Civic Solidarity and Public Health Ethics

Abstract

Is solidarity in bioethics or public health ethics necessary? If so, why? Is there room for a principle of obligatory solidarity in bioethics or in public health ethics? In the first part of this paper, I assess the meaning of the value of solidarity in ethics. In the second part, I propose insights into the republican interpretation of solidarity, or, more correctly, “civic” solidarity. This is crucial to be able to distinguish between different sources of, and justifications for, solidarity, some legitimate and some not legitimate. In the third part of the paper, I apply the republican concept of civic solidarity to the field of bioethics and public health ethics. This is intended to show how civic republicanism can correct both liberal deficiencies and communitarian excesses in bioethics. Civic solidarity is essential to finding this middle way. It is a key concept, considering the challenges that we face as citizens, health professionals and patients. Finally, the paper concludes with a summary and a plan for further research in this area.

1. Introduction

Is solidarity in bioethics or public health ethics necessary? If so, why? These questions are not pointless. If solidarity were a principle, then what exactly would it add to the four main (prima facie) principles of bioethics: autonomy, justice, beneficence and non-maleficence [1]? These principles would seem to be a sufficient basis for all discussions on biomedical ethics (or at least, they have sufficed until now). One might say that solidarity could be reduced to either justice (in distributive and redistributive terms) or beneficence. That would be reasonable for the sake of simplicity and the principle of economy of thought. Any addition to the four principles paradigm in bioethics must be very well justified. Considering the substantial differences in recent scholarship among most of the proposals for introducing solidarity to the field, it is sensible to say that solidarity is a candidate for being a principle. Perhaps it might be a secondary or auxiliary principle. Or maybe something else, such as the “putty” of justice [2,3]. According to some people, solidarity is not a principle on its own terms, so does that mean it is not needed? Solidarity seems to be a rhetorical device in terms of exhortations to the common good, although it is not at all clear whether that common good currently exists in plural societies. At best, solidarity may have a supererogatory role of assisting others: “manifestations of solidarity may be morally commendable but they cannot be made binding” [4]. However, none of the four principles of biomedical ethics is supererogatory. All of them are simply obligatory. Is there room for a principle of obligatory solidarity (paradoxical as that may seem) in bioethics (especially in public health ethics)? This is the subject of the present paper.

The paper is divided into three parts and a conclusion. In the first part, I will assess the meaning of the value of solidarity in ethics. What counts as solidarity and what does not is important in framing the debate about bioethics and public health ethics. Thus, the first part of the paper is an evaluation of the normative content of solidarity and an analytical clarification of the term. In the second part of the paper, I will propose insights into the republican interpretation of solidarity, or, more correctly, “civic” solidarity. This is crucial to be able to distinguish between the different sources of, and justifications for, solidarity, some legitimate and some not. In the third part, I will apply the republican concept of civic solidarity to the field of bioethics and public health ethics. This is intended to show how civic republicanism can correct both liberal deficiencies and communitarian excesses in bioethics. Civic solidarity is essential to finding this middle way. It is a key concept, considering the challenges that we face as citizens, health professionals and patients. Finally, the paper concludes with a summary and a plan for further research in this area.

2. Solidarity: What It Is and What It Is Not

There are essentially two fields in which (human) solidarity has been an issue: sociology and ethics (we could add, among other disciplines, social psychology, anthropology or ethnography, but that would not change my argument). Sociology takes solidarity as a descriptive term. Ethics takes it as a normative term. As a descriptive term, solidarity refers to the social practices that de facto hold together a human group. Durkheim’s mechanical and organic solidarity are typical examples of this sociological approach to solidarity. They point towards the cohesiveness of small, undifferentiated communities (mechanical solidarity) or to more complex, modern societies based on the division of labor (organic solidarity). Solidarity here is a (Durkheimian) “social fact” [5]. It is important to bear in mind the factual aspect. “Solidarity” refers to something that “is” (or maybe “is not”—it depends on the accuracy of the scientific description), something that sociologists discover or uncover among the tangle of society. Although there was an interesting program in France aimed at defending political solidarity (solidarisme) based on these sociological theses [6], this path is an obvious cul-de-sac for us. We are not looking for a fact. We are looking for a value. And we cannot derive an “ought” from an “is”. In other words, “there is a class of statements of fact which is logically distinct from a class of statements of value. No set of statements of fact by themselves entails any statement of value. Put in more contemporary terminology, no set of descriptive statements can entail an evaluative statement without the addition of at least one evaluative premise. To believe otherwise is to commit what has been called the naturalistic fallacy” [7]. This is not to say that Hume’s guillotine (rather than the “naturalistic fallacy”) is a dogma. It is possible to find some counterexamples to this thesis, as Searle and others try to do, or we can even deny a rigid separation between facts and values. However, everyone would concede that the fact that we can demonstrate that there really is some kind of solidarity among people does not guarantee that this sort of solidarity is ethical (i.e., ought to be). Think of solidarity among gangsters, corrupt politicians, or terrorists. “The mutual support of a firing squad or terrorist cell is no less ‘solidarity’ than the mutual support of a healthcare system” [3]. The mere existence of solidarity (of whatever kind) does not entail per se a positive evaluation in moral terms. That depends on the telos of the solidarity in question. Moreover, the same goes for all other solidarities seen as mere “social facts”. Without deliberately ignoring the facts disclosed by the social sciences (or even the natural ones), ethics has a normative language of its own and cannot be solely based on empirical facts.

Let us suppose that solidarity is a virtue. We do not know it yet, so this is just a supposition. We could define it in Aristotelian terms as “a voluntary and acquired disposition” (we can find these two definitions in Aristotle’s works: “κατὰ γὰρ τὰς τούτων διαφορὰς ἀκολουθοῦσιν αἱ ἕξεις. οὐ μικρὸν οὖν διαφέρει τὸ οὕτως ἢ οὕτως εὐθὺς ἐκ νέων ἐθίζεσθαι, ἀλλὰ πάμπολυ, μᾶλλον δὲ τὸ πᾶν.” (Nic. Eth. 1103b.20-25) and “ἡ ἀρετὴ ἑκούσιόν ἐστιν” (Nic. Eth. 1114b.15)). Virtues depend on willingness and education. Natural or automatic dispositions (if they exist) are not “virtues” at all. On the other hand, to act in solidarity is to act from a disposition or “hexis” (a stable, determinate and prohairetic tendency condition that has a certain quality). Needless to say, an act of solidarity by chance (if possible) is not “solidarity as a virtue” either. Acts per se do not constitute the criterion by which we can determine the moral value of a virtue. Of course, I do not deny that acts (or the outcomes of acts) can be very important in moral thinking (as they are in consequentialist ethics). However, I am not considering solidarity now in utilitarian terms. That mental exercise could indeed be performed, but it is not my aim here, because the eudaimonism with which I am playing differs from the utilitarian one. My aim is to show that the hypothetical virtue of solidarity cannot be defined just as an act. Take courage as a virtue, for example. In my opinion, Philippa Foot is right when she says that “the man who is ready to pursue bad ends does indeed have courage, and shows courage in his action, but that in him courage is not a virtue” [8]. The key concept here is the (good or bad) end. To talk about a moral virtue, first we need to establish the good and bad ends in light of which we can assess the moral quality of a presumed virtue (these good ends will have to be translated into a series of normative premises). This is what I referred to as “telos” above. Solidarity as an ethical virtue cannot: (1) be reduced to a mere fact; (2) be considered a mere action; and (3) be disconnected from (a) a set of evaluative premises and (b) a hexis (or human disposition). Any theory of solidarity as an ethical virtue must fulfill at least these conditions (and maybe others as well).

We are now in a position to consider “solidarity” as a “thick” term (or “essentially contested concept” [9]). Being “thick” (that is, a descriptive term whose use is always also evaluative [3]), the earlier distinction between facts and values would not matter much. Let us admit that the use of the term “solidarity” is already embedded in an evaluative framework. This does not mean, however, that “solidarity” will always serve as praise and that any solidarity whatsoever is (ethically) good enough. Rhetorically, we can even refer to acts of “solidarity” of a criminal squad in ironical terms (or we can praise an act as solidarity without morally agreeing with it). Some people will praise a behavior as (ethical) “solidarity” and others will not (depending on their evaluative premises). Be that as it may, from our perspective, solidarity will have to be thought of as an “enacted commitment (…). If it is to enact a commitment, an instance of action in solidarity must flow from an enduring orientation that disposes the agent so to act when relevantly similar opportunities arise, and to seek out opportunities in order to act in them. (There might never actually be another such opportunity, but the possibility must exist)” [3]. That is, it is necessarily a disposition (a form of being). The crux of the matter is that we must look for a criterion to discern which of the dispositions are truly virtues (or which values are ethically relevant). In other words, solidarity as a virtue further specifies which of the evaluative conditions deserve the qualification and which do not. The theory of solidarity as a virtue needs a theory of virtues and vices [8]. Being evaluative as such is not enough to ground a good explanation of the goodness of solidarity. Therefore, if we want to maintain the distinction between facts and norms, we need normative statements to ground our theory of solidarity as a virtue (facts will not be enough); however, if we want to dispense with this distinction, because we think that we are already in a normative framework (and “solidarity” as pure fact does not exist), we will need another way to discern which of these values are ethically relevant and count as virtues. We are obliged to look for a normative theory of solidarity; obliged to specify which solidarity we value.

Before we can do that, an additional definition of solidarity is needed. Sometimes we use a word and we think that we completely understand its meaning. This happens all the time. However, most of the time we are unable to give a good definition of the word in question. Without falling to the Socratic (or definist) fallacy, everyone would concede that it is always possible (and desirable) to analyze a term (or clarify a meaning). What is solidarity and what is it not? The answer to this question will be helpful in the field of bioethics. I am not saying that we must have a definition of solidarity to be able to use the term. I am just saying that a proposal for its definition would be very useful for defining a theory of solidarity as a virtue in public health ethics.

“Solidarity” is a very tricky word. It refers to a value. For this reason, I have sketched a conception of solidarity as a moral virtue. However, this does not suffice. We also need to know what the differences are between solidarity and other (very similar) values, such as charity, beneficence, or justice. My strategy for identifying solidarity will be based upon the origins of the word. I do not claim that the real meaning of a word (or its appropriate use) is revealed by its etymology. I am suspicious of making a claim about the present meaning of a word based exclusively on that word’s etymology, which is a well-known etymological fallacy. However, the genealogy of a word can cast a light on the subject. It gives us some information, although it will not settle the issue once and for all. My hypothesis is that “solidarity” has traveled a long way since its origins; specifically, that “solidarity” (in our present use of the word) is the result of a double “conceptual metaphor” [10]. Looking at the process of its formation, we can distinguish a set of intuitions that belong to the semantic field of “solidarity” rather than other semantic fields.

Simply put, a conceptual (or generative) metaphor consists in understanding an idea in terms of another. We need two conceptual domains: a source domain and a target domain. There is an analogical switch from the source domain (concrete, simple, physical, intuitive, near, quotidian and easy to understand) to the target domain (abstract, distant, complex and often controversial). The first move of the conceptual metaphor is as follows:

(1)

Source domain or A: something is solid (cannot be divided in parts or be broken). Out of interest, “solid” comes from the Latin “solidus”, which in turn comes from the Proto-Indo-European *sol- (whole, well-kept, unbreakable). Both “solidarity” and “salutary” come from this root. However, the fraternity of health and public virtue does not interest us here, unless we want to fall into the dark world of etymological fallacies.

(2)

Target domain or B: according to the Roman law of obligations, “the unlimited liability of each individual member within a family or other community to pay common debts was characterized as obligatio in solidum” [4]. These are, of course, the “solidary obligations”, which cannot be made pro rata s. in partem. That is, every debtor in a joint obligation is liable in solidum for the whole: the debt cannot be broken into pieces. The metaphorical projection operates from the quality of a physical object (solid) to the quality of an obligation in the field of the law. We understand something (the legal obligation) in terms of something else (the physical quality of an object). In this case, the creditor can ask any debtor for the total sum of the debt, so we can say that they are in solidarity.

The value of solidarity that we are searching for cannot be an item of the law of obligations between creditors and debtors. Nonetheless, this is the origin of our concept.

There is a subsequent projection from the legal domain to the ethical domain. This second conceptual metaphor works as follows:

(1)

Source domain or B: again, the Roman law of obligations and all subsequent laws of obligations (based on those ancient conditions for guaranteeing the recovery of a debt).

(2)

Target domain or C: a moral or political value (something ethical and normative) of mutual responsibility according to which (a) every part is liable for the whole; (b) there is a moral commitment (not necessarily described in deontological terms as a “duty”) to assist others in need; (c) there is a “solid” attachment among members of the same group. This is a generalization and has been applied out of the context of the original, legal framework. In effect, C is related to both A and B (as, incidentally, is A to B).

These three conditions for solidarity (as a value) permit an important clarification. Those who do not agree with my definition in (4) will have to take it as my humble stipulation. From here on, this will be the definition I use to build up my theory of solidarity applied to bioethics and public health ethics. It defines some boundaries, for example, that one can be charitable and benevolent towards another without being in solidarity with them. Only the second clause, (b), applies to charity and benevolence. To be charitable to someone, one does not have to feel a “solid” attachment to that person as a member of the same group (c) and, more importantly, charity has nothing to do with a liability for the whole (with its consubstantial common good) to which both the assistant and the assisted belong (a). Justice, on the other hand, broadly speaking, refers to a fair procedure for the distribution of primary goods [11]. Although it is highly disputable whether the Rawlsian principle of difference can be understood as a sort of “solidarity” [4], in theory the allocation of primary goods in a well-ordered society is not the same as a solid attachment to each other among members of the same group that prompts them to assist each other. This is because one can feel the goodness in assisting someone in trouble, whether the distribution of goods is fair or not. Imagine that the person in need has spent all their money gambling. Solidarity does not deny justice, but may sometimes supersede it; therefore, they cannot be the same.

3. Civic Solidarity: What It Is and What It Is Not

Solidarity cannot be reduced to the bioethical principles of beneficence and justice. This thesis does not entail that we must embrace any kind of solidarity, nor does it mean that we have to add solidarity to these principles, among other reasons, because it is not at all clear whether solidarity is truly a principle. It is just a way of distinguishing different values.

Let me recall the conclusions we have reached so far:

(1)

The value of solidarity comes from a double conceptual metaphor: A (solid) is projected to B (obligatio in solidum); and B to C (the value of solidarity proper).

(2)

The value of solidarity consists of: (a) a mutual responsibility according to which every part is liable for the whole; (b) a moral commitment to help others; and (c) a strong attachment among these parts to form a group on its own terms.

I have also posited that solidarity is a virtue. This supposition slightly distances us from the principlist perspective of the principles of biomedical ethics [1] and takes us closer to the perspective of virtue ethics [8]. However, it captures something reliable. It is very common, when we talk about a solidary act, that we also tend to think about a quality of the person who performed it; that is, we think that such a person is solidary (we value their form of being and we seem to understand that the solidary act somehow flows from their character). The problem with that is that a set of evaluative premises is necessary to label the solidarity in question as ethically valuable. Not all courageous acts are virtues, nor are all solidary acts virtues. Hence, a virtue theory is necessary.

Leaving aside other forms of solidarity, such as cosmopolitan solidarity in global ethics, ecological solidarity in animal ethics, or ethnic solidarity in nationalist terms (none of which I will discuss here), my point has to do with civic solidarity; the adjective here is of paramount importance. I am not looking for a virtue theory in general—I am only interested in civic virtues [12]. This qualification restricts the range of the theory and, at the same time, relates it to the condition of citizenship. Thus, what is a good citizen? I admit that it is a difficult question. It is not a question about legal status. The adjective “good” implies that the question is plainly normative. First and foremost, one could say that a good citizen obeys all the laws of their country (this is what is commonly referred to as a “good citizen”). This is one way to put it, but it will not be mine. One can be a good citizen in spite of, or precisely due to, civil disobedience. Therefore, complying with all the laws cannot be the criterion. Thus, we need a normative citizenship theory that, among other things, we can even use to know when we should obey a law and when we should not (although compliance with the law and civil disobedience are not my current targets). Summing up, we need a theory which transcends positive laws; that is, we need an axiology of citizenship. The good news is that this theory exists and has a long history, dating back to ancient Athens and Rome. It is called “civic republicanism”.

It is necessary to specify what I mean by “civic republicanism”. I will do so succinctly but thoroughly. In the first place, civic republicanism is a tradition of thought, a tradition that appears in various historical contexts. Given that we are not interested in a “historical reconstruction” of any of these contexts, I will use the civic republican tradition of texts as a resource for a “rational reconstruction” [13] that will be applied to present concerns. That is, it will be a contemporary appropriation of civic republicanism. In other words, I do not want “to retrieve a lost vision of public life, but (…) to explore a new vision of what public life might be” [14]. I am neither the first nor the only person to undertake this type of intellectual exercise [15,16,17]. Simply put, it is a philosophical methodology that invites us to select contents from historical civic republican sources that, with the pertinent adaptations, are useful for the conditions of contemporary democratic societies. Secondly, the basic elements that matter for a synthetic reconstruction of republican citizenship are the following: liberty, equity and solidarity [18]. These three ideas are very similar to (though not exactly the same as) the famous revolutionary triad of the French Revolution: liberté, égalité, fraternité. Finally, I will propose an overview of civic solidarity within the republican framework.

Firstly, let us consider libertas. I will use its translated terms “liberty” and “freedom” interchangeably. I am mainly interested in the political meaning of these terms. Nowadays, the hegemonic conception of (political) freedom is linked to what has been called the “Berlin-Constant framework” [14]. This framework provides the core element of liberalism (as opposed to civic republicanism). What is this element? According to the liberal framework, freedom should be understood as non-interference. “I am free as long as I am not an object of effective, external interferences, such as laws”. That is all. It is a factual definition of freedom that we can find both in Berlin and Constant, although Constant’s position on this matter could be considerably nuanced. Berlin describes Constant as the “father of liberalism”; as he saw it, Constant demanded “a maximum degree of non-interference compatible with the minimum demands of social life” [19]. Since the value of freedom as non-interference has to do “with the area of control, (but) not with its source” [20], Berlin even claims that the subjects under Frederick the Great of Prussia and Joseph II of Austria (two classic examples of enlightened despots during the age of absolutism) may have been freer than the citizens in some democracies. How so? Because these two autocrats allowed their subjects a wider area of non-interference than some democratic governments (Berlin does not specify which ones, but we can guess). According to this liberal conception, effective interference is all that matters. One might object that there are a number of conceptions of liberalism (including those of John Rawls, John Stuart Mill and Elizabeth Anderson, among others) that do not line up with my definition of the “liberal freedom”. Am I using a rather Robert Nozick-esque definition of “liberal”? I do not think so. Rawls and Nozick share the same conception of liberty as non-interference (Rawls, for instance, praises Constant’s liberty of the moderns throughout his Political Liberalism). They disagree about matters of redistributive justice (that is, for example, about the difference principle). In this sense, there is also a deep divide concerning egalitarianism between Anderson and Nozick. Finally, Berlin often quotes Mill as a proponent of liberty as non-interference [19]. I claim that all these authors share the same conception of “liberty”, but not the same conception of “liberalism” since their theories (based upon freedom as non-interference) differ greatly. A famous example has been used to challenge this viewpoint. Imagine that you are a slave. Now imagine that your master has never, neither before nor now, interfered in your decisions and actions. In liberal terms, you are free. How can a slave be free? Quentin Skinner (a neo-Roman republican) has shown that liberty before liberalism was related to the possibility of interference and not only with actual interference [21]. A good master, as Cicero used to say, is still your master (so you are not really free). You will have a lower status because your master can interfere in your life when they please. What is more, you will probably tend to behave servilely so that your master continues to treat you well. Republican freedom is independence, not just non-interference.

The origin of the “Berlin-Constant framework” arose out of a well-known argument. Hobbes was its author. I will quote it so that we can see the non-interference thesis in all its glory:

“There is written on the turrets of the city of Lucca in great characters at this day the word LIBERTAS; yet no man can thence infer that a particular man has more liberty or immunity from the service of the commonwealth there than in Constantinople. Whether a commonwealth be monarchical or popular the freedom is the same”.

(Leviathan, xxi, §8, 110)

That is to say, a subject in monarchical Constantinople is as free as a citizen of popular (and by the way, republican) Lucca. According to Hobbes, ancient “libertas” is meaningless. Liberty is just immunity from the service of the commonwealth (non-interference). The source (“whether a commonwealth be monarchical or popular”) does not matter much. Now look at Harrington’s answer to Hobbes. James Harrington was a committed republican and a contemporary of Thomas Hobbes. I will quote him at length:

“For to say that a Lucchese has no more liberty or immunity from the laws of Lucca than a Turk has from those of Constantinople; and to say that a Lucchese has no more liberty or immunity by the laws of Lucca, than a Turk has by those of Constantinople, are pretty different speeches. The first may be said of all governments alike; the second scarce of any two; much less of these, seeing it is known that, whereas the greatest Bashaw is a tenant, as well of his head as of his estate, at the will of his lord, the meanest Lucchese that has land is a freeholder of both, and not to be controlled but by the law, and that framed by every private man to no other end (or they may thank themselves) than to protect the liberty of every private man, which by that means comes to be the liberty of the commonwealth” [22].

Harrington dismisses being free from the laws (something that may be said of all governments). Politically, this (liberal) freedom is irrelevant. What really matters is being free by the laws. A rich bashaw in Constantinople is subject to the will of his lord, that is, the sultan (something that is characteristic of Eastern and Western despotisms alike). Being momentarily immune from the laws does not guarantee the bashaw’s freedom, since he remains subject to the will of the sultan (he remains subject to the possibility of arbitrary interferences). On the other hand, the laws in Lucca guarantee the (republican) freedom of all its citizens, even the poorest ones. The laws of Lucca are framed to generate freedom as non-domination. By law, no citizen is allowed to dominate another citizen; that is, no citizen, poor as they may be, can be subservient to another citizen. Public power ensures this. In Lucca, laws protect every individual from being subject to the arbitrary will of another individual (against dominium) and, at the same time, they protect them from being subject to the arbitrary will of the government (against imperium). This is the liberty of the commonwealth or a “free state” [21]. Republican laws are, thus, non-arbitrary interferences.

The civic republican concept of freedom is framed by means of a conceptual metaphor. The source domain is the master–slave relationship. The target domain results from a projection of this relationship onto the life of citizens (reciprocally between each other and in relation to the state). “Since the whole concept and structure of the master-slave relationship is projected en bloc into the derived political domain, then not only are a large number of individual terms and images made available for use in the political domain, but these terms and images also retain their connotations and the relations that obtain among them. Thus, if in the parent domain (source domain where language is used in a literal, non-metaphorical sense) freedom is the condition of not having a master, so too in the derived domain (or target domain, in which a different social experience is expressed and structured according to the same categories of the source domain)” [23,24]. What protects me from being a (conceptually metaphorical) slave is my condition of true citizenship. Ancient Romans knew this very well: libertas est civitas. “Keine civitas ohne libertas (und) keine libertas ohne civitas” [23]. If it is true that there is no solid liberty without citizenship, then civic republicanism gives a better account of political freedom than Berlin’s liberalism. The simple fact of non-interference, aside from civic status, means nothing: “Außerhalb dieses status sei sie farblos, gestaltlos und für die Praxis bedeutungslos; sie verflüchtige sich in ein Nichts” [25]. Liberty and citizenship are closely related to each other: by definition, no citizen can be unfree and no real freedom exists without the public recognition of a shared status based upon non-domination (citizenship).

Properly reconstructed, this old republican insight is enormously productive for assessing the normative conditions of citizenship in our contemporary democracies. We can extend the target domain of the conceptual metaphor of freedom (from the source domain of the master–slave relationship) to wives who are economically dependent on their husbands (patriarchal domination); to workers under the sway of capitalists (class domination); to customers who are obliged to buy a basic product from a monopoly (economic domination); and to social service users who are at the whim of unchecked bureaucrats (state domination), among many others [14]. To avoid all these dominations, public powers ought to guarantee the conditions of republican freedom for all citizens. They can do this, for instance, by means of a basic income that allows all citizens to be materially independent of others. However, they can also do it by means of other non-arbitrary interferences and regulations. This is precisely one of the pillars of the civic axiology we were looking for. Indeed, this conception “appears to be an inevitably moralized, normative conception of liberty” [15].

Secondly, let us briefly examine another key pillar of civic republicanism: equality. There are two different notions of equality in republican sources. “Equality” can mean Athenian ἰσονομία (isonomia) or Roman aequum ius. “Notionally, too, aequum ius is entirely different from the Athenian isonomia, and this difference throws much light on the meaning of the Roman concept. Uppermost in ἰσότης is the notion of parity, whereas in aequitas it is fairness, justice, equity. Isonomia is equality of rights and parity of standing interpreted in terms of extreme democracy, whereas aequum ius or aequae leges means above all equality before the law, but not equality of political rights enjoyed by all citizens” [26]. On this basis, we can reconstruct two different political theories: either we stress the participatory aspect of equality (as neo-Athenian republicanisms do) or equality with legal guarantees (as neo-Roman republicanisms do). Without necessarily denying the fruitfulness of civic humanism, I will stick to civic republicanism for the sake of my argument. To be able to add equality to liberty as a republican value, all we now need is the following condition: “If a citizen society is bonded by law enshrining equal justice, then it follows that its members—the citizens—must have an equal status if they are to receive justice: they must have equal rights” [27]. Equal status is our equality prima facie, that is, “equality in relational terms, as an equality of standing or an equality of status” [28]. Needless to say, this “equal status” is nothing else than citizenship: aequitas est civitas. However, I am also open to enriching this definition with a consideration of “redistributive policies in line with an egalitarianism with respect to the meeting of basic needs, a principle of republican equality that guarantees everyone a level of capabilities minimally necessary for operating as a free and independent citizen” [29], although this addition (redistributive policies) is very close to solidarity.

The third pillar of the republican axiology is precisely the research objective of this paper: civic solidarity. Let us remember my previous definition of solidarity. To achieve solidarity, these were the three clauses involved:

(a)

Every part ought to be liable for the whole (with its consubstantial common good).

(b)

There ought to be a moral commitment to assist others in need.

(c)

There ought to be a “solid” attachment among members of the same group (groups can be of different types).

None of these clauses specified a particular axiology. This is why we were able to imagine “solidary” acts-and-dispositions that per se were not virtues. However, now we are in a position to define an axiological context. We just have to apply the civic republican framework to this definition. The result will be, properly speaking, civic solidarity; that is, solidarity among citizens (so not necessarily among members of the same ethnicity; not necessarily among members of the same gender; not necessarily among members of the same sentient condition; not necessarily among members of the same social class; and not necessarily among members of the same animal species). All other solidarities are not relevant here. They can be very valuable (or not), but that is out of my scope. In my prior examples, the worker threatened by the employer or the woman threatened by her husband ought to be qua citizens defended through civic solidarity. Not because they happen to be of a determinate gender or social class, but because they are citizens. Regardless of their social class or gender, they are to be guaranteed equal status and liberty free from domination. All other partial solidarities can be very useful for the republic or, on the contrary, they can be harmful. However, they are not civic solidarity. Civic solidarity, as a form of civic friendship, is all-encompassing [30].

In (a), every part is every citizen. However, what is the whole? The whole is the “republic”. However, what does that mean? It means that we are talking about the political virtues that sustain freedom as non-domination and equality of status (citizenship in itself). The part is the citizen and the whole is citizenship (civitas = res publica). Rawls considered these virtues in terms of “classical republicanism”: participation to preserve democratic liberties [31]. Neo-Roman republicanism also conceives this political participation in instrumental terms: the part takes care of the whole; that is, the citizen takes care of the republic. Citizens have powerful reasons to do so, because their liberties could be in danger if they were to resort to mass private reclusion (political apathy often entails abuse of power and despotism). Even the liberal Benjamin Constant would agree with that [32]. The common good is precisely the good of citizenship as such. Let me suggest that in practice we do not have to epistemologically discover this common good, but we have to invent it by means of civic deliberation, agonistic participation and democratic contestation. “Our self-image would employ images of making rather than finding, the images used by the Romantics to praise poets rather than the images used by the Greeks to praise mathematicians” [33]. Solidarity in this way becomes a civic exhortation: “To move our compatriots to commit themselves to the common liberty of their people we have to appeal to feelings of compassion and solidarity that are—when they are—rooted in bonds of language, culture, and history. The work to be done is to translate these bonds into Love of common liberty. To make this alchemy of passions possible we surely need moral arguments that appeal to reason and interests, but we must also be able to resort, as good rhetoricians do, to stories, images, and visions” [34].

In (b), we encounter one of the main intuitions of solidarity. Civic assistance can take a lot of forms. Siding with the least well off is justified by the fact that their civic status could be endangered. Thus, when it is necessary, good citizens help each other. This can happen directly (through the practice of the civic virtue of solidarity in a civil association or community service) or indirectly (through taxes and public provisions in terms of redistribution of wealth). In some countries (for example, Spain), there is an explicit principle of solidarity that allows for a transfer of resources from richer to poorer regions.

Finally, in (c), the group in question is citizenship. We need this clause because “one is not solidary with just anybody, but only with the other members of the particular community to which one believes oneself to belong” [4]. In civic solidarity the group corresponds to the community of citizens. The civic humanist Leonardo Bruni explains in his Laudatio florentinae urbis that the poor citizens of Renaissance Florence, when they faced an attack by the rich citizens, used to say: “Ego quoque florentinus sum civis”; that is, “I am also a Florentine citizen”. The “also” is crucial because it refers to a solidary link between citizens so solid that it precludes aggressions and facilitates mutual support. In this case, the group has a political nature. It is not ethnical or religious. It is an identity based upon liberty and equality enacted in a particular republic. It is not at all farfetched to reconstruct Bruni’s anecdote in contemporary terms. The (civic) attachment must avoid any kind of domination and discrimination among citizens. This last characteristic will be important in the next section of the paper, and again: all solidarities that transcend the scope of citizenship (for example, receiving foreign refugees), even though they can be very valuable and praiseworthy, are not civic solidarity in stricto sensu.

One last word about the three civic republican pillars: liberty, equality and solidarity. It is often taken for granted that these values are independent, similar to ideas in Plato’s theory of forms. They are supposed to be three different concepts (each with its own definition) that substantiate the idea of citizenship. It is obviously true that they are not the same. Liberty is neither equality nor solidarity. However, they are intimately related. Liberty, in a republic, has to be seen as aequa libertas (equal liberty). The value of equality (aequa societas) could also be used to justify solidary acts or redistributive measures, and in fact, civic solidarity, when practiced, makes it possible to preserve both republican liberty and equality of status. There are subtle connections between the three. There is no need to worry about these blurring boundaries. I am tempted to say that this interdependence shows the solidity of the axiological account that we have reconstructed. The truth is that the world of values is entangled.

4. Civic Solidarity in Public Health

Broadly speaking, there are two main theoretical approaches to bioethics: the liberal approach and the communitarian approach. I deliberately leave out the empirical bioethics, clinical bioethics, narrative bioethics, feminist bioethics, medical humanities and other kinds of approaches that cannot be easily divided into these two categories. Put another way, for the sake of argument, I agree with File’s point that bioethical thinking (and practice) takes place along the liberal/religious communitarian axis [18]. Of course, this statement should be nuanced: liberalism and communitarianism may be too vague to accurately capture the core and argumentation of a bioethical thesis. Moreover, these two poles are not necessarily in conflict (even though this is not at all unusual). For instance, Daniel Callahan states that “many well accepted principles reflecting a commitment to liberal individualism can be converted into communitarian principles, and (…) they will be richer for it” [35]. Somehow, though, there is an obvious tension between an emphasis on community values as such, on the one hand, and an emphasis on individual autonomy, freedom of choice and self-definition, on the other.

I believe civic solidarity to be one of the values that can cut across the liberal/communitarian divide in bioethics. Not any kind of solidarity, admittedly; only civic solidarity can do the job. It is a fact that “modern liberal and liberal egalitarian thinkers invoke solidarity rather rarely” [2]. There are, of course, some recent exceptions to this trend [36]. In what follows, I will attempt to take a complementary path to justify some public health measures in terms of civic solidarity. Civic republicanism (and its suitable form of solidarity) can redescribe the debate between liberals and communitarians and, at the same time, can offer good grounds on which to adequately address bioethical dilemmas and conflicts that take place in public health. Arguably, “solidarity is rarely mentioned in the literature on the ethical issues that arise in public health policy and practice” [37]. However, in bioethics, one can find claims for solidarity based on three common communitarian theses [38]:

(1)

Communities cannot be reduced to individuals and their rights.

(2)

Community values are not simply extrapolated values of the autonomous individual, but they must include the values of reciprocity, trust, solidarity and tradition.

(3)

Ethical autonomy without common values is impossible.

The conclusion is that “the moral relation of the individual and the state demands a reciprocity of responsibility that places those values sustaining the community as paramount” [38]. Or, in an analogy with ecology, it can be said that “the important question for ecologists when new species are introduced into an existing environment is not just how well they will flourish individually, but what they will do to the network of other species. Will they live in harmony with them, perhaps improving the whole ensemble, or will they prove destructive? Or will they perhaps do a little of both? The function of communitarianism is to force us to ask the ecology question, now brought into the realm of ethics” [35]. The answer to the ecology question, and one of the values that sustain the community, is, in either case, solidarity.

The problem with communitarian solidarity is that sometimes it can be too demanding. “Communitarians are to be distrusted because they call us into a kind of solidarity with others in public life that would be disastrously totalitarian, threatening our private bonds and spiritual freedom” [39]. However, this depends on the kind of solidarity. Being communitarian does not guarantee that it is not totalitarian or that it does not threaten autonomous spiritual freedom. I am not saying that communitarian solidarities are per se oppressive. I am just pointing out that communitarian solidarities in some groups (without republican checking) might foster domination, among other evils. Furthermore, the Rawlsian fact of pluralism undermines the possibility of a conception of the good life shared by all the citizens of a state. Take, for example, a state that symbolically associates itself with one religion even though it does not forbid others and protects all of them equally. “Symbolic religious establishment, on that view, may not be a distributive wrong but it can be an expressive wrong, insofar as it undermines the equal status of citizens” [28]. What counts for symbolic religious establishment could also count for symbolic nationalist establishment. Another example might be, “communitarians, such as an Israeli minister of health (a member of an ultra-Orthodox religious party), support inclusion of life-prolonging drugs in the private insurance schemes, since they consider the latter as forms of intragroup solidarity, grounded on the values of specific communities within Israeli society” [18]. Exclusionary understandings of solidarity may undermine the right to health for all citizens and may exclude and damage the republican freedom of other citizens (freedom to participate in defining the common good). Notice that some liberals might agree with the ultra-Orthodox in terms of freedom of choice. On the contrary, civic solidarity, properly understood, offers a different solution to the one offered by both liberals and communitarians.

There is a remarkable deficit in solidarity if autonomy always trumps all other values, as happens in some individualist liberal approaches to public health. It happens not only in theoretical issues, but also and predominantly in social understandings in practice. For instance, in the USA: “Americans prioritize individual decision-making over collective well-being, marked by a refusal to sacrifice perceived individual rights” [40]. With reference to solidarity, liberalism broadly understood errs on the side of meagerness. For its part, communitarianism overdoes solidarity. There seems to be an excess of undesirable solidarities in some communitarian approaches to bioethics if the individual cannot be expected to “take a distanced view of the practices and the values promoted by one’s community” [41]. We need a middle term, which is a kind of solidarity tempered by civic republican conditions. In other words, our situation “requires republican civic (and not communitarian ethno-cultural) solidarity” [18].

Let us understand this civic solidarity from a republican point of view. It is no other than Pettit’s civility: that which “requires a disposition on the part of the people, even of people of quite different perspectives, to display a civility that relates to the society as a whole” [14]. In specific circumstances, if we allow ourselves to speak in terms of duties, it will require of us “a pro tanto duty of solidarity, and (…) this duty is the principal means by which ordinary citizens promote equity. Hence in the face of demands for social change we ought to join, durably and hence deferentially, in collective action alongside those who suffer the greatest inequity” [42] or domination. One famous example of this solidarity is the civic campaign (followed by several lawsuits) in the USA against Purdue Pharma and its controversial product, Oxycontin [43]. The fact that the private pharmaceutical company knew the highly addictive effects of the drug and hid them from patients is a very clear arbitrary (unchecked) interference against them. Civic solidarity was necessary to side with the victims and expose the public health scandal. Considering all the physicians involved in this case, “we could see the doctor-patient relationship as a microcosm of civic space, not a private economic transaction; we could see it as an aspect of communal moral life writ small” [44]. Nevertheless, it is also true that doctors who prescribed Oxycontin were deceived by the company, so they were also the victims of arbitrary interference.

Republicans claim that it is convenient to consider citizenship as “an integrative experience which brings together the multiple role activities of the contemporary person and demands that the separate roles be surveyed from a more general point of view” [45]. Citizenship, from this point of view, should be understood as “unbounded reciprocity” [46], and not as a substantive communitarian ethos. This more general point of view is neither a comprehensive doctrine nor a formalistic and neutral vacuum. The axiology of citizenship implies freedom as non-domination, civic equity and solidarity. It is exactly in this sense that, according to the double conceptual metaphor of solidarity, “each individual vouches for the community and the community vouches for each individual” [4]. The ties ought to be so solid as to cast citizens’ minds to the common good (understood in civic republican terms only). Therefore, the self is not unencumbered [47], but it cannot be arbitrarily dominated either. Unlike some communitarian ties, civic ties must be civically controlled. Communitarian ties cannot be forbidden unless they fuel domination, inequality between citizens and (selfish, exclusionary) discriminations. Republicanism, in principle, is not against partial associations, provided they are voluntary and do not damage the public good. Moreover, some partial associations, as Pettit says [14], can even foster republican goals, such as labor, feminist, ecologist and LGTBQI+ associations.

However, civic solidarity has to do with the community of citizens as a whole. We do not live isolated lives, neither individually nor factionally. We are embedded in complex systems of interdependence. Public health ethics takes this fact into account and takes it very seriously. There is a key concept in civic humanism: “human flourishing”. This concept has already been applied to public health debates: “We need not take existing practices and understandings of membership, solidarity and place as givens—transactional constraints for public health to work within. We should also take them as transformative concepts—moral possibilities for justice and human flourishing for public health to assist in enabling. (…) The time has come for public health knowledge and discourse to show all of us, specialists and ordinary citizens alike, that our personal freedom is inextricably linked to the flourishing of others” [48]. The health of an individual citizen is partially dependent on a healthy environment. As obvious as it may be, we must bear in mind that public health measures aim to improve global health conditions. Therefore, whether we actively contribute to the implementation of these measures or we are simply subject to them, civic solidarity is not only a desideratum but also a precondition for our own health.

In the ongoing debates about collective responsibilities for health and well-being, feminist bioethics have highlighted the relational dimension of human life. This is essential. Since the activities that assume individual autonomy are inherently social, the role of community and of communal approaches to health is vital [49]. Both in the republican conception of civic solidarity applied to public health and in feminist bioethics, the concept of relationality does not compromise autonomy, but rather provides the bases for its exercise. In our case, this translates into removing practices that discriminate against vulnerable people and activating education and support plans for communities to strengthen the support networks necessary to care for, treat and prevent health problems [49]. The social determinants of health also matter a lot.

Public powers limit rights but at the same time guarantee them. If they are truly “public”, they are republican. If they are truly “public”, they are not external private powers that compel paternally, patriarchally or despotically. If they are truly “public”, they belong to everyone and to no one in particular. Individual freedom is a public good, which needs a positive provision of resources to guarantee it, protect it and prosecute its injuries. The right to health is a public good too. Health and freedom are not conceptually separated by a wall that protects one (freedom) from the other (health). They are equally rights that imply duties—although it is true that we often have to choose what we prioritize and why. Thus, freedom is not a wall against the law, but a door to the law. It has a private and a public dimension. He has two faces, like the Roman god Janus (god of doors according to Cicero in his De natura deorum, 2.67). It protects me against arbitrary interferences (I close the door) and it guarantees my status with non-arbitrary interferences that as a citizen I can help determine (I open the door). As John Maynor claims, “modern republicans want citizens to engage with the state and each other as they explore their differences through deliberation and discussion in the open and inclusive forums of the republic. By stressing democratic contestation throughout the policymaking processes as a way to minimize domination, a modern republic can react to the changing nature of life in the modern world” [50]. In the case of a pandemic, for instance, public health measures must be parliamentary reviewable, and there must be government accountability, citizen audits or other fiduciary procedures. If these conditions are met, republican freedom will not be violated.

We should start from the fact that the promotion of a health policy is a moral obligation that every state ought to impose. My argument is limited only to the so-called “national” civil liberties and solidarities. As I stated on page 10, “all solidarities that transcend the scope of citizenship (for example, receiving foreign refugees), even though they can be very valuable and praiseworthy, are not civic solidarity in stricto sensu”. I admit that this can be very problematic, especially in the context of global pandemics and health issues that cross borders. Obviously, the promotions of health policy should not stop at the national borders, since there is a political obligation on an international level (such as, for example, international declarations on the right to health care to which nations have agreed, etc.). It would be very interesting to develop this perspective from the cosmopolitan visions of republicanism [51]. However, in this paper, I stick to the community of citizens of the different particular res publicae and not to the hypothetical global res publica. Now, all laws, to be legitimate in a republican sense, must make political obligation agree with civil liberty. “Republicans understood that it was popular sovereignty’s constant location of power and authority in the people themselves, not in the state or its national institutions, that allowed these very institutions to breathe, take life, and have force. When applied, the principle of popular sovereignty ensured that the decisions of any national body were made through its people’s determination, and with their participation and consent” [52]. The order of a tyrant and the law are distinguished precisely because the latter respects freedom and it is based on the consent of citizens. In extraordinary situations such as a pandemic, however, citizen rights and freedoms can also be limited with the consent of the demos and for sufficient reasons (scientifically backed even with a variable margin of uncertainty) that justify it in terms of the general interest and civic solidarity. A global epidemic, inasmuch as it represents a serious threat to public health, justifies these extraordinary measures, as long as they are proportionate and prudent (and parliamentary reviewable). To say it with the Judgment of the Contentious-Administrative Chamber of the Supreme Court of the Spanish State of 20 November 2020 (rec. 140/2020), rapporteur: Celsa Pico Lorenzo, who responded to an appeal against the obligation to wear a mask based on the defense of individual liberties, “the health of citizens is an essential element of the general interest that the public powers must attend to. In an indisputable pandemic situation such as the one generated by the COVID 19, which is clearly not limited to Spanish territory, it is clear that the general interest must prevail over the individual interest, that is, the right to life of the majority of citizens must prevail over the individual claim exercised here to contract the virus to acquire immunity. We start from the presumption that the measures adopted by the public powers tend to the survival of the community”. Salus populi suprema lex esto.

Indeed, “the health (welfare, good, salvation, felicity) of the people should be the supreme law” (Cicero, De leg. III, 3, 8). In the context of the COVID-19 pandemic, public health measures should be somewhere in the middle between two extremes or limits: on the one hand, denialism and, on the other, overestimating the scope of the pandemic by means of slippery slope fallacies (or catastrophizing). A conception of the common good as a criterion (deliberately agreed and focused on the imperative of public health) for correct action is necessary to compensate the responses to the sanitary crisis. If some community participation (in terms of civic solidarity) is to be expected, the recommendations or health programs must also reflect citizen sentiment.

Moreover, the virtue of civic solidarity is not only useful but also an essential instrument for the management or control of most, if not all, of the most prevalent problems in public health: chronic and degenerative diseases, through community health programs; mutual aid groups, to facilitate adherence to the recommendations on healthy habits; expert patients who advise and accompany other patients or caregivers in dementia, diabetes, heart failure, alcohol or tobacco dependence would be some examples in which there is strong evidence of success [53]. The weaknesses of the libertarian/each-person-for-themselves approach to health care are evident. “In practice this means that for public health to respond to the coming health needs of complex societies, it must have recourse to values and purposes that the members of these societies will understand if they think and act like ‘citizens’ in the classic sense (regardless of their legal or immigrant status) by coming to see private troubles as public problems. Public health professionals must be civic educators. Public health must identify and interpret for society changes in patterns of disease and risk that are not analytically reducible to individual behavior, but have systemic properties that come from structures of interpersonal relationships” [54].

Finally, I will evaluate an objection that is often directed against civic republicanism. It is often said that the value of non-domination falls short of the expectations of social solidarity [28]. There are situations in which citizens can be endangered but not (strictly speaking) dominated, not even potentially. There is a case of this in public health ethics. Suppose that a pandemic hits one sector of the population (the elderly, for example) especially hard. They will be endangered but not dominated. Solidarity with them would be highly desirable, but it would not be justified in terms of non-domination: a virus cannot dominate. According to my definition, one could say that this solidarity is not civic solidarity. However, that is strange. There are many other cases similar to this (in other contexts as well) and this reasoning would end up multiplying ad infinitum the forms of solidarity. However, my definition of civic solidarity does not solely depend on freedom as non-domination. It has also to do with equity. Aequitas est civitas. Helping the elderly in the case of a pandemic means not leaving them behind. The equal status of citizens (be they young or old) justifies civic solidarity with those disadvantaged by bad luck. The citizen is my equal and they cannot be ignored if their status is to be respected. However, if equality does not do the job either, there is a last alternative. Civic solidarity can be redescribed as “political fraternity” [55].

5. Conclusions

First of all, I sketched out a conception of virtue ethics as an alternative to principlism [56]. Then, I attempted to show that the virtue of civic solidarity is a particular kind of solidarity that belongs to the normative core of civic republicanism, along with liberty (as non-domination and perhaps also as participation) and civic equality. To do so, I started with an analytic definition of solidarity. Solidarity, in general, is a moral value that is the result of a double conceptual metaphor: (1) from solid to obligatio in solidum and (2) from obligatio in solidum to solidarity as a moral value proper, according to which every part is liable for the whole; there is a moral commitment to assist others in need; and there is a “solid” attachment among members of the same group. Then, I applied the civic republican framework to this formal definition: in civic solidarity (a qualified solidarity), the part is the citizen and the whole is citizenship. In this sense, assisting other citizens in need is a way of displaying a civic virtue called “civic solidarity”. This can be done directly, without any institutional mediation, that is, among the citizens themselves, or it can be done by means of (non-arbitrary) institutional arrangements that compel citizens to act in solidarity by law. In republicanism, a law can be viewed as a liberating agency that can secure non-domination and guarantee equality as well as a strengthener of solidarity (which maintains the quality of citizenship and equal status). Of course, not all laws are republican laws. Legalism is not the same as republicanism. There are conditions that have to be met so that a law can be viewed as a liberating agency (strengthener of solidarity): the rule of law, the possibility of democratic contestation, the reference to a consensual common good and the checks and balances among distinct branches, among others.

Civic republicanism offers a type of synthesis of liberal bioethics and communitarian bioethics. Liberalism is suspicious of solidarity taken as not supererogatory. It has very good reasons to be suspicious of it. Solidarity in some communitarian approaches to bioethics threatens the autonomy of individuals. Civic solidarity (so not any kind of solidarity) provides a justification of obligatory solidarity (born out of the Roman republican obligatio in solidum) that respects liberty as non-domination and citizens’ equality. Therefore, the republican axiology does not imply a substantive compromise with a comprehensive doctrine and a conception of the good life. The reciprocity among citizens must be unbounded and the interferences must not be arbitrary. Republican institutions and arrangements guarantee freedom as non-domination and civic equality. In other words, citizenship in its true sense is republican. Given this fact, civic solidarity is a civic virtue that strengthens liberty and is not opposed to liberty. In the field of public health ethics, civic solidarity can play a promising role. Indeed, it has happened already: in COVID-19 vaccination campaigns; in the Sackler case of Purdue Pharma and Oxycontin in the USA; and in preserving the right to health care in some countries’ welfare states. The overall argument of this paper is that bioethics should look to improve its understandings and practices of solidarity by embracing republican principles, but in particular, as a clear paradigm, I mainly focused on the fact that public health ethics can benefit from the republican virtue of civic solidarity, both in theory and practice.

Further research is needed on this issue. One field is theoretical: public health measures whose normative justification is based upon civic solidarity should be framed in republican terms. Thus, what we need is to know what sort of checks and balances, guarantees and deliberative procedures should be implemented. Institutional design is paramount. The other field is practical: in order to show the strengths of civic republican bioethics, the philosopher has to be able to apply the axiology of civic solidarity in specific, detailed cases. Applied philosophy is also a requirement.