Alison Reiheld suggests that better treatment of dependency workers may lead to better treatment of dependent persons.

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Recently, Craig Klugman wrote a thought-provoking blog entry over at bioethics.net on the importance of providing respectful high quality long-term care options for elderly persons in the U.S. In this blog, Klugman laments the fact that many “skilled nursing facilities” still “warehouse” their elderly residents, providing them with medical care but still treating them as people waiting for death rather than persons who can still grow and learn and contribute.

While attention to the limited care options available for the elderly in both the U.S. and Canada is important, so too are a range of issues facing dependency workers—those who provide the care that dependent elderly persons receive.

Readers may be familiar with long-standing arguments within feminist theory about the value of dependency work (AKA caregiving) to society.  Without someone to care for dependent persons, the ill are less likely to recover, the disabled are less likely to flourish, babies and young children will either perish or fail to thrive, and society as a whole will rapidly disintegrate. Simply put, society cannot function without dependency work (see, for example, Eva Kittay’s Love’s Labor).

Given this fact, it is often argued that much is owed to those who do this work, and yet so little is given.  Long-term care facilities in the U.S. have notoriously high staff turnover rates, with some estimates as high as 48.7% nursing staff loss in a 12-month period (see figure 1.7).  This is due not only to difficult working conditions but also to lower pay for nurses in long-term care facilities as compared with other health care settings. In-home care workers (90% of whom are women) are even more poorly compensated.  In the U.S. they earn an average of approximately US$17,000/year.  This is unfair, not merely unfortunate, whether from the perspective of an ethic of care or a social contract theory of justice.

Basic concerns about labor fairness prompted an attempt in the United States through 2011-12 to revise the Fair Labor Standards Act (FLSA) so as to finally move some in-home care workers into coverage by the FLSA, which had not governed their working conditions. A NPR story earlier this year chronicles that effort, and describes the overall situation nicely.  Hot off the presses: this effort has finally seen success. On September 17, 2013, the White House announced that home health workers will enjoy federal minimum wage and overtime protections starting in 2015.  However, this does little to address the status of facility-based dependency workers.  Efforts to provide a more just system of compensation for dependency workers, whether in homes or in facilities, may well lead to higher quality, better-trained workers due to less turnover and longer-term relationships with those for whom they care.  But there still remains the question of who will pay.  As Klugman notes, the out-of-pocket cost of care is high.

The situation is surprisingly similar in Canada.  As in the U.S., Canadian patients rely heavily on private care at home or in facilities. Dependency workers also face similar problems to those faced in the U.S. This past summer, 1200 dependency workers in Alberta voted overwhelmingly to strike from their jobs in eight long-term care facilities.  Unlike many dependency workers in long-term care facilities in the U.S., these workers are members of a union: the Alberta
Union of Provincial Employees.  AUPE president Guy Smith told a news conference that the workers in question earn roughly 20% less than their counterparts in other facilities, and that many are women who are new to Canada and working only part time. Home-based health aides in Canada can expect to earn an average of CA$25,137, 47% below the nationwide average salary.

This issue stands to increase in severity in coming years in both nations. In Canada, 2011 data showed persons over the age of 65 constitute 14.8% of the population and this is projected to rise to 16.5% by 2016. In the U.S., this same age demographic constitutes 13% of the population, up from 12.4% in 2000. The issue of how we care for our elderly dependent persons—the care options we provide for them, whether we view them as burdens or as persons with much to both learn and teach, the quality of care they can receive, their ability to access it—is not going away.  Nor is the issue of how dependency workers are treated.

We ought to do better by our elderly.  We either are them or, if we live sufficiently long, will become them.  As a group, the elderly cared for the young when the young could not care for themselves.

The work of caring for dependent persons—whether young or old, temporarily or permanently—is critically important work to our society.  Doing better by dependency workers may lead to doing better by dependent persons, as well as being a simple matter of fairness and respect for all concerned.

In an ideal world, we would indeed treat both dependency workers and dependent persons better.  Alas, we do not live an ideal world: better treatment of dependency workers will result in more expensive long-term care. Does this mean that the needs of dependency workers and the needs of dependent persons are at odds? Can the needs of both be fairly met? Is this a zero-sum game?

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Alison Reiheld is an Assistant Professor of Philosophy at Southern Illinois University – Edwardsville, US.

An earlier commentary by the author on this same topic was initially posted on August 10, 2014 on the IJFAB blog.  It has been revised here for a Canadian audience.  Visit  http://www.ijfab.org/blog/.