Case 5: Solidarity in healthcare financing
Learning goals
1. How do sociological theories on solidarity explain this concept, and what motives for
solidarity behaviour can be derived from these theories?
2. Which forms of solidarity exist in healthcare and how is solidarity institutionalized in
(different) healthcare financing arrangements?
3. How do solidarity and justice relate to each other in the distribution of scarce healthcare
resources?
4. How can the increasing emphasis on individual responsibility be explained using Rawis’
theory of justice?
5. Are there any limits to solidarity in healthcare? Why is it controversial to use individual
responsibility as a criterion for the distribution of scarce health resources?
Literature
- Van Oorschot W. Shared identity and shared utility. On solidarity and its motives. Tilburg: Work and
Organization Research Centre; 1998.
- Jeurissen PPT, Sanders FBM. Solidarity: who cares? In: Steenbeek OW, Van der Lecq SG (eds). Costs
and benefits of collective pension systems. New York: Springer, 2007: page 33-46.
- Schmid A, Siemsen P, Götze R. Keeping an eye on IRIS: Risk and income solidarity in OECD
healthcare systems. TranState Working Papers, No. 191. Bremen: Universität Bremen, 2015: page 1-
5.
- Buyx A, Prainsack B. Lifestyle-related diseases and individual responsibility through the prism of
solidarity. Public Policy & Law, 2012;7:79-85.
- Cappelen AW, Norheim OF. Responsibility in health care: a liberal egalitarian approach. J Medical
Ethics, 2005;31:476-480.
1. How do sociological theories on solidarity explain this concept, and what motives for solidarity
behaviour can be derived from these theories?
Defining solidarity
There is no consensus on the definition of solidarity. Solidarity is a highly contested concept in the
political debate and its meaning seems to be strongly influenced by the political perspective taken.
There is more and more emphasis on the individual responsibility nowadays in Western-European
countries.
- Solidarity: an ambiguous and ethical concept in policymaking, connected to social justice.
1
, - Solidarity: relations of personal commitment and recognition (Ter Meulen).
à Solidarity is not just a feeling (having empathy for other people), it is an act – it requires
behaviours and action.
à Distinguish of solidarity between warm feeling vs. cold feeling
Policy trend in many countries
- Since 1980s, policy trend of decreasing solidarity and increasing individual responsibility;
- Financial protection becoming less universal, more selective and conditional.
- What drives this policy trend?
o Ageing, increasing costs à sufficient explanation?
o Explanations based on sociological theories vs. theory of justice.
Current debates on solidarity:
- Obamacare
- Sustainability of arrangements in the Netherlands is questioned
- Behavioural factors and health
Sociological theories on solidarity
Theories of sociologists who perceive solidarity as a characteristic of a social system, thus not as a
belief or a feeling held by individual people
à From this can be concluded that: solidarity can be defined as an actual state of interrelations
between individuals, groups and the larger society, which enables the common good of groups and
society to be served. The theories:
2
, Durkheim - macro-level - characteristic of a social system
Two main sources for social solidarity: `...the likeness of consciences and the division of social labour'
- Mechanic solidarity (Durkheim) – shared identity – macro level
o `Likeness of consciences’ refers to a situation in which individuals share the same
fundamental cultural elements
o The individual identifies strongly with the group
o Broader societies and collectivises: Individuals share the same fundamental cultural
elements, which they use as a basis for recognising and accepting each other as
members of the same collectively
o The cultural bond as the heart of the mechanic solidarity (dominant in homogeneous
pre-modern societies)
- Organic solidarity (Durkheim) - shared utility – macro level:
o ‘The division of labour’: causes people to become mutually dependent on each
other for their life opportunities: Division of labour thus gives rise to structural
bonds, people are connected
o Organic solidarity presupposes explicitly that individuals allow collective interests to
prevail over their own: can be internalised during the socialisation process and
thereby seen an experienced as an intrinsic moral duty (and not a externally forces
behaviour)
o Organic solidarity: structural interdependence as the heart of this, present in modern
societies with a high DoL → functional necessity for survival and existence of the
system
Weber - micro-level - solidarity characterises & social relations between individuals
Weber argues that both types can be present in one and the same relationship
- Communal relationships – shared identity:
o Individuals treat each other according to fellow feelings = a subjective feeling of
belonging together: Feeling like you are all the same with the same identity.
o Examples of such a relationship are a religious brotherhood and a national
community.
o The core is formed by a shared we-ness, in understanding and accepting that one is a
member of the same group.
o A micro-version of the mechanic solidarity of Durkheim.
3
Learning goals
1. How do sociological theories on solidarity explain this concept, and what motives for
solidarity behaviour can be derived from these theories?
2. Which forms of solidarity exist in healthcare and how is solidarity institutionalized in
(different) healthcare financing arrangements?
3. How do solidarity and justice relate to each other in the distribution of scarce healthcare
resources?
4. How can the increasing emphasis on individual responsibility be explained using Rawis’
theory of justice?
5. Are there any limits to solidarity in healthcare? Why is it controversial to use individual
responsibility as a criterion for the distribution of scarce health resources?
Literature
- Van Oorschot W. Shared identity and shared utility. On solidarity and its motives. Tilburg: Work and
Organization Research Centre; 1998.
- Jeurissen PPT, Sanders FBM. Solidarity: who cares? In: Steenbeek OW, Van der Lecq SG (eds). Costs
and benefits of collective pension systems. New York: Springer, 2007: page 33-46.
- Schmid A, Siemsen P, Götze R. Keeping an eye on IRIS: Risk and income solidarity in OECD
healthcare systems. TranState Working Papers, No. 191. Bremen: Universität Bremen, 2015: page 1-
5.
- Buyx A, Prainsack B. Lifestyle-related diseases and individual responsibility through the prism of
solidarity. Public Policy & Law, 2012;7:79-85.
- Cappelen AW, Norheim OF. Responsibility in health care: a liberal egalitarian approach. J Medical
Ethics, 2005;31:476-480.
1. How do sociological theories on solidarity explain this concept, and what motives for solidarity
behaviour can be derived from these theories?
Defining solidarity
There is no consensus on the definition of solidarity. Solidarity is a highly contested concept in the
political debate and its meaning seems to be strongly influenced by the political perspective taken.
There is more and more emphasis on the individual responsibility nowadays in Western-European
countries.
- Solidarity: an ambiguous and ethical concept in policymaking, connected to social justice.
1
, - Solidarity: relations of personal commitment and recognition (Ter Meulen).
à Solidarity is not just a feeling (having empathy for other people), it is an act – it requires
behaviours and action.
à Distinguish of solidarity between warm feeling vs. cold feeling
Policy trend in many countries
- Since 1980s, policy trend of decreasing solidarity and increasing individual responsibility;
- Financial protection becoming less universal, more selective and conditional.
- What drives this policy trend?
o Ageing, increasing costs à sufficient explanation?
o Explanations based on sociological theories vs. theory of justice.
Current debates on solidarity:
- Obamacare
- Sustainability of arrangements in the Netherlands is questioned
- Behavioural factors and health
Sociological theories on solidarity
Theories of sociologists who perceive solidarity as a characteristic of a social system, thus not as a
belief or a feeling held by individual people
à From this can be concluded that: solidarity can be defined as an actual state of interrelations
between individuals, groups and the larger society, which enables the common good of groups and
society to be served. The theories:
2
, Durkheim - macro-level - characteristic of a social system
Two main sources for social solidarity: `...the likeness of consciences and the division of social labour'
- Mechanic solidarity (Durkheim) – shared identity – macro level
o `Likeness of consciences’ refers to a situation in which individuals share the same
fundamental cultural elements
o The individual identifies strongly with the group
o Broader societies and collectivises: Individuals share the same fundamental cultural
elements, which they use as a basis for recognising and accepting each other as
members of the same collectively
o The cultural bond as the heart of the mechanic solidarity (dominant in homogeneous
pre-modern societies)
- Organic solidarity (Durkheim) - shared utility – macro level:
o ‘The division of labour’: causes people to become mutually dependent on each
other for their life opportunities: Division of labour thus gives rise to structural
bonds, people are connected
o Organic solidarity presupposes explicitly that individuals allow collective interests to
prevail over their own: can be internalised during the socialisation process and
thereby seen an experienced as an intrinsic moral duty (and not a externally forces
behaviour)
o Organic solidarity: structural interdependence as the heart of this, present in modern
societies with a high DoL → functional necessity for survival and existence of the
system
Weber - micro-level - solidarity characterises & social relations between individuals
Weber argues that both types can be present in one and the same relationship
- Communal relationships – shared identity:
o Individuals treat each other according to fellow feelings = a subjective feeling of
belonging together: Feeling like you are all the same with the same identity.
o Examples of such a relationship are a religious brotherhood and a national
community.
o The core is formed by a shared we-ness, in understanding and accepting that one is a
member of the same group.
o A micro-version of the mechanic solidarity of Durkheim.
3
