This essay investigates the demands on adult children to provide care for their elderly/ill parents from a socio-moral perspective. In order to narrow the examination, the question pursued here is agent-relative: What social and moral complexities are involved for the adult child when her parent(s) need care? First, this article examines our society’s expectation that adult children are morally obligated to provide care for their parents. Second, the essay articulates how transgressing against this normative expectation can inure significant moral criticism. The final sections present these tensions within the context of disability. Keywords:
Eldercare, Filial Obligations, Filial Duty, Filial Care, Moral Trauma
Beyond our evaluative practices (medical evaluations) and our practical reasoning (financial constraints, familial ties, logistics) are countless other constraints and assumptions about what is demanded, what is supererogatory, and what is harmful, in the discussion of elder care. The aims of this essay are less about articulating the grounds of filial duty, and more about exploring some of the latent moral pressures facing adult children who are asked to be involved, in some capacity, in care-giving for their parent(s). This is a perspective piece, from the point of view of moral theory, on the social expectation of filial obligation as it intersects with societal norms. This paper does not advance a position, but instead articulates some of the relevant (but latent) moral considerations in eldercare.
This essay has three sections: First, a discussion of the pressures all adult children face when deciding how involved they ought to be in their elderly/needy parent’s care. I incorporate legal and social literature that recognizes filial obligations, with a brief reflection on academic counterarguments. In the second section, I articulate some of the moral tensions the adult child experiences in relation to these social and legal pressures. I discuss how the adult child faces potential moral exclusion if she decides not to care for her parent. In the third section, I address the unique aspects of filial care in families with abuse histories, and how there may be no clearly best choice. I conclude that the moral tensions, combined with the potential social exclusion and criticisms, are disabling to the agent in nuanced and specific ways, relevant to a discussion about families, disabilities, and the complexities of filial obligations.
Conceptual Discussion of the Obligation to Provide Care
There is an identifiable, measurable expectation in our society that children have obligations to their parents (Aneshensel, Pearlin, Mullan, Zarit, and Whitlatch, 2011); it is not a strict duty with clear parameters, but more of a normative expectation grounded in conceptions of natural connection and concern, reciprocity, empathy, and parental respect. J. Pepin articulates what is meant when we use the terms caring and caregiving, noting that “caregiving has been conceptualized mainly as an activity or set of tasks, while caring has been conceptualized mainly as commitment, respect and protection toward the cared for, as well as an activity,” (Pepin, 1992, p. 130). Here I will use filial care as an umbrella-term to mean caring for/caregiving (as a contrast to care about), to refer to a host of actions and intentions aimed at bettering the welfare of the parent.
The presumption that children have an obligation to care for their parents is existential; by virtue of being offspring of, society expects some level of filial care. Admittedly, the force of such an obligation is difficult to articulate, since factors such as the parent’s specific needs, desires, and history may mitigate it (see Finch and Mason, 1990), but the content of the obligation is verbally explicit, legally supported, and socially reinforced. There are also distinct culturally-specific pressures (in my own experience, Pakistani, Indian, Chinese and Greek families have explicit codes of filial care). While I generalize about American culture rather than cultural specifics, we notice these filial expectations across religious and cultural inheritances (Forssén, Carlstedt, and Mortberg 2005).
These cultural, societal expectations are also codified in US legal statutes; currently in the US, filial care laws are civil statutes, but criminal penalties can and have been imposed in 12 states (Rickles-Jordan, 2007). As of this writing, 30 states have filial care laws that establish a legal obligation upon adult children to provide some sort of care for indigent and/or elderly parents. Laws require that adult children—who have the financial ability—provide necessary food, clothing, shelter, or medical attendance for their elderly parents, who are unable to provide for themselves. Historically, these laws date back to Britain’s Poor Relief Act of 1601, which required children to financially support their poor, aging parents and grandparents. Today, failure to abide by these social expectations can result in punishment, as in filial care legislation which imparts fines. Criminal penalties have rarely been enforced, but in the current climate of increasing eldercare costs and an aging citizenry, enforcement could certainly increase.
These laws reflect how American society values family solidarity and mutual aid, how legally obligating close family members is considered socially legitimate (Finley et al, 1988, Phillips, 1995, AARP International, 2008), and that filial obligations have social benefits (Marcoen, 2005). Feminist theorists like Carol Gilligan, Jean Beker Miller, Adrienne Rich, and others have argued that women are pressured to care more than are men, which is consistent with social coss-cultural meta-analyses (Phillips, 1995; Forssén, Carlstedt, and Mortberg 2005; Hongwei, Fang, and Kolanowski, 2008). In this way, filial care decisions are not made wholly privately, as they intersect with members of the broader healthcare culture, members of the family and community, and perhaps with social workers and law enforcement.
Conceptual Discussion of Moral Theory, Filial Duty, and Common Morality
Common morality, the system of everyday rules that we use in our judgements about what one ought to do, is a system that bears upon members of society and the relationships they, and we, value (Gert, 2004). While moral theorists have largely argued that there is no debt, per se, that children owe their parents (Daniels, 1982; English, 1992), we take filial obligation as moral (Zhan, 2005; Forssén, Carlstedt, & Mortberg, 2005; AARP International, 2008). In the US, while there are differences in culture, religion, and community mores, there is a cross-culturally articulated expectation that children are morally obligated, to some degree, to provide care for their aging parents (Williamson & Schulz, 1990; Guberman, Maheu, & Maille, 1992; Wuest et al., 2007).
The social phenomenon that filial obligation includes a moral quality aligns with our collective morality narrative: the “good” child takes care of their parent, the “bad” child does not. Consider, for example, the son who refuses to care for his needy, sick mother, and the cousin who is aghast at his behavior, and the aunt who is disgusted by his selfishness. The criticisms are of a moral kind: the son is failing to be a good son, and every adult child who decides not to provide care makes himself eligible for moral scrutiny (Opie, 1994; Hodgetts, Pullman, & Goto, 2003). Because our community locates respect and care for our parents as a “central part of the moral standard,” (Callahan, 1985, p. 33), to not provide care is considered a moral failing.1 The agent who fails to care for her parent transgresses against common morality, making herself eligible to be perceived as failing, morally (Hodgetts, Pullman, & Goto, 2003).
To be excluded or censured on the grounds that one has failed, morally, is significant: moral criticism by one’s family, friends, and society has been connected to cases of self harm, illness, substance abuse, domestic abuse, career struggles, and other indices of social and personal failure (Hendin and Haas, 1984; Young, 1996; Block Lewis, 2002; Maguen et al, 2010). This research regards agents who have transgressed against moral norms and who consider themselves to be immoral, and whose moral standing is diminished in the eyes of others. Thus, they are considered by their community (and often, by themselves) as morally other. The possibility, if not probability, of social and moral censure for failing to care is phenomenal, manifested in social exclusion, strained familial relations, and a host of other familial/social stresses in the ways that families exclude, criticize, disparage, mistrust, and censure (see Bauman, 2005, p. 107-115; Opie, 1994; Wuest, 1998; Ryvicker, 2009). Certainly, one could argue that the moral community, for example the critical cousin and aunt, are misguided in their moral censure, but what is salient is that, whether the aunt and cousin are right or wrong, their responses are reasonable within our social context. The literature that addresses moral censure often refers to it as a kind of trauma, moral trauma, where the agent’s moral standing and worth are criticized in such a way that the agent is considered less-moral than the norm. If the reader is interested in delving further into the area of moral trauma, good work is being done in the area of military ethics and soldier psychology (see Nancy Sherman’s work, Georgetown).
To damage our moral standing in our community is significant, such that I (and other moral theorists like Paul Bloomfield) consider moral exclusion disabling. This is because, for most of us, there are compelling self-interested reasons to conform to socially accepted moral norms, and transgressing against norms can be deeply problematic for us psychologically, as well as prudentially (Bloomfield 2008; Opotow, 1990; see also the moral philosophy of Julia Annas, T.H. Irwin, and D. Falk).
These considerations are not often articulated in filial care discussions, and I think this is a mistake. Our societal conception of filial obligations is intimately connected with how we and others perceive our moral worth, and thus has important connections to discussions about family, social standing, and disability. Moral exclusion is an experience not often discussed in mainstream healthcare ethics, but should be. Moral philosophers, disability theorists, and healthcare practitioners have many areas of overlap, and this is one of those areas. Re-Traumatization and the Adult Child of Abuse
Adult children of abuse report that they, too, feel the pressures to care, that their abusive histories does not exempt them from common morality’s expectations. This is because we are both sensitive to, but also insensitive to, abuse histories. While studies are few, common morality expects some degree of filial care even in families with past abuse (Wuest, 1998; Guberman, Maheu, & Maille, 1992; Baines, 2006). These expectations are held by the broader family as well as on the part of the adult children themselves (Baines, 2006). Because common morality, which includes the family, society, as well as the adult children themselves, expects filial duties despite past abuse, this is another area where discussions of moral trauma are important. Children of abuse are especially challenged with self-worth, extreme self-criticism, and viewing themselves as bad (Scott & Eliav, 2005). Childhood abuse can make it difficult for the adult child to fully realize her own morality, and the potentiality for moral othering may be a kind of re-traumatization perhaps evocative of abusive patterns (Scott & Eliav, 2005, in Kendall-Tackett, ed. For a discussion of re-traumatization I look to Nguyen, 2011, but research and opinion are mixed about what constitutes traumatization, see Ali Jackson, ed, 2007).
While we might expect that abusive histories are a valid reason for adult children to be excused from filial obligations, this does not seem, operatively, to be the case. In this way, adult children of abuse have special reasons not to provide care for their abusers (reasons grounded in lack of fellow-feeling, lack of reciprocity), but also special reasons to provide care (grounded in common morality’s moral expectations): this paradox reflects a complexity of expectations, both psychological and social.
Reasons for the adult child not to provide care include considerations for the well-being of both caregiver and parent. In families where there is a history of strained relations, caregivers report that providing care was a significant negative impact to their own well-being (Guberman et al. 1993), with detrimental outcomes for themselves like emotional stress, anxiety, and psychosocial disorders (Wuest, 1998). Negative health outcomes for both caregivers and parents are prevalent in caregiving relationships with abusive histories (Wuest, Hodgins, Malcolm, Merritt-Gray, & Seaman, 2007).
In the field of eldercare, there is a concern that adult children of abusive histories are “more likely to abuse their parents if they provide care for them,” (Ali Jackson, ed., 2007, p. 292), due to issues of retribution, revenge, frustration, and modeling of inter-generational abuse. At its most basic, caregiving without strong fellow-feeling can be deeply problematic for both the caregiver and the care-receiver (Guberman, Maheu, & Maillé, 1992; Noddings, 2003; Duke Filonowicz, 2008), and studies citing these problems seem just as prevalent as studies noting the benefits.
Reasons for the adult child to provide care include avoiding the kinds of moral criticism and censure she would expect from family, friends, and the community. Some theorists have articulated that caregiving is an opportunity to transform abuse history and shift the relationship; indeed, the desire to make connections with family members stood out as motivation for why some chose to be caregivers (Phillips, 1995; Goren, 2007). The adult child of abuse faces a complex dilemma: her community will likely criticize her if she does not provide care, in ways perhaps evocative of past abuse patterns, or, she risks re-exposing herself to old or new traumas, if she does provide care. The adult child of abuse is located in a special and nuanced area of tension, in which there is likely no ‘best choice.’
In this essay I have aimed to articulate filial obligations as they are located in our own, and in our society’s, conception of ourselves as “good children.” Inquiring into the best options for our parents’ health is varied and complex, but this is, of course, not surprising; families are complex, our communities are complex. As the elderly population grows, and as healthcare resources are stretched, the expectation is that family members, primarily adult children, will provide care will be pressing. The current work of bio-ethicists, healthcare practitioners, legislators, and social theorists guides us toward eldercare best practices, and it is my hope that the impact—psychologically, emotionally, as well as morally—on the caregiver will be integral in these decisions. The moral othering that the adult child experiences can be distinct to the point that it is appropriate to talk about it within the context of disability, especially when we recognize the deep emotional strain moral criticism can inure to agents. The temptation is to address only the pragmatics, economics, and logistics of eldercare, and to minimize the social and the psychological aspects. But, in terms of the moral complexities of our lives, these latter aspects require equal consideration in any discussion of families and filial care.
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1 Let me clearly acknowledge that common morality is wrong, for various reasons. The moral community is necessarily under-informed; they have under-examined (and potentially false) beliefs about the optimum health of the parent, and under-examined (and, according to philosophers, false) beliefs about what the child owes her parent. Yet, while the expectation of a duty to care is impoverished, it is salient, weighty, and impactful, such that the adult child likely has strong sympathies, if not outright agreement, with her moral community.
Adult Children and Eldercare: The Moral Considerations of Filial Obligations