No Place Like Home?: Feminist Ethics and Home Health Care

6. Looking Ahead: Can Home Care Be Reformed?

Looking Ahead Can Home Care Be Reformed? This chapter is perhaps the most important in this book. It lays the grounds for what I take to be a minimally decent system of home health care. In light of the criticisms I have leveled against home care in its current condition, I will herein consider what needs to be done to make the home care enterprise an ethical one. The arguments I construct will come from two marginalized critical perspectives: Marxism and feminism. From a Marxist perspective, I will consider the limits of markets in health care and home care; I will also consider the way that value has been constructed so that noncapitalist means of producing and reproducing human life (through women’s reproduction, childcare, and care of society’s dependents) have been devalued and obscured. In a capitalist economy, women’s care work becomes virtually nonexistent because it is “nonproductive” work, and this, I will argue, is part of the problem. Second, from a feminist perspective I will consider the moral limits of our current system of home care, where the care that is offered to clients is entirely dependent upon our economic ability (and willingness) to put money toward such care. As I will argue, we have done a kind of moral reversal in the way that home care services are 6 viewed: Instead of seeing ourselves as a moral community with certain obligations to care for one another, we see ourselves as an economic entity with prior economic obligations that limit how much we are willing to spend on care. From these two marginal perspectives, I will indicate why the current manifestation of home care is immoral and why transformation, and not just affirmative reform strategies, should be the ultimate goal for ethicists and home care policymakers. Alienation, Value, and Markets in Home Care To begin with my Marxist concerns, consider the practice of home care within our current capitalist system. In treating home care, one cannot divorce it from the broader problems created by the U.S. system of managed care. Some of my comments, then, will refer directly to the organization of home care, and some will refer to the general provision of health care. Furthermore, my critical position is not dependent on the kind of “revolution” with which Marxists are generally disparagingly associated, for while I do think that serious class-based inequalities need to be rectified, my account of the required transformations in our provision of care is not reliant upon a broader social revolution. In this, I concur with Milton Fisk’s assertion that “there is the option . . . of moving a few sectors at a time with a political program for transforming them in accord with similar general aims. This contrasts with the option of focusing from the outset on changing the foundations of the society as a whole” (187). Consider the problems associated with home care as it is practiced within a market-based system of health care. Home care workers are alienated in the classical Marxist sense. On Marx’s critique, all workers under capitalism are alienated, as we are all separated from the things we are creating and exploited in their production. Since, for Marx, we are what we make, alienation is caused by both our part in the production of meaningless objects, as well as our estrangement from our work as we reproduce our “species-being.” But care workers are doubly alienated by their work and life conditions. That is, they are held to the general expectation that they will care for and about their clients; yet the home care system is set up in such a way as to block the authentic expression of care. What makes the process worse is that the organization of home care separates the very things that make home care workers human—the moral capacity to care—from their work, while at the same time invoking their care for others as the grounds for paying them badly. The result is an incoherence in the system, crazymaking for workers doing the menial jobs, and, ultimately, alienation of the worst kind. Looking Ahead 121 I cited examples in chapter 2 that relate to this concern for alienation. Care plans that reduce the work done by aides to washing and dressing bodies and feeding mouths, scarcely giving them enough time to complete the bare mechanics of these acts, turn them into “instruments” in...