important for understanding and addressing the social and economic

  factors that greatly magnify the health impacts of natural disasters,

  e.g., of hurricanes or tsunamis or volcanic eruptions. Whereas

  solidarity with affected people has most often been episodic and

  motivated by empathy with them, attention to the structural factors that

  exacerbate the impact of these disasters on vulnerable populations

  expands the scope of what needs to be done in a forward-looking

  justice-oriented perspective. As suggested earlier, structural

  injustices that lead impoverished people to live in weak dwellings or in

  insecure geographical areas also expose them differentially to the

  health and other effects of weather or environmental catastrophes.

  Beyond the specific catastrophes, we can see that climate change itself

  has greater impacts on those groups as well, effects that will only

  increase over time. Cases that illustrate the ways that structural

  injustices intensify natural disasters (if not also contributing to

  causing them) are manifold, and the solidarity movements that have

  responded to these disasters are instructive for our purposes. A well

  known case is Hurricane Katrina in New Orleans in 2005, where African

  Americans made up 80\% of the people in flooded low-lying communities,

  sometimes residing in inadequate housing like trailers, and without the

  means to escape the rising waters (especially due to low rates of car

  ownership). Not only did these minority communities bear the large part

  of the deaths and injuries from the hurricane, but also they experienced

  abiding health problems, e.g., those due to mold. Yet, despite the

  grossly inadequate federal response to this disaster, residents offered

  each other mutual assistance and were also aided by solidarity groups

  like Common Ground, which helped with community rebuilding, including

  founding a free health clinic, and aiding with wetlands restoration. A

  related example is the response to Hurricane Sandy in the New York/New

  Jersey area, where healthcare workers set up free clinics in trucks, and

  helped to raise money for much needed medical supplies for the various

  communities that lacked adequate resources of their own to deal with the

  storm aftermath. Internationally, structural injustices significantly

  contributed to the grave impact of the 2010 Haiti Earthquake, in which

  over 200,000 people were killed and over 300,000 injured, with more than

  1.5 million rendered homeless. Before the quake, many Haitians were

  impoverished and lived in slum conditions, leaving them highly

  vulnerable to floods and other natural disasters. The International

  Monetary Fund had implemented austerity programs in the preceding

  decades, which contributed to an evisceration of the public health

  systems and in turn to the health crisis following the earthquake, where

  there were radically insufficient medical supplies available.

  In the period that preceded the quake, an estimated 75\% of Haiti''s

  healthcare services had been provided by multinational and faith-based

  non-governmental organizations (NGOs), and its entire health supply

  system was externally run. The aid following the quake likewise involved

  a massive influx of international non-governmental organizations

  (INGOs), but Haitian NGOs were marginalized, as were the Haitian

  authorities, and over 90\% of the aid money went to international

  actors, including the UN and INGOs, and to the private sector. This aid,

  too, was unequally distributed between the capital and rural areas, and

  between well-off and less well-off areas of Port-au-Prince itself. In

  contrast, more adequately addressing the medical needs arising from the

  quake, some international healthcare NGOs succeeded in working in

  solidarity with local Haitians, in particular, the INGO Partners in

  Health, which explicitly incorporated a focus on the impacts of

  structural factors in their efforts. A more recent case is provided by

  Hurricane Maria, which devastated Puerto Rico in the summer of 2017.

  This natural disaster likewise calls attention to political economic and

  social structural factors that greatly aggravated the situation. Years

  of austerity, this time managed by the U.S. government and banks, along

  with massive debt, left hospitals without many doctors and with

  inadequate medical supplies needed to deal with injuries following the

  storm. Puerto Rico''s defective electrical grid also hampered the

  recovery from the hurricane. The inadequacies of this grid were

  exacerbated by the freeze imposed on a public infrastructure fund, which

  was instead used to funnel support to public-private partnerships under

  the same restructuring program. Moreover, in Puerto Rico, as in Haiti,

  we observe inequalities in the response to affected communities in the

  capital vs. in poorer rural areas. Solidarity work by healthcare

  workers, including doctors from Cuba, along with aid from the Puerto

  Rican diaspora, has been important in recovery and rebuilding efforts,

  but has not been able to make up for the lack of support from the U.S.

  government. It is evident, then, that effective action requires

  understanding the economic and social factors that condition people''s

  life chances and their health, including the limitations imposed by

  their places of residence. Indeed, the economic functioning of

  capitalism seems to be a major causal factor not only in these discrete

  natural events but also in climate change itself. While no single

  solidarity movement can counter these structural or systemic effects,

  establishing a linkage between a particular event and the deeper

  structural conditions for its differential impact on impoverished or

  vulnerable populations is important for adequate public policy going

  forward, and for the provision of the right forms of assistance in the

  present. It suggests the need for aid that not only restores the

  situation to the one that preceded the environmental event in question

  but that establishes a better, and more resilient, situation going

  forward. Clearly, an interlinking and networking of solidarity movements

  and of civil society organizations, as well as of public policy, would

  be necessary for the social transformative changes required.

  Similar arguments concerning the need for solidarity activity to remedy

  structural injustices can be advanced in regard to other central

  national or global health problems: for example, the provision of clean

  water, as in the case of Flint, Michigan, or the protection of the water

  supplies from fracking, or from underwater pipelines as in the case of

  Standing Rock, where there was a substantial solidarity struggle in

  support of the affected Sioux indigenous people in 2016-2017.

  Internationally, the health challenges include the need for wider and

  cheaper provision of drugs to counter HIV-AIDS along with a host of

  other illnesses; ways of dealing with malaria and with preventable

  epidemics; providing clean water worldwide; and addressing the range of

  health issues that result from trafficking, child labor, and slave

  labor. In all these cases, solidarity movements would need to join up

  with others working to counter exploitation and the dominion of the

  profit motive, or struggling to rectify the deep inequalities in social

  and economic conditions, along with the effects of absolute poverty.

  Likewise, in regard to the overarching problem of climate change itself,

  we have already seen the emergence of major transnational solidarity

  movements, often taking the form of networks of local groups, and

  including the participation of numerous healthcare workers. Examples are

  the older Via Campesina, the People''s Climate Movement, and 350.org,

  among many others. In the international context, mention should also be

  made of the way structural injustice frames medical problems arising

  from illness and other natural causes, but also those arising from war

  and other forms of violence. Some solidarity movements in those contexts

  have focused on offering aid to the injured, as with the `White Helmets''

  operating in rebel-held areas of Syria, extracting the living from the

  rubble following Syrian government bombings. While this group is

  composed mainly of volunteers and is anti-authoritarian, it otherwise

  eschews any specific political affiliation. The Kurdish YPG (People''s

  Defense Units) in northern Syria, which also has healthcare units

  operating in areas under attack, presents a somewhat different case,

  since it is explicitly anti-capitalist in orientation. However, a full

  discussion of these complex cases would take us beyond the scope of the

  present discussion. We can, in conclusion, return to two of the cases

  analyzed by Prainsack and Buyx and attempt to view them through the lens

  of structural injustice, with the resulting transformed interpretation

  of the solidaristic action required in those bioethical contexts. While

  less dramatic than the leading examples analyzed above, where solidarity

  needs to be directed explicitly towards countering structural

  injustices, the Prainsack and Buyx cases pose some interesting issues

  for consideration. The two applications of solidarity are those of

  governing health databases (as they put it), and personalized medicine

  and healthcare. As we have noted, in the course of their acute analysis,

  Prainsack and Buyx occasionally point to the dangers of the commercial

  uses of medical databases. But we can ask whether their recognition of

  these dangers fully informs their own account. Perhaps because they wish

  to make proposals that can be adopted immediately, the authors employ

  the notion of solidarity to recommend only modest restrictions on the

  use of these databases.

  For example, they urge that their use contribute to some public good at

  the same time as they retain their commercial or profit-oriented

  purposes, where these latter can even remain primary. The authors also

  tend to accept the existing limits on public funding for research as a

  given, rather than strongly arguing for its expansion by way of

  solidarity actions, however difficult accomplishing this might be in the

  present. In fact, the use of health databases for the purpose of private

  profit is a social choice that a society need not endorse. Likewise, the

  scope and extent of public funding is also a matter of policy and

  legislation, even if alternative directions would be difficult to

  implement in the context of a capitalist political economy. It is

  constraints posed by the latter that I would highlight in an alternative

  structural perspective on solidarity, taking us beyond the commitment to

  assist others that these authors foreground in their analysis. Indeed,

  one can further argue that the solidarity that Prainsack and Buyx seek,

  as a willingness to share one''s own data in large databases, can

  actually be undercut by structural injustices. This is evident

  especially in regard to the potential commercial use of the data.

  Informed people, aware of the dangers that this background structural

  feature poses, may well be resistant to taking a chance on acting in the

  solidaristic ways that these authors recommend. People may be wary of

  these commercial uses and indeed, may even come to expect them, so they

  would decide against contributing their own information, despite

  assurances of confidentiality. In this way, the existing tendency toward

  an overriding concern with private self-interest is reinforced by the

  very existence and continuation of these structural background

  conditions. In this context, efforts to eliminate structural injustice,

  if effective, could be expected to assist in promoting the sorts of

  solidarities that Prainsack and Buyx seek. Another specific difference I

  have with these authors'' otherwise excellent account of databases and

  their governance has to do with their rather puzzling remarks about

  dealing with the risks that must be accepted by those who contribute

  their health data to the database. For Prainsack and Buyx, solidarity is

  supposed to motivate people to provide their own health data to these

  databases and they argue that only `broad consent'' is needed for the use

  of this data by researchers rather than more traditional forms of

  informed consent, which they regard as excessively demanding and costly

  in this context. The authors propose that less attention should be given

  to preventing the risks of re-identification (with the potential

  discrimination that might follow) and more attention given to mitigating

  or compensating for harms that may accrue to individuals from misuse of

  their data in the future. This includes, they suggest, making fewer

  efforts to assure individual consent in a strong sense, and instead

  placing more emphasis on putting funds aside to remedy harms or injuries

  arising from misidentification or, more generally, from the misuse of

  information. I believe that encouraging solidaristic actions and

  practices of the sort these authors seek to engender would instead be

  aided by focusing even more than is presently done on preventing and

  limiting the risks that inevitably attend contributing one''s personal

  health data for use in medical databases.

  This is so not only for instrumental reasons, namely, because otherwise

  people will not participate out of (largely rational) fear of these

  untoward consequences. A greater emphasis on limiting risk is also

  essential in recognition of the real structural problems that frame

  these databases, namely, the great commercial potential they hold and

  their openness to corporate use of the included health information in

  the interests of profits, along with the deep challenges involved in

  safeguarding privacy online. These structural features would not be

  meliorated by the authors'' otherwise fine proposals to allow

  contributors to access their own raw data, and to be informed of

  possible health impacts on them personally that emerge from the research

  the databases facilitate. To adequately deal with the various social,

  technological, and medical challenges posed by these large databanks

  requires solidarity action in the interest of structural change besides

  the reforms the authors have sketched. Further, although Prainsack and

  Buyx helpfully suggest in passing that a few patients should be included

  among those who serve on the proposed governance boards for large

  databanks, it seems that the majority on these boards would be made up

  of standing groups of people whose only requirement is not to have

  conflicts of interest in regard to the potential uses of the databanks.

  This delimitation seems insufficient to assure the responsibility owed

  to the contributors of data, particularly in view of the background

  functioning of social and economic institutions that give managers and

  other elites the preponderance of power. Inasmuch as ethics boards are

  also ruled out by the authors as trustees (because they are

  overburdened, in their view, or may not be knowledgeable about the

  specific research in question), it is unclear how these governance

  boards would best be constituted on their approach. A strongly

  solidaristic view would require that a substantial number should be

  drawn from patients or their representatives, though it would clearly

  also be important to include a sizable number of scientists and other

  experts. We can see then that quasi-democratic requirements emerge for

  the governance of these databanks, such that those affected by them

  would have some say in overseeing them. This follows as well from the

  feature of deference, which I suggested is an important aspect of an

  adequate conception of solidarity. Deference is required toward those

  one is assisting, who should have a major role in specifying their needs

  and how they want to be assisted. Efforts must thus be made to hear from

  them systematically. This involves new forms of democratic, or perhaps

  quasi-democratic, input into the policies or actions in question. I use

  the qualification `quasi'' here to indicate that the input in question

  may not always have to be formal, though there is certainly a place for

  formal rights of participation on governance boards by some

  representatives of patients or even the public at large. This sort of

  deference to patients and democratic input by them also casts light on

  the final example of solidarity in action, drawing again from the

  Prainsack and Buyx account. They analyze the case of `personalized

  medicine'' or `precision medicine,'' which most often refers to the use of

  analytical software and databases to target medicine and healthcare to

  individuals in ways that are unique to them, e.g., by the use of

  genomics and through such software systems as IBM''s Watson.

  The authors rightly point out that group characteristics continue to be

  important to these analyses, since data about groups provide the

  parameters for evaluating the medical status of individuals. But in

  personalized or precision medicine, the focus comes to be on the

  intersection of these group findings within particular differentiated

  individuals. Moreover, the authors usefully propose to extend the

  characteristics that are taken into account in personalized practices to

  include also social ones, as well as individuals'' cultural and personal

  preferences. In regard to the identification of group characteristics

  and their embodiment in unique ways in individuals, it is clearly

  important to adopt a socially critical perspective as to what

  constitutes a relevant group. That is, taking structure into account

  suggests the importance of becoming aware of social preconceptions and

  potential bias in the identification of a group. This holds not only for

  standard ascriptive group identifications along the lines of gender,

  race, etc., but also of newer sets of subgroups or emerging crosscutting

  groups. It would also affect the ways both researchers and clinicians

  identify the social background conditions and the social and cultural

  preferences of the individuals, if these are to be taken into account

  and added to personalized medicine and healthcare, as Prainsack and Buyx

  propose. We can delineate one final implication of the importance of

  participation in healthcare by those affected, which I have suggested

  follows from a conception of solidarity that includes deference and

  hearing from others as to how they want to be aided or assisted.

  Clearly, a fuller view of personalized medicine would not only look at

  evidence-based therapies targeted at individuals drawing from large

  databases of relevant research, but should be open to input from

  patients themselves about the aims and methods of therapy. Even the

  basic interpretation of health and wellness, both of which are clearly

  shared goals of patients and clinicians, can be open to patients'' input.

  This sort of participation by those affected by the practice of medicine

  and healthcare need not be understood in a way that diminishes the role

  of science or expertise. Rather, it reflects the recognition that

  solidarity with patients requires openness to their own perspectives and

  goals, and ideally involves their participation in co-determining their

  own care. Given the range of research knowledge and existing therapies,

  a truly personalized medicine would not only home in on targeted precise

  therapies, but would involve an interactive and cooperative process of

  health building and health sustenance. As argued here, it would also

  require practices of attunement to, and solidarity with, a patient''s

  social context, needs, and aspirations. Further, understanding that

  social context, in turn, requires a focus on the differential power and

  inequalities that result from prevailing political and economic

  institutions, that is, an attention to structural injustice. The author

  declares no conflict of interest. Carol C. Gould is Distinguished

  Professor in Philosophy at Hunter College and in the Doctoral Programs

  in Philosophy and Political Science at the Graduate Center of The City

  University of New York, where she is also Director of the Center for

  Global Ethics and Politics. She is Editor of the Journal of Social

  Philosophy. Her most recent book is Interactive democracy: The social

  roots of global justice (Cambridge University Press, 2014.) Prainsack,

  B., \& Buyx, A. (2017).

  Solidarity in biomedicine and beyond.

  Cambridge: Cambridge University Press. See for example, Gunson, D.

  (2009). Solidarity and the universal declaration on bioethics and human

  rights. Journal of Medicine and Philosophy, 34, 241-260. I discuss this

  question in Gould, C. C. (2014). Interactive democracy: The social roots

  of global justice. Cambridge: Cambridge University Press. Prainsack \&

  Buyx, op. cit. note 1; and Prainsack, B., \& Buyx, A. (2011).

  Solidarity: Reflections on an emerging concept in bioethics. Retrieved

  February 25, 2018, from

  https://nuffieldbioethics.org/wp-content/uploads/2014/07/Solidarity\_rep

  ort\_FINAL.pdf Prainsack \& Buyx, op. cit. note 1, p. 52. Ibid., pp. 68,

  77, 93. Ibid., pp. 76, 77, 93. Gould, C. C. (2007). Transnational

  solidarities. Journal of Social Philosophy, 38(1) (Special Issue on

  Solidarity, C. Gould \& S. Scholz), 146-162; Gould, op. cit. note 3, pp.

  99-131. Bayertz, K. (1999). Four uses of `solidarity''. In K. Bayertz

  (Ed.), Solidarity (pp. 3-28). Dordrecht: Kluwer. More recent

  articulations of the Catholic notion of solidarity, in particular, have

  seen it as tied labor, e.g., in the Polish Solidarnosc movement or to

  Latin American social movements. See for example, Beyer, G. J. (2014).

  The meaning of solidarity in Catholic social teaching. Political

  Theology, 15(1), 7-25. Clearly, too, as Beyer points out, Christianity

  is not unique among religions in appealing to some conception of

  solidarity. See also Schoenfeld, E. \& Mestrovic, S. G. (1989).

  Durkheim''s concept of justice and its relationship to social solidarity.

  Sociology of Religion, 50(2), 111-127. For a discussion of the some of

  the meanings of solidarity in historical context, see Brunkhorst, H.

  (2005). Solidarity: From civic friendship to a global legal community.

  Cambridge, MA: MIT Press; Pensky, M. (2008). The ends of solidarity:

  Discourse theory in ethics and politics. Albany, NY: State University of

  New York Press. For a discussion of the distinction of solidarity from

  charity and from humanitarian aid, see Gould, op.cit. note 8. Gould, C.

  C. (1983). Beyond causality in the social sciences: Reciprocity as a

  model of non-exploitative social relations. In R. S. Cohen \& M. W.

  Wartofsky (Eds.), Epistemology, methodology and the social sciences:

  Boston studies in the philosophy of science (Vol. 71, pp. 53-88).

  Boston: D. Reidel; Gould, C. C. (1988). Rethinking democracy: Freedom

  and social cooperation in politics, economy, and society (pp. 31-90).

  Cambridge: Cambridge University Press. Gould, op. cit. note 8. Note that

  Andrea Sangiovanni adds this sort of national solidarity as a third

  traditional root of the notion, in addition to those derived from the

  Christian and socialist traditions. See Sangiovanni, A. (2015).

  Solidarity as joint action. Journal of Applied Philosophy, 32, 340-359.

  Eckenwiler, L., Straehle, C., \& Chung, R. (2012). Global solidarity,

  migration, and global health inequity. Bioethics, 26, 382-390. Gunson,

  op. cit. note 2, p. 247. Ibid. For an intensive discussion of the

  concept of political solidarity and its forms, see Scholz, S. J. (2008).

  Political solidarity. University Park: Penn State University Press.

  Gunson, op. cit. note 2, p. 248. Gould, C. C. (1978). Marx''s social

  ontology: Individuality and community in Marx''s theory of social

  reality. Cambridge, MA: MIT Press; Gould (1988), op. cit. note 13, pp.

  91-132. For a development of the implications of this social ontology

  for understanding human rights and solidarity, see Gould, op. cit. note

  3.

  See especially Gould (1988), op. cit. note 13, pp. 31-90 and Gould, op.

  cit. note 3. Ibid. Ibid. For a related argument, see Young, I. M.

  (1990). Justice and the politics of difference. Princeton, NJ: Princeton

  University Press; Young, I. M. (2000). Inclusion and democracy. Oxford:

  Oxford University Press. On interdependence and vulnerability, see Held,

  V. (2006). The ethics of care: Personal, political, and global. New

  York, NY: Oxford University Press. For a discussion of the material and

  social conditions for human agency, including healthcare, see Gould, C.

  C. (2004). Globalizing democracy and human rights. Cambridge: Cambridge

  University Press. Regarding the connection of these conditions to

  economic and social human rights, see also Gould (1988), op. cit. note

  13, pp. 190-214, and Gould, op. cit. note 3, pp. 13-57. My own treatment

  of the notion of negative and positive freedom was indebted especially

  to Macpherson, C. B. (1973). Democratic theory: Essays in retrieval.

  Oxford: Oxford University Press. See Gould, op. cit. note 13, pp. 18-20,

  38-40, where I also discuss some differences from his view. Gould

  (1988), op. cit. note 13. Habermas, J. (1990). Justice and solidarity:

  On the discussion concerning Stage 6. Tr. S. W. Nicholson. In T. E. Wren

  (Ed.), The moral domain: Essays in the ongoing discussion between

  philosophy and the social sciences (pp. 244-245). Cambridge, MA: MIT

  Press. Gould (2004), op. cit. note 24; Gould, op. cit. note 8. Gould,

  op. cit. note 8. See also the account of solidarity and justice in

  Ferguson, A. (2009). Iris Young, global responsibility, and solidarity.

  In A. Ferguson \& M. Nagel (Eds.), Dancing with Iris: Between

  phenomenology and the body politic in the political philosophy of Iris

  Marion Young (pp. 185-197). New York, NY: Oxford University Press.

  Gould, ibid: 157; Gould, op. cit. note 3, p. 111. Rippe, K. P. (1998).

  Diminishing solidarity. Ethical Theory and Moral Practice, 1(3),

  355-373. I have discussed inclusiveness and democracy in social

  movements in Gould, op. cit. note 3, pp. 99-131. Giddens, A. (1984). The

  constitution of society. Cambridge: Polity Press. Young, I. M. (2003).

  Political responsibility and structural injustice. Lawrence: University

  of Kansas, p. 7. Ibid, p. 6. Young, I. M. (2006). Responsibility and

  global justice: A social connections model. Social Philosophy and

  Policy, 23(1), 102-130. I discuss Young''s conception of responsibility

  for global justice in Gould, C. C. (2009). Varieties of global

  responsibility: Reflections on Iris Marion Young''s last writings. In

  Ferguson \& Nagel, op. cit. note 29, pp. 199-211. Ibid. Although the

  focus in this article is primarily on the injustice and exploitation

  resulting from capitalist structures, it is evident that political

  economic institutions serve to replicate racism and patriarchy in

  addition to economic exploitation. A fuller account would need to

  consider the interrelations among these various forms of systemic or

  structural injustice, and the ways they produce unequal access to

  healthcare, along with deeply problematic impacts on health and

  well-being. Durkheim, E. (1964). The division of labor in society. Tr.

  G. Simpson. New York, NY: The Free Press. For further discussion, see

  Gould, op. cit. note 3, chapter 6. For a discussion of a range of

  environmental injustices and movements to address them, see Bullard, R.

  D. (Ed.). (2005). The quest for environmental justice: Human rights and

  the politics of pollution. San Francisco, CA: Sierra Club Books.

  For a useful discussion of the interaction of natural and social factors

  in Katrina and other U.S. disasters, see Tierney, K. (2006). Social

  inequality, hazards, and disasters. In R. J. Daniels, D. F. Kettl, \& H.

  Kunreuther (Eds.), On risk and disaster: Lessons from Hurricane Katrina

  (pp. 109-128). Philadelphia: University of Pennsylvania Press. See also

  the helpful analyses in Bullard R. D. \& Wright, B. (Eds.). (2009).

  Race, place, and environmental justice after Hurricane Katrina:

  Struggles to reclaim, rebuild and revitalize New Orleans and the Gulf

  Coast. Boulder, CO: Westview Press. Disasters Emergency Committee. Haiti

  earthquake facts and figures. UK. Retrieved February 24, 2018, from

  https://www.dec.org.uk/articles/haiti-earthquake-facts-and-figures The

  Haiti Case Study. (2012). NATO-Harvard Working Paper. Retrieved February

  24, 2018, from

  https://www.jallc.nato.int/products/docs/haiti\_case\_study.pdf Luge, T.

  (2010). Haiti case study. Retrieved February 24, 2018, from

  https://www.slideshare.net/Timoluege/2010-haiti-earthquake-response-case

  -study Chen, M. (2017, June 8). The bankers behind Puerto Rico''s debt

  crisis. The Nation. New York, NY. Retrieved February 23, 2018, from

  https://www.thenation.com/article/bankers-behind-puerto-ricos-debt-crisi

  s/ Prainsack \& Buyx, op. cit. note 1, p. 104. Ibid., pp. 114, 115.

  Ibid., p. 115. Ibid., p. 119. INTRODUCTION CURRENT INTERPRETATIONS OF

  SOLIDARITY IN HEALTHCARE TWO SENSES OF SOLIDARITY AND THEIR RELATION TO

  JUSTICE STRUCTURAL INJUSTICE AND SOLIDARITY SOME IMPLICATIONS FOR

  HEALTHCARE CONFLICT OF INTEREST Footnotes The concept of solidarity has

  recently come to prominence in the healthcare literature, addressing the

  motivation for taking seriously the shared vulnerabilities and medical

  needs of compatriots and for acting to help them meet these needs. In a

  recent book, Prainsack and Buyx take solidarity as a commitment to bear

  costs to assist others regarded as similar, with implications for

  governing health databases, personalized medicine, and organ donation.

  More broadly, solidarity has been understood normatively to call for

  `standing with'' or assisting fellow community members and possibly also

  distant others in regard to their needs, whether for its own sake or in

  order to realize the demands of justice. I argue here that the

  understanding of solidarity in the existing bioethics literature is

  unduly restricted by not sufficiently theorizing the notion of

  structural (or systemic) injustice and its import for understanding

  solidarity. Extending traditional conceptions of labor and social

  movement solidarity, I contrast unitary solidarity within a given group

  with `networking solidarities'' across groups. I analyze the meaning of

  structural injustice and its significance for solidarity, including

  countering institutionally entrenched inequalities and economic

  exploitation. I then apply this broadened conception to healthcare,

  discussing structural problems with the U.S. insurance system and the

  solidarity movements addressing its deficiencies. I analyze some natural

  disasters and global health challenges that were aggravated by

  structural injustices, along with the solidarity movements they

  engendered. Finally, I revisit the questions of governing health

  databases and of personalized medicine with the enlarged conception of

  solidarity in view.'
affiliation: 'Gould, CC (Corresponding Author), 333 Cent Pk West,Apt 16, New York,
  NY 10025 USA.

  Gould, Carol C., CUNY, Hunter Coll, Dept Philosophy, New York, NY 10021 USA.

  Gould, Carol C., CUNY, Grad Ctr, Doctoral Program Philosophy, New York, NY 10021
  USA.

  Gould, Carol C., CUNY, Grad Ctr, Doctoral Program Polit Sci, New York, NY 10021
  USA.'
author: Gould, Carol C.
author-email: carolcgould@gmail.com
author_list:
- family: Gould
  given: Carol C.
da: '2023-09-28'
doi: 10.1111/bioe.12474
eissn: 1467-8519
files: []
issn: 0269-9702
journal: BIOETHICS
keywords: healthcare; justice; solidarity
keywords-plus: JUSTICE
language: English
month: NOV
number: 9, SI
number-of-cited-references: '35'
pages: 541-552
papis_id: aa07d1e90a6ed209308d451f69f825e9
ref: Gould2018solidarityproblem
researcherid-numbers: 'Baldissera, Annalisa/AHD-6334-2022

  Fazli, Ghazal/AAE-8320-2022'
times-cited: '34'
title: Solidarity and the problem of structural injustice in healthcare
type: Article
unique-id: WOS:000450332600002
usage-count-last-180-days: '85'
usage-count-since-2013: '1528'
volume: '32'
web-of-science-categories: Ethics; Medical Ethics; Social Issues; Social Sciences,
  Biomedical
year: '2018'