Decent care and decent employment: family caregivers, migrant care workers and moral dilemmas

ABSTRACT

This paper examines moral dilemmas faced by family caregivers of older adults who employ live-in migrant care workers. Being both a family caregiver as well as an employer of a live-in migrant care worker often puts family members at a crossroad, where moral decisions must be made. Lacking a formal role, family members do not have a professional code of ethics or other clear rules that can guide their actions, and their choices are rooted in cultural, community, familial, and personal values. This paper discusses moral dilemmas that result from family caregivers’ dual commitment, to the wellbeing of their older sick relative who is the recipient of care, and to the wellbeing of the live-in care worker whom they employ. The paper uses relational ethics as a theoretical framework to discuss three cases that involve complex moral decision making in real life.

KEYWORDS:

• Family caregivers
• migrant care-workers
• moral dilemmas
• relational ethics
• aging in place

INTRODUCTION: ‘AGING IN PLACE’ AND ETHICAL ISSUES

“Aging in place” is a leading gerontological approach that perceives the home as a better alternative for older adults’ health, as well their family members’ peace of mind (Hoens & Smetcoren, 2021). As “aging in place” becomes a preferred solution in many parts of the world (Ahn et al., 2020), the role of family caregivers has become more demanding and challenging, particularly in cases involving older people with dementia who require round-the-clock nursing care. Employing a live-in care worker as a way of seeking support is becoming increasingly common in many countries (Ayalon., 2015).

The employment conditions of migrant care workers are the basis for defining them as a unique group, as well as for moral discussions regarding their employment (Perlman, 2012). At the root of this moral issue is the situation where workers from one country are employed in another, under restrictive conditions that differ from those to which citizens of the employing country are subject. The harm suffered by migrant care workers may be explained in terms of structural injustice. Structural injustice occurs when social processes place large categories of people under a systematic threat of control or a denial of means to develop and realize their abilities and freedom, while at the same time, these processes enable others to control or access a wider variety of opportunities to help them develop and realize their abilities (Eckenwiler, 2020).

One can argue that since an “exploitative transaction” nevertheless also benefits the exploited party, it is preferable to a situation where there is no transaction at all. Consequently, the exploited party will choose it, apparently voluntarily, but, in reality, without much choice. This issue is expressed on a global level, predominantly in the context of professional labor (doctors, nurses, etc.), but also, and no less so, in the employment of migrant homecare workers (Brush et al., 2004).

Scholars also argue that even though the employment is entered into voluntarily and legally, allowing both parties to improve their situation, there is nevertheless an alternative theoretical arrangement whose outcome would be more favorable for the workers, and therefore there is often a moral flaw in the employment of migrant workers. Morality in employment means, for example, if after some period of residence in the country of employment, the migrant workers would be allowed to obtain permanent resident status (as is the case in countries such as Canada); or if migrant workers were paid an equal or a higher hourly wage than the norm in the local economy; or if their job entailed fewer working hours, and if additional hours beyond the normal eight-hour working day were to be paid as overtime (Wadehra, 2021). As a result of the lack of such measures, migrant workers are considered the “exploited party.” The stronger party, the employer, has the ability and interest to block a theoretically fairer deal (Miller, 2007).

A significant number of migrant care workers are women who were trained as nurses, and who might have held roles in health systems in their countries of origin had they not sought to work abroad. Others might be women with no formal healthcare training, but who have a role within their families in terms of provision of care to children, the sick, and the elderly. Their migration should be perceived as conflicting with the care needs of their communities, mainly in light of the fact that, in some cases, poorer countries have failing healthcare systems (Daniels, 2008). It can also be argued that their basic rights of living a life of choice, well-being (Ruger, 2006), and basic human rights, are threatened (Eckenwiler, 2020).

As part of the feminization of international migration, women seeking work in more affluent countries have become a particularly integral part of the global economy (Ehrenreich & Hochschild, 2002). When global migration is fueled by ideological construction of work in terms of notions of appropriate femininity, as well as in terms of racial and cultural stereotypes, it presents a particular cause for concern. The construction of Filipinas, for example, as obedient, meticulous workers, “sacrificing heroines” (Schwenken, 2008), or of Indian and Caribbean women as naturally warmhearted and happy, serves the purpose of governments, recruiters, and even private families who consume their services. However, these stereotypes limit women’s opportunities and choices.

Work migration from low-income countries often takes place in the context of nationalist rhetoric, supporting neoliberal economic policies. One form of this rhetoric is organized around benefits to certain countries’ economies. Here, the worker’s subjectivity “organizes and adjusts itself,” not necessarily because of force or coercion, but, supposedly, because (her) choices align with “community interests.” Another rhetorical strategy implies that migrating women benefit from expanded opportunities for choice and equality (Schild, 2007). However, although married women with children are encouraged and even pressured by governments, family members, or by the poor conditions they face at home, to provide for their families and countries by taking jobs abroad, they are also often blamed for the social ills in their countries of origin, such as divorce, children’s poor school performance, and teen pregnancy (Parreñas, 2000).

Who is responsible for addressing the harm caused to migrant care workers and their families and communities, in the workers’ countries of origin who face serious burdens of disease and labor shortages? The set of agents involved, who are therefore responsible, includes governments in both the destination countries and the countries of origin, international recruitment companies, international health corporations, and staffing agencies. But what about private people who employ migrant care workers – do they also bear this moral responsibility? What are the moral consequences of their role as employers of migrant workers?

Much of the literature on homecare work and employment focuses on the perspective of the migrant care workers themselves, particularly disadvantaged migrant women (Parrenas, 2000). Family members who employ migrant care workers are often presented as holding power and as being exploitative and victimizing (Mehta, 2017). This literature, which seeks to give voice to the workers, includes, for example, testimonies from workers who ran away from their employers and who describe cases of starvation, physical and emotional violence, humiliation, and abuse (e.g., Braedley et al., 2018; Ehrenreich & Hochschild, 2002). In Israel, too, many migrant workers reported experiences of abuse and humiliation by their employers (Green & Ayalon, 2016). These difficult international reports require attention and intervention, but, there is also a need to obtain more information about the experiences of the employers of migrant care workers, since they face complicated moral dilemmas that should not be overlooked.

This paper does not address global moral questions; instead, we address the ways in which broad moral questions translate into the everyday practicalities of homecare. Specifically, the paper focuses on moral dilemmas faced by family caregivers who employ migrant homecare workers to care for older parents living with dementia. The extensive literature addressing the challenges and burdens of family caregivers focuses mainly on their relationship with their sick loved ones (e.g., Carmeli et al., 2019; Halevi Hochwald et al., 2022; Strommen et al., 2020). Here we wish to shed light on another aspect of the caregivers’ role – the role of employers, and on the moral dilemmas stemming from their dual role as both family caregivers and employers.

Relational ethics

Relational ethics is based on Gilligan’s ideas of “ethics of care,” and focuses primarily on relationships and the inherent interconnectedness of human beings (Gilligan, 1982). It is associated with concrete circumstances and situations, and is tangible: best expressed through activity and daily experience and not as a set of laws (Pollard, 2015). Since Gilligan, moral philosophers have expanded the “ethics of care” into a unique moral discipline, expanding on Gilligan’s primarily psychological theory (Hawk, 2011).

The relationship in the homecare “triad of care” is characterized by much inter-dependency: the care recipient, the live-in care worker and the family caregivers – all deeply depend upon each other for their wellbeing in numerous ways (Author 1, 2021). From this perspective, we have chosen “ethics of care” as an ethical approach to relate to when discussing moral dilemmas in this paper. Caring for a family member who has lost his or her ability to make decisions and act autonomously, such as those with advanced dementia, presents family caregivers with moral dilemmas regarding the needs of the cared-for relative (Smebye et al., 2015). Employing migrant care workers presents family caregivers with yet another set of moral dilemmas. However, as has been argued previously (e.g., Salami et al., 2017), the literature does not devote sufficient attention to examining challenges family caregivers face as a result of becoming the employers of live-in migrant care workers. One of the issues that has not so far been explored, is related to how family caregivers cope with moral dilemmas stemming from their dual role and dual loyalty – to the wellbeing of the older care recipient as well as to the employed care worker’s wellbeing. This study seeks to fill some of this gap.

Research context: employing migrant care workers in Israel

The context of the study is Israel. In 1984, Israel enacted the Long-Term Care Benefit Law, which enables the financing of homecare and is designed to allow older people to continue to live in the community through the provision of personal care to those who need assistance with daily living. The amount of long-term care benefit to which an individual is entitled is calculated according to functional dependency tests (ADL) and his or her income. In order to employ a care worker, a person must obtain an employment permit, and the official employer of the care worker is the care recipient. Holders of migrant care worker employment permits must allow the worker to reside in their home.

According to data from the Population and Immigration Authority, in 2022 there were over 75,000 migrant care workers in Israel, of which 59,604 were legal workers and 14,609 were illegal ones (Population and Immigration Authority, 2022, Table 5). Most of the legal migrant workers resident in Israel at the end of 2021 came from the following countries: the Philippines (35%), India (25%), and Uzbekistan (15%). The breakdown of the data by age and gender shows that the most common age group across all labor categories is 31–40, and that the majority (83%) were women (Population and Immigration Authority, 2022). Migrant care workers receive a valid visa for one year, which can be renewed annually for a period of five years and three months, or until the death of the last care recipient with whom they worked before the expiration of their basic visa period. Workers must leave Israel upon the expiration of their work visa, and persons who fail to do so will be subject to arrest and deportation. A migrant worker would also expect to be subject to deportation in the event of abuse, violation of the law or of any regulation, such as making false statements, or if the worker is found to have first-degree relatives (other than brothers or sisters) in Israel. The law also states that if a worker gives birth during her work in Israel, she must take the infant away from Israel upon the completion of her three months maternity leave.

A pamphlet published by the Ministry of Welfare and Social Affairs (Population and Immigration Authority, 2021) sets out the conditions of employment and social rights for migrant care workers, and includes the following clauses:

1. The private HR agency must provide workers with information about their rights in a language that they and their employers understand.

2. Prior to the commencement of employment, an employment relations agreement must be signed in a language the worker understands.

3. Workers may only be employed in a full-time position and only by an employer who holds a valid employment permit. The scope of the worker’s employment contract is six working days per week without specified working hours.

4. Workers are entitled to a weekly rest day of 25 hours.

5. Foreign workers are subject to the same laws as Israeli workers, and it is forbidden to fire an Israeli worker who is pregnant.

6. The rules for absence from work, such as due to illness, that apply to an Israeli employee, shall apply to the foreign worker as well.

7. It is mandatory to provide workers with adequate housing for the entire period of their employment.

8. It is mandatory to arrange medical insurance for the worker.

9. Workers are entitled to paid vacation days, holidays, and recuperation days.

10. Like all workers in Israel, migrant workers are entitled to a minimum wage.

11. Dismissal conditions are identical to those for any other worker in the country.

METHODOLOGY

This paper is based on a qualitative study conducted by the first author, which dealt with homecare for older people in Israel (, 2021). It included interviews with care workers, family members who employ care workers, and service providers. This paper focuses on one of the important themes that arose from that study, relating to the experiences of family members in dealing with moral dilemmas arising from their dual loyalties of being family caregivers as well as employers.

In order to provide a rich, detailed description, the paper is based on three case studies. According to Yin (2018), case study research is a type of experimental research, empirical in nature, which investigates a phenomenon that is part of the fabric of everyday life. Our paper examines three seemingly different cases, as we try to generate some general theoretical and practical insights (Stake, 1995). The cases are real, but names and identifying details have been changed, to protect the identity of those involved. The study obtained approval from the Ethics Committee of the authors’ academic institution, and the interviewees whose stories are presented below signed an informed consent form and gave consent for their story to be included in academic publications resulting from the study.

To address the complex ethical issues that arise from the cases we used the Ethical Assessment Screen (Boland-Prom & Anderson, 2005). This model is particularly suitable for analyzing cases that have difficulties that professionals in therapeutic fields refer to as “dual loyalty.” Dual loyalty is loyalty to two separate interests that potentially entails a conflict of interest (Pont et al., 2012). The Ethical Assessment Screen model presents 14 questions, the answers to which should lead to an answer regarding the appropriate action in an ethical dilemma, and in particular in a dual loyalty dilemma. The questions include matters such as the conflict of values and emotions that are inherent in the issue, the possible courses of action, and the impact of decisions on the various parties involved. The discussion of dual loyalty also includes considerations related to the context of the case – to what extent are the parties involved independent and able to choose autonomously? What are the laws involved in the issues? What are the cultural norms of those involved in the dilemma? (Boland-Prom & Anderson, 2005). However, in this paper we did not follow the model step by step. Rather, we used it to guide our analysis of the cases presented, by focusing our analysis on three main questions from the model: (1) Who is involved and what are their motivations? (2) Which values are in conflict? (3)What are the optimal moral solutions?

Other considerations we used in analyzing the cases include identifying characteristics of the relationship, such as the extent to which it involves physical intimacy, personal favors, emotional needs, dependency between the involved parties, and motivations for action. Other important dimensions that shaped the ethical dilemmas were influences of contextual events and the power relations between those involved.

Case 1: Sirens in Tel Aviv

On the morning of November 12, 2019, following rocket fire from Gaza, air raid sirens were triggered in Tel Aviv. It was a warning to all those living in the area to proceed immediately to shelters or protected spaces. Minutes later, the first author received two text messages. The first was sent on behalf of the HR agency through which Emily, her mother’s Indian home care worker is employed: “Dear care workers, further to the instructions of the Home Front Command, no work is to take place in your area today. Kindly comply with the instructions.” The second text was addressed to care recipients. It read: “Dear patients, in light of the security situation and in accordance with the instructions of the Home Front Command, your care worker will not be coming to work. We will continue to monitor updates. Have a quiet and peaceful day, B.T. Care Agency.”

At that early hour, she had just arrived at work, some 100 km from the areas affected by the air raid sirens. Her phone rang, and Emily, in a stressed voice, asked her what she should do if the siren went off again. Her automatic response was that, in the event of another siren, Emily should leave the mother in bed, lock the apartment door, and go to the shelter quickly. The cared for mother has severe dementia, lives on the ground floor of an old apartment building in Tel Aviv, and the basement shelter is at the bottom of a narrow, steep flight of approximately 20 stairs. She is unsteady on her feet and usually resists when you try to coax her along. Trying to take her to the shelter would take a long time, and would prevent Emily from getting to the shelter in time. The thought that flashed through the daughter’s mind in those moments was, “I am responsible for Emily’s safety, she is a young woman and the mother of a toddler, she came here from India to take care of my mother, and should not be part of this conflict at all.”

The daughter listened to my own voice and told myself that she had done the right thing for Emily. But did she do the right thing for her mother?

Case 2: “And then she got pregnant”

Eden’s mother, Ruth, had been diagnosed with Alzheimer’s. She is paralyzed, bedridden, and hardly communicates. Lynne, a migrant care worker, had been living with Ruth for seven years. Some of that period they enjoyed a pleasant relationship, but then, all kinds of disturbing things began to happen. This is Eden’s description:

She told us that she had a boyfriend and that sometimes he would come visit her in the house and we agreed…One day she told me with a very pained, long face that she had found out that this boyfriend had a wife in the Philippines and also another girlfriend in Tel Aviv, and she had dumped him.

Around that time, the mother’s situation deteriorated, and the sisters had to employ an auxiliary worker to help bathe the mother and carry her around. Lynne introduced them to a guy whom she said was her cousin, and they employed him for several hours each day. But things got complicated:

One day she said she was pregnant. She said it was with the man who she’d broken up with, that at the last minute she’d gotten pregnant by him. And she decided to keep the baby. She worked with mom until right before the birth. When the baby was born she asked to continue to live with my mother with the baby.

My sister and I disagreed. I was actually in favour of them staying, but my sister said that apart from the fact that having a baby in the house would disturb mom, having two care workers in the house wasn’t a good idea … (that) the other care worker we brought in to replace her [during her maternity leave] would probably have some tensions with Lynne. Anyway, eventually I was convinced and Lynne moved to some rental apartment, and after three months she took the poor baby to her parents in the Philippines and stayed there for several months, and then she came back to care for our mom.

What we were not aware of … was that the guy we thought was her cousin was actually her boyfriend, and that he was the father of the baby. We found that out from the care worker we hired to replace Lynne … She told us that the ‘cousin’ was coming to the house, that he was actually living in the house without us knowing, that he often came home drunk, and that one time he even beat Lynne.

The sisters talked to Lynne and asked her if he really was the father of her son, and why she had not asked permission for him to live there with her. Eden said that Lynne shrugged it off and said he did not live there, he had just left some stuff there, and that to this day she is not sure what was really going on:

I don’t know who to believe, because it was obvious to me that there was serious competition between the two women about who was going to stay working with us. So, to this day I don’t know. But a lot of things built up and we decided to part ways with Lynne … I gave her a reference so she could get another job, and she did, in fact, get a job after us.”

Case 3: Dubi’s search for the “right formula”

Dubi is in his early sixties. His father died young, and his only brother was living abroad. Throughout the years, Dubi took care of his mother, visiting her in her Tel Aviv apartment at least once a week. He would take her home for dinners, help with the bills, and arrange everything necessary. As the mother’s health situation deteriorated, Dubi said she “neglected herself:” she can’t cook, forgets to eat, forgets to take medication, she does not remember to take a bath. The mother, Yulia, also became very anxious and started calling Dubi on the phone every few minutes. Based on the medical diagnosis of dementia, Dubi obtained an employment permit, contacted a nursing and placement company, and asked them to send him a live-in care worker. Dubi said that at first his mother did not like the idea, but before long she has bonded with Nima so that when Nima goes out, she does not know what to do.

Mom has developed a dependence on her and she won’t let her move. It comes down to the fact that when Nima says she wants to go to the supermarket, my mother says she’s not feeling well, so that Nima doesn’t go out. She doesn’t want to be without her at all. When Nima leaves the house even for five minutes, mom gets very nervous.

Dubi said that in the past he used to walk his mother up the stairs when they came back from dinners at his home, but now his mother only wants Nima:

One day I said to Mom, ‘Come on, I’ll go upstairs with you.’ She wouldn’t. She said: ‘No, let’s wait for Nima.’ Funny how people get used to something so quickly.

Generally, Dubi was pleased with this arrangement, but what made it complicated for Dubi, was that Nima approached him asking his permission to host her boyfriend in the mother’s apartment:

She has a boyfriend here. She asked me for permission to invite him home from time to time, and I haven’t given her an answer about that yet, because I’m still undecided. According to the contract, they’re not allowed to host people, because you never know how these things develop. Nevertheless, a job like this is very hard work and sometimes you need a little bit of this time to take a breather. I understand that beyond the money thing, a person should be allowed to maintain their sanity.

When I met Dubi for an interview it was just after Nima approached him with her request, and Dubi had not answered her yet. In the interview he shared his thoughts:

So the formula I have in mind is to say that between 10 in the morning and 6 in the afternoon, if he comes to visit, then that’s fine. Or, she could go down to him in the afternoon. I said to her, ‘Look, there’s a neighbour who almost every afternoon comes up to Mom and sits with her for two hours. You can perhaps go out during that time.’

ANALYSIS OF CASES AND DISCUSSION

The cases above show that in the daily reality of homecare, family caregivers who employ live-in care workers often face dual commitments and moral dilemmas. In order to analyze these three cases, and understand the nuances of the dilemmas they present for the family caregivers, we examine the case studies using a model of decision-making in dilemmas of dual loyalties (e.g., Boland-Prom & Anderson, 2005; Reamer, 2020). We refer to three main questions that this model poses: 1. Who is involved in this case and what are their motivations? 2. Which values are in conflict and are thus creating difficulties in deciding what the right thing to do is? 3. What are the optimal moral solutions to the dilemma?

Who is involved and what are their motivations?

In the first case, there are three parties directly involved in the situation: 1. The older mother, who cannot express herself, and who was probably not fully aware of the alarming situation; 2. The worried care worker who, for the first time in her life, encountered such an alarming situation, and 3. The daughter, who had more experience with alarms like this but was herself quite stressed. The daughter had to give a quick answer to the worker’s question. She had no time to think, nor did she have any professional ethics to guide her choice. The employment contract signed with Emily did not include any reference to such a moment, and the text messages from the HR agency did not contain anything that could guide a decision. In fact, the messages were completely disconnected from the real situation, since the care worker did not need to leave her home to go to work. In home care, the home is also the workplace.

The split-second decision made was about choosing between the daughter’s obligations as an employer to Emily’s emotional and physical well-being, and her obligation as a daughter to the well-being of her mother, who cannot take care of herself and is totally dependent on support. The main motivation in the moment was to calm the worker’s anxiety and try to act rationally. The daughter knew that her mother could not make it to the shelter in time, due to her medical condition, so she thought that instead of having both women exposed to risk, it makes more sense that at least one, Emily, would be safe.

The second case involved more participants: Ruth, her two daughters Eden and Keren, the worker (Lynne), and the replacement worker. The baby and his father were additional participants. A moral dilemma can present itself as an inner conflict, but also as a conflict between siblings, when each prioritizes different moral stands and/or needs. In this case, each sister, presumably, has her own moral priorities, as well as personality and professional background, which influences her position and perspective. Eden, to begin with, felt bad knowing that Lynne had left her child in the Philippines when she went to work abroad. The values that drive her are empathy, a sense of responsibility and protectiveness toward the helpless, including both Lynne, Lynne’s child who was left behind and the baby that was about to be born. Her sister Keren, as Eden puts it, is “the more practical of the two of us.” We did not interview Keren, so our knowledge about her attitude is based on Eden’s descriptions. Her commitment was mainly, perhaps only, to her mother’s wellbeing. It seems that the values that drive her were mainly related to her responsibility as a daughter. At least outwardly, each of them represented a different moral position. Since both sisters are also heirs to their mother’s property, they may also have an interest in protecting it from unauthorized parties entering the house, such as Lynne’s boyfriend. However, the sisters’ relationship with Lynne, and in particular this dilemma, created tension between them.

Another person involved in this situation is Lynne. She has lived in Ruth’s house for seven years. In practice, this is her “home” in Israel. The sisters visit the house once or twice a week, while Lynne lives there all the time; she has a room there, while they do not. Right now, at this stage, just after giving birth, Lynne wanted to stay in her familiar and safe space. Her personal interest is clear. Lin is a stranger in the country, pregnant from a man with whom she has an unclear relationship. She comes from a background of poverty which pushed her to migrate. It will save Lynne money if she can stay in Ruth’s house. She needs money and is afraid to lose her job. She was hiding the truth from the sisters. Lynne’s unborn child is also affected by this decision. We cannot ask him, but most likely he needs the conditions in which his mother feels best. Do Eden and Keren have any obligations to this baby?

Another person involved is the man who was with Lynne, who might be the baby’s father. When it comes to this man, the facts are unclear. Is he the baby’s father? Does he live in Ruth’s house or does he only stay there sometimes? Was he violent toward Lynne as the substitute care worker told the sisters? Bringing a partner into an employer’s home without permission is a violation of the work contract; but what about Lynne’s basic rights to have intimate relations? And, if he is the father of Lynne’s baby, what about his right to exercise his paternity? And last but not least – the substitute care worker. She wanted Lynne’s job, was critical of Lynne, and reported to Eden and Keren things that were allegedly going on behind their backs. Neither Eden nor we know if the reports were accurate, and was she motivated by loyalty to her employers, or perhaps by self-interest?

The third case, like the first, involved three main parties: the mother – Yulia, the migrant worker – Nima, and the son – Dubi. Yulia wanted all Nima’s attention to herself, and expressed her attachment to Nima in many ways. Nima’s motivation seem to be to keep her job as a live-in care worker, as well as have her own personal life which includes a relationship with a partner. In order to bring a partner into her employer’s home she needed consent, and so she turned to Dubi. Dubi’s main motivation is to ensure that his mom gets the care she needs, and to be able to continue with his own life undisturbed.

Dubi was pleased with Nima’s work, but when Nima expressed her desire to spend time with her boyfriend in the house where she lived with his mother, Dubi faced a dilemma. On the one hand, he was worried that consenting to her request would deprive his mother of the attention she wanted, as well as fearing any unexpected consequences of such visits by the boyfriend. On the other hand, he wanted Nima to be content, understood her needs, and accepted her rights to have intimate relations.

Which values are in conflict

In all three cases, we think that the conflict is not so much over conflicting values, since care and concern for someone else’s well-being, whether the cared-for mother or the care-worker, was the central value, guiding all the family caregivers involved in these cases.

However, perhaps, in the back of the daughter’s mind, in the first case, what guided her response to Emily and the prioritization of her wellbeing, was the logic concerning the value of life. The mother is old, her life expectancy is shorter and her illness takes away her quality of life. Emily is young and has a toddler waiting for her in India, so let the young person live. And also, as an employer, the daughter thought she would suffer great guilt in case something happens to Emily because she waited for her mother. Looking at this raises a moral question: How can one determine what is the value of life, and whose life is more valuable?

In the second case, the sisters’ dilemma was generated because one of them felt more committed to realizing these values – commitment to the wellbeing of another person – in support of her mother, while the second felt responsible for realizing the same values both for her mother and for the migrant care worker. As in many cases of moral dilemmas, every choice people make has consequences that will affect others. Moral orientations vary among individuals, contexts, and over time and cause moral distress because it affects all involved (Piquette et al., 2023). If the sisters demanded that Lynne leave the house, it would be more difficult for Lynne and her baby. However, if Lynne stayed in Ruth’s house, there was a reasonable chance that it would be a disturbance that would influence Ruth’s well-being. Looking at the issue from this perspective of zero-sum game lead to the conflict. The other alternative would be conducting a “relational ethics inquiry” that aims to reach a solution that would be best to all the participants (Carnevale et al., 2017).

In the third case, the dilemma was again not between different values, but between prioritization of the mom’s wellbeing – getting full attention, or Nima’s wellbeing – having a fulfilling intimate relationship in the house she lives in. Dubi’s own wellbeing was another issue. He felt that having peace of mind and a sense of security can be achieved only if both women have their needs fulfilled. Can this wish be also considered as moral, or would such motivation be considered as selfish? From a relational ethics point of view, interconnectedness is a core principle of any relationship (Hopner & Liu, 2021), and therefore the wellbeing of everyone involved is equally valuable.

What are the optimal moral solutions?

The third, and perhaps the most important question we wish to ask, is what are the optimal moral solutions to the dilemmas presented in the three cases? However, there is no clear answer to this question.

Relational ethics framework is aimed at creating a “moral space” where responsiveness and responsibility for the other as well as yourself is enacted and ethical questions answered (Pollard, 2015). However, within complex environments, where power dynamics, complementary interests, and competing interests are addressed, there is no one ideal moral solution. Therefore, rather than providing an ideal moral solution for each case, we would like to discuss how each of the employers imagined what would be the most moral way to face the dilemma they faced, and how the employers negotiated their loyalty to both parties.

Regarding the first case, the moral solution would be to avoid the situation, by having an accessible shelter, one that is suitable for people with mobility difficulties. As this was not the case, any decision made was not completely moral. Considering the very low probability of an actual landing of a rocket in general, and its landing on a specific house in particular, and considering the older woman was not fully aware of what was happening, telling the anxious worker to run to the shelter seemed, to the employing daughter, as the optimal decision in that situation. Previous studies pointed that when it comes to avoiding harm, people usually try to treat everyone equally, but when it comes to saving lives, age often plays an important role (e.g. Goodwin & Landy, 2014).

Regarding second case, to answer this, we reflect on how Eden presented the conflict between her and her sister. The possible courses of action were presented as dichotomous: Either Lynne will move to an alternative apartment for her maternity leave, or she will stay in Ruth’s home. Perhaps, the way out of the dilemma is opening the spectrum of possibilities and searching for more options. This process needs to be performed through a dialogue, involving both the sisters and Lynne, aimed at understanding the various needs and trying to meet as many of these as possible. We address this in the discussion. Practically speaking, if Ruth’s home is large, it may be possible for Lynne to stay with the baby in this house, in a different wing or floor. Otherwise, the sisters might help Lynne to find a suitable place to live separately, but in the same familiar neighborhood, or even the same apartment building. We assume that using relational ethics as a guideline for answering the question “what is the right thing to do?” In this specific situation and dilemma could yield several other practical options

Regarding the third case, Dubi himself presented what he imagined would be the ideal moral solution: a ’formula’ of setting specific times for Nima to invite her boyfriend home, and specific times that she can meet him outside. Through this he was aiming at a solution that would respond, at least partially, to both Nima’s and his mother’s needs.

DISCUSSION

Much of the existing discourse addressing employment relationships in homecare settings focuses on the asymmetrical power relations and the legal, social, and symbolic expressions of exclusion suffered by the working migrants (e.g., Liang, 2021). While this stratified labor market approach is highly important for the understanding of the migrants’ experiences, it provides little knowledge regarding those of the employers. It also tends to present a dichotomous worldview of a zero-sum game; namely what benefits one side, harms the other. The aim of this paper, while not negating the power asymmetry between migrant workers and their employees, is to contribute to this knowledge gap regarding the employers’ perspective, and present a more nuanced, multi-sided, and emphatic picture of these employment relationships.

The three cases have some main things in common. First, in all cases due to severe dementia, the daughter/s or son are, practically, the care-worker’s employers. They are responsible for payments, legal requirements, and the living conditions in the home, and they are the ones the workers approach with requests. In all cases, the older parents were not able to make their voice heard, or make decisions, and the daughter/son had to make a decision that has consequences for both the parent and the worker. Second, in all three cases the family caregivers were faced with a similar dilemma, in the sense that what was at stake is double loyalty: to the parent’s wellbeing on the one hand, and to the care worker’s, on the other. In other words, the cases presented a conflict between a commitment to decent employment vs. a commitment to decent care.

Family connections are an important factor in Jewish Israeli culture. They call for a familial bond, which, even if at times complex or conflicted, is marked by intensity and commitment (Dorff, 2005). At the same time, relations in general and employment relations in particular, are guided by universal values that call for a fair, humane, respectful, and even empathetic attitude toward all people, and in particular if they are from disadvantaged groups. Situations such as the cases described here present moral dilemmas, since familial values and norms regarding commitment to the care of parents conflict with values and norms pertaining to the responsibility toward the person the family is employing.

The laws that regulate the employment of migrant workers mostly concern formal relationships, issues such as wages, workers’ social rights and visa limitations. When family members “step into the role” of employer, they are provided with little guidance, training, mentorship, or support. The laws do not, and probably cannot, encompass all the situations inherent in such complex employment relationships. The various organizations and institutions involved in this relationship – the HR companies and the health and the welfare systems, intervene only in extreme and exceptional cases, such as violence. This leaves family caregivers with the need to cope alone with moral dilemmas, and different people cope in different ways, depending on their personalities, resources, perceptions, and cultural backgrounds.

The ethical difficulties in the second and the third cases arose, among other things, because the sisters/son did not have an open and honest dialogue with the workers, and disregarded them as autonomous subjects (Anthias, 2008). Finding answers through dialogue, where all parties can express their needs and concerns, and seeking strategies that can address everyone’s needs as far as possible, would meet the basic concept of ethics of care, as presented by Gilligan (1982). Gilligan’s theory discusses finding solutions that attempt to meet the majority of needs of the majority of those involved in a conflict, with the understanding that it is impossible to fully satisfy all the wishes of all the parties. This ethical approach, based on a perspective of “interconnectedness,” is particularly important for this study. The basic assumption of our approach is that the “care triad” is one unit, where each member’s wellbeing is dependent on the others,’ rather than approaching the homecare relations in terms of a zero-sum game, where one wins and the other loses.

For this to occur, dialogue is essential (Author 2, 2004). Nevertheless, one cannot wonder how relational ethics and the principle of mutuality and dialogue can be applied in cases where the relationship is basically hierarchical, in light of the employer-employee and local-foreigner power relations embedded in the situations presented here. Therefore, in order to have a dialogue, there is often a need for a third party to mediate and act as a guide. Regarding dialogue between people from different cultures, who speak different languages, which is the case in the relationship between migrant workers and their employers, the involvement of a third party can be particularly essential. The mediators should be familiar with the culture and language of the local family as well as those of the migrant worker. They should come with an empathetic approach toward the feelings and needs of all parties involved, not representing either the family or the worker. Such empathetic dialogue should take into consideration that there is no perfect solution to be found, and no one-size-fits-all formula that can be applied to all cases.

CONCLUSIONS AND IMPLICATIONS

Many governments, including the Israeli one, would like older people who require nursing care to receive care within their own homes. However, for homecare to occur in a benevolent manner, a great deal of institutional support is required, much more than is currently available. This should include guidance and advice, as well as emotional and social support, to both the workers and their employers.

The employment of migrants in private homes of older people creates a very vulnerable social environment. The family home becomes an arena of employment relationships as well as an inter-cultural space of encounter, and also a place where nursing care is provided. The relationships in such a vulnerable environment are crucial for the wellbeing of the older person and her/his formal and informal caregivers. Part of this vulnerability is related to various types of moral issues. The set of agents involved, that include governments in both the destination countries and the countries of origin, international recruitment companies, international health corporations, and staffing agencies do not provide sufficient answers to the needs of the participants in the homecare relations. Most of the burden, including the burden of facing moral dilemmas – is carried by private people who receive almost no training or support for handling moral issues, such as those that were discussed in this paper.

There is a need for greater support for good relations between the interdependent parties, perhaps including informational support for employers and employees, regulations that attend to important issues, and mediation or ombudsman services. Specifically, there is a need to train professionals who can provide mediation services based on the idea of interconnectedness, empathy and on relational ethics. The care recipient, the family members, and the migrant care worker are a single unit, and the wellbeing of each is deeply dependant on the wellbeing of the other. In order to address the moral dilemmas, such as those discussed here, in the best possible way, the needs and values of all parties must be taken into consideration, as well as the context – the cultural, social, and political background characteristics, where the homecare is situated.

Without such interventions, the stress and burden that both care workers as well as family caregivers experience often push them to a mode of survival, and this is not a good breeding ground for dealing with moral conflicts. The results of such situations are painful, for all parties, and do not allow neither decent care nor decent employment. It is therefore immoral to leave the participants of this delicate care arrangement on their own.

Disclosure statement

No potential conflict of interest was reported by the author(s).