Response to Ruud ter Meulen

Ruud ter Meulen makes a strong case for the importance of solidarity (under an inclusive interpretation which does not reflect an ‘us and them’ approach) in care. His analysis of the ways in which solidarity has undergone a transformation in the direction of shared utility, to be subsequently replaced by the concept of justice, is illuminating. The question remains, however, of how solidarity of the appropriate sort is to be cultivated. Solidarity has been much in the political news of late, largely in response to perceived threats. It has also been increasingly prominent in discussions of science and technology, for example in relation to genomics and how the genome, the ‘common heritage of humanity’, should be regarded. When we turn to health care delivery, however, what does it mean, and how can it be facilitated?

The meanings of solidarity

As ter Meulen shows, the definition of solidarity is not a straightforward matter. A typical dictionary definition of solidarity explains it as unity arising from community of interests, but what this ‘community’ and ‘unity’ amount to is variable in different interpretations. Despite some dictionary definitions referring to the unity as a feeling, Spinosa et al.^[1] have suggested that solidarity is not to be understood as a subjective feeling – they describe it, rather, as the experience of a group identity, a ‘we’, that sees things and deals with things in terms of shared concerns. It may be true that in some circumstances, where we are standing ‘shoulder to shoulder’ with others, we do come to experience awareness of emotions which we identify as feelings of solidarity with them. Such feelings are, however, not a necessary condition of solidarity. The shared concerns, moreover, may not always be at the forefront of our minds – sometimes they are mediated by others. This leads us to one of several distinctions that need to be drawn. First, Rosemary Nagy talks about the distinction between ‘thick’ and ‘thin’ solidarity.

In short, ‘‘thick’’ may be characterized as bottom-up, interpersonal, unmediated solidarity brought about by moral transformation and substantive agreement. ‘‘Thin’’ is top-down, generalized, mediated solidarity brought about by political re-orientation and procedural agreement. Neither is without hazards or benefits.^[2]

The difference is clear. As thin solidarity is procedural and takes place at the political (and also at the institutional) level, it does not involve substantive moral agreement. It is not ‘face to face’ – hence the reference to mediation. Thick solidarity depends on the possibility of face to face moral agreement or mutual recognition. In our communities and societies today, some of which are large and impersonal, we do not always have the possibility of the ‘face to face’. The question then becomes – how can solidarity be cultivated?

Sometimes a group identity is constituted by a community of shared interests that people have ‘in common’, such as when they choose to band together for a common purpose – as in a coalition for utility, as ter Meulen shows. The members of a special-interest society with a particular objective would be an example of this. There is, however, a sense in which people can have common interests simply by virtue of their very being, as members of a group or community. For example, we have common interests by virtue of being members of our geographical communities, independently of whether we have signed up as members of them. The question arises as to whether being members of the same species can give rise to a sense of human solidarity in this sense. What, then, counts as a community? The Ethics Committee of the Human Genome Organisation, in its Statement on Benefit Sharing, made a distinction between communities of origin and communities of circumstance:

Both types of communities can be defined across several dimensions, including geography, race/ethnicity, and religion or disease state. For example, a small town may be a community of origin if most inhabitants were born there, or a community of circumstance if most are newcomers. Persons with the same disease could form a community of origin if there is a family history, as may be the case for monogenic disorders (single gene), or a community of circumstance, which is usually the case for common multifactorial diseases.^[3]

In a later Statement, the Committee took the view that the human species can indeed count as a relevant community as the following quotation (in relation to participation in population genomic research) makes clear:

Solidarity: Because of shared vulnerabilities, people have common interests and moral responsibilities to each other. Willingness to share information and to participate in research is a praiseworthy contribution to society.^[4]

The point here is that, despite apparent differences between people in wealth and status, all human beings are vulnerable to illness, disease and ultimately death. We therefore have common interests in the light of that fact, and they provide a foundation for solidarity.

Solidarity and equity

One of the potential problems with solidarity, however, as ter Meulen has pointed out, is its perceived exclusiveness under one interpretation. Solidarity within a group is often combined with, if not actually reinforced by, differentiating its members from those of other groups. Solidarity implies reciprocal recognition, and has been appealed to in ethics as an antidote to the focus on the individual right holder, a focus which in the second half of the twentieth century diverted attention from notions of the common good. As regards the purported relationship between solidarity within a group and hostility or at least indifference to those outside it, what can be said about the possibility of solidarity with human beings in general? One could make out an argument for solidarity with members of one’s species against other species; or a hypothetical argument about the relationships with beings from other planets, but the point is that this should not be necessary, if it is possible simply to recognize the common concerns that all humans have.

This requires a move from ‘I’ to ‘we’, a move which Spinosa et al.^[5] have talked about in terms of transformation. They suggest that this ‘we’ comes to recognize itself when the actions it engages in transform it. Transformation can be understood in different ways. A transformation may constitute an activation, or awakening, of latent solidarity; or it can be transformative in a stronger sense, that of changing people’s perspective from ‘I’ to ’we’. It is not always the case, after all, that solidarity is latent. How can this transformation take place?

It is important, first, to recognize the relationship between the possibility of solidarity and equity. It is difficult for solidarity to co-exist across gross differentials and conditions of injustice. It is challenging for the possibility of the ‘we’ perspective. Just as Habermas recognized that solidarity may be threatened by an adversarial rights-based view, so a social context in which clear injustice obtains is inimical to the possibility of solidarity except for those in similar situations. It is necessary to think beyond the self, in conditions in which people have an equal voice:

Under the pragmatic presuppositions of an inclusive and non-coercive rational discourse among free and equal participants, everyone is required to take the perspective of everyone else, and thus project herself into the understandings of self and world of all others; from this interlocking of perspectives there emerges an ideally extended we-perspective from which all can test in common whether they wish to make a controversial norm the basis of their shared practice; and this should include mutual criticism of the appropriateness of the languages in terms of which situations and needs are interpreted. In the course of successfully taken abstractions, the core of generalizable interests can then emerge step by step.^[6]

Realistically, however, that is not the situation that currently obtains, politically and economically in many societies. Nevertheless, in health care, it is to be hoped that there is scope for the mutual recognition of common vulnerabilities, even though this is unlikely to remain unaffected by the circumstances of a very unequal society. Few if any escape the dependency that ill health brings with it. So how can solidarity be cultivated?

Cultivating solidarity

Bearing in mind these points, there are at least two different possibilities: individual people or events can bring about a transformation towards recognition of solidarity; or institutions may do this.^[7]

The paradigmatic case of individual transformative action is that of a key cultural figure. Individuals can act as bridges between others, cultivating solidarity in wider society. Some of these individuals may have positions of power, or be able to act as role models. Nelson Mandela’s role in post-apartheid South Africa is an example, bringing together different groups after a very traumatic period. Such individuals are rare, but specific events can also have a transformative effect, when people come to see things differently – perhaps after the death or loss of a key figure in tragic or unjust circumstances, or a large scale natural disaster. In the context of health care, events such as distressing revelations about the consequences of poor care may have an effect, and there may occasionally be inspiring examples of willingness to bear costs for the sake of others, as in the case of the volunteers travelling to Africa to work with Ebola. Such cases are the exception, however, and cannot be relied upon to produce the necessary transformation.

But transformative action also has to be considered at the institutional level. Institutions may indeed serve as a rallying point for a community. In the US, for example, Spinosa et al. have pointed out the role of the Supreme Court, in its judgments, as giving voice to shared values. This is an example of making heard the latent solidarity – spelling out what the shared commitments actually are. The law also has the capacity to influence changes in shared values, however, in different ways in different jurisdictions. But on the other hand the courts may also serve to divide and alienate if they support and promote the interests of only one sector of society.

Similar considerations apply to other institutions, and even those that are founded on a notion of solidarity may struggle to deliver on that promise. A key example here is that of the NHS in the UK: a health care system which was founded for the benefit of all, so that resources would be allocated on the basis of need at the point of delivery. But demographic change, rising expectations, extended life spans have all put the system under great strain, leading to the possibility of adversarial relationships between the ‘me’s’ struggling for a slice of the necessarily limited cake, as illustrated by ter Meulen.

Arguably what is needed is a combination of the individual and the institutional approach: for individual practitioners to be willing to engage in institutional review, and if necessary, change. Williams and Chadwick have examined the ways in which institutions enable some modes of action but disable others, and argued that in health care professional conduct should include participating in those institutions to ensure that they are continually subject to revision:

[…] what counts as professional conduct […] depends on the collective moral learning that is embodied in decent institutions, and developed by them on an ongoing basis.^[8]

Professional responsibility includes, not just displaying solidarity in the ‘face to face’ interactions with users of the service, but also engaging with the institutions that determine the collective modes of caring for people’s health. While it is not suggested this is easy and straightforward, it is important at least to recognize the possibility of change and what it requires.

Ethical perspectives can change for a number of other reasons, apart from the effects of institutions within which we operate. Sometimes, existing frameworks simply do not work in new situations. Developments in science and technology, in particular, make certain positions no longer tenable and change the very concepts we employ. In the last decade or so there has been a perceived – or argued for – shift in ethics, arising primarily in the sphere of biomedicine, involving greater emphasis on principles of solidarity, equity and public good, as opposed to the predominance of autonomy-based argument.^[9]

Geoffrey Warnock in The Object of Morality argued that morality is a response to certain features of the human condition.^[10] This is subject to certain limitations: limited resources, limited knowledge, limited wisdom and limited sympathies. Where morality is concerned, it is the last of these that is arguably the most significant. There is a natural tendency to take more seriously the interests of ourselves or our own, whether ‘our own’ are family, friends or compatriots. This is important when we come to discuss the possibilities of solidarity.

It is the task of ethics as an academic discipline to study how the point or object of morality can be fulfilled; and to suggest ways of negotiating these conflicts of interest by proposing principles by which to resolve them. It would be a mistake, however, to think that there is a defined set of universal principles that can be discovered to ‘apply’ to all times and places without being subject to reinterpretation. As noted above, ethics evolves, and at the present time we are witnessing greater interest in the principle of solidarity.^[11] The work of Ruud ter Meulen in itself contributes to the cultivation of solidarity through ethical argument, by pointing out the potential for vulnerabilities and conflicts of interests to go unnoticed, and showing how the principle of solidarity can do the ethical work required.^[12]