Solidarity and the Encapsulated and Divided Histories of Health and Human Rights

Abstract

This article examines the central but neglected principle of solidarity in human rights, health and bioethics, a concept subject to contention, evasion and confusion. It addresses the general ambivalence toward solidarity within law, philosophy and politics by discussing solidarity’s co-evolution with inegalitarian encapsulations and divisions of human rights. It argues that a renewed conception of solidarity is essential to meet increasingly salient ethical demands, as gender equality and the individualization of responsibilities coincide with deficits of care and collective responsibility. Questions of embodiedness, (inter)dependence, care and asymmetry are neglected by dominant liberal approaches, but are key to rethinking solidarity.

1. Introduction: The Principle of Solidarity

This article examines the central but under-theorized principle of solidarity in human rights, and considers the perspectives of health and care. Solidarity can be regarded as a founding general principle of human rights (“fraternity”, alongside liberty and equality) [1]. Article 1 of the Universal Declaration of Human Rights (UDHR) states that: “[A]ll human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood.” Within the more narrowly defined domain of bioethics, solidarity appears with “cooperation” in the 14 stated principles (or bundles of principles) in the Universal Declaration on Bioethics and Human Rights (UDBHR). Article 24.3 of the UDBHR concerning “international cooperation” states that:

“States should respect and promote solidarity between and among States, as well as individuals, families, groups and communities, with special regard for those rendered vulnerable by disease or disability or other personal, societal or environmental conditions and those with the most limited resources”.

[2]

“Solidarity” may appear less prominent in the UDBHR text if compared to “brotherhood” in the UDHR, and Prainsack and Buyx note in their extensive review [3] that solidarity is not often explicitly addressed in the bioethics literature. Yet solidarity constitutes a prominent idea or value in bioethics, and it can be reasonably argued that the entire UDBHR is implicitly solidaristic [3,4]. The Report of the IBC (International Bioethics Committee on Social Responsibility and Health) suggests that the principle of solidarity “supports the whole framework of social responsibility” in the UDBHR, by basing the interpretation of social responsibility for health on three main principles: justice, solidarity and equality [2].

Solidarity has been the subject of contention, evasion and confusion in human rights. The relative neglect of the concept is attributed to the dominance of liberalism in modern moral and political theory, and its preference for autonomy [1]. Solidarity is an ambivalent ideal, connoting pre-political bonds of brotherhood, family, kinship or tribe, while promising that such ascriptive ties can be transcended through expanded ethics, norms and politics. Solidarity is said to act as a bridge between pre-modern and definitively modern ideals of belonging, bonding, and inclusion [5] by focusing our attention on the practical responsibilities of belonging in a social-moral community.

The moral philosopher David Wiggins suggests that solidarity can be thought of as a “phenomenological-cum genealogical basis or root for the ethical in human rights”, a proto-ethical predisposition and antecedent demand for “the simplest form of ethical thinking”. In his view, solidarity is not an ethical principle in itself, but “a predisposition that conditions, civilizes and humanizes ordinary pursuits” in ways that “shore up the ideal” [6].

The proto-political conception of solidarity may derive from a number of different foundations, such as natural sympathy, social virtue, utilitarian calculation or functional demands. Any or all of these justifications may provide the foundations for mutual obligation, expressed by the Roman Law principle of “in solido”, or “solidum”, meaning the “whole thing which every member is entitled to expect from each and every other” [6]. Stjernø takes a concretely political, “statist” approach to this principle, defining solidarity as a redistributive ethic involving “the preparedness to share resources with others by personal contribution to those in struggle or in need through taxation and redistribution organised by the state” [7]. Defined in this way, solidarity emerges as a practical concept, involving “enactments of the willingness to carry costs and to assist others” [3]. This ultimately depends on the existence of “fellow-feeling” and a form of contract that unites “winners” and “losers” and legitimizes transfers from the former to the latter [8]. The spectrum of perspectives spans the possible tension between constitutive and liberal views of solidarity. Constitutive views emphasise the common good, even to the point of being “statist”, while the classical liberal views (which are more predominant in human rights thinking) prioritize the protection, or even emancipation, of the individual from the power of the state [9].

The concept of solidarity invokes basic questions about the sociological underpinnings of ethics and rights, and the nature of “values” in determining what constitutes a collective way of life and a desirable state of affairs. “Values” indicate informally established, socially enforced moral rules that constitute communities as such. Social moral rules both establish solidary bonds and provide the basis for such bonds, for example through mutual respect, care for members’ wellbeing, or group pride. Solidary relationships are not merely useful to individual members of a group, they are also collectively valuable because they recursively foster valued group characteristics such as trust and care [10].

Brunkhorst’s historical approach characterizes solidarity as a principle that has evolved through a series of stages. Inclusivity has increased as the concept has evolved, from selective forms of ancient civic friendship, to Judaeo-Christian brotherliness, on to modern patriotism and eventually toward an inclusive global legal order [11]. Others think that the full development of an inclusive global order will require supplementation with a more robust doctrine of humanism [12]. Axel Honneth [13] and Jürgen Habermas [14] provide thickly theorized perspectives on solidarity, as both precondition and outcome of an intersubjective social order constructed through recognition and communication, respectively. There is a perhaps surprisingly close fit between Honneth’s and Habermas’ essentially secular conceptions and Catholic theories of solidarity and human rights that tie together recognition, relationality and collective action through relationships of mutuality. For example, the following explanation is attributed to the influential Catholic human rights theorist Jacques Maritain:

“Asked what the practice of solidarity concretely requires of us, Maritain would suggest it is the mutual recognition, and the united action to ensure the respect—of human rights— rights that concern us all as human beings”.

[9]

European social policy debates tend to contrast collectivist “Continental” values with Anglo-American liberal individualism, and to express concern about the displacement of the former by the latter [15,16,17,18]. However, despite these concerns, there seems to be a reluctance to discuss solidarity as a foundational issue [19]. North American communitarians are concerned by the internal decline of solidaristic values, and think that this has a deleterious effect on democracy [20,21]. All the while, the basic socio-political envelope for collective organization, the state, is being undermined by the realities of globalization. This makes it more difficult to conceptualize solidarity in a world where “community” stands for a world which is not, regrettably, available to us, but which we would dearly wish to inhabit and which we hope to repossess [22]. The current forces of globalization pull people toward “affectively saturated and tradition-appropriating modes of political inclusion and exclusion”, as national sovereignties and other stable institutional identities appear to be in decline [5]. Societies seem to be fragmenting along generational, gendered, geographical and class lines into groupings with very different social and political attitudes. This holds serious implications, challenging the practical social solidarity arrangements that are currently in place [23].

The problem of fragmented collectivities has been addressed by the sophisticated feminist debates on the necessity and limitations of individual autonomy, but keeping concerns with collective struggle against inequality and oppression in view. Scholz [24] defines “political solidarity” as collective struggle for the achievement of concrete ends, formatively oriented towards liberation, justice, or the ending of oppression or injustice. However, in diverse contemporary societies, we cannot assume that there will be agreement about concrete goals or even formative orientations, nor should we assume that solidarity can only encompass reactive forms against oppression [25]. These debates have informed the emergence of concepts such as “relational autonomy” [26] and “reflective solidarity” [27]. Dean’s work on “reflective solidarity” is especially helpful for highlighting the relevance of feminist debates to the discussion of solidarity and establishing a feminist “dialogue of solidarity”. Her theory of “reflective solidarity” responds to contemporary identitarian politics by proposing that it is possible to construct a coalition of feminist concerns. This theory draws upon Habermasian concepts of solidarity based on the strategy of recognising, connecting and communicating across differences [27,28].

Debates about solidarity reflect the central conundrums in sociology and human rights about society versus individual, duty versus freedom, order versus progress and stability versus emancipation. Collective moral rules have a “dark side”—a repressive aspect that potentially obscures the moral and ethical agency of individuals under the veils of social convention, tradition, culture or community. The appeal to collective values entails potential problems of moral and cultural relativism. Value conflicts may occur where different communities coexist with incommensurable values or different thresholds of tolerance [29]. Collective values may be critically questioned when they appear to be discourses of leaders, serving selective interests, while foreclosing on the abilities of the led to determine their own ethical choices [30]. Communitarian ideas of inclusion logically imply exclusion, challenging the human rights ambition for an inclusive, but unbounded, moral reach. No community can be unbounded, hence human rights in its actually existing forms excludes, neglects and denies the rights of those found to be non-citizens, not quite human, and less than human, as well as ignoring the non-human.

A historical analysis shows solidarity to be an ambivalent, mixed concept that criss-crosses the left-right and secular-religious ideological poles. Solidarity turns out to be a many-sided concept, encompassing a variety of historical roots, ideological commitments and tendencies. This many-sidedness begs the question of whether it is amenable to a coherent discussion at all. Theoretically, it may suffice to define solidarity as a condition involving acts of cooperation in support of shared ends, where the relationships formed by cooperative acts are also valued for their own sake [10]. The concept of solidarity in human rights appeals to the very core of human rights as universal to humans qua humans, as well as to humans qua members of society. However, it also raises fears of overwhelming political burdens and demands, precisely because it points to larger concepts of humanity that transcend any particular group, and binds by the legal principle of “joint and several responsibility”. Such expansive claims are “unhomely” and potentially impinge on “respect for a certain space around each human” [6]. Recalling the French Revolution, we can see how the criteria for inclusion can slip from the universal, how the revolutionary slogan “fraternité ou mort” acquired ominous overtones, promising violence first against non-brothers and then against false brothers [31].

Solidarity is thus a contradictory idea—there are great concerns about its absence or decline, but also a wariness about being too positive about it, knowing its potential to exclude, impinge on individual autonomy, or even justify totalizing violence against the other. The history of revolutions has instilled a fear of its binding appeal, mobilizing power and revolutionary effects. The result is that existing solidarity has tended to manifest as ambivalent admixtures of idealism and pragmatism, accommodating the preservation of settled orders and hierarchies, co-opting egalitarian moments and forestalling more radical possibilities.

Is solidarity a descriptive or a prescriptive concept? Does it matter whether the social forms it adopts are radical or conservative, virtuous or vicious? Does it make sense to see Nazi solidarity in the same way as working class or Civil Rights solidarity? A moral philosopher might try to answer the question by conducting a contingent moral evaluation, balancing the value of group solidarity against the evils that might have been involved to bring such solidarity about, or by requiring morally valuable, or at least permissible, ends and means to render solidarity a worthy concept [10]. A social scientist might adopt a more inductive approach to discover which meanings emerged out of which particular contexts. This part of the discussion tries to understand how ideas of solidarity emerged, and why this difficult and contradictory concept is an increasingly salient practical ethical demand. Following egalitarian social contract critiques, it notes that solidarities historically encapsulated as they united or emancipated. This enfolded domination and subjection into the social contract, along the lines of gender, race and coloniality. Improving gender equality across societies has contributed to a wider trend toward ethical individualization. However, individualization—especially in the realms of work and care—coincides with increasing anxieties about deficits and difficulties surrounding practical arrangements of solidarity, as attitudinal trends put “solidarity under strain” [18,19]. Moving to the international domain, demands for decolonization and full human rights can no longer be managed by deferring to national solidarities, as globalization and democratic demands question both state forms of solidarity and international obligations to cooperate.

2. Solidarity, Contract and Domination—A History of the Present

A few commentators have noted how solidarity is emerging from the shadows, after decades of neglect [12]. This section discusses the historical trajectories of concepts of solidarity that contribute to the ambivalent, divergent and generally uncomfortable understandings that we have today. To use the phrase “a history of the present” is to invoke Michel Foucault’s strategies of “archaeology” and “genealogy” to scrutinise ideas of “solidarity” as “discourses” [32]. The objective is to interrogate the rhetoric in ways that attend to historical continuities, discontinuities and transformations. Foucault’s archaeological and genealogical approaches involve exposing and identifying particular discourses, recognising non-linear and layered possibilities in historical enquiry, critique and reflection. A history of the present enables us to move beyond the present by exposing hidden aspects and asking how discourses were constructed. This allows us to problematize particular issues of solidarity in the present and relate them to the past [33]. Rejecting the notion of “grand truths”, a genealogical approach avoids assumptions of linear, progressive development and binary modes of thought [34]. An explicitly resistant, subaltern perspective from South Africa that corresponds with Scholz’s view of political solidarity [24] employs a history of the present to “identify the manner in which power is circulated…and mechanisms by which citizens are controlled”, “articulate the ways in which subjectivities are created—and resisted” and to offer ways to “recover overlooked subjects and marginalised voices” [35].

Moyn compellingly argues that the history of human rights must desist from the impulse to use the past selectively. Instead of praising the limited human rights movement that we have now, we must use the past in a better way, to see how future human rights might be transformed [36]. The principle of solidarity stands at the centre of how human rights might relate to questions of broader societal welfare, collective emancipation and struggles for social and economic rights, which must regain their importance after decades of marginalization and neglect.

To make sense of how different strands of solidarity can be understood, this discussion employs the visual metaphor of a rope. There are three basic types of ropes. Ropes consist of several strands that may be laid in either a left-handed or a right-handed direction, with or without a central core. The simplest kind of rope is composed of three strands, which we may think of as the three UDBHR principles of justice, solidarity and equality. Coincidentally, simple “hawser-laid” ropes are usually constructed in a right-handed fashion. The second basic type of rope is “shroud-laid”, consisting of three strands wound around a fourth, core strand, also usually constructed in a right-handed fashion. We might think of the three principles of justice, solidarity and equality wrapped around the core of a social contract which defines citizens, subjects (non- or not-quite-citizens; the needy and the vulnerable), standards of social-moral decency and concrete responsibilities. Finally, cable-laid ropes are nine-stranded, composed of three hawser-laid ropes, and may be constructed in either a right- or left-handed fashion. We might think of the three ropes as solidarity traditions relating to humanism, the democratic-communicative domain, and the international or global order. Whether the cable is laid right- or left-handed will depend on how conservative or radically egalitarian the perspective is. In the same way that ropes must be secured at their ends, so must solidarity traditions be bound by defined ethical commitments. “The end of a rope must always be secured, or it is evident from its construction that it will on the slightest usage become frayed out” [37]. Thus, it is too with ethical commitment, which must bind itself to new kinds of “political subjectivities that are not arbitrary or relativistic, but which are articulations of an ethical demand whose scope is universal and whose evidence is faced in a concrete situation” [38].

Since the social and institutional bases of solidarity are important considerations for bioethics, public health and global health [2,3,25], the eventual proposition here is that extant structures have to be reconfigured. It tentatively suggests that reflective solidarities constructed around health and care might serve to reconstruct a new social contract that is less discriminatory than ones that came before. A reconstruction of human rights principles of justice, solidarity and equity will have to take into account the different ways at which practical responsibility has been historically arrived. However, their strands will have to be rearranged to consider the specific demands for equality and justice in health and care. The right to health arguably opens the way for a different conception of persons in the world, enabling a focus on embodied persons and their practical human need for wellbeing and care. Solidarity as a practical principle can work to distribute resources and seek justice by fairly avoiding and ameliorating impairments, preventing avoidable illnesses and deaths, and reflectively considering the limitations of resources that include time and care, and not just medical supplies, medical personnel or health facilities [39].

2.1. Solidarity, Socialism and Social Democracy

Solidarity has historically been closely linked with the political project of socialism, and the development of the working-class movement and social democratic politics. The labour movement has always claimed that solidarity is its defining feature. A founding figure of German social democracy, Wilhelm Liebknecht, took solidarity to be the starting point of socialism: “the concept of general human solidarity is the highest cultural and moral concept: to turn it into reality is the task of socialism.” Eduard Bernstein similarly claimed that:

“...no principle, no idea, exerts greater force within the working-class movement than the recognition that it is necessary to exercise solidarity…all the other great principles of the social law…pale in comparison—whether it is the principle of equality or the principle of liberty”.

[40]

The power of action taken in solidarity represents the particular emancipatory contribution of the labour movement. Individuals who historically lacked standing were able to gain enough power to bring about social transformation through collective action. Historically, the working class movement produced socialist ideas and the political parties of the left. These integrated collectivized labour into national politics and secured better pay and conditions for formally organized workers.

However, labour solidarities enacted historical exclusions and encapsulations. Unions are not universalistic social structures, but “[unite] workers according to their tools of their trade or the nature of their product, that is according to the contours imposed upon them by the capitalist system” [41]. The key working class demand for a “family wage” bid up workers’ wages on the basis that they needed to support families, not just individual workers. The family wage thus formed the core of a patriarchal wage system that directly discriminated against women and children, who were subordinated to male workers. Women and children were paid much less, and their employment was restricted, including outright bars for married women. As Zeldin observes, the proletariat, having got the vote, were by no means keen to share it with women. While the French General Confederation of Labour declared in favour of equal wages for women in 1898, they were quick to limit “equal” treatment only to spinsters and widows, as they maintained that women should be dependent on men: “in general man must feed woman” [42]. The Fabians advised working class women to desist from seeking paid employment in deference to the family wage. A woman should instead seek “economic salvation through solidarity and co-operation with her own class” [43].

2.2. Solidarism, Social Order and Dominance

The roots of the doctrine of solidarism lie in France’s nineteenth-century politics of restoration and accommodation. Solidarism represented a compromise between emerging capitalism and socialism, between secular and religious powers, and between extant and emergent social classes. The age of revolutions raised concerns about social cohesion and order. As the transition to modern, capitalist industrial society and liberal individualism took root, worries arose that traditions, common ideas and shared sentiments which formed the “glue” holding society together were being dissolved. Anxiety, reaction and opportunity united a spectrum of ancien regime, conservative, state and popular forces in formulating a response.

Solidarism could be described as “the official social philosophy of the French Third Republic”, a “new social doctrine virtually adopted by the republican government to meet the increasing challenges of industrialization” [44]. During this period, “original efforts were made to adopt new approaches in institutional, religious, social and diplomatic ways” [45], yielding a nineteenth century blend of radical and restorationist answers to the basic problem of stability in social change. Following a decade of revolutionary upheaval, involving the overthrow of the ancien regime, the Terror, the unleashing of anticlericalism and expansionary overseas wars, Napoleon Bonaparte instated the First Empire. This restored some of the Catholic Church and aristocracy’s traditional position, but not their independent power. The clergy became salaried government employees, controlled by Paris instead of Rome and the aristocracy was restrained. The Second Republic of 1848 was similarly replaced by the Second Empire, and when that collapsed, the Third Republic assumed government in 1870, ruling until the Vichy regime was established in 1940 [46].

The foundations of solidarism were advanced by the French social philosophers—the rather appropriately named Bourgeois, Gide and Guyot [45]. Their philosophy reflected the development of social science as a positive “science”, with essentially conservative characteristics [47]. The emergence of social science opened up a potential epistemological divide between notions of citizen rights based on firm, though vague, claims of “positive science”, and notions of human rights based on claims of natural law. Both secular solidarist and Catholic social thought traditions attempted to mend the epistemological divide by positing a central relational category that made individual freedom and collective cohesion mutually determining, thereby solving the theoretical tension between natural law and scientific positivism.

Irrespective of whether the theoretical foundations were justified by positive science or natural law, either route supported the theoretical equality of persons. In practice, however, convention embedded the assumption that some “persons” were self-governing, direct holders of rights, while other “subpersons” [48] could be acceptably governed as dependants with partial and lesser rights, subject to the discretion of “full” persons. Domination can occur by ignoring or actively crushing the dominated subject’s capacity for action, but it also be routinely supplemented by governance. Governance recognises the subject’s capacity for action, and enables the subject to adjust themselves to a given order [49], such as patriarchy through the subject’s identification with an ideal category such as “mother”, “wife” or “child”. The social contract ordered society by simultaneously idealizing and repressing certain classes of subjects: women, children, “noble savages” and those who were to be “developed” or “civilized”.

In post-revolutionary France, women were confined to a legal position that was “very definitely inferior to that of men” [42]. Secularist republicans mistrusted women, and tried to exclude or contain their potential political agency. They saw women as traditionally supportive of the Church, since the Church relied on women to reproduce its patriarchal “moral monopoly” within the private domains of the home and the family, while accepting domination in the public domain by men [50]. Numerous conditions accorded women less access to justice and less standing and rights under the law. Women had no independent right to their children or property, received half the wages of men and were excluded from most professions. They had less and inferior education and many leading Enlightenment thinkers held strikingly misogynistic views, particularly opposing education for women. Rousseau argued that women’s education should be strictly limited to domestic matters, while others argued that knowledge itself was dangerous to women [42].

As Pateman’s feminist reading of social contract theory shows, the key social institutions of marriage and employment enact singular contracts concerning property in the person that involve women’s relationships of subordination to men [51]. Charles Mills produced an analogous reading of race as a similarly constituted subordinating structure between dominating and dominated races [52], while the colonial “settler contract” voided native persons’ claims to personhood, turning them into dispossessed colonial subjects [53]. Pateman points out that the powerful states which pride themselves in their democratic credentials (and indeed seek to spread democratic values as a contemporary foreign policy) were founded on the doctrine of terra nullius, a fundamentally illegitimate contract of dispossession.

2.3. Solidarity and Conservative Christian Democracy

Christian democracy emerged in early twentieth century Europe to propound new concepts of solidarity and cooperation. Christian Democrats sought a non-radical platform for political discourse and policy informed by Christianity, but in a form suited to a pluralist modern society. The French Catholic philosopher, Jacques Maritain, who was a primary source of ideas for Christian Democracy [54], advanced ideas about humanism and solidarity which influenced the drafting of the UDHR.

The ideas of the French Solidarists were also adapted by German Jesuits engaged in the analysis and critique of capitalism, including Heinrich Pesch, Gustav Gundlach and Oswald von Nell-Breuning. Like Maritain, they justified their social philosophy on the universalistic foundations of natural law, combining solidarism, personalism (a theory of human uniqueness and nature) and a theory of the social market into a German form of “Catholic Social Teaching” [55]. The historical convulsions of the nineteenth century had led the Church to question both liberal and revolutionary socialist thought. Pope Leo XIII was prompted to issue the encyclical Rerum Novarum (Revolutionary Change: On the Conditions of Labour) in 1891, which raised the “social question” in Catholic thought [56]. Rerum Novarum moderated support for the market and private property with the argument that wages ought not to be insufficient to support a frugal and well-behaved wage-earner. Wage insufficiency, defined in this obedient and minimalistic way, was critiqued as domination and injustice. The encyclical deemed it proper for the Church to speak out on social issues and teach “correct social principles” in order to ensure class harmony and avoid revolution. It advised state social policy to modify capitalism without overturning it [57].

Catholic solidarism sought to delineate a political identity distinct from both individualistic liberalism, and collectivist socialism, by positing that “man is not an individuum; from his very nature he has a social dimension and only within society he can develop his abilities and possibilities” [56]. However, some tensions between the humanitarian and social claims and questions about the viability of the capitalist system remained within this perspective. To answer this, the concept of the “Social Market Economy” interposed certain stable social collectivities—unions and professional groupings—into the regulation of both capitalism and social life. The profession-centred idea of corporatism proposed to eliminate the question of class struggle. Class differences could be overcome through the joint organization of entrepreneurs and employees. Employees would become shareholders in firms, and overcome the status of being solely wage earners. However, under National Socialism (Nazism), the corporatist coordination of entrepreneurs and workers came under the totalizing control of the state. The role of the professions was bypassed and atrocious forms of domination took place. After 1949, the Christian Democrats implemented an expanded model of the social market economy in West Germany. The state intervened to coordinate the social security system comprising pension arrangements, universal health care and unemployment insurance, within a free-market economy. This “social market economy” was generally accepted as a basic European model for the social contract after the 1940s [58].

Scholars seeking to revive the idea of solidarity in recent years note the potential convergence of developments in social theory and Christian theology, particularly with respect to the discourse, recognition and communication theories of Honneth and Habermas, but tend to neglect the practical solidarity arrangements of the social economy. Habermas has recently become interested in engaging with religious thought and revising his theory of communicative democracy to accommodate faith-based solidarity [59]. The limits of capitalism, gender and biopolitics comprise the grounds where the most disputes have emerged. Questions about the social bases of political solidarity depend on the context and much depends on whether attitudes of collective identification, mutual respect and mutual trust have been fostered or eroded [25].

2.4. “Third Generation”’ Solidarity Rights: The “Right to International Cooperation”

“Third generation” human rights, or “solidarity rights” are sometimes understood in terms of protections for minority and indigenous peoples’ cultural practices, languages and institutions. These protections fall under the ambit of “cultural rights”, which came to the fore in the 1990s [60]. However, as Alston documents, this current understanding evades the deeply contested rise and fall of collective rights as a political and economic phenomenon. In Alston’s view, the important global arguments for human rights centred on the possible and potential interpretation of “peoples”, entailing duties of international cooperation as a matter of global solidarity. The debates about the “vulnerable” position of minority cultures, and the particular challenges minority issues pose for rights theory as group rights, must be understood as a last reminder, together with the Millennium Development Goals (MDGs), of the decline of collective rights. This decline represented the failure of “Third World” claims for a decolonial equalization of global political economy, demands for which arose in the 1970s, but lost momentum by the 1990s [61].

While the minority rights agenda addresses hard puzzles of identity and solidarity with respect to nonminority obligations in a globalized world, the collective rights question lays bare even harder questions about larger demands for global solidarity and justice. Minority rights claims against states must be understood against a wider global canvas of failures to secure remedies for collective rights claims for over half a century. Developing states sought recompense for the historic expropriation, violence and domination of colonialism, reaching across large geographical spaces and potentially half a millennium of historical time, to fundamentally redress the lasting effects of colonial political economy. This echoes the wider, general question about recompense and whether the international human rights regime is able to deliver remedies for historical wrongs, beyond a small number of criminal indictments and official apologies by successor governments to the descendants of the illegitimately dispossessed peoples.

The colonial era is described by Roy as “a time of doubleness” where violent and humanitarian apparatuses co-existed. Rule occurred simultaneously through coercion and consent [62]. Social welfare became an explicit consideration of rule with the advent of the “dual mandate” model of colonialism. This assigned a tutelary, protective and developmental role to colonizers, even as they sought to profit from colonization. The dual mandate rationale continued into the era of decolonization in the form of “trusteeship”, whereby former colonial powers continued to govern as “trustees” of “dependent territories”. Under the British Colonial Development and Welfare Act (1939) trusteeship assigned the colonial government the responsibility for ensuring their subject population received “minimum standards of nutrition, health and education” [63]. After 1945, “development” was presented as the solution to a global problem of “underdevelopment” in a new era of decolonization and international cooperation. An international “New Deal” was promised, as President Truman declared that “[t]he old imperialism—exploitation for foreign profit—has no place in our plans. What we envisage is a program of development based on the concepts of democratic fair-dealing” [64].

Postcolonial “development” planning extended a colonial present, offering complicit forms of neo-imperial governance to be carried out by differentiated postcolonial ruling classes. Former subjects attained nominal citizenship, but not full social rights [65], which were now made subject to the attainment of “development.” Liberal progress was reshaped into national programmes for economic modernization and growth. Under the influence of the Truman Doctrine of “freedom versus tyranny”, human rights came to be treated in a selective and divided manner, now familiar as the “generational” theory of human rights.

At the United Nations, a growing awareness and solidarity emerged across developing countries, based on shared critical analyses of the unequal and neo-colonial nature of global development. Alston notes that in the early decolonial days of drafting the UN Charter, self-determination was merely a principle, not a right. However, after 1971, the right to political self-determination became a concrete reality [61]. The developing countries recognized that political self-determination was insufficient as long as economic self-determination remained unattainable under the existing international economic system. This led to the emergence of a reactive and resistant form of global solidarity that attempted to articulate its demands for economic and social justice through the mechanism of the UN General Assembly. In 1972, the Senegalese jurist Keba M’Baye connected “development” with the emerging human rights agenda of the United Nations, articulating the idea of a Right to Development [66]. Developing countries brought a collective Declaration demanding a New International Economic Order (NIEO) at the UN General Assembly in 1974 [67]. The demands included fairer financing and terms of trade, controls and responsibilities for multinational corporations, and greater equality and influence for developing countries within the United Nations. The UN Human Rights Commission began to examine the issue of development from a human rights perspective in 1977, leading to the 1986 UN Declaration on the Right to Development [68]. Since neither the NIEO, nor the Right to Development yielded significant reforms, these global solidarity claims came to be seen as little more than “an expression of South frustration in the face of intransigent North power” [66].

In 1979, Karel Vasak explained the Right to Development as one of a new “third generation” of human rights that had emerged, along with the right to a healthy environment and to peace. He suggested that the three “generations” of human rights corresponded respectively to the three proclaimed ideals of liberty, equality and fraternity, positing that these new rights were “solidarity rights” [61,66]. The Right to Development was met with suspicion on the part of more orthodox liberal human rights practitioners and theorists. The generational schema fell victim to Cold War polarities. Hence, the predominant liberal view was that the “first generation” individual civil and political rights (which were supported by the capitalist “First World” powers) were more “justiciable” than “second generation” economic, social and cultural rights (which were off-limits because of their identification with the socialist “Second World”). Third generation “solidarity rights”, which were identified with the developing nations, were given short shrift as a “search for a unicorn” because of their highly politicized background of Third World demands, and a lack of established jurisprudence [69]. The aversion to this politicised struggle reappears in contemporary advocates of “rights-based approaches”, who reject the collectivist political tenor associated with the Right to Development, in favour of a more technical ameliorative approach to international cooperation, most recently in the format of the MDGs [70].

In the larger global context, “solidarity” became bound up with collective, developing country claims for a NIEO and the Right to Development. Decolonization coincided with the division of the global political universe into three “worlds” under global liberal hegemony. This transformation reprised the historical encapsulation of the former colonies in a new form, by dividing human rights into presumed hierarchies of “generations” and identifying “Third World” solidarity with later and less justiciable “generations” of rights. This had a containing effect on the possibility of substantively egalitarian collective rights claims. Cross-developing country solidarity claims were prioritized by developing countries themselves. This encapsulated claims for the economic and social rights associated with citizenship within what Mamdani calls “the politics of the not-yet” [65]. In the international arena, these claims were ignored in favour of a limited agenda of technical development assistance, establishing the 0.7% GDP budget target for international assistance funding to be transferred from developed to developing countries, later supplemented by the MDG scheme of development goals and targets.

Wellman’s revisionist reading of Vasak’s generational theory attempts to rescue both solidarity rights and the principle of solidarity [71]. Wellman explains that Vasak advocated “third generation” solidarity rights in order to remedy the deficiencies of the excessive individualism, even egoism, of first generation human rights. First generation rights were the negative rights of citizens, to be protected from excessive state interference. Second generation economic and social rights represented citizens’ positive rights to demand that the state enact policies to benefit them and confer substantive equality. However, what was missing was the interaction between individual and society. Hence, the new third generation rights would enable individuals to overcome solitary autonomy and allow them to achieve their human potential through cooperative participation in social life.

Wellman makes a valiant effort to rescue solidarity from the encapsulation of third generation “solidarity rights”, by re-articulating a theory of indivisible rights. However, the historical rise and fall of collective rights has led to international solidarity becoming relegated to two remnants—“international cooperation” for “development”, narrowly defined as a set of global goals, and the collective rights of minorities to protection. This fails to acknowledge the deep critiques and radical demands emanating from developing countries for post-imperial economic justice. It renders invisible the consistently frustrated demands for more substantively egalitarian global governance by developing countries over half a century.

3. Public Health, the Right to Health and Global Health

Public health, the right to health and global health provide interesting frames for re-thinking solidarity, because certain normative claims are made for health. Health is considered a universal human value [72], while solidarity is considered a key value for health [73]. Focusing explicitly on how solidarity is relevant in various applied health and bioethics contexts, Prainsack and Buyx outline a three-tiered approach to solidarity, which they define as “shared practices reflecting a collective commitment to carry ‘costs’ (financial, social, emotional, or otherwise) to assist others”. These three tiers are: (i) solidarity at the interpersonal level; (ii) group practices of solidarity and; (iii) contractual and legal manifestations of solidarity [3].

Public health and “global health” are domains of governance that evolved somewhat independently from rights as a framework for the third tier of contractual-legal solidarity, as defined by Prainsack and Buyx [3] and from the rights framework’s foundations in politics and law. Public health developed as a response to the social and medical problems of nineteenth-century industrial and colonial capitalism, addressing scientific, medical problems of disease. Public health focuses on aggregate populations, not individuals, engaging responsibilities that exceed the scope of non-interference presumed by liberal-individual conceptions of human rights [74]. As such, public health is often seen as problematic by liberal rights theorists for its paternalistic, even coercive character. As public health is largely preventive and focused on harm reduction in a context of uncertainty and risk, it is unlike conventional medical or legal frameworks, which tend to seek appropriate remedies for a harm that is already manifest. Public health is “public” in two senses: by targeting a social entity—a “public” (that is, a population, community or group)—for an intervention, and public in its mode of intervention, by requiring some form of collective action [74].

Global health developed out of international health, a field that evolved independently of human rights. However, its evolution had major, structural effects on global governance and the interpretation of the right to health agenda. Global health governance is centred on the agency of the World Health Organization (WHO), but has its historical origins in non-state, global philanthropic foundations at the beginning of the twentieth century. The Rockefeller Foundation brought the field of international health into existence at the beginning of the twentieth century, while the Gates Foundation rejuvenated global health in the face of its “midlife crisis” at the end of the twentieth century. This aligned global health with the MDGs, all of which, directly or indirectly, concern health. The Rockefeller programmes set the agenda and content of international health, defining principles, practices, and institutions and working primarily through government agencies. Its newer counterpart favours mixed health systems according a greater role to the private, corporate sector. Birn’s history of global health shows it to be a deeply political project, despite its technical and “neutral” scientific claims [75]. Having a global health agenda set by private philanthropies is arguably a benevolent expression of global solidarity for collective benefit, enacting solidarity transfers from the very wealthiest individuals to the very poorest and most disadvantaged denizens of the world. However, such transfers from philanthropists to beneficiaries are highly asymmetric, and bypass the social contract, thereby perpetuating the “politics of the not-yet”, even though they support the production of collective goods such as disease eradication and the amelioration of extreme health inequalities.

The first attempt by the WHO to bring together the fields of public health, global health and rights took place at the 1978 Alma-Ata conference. This conference raised the possibility that the differentiated concerns of medicine and social justice might converge under the umbrella of the right to health. This approach balanced the expansive rights-based aspiration of “the highest attainable standard of health” with the reality of resource constraints, by taking a primary health approach. This promised an inclusive and multi-level top-down, horizontal and bottom-up approach, involving government action, action by the health professions and mobilization of civil society. The Alma-Ata agenda aligned economic and justice criteria, since a rights-based approach focuses on priority for the worst-off, and “minimum core obligations” [76] as a grounding for understanding “cost-effectiveness”.

The right to health is “a vague and complex idea, with a morally valid core”, requiring the provisions of international law to be grounded in philosophical and sociological understanding [77]. The rights frame is distinct from the public health frame because it imposes criteria of non-discrimination, directing interventions towards the most pressing core needs, and assigning priority to those who are most discriminated or stigmatized [78]. The former Special Rapporteur on the Right to Health, Paul Hunt, advanced the Right to Health as a route to improving the effectiveness, inclusiveness and equity of health policies, seeing it as an effective means to empower the disadvantaged, by a framework of international norms, states’ obligations, and international monitoring, enabling the accountability of states [78]. These claims depend, in turn, on the existence of agreed foundations for thinking about “effectiveness”, “inclusion” and “equity”, plus both theory and data to support and guide the availability and just distribution of resources [77].

While health is fundamentally expressed in individually discrete bodies, expressing unique DNA, the insight from the sociology of health is that, from the moment of birth until death, life chances and health status are powerfully influenced by the social circumstances and forces that determine how a person will live and die. Individual bodies are embedded in the social context, or the “social body”. “In large part, illness, death, health and well-being are socially produced” [79]. On one hand, there is increased importance placed on the social determinants of health and the “long causal chains” determining ill-health [39]. However, on the other hand, the current trend in public health programming is to emphasise individual personal responsibility and lifestyle behaviour. The “epidemiological transition” from a pattern of high infant mortality and infectious disease to one of longer lives and chronic, non-communicable illnesses is a major societal transition that puts individual behaviour at the centre of health concerns. However, the turn to personal responsibility has evoked a cautious scepticism from the perspective of global health justice [80]. Not all choices are within the control of individuals, and most are socially and economically influenced.

In setting out the scope for public health ethics, Dawson argues that it ought to take into account the view that human interests in health are intrinsically social and that public health ethics should be “substantive” [74]. His argument against the liberal frame of medical ethics also applies with respect to the liberal frame of human rights. Public health is concerned with the health of the public or a population as a whole, and population health is more than the sum of individual “healths” Disease prevention, health risk and precaution work at an aggregate level that cannot be decomposed to symmetrically assign responsibilities and outcomes to individuals. A substantive view from public health requires bioethics and human rights to consider the group, community, population, public goods, common goods, solidarity, reciprocity, welfare, well-being and justice [74].

Arguably, the biological nature of human life makes human bodies less than straightforward as subjects for just and effective treatment by recourse to “one size fits all” ethical assumptions and ways of allocating responsibility and desert. Absolute equality in health is neither achievable, nor perhaps even desirable, as different individuals possess different health statuses for biological as well as social reasons. In addition, these change over time. Health equity is an alternative concept dealing with systematic inequalities in health and its social determinants, only focusing on unfair inequalities as not all health disparities are unfair—it is not unfair that new-born girls tend to have lower birthweights than new-born boys, or that women have a longer life expectancy than men [81]. It is unfair to do nothing in cases where women “achieve” equality in life expectancy through discrimination that leads to the erosion of their biological advantage, thereby levelling-down their life expectancy to that of men. It is not “unfair” that only women are capable of bearing children, but it is unfair that the great majority of perinatal deaths and injuries that were preventable have not been prevented, leading to hundreds of thousands of preventable excess deaths and injuries among women every year [82].

Health carries many reminders about the limits to the usual legal conceptions of the “person” posed by the messy, dependent and imbricated nature of human life. Furthermore the public health mission requires a different kind of expressive justice than that which is most familiar to the law. The retributive concern, so paramount in criminal justice, also has limited relevance. The ways that health is obviously physically and socially embodied troubles the fundamental assumptions underpinning liberal human rights, democracy and markets. The enlightenment project treats persons as discrete, autonomous, rational individuals and assumes that egalitarian relations between persons ought to be symmetrical. However, as embodied beings, we are implicated in fundamental asymmetries of bodies and care—the state of personal autonomy is not an initial condition for human beings, it is a social achievement [83].

The case of one of public health’s main interventions, vaccination, illustrates how health is collectively embodied, with population effects that are not reducible to individual benefits. “Herd immunity” occurs when a sufficient proportion of a population is vaccinated, reducing the disease risk to all members of the community as the vaccinated bodies in the community protect any unvaccinated body in the population. Some members of the population are unvaccinated through no fault of their own: infants who are too young, those with impaired immune systems, and those who have missed vaccinations.

Examining the question of mass immunization for pandemic preparedness in the case of the H1N1 “swine flu” pandemic, Prainsack and Buyx find that that principle of solidarity may not suffice to generate collective action where risks and benefits are unevenly distributed. In such cases, other principles such as public health “stewardship” may be more useful to justify the implementation of large-scale immunization. However, others have extended this debate by suggesting that the manner in which pandemic preparedness and responses are implemented can foster or undermine solidarity [25]. In the case of vaccination, not all diseases, vaccines or potential recipients are the same, so deciding what a policy should be from a human rights perspective is not straightforward. Collective benefits have to be balanced against the downsides of paternalism or coercion, where individuals wish to withdraw themselves or their children from vaccination programmes. Questions of risks, harms and benefits are complex, raising the importance of transparency, information and education, research and meaningful, good quality public deliberation for resolving the issues [84].

The complex world of public health may involve very long connecting chains of action and consent linking individual bodies and the collective good. In the case of bioethics governing “biobanking” of bodily materials for medical research, it has been argued that public governance models have been too focused on protecting individual rights, narrowly interpreted as research participants’ autonomy. This causes excessive costs and delays to medical research that would otherwise benefit the collective good. The suggestion is that solidarity can help to reframe the relationship and to enable medical research to be conducted far more efficiently while ensuring that potential harm is mitigated [2,85].

Dawson writes about solidarity and public health ethics from a perspective of concern about the importance of social connection, and the language to express such social connections. The erosion or loss of this will negatively impact public health. He advocates the promotion of a public health ethics that contains a notion of common goods, and a richer, more socially based general view of ethics, evoking positive, non-individualistic values such as solidarity, reciprocity and social justice.

Recognizing the embodied nature of health opens a door to complex substantive arguments about solidarity and health rights. It also lays out a difficult terrain where bioethics meets biopolitics. The question is how to recognise the importance of the social (re)production of health and value constitutive, cooperative and solidary relationships and arrangements, while remaining attentive to problems of harm, coercion, domination and neglect. The liberal rights perspective calls attention to situations where an individual’s right to health may be compromised by coercively solidary considerations, trading off the individual’s body and consent in favour of the social body and the demands of body politic. The (mine)field of reproductive health offers numerous examples of collective arrangements and standards that are inimical to individual bodily health, rights or dignity, inter alia female or male genital mutilation, restrictions on sexual health information and education, contraception and abortion, or denial of recognition and support for body dysmorphia. In the more tightly defined and applied field of bioethics, the recent interpolations of non-secular understandings into debates about international bioethics norms and procedures has led some authors to call for caution, flagging the morally and politically fractious nature of the field [86].

4. Care and the Reconfiguration of Social Democracy

Within advanced capitalist social democracies, concerns about solidarity’s decline and its relevance to health have tended to centre on questions of care and intergenerational solidarity. These concerns can be expected to intensify given present demographic and democratic trends, with major implications for the ways that social democracies are organised. It is noted the “higher” levels of contractual and legal solidarity have historically emerged out of lower level affinities and arrangements. In the case of welfare state arrangements, it seems that “third tier” structures of solidarity in the form of the welfare state are assumed to be “more or less intact”, but the lower levels of affinities and arrangements that the higher tier depends upon have partly broken away [3].

The fundamental human conditions of infancy, illness, impairment and ageing require large solidarity transfers from caregivers to care recipients. A central problem that has to be faced is that the desired symmetries of capitalism and democracy cannot be made to fit with the asymmetry of care and the absolute nature of embodied needs. We are not all responsible for the same things at the same time. The asymmetry of care is bound up with the time and other interdependences of every embodied individual within the social body, as all human beings have to be born and nurtured, all get ill and experience various impairments and die. Care and democracy do not seem to fit together at all [83], because not all the work of human caring can be made commensurable with autonomy and individualism under the conditions of a market economy. Actually existing capitalism and democracy are ill-suited to the dependent and diachronous nature of the human being, whose needs and capacities change quite radically over time.

Joan Tronto argues that the dual crises of care and democracy flag up the need for a paradigm change towards a more “caring democracy”, which would be focused on relationships and responsibility, instead of autonomy and contractual obligations [83]. This would, in effect, involve a radical redefinition of basic democratic terms, balancing freedom from domination and equality of voice with justice. Tronto echoes Dean’s formulation of reflective solidarity [28] by redefining justice as an ongoing process of assigning and re-assigning caring and other responsibilities within a framework of non-domination and inclusion. In Tronto’s view, having “care” as a central value would change how we see, and deal with, medical care and public health. She argues that the ethic of care cannot stand alone—care needs democracy to be complete, while democracy needs care to solve its unfulfilled ambition of inclusion. The ambitions for equality and inclusion pose huge challenges to the predominant liberal model of ethics and human rights, requiring not only substantive achievement of distributional justice, but relational questions about how we are to reconfigure our working, economic, familial, and intimate arrangements to achieve more humanly satisfactory lives. In essence, Tronto and Dean articulate visions of caring democracy and reflective solidarity as expressive-collaborative morality and ethics. Tronto redefines moral life as a continuing and consequential negotiation about needs, care and responsibility. Dean offers reflective solidarity, not as a panacea, but as a strategy for feminists and others to develop new kinds of connections and processes, to build coalitions capable of effecting necessary changes that can alleviate inequities and sufferings [27,28].

Health and social policy debates are strongly concerned at present with what constitutes “quality” or “good” care. For some egalitarians, solidarity is bound up with the requirements of “affective equality”. Lynch and others, for example [87], conceptually connect solidarity with love and care, seeing all three as types of work that are required to maintain society and enable collective and individual human self-preservation and self-realization. Affective egalitarian theory defines solidarity as “tertiary care relations.” Analogous to Prainsack and Buyx’s “third tier” solidarity [3], albeit less formally expressed, Lynch and others define tertiary care relations as those relations required to maintain general, secondary care work, while primary care relations are defined as “love labour”. “Love labour” represents affective care work, entailing emotional, mental and cognitive relations over and above the actual physical work of “generalised care” [88]. The affective equality argument problematizes the resort to markets to solve the problem of care, because there is asymmetry and tension between the logic of profitability and the need for emotional engagement. Caring work has low status in society as well as low market value. Care provision is deeply imbricated with oppressive and exploitative relations of class, ethnicity and migration. High and increasing demands for care inevitably accentuate inequalities between “care commanders” and care providers. In a globalized world, this means the displacement of a “care gap” to low-income people and low-income countries. Migrant labour fills the care gap in higher income countries, exacerbating the care gaps in their families and countries of origin.

There are increasing practical demands for care and solidarity transfers as the world enters ageing, but more gender-equitable societies, in which all individuals hold normative entitlements to health and care as human rights. The existing patriarchal, historical and political encapsulations and evasions have to be faced up to, not just as ethical demands for egalitarian inclusion, but as urgent practical societal requirements for “sustainability”. A re-thinking of solidarity is necessary in order to sustain the practical arrangements for just health and care.

5. Conclusions

This article has suggested that we must reconsider the place of solidarity in a democratic and egalitarian approach to bioethics and human rights. It employed the visual metaphor of a rope to deconstruct, and to hopefully reconstruct, the idea of solidarity in human rights in the future. The simplest approach was to consider solidarity as one of three equal principles of human rights, either complementing those of liberty and equality underpinning human rights in general, as in the UDHR, or the principles of justice and equality in social responsibility for health, as expressed by the UDBHR. The second part of the article examined the principles of justice, solidarity and equality, wrapped around the core of a social contract. Taking a “history of the present” approach, the discussion highlighted the fundamental critique of real-world conceptions of solidarity, which wound, in essentially conservative or reformist ways, around historical contracts of domination with obvious implications for substantive equality and justice. Finally, we might think of a reconstructed conception of solidarity that cannot ignore the three ropes of solidarity traditions, but must reconfigure the strands differently, comprising (i) a concept of the human person as relational or mutual; (ii) the generalized democratic-communicative domain where complex and difficult realities of health and care can be negotiated and re-negotiated; and (iii) the international or global order, where demands for global justice and socio-economic rights have been deferred and remained largely unfulfilled. The question of how radically egalitarian and redistributive this reconstruction will be remains an open question. Welfare provision has to be underpinned by moral arguments about justice, and as Fives so clearly explains, the two most popular approaches to welfare, rights and utilitarianism, are only quasi-principles, which must, ultimately, depend on one of three possible principles of justice: need, merit or equality. Ultimately, it is the welfare principle of equality that is, in itself, the closest principle to justice [29].

The discussion raised the question of what ethical commitment must bind itself to, drawing on Critchley’s philosophical plea for new kinds of political subjectivities that are not arbitrary and not completely relativistic, but articulate ethical demands that are both universal in scope and substantively concrete [38]. To begin with, we have to face the history of our presently existing concepts of solidarity, and the deeply embedded patriarchal, historical and political encapsulations and evasions that they entail. We briefly considered the frames of public health, global health and the right to health, signalling that a re-orientation that engages with these key domains will not be easy. A re-thinking of solidarity as essentially relational makes the consideration of caring and affective equality necessary in order to reconstruct the practical responsibility for just health and care in different spheres and localities, and on different geographical scales.

Some ethicists are sceptical about the human right to health because they consider it to be over-reaching, and too burdensome [89]. However, it need not be so if the realization of the right to health entails a democratic negotiation about how to justly interpret and operationalize the “highest attainable standard of health”. This comprises the centrepiece of solidarity itself, around which the elements of social responsibility for health, equity and justice wind. The traditions of collective action, mutuality through deliberation, feminist coalition and/or Catholic social teaching and global justice claims have all contributed distinct strands to the solidarity concept. These would not have to lose their distinct characters, nor would the evolutionary, accommodating and hybrid character of solidarity have to be forgotten. What is really at stake is what we mean by “democracy” and “persons” in our consideration of the ethical. The perspectives of health and care raise fundamental challenges for the way we think about “persons”, and deeply challenge democracy to be both more democratic and more humane, taking into consideration the asymmetry, dependence and affective nature of human existence. The eventual proposition here is that extant structures have to be reconfigured, and that health might form the core of a substantive social contract that is less discriminatory than one that came before it. A critical, decolonial approach can take a path that lies somewhere between the liberal over-optimism that simply overlooks the contracts of domination and the leftist over-pessimism that merely states that we are bound to move from one contract of domination to the next: “we can choose a perspective that does not subscribe either to the facile view that humankind is inevitably and inexorably moving towards a just world order or the idea that resistance to domination is an empty historical act” [90].

Solidarity is the human prerequisite of the social. However, while solidarity is somehow basic and fundamental to the very possibility of society or politics, there are no guarantees that collectivities will work, or that they will be characterized by cooperation and not conflict. There are conflicting claims of solidarity and a perception of eroding solidarity in the face of increased pressures, intensifying questions about how much solidarity can be extended to strangers and others [91]. Cole suggests that liberal theory ought to include forms of praxis that first listen to the theorizing of the oppressed and learn to theorize from their viewpoint. Failure to do so will mean that liberal theory will continue to represent the standpoint of the powerful, and fail to make sense of freedom and social justice from the standpoint of the excluded [60]. Liberal theories of justice have generally failed to account for power, and failed to engage with less powerful “others” to seek possibilities for radical transformation. The perspective from health and care reminds us that as embodied and interdependent persons, the label “others” can also be applied to us, who need to be born, nurtured, cared-for and cared-about.

Egalitarianism and democracy can be well served by putting some theory of public good back into public health. Kallhoff’s theory of public goods provides an essential supplement to theorizing solidarity in a democratic context, by providing a conception of how public goods generate as well as serve the public. They do so by providing spheres of mutual awareness, spheres of reliability and spheres of experienced equality [92]. Public health, global health and the right to health are spheres that enable strangers to come together in a public way and provide an awareness of sharing a common realm, of “health systems” or “global health.” “Reliability” stems from public goods being more stable and complex than other goods—we can consider the case of herd immunity here, and of vaccination programmes, which need to be underpinned by guarantees of their safety and efficacy based on evidence and research. The latter provide “a subtle layer in our understanding that provides us with a minimal amount of safety” and empirical bases as well as good philosophical arguments for social trust [92]. Finally, the criterion of experienced equality, means that the way that health rights are claimed must be truly egalitarian, and therefore, top-down or philanthropic approaches can only be part, but never all, of the solution. For the human right to health to be vindicated, there must be human rights in, and through, health. Human rights can be seen as a framework for solidarity, if through human rights, such as the right to health, people can become empowered to challenge domination and encapsulation and construct themselves as full participants in the project of humanity.