wow-inequalities/02-data/intermediate/wos_sample/ac52cfe134300c2909b7f56d4fd98105-derpmann-simon/info.yaml

abstract: 'Political struggles not only change social institutions and conventions,

  they also often shape normative language. Moral notions of lasting

  significance are like geological formations insofar as they are usually

  not formed in a void but under considerable pressure. While some notions

  are fundamentally linked to legal documents or academic treatises,

  others are mainly advanced in songs, pamphlets, or manifestos.

  Philosophical attempts to define these evolved notions are often

  sensitive to their particular histories in order to avoid detachment

  from common pre-theoretical usage. After all, moral theory would be

  ill-advised to rid itself of considered conceptual intuitions unless

  there are strong grounds for revision. Even though theoretical

  reflection may produce reasons to deviate from prevailing understandings

  of core moral notions, it must eventually rely on some form of a

  semantic orientation. The line between reconstructing and redefining

  moral notions is particularly hard to draw when it comes to

  comparatively young and polymorphic notions, such as solidarity. It is

  difficult to provide a finite definition of `solidarity'', as the term

  has been appropriated in the pursuit of a variety of causes. Different

  theoretical reconstructions explicate solidarity as a form of unity,

  fraternity, civic friendship, charity, humanity, or camaraderie. Instead

  of reflecting on this variety of meanings, the present contribution

  examines the reference to solidarity within a specific context of moral

  debate. There are recurring calls for solidarity in contemporary

  oppositions to the erosion of the protective reliabilities of society,

  as it becomes manifest in the reduction, privatization, or

  stratification of both social security in general and health care in

  particular. In this context, solidarity is invoked as a relation that

  connects all members of society, providing a reason to accept or support

  the introduction or continuation of universal health care. In the

  following, I am concerned with the adequacy of the moral terminology

  implied in this line of reasoning. My claim is that - at least relative

  to the purpose of moral philosophy to provide a systematic,

  comprehensive, and fine-grained account of moral obligation - a specific

  partisan notion of solidarity is of greater systematic value to moral

  terminology than the alternative universal notion. At least one central

  strain of moral references to `solidarity'' does not conceive it as a

  notion of universal moral inclusion, but of communal relatedness. This

  conception of solidarity imprints the term with a specific

  community-related perspective, i.e. the distinctive normative and

  motivational force of solidarity relations is taken to reside in a

  specific form of partiality toward significant groups like unions,

  cooperatives, parties, committees, etc. Ralph Chaplin''s Solidarity

  Forever, for instance, memorably assigns the distinctive strength of

  references to solidarity to union''s inspiration. In this understanding,

  the reference to solidarity bears a specific moral and political

  relevance because it conveys a normative insight to members of specific

  communities, explicating why they may be obliged to take a stand for a

  common cause, even if this involves going well beyond what can be

  expected of them merely qua moral subjects. I aim to show that a

  conception of `solidarity'' that confines it to this decidedly partisan

  moral relation provides a significant contribution to moral philosophy

  because it grasps a specific and important facet of moral obligation.

  In the following, this structural feature of solidarity is discussed

  with regard to the moral foundation of health care policies. I argue

  that the demand to universal access to health care should be conceived

  as a matter of justice, decency, or humanity, rather than of solidarity,

  because the failure or refusal to provide adequate health coverage does

  not disregard individuals as members of specific communities, but as

  moral subjects. My argument for this terminological suggestion comes in

  three sections. The first section establishes a normative notion of

  solidarity as a source of - essentially partisan - communal obligations

  reflecting on shared identificatory attributes like convictions, social

  positions, or significant histories. Under this description, solidarity

  is understood to pose a particular type of special obligations, creating

  moral requirements that obtain apart from and beyond the demands of

  universal morality. The reference to solidarity unfolds a particular

  theoretical potential when it captures a distinct form of communality.

  The second section locates the normative foundation of calls for

  universal health care in the domain of justice by understanding the

  provision of basic health care as a right of every moral subject that is

  independent of normatively significant commonalities. The third section

  concludes that solidarity is a notion that does have a place in

  health-related norms, but that does not provide the best moral

  foundation of demands for universal health care. Rather, relations of

  solidarity establish forms of moral obligations that are indispensable

  when social systems fail to provide justice or reach their legitimate

  limits. The first step of the argument brings `solidarity'' into view as

  a systematic term of moral philosophy as opposed to its role in

  sociology or political theory. This perspective focuses on solidarity as

  a relation that provides specific moral reasons, such as the reason to

  accept and obey practices of mutual assistance, to put oneself at risk

  or at a disadvantage for the benefit of others, to endure hardships for

  the common good, etc. Thus, the reference to solidarity within moral

  justification bears a discursive force in its own right. The main

  difficulty in the appropriation of solidarity to moral philosophy is to

  individuate and explicate a defining set of features of recognized uses

  of the term. Due to the variety of relations, attitudes, and

  dispositions that are commonly referred to as solidarity, no coherent

  notion can be expected to be able to simultaneously capture obligations

  toward humankind, or the exploited and the poor, among comrades and

  sisters in arms, and between the members of parties, teams, clubs,

  gangs, unions, collectives, and social movements. One reaction to this

  diagnosis is to accept that solidarity is a pluralistic notion that

  cannot be reduced to either of these meanings. However, this approach

  would possibly have to allow a very broad understanding of `solidarity''

  that could render the notion empty or incoherent. Such a conception of

  solidarity may pose no difficulties within everyday language, but it can

  be argued to be unsuitable for the kind of justification sought in moral

  philosophy. There are legitimate doubts about the confinement of moral

  notions like solidarity to the narrow boundaries of philosophical

  concepts for systematic purposes. However, if the language of moral

  philosophy is not to become artificial, it has to adopt notions of our

  common language and alter them to avoid incoherences.

  A moral account of solidarity is only of systematic value if the

  reference to `solidarity'' captures a specific type of obligation that

  can be distinguished from other moral obligations. Without an

  explanation in what regards obligations of solidarity are different

  from, go beyond, or are more specific than obligations of justice,

  humanity, charity, fidelity, or loyalty, there is arguably no need for a

  distinct theory of solidarity within moral philosophy. Thus, a

  convincing exposition of solidarity should fulfill a condition of

  conceptual discriminability, and of irreducibility. If it is to play any

  significant role in moral philosophy, `solidarity'' has to refer to a

  moral relation sui generis. Once some defining features of solidarity

  are established, the meaning of references to solidarity in debates

  about public health care can be addressed. In approaching a sound notion

  of solidarity, different accounts can be distinguished with regard to

  their position on its normative scope, i.e. with regard to the extension

  of the groups within which subjects are considered to have mutual

  obligations and corresponding claims of solidarity. The main dividing

  line that is relevant to the present context - to the analysis of the

  systematic function of references to solidarity within moral philosophy

  - must be drawn between universalist and partisan accounts of

  solidarity. Some prominent accounts of moral solidarity conceive it as a

  universal relation that extends to all humanity, or to all members of

  society, making solidarity the basis of a universal form of moral

  obligation. David Wiggins and Jurgen Habermas, for instance, invoke

  different notions of universal solidarity for different conceptual

  reasons. While Wiggins refers to solidarity in order to designate a

  fundamental form of a pre-reflective universal recognition implying

  negative duties, Habermas describes solidarity as a non-formal positive

  attitude of care complementing formal requirements of justice. Both

  accounts provide valuable insights into the nature of political and

  moral obligation. Yet, the competing understanding of solidarity as

  specific by virtue of its partiality comes with considerable systematic

  advantages. Wiggins understands solidarity as a fundamental moral

  relation that is characterized, among other things, by its universality.

  In this understanding, solidarity is a particular form of recognition

  that forms the basis of morality altogether. This form of recognition

  entails deontological constraints, but these constraints are not solely

  based on demands of reason. Thus, solidarity resembles Kantian respect

  in terms of the demands it poses, but with regard to the underlying

  attitude, solidarity resembles Humean sympathy. In the course of

  outlining obligations of solidarity, Wiggins identifies solidarity as

  `the {[} horizontal ellipsis ] thing that any human being owes to any or

  all other human beings, namely the solidum that is presupposed to the

  ordinary morality of all interaction between human beings''. As the very

  bedrock of moral relatedness, solidarity must extend to every moral

  subject alike. Solidarity is the basic form of recognition that

  interconnects moral subjects through their mutual consideration as

  bearers of a point of view that commands respect. Habermas brings forth

  a different account of solidarity, but he also uses the term to denote a

  relation with a universal extension.

  In this account: Solidarity {[} horizontal ellipsis ] is rooted in the

  realization that each person must take responsibility for the other

  because as consociates all must have an interest in the integrity of

  their shared life context in the same way. Justice conceived

  deontologically requires solidarity as its reverse side. Habermas

  distinguishes the fundamental moral demands of justice that are directly

  based on the principles of discourse from complementary demands of

  sympathy or care that are based on solidarity. While justice

  substantiates negative obligations, solidarity requires moral subjects

  to strive at promoting the welfare of others. Thus, Habermas supplements

  the discourse theory of morals with the relation of solidarity in order

  to be able to account for materially rich notions of social relatedness.

  However, in this description the `shared life-context'' relevant to

  solidarity is not economic class, social position, or political stance

  but society as a whole. For Habermas, justice and solidarity differ with

  regard to the content of their obligation, yet they are similar in their

  universal scope, as solidarity is conceived of as extending toward all

  members of society. While both accounts capture an important aspect of

  moral and political obligation, their recourse to `solidarity'' is not

  without problems. There is no incontestable argument that would be

  sufficient to reject these two notions of universal solidarity. While

  there is no `separate essence'' of solidarity that could be referred to

  in order to argue for the conceptual necessity of solidarity''s

  partiality, some features may reasonably be stipulated as being

  essential to solidarity with a view to its systematic function within

  moral philosophy. Thus, I aim to uncover some systematic disadvantages

  of assigning `solidarity'' in the description of a universal relation

  within moral philosophy. The universal notion of solidarity misses - or

  deliberately excludes - something that is at the core of a competing

  account of solidarity. What is this feature of solidarity that is lost

  in its universalization? As indicated before, influential references to

  solidarity identify unity, cohesion, or community as essential elements

  of solidarity. The idea that is at the core of this understanding of

  solidarity can be illustrated with reference to a terminological

  precursor of `solidarity''. A legal construction of Roman civil law, the

  obligatio in solidum, describes a joint liability, or a liability for

  the whole, that is incurred when individual debtors assume

  responsibility for a collective loan. Accordingly, one can argue that

  obligations of solidarity require a solidum, i.e. some form of an

  entirety or a whole that serves as a point of reference in the content

  of solidary obligations. Wiggins understands the solidum to refer to the

  firmness of solidarity by making the relation of solidarity `the root of

  the ethical'', or the hard core of morality. For Habermas, the solidum

  may be society as a whole comprising moral subjects viewed as

  consociates. These references to a solidum, however, have to be

  distinguished from those that base solidarity in communal relations

  entailing significant forms of relatedness that go beyond the

  obligations of moral subjects qua moral subjects. Solidarity qua

  partisan relation refers to a morally significant solidum in terms of a

  wholeness or unity of distinct communities.

  The question with regard to universal solidarity is what the reference

  to a solidum contributes normatively beyond the consideration of others

  as mere moral subjects. In the case of partial solidarity, significant

  commonalities determine the range and the dimension of specific

  obligations of solidarity. If a solidary community is of moral

  significance, then it must entail a relevant distinction between

  subjects as members of the community and others as - mere - moral

  subjects, just like friends, comrades, or family members have to make

  this distinction in order to satisfy the normative implications entailed

  in friendship, camaraderie, or family. The moral significance that is

  missing in accounts of universal solidarity concerns the role of

  expressions like `my'' or `our'' as irreducible constituents of moral

  reasons that are indicative of communal obligation. In this manner, the

  reference to others as `my friend'', `my sister'', or `my ally'' expresses

  a structural characteristic of morally significant relations within a

  community. Thus, the obligation toward one''s own community is not merely

  an obligation toward some community based on a neutral moral property

  but on a reason that necessarily entails a reference to the bearer of

  the obligation. This demonstrates that the universal relation that

  Wiggins and Habermas have in mind cannot be regarded as one specific

  form of - a human or a moral - solidarity that may coexist with narrower

  forms of national, ethnic, cultural, or political solidarities. The

  problem is that human solidarity lacks the significant reference to a

  solidum. While there is a difference between characterizing someone as a

  friend or a comrade and referring to her as one''s own friend or as my

  comrade, it is plainly difficult to comprehend what would distinguish

  someone as `my fellow human'' from someone as merely `a human''. The

  solidarity within civil rights movements or political unions requires a

  reference to others in relation to the subject of solidarity exposing

  their significant commonality as feminists, homosexuals, workers,

  anarchists, etc. Thus understood, relations of solidarity, and the

  entitlements and obligations associated with them, only extend to those

  who are related via significant commonalities, and the content of

  solidary obligations is explained and limited by these commonalities as

  well. This structural difference between agent-relative and neutral

  moral reasons suggests that the notions of universal and partisan

  solidarity are incompatible; but this does not imply that the universal

  notion has to give way to the partisan notion of solidarity. My argument

  rests on the assumption that, while the notion of partisan solidarity

  captures a specific moral phenomenon for which there is no comparable

  alternative, the partisan conception does not take anything away from

  those accounts that refer to universal solidarity, because other

  established moral notions like humanity, charity, or beneficence suffice

  to capture what appears to be invoked in references to universal

  solidarity. While it is impossible to pre-decide this issue for all

  potential conceptions of universal solidarity, the relation that Wiggins

  has in mind may be re-described as humanity, compassion, or

  fellow-feeling, or maybe as a basic form of moral recognition.

  At any rate, other terms than `solidarity'', which is commonly associated

  with a much more specific meaning, may be conceived as fitting to

  describe such a fundamental form of moral relatedness. Similarly, one

  may concede that Habermas makes a valid material point to emphasize

  positive obligations between all members of society. Yet, there may be

  alternative notions, like care, mutual concern, or civility, that

  capture what Habermas has in mind. If using the term solidarity to

  describe universal moral relations leaves a specific form of moral

  obligation without a label, more needs to be said about the

  distinctiveness of the communality that is supposed to be entailed in

  this form of moral obligation. Solidarity is often regarded as an

  inherently inclusive ideal to counter the narrowness of commitments to

  blood, soil, and nation. This appears to be incompatible with the

  defense of an essentially partial, and thus exclusive, notion of

  solidarity. However, solidarity cannot only be distinguished from

  universally inclusive obligations, but also from immediate and exclusive

  forms of moral relatedness like patriotism, friendship, or loyalty. Thus

  conceived, solidarity comprises a very specific strain of a wider set of

  what may be considered associative obligations. These obligations, in

  turn, belong to a wider class of special obligations comprising

  contractual duties, reparative duties, and duties of gratitude.

  Solidarity''s normative force depends on meaningful commonalities like a

  joint struggle, a common ideal of a good life, or a social utopia, in

  relation to which a solidary subject positions herself, while being

  aware that others do the same. Solidarity is special insofar as it

  contains a shared partisan involvement with a group that is not

  strategic, but that is nonetheless `mediated by thought and belief''. Due

  to its normative foundation in reflected commitments, solidarity tends

  to be more inclusive than immediate ties of kith and kin. Even though

  solidarity is - inevitably - more exclusive than humanity, it allows for

  inclusion of those who are willing to join with an identificatory

  commitment. If solidarity relations pertain to a specific form of

  communal obligation which holds some significance in moral life, and for

  the description of which moral philosophy possesses no viable

  alternative, then abandoning this notion noticeably impoverishes moral

  language. This pragmatic argument about philosophical terminology does

  not question the existence of universal obligations, but it suggests

  that the term solidarity is misplaced in the denotation of universal

  obligations or affiliations; or at least that the decision to understand

  solidarity as universal is accompanied by a systematic disadvantage to

  moral philosophy. In the remainder, I am interested in the possible

  normative role of this account of solidarity within bioethics and health

  justice. The previous argument does not, by itself, show that the term

  solidarity is misplaced in the formulation of moral demands for

  universal health care. In order to substantiate this thesis, more needs

  to be said about the vindication of health-related claims and

  obligations. My terminological suggestion presupposes that public health

  care is not - or at least not primarily - a matter of communal or

  partisan obligation, even though the prevalent vocabulary of health care

  entails some conceptual vicinity to notions like solidarity.

  The extent to which the moral demand to universal health care can be

  argued to be based on solidarity depends on the general nature of the

  normative foundation of the provision of public health care. According

  to the broad WHO definition, universal health care or coverage exists

  when `all individuals and communities receive the health services they

  need without suffering financial hardship''. Beyond safeguarding access

  to health services, which can be realized through different types of

  government interventions from providing health services to structuring

  public and private insurance schemes, universal health coverage also

  extends to public health measures addressing disease prevention or

  health equality. In the first instance, universality is defined in

  relation to existing societies, requiring all members, citizens, or

  residents to be adequately protected against the contingency of disease

  and infirmity. Solidarity is often invoked in this context because it is

  considered to be closely connected to core mechanisms of health

  protection, such as the mutual assistance and the socialization of the

  costs of health protection and health services. Depending on the extent

  of commodification, i.e. on the absence of government intervention

  regarding premiums, redistribution, coverage, compulsory membership,

  etc., some health care regimes rely on conventional insurance models,

  while others operate through different forms of government intervention.

  The fundamental distinction to be made concerns different ideas of the

  socialization of health-related burdens and risks. Many forms of

  protection against disability, fire, theft, debt default, etc. are

  covered through insurance policies that are privately offered on

  markets. In these schemes, individuals pay risk-equivalent premiums to a

  common fund in order to pool resources that are distributed to

  individuals suffering the harm covered by the respective scheme of

  collective protection. The principle underlying these forms of insurance

  - an idea that increasingly governs systems of private health insurance

  as well - does not rest on a moral notion of solidarity at all, as the

  rationale for participation is fully reducible to a non-moral motivation

  of self-interest. In fact, one of the major criticisms of the

  privatization of health insurance is directed at the loss of solidarity

  involved in individualization and the crowding out of poor-risk

  patients. In contrast to the market model of health insurance, most

  forms of state-regulated or state-run health care are not organized in

  the form of a collection of risk-equivalent premiums but entail some

  redistributive measures, such as the provision or support of social

  health insurance or tax-based financing of health services. Public

  health systems deliberately ignore factors like age, gender, social

  status, or pre-existing health conditions that have an impact on the

  estimated costs of health services to be covered in the case of

  maternity, illness, or injury. This renunciation to select, isolate, and

  exclude poor risks may be considered an institutionalization of a

  genuinely moral form of solidarity. This moral notion of solidarity as a

  measure to socialize risk and burdens is ubiquitous in the development

  of the welfare state. Thus, references to solidarity in the context of

  health provision may be considered rudiments of the normative frameworks

  of initial efforts to establish social health care that were conceived

  to replace vanishing traditional forms of social protection.

  Toward the establishment of universal public health care, local

  protective institutions like the family, tribe, or village are gradually

  supplemented or replaced by initially delineated communities of a

  company''s workforce, the members of a cooperative, a union, craft, or

  class. The history of the development of public health care is permeated

  with references to solidarity as an ideal of moral inclusion. Thus, the

  historic achievement of the modern welfare state could be seen in its

  incorporation of numerous local solidarities into a single

  all-encompassing system of solidarity as it may be found in programs of

  social health insurance and tax-based health systems. If original forms

  of social protection are describable as forms of solidarity, then the

  public provision in systems of universal health care may be argued to be

  an extension of the initially limited forms of group solidarity toward a

  universal solidarity within society as a whole. One could argue that the

  development of a separation of privately organized insurance schemes

  from a universal system of health care runs contrary to the modern

  process of expanding health insurance and solidarity instead of

  fragmenting or restricting it. Thus conceived, solidarity would be an

  adequate normative reference condemning trends toward atomization and

  self-reliance, and away from the collectivization of health risks.

  Despite the initial plausibility of this description, the previous

  distinctions suggest that the relations of solidarity within initially

  separate schemes of insurance and social protection undergo a

  substantial transformation by being universalized, thus possibly calling

  for a description in a different moral vocabulary. The normative

  innovation that is entailed in the shift from communal toward universal

  inclusion in health care provision is decisive to the present argument

  regarding moral terminology. It suggests that universal health care is

  better justified in a different vocabulary than that of solidarity.

  There is a fundamental argument that casts conceptual doubt on the idea

  of understanding solidarity as a foundation of universal health

  coverage. Even though many factual instances of health care provision

  may be described as based on solidarity, there is a decisive difference

  to the moral foundation of universal health care. In order to conform

  with the previous understanding, the reference to solidarity in

  arguments supporting universal health care would require a commonality

  that serves as the solidum substantiating health-related obligations of

  solidarity. However, the principle of universal inclusion appears to

  contradict the supposition of a solidum that would substantiate a

  distinction between members and non-members. One evident candidate for

  such a commonality would be the human vulnerability to disease,

  infirmity, or injury. In this line of argument, health claims could be

  considered to be based on a shared vulnerability that transcends

  individual claims of justice stemming from general attributes. However,

  the attempt to base health-related moral claims on a commonality of

  human vulnerability that unites all human individuals is not convincing.

  Rather than some form of a commonality, the universal presence of a

  morally relevant feature appears to do the normative work here. It is

  hard to comprehend how the universal vulnerability to disease and

  infirmity would serve as an identificatory point of reference to

  substantiate moral obligations toward others beyond their significance

  as moral subjects.

  In contrast to the universal fragility, the commonality of the specific

  situation of persons with AIDS or cancer can be conceived as such a

  point of reference, which is reflected in the membership of patient

  associations. Another problem of accounts of health-related universal

  solidarity is that they seem unable to show what this basal

  identification would add to our idea of moral obligation. If all humans

  share this vulnerability to disease and infirmity, then all that they

  could be said to owe to one another as vulnerable subjects is already

  encompassed in their obligations toward one another as human beings. The

  alternative to understanding moral demands on health care as stemming

  from some morally significant commonality is to devise them as

  universally dispersed entitlements of justice. In this understanding,

  claims to health do not go beyond the basic forms of moral obligation,

  and thus require no special obligation. They are neither supererogatory

  nor are they based in some special form of communality. This idea is

  reflected as a right to health, which - even though more has to be said

  about its peculiar object - is widely regarded as a fundamental human

  right. While the borders of nation-states inevitably set a frame for the

  political implementation of moral demands to health, the justification

  of these demands does not depend on the reference to this contingent

  frame. The reference to a `human right'' to health suggests that moral

  claims to health are not morally based in membership, or citizenship,

  but in the status of moral persons. There are two conceptual advantages

  to conceiving of claims to health in terms of justice, rather than

  solidarity. First, based on the distinction between communal and

  universal forms of obligation, solidarity remains available as a

  powerful reference to a specific form of communal obligation that

  obliges members of specific groups like unions, civil rights movements,

  political associations, cultural collectives, etc. toward each other

  beyond neutral morality. Second, the moral significance of

  health-related claims is reflected in the fact that they are not

  inferred from a commonality complementing the fundamental demands of

  morality, but they are situated at the center of social morality.

  Condemning the absence of sufficient health services by bemoaning a lack

  of solidarity may not be misconceived entirely, but it does not address

  the gravity of the moral offense entailed in violating or neglecting

  demands of justice. The rights-based argument for universal health care

  can be approached in different ways. It can be interpreted as stemming

  from a right to a specific health status, as a right to a range of

  health care services, or as the right to the opportunity to participate

  in an adequate system of health protection. While these distinctions are

  of importance when it comes to evaluating health systems, the point in

  the context of the present analysis is that there is a vindication of

  moral claims to the provision of health care that is independent of

  considerations of solidarity, because these claims are independent of a

  normatively relevant solidum. In theories of justice, health is widely

  understood as a universally valued good that is worthy of protection,

  and whose importance generates strong obligations for society,

  obligations to corresponding rights. However, the reference to a right

  to health, if understood as a right to be healthy, arguably contains a

  mistake about the possible objects of moral entitlements.

  The crucial issue is that the adequate object corresponding to a right

  cannot be a status, but it must be an action, or a set of rules or an

  institution. While societies do have an impact on population health

  through measures of environmental awareness, workplace safety,

  education, etc., health is something that cannot be unconditionally owed

  to a person. The right to a certain health status at any rate poses an

  unreasonable, or even an unrealizable demand. This problem leads to the

  assumption that there is no right to health, but only to health-related

  resources and services like vaccines and vaccinations, X-rays,

  counseling, appendectomies, etc. Accordingly, legal interpretations of

  the right to health acknowledge that it `must be understood as a right

  to the enjoyment of a variety of facilities, goods, services, and

  conditions necessary for the realization of the highest attainable

  standard of health''. This further criterion regarding the range of

  health services by reference to their adequacy to achieve the `highest

  attainable standard'' of health is particularly instructive, because it

  shows that the mere reference to a right to health care is incomplete.

  The modified reference to a health status that is not absolute but

  relative to specific personal and social conditions serves the purpose

  of delineating a reasonable, but possibly comprehensive, standard of

  what can be reasonably required in the promotion of health. The reason

  not to understand the right to health by reference to a fixed catalogue

  of health services is that the legitimate requirements on health systems

  depend on the available resources. The right to health as a right to the

  highest attainable standard of health can thus be understood as a right

  to the opportunity to achieve a standard of health that is realizable

  under the prevailing social circumstances. The point that is crucial to

  the present inquiry is that these justifications of the provision of

  public health care may - or even should - forgo references to a form of

  solidarity that is based on significant commonalities. Basic health care

  can be argued to be a demand of justice, and should not be translated to

  a demand of solidarity, as this shift of terminology has moral

  implications. There is a justified demand for universal health care that

  does not appeal to our specific commonality as beings that are

  vulnerable to disease and injury or to our membership in specific

  communities, but that is simply based on the fundamental intrinsic and

  instrumental importance of health. As the main topic of the present

  inquiry is moral terminology, my primary aim is not to substantiate the

  material commitments regarding health-related moral claims that have

  been incurred along the way but to specify the role of solidarity in the

  justification of public health care. An admittedly surprising result is

  that the foundation of moral claims to health via health rights may be

  subsumed under the Habermasian conception of solidarity. However, my

  disagreement with Habermas does not concern his substantiation of

  universal claims to positive measures of assistance but the choice of

  terminology relative to the functions of moral theory. Thus, my concern

  regarding the universalization of the term solidarity, and its

  subsequent suitability to communal obligations, remains.

  The problem of the universal notion of solidarity in this context

  consists of the dilemma of either providing an insufficient

  substantiation of fundamental health-related moral claims or of diluting

  a notion of communal relatedness that is relevant in other situations.

  Two more points should be made in order to better grasp the potential

  role of references to a moral notion of solidarity. The previous

  characterization of solidarity indicates that philosophical conceptions

  of solidarity remain relative in at least three regards. First, the

  field of obligations associated with solidarity depends on normative

  background assumptions incurred in philosophical accounts of morality.

  Relations of partial solidarity do not necessarily replace or outweigh

  universal forms of moral obligation. They constitute merely one

  dimension in a complex fabric of interpersonal moral relations. If

  solidarity is conceived of as a type of a special duty, i.e. as a form

  of obligation that exceeds the demands of neutral morality, then the

  potential range of obligations of solidarity depends upon what is

  included in the sphere of general moral obligation, and what is not.

  This points to a second relativity of solidarity as a moral notion. As

  indicated before, the moral force of obligations of solidarity depends

  on the moral legitimacy of the commonalities generating solidarity

  relations. On the one hand, moral obligations stemming from solidarity

  can be overridden by demands of justice, but, on the other hand, they

  also have to meet an internal criterion of moral adequacy. The partisan

  conception of solidarity does not imply that any form of commonality can

  be invoked to establish a special obligation toward the members of a

  group. From a sociological perspective, the cohesion within the mafia or

  among White supremacists may be described as solidarity, but in virtue

  of the repulsiveness of their ideological foundation, these relations do

  not have to be accounted for as morally binding because the immoral

  content of a common conviction can operate as a defeating reason to the

  moral validity of its role as an identificatory commonality. In this

  sense, solidarity is normatively dependent without being reducible to

  neutral morality. Finally, the importance of relations of solidarity is

  dependent on the social environment in which they arise. This may, in

  part, explain the current social reversion to the vocabulary of

  solidarity. Within just societies, solidarity provides a reference point

  in the self-location of individuals within identificatory communities.

  This function is important to the generation and embedding of individual

  personalities. However, under non-ideal circumstances, solidarity may

  assume a core function in the enforcement of basic moral claims, and in

  the compensation of the shortfalls of social institutions. Two reasons

  appear to be pressing for conceptual clarity when making reference to

  solidarity. First, there is a danger of underrating the moral weight of

  claims to health care. In the understanding defended above, solidarity

  is imprinted with the idea that its obligations are special insofar as

  they go beyond what persons owe one another as moral subjects.

  Overstretching this notion opens the possibility of understanding the

  inadequate provision of health care as something that is regrettable,

  but that is outside the domain of justice. Solidarity marks those

  obligations that stem from their relatedness as members of morally

  significant communities.

  The obligation to provide a social system of protection against the

  harms caused by disease and injury extends to persons irrespective of

  their class, heritage, or belonging. Meeting this basic demand does not

  mark the solidarity of a society, but its decency. It is not something

  that must be justified by reference to an additional condition like a

  morally significant commonality. Second, relations of solidarity provide

  extremely important normative and motivational resources of social

  engagement. The preceding argument does not imply that solidarity is

  dispensable when it comes to analyzing and posing moral demands and

  corresponding obligations that are related to health. Beyond this,

  solidarity as a social relation and the obligations that it generates

  can be argued to be particularly relevant in times of crisis. Solidarity

  is less likely to be invoked in societies that manage to avoid the

  emergence of grave inequalities, discrimination, or injustice, than in

  societies that are unwilling or unable to provide adequate frameworks

  for just cooperation. The normative and motivational force of the ties

  invoked by solidarity is particularly relevant when basic moral demands

  are not met, and all non-ideal societies are in need of these kinds of

  solidarities. When Greece was hit by economic crisis and austerity, food

  solidarity centers, social kitchens, and solidarity clinics emerged

  throughout the country to countervail the gaps left after the retreat of

  government from the provision of welfare. In this manner, local

  solidarities may prove crucial in mitigation the effects of social

  regression. Similarly, the civil society in the United States may be

  forced revert to these mechanisms of social protection when those with

  no or low income and those vulnerable to disease and infirmity - i.e.

  the poor and the poor-risks - are effectively deprived of access to

  health care through market expansion and government retreat. The call

  for the emergence of solidarity in these contexts, however, should be

  strictly distinguished from the indignation about the absence of

  justice. It is in these contexts that a precise notion of solidarity is

  required so that it can unfold its full normative potential and the

  motivational force of union''s inspiration. The main concern of the

  previous argument is that a notion of universal solidarity is employed

  at the cost of the ability to give expression to a different moral idea

  of a wide but nonetheless thick communality. Ralph Chaplin considered

  solidarity to be able to summon a power greater than hoarded gold and

  greater than the might of armies, and it seems like the power of

  establishing this form of communality is one of the reasons for the

  ubiquity of references to solidarity. The actual relations of solidarity

  may not vanish due to a lack of vocabulary to refer to them, but their

  potential to generate moral action may decrease as a result of our

  inability to discern them. The author declares no conflict of interest.

  See e.g. Stjerno, S. (2005). Solidarity in Europe. The history of an

  idea. Cambridge, UK: Cambridge University Press. A topography of the

  term is offered in Bayertz, K. (1999). Four uses of ``solidarity{''''}. In

  K. Bayertz (Ed.), Solidarity (pp. 3-28). Dordrecht, The Netherlands:

  Kluwer Academic.See e.g. ter Meulen, R., Arts, W., \& Muffels, R.

  (Eds.). (2001). Solidarity in health and social care in Europe.

  Dordrecht, The Netherlands: Kluwer Academic.

  The famous first lines run as follows: `When the union''s inspiration

  through the workers'' blood shall run, there can be no power greater

  anywhere beneath the sun. Yet what force on earth is weaker than the

  feeble strength of one, for the union makes us strong''. Chaplin, of

  course, does not just refer to a principle of unity or union, but to the

  union as a form of political organization. However, union - qua relation

  of unity - is a defining principle of the type of organizations - like

  trade unions or cooperatives - that Chaplin praises.A similar argument

  can be found in Butler, S. (2012). A dialectic of cooperation and

  competition: Solidarity and universal health care provision. Bioethics,

  26, 351-360. Butler understands solidarity as one of the four tiers of

  social competition and cooperation. His conclusion is that `whatever

  justifications might exist for universal health care provision, none of

  them are properly referred to as being based in solidarity'' (ibid: p.

  351). Another defense of a partisan conception of solidarity is advanced

  in Heyd, D. (2015). Solidarity:A local, partial and reflective emotion.

  Diametros, 43, 55-64.For the distinction between prescriptive and

  descriptive notions of solidarity in bioethics, see Prainsack, B., \&

  Buyx, A. (2012). Solidarity in contemporary bioethics - Towards a new

  approach. Bioethics, 26, 343-350. See also Kolers, A. (2016). A moral

  theory of solidarity. Oxford, UK: Oxford University Press, p. 28.This

  implies that solidarity''s role in moral philosophy amounts to more than

  that of a `shaping sensibility''. See Jennings, B., \& Dawson, A. (2015).

  Solidarity in the moral imagination of bioethics. Hastings Center

  Report, 45, 31-38.On this dilemma, see Prainsack \& Buyx, op. cit. note

  5, p. 344.This does not only mean that solidarity must be

  distinguishable from other norms, but it also excludes accounts of

  solidarity that consider it a mere instrument in the pursuit of

  superordinate objects like justice or non-discrimination. While some

  forms of solidarity may be embedded in struggles for justice, this does

  not warrant the strong claim that `justice implicates solidarity'', as

  suggested in Jennings \& Dawson, op. cit. note 6, p. 38. If solidarity

  was merely instrumental to justice, there would be nothing wrong with

  breaches of solidarity, as long as they promote - or are intended to

  promote - overall justice.For a discussion of Wiggins, see Nagel, T.

  (2010). Wiggins on human solidarity. In T. Nagel (Ed.), Secular

  philosophy and the religious temperament: Essays 2002-2008 (pp.

  147-152). New York, NY: Oxford University Press. See also Derpmann, S.

  (2014). Solidarity, moral recognition, and communality. In A. Laitinen

  \& A. Pessi (Eds.), Solidarity: Theory and practice (pp. 105-125).

  Lanham, MD: Lexington Books.Wiggins, D. (2009). Solidarity and the root

  of the ethical. Tijdschrift voor Filosofie, 71, 239-269.Habermas, J.

  (1990). Justice and solidarity: On the discussion concerning stage 6. In

  T. E. Wren (Ed.), The moral domain (pp. 224-251). Cambridge, MA: MIT

  Press, p. 244. A critical reflection of the universality entailed in

  Habermas'' account can be found in Wildt, A. (1999). Solidarity: Its

  history and contemporary definition. In K. Bayertz (Ed.), Solidarity

  (pp. 209-220). Dordrecht, The Netherlands: Kluwer Academic, p.

  216.Regarding the extension of solidarity in Habermas'' conception, see

  Rehg, W. (1994). Insight and solidarity.

  A study in the discourse ethics of Jurgen Habermas. Berkeley, CA:

  University of California Press, pp. 107-111. Rehg does not reject this

  account, but he criticizes that Habermas does not sufficiently

  distinguish moral solidarity from more concrete lifeworld solidarities.

  Beyond this, I argue that the admission of a notion of moral, i.e.

  universal solidarity undermines the crucial structure of `lifeworld

  solidarities'' as essentially partial.Wildt, op. cit. note 11, p.

  218.Both Axel Honneth and Rainer Forst observe that the point of

  solidarity is lost in Habermas''s conception due to the absence of an

  element of `particularism''. See Honneth, A. (2007). Disrespect. The

  normative foundations of critical theory (pp. 99-128). Cambridge, UK:

  Polity Press and Forst, R. (2002). Contexts of justice. Political

  philosophy beyond liberalism and communitarianism (p. 304, note 21).

  Berkeley, CA: University of California Press.Richard Rorty places this

  morally significant `we'' at the heart of his conception of solidarity:

  `The force of ``us{''''} is typically contrastive in the sense that it

  contrasts with a ``they{''''}, which is also made up of human beings''. See

  Rorty, R. (1989). Contingency, irony, and solidarity. New York, NY:

  Cambridge University Press. A distinction of different meanings of this

  `we'' can be found in Dean, J. (1995). Reflective solidarity.

  Constellations, 2, 114-140, 124 ff.This is why Heyd rejects ter Meulen''s

  notion of a `humanitarian solidarity'' based `on identification with the

  values of humanity and responsibility for the other''. See Heyd, op. cit.

  note 4, p. 57.For the limits to universal solidarity and the relation

  between local, national, and cosmopolitan solidarities, see Derpmann, S.

  (2009). Solidarity and cosmopolitanism. Ethical Theory and Moral

  Practice, 12, 303-315.Ronald Dworkin defines these obligations as `{[}

  horizontal ellipsis ] the special responsibilities social practice

  attaches to membership in some biological or social group, like the

  responsibilities of family or friends or neighbors''. See Dworkin, R.

  (1986). Law''s empire. Cambridge, MA: Harvard University Press, p. 196. A

  similar terminology is given by Scheffler, S. (2001). Boundaries and

  allegiances: Problems of justice and responsibility in liberal thought.

  New York, NY: Oxford University Press, pp. 48-49.See Heyd, op. cit. note

  4, p. 59. In a similar manner, Jodi Dean defends a `reflective''

  understanding of solidarity. See Dean, op. cit. note 15. Avery Kolers

  highlights this aspect as well, as he understands solidarity - as

  distinguished from loyalty - to be primarily based on a reason, not on a

  prior connection to a group. See Kolers, op. cit. note 5, p. 44

  ff.Problematic examples may be those where the common commitment itself

  is exclusionary. While anyone may join the cause of suffragettes and

  suffragists, tax resisters, guerrilla gardeners, or dadaists, specific

  groups are excluded in the very content of the ideologies that unite

  White supremacists, sexists, etc.WHO. (2016). Fact sheet: Universal

  health coverage (UHC). Retrieved from

  http://www.who.int/mediacentre/factsheets/fs395/en/. Accessed on March

  6, 2018.See e.g. Borner, S. (2013). Belonging, solidarity and expansion

  in social policy. Basingstoke, Hampshire, UK: Palgrave Macmillan, p. 35

  ff. and Weale, A. (1990). Equality, social solidarity, and the welfare

  state. Ethics, 100, 473-488.

  In many cases, this form of insurance solidarity, however, is far from

  being universal. If individuals are granted the opportunity to opt out

  of insurance schemes that host high-cost risks, thereby reducing their

  own fees as well as the socially available funds for redistribution,

  there is no solidarity in a comprehensive sense but rather solidarity

  within coexisting social groups.For a systematic account of solidarity

  with regard to its relation to health care, see Jaeggi, R. (2011).

  Solidarity and indifference. In R. ter Meulen, W. Arts, \& R. Muffels

  (Eds.), Solidarity in health and social care in Europe (pp. 287-308).

  Dordrecht, The Netherlands: Kluwer Academic.There is a general problem

  concerning the term `universal'' in this context, as the universalism of

  moral theory is contradicted by the localism of its implementation in

  national health systems. Even though quite a number of moral demands are

  spelled out in universal terms, the moral claim to health is primarily

  implemented through the rights of citizens or residents of nation

  states. Thus, one could object that all existing health systems are

  partial toward the members of specific societies, and that they may be

  regarded to be morally based in national solidarity. The recognition of

  a universal demand to health is not exhausted in the protection and

  promotion of health of citizens of a particular state but would require

  the consideration of any moral subject. I will widely bypass this

  fundamental complexity that affects all theories of political justice

  and focus on universal health-related moral claims within given

  societies. The following section reconstructs the normative foundation

  of health systems by reference to a universal right to health as it is

  formulated in UN conventions, while its implementation is de facto

  translated to the fragmented responsibilities of nation states.This

  argument is also made by Heyd, op. cit. note 4, pp. 62-63.For

  institutional formulations - and interpretations of this right, see

  Committee on Economic, Social and Cultural Rights. (2000). Substantive

  issues arising in the implementation of the international covenant on

  economic, social and cultural rights. General comment No. 14. ``The

  right to the highest attainable standard of health.{''''} Retrieved from

  http://www.refworld.org/docid/4538838d0.html. Accessed on March 6,

  2018.On this argument, see Hessler, K., \& Buchanan, A. (2002).

  Specifying the content of the human right to health care. In R. Rhodes,

  M. Battin, \& A. Silvers (Eds.), Medicine and social justice: Essays on

  the distribution of health (pp. 84-101). New York, NY: Oxford University

  Press.See CESCR, op. cit. note 27, art. 12, sec 9.Daniels recognizes the

  need for this extension of his initial account. See Daniels, N. (2008).

  Just health. New York, NY: Cambridge University Press, pp. 2-3. On this

  topic, see also Wolff, J. (2012). The human right to health. New York,

  NY: W. W. Norton \& Company, pp. 13-34. INTRODUCTION: FORGING

  `SOLIDARITY'' SOLIDARITY AS A MORAL IDEA Solidarity as a relation sui

  generis Solidarity as a form of communal obligation THE MORALS OF HEALTH

  CARE Solidarity and universal health care Health and human rights

  SOLIDARITY AND HEALTH POLICY The relationality of solidarity The

  importance of telling solidarity and justice apart CONFLICT OF INTEREST

  Footnotes Solidarity is commonly invoked in the justification of public

  health care.

  This is understandable, as calls for and appeals to solidarity are

  effective in the mobilization of unison action and the willingness to

  incur sacrifices for others. However, the reference to solidarity as a

  moral notion requires caution, as there is no agreement on the meaning

  of solidarity. The article argues that the reference to solidarity as a

  normative notion is relevant to health-related moral claims, but that it

  does not provide a convincing foundation of claims to universal health

  care. References to universal solidarity obliterate an important

  distinction between those moral demands that are founded on principles

  like justice, recognition, or humanity, and those demands that stem from

  partisan relations in communities. While there is no `separate essence''

  of solidarity that could be referred to in order to argue for the

  conceptual necessity of solidarity''s partiality, some features may

  reasonably be stipulated as being essential to solidarity with a view to

  its systematic function within moral philosophy. The normative and

  motivational force of the ties invoked by solidarity is particularly

  relevant when basic moral demands are not met, and societies are in need

  of significant forms of communal relatedness.'
affiliation: 'Derpmann, S (Corresponding Author), Westfalische Wilhelms Univ, Philosoph
  Seminar, Dompl 23, D-48143 Munster, Germany.

  Derpmann, Simon, Univ Munster, Dept Philosophy, Munster, Germany.'
author: Derpmann, Simon
author-email: simon.derpmann@wwu.de
author_list:
- family: Derpmann
  given: Simon
da: '2023-09-28'
doi: 10.1111/bioe.12444
eissn: 1467-8519
files: []
issn: 0269-9702
journal: BIOETHICS
keywords: 'health care; justice; partiality; solidarity; universality; welfare

  state'
language: English
month: NOV
number: 9, SI
number-of-cited-references: '29'
orcid-numbers: Derpmann, Simon/0000-0002-5851-1298
pages: 569-576
papis_id: 9bddfadad70bb519bf38fac55fb46af3
ref: Derpmann2018unionsinspiration
researcherid-numbers: 'Baldissera, Annalisa/AHD-6334-2022

  Fazli, Ghazal/AAE-8320-2022

  '
times-cited: '3'
title: 'Union''s inspiration: Universal health care and the essential partiality of
  solidarity'
type: article
unique-id: WOS:000450332600005
usage-count-last-180-days: '28'
usage-count-since-2013: '333'
volume: '32'
web-of-science-categories: Ethics; Medical Ethics; Social Issues; Social Sciences,
  Biomedical
year: '2018'