Abstract
There is currently significant interest in analysing the ethical issues that arise when providing care and support to older adults. Reflecting in part the diversity of approaches that are taken to meet the needs of older adults in paid (sometimes referred to as ‘formal’) and unpaid (sometimes referred to as ‘informal’) care settings, these approaches have tended to be distinctively local in character. Thus, analyses have focused overwhelmingly on ethical analyses of caregiving in particular national contexts shaped by unique policy requirements or regulatory frameworks, or they have sought to make sweeping, abstracted and sometimes essentialist observations about divergent normative approaches that have shaped caregiving differently in the ‘west’ and the ‘east’.
A similar pattern can be observed in the scholarship that has emerged over the last year, during the COVID-19 pandemic. Ethicists have undertaken important work to identify blind-spots in the policy and practical responses for older adults, revealing failures to safeguard the interests of those living in nursing homes adequately, 1 –3 or, in contrast, by diagnosing the ethical wrongs that can arise through a ‘protection first’ approach that has prevailed in nursing homes. 4 Once again, however, these analyses have been focused on different national contexts as different jurisdictions have modified their ‘standard’ models and practices of caregiving in light of how local challenges have manifested themselves.
There is no doubt that these contributions have been of significant value. However, in our view, if we are to make further progress, the ethical spotlight needs to broaden out from the local to the global. We need to recognise that ageing is a global phenomenon, and, therefore, that there is value in digging more deeply and extensively into the distinctive normative approaches that shape care and support to older adults in different parts of the world. We also need to embrace and consider the detailed particularities of caregiving policies, laws and practices in different jurisdictions to get a clearer sense of how roles and responsibilities are enacted and can be understood.
In previous work, we have endeavoured to take some initial steps to begin this process of ‘globalising’ the practical ethical discourse on ethics, care and ageing. 5,6 We used qualitative research to capture complex ethical tensions that arise for caregivers in paid and family care settings, in both the United Kingdom and China. We also brought together academics with expertise in care and ageing working across 11 countries to dissect these issues, and the broader legal, policy and normative discourses in which they arose. Strikingly, the main insight that emerged in this research was the existence of considerable complexity in how family and paid caregiving roles and responsibilities interact with policies and practices. These relate to, for example, changing family forms, migration, technological advancements in care, changing birth control policies, changing social and cultural attitudes, government initiatives to regulate family care provision and the growth of paid caregiving services.
We also observed that scrutinising the rights and wrongs of caregiving roles and responsibilities is complicated by normative expectations that seem to be increasingly in flux in a globalised world. In China, for example, filial piety rooted in Confucianism was a much-discussed value, but one that was assessed as increasingly misunderstood and subject to political manipulation. In the United Kingdom and the United States, values such as dignity and solidarity have become prominent in ethical and political discourses around family care, but are not typically formulated in ways that are conceptually clear or action-guiding. Moreover, when examined in detail, we identified significant overlaps between how these values functioned to undergird caregiving responsibilities. It became clear that, although expressed differently, these disparate concepts should be understood as capturing different dimensions of a range of universal goods, shared across cultures, though in ways that could not (and perhaps should not) be distilled into a single overarching idea or ethical theoretical framework.
There is clearly more work to do to further develop this ‘global turn’ in the practical ethical analysis of caregiving for older adults. Uncertainties about generational entitlements and responsibilities prevail, at a time when, in different countries, new policy and regulatory proposals are gaining traction in ways that would radically transform an established social contract for caregiving in later life. Discussions of the ethics of family caregiving must also acknowledge that ‘family’ is a contested term and that the structure of families and family relationships are ever changing in complex ways. A global lens on the ethics of caregiving practices should also pay attention to the pivotal role that women play 7 and be attentive to scholarship on intersectionality. This enables a close analysis of race, class, gender and sexuality which can shed important new insights on how care is practised and experienced, and how it ought to be configured and re-configured, across and within national borders.
Taking a global and cross-cultural approach to the ethics of caregiving for older adults can be propelled by comparative research that reveals how ethical tensions play out, and how ethical values should be specified, in different contexts around the world. In this special issue, we present some of this research.
Those papers emerging from across different countries in Europe give rise to a range of new insights. These include the importance of drawing on the views of older adults to specify and enact respectful interventions in care work, both in terms of older people’s dignity and autonomy, and the challenges in drawing on psycho-social interventions to enhance the well-being of people with dementia. As paid caregiving settings are becoming increasingly reliant on the employment of immigrants, challenges and opportunities associated with propagating ‘good care’ when caregivers need to collaborate across social and cultural divides are also explored. A set of papers largely focused on China explore how distinctive socio-ethical commitments shape caregiving expectations, in both theory and practice. From the theoretical standpoint, Confucian formulations of filial piety are connected to broader insights on dignity, healthy ageing and intergenerational justice. From a practical standpoint, contemporary Chinese expectations regarding filial party are examined to show how different roles and responsibilities involving family members and professional caregivers are configured in a nursing home. The gendered dynamics of caregiving are also revealed and subject to critical analysis by identifying how social structures and expectations in rural Chinese communities propagate gender injustice.
The papers in this issue provide a cross-cultural snapshot of the distinctive ethical dimensions of caregiving during, what Davis and Scherz 8 refer to as, ‘the evening of life’. We hope that readers will view and interrogate the contributions as a set of connected insights. We think there is real potential in further discussing the comparative themes that can be drawn between these insights, as part of scholarship that goes ‘beyond the local’ when interrogating the ethics of caregiving for older adults. Perhaps in approaching, what are generally framed as, ‘the challenges of ageing’ we should also not lose sight of the insights from Wilfred M. McClay. In writing of ‘Epiphanies, Small and Large’, 9 he says that ‘[a]ging is not a problem to be solved, but a meaning to be lived out’.