Diametros 43 (2015): 28–43
doi: 10.13153/diam.43.2015.712

Rescuing Solidarity from Its Carers. A Response to Professor ter Meulen

Giovanni De Grandis

Abstract. The paper points out three serious problems in Ruud ter Meulen’s view of solidarity and of its role in healthcare ethics. First, it is not clear whether and to what extent ter Meulen expects normative concepts to be rooted in existing social practices: his criticism of liberal theories of justice seems to imply a different view on this issue than his implicit assumption that normative concepts are independent from social and historical trends. Second, it is not clear at which level his notion of solidarity is meant to be applied: does it provide principles for individuals or for institutions? Nor is it clear at what level of generality it should work: is it meant for healthcare institutions or for states, for citizens or for healthcare practitioners? Third, it is not at all clear how the communitarian and the universalist aspirations in his conception of solidarity can be reconciled.

In light of such difficulties it is argued that within philosophical discourse solidarity can be a useful notion only if it can be clearly distinguished from existing and commonly used ethical concepts. Three examples of such narrow and specific uses of solidarity are presented. Finally, a sceptical view of confining the work of applied philosophers to articulating normative concepts is put forward and an alternative view of blending empirical and philosophical analysis is proposed. This vision of field philosophy requires serious attention and careful understanding of the circumstances and constraints within which normative recommendations operate. It is suggested that such a modest and empirically grounded understanding of normative work is a better way of honouring the belief that philosophy is rooted in social institutions and in complex webs of relations.

Keywords: solidarity, justice, community, individuality, healthcare ethics, ethics in practice, field philosophy, normative and descriptive ethics.

1. Introduction. Imagine…

“Imagine all the people
Sharing all the world…
You may say I’m a dreamer”.
John Lennon, Imagine

Most of our readers have presumably spent a good deal of time dealing with liberal theories of justice. Since Rawls’s landmark work,[1] the offer has broadened and criticisms of liberal justice have become an industry. By now those who have managed to keep apace with this debate know that liberal justice has been blamed for countless flaws: abstractness, formalism, coldness, lack of altruism, generosity and public spirit, neglecting community, feelings, the most vulnerable and so on and so forth. Some of these criticisms are more robust than others, some target the theoretical consistency and the anthropological assumptions of liberal justice, other the unintended psychological and social consequences. Advocates of liberal justice have worked hard to address these criticisms, and several theories have been improved and made more inclusive and sensitive. Other liberals have refused to compromise and posed as the true hard-nose liberals against the soft minded traitors willing to compromise with the anti-liberal critics. As a result there is now a broad offer of liberal theories of justice, as well as a broad offer of social, political and ethical theories which present themselves as alternative to them. There is a rich offer and with it comes the hard, and time-consuming business of making a wise choice. Tough!

But now close your eyes. Think of all the good qualities and aspirations of the best liberal theories of justice: fairness, impartiality, respect for individual rights, preservation of individual freedom, compatibility with legal procedures, economic efficiency, universalism… Great, isn’t it?

— Yes!

But now think of all the attractive features of the alternatives to liberal justice: grounding in actual practices, concern for nurturing communities, respect and care for the most vulnerable, recognition of individuality and collective identities, a warm and personal touch in dealing with individual needs… Amazing, right?

— I’m impressed indeed.

Now imagine that there is a concept that can include all these wonderful qualities, I mean both the qualities of liberal theories and the values advocated by its critics, imagine that they can all go together under the banner of solidarity. What’s not to be liked about solidarity?

— Oh I love this solidarity. It is magic! (Pause) Hmm, but shall I open my eyes now?

You have got my point: there is nothing not to be liked in Ruud ter Meulen’s ideal of solidarity, but the flawed logic. In the rest of this paper I am going to argue three points:

  1. Ter Meulen does not succeed in providing a consistent and unequivocal conception of solidarity.
  2. Solidarity can be given more specific meanings, which avoid confusion with well-established ethical and political concepts and which are compatible with liberal justice and autonomy.
  3. What we need in bioethics (and more generally in applied ethics) are not new theoretical articulations of normative concepts, but a better integration of ideals and practices, i.e. a moral thinking that has the courage of leaving the domain of theory and of engaging with empirical reality. It is no longer the time for advocating the Aufhebung of the distinction between normative ethics and descriptive ethics: it is time to practice it, to work in the trading zone between normative ethics and rooted practices.

2. Solidarity: panacea or snake oil?

What is exactly the role that solidarity is supposed to play in healthcare? Ter Meulen tells us that solidarity should not replace justice but integrate and supplement it. But understanding in what this integration of justice consists is far from easy since he discusses many different views of solidarity: some descriptive and some normative, some socio-political and some individual and psychological, some endorsed and some criticized. Throughout the article the notion of solidarity shows many faces and it is not easy to pin it down. Let us track the various steps of ter Meulen’s description of solidarity.

First we are given a suggestion about the reasons why solidarity has not proven very popular: the problem is that solidarity is perceived as vague (it lacks a precise definition and a specification of the duties associated to it), communitarian, and incompatible with individual freedom and autonomy.[2] By the end of the article readers will have no doubt that ter Meulen wants to show that solidarity can be articulated precisely and made compatible with freedom and autonomy, although they may wonder whether he has succeeded and may also be confused about the relation between solidarity and communitarian values, since ter Meulen suggests that he wants solidarity not to have the exclusionary feature of communitarian values, while he endorses all the communitarian arguments against liberalism’s alleged abstract and selfish individualism. So we will need to assess whether ter Meulen succeeds in offering an account of solidarity that overcomes vagueness and secures freedom and autonomy. We will also need to clarify the relation between solidarity and communitarian values.

Ter Meulen introduces a distinction between instrumental and humanitarian (or intrinsic) solidarity. The former resembles a form of enlightened self-interest: participating in cooperative ventures brings good dividends to individuals, it is predicated on a do ut des logic that ter Meulen identifies with reciprocity. Humanitarian solidarity instead is described as disinterested and benevolent: it is grounded on a proactive response to the needs and vulnerability of others, especially of those who are in a position of dependence. There is no doubt that ter Meulen considers humanitarian solidarity morally superior to the instrumental version. However, this fairly clear characterization of solidarity is complicated by the following historico-sociological excursus. Following the account of some prominent sociologists ter Meulen sees the modernization process as bringing about a transition from a communitarian (affective) solidarity to an instrumental (rational) version of solidarity, for both contractual solidarity and organic solidarity are instrumentally justified. Notice that this process goes together with a transformation in people’s sense of identity, which evolves from a pre-reflective identification with the group (collective conscience in Durkheim’s terminology) to an individualized conscience. Another point worth of attention is that European health care systems are presented as an outcome of organic (and instrumental) solidarity.

The paper then moves on to cover the moral interpretations of solidarity. We need to pay special attention to the transition in ter Meulen’s article from the descriptive and the normative notions of solidarity. Given that we know that ter Meulen advocates a normative view of humanitarian solidarity, what role does the discussion of the socio-historical descriptive views of solidarity play in the economy of his argument? This is a crucial point, because on the one hand ter Meulen refuses to draw the conclusion that a transition from solidarity to justice is an unavoidable outcome of modernization (this is where he refuses to follow Bayertz[3]), while on the other hand in his criticism of liberal justice he relies heavily on communitarian arguments based on the so-called sociological thesis (i.e. the thesis according to which both the sense of identity of individuals and the basic ethical assumptions on which liberals rely are dependent on pre-reflective social relations not reducible to instrumental rationality). This means that ter Meulen needs to assert the independence of morality from social structures in order to avoid a socio-historical determinism that would condemn solidarity as outdated and nostalgic — because associated with a mentality disappeared from modern societies — while at the same time he criticizes liberalism for ignoring the sociological basis of normative concepts. If this double standard is not to be perceived as an opportunistic and inconsistent move, we are owed an explanation of why this double-dealing strategy is justified.

Let us now look at how the favoured normative conception of solidarity is constructed and what it looks like. Ter Meulen’s view of solidarity is characterized primarily by five features: a) it is non-instrumental, b) it is relational, c) it is grounded in the life-world, d) it is universalistic and e) it is an expression of a shared commitment to the common good. Some of these features raise some difficult issues when applied to the specific challenges that healthcare systems are currently facing, however I will only mention one such problem and then focus on the impossibility of reconciling these five features into a consistent and workable concept.

In describing humanitarian solidarity as non-instrumental (a) ter Meulen stresses that it is based on disinterested benevolence, on individuals’ ability to accept obligations that spring from the perception of the needs of others and of their dependence on our help. The normative response to this demand coming from human needs and vulnerability is described in terms of responsibility. This responsibility is rooted in our ability to enter into relationships of mutual recognition (b), i.e. relations in which we make an effort to see things and moral demands from the other’s point of view and we acknowledge it as a source of valid normative demands. Such relations of mutual recognition are what makes it possible to establish meaningful personal and moral relations in the life-world (c), and it is by actually entering into such relationships that we develop our ability for moral feelings and moral reasoning. However, such relations are not limited to members of our own community: once we have developed the relevant moral capacities, we can extend them to foreigners and indeed we should not be confined to any parochialism (d). This makes it possible both to extend our care and responsibility to strangers and foreigners and to respect individuals within our community whose views and values are not those defining the collective identity. Finally, solidarity can provide a foundation for the institutions that support the welfare of citizens only if citizens have a bond of solidarity based on a shared conception of the good and a sense of a shared fate (e).

Taken independently, these normative commitments are not uncontroversial, but can be defended with good arguments. However, I find particularly questionable the advocacy of disinterested benevolence in the context of a discussion of healthcare institutions. It is very well known that the increasingly pressing need to make difficult priority choices, to ration and limit access to some treatments, and to set limits to the provision of services are the result of a combination of technological, demographic, epidemiological and socio-economic factors.[4] In this context advocating an unconditional benevolence and the ensuing responsibility to care for others sounds utopian and out of touch with reality. Furthermore it is morally questionable to attack the notion of reciprocity as mean:[5] for reciprocity is needed in order to preserve the fairness of the system and to prevent abuses and free-riding, which, besides being morally indefensible behaviours, are both undermining the sustainability of the system and trust among citizens if they go unchecked. What is needed is not an all-out attack on reciprocity, but a proviso that specifies that reciprocity needs to be foregone when we deal with citizens whose disabilities or disadvantaged circumstances prevent them from contributing to co-operative schemes. This is all that a sound humanitarianism (or sound solidarity) asks us. Relinquishing responsibility for not abusing the system while demanding unbounded responsibility for the needs of others looks both as a strikingly unbalanced distribution of responsibilities and as a recipe for generating public outrage and mistrust.

However, what I find especially unconvincing in the construction of the normative notion of solidarity proposed by ter Meulen is that it is very unclear what kind of normative concept is the solidarity described. Features a, b and c are applicable to individual ethics, but ill-suited to inform healthcare institutions. Ter Meulen never uses the important distinction between 1) the values of a just state, 2) the values that should inform an institution and its mission, 3) the values that people need to share in order to support that institution and 4) the values that are required of people working within that institution. Principles for states are not the same as those for other institutions, which in turn are different from principles for individuals and these should be divided into principles for all (or at least for citizens, if we prefer a communitarian to a universalist approach) and principles for professional roles. What is exactly the role of the proposed conception of solidarity? Is it addressed to society as a basis for supporting comprehensive health care free on point of delivery? Is it proposed as the mission — as the inspiring value — of modern healthcare systems? Is it recommended as the ethos of healthcare practitioners? As principles addressed to a citizenship that is expected to support institutions that provide basic healthcare for all, they appear to be unnecessarily demanding and rash in rejecting arguments based on mutual interest and rational prudence. Public institutions like a universal healthcare system should be based on moral values shareable by all citizens, and hence should better be minimalist in their demands. Inclusion into the political community cannot presuppose disinterested benevolence. To do so is tantamount to telling citizens whose moral views do not include a commitment to extensive benevolence that they cannot be part of society, that they are not good enough to be part of our political community. This might be sound policy for puritanical religious sects, but is completely self-defeating and disastrous as a basis for political union. So points a-c cannot provide a view of a shared political commitment and of the common good (point e), because they are over-demanding and divisive. Points a-c might then be interpreted as principles for health-carers, as it may be suggested by the discussion of Margalit’s argument about the modality of service delivery. But in the context of mounting healthcare demands and budget cuts — a context repeatedly evoked by ter Meulen — can we really impose on a healthcare workforce such a demanding professional ethics without giving them anything in return? Can we accept that the citizenship as a whole cannot have very altruistic commitments and yet demand from a subset of public employees to endorse an ethic of altruistic self-sacrifice? This sounds like a perfect strategy to exasperate the shortage of healthcare personnel that already afflicts many countries and that encourages a thoroughly unfair international flow of health-carers from poorer nations to wealthier nations.

Finally there are further problems in keeping together the various features of humanitarian solidarity. Features d and e are at odds. Feature e presupposes a communitarian point of view that is not compatible with the universalism and acceptance of individual autonomy presupposed by d. Ter Meulen acknowledges that recognition of identity and dignity poses a challenge to communitarian views of solidarity which can lead to exclusion and overlook individual autonomy.[6] Yet a little later he reintroduces a communitarian view when he embraces Charles Taylor’s republicanism, a view that presupposes a sense of belonging that is particular and contingent (since it is based on sharing a common fate), and a shared conception of the common good. The problem is that universalism and respect for individual freedom and autonomy sit uncomfortably with a communitarian ethos, which is instead better suited to provide social rooting to moral principles and values. Now this is not a secondary feature of ter Meulen’s argument, for the polemic he wages against liberal theories of justice is based on the alleged exaggerated individualism and lack of grounding in actual and morally rich intersubjective relations. So if ter Meulen drops the communitarian elements of his view, then solidarity can no longer present itself as alternative to liberalism. Indeed when he argues for reflective solidarity as an inclusive and recognition-based notion that brings together respect for rights and dignity with concern for well-being, he has to rely on the same kinds of abstractions that are targeted by critics of liberalism. Reflective solidarity is possible only through a process of abstraction from differences, a creation of an artificial shared identity that has not, and cannot have, any root in the actual life-world, characterized as it is by stubborn boundaries, identities defined through mutual opposition and exclusionary practices — i.e. the conditions that generate the otherness of “the other”. So solidarity is caught between the aspiration to be in touch with the pre-reflective, emotional and deep commitments that are seen as lacking in liberal justice — and yet as its necessary but unacknowledged presuppositions — and the aspiration to transcend the parochialism and exclusionary nature of local and communitarian allegiances — something that can be achieved only by performing the same work of abstraction and distancing from the warm, emotionally rich and pre-reflective universe of the life-world with its real practices, habits and shared meanings. The solidarity that can include the distant and foreign other is a solidarity that can only be based on the thin and abstract nature of our shared and common humanity, not on lived practices and on thick and shared conceptions of the good.

To sum up, I have levelled three main criticisms to ter Meulen’s conception of solidarity.

  1. It cannot claim an underpinning in descriptive notions of solidarity while at the same time claiming the independence of normative concepts from existing socio-historical forms of life.
  2. It needs to be specified as a conception that provides either values for institutions or for individuals, and in the latter case – if it addresses human beings, citizens or professional roles.
  3. It has to be described either as an alternative to the abstractness and individualism of liberal justice, or as a universalist notion fully compatible with individual freedom and autonomy. It seems impossible to have it both ways.

Because of these ambiguities and tensions ter Meulen has not succeeded in freeing the notion of solidarity from its alleged vagueness.

3. Three alternative characterizations of solidarity

In this section I explore some possible interpretations of solidarity that would make this concept narrower and more specific than the broad and ambitious interpretation proposed by ter Meulen. First I show that in Rawls’s theory of justice we find a quite neglected notion of fraternity that could be seen as well as an articulation of a conception of solidarity. If convincing, my reading of Rawls’s fraternity as akin to solidarity would demonstrate that solidarity and egalitarian versions of liberal justice are fully compatible and indeed complementary. Second, I propose two other possible ways of defining quite specifically the concept of solidarity that would avoid overlapping with other well-established ethical concepts and therefore could contribute to analytical precision. Let me make clear that these three alternative characterizations of solidarity are not presented as different features of an integrated view of solidarity. They are three separate suggestions and I am making no claim about their mutual relations and compatibility. Furthermore, while the first is a normative conception of solidarity, the following two are presented as contributions to analytical precision in the use of concepts.

The reason for making suggestions at different levels of philosophical discourse is to stress that in the context of philosophical discourse we can talk about solidarity either to provide a critical analysis of the way in which the concept is used in public discourse, or we can adopt it as a philosophical technical term — and this is what ter Meulen has attempted to do. The problem is that in order to be a useful philosophical concept (a term-of-art), solidarity needs to be clearly distinguished from other existing and ordinarily used philosophical concepts, otherwise it engenders conceptual confusion instead of helping to think precisely.

Unfortunately, entering the English-speaking philosophical vocabulary, solidarity finds itself into a space that is already crowded, almost saturated with ethical and political concepts, so that there are few semantic niches available, apart from being a slightly foreign synonym of other familiar concepts (e.g. group-cohesion, altruism, mutuality etc.).[7] Of course this does not mean that philosophers have reasons for objecting to the use of the concept of solidarity in public discourse on healthcare policy. Solidarity is a well-entrenched concept in many European countries and will continue to play an important role in public debates whether philosophers like it or not — and personally I do not see any serious reason for rejecting it.

A liberal egalitarian version of solidarity

Rawls introduces the concept of fraternity while discussing his famous difference principle, which is part — together with the principle of fair equality of opportunities — of his second principle of justice. This principle states that:

Social and economic inequalities are to be arranged so that they are both (a) reasonably expected to be to everyone’s advantage, and (b) attached to positions and offices open to all.[8]

In explaining the egalitarian spirit of the difference principle — part (a) of the above-quoted second principle — Rawls explains that it can be seen as an interpretation of the third of the famous principles of the French revolution: liberté, egalité, fraternité. Fraternity, Rawls notes, has played a much smaller role than liberty and equality in the development of democratic theory. Furthermore, he suggests that it is not so much a specific political concept, but rather the expression of a democratic ethos, which is nonetheless important in order not to lose sight of the meaning and of the genuine spirit of democratic rights. So the ideal of fraternity has not been seen as one that could be expressed formally through rights and legal concepts, but as the moral disposition and feeling that should infuse life and civic passion into democratic politics — however, Rawls believes that the difference principle has now provided a way of operationalizing it at the institutional level as well. Rawls explains that fraternity implies ‘a sense of civic friendship and social solidarity.’[9] But how does Rawls explain the content of the principle of fraternity? He describes it as

[…] the idea of not wanting greater advantages unless this is to the benefit of others who are less well off.[10]

Fraternity is thus the willingness to set limits to the pursuit of one’s own individual advantage, limits that express the commitment to share some of the personal gains to the less fortunate members of society. This is a moral feeling that is not an expression of universal benevolence, but of a commitment to some measure of sharing with one’s fellow citizens. It is a recognition of the fact that through participation in a (reasonably just) political society we all benefit from the restraint and law-abidance of other citizens and hence, on the basis of a principle of mutual benefit and reciprocity, we should reciprocate by sharing with our less fortunate fellows part of our gains. This principle clearly sets limits to self-interest and is incompatible with ruthless individualism. However, it is important to repeat, it is not just a principle of universal benevolence or sympathy, because it is justified on the basis of the fact that each member of society greatly benefits from participating in it and hence for a basic principle of fairness and reciprocity one has to give something back, in particular to those who have had fewer benefits from living in society. Rawls sees his difference principle as a way of giving an institutional expression to this ideal: an institutional expression that he does not see as a substitute for feelings of solidarity and civic friendship, but rather as promoting their development. It is by living within institutions that embed and incorporate the spirit of the principle of fraternity that one is more likely to develop the feelings of social solidarity. I make this inference on the basis of an obvious analogy with the argument that Rawls offers in chapter VIII and explaining how the sense of justice is developed through being socialized within a just society.

In spite of the great influence exercised by Rawls’s work, his notion of fraternity has not received much attention and has not become of common use. I think it is safe to say that fraternity has not entered the mainstream political and ethical vocabulary in the English-speaking world.[11] Solidarity is beginning to gain popularity, but it has not yet found an agreed interpretation, so I suggest that it may be defined along lines similar to those used by Rawls to interpret fraternity. Since his proposal has not managed to give currency to the idea of fraternity, this would not create any serious conceptual confusion — incidentally it would also avoid the gender bias intrinsic in the notion of fraternity. It would be old wine with a new label, but if the wine has aged well and sold poorly there is nothing wrong in giving it another chance to be appreciated. So I do not see any serious objection to “rebranding” Rawlsian fraternity as solidarity. If one believes in the active power of normative concepts, it could serve many of the purposes for which ter Meulen invokes solidarity — tempering individualism, buttressing support for public commitment to universal healthcare, fostering the moral feelings that are a necessary complement to rights and regulations, helping to see disadvantaged fellow citizens as appropriate subjects of our obligation to help — without having the flaws that I have found in his proposal. However, I must confess that I am sceptical about the ability of philosophical ideas to produce changes in public policy and even more sceptical about their chances of changing professional practices. I will briefly outline a different way of doing applied ethics in the last section. Before that I want to suggest two other possible uses of the concept of solidarity.

Two very specific analytical uses of solidarity

The first is what I call a rhetorical use of solidarity, the second – a technical use.

1) The rhetorical use
Solidarity can be used to describe a specific type of appeal that is addressed to the better off members of society in order to persuade them to support the provision of basic services, or to guarantee minimum standards of living, to other members of their community. In this sense solidarity addresses or tries to arouse communitarian feelings rather than using the colder and more formal idiom of justice. It may be argued that the rhetorical appeal to solidarity is different from appeals to justice not only in addressing different motivational levers in the audience, but also in its normative force: it sounds more as an invitation than as a demand. If it is claimed that justice requires, say, universal access to basic healthcare within a country, what is intended is that everyone has a claim of justice to have access to basic healthcare and that it would be wrong to deny access. Those casted in terms of justice are strong claims. But if it is argued that the national health policy should be inspired by solidarity and grant basic health services to everyone, what is meant is that it would be a good thing and that it would foster feelings of mutual concern. Having a different and less generous policy would be callous or selfish, but not, strictly speaking, unjust. An appeal to solidarity is an invitation to act on our most generous and communitarian feelings or a reminder of the benefits of social cohesion and feelings of belonging; as such it is less peremptory than an appeal to justice. While a claim of justice sounds like ‘You have to…’, an appeal to solidarity sounds more like ‘Wouldn’t it be good to…’ or like ‘Is this not what our community is about?’ From a rhetorical point of view solidarity does seem indeed a gentler, warmer, more communitarian concept than justice.

2) The technical use
Solidarity could be used to describe a specific provision associated with some forms of collective action and institutions. In this case solidarity indicates that the collective endeavour is based on ruling out the possibility of opting out and of excluding members. In other words, it describes a commitment whereby it is understood that the group behaves as one, that self-interest or efficiency do not count as excuses for exceptions and that it is not allowed to disaggregate benefits and burdens. When such a commitment is in place, we can say that the collective cohesion is cemented by solidarity. Solidarity can thus be described as the moral and emotional foundation — or, if we believe that morals are the product of practices, as the moral and emotional effect — of these anti-exclusionary and anti-opt-out clauses. So described, solidarity can be seen as the willingness to pool some effects of good and bad luck and to treat them as a social rather than as individual features. This is equivalent to saying that the pooling is explicitly not conditional on how the costs and benefits of such a choice will turn out to be distributed. No matter how bad things turn out to be for some, the group will not leave them to their own devices and will shoulder the costs. No matter how well things go for some, they will still endorse the scheme of mutual support. So-called luck egalitarianism could then be seen as an extreme form of solidarity, i.e. solidarity that is unlimited in scope because it is extended to every kind of good (except negative freedom, of course). The American with Disabilities Act[12] offers a more relevant and health-related example of solidarity: a political community that commits itself to shoulder the costs of removing the barriers that bad luck has imposed on some citizens in their fruition of some highly significant services and opportunities (e.g. employment, transports and accommodation).

4. From conceptual disputes to implementation strategies

Readers may think that so far I have expressed a rather negative — perhaps even cynical — and uninspiring view of the possibilities of normative ethics. So I now want to show that my sceptical and humble approach to normative ethics does not prevent me from setting a very important task to bioethics and to applied ethics in general. Instead of starting with articulating general normative principles, ethicists should start by looking at the reality in which they are immersed and by mapping the ethical terrain. For instance, let us start from the problem raised by Avishai Margalit and summarized in ter Meulen’s paper: it is not only important which health care services are offered, but also how they are delivered to patients, for we do not want them to feel humiliated. How can an ethicist contribute to addressing this problem? Ter Meulen follows a well-consolidated path among moral philosophers: our contribution to the solution of the problem is more and better theory; once we have the right normative tools, the solution of the problem will only be a matter of good political will. I am very disillusioned with this approach, because it fails to deliver and because it fails to take responsibility for (failed) outcomes — it is not the philosopher’s fault if the world does not listen, so goes the excuse. But the truth is that it is the philosophers’ fault if their message is dead letter. Normative recommendations should be addressed not to a mythical all-powerful political authority capable of implementing any decision it cares to make or to society at large under the idealistic assumption that ideas will trigger cultural change. Normative recommendations should be tailor-made to address the plurality of actors who at various levels have some power to promote or hinder the sought-after change.[13] How can this be done? I propose a pragmatic method in three steps:

  1. Values analysis
  2. Affordances analysis
  3. Strategic opportunism

Let me illustrate these ideas very briefly. But first let me make clear that the method is a combination of empirical observation and normative reasoning — my own version of “field philosophy.”[14] Value analysis consists first of all in mapping all stakeholders and power-holders and then in understanding what are their values and interests. Ideally this requires the combination of social-scientific methods and philosophical skills and sensibility — which are needed in order to translate the different vocabularies of stake- and power-holders into a common and consistent ethical language. The following step, affordances analysis, consists in mapping what are the constraints as well as the margins of action and discretion of all relevant actors. Constraints and opportunities are determined not only by their values and interests, but also by legal and administrative regulations, available resources, professional culture and deontology, traditions, cognitive frames, path dependencies, available knowledge and technologies. Once values and affordances analysis have been carried out, philosophers will have a picture of what is actually possible and will understand that making impossible demands is not going to help anybody, and possibly it will only increase frustration and dissatisfaction, exasperate tensions and possibly even direct blame in the wrong direction. What needs to be done is instead to analyse the realistic possibilities and assess them balancing the two conflicting desiderata of A) achieving the maximum incremental improvement now, and B) promoting those trends that are more likely to engender further improvements in the future. I call this balance strategic opportunism because it is an attempt not to miss opportunities, not only the immediate ones (tactical gains), but also the likely future ones (strategic gains). Finally, this result is not going to be achieved through imposing one’s own interpretation of the best available course of action, but it needs to be negotiated and agreed with all relevant actors. Philosophers should become promoters of reasonable compromises and forget about the time-honoured and die-hard Platonic phantasy of becoming the new Lycurgus.[15]


I consider ter Meulen’s attention to the thought of great sociologists like Durkheim, Weber and Elias as a sign that he does not believe that we should consider human beings as unencumbered agents (to borrow Michael Sandel’s fortunate phrase),[16] but as situated within a complex web of social norms, relations, traditions and expectations. He is quite explicit about the need to pay attention to other people’s point of view and reasons — that is the point of his notion of reflective solidarity. Given these premises I trust he will see that my proposal is a concrete way of honouring in practice, and not only in theory, our shared aspiration towards a bioethics that is both humane and rooted in social reality.


  1. Rawls [1999], the treatise was originally published in 1971.
  2. Meulen [2015] p. 1.
  3. See ibidem, p. 8.
  4. As former British Health Minister Enoch Powell famously remarked, “There is virtually no limit to the amount of health care an individual is capable of absorbing.” This simple fact is even surer now. For instance ageing populations together with continuing progress in medical technologies and pharmacology produce increasing prevalence of chronic diseases that demand expensive care for years (Gruenberg [1977]). These and other causes have contributed to an uncontrollable expansion of demands for health care. As a result, no matter how much the health budget grows, “it is still not possible to meet all competing health needs. Limits must be set” (Daniels [2008] p. 25). This is why issues of rationing and priority setting have become so central in bioethics and health policy.
  5. See Meulen [2015] p. 12.
  6. Ibidem, p. 15.
  7. It could be argued, and not without good reasons, that the fact that English has become the international language for philosophy affects which concepts are used and how they are interpreted so as to generate a bias in favour of Anglo-Saxon culture. Interesting as it is, this is a topic for a completely different paper.
  8. Rawls [1999] p. 53. Rawls gives a slightly different version of this principle in his later works (the revisions introduced in the 1999 edition of A Theory of Justice were actually prepared in 1975): Political Liberalism (Rawls [1993] p. 6) and Justice as Fairness: A Restatement (Rawls [2001] p. 42–43). Ter Meulen in his article misquotes the principle in a way that changes its meaning substantially: instead of being ‘to everyone’s advantage’ inequalities become ‘to one’s advantage’ (Meulen [2015] p. 2), which is quite different.
  9. Rawls [1999] p. 90.
  10. Ibidem.
  11. Rawls himself, not exactly a thinker afraid of repeating himself, dropped the idea in his following works — “fraternity” does not appear in the index of either Political Liberalism or Justice as Fairness: A Restatement.
  12. http://www.ada.gov/pubs/adastatute08.htm
  13. To be sure, the method that I recommend should not be read as a ban on more theoretical and less empirically grounded philosophy. On the contrary, both are necessary. As it is shown by the fact that perceptive theoretical articulations of new ideas, like that of Margalit, are needed to point the attention towards the more urgent ethical needs.
  14. I borrow the expression from Frodeman, Briggle and Holbrook [2012].
  15. I understand reasonableness along the lines suggested in Toulmin [2001]. For an interesting example, from healthcare ethics, of a method that has some relevant affinities with the one that I propose, see Martin and Singer [2003].
  16. Sandel [1984].


  1. Daniels [2008] – N. Daniels, Just Health. Meeting Health Needs Fairly, Cambridge University Press, Cambridge, UK 2008.
  2. Frodeman, Briggle and Holbrook [2012] – R. Frodeman, A. Briggle, B. Holbrook, “Philosophy in the Age of Neoliberalism,” Social Epistemology 26 (3–4) 2012, p. 311–330.
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