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

Notes

NOTES Introduction 1. Indeed, the problem remains of how—and when—to accomplish ethics training in home care, given the impossibility of finding a common meeting time for aides and given the wide variety of the health care aides’ backgrounds and experience. 2. This also explains why aides are matched with cases that are far beyond their caretaking capacity. Supervisors become so desperate for an aide that they will assign unqualified workers to clients with skilled care needs. 3. Indeed, one aptly entitled article, “Women’s Sense of Responsibility for the Care of Old People: ‘But Who Else Is Going to Do It?’” deals with this very issue of women’s sense of responsibility for caretaking. See Aronson (1992). 4. “Community-based” care means care that is accomplished outside of institutions , within the broader community. Home care is one type of community-based care, since it supposedly takes place within the community, is overseen by the community -at-large, and is more inclusive of the cared-for. Yet Eva Kittay challenges the assumption that community-based care provides better care by asking, “Might not a well-run institution with a devoted administrative staff that guarantees a uniform level of good-quality care be preferable even to a small group home in which the quality of care can be more directly subject to the vicissitudes of personnel (whose turnover rates are high) and inadequate?” (2000, 71). 5. “Caring for Ailing Aged Linked to Strain, Death,” Chicago Tribune, December 15, 1999. 6. While a client’s specific request for a female caretaker does make an issue of sex and gender, it is not an instance of sexism. It is not on irrelevant grounds, for example, that an elderly women specifies a female caretaker when she requires assistance with bathing and peri (or genital) care. Elderly women may justifiably prefer female caretakers to perform such intimate tasks. 7. Autonomous people, according to the Kantian tradition, are self-governing, have reason and will, and have the capacity to make their own choices and develop their own life plans. Traditionally, autonomy requires respect for individual persons, meaning one person does not have authority over another and thus should not coerce others, limit their activities, or impose his will on others. Privacy rights—and rights to noninterference—are directly associated with this principle of autonomy. As I will argue later in this book, the conception of autonomy as privacy or noninterference is not helpful to an ethical analysis of home health care. 8. Thanks to my colleague David Ozar for helping me think through this issue of autonomy in long-term care situations. 9. Martha Holstein (1999, 2001), Joan Tronto (1993, 1998), and Rosalie Kane and Carrie Levin (1998) have offered feminist ethical treatments of home health care. 1. Why Home Care? 1. My vision on this issue has been trained by thinkers like Martha Fineman, Eva Kittay, Susan Moller Okin, and Catharine MacKinnon. These feminists have begun to lay the groundwork for a feminist theory of the state (as MacKinnon calls it), one which includes attention to remuneration for women’s caretaking in liberal democratic, capitalist societies. See Fineman’s argument (2000) for the formal recognition of women’s caretaking that results in a huge subsidy to the state. 2. More recently, studies indicate that home health care is not less expensive than institution-based care. While there have certainly been savings in the areas of hospital and nursing home care, the increasing technologization of home care services and the increasing number of patients requiring them means that savings may not be as great as predicted. See Arno, Levine, and Memmott (1999). 3. This widespread lack of insurance results from unemployment (since many Americans are either unemployed or are only employed part-time) and employment with companies that are too small to provide health care benefits to employees. An employer-based health insurance system means that only large companies with a huge employee base can afford to insure employees through a system of managed care. In addition, Medicaid is only available to citizens who are devastatingly poor, meaning that many Americans, while gainfully employed, do not have any health insurance whatsoever. 4. According to Feder, Komisar, and Niefeld, “In 1998 Medicaid financed about 40 percent of the nation’s long-term care spending of $150 billion and 44 percent of spending on nursing home care” (2000, 41). 5. Ginger Orr, “Home-Care Agencies Seek Funding Remedy,” Chicago Tribune , May 2, 2000. 6. “Caring for Ailing...