Solidarity and Public Health

Abstract

We argue that an unqualified use of the term solidarity in public health is not only equivocal but problematic toward the ends of public health. The term may be deployed normatively by public health advocates to strengthen the bonds among public health practitioners and refer to an ideal society in which the importance of interdependence among members ought to be acknowledged throughout the polity. We propose an important distinction between partisan solidarity and societal solidarity. Because any moralized belief in a vision of a broad societal solidarity will be a contested political ideal, political reality would limit solidarity based on such a vision to partisan solidarity. An idealized vision of societal solidarity is simply not politically feasible in pluralistic, liberal, democratic societies. However, although societal solidarity is unlikely with respect to any particular policy, it might be hoped for with respect to constitutional procedures that provide boundaries for the agon of the political process. We suggest that moralizing assertions of a solidaristic ideal in a pluralistic society might be counterproductive to generating the political support necessary for public health per se and establishing legitimate public health policy. A pragmatic political approach would be for public health advocates to generate sufficient strong political support for those public health policies that are most amenable to the political and social realities of a time and place.

Introduction

Over the past two decades, public health advocates have argued for the importance of solidarity with respect to public health. In the most recent version of its Public Health Code of Ethics, the American Public Health Association (APHA) states the importance of the value of solidarity for public health professionals (APHA, 2019). In Sects. 1 and 2, this Code asserts a broad, aspirational remit for the field of public health. Section 1 refers to “shared foundational values of public health”, which “provide the high-level moral justification for public health work”. Indeed, the Code is said to “derive from values and standards widely shared in the public health profession”. Moreover, the understanding of health at the core of the Code is expansive, referring to “flourishing and well-being”. By aiming at well-being and flourishing, public health is said to stand against “domination, inequity, discrimination, exploitation, exclusion, suffering, and despair”, which suggests standing for social justice. Section 2 lists core public health values; the fourth of which is “interdependence and solidarity”. The meaning of the term solidarity is not explicit in the comment on this value. Section 2 concludes by referring to public health’s “own ideals and those of the broader society”. However, the Code fails to specify whether the ideals are shared between the field and broader society, how the field should respond to the political context in which it finds itself, and how solidarity might be invoked to shed light on the relationship between the field and the broader society.

Without clear specification, the use of the term solidarity, in public health and elsewhere, is equivocal, implying but not specifying a moral obligation of some sort, usually relative to a social group. An unclear reference to solidarity is not limited to the APHA Code (West-Oram 2018; West-Oram 2021; Savulescu 2021). In order to understand how solidarity might pertain to public health and the profession of public health, specification of the term solidarity and its role in public health in particular and in public policy in general is required. To critique the use of the term solidarity in public health, we first examine how political theorists and then public health analysts have used the term.¹ Because they often invoke solidarity normatively in a political context, we explore ways that solidarity might pertain to political society, and in particular to the pluralistic liberalism of Western democracies, especially that of the US. Given that solidarity is typically associated with social groups, we describe temporal emergence of group solidarity and distinguish between instrumental solidarity and moral solidarity. For a clear understanding of the way solidarity relates to public health policy and the profession of public health in a liberal, pluralistic society, we suggest that a distinction between partisan solidarity and societal solidarity is of central importance. We argue that in a pluralistic, liberal society, public health policy must be accomplished through adversarial partisan political processes, something like Gray’s (1995) “agonistic liberalism”, and in many cases, public recognition of the legitimacy of the policy may be sufficient for compliance with it. Although societal solidarity concerning the good of the policy itself will likely be exceptionally rare at best in a pluralistic, liberal society, societal solidarity with other citizens may remain.

A central issue our critique raises is the putative obligation (implicit in the Code) for public health professionals who serve in government to be advocates of what amounts to a partisan political position. This issue becomes increasingly important the further public health activities are from the traditional core mission of public health, which is to say the further they move towards advancing aspirational goals such as promoting human flourishing and supporting the abstract concept of social justice. Is the public health community expected to unite in a partisan solidarity around these moral concepts? Would the solidarity concern the aspirations of the public health community, or would the solidarity be based on broad political support from the entire polity? In considering these issues, we draw on the political realism of Gray and Geuss in contrast to the political idealism of Rawls, which is more prominent among public health analysts. A key distinction here is whether the normativity invoked at the political level ought to be based on a moralized ideal, perhaps a view of justice, or whether the policy establishment ought to take into account the political context in which public health issues occur and attempt to marshal as much support as possible. As the coronavirus story demonstrates clearly in the US (and elsewhere in the West), the success of the immediate challenge of highly contagious and debilitating disease for public health policy will be limited if the only solidarity available is partisan solidarity. Moreover, if a moralized approach to public health advocacy exceeds its ability to generate sufficient partisan political support, the problem may reflect adversely on the level of support for core public health activities. We hope that a clearer understanding of solidarity relative to public health will improve the chances of support for public health activities that are most readily defended in a liberal, pluralistic society.

Groupings, groups, and Social Groups

The idea of a social group is of central importance to our analysis of solidarity. Although a demographer might consider people as a group based on some similarity in characteristics among them, the social group is something different from the demographic group. Even when the people so categorized might be considered to be a group, they might or not be social groups, depending on the classification scheme. For a meaningful description of a demographic group, it might well make sense to aggregate individual characteristics. From an external (etic) perspective, a demographic group might be amenable to such demographic analysis. However, they would not be a social group unless some social relationship existed among the people (recognized from their emic perspective) to form the basis of a social group. The stronger the social relationship(s), the stronger the sense of a social group.²

Although in the section title above we refer to both groups and social groups, we consider that any group other than a demographic group exists on a continuum according to the strength of the group as understood by its members and/or as demonstrated by the actions of the group. The ongoing interactions within a social group account for the dynamic aspect of social groups. Interactions among group members over time can be breathtakingly complex.³ A complex systems approach leads to the idea that a group may have emergent properties (Krieger 2012; Schneider and Winslow 2014; Winslow 2017).⁴ The idea of emergence highlights the dynamic nature of a group.⁵ For a complex whole, the future properties of the group are impossible to predict from their individual components at some moment in time. How a group will interact with an external environment adds additional complexity.⁶ When the group members are humans, with their breathtakingly complex modes of interaction among themselves, the complexity is further magnified. For the purpose of the present work, the strength of a social group will be considered an emergent property (a property that is dynamic and can increase or decrease), and the strength of the group will be related to the sense of solidarity within and among the group, where solidarity involves giving other people or a social group a status in our reasoning that is analogous to the status that we give our ourselves (Hussain 2018). A call for solidarity might serve as a rhetorical means of attempting to increase the strength of a group, and it also may be an indication that the current strength may be less than the caller desires.

In modern Western societies, a vast variety of social groups exist. To provide just a few dimensions of the variety, groups may have few or many members, be formal or informal, and be voluntary or not. Types of groups include clubs, churches, corporations, political parties, professional societies, or even society itself. When society is pluralistic, these various social groups may hold different, even competing, views of the world -- and thereby conceptions of the good. With overlapping individual membership, a network of overlapping social groups exists. The strength of these social groups varies, as does the strength and type of social solidarity accruing to each. “Society” may be considered the most inclusive of these social groups, according to national or geographic boundaries. Thus, societal solidarity is the broadest kind of social solidarity.⁷ Distinguishing between societal solidarity and the more general idea of social solidarity, which includes solidarity of sub-groups of society as well as of society as a whole, is an important theme in the present work. This distinction is required in order to specify different kinds of solidarity in a liberal, pluralistic society, and it has implications for generating support for public policy.

Solidarity

The etymology of “solidarity” traces to the Roman republic. In Latin, the term “solidus” means solid, dense, tight, dense, or united. Citizens of the Roman Republic were expected to exhibit civil solidarity. Solidarity evokes the idea that community members are connected in such a way that they must “stand in” for each other (Jaeggi 2001, p. 288). During the French Revolution, the idea of solidarity was implicit in the slogan “liberty, equality, and fraternity.” However, the value of fraternity is not a simple heritage of the Enlightenment, as it has roots in solidarity described in prior Catholic religious thought (Pasini & Reichlin 2001, p. 309).

Inspired by French revolutionary ideologists such as Rousseau, socialist advocates invoked solidarity to unite workers against the alienating forces of capitalism. Reflecting on the nature of capitalist society, Durkheim conceptualized solidarity as divided into two forms: mechanical (or traditional) and organic (or functional) (Meulen, Arts & Muffels 2001, p. 7). Mechanical solidarity pertained to small human groups in which most individuals were similar in outlook (Merton 1934). This describes the solidarity of the clan or tribe. It looked to the nature and interests of the group for a moral framework. Organic solidarity is a more abstract concept, explaining the coherence of modern society through the mutual interdependence of the division of labor.⁸ Organic solidarity is a thinner, abstract concept than the thicker mechanical solidarity. Durkheim’s consideration of solidarity as a societal concept remains influential, even as the idea of solidarity within more limited social groups has been explored since then. In analyses at the societal level, Durkheim considered differences in societal solidarity according to the type of society. His focus on the societal level has been influential in analyses of solidarity such as those by Comte, Weber, Simmel, and Tonnies (Arts & Verburg 2001, p. 21). Because such analyses are more prominent among European academic circles, political theorists such as Bayertz (1999) and ter Meulen (2001) conceive of solidarity as a typically European principle that contrasts with the individualistic values prevailing in the United States.

Influential scholarly studies of the general concept of solidarity include Bayertz (1999), Prainsack and Buyx (2011), and Scholz (2008; 2015). Bayertz (1999, p. 4) presents four senses of the term, which he labels the four “uses of solidarity”: (1) concerning morality, solidarity addresses “positive obligations to act” rather than “ward[ing] off dangers to the individual”, (2) concerning society, solidarity is the “cement holding together a society”, (3) concerning rights and liberation, solidarity is associated with social movements, and (4) concerning the welfare state, solidarity plays a legitimating role. Prainsack and Buyx (2017, p. 43) discuss solidarity from their perspective as sociologists, advocating for a view of solidarity as enacted skillful acting, not a value, principle, feeling, or obligation. Scholz (2008) identifies three types of solidarity: social, civic, and political. In her view, social solidarity describes solidarity of a social group, referring to group cohesiveness; civic solidarity describes a sense of mutual obligation between citizen and state; and political solidarity is associated with a “smaller group in response to a larger group” in advocating social justice (Scholz 2008, pp. 5–6 & 198).

Despite the differences among them, Scholz (2008, p. 17) posits that all these forms of solidarity have something in common (the “genus” of solidarity), namely they refer to processes whereby individuals strengthen their bonds among one another. Similarly, Bayertz (1999) explains that all the various uses of solidarity connect to a core meaning: solidarity is the “tie which binds all of us human beings” (p. 5). Thus, solidarity has been called the glue, the “cement” (Bayertz 1999), and/or the “putty” (Prainsack and Buyx 2011) of human social groups. Solidarity as being thick or thin also evokes a physical sense. These physical metaphors point to a phenomenon that is elusive in definition. In their emphasis on material/physical structure, the metaphors elide the importance of change over time: the ephemerality of emergence of and loss of solidarity. In their emphasis on the inanimate, they miss the immense interactive complexity of animate life, and especially of human social relationships considered groupwise.

In times of trouble, pointing out a deficiency of solidarity as a problem suggests its normal background importance in human affairs. Any social group has at least proto-solidarity, from which solidarity can emerge when social circumstances are propitious. The instrumental solidarity emerging from perceived common interest or common concern may further develop into the moral solidarity from an understood common sense of the good among the group members.⁹Solidarity is not simply social group cohesiveness, but a sense of group cohesiveness motivating action by individuals in the interest of the good of indeterminate others. Solidarity is evidence that individuals understand at least an instrumental “ought” and even that perhaps a normative “ought”, has emerged groupwise. For moral solidarity, individuals can feel an obligation to other individuals and also to the group itself, in effect bringing a strong group into being (Krieger 2012, p. 649). To attempt to conjure a nascent sense of solidarity is also to attempt to conjure a strong social group. A call for group solidarity when it does not yet exist can be a rhetorical means of attempting to influence the behavior of others.¹⁰

For Durkheim’s mechanical solidarity, both instrumental and moral solidarity were readily achieved, but at the cost of reflexive examination. It is potentially problematic when the group perspective is unreflexively accepted as the moral perspective. A band of robbers could have such solidarity, and it would hardly be considered good outside the band. Thus, solidarity is not necessarily a good moral value (Jaeggi 2001). With respect to group behavior, it might be considered an instrumental virtue, like courage. Whether it is used well depends on the end. From a group’s (emic) perspective, it may be a good, but from a broader (etic) perspective, it may be bad.¹¹

The Social, the Societal, and the political

The Classical Greeks had no vocabulary to distinguish the societal from the political. In the glossary that Ostwald (1999, p. 313) provides for his translation of Nicomachean Ethics, he says that “the polis, the city state … also covers our concept of society (for which the Greeks had no independent word), and politike is the science of society as well as the science of the state”. Barker (1962, p. xlvii), in the introduction to his translation of the Politics, notes that Greeks of the period make “no distinction between the province of the state and that of society”. Aristotle’s Ethics and Politics together describe an “integrated system of social ethics” that described an ideal of a good polis that allowed individuals to pursue the good life (eudamonia), and was politically stable (Baker 1962: xlvii). We draw on Aristotle’s approach to politics in pointing out the close relationship between the societal and the political, and we employ this relationship in our choice of the term “societal solidarity” for the distinction between societal solidarity and partisan solidarity (see below).

The formal function of society is the realm of the political, not in the partisan sense but more broadly (Coggon 2012; Gray 2000; Geuss 2008; Rawls 2005). In Political Liberalism, Rawls writes of the importance of an overarching “domain of the political”. Although Rawls (2005) develops an ideal theory and Gray (1995) develops a theory from political realism, for both there is a political framework that is to be an overall agreement among citizens about how some issues at the political level are to be addressed and resolved through the creation of legitimate public policy through legislation. Despite severe disagreement among groups of partisans advocating different views, allegiance to a political framework is to hold sway once a policy decision is reached. Although there may be no societal solidarity about the merits of a particular policy, societal solidarity is manifest by recognition of the legitimacy of the policy reached under the aegis of the mutually agreed upon political framework. Gray (1995) emphasizes the public agon among partisans and accepts a modus vivendi among them, whereas Rawls seeks an “overlapping consensus” around a common political concept of justice.

The most common way that societal solidarity is manifest is formally through what some might consider political solidarity. In this paper, we will use the term societal solidarity, even as it is expressed through allegiance to a political conception.¹² At the level of a nation, the political structure allows for a form of governance; in most liberal democratic constitutional republics, the political structure allows for the exercise of partisan politics to resolve differences and create public policy. The partisan struggle follows from a banding together of social groups of like-minded partisans and the possible emergence of partisan solidarity. Partisan solidarity is easily confused with political solidarity because “politics” is very commonly used as a pejorative description of excessive partisan zeal. For an understanding of solidarity as it relates to public policy, it is useful to avoid the adjective “political”. Societal solidarity is an institutionalized form of one sense of political solidarity.¹³ To avoid confusion from the word “political” concerning the distinction we seek to make, we contrast societal solidarity and partisan solidarity.¹⁴

One reason why it is important to distinguish societal solidarity and partisan solidarity is to understand that both are forms of social solidarity, but differ in the nature of the group members. A group of like-minded political partisans is a sub-group of society as a whole. Advocates of social change to improve social justice typically have a partisan bias in that their advocacy is confounded with a particular progressive partisan political position (see Gostin 2003). Since solidarity as a concept pertains to any social group, not only individual partisan groups but also partisan groups taken together groupwise as society can in principle both exhibit solidarity. We attempt to clarify the relationship between the two levels of groups. Indiscriminate reference to the general concept of solidarity is not the way to clarify this relationship.

In a constitutional government, citizens and officials owe allegiance to the constitution to the extent that it can be considered a procedural mechanism for peacefully resolving partisan differences. In such a system, political stability requires societal solidarity overall, even as partisan solidarities are allowed as long as they do not interfere with political-level allegiance.¹⁵ A thick partisan solidarity may motivate political engagement emotionally, but the citizen partisans and the partisan groups considered together are nevertheless expected to maintain at least a thin societal solidarity and work within the rational guard rails of the constitution in societal solidarity. An important aspect of this societal solidarity is that it is expected in spite of disagreement concerning specific policy outcomes.¹⁶ In fact, and remarkably, Kolers (2016) claims that solidarity (considered generally) is not present except for situations in which individual conscience is challenged; solidarity with others exists nevertheless, out of consideration for the perspective of those who challenge one’s conscience. This understanding of solidarity would be consistent with public health practitioners joining in a collective professional conception of public health ethics, despite possible differences among themselves concerning core values of public health.

Solidarity and Public Health

The challenge for invoking solidarity as a public health value is magnified due to the difficulty in defining public health. Both “public” and “health” are terms about which reasonable people can disagree. The meaning of the combination of the two is even more contested. From a political philosophy perspective, Coggon (2012) goes to pains to explore what might make health a public concern. He and others have shown that disputes about public health ultimately are political disputes (for a detailed explanation of the political nature of public health concerns, see Sect. 6 below). Consequently, arguing for solidarity with respect to public health may entail a partisan political exhortation.

Coggon (2012) attempts to address some of the ways in which public health is understood by suggesting that public health has seven “faces”: (1) a political tool, (2) a theory of government, (3) the social infrastructure, (4) a professional enterprise, (5) a blind benefit, (6) conjoined beneficiaries, and (7) the population’s health. He considers the sixth face to be a solidaristic sense, in that health is shared in a population.¹⁷ Each “face” is itself complex, and the distinctions among the different faces is often unclear, but a rough distinction is still useful to illustrate the complexity. In the present work, we tend to focus on public health as a political tool, as a theory of government, and as a professional enterprise. The combination of these leads to questions about how the ethics of the profession might speak to how public health should be positioned and understood in a political society.

The practice of public health is so varied as to make it a considerable challenge to not only determine the domain of public health, but also to determine who might be a public health practitioner. Relatedly, a key question is whether a moral position held by practitioners can legitimately establish a political foundation for public health. In particular, whether public health professionals’ concept(s) of solidarity can serve to politically justify public health policy. In addition to Coggon’s seven faces, public health may be thought of in a broad or a narrow way, the former as limited to contagious disease and other medical problems requiring a cooperative response, and the latter as including well-being and flourishing of populations. How to determine whether public health should be broadly or narrowly understood is itself a political question. Establishing something called “public health ethics” and a potential role of solidarity in it demands that these ambiguities be made less equivocal.

For at least the last 20 years, several authors have explored the ways that solidarity might relate to public health policy and the profession of public health. At times, solidarity refers to something like a virtue relative to a group, and at others, it seems to speak to a normativity based on what society should value. With funding from the Nuffield Council, Prainsack and Buyx (2011) wrote a monograph that first explored solidarity and then went on to relate solidarity to bioethics. Concurrently, a series of other authors (see below) addressed the concept of “solidarity” as it related to public health. A core disagreement among these works was whether solidarity per se could be used as justification for public health. To put it differently, a core disagreement among public health scholars was whether solidarity is a normative concept. In public health ethics, advocates of something called “solidarity” often regard solidarity as a morally valuable good. However, political philosophers such as Scholtz and sociologists such as Prainsack and Buyx have argued that solidarity lacks this moral force (see Kolers 2021). The ramifications of invoking a moralized concept of solidarity in support of policy are uncertain. Moral conviction can be used to mobilize advocates in the political process, but it can also result in rejection of the rule of law (Skitka and Morgan 2014), resulting in diminished societal solidarity. Gray (2000) and Geuss (2008; 2015) suggest that moral assertions can be problematic in the political domain, as they might tend to close off discussion and make deliberation more of a challenge.

Prainsack and Buyx (2011) took the position that solidarity is a sociological concept and not appropriate as a justification in and of itself for public health policy. Others responded to this work attempting to use solidarity for normative justification (Dawson and Jennings 2012; Dawson and Verweij 2012). Dawson and Jennings (2012) point to values underlying public health activities, and assert that solidarity is the idea that brings them together. Dawson and Verweij (2012) argue explicitly that solidarity is a moral concept, writing of a “constitutive solidarity” that draws on a normative foundation of a desirable ideal political society. More recently, Jennings (2018) has argued for the importance of solidarity and care. A commitment to an ethical ideal of social justice might be the basis for this idea of solidarity. In earlier works, Jennings (2007) draws on the historical-political context of the classical republicanism of the Roman republic to explain the practice of solidaristic behavior as “standing up beside another, thereby signaling publicly one’s recognition of that person’s (or group’s) moral standing.” (Jennings 2019, p. 10; see also Jennings and Dawson 2015) This understanding of solidarity is inherently normative because it builds upon the notion that individuals’ lives and agency are “bound together with the rights, well-being, health, and dignity of others.” (Jennings 2019, p. 10) Indeed, Jennings refers to it as a “substantive ethical vision of solidarity” and argues that it should “ignite the moral imagination of the twenty-first century.” (Jennings 2019, p. 11) The hope is that this commitment will accomplish a broad progressive agenda that includes public health (Gostin 2003). The partisan political barriers to acceptance of this vision of what seems to be a universal solidarity are not addressed.

Our distinction between societal and partisan solidarity provides a different approach to this disagreement, but ultimately aligns with Prainsack and Buyx’s (2012, Ch. 1–5) position that solidarity per se cannot do the work of justification in public health. Our thinking is informed by the political realism of Gray (2000) and Geuss (2008), which emphasizes political justification over moral justification. Bayertz (1999) described justification of the welfare state as one of the “four uses” of solidarity. Since public health policy can overlap with welfare policy, Bayertz’s description might be thought to give insight into a sense in which solidarity might be thought to justify public policy, including public health policy. Several authors have argued that differences in societal norms account for differences in welfare policy and public health policy among nations, and they ascribe these more expansive welfare systems as exhibiting putative societal solidarity (Meulen et al. 2001).

The contrast between European Nations and the US is often cited (Scholz 2008, p. 9) to argue that the US is a more individualistic society and its citizens less solidaristic (Fuse Brown, Lawrence, McCuskey, and Wiley 2020). By this reasoning, the welfare system, including its public health components, is less expansive in the US. As we use the term, societal solidarity with respect to welfare policy does not exist in either Europe or the US. We argue instead that societies are neither intrinsically solidaristic or not solidaristic, but differ in the level of partisan political support for welfare policy, and the level of political support will vary over time, emerging politically according to particular circumstances. Even for the putatively solidaristic societies of European countries, economic and political stresses may alter the level of support for welfare policies. As Gevers et al. (2001) argue, the acceptance of individualistic and neo-liberal principles in Western societies has increasingly eroded Europeans’ supportive attitudes towards public health care services. More recently, Pornschlegel (2021) explains the limited success of European nations’ uses of solidarity to respond to the challenges European citizens faced during the early stages of the COVID-19 pandemic.

Although differences in political support for public welfare systems likely reflect to some extent cultural differences, the important distinction is instead a different level of partisan political support, one either sufficient or not to produce relatively expansive welfare and public health policies. Robertson (1998, p. 1422) argues that welfare policy might be justified on the basis of need; and yet she goes on to argue that human needs are both fluid and contingent as well as infinitely contestable, to be worked out through “the true business of politics – the mediation of competing need claims.” In discussions of public health and solidarity it is important to recognize that the APHA core value of “interdependence and solidarity” would seem to use solidarity in a normative sense more as a moral value to which the broader society ought to subcribe, and to which public health professionals are expected to subscribe, than to argue explicitly that societal solidarity around this value would provide justification for public health policy. Public health professionals ascribing to this normative solidarity should recognize that public health policies would be subject to the political business of mediating claims in a pluralistic society. Part of the task for advocates of public health is to function effectively and legitimately with respect to this political mediation.

Public Health as Public Policy

“Public policy” as a term suffers from some of the same ambiguities as “public health”. Coggon (2012) acknowledges that his central question, “What makes health public?” also applies more broadly, to policy of any type, not just public health policy. Coggon (2012) considers the circumstances under which addressing a particular problem should be thought of as in everyone’s interest. The answer to the broader question of “what makes a problem public?” provides the basis for deciding whether addressing the problem is politically justified. That evaluation of justification will be a political one, especially in a pluralistic society, as members of the public can be expected to disagree about what problems the state should address. Even if agreement about justification is reached, the manner in which the problem might be addressed -- that is to say, what government policy might be -- is also a political one. Beyond concern about the term “public”, the term “policy” is not unambiguous. Coggon (2012) elaborates on some of this ambiguity. In this paper, we focus on policy developed under the aegis of the state.

Public policies are developed in response to a wide variety of public concerns. To some extent, advocates for policies in a particular area are competing for scarce state resources with advocates for policies in other areas. Advocates argue about the relative importance of the competing goods involved, and these arguments are mediated and resolved in the political domain. At times, advocates may find that their political advocacy is subsumed by partisan politics, and rather than contributing to rational deliberation, they become embroiled in the agonistic struggle described by political realists (see Gray 1995). Many public policy disagreements are at the root disagreements about political philosophy, and arguments concerning public health policy are no different. Thus, promotion of solidarity about some particular public policy, or about an appropriate political foundation for public policy, can be so abstract and idealistic as to be irrelevant to the politics of gaining and maintaining political support.

As noted above, the scope of “public health” can be framed narrowly or broadly. The framing is a matter of political philosophy that tends to align with partisan political positions about public policy and the proper role of the state (Rothstein 2002; 2004; 2009; Goldberg 2009). Some public health advocates suggest that the domain of public health is so broad as to include well-being in general, leading to an understanding of public health that subsumes much of public policy (Gostin 2003; Goldberg 2009). Public health policy can be a particularly contentious kind of public policy, one for which partisan disagreement can be so strong as to stress allegiance to a larger political framework, which is to say to stress the prospects for societal solidarity. Development of public policy through competing factions while maintaining political stability is a challenging task for a liberal, pluralistic society.¹⁸ A central question concerning public health in political philosophy is whether health is important for its own sake, whether it is important to further other societal goods, or whether it is primary in importance (Wilson 2009).

For many public health advocates, health is considered an unqualified good, capable of trumping other partisan interests.¹⁹ However, Coggon (2012) points out that even for a “health monist” different aspects of health may sometimes be in conflict. Wilson (2009) describes limitations of undue prioritization of health, arguing that effects of public health policy interact with effects of other public policies. He says that public health policy should take into account other forms of societal good. Geuss (2008; 2015) speaks to the problems of political function that result from insisting on the dominance of a particular moral perspective in practical political life. Coming from an entirely different perspective, Rawls warns that comprehensive moral doctrines should be excluded from liberal political conceptions.

Dawson (2014; 2016) recognizes that public health policy is a subset of public policy. Jennings (2014) speaks to the special challenge of public health policy: “It is a core health and welfare function of the modern state, and it is at the pivot point of contemporary struggle over the meaning and social embodiment of the two key values of our political and ethical tradition: liberty and equality.” (p. 553) Bayer and Fairchild (2004) describe some of the political ramifications of promoting certain types of public health policies. Many policies not initially developed with public health goals in mind can have indirect effects on public health, of the population as a whole or differentially on particular demographic segments of the population. Should these policies be considered primarily the purview of public health professionals? Should public health as a field be charged with oversight of them, in the name of social justice? These morally charged questions are best settled in the political domain. Rawls’s ideal theory suggests that a common understanding of justice might underly a political resolution, whereas Gray and Geuss worry that the aggressive promotion of an abstract yet morally charged perspective serves to close off political debate and detract from political stability that might have resulted from public resolution through political means (see Geuss 2015). Nevertheless, socially progressive public policy appears to be a core value in the field of public health.²⁰

Because public policies not explicitly aimed at influencing public health can have an effect on population health, we might consider whether public health considerations should drive public policy in general or whether broad public policy considerations should establish a political context within which public health policy would be congruent. By drawing on Rawls, Peter (2001, p. 161) sees societal approaches to public health as a “political problem with a political solution.” Yet, in Political Liberalism, where Rawls (2005, p. 21) modifies his prior argument about the political conception, he continues to struggle with whether health care should be on his list of primary goods (it was not included in this list in Theory of Justice): he considers it to be an unresolved “problem of extension” of his thinking. In essence, he brackets health in order to try to establish an example of political stability drawing on political conceptions in a liberal, pluralistic society so that individuals with different conceptions of the good can coexist. Making public health central to an understanding of public policy, in general, would be inconsistent with Rawls’s omission of public health as a primary good in order to maintain political stability. The question of health as a possible primary good is arguable and must be argued if claimed; Wilson (2009) criticizes Daniels for not explicitly making an argument for health as a primary good in Just Health.

In lieu of some ideal of societal solidarity concerning public health policy, perhaps the goal of public health advocates should be limited to, as per Gray’s and Geuss’s agonistic politics, the generation of public health policy according to the constitutional mechanism for resolving differences (Rothstein 2002), even as a sizeable minority of the polity may disagree with that policy (Jennings 2014), such that the outcome would likely be something far from societal solidarity with respect to that policy (Childress and Bernheim 2008; Gray 1995; 2000). The goal would be less idealistic and more pragmatic, although perhaps not as satisfying for advocates committed to social change (Rothstein 2002). Success in a partisan political process could come through compromise, or it could come from rallying sufficient adamant political support for a desired position. Political effectiveness in service to good ends is a politically normative notion distinct from moral normativity (Gray 2000; Geuss 2008). If a public health policy is developed and proposed with public health benefits asserted as the goal, support would be sought primarily on the basis of those health benefits. If a social good is advocated as either an explicit or the overarching goal, then some who otherwise support the public health policy and who also support the associated view of the social good might be more strongly inclined to support the policy (Bayer and Fairchild 2004). However, citizens with a different view of the social good might reject an otherwise supported proposed public health policy on that basis alone. It would seem that, for a successful partisan political effort for establishing a public health policy, it would be best to minimize potentially problematic arguments in order to establish the desired policy. A certain tension between the partisan solidarity of advocates and the societal solidarity of fellow citizens is inevitable, placing pragmatic boundaries on the idealism of partisans.

Take the example of social justice and its role in public health. Several authors in the field assert that social justice is foundational to public health. Krieger and Birn (1998, p. 1605), for instance, make the strong claim that “a vision of social justice is the foundation for public health”. We instead claim that public health policy should accommodate some sense of social justice, but that public health should be targeted to and primarily justified by arguments specific to its domain. Of course, ideally, any public policy should be not be societally unjust; at least, it should not make society less just.²¹ The inarguable fact of so-called “social determinants” of health that are evident by epidemiological research leads naturally to potential issues of justice. The presence of disparities and the evaluation of these as inequities can lead public health practitioners to a sense of solidarity with those who suffer from their social circumstances, but this sense is not what we mean by societal solidarity but rather a partisan solidarity. Moreover, this moral sensitivity does not necessarily settle a larger discussion about what public policies should be preferred over others. Deploying the idea of solidarity indiscriminately as a value of those working in the field may tend to resonate with public health advocates. But it is often not clear whether the solidarity invoked is to be societal solidarity or partisan solidarity, or perhaps professional solidarity. Different social groups, however, will have different ideas of what comprises social justice (see Miller 2003). Part of the essential disagreement about public health policy is a societal divide concerning the meaning of “social justice”.

Combining a strongly moralized view of health and a strongly moralized but abstract idea of social justice claims help make public health advocacy an especially moralized domain. It is problematic to argue that social justice is the (sole) foundation for public health. There are contested value issues related to social justice even in determining summary measures of population health (Schroeder 2017). In addition, many social justice concerns are based on issues of distributional justice, a contested notion in general as well as in public health (Reid 2016). When the social group is homogeneous, social justice can be considered what is within acceptable in a commonly understood social practice; if the social group is the society as a whole, social justice, or societal justice, might be formally established as political justice. However, in a pluralistic, liberal democratic society, there will likely be sharply divergent views of social justice (Bayer and Fairchild 2004), and if there is a stable political structure, these would be debated and resolved through an adversarial partisan political process.

Social justice and the differing political philosophies that speak to different understandings of this abstract concept are often at the heart of the disagreements in public health, disagreements that should be resolved according to societal solidarity through established constitutional procedures. Thus, an alternative approach for public health advocates might be to decouple public health advocacy and an understanding of social justice that is either the underlying goal or as an explicit goal of public health policy. Although clearly there are social determinants of health (Daniels 2007; Wilson 2009), and these tend to be related to concerns about social justice, attempting to find political support for both public health and social justice combined is a bigger challenge than either alone, and claiming the moral high ground for doing so does not lessen that challenge. It is vital that political support be sufficient for core public health policies. If social justice is an expressed motivation for these policies, political disagreement may well ensue even if the policies are themselves reasonable for public health. That is not to say that social justice is not a proper societal/political goal; instead, it is to say that social justice might more advantageously be addressed in its own right. As noted above, Coggon (2012) argues that legitimate public health policies must be in the interest of all. In this respect, social justice plays a significant role in public health policy making: a legitimate public health policy must avoid creating social injustice. It would be unfortunate indeed if, in attempting to achieve social justice, public health advocates both jeopardized those public health policies of acutest health importance to the country and also failed to improve social justice (Rothstein 2002; 2009; Latham 2016).²²

Conclusion: Public Health, partisan Solidarity, and Societal Solidarity

We have argued that unqualified use of the term solidarity in public health is equivocal. The term may be deployed normatively by public health advocates to attempt to strengthen the bonds among public health practitioners. From an advocate’s perspective, a commitment to solidarity might also be understood to be a claim that the larger polity should have an ethical obligation to subscribe to the same political ideal. However, it is unclear why the larger polity could reasonably be expected to subscribe to it. Public health advocates justify the ethical obligation to solidaristic behavior on the grounds of the promotion of abstract moral values, such as social justice or as the achievement of social goods such as the invigoration of the citizenry and the creation of higher opportunities to access education and health care. Unfortunately, these idealistic efforts based on partisan solidarity fail to account for the reality of the pluralistic (and agonistic) character of liberal, democratic societies. In particular, public health professionals ascribing to this normative partisan solidarity overlook the fact that public health policies are subject to the political business of competing moral claims in a pluralistic society. Broad agreement on the importance of solidaristic behavior with respect to policy, i.e., societal solidarity, especially if solidarity is invoked to promote abstract and disputed moral values, cannot be expected in pluralistic societies. Societal solidarity concerning public health policy is unlikely in a pluralistic society; rather societal solidarity will at best pertain to the overarching political structure within which agonistic disputes among partisan solidarities are to be legitimately resolved. Perhaps it would be a contribution both to the field and to the larger society if the use of the term solidarity were subject to rigorous critique within the public health community, to include whether and how it might be invoked practically, whether within the public health community or among the broader pluralistic, liberal society, to increase legitimate support for public health policies. What constitutes the core of public health might be construed not so much as a political ideal, but as those policies for which legitimate political support can be marshalled and maintained.

Consider the recent case of COVID-19 public health recommendations and regulations. An effective public health response to such a highly contagious disease required strong population-level compliance with public health interventions such as vaccines and wearing masks. However, public policy based on voluntary compliance has been only partially effective. Partisan political divisions about the field of public health have impeded population-level compliance, because when compliance is voluntary, solidaristic partisan divides serve to preclude strong overall compliance, even when there is majority support for compliance (as it was the case in the majority of European nations). Asking for voluntary compliance with COVID-19 public recommendations indicates a lack of political will for mandatory compliance, either because mandatory compliance does not have sufficient political support for legislation to be enacted based on the medical knowledge of the problem, or because societal solidarity (at the level of the political structure) is not thought to be sufficient to bear the political stresses it would cause. If an effective response to a highly contagious disease requires something like societal-level solidarity concerning the policy response, the problem might seem insurmountable, as we have argued that societal solidarity regarding a particular policy is not feasible in a liberal pluralistic society. Nevertheless, the legitimate political process may result in a policy that may draw on societal solidarity at the level of the political structure for the same reasons that societal solidarity with respect to that structure is required: if the stability of the political structure would be otherwise impossible. Thus, in extreme public health situations something like societal solidarity regarding a coercive public health policy is possible even in the face of pluralism in deliberations concerning establishment of that policy.

How might the prospects of this possibility be enhanced? We suggest three ways: (1) Establish broader support for the notion of public health by emphasizing the core activities of public health, those that are most amenable to generating broad political support through partisan political advocacy. (2) For any advocated public health policy, make strong attempts to educate the general public concerning the science behind it as well as the political argument that drawing on that science can lead to legitimate public policy, in the interest of all. (3) Institute educational programs concerning the political structure of liberal democracy and the philosophy behind it, emphasizing the way that constitutional government can legitimate an overall societal solidarity that must hold sway over partisan solidarities that compete in the agon of the political process and through deliberation, toleration, and compromise result in legitimate public policy.