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2023-09-28 14:46:10 +00:00
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
2023-10-01 08:15:07 +00:00
type: article
2023-09-28 14:46:10 +00:00
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'