Background paper: Solidarity in public health

Transcription

1 1 Professor Barbara Prainsack Department of Social Science, Health & Medicine King s College London Strand London WC2R 2LS barbara.prainsack@kcl.ac.uk phone: 0044-(0) Professor Alena Buyx Institute of Experimental Medicine Christian-Albrechts University of Kiel Arnold-Heller-Str 3, Haus Kiel, Germany a.buyx@iem.uni-kiel.de phone: 0049-(0) Background paper: Solidarity in public health 1 ST DRAFT - London and Kiel, 28 September 2015

2 2 1. Why solidarity? Healthcare systems everywhere are confronted with numerous challenges, ranging from demographic change and epidemiological transition to shrinking healthcare budgets. Against this background, it is particularly challenging to devise policies and practice guidelines that are evidence-based, effective, proportionate and ethical. Determining what ethical principles and values should guide and justify policy-making decisions is of particular importance. Principles and values such as cost-effectiveness, transparency, stewardship, autonomy, beneficence, fairness, justice and many others have been examined for their potential to inform policy making for some time now. Several suggestions have been made as to how such values can inform the design of ethical healthcare and public health (AMS, 2011; Nuffield Council on Bioethics, 2007, 2010; RCP 2011; for an overview see Faden & Shebaya, 2015). In this paper we focus on the concept of solidarity, which has underscored welfare state arrangements and public healthcare systems in Europe and other world regions for a long time implicitly, or explicitly. More recently, economic pressures and demographic changes have started to erode solidaristic institutions and practices in our societies. In the context of healthcare specifically, discussions of two-tiered or two-class medicine reflect the impression that we are no longer all in it together (e.g. Harrison, 2014). Concerns are mounting that the commitment to mutual assistance which lies at the heart of publicly funded healthcare systems is weakening, and that a shift away from solidaristic arrangements towards systems driven more by cost-containment, competition and consumer -orientation will leave patients and citizens out in the cold (Sabin, 2013; Hunter, 2013). A domain where references to solidarity are still relatively strong is ethics and policy development in the context of public health. Many scholars explain this by the fact that public health, in contrast to other areas of medicine and bioethics that are guided much more strongly by individual autonomy, is concerned with society as a whole, and thus has a much stronger community-focused orientation (Callahan & Jennings, 2002: 170; see also O Neill, 2002, 2003; Tauber, 2002; Callahan, 2003; Widdows, 2011: 85). Traditionally, solidarity has often been alluded to in public health when state authorities restrict personal freedom and autonomy for the sake of a collective good. Examples are mandatory vaccination and registration policies, restrictions on movement in connection with the prevention of

3 3 pandemics, and also individual taxation for the sake of funding public health care. As we argued elsewhere (Prainsack & Buyx, 2011), very often, solidarity is treated as a justification for such measures without further explanation of how and why solidarity supposedly warrants that the boundary between individual freedom and the public good is drawn at a particular point. Rarely have authors provided a clear definition of solidarity when making such claims. As a result, solidarity has been seen to assume the role of a concept that is so vague that it can be used to defend any measure or policy that seems desirable from a particular point of view. That solidarity was used to justify injustice and violence in communist systems has further detracted from its reputation and the conviction that it can be a useful guide for practice and policy making. We argue not only that there is a place for solidarity in healthcare, but that in times of our societies and our healthcare systems undergoing profound changes we need not less solidarity, but more. This, we believe, is particularly so in the context of public health. With its population-based perspective, public health, unlike clinical medicine, has core elements that are communal; it often relies on social and structural change and action. By expanding on existing practices of mutual support, by harnessing people s willingness to support each other, and by introducing solidarity-based frameworks, we can increase the focus on what connects us, instead of what sets us apart. We can also help to decrease inequalities. Finally, we argue that solidarity is able to provide concrete guidance for policy and practice once its meaning and its difference from related concepts are clarified. To the latter point we turn in the next section. 2. Historical background The concept of solidarity has a patterned history; it has played important roles in many different fields. Etymologically, the term solidarity stems from the Roman law concept of in solidum, which meant that several people could jointly owe a debt, or be creditors together. Typically this applied to members of a household. Initially understood as a legal term, solidarity found entrance in Napoleon s Code Civil in 1804 and is still used in civil law in many Western countries today. The concept entered the political domain in the late eighteenth Century, fuelled by French revolutionaries who also used the closely related term fraternité (brotherhood) to refer to a feeling of political community and the wish to emphasise what was held in common (Sternø, (2005: 27). This feeling of political

4 4 community was soon extended to larger groups for which the revolutionaries claimed to speak. The French sociologist Emile Durkheim ( ) moved solidarity into the limelight of social theory (Durkheim, 1893). He developed a systematic conceptualisation of solidarity, differentiating between what he called mechanical solidarity on the one hand, and organic solidarity on the other. People in early societies, prior to the era of division of labour, Durkheim argued, were bound together by the shared circumstances of their lives; they often did similar types of work, lived in the same village, or fought against shared natural threats. This is what Durkheim called mechanical solidarity. The increasing specialisation of labour, which went hand-in-hand with other changes in demographic structures, altered the nature of the bond that connected people. The result was what Durkheim called organic solidarity, namely bonds that connected people who were dependent on each other in a much more instrumental way. It was no longer a society of people bound together by shared live circumstances and common interests. Given the focus on shared ways of living and shared interests it is not surprising that solidarity also played an important role in workers movements. Workers often irrespective of national borders were seen as bound together by the need to pursue their interests vis-àvis the capitalist class (see also Silver, 1994: 550). But also within religious traditions, the idea of mutual support between people who share important things in common played an important role. In Catholic traditions, for example, the fates of friars and nuns, which were tied to one another in very immediate ways, served as an ideal for how people sharing a particular situation should feel connected to each other, and assist each other. It is here that the difference between solidarity and charity (which we will discuss further below) becomes clearly apparent: While charity, as the historian Karl Heinz Metz (1999: 199) put it, was the expression of a moral relationship voluntarily entered into by the rich towards the poor, solidarity denoted the idea of fellowship between people who share important characteristics or life circumstances in common. Even if people were not equal in the place they held in society, or in their access to resources, then at least they were equal in that they were created in the image of God. While it were Christian denominations that used the concept of solidarity most explicitly, what virtually all religions share in common are concerns with social justice, the fellowship of all beings created in the image of God.

5 5 In sum, although the notion of solidarity has been used in different contexts and with different purposes throughout history, the following core elements are typically present when solidarity is alluded or referred to: 1. a sense of being bound together, sharing similar objectives or circumstances; 2. mutual assistance and help, particularly in situations of hardships; 3. a symmetric, equal relationship between those engaged in solidary arrangements; and 4. a link to both individual and collective wellbeing. Box 1: Core elements of solidarity in history and academic scholarship 3. What is solidarity? A definition for policy and practice Having been unsatisfied with merely the description of core features of solidarity, we developed a more specific definition of solidarity in a Report published by the Nuffield Council on Bioethics in 2011 (Prainsack & Buyx, 2011). Since then, this has been revised and improved, and tested in several empirical settings (Prainsack & Buyx, 2012, 2013, 2014; Buyx & Prainsack, 2012; Prainsack, 2014; also Prainsack & Buyx, forthcoming). The definition determines clear requirements that enable to (a) at the level of description, assess whether a particular practice or policy is an instance of solidarity or not, and (b) at the level of prescription, to derive from the concept of solidarity clear guidelines for practice and policy. In its most bare-bone form, solidarity signifies practices reflecting a commitment to carry costs (financial, social, emotional, or otherwise) to assist others with whom those engaging in these practices recognise similarity in a relevant respect. Box 2: A definition of solidarity (see Prainsack & Buyx 2011; forthcoming) A few further explanations are in place here. First of all, this approach is influenced by the philosophical tradition of pragmatism, a core tenet of which is that acting and knowing are inseparable from one another (Cook and Wagenaar, 2012). This means that solidarity is seen as something that is, first and foremost, enacted, rather than an abstract value or an inner sentiment. Solidarity is always practice. Second, the term costs, in the above definition is not to be understood narrowly as monetary costs. It includes contributions such as time, effort and emotional investments, or money, that

6 6 groups or individuals make to assist others. And although the acceptance of such costs for the sake of assisting others is a requirement of solidarity, it does not preclude that groups or individuals enacting solidarity also benefit from them. This means that solidaristic practices do not have to be solely selfless, i.e. purely altruistic. At the same time, the expectation of a direct benefit must not be the sole motivation for a practice, otherwise the practice could not be considered solidaristic. For example, if we helped somebody else merely because we expected payment, then this would not be an act of solidarity. The third point that we would like to expand on is the similarity in a relevant respect that people recognise with others whom they are then willing to support. A person recognises similarity in a relevant respect with somebody else when they perceive that they share something in common with another person or group that matters in a specific situation. What it is that matters thus depends on the context of the situation. If we donated money to an earthquake victim in another region because we had once lived through an earthquake ourselves, then the shared experience of experiencing a traumatic earthquake constitutes our similarity in a relevant respect with the person whom we support. The fact that the person whom we are helping may, for example, be of a different race, or hold political views that we detest, is irrelevant for our potential solidarity with them in this concrete situation. (If it does turn out, however, that we share more things in common with the person whom we are helping, then this could be the basis for our bond becoming stronger than merely a bond of solidarity; for instance, we could eventually become friends, which are bound together by a much denser net of connections.) Three tiers of solidarity Solidarity does not only take place between individual people, of course. More widely shared practices and institutions of mutual assistance are the life blood of societies in which solidarity flourishes. The definition thus distinguishes between three tiers of solidarity (Figure 1) as follows: The first tier of solidarity is that which is practiced between individual people. At this level, solidarity comprises manifestations of people s willingness to carry costs to assist others with whom the person recognises similarity in at least one relevant respect. If practices of solidarity between people become so common in a given context or community that they come to be seen as a normal thing to do, then we speak of tier 2 solidarity (group-

7 7 based, or community-based, solidarity). On this second 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. People who share a situation typically share certain risks or positive goals that emerge out of, or define, that situation. For example, those with a particular disease might support each other, share health information to minimise the negative effects of the disease, and organise events to raise funds for research into the disease. The results of all these activities are practices from which values or principles emerge that are shared by the members of such groups and communities. If the values or principles emerging through group or community practices in this manner solidify (or have solidified) into contractual provisions, or administrative or 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. Other examples include contracts between different private actors and international declarations or treaties, such as virus sharing agreements in the context of pandemics, progressive taxes, or public housing. Contractual, administrative and legal solidarity are highly institutionalised enactments of the willingness to accept costs to support others who we recognise as similar to us (however this similarity is defined in a particular instance). Not all forms of solidarity on this higher level emerge directly out of practices on the lower levels, of course. However, for solidaristic norms and laws to be stable, they must be supported by, or at least be compatible with, actual practices of people at the interpersonal and group level.

8 8 Box 3: Three tiers of solidarity. Source: Authors This definition of solidarity has two advantages: it provides a definition of what solidarity is, and what it is not. It can thus help debunk the misapplication of the label solidarity to policies and practices and help recognise when we have true cases of solidarity in front of us. Second, it can inform policy making by highlighting the importance of real and/or imagined communities who recognise similarity with each other in shaping practices and public attitudes towards solidaristic arrangements. 4. How is solidarity different from other concepts? Charity and altruism Solidarity is not the same as charity and altruism, although some people use these terms interchangeably. The main difference between solidarity and charity is that with the former, the decisive motivation for action is the recognition of similarity, not of difference. Acts of charity, in contrast, entail that somebody who is in a powerful position gives something to somebody in a weaker position; the relationship is asymmetric (at least in this respect).

9 9 Charity thus relates to the differences in status and needs between people, while solidarity focuses on what they have in common. Altruism reflects the idea that somebody s action is either self-serving or other-regarding, with altruism often being understood as solely other-regarding. This dichotomous understanding between self- and other-regarding practice is increasingly rejected; most of our practices contain elements of both and are thus both self- and other regarding. While most definitions of altruism do not allow for such mixed motives, the definition of solidarity presented here does. Moreover, altruism is a disposition of a person towards the world, whereas solidarity is a relational concept which requires somebody at the receiving end: One is always solidaristic with somebody. Love and friendship Solidarity is subsidiary to friendship and love; in other words, wherever there are stronger bonds, solidarity does not apply. Friends, family, and lovers are bound together by a multitude of shared values, habits, practices, experiences, and plans so that they are a community of fate in a much thicker and deeper sense than it is typically the case for solidarity. Solidarity thus is, in other words, particularly pertinent to situations where no other ties exist to bind people together. Reciprocity Many authors see reciprocity as closely related to, or even synonymous with, solidarity. And indeed, the relationship between these concepts is such that for solidarity to spread and institutionalise, a certain level of reciprocity is needed (see Box 3). If reciprocity is the decisive motivation for a practice then this practice cannot be seen as solidaristic, as mentioned above. But particularly at higher levels of institutionalisation, indirect 1 forms of reciprocity can play an important role of stabilising solidaristic arrangements, and overall attitudes of reciprocity will help maintain and enliven solidaristic policies and laws. 1 Direct reciprocity applies to situations where a person receives something in return for something else in one discrete transaction. Exchanges of goods, services, or favours are directly reciprocal if they take place between the same group of actors, and without a significant time lap. Peter giving Tanya money in return for Tanya handing over her car, Lou cooking dinner next Wednesday because Adam cooked dinner for her last Wednesday and next week will be Lou s turn, are instances of direct reciprocity. Indirect reciprocity, in contrast, applies to situations where somebody does or gives something without expecting to receive the same thing from the same person in the same transaction. Keith giving blood hoping that someone else will do this so that he will get blood if and when he needs it without knowing whether or when he will need it and who would help him would be an instance of indirect reciprocity.

10 10 5. Putting solidarity to work: Concrete examples 1 st case: A solidarity-based perspective on policy-making in the domain of lifestyle-related diseases Whether individual responsibility should be used as a criterion to distribute healthcare, for example by excluding the treatment of conditions based on lifestyle and health behaviour from publicly funded healthcare or insurance plans, has been a bone of contention for a long time. Some countries have policies in place that do consider individual responsibility in organising access to healthcare (for examples, see Buyx & Prainsack, 2012; see also Dubois, 2011). Often such policies are justified by explicit or implicit appeals to solidarity, with arguments presented in the following way: Those engaging in certain unhealthy lifestyles have a higher risk of contracting particular diseases or a higher risk of illness overall. This higher risk is often linked to higher costs. The argument has been made that the reckless therefore endanger public healthcare systems based on solidarity by imposing the costs of their self-chosen, unnecessary health issues on everyone else who is contributing to the system (for overviews of this debate, see Buyx, 2008; Rosen et al., 2010). In this view, whether a person should be excluded from the scope of people who deserve our solidarity is a question of the kind of risk at stake. If people incur higher costs because they are struck by illness as a result of factors that are considered to be beyond their control (socalled brute luck ; the paradigmatic example is the one of a person who has never smoked who is suffering from lung cancer), then this situation results from a risk that most people recognise as their own: We could all be afflicted by illness, accidents, or other kinds of suffering that we could not reasonably have protected ourselves from. This situation represents one of the basic vulnerabilities of human and social life. If, on the other hand, people suffer from illness as a result of allegedly deliberate actions, or actions against better knowledge (so-called option luck ), then they are taken to be accountable and indeed responsible for their condition. They are seen as belonging to a group with a different risk profile from innocent people, both empirically and in a moral sense. Smokers with emphysema or coronary heart disease, or overeaters with diabetes type 2, are often seen in this light. Many are unlikely to recognise any similarities with such people and as a result, they feel that they are literally in a different risk category than those who do not

11 11 care about protecting their health in the same diligent way. People with supposedly healthy lifestyles may call for higher premiums charged to the perceived self-indulgent, or exclude them from solidaristic insurance arrangements. In other words, if what we see when looking at others are primarily things that set them apart from us, then we will not feel bound to them by solidarity. This is an example of a frequent misunderstood application of solidarity to the public health and healthcare context, which rests on a mistaken, narrow conception of the risks involved. In fact, an argument based on solidarity (as understood here) will come to an almost opposite conclusion. First of all, the attribution of higher risk based on allegedly chosen lifestyle presupposes a problematic notion of causality. While data from epidemiology and public health research show that behaviour is a major causal factor in many diseases, it is typically impossible to determine exactly what led to a particular condition in any individual person. Also, most lifestyle-related diseases are multi-factorial. Decades of research have shown that almost every condition or disease is the result of a complex interaction of heritable and nonheritable factors having to do with people s lifestyles, social and natural environments etc. In addition, more recent research in epigenetics has shown that some environmental influences, such as the consumption of particular foods, can change the way genes are switched on or off, leading to a situation where the social is effectively folded into the genetic, and vice versa (Petronis, 2010). Against this backdrop of lack of knowledge and empirical uncertainty, the notion of what we can be held accountable for is clearly a moving target. For this reason that is, because decisions about causality would be made under conditions of complex uncertainty individual responsibility has been rejected as a basis for allocating healthcare resources (Yoder, 2002). In addition, as Schmidt argues, discussions about responsibility for health and disease tend to distract the attention of policy makers away from addressing the underlying and hugely important social determinants of health (Schmidt, 2009: 130; see, also Marmot, 2004). Health behaviour cannot be taken as subject to individual choice only, but is rather shaped significantly by upbringing, education, wealth and many other social and environmental factors. Moreover, although we may actively work towards decreasing some risks that we know we face, we may have much higher risks in other aspects of our lives that we are not even aware

12 12 of. There are so many risks in our daily lives that highlighting certain known behavioural risks related to health alone cannot be justified. The stratification of populations according to a particular list of lifestyle-related conditions is inevitably arbitrary as it excludes some areas where people s individual risk could be very different from the areas upon which the stratification focuses. At the level of an entire nation, relevant for public healthcare systems, it becomes immediately apparent that we are unable even to begin stratifying people into different risk groups with respect to health in any empirically justified way. In sum, the reference to lifestyle, and the idea of personal responsibility for health, if used to claim a violation of solidarity and to limit somebody s access to healthcare resources, constitute a largely arbitrary choice amongst a myriad of risks that affect health, including many social and environmental factors that are beyond people s control. Expressed in the language of solidarity as developed here, there is no basis on which to justify that some people or groups are considered not to be similar in a relevant respect (namely, with regards to health risks) to others in the healthcare system. A solidarity-based approach would instead mandate that access to healthcare should be granted mainly on the basis of need, because need is a category in which sameness in the relevant sense can empirically be determined far easier than in lifestyle risk stratification. To give just one example: need is an established category in clinical assessments of urgency and severity of illness across most areas of health care. Clinicians all over the world routinely group patients into different classes of need (e.g. cancer staging). Such groupings are, and should continue to be, utilised in the assessment of need guiding allocation of scarce resources. Personal responsibility and individual health behaviour, however, should not be used to stratify patients into such different groups; certainly not in the name of solidarity. This means that when developing policies for public health, any such stratification of patients and populations into behavioural risk groups and the like can not only not be done by referring to solidarity. It should clearly be labelled as a policy that decreases solidarity. 2 nd case: Are nudges in pubic health compatible with solidarity? If individual behaviour should not be used to stratify and subsequently exclude people in public healthcare systems, what then can be done to address the increasing burden of disease from illnesses that do have a behavioural component? This difficult question is currently often being answered by reference to the concept of nudging people towards better health

13 13 decisions. The authors who summarised a lot of research on choice behaviour and coined the term Nudge in the book of the same name in 2008, Richard Thaler and Cass Sunstein, define nudges as any aspect of the choice architecture that alters people s behavior in a predictable way without forbidding any options or significantly changing their economic incentives (Thaler & Sunstein, 2008: 6). Using insights and methods from behavioural economics and psychology, these authors distinguish nudging from coercive or binding measures such as laws or contracts. Smoking bans, for example, are not nudges, because they represent a legally enforceable rule even if they may make some people stop smoking voluntarily. Some in public health have taken up the idea of nudges quite enthusiastically. Studies into incentives for healthy behaviour have increased, including work on improving eating behaviour, avoiding deaths from cold, supporting smoking cessation, and lowering cardiovascular risk (see e.g. Allmark & Tod, 2013; Blumenthal-Barby & Burroughs 2013; Holt et al., 2006; Marteau et al., 2013; Wansing & Hanks 2013). Nudging continues to gain currency also in light of the increasing emphasis on prevention in the context of precision medicine and personalised healthcare. At the same time, criticism of the very idea of nudging has been mounting (Bonell et al. 2011; Wells 2010). Are nudges in public health solidaristic (Prainsack & Buyx 2014)? Again, because solidarity foregrounds similarities between people, it is not so much concerned with chasing the offender i.e. punishing those who allegedly chose unhealthy lifestyles. Instead, it seeks to ensure that all of us live in conditions that enable healthy lifestyles. Providing secure sidewalks and reliable public transportation that enable people to leave their cars at home (or even sell them) are illustrations of this; other examples include providing healthy food in schools and work places. All these are typical nudges, aimed at giving an incentive for healthy living to everyone. What distinguishes such measures from other kinds of incentives, namely those that target only subsets of the population, therefore, is that they are targeted at the entire population. With the exception of people rich enough to afford private chefs and drivers, these incentives are directed at everybody and stigmatise no one. Nudges that target only one specific sub-group in the whole population, in contrast, seem problematic from a solidarity-based perspective, because they emphasise what sets these people apart from others. This is particularly troubling in cases where the nudge is targeted at

14 14 a group whose defining characteristic carries stigma, such as being overweight, smoking, being frail, or ill. The table below (Table 1) provides an overview of different types of potential public health nudges, separated along the lines of whom they target, and how likely the criteria used for stratification are to stigmatise the target group. Target of nudge Example of nudge Compatible with solidarity? everyone tax breaks for investments Yes. Measures that benefit in health; investments in vulnerable populations clean air, reducing most (e.g. reduction of pollution and noise from noise and pollution) should road and air traffic; be prioritised over investments in walkeable measures that benefit cities privileged populations people with certain objectively measurable biomarkers that do not carry social stigma people with certain objectively measurable biomarkers that do carry social stigma people with characteristics that are ascribed to them by others Freedom pass enabling residents from 60 years of age to use local public transportation without payment (important for public health reasons as it can maintain mobility) vouchers for weight loss programmes for people above a certain BMI incentives for sex workers to give up custody of their children based on the assumption that the children s mental and physical health and development would otherwise suffer most (e.g. tax breaks) Yes, but measures that are targeted at everyone and that vulnerable people are most likely to benefit from are to be prioritised over nudges in this category. No No Table 1: What forms of nudging are compatible with solidarity? [source: authors] We posit that nudging is compatible with a solidarity-perspective in principle when nudges are aimed at everyone, when they foreground similarities between people, and when they are designed to crate societal benefits. Within these nudges, those of which vulnerable groups are most likely to benefit such as the improvement of healthy and affordable housing, good sidewalks, and pollution and noise reduction are to be given priority over nudges that are formally aimed at everybody but likely to help mostly those people who are already

15 15 privileged (e.g. tax credits for fitness club memberships). A solidarity-based perspective enjoins policy makers to be very careful about how they define target groups, and particularly so, when they make use of the knowledge and tools of personalised medicine. Nudges that are based specifically on differences between people can actually work against the sense of shared vulnerability in the face of illness and death within healthcare systems. They would thus run counter to the overall aim of protecting the broad and inclusive solidarity (still) underlying our embattled healthcare systems. This problem is even more pronounced in the case of nudges where the distinguishing features used for defining the target group carry the risk of stigma, or if the nudge itself is likely to increase existing stigmas. Examples of this would be nudges aimed at groups whose members are treated as deficient in some sense (e.g. smoking pregnant women, Marteau et al., 2013). Such targeted nudges have been shown to be highly effective. However, in such a case the nudge itself can increase stigma (examples are financial incentives such as vouchers or small cash payments to nudge such women to stop smoking, Wolff 2015). This is not to say that policy planners should not strive to reduce smoking in pregnant women; but to be in line with an idea of solidarity, nudges would have to be devised in such a way that they avoid setting these women apart from mainstream society. In consequence, such nudges would possibly address a bigger and less specified target group, or use an incentive focusing on shared characteristics or behaviours instead of being based on personalisation. For example, public investments in affordable housing and secure jobs would be an incentive for healthier living to pregnant women, without focusing narrowly only on smoking. In sum, we conclude that nudges that are aimed at the general population are, in principle, compatible with solidarity. However, similarly to the argument in the first case example, whenever nudges stratify people intro groups according to characteristics relevant to their health (e.g. risk groups), many nudges take on a very problematic role. Current enthusiasm for development of often highly effective nudges in public health should be tempered by the awareness that such nudges can run counter to the idea of solidarity. Solidaritycompatible nudges certainly have a role to play and there is still much room for their development, refinement and broader implementation. However, targeted nudges in particular have to be very carefully examined whether they aim at characteristics and behaviours that connect people or those that set them apart.

16 16 3 nd case: A solidarity-based perspective on policy-making for the prevention and containment of pandemics Pandemics can pose a great strain on national governments needing to find ways to prevent or contain them. At the same time, they can also incur significant costs for people who are personally unaffected, through the enforcement of pandemic prevention or contention measures, such as restrictions on movement, compulsory vaccination, etc. Finally, they can create tensions within the international community. While most of the decision-making challenges play out at level of national populations, pandemics raise questions about solidarity in at least three ways: at the level of solidarity between individual people and their willingness to accept costs to assist others in such a situation; at the level of relationships between individuals and state actors, as the latter may intrude into spheres of individual freedom and decision making for the sake of avoiding or mitigating societal harm; and at the level of relationships between countries and other global actors. Pandemics are a core issue of the state s concern for health in two ways. First, epidemics and pandemics typically appear in population clusters; wherever large numbers of people share space, tools, and instruments, or means of transportation, the risk of the spread of infectious diseases is particularly high. Because it has become the task of modern states to regulate public hygiene, organise public transportation, and give planning permissions for housing etc., the spread of infectious diseases is more closely linked to the efficiency or inefficiency of governmental action than in many other disease areas. Pandemics are thus an almost paradigmatic public health issue, notwithstanding the role of individuals alleviating and containing an epi- or pandemic. Secondly, because some infectious diseases have a high mortality rate, and because their spread can pose such a fundamental threat to the population of entire regions, states, or whole continents, even people who usually call for governmental restraint from meddling with people s affairs and intruding into individual spheres tend to accept strong governmental action in connection with the containment of contagious diseases. In what other context would people accept that governments restrict the freedom of movement of people (e.g. forced isolation), or withhold life-saving medication or treatment from those who need it (e.g. triage)?

17 17 Vaccination represents only one issue where questions of solidarity, understood as the willingness to accept costs to assist others, becomes pertinent. The case of pandemics poses complex challenges regarding the role of solidarity in supporting or bringing about desirable solutions in public health contexts. The main reason here is the difficulty to achieve that people see relevant similarities with others one of the core elements of solidarity. In a pandemic, risks and costs are distributed very unevenly. Because pandemics have a rapid and condensed timescale (usually somewhere around 15 weeks), risks and stakes at the point of decision-making for public health policy are very diverse: A healthy young person without children, for example, typically has a lower risk and may thus be far less worried about the worst case of contracting this disease than an elderly person, a person with a weak immune system, or a parent. At the same time, the costs of containing pandemics can be very considerable, particularly for unaffected people. People at relatively low risk in the context of a particular pandemic may be willing to enact solidarity if the costs are relatively small, such as washing their hands more frequently. They may not, however, be willing to accept larger costs, such as not being able to travel by plane, which impedes their work, or to get vaccinated if they believe rightly or wrongly that the vaccination itself could have side effects. In sum, people at relatively low risk might not recognize similarity in a relevant respect with others who are at much higher risk. For those at high risk, no costs incurred by measures to contain the pandemics may be too high. Yet for those at relatively low risk, actions that impose additional risks on them such as the risk of loss of income and mobility may already be too high. This leads to a sobering result regarding the application of solidarity at the person-state level: Because the recognition of sameness with others plays such an important role in fostering solidarity at the level of the individual, it is unreasonable to expect that entire populations, where risks and stakes are very unevenly distributed, can be (hypothetically) expected to accept the costs of containing pandemics out of solidarity with each other. This is not to say that they should not accept such costs; the justification for this, however, will need to be a different one than appeals to solidarity. Pandemics thus represent a case where the potential of mobilising solidarity to reach goals that are desirable in a public health context is limited, and where appealing to solidarity to justify intrusive interventions at the individual level means overstretching the justificatory potential of the concept. Such interventions might be

18 18 important and necessary, and will have to be enacted in many cases but they need to be based on other arguments than solidarity (for example, on the stewardship duty of the state to protect its weakest citizens). That said, solidarity can play an important role in the prevention and containment of pandemics at the interpersonal level. As Benedict Anderson (1991) famously argued, the mere awareness that there are people in far-away places with whom we share things in common (language, natural or political threats, etc.) has created imagined communities for instance, kinship between people who may never have met in person. Such kinship is currently emerging especially through social media, which enable us to engage and thus recognize all sorts of similarities with people whom we would otherwise not have met. Social media are increasingly used to monitor and predict disease spread, to disseminate useful and up-to-date information, and to morally support people in need (Chew & Eysenbach, 2010). For example, HIV/AIDS treatment activism has for some time now been orchestrated via platforms such as Twitter and Facebook, and connection with virulent E.coli infections in Germany, crowdsourcing platforms were used to decode the molecular structure of the E.coli strain, significantly speeding up the process (Casey et al., 2011). In the wake of catastrophes such as the Japanese earthquake of early 2011 or the storm Sandi on the US East Coast in 2013, solidarity also took place in both virtual and non-virtual ways, with communities organizing person searches, shelter, medical care and other help and support on the ground for each other and for vulnerable people. Such activities are directly transferable to pandemics. Healthcare policy-makers have yet to fully exploit the potential for solidarity in this context. Particularly online, where imagined communities are common and thresholds and costs of interaction are low, citizens could be enlisted to help in case of a pandemic. But there is also much scope to develop solidarity-based initiatives at the local community level, which we believe might be very successful and effective in managing the pandemics of the future. At the heart of any such initiative lies the recognition of what connects us, and thus what recognition of similarity in a relevant respect can be based on. It is therefore important to foster a perspective of such connection and relationality both in the population, but also, we believe, in the professional communities that decide on public health policy and practice.

19 19 Conclusion There is great potential to utilise a clear understanding of solidarity in future policy making in public health and healthcare. Unjustified mislabelling should be avoided and any application of solidarity has to be done carefully and based on empirical findings from the specific context. If this is done, we believe solidarity-based policies and practices can not only be developed and implemented successfully. We also expect that they will have, in turn, knockon effects, enabling other solidarity practices in a virtuous circle. Besides concrete policy making, however, solidarity can also inform the larger debates on the role public health should have within our societies in general and within the healthcare system specifically. From a solidarity-based perspective, there is reason to work towards facilitating a higher appreciation of the importance of preventive and public health measures, both when allocating resources and in public perception and understanding. In a healthcare system with limited resources, public health and the medical sector are effectively in a situation of competition with the latter having far more public attention and powerful backing than the former. A stronger emphasis on similarities and shared commitments in a solidarity-based approach to allocating healthcare resources would therefore involve a focus on public health, due to its inherent reference to collective risk- and benefit sharing. All this would necessitate some significant shifts in healthcare policy making, but go a long way to (re-)implement the idea of public healthcare as a matter of solidarity, rightly understood.

20 20 Summary In its most bare-bone form, solidarity signifies practices reflecting a commitment to carry costs (financial, social, emotional, or otherwise) to assist others with whom those engaging in these practices recognize similarity in a relevant respect. Solidarity is first and foremost a practice, that is, something that is enacted rather than merely felt or thought Solidarity at tier 1 takes place at the interpersonal level: a person accepts costs to help another with whom she or he recognizes similarity in a relevant respect When such practices (at tier 1) become common practice in a community or group then we speak of tier 2 solidarity When solidaristic practices manifest themselves in contractual and legal norms then we speak of tier 3 solidarity Solidarity foregrounds similarities between people rather than differences Solidarity can inform policy making in many public health areas, for example socalled lifestyle diseases; nudges for healthy behaviour; or pandemics. Looking at healthcare policy through the lens of solidarity means to pose more emphasis on public health, due to its connection to collective risk- and benefit sharing

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