Solidarity is a central value in Swedish healthcare. Not only are healthcare costs financed by taxpayers proportional to their income (solidarity-based funding), solidarity is also one of the basic ethical principles for priority setting in healthcare (the so called need- and solidarity principle). Despite its significance, the term 'solidarity' has been given different, sometimes contradictory meanings, in both academic and political contexts. In a political context such contradictions can be handled since political standpoints always try to embrace a big variety of meanings within a certain terminology. In the context of healthcare, though, semantic ambiguities will severely hamper efficient decision‐making.
Against this background this report aims at examining potential semantic ambiguities/contradictions with respect to the meaning of 'solidarity' as it is used in Swedish public debates on healthcare funding and prioritization between 1990 and 2010. We investigated relevant public reports and policy documents on prioritization as well as articles in medical journals and major daily newspapers in which the meaning of 'solidarity' had a key role. The selected data were analyzed with a method based on the systems-theoretical epistemology by sociologist Niklas Luhmann.
The study shows that 'solidarity' as a value in Swedish healthcare appears in two separate, at best loosely coupled debates. One mainly takes place in mass media and is a political debate on whether the healthcare system should be opened to private investors and insurances. Here, solidarity is discussed as a means of healthcare funding. The other debate takes place in professional forums and discusses formulations of guidelines for priority setting. Here, solidarity is discussed as an integral part of an ethical platform for priority principles.
Our study of the debate in media reveals that there are surprisingly few differences in the meaning of 'solidarity'. There is a vast consensus that those who are better off should stand up for the weak, which resembles a Christian liberal understanding of solidarity. The positions differ in the reference of solidarity: who is the legitimate recipient/address of solidarity? We found that these references can be interpreted with help of the guiding distinction agency/(in)equality. If society is mainly understood as a stratified society, the agency of patients is seen as a potential reason for inequality and a threat for equality. By contrast, if society is mainly seen as an assembly of individual agents, too much significance given to equal health outcomes is interpreted as a limitation of people's scope. Whether agency appears as a threat or blessing depends on two mutually exclusive value systems that are guided by their own views on the distinction agency/(in)equality.
We argue that the difference between the two most important positions in the other debate, i.e. the prioritization debate, also can be described in terms of the distinction agency/(in)equality. The positions are clearly expressed in two major reports: the Swedish Government Official report Health Care's difficult choices as provided by the Priorities Commission and the report by The Swedish National Centre for Priority Setting Resolving Health Care's difficult choices. Both reports conclude a proposal of guidelines for priorities. In the same way as in the fundingdebate, the term 'solidarity' in the priorities-debate is used in the meaning that the better off should help the weak. Again, the difference is to be found in the references of solidarity, that is, the definition of the 'weak': Who can justifiably be considered as weak? The Priorities Commission defines weakness by low socioeconomic status. In the report by the Swedish National Centre for Priority Setting the weak are rather identified by lack of sufficient agency (such as children, dementia-patients, unconscious patients or mentally ill).
In accordance with the guiding difference agency/(in)equality we can distinguish an agency-based solidarity (the weak as non-agents) underlying the report by the Swedish National Centre for Priority Setting and an inequality-based solidarity (the weak are the marginalized) underlying the report by the Priorities Commission. These different references of 'solidarity' have considerable consequences on which role the solidarity principle can play in an ethical platform.
Linköping: Linköping University Electronic Press, 2012. , 45 p.