Rob Houtepen

The expectation(s) of solidarity: matters of justice, responsibility and identity in the reconstruction of the health care system.

We analyse solidarity as a mixture of social justice on the onehand and a set of cultural values and ascriptions on the otherhand. The latter defines the relevant sense of belonging togetherin a society. From a short analysis of the early stages of theDutch welfare state, we conclude that social responsibility wasoriginally based in religious and political associations. In theheyday of the welfare state, institutions such as sick funds,hospitals or nursing homes became financed collectively entirelyand became accessible to people of all denominations. Solidaritywas transformed in a more general category, related to the statusof Dutch citizenship. Responsibility was transformed tocollective responsibility.Financial pressures on the Welfare State have resulted in adebate on choices in health care and in a number of systemreforms, so far relatively small. In the surrounding discourse,justice was linked to private responsibility. Both fromgovernment officials and from participants in the societaldebate, moralistic overtones could be heard concerning the threatof overburdening of the health care system by citizens.In this paper, we develop a concept of reflexive solidarity thatlinks elements of social justice to conceptualisations ofresponsibility that address policy makers and health careinstitutions as well as citizens, in their role of carereceivers. A short analysis of the phenomenon of personal budgetsin care services should prove that our concept of reflexivesolidarity is not empty. Linked to, but beyond the concept ofjustice, issues of social responsibility can be addressed withoutmoralistic overtones.

Coordinating the norms and values of medical research, medical practice and patient worlds-the ethics of evidence based medicine in orphaned fields of medicine.

Evidence based medicine is rightly at the core of current medicine. If patients and society put trust in medical professional competency, and on the basis of that competency delegate all kinds of responsibilities to the medical profession, medical professionals had better make sure their competency is state of the art medical science. What goes for the ethics of clinical trials goes for the ethics of medicine as a whole: anything that is scientifically doubtful is, other things being equal, ethically unacceptable. This particularly applies to so called orphaned fields of medicine, those areas where medical research is weak and diverse, where financial incentives are lacking, and where the evidence regarding the aetiology and treatment of disease is much less clear than in laboratory and hospital based medicine. Examples of such orphaned fields are physiotherapy, psychotherapy, medical psychology, and occupational health, which investigate complex syndromes such as RSI, whiplash, chronic low back pain, and chronic fatigue syndrome. It appears that the primary ethical problem in this context is the lack of attention to the orphaned fields. Although we agree that this issue deserves more attention as a matter of potential injustice, we want to argue that, in order to do justice to the interplay of heterogeneous factors that is so typical of the orphaned fields, other ethical models than justice are required. We propose the coordination model as a window through which to view the important ethical issues which relate to the communication and interaction of scientists, health care workers, and patients.

Realizing autonomy in responsive relationships

The goal of this article is to augment the ethical discussion among nurses with the findings from empirical research on autonomy of older adults with type 2 diabetes mellitus. There are many factors influencing autonomy. These include: health conditions, treatment, knowledge, experience and skills, personal approach as well as familial patterns, type of relationship, life history and social context. Fifteen older adults with type 2 diabetes mellitus were interviewed in a nurse-led diabetes clinic. These participants perceive three processes which support autonomy in responsive relationships: preserving patterns of concern and interaction, nurturing collaborative responsibilities and being closely engaged in trustful and helpful family relations. People with diabetes realize autonomy in various responsive relationships in their unique life context. Next, we performed a literature review of care ethics and caring in nursing with regard to relational autonomy. We classified the literature in five strands of care: attitude-oriented, dialogue-oriented, activity-oriented, relationship-oriented and life-oriented. According to our respondents, autonomy in responsive relationships is fostered when patient, nurses, professionals of the health team and family members carry out care activities supported by a relational attitude of care. They can best realize autonomy in relationships with others when several essential aspects of care and caring are present in their lives. Therefore, we advocate a comprehensive approach to care and caring.

Value judgements in the decision-making process for the elderly patient

The question of whether old age should or should not play a role in medical decision-making for the elderly patient is regularly debated in ethics and medicine. In this paper we investigate exactly how age influences the decision-making process. To explore the normative argumentation in the decisions regarding an elderly patient we make use of the argumentation model advanced by Toulmin. By expanding the model in order to identify normative components in the argumentation process it is possible to analyse the way that age-related value judgements influence the medical decision-making process. We apply the model to practice descriptions made by medical students after they had attended consultations and meetings in medical practice during their clinical training. Our results show the pervasive character of age-related value judgements. They influence the physician’s decision in several ways and at several points in the decision-making process. Such explicit value judgements were not exclusively used for arguments against further diagnosis or treatment of older patients. We found no systematic “ageist” pattern in the clinical decisions by physicians. Since age plays such an important, yet hidden role in the medical decision-making process, we make a plea for revealing such normative argumentation in order to gain transparency and accountability in this process. An explicit deliberative approach will make the medical decision-making process more transparent and improve the physician–patient relationship, creating confidence and trust, which are at the heart of medical practice.

Reconsidering Solidarity by Conceptual Analysis

What might we expect from philosophical analysis, given the findings of the empirical analyses presented in the first part of the volume? The conclusions drawn in part I by Muffels and Verburg enable us to derive the clues. First, they notice that the national and European debates on the reform of the Welfare State hardly take place in explicit terms of solidarity. At the same time, they remark that the welfare system as such and the value of solidarity are very little contested. Thus, both the notion of solidarity and its relation to national welfare systems may be presumed to have a highly self-evident character. Muffels and Verburg have in their chapter delegated the task of conducting a conceptual and normative analysis of solidarity to the philosophers. Thus, their first task is to pursue conceptual analysis and all of the philosophers contributing to part II of thebook have complied with that. Both the more contractual liberal model of solidarity and the more social interactional model, outlined in the Introduction, will be discernible in those analyses.

Trust in medical decision-making concerning older people: The views of key professionals in the Dutch health care practice

This article deals with the issue of public trust in decisions made by individual physicians, concerning older people, as perceived by various key professionals. While trust is a basic element in our health care service, it is at the same time a difficult phenomenon to conceptualize. This article tries to contribute to a better understanding of what trust in medical practice entails and what are the necessary conditions for a society to put trust in the medical profession. The focus is on care for older people under the condition of scarcity in health care resources. Our study has a qualitative design consisting of semi-structured in-depth interviews with 24 key professionals focusing on decision-makers and those in line of professionally organizing or influencing the decision-making process. We found roughly three categories of trust: distrust; trust; and qualified trust. In each category we found different reasons to give or withhold trust and different views on how far the discretionary power of doctors should go. We recommend promoting trust by addressing the criteria or limits brought forward in the qualified trust category. The preconditions as identified in the qualified trust section provide the boundaries and marking points between which physicians have to move regarding the care for older people. The qualifications provide us insight in where and how to invest in trust under these and under different circumstances. An important conclusion is that trust is never finished: trust needs to be gained and negotiated in a continuous process of action and interaction.

Beyond Justice and Moralism: Modernity and Solidarity in the Health Care System

Most welfare states have been in a period of attempted reconstruction and retrenchment for the past twenty years. In health care, the direction of reforms has been largely similar in most countries: to reduce the package of public services and to increase the private contributions of beneficiaries. The concept of solidarity has been utilised by nearly all of the proponents in the debates on such reforms. It appears to refer to two interrelated connotations: a benevolent attitude towards weaker groups in society and a commitment to fair or even egalitarian distribution of health care services. The poblem with the first connotation is that a deeply a-symmetrical concept of social relations may be disguised by the declaration of good intentions. The problem with the second connotation is that it appears to be identical with a concept that is much more common in the Anglo-Saxon world and that has been analysed and debated much more thoroughly than solidarity: justice. Why bother with the concept of solidarity in issues of health care reconstruction, if the only thing it appears to add to the concept of justice is some variation upon the equally well-worn concept of benevolence? Another problem with this use of the concept of solidarity is that it appears to be a notion that is mostly invoked for merely defensive purposes: the concept serves to tell us which groups and services should not be tampered with. However laudable this may be, this would place the concept outside the frontline of debates on possibilities to adapt the health care system to changing circumstances, without limiting this reconstruction to cutbacks and private payments.

Solidarity, Justice, Reflexivity and Participatory Citizenship

As indicated in the introduction to this part of the volume, we have asked the authors of this philosophical part to reflect upon the concept of solidarity from the vantage point of their specific country and philosophical tradition. This did not forestall more general conceptual analysis in our project, which has first and foremost been delivered by the German chapter from Rahel Jaeggi. Applying ordinary language analysis, she concludes that solidarity is distinguished from friendship (too strong), interest coalitions (too weak), loyalty (too particularistic), compassion or humanitarian aid (too private, noncommittal and a-symmetrical). Solidarity appears to imply a sense of ‘non-instrumental cooperation based on identification with a common cause’. Jaeggi traces this notion to Hegel’s concept of ‘Sittlichkeit’ (‘ethical life’, as distinguished from morality) as a constitutive sense of commonality and a cooperative relationship that transcends altruism or self-interest. According to this model, certain social conditions are inherent to self-understanding and constitutive for self-realisation, enabling an ‘enlargement of self’. Not every form of commonality leads to solidarity, however, partly because of overlapping or mutually exclusive commonalties, partly because commonality may stem from and result in morally indefensible practices. Commonality is not a natural phenomenon, but a social construction, constituted in action that is perceived to be beneficial and rightful.

Personal Budgets for the Elderly: A Case Study in Dutch Solidarity

Although the Dutch elderly are not officially discriminated against by age criteria or policy regulations, they are intensively ‘touched’ by the scarcity of resources and by the policy attempts to manage this scarcity. Especially, the increasing waiting lists for home care and nursing home care, the introduction of systems requiring more private funding and personal financial responsibility and the (possible) rationing of acute care services on the basis of economic evidence are examples of the way the elderly are unequally treated by society particularly with respect to their access to care services.