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Abstract

This entry ﬁrst presents some of the deﬁnitions and theoretical approaches to solidarity. Then, ﬁve different uses of solidarity within global bioethics are discussed: public health, welfare, universal health care, a right to health care, and a focus on the vulnerable.

Introduction

The concept “solidarity” may be usefully contrasted with both “charity” and “justice,” although the three are also intimately related both historically and conceptually. Whereas justice generally pertains to just distributive or retributive arrangements such as “fairness” or “maximization of utility” (among other things), “charity” connotes the obligation of privileged individuals to aid those in need, whether the need be material, physical, or emotional. “Solidarity” involves elements of both in referring to the willingness to acknowledge social bonds with others and to act on behalf of the needs or interests of those others, whether or not those needs and interests are shared.

Solidarity in moral and political philosophy is generally understood to fall within the literature on collective responsibility and may be understood descriptively or normatively. As a descriptive concept, the term denotes the extent of cohesion in a community or group. As a normative concept, solidarity connotes a number of possible meanings from a principle that motivates justice-seeking behavior to a relation that informs particular duties. After a brief presentation of the deﬁnition of the concept in different contexts, solidarity as a moral relation and solidarity as a moral principle are discussed. Then, ﬁve different uses of solidarity within global bioethics are presented, highlighting accounts that appeal to solidarity as a moral relation or a moral principle: public health, welfare, universal health care, a right to health care, and a focus on the vulnerable.

Defining Solidarity In Context

A wide variety of deﬁnitions have been offered for solidarity, and an expanding array of theoretical approaches explains its role in moral and political theory. The very general deﬁnition above attempts to capture what is found in most deﬁnitions: a form of unity or social bond and a requisite action in response to that unity. Most deﬁnitions also posit an element of personal transformation, that is, individuals in solidarity are transformed by their participation in the solidaristic group or activity. The theoretical approaches add nuance to the earlier classiﬁcation of descriptive and normative frameworks. Three basic types emerge: social solidarity, political solidarity, and civic solidarity.

Social solidarity was made famous by Emile Durkheim who described the social relations of different forms of society. A society marked by relative similarities between members is said to exhibit mechanical solidarity. In contrast, more advanced societies exhibit what Durkheim called organic solidarity which is characterized by an extensive division of labor. Durkheim described morality emerging out of these relations of solidarity. Social solidarity, then, is the social cohesion among participants. Political solidarity is the solidarity associated with social movements against injustice. Unlike social solidarity, political solidarity does not rely on or emphasize the bonds between group members but rather the actions they take in concert with one another to effect change. Finally, civic solidarity is the solidarity between citizens and their formal organized governments; the term here is used to denote the state’s obligations to protect citizens against vulnerabilities, especially those vulnerabilities that arise from or are intensiﬁed by social existence. These three theoretical approaches to solidarity yield many different manifestations of solidarity thereby lending to the wide and diffuse usage of the term in social and political practice (see Bayertz 1999; Scholz 2008).

One way to highlight the distinctions among the various deﬁnitions and theoretical approaches to solidarity is to note how they address obligations of solidarity. Social solidarity, which pertains to the cohesion of a community, appears to establish a particularistic framework wherein the obligations are determined by the nature, extent, and aims of the particular community. Families have obligations to members that are particular to that social unit; we would not expect strangers to have the same sorts of obligations that we expect of parents or siblings (and indeed even those relations inform particular duties). Sports teams, classmates, members of professional societies, and countless other groupings or communities have relations of social solidarity informed by the speciﬁc nature, extent, and aim of the community. Social solidarity might also extend to all humanity, sometimes called human solidarity, in which case solidarity is not particularistic but universal. In this latter case, the obligations extend to all humanity but pertain to the bonds that tie human beings together. In other words, there might be certain obligations of solidarity that all human beings have that are not readily conceived under rubrics of justice or charity. An example of such a solidaristic obligation is the obligation to recognize another human being as part of the collective humanity.

Civic solidarity is particular to a given society; the entire community is obliged to protect each citizen, and each citizen in turn must also ensure the community’s ability to work for the common good. With cooperative international organizations, it is possible to conceive of a civic solidarity functioning transnationally. For instance, the coordinate multinational efforts to stem the outbreak of SARS (severe acute respiratory syndrome) or MERS (Middle East respiratory syndrome) may be held up as examples of global civic solidarity insofar as regional and international organizations were responding to obligations to protect vulnerable populations against some of the health hazards accompanying globalized relations.

Obligations of political solidarity are shaped by those actions that advance the overall social justice aim of the group. However, that aim in and of itself informs actions toward one another and toward those outside the group (often those individuals or societies the solidaristic group is trying to change).

As may be evident, solidarity in bioethics is primarily a form of civic solidarity. A further distinction helps in analyzing the varying uses of solidarity in bioethics. This distinction is between solidarity as a moral relation and solidarity as a principle (a third distinction, solidarity as a disposition, may also be identiﬁed but it is arguably an affective facet of the principle within bioethics literature (see, for instance, Houtepen and ter Meulen 2000b)). In the ﬁrst instance, the concept refers to the solidaristic group or the relationship between solidary actors. In the second, solidarity is a truth or claim that determines or informs a series of moral actions, often these actions are undertaken by individuals, but at times the principle of solidarity clearly refers to state-based action.

Solidarity As A Moral Relation

Accounts of the moral relation of solidarity vary according to the type or basis of the bonds that bring people together into a solidary community. Three common accounts of those bonds include commonality of physical attributes, shared experiences, and mutual interests.

Commonality of attributes is used to assert or imply connections between individuals who outwardly appear to resemble each other. For instance, peoples of similar gender or race may presume a connection with others of that gender or race simply based on the commonality. Similarly, shared experiences, like surviving cancer or being at risk for serious disease, can inspire relations of solidarity wherein the individual members not only sense a connection to one another but act on that connection. Finally, mutual interest can unite otherwise dissimilar people. This is often considered the basis of welfare state politics and hence plays an important role in conceptions of solidarity for bioethics. In each of these, it might be argued that those in solidarity exhibit partiality toward similarly situated others. That may indeed be the very meaning of the solidarity, i.e., a particular relation informed by commonality that allows partiality in moral decision-making. However, partiality may not be the only or even an accurate assessment of the solidaristic relation. Solidarity as a moral relation may also be understood as inclusive, taking into account the interconnections within community into account while also valuing diversity or difference among individuals (Baylis et al. 2008).

These accounts of the relation of solidarity capture elements frequently associated with everyday language use of the concept. Mutuality, reciprocity, recognition, and allegiance to others ﬁll in at least some of the content of the concept of solidarity. In varying ways, they demonstrate the place of solidarity within relational ethics more generally.

Solidarity As A Principle

As a principle, solidarity is set as a rule or truth which informs other obligations, including commitment to the common good and personal responsibility, or perhaps even more extensive moral and political systems. The principle of solidarity asserts the connectedness or interdependence of human beings as an empirical fact and seeks to achieve other such fundamental values as justice and equality.

As a principle in bioethics, solidarity is sometimes articulated as a counter to justice and autonomy (Hoedemaekers and Dekkers 2003; Butler 2012). Whereas autonomy emphasizes the individual, solidarity emphasizes community or the connections between members of communities. It is this sense that appears prominently in the European tradition generally and European bioethics and biolaw speciﬁcally. In the United States, the principles of bioethics are autonomy, nonmaleﬁcence, beneﬁcence, and justice. Solidarity sometimes explicitly replaces the emphasis on autonomy or augments dignity and vulnerability in a revised list of the basic principles: autonomy, dignity, integrity, and vulnerability (Sass 2001, p. 219). Stone (2012) argues that principles of solidarity and care, which he distinguishes, ought to augment the standard principles of bioethics and inﬂuence ethical decision-making to focus on the vulnerable. The poor, elderly, young, or disenfranchised are often made more vulnerable by certain social conditions. Solidarity as a principle to aid the vulnerable in this sense demands social measures to ameliorate the vulnerability and strive for equality. Acting on this principle may include welfare policies to try to create more just and equitable conditions, but it may also mean that the vulnerable populations ought to be brought into consideration or even be the focus of any public policy (Stone 2012).

Sass also suggests that “solidarity” may be understood as “justice” within the context of principles of bioethics. Further solidarity is often paired with a principle of subsidiarity in European tradition. Subsidiarity means that decisions ought to be made within the community that has the relevant information and that is most directly affected by the decision. Hence, decisions that affect the family ought to be made by the family if it has the requisite information. Higher levels of decision-making bodies enter when the requisite information is not present. Solidarity and subsidiarity work together because the solidaristic community provides both the context for the decision and the information on which the outcome is based.

An alternative approach to the principle of solidarity is that the principle of solidarity supports and sustains other principles operative in the bioethics literature such as justice and benevolence. Solidarity, in other words, may be a condition for acting on moral principles. This approach is sometimes seen in human rights discussions (Harmon 2006; Gunson 2009; Scholz 2014); a willingness to aid others and a recognition of social bonds are, it seems, a presumption or requirement for responding to human rights principles. Solidarity points to the social bonds and institutional mechanisms necessary for justice.

Solidarity For Global Bioethics

Solidarity as a moral relation and as a principle has come to play a prominent role in bioethics and biolaw literature globally. Five speciﬁc contexts for the discussion of solidarity are public health, social security and the welfare state, universal health care, the right to health care, and aid to the poor and socially vulnerable (see also Prainsack and Buyx 2012).

“Solidarity” in bioethics applies the insights of the moral relations and principles of solidarity to access to health care within a state and beyond state boundaries. In large part, state-based policies that ensure access to health care and prevention of disease emerge out of a larger commitment to welfare for citizens. The connection between health and welfare may be justiﬁed through the fact that the well-being of individuals serves the common good or through an obligation to aid the sick and inﬁrm (see van Donselaar 1998). Consumerism, individualism, and privatization pull against solidarity in the distribution of health care (Stjernø 2005, p. 338; Baylis et al. 2008, p. 204).

Public Health

Public health is generally understood as focusing on the common good by maintaining the formal organization of institutions and practices with the goal of preventing disease, promoting health, and coordinating care or access to health provisions. Civic solidarity, instantiating the state’s obligations to protect citizens against social vulnerabilities, includes or requires signiﬁcant attention to health-related aspects of social life. Domestically, social life creates multiple avenues that may make some citizens more vulnerable than others. The placement of low-incoming housing in close proximity to polluting factories, for instance, exacerbates already existing material inequalities thereby making this subset of the population more vulnerable. Similarly, the lack of access to routine medical exams and the cost of tools for proper hygiene potentially affect persons in the lower rungs of the income brackets more than others. These public health issues, as well as new threats due to relations of globalization and terrorism, may also be seen on a global scale. Solidarity in the context of public health focuses on measures that ensure communal well-being; it may be grounded in mutual recognition (Houtepen and ter Meulen 2000a) or on more inclusive accounts of interdependency or interconnection (Baylis et al. 2008). In either case, solidarity shapes public policy to counter excessive individualism and ensure equal access to the means for preventing disease, accessing health care, and promoting ﬂourishing life.

Relations of solidarity are particularly important in global public health debates; the threat of pandemics requires a global perspective toward public health. Solidarity can play a central role in an ethical framework that seeks to justify obligations across borders as well as protect especially the most vulnerable populations. The ease and pace of travel further create a situation wherein diseases can more quickly spread across borders and around the world. Epidemics can no longer be thought of as contained and containable within nations or even regions. Coordination among nations and within the international community is necessary in order to meet these new challenges. Baylis, Kenny, and Sherwin (2008), for instance, describe a relational solidarity, paired with relational personhood, speciﬁcally aimed at public health planning for pandemics. Solidarity is the umbrella concept for international coordination of this sort.

Social Security And Welfare State

Solidarity in the European tradition is instantiated in and synonymous with the welfare state. Welfare systems vary but the basic premise is that resources are reallocated to provide for the wellbeing of all citizens. One way to do this is through a well-established insurance system and social security in the event of disability or retirement. Solidarity seeks to ensure that hard times may be weathered more easily by ensuring that social networks can maintain the basic needs of all citizens. Because it is a universal good, health care generally has more public support, even when support for other welfare programs declines (Houtepen and ter Meulen 2000b; Bergmark 2000). Health care and other welfare programs ensure political inclusion by decreasing the social vulnerabilities that might inhibit an individual’s ability to participate in civil and political life.

One of the many debates affecting conceptions of solidarity as welfare is whether the achievement of equality in health-care provision evinces a high degree of solidarity or whether extensive state welfare regimes for the distribution of health care and elder care actually erode solidarity networks like families, neighborhoods, and local communities. This is referred to as the debate between the value of institutionalized solidarity and the importance of a solidarity that emerges through individual social bonds or connections to others that inspire what are called individual expressions of solidarity. Another way to think of this is as a debate between civic solidarity (or the obligations of the state to its citizens) and social solidarity (or the cohesion between fellow citizens and their willingness to respond to each other’s needs).

Addressing the situation in Europe, Houtepen and ter Meulen (2000b) suggest that within some contexts, the traditional form of solidarity, rooted in voluntary societies, has given way to institutionalized forms of risk sharing they call “contractual solidarity in welfare.” One potentiality, however, is that the demand for health care will continue to outpace the supply – a growing concern given increasing life expectancies – and intergenerational solidarity will continue to erode. This example illustrates the practical importance of the debate regarding institutionalized solidarity versus individual expressions of solidarity.

Universal Health Care

Arguments for universal health care appeal to solidarity both as a principled justiﬁcation for universal provisions and as a relational commitment to universal provision. Universal health care means that health care ought to be universally available and that the quality of care ought to be equitably distributed. Differences in socioeconomic status ought not to affect the accessibility of care; of course, public health policies seek to ameliorate inequalities within individual nations, but international organizations are charged with the responsibility to ensure equitable global distribution of health resources. Thus a mandate to attend to the needs of poorer nations is incorporated in the calls for universal health care.

The global disparity in access to health care parallels or is causally related to global economic inequality. Solidarity in this context means there is a communal obligation to address health-care needs, especially for the most vulnerable, and some might also suggest that there needs to be more responsibility on the part of international organizations to pressure nations to provide universal access to health care and social security in the case of age, illness, or disability. Of course, it might also be argued that justice, or more specifically distributive justice, is more appropriate to the discussion of universalized health care (Butler 2012), but such a claim echoes the debate regarding the relation between justice and solidarity discussed earlier.

Right To Health Care

Another meaning of solidarity in bioethics concerns a right to health care, a subsidiary of the human right to health. Although in some ways claiming a right to health is impossible insofar as health is simply out of reach for some individuals, the right implies that every human being has a right to the resources necessary for the highest possible attainment of health. These include the systems discussed under public health and universal health care, i.e., access to medical care, social security, healthy living conditions (proper sanitation, adequate food, and safe environment). Solidarity functions as both a relation and a principle in this context. Recognition of human interdependence – including the acknowledgment of how pollution in one part of the world adversely affects other regions – informs a network of moral obligations that both avoid the interference in the right to health and work to positively ensure that right for all others. The former, noninterference in the right to health, is justice; the latter, positive action to ensure the exercise of that right, is solidarity.

As a principle, solidarity stands in for the right to health in a nonreductive way. That is, the right to health is really a complex right operative on interpersonal, national, and international levels and involving all those aspects of life and social existence that impact mental, physical, and material well-being. The principle of solidarity stands as an indicator of that inclusive understanding of the right to health; it also challenges moral theorists to incorporate the interconnections of peoples and actions in the shaping of theory and policy.

The United Nations speciﬁes its mandate to promote solutions to health problems internationally in its Charter, Chapter IX, Article 55:

With a view to the creation of conditions of stability and well-being which are necessary for peaceful and friendly relations among nations based on respect for the principle of equal rights and self-determination, the United Nations shall promote: (a) higher standards of living, full employment, and conditions of economic and social progress and development; (b) solutions of international economic, social, health, and related problems; and international cultural and educational cooperation; and (c) universal respect for, and observance of, human rights and fundamental freedoms for all without distinction as to race, sex, language, or religion.

Subsequent documents further elaborate on the right to health. Gunson (2009) shows how the Universal Declaration on Bioethics and Human Rights, although mentioning solidarity only three times in the text, is actually built on a framework of the principle of solidarity. The same may be said for other agreements and statements of the international community.

Similarly, the Charter of Fundamental Rights of the European Union includes the right to preventive health care (Article 35; EUROPA 2000). Basic preventative health care is a good for society as a whole; it has a positive effect on wellbeing individually and communally, tends to decrease emergency health expenditures, and plays a signiﬁcant role in planning to avoid transnational pandemics.

Focus On The Vulnerable

Finally, throughout all discussions of solidarity is a strong thread, already alluded to, that mandates a focus on the poor and vulnerable. It is this sense that is evident in the Catholic social teaching and a wide variety of social movements. The former calls for a dedicated commitment to remedying the inequalities that keep fellow human beings from full human dignity.

As explained previously, one way to understand the principle of solidarity is as an augmentation to traditional principles of bioethics that redirects the focus of concern to the most vulnerable. Motivating that focus may be accomplished through a recognition of ourselves in those who are vulnerable or as a rationally justiﬁed obligation to aid those in need. There is a long tradition using the term “solidarity” to indicate the need for this focus on the poor and vulnerable.

Conclusion

Although each of the categories of solidarity within bioethics may be analyzed distinctly, there is signiﬁcant overlap as well. A right to health care may be achieved through the provision of universal health care; health care as an element of welfare provisions helps to meet the needs of vulnerable populations. Solidarity manifests so differently because of the varying nature of social bonds as well as the aims or goals of the solidaristic community. All forms share in common the willingness to acknowledge social bonds with others and to act on behalf of the needs or interests of those others. It is also precisely this that leads some to wonder whether there is a crisis of solidarity. Individualism and consumerism have infected social existence to such a degree that even those societies that have supported and defended health care as a requirement of solidarity are beginning to question that commitment (Houtepen and ter Meulen 2000b).

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