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Bioethics ISSN 0269-9702 (print); 1467-8519 (online) Volume 26 Number 7 2012 pp 343–350
doi:10.1111/j.1467-8519.2012.01987.x
ARTICLES SOLIDARITY IN CONTEMPORARY BIOETHICS – TOWARDS A NEW APPROACH bioe_1987
343..350
BARBARA PRAINSACK AND ALENA BUYX
Keywords solidarity, bioethics, Nuffield Council on Bioethics (NCoB)
ABSTRACT This paper, which is based on an extensive analysis of the literature, gives a brief overview of the main ways in which solidarity has been employed in bioethical writings in the last two decades. As the vagueness of the term has been one of the main targets of critique, we propose a new approach to defining solidarity, identifying it primarily as a practice enacted at the interpersonal, communal, and contractual/legal levels. Our three-tier model of solidarity can also help to explain the way in which crises of solidarity can occur, notably when formal solidaristic arrangements continue to exist despite ‘lower tiers’ of solidarity practices at inter-personal and communal levels having ‘broken away’. We hope that this contribution to the growing debate on the potential for the value of solidarity to help tackle issues in bioethics and beyond, will stimulate further discussion involving both conceptual and empirically informed perspectives.
INTRODUCTION In recent bioethics literature, solidarity has been increasingly employed, often in different ways and contexts of meaning. Against this background, the UK’s Nuffield Council on Bioethics (NCoB), with the joint support of the Arts and Humanities Research Council (AHRC) and The Nuffield Foundation, established a six month Fellowship to explore and analyse the use of solidarity in recent bioethical writings. Such a systematic analysis of the uses of solidarity can help to clarify the meanings of the concept. It can further enhance its capacity to contribute to bioethical thought in a constructive manner, and help facilitate a more effective application of the term in policy making. Over the course of the Fellowship, the authors of this paper have examined the ways in which solidarity has been employed in bioethical writings1 and discussions in 1
The term ‘bioethical writings’ in this context includes work in public health insofar as either (1) it had ‘bioethics’ in the title, keywords, or abstract, or (2) it is prominently discussed in bioethical literature in the stricter sense of the word, or both. For more details, see B. Prainsack & A. Buyx. 2011. Reflections on an emerging concept in bioethics.
the last two decades. In the following paper, building on this inquiry, we present some central findings and develop a new approach to understanding the term. The first thing to observe is that solidarity is a particularly elusive concept. Given how many authors consider solidarity to be highly relevant for the functioning of a society, it is perhaps surprising that relatively few books2
Nuffield Council on Bioethics: London. Available at: http://www. nuffieldbioethics.org/sites/default/files/Solidarity_report_FOR_WEB. pdf [accessed 26 January 2012]. 2 An overview of all the literature considered and analysed in the course of the inquiry can be found in our Report (Prainsack & Buyx, op. cit., note 1). Throughout this article, we give example references instead of comprehensive lists of references. Books dedicated to the topic of solidarity in the last two decades include the following (most of which touch upon, but do not deal specifically with, bioethics): J. Dean. 1996. Solidarity of Strangers: Feminism after identity politics. Berkeley: University of California Press; K. Bayertz, ed. 1998. Solidarity. Dordrecht: Kluwer; R. Ter Meulen, W. Arts, & R. Muffels, eds. 2010. Solidarity in Health and Social Care in Europe. Dordrecht: Kluwer; S. Sternø. 2004. Solidarity in Europe. The History of an Idea. Cambridge: Cambridge University Press; S. Scholz. 2008. Political Solidarity. University Park, PA: University of Pennsylvania Press.
Address for correspondence: Dr. Barbara Prainsack, Professor in Sociology and Politics of Bioscience, Department of Sociology and Communication, School of Social Sciences, Brunel University, Kingston Lane, Uxbridge, Middlesex, UK. Tel: +44/(0)7912622901, E-mail:
[email protected] Conflict of interest statement: No conflicts declared © 2012 Blackwell Publishing Ltd., 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA.
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and papers3 have been dedicated explicitly to this concept. Moreover, many of us struggle even to define it. These two issues are arguably connected, in the way that some of the most important concepts in our lives, such as health, love, or happiness, are fundamental, yet suffer from similar problems of definition. Because they matter to everyone, they must be open enough to accommodate a large range of experiences, feelings, and practices; yet at the same time they need to be specific and firm enough to serve as points of reference to justify or explain actions. That said, solidarity is slightly different from other concepts that everyone accepts as underpinning human existence. Whether solidarity is one of these fundamental concepts of (social) life depends strongly upon how the term is understood. If we use the term solidarity in a prescriptive manner, so that it (normatively) calls for mutual support within a specific group of people, or for more social cohesion in society as a whole, then the assessment of the value and importance of solidarity takes on a political form. Depending on whether we conceive of people as singular and principally autonomous actors who form social or political coalitions out of their free will, or whether we see humans as defined by, and inseparable from, the relations that they are embedded in (human and otherwise), the assessment of the fundamental importance of solidarity to support social life will vary. If, however, we use the meaning of the term not prescriptively but primarily descriptively, namely as describing an empirical fact – that particular people are tied together by bonds of mutual assistance, common goals, and/or other aspects of a situation that they share – then solidarity is a feature of all social and political interaction; a fact of life.
SOLIDARITY IN THE BIOETHICAL LITERATURE Explicit references to the term solidarity have been relatively rare in recent bioethical writings. Few papers make explicit reference to solidarity in their title, abstract, or keywords; and less than a dozen books (most of which are not specifically about bioethics) have been devoted to 3
E.g. K. Hinrichs. The Impact of German Health Insurance Reforms on Redistribution and the Culture of Solidarity. J Health Polit Policy Law 1995; 20(3): 653–687; S. Boshammer & M. Kayß. Review Essay: The Philosopher’s Guide to the Galaxy of Welfare Theory: Recent English and German Literature on Solidarity and the Welfare State. Ethical Theory and Moral Prac 1998; 1: 375–385; M. Trappenburg. Lifestyle Solidarity in the Healthcare System. Health Care Anal 2000; 8(1): 65–75; R.E. Ashcroft, A.V. Campbell, & S. Jones. Solidarity, Society and the Welfare State in the United Kingdom. Health Care Anal 2000; 8: 377–394; R. Chadwick & K. Berg. Solidarity and Equity: New Ethical Frameworks for Genetic Databases. Nature Rev Genet 2001; 2(4): 318–321; M. Häyry. Precaution and Solidarity. Camb Q Healthc Ethics 2005; 14(2): 199–206.
this topic in the last 20 years. Textbooks and compendia used by bioethicists, such as for example the Oxford Handbook of Bioethics,4 Beauchamp and Childress’ Principles of Biomedical Ethics (2001),5 Ashcroft and colleagues’ (2007) Principles of Health Care Ethics,6 or the online publication Stanford Encyclopedia of Philosophy, do not contain dedicated chapters discussing solidarity. Where they exist, explicit references to solidarity appear mainly in four different contexts within the bioethical literature: 1. The first context is that of public health. It is because public health, by definition, focuses to a large extent on collective measures, that the connections between social actors, rather than these social actors as independent entities, are in the centre of attention for many scholars in this field. Also, notions of personhood in public health writing tend to accommodate the non-instrumental nature of attachments between people more strongly than in other academic domains (see, for example, Baylis et al.’s work on relational autonomy).7 These attachments are frequently described as a form of solidarity which, in turn, is discussed as a value capable of justifying the stronger involvement of state authorities in public health, compared to medical care.8 2. The second context in which solidarity is mentioned explicitly is that of justice and equity in healthcare systems. Although every welfare state contains some solidaristic elements, the common understanding among authors in this field is that the larger the extent to which any given system redistributes resources among the members of the collective, the more it is an articulation of solidarity. There is no consensus among authors on the nature of the relation between solidarity and justice and equity; the extent to which solidarity is seen an expression of justice or equity depends on different understandings of who is deserving of support.9 Bonnie and 4 B. Steinbock. 2007. The Oxford Handbook of Bioethics. Oxford: Oxford University Press. 5 T.L. Beauchamp, & J.F. Childress. 2001. Principles of Biomedical Ethics (5th edn). Oxford: Oxford University Press. 6 R.E. Ashcroft et al., eds. 2007. Principles of Health Care Ethics (2nd edn). London: John Wiley. 7 F. Baylis, N.P. Kenny, & S. Sherwin. A Relational Account of Public Health Care Ethics. Public Health Ethics 2008; 1(3): 196–209. 8 E.g.: N. Kass. An Ethics Framework for Public Health. Am J Public Health 2001; 91(11): 1776–1782; J.F. Childress et al. Public Health Ethics: Mapping the Terrain. J Law, Med Ethics 2002; 30: 170–178; S. Anand, F. Peters, & A. Sen, eds. 2004. Public Health, Ethics, and Equity. Oxford: Oxford University Press; M. Powers & R. Faden. 2006. Social Justice: The Moral Foundations of Public Health and Health Policy. New York: Oxford University Press. 9 E.g.: I. van Hoyweghen & K. Hostman. Solidarity Matters: Embedding Genetic Technologies in Private and Social Insurance Arrangements. New Gen and Soc 2010; 29(4): 343–350. R. Ter Meulen et al.
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Solidarity in Contemporary Bioethics – Towards a New Approach colleagues,10 drawing upon current discussions in the Netherlands, which increasingly spill over into other societies, further distinguish between three types of solidarity in the context of health and social care insurance in particular: First, risk solidarity is expressed in arrangements that insure everyone under the same conditions, independent of their actual individual risks. Second, income solidarity is expressed in arrangements where those with higher incomes pay more and thereby subsidize the care for those with lower incomes. Third, lifestyle solidarity is a more recent term that has been used to signify arrangements that offer insurance under the same conditions to those who engage in high risk lifestyles as to those with low risk lifestyles. 3. The third context in which solidarity is discussed explicitly is when it is invoked normatively in connection with providing assistance to poor countries and societies in the context of global health. Most authors writing about solidarity and global health are concerned with arguing whether or not social cohesion and community is possible across national borders, and if so, how it could be achieved. Although relatively few focus on what substantive values such a global community and solidarity should help to materialize, most assume that a better distribution of resources, and more equal access to healthcare across the globe, would result from global solidarity.11 4. The fourth context in which the notion of solidarity is discussed explicitly is when it is referred to as a European, as opposed to North American, value.12 Matti Häyry, for example, regards both precaution and solidarity as particularly (continental) European values vis-à-vis the ‘American “autonomy and justice” op.cit. note 3; D. Wilker. 2004. Personal and Social Responsibility for Health. In Public Health, Ethics, and Equity. In: S. Anand, et al., eds. Oxford: Oxford University Press. 109–134; K. Schuyt. 1995. The Sharing of Risks and the Risks of Sharing: Solidarity and Social Justice in the Welfare State. Ethical Theory and Moral Prac 1995; 1: 297–311. 10 L.H.A. Bonnie et al. Degree of Solidarity with Lifestyle and Old Age among Citizens in the Netherlands: Cross-sectional Results from the Longitudinal SMILE study. J Med 2010; 36: 784–790. 11 E.g.: S. Abdallah, S. Daar, & P.A. Singer. Global Health Ethics: the rationale for Mutual Caring. Int Aff 2003; 79: 107–138; S. Holm & B. Williams-Jones. Global Bioethics – Myth or Reality? BMC Med Ethics 2006; 7: 10; J.P. Ruger. Ethics and Governance of Global Health Inequalities. J Epidemiol Community Health 2006; 60: 998–1002; N. Daniels. 2008. Just Health. Cambridge: Cambridge University Press; M.A. Verkerk, & H. Lindemann. Theoretical Resources for a Globalised Bioethics. J Med Ethics 2010; 37: 92–96. 12 E.g.: S. Harmon. Solidarity: A (new) Ethic for Global Health Policy. Health Care Anal 2006; 14: 215–236; C. Gould. Transnational Solidarities. J Soc Philos 2007; 38(1): 146–162; D. Gunson. Solidarity and the Universal Declaration on Bioethics and Human Rights. J Med Philoso 2009; 34(3): 241–260; L.O. Gosti et al. 2010. National and Global Responsibilities for Health. Georgetown Law Faculty Publications and Other Works. Paper 471. Available at: http://scholarship.law. georgetown.edu/facpub/471 [accessed 18 April 2011].
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approach, which is often seen as overemphasising the role of individuals as consumers of health services’.13 Precaution and solidarity, Häyry argues, ‘embody values that transcend hedonism and egoism’.14 Less explicitly, yet in a no less a relevant manner, solidarity as a European value is discussed in the literature on European welfare states. Hinrichs,15 for example, regards a ‘culture of solidarity’ as the basis for the German welfare state. It should be noted, however, that solidarity as an idea or a value is much more prominent in bioethical writings than explicit uses of the term would suggest. There is a significant difference between the number and scope of discussions in which the term solidarity is employed explicitly, and discussions where situations, norms, and dilemmas that are associated with solidarity appear in the literature. For example, discussions on human enhancement often revolve around the theme of societal and inter-generational solidarity, in particular in connection with the work of Michael Sandel16 and Jürgen Habermas.17 Moreover, all debates on how to strike the right balance between individual rights and the common good, mutual assistance and altruism, or arrangements to mitigate and compensate for risks, could be seen as concerning solidarity, if they consider actions that people are willing to take to assist others to whom they feel connected in some relevant way. This simultaneity of implicit and explicit uses of the term solidarity leads to the term being underdetermined in much of the debate. Unless authors give an explicit account of their particular use of solidarity,18 the concept is more often employed as a label for a number of differing lines of argument.
A NEW APPROACH TO UNDERSTANDING SOLIDARITY This vagueness has been criticised by some authors within the debate. For instance, Jorgen Husted argued that both those in favour and those against the use of genetic information for insurance underwriting in the 1990s based 13 Häyry, op. cit. note 3, p. 199; see also M. Häyry. Another Look at Dignity. Camb Q Healthc Ethics 2004; 13: 7–14. 14 Häyry, op. cit. note 3, p. 199. See also S. Holm. Not Just Autonomy – the Principles of American Biomedical Ethics. J Med Ethics 1995; 21: 332–338. 15 Hinrichs, op. cit. note 3, p. 653. 16 E.g. M.J. Sandel. 2007. The Case against Perfection: Ethics in the Age of Genetic Engineering. Cambridge, MA: Belknap Press. 17 E.g. J. Habermas. 2003. The Future of Human Nature. Cambridge: Polity. 18 In the Report, we provide an overview of such explicit approaches, including historical uses and e.g. communitarian, rational choice, contractual or reflective solidarity, amongst others (Prainsack & Buyx, op. cit. note 1, ch. 2).
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their claims on the notion of solidarity.19 Similarly, in the current debates on whether or not those with ‘high-risk lifestyles’ should pay higher premiums for health insurance, solidarity is mobilised by both opponents and supporters of lifestyle-stratification.20 It could be argued that such vagueness has benefits, such as a certain level of openness that allows wider ranges of people with different professional and disciplinary backgrounds to contribute to the discussion. However, we believe that such benefits are clearly outweighed by the benefits of a transparent meaning of the term involved. We have therefore developed a working definition of solidarity, on the basis of the analysed bioethical literature, as well as on the most pertinent writings in political and social theory. This definition is not meant to ‘re-invent’ solidarity; indeed it includes many aspects that are present in existing approaches. Our working definition seeks to set out the elements that facilitate a discussion of the consequences of its application in various contexts in a clear and explicit way. It does not aim to provide a ‘fixed’ definition of the concept of solidarity, but rather to serve as a starting point for future discussions and debate, and to offer a tool to facilitate more systematic and perhaps more tangible ways of employing solidarity in bioethical and policy debates. In our understanding, and in its most bare-bone form, solidarity signifies shared practices reflecting a collective commitment to carry ‘costs’ (financial, social, emotional, or otherwise) to assist others. It is important to note that solidarity is understood here as a practice and not as an inner sentiment or an abstract value. As such, it requires actions – motivations, feelings such as empathy etc. are not sufficient to satisfy this understanding of solidarity, unless they manifest themselves in acts. The term ‘costs’, here, is understood to mean a wide range of contributions in terms of time, effort and emotional investments, or money, that groups or individuals make to assist others. By focusing on costs, it does not exclude scenarios where groups and individuals involved in solidaristic practices also benefit from this involvement. For example, if I sign up to become a bone marrow donor, it could make me feel good about myself and help someone else; or my neighbor who does a lot of volunteer work could receive 19
J. Husted. 1999. Insurance, Genetics and Solidarity. In: Genetics and Insurance. T. McGleenan, U. Wiesing, & F. Ewald, eds. Oxford: BIOS. 1–16. See also K.-P. Rippe. Diminishing Solidarity. Ethical Theory Moral Pract 1998; 1: 355–374; N. Capaldi. 1999. What’s Wrong with Solidarity? In Solidarity. K. Bayertz, ed. Dordrecht: Kluwer Academic Publishers: 39–56; D. Gunson, op. cit. note 14. 20 Those opposing it argue that it would compromise the principle of solidarity within a nation if some people were singled out on the basis of behaviours that some claim they should be held accountable for; those supporting models of lifestyle-risk stratification in the context of health insurance say that those choosing to smoke, or to engage in dangerous sports, compromise solidarity by potentially incurring higher costs for the collective.
an award for her contributions (which, of course, does not mean that her charity work serves the sole purpose of obtaining recognition). Such benefits – or even the expectation of a benefit – are not a precondition for solidarity, but nor do they undermine it. Although solidarity is to be understood primarily as a shared practice (or a cluster of such practices) reflecting a collective commitment, simply claiming that such practices exist would be unsatisfactory. Our working definition therefore consists of a conceptualization which identifies three tiers by which individuals come to engage in practicing solidarity. They stand in a hierarchy of institutionalisation: The first tier of solidarity concerns the inter-personal level; the second pertains to group practices; and the third to contractual and legal manifestations.
Three Tiers of Solidarity Tier 1 – interpersonal level The first tier of solidarity applies to the level of individuals. At that level, solidarity comprises manifestations of the willingness to carry costs to assist others with whom a person recognizes sameness or similarity in at least one relevant respect. The recognition of similarity21 with one (or more) other people in one relevant respect22 can take many forms: It entails the awareness of being associated – by choice, by ‘fate’, or other circumstances, with others. It is, paraphrasing Rahel Jaeggi,23 an instance of seeing one’s own potential or actual fate, or that of loved ones, in the fate of another. For example, I recognize similarity with my fellow air traveller in that we both will miss a connecting flight due to our delayed departure.24 What 21
We will use the term ‘similarity’ to include ‘sameness’ in the course of this argument. 22 See also C. Calhoun. Imagining Solidarity: Cosmopolitanism, Constitutional Patriotism, and the Public Sphere. Public Culture 2002; 14(1): 167–171, slightly different in Feinberg (J. Feinberg. 1970. Doing and Deserving: Essays in the Theory of Responsibility. Princeton: Princeton University Press: 234), with the notion of ‘community of interest’, which is closely related to people ‘sharing a common lot, the extent to which their goods and harms are necessarily collective and indivisible’. Regarding global solidarity based on conditions shared by all people across the globe – a ‘postethnic perspective’, see D. Hollinger. 1995. Postethnic America: Beyond Multiculturalism. New York: Basic Books. P. 109. 23 R. Jaeggi. 2010. Solidarity and Indifference. In Ter Meulen et al., op. cit. note 3, pp. 287–308. See also A. Evers & M. Klein. Solidarity and Care in Germany. In Ter Meulen et al., op. cit. note 3, pp. 160–187; these authors (p. 178) refer to the same phenomenon of recognition of sameness in a relevant respect in their section on ‘reasons for solidarity’. The mention ‘a notion of reciprocity’ as a reason for solidarity: ‘People are willing to pay contributions because of their own (potential) need of health services later in life.’ 24 We owe this example to Ruth Chadwick, whose helpful comments on drafts of the working definition we gratefully acknowledge.
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Solidarity in Contemporary Bioethics – Towards a New Approach counts as similarity in a relevant respect is dependent on the context of the practice that I am engaged in: If I sit on an aeroplane and worry about making it to a meeting on time, then similarity in a relevant respect to the person next to me will pertain to both of us going to the same meeting, both of us making it on time, or both of us missing the connection; the fact that my neighbour is, for example, diabetic is immaterial for my potential solidarity with her in this situation, even if I may share this and other characteristics with her as well. We have already stated that the recognition of sameness itself does not represent solidarity unless it is accompanied by acts, that is, outer manifestations of the willingness to carry costs in order to assist others. To remain with our example, the recognition that the woman in the plane seat next to me will also miss her connecting flight does not represent solidarity on my part (this would be better described as sympathy or empathy). If, however, I offer her the use of my mobile phone to make arrangements upon arrival, then this is an instance of a solidaristic practice. (The extent of the costs is not decisive. Solidarity includes both enactments of the willingness to assist others which would incur relatively small costs – such as my offering my mobile phone to my fellow air traveller – and those which would incur significant costs, such as donating an organ.) Solidarity, on this understanding, will regularly be directed especially but not exclusively towards the most vulnerable in this group.25 Vulnerability as such can be a factor giving rise to the recognition of sameness. In the acute vulnerability and need of my fellow human being I recognise myself when I have been, or might be, in such acute need. Again, the practical context (time, place, social and economic factors) plays a big role because there are some vulnerabilities that I would never recognize as potentially my own (e.g. the possible vulnerability to be addicted to gambling if I never liked gambling, nor had any propensities for other addictive behaviours). It depends therefore on the particular person and the concrete practical context what and whose vulnerabilities would make me recognize sameness.
Tier 2 – group practices In cases in which a particular solidaristic practice at the inter-personal level becomes so normal that it is more widely seen as ‘good conduct’ in a given situation, it can solidify into forms of institutionalisation. This is the case, for example, with respect to self-help groups that practise more institutionalised solidarity. On this tier, solidarity can be described as manifestations of a collective commitment to carry costs to assist others (who are all linked by means of a shared situation or cause). This is the second and arguably most prominent tier of solidarity. People who share a situation typically share certain risks or positive goals which emerge out of, or define, that situation. People negotiate ways of conduct in that situation (e.g. how to reduce the risk, to prevent harm, or to reach a certain common positive goal). For example, those with a particular disease might support each other, share health information to mimimize the negative effects of the disease, and organize events to raise funds for research into the disease. The results of all these activities are shared practices from which values or principles emerge that are shared by the members of such groups and communities.
Tier 3 – contractual and legal manifestations If these values or principles solidify26 not only into social norms but manifest themselves in contractual or other legal norms, then we have an instance of tier 3 solidarity, the most formal form of solidarity. Examples are welfare state and welfare society arrangements, or legal arrangements underpinning publicly funded healthcare systems such as the NHS or German statutory insurance.27 Other examples include contracts between different private actors and international declarations or treaties (such as virus sharing agreements in the context of pandemics).28 Such legal and contractual arrangements are highly institutionalized enactments of carrying costs to assist others one recognizes sameness with, for example by collecting taxes from the population to fund the services provided to those in need of healthcare. 26
25
Empirical research from the US shows, however, that the more vulnerable in terms of socio-economic status seem to be more willing to give to others than those who are more privileged (e.g. P.K. Piff et al. Having Less, Giving More: the Influence of Social Class on Prosocial Behaviour. J Pers Soc Psychol 2010, 99(5): 771–784; Independent Sector 2001.). This does not apply to volunteering: levels of volunteering were found to increase with household income: Independent Sector, op. cit. this note; Giving and Volunteering in the United States. Available at: http://www.cpanda.org/pdfs/gv/GV01Report.pdf [Accessed 12 Dec 2011]). It is unclear whether these findings can be generalised to other societies. In addition, the focus of these studies was charitable giving, not solidarity; although the two are connected, we maintain that the points of gravity of the two notions are different (see below).
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For example, Jaeggi (op. cit. note 20, p. 305) speaks of ‘crystallised’ forms of solidarity. Arts and Verburg describe European welfare states explicitly as ‘systems of organised solidarity’ (W. Arts & R. Verburg. 2010. Modernisation, Solidarity and Care in Europe: The Sociologist’s Tale, in Ter Meulen et al., op. cit. note 3, p. 25). 27 In fact, the German law regulating statutory health insurance and healthcare provision, the German Social Security Code (Sozialgesetzbuch), states in book V article 1 that health insurance amounts to a solidarity-based community (Solidargemeinschaft) (SGB V § 1, available at: http://www.gesetze-im-internet.de/sgb_5/__1.html.) [Accessed 12 Dec 2011]). 28 D.P. Fidler, & L.O Gostin. WHO’s Pandemic Influenza Preparedness Framework: A Milestone in Global Governance for Health. JAMA 2001; 306(2): 200–201.
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While the ‘lower’ tiers of solidarity can exist without the ‘higher’ levels, ‘higher’ levels have typically been preceded by ‘lower’ levels. In other words, instances of tier 3 solidarity have, some time in history, emerged out of tiers 1 and 2, although the lower tiers might have changed following the institutionalisation into level 3. For example, it could be the case – as many claim is the case with welfare state arrangements at present – that tier 3 is more or less intact, while tiers 1 and 2 have, at least partly, broken away. The reverse, however, does not apply. Not every practice of solidarity at tiers 1 or 2 solidifies into tier ‘higher’ tiers, nor is it desirable that all of them do. There are certain things that smaller communities can do better than, for example, nation states, as the former are much ‘closer to the ground’.29
DISCUSSION Distinguishing Solidarity from Related Concepts One of the main difficulties when analysing solidarity is that there is a number of related concepts that in some of the literature are used almost synonymously. This could give rise to a number of criticisms of the understanding of solidarity that we have set out above. To provide a clearer understanding of solidarity, therefore, it is important to try and distinguish some of the features of these concepts. Firstly, it is crucial to emphasise that solidarity manifests itself not merely in the sentiment of empathy. Empathy, or similar sentiments, can of course be involved in solidaristic practices. However, solidarity, according to the definition above, takes the form of enactments of the willingness to carry costs to assist others. In this sense, solidarity is embodied and enacted rather than merely ‘felt’. In other words, while empathy can consist of mere inner sentiment (I walk by an injured person in the street and feel sorry for her), solidarity requires some level of outer articulation (e.g. I offer to carry her bags up the stairs in the Tube). Another difference is that while empathy requires such a sentiment (e.g. my feeling sorry), solidarity can entail such a sentiment as preceding an act of giving, but does not have to; an act of giving out of solidarity can be based on a purely rational, or even habitual, decision to do so. Secondly, as mentioned earlier, the fact that solidaristic acts are preceded by the recognition of sameness with another person or group in one relevant respect means 29 This statment is not meant to describe actual historical developments, but to provide an idealised and simplified model of how solidarity manifests itself in practices of individuals and groups, and legal practices and forms. A question remains whether all laws or constitutional norms that mandate or imply carrying costs to assist others qualify as shared practices reflecting collective commitment.
that the recognition of sameness is based on an overall symmetrical relationship,30 not on an overall asymmetrical relationship. This distinguishes our understanding of solidarity from charity in an important way. Solidarity is practised in a context of potential or actual symmetry within the group (‘we are all in the same boat’; we are all the same in a relevant respect, even if we may be very different in many other respects in life). Charity, as a mostly unilateral practice, fundamentally relies on an asymmetrical relationship between a giver and receiver – I give to you because I am rich and you are poor; were we both rich, I would not extend my charity towards you (but I may be bound to you by other factors). Charity and solidarity thus share an important feature – the willingness to carry costs to assist others – but they differ importantly with regards to the element of sameness and the type of relationship between giver and receiver. Solidarity might also share features with the concept of altruism, but again, there are important differences. Altruism is a more general attitude towards (all) others, whereas solidarity comprises concrete practices within a community of people who are sharing certain things in common. The outcome may well be the same, but the motivations differ: I may help someone because I am motivated by a sense of altruism, and thus generally think that it is important to help others without thinking of my own benefit, or I might help someone because I recognize sameness in a relevant sense with her and I am thus enacting solidarity. These differences are important on the theoretical level, though it will often be difficult from the outside to clearly distinguish between solidarity, charity and altruism, particularly on level 1. We do not find this troubling. These other values or sentiments31 are neither incompatible with solidarity, nor necessarily clearly separable from solidarity without a careful analysis of a behaviour, mainly owing to the fact that people do have mixed motivations. However, we believe that when it comes to tiers 2 and 3, the differences between these values are both more marked and more significant. The institutionalization of altruism or charity, particularly regarding any legal claims, will take a different form than is the case with solidarity, and, we argue, will also need different justifications. 30
The emphasis on symmetry in relationships does not imply that the relationship between two people is necessarily symmetrical in every respect; it means only that the recognition of similarity or sameness in one relevant respect (that Mary and I are ‘the same’ in the sense that we suffer from the same metabolic disorder; or that the man attacked by a group of drunk people is the same as me in the sense that I recognise human vulnerability). What is considered a relevant respect always depends on the particular context of the situation. 31 Prainsack & Buyx, op. cit. note 1, ch. 4, includes discussions of further concepts that can overlap with solidarity, such as friendship, reciprocity, dignity, reciprocity, altruism, and trust.
© 2012 Blackwell Publishing Ltd.
Solidarity in Contemporary Bioethics – Towards a New Approach
Solidarity as a Descriptive Concept? In debates that address important policy issues, such as for example welfare state arrangements, it is sometimes assumed that solidarity is intrinsically good, i.e. beneficial for individuals and society by its very nature. This can lead to a lack of reasoned justification and argument – invoking solidarity sometimes appears to take the place of offering a more careful analysis of e.g. benefits and costs and other relevant factors that should be considered in the justification for a particular course of action or policy. Following our largely descriptive understanding of solidarity as set out in the working definition, solidarity cannot be utilised in such a blanket ‘positive’ way: while practices of solidarity in the context of health and bioethics regularly bring about solutions that are considered beneficial for individuals or for public health goals, not all solidaristic practices can be considered beneficial even in the broadest sense of that term. For example, if I recognize similarity with a belligerent separatist group and join their military cause by enlisting in their army and killing people, this could be framed in terms of being a manifestation of my willingness to carry costs to assist others and thus constitute a solidaristic practice. Yet most people would not see this as a positive or beneficial practice of solidarity. It is important to note that our understanding of solidarity, depending on the context, might require additional steps of justification before it can be recommended as a policy position. Simply pointing out that acts and practices are based on solidarity is not sufficient for this purpose. This understanding of solidarity also preempts a difficulty that can emerge from the tension between explicitly liberal or communitarian conceptions of society. Liberal writers often find it difficult to incorporate solidarity (and other similar notions) as meaningful elements of their conception of the free and liberal society, and communitarian authors sometimes claim that solidarity is simply not compatible with the concept of the person and the relationship between individuals and the state that liberal writers espouse. This issue does not apply to an understanding of solidarity as set out in this paper – although the working definition has been informed to some degree by relational positions (which see people’s identities and preferences as co-determined by the relationships that they are embedded in), it is not as such incompatible with a liberal concept of society. According to the definition, actions based on solidarity could be seen as both the result of a deliberate decision of an autonomous individual (whose autonomous existence precedes her social relations), or as something that co-emerges with the dense web of our social relations which literally ‘make up people’.32
In other words, the definition could be embedded in a concept of a society where solidarity is seen as something that people decide to act upon (or not). Alternatively it could be embedded in an understanding of a society where solidarity is an inherent aspect of humanness and personhood. Such an understanding of solidarity also bridges the separation between prescriptive and descriptive uses of the term that we mentioned in the very beginning of this article. The working definition, as discussed so far, is descriptive as it helps to determine whether solidarity, or other terms, best describe a certain form or context of social/political interaction. It can, however, be seen to be prescriptive insofar as it contains substantial statements about understandings of persons as at least partly shaped by their social relations, including those that pertain to them in their capacity as a citizen. What follows from this is that societal and political arrangements that consider these social relations could be preferable to arrangements that do not.33
CONCLUSION In this paper we have summarized some of the main points from our inquiry into solidarity as a core value in contemporary bioethics. We then sketched a new approach to defining solidarity. This approach regards solidarity primarily as something that is enacted at the interpersonal and communal level, and that – to the extent that it becomes normative – can solidify into informal as well as formal contractual and legal arrangements. Our three tier model of solidarity can potentially also help to understand the way in which societal or political crises emerge. For example, the decline of the welfare state since the late 1970s has received a lot of attention in public debates. This decline amounts to a hollowing out of institutionalized solidaristic arrangements, such as public health care, or solidaristic universal (often national) insurance systems which do not favour the healthy and wealthy. This situation can be described as one in which formal solidaristic arrangements (tier 3 solidarity) have become unstable – and have begun to be abolished – partly as a result of ‘lower tiers’ of solidarity at the inter-personal and communal levels having been replaced by other dominant values and practices (i.e. tiers 1 and/or 2 of solidarity having ‘broken away’; the breaking away of solidaristic practices at the interpersonal and communal levels is of course linked to larger political, economic, and discursive changes). With regard to health care, for example, the introduction of competition and 33
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I. Hacking. Making up People. London Review of Books, 2006; 28(6): 23–26.
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We explore the prescriptive use of the definition fully in the second part of the Report using a number of case studies from policy making, see Prainsack & Buyx, op. cit. note 1.
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corporate management styles in the public sector both represents and exacerbates a shift from solidarity-based to actuarial reasoning in the distribution of duties and responsibilities, where those who are thought to incur more costs for ‘the system’ are increasingly held responsible. This development is closely linked to larger societal discussions on resources getting scarcer and the need for cost containment becoming increasingly urgent. Clearly, future work will be needed to test out this understanding in different contexts and to explore its robustness and its potential for application.34 We therefore hope that this contribution to the growing debate on the potential for the value of solidarity to help tackle issues in bioethics and beyond will stimulate further discussion involving both conceptual and empirically informed perspectives. 34 In the second part of our Report, we offer three examples of application in policy making contexts, see Prainsack & Buyx, op. cit. note 1.
Acknowledgements We are grateful to the current and former members of the NCoB, in particular Roger Brownsword, Robin Gill, Søren Holm, Tim Lewens, Nikolas Rose, and Jonathan Wolff; to the participants of the two ‘solidarity’ workshops at the NCoB on 13 May and 7 July 2011; to the editors and two anonymous reviewers of an earlier version of this paper; and to the following individuals, for their insightful comments on earlier drafts: S.D. Noam Cook, Kathryn Ehrich, Roy Gilbar, Ine van Hoyweghen, Frank J. Leavitt, Andrew Papanikitas, Anne Phillips, Kadri Simm, and Hendrik Wagenaar. Barbara Prainsack has published widely on the societal, ethical, and regulatory dimensions of biomedicine and bioscience (genetic and genomic science and technologies in particular). From January to July 2011, she was AHRC/ESRC Fellow for the project ‘Solidarity as a Core Value in Bioethics’ at the Nuffield Council on Bioethics in London, UK. Alena Buyx has a background in medicine, philosophy and sociology. She oversees bioethical projects, such as the Council’s solidarity project, coordinates Working Parties and represents the Council. Previously, Alena worked at the Harvard Program in Ethics and Health and at Muenster University. She has published widely on bioethical issues.
© 2012 Blackwell Publishing Ltd.
