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Solidarity and Responsibility in Health Care

Solidarity and Responsibility in Health Care Downloaded from https://academic.oup.com/phe/article/12/2/133/5528519 by DeepDyve user on 14 July 2022 PUBLIC HEALTH ETHICS VOLUME 12 NUMBER 2 2019 133–144 133 Ben Davies , Uehiro Centre for Practical Ethics Julian Savulescu , Uehiro Chair in Practical Ethics Corresponding author: Ben Davies, Uehiro Centre for Practical Ethics, Suite 8, Littlegate House, 16–17 St Ebbes Street, Oxford OX1 1PT, UK. Tel.: +44 (0)1865286893; Email: benjamin.davies@philosophy.ox.ac.uk Some healthcare systems are said to be grounded in solidarity because healthcare is funded as a form of mutual support. This article argues that health care systems that are grounded in solidarity have the right to penalise some users who are responsible for their poor health. This derives from the fact that solidary systems involve both rights and obligations and, in some cases, those who avoidably incur health burdens violate obligations of solidarity. Penalties warranted include direct patient contribution to costs, and lower priority treatment, but not typically full exclusion from the healthcare system. We also note two important restrictions on this argument. First, failures of solidary obligations can only be assumed under conditions that are conducive to sufficiently autonomous choice, which occur when patients are given ‘Golden Opportunities’ to improve their health. Second, because poor health does not occur in a social vacuum, an insistence on solidarity as part of healthcare is legitimate only if all members of society are held to similar standards of solidarity. We cannot insist upon, and penalise failures of, solidarity only for those who are unwell, and who cannot afford to evade the terms of public health. Consider the following cases: Solidarity in Healthcare A 58-year-old man is admitted to hospital follow- Some healthcare systems, such as the UK’s National ing a heart attack, which doctors believe has been Health Service, are described as being grounded in soli- caused in part by moderate obesity. The man de- darity. Rather than people being responsible only, and scribes himself as doing ‘as little exercise as pos- entirely, for their own health, the NHS pools risk sible’, even though he was explicitly warned by his through taxation and free-at-the-point-of-use care. GP five years previously that this inactivity pre- sented a serious risk to his health and turned Users who are better off (e.g. healthier or wealthier) down an offer of help with getting more exercise. take on some of the financial risk of worse-off users. (Inactivity) This article focuses on the relationship between solidar- A 45-year-old woman who smokes twenty cigarettes ity and personal responsibility in healthcare. We argue daily develops chronic obstructive pulmonary dis- that solidarity can generate obligations, and that failure ease. Although her doctor warned her about the to meet these obligations can legitimately be penalised. risks, she was given no support in quitting, and However this can only occur in the right context: both in has found it difficult. (Smoking) terms of an appropriate opportunity to choose, and the A 28-year-old man is admitted to A&E following a nature of the society in which such obligations sup- car accident. He has been driving safely for ten years posedly arise. but later admits that he neglected to put on his seatbelt because he was running late. (Seatbelt). Solidarity and Responsibility Does solidarity recommend treatment, refusal to treat, Solidarity is a two-way street: a system based on or something else in cases like these? In part, this will solidarity can require certain kinds of responsible depend on how we conceive of solidarity. At heart, how- behaviour from participants. ever, the dilemma is this: while each individual is vul- Failures of solidarity are best enforced when pa- nerable, and dependent on society to become well again, tients have been offered ‘Golden Opportunities’, they have each made choices that not only impact their under conditions conducive to decision-making. own health, but also place costs on society at large. To We should not focus narrowly on solidarity treat each individual will require resources that could be within healthcare. It also matters whether soli- spent elsewhere and may lead to delayed or cancelled darity is practiced in the broader society. treatment for others who are unavoidably ill. In such doi:10.1093/phe/phz008 Advance Access publication on 4 July 2019 ! The Author(s) 2019. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Downloaded from https://academic.oup.com/phe/article/12/2/133/5528519 by DeepDyve user on 14 July 2022 134 DAVIES AND SAVULESCU cases, the claims of solidarity may seem to pull us in expressed by active support for policies that involve separate directions. the sharing of risk and benefit; this includes concrete This article argues that a solidary health system can political action such as voting for solidarity-supporting political parties; campaigning for policies that support consistently make demands of its members, and impose penalties on them when they are not met. Our view is others’ interests as well as one’s own; and participating in (well-directed) socio-political schemes that support that solidarity requires that people make only reasonable demands of one another. Where people fail to act rea- solidarity-enhancing institutions, e.g. paying one’s ‘fair share’ in taxation. sonably, and were well placed to do so, members of a solidary system are entitled to refuse to cover the costs While solidarity cannot come from institutional design alone, we may nonetheless describe as solidary that come from that failure. Finally, we outline some of the constraints on this argument: not all cases where to some degree principles and institutions that both aim to enforce solidary norms, and which are supported for individuals act in ways that affect their health are failures of solidarity. solidary reasons by at least some participants. This would, in Nagy’s (2002: 329) terms, be an instance of ‘thin’ solidarity, in contrast with the ‘thick’ solidarity that is generated in a bottom-up way by ‘substantive’ What is Solidarity? moral agreement. At the macro level, then, institutions In common use, solidarity refers to fellow-feeling and, and practices can be more or less solidary depending on importantly, mutual support between individuals. This the proportion of participants who support them for might be because of a shared purpose, as in cases of solidary reasons and, depending on whether they are solidarity amongst striking workers. But it may involve intended to be derived from, and supportive of, solidary taking on a goal because of one identifies with those relationships among participants. already involved. While solidarity has been adapted in In addition, it is sometimes legitimate to enforce different ways by various traditions (Prainsack and social arrangements with the aim of fulfilling solidary Buyx, 2011; Prainsack and Buyx, 2017: 19–42), one if obligations, even if solidary feeling and action is low its most prominent contemporary uses is to invoke within a community. Whether the resulting arrange- ‘emotionally and normatively motivated readiness for ment genuinely fulfils obligations of solidarity depends mutual support’ (Laitinen and Pessi, 2014: 1). This in- in part on how we conceive the relationship between the cludes a willingness to promote others’ interests, or the descriptive and normative facets of the concept. Our interests of the group, even at personal cost. view is that we can criticize certain institutional arrange- Solidarity can act as a descriptive concept, explaining ments for a failure to show solidarity because they the emergence of norms or institutions. Some argue that govern social relationships that should be at least some- the NHS was founded in a spirit of solidarity following what solidary in nature. Robust solidarity governs ob- the Second World War. It can also act as a normative ligations that group members feel as a result of their motivation, where group membership generates what membership, and we assume that this feeling can be Shelby (2002: 68) calls ‘robust solidarity’: rather than more or less accurate depending on the circumstances: merely describing practices as solidary, robust solidarity sometimes people will fail to feel solidary obligations, requires that group members feel obligated to act in even though they do in fact exist. Recent writing on certain ways as a result of solidary bonds. Since the solidarity (West-Oram and Buyx, 2017: 217–218; NHS is funded by taxation and free at the point of use West-Oram, 2018) emphasises the potential for building (for many), it involves mutual support between mem- solidarity (including at the global level) out of self-inter- bers of UK society. On this basis, one might think that est. While state institutions cannot create solidarity in- each of the individuals involved in Inactivity, Smoking organically, they can ‘provide the social bases for and Seatbelt have a claim to treatment based in solidar- realizing relations of ... solidarity’ (Krishnamurthy, ity. They are vulnerable members of the relevant society 2013: 134). and their fate is at the discretion of a system that was A critical element of solidarity is its characterisation established to help people in just their positions. as ‘we-thinking’. This distinguishes it importantly from Solidarity’s association with individual action (Buyx charity, which is purely other-directed. In a solidarity- and Prainsack, 2017: 43–48) may make it seem an in- based arrangement people not only give to others, but appropriate label for a complex institution like the NHS. are entitled to expect something back. Again, this is But while solidarity may be most obviously expressed in often derived from shared group membership, or at direct contact between individuals, it can also be least some shared characteristics or interests. As Downloaded from https://academic.oup.com/phe/article/12/2/133/5528519 by DeepDyve user on 14 July 2022 SOLIDARITY AND RESPONSIBILITY 135 Prainsack and Buyx argue (2017: 53–54), solidarity re- by the expectation of reciprocity. Rather, we claim only quires the recognition of similarity, and its prioritisation that solidarity generates obligations to contribute to (at least in one respect) over difference (see also West- solidary systems and institutions, dependent on one’s ability. Oram and Buyx, 2017: 216, who emphasise solidarity’s focus on the similarities between individuals, compared As well as reciprocity, solidary also requires a com- mitment to action. Taken together, these commitments with charity’s focus on, e.g. wealth differences). In our view, this means that a principle of solidarity make it clear why solidarity-based institutions may demand a degree of personal responsibility from their does not direct us uniformly towards treatment in our test cases. Although individuals operating in a solidary participants. On the other hand, a willingness to aban- don those who make poor choices with respect to their system have claims on others, and the system in which they operate, since solidarity is reciprocal people also own health seems to be the antithesis of solidarity. We can agree that those who knowingly place avoidable bur- have obligations to others and may have obligations to behave in certain ways within that system. This suggests dens on a public health system have in some cases failed an obligation of solidarity, without concluding that they two relevant questions. Have the individuals in our cases failed an obligation of solidarity? And if they have, is the have thereby forfeited their solidarity-based claims. We therefore need to consider what the relevant obligations obligation of the kind where failure warrants a penalty are, and whether they warrant penalties in cases where within that system? This is the topic of the next section. they are violated. One candidate for a relevant solidary obligation is the obligation not to externalise the costs of one’s decisions Obligations of Solidarity in ways that burden others. In its simplest form, though, Solidarity’s characterisation as ‘we-thinking’ seems to us this cannot be correct. For the very idea of solidarity is to require a degree of reciprocity, and hence obligation. precisely that we share, to some extent, in one another’s One might object to this claim, noting that some solid- burdens. Buyx and Prainsack (2011) argue against using ary actions do not appear to involve reciprocity. For solidarity to ground health-related liabilities on such a instance, Prainsack and Buyx imagine a low-level ex- basis. They suggest that any attempt to do so will focus ample of solidarity, lending a fellow passenger one’s on easily identifiable failures of responsibility, obscur- phone when you are both stranded at the airport. ing the fact that all of us make choices that raise the risk Similarly, we can surely experience solidarity with of some health burden or other. It would be unfair to those who are unable to reciprocate, at least in kind. refuse to externalise some kinds of freely chosen health How, then, can we suggest that solidarity requires burdens, and not others. Indeed, such a selective policy reciprocity? risks narrowing the range of conceptions of the good It is thus important to clarify the idea of reciprocity in life. We ought in principle to support choices which, three ways. Firstly, reciprocity does not require an iden- though entailing risks, either plausibly aim at well-being tical give and take. Rather, it requires ‘playing one’s or which are fully autonomous on either a Millian or part’. Particularly at the institutional level, where thou- Kantian conception. sands or millions are involved in a solidary institution, In our view, an argument for holding people respon- solidarity cannot require that everyone gets back exactly sible based on solidarity should identify types of burdens what they put in; indeed, as we argue below, such a that people cannot expect others to shoulder in the transactional institution is not genuinely solidary at all. name of solidarity. One option is to adopt a luck- Secondly, as the phone example makes clear, solidary based focus. Translated to the language of solidarity, reciprocity need only be hypothetical. In lending your this suggests that solidarity requires others to accept our phone to a fellow passenger there is an implicit assump- externalised costs when those costs arise as a result of tion, we suggest, that they would do something similar bad ‘brute luck’, i.e. misfortune due to unforeseeable for you or someone else in a similar position. If you had accident, or misfortune imposed on us by others, but evidence to the contrary (e.g. you had just seen them that it does not require that society externalise the costs refuse to lend some change to a fellow passenger to buy a of burdens that are due to bad ‘option luck’, i.e. out- drink), you might feel less inclined towards solidarity comes that were foreseeably avoidable by the agent. with them. But this seems to misclassify many cases. A wide range Finally, our claim that solidarity is reciprocal does not of options are avoidable, will involve some health bur- mean that we disagree with Prainsack and Buyx’s claim dens, and yet are entirely reasonable to choose. This (2017: 62) that solidary action cannot be solely motivated includes choosing to meet existing moral obligations, Downloaded from https://academic.oup.com/phe/article/12/2/133/5528519 by DeepDyve user on 14 July 2022 136 DAVIES AND SAVULESCU choices where alternative options also have significant types of entitlements people may claim on grounds of costs, and choices which, despite being risky, also offer justice. Secondly, we earlier suggested that obligations of considerable prospective benefits. It would be unreason- solidarity may exist even in the absence of relevant feel- able, and in violation of solidarity, to refuse to support ing. If people stand in certain relations to one another people who make such choices. (e.g. the relationship of fellow citizen), justice may itself Instead, we suggest that solidarity licenses sanctioning demand a level of solidarity. While our interest is in people who externalise costs to others when this exter- exploring the parameters of what solidarity requires of nalisation is unreasonable. Solidarity requires us to take us, this is indeed intimately related to justice. Yet the up common cause with those who are suffering only if centrality of justice to our discussion does not negate the they show a reciprocal concern for us, so long as they are importance of solidarity. able to do so. Those who choose to impose unreasonable Finally, however, we accept that justice is in some burdens on others—or choose, unreasonably failing to sense prior to solidarity. This is both because minimal consider the burdens on others—have failed to show standards of justice are a prerequisite for solidarity (e.g. this reciprocal concern. Krishnamurthy, 2013), and because justice sets bound- In practice, it will be difficult to determine whether a aries on what solidarity can demand of us. However, we choice is aiming at a reasonable conception of the good assume that in the allocation of health care resources, we life or is fully autonomous. However, we may restrict cannot treat everyone who would benefit, and that just- our scope to those who are responsible for their own ice may not offer comprehensive, decisive instruction on health burdens under certain choice conditions. Even if which individuals should lose out. This means that con- we all make decisions that ultimately impact our health, siderations of justice (e.g. claims of reparation on the it is not true that we all make such decisions under the basis of past injustice, or claims that one is uncondition- relevant set of conditions, i.e. conditions that are suffi- ally entitled to a minimal amount of care) may constrict ciently conducive to well-considered, uncoerced choice, which conditions are properly subject to penalties; but and which are unreasonable given the context. where at least some patients must lose out, and justice Prainsack and Buyx’s concern holds only if all health- thus cannot preclude any particular individual from impacting choices demonstrate equivalent failures of facing additional burdens, the considerations of solidar- solidarity. This is not obvious. Some behaviours, despite ity that we outline are relevant. carrying health risks, also carry considerable health benefits. If I end up worse off after following medical advice, this does not constitute a failure of solidarity in The Conditions of Penalising the same way as a decision to ignore, or to fail to attend to, medical advice. Similarly, personally unhealthy Solidarity Failures choices that appear to violate obligations of solidarity Some choices that affect our health meet the highest may be the only way to fulfil other obligations: for in- standards of autonomy: they are made with full know- stance, working long hours at great cost to one’s health ledge of consequences, using well-functioning rational to be able to feed one’s children. We thus cannot move capacities, in circumstances where a reasonable array of from the fact that we all make choices that harm our options is available. The case of Inactivity meets these health to the claim that it is unjustified to pick any criteria. By stipulation, the patient could exercise more subset of those choices as appropriately subject to sub- but chooses not to, and does so with reasonable under- stantive responsibility. Some such choices are more rea- standing of the potential risks over a considerable length sonable than others. What this does suggest, however, is of time. that we cannot consider solidarity in health-based deci- Other choices fail to meet these standards. Many be- sions in isolation from our broader social context, or the haviours that are cited as leading to ‘lifestyle-related dis- conditions of choice. eases’, including our case of Smoking, are chosen It is worth saying something at this stage about the without explicit coercion, but under strong social influ- relationship of solidarity to justice. Since we are con- cerned with the imposition of unreasonable costs, it may ences beyond individuals’ control, and they are often only threats to health when part of unreflective, long- seem that the real topic of our discussion is distributive justice. There are three things to say about our view on term habits, driven in part by advertising and other life- style constraints and pressures. Other health-affecting this. Firstly, the requirements of justice are affected by solidarity. Although solidarity is not itself always obliga- choices are impulsive errors of judgement or mistakes. tory, the existence of solidary relationships affects the Seatbelt is a case of this type. Downloaded from https://academic.oup.com/phe/article/12/2/133/5528519 by DeepDyve user on 14 July 2022 SOLIDARITY AND RESPONSIBILITY 137 Smoking and Seatbelt present problems for many Indeed, many failures of practical rationality (doing standard analyses of responsibility because they exhibit what you should do) are attributable to failures of the- a mixture of failure and success with respect to features oretical rationality (believing what you should be- that make decisions responsible. For instance, neither is lieve). And many failures of theoretical rationality chosen after a period of reasonable reflection, nor are are blameworthy since the agent is responsible because they (we stipulate) endorsed by second-order desires. she should have known (or believed) better. There are Smoking may be in character for our patient if that is cases where it is not only legitimate but required to understood as concerning what a patient typically does, apply substantive responsibility to failures of intention. but not if we understand character in terms of higher If a company fails in implementing appropriate safety order desires. Seatbelt is out of character in both senses. measures, leading to an accident, it cannot escape liabil- While there are cases of inactivity that also involve these ity by protesting that it did not plan the accident. If I barriers (see fn7), the patient in our case, we stipulate, cause a car crash because I am distracted, I cannot escape faces more favourable conditions. He faced many criminal penalties or compensation for victims for this opportunities, and no special barriers, to doing more reason alone. In both cases, an obligation exists, and exercise, including having the spare time and money failure to fulfil it is not intentional, but negligent. such that doing so would not be burdensome. He also, One problem with many potential ways of involving we imagine, reflected on whether to exercise, knowing responsibility in healthcare is their excessive simplicity. its effect on his health. But he decided that he would This applies to the behaviour required to trigger a pen- rather avoid exercise and risk poor health. alty: one bad habit, or even one mistake, is sometimes One argument in favour of solidarity-based penalties seen as enough to justify considerably different treat- is that participation in solidary practices or institutions ment. This problem also applies to the finality of the generates obligations, and failure to meet those obliga- decision to penalise. As Eyal (2013) notes, responsibility tions can justify either exclusion from the practice, or penalties often set patients up to fail by conditioning penalties within it. A system of tax-funded healthcare is ‘the very aid that patients need to become healthier on such a practice. For instance, Buyx (2008) suggests that, success in becoming healthier’. while solidarity places a constraint on the degree to This latter issue has led to several related proposals which we may hold people substantively responsible around how we should think about responsibility in for their own health, it does not ground an absolute healthcare. Feiring (2008), for instance, distinguishes objection to the inclusion of personal responsibility in between ‘backward-looking’ and ‘forward-looking’ re- healthcare, since solidarity cuts both ways. If my deci- sponsibility, suggesting that while we cannot penalise sions demonstrate a failure to show due regard to other patients for their past irresponsibility, we can set condi- members of my community, I fail to demonstrate ap- tions for future healthcare. However, as Albertsen propriate solidarity. (2015) notes, there is something paradoxical about In none of our cases is there an intention to betray this proposal: even if the conditions that we set upon solidarity or violate obligations. People don’t smoke or commencement of treatment are forward-looking at drive unsafely with the health budget in mind. If any- that point, they become backward-looking if we later thing, this absence is even starker in cases involving neg- penalise patients for failing to meet them. lect. The smoker might consider the alternative and More promising is the idea that responsibility can be intentionally reject it. Not so the person who neglects invoked only when patients have refused a ‘Golden to put on their seatbelt because they are distracted and in Opportunity’ (Savulescu, 2018) and appropriate a hurry: even their failure to act appropriately seems choice conditions have been determined and set. unintentional. With respect to solidarity, then, these Golden Opportunities involve patients being given con- cases are all marked not by intentional refusal to fulfil crete, health-promoting behavioural changes. an obligation, but by failure to consider that there is Importantly, this includes the stipulation that patients such an obligation at all, and possibly by further failures must be given ‘considerable support’ in their lifestyle of intention as well. change: merely being told that a behaviour is unhealthy, However, that an outcome is due to someone’s failure as in Smoking, is not enough. does not preclude responsibility for that outcome; nor What is most relevant about Golden Opportunities is does failure to consider an obligation exempt us from it. not whether the relevant behaviour is in the past or Raz (2010) argues that people are responsible for actions future, but whether it is performed under circumstances that are ‘governed’ by our rational agency, even when that are conducive to responsible choice. Additionally, that agency fails (e.g. because we failed to pay attention). Golden Opportunities must be ‘realistically adoptable’. Downloaded from https://academic.oup.com/phe/article/12/2/133/5528519 by DeepDyve user on 14 July 2022 138 DAVIES AND SAVULESCU We cannot demand that the long-distance haulier takes to help her quit, instead struggling with it herself. 10,000 steps every day, or that the single parent working Depending on the nature of the help offered, the patient two jobs cooks fresh food every evening. Part of the in Inactivity may be considered to have been offered a spirit of solidarity involves recognising that not every- Golden Opportunity. The only element missing is his one can contribute to keeping collective costs down in doctor making it clear that the offer of help is subject to the same way, or to the same degree. In this sense, while a penalty if refused. Prainsack, Buyx, and West-Oram are right to say that Since Inactivity involves a patient who is obese, it is solidarity is centred on similarity, it is not possible to important to reiterate that it is not obesity itself that practice genuine solidarity without recognising entails a Golden Opportunity. We accept the consider- difference. able role of environment and genetics in obesity. This is However, it is also important to acknowledge that one reason that Golden Opportunities are structured as patterns in the barriers people face in making healthier they are. Results are important for Golden choices. Genetic predisposition may mean that an indi- Opportunities: a patient only faces a Golden vidual faces weight gain when following what, for others, Opportunity when there is good reason to believe that would be a healthy lifestyle. In addition, there is consid- the relevant change will improve their health. But pa- erable evidence that poverty and social inequality con- tients are not thereby judged by the health results, but by tribute to poor health (e.g. Marmot, 2005). This may the behavioural changes they adopt. If the patient in occur in various ways; most pertinent for our purposes Inactivity makes a sincere effort to exercise more, that is the recognition that poverty and inequality bring with is sufficient for his having taken his Golden them reduced opportunities. People who face poverty Opportunity. Similar points apply to our claim that have less time, less money and less energy to make the patient in Smoking could have faced a Golden healthy choices. A judgement that an opportunity is Opportunity if offered support with quitting. What pa- realistically adoptable, then, must take account of the tients are held responsible for is not solely the health- structural barriers patients may face in changing affecting behaviour, but the decision whether to accept behaviour. effective help overcoming it. Finally, we should stress One of us (JS) has previously suggested that a genuine that including personal responsibility within a health- Golden Opportunity is one where there is no overall care system does not preclude acknowledging the sig- trade-off in value either because there is a reduced risk nificant role of other factors on patient health. for the same value—for instance, swapping cigarette A further condition concerns the type of penalty that smoking for vaping retains the pleasure of smoking— is appropriate. Eyal’s concern about removing the or the same risk for increased value. However, since our means patients need to reach the goal they are penalised justification for introducing responsibility as a limited for not achieving applies most obviously to patients who rationing tool is solidarity, it is acceptable to allow some have not had opportunities to adopt healthier behav- value loss overall, since solidarity involves a willingness iours. However, it may also speak against the relevant to accept some personal costs for the benefit of others penalty being straightforward denial of care. One alter- (Prainsack and Buyx, 2017: 52–53). If a patient finds native is to recover costs pre-emptively through taxation vaping less pleasurable than smoking, but the health or mandatory insurance (e.g. Cappelen and Norheim, risk is significantly lower, it is reasonable to require 2004; Bærøe and Cappelen, 2015). this as a behavioural change. Once we set these param- There are two obvious worries about this. Firstly, not eters, Buyx and Prainsack’s concern that everyone makes all unhealthy behaviours are taxable: some are illegal; decisions that externalise costs in a way that is relevant some behaviours that can be subject to mandatory in- to solidarity looks far less likely to be true. For when surance if done in licensed ways (such as extreme sports) confronted with a clear, health-improving option, and can be practiced outside approved contexts; and some offered support in making it, many will choose to take would require excessive monitoring to properly track. that option. In this context, it seems clear that a tax/insurance ap- Returning to our three cases, our view is that only proach can only work as a best-case scenario, not as a Inactivity meets the requirements set by Golden catch-all. In cases where costs cannot be recovered pre- Opportunities. Golden Opportunities do not apply in emptively, other approaches may be justified. cases of impetuous mistakes in reasoning, as in Seatbelt, Nonetheless, we still need not turn immediately to out- even if these are autonomous and avoidable. While one right denial of care. Other possible approaches include might face a Golden Opportunity with respect to smok- partial covering of health costs (subject to ability to ing, the patient in Smoking has not been offered support pay), and lower priority on waiting lists. Downloaded from https://academic.oup.com/phe/article/12/2/133/5528519 by DeepDyve user on 14 July 2022 SOLIDARITY AND RESPONSIBILITY 139 The second worry is that the overall burdens that each individual can decide whether to participate or (including costs involved in public education and dis- not. A system based on solidarity does not work like this. suasion, as well as in medical research funding that Solidary obligations arise because of relationships and could be directed elsewhere) of some risky activities similarities that already exist between individuals. It is are so great that no realistic tax or insurance could because we cannot abandon people that they in turn cover the costs. If we cannot recover all relevant costs derive obligations to play their part by not overly bur- pre-emptively, and no other penalties are applied, then dening the system we share: it would be unreasonable of responsible individuals will still free-ride to some extent them to burden that system, since it is a system the rest on a solidary social scheme. of us cannot ethically—and perhaps even practically— However, this concern only holds if obligations of opt out of. As such, the failure of pre-emptive taxes and solidarity apply to every one of our actions, and if insurance to cover all costs associated with a behaviour they are unrestricted in terms of the costs that can be does not undermine this proposal, because a solidary imposed for those who violate their obligations. If there system does not require precise matching between pay- are limits on both these factors, an inability to recover ments into a scheme and the benefits one gets out. the total costs which result from a particular behaviour Solidary obligations also do not require perfect compli- does not invalidate pre-emptive cost recovery as a rea- ance in all behaviours. Individuals can behave self-inter- sonable option. For instance, assume that realistic alco- estedly, and perhaps sometimes selfishly or negligently, hol taxes cover only 75 per cent of the costs associated on some occasions and still conform broadly to their with excessive drinking, because higher taxes would obligations of solidarity. Individuals who are part of a drive people to the black market, lowering overall tax ‘we’ are also still individuals; even in a solidarity-based revenue while leaving alcohol-related health problems system, a balance must be struck between the demands unchanged. If the obligations arising from solidarity of solidarity, and the rights of individuals not to have to needed to cover 100 per cent of costs from solidarity- behave perfectly. violating behaviour, this would leave 25 per cent of costs There are two general arguments against solidarity unjustifiably remaining. But if solidary obligations re- requiring absolute compliance. The first, assuming quire only that people who make unhealthy choices that group membership is the basis of solidary obliga- (under the right conditions) cover some of the asso- tions, is that people have multiple such affiliations that ciated costs, this incomplete recovery may not be a may compete with one another. No single system or problem. group can demand perfect compliance. The second ar- In fact, solidarity does not demand that those who fail gument connects to some extent with Buyx and their solidary obligations must cover all relevant costs. Prainsack’s sceptical view of solidary penalties. Even This would apply only if a single violation of solidary with a limit on the kinds of choices for which we can obligations justified excluding someone from solidarity- be held responsible, most people will not comply per- based institutions entirely. Segall (2005: 339) contrasts fectly with responsible behaviour even if they are moti- genuinely reciprocal arrangements (of which we assume vated by solidarity. We are all subject to temptation, to solidarity is one type), with schemes of cooperation that weakness of will, and to moral fatigue. do not generate public goods, and so from which indi- This does not mean that we can define, in the abstract, viduals can be excluded. As Segall argues, public goods a precise level of solidarity that constitutes meeting one’s are non-excludable, and so ‘an obligation to contribute solidary obligations. If solidary obligations arise from applies because the fruits of social cooperation have “a the bonds and connections involved in particular insti- quality of normative non-excludability”’. tutions and social practices, exactly what is required will To put this in the language of solidarity, it only makes depend on the nature of the group or scheme, and per- sense to talk of participants failing their solidary obliga- haps even the views of those involved. Nonetheless, tions if we are operating a system that is to some degree requiring some minimal degree of solidarity through independent of individual participants’ decisions to opt the kind of healthcare planning found in Golden in. If our cooperative scheme were structured so that Opportunities does not require perfection from pa- what you put in is what you eventually get out, there tients, but only a minimal or sufficient commitment could be no obligation to other participants to reduce to taking on some of the burdens of promoting their costs. This is because if you act in a way that means you own health. put less in, the only outcome is that you personally get A solidarity-based system that relies on Golden less out, and because the absence of public goods means Opportunities places conditions on full inclusion in Downloaded from https://academic.oup.com/phe/article/12/2/133/5528519 by DeepDyve user on 14 July 2022 140 DAVIES AND SAVULESCU the healthcare system. One potential criticism is that We accept these concerns as significant and legitim- these policies penalise only some individuals for failure ate. With respect to miscategorisation, it is a require- to comply with certain behavioural requirements. ment of any fair system that aims to hold individuals Nobody is responsible for their poor health in a responsible that it is open to challenge, and that re- vacuum; social conditions and biological predispos- sources are provided for such challenges. In addition, itions both play significant roles. For instance, if we the danger of misuse of responsibility may suggest limits take two moderate smokers, only one may be unlucky on the type of penalties that are appropriate. In particu- enough to be genetically predisposed to developing lar, our view is that total denial of care is unlikely to be a cancer from their level of smoking. Since Golden suitable penalty for this reason. Further, if a solidary Opportunities kick in only once someone risks develop- system does aim to make use of the concept of respon- ing a significant health problem, only the unlucky will be sibility, we must also recognise the importance of placed at risk of exclusion. increasing the opportunities people have to make A related problem stems from wealth. Few states have healthy decisions. The idea of support inherent in placed outright bans on private healthcare and so most Golden Opportunities does not only relate to advice, but to funded resources and programmes of which citi- public healthcare systems allow wealthier patients the option of opting out of the public system. One might zens can make use to improve their health. Our claim, worry that Golden Opportunities therefore risk intro- however, is that if people have the opportunity to make ducing a system whereby poorer patients have a duty of healthy choices, it is sometimes reasonable to hold them solidarity enforced through potential denial of medical responsible for choosing not to. care, but wealthier patients can engage in risky behav- Perhaps the more fundamental challenge comes from iours and then refuse Golden Opportunities at no per- the idea that invoking responsibility, whether appropri- sonal cost. This will also raise worries about the ate or not, risks undermining responsibility through its targeting of certain kinds of already stigmatised behav- focus on difference and division. Again, we acknowledge iours and groups (e.g. Friesen op cit), and of targeted the risk. However, it is worth noting a countervailing moralisation, where an already less well-off, or vulner- risk. If there is a general perception that many individ- able, minority are morally blamed for failing to main- uals are behaving unreasonably, this may itself weaken tain adequate health (e.g. Brown, 2018). the ties of solidarity. Moreover, as we outline below, an These issues highlight the importance of the broader acknowledgement of difference is consistent with a sim- social environment in thinking about solidarity. No ultaneous emphasis of similarity. healthcare system exists in isolation. To avoid inequit- One way to emphasise similarity, which also responds able distribution of burdens, any attempt to enforce cer- to some extent to the concern about genetic and social tain healthy standards of behaviour for those who are luck raised above, involves expanding the idea of Golden already in poor health (or at risk of it) must operate Opportunities by recognising that they may apply to within a broader social system that also exhibits many more of us than just those who indulge in the solidarity. standard ‘bad habits’ or who have serious health prob- However, one might worry that any policy which war- lems. Recall Buyx and Prainsack’s concern about using rants exclusion of some individuals from healthcare pre- solidarity as a rationing tool: we all make choices that sents practical risks. Although we endorse a careful impact our health. Most of us, then, will have the op- consideration of individual circumstances, in reality portunity to make changes to our lifestyles that will give two types of worry arise. First, any new criterion by moderate health benefits, or at least maintain our cur- which people can be excluded from healthcare, or rent level of health. levied additional charges, is a criterion that can be mis- A focus on solidarity can help us to see that what is used either through error, or intentionally by govern- relevant is not simply how much of a financial cost an ments or insurers keen to save costs. Second, a more individual’s health needs place on the health service, but general worry is that focusing on failures of reciprocity on whether individuals are willing to make moderate, might undermine solidarity in general, because of its reasonable sacrifices to avoid burdening others. The in- emphasis on difference, rather than on the similarity corporation into a national health service of a Personal that grounds solidarity. Although we have endorsed Health Plan, developed in coordination with the rele- strict limits on the conditions under which responsibil- vant patient, in recognition of their own limits and as- ity can lead to penalties, one might worry that it is pirations, is one potential way to expand the range of the bound to increase stigmatisation of already vulnerable basic idea of the Golden Opportunity. Such plans must groups. be developed with recognition that health is not the sole Downloaded from https://academic.oup.com/phe/article/12/2/133/5528519 by DeepDyve user on 14 July 2022 SOLIDARITY AND RESPONSIBILITY 141 value for anyone, nor the primary value for many. Our private healthcare is consistent with a solidarity-based demands on one another cannot be that we optimise our approach. For instance, some argue that pushing the health. For instance, some individuals may reasonably wealthy out of benefits systems leads to an overall de- prefer to risk physical injury in pursuit of sporting crease in public support for those systems. To para- achievement. Others may risk other kinds of health phrase social researcher Richard Titmuss (1967) problems by adopting a sedentary lifestyle because (cited in Alcock et al., 2001), the worry is that public they value work that requires long hours at a desk. services for the poor end up being poor public services. Both individuals may be able to lower the relevant However, this will depend on the level at which exclu- risks they face, and to improve their behaviour in sion begins. It is one thing for a service to be limited to areas that are less fundamental to their central goal, the very worst off, and hence fail to benefit the majority; such as diet. As such, while Savulescu’s original ex- it is another thing for it to be limited to all but the very amples of Golden Opportunities are rare, our view in best off (and then, only those in that group who behave this article is that the structure of the Golden irresponsibly), and thus accessible to most. Opportunity can in fact be made available to a signifi- cant proportion of individuals. Finally, we turn to the potential for the better-off to Conclusion escape any potential penalties in healthcare. This Our three cases—Inactivity, Smoking and Seatbelt—all means that demands of solidarity must extend beyond the healthcare system. It is hypocritical to insist that involve people making choices that impose costs on the public purse which are, in some sense, avoidable. In some sections of the population engage in ‘we-thinking’ (and its associated behaviour) without also insisting on some cases, such choices may violate obligations that arise from being involved in a solidary arrangement such thinking for the rest of the population. Any soli- darity-based enforcement of personal responsibility in and do so in such a way as to warrant penalties. healthcare, then, should come in tandem with policies However, we have argued that a violation of solidary designed to penalise failures of solidarity among the obligations requires more than avoidability: it requires wealthy, e.g. through tax avoidance, exploitative work- both that the risk taken is unreasonable, and that it was ing conditions, pollution, and so on. To punitively made under conditions that are conducive to autono- pursue solidarity only in a way that will disproportion- mous choice, as embodied in being offered a Golden ately affect the more vulnerable is to pursue solidarity in Opportunity. Inactivity meets these conditions, so name early, and its opposite in practice. Moreover, if long as his refusal of help is made in knowledge of the private patients are not fully internalising the costs of potential penalties. Finally, we argued that imposing their choices, then the same obligations of solidarity solidary obligations through penalties requires looking would apply. to the broader social environment. Only if solidarity is Concerns about equitability also add a further reason practiced and enforced here, particularly with respect to to avoid absolute denial of basic care as a penalty. Even if the most secure, is it reasonable to enforce it amongst one thinks that denial of basic care can be a legitimate those who need medical care. penalty for failures of solidary obligations, it cannot be legitimate to have a system that in practice denies basic care only to those who cannot afford private care. It may Notes also point us towards certain ways of implementing other forms of substantive responsibility. For instance, 1. The following discussion is based primarily on a system like the NHS, which is what we might call if substantive responsibility requires that one contrib- utes financially to the costs of one’s care in a way that ‘fully solidary’. Clearly this is not the only possible way to structure a health system. One might, for those who are not responsible for their medical needs are not required to, such contributions may need to be instance, have a system which, although funded lar- gely by progressive taxation, expects minor co-pay- weighted according to ability to pay, or kick in only when doing so would not affect a person’s basic needs. ments from patients at the point of service (e.g. £1 every time one visits a GP). Such payments could be One might think, on the other hand, that those who can afford private healthcare might face harsher penal- capped for those with chronic conditions, and waived for the very worst-off. Such a system might ties than those who cannot, including being excluded from the solidarity-based system altogether. Whether encourage solidarity by getting patients to see them- this is an appropriate solution will depend on whether selves as contributing directly to the health system. Downloaded from https://academic.oup.com/phe/article/12/2/133/5528519 by DeepDyve user on 14 July 2022 142 DAVIES AND SAVULESCU But there is, of course, a danger of putting off pa- treatment past a particular age (e.g. Callahan, tients who need medical attention, but are con- 1995). See Overall (2005) for response. 13. This judgement is based not on the type of behav- cerned about the cost. The fact that a health iour—there are many cases of inactivity that are not system requires some up front payment from pa- easily avoidable—but on the circumstances of tients does not prevent it from being solidary. So choice. long as there is some subsidisation of the worse-off 14. Vallentyne (2008) by the better-off, we have a somewhat solidary 15. Frankfurt (1971); Dworkin (1988) system. Our view applies, at a minimum, to the sec- 16. Christman (1991). tions of a healthcare system that are governed by 17. Savulescu and Momeyer (1997). such solidary practices. 18. One thing that does mark these cases out, however, 2. Tallis (2016); Broxton (2017); Heath (2018). is that they fall within pre-existing institutional or Though see Molloy (2018). social frameworks where it is reasonable to expect to 3. See also Taylor (2015) be penalised for such failures. Any case for substan- 4. NHS services are subject to an Immigration Health tive responsibility being attached to failures of solid- Surcharge for many people applying to enter or ary obligations must occur within such clear remain in the UK. See: www.gov.uk/healthcare-im- institutional framework. In other words, it should migration-application. be clear to individuals who might face penalty that 5. For instance, Fenger and van Paridon (2012: 51–2) this is a possibility. distinguish between ‘individual’ and ‘institutional’ 19. One might worry here that Golden Opportunities solidarity (in Reinventing Social Solidarity Across seem likely to occur quite rarely, and so may be of Europe), the latter of which ‘involves a certain limited use in a national health care system. We amount of pressure, a certain degree of organisation suggest a potential expansion of the concept below. and the presence of a set of formal or informal rules’. 20. It is worth noting in this context that the question of See also Prainsack and Buyx’s discussion of different costs is more complex than it may seem. For in- ‘tiers’ of solidarity, the most general sometimes stance, West-Oram (2018: 582) notes that a solidary involving state coercion to implement solidary prac- approach to healthcare can sometimes offer benefits tices (2017: 54–7). Even if such institutional prac- even to net financial contributors, such as the effect tices are not backed up by explicit feelings of of herd immunity through free vaccinations. solidarity from the majority of the population, Assume that offering relevant vaccinations (backed they typically rely on the ‘willingness of individual up by sufficient information on their importance persons to carry costs to benefit others’ (West- and safety) to any patient who visits a doctor or Oram, 2018: 581). Prainsack and Buyx (2017: 36) hospital is a Golden Opportunity. Some adult pa- note the distinction between solidarity as an essen- tients who refuse this opportunity may then become tially voluntary ‘community value’, and as ‘system unwell. Even if it is permissible to penalise these value’, enforceable by law. patients, it may be overall better to treat them for 6. For instance, Fraser (2008: 150–3) argues that soli- free if their condition is both infectious and serious. darity can exist both as a result of a subjective sense 21. Bærøe and Cappelen, op cit 838; Wolff (1998). of solidarity, but also due to causal interdependence. 22. This is also the reason that the patients in our cases In the latter case, we might say that given the exist- cannot, for instance, appeal to the fact that they have ence of such dependencies, individuals and states contributed towards the funding of the NHS, have obligations of solidarity even in the absence thereby supporting others in their unhealthy of any relevant sentiment. choices. Such a view would imply that those who 7. See also Friesen (2016). have not paid in have less right to behave unreason- 8. Hope et al. (2008) ably than those who have—or, that those who have 9. Savulescu (2007) not paid in as much have less right than those who 10. E.g. Arneson (2000); Cohen (2011); Lippert- have paid in more. Rasmussen (2015); Segall (2016) 23. It is also important to emphasise that holding people 11. See Vallentyne (2002) for a discussion of various responsible for certain decisions need not involve a ways of understanding the distinction. judgement of their character. Rather, the claim is 12. Some think, for instance, that elderly patients that solidarity entitles us to expect people to behave unreasonably if they expect life-extending impose only reasonable costs on others. Downloaded from https://academic.oup.com/phe/article/12/2/133/5528519 by DeepDyve user on 14 July 2022 SOLIDARITY AND RESPONSIBILITY 143 24. An alternative is to prevent individuals from buying Dworkin, G. (1988). The Theory and Practice of direct health services outside of the basic package Autonomy. Cambridge: Cambridge University Press. provided by the state (e.g. Gutmann, 1981: 553; Eyal, N. (2013). Denial of Treatment to Obese Patients—the Wrong Policy on Personal Walzer, 1983: 90). Responsibility for Health. International Journal of Health Policy and Management, 1, 107–110. Feiring, E. (2008). Lifestyle, Responsibility, and Justice. Funding Journal of Medical Ethics, 34, 33–36. Fenger, M. and van Paridon, K. (2012). Towards a This work was supported by a grant from the Wellcome Globalisation of Solidarity? In Ellison, M. (ed.), Trust [WT104848/Z/14/Z]. Reinventing Social Solidarity across Europe. Bristol: Conflict of interest: Bristol University Press, pp. 49–70. The authors declare that they have no conflict of Frankfurt, H. (1971). Freedom of the Will and the interests. Concept of a Person. The Journal of Philosophy, 68, 5–20. Fraser, N. (2008). Scales of Justice. London: Verso. Friesen, P. (2016). Personal Responsibility within References Health Policy: Unethical and Ineffective. Journal of Albertsen, A. (2015). Feinberg’s Concept of Forward- Medical Ethics, 44, 55–58. Looking Responsibility: A Dead End for Gutmann, A. (1981). For and against Equal Access to Responsibility in Health Care. Journal of Medical Healthcare. The Milbank Memorial Fund Quarterly Ethics, 41, 161–164. Health and Society, 59, 542–560. Arneson, R. (2000). Luck Egalitarianism and Heath, I. (2018). Back to the Future: Aspects of the NHS Prioritarianism. Ethics, 110, 339–349. That Should Never Change. BMJ, 362, k3187. Bærøe, K. and Cappelen, C. (2015). Phase-Dependent Hope, T., Savulescu, J., and Hendrick, J. (2008). Medical Justification: The Role of Personal Responsibility in Ethics and Law: The Core Curriculum, 2nd edn. Fair Healthcare. Journal of Medical Ethics, 41, 836– London: Churchill Livingstone. Krishnamurthy, M. (2013). Political Solidarity, Justice, Brown, R. (2018). Resisting Moralisation in Health and Public Health. Public Health Ethics, 6, 129–141. Promotion. Ethical Theory and Moral Practice, 21, Laitinen, A. and Pessi, A. (2014). Solidarity: Theory and 997–1011. Practice. An Introduction. In Laitinen, A. and Pessi, Broxton, A. (2017). “ Why Should the People Wait Any A. (eds), Solidarity: Theory and Practice. Plymouth: Longer?” How Labour Built the NHS. LSE blog, July Lexington Books, pp. 1–29. 8th 2017, available from: http://blogs.lse.ac.uk/poli- Lippert-Rasmussen, K. (2015). Luck Egalitarianism. ticsandpolicy/why-should-the-people-wait-any- London: Bloomsbury. longer-how-labour-built-the-nhs. [accessed 18 Marmot, M. (2005). The Status Syndrome: How Social January 2019]. Standing Affects Our Health and Longevity. London: Buyx, A. (2008). Personal Responsibility for Health as a Bloomsbury. Rationing Criterion: Why we Don’t like it and Why Molloy, C. (2018). Don’t Invoke the NHS to Sell a False Maybe we Should. Journal of Medical Ethics, 34, 871– Idea of “ Good Nationalism”. Open Democracy, May 874. 8. https://www.opendemocracy.net/ournhs/caro- Callahan, D. (1995). Setting Limits: Medical Goals in an line-molloy/dont-invoke-nhs-to-sell-false-idea-of- Ageing Society with “ a Response to My Critics. good-nationalism. [accessed 18 January 2019]. Washington: Georgetown University Press. Nagy, R. (2002). Reconciliation in Post-Commission Cappelen, A. and Norheim, O. (2004). Responsibility in South Africa: Thick and Thin Accounts of Health Care: A Liberal Egalitarian Approach. Journal Solidarity. Canadian Journal of Political Science, 35, of Medical Ethics, 31, 476–480. 323–346. Christman, J. (1991). Autonomy and Personal History. Overall, C. (2005). Aging, Death and Human Longevity. Canadian Journal of Philosophy, 21, 1–24. London: University of California Press, Ltd. Cohen, G. (2011). On the Currency of Egalitarian Justice Prainsack, B. and Buyx, A. (2011). Solidarity: Reflections and Other Essays in Political Philosophy. Princeton, on an Emerging Concept in Bioethics. London: NJ: Princeton University Press. Nuffield Council on Bioethics. Downloaded from https://academic.oup.com/phe/article/12/2/133/5528519 by DeepDyve user on 14 July 2022 144 DAVIES AND SAVULESCU Prainsack, B. and Buyx, A. (2017). Solidarity in Tallis, R. (2016). End of the NHS? Times Literary Biomedicine and Beyond. Cambridge: Cambridge Supplement, September 17th 2016, available from: University Press. https://www.the-tls.co.uk/articles/public/end-of- Raz, J. (2010). Responsibility and the Negligence the-nhs/.[accessed 18 January 2019]. Standard. Oxford Journal of Legal Studies, 30,1– Taylor, A. (2015). Solidarity: Obligations and Expressions. 18. The Journal of Political Philosophy, 23, 128–145. Savulescu, J. (2007). Autonomy, the Good Life, and Titmuss, R. (1967). Welfare State and Welfare Society. Controversial Choices. In Rhodes, R., Francis, L. In Alcock, P., Glennerster, H., Oakley, A., and P., and Silvers, A. (eds), The Blackwell Guide to Sinfield, A. (eds), Welfare and Wellbeing: Richard Medical Ethics, Part 1, Chapter 1. Oxford: Titmuss’ Contribution to Social Policy (2001). Blackwell Publishing, pp. 17–37. Bristol: Policy Press, pp. 113–124. Savulescu, J. (2018). Golden Opportunity, Reasonable Vallentyne, P. (2002). Brute Luck, Option Luck, and Risk and Personal Responsibility for Health. Journal Equality of Initial Opportunities. Ethics, 112, 529– of Medical Ethics, 44, 59–61. 557. Savulescu, J. and Momeyer, R. W. (1997). Should Vallentyne, P. (2008). Bad Luck and Responsibility. Informed Consent be Based on Rational Beliefs?’. Politics, Philosophy & Economics, 7, 57–80. Journal of Medical Ethics, 23, 282–288. Walzer, M. (1983). Spheres of Justice: A Defense of Segall, S. (2005). Unconditional Welfare Benefits and Pluralism and Equality. USA: Basic Books. the Principle of Reciprocity. Politics, Philosophy & West-Oram, P. (2018). Solidarity as a National Health Economics, 4, 331–354. Care Strategy. Bioethics, 32, 577–584. Segall, S. (2016). Health, Luck and Justice. Princeton: West-Oram, P. and Buyx, A. (2017). Global Health Princeton University Press. Solidarity. Public Health Ethics, 10, 212–224. Shelby, T. (2002). Foundations of Black Solidarity: Wolff, J. (1998). Fairness, Respect and the Collective Identity or Common Oppression. Ethics, Egalitarian Ethos. Philosophy & Public Affairs, 27, 112, 231–266. 97–122. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Public Health Ethics Oxford University Press

Solidarity and Responsibility in Health Care

Public Health Ethics , Volume 12 (2) – Jul 1, 2019

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Downloaded from https://academic.oup.com/phe/article/12/2/133/5528519 by DeepDyve user on 14 July 2022 PUBLIC HEALTH ETHICS VOLUME 12 NUMBER 2 2019 133–144 133 Ben Davies , Uehiro Centre for Practical Ethics Julian Savulescu , Uehiro Chair in Practical Ethics Corresponding author: Ben Davies, Uehiro Centre for Practical Ethics, Suite 8, Littlegate House, 16–17 St Ebbes Street, Oxford OX1 1PT, UK. Tel.: +44 (0)1865286893; Email: benjamin.davies@philosophy.ox.ac.uk Some healthcare systems are said to be grounded in solidarity because healthcare is funded as a form of mutual support. This article argues that health care systems that are grounded in solidarity have the right to penalise some users who are responsible for their poor health. This derives from the fact that solidary systems involve both rights and obligations and, in some cases, those who avoidably incur health burdens violate obligations of solidarity. Penalties warranted include direct patient contribution to costs, and lower priority treatment, but not typically full exclusion from the healthcare system. We also note two important restrictions on this argument. First, failures of solidary obligations can only be assumed under conditions that are conducive to sufficiently autonomous choice, which occur when patients are given ‘Golden Opportunities’ to improve their health. Second, because poor health does not occur in a social vacuum, an insistence on solidarity as part of healthcare is legitimate only if all members of society are held to similar standards of solidarity. We cannot insist upon, and penalise failures of, solidarity only for those who are unwell, and who cannot afford to evade the terms of public health. Consider the following cases: Solidarity in Healthcare A 58-year-old man is admitted to hospital follow- Some healthcare systems, such as the UK’s National ing a heart attack, which doctors believe has been Health Service, are described as being grounded in soli- caused in part by moderate obesity. The man de- darity. Rather than people being responsible only, and scribes himself as doing ‘as little exercise as pos- entirely, for their own health, the NHS pools risk sible’, even though he was explicitly warned by his through taxation and free-at-the-point-of-use care. GP five years previously that this inactivity pre- sented a serious risk to his health and turned Users who are better off (e.g. healthier or wealthier) down an offer of help with getting more exercise. take on some of the financial risk of worse-off users. (Inactivity) This article focuses on the relationship between solidar- A 45-year-old woman who smokes twenty cigarettes ity and personal responsibility in healthcare. We argue daily develops chronic obstructive pulmonary dis- that solidarity can generate obligations, and that failure ease. Although her doctor warned her about the to meet these obligations can legitimately be penalised. risks, she was given no support in quitting, and However this can only occur in the right context: both in has found it difficult. (Smoking) terms of an appropriate opportunity to choose, and the A 28-year-old man is admitted to A&E following a nature of the society in which such obligations sup- car accident. He has been driving safely for ten years posedly arise. but later admits that he neglected to put on his seatbelt because he was running late. (Seatbelt). Solidarity and Responsibility Does solidarity recommend treatment, refusal to treat, Solidarity is a two-way street: a system based on or something else in cases like these? In part, this will solidarity can require certain kinds of responsible depend on how we conceive of solidarity. At heart, how- behaviour from participants. ever, the dilemma is this: while each individual is vul- Failures of solidarity are best enforced when pa- nerable, and dependent on society to become well again, tients have been offered ‘Golden Opportunities’, they have each made choices that not only impact their under conditions conducive to decision-making. own health, but also place costs on society at large. To We should not focus narrowly on solidarity treat each individual will require resources that could be within healthcare. It also matters whether soli- spent elsewhere and may lead to delayed or cancelled darity is practiced in the broader society. treatment for others who are unavoidably ill. In such doi:10.1093/phe/phz008 Advance Access publication on 4 July 2019 ! The Author(s) 2019. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Downloaded from https://academic.oup.com/phe/article/12/2/133/5528519 by DeepDyve user on 14 July 2022 134 DAVIES AND SAVULESCU cases, the claims of solidarity may seem to pull us in expressed by active support for policies that involve separate directions. the sharing of risk and benefit; this includes concrete This article argues that a solidary health system can political action such as voting for solidarity-supporting political parties; campaigning for policies that support consistently make demands of its members, and impose penalties on them when they are not met. Our view is others’ interests as well as one’s own; and participating in (well-directed) socio-political schemes that support that solidarity requires that people make only reasonable demands of one another. Where people fail to act rea- solidarity-enhancing institutions, e.g. paying one’s ‘fair share’ in taxation. sonably, and were well placed to do so, members of a solidary system are entitled to refuse to cover the costs While solidarity cannot come from institutional design alone, we may nonetheless describe as solidary that come from that failure. Finally, we outline some of the constraints on this argument: not all cases where to some degree principles and institutions that both aim to enforce solidary norms, and which are supported for individuals act in ways that affect their health are failures of solidarity. solidary reasons by at least some participants. This would, in Nagy’s (2002: 329) terms, be an instance of ‘thin’ solidarity, in contrast with the ‘thick’ solidarity that is generated in a bottom-up way by ‘substantive’ What is Solidarity? moral agreement. At the macro level, then, institutions In common use, solidarity refers to fellow-feeling and, and practices can be more or less solidary depending on importantly, mutual support between individuals. This the proportion of participants who support them for might be because of a shared purpose, as in cases of solidary reasons and, depending on whether they are solidarity amongst striking workers. But it may involve intended to be derived from, and supportive of, solidary taking on a goal because of one identifies with those relationships among participants. already involved. While solidarity has been adapted in In addition, it is sometimes legitimate to enforce different ways by various traditions (Prainsack and social arrangements with the aim of fulfilling solidary Buyx, 2011; Prainsack and Buyx, 2017: 19–42), one if obligations, even if solidary feeling and action is low its most prominent contemporary uses is to invoke within a community. Whether the resulting arrange- ‘emotionally and normatively motivated readiness for ment genuinely fulfils obligations of solidarity depends mutual support’ (Laitinen and Pessi, 2014: 1). This in- in part on how we conceive the relationship between the cludes a willingness to promote others’ interests, or the descriptive and normative facets of the concept. Our interests of the group, even at personal cost. view is that we can criticize certain institutional arrange- Solidarity can act as a descriptive concept, explaining ments for a failure to show solidarity because they the emergence of norms or institutions. Some argue that govern social relationships that should be at least some- the NHS was founded in a spirit of solidarity following what solidary in nature. Robust solidarity governs ob- the Second World War. It can also act as a normative ligations that group members feel as a result of their motivation, where group membership generates what membership, and we assume that this feeling can be Shelby (2002: 68) calls ‘robust solidarity’: rather than more or less accurate depending on the circumstances: merely describing practices as solidary, robust solidarity sometimes people will fail to feel solidary obligations, requires that group members feel obligated to act in even though they do in fact exist. Recent writing on certain ways as a result of solidary bonds. Since the solidarity (West-Oram and Buyx, 2017: 217–218; NHS is funded by taxation and free at the point of use West-Oram, 2018) emphasises the potential for building (for many), it involves mutual support between mem- solidarity (including at the global level) out of self-inter- bers of UK society. On this basis, one might think that est. While state institutions cannot create solidarity in- each of the individuals involved in Inactivity, Smoking organically, they can ‘provide the social bases for and Seatbelt have a claim to treatment based in solidar- realizing relations of ... solidarity’ (Krishnamurthy, ity. They are vulnerable members of the relevant society 2013: 134). and their fate is at the discretion of a system that was A critical element of solidarity is its characterisation established to help people in just their positions. as ‘we-thinking’. This distinguishes it importantly from Solidarity’s association with individual action (Buyx charity, which is purely other-directed. In a solidarity- and Prainsack, 2017: 43–48) may make it seem an in- based arrangement people not only give to others, but appropriate label for a complex institution like the NHS. are entitled to expect something back. Again, this is But while solidarity may be most obviously expressed in often derived from shared group membership, or at direct contact between individuals, it can also be least some shared characteristics or interests. As Downloaded from https://academic.oup.com/phe/article/12/2/133/5528519 by DeepDyve user on 14 July 2022 SOLIDARITY AND RESPONSIBILITY 135 Prainsack and Buyx argue (2017: 53–54), solidarity re- by the expectation of reciprocity. Rather, we claim only quires the recognition of similarity, and its prioritisation that solidarity generates obligations to contribute to (at least in one respect) over difference (see also West- solidary systems and institutions, dependent on one’s ability. Oram and Buyx, 2017: 216, who emphasise solidarity’s focus on the similarities between individuals, compared As well as reciprocity, solidary also requires a com- mitment to action. Taken together, these commitments with charity’s focus on, e.g. wealth differences). In our view, this means that a principle of solidarity make it clear why solidarity-based institutions may demand a degree of personal responsibility from their does not direct us uniformly towards treatment in our test cases. Although individuals operating in a solidary participants. On the other hand, a willingness to aban- don those who make poor choices with respect to their system have claims on others, and the system in which they operate, since solidarity is reciprocal people also own health seems to be the antithesis of solidarity. We can agree that those who knowingly place avoidable bur- have obligations to others and may have obligations to behave in certain ways within that system. This suggests dens on a public health system have in some cases failed an obligation of solidarity, without concluding that they two relevant questions. Have the individuals in our cases failed an obligation of solidarity? And if they have, is the have thereby forfeited their solidarity-based claims. We therefore need to consider what the relevant obligations obligation of the kind where failure warrants a penalty are, and whether they warrant penalties in cases where within that system? This is the topic of the next section. they are violated. One candidate for a relevant solidary obligation is the obligation not to externalise the costs of one’s decisions Obligations of Solidarity in ways that burden others. In its simplest form, though, Solidarity’s characterisation as ‘we-thinking’ seems to us this cannot be correct. For the very idea of solidarity is to require a degree of reciprocity, and hence obligation. precisely that we share, to some extent, in one another’s One might object to this claim, noting that some solid- burdens. Buyx and Prainsack (2011) argue against using ary actions do not appear to involve reciprocity. For solidarity to ground health-related liabilities on such a instance, Prainsack and Buyx imagine a low-level ex- basis. They suggest that any attempt to do so will focus ample of solidarity, lending a fellow passenger one’s on easily identifiable failures of responsibility, obscur- phone when you are both stranded at the airport. ing the fact that all of us make choices that raise the risk Similarly, we can surely experience solidarity with of some health burden or other. It would be unfair to those who are unable to reciprocate, at least in kind. refuse to externalise some kinds of freely chosen health How, then, can we suggest that solidarity requires burdens, and not others. Indeed, such a selective policy reciprocity? risks narrowing the range of conceptions of the good It is thus important to clarify the idea of reciprocity in life. We ought in principle to support choices which, three ways. Firstly, reciprocity does not require an iden- though entailing risks, either plausibly aim at well-being tical give and take. Rather, it requires ‘playing one’s or which are fully autonomous on either a Millian or part’. Particularly at the institutional level, where thou- Kantian conception. sands or millions are involved in a solidary institution, In our view, an argument for holding people respon- solidarity cannot require that everyone gets back exactly sible based on solidarity should identify types of burdens what they put in; indeed, as we argue below, such a that people cannot expect others to shoulder in the transactional institution is not genuinely solidary at all. name of solidarity. One option is to adopt a luck- Secondly, as the phone example makes clear, solidary based focus. Translated to the language of solidarity, reciprocity need only be hypothetical. In lending your this suggests that solidarity requires others to accept our phone to a fellow passenger there is an implicit assump- externalised costs when those costs arise as a result of tion, we suggest, that they would do something similar bad ‘brute luck’, i.e. misfortune due to unforeseeable for you or someone else in a similar position. If you had accident, or misfortune imposed on us by others, but evidence to the contrary (e.g. you had just seen them that it does not require that society externalise the costs refuse to lend some change to a fellow passenger to buy a of burdens that are due to bad ‘option luck’, i.e. out- drink), you might feel less inclined towards solidarity comes that were foreseeably avoidable by the agent. with them. But this seems to misclassify many cases. A wide range Finally, our claim that solidarity is reciprocal does not of options are avoidable, will involve some health bur- mean that we disagree with Prainsack and Buyx’s claim dens, and yet are entirely reasonable to choose. This (2017: 62) that solidary action cannot be solely motivated includes choosing to meet existing moral obligations, Downloaded from https://academic.oup.com/phe/article/12/2/133/5528519 by DeepDyve user on 14 July 2022 136 DAVIES AND SAVULESCU choices where alternative options also have significant types of entitlements people may claim on grounds of costs, and choices which, despite being risky, also offer justice. Secondly, we earlier suggested that obligations of considerable prospective benefits. It would be unreason- solidarity may exist even in the absence of relevant feel- able, and in violation of solidarity, to refuse to support ing. If people stand in certain relations to one another people who make such choices. (e.g. the relationship of fellow citizen), justice may itself Instead, we suggest that solidarity licenses sanctioning demand a level of solidarity. While our interest is in people who externalise costs to others when this exter- exploring the parameters of what solidarity requires of nalisation is unreasonable. Solidarity requires us to take us, this is indeed intimately related to justice. Yet the up common cause with those who are suffering only if centrality of justice to our discussion does not negate the they show a reciprocal concern for us, so long as they are importance of solidarity. able to do so. Those who choose to impose unreasonable Finally, however, we accept that justice is in some burdens on others—or choose, unreasonably failing to sense prior to solidarity. This is both because minimal consider the burdens on others—have failed to show standards of justice are a prerequisite for solidarity (e.g. this reciprocal concern. Krishnamurthy, 2013), and because justice sets bound- In practice, it will be difficult to determine whether a aries on what solidarity can demand of us. However, we choice is aiming at a reasonable conception of the good assume that in the allocation of health care resources, we life or is fully autonomous. However, we may restrict cannot treat everyone who would benefit, and that just- our scope to those who are responsible for their own ice may not offer comprehensive, decisive instruction on health burdens under certain choice conditions. Even if which individuals should lose out. This means that con- we all make decisions that ultimately impact our health, siderations of justice (e.g. claims of reparation on the it is not true that we all make such decisions under the basis of past injustice, or claims that one is uncondition- relevant set of conditions, i.e. conditions that are suffi- ally entitled to a minimal amount of care) may constrict ciently conducive to well-considered, uncoerced choice, which conditions are properly subject to penalties; but and which are unreasonable given the context. where at least some patients must lose out, and justice Prainsack and Buyx’s concern holds only if all health- thus cannot preclude any particular individual from impacting choices demonstrate equivalent failures of facing additional burdens, the considerations of solidar- solidarity. This is not obvious. Some behaviours, despite ity that we outline are relevant. carrying health risks, also carry considerable health benefits. If I end up worse off after following medical advice, this does not constitute a failure of solidarity in The Conditions of Penalising the same way as a decision to ignore, or to fail to attend to, medical advice. Similarly, personally unhealthy Solidarity Failures choices that appear to violate obligations of solidarity Some choices that affect our health meet the highest may be the only way to fulfil other obligations: for in- standards of autonomy: they are made with full know- stance, working long hours at great cost to one’s health ledge of consequences, using well-functioning rational to be able to feed one’s children. We thus cannot move capacities, in circumstances where a reasonable array of from the fact that we all make choices that harm our options is available. The case of Inactivity meets these health to the claim that it is unjustified to pick any criteria. By stipulation, the patient could exercise more subset of those choices as appropriately subject to sub- but chooses not to, and does so with reasonable under- stantive responsibility. Some such choices are more rea- standing of the potential risks over a considerable length sonable than others. What this does suggest, however, is of time. that we cannot consider solidarity in health-based deci- Other choices fail to meet these standards. Many be- sions in isolation from our broader social context, or the haviours that are cited as leading to ‘lifestyle-related dis- conditions of choice. eases’, including our case of Smoking, are chosen It is worth saying something at this stage about the without explicit coercion, but under strong social influ- relationship of solidarity to justice. Since we are con- cerned with the imposition of unreasonable costs, it may ences beyond individuals’ control, and they are often only threats to health when part of unreflective, long- seem that the real topic of our discussion is distributive justice. There are three things to say about our view on term habits, driven in part by advertising and other life- style constraints and pressures. Other health-affecting this. Firstly, the requirements of justice are affected by solidarity. Although solidarity is not itself always obliga- choices are impulsive errors of judgement or mistakes. tory, the existence of solidary relationships affects the Seatbelt is a case of this type. Downloaded from https://academic.oup.com/phe/article/12/2/133/5528519 by DeepDyve user on 14 July 2022 SOLIDARITY AND RESPONSIBILITY 137 Smoking and Seatbelt present problems for many Indeed, many failures of practical rationality (doing standard analyses of responsibility because they exhibit what you should do) are attributable to failures of the- a mixture of failure and success with respect to features oretical rationality (believing what you should be- that make decisions responsible. For instance, neither is lieve). And many failures of theoretical rationality chosen after a period of reasonable reflection, nor are are blameworthy since the agent is responsible because they (we stipulate) endorsed by second-order desires. she should have known (or believed) better. There are Smoking may be in character for our patient if that is cases where it is not only legitimate but required to understood as concerning what a patient typically does, apply substantive responsibility to failures of intention. but not if we understand character in terms of higher If a company fails in implementing appropriate safety order desires. Seatbelt is out of character in both senses. measures, leading to an accident, it cannot escape liabil- While there are cases of inactivity that also involve these ity by protesting that it did not plan the accident. If I barriers (see fn7), the patient in our case, we stipulate, cause a car crash because I am distracted, I cannot escape faces more favourable conditions. He faced many criminal penalties or compensation for victims for this opportunities, and no special barriers, to doing more reason alone. In both cases, an obligation exists, and exercise, including having the spare time and money failure to fulfil it is not intentional, but negligent. such that doing so would not be burdensome. He also, One problem with many potential ways of involving we imagine, reflected on whether to exercise, knowing responsibility in healthcare is their excessive simplicity. its effect on his health. But he decided that he would This applies to the behaviour required to trigger a pen- rather avoid exercise and risk poor health. alty: one bad habit, or even one mistake, is sometimes One argument in favour of solidarity-based penalties seen as enough to justify considerably different treat- is that participation in solidary practices or institutions ment. This problem also applies to the finality of the generates obligations, and failure to meet those obliga- decision to penalise. As Eyal (2013) notes, responsibility tions can justify either exclusion from the practice, or penalties often set patients up to fail by conditioning penalties within it. A system of tax-funded healthcare is ‘the very aid that patients need to become healthier on such a practice. For instance, Buyx (2008) suggests that, success in becoming healthier’. while solidarity places a constraint on the degree to This latter issue has led to several related proposals which we may hold people substantively responsible around how we should think about responsibility in for their own health, it does not ground an absolute healthcare. Feiring (2008), for instance, distinguishes objection to the inclusion of personal responsibility in between ‘backward-looking’ and ‘forward-looking’ re- healthcare, since solidarity cuts both ways. If my deci- sponsibility, suggesting that while we cannot penalise sions demonstrate a failure to show due regard to other patients for their past irresponsibility, we can set condi- members of my community, I fail to demonstrate ap- tions for future healthcare. However, as Albertsen propriate solidarity. (2015) notes, there is something paradoxical about In none of our cases is there an intention to betray this proposal: even if the conditions that we set upon solidarity or violate obligations. People don’t smoke or commencement of treatment are forward-looking at drive unsafely with the health budget in mind. If any- that point, they become backward-looking if we later thing, this absence is even starker in cases involving neg- penalise patients for failing to meet them. lect. The smoker might consider the alternative and More promising is the idea that responsibility can be intentionally reject it. Not so the person who neglects invoked only when patients have refused a ‘Golden to put on their seatbelt because they are distracted and in Opportunity’ (Savulescu, 2018) and appropriate a hurry: even their failure to act appropriately seems choice conditions have been determined and set. unintentional. With respect to solidarity, then, these Golden Opportunities involve patients being given con- cases are all marked not by intentional refusal to fulfil crete, health-promoting behavioural changes. an obligation, but by failure to consider that there is Importantly, this includes the stipulation that patients such an obligation at all, and possibly by further failures must be given ‘considerable support’ in their lifestyle of intention as well. change: merely being told that a behaviour is unhealthy, However, that an outcome is due to someone’s failure as in Smoking, is not enough. does not preclude responsibility for that outcome; nor What is most relevant about Golden Opportunities is does failure to consider an obligation exempt us from it. not whether the relevant behaviour is in the past or Raz (2010) argues that people are responsible for actions future, but whether it is performed under circumstances that are ‘governed’ by our rational agency, even when that are conducive to responsible choice. Additionally, that agency fails (e.g. because we failed to pay attention). Golden Opportunities must be ‘realistically adoptable’. Downloaded from https://academic.oup.com/phe/article/12/2/133/5528519 by DeepDyve user on 14 July 2022 138 DAVIES AND SAVULESCU We cannot demand that the long-distance haulier takes to help her quit, instead struggling with it herself. 10,000 steps every day, or that the single parent working Depending on the nature of the help offered, the patient two jobs cooks fresh food every evening. Part of the in Inactivity may be considered to have been offered a spirit of solidarity involves recognising that not every- Golden Opportunity. The only element missing is his one can contribute to keeping collective costs down in doctor making it clear that the offer of help is subject to the same way, or to the same degree. In this sense, while a penalty if refused. Prainsack, Buyx, and West-Oram are right to say that Since Inactivity involves a patient who is obese, it is solidarity is centred on similarity, it is not possible to important to reiterate that it is not obesity itself that practice genuine solidarity without recognising entails a Golden Opportunity. We accept the consider- difference. able role of environment and genetics in obesity. This is However, it is also important to acknowledge that one reason that Golden Opportunities are structured as patterns in the barriers people face in making healthier they are. Results are important for Golden choices. Genetic predisposition may mean that an indi- Opportunities: a patient only faces a Golden vidual faces weight gain when following what, for others, Opportunity when there is good reason to believe that would be a healthy lifestyle. In addition, there is consid- the relevant change will improve their health. But pa- erable evidence that poverty and social inequality con- tients are not thereby judged by the health results, but by tribute to poor health (e.g. Marmot, 2005). This may the behavioural changes they adopt. If the patient in occur in various ways; most pertinent for our purposes Inactivity makes a sincere effort to exercise more, that is the recognition that poverty and inequality bring with is sufficient for his having taken his Golden them reduced opportunities. People who face poverty Opportunity. Similar points apply to our claim that have less time, less money and less energy to make the patient in Smoking could have faced a Golden healthy choices. A judgement that an opportunity is Opportunity if offered support with quitting. What pa- realistically adoptable, then, must take account of the tients are held responsible for is not solely the health- structural barriers patients may face in changing affecting behaviour, but the decision whether to accept behaviour. effective help overcoming it. Finally, we should stress One of us (JS) has previously suggested that a genuine that including personal responsibility within a health- Golden Opportunity is one where there is no overall care system does not preclude acknowledging the sig- trade-off in value either because there is a reduced risk nificant role of other factors on patient health. for the same value—for instance, swapping cigarette A further condition concerns the type of penalty that smoking for vaping retains the pleasure of smoking— is appropriate. Eyal’s concern about removing the or the same risk for increased value. However, since our means patients need to reach the goal they are penalised justification for introducing responsibility as a limited for not achieving applies most obviously to patients who rationing tool is solidarity, it is acceptable to allow some have not had opportunities to adopt healthier behav- value loss overall, since solidarity involves a willingness iours. However, it may also speak against the relevant to accept some personal costs for the benefit of others penalty being straightforward denial of care. One alter- (Prainsack and Buyx, 2017: 52–53). If a patient finds native is to recover costs pre-emptively through taxation vaping less pleasurable than smoking, but the health or mandatory insurance (e.g. Cappelen and Norheim, risk is significantly lower, it is reasonable to require 2004; Bærøe and Cappelen, 2015). this as a behavioural change. Once we set these param- There are two obvious worries about this. Firstly, not eters, Buyx and Prainsack’s concern that everyone makes all unhealthy behaviours are taxable: some are illegal; decisions that externalise costs in a way that is relevant some behaviours that can be subject to mandatory in- to solidarity looks far less likely to be true. For when surance if done in licensed ways (such as extreme sports) confronted with a clear, health-improving option, and can be practiced outside approved contexts; and some offered support in making it, many will choose to take would require excessive monitoring to properly track. that option. In this context, it seems clear that a tax/insurance ap- Returning to our three cases, our view is that only proach can only work as a best-case scenario, not as a Inactivity meets the requirements set by Golden catch-all. In cases where costs cannot be recovered pre- Opportunities. Golden Opportunities do not apply in emptively, other approaches may be justified. cases of impetuous mistakes in reasoning, as in Seatbelt, Nonetheless, we still need not turn immediately to out- even if these are autonomous and avoidable. While one right denial of care. Other possible approaches include might face a Golden Opportunity with respect to smok- partial covering of health costs (subject to ability to ing, the patient in Smoking has not been offered support pay), and lower priority on waiting lists. Downloaded from https://academic.oup.com/phe/article/12/2/133/5528519 by DeepDyve user on 14 July 2022 SOLIDARITY AND RESPONSIBILITY 139 The second worry is that the overall burdens that each individual can decide whether to participate or (including costs involved in public education and dis- not. A system based on solidarity does not work like this. suasion, as well as in medical research funding that Solidary obligations arise because of relationships and could be directed elsewhere) of some risky activities similarities that already exist between individuals. It is are so great that no realistic tax or insurance could because we cannot abandon people that they in turn cover the costs. If we cannot recover all relevant costs derive obligations to play their part by not overly bur- pre-emptively, and no other penalties are applied, then dening the system we share: it would be unreasonable of responsible individuals will still free-ride to some extent them to burden that system, since it is a system the rest on a solidary social scheme. of us cannot ethically—and perhaps even practically— However, this concern only holds if obligations of opt out of. As such, the failure of pre-emptive taxes and solidarity apply to every one of our actions, and if insurance to cover all costs associated with a behaviour they are unrestricted in terms of the costs that can be does not undermine this proposal, because a solidary imposed for those who violate their obligations. If there system does not require precise matching between pay- are limits on both these factors, an inability to recover ments into a scheme and the benefits one gets out. the total costs which result from a particular behaviour Solidary obligations also do not require perfect compli- does not invalidate pre-emptive cost recovery as a rea- ance in all behaviours. Individuals can behave self-inter- sonable option. For instance, assume that realistic alco- estedly, and perhaps sometimes selfishly or negligently, hol taxes cover only 75 per cent of the costs associated on some occasions and still conform broadly to their with excessive drinking, because higher taxes would obligations of solidarity. Individuals who are part of a drive people to the black market, lowering overall tax ‘we’ are also still individuals; even in a solidarity-based revenue while leaving alcohol-related health problems system, a balance must be struck between the demands unchanged. If the obligations arising from solidarity of solidarity, and the rights of individuals not to have to needed to cover 100 per cent of costs from solidarity- behave perfectly. violating behaviour, this would leave 25 per cent of costs There are two general arguments against solidarity unjustifiably remaining. But if solidary obligations re- requiring absolute compliance. The first, assuming quire only that people who make unhealthy choices that group membership is the basis of solidary obliga- (under the right conditions) cover some of the asso- tions, is that people have multiple such affiliations that ciated costs, this incomplete recovery may not be a may compete with one another. No single system or problem. group can demand perfect compliance. The second ar- In fact, solidarity does not demand that those who fail gument connects to some extent with Buyx and their solidary obligations must cover all relevant costs. Prainsack’s sceptical view of solidary penalties. Even This would apply only if a single violation of solidary with a limit on the kinds of choices for which we can obligations justified excluding someone from solidarity- be held responsible, most people will not comply per- based institutions entirely. Segall (2005: 339) contrasts fectly with responsible behaviour even if they are moti- genuinely reciprocal arrangements (of which we assume vated by solidarity. We are all subject to temptation, to solidarity is one type), with schemes of cooperation that weakness of will, and to moral fatigue. do not generate public goods, and so from which indi- This does not mean that we can define, in the abstract, viduals can be excluded. As Segall argues, public goods a precise level of solidarity that constitutes meeting one’s are non-excludable, and so ‘an obligation to contribute solidary obligations. If solidary obligations arise from applies because the fruits of social cooperation have “a the bonds and connections involved in particular insti- quality of normative non-excludability”’. tutions and social practices, exactly what is required will To put this in the language of solidarity, it only makes depend on the nature of the group or scheme, and per- sense to talk of participants failing their solidary obliga- haps even the views of those involved. Nonetheless, tions if we are operating a system that is to some degree requiring some minimal degree of solidarity through independent of individual participants’ decisions to opt the kind of healthcare planning found in Golden in. If our cooperative scheme were structured so that Opportunities does not require perfection from pa- what you put in is what you eventually get out, there tients, but only a minimal or sufficient commitment could be no obligation to other participants to reduce to taking on some of the burdens of promoting their costs. This is because if you act in a way that means you own health. put less in, the only outcome is that you personally get A solidarity-based system that relies on Golden less out, and because the absence of public goods means Opportunities places conditions on full inclusion in Downloaded from https://academic.oup.com/phe/article/12/2/133/5528519 by DeepDyve user on 14 July 2022 140 DAVIES AND SAVULESCU the healthcare system. One potential criticism is that We accept these concerns as significant and legitim- these policies penalise only some individuals for failure ate. With respect to miscategorisation, it is a require- to comply with certain behavioural requirements. ment of any fair system that aims to hold individuals Nobody is responsible for their poor health in a responsible that it is open to challenge, and that re- vacuum; social conditions and biological predispos- sources are provided for such challenges. In addition, itions both play significant roles. For instance, if we the danger of misuse of responsibility may suggest limits take two moderate smokers, only one may be unlucky on the type of penalties that are appropriate. In particu- enough to be genetically predisposed to developing lar, our view is that total denial of care is unlikely to be a cancer from their level of smoking. Since Golden suitable penalty for this reason. Further, if a solidary Opportunities kick in only once someone risks develop- system does aim to make use of the concept of respon- ing a significant health problem, only the unlucky will be sibility, we must also recognise the importance of placed at risk of exclusion. increasing the opportunities people have to make A related problem stems from wealth. Few states have healthy decisions. The idea of support inherent in placed outright bans on private healthcare and so most Golden Opportunities does not only relate to advice, but to funded resources and programmes of which citi- public healthcare systems allow wealthier patients the option of opting out of the public system. One might zens can make use to improve their health. Our claim, worry that Golden Opportunities therefore risk intro- however, is that if people have the opportunity to make ducing a system whereby poorer patients have a duty of healthy choices, it is sometimes reasonable to hold them solidarity enforced through potential denial of medical responsible for choosing not to. care, but wealthier patients can engage in risky behav- Perhaps the more fundamental challenge comes from iours and then refuse Golden Opportunities at no per- the idea that invoking responsibility, whether appropri- sonal cost. This will also raise worries about the ate or not, risks undermining responsibility through its targeting of certain kinds of already stigmatised behav- focus on difference and division. Again, we acknowledge iours and groups (e.g. Friesen op cit), and of targeted the risk. However, it is worth noting a countervailing moralisation, where an already less well-off, or vulner- risk. If there is a general perception that many individ- able, minority are morally blamed for failing to main- uals are behaving unreasonably, this may itself weaken tain adequate health (e.g. Brown, 2018). the ties of solidarity. Moreover, as we outline below, an These issues highlight the importance of the broader acknowledgement of difference is consistent with a sim- social environment in thinking about solidarity. No ultaneous emphasis of similarity. healthcare system exists in isolation. To avoid inequit- One way to emphasise similarity, which also responds able distribution of burdens, any attempt to enforce cer- to some extent to the concern about genetic and social tain healthy standards of behaviour for those who are luck raised above, involves expanding the idea of Golden already in poor health (or at risk of it) must operate Opportunities by recognising that they may apply to within a broader social system that also exhibits many more of us than just those who indulge in the solidarity. standard ‘bad habits’ or who have serious health prob- However, one might worry that any policy which war- lems. Recall Buyx and Prainsack’s concern about using rants exclusion of some individuals from healthcare pre- solidarity as a rationing tool: we all make choices that sents practical risks. Although we endorse a careful impact our health. Most of us, then, will have the op- consideration of individual circumstances, in reality portunity to make changes to our lifestyles that will give two types of worry arise. First, any new criterion by moderate health benefits, or at least maintain our cur- which people can be excluded from healthcare, or rent level of health. levied additional charges, is a criterion that can be mis- A focus on solidarity can help us to see that what is used either through error, or intentionally by govern- relevant is not simply how much of a financial cost an ments or insurers keen to save costs. Second, a more individual’s health needs place on the health service, but general worry is that focusing on failures of reciprocity on whether individuals are willing to make moderate, might undermine solidarity in general, because of its reasonable sacrifices to avoid burdening others. The in- emphasis on difference, rather than on the similarity corporation into a national health service of a Personal that grounds solidarity. Although we have endorsed Health Plan, developed in coordination with the rele- strict limits on the conditions under which responsibil- vant patient, in recognition of their own limits and as- ity can lead to penalties, one might worry that it is pirations, is one potential way to expand the range of the bound to increase stigmatisation of already vulnerable basic idea of the Golden Opportunity. Such plans must groups. be developed with recognition that health is not the sole Downloaded from https://academic.oup.com/phe/article/12/2/133/5528519 by DeepDyve user on 14 July 2022 SOLIDARITY AND RESPONSIBILITY 141 value for anyone, nor the primary value for many. Our private healthcare is consistent with a solidarity-based demands on one another cannot be that we optimise our approach. For instance, some argue that pushing the health. For instance, some individuals may reasonably wealthy out of benefits systems leads to an overall de- prefer to risk physical injury in pursuit of sporting crease in public support for those systems. To para- achievement. Others may risk other kinds of health phrase social researcher Richard Titmuss (1967) problems by adopting a sedentary lifestyle because (cited in Alcock et al., 2001), the worry is that public they value work that requires long hours at a desk. services for the poor end up being poor public services. Both individuals may be able to lower the relevant However, this will depend on the level at which exclu- risks they face, and to improve their behaviour in sion begins. It is one thing for a service to be limited to areas that are less fundamental to their central goal, the very worst off, and hence fail to benefit the majority; such as diet. As such, while Savulescu’s original ex- it is another thing for it to be limited to all but the very amples of Golden Opportunities are rare, our view in best off (and then, only those in that group who behave this article is that the structure of the Golden irresponsibly), and thus accessible to most. Opportunity can in fact be made available to a signifi- cant proportion of individuals. Finally, we turn to the potential for the better-off to Conclusion escape any potential penalties in healthcare. This Our three cases—Inactivity, Smoking and Seatbelt—all means that demands of solidarity must extend beyond the healthcare system. It is hypocritical to insist that involve people making choices that impose costs on the public purse which are, in some sense, avoidable. In some sections of the population engage in ‘we-thinking’ (and its associated behaviour) without also insisting on some cases, such choices may violate obligations that arise from being involved in a solidary arrangement such thinking for the rest of the population. Any soli- darity-based enforcement of personal responsibility in and do so in such a way as to warrant penalties. healthcare, then, should come in tandem with policies However, we have argued that a violation of solidary designed to penalise failures of solidarity among the obligations requires more than avoidability: it requires wealthy, e.g. through tax avoidance, exploitative work- both that the risk taken is unreasonable, and that it was ing conditions, pollution, and so on. To punitively made under conditions that are conducive to autono- pursue solidarity only in a way that will disproportion- mous choice, as embodied in being offered a Golden ately affect the more vulnerable is to pursue solidarity in Opportunity. Inactivity meets these conditions, so name early, and its opposite in practice. Moreover, if long as his refusal of help is made in knowledge of the private patients are not fully internalising the costs of potential penalties. Finally, we argued that imposing their choices, then the same obligations of solidarity solidary obligations through penalties requires looking would apply. to the broader social environment. Only if solidarity is Concerns about equitability also add a further reason practiced and enforced here, particularly with respect to to avoid absolute denial of basic care as a penalty. Even if the most secure, is it reasonable to enforce it amongst one thinks that denial of basic care can be a legitimate those who need medical care. penalty for failures of solidary obligations, it cannot be legitimate to have a system that in practice denies basic care only to those who cannot afford private care. It may Notes also point us towards certain ways of implementing other forms of substantive responsibility. For instance, 1. The following discussion is based primarily on a system like the NHS, which is what we might call if substantive responsibility requires that one contrib- utes financially to the costs of one’s care in a way that ‘fully solidary’. Clearly this is not the only possible way to structure a health system. One might, for those who are not responsible for their medical needs are not required to, such contributions may need to be instance, have a system which, although funded lar- gely by progressive taxation, expects minor co-pay- weighted according to ability to pay, or kick in only when doing so would not affect a person’s basic needs. ments from patients at the point of service (e.g. £1 every time one visits a GP). Such payments could be One might think, on the other hand, that those who can afford private healthcare might face harsher penal- capped for those with chronic conditions, and waived for the very worst-off. Such a system might ties than those who cannot, including being excluded from the solidarity-based system altogether. Whether encourage solidarity by getting patients to see them- this is an appropriate solution will depend on whether selves as contributing directly to the health system. Downloaded from https://academic.oup.com/phe/article/12/2/133/5528519 by DeepDyve user on 14 July 2022 142 DAVIES AND SAVULESCU But there is, of course, a danger of putting off pa- treatment past a particular age (e.g. Callahan, tients who need medical attention, but are con- 1995). See Overall (2005) for response. 13. This judgement is based not on the type of behav- cerned about the cost. The fact that a health iour—there are many cases of inactivity that are not system requires some up front payment from pa- easily avoidable—but on the circumstances of tients does not prevent it from being solidary. So choice. long as there is some subsidisation of the worse-off 14. Vallentyne (2008) by the better-off, we have a somewhat solidary 15. Frankfurt (1971); Dworkin (1988) system. Our view applies, at a minimum, to the sec- 16. Christman (1991). tions of a healthcare system that are governed by 17. Savulescu and Momeyer (1997). such solidary practices. 18. One thing that does mark these cases out, however, 2. Tallis (2016); Broxton (2017); Heath (2018). is that they fall within pre-existing institutional or Though see Molloy (2018). social frameworks where it is reasonable to expect to 3. See also Taylor (2015) be penalised for such failures. Any case for substan- 4. NHS services are subject to an Immigration Health tive responsibility being attached to failures of solid- Surcharge for many people applying to enter or ary obligations must occur within such clear remain in the UK. See: www.gov.uk/healthcare-im- institutional framework. In other words, it should migration-application. be clear to individuals who might face penalty that 5. For instance, Fenger and van Paridon (2012: 51–2) this is a possibility. distinguish between ‘individual’ and ‘institutional’ 19. One might worry here that Golden Opportunities solidarity (in Reinventing Social Solidarity Across seem likely to occur quite rarely, and so may be of Europe), the latter of which ‘involves a certain limited use in a national health care system. We amount of pressure, a certain degree of organisation suggest a potential expansion of the concept below. and the presence of a set of formal or informal rules’. 20. It is worth noting in this context that the question of See also Prainsack and Buyx’s discussion of different costs is more complex than it may seem. For in- ‘tiers’ of solidarity, the most general sometimes stance, West-Oram (2018: 582) notes that a solidary involving state coercion to implement solidary prac- approach to healthcare can sometimes offer benefits tices (2017: 54–7). Even if such institutional prac- even to net financial contributors, such as the effect tices are not backed up by explicit feelings of of herd immunity through free vaccinations. solidarity from the majority of the population, Assume that offering relevant vaccinations (backed they typically rely on the ‘willingness of individual up by sufficient information on their importance persons to carry costs to benefit others’ (West- and safety) to any patient who visits a doctor or Oram, 2018: 581). Prainsack and Buyx (2017: 36) hospital is a Golden Opportunity. Some adult pa- note the distinction between solidarity as an essen- tients who refuse this opportunity may then become tially voluntary ‘community value’, and as ‘system unwell. Even if it is permissible to penalise these value’, enforceable by law. patients, it may be overall better to treat them for 6. For instance, Fraser (2008: 150–3) argues that soli- free if their condition is both infectious and serious. darity can exist both as a result of a subjective sense 21. Bærøe and Cappelen, op cit 838; Wolff (1998). of solidarity, but also due to causal interdependence. 22. This is also the reason that the patients in our cases In the latter case, we might say that given the exist- cannot, for instance, appeal to the fact that they have ence of such dependencies, individuals and states contributed towards the funding of the NHS, have obligations of solidarity even in the absence thereby supporting others in their unhealthy of any relevant sentiment. choices. Such a view would imply that those who 7. See also Friesen (2016). have not paid in have less right to behave unreason- 8. Hope et al. (2008) ably than those who have—or, that those who have 9. Savulescu (2007) not paid in as much have less right than those who 10. E.g. Arneson (2000); Cohen (2011); Lippert- have paid in more. Rasmussen (2015); Segall (2016) 23. It is also important to emphasise that holding people 11. See Vallentyne (2002) for a discussion of various responsible for certain decisions need not involve a ways of understanding the distinction. judgement of their character. Rather, the claim is 12. Some think, for instance, that elderly patients that solidarity entitles us to expect people to behave unreasonably if they expect life-extending impose only reasonable costs on others. Downloaded from https://academic.oup.com/phe/article/12/2/133/5528519 by DeepDyve user on 14 July 2022 SOLIDARITY AND RESPONSIBILITY 143 24. An alternative is to prevent individuals from buying Dworkin, G. (1988). The Theory and Practice of direct health services outside of the basic package Autonomy. Cambridge: Cambridge University Press. provided by the state (e.g. Gutmann, 1981: 553; Eyal, N. (2013). Denial of Treatment to Obese Patients—the Wrong Policy on Personal Walzer, 1983: 90). Responsibility for Health. International Journal of Health Policy and Management, 1, 107–110. Feiring, E. (2008). Lifestyle, Responsibility, and Justice. Funding Journal of Medical Ethics, 34, 33–36. Fenger, M. and van Paridon, K. (2012). Towards a This work was supported by a grant from the Wellcome Globalisation of Solidarity? In Ellison, M. (ed.), Trust [WT104848/Z/14/Z]. Reinventing Social Solidarity across Europe. Bristol: Conflict of interest: Bristol University Press, pp. 49–70. The authors declare that they have no conflict of Frankfurt, H. (1971). Freedom of the Will and the interests. Concept of a Person. The Journal of Philosophy, 68, 5–20. Fraser, N. (2008). Scales of Justice. London: Verso. Friesen, P. (2016). Personal Responsibility within References Health Policy: Unethical and Ineffective. Journal of Albertsen, A. (2015). Feinberg’s Concept of Forward- Medical Ethics, 44, 55–58. Looking Responsibility: A Dead End for Gutmann, A. (1981). For and against Equal Access to Responsibility in Health Care. Journal of Medical Healthcare. The Milbank Memorial Fund Quarterly Ethics, 41, 161–164. Health and Society, 59, 542–560. Arneson, R. (2000). Luck Egalitarianism and Heath, I. (2018). Back to the Future: Aspects of the NHS Prioritarianism. Ethics, 110, 339–349. That Should Never Change. BMJ, 362, k3187. Bærøe, K. and Cappelen, C. (2015). Phase-Dependent Hope, T., Savulescu, J., and Hendrick, J. (2008). Medical Justification: The Role of Personal Responsibility in Ethics and Law: The Core Curriculum, 2nd edn. Fair Healthcare. Journal of Medical Ethics, 41, 836– London: Churchill Livingstone. Krishnamurthy, M. (2013). Political Solidarity, Justice, Brown, R. (2018). Resisting Moralisation in Health and Public Health. Public Health Ethics, 6, 129–141. Promotion. Ethical Theory and Moral Practice, 21, Laitinen, A. and Pessi, A. (2014). Solidarity: Theory and 997–1011. Practice. An Introduction. In Laitinen, A. and Pessi, Broxton, A. (2017). “ Why Should the People Wait Any A. (eds), Solidarity: Theory and Practice. Plymouth: Longer?” How Labour Built the NHS. LSE blog, July Lexington Books, pp. 1–29. 8th 2017, available from: http://blogs.lse.ac.uk/poli- Lippert-Rasmussen, K. (2015). Luck Egalitarianism. ticsandpolicy/why-should-the-people-wait-any- London: Bloomsbury. longer-how-labour-built-the-nhs. [accessed 18 Marmot, M. (2005). The Status Syndrome: How Social January 2019]. Standing Affects Our Health and Longevity. London: Buyx, A. (2008). Personal Responsibility for Health as a Bloomsbury. Rationing Criterion: Why we Don’t like it and Why Molloy, C. (2018). Don’t Invoke the NHS to Sell a False Maybe we Should. Journal of Medical Ethics, 34, 871– Idea of “ Good Nationalism”. Open Democracy, May 874. 8. https://www.opendemocracy.net/ournhs/caro- Callahan, D. (1995). Setting Limits: Medical Goals in an line-molloy/dont-invoke-nhs-to-sell-false-idea-of- Ageing Society with “ a Response to My Critics. good-nationalism. [accessed 18 January 2019]. Washington: Georgetown University Press. Nagy, R. (2002). Reconciliation in Post-Commission Cappelen, A. and Norheim, O. (2004). Responsibility in South Africa: Thick and Thin Accounts of Health Care: A Liberal Egalitarian Approach. Journal Solidarity. Canadian Journal of Political Science, 35, of Medical Ethics, 31, 476–480. 323–346. Christman, J. (1991). Autonomy and Personal History. Overall, C. (2005). Aging, Death and Human Longevity. Canadian Journal of Philosophy, 21, 1–24. London: University of California Press, Ltd. Cohen, G. (2011). On the Currency of Egalitarian Justice Prainsack, B. and Buyx, A. (2011). Solidarity: Reflections and Other Essays in Political Philosophy. Princeton, on an Emerging Concept in Bioethics. London: NJ: Princeton University Press. Nuffield Council on Bioethics. Downloaded from https://academic.oup.com/phe/article/12/2/133/5528519 by DeepDyve user on 14 July 2022 144 DAVIES AND SAVULESCU Prainsack, B. and Buyx, A. (2017). Solidarity in Tallis, R. (2016). End of the NHS? Times Literary Biomedicine and Beyond. Cambridge: Cambridge Supplement, September 17th 2016, available from: University Press. https://www.the-tls.co.uk/articles/public/end-of- Raz, J. (2010). Responsibility and the Negligence the-nhs/.[accessed 18 January 2019]. Standard. Oxford Journal of Legal Studies, 30,1– Taylor, A. (2015). Solidarity: Obligations and Expressions. 18. The Journal of Political Philosophy, 23, 128–145. Savulescu, J. (2007). Autonomy, the Good Life, and Titmuss, R. (1967). Welfare State and Welfare Society. Controversial Choices. In Rhodes, R., Francis, L. In Alcock, P., Glennerster, H., Oakley, A., and P., and Silvers, A. (eds), The Blackwell Guide to Sinfield, A. (eds), Welfare and Wellbeing: Richard Medical Ethics, Part 1, Chapter 1. Oxford: Titmuss’ Contribution to Social Policy (2001). Blackwell Publishing, pp. 17–37. Bristol: Policy Press, pp. 113–124. Savulescu, J. (2018). Golden Opportunity, Reasonable Vallentyne, P. (2002). Brute Luck, Option Luck, and Risk and Personal Responsibility for Health. Journal Equality of Initial Opportunities. Ethics, 112, 529– of Medical Ethics, 44, 59–61. 557. Savulescu, J. and Momeyer, R. W. (1997). Should Vallentyne, P. (2008). Bad Luck and Responsibility. Informed Consent be Based on Rational Beliefs?’. Politics, Philosophy & Economics, 7, 57–80. Journal of Medical Ethics, 23, 282–288. Walzer, M. (1983). Spheres of Justice: A Defense of Segall, S. (2005). Unconditional Welfare Benefits and Pluralism and Equality. USA: Basic Books. the Principle of Reciprocity. Politics, Philosophy & West-Oram, P. (2018). Solidarity as a National Health Economics, 4, 331–354. Care Strategy. Bioethics, 32, 577–584. Segall, S. (2016). Health, Luck and Justice. Princeton: West-Oram, P. and Buyx, A. (2017). Global Health Princeton University Press. Solidarity. Public Health Ethics, 10, 212–224. Shelby, T. (2002). Foundations of Black Solidarity: Wolff, J. (1998). Fairness, Respect and the Collective Identity or Common Oppression. Ethics, Egalitarian Ethos. Philosophy & Public Affairs, 27, 112, 231–266. 97–122.

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Public Health EthicsOxford University Press

Published: Jul 1, 2019

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