Gendered caregiving and structural constraints: An empirical ethical study

Abstract

Background:

The pressing issue of aged care has made gendered caregiving a growing subject of feminist bioethical enquiry. However, the impact of feminism on empirical studies in the area of gendered care in Chinese sociocultural contexts has been less influential.

Objectives:

To examine female members’ lived experiences of gendered care in rural China and offer proper normative evaluation based on their experiences.

Research design:

This article adopted an empirical ethical approach that integrates ethnographical investigation and feminist ethical inquiry.

Participants and research context:

This article focused on three cases of gendered caregiving for sick older members collected from a 6-month fieldwork conducted in a primary hospital in rural China.

Ethical consideration:

Approval was obtained from the university ethics committee.

Findings:

The empirical work highlights caregivers’ voices of weiqu (a sense of unfairness) resulting from their constrained choice when being pressured to engage in caregiving, which is associated with a disadvantageous socio-institutional and structural backdrop in current rural China. Informed by the conception of structural injustice, the normative analysis of this article traced various forms of social norms, structural deficiencies and ageing welfare institutions, as they intertwine and transmit into additional care deficiencies against rural families and their female caregivers.

Conclusion:

This article identified the constraint of gender hierarchy and its intersection with external social structure that exacerbate gendered oppression and exploitation of female labour in rural China. Normatively, this article argues that the current configuration of rural family care, featured by structural impediments and exploration of female labour, is unjust. Some policy recommendations are proposed to empower caregivers and advance care for rural older people.

Keywords

Ageing care empirical ethics gendered care rural China structural injustice

Introduction

Due to the rapid growth in the ageing population on a global scale, the pressing issue of ageing care has made gendered caregiving a growing subject of feminist bioethical enquiry, particularly in the developed social setting such as Northern America and Europe.^1

–5 Nonetheless, the impact of feminism on empirical studies in the area of gendered care in Chinese sociocultural contexts has been less influential.^6
–8 Among existing feminist work related to gender inequality in China, the majority focuses on the impact of economic reforms on gendered gaps in income and employment rates, particularly in urban settings.^7,9
–11 However, women’s experiences of family caregiving, such as caring for the sick aged, is still an under-studied topic. From the perspective of feminist care economy, scholars have identified that, although women have benefitted considerably from their participation in the labour market, their gendered experiences of unequal domestic care persist. For example, it has been pointed out that there is an intensified pressure on urban female members in bearing their dual burdens of paid work and unpaid domestic labour during the process of China’s socio-economic transformations.⁷

Although these urban females are caught by the pressure of domestic care obligation, they are relatively better situated with more resources and viable options to better arrange caring issues. In contrast, the situation of their rural counterparts, especially older rural women, is apparently worse, as due to their age and gender disadvantages, they are left behind and deprived of opportunities to participate in the formal labour market. Instead, after other male labourers’ and younger female siblings’ outwards migration to affluent urban areas, they are typically charged with caring for the older people and grandchildren. They also have little power and autonomy, due to their socio-economic disadvantages, to engage in care-related decision-making or say ‘no’ to the uneven caring burden. These struggling rural women’s voices, however, have been largely omitted from existing feminist literature. Focusing on examining rural women’s experiences of aged care in the face of China’s demographic, social and institutional transitions, this article seeks to address some knowledge gaps.

This article adopts an empirical ethical approach¹² that integrates ethnographical investigation and feminist ethical enquiry. Empirically, the epistemological approach of this article is highly interpretative and subjectivist. After introducing the sociocultural and institutional backdrop under which the practice of ageing care of rural families takes place, this article begins with an ethnographical account of caring for older inpatients in three rural families. Throughout the fieldwork, caregivers’ weiqu (sense of unfairness or being wronged) from being pressured to endure unequal care, yet their plight of having no power to resist or seek alternative care options, is highlighted. These three cases are highly representative in offering a contextual understanding regarding the common predicament experienced by most female caregivers in rural China.

Moreover, these rural families’ experiences enable an analytic lens through which the close connection between private caregiving and external social institutional structures can be illuminated, focusing on caregivers’ constrained choice and its structural contributes.

Informed by the conception of structural injustice developed by Iris Young, this article conceptualises gendered family care integrated with a range of institutional engagement, consisting of the healthcare industry, ageing care sector and the government policies, as well as the impact of social transformations. By undermining the care capacities and resources of individual families, these structural forces generate injustice against rural families and heighten the exploitation of female care labour. The conception of structural injustice is also with practical implication to inform social changes, focusing on the responsibility of the state in ameliorating unjust social structures through organising social institutions to create supportive social conditions. Some policy recommendations concerning health and ageing care reform in rural China are also proposed.

Background

Like many countries in the world, China is currently witnessing a rapid growth of its ageing population; a trend that is accompanied by the tremendous challenge of supporting ageing healthcare. As observed elsewhere, it is reported that over half of the aged population in China live with chronic diseases and other co-morbidities that require long-term care services.¹³ Accessing aged care is singularly challenging in Chinese rural settings, where nursing care and social pension resources are often lacking because of rural–urban disparities in government-funded support.^14,15 Data from two surveys conducted by the Chinese Ministry of Health and Family Planning in 2015 show that only 33% of China’s total medical care resources were allocated to rural areas, even though the rural population in China constitutes over half the country’s entire population.¹⁶ In addition, since China initiated market economy reforms in the 1980s, the government gradually withdrew its funding from social welfare systems, such as healthcare, old-age support and education. The diminishing institutional support and lack of access to social care services imposed on older people and their families tremendous financial and physical burden of ageing healthcare.

Insufficient access to institutional support that rural dwellers encounter is intensified by the Chinese household registration policy, the hukou system.^14,17 The hukou system assigns all residents to one of two types of households, either rural or urban, designating the type of employment that residents are entitled to. Based on this divide, rural residents were granted with inferior access to state-provided old-age support and social welfare resources. For example, due to the restricted scope of health insurance coverage regulated under the hukou divide, rural residents seeking healthcare are faced with lower rates of insurance coverage (in contrast to urban dwellers) and much more out-of-pocket expenses when seeking healthcare at upper-level hospitals. The hukou policy also excludes rural older people from equal access to social pension systems, as only urban residents have access to formal employment and employment-based pensions after retirement. Rural residents, who mainly work in the agricultural sector, must rely on their personal savings and families to secure late-age care and support.

Consequently, caring for the aged imposes tremendous financial and physical burden on rural families, who are assumed to be primarily responsible for late-age care and support in line with the Confucian norm of filial piety.^18
–20 Scholarship on family care has pointed out that filial piety is the foundation in maintaining adult children’s sense of obligation to provide emotional and material support for their ageing parents.^21,22 Moreover, the filial norm juxtaposes a hierarchical status of family relations, regulating the authority of parents and requiting adult children to obey their parents.¹⁹ The hierarchal quality of filial norm is also patriarchal and male-dominated,^6,20 as sons tend to receive more care and support from their parents over female siblings. Reciprocally, they are also expected to bear the primary burden of care and support by co-residing with their parents during their old age. Nonetheless, it is daughters-in-law who perform the substantial caregiving for older people on behalf of their husbands.^23,24 This is a major difference from the gendered care identified in the Western context, where women take on parental care tasks primarily through their roles as daughters.⁶

The family-based aged care model has come under pressure since China experienced rapid socio-economic transformations. Over the process of modernization, numerous rural young people have migrated to urban areas to seek better employment. Consequently, rural families have experienced diminishing resources and undermined capabilities in their provision of aged care.^23,25 Meanwhile, the conventional family ethics that emphasises younger generations’ filial obligation to parental care has also decreased, being replaced by a growing sense of individualism among younger generations, pursuing their personal interests over fulfilling aged care obligations.^26
–28 Caring for the aged is no longer viewed as the normative obligation that everyone must comply with reference to the cultural norm of filial piety, with both individual families and the state having become reluctant to support ageing welfare. Extreme cases report abuse and ill-treatment of older people at the hand of family members.²⁹

There is also a trend of resilience and revival of families with various coping strategies to sustain caregiving against the backdrop of social transformations. For instance, in the face of the challenge of geographical separation posed on ageing care in migrant families, many studies report daughters’ increased role in the provision of care as a replacement of caregiving from sons and daughters-in-law.^23,30,31 In addition, hiring paid-caregivers has become an outsourced remedy to the insufficient care provision from families.³² Another change is the increased reliance on older spouses, primarily on wives, to secure caregiving and ageing support. Despite these changes and variations, however, the gendered stereotype of caregiving, which associates physical caring labour with females, prevails.

The challenge of social transformations on ageing care may not be clearly felt as long as older people are still healthy, only becoming particularly prominent when older people fall sick and are hospitalised. This is because the Chinese health system only trains its nursing staff to focus primarily on conducting technique-oriented care interventions. Therefore, a set of inpatient bedside care tasks, including feeding, toileting, changing patient positions and maintaining daily hygiene, ultimately fall on patients’ families.³² This resembles the fragmentation of healthcare systems identified in Western setting,³³ where families are forced to fill the care gap for early discharged patients. The high-demand nature of physical nursing care also makes older people hospitalisation an ideal site for a feminist investigation of the changing dynamics of gendered family care in current rural China.

Research questions

In the face of both the under-developed social welfare systems and the challenge of family care provision under the circumstance of socio-economic transformations, this article addressed the following research questions:

What are female members’ lived experiences of caring for sick older members in rural Chinese families?

What kind of ethical issues do this gendered caregiving raise and how should these issues be evaluated?

Methods and ethical consideration

This article employs ethnographic methods, comprising of participant observations, semi-structured interviews and unstructured interviews, to document female members’ lived voices and experiences of caring for sick older members. The field work was conducted between January and June of 2016 in a rural primary hospital, Qincun Hospital, in Guangdong Province, Southern China. Throughout the field work, 20 hospitalised older patients and their family caregivers, four paid-caregivers, and other involved parties were interviewed. Data collection began with informal interviews so as to establish good rapport and trust relationships with older patients and their caregivers. In the case of each patient, one semi-structured interview with three to four follow-up unstructured interviews were conducted. The interviews mainly focused on examining the cooperation and division of the tasks regarding supporting and caring for hospitalised older members within respective families, as well as the lived experiences and expressed subjectivities of individuals from engaging in family caregiving activities. All interviews were conducted in and transcribed to Chinese by the first author.

The field work was conducted between January and June of 2016 in a rural primary hospital, Qincun Hospital in Guangdong Province, China. Qincun Hospital is located in the Qincun Town, a rural locality which is financially impoverished and geographically isolated. It is also of a relatively moderate size and scale,ⁱ which could better facilitate the participation of medical staff and patients in the observational work and interviews conducted for the study.

To protect the confidentiality and privacy of the research participants, all identifying information was removed, with all names used in this article, including informants and locations, being pseudonyms. All participants involved in this study gave their informed consent. The Human Ethics Committee of the University of Otago in New Zealand approved the research (Reference No. 15/106).

Weiqu: the lived experiences of three caregivers

This section offers an empirical account of gendered caregiving for older inpatients in Qincun Hospital, based on the experiences of three caregivers, Aunt Liu, Li Zhi and Aunt Zheng, who stepped in caregiving through their respective roles as a daughter, a wife and a family-paid-caregiver. Despite the different roles and positions of three caregivers, they revealed a similar voice of weiqu from being pressured into providing care. The Chinese term weiqu, literally translated as feeling of being wronged or sense of unfairness, refers to the mental status when people encounter unfair treatment and injustice, yet must accept them without explicit protest. Weiqu therefore captures the unequal and oppressive facets of family care and the powerless position and undermined autonomy of female caregivers. The situation of each family care case is complex, as well as the process of managing and negotiating care highly dynamic. An in-depth case study approach is well-suited to capture such complexity and dynamics, avoiding levelling their experiences as an account of static descriptions.

A daughter caring for her parents

Against the social backdrop of decayed family care convention, as previously introduced, it is common for daughters to step in to care for their natal parents in the absence of caregiving from sons and daughters-in-law. Aunt Liu, a 62-year-old daughter, had been fully engaged in her parents’ bedside care since both of them were hospitalised in Qincun Hospital for advanced stomach cancer and coronary heart symptoms, respectively. Like most Chinese rural older people, the parents did not have enough social pension to cover their basic living costs and hospital care. Their adult children, Aunt Liu and her three younger brothers, bore the primary responsibility for managing financial support and physical caregiving for their parents. However, all of them had migrated to cities to seek employment during their parents’ hospitalisation. Aunt Liu’s brothers and sisters-in-law were assumed to be primary caregivers of the older parents, but were tied up with their profitable business in Guangzhou, the capital city of Guangdong Province, and found it unrealistic to abandon their work for their parents’ care. Thus, they arranged for their sister, Aunt Liu, who worked as a part-time cleaner in a shopping centre in Shenzhen City, to take over their parents’ care on their behalf. In cooperation, they pooled 6000 yuan (US$930) per month together to support their parents’ treatment and compensate for their sister’s caregiving. This arrangement was mainly negotiated and determined among the three brothers, with minimal input from Aunt Liu.

Aunt Liu felt weiqu with being arranged to manage the parents’ care by her brothers: “A long time ago when I was poor, they (the brothers) never gave me any sort of help. Now they need me, and so they just hire me. This is unfair!’ In addition, she also felt discouraged because of the ill-treatment she had previously endured from her parents as they adhered to the tradition of favouring sons over daughters. For example, the parents once rejected Aunt Liu’s request to attend school and instead arranged for her to work outside to support the schooling fees of her brothers. She placed the blame on her parents’ rejection of supporting her education, a decision that led to her financial disadvantage and serving as the bedside caregiver:

If they [the parents] had just offered me a chance to go to school and I would make a better salary, I would also have been capable of saying ‘no’ [when my brothers asked me to take care of the parents].

However, taking into account the predicament faced by the whole family, Aunt Liu repressed her resentment and agreed to take on family care. Since the parents’ hospitalisation, Aunt Liu and her parents had been successfully cooperated in the daily routine of treatment and care. For example, every day around 8:30 am in the morning, Aunt Liu managed a 10-min commute to deliver her parents to hospital for transfusion, which usually ended around 12 noon. Aunt Liu then would give her parents a ride back home as due to the lack of nursing care required to meet the daily care demands of patients in Qincun Hospital, the older couple were allowed to return home for care after finishing their intravenous treatment.

This routine went smoothly, until one day when Aunt Liu was ill with a severe cough and found it difficult to continue the routine. She asked her parents if they would agree to put off their hospital treatments for 1 or 2 days, but her mother rejected and asserted ‘my sons have paid you to bring me to the hospital!’ Aunt Liu felt extremely wounded, asserting the mother ‘had no sympathy for her’ and only thought of her as a ‘hired nanny’, but considering that she was paid by the brothers, she repressed her weiqu and instead, turned to her husband for help. She requested her husband's assistance with continuing the parents’ care and treatment, but he asserted: ‘I am the son-in-law, [it is] not convenient to take care of them…Why don’t they [the parents] ask their sons to hire other people to take care of them?’ As a final resort, Aunt Liu enlisted the help of her son to pressure his father into her parents’ care, as she reasoned: ‘My husband never listens to me, a wife, but he always listens to my son’. The son’s persuasion worked, and the husband agreed to take care for his parents-in-law on Aunt Liu’s behalf.

During the process of caring for her parents, Aunt Liu was further irritated on an occasion when two of her brothers had not given her 4000 yuan of remittance as they promised. In the Chinese cultural context, however, it was embarrassing for Aunt Liu to argue for money in front of families, due to the potential harm that might bring to her family intimacy. ‘But I can’t ask them for money directly. You know, they will think as a sister I am too petty’. The need to maintain generosity and benevolence in the face of the unmet financial rewards and her brothers’ neglect stirred in Aunt Liu yet another source of weiqu.

A wife caring for her husband

The second case is about an emotionally wounded wife Li Zhi, who took care of her 65-year-old hospitalised husband Ye Gang. Ye Gang used to be a migrant worker, and had been living and working in Guangzhou for almost 20 years before he fell ill. Eight months prior, he experienced a stroke and collapsed on a construction site. Without proper care and rehabilitation, his symptoms deteriorated, and he gradually became paralysed and incontinent. He then headed back home, asking Li Zhi and their four children for help with his care and follow-up treatment. The whole family felt detested with his request, because Ye Gang had engaged in an extra-marital relationship with a young woman, with whom he had then established a new family since the second year of his migration. This extra-marital relationship lasted until the moment Ye Gang fell ill and his paramour took all the valuable household stuff and left him.

Ye Gang’s four children refused to offer any sort of care or financial support, because, due to his affair, he once stopped offering remittance for their schooling fees. Consequently, all four children only finished their junior high schools before started working outside. Also, because of their current geographical separation from Ye Gang after their migration, they could not look after him. Li Zhi then came to be the only person suited for dealing with Ye Gang’s long-term care. Another concern pressured Li Zhi to do so was her marital status with Ye Gang: ‘because legally we are still married, so I have the duty of care for him! Otherwise, I would not need to put up with this anymore!’ Li Zhi had tried many times to request a divorce: ‘But he [Ye Gang] did not agree. Neither did my children…I am just a woman, with no money and power. If he [Ye Gang] did not agree, I have no way to make it happen’.

Li Z’s financial situation was extremely constrained. After Ye Gang’s migration, she was left behind to take care of their four children while continuing to work some odd jobs on a local farm, with a monthly salary of 2000 yuan (approximately US$300) earned to raise the whole family. The predicament of having no financial assets to make other care options further exacerbated her weiqu and resentment, as she complained: ‘I wish I have some extra money, so I could have brought him to rehabilitation or hired someone [to take care of him], rather than take care of him by myself!’

While Li Zhi expressed her weiqu, repressed emotion and resentment, she also expressed some sense of sympathy for him as a ‘wounded’ man and patient that was linked to her agreement to care. In many interviews, she felt pity at the injustice of the manner in which Ye Gang was abandoned by his paramour, who had benefitted a lot from Ye Gang but shirked her responsibilities to care. Li Zhi described the paramour as ‘having no conscience [mei liangxin] at all’: ‘he gave all he had to her. How could she just run away and leave him along in hospital with only 300 yuan (approximately US$45)?’ Another source of her sympathy was concerned with the causation of Ye Gang’s disease, which was due to his ‘too thrifty’ lifestyle, as Li Zhi suspected: ‘his problem is because didn’t have enough nutrition…He gave all of his salary to that woman, but was reluctant to even just have a decent breakfast’. The problem of malnutrition, according to Li Zhi, was a manifestation of Ye Gang’s altruistic spirit: ‘It’s just him, always put others prior to himself. Before he went outside the marriage, he gave every penny he earned to me as well’.

Li Zhi’s sympathy and reconciliation to a certain degree mirrored the conventional expectation of ‘feminine’ virtue as a good wife who should have lofty morals and a noble enough character to forgive her husband’s infidelity. ‘He once told people in my village that he owed me…He knew he was wrong and I don’t want to be too petty…‘, she reasoned. Also motivating her caregiving was her concern with Ye Gang’s position as a vulnerable patient: ‘I am not in the right position to divorce him…If I divorce him at this moment, I think it would be wrong!’ – a moral reasoning suggesting the social expectation on females to demonstrate benevolence, diligence and uncomplainingly endure weiqu and suffering. Li Zhi even mentioned the contamination of the social environment that in a way had normalised Ye Gang’s a infidelity: ‘It is useless to blame the whole thing on him! It is also about the social atmosphere…This is my fate. It tortures me’. In current China, it was common for men to provide a woman with financial reward in exchange for gaining sexual and romantic freedoms outside marriage. Although it was not ethically advocated, it was somehow socially accepted because it positively conveys a patriarchal image of a man who is financially successful and attractive.

A woman who was paid to care for the aged

In the situation where families were unable to manage face-to-face bedside care for hospitalised older members, hiring a paid-caregiver was the preferred alternative. There were four paid-caregivers in Qincun Hospital, all of whom were females, illiterate and were deprived of a formal source of income before entering into the sphere of caring for other inpatients. Some of them were already in their late-age (even older than their recipients) and suffered from severe chronic symptoms that themselves needed to be cared for while struggling with other older patients’ care. Aunt Zheng, a 52-year-old widow, was the youngest one among these four caregivers. During the time of the current study, Aunt Zheng was taking care of an 88-year-old mother, who had been frequently admitted in and discharged from Qincun Hospital after she suffered a stroke 2 months prior. The mother was paralysed and incontinent, imposing upon Aunt Zheng a tremendous physical workload in assisting in her 24/7 bedside care.

Aunt Zheng’s husband had died over a decade ago, leaving a daughter and a son to be raised by her as the sole parent. Although both of her children had grown up to the age to be self-reliant, the responsibility of providing care and financial support borne by Aunt Zheng as a mother was tremendous. Aunt Zheng’s daughter and son-in-law had been incarcerated for drug-dealing 3 years ago, leaving their 3-year-old son with Aunt Zheng to look after. Aunt Zheng’ was still unmarried during the time of the study. In China, conventionally speaking, it is the parents’ responsibility to prepare a house for their sons before getting married or else, ‘no girl will marry my son if he does not have his own house…’, as Aunt Zheng described. She did not have other options but continued working outside to provide for her grandson and pay off her son’s mortgage.

In such circumstances, was Aunt Zheng capable and pleased with her job? In taking care of the mother, Aunt Zheng received a salary of 4000 yuan (around US$600) per month pooled by the mother’s three sons. The rewards seemed generous, but the physical labour of her caregiver role was at the expense of her already undermined health condition. ‘She [the mother] cried all the time. I have a very serious heart problem. Last night, when I was close to falling asleep, she yelled. That always scared me, and I have to have quick-acting pills to rescue me’. In addition to her undermining health condition, her sense of dignity and self-esteem was also affected.

If I had other options, I would not choose to cihou (wait and serve at the bedside) others…This work is so dirty and disgraceful; you need to endure blame and abuse from people who pay you and they never treat you nice!

But why did Aunt Zheng choose to work as a caregiver rather than another type of job? ‘What kind of work do you expect me to do? I am an old woman, and never went to school before…’ Aunt Zheng cried with a voice of weiqu, she was old, sick and illiterate, which prevented her from engaging in other types of labour sectors. Most paid-caregivers are expected to only assist in the daily activities of inpatients, a kind of caregiving that is relatively unskilled and trivial, without a high entry threshold for caregivers’ educational attainment and professional skills. Working as a paid-caregiver seemed to be the only choice of employment in Aunt Zheng’s situation.

Gendered family care as a matter of structural injustice

These three cases flesh out a poignant picture regarding women’s experiences of caring for inpatient older members in rural China. In these cases, the way care was organised is highly gendered, with the burden of care imposed disproportionally on female members whose situations however might not be suited in providing direct caregiving, due to issues such as the distorted relations with recipients or their ill health conditions. Emotionally, caregivers felt unwilling, discouraged and wounded, expressing a strong voice of weiqu from engaging in caregiving. However, they were deprived of proper means to resist their caring roles and obligation, or opportunities in making care-related decisions with regard to whether and how they should engage care. Underlying their weiqu is the predicament of having no alternative of caregivers when they were forced to care. For instance, this predicament is concerned with the situation of having no power to say ‘no’ when Aunt Liu was tasked to provide her parents’ physical care in contrast to her brothers offering remittance. It is associated with the pressure of family care obligation Li Zhi assumed to have for Ye Gang, as bounded by their marriage, as well as her lack of the opportunities in seeking other alternative care arrangements due to her financial constraints. One might say the situation of having no alternative might not be that obvious in the case of Aunt Zheng, who seems to be willing to step in care and caregiving has that expanded her job opportunities. However, the situation constructing her role as a caregiver remains constrained. As opportunities for outward migration and working in other workforce sectors become open to the younger generations, caring for those left-behind older people is the only choice of employment to stay afloat in her case, rather than her genuine autonomous preference.

The problem of gender inequality is vital to our understanding of caregivers’ constrained choice, as it constructs a disadvantageous familial and social status of female members over their engagement of ageing care. Many feminist scholars have emphasised the moral importance of justice to family care, with respect to, for example, organising equal distribution of domestic care labour between males and females and protecting vulnerable members’ rights and autonomy.^34

–37 However, gender does not act along in producing weiqu and constrained choices in relation to ageing care provision of females. In addition, a range of forces and constraints at the external social structural and political institutional levels also plays a significant role in contributing to caregivers’ constrained choices, as they condition the provision of rural ageing care, hence the related opportunities and resources available to caregivers within their given institutional setting.

The conception of justice as ‘enabling’ offers a theoretical lens to appreciate caregivers’ constrained choice when they were beset by pressures from external social structure. Within contemporary moral and political philosophy, the conception of justice has seen a shift from attending to the distribution of ‘primary goods’ to the discussion of people’s capacities to function³⁸ or, put in another way, an ‘enabling’ account of justice (p. 217).³⁹ In Iris Young’s work on structural injustice, she reminds people to attend to the social and political conditions that support or constrain people’s capacities and their freedom of ‘beings and doings’. Those social conditions and institutional rules that constrain individuals’ opportunities for developing and exercising their capacities constitute structural injustice.⁴⁰ A focus on the constraints of social structures further calls for reforming social and institutional forces, and by doing so, enables people’s capacities for self-development and self-determination (p. 218).⁴⁰

Lisa Eckenwiler adopts Young’s work on structural injustice and proposes an ecological approach to analyse injustice related to long-term care in the United States.^2,3 Thinking ecologically reminds people to examine the configuration of existing social and institutional structures as they stand to create injustice against migrant caregivers from under-developed regions. Eckenwiler therefore argues for critically analysing the social process and political conditions that impact the performance of ageing care and deprive the means and capacities of those female caregivers, focusing on the connections between policies, places and people. Moreover, the injustice people suffer is positional; those who are from socially economically deprived settings are more vulnerable to the constraints of unjust structures than those from affluent settings (p. 217).²

A conception of justice as enablement informs the current study to attend to the impacts of broad social process and political conditions on the provision of care within private families. Those social, political structures intertwine and operate through a range of norms, policies and institutional forces. By imperilling individual families in their resources and capacities to provide aged care, they create additional care deficiencies and oppression against female caregivers, whereas normalise gender injustice and oppression as natural and thus nothing wrong. By understanding ageing care through a lens of gender hierarchy and its intersection with external social process and institutional structures, we are better-equipped to understand these female members’ weiqu, not only in terms of a certain type of personal emotion but also as an ethical concern of injustice in a broad social structural sense. The following discussion critically analyses a set of social norms, policies and institutional structures as it discourages rural family caregiving and constructs oppression against rural female members.

The gendered obligation to care and its emotional complexity

The norm of gendered obligation to ageing care, by assigning caregiving responsibilities primarily to families and further to those female members, is central to the construction of injustice and oppression witnessed in these cases. Although family care conventions have seen changes over the process of socio-economic transformations, the gendered stereotype, as normalised under the pre-existing patriarchal sociocultural scripts, of associating caring labour with females, prevails. Aunt Liu’s case was very representative, in which she was arranged to be responsible for physical care activities in contrast to her brothers with offering remittance. Gender hierarchy also marginalised her in a powerless position to renegotiate her parents’ care in the face of the family care crisis caused due to her own sickness: her parents rejected her requests for forms of rearrangements by simply claiming the payment Aunt Liu received from her brothers in exchange of her caregiving. Power imbalance was also implied in the process of caregiving negotiation she had with her husband, who refused to assist the parents’ inpatient care on her behalf until their son was involved to resolute this crisis.

This gender-induced powerlessness also determines the way female members respond to weiqu and unequal care. Institutionalised by the patriarchal structural norms, the cultural stereotype of ‘feminine’ virtue as caring and benevolent encourages, pressurised or even socio-culturally coerced women to be compliant in the face of weiqu and unfairness, a moral disposition under which gendered oppressions have been normalised as ‘virtuous’. Li Zhi paramour’s abandonment and ‘lack of conscience’ for Ye Gang as doing the ‘right thing’ was the case, largely mirroring the gendered social expectation on females with the virtue of subservience and compliance towards their husbands and families. The interpretation of feminine virtue becomes especially conspicuous when Li Zhi repaid Ye Gang’s infidelity with caregiving, sympathy and reconciliation, in contrast to the paramourliance towards thei’lack of conscience’, therefore immoral. Aunt Liu’s decision of repaying the parents’ ill-treatment with caregiving suggests a similar moral reasoning. In the face of the parents’ wrongness of favouring sons over their daughter, Aunt Li’s generosity and care enables her to accumulate moral capital and regain respect within families and local communities.

The situation Aunt Liu and Li Zhi encountered is oppressive. Yet, having inhabited a patriarchal structure long enough, they have become accustomed to and even internalise their oppressed status as ‘virtuous’, and might not have been fully aware of the gendered oppression lying behind these ‘feminine’ virtues. For example, following a fatalism causality, Li Zhi attributed the situation of caring for her unfaithful husband as an evitable feature of her fate, or as the consequential contamination of social environment, instead of placing responsibility for them solely in Ye Gang’s wrongness. Nevertheless, that did not mean Li Zhi’s sense of weiqu was totally relieved under a local moral discourse. Much more attention should be given to her vulnerable and powerless position behind silence and endurance, which makes the application of feminist scrutiny in Chinese context essential, to empower females with better voices to engage family life. This also aligns with the goal of achieving human flourishing; an account of shared moral values ought to be upheld globally irrespective of the sociocultural differences.⁴¹

In addition to this gender facet, an account of family care obligation is also mandatory and unchosen in feature. In the case of Aunt Liu and Li Zhi, the assumption is that their family role of being a daughter and a wife have assigned them an account of obligations to handle the burden of care, irrespective of whether their situations were suited to doing so. Meanwhile, the family care obligation is highly complex and emotional. As previously endured resentment and unfair treatment from their families reopened in the ageing care setting, it would be extremely hard for Li Zhi and Aunt Liu to see care as obligations that must be handled, and even harder for them to work on caregiving. The consequence is undermined well-being and interests of caregivers and their older recipients, heightening their already strained family relations. What should be recognised is the emotional complexity of family relations and the fact that not every family member is willing or suited to manage direct caregiving for older members. Chau-Kiu Cheung and Kwan Yui-Huen once have argued that filial support should be practised by children willingly and altruistically, rather than ‘as a result of authoritarian commands or coercion’.⁴²

The devalued moral significance of caregiving

Another source of injustice that discourages rural females comes from the devalued moral worth of caregiving. There is a concern of devaluation of the significance of caregiving revealed from these rural families’ experiences, in which, much resembling findings reported in the West,⁴³ caregiving is viewed as ‘dirty’ and associated with the inferior status of female members. For instance, caregiving was described as ‘dirty and disrespectful’ in Aunt Zheng’s case; if she had other options, she would never choose to ‘cihou’ others. Devaluation is also suggested in the narratives of Aunt Liu’s parents. Despite Aunt Liu practising the most demanding and intimate aspects of care, her physical caregiving, however, was equalised as the consequence of the financial payment of her brothers by her parents. Aunt Liu felt herself like a paid ‘nanny’, instead of a family member and her caregiving should be respected and appreciated. As the moral significance of care devalued, caregivers’ personal dignity and sense of self-respect undermined, which further discouraged their willingness to engage in care.

Not only caregivers but also older recipients are challenged by the devalued importance of care that discourages them from seeking healthcare and family support. Traditionally, older people enjoyed a relatively high gerontological status and were honoured for their mastery of wisdom and historical knowledge in China.⁴⁴ Caring for the aged then is a ubiquitous practice that all social members ought to comply with. However, since the initiation of market economy reforms in the 1980s, the processes of privatisation and marketisation have engendered a new discourse of self-reliant and self-enterprising individuals who are encouraged to be competitive, bearing their own interests and welfare through engaging market economy.^44,45 In contrast, the image of rural older people are always described as dependent, backward and uncultured⁴⁶; such a profile does not match with the image of competitiveness and profitability of market economy. This ageist discourse is further heightened by the social script by labelling rural residents as ‘second-level citizen’ due to their inferior hukou status.^13,15 Older people’s health care needs are devalued as ‘worthless’ socio-economic burden. This cultural devaluation further discourages the individual provision of ageing care.

Underlying the trend of devaluation and discriminations is the failure to recognise the moral significance of care and needs to respond to human vulnerability and dependency at the whole level of Chinese society. Resulting from the irreversible condition of ageing, all human beings will inevitably fall into dependency and sickness. To become independent, one must first rely on the care and support from others so as to regain autonomy and agency. The provision of care is thus highly essential for older people to regain their capacity to cope with physical needs and maintain their independence and dignity. Recognising the significance of care requires proper support and respect for those who care for older people’s dependent needs, and the values and worth of their caregiving ought to be upheld and appreciated by the society as a whole. Meanwhile, the provision of care also gives rise to an obligation of justice. Many scholars have argued for the need to treat caring for the dependents as a substantial ground of justice.^47,48 Care should begin with recognising the inherent value of older people who have an equal and legitimate claim to healthcare resources, therefore, their needs ought to be treated seriously and their care responded to with respect and dignity.⁴⁹

The constraint of the rural–urban structural divide

Another source of injustice that should be responsible for the oppressive care arrangement against rural Chinese females is the lack of access to institutional care and other social welfare resources among rural populations, which has been a produce of persistent rural–urban structural divide. As introduced earlier in this article, under the hukou-based divide, there are obvious asymmetries between rural and urban residents in accessing social and institutional care services that have directly impacted their late-age care experiences. Most urban older residents have certainly better access to a range of social welfare resources, such as pension systems and medical care resources as assigned by their urban hukou status. Also, urban females are better situated with more resources available to make alternative care arrangements, such as seeking residential care or hiring professional caregivers for their older members. Rural older residents, in contrast, are deprived of proper access to needed care and support under the hukou-based rural–urban structural divide in a way that, in turn, shifts the major responsibilities of care onto their families and their female members.

Understanding caregivers’ constrained choice as structurally determined enables people to see how the caring labour of rural females is exploited as a means in response to the diminishing institutional support and under-developed rural social welfare system. This means gendered care experiences of rural females cannot be singularly relegated as private family issues, rather, they should be raised as a concern of structural justice against persistent gender oppression and unjust social structures targeted at rural populations and female caregivers in particular. Both caregivers and their older recipients have no choice as they struggled to sustain caregiving and being-cared-for against a disadvantageous socio-institutional backdrop in China. Underlying caregivers’ weiqu is not only their personal unwillingness to ageing care but also their dissatisfaction towards the under-developed social welfare system in rural China. Therefore, an account of discussion of gendered care points to the insufficient role of the state in organising social institutions to empower rural aged care. It thus becomes necessary to ask whether it is just for the state to rely on rural families and the exploitation of their female members’ labour to sustain ageing care while, in the meantime, allow structural constraints operate in ways that contract caregivers’ family resources and capabilities in the provision of care for older members.

Assigning the responsibilities of care and policy suggestions

By understanding caregivers’ constrained choice as a matter of structural injustice, equally important is to ask what can be done to eradicate the constrained structures and alleviation oppression against females. The answer lies with the efforts of both individual families/caregivers and the state. The normative analysis of this article points to the unequal and oppressive facet of gendered caregiving. Nonetheless, this does not intend to conclude that the practice of family care per se is morally unsettling or ought to be relegated. Instead, the role of families in dealing with aged care issues ought to be retained, given the continued influence of Confucian family ethics and the fact that family-based ageing support convention still prevails and, in addition to a voice of weiqu, many rural families also expressed a willingness to provide aged care in the current study. However, the caring efforts of individual families are far from sufficient, especially when they are constrained by external social institutional structures. To be supportive, the state should offer more targeted interventions aimed to ameliorate institutional disadvantages and create room and conditions that enable aged care. This article argues for a state–family partnership model in response to care for rural ageing members. With more resources and viable choices available for rural older people and their families, it is expected that those oppressions and struggles that many caregivers and their families encountered could be eliminated. In this respect, some social policy recommendations are also set out to guide further changes.

First, developing a comprehensive and equitable state welfare system is fundamental to rural late-age care and support. This article strongly recommends that the Chinese state takes steady measures to promote, lead and manage the forms of ageing welfare resources with a targeted approach towards rural populations. This form of social pension system also ought to be structured in a way that allows rural older persons who are at the bottom of the socio-economic ladder to receive sufficient financial assistance so as to meet their basic healthcare needs, especially when they are derived of appropriate family care.

Second, to support families to better take care of older people, efforts must be made to address the geographical impediments caused by the younger generation’s migration that impedes rural families to provide care. This article also appeals for the development of proper social policies focusing on encouraging rural-to-urban family migration and family re-unification after younger generations settle in urban locales. Some useful assistance could be, for instance, extending the coverage of urban social welfare and healthcare insurance by giving priority to addressing the access of rural migrations and their families.

Third, while this article argues for maintaining family caregiving, it should be recognised that, due to the conflicted nature of family relations, not all families and their members are suited to care for older people. So are some family-paid-caregivers who are less skilful and whose physical conditions are not suited, such like Aunt Zheng. The quality of care provided for older people thus becomes a major concern. The state should establish proper supervisory and institutional regulations at the community level to ensure that care from family members or paid-caregivers is high quality, respectful and dignified. This article also acknowledges the tremendous financial, physical and emotional burden of care for the aged. Proper incentives and compensative policies ought to be established to alleviate the physical burden and emotional stress caregivers faced from engaging in care.

Fourth, there should be more affordable and viable options, such as skilled nursing homes and gerontological care facilities, targeted towards rural families available at a grassroots and community level. Equally important is to empower rural older people to actively utilise healthcare and ageing support resources. This aim can be achieved through increasing the healthcare literacy of older people and strengthening the existing ageing healthcare system. More fundamental work that needs to be done is about altering the prevailing discouraging attitudes towards rural older people and female caregivers, raising the public recognition regarding the moral significance of caregiving and being-cared-for and empowering the vulnerable.

Conclusion

Integrating empirical study with feminist ethical enquiry, this article examined the gendered caregiving for sick older people in rural China. Based on three cases of caring for sick ageing members collected during a 6-month fieldwork conducted in a rural primary hospital in Guangdong Province in Southern China, this article identified issues of injustice and oppression against female caregivers manifested as the constrained choices of individuals for care-related decision-making. Underpinning their constrained choice, informed by the conception of structural injustice, was the concern of gender inequality as it intersects with a range of unfavourable norms and structural impediments that create additional care deficiencies against rural older people and their families, undermining the well-being and interests of caregivers as well as of those older recipients; however they are beyond the scope of discussion in this article. Normatively, this article argues that the current configuration of rural aged care with its structural impediments and exploration of female labour is unjust. Further informed by the conception of structural injustice, this article proposed that the state should provide more social welfare resources and organise more effective social institutions to empower rural families with more viable choices to enable them better arrange provision of aging care in a more respectful manner.

This research invites further feminist investigations on the subject of gender and family care across different sociocultural contexts. This invitation is not only for the purpose of promoting justice and gender equity globally but also for broadening the conventional discussion of gender inequalities in mainstream feminist ethical scholarship in the West. Further academic discussions are also needed to integrate empirical studies into bioethical enquiry and promote more interdisciplinary dialogues. This article also has its limitations, as it focuses primarily on the experiences of three caregivers. Although sought, older recipients’ voices and perceptions are absent to certain degree. Other ethical dimensions, for example, the problem of questionable nursing care delivery from Chinese hospitals as well as the violation of older parents’ rights and autonomy over the process of clinical decision-making, are also apparent.

Footnotes

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: This study is a part of PhD thesis of the first author and was supported by the University of Otago.

ORCID iD

Xiang Zou

Note

References

Glenn

. Forced to care: coercion and caregiving in America. Cambridge, MA: Harvard University Press, 2010.

Eckenwiler

. Women on the move: long-term care, migrant women, and global justice. Int J Fem Approaches 2011; 4: 1–31.

Eckenwiler

. Care worker migration and transnational justice. Public Health Eth 2009; 2: 171–183.

Hugo

. Care worker migration, Australia and development. Popul Space Place 2009; 15: 189–203.

Lutz

Palenga-Möllenbeck

. Care work migration in Germany: semi-compliance and complicity. Soc Policy Soc 2010; 9: 419–430.

Zhan

Montgomery

RJV

. Gender and elder care in China: the influence of filial piety and structural constraints. Gender Soc 2003; 17: 209–229.

Cook

Dong

X-y

. Harsh choices: Chinese women’s paid work and unpaid care responsibilities under economic reform. Dev Change 2011; 42(4): 947–965.

Song

Feldman

. Intergenerational support and subjective health of older people in rural China: a gender-based longitudinal study. Australas J Ageing 2009; 28(2): 81–86.

Shu

Bian

. Market transition and gender gap in earnings in urban China. Soc Forces 2003; 81: 1107–1145.

10.

. Marketization, occupational segregation, and gender earnings inequality in urban China. Soc Sci Res 2017; 65: 96–111.

11.

Meng

. Male–female wage determination and gender wage discrimination in China’s rural industrial sector. Labour Econ 1998; 5: 67–89.

12.

Dunn

Ives

. Methodology, epistemology, and empirical bioethics research: a constructive/ist commentary. Am J Bioeth 2009; 9(6–7): 93–95.

13.

Long

. ‘How would we deserve better?’ Rural-urban dichotomy in health seeking for the chronically ill elderly in China. Qual Health Res 2016; 26(12): 1689–1704.

14.

Chan

Zhang

. The hukou system and rural-urban migration in China: processes and changes. China Q 1999; 160: 818–855.

15.

Nie

J-B

. Erosion of eldercare in China: a socio-ethical inquiry in aging, elderly suicide and the government’s responsibilities in the context of the one-child policy. Ageing Int 2016; 41: 350–365.

16.

National Bureau of Statistics of China. The central committee fiscal expenditure on health care report. Beijing, China: National Bureau of Statistics of China, 2015.

17.

Zhang

Treiman

. Social origins, hukou conversion, and the wellbeing of urban residents in contemporary China. Soc Sci Res 2013; 42(1): 71–89.

18.

. Will families support their elders? Answers from across cultures. In: Nelson

(ed.) Ageism: stereotyping and prejudice against older persons. Cambridge, MA: MIT Press, 2002, pp. 295–309.

19.

Dai

Dimond

. Filial piety. A cross-cultural comparison and its implications for the well-being of older parents. J Gerontol Nurs 1998; 24(3): 13–18.

20.

Zhan

. Aging, health care, and elder care: perpetuation of gender inequalities in China. Health Care Women Int 2005; 26(8): 693–712.

21.

Chou

. Filial piety by contract? The emergence, implementation, and implications of the ‘family support agreement’ in China. Gerontologist 2011; 51(1): 3–16.

22.

Ikels

. Filial piety: practice and discourse in contemporary East Asia. Stanford, CA: Stanford University Press, 2004.

23.

Cook

Liu

. Can ‘distant water…quench the instant thirst’? The renegotiation of familial support in rural China in the face of extensive out migration. J Aging Stud 2016; 37: 29–39.

24.

Guo

Chi

Silverstein

. Trajectories and determinants of elder care in rural China during an 8-year period: why having sons makes a difference. Res Aging 2016; 38(5): 531–553.

25.

Liu

. Ageing, migration and familial support in rural China. Geoforum 2014; 51: 305–312.

26.

Croll

. The intergenerational contract in the changing Asian family. Oxford Dev Stud 2006; 34: 473–491.

27.

Yan

. The individualization of Chinese society. English ed. Oxford; New York: Berg, 2009.

28.

Warburton

, et al. Intergenerational solidarity and old-age support for the social inclusion of elders in Mainland China: the changing roles of family and government. Ageing Soc 2013; 33: 44–63.

29.

Wenyi

. Challenges of long-term care provisions for the elderly in urban China. China Int J 2014; 12: 144–160.

30.

Shi

. ‘Little quilted vests to warm parents’ hearts’: redefining the gendered practice of filial piety in rural north-eastern China. China Q 2009; 198: 348–363.

31.

Zhang

. China’s new rural daughters coming of age: downsizing the family and firing up cash-earning power in the new economy. Signs 2007; 32: 671–698.

32.

Hui

Wenqin

Yan

. Family-paid caregivers in hospital health care in China. J Nurs Manag 2013; 21(8): 1026–1033.

33.

Levine

. Rough crossings: family caregivers’ odysseys through the health care system. New York: United Hospital Fund, 1998.

34.

Held

. The meshing of care and justice. Hypatia 1995; 10: 128–132.

35.

Jecker

. Taking care of one’s own: justice and family caregiving. Theor Med Bioeth 2002; 23(2): 117–133.

36.

Allen

Jaramillo-Sierra

. Feminist theory and research on family relationships: pluralism and complexity. Sex Roles 2015; 73: 93–99.

37.

Ruddick

. Injustice in families: assault and domination. In: Held

(ed.) Justice and care. Boulder, CO: Westview Press, 1995, pp. 203–223.

38.

Brighouse

Robeyns

. Measuring justice: primary goods and capabilities. Cambridge: Cambridge University Press, 2010.

39.

Eckenwiler

. Care worker migration, global health equity, and ethical place-making. Women Stud Int Forum 2014; 47: 213–222.

40.

Young

. Responsibility and global justice: a social connection model. Soc Philos Policy 2006; 23: 102–130.

41.

Nie

J-B

Fitzgerald

. Connecting the East and the West, the local and the universal: the methodological elements of a transcultural approach to bioethics. Kennedy Inst Ethics J 2016; 26(3): 219–247.

42.

Cheung

C-K

Kwan

AY-H

. The erosion of filial piety by modernization in Chinese cities. Ageing Soc 2009; 29: 179–198.

43.

Twigg

. Bathing – the body and community care. Hove: Psychology Press, 2000.

44.

Benjamin

Brandt

Rozelle

. Aging, wellbeing, and social security in rural northern China. Popul Dev Rev 2000; 26: 89–116.

45.

Zhang

Ong

. Privatizing China: socialism from afar. Ithaca, NY: Cornell University Press, 2008.

46.

Murphy

. Turning peasants into modern Chinese citizens: ‘population quality’, discourse, demographic transition and primary education. China Q 2004; 177: 1–20.

47.

Schinkel

. Justice and the elderly. In: Pinxten

(ed.) Ethics, health policy and (anti-) aging: mixed blessings. 1st ed. Dordrecht: Springer, 2014, pp. 247–269.

48.

Schmidtz

. The elements of justice. Cambridge: Cambridge University Press, 2006.

49.

Gallagher

Wainwright

, et al. Dignity in the care of older people – a review of the theoretical and empirical literature. BMC Nurs 2008; 7: 11.