abstract: 'The concept of solidarity has recently come to prominence in the healthcare literature. When understood descriptively, it usefully supplements other conceptions like reciprocity (e.g., between healthcare providers and their patients), patient-centered medicine, or care ethics. In the context of health insurance (especially in Europe), an appeal to solidarity effectively addresses the problem of the motivation for taking seriously the medical needs of compatriots by emphasizing shared vulnerabilities and needs. If understood more broadly as human solidarity, the notion proposes attention to the health of distant others, as a condition of their dignity. And taken normatively, it fills in some of the requirements of the abstract norms of justice and equality by advocating `standing with'' or aiding fellow community members or possibly also distant others in regard to their medical needs. Solidarity may be understood be required either for its own sake, when taken as a separate norm, or as a way to realize the demands of justice and equal treatment in matters of health. The current focus on solidarity in the healthcare literature is useful and important, in my view. Yet, to my mind, the understanding of it tends to be unduly restricted. For one thing, the literature has most often focused on solidarity within nation-states, as a relation among compatriots that supports universal healthcare. The notion is also seen as having import for contemporary developments like large health databases, biobanks, personalized medicine, and organ donation. A few authors extend solidarity more widely, particularly in interpreting the Universal Declaration on Bioethics and Human Rights, with its reference to solidarity in Article 13 and its implication in some other articles. Yet, these various uses of the conception of solidarity in healthcare have thus far tended to either disregard or even to actively eschew its traditional meanings of labor solidarity or social movement solidarity, or indeed, any use of the term that posits an `other'' against which solidarity might be practiced (although it is generally recognized that the concept is bounded and particular). I suggest that the neglect of some important historical (and contemporary) senses of solidarity-and especially social movement solidarity-leads to a blind spot in the current bioethical theories. An alternative reading of solidarity in healthcare drawing on social movement and labor contexts would highlight a crucial dimension of contemporary healthcare provision, namely, structural injustice. Systemic forms of injustice militate against adequate healthcare for all, and suggest the need for solidaristic action to struggle against and to remedy existing entrenched inequalities. Omitting an account of structural injustice and even of justice itself from the core meaning of solidarity leads, I argue, to a rather weak and too easy sense of what solidarity requires, and is ill suited to serve as an adequate normative guide for improving healthcare in the present. This is the case most obviously in regard to healthcare in the United States with its unequal health system, but I suggest it applies more generally and even in Europe, and certainly if we take the obligations of solidarity to extend transnationally. While traditional notions of solidarity within existing communities and nation-states remain significant, I believe that an adequate conception of solidarity needs to show how it is connected to justice. It also needs to extend transnationally, given our increasingly interconnected world, which raises difficult questions of the relation between national and transnational solidarities, and the justifications we can give for prioritizing the health and healthcare of those closer to us. In this essay, I will begin by briefly indicating how the existing approaches to solidarity in healthcare, despite their trenchant analyses of many of its features and applications, remain abstract and without sufficient critical import by not directly considering the impact of structural injustices. I will then attempt to sketch how an understanding of institutional barriers to equal treatment, along with the commitment to achieving justice concretely, need to inform not only our application of solidarity in practice but also our understanding of the core meaning of solidarity itself. I will not be able to address here the complex question of the priority that is often given to the needs of those close to us and the related question of negotiating our obligations to engage in national vs. transnational solidarity efforts, but I have taken this up in other work. In a series of books and articles, Barbara Prainsack and Alena Buyx have taken the lead in calling attention to the relevance of the concept of solidarity for bioethics. They have articulated a general conception and sketched several potential implications for healthcare and bioethics more widely. They advance the following definition: `Solidarity is an enacted commitment to carry ``costs{''''} (financial, social, emotional, or otherwise) to assist others with whom a person or persons recognize similarity in a relevant respect.'' Prainsack and Buyx usefully develop the notion of solidarity as a practice and see it as operating within three domains: the interpersonal, the group, and the administrative/legal. Their conception is largely descriptive, although it has some normative preconditions, and involves what they call axiological/axiomatic normativity of some sort. The difficulty of this latter phrase aside, Prainsack and Buyx seem willing to countenance morally negative expressions of solidarity (e.g., among members of a gang or even a terror group) in the interest of preserving the analytic utility of the concept. Moreover, they sharply distinguish solidarity from justice, regarding the latter as deontic and thus as not part of the concept of solidarity itself. But given their attention to the context of the practice of solidarity, they expect that norms like justice would be brought to bear, presumably to qualify the practice of solidarity. Since Prainsack and Buyx''s approach is perhaps the most highly developed conception of solidarity in the bioethics literature, it can serve as a useful foil for elaborating my own account, drawing on and extending my previous work on this theme. The main strength of their approach, it seems to me, lies in its aptness for understanding solidarity as a group practice, and especially within nation-states. Indeed, their view, with its emphasis on bearing costs to assist others within a group, seems to line up primarily with what has been called a `civic solidarity'' conception, one that has been prominent in connection with European welfare states. The idea that solidarity can come to be entrenched administratively and legally also points to the dominance of that European model in their understanding (though their conception is supplemented with what they call interpersonal solidarity). Importantly, these authors'' emphasis on solidarity as a practice helpfully ties solidarity to action. They suggest that this action orientation serves to distinguish solidarity from empathy or other sentiments. However, the centrality in their account of bearing `costs'' with the aim of assisting others brings the model close to the Christian tradition of solidarity with its emphasis on relieving suffering and aiding the poor. Their perspective likewise focuses on individual activity in aiding others, rather than on collective action. (The term `costs'', however, has financial connotations that do not sit altogether easily with this religious perspective.) The Christian tradition of solidarity can be distinguished (at least in its older forms) from the alternative socialist tradition of labor union solidarity, where solidarity is aimed at promoting shared interests and overcoming domination and exploitation with the aim of achieving justice. In this article, I will suggest that this latter understanding of solidarity introduces an important normative aspect of the concept of solidarity, one that is largely lacking in Prainsack and Buyx''s account. Although Prainsack and Buyx are at pains to differentiate between solidarity and charity (which is indeed an important distinction), I find their argument on this point unconvincing. They claim that charity is marked by assistance for others who are perceived as `different'' from oneself, rather than as being `similar in a relevant respect.'' The problem is that this distinction could be seen as having a question-begging aspect, inasmuch as the authors seem to posit by definition that in cases where people choose to donate to charities for people with a similar condition to their own (e.g., a particular illness), they are in fact acting in solidarity rather than charity. At the very least, more argument would be needed to establish the difference in question. Indeed, the issue of what is perceived as `similar'' and what counts as `a relevant respect,'' remains rather vague in their account. Clearly, perceptions of similarity and difference are notably various and variable. Can the perception of similarity with another in a relevant respect always be explained in a way that itself makes no reference to the solidarity that is supposed to follow from it, as it would have to be to avoid circularity? Is it, for example, the abstract status of being a fellow citizen that generates solidarity or does our tie to these others already presuppose pre-existing solidarities, e.g., as being members of our nation? The account would need to explicitly address questions such as these and also explicate what counts as `similar in a relevant respect'' to concretize this notion and give it real utility. In my own view, as developed elsewhere and as will become clear below, the distinction of solidarity from charity turns rather on the connection that solidarity bears to justice, and to the overcoming of domination and exploitation. It can also be seen to involve reciprocity in a sense to be indicated, which charity does not. Indeed, Prainsack and Buyx sharply distinguish between solidarity and reciprocity, taking the latter in the narrow sense of what I have elsewhere called instrumental reciprocity or `tit for tat'' reciprocity. In my view, reciprocity is a fundamental social relation that in fact takes several forms besides such instrumental ones, and I believe that reciprocity remains important for properly understanding solidarity. This potential for reciprocity helps to distinguish solidarity from charity, since charity evidently does not presuppose reciprocation from the needy or those aided. The reciprocity that applies to solidarity actions can be seen in the notion of mutual aid, which has been part of traditional understandings of labor and social movement solidarity. The mutuality involved here is itself a developed form of reciprocity, but one characterized not instrumentally in the manner of Prainsack and Buyx. Rather, reciprocity and the solidarity that incorporates it are here seen as aiming at improving the situation of the other, at least partly for its own sake, and not only for the subsequent return of benefit that could be expected from doing so. Although they do not explicitly tie solidarity to the overcoming of domination and exploitation, Prainsack and Buyx do helpfully take note of the dangers for healthcare posed by commercial interests, as well as entrenched inequalities. This is evident, for example, in their account of the problems that afflict the use of large databases and biobanks, as well as the perils that attend some proposed uses of personalized medicine. But these problematic dimensions of contemporary life are treated more as background conditions rather than as structural and institutional features against which solidarity actions with others need to struggle. Moreover, we can observe that the prevalence of commercial interests in regard to health databases can undercut the very possibilities for solidarity that these authors seek, by deterring people from contributing their information to them from fear of such commercial use. This lends an additional practical motivation to taking these structural background conditions seriously, if solidarity is to be encouraged. Certainly, these authors are right to highlight forms of solidarity that may arise in pursuit of common aims or shared goals, as within a political community (often taken as national). But I would suggest that solidarity is also centrally a process aimed at overcoming forms of domination and structural injustice, where people share an interest in doing so. This struggle against domination can sometimes itself take an instrumental form. But when it involves normative solidarity, it is properly understood as motivated by a shared interest in justice rather than simply the pursuit of benefits. As I have suggested, the classic account of solidarity in this sense is that of labor movement solidarity, but similar notions have characterized a range of social movements, e.g., in Latin America and elsewhere, whether aimed at agrarian reform or at overcoming authoritarian rule, where they take the form also of democratic movements. I propose that these examples, with the processive and critical notion of solidarity they imply, have implications for an adequate conception of solidarity for healthcare and for its applications there. Before turning to this socially critical notion of solidarity, we can note a drawback in the standard reading that takes solidarity as a unitary notion within a single group or community like the nation-state. Insofar as the group is limited to compatriots, or to members of smaller pre-existing groups, it evidently does not address the needs or vulnerabilities of others situated outside these groups'' borders. Although there may be unitary groups or communities that are transnational, within which traditional forms of solidarity can be found, increasingly we see that cross-border or transnational relationships take a networked form and involve relations to `outsiders''. What sorts of solidarities are possible there both generally and in the context of healthcare? Some bioethicists have recently addressed this issue by introducing a notion of human solidarity or global solidarity. In the analysis given by Gunson, the notion of solidarity held to be suitable for global contexts and seen as underlying the Universal Declaration on Bioethics and Human Rights is explicitly understood as `weak solidarity,'' namely, `the willingness to take the perspective of others seriously.'' It does not add the requirement `to act in support of it,'' which he holds is characteristic of `strong solidarity,'' such as is involved in political solidarities or in social movements to counter exploitation or achieve justice. Gunson explicates weak solidarity as involving listening to others and `caring for others,'' but not necessarily as including efforts at reducing inequalities, or even a specific concern with those. He sees the Universal Declaration on Bioethics and Human Rights as appealing to a notion of human dignity, but seems to think that weak solidarity is sufficient to respect and uphold that dignity. I would suggest that the appropriate sense of dignity is the robust and demanding one that we find explicitly enunciated in the Universal Declaration of Human Rights, where dignity is taken in an egalitarian sense, and is held to imply certain labor rights, along with health itself as a human right. A related notion of dignity is likewise appealed to numerous times in the Universal Declaration on Bioethics and Human Rights, which also includes a specific reference to solidarity, as a goal of international cooperation, along with demands on governments for meeting health research and healthcare needs. But this Declaration could usefully go further to specify some of the practices that would help to realize these aims, and I suggest that strong, rather than weak, forms of solidarity would be required in order to fulfill them, and not merely the caring for and aiding others that Gunson and also Prainsack and Buyx emphasize in their accounts. We can distinguish two main senses of solidarity, as already adumbrated, each of which has import for healthcare and the structural injustice that may constrain it. One sense is unitary solidarity, often taken as pertaining to the relations among citizens within a state, but applying as well to the relations among members of smaller pre-existing groups. The second is what I call networking solidarity, evident when groups (often, though not necessarily, transnational), or sometimes also individuals, link up to work on projects aimed at overcoming oppression or exploitation. The first form of solidarity-unitary group solidarity-is often illustrated with the motto of the three musketeers: `One for all and all for one,'' but that is a rather specific and highly demanding version of it. Nonetheless, it has the advantage of calling attention to solidarity as involving a clear awareness of a `we'' or `us''. Although some sense of a `we'' can be discerned in both forms of solidarity analyzed here, it applies to each type somewhat differently, as we shall see. In contrast, the individualist approach to solidarity advanced by Prainsack and Buyx tends to diminish the role of shared or collective activity, although it helpfully includes a notion of identification with an other who in their view are aided because they are regarded as `similar in some respect.'' In the account that I have developed, the first sense of solidarity pertains to relations among co-participants in an ongoing group, oriented to shared goals. Not all of the participants necessarily share all the goals of the group though they are generally committed to the main ones and to the group''s persistence and viability as a whole. Note that solidarity here may not always require a pre-existing shared identity or culture (although it often does), but may emerge from the constitution of an ongoing `we'' in the context of collective or group agency. The shared goals of the group are not aggregative, that is, a sum of each individual''s similar goals, but arise in common endeavors (normally including a multiplicity of overlapping subordinate goals), where the overarching goals are at least partly constitutive of the group itself. The various aims and goals are not always explicitly reflected on and are often embedded or institutionalized in the practices of the group. While such a conception of solidarity is often thought to be merely descriptive, I see it (as will be the case for the second sense as well) as grounded in a social ontology of what I have called individuals-in-relations, and as having normative dimensions. In this first case of group solidarity, as an instance of what I have elsewhere called `common activities,'' the norms go beyond the commitments involved in the constitution of any group whatever, and extend to the recognition (though often only implicit) of the fundamentally equal status of the individuals who constitute the group as agents. In virtue of this equality, I have argued elsewhere that the members should be granted equal rights to participate in processes of affirming and revising the goals of the group and should also have some say in how the various shared goals are carried out. This follows from an understanding of justice as what I have termed `equal positive freedom,'' or prima facie equal rights to the conditions of self-development, where such social contexts of activity are among these necessary conditions for individuals. In virtue of their equal agency, no individual has a right to dominate others in determining these common activities, that is, they have equal rights of co-determination of them. In this perspective, solidarity can be seen as an integral part of a set of norms that encompasses justice, as requiring the equal freedom of these relational individuals to develop themselves over time, and the norm of democracy, going beyond its traditional meanings of voting and majority rule to include equal rights of participation in co-determining group ends. In this account, which emphasizes people''s interdependence and their embodied nature, the sort of mutual support involved in group solidarity emerges as a crucial condition for the self-transformative activity of individuals and for the persistence of the group itself. We can say then that the requirement to realize justice along with a broad range of human rights through solidaristic activity arises from people''s interdependence and from the fact that their free development as agents requires a set of conditions, both material and social. Justice calls for the protection of the traditionally recognized negative liberties, but goes beyond it to require the availability of conditions that support people''s self-developing activity (both as individuals and as collectives) over time, that is, their positive freedom. Crucial among these conditions are health and healthcare, as well as education and other central social needs. Given the individuals'' fundamental equality as agents, with both individual dignity and shared needs, the norm of justice as requiring action to realize equality not only qualifies any potential group solidarity, as it does on the Prainsack and Buyx account, but is properly a core aspect of solidarity itself as a normative practice. From this perspective, the solidarities that obtain within a group not only help to realize justice concretely, but also can be said to constitute `the other side of justice'' (in Habermas''s phrase). Solidarity actions not only reflect people''s pre-existing feelings of connection to each other, but also can function in practice to solidify their understanding of shared neediness and their interdependence in meeting these needs and pursuing shared goals. The interdependence involved in common endeavors like political communities, together with the equal vulnerability of members of such communities, involves forms of reciprocity and gives rise to the requirement of mutual aid that is characteristic of solidarity. Further, the conditions for the realization of both individual freedom and of the shared goals of the group can in fact be seen to require the absence of domination and exploitation, that is, the overcoming of these one-sided forms of recognition not only in interpersonal relations, but also as they are entrenched in structural or institutional forms. Included here are types of economic functioning that systematically disadvantage large groups of people, along with other forms of institutional discrimination on the basis of race or gender, or other minority characteristics. Although existing solidarity groups are not always fully aware of the relevance to them of overcoming such injustices, I believe that such demands of justice are in fact integral to solidarity as a norm and not external to it, as on the empirically oriented account advanced by Prainsack and Buyx. Moreover, we can see that ongoing (and not merely pre-given) solidaristic social action within a collectivity and community is needed as a way to more fully achieve justice within it. These interrelations between solidarity and justice are even more evident in the second sense of solidarity, which I have called networking solidarities. This second form is most often found in social movements. Conceptually it arises primarily from classic notions of labor solidarity, which I have suggested can be extended to these movements and can even characterize the relations that are increasingly evident among civil society associations, e.g., NGOs. Networking solidarity is a form particularly apt for capturing constructive relations of support toward distantly situated others, but it can also apply within, as well as across, borders. This form of solidarity is generally aimed at overcoming forms of domination and exploitation, but may also include networking to help alleviate suffering. As a relation among groups (or sometimes even among individuals), I have elsewhere argued that it manifests a type of social empathy or the understanding of another group''s situation and perspective, but such solidarity does not consist in sentiment per se. Rather, it necessarily involves action or a readiness to take action on behalf of, and in support of, others. Here, too, there is generally a commitment to a common cause, and when properly understood, I think, a commitment to justice. Although this form of solidarity in practice has tended to involve better-off people working to help those who are less advantaged, we can find a form of reciprocity implicit even here, in particular, an expectation of reciprocal action and mutual aid were it needed. More direct reciprocity is evident in traditional labor union solidarity, as well as in some social movements, where the solidarity actions are among people perceived to be similarly situated. In these various cases of networking solidarity, I have argued that normatively solidarity requires deference to the needs and goals of others as they themselves understand them. And ideally, solidarity movements should embody democratic modes of decision making among the participants, given their equal status as members, and their shared commitment to the overarching goals of their movement. Although there are some fully shared goals that motivate these forms of networking solidarity, especially inasmuch as they often take a project-oriented form, different subgroups act to realize these goals in ways they themselves determine, and they liaise or link up with each other to decide how each group can best participate and contribute. As groups or associations of their own, they tend to have their own sets of goals and plans unrelated to these solidarity actions. But they take themselves to be part of the larger movement or set of associations, aimed at overcoming forms of domination or suffering. Moreover, they often make use of online forms of networking and social media to coordinate their efforts with each other, and they offer each other mutual support and encouragement. Although the groups or individuals linking up in these networks can in some sense be regarded as themselves constituting a superordinate group, and thus from an abstract perspective as not being essentially different from the first form of group solidarity, the latter is unitary and understood by the members as a single group, most often pre-existing, while the former involves loose relations among groups (or sometimes also individuals) undertaken for the purpose of a given project or aim. In practice, then, we can regard these two forms of solidarity as distinct, and see them as manifested in two different types of social phenomena. The `we'' in the case of networking solidarity is constructed serially and diversely by its member groups (or individuals), and is oriented to a particular cause. Nonetheless, insofar as they take overcoming domination, oppression, or exploitation as their aim, they are at least partly defined by an egalitarian commitment to justice, and the `we'' should remain open to others similarly committed. It must be granted that labor solidarity and most social movement solidarity have often involved shared interests and an antagonistic relation to others regarded as exploitative or authoritarian. Indeed, the first sense of solidarity, as group solidarity, admits of a similar antagonistic relation to outsiders, e.g., in the case of hostility toward other nation-states. Nonetheless, we can see how normatively each of these forms of solidarity has the potential to develop in ways that are more inclusive rather than exclusive. In the national case this is possible if borders are not understood to reflect unitary shared identities but come to be regarded as contingent and indeed as porous, or at least much more so than at present. Likewise, labor and social movement solidarity are in principle open to all those who wish to join in their efforts to work toward social (and indeed global) justice, even though it must be admitted that in practice those benefiting from exploitation are unlikely to join in. The connection of solidarity to social and global justice suggests the need to theorize more fully how structural or systemic forms of injustice set the frame and motivation for many solidarity movements and can serve to orient their practices. The notion of structural injustice is perhaps most relevant to networking solidarities, especially where they explicitly aim at establishing justice and therefore would have to address such institutional forms of injustice. But this notion can also apply to unitary solidarity groups, if they seek to adequately meet the basic needs and respect the human rights of their members, who are affected by these forms of injustice. That structures or systems may operate so as to consistently produce injustices has been a prime insight in Marxist theories, which highlight the way the capitalist economic system exploits workers, apart from the specific intentions of individuals, who often do not aim at such exploitation. While classical liberal theories tend to put great weight on individual action and intention, the Marxist emphasis on structure and on the functioning of the capitalist system focuses us on the underlying ways in which corporations operate in accordance with the requirement to increase profits by way of the exploitation of labor. Marxist theory also brings to the forefront the notion of objectification. This refers to the significance of the embodiment of intentions and plans in artifacts and on the need to be recognized by others if people are to understand themselves. That is, it introduces elements of externality required for self-transformation, whether individual or cultural. In such an approach, not only the social, but the material, environment for human action can in various ways reflect existing class and other salient group differences. This environment for action also generates steady expectations and encourages certain modes of comportment in people who tend to operate in accordance with prevailing social practices and rules. At the same time, people have the capacity to change these practices and rules over time, though often only through collective choices and action. (This point may not always be duly appreciated in theories of structural injustice themselves.) More contemporary analyses of the structural factors that contribute to injustice, as found for example in the work of Anthony Giddens and Iris Young, cast light on how individuals can reproduce problematic practices through their choices within these structural constraints. While Giddens focused on processes of what he called structuration, Young highlighted consumer choices and other social practices that serve to produce and reproduce injustices, in a certain sense unwittingly, for example, by impacting sweatshop workers at a distance or by limiting access to the existing housing stock. According to Young:Structural injustices are harms that come to people as a result of structural processes in which many people participate. These participants may well be aware that their actions contribute to the processes that produce the outcomes, but for many it is not possible to trace the specific causal relation between their particular actions and some particular part of the outcome. This emphasis on structure, Young argues, turns our attention to `how the institutions of a society work together to produce outcomes that support or minimize the threat of domination,'' where these outcomes largely depend on the social positioning that conditions people''s diverse life prospects. In later work, Young''s emphasis turns more to the ways that practices that connect people to each other implicate them in these processes of social and structural reproduction. On her view, the connections in which people stand give rise to what she calls a `forward looking'' sense of political responsibility, and evoke the need to stand in solidarity with others. Leaving aside the difficult issue of responsibility, we can observe that focusing primarily on the amorphous practices of social life can lead us away from understanding the workings of contemporary political economy and its detrimental effects on those who lack the power to take any part in determining its direction. I have also criticized a view that would simply characterize everyone-whether workers or top executives-as implicated in these processes and practices, seeing these groups as distinguished only by degree. Rather, some have substantial control over the processes to which others are subjected. But for the purpose of the analysis here, we can take structural or systemic injustice to refer both to the operation of the formal political-economic institutions of capitalism (along with racism and patriarchy), and to the more informal practices and rules of social life, which also contribute to the production and reproduction of inequalities. How, then, are these structures and the injustices they produce connected to solidarity, as analyzed here? Without attempting a thorough account, we can observe that capitalist economic institutions have in fact disrupted earlier forms of solidarity, such as those characteristic of pre-capitalist political economies, marked by what Durkheim called mechanical solidarity. At the same time, new forms of solidarity have been created, e.g., through the division of labor (as described in Durkheim''s term organic solidarity). In political contexts as well, older solidarities within local communities have tended to give way to national, or even transnational, forms. Yet, of greater relevance for us here are the ways in which political economic institutions, with the inequalities and forms of domination and exploitation they may generate, frame and motivate new solidarity movements to address these injustices. Recognizing how institutions and practices function in ways that assign differential power to various groups in society is essential if justice is to be constructed through solidaristic action. Even where solidarity actions aim only at relieving suffering and do not directly attempt to eliminate oppression or explanation, some understanding of the social and institutional context of those to be aided is needed if the solidarity actions are to be effective. For example, efforts to address the aftermath of hurricanes and also to mitigate them going forward call for attention to the social conditions that lead impoverished or minority groups to be disproportionately affected by such natural events-by reason of where they live, or the ways they lack protection against excessive damage from these natural events. In such situations, empathy with the situation of others, and even specific action to assist them, however important they may be, are insufficient unless they are coupled with an understanding of the impacts of the structural features of political economy and the injustices to which the operations of these institutions give rise. This is even more evidently the case where solidarity movements aim directly at overcoming oppression and exploitation, e.g., ending sweatshop labor. In such cases, effective action must not only support workers individually or remedy their specific situation but requires a socially critical analysis of the prevailing context that gives rise to the exploitation in the first place, which may also provide indications of how to address it. We can grant that solidaristic practices, whether in healthcare or other contexts, may well have their own utility as an expression of our sociality and our enjoyment of acting in common, and in this sense solidarity can even be said to have some value apart from its functioning to help in constructing justice. But the argument here is that these practices can be truly effective in meeting their aims only if they go well beyond charity and also beyond practices that simply `incur costs to assist others recognized as similar'' (in the Prainsack/Buyx formulation). If they are to conduce toward justice, these solidarity practices and movements need to address the ways that social, economic, and political institutions systematically function to deny some groups of people the basic means of life, and give rise to pervasive inequalities in people''s opportunities for self-development and for participating in processes of collective self-determination. This is the case most clearly for what I have called networking solidarities, but it can apply to solidarity within more unitary contexts like nation-states to the degree that the bonds involved (e.g., among citizens) are not merely pre-existing but affirmed and reinvented over time. Even more demandingly, at a normative level, we can say that solidaristic action needs to take seriously the requirement for deep social transformation in the direction of social, and indeed global, justice. In this way, as I have argued elsewhere, although solidarity remains particularistic in its orientation to specific problems and specific groups or individuals, it can keep in view the demands of universal human dignity. And solidarity movements can verify that their particular goals contribute (in however limited a way) to the broader goal of egalitarian social transformation. Thus, dispositions to empathy, deference, and mutual aid remain important components of solidaristic social action, but a critical analysis of the social context and concretely taking action oriented to alleviating structural injustices are needed as well. In addition, since the institutional context, with its given power relations, frames the various solidarity movements, sometimes the prevailing power formations are replicated within these movements themselves. I suggest that this calls for groups and agents to be self-reflective about these effects of the structural context in which they function, and to be on guard about the dangers of their own possible complicity in its replication and perpetuation. An important proviso should be mentioned before returning to the case of healthcare and considering the impact of the notions of solidarity analyzed here. That is, although solidarity has here been related to justice, with the concomitant need to analyze and address the structural injustices that frame solidarity action, there is no implication that solidarity movements or other solidarity activities are sufficient for achieving the institutional changes that justice requires. For that, democratic legislation and various political and economic transformations are also needed. But solidarity, whether binding the members of a nation-state, or interpreted in newer networking forms, are one important way of constructing the conditions for these transformations, or even, in some cases of prefiguring more just relations within the social relations of solidarity themselves. There is no question that the new focus on solidarity holds considerable import for healthcare, as Prainsack and Buyx have effectively argued. But the issue for us is what further benefit would result from incorporating solidarity''s connection to justice, holding in view the significance of countering structural or systemic injustices. Given the vast range and specifics of healthcare and the social and economic factors conducive to health, I will focus on only a few of the most obvious implications for the practice of healthcare and for the potentially solidaristic activities of practitioners. We can ask: what difference would it make if we take seriously the need to address the differential structural power of the individuals and groups involved in healthcare, whether as practitioners or those served by them? And what is the scope and nature of the solidarity thus required? I will suggest in this final section that understanding solidarity in relation to structural injustice can not only shed new light on the sorts of examples that Prainsack and Buyx consider, but also, more importantly perhaps, highlight an entirely different range of examples of healthcare solidarity from the ones those authors consider. It takes us beyond such cases as the readiness to assist others through participating in healthcare databases or biobanks to cases of active participation in social movements aimed at improving healthcare nationally or transnationally, or, more defensively, to protesting structural injustices that lead to the wrongful denial of healthcare or to deep inequalities in its allocation. An obvious case of structural injustice in healthcare is provided by the deficiencies evident in the U.S. health insurance system (or lack of a system). Europeans have long recognized the centrality of solidarity with fellow citizens needed to undergird a willingness to contribute through taxes to a universal healthcare system. The types of provision in fact vary considerably, from socialized medicine as in the UK to state-funded support for private insurance provision, as in the Netherlands, along with dual systems mixing public and private support. But the universality at which these systems aim reflects the recognition of people''s shared vulnerabilities in matters of health, and even an understanding that healthcare is a human right required by justice. There is also the acknowledgement that systematic or structural provision (or at least a guarantee) of healthcare is required in order to realize the universality at stake here. It is perhaps worth mentioning that despite their achievements, structural injustices do nonetheless persist in many of the European systems themselves. This is particularly the case where there are two tiers of provision such that private insurance is needed in order to gain superior care that (ideally at least) should be available to all. (Granted that in some European countries the public providers may actually be superior to private ones in some respects.) The lack of universal healthcare in the United States is evidently primarily due to the existence of structural injustice, rather than simply reflecting an absence of solidarity among compatriots. To state the obvious: the U.S. private insurance industry-and especially its leading large for-profit companies-is immensely powerful and, currently at least, enormously profitable. As part of the dominion of capitalist economic forms, these private firms also have inordinate influence over politics, as do the large drug companies. The activities of these companies exemplify the role of the `power of money'' that is widely prevalent in U.S. politics and society, which in turn circumscribes the possibilities for public policy and law. Corporate lobbying and campaign contributions from corporations and the wealthy notably undercut political equality in the United States and can also prevent attention to the basic tasks involved in meeting human needs in equitable ways. Beyond this, it can be argued that the systematic differences between people''s starting positions, depending on their class and race, in large measure fall out of existing economic functioning, particularly given the resistance of the powerful to the redistributions that would be needed for genuinely equal opportunities. Moreover, these differential and deleterious starting positions conduce to worse health outcomes for children affected by them, and for many adults over the course of their lives. In view of this systemic injustice, the sort of solidarity needed, then, is not only an empathic identification with other citizens (or better, with all members of the political community, including non-citizens). Rather, for meaningful change, attention also needs to be paid to the structural barriers to equal and universal healthcare. Although improvements and reforms can probably be made even without fundamental changes in these background structural economic and political conditions, realizing the goal of genuinely equal treatment would require transforming those basic economic structures themselves. And this in turn calls for social movements aimed at these transformations. In the case of the United States, some healthcare workers in fact have taken the lead in solidarity actions to preserve the existing limited forms of health insurance against efforts to strip vulnerable people of their coverage altogether. This represents an example of a type of solidarity action in the service of justice. Needless to say, much more needs to be done to develop a fully critical solidarity movement of the sort required. Indeed, some healthcare worker groups-notably National Nurses United and Physicians for Universal Healthcare-have taken the lead in spearheading the movement for Medicare for All, going considerably beyond the efforts to prevent repeal of the Affordable Care Act. They originally argued for a public option when that healthcare law was under development, and have gone on to organize healthcare consumers in various locales across the United States, including rural areas and those with large industries, to press for systemic changes in health insurance and in healthcare delivery, such as through establishing non-profit community health centers. In both domestic contexts and more global ones, connecting solidarity to structural injustice has been important for understanding and addressing the social and economic factors that greatly magnify the health impacts of natural disasters, e.g., of hurricanes or tsunamis or volcanic eruptions. Whereas solidarity with affected people has most often been episodic and motivated by empathy with them, attention to the structural factors that exacerbate the impact of these disasters on vulnerable populations expands the scope of what needs to be done in a forward-looking justice-oriented perspective. As suggested earlier, structural injustices that lead impoverished people to live in weak dwellings or in insecure geographical areas also expose them differentially to the health and other effects of weather or environmental catastrophes. Beyond the specific catastrophes, we can see that climate change itself has greater impacts on those groups as well, effects that will only increase over time. Cases that illustrate the ways that structural injustices intensify natural disasters (if not also contributing to causing them) are manifold, and the solidarity movements that have responded to these disasters are instructive for our purposes. A well known case is Hurricane Katrina in New Orleans in 2005, where African Americans made up 80\% of the people in flooded low-lying communities, sometimes residing in inadequate housing like trailers, and without the means to escape the rising waters (especially due to low rates of car ownership). Not only did these minority communities bear the large part of the deaths and injuries from the hurricane, but also they experienced abiding health problems, e.g., those due to mold. Yet, despite the grossly inadequate federal response to this disaster, residents offered each other mutual assistance and were also aided by solidarity groups like Common Ground, which helped with community rebuilding, including founding a free health clinic, and aiding with wetlands restoration. A related example is the response to Hurricane Sandy in the New York/New Jersey area, where healthcare workers set up free clinics in trucks, and helped to raise money for much needed medical supplies for the various communities that lacked adequate resources of their own to deal with the storm aftermath. Internationally, structural injustices significantly contributed to the grave impact of the 2010 Haiti Earthquake, in which over 200,000 people were killed and over 300,000 injured, with more than 1.5 million rendered homeless. Before the quake, many Haitians were impoverished and lived in slum conditions, leaving them highly vulnerable to floods and other natural disasters. The International Monetary Fund had implemented austerity programs in the preceding decades, which contributed to an evisceration of the public health systems and in turn to the health crisis following the earthquake, where there were radically insufficient medical supplies available. In the period that preceded the quake, an estimated 75\% of Haiti''s healthcare services had been provided by multinational and faith-based non-governmental organizations (NGOs), and its entire health supply system was externally run. The aid following the quake likewise involved a massive influx of international non-governmental organizations (INGOs), but Haitian NGOs were marginalized, as were the Haitian authorities, and over 90\% of the aid money went to international actors, including the UN and INGOs, and to the private sector. This aid, too, was unequally distributed between the capital and rural areas, and between well-off and less well-off areas of Port-au-Prince itself. In contrast, more adequately addressing the medical needs arising from the quake, some international healthcare NGOs succeeded in working in solidarity with local Haitians, in particular, the INGO Partners in Health, which explicitly incorporated a focus on the impacts of structural factors in their efforts. A more recent case is provided by Hurricane Maria, which devastated Puerto Rico in the summer of 2017. This natural disaster likewise calls attention to political economic and social structural factors that greatly aggravated the situation. Years of austerity, this time managed by the U.S. government and banks, along with massive debt, left hospitals without many doctors and with inadequate medical supplies needed to deal with injuries following the storm. Puerto Rico''s defective electrical grid also hampered the recovery from the hurricane. The inadequacies of this grid were exacerbated by the freeze imposed on a public infrastructure fund, which was instead used to funnel support to public-private partnerships under the same restructuring program. Moreover, in Puerto Rico, as in Haiti, we observe inequalities in the response to affected communities in the capital vs. in poorer rural areas. Solidarity work by healthcare workers, including doctors from Cuba, along with aid from the Puerto Rican diaspora, has been important in recovery and rebuilding efforts, but has not been able to make up for the lack of support from the U.S. government. It is evident, then, that effective action requires understanding the economic and social factors that condition people''s life chances and their health, including the limitations imposed by their places of residence. Indeed, the economic functioning of capitalism seems to be a major causal factor not only in these discrete natural events but also in climate change itself. While no single solidarity movement can counter these structural or systemic effects, establishing a linkage between a particular event and the deeper structural conditions for its differential impact on impoverished or vulnerable populations is important for adequate public policy going forward, and for the provision of the right forms of assistance in the present. It suggests the need for aid that not only restores the situation to the one that preceded the environmental event in question but that establishes a better, and more resilient, situation going forward. Clearly, an interlinking and networking of solidarity movements and of civil society organizations, as well as of public policy, would be necessary for the social transformative changes required. Similar arguments concerning the need for solidarity activity to remedy structural injustices can be advanced in regard to other central national or global health problems: for example, the provision of clean water, as in the case of Flint, Michigan, or the protection of the water supplies from fracking, or from underwater pipelines as in the case of Standing Rock, where there was a substantial solidarity struggle in support of the affected Sioux indigenous people in 2016-2017. Internationally, the health challenges include the need for wider and cheaper provision of drugs to counter HIV-AIDS along with a host of other illnesses; ways of dealing with malaria and with preventable epidemics; providing clean water worldwide; and addressing the range of health issues that result from trafficking, child labor, and slave labor. In all these cases, solidarity movements would need to join up with others working to counter exploitation and the dominion of the profit motive, or struggling to rectify the deep inequalities in social and economic conditions, along with the effects of absolute poverty. Likewise, in regard to the overarching problem of climate change itself, we have already seen the emergence of major transnational solidarity movements, often taking the form of networks of local groups, and including the participation of numerous healthcare workers. Examples are the older Via Campesina, the People''s Climate Movement, and 350.org, among many others. In the international context, mention should also be made of the way structural injustice frames medical problems arising from illness and other natural causes, but also those arising from war and other forms of violence. Some solidarity movements in those contexts have focused on offering aid to the injured, as with the `White Helmets'' operating in rebel-held areas of Syria, extracting the living from the rubble following Syrian government bombings. While this group is composed mainly of volunteers and is anti-authoritarian, it otherwise eschews any specific political affiliation. The Kurdish YPG (People''s Defense Units) in northern Syria, which also has healthcare units operating in areas under attack, presents a somewhat different case, since it is explicitly anti-capitalist in orientation. However, a full discussion of these complex cases would take us beyond the scope of the present discussion. We can, in conclusion, return to two of the cases analyzed by Prainsack and Buyx and attempt to view them through the lens of structural injustice, with the resulting transformed interpretation of the solidaristic action required in those bioethical contexts. While less dramatic than the leading examples analyzed above, where solidarity needs to be directed explicitly towards countering structural injustices, the Prainsack and Buyx cases pose some interesting issues for consideration. The two applications of solidarity are those of governing health databases (as they put it), and personalized medicine and healthcare. As we have noted, in the course of their acute analysis, Prainsack and Buyx occasionally point to the dangers of the commercial uses of medical databases. But we can ask whether their recognition of these dangers fully informs their own account. Perhaps because they wish to make proposals that can be adopted immediately, the authors employ the notion of solidarity to recommend only modest restrictions on the use of these databases. For example, they urge that their use contribute to some public good at the same time as they retain their commercial or profit-oriented purposes, where these latter can even remain primary. The authors also tend to accept the existing limits on public funding for research as a given, rather than strongly arguing for its expansion by way of solidarity actions, however difficult accomplishing this might be in the present. In fact, the use of health databases for the purpose of private profit is a social choice that a society need not endorse. Likewise, the scope and extent of public funding is also a matter of policy and legislation, even if alternative directions would be difficult to implement in the context of a capitalist political economy. It is constraints posed by the latter that I would highlight in an alternative structural perspective on solidarity, taking us beyond the commitment to assist others that these authors foreground in their analysis. Indeed, one can further argue that the solidarity that Prainsack and Buyx seek, as a willingness to share one''s own data in large databases, can actually be undercut by structural injustices. This is evident especially in regard to the potential commercial use of the data. Informed people, aware of the dangers that this background structural feature poses, may well be resistant to taking a chance on acting in the solidaristic ways that these authors recommend. People may be wary of these commercial uses and indeed, may even come to expect them, so they would decide against contributing their own information, despite assurances of confidentiality. In this way, the existing tendency toward an overriding concern with private self-interest is reinforced by the very existence and continuation of these structural background conditions. In this context, efforts to eliminate structural injustice, if effective, could be expected to assist in promoting the sorts of solidarities that Prainsack and Buyx seek. Another specific difference I have with these authors'' otherwise excellent account of databases and their governance has to do with their rather puzzling remarks about dealing with the risks that must be accepted by those who contribute their health data to the database. For Prainsack and Buyx, solidarity is supposed to motivate people to provide their own health data to these databases and they argue that only `broad consent'' is needed for the use of this data by researchers rather than more traditional forms of informed consent, which they regard as excessively demanding and costly in this context. The authors propose that less attention should be given to preventing the risks of re-identification (with the potential discrimination that might follow) and more attention given to mitigating or compensating for harms that may accrue to individuals from misuse of their data in the future. This includes, they suggest, making fewer efforts to assure individual consent in a strong sense, and instead placing more emphasis on putting funds aside to remedy harms or injuries arising from misidentification or, more generally, from the misuse of information. I believe that encouraging solidaristic actions and practices of the sort these authors seek to engender would instead be aided by focusing even more than is presently done on preventing and limiting the risks that inevitably attend contributing one''s personal health data for use in medical databases. This is so not only for instrumental reasons, namely, because otherwise people will not participate out of (largely rational) fear of these untoward consequences. A greater emphasis on limiting risk is also essential in recognition of the real structural problems that frame these databases, namely, the great commercial potential they hold and their openness to corporate use of the included health information in the interests of profits, along with the deep challenges involved in safeguarding privacy online. These structural features would not be meliorated by the authors'' otherwise fine proposals to allow contributors to access their own raw data, and to be informed of possible health impacts on them personally that emerge from the research the databases facilitate. To adequately deal with the various social, technological, and medical challenges posed by these large databanks requires solidarity action in the interest of structural change besides the reforms the authors have sketched. Further, although Prainsack and Buyx helpfully suggest in passing that a few patients should be included among those who serve on the proposed governance boards for large databanks, it seems that the majority on these boards would be made up of standing groups of people whose only requirement is not to have conflicts of interest in regard to the potential uses of the databanks. This delimitation seems insufficient to assure the responsibility owed to the contributors of data, particularly in view of the background functioning of social and economic institutions that give managers and other elites the preponderance of power. Inasmuch as ethics boards are also ruled out by the authors as trustees (because they are overburdened, in their view, or may not be knowledgeable about the specific research in question), it is unclear how these governance boards would best be constituted on their approach. A strongly solidaristic view would require that a substantial number should be drawn from patients or their representatives, though it would clearly also be important to include a sizable number of scientists and other experts. We can see then that quasi-democratic requirements emerge for the governance of these databanks, such that those affected by them would have some say in overseeing them. This follows as well from the feature of deference, which I suggested is an important aspect of an adequate conception of solidarity. Deference is required toward those one is assisting, who should have a major role in specifying their needs and how they want to be assisted. Efforts must thus be made to hear from them systematically. This involves new forms of democratic, or perhaps quasi-democratic, input into the policies or actions in question. I use the qualification `quasi'' here to indicate that the input in question may not always have to be formal, though there is certainly a place for formal rights of participation on governance boards by some representatives of patients or even the public at large. This sort of deference to patients and democratic input by them also casts light on the final example of solidarity in action, drawing again from the Prainsack and Buyx account. They analyze the case of `personalized medicine'' or `precision medicine,'' which most often refers to the use of analytical software and databases to target medicine and healthcare to individuals in ways that are unique to them, e.g., by the use of genomics and through such software systems as IBM''s Watson. The authors rightly point out that group characteristics continue to be important to these analyses, since data about groups provide the parameters for evaluating the medical status of individuals. But in personalized or precision medicine, the focus comes to be on the intersection of these group findings within particular differentiated individuals. Moreover, the authors usefully propose to extend the characteristics that are taken into account in personalized practices to include also social ones, as well as individuals'' cultural and personal preferences. In regard to the identification of group characteristics and their embodiment in unique ways in individuals, it is clearly important to adopt a socially critical perspective as to what constitutes a relevant group. That is, taking structure into account suggests the importance of becoming aware of social preconceptions and potential bias in the identification of a group. This holds not only for standard ascriptive group identifications along the lines of gender, race, etc., but also of newer sets of subgroups or emerging crosscutting groups. It would also affect the ways both researchers and clinicians identify the social background conditions and the social and cultural preferences of the individuals, if these are to be taken into account and added to personalized medicine and healthcare, as Prainsack and Buyx propose. We can delineate one final implication of the importance of participation in healthcare by those affected, which I have suggested follows from a conception of solidarity that includes deference and hearing from others as to how they want to be aided or assisted. Clearly, a fuller view of personalized medicine would not only look at evidence-based therapies targeted at individuals drawing from large databases of relevant research, but should be open to input from patients themselves about the aims and methods of therapy. Even the basic interpretation of health and wellness, both of which are clearly shared goals of patients and clinicians, can be open to patients'' input. This sort of participation by those affected by the practice of medicine and healthcare need not be understood in a way that diminishes the role of science or expertise. Rather, it reflects the recognition that solidarity with patients requires openness to their own perspectives and goals, and ideally involves their participation in co-determining their own care. Given the range of research knowledge and existing therapies, a truly personalized medicine would not only home in on targeted precise therapies, but would involve an interactive and cooperative process of health building and health sustenance. As argued here, it would also require practices of attunement to, and solidarity with, a patient''s social context, needs, and aspirations. Further, understanding that social context, in turn, requires a focus on the differential power and inequalities that result from prevailing political and economic institutions, that is, an attention to structural injustice. The author declares no conflict of interest. Carol C. Gould is Distinguished Professor in Philosophy at Hunter College and in the Doctoral Programs in Philosophy and Political Science at the Graduate Center of The City University of New York, where she is also Director of the Center for Global Ethics and Politics. She is Editor of the Journal of Social Philosophy. Her most recent book is Interactive democracy: The social roots of global justice (Cambridge University Press, 2014.) Prainsack, B., \& Buyx, A. (2017). Solidarity in biomedicine and beyond. Cambridge: Cambridge University Press. See for example, Gunson, D. (2009). Solidarity and the universal declaration on bioethics and human rights. Journal of Medicine and Philosophy, 34, 241-260. I discuss this question in Gould, C. C. (2014). Interactive democracy: The social roots of global justice. Cambridge: Cambridge University Press. Prainsack \& Buyx, op. cit. note 1; and Prainsack, B., \& Buyx, A. (2011). Solidarity: Reflections on an emerging concept in bioethics. Retrieved February 25, 2018, from https://nuffieldbioethics.org/wp-content/uploads/2014/07/Solidarity\_rep ort\_FINAL.pdf Prainsack \& Buyx, op. cit. note 1, p. 52. Ibid., pp. 68, 77, 93. Ibid., pp. 76, 77, 93. Gould, C. C. (2007). Transnational solidarities. Journal of Social Philosophy, 38(1) (Special Issue on Solidarity, C. Gould \& S. Scholz), 146-162; Gould, op. cit. note 3, pp. 99-131. Bayertz, K. (1999). Four uses of `solidarity''. In K. Bayertz (Ed.), Solidarity (pp. 3-28). Dordrecht: Kluwer. More recent articulations of the Catholic notion of solidarity, in particular, have seen it as tied labor, e.g., in the Polish Solidarnosc movement or to Latin American social movements. See for example, Beyer, G. J. (2014). The meaning of solidarity in Catholic social teaching. Political Theology, 15(1), 7-25. Clearly, too, as Beyer points out, Christianity is not unique among religions in appealing to some conception of solidarity. See also Schoenfeld, E. \& Mestrovic, S. G. (1989). Durkheim''s concept of justice and its relationship to social solidarity. Sociology of Religion, 50(2), 111-127. For a discussion of the some of the meanings of solidarity in historical context, see Brunkhorst, H. (2005). Solidarity: From civic friendship to a global legal community. Cambridge, MA: MIT Press; Pensky, M. (2008). The ends of solidarity: Discourse theory in ethics and politics. Albany, NY: State University of New York Press. For a discussion of the distinction of solidarity from charity and from humanitarian aid, see Gould, op.cit. note 8. Gould, C. C. (1983). Beyond causality in the social sciences: Reciprocity as a model of non-exploitative social relations. In R. S. Cohen \& M. W. Wartofsky (Eds.), Epistemology, methodology and the social sciences: Boston studies in the philosophy of science (Vol. 71, pp. 53-88). Boston: D. Reidel; Gould, C. C. (1988). Rethinking democracy: Freedom and social cooperation in politics, economy, and society (pp. 31-90). Cambridge: Cambridge University Press. Gould, op. cit. note 8. Note that Andrea Sangiovanni adds this sort of national solidarity as a third traditional root of the notion, in addition to those derived from the Christian and socialist traditions. See Sangiovanni, A. (2015). Solidarity as joint action. Journal of Applied Philosophy, 32, 340-359. Eckenwiler, L., Straehle, C., \& Chung, R. (2012). Global solidarity, migration, and global health inequity. Bioethics, 26, 382-390. Gunson, op. cit. note 2, p. 247. Ibid. For an intensive discussion of the concept of political solidarity and its forms, see Scholz, S. J. (2008). Political solidarity. University Park: Penn State University Press. Gunson, op. cit. note 2, p. 248. Gould, C. C. (1978). Marx''s social ontology: Individuality and community in Marx''s theory of social reality. Cambridge, MA: MIT Press; Gould (1988), op. cit. note 13, pp. 91-132. For a development of the implications of this social ontology for understanding human rights and solidarity, see Gould, op. cit. note 3. See especially Gould (1988), op. cit. note 13, pp. 31-90 and Gould, op. cit. note 3. Ibid. Ibid. For a related argument, see Young, I. M. (1990). Justice and the politics of difference. Princeton, NJ: Princeton University Press; Young, I. M. (2000). Inclusion and democracy. Oxford: Oxford University Press. On interdependence and vulnerability, see Held, V. (2006). The ethics of care: Personal, political, and global. New York, NY: Oxford University Press. For a discussion of the material and social conditions for human agency, including healthcare, see Gould, C. C. (2004). Globalizing democracy and human rights. Cambridge: Cambridge University Press. Regarding the connection of these conditions to economic and social human rights, see also Gould (1988), op. cit. note 13, pp. 190-214, and Gould, op. cit. note 3, pp. 13-57. My own treatment of the notion of negative and positive freedom was indebted especially to Macpherson, C. B. (1973). Democratic theory: Essays in retrieval. Oxford: Oxford University Press. See Gould, op. cit. note 13, pp. 18-20, 38-40, where I also discuss some differences from his view. Gould (1988), op. cit. note 13. Habermas, J. (1990). Justice and solidarity: On the discussion concerning Stage 6. Tr. S. W. Nicholson. In T. E. Wren (Ed.), The moral domain: Essays in the ongoing discussion between philosophy and the social sciences (pp. 244-245). Cambridge, MA: MIT Press. Gould (2004), op. cit. note 24; Gould, op. cit. note 8. Gould, op. cit. note 8. See also the account of solidarity and justice in Ferguson, A. (2009). Iris Young, global responsibility, and solidarity. In A. Ferguson \& M. Nagel (Eds.), Dancing with Iris: Between phenomenology and the body politic in the political philosophy of Iris Marion Young (pp. 185-197). New York, NY: Oxford University Press. Gould, ibid: 157; Gould, op. cit. note 3, p. 111. Rippe, K. P. (1998). Diminishing solidarity. Ethical Theory and Moral Practice, 1(3), 355-373. I have discussed inclusiveness and democracy in social movements in Gould, op. cit. note 3, pp. 99-131. Giddens, A. (1984). The constitution of society. Cambridge: Polity Press. Young, I. M. (2003). Political responsibility and structural injustice. Lawrence: University of Kansas, p. 7. Ibid, p. 6. Young, I. M. (2006). Responsibility and global justice: A social connections model. Social Philosophy and Policy, 23(1), 102-130. I discuss Young''s conception of responsibility for global justice in Gould, C. C. (2009). Varieties of global responsibility: Reflections on Iris Marion Young''s last writings. In Ferguson \& Nagel, op. cit. note 29, pp. 199-211. Ibid. Although the focus in this article is primarily on the injustice and exploitation resulting from capitalist structures, it is evident that political economic institutions serve to replicate racism and patriarchy in addition to economic exploitation. A fuller account would need to consider the interrelations among these various forms of systemic or structural injustice, and the ways they produce unequal access to healthcare, along with deeply problematic impacts on health and well-being. Durkheim, E. (1964). The division of labor in society. Tr. G. Simpson. New York, NY: The Free Press. For further discussion, see Gould, op. cit. note 3, chapter 6. For a discussion of a range of environmental injustices and movements to address them, see Bullard, R. D. (Ed.). (2005). The quest for environmental justice: Human rights and the politics of pollution. San Francisco, CA: Sierra Club Books. For a useful discussion of the interaction of natural and social factors in Katrina and other U.S. disasters, see Tierney, K. (2006). Social inequality, hazards, and disasters. In R. J. Daniels, D. F. Kettl, \& H. Kunreuther (Eds.), On risk and disaster: Lessons from Hurricane Katrina (pp. 109-128). Philadelphia: University of Pennsylvania Press. See also the helpful analyses in Bullard R. D. \& Wright, B. (Eds.). (2009). Race, place, and environmental justice after Hurricane Katrina: Struggles to reclaim, rebuild and revitalize New Orleans and the Gulf Coast. Boulder, CO: Westview Press. Disasters Emergency Committee. Haiti earthquake facts and figures. UK. Retrieved February 24, 2018, from https://www.dec.org.uk/articles/haiti-earthquake-facts-and-figures The Haiti Case Study. (2012). NATO-Harvard Working Paper. Retrieved February 24, 2018, from https://www.jallc.nato.int/products/docs/haiti\_case\_study.pdf Luge, T. (2010). Haiti case study. Retrieved February 24, 2018, from https://www.slideshare.net/Timoluege/2010-haiti-earthquake-response-case -study Chen, M. (2017, June 8). The bankers behind Puerto Rico''s debt crisis. The Nation. New York, NY. Retrieved February 23, 2018, from https://www.thenation.com/article/bankers-behind-puerto-ricos-debt-crisi s/ Prainsack \& Buyx, op. cit. note 1, p. 104. Ibid., pp. 114, 115. Ibid., p. 115. Ibid., p. 119. INTRODUCTION CURRENT INTERPRETATIONS OF SOLIDARITY IN HEALTHCARE TWO SENSES OF SOLIDARITY AND THEIR RELATION TO JUSTICE STRUCTURAL INJUSTICE AND SOLIDARITY SOME IMPLICATIONS FOR HEALTHCARE CONFLICT OF INTEREST Footnotes The concept of solidarity has recently come to prominence in the healthcare literature, addressing the motivation for taking seriously the shared vulnerabilities and medical needs of compatriots and for acting to help them meet these needs. In a recent book, Prainsack and Buyx take solidarity as a commitment to bear costs to assist others regarded as similar, with implications for governing health databases, personalized medicine, and organ donation. More broadly, solidarity has been understood normatively to call for `standing with'' or assisting fellow community members and possibly also distant others in regard to their needs, whether for its own sake or in order to realize the demands of justice. I argue here that the understanding of solidarity in the existing bioethics literature is unduly restricted by not sufficiently theorizing the notion of structural (or systemic) injustice and its import for understanding solidarity. Extending traditional conceptions of labor and social movement solidarity, I contrast unitary solidarity within a given group with `networking solidarities'' across groups. I analyze the meaning of structural injustice and its significance for solidarity, including countering institutionally entrenched inequalities and economic exploitation. I then apply this broadened conception to healthcare, discussing structural problems with the U.S. insurance system and the solidarity movements addressing its deficiencies. I analyze some natural disasters and global health challenges that were aggravated by structural injustices, along with the solidarity movements they engendered. Finally, I revisit the questions of governing health databases and of personalized medicine with the enlarged conception of solidarity in view.' affiliation: 'Gould, CC (Corresponding Author), 333 Cent Pk West,Apt 16, New York, NY 10025 USA. Gould, Carol C., CUNY, Hunter Coll, Dept Philosophy, New York, NY 10021 USA. Gould, Carol C., CUNY, Grad Ctr, Doctoral Program Philosophy, New York, NY 10021 USA. Gould, Carol C., CUNY, Grad Ctr, Doctoral Program Polit Sci, New York, NY 10021 USA.' author: Gould, Carol C. author-email: carolcgould@gmail.com author_list: - family: Gould given: Carol C. da: '2023-09-28' doi: 10.1111/bioe.12474 eissn: 1467-8519 files: [] issn: 0269-9702 journal: BIOETHICS keywords: healthcare; justice; solidarity keywords-plus: JUSTICE language: English month: NOV number: 9, SI number-of-cited-references: '35' pages: 541-552 papis_id: aa07d1e90a6ed209308d451f69f825e9 ref: Gould2018solidarityproblem researcherid-numbers: 'Baldissera, Annalisa/AHD-6334-2022 Fazli, Ghazal/AAE-8320-2022' times-cited: '34' title: Solidarity and the problem of structural injustice in healthcare type: article unique-id: WOS:000450332600002 usage-count-last-180-days: '85' usage-count-since-2013: '1528' volume: '32' web-of-science-categories: Ethics; Medical Ethics; Social Issues; Social Sciences, Biomedical year: '2018'