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

3. Women’s Care Work as a Subsidy to the State

Women’s Care Work as a Subsidy to the State In chapter 1, I argued that the home care system, in its current state, is morally lacking: It is founded on the broader system of managed care in the United States and is informed by the value of acute care that infuses health care practice at the macro level. Chapter 2 concerned the philosophy of home care and argued that there are competing and warring philosophies at the industrywide and home-based levels. In this chapter I will develop my argument that justice in home care requires the recognition of home care work as a social subsidy. Indeed, home care is not an area of narrow concern but involves broad cultural norms concerning the value of women’s care work, the assignment to women of nurturing and caretaking, and their resulting economic and moral oppression. Home Caretaking as Subsidy There are at least two possible responses to the system of home health care in its current incarnation: Work within the system to render it as efficient, as cost-effective, and as fair as possible to all parties involved, 3 or opt for a different kind of system. In what follows I will petition for the latter, for the problems with our home health care system run too deep for mere reform. Since the very lives and livelihoods of some of our most vulnerable citizens are at stake, we require a system of home care delivery that is sensitive to their needs. So for those who require assistance with their activities of daily living (ADLS) and instrumental activities of daily living (IADLs), and for those who are called upon to offer the caretaking assistance , a re-vision of the home health care system is in order. The informal provision of home health care is the foundation for home health services. Since patients are sent home from hospital “sicker and quicker,” and formal home care services are generally provided for only 60 days after discharge from a hospital, this means that a great deal of caretaking falls upon families themselves. Home health services have also faced recent serious cutbacks, meaning that families must become ever more resourceful in finding means to provide care for their dependent family members . Usually this “resourcefulness” requires female family members to take leave from their paid employment in order to be available as familial caretakers ; the result of such leaves can often be financially devastating to families , since women’s employment is no longer supplemental and their income is no longer simply “pin money.” Yet women’s sense of responsibility for care of their family members results from the question of who else is going to do it. The inevitable answer is “no one.” To a large degree, economic privilege determines the degree to which families are strained by the demands of home care. For example, when working as a home health aide, I encountered two families dealing with remarkably similar situations. In both cases the clients with whom I was working, John and Bill, were teenagers who had been struck by cars as children . Both suffered severe brain damage. Their mothers were heads of household. But in one situation, John’s mother had tapped her educational and community resources to sue the city for her son’s accident; she had been awarded millions of dollars in compensation. Bill’s mother had very little education, lacked any knowledge or understanding of her rights, had no community support in petitioning for them, and so never sought the legal compensation she was likely to be awarded. While neither boy received the amount of formal home care required, and both had to rely heavily on care by their mothers, John’s care was much less onerous on his mother than was Bill’s. Indeed, with the money from her lawsuit, John’s mother was able to furnish him with a large, comfortable, fully equipped wheelchair-accessible home and van, and she had the economic ability to pay for extra attendant care to ease her own care burden. By contrast, Bill and his mother had no options available and remained in their low-income 52 No Place Like Home? townhouse, where he was daily required to negotiate the narrow stairs leading from the living room to his bedroom. After completing his toiletries, I would “spot” Bill as he came down the steep stairs. The shabby living room of their...