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What Do Husbands and Wives Owe Each Other in Old Age

Authors:
  • University of Washington School of Medicine Seattle
Long-Term
Care
Decisions
Ethical
and
Conceptual
Dimensions
edited
by
Laurence
B.
McCullough
Center
for
Ethics,
Medicine,
and
Public
Issues
and
Huffington
Center
on
Aging
and
Nancy
L.
Wilson
Huffington
Center
on
Aging
BAYLOR
COLLEGE
OF
MEDICINE
HOUSTON,
TEXAS
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Johns
Hopkins
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Press
Baltimore
and
London
©
1995
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CHAPTER
EIGHT
What
Do
Husbands
and
Wives
Owe
Each
Other
in
Old
Age?
Nancy
S.
Jecker
What
are
the
ethical
responsibilities
of
a
spouse
whose
partner
suffers
from
a
chronic
disabling
disease?
For
example,
may
a
loving
wife
or
hus-
band
relinquish
caregiving
responsibilities
for
a
partner
who
has
been
disabled
by
a
stroke
and
is
no
longer
able
to
speak,
move,
or
swallow?
If
so,
on
what
basis
does
one
distinguish
between
meeting
and
abandoning
responsibility?
When
does
shouldering
monumental
caregiving
tasks
be-
come
self-destructive
or
self-effacing
rather
than
laudatory?
And
how
do
different
disease
conditions
modify
the
answer?
Does
it
make
a
differ-
ence
if
a
loved
one
suffers
mental,
rather
than
physical,
impairments?
For
example,
is
it
harder
or
easier
to
justify
placing
in
a
nursing
home
a
partner
with
an
irreversible
and
progressive
dementia,
such
as
Alz-
heimer's,
who
no
longer
understands
his
or
her
situation
or
recognizes
family
members?
What do
marriage
vows
mean
anyway,
and
under
what
circumstances
can
persons
ethically
alter
or
revoke
them?
These
ethical
questions
concerning
caregiving
arise,
in
part,
because
of
a
long
history
of
spousal
caregiving
in
the
United
States
(Holstein
and
Cole,
Chap.
2.),
reinforced
by
government
policies
(Wilson,
Chap.
3).
This
chapter
addresses
the
ethical
nature
and
limits
of
the
formal,
legally
recognized
marriage
between
a
man
and
a
woman
by
focusing
on
relationships
among
elderly
spouses
who
have
been
married
for
a
consid-
erable
part
of
their
adult
lives.
Although
some
of
what
I
claim
bears
rele-
vance
to
younger
married
partners
and
to
newly
married
elderly
spouses,
1
will
not
develop
or
discuss
this
at
any
length.
Nor
will
I
elaborate
the
implications
that
the
discussion
has
for
nonmarried
partners
in
long-
term
heterosexual
or
homosexual
relationships.
Throughout
my
concern
is
with
what
is
owed
to
the
average
husband
or
wife
in
an
intact
and
rea-
156
NANCY
S.
JECKER
sonably
good
relationship.
I
will
not
consider
what,
if
anything,
is
owed
when
serious
offenses,
such
as
physical
or
psychological
abuse,
have
been
committed.
All
of
these
topics
merit
more
attention
than
they
have
so
far
received
and
constitute
part
of
a
larger
discussion
of
familial
ethics
in
long-term
care
decision
making. A
more
complete
discussion
would
encompass
not
only
spousal
relationships,
but
also
sibling
relationships,
parent-child
relationships,
and
various
nontraditional
relationships.
Why
We
Need
an
Ethical
Analysis
of
Marriage
At
first
we
want
to
be
romantic;
later,
to
be
bearable;
finally,
to
be
under-
standable.
(Bogan,
1992,
p.
71)
Questions
about
ethical
responsibilities
in
marriage
challenge
us
to
turn
a
critical
eye
on
our
most
intimate
relationships
with
other
persons.
Examining
intensely
personal
relationships
in
this
way
is
something
we
are
apt
to
resist.
We
may
find
mystification
of
love
relationships
roman-
tic,
or
fear
that
rational
dissection
and
analysis
will
be
their
undoing.
Alternatively,
loving
relationships
might
be
assumed
to
defy
rational
scrutiny
altogether.
Or
it
might
be
thought
that
the
strong
feelings
of
love
and
connection
that
underlie
intimate
relationships
are
enough
to
carry
people
through
tumultuous
times,
making
ethical
forethought
un-
necessary.
Despite
an
inclination
to
resist
applying
ethical
analysis
to
marital
relationships,
our
tendency
to
hold
these
relationships
immune
from
eth-
ical
reflection
is
ill-advised.
Doing
so
poorly
prepares
us
to
face
the
inevitable
hard
choices
these
relationships
pose.
Far
from
"coming
natu-
rally,
our
response
to
wrenching
and
complex
problems
in
marital
life
will
often
require
our
deepest
moral
reflection
and
discipline.
In
loving
relationships,
unlike
relationships
with
acquaintances
or
strangers,
we
feel
the
constant
tug
of
strong
emotions.
We
perceive,
without
exaggera-
tion,
that
our
choices
are
momentous
and
will
serve
as
lessons
to
be
passed
on
to
our
children.
How
well
or
poorly
we
handle
marriage
can
shape
the
fate
of
our
families
and
all
of
our
personal
life.
The
partner-
ship
at
stake
may
not
endure,
but
it
is
truly
unique
and
irreplaceable.
Wh.le
these
considerations
clearly
make
ethical
deliberation
more
chal-
lenging
and
difficult,
they
also make
it
more
urgent
and
important.
This
said,
it
is
hard
to
understand,
much
less
support,
the
general
neglect
of
ethics
in
marriage
by
contemporary
moral
philosophy.
What
attention
has
been
devoted
to
family
ethics
has
tended
to
focus
primarily
on
Altai
relationships
between
parents
and
offspring, while
saying
com-
What
Do
Husbands
and
Wives
Owe
Each
Other?
157
paratively
little
about
the
relationship
between
spouses.
The
discussion
of
marital
ethics
that
has
occurred
places
an
undue
emphasis
on
sexual
ethics
and
is
often
preoccupied
with
topics
such
as
premarital
sex
and
adultery.
Little
has
been
written
about
the
ethical
responsibilities
of
mar-
riage
partners
in
old
age
or
about
the
nonsexual
duties
marriage
partners
undertake.
Before
turning
to
discuss
ethics
in
marriage
directly,
it
is
important
to
underscore
at
the
outset
that
my
discussion
will
make
certain
limiting
assumptions.
Ethics
in
marriage,
as
I
will
be
using
this
phrase,
refers
to
ethical
considerations
relevant
to
formal,
legally
recognized
marriages
as
they
exist
in
contemporary
Western
society.
It
is
hard
to
set
forth
a
set of
necessary
and
sufficient
conditions
for
this
conception
of
marriage,
and
I
will
not
attempt
this.
Instead,
I
want
to
indicate
briefly
a
family
of
fea-
tures
commonly
associated
with
getting
married
in
our
society.
These
in-
clude
[a)
a
formal
ceremony
in
which mutual
obligations
are
under-
taken;
(b)
the
involvement
of
two
and
only
two
persons;
(c)
a
willingness
on
the
part
of
the
persons
involved
to
have
sexual
relations
with
each
other
and
no
one
else;
(d)
feelings
of
mutual
love
and
affection
between
persons;
and
(e)
legal
recognition
of
marital
status
and
assignment
of
legal
rights
and
duties
(Wasserstrom,
1979).
Needless
to
say,
we
can
readily
imagine
marriages
that
lack
one
or
more
of
these
features.
Thus,
common-law
marriages
exist
without
a
formal
ceremony;
marriages
take
place
between
persons
who
lack
the
capacity
or
will
to
engage
in
sexual
relations;
and
people
sometimes
marry
for
reasons
of
convenience
or
state
without
loving
each
other.
For
purposes
of
clarity
and
simplicity,
however,
I
will
assume
that
the
five
features
listed
above
are
present
when
I
refer
to
ethics
in
marriage.
I
in
no
way
intend
to
suggest
that
other
forms
of
marriage
are
less
valid
or
important.
Ethical
Foundations
of
Marriage
Diverse
ethical
foundations
might
be
pointed
to
as
forming
the
basis
for
ethical
responsibilities
in
marriage.
Commitment
to
a
Relationship
Unlike
many
other
family
relationships
that
arise
without
the
consent
of
the
parties
involved,
a
spousal
relationship
comes
about
as
a
result
of
each
person's
voluntary
decision.
By
contrast,
children
cannot
choose
whether
or
not
they
will
have
a
parent-child
relationship
or
(ordinarily)
who
their
parents
will
be.
Thus,
duties
of
children
to
parents
may
spring
What
Do
Husbands
and
Wives
Owe
Each
Other?
159
less
by
the
literal
vows
couples
make
than
by
the
underlying
commit-
ment
these
vows
convey.
Thus,
we
should
not
look
to
the
actual
words
spoken
in
the
marriage
ceremony
to
discern
the
ethical
basis
of
marriage.
Instead,
we
should
search
for
the
broader
meaning
and
significance
that
the
vows
represent.
In
one
view
marrying
conveys
a
commitment
to
support
and
nurture
a
certain
kind
of
valued
relationship.
Although
the
impetus
for
making
such
a
commitment
may
be
romantic
love,
the
commitment
outlasts
romantic
feelings.
A
commitment,
after
all,
represents
"more
than
a
fair-
weather
agreement.
Otherwise
there
is
nothing
in
it
that
may
be
tested;
there
is
in
fact
no
real
element
of
commitment"
(Graham, 1989,
p.
210).
Moreover,
unlike
commitments
to
other
kinds
of
relationships,
a
mar-
riage
commitment
is
a
commitment
to
a
personal
relationship.
When
one
stands
in
a
personal
relationship,
one
holds
a
particular
individual's
good
as
one's
own.
By
contrast,
in
quasipersonal
or
impersonal
relation-
ships,
one's
concern
is
with
having
a
certain
kind
of
relationship
or
with
gaining
some
outside
end
(Hardwig,
1989).
In
the
latter
instances,
the
particular
person
with
whom
one
stands
in
a
relationship
is
incidental
to
one's
desire.
According
to
a
slightly
different
reading,
marrying
does
not
express
a
commitment
to
continue
a
personal
relationship
with
someone;
rather,
it
produces
or
brings
into
existence
a
committed,
personal
relationship
over
time
(Graham, 1989).
Marrying
accomplishes
this
by
creating
con-
ditions,
social
and
legal
sanctions
for
example,
that
make
it
more
likely
that
people
will
realize
their
aspiration
to
have
a
lifelong
love.
Through
marrying,
people
explicitly
affirm
such
a
relationship
as
a
shared
desire,
and
affirm
an
intention
to
work
together
to
make
this
desire
come
true.
Yet
what,
more
precisely,
does
having
a
personal
relationship mean?
How
does
one
know
when
such
a
relationship
is
accomplished?
Al-
though
in
some
respects
personal
relationships
resemble
impersonal
and
quasipersonal
relationships,
they
also
exhibit
distinct
features.
First,
the
rules
governing
impersonal
and
quasipersonal
relationships
are
more
or
less
explicit
and
the
requirements
incumbent
upon
parties
more
or
less
apparent.
Thus,
a
teacher
relating
to
students
will
be
expected
to
follow
certain
practices,
such
as
lecturing,
holding
office
hours,
and
grading
as-
signments.
Although
every
class
of
students
is
unique,
the
general
pat-
terns
and
standards
of
conduct
are
fairly
clear
and
repeated
with
each
new
group.
By
contrast,
personal
relationships
unfold
in
profoundly
un-
predictable
ways.
We
surprise
people
we
love
with
important
revelations
i6o
NANCY
S.
JECKER
about
ourselves
and
by
showing
whole
sides
of
our
personality
that
are
not
publicly
known.
Even
the
daily
dance
of
the
relationship
is
more
apt
to
contain
spontaneous
and
unpredictable
elements.
We
laugh
and
cry
with
those
we
love,
we
engage
in
horseplay,
and
we
respond
with
anger.
These
behaviors
and
our
response
to
them
do
not
follow
fixed
rules
or
patterns.
Rather,
in
personal
relationships
we
may
find
ourselves
swim-
ming
in
waters
where
we
have
never
been,
charting
a
course
through
seas
that
are
both
unfamiliar
and
murky.
A
second
distinguishing
feature
of
personal
relationships
is
that
such
relationships
involve
a
series
of
intimate
exchanges.
For
example,
friends
share
projects,
go
to
some
length
to
help
each
other,
reveal
secrets,
and
engage
in
troubles
talk.
By
contrast,
acquaintances
wave
when
they
see
each
other,
discuss
the
weather,
or
share
what
they
did
over
the
holiday.
Finally,
sustaining
a
personal
relationship
requires,
by
definition,
contin-
uing
to
care
about
and
be
invested
in
the
good
of
a
specific
other.
Al-
though
persons
in
impersonal
or
quasipersonal
relationships
may
resolve
to
stand
by
particular
persons,
they
do
not
necessarily
resolve
to
love
or
feel
regard
for
them.
How
can
an
individual
committed
to
a
personal
relationship
recon-
cile
that
commitment
with
a
serious
and
disabling
illness
befalling
the
other
person?
Is
it
ever
the
case
that
illness
makes
fulfilling
one's
com-
mitment
an
improbable
or
even
impossible
feat?
In
other
words,
are
there
instances
where,
although
it
is
possible
to
continue
a
relationship,
it
is
not
even
conceivable
that
one
could
continue
to-carry
on
a
personal
relationship?
Take,
for example,
a
situation
in
which
a
wife
is
unable
to
control
her
bodily
functions;
experiences
severe
tremors,
muscular
rigid-
ity,
and
hypokinesia;
and
is
unable
to
speak.
Here,
a
husband
could
con-
ceivably
continue
loving
his
wife
in
a
deep
and
personal
way
and,
de-
spite
obstacles,
could
continue
to
engage
in
intimate
and
spontaneous
exchanges
with
her.
Still,
doing
so
may
mean
forging
an
entirely
new
repertoire
of
intimacies.
Physical
intimacies
will
no
longer
include
recip-
rocal
sexual
relations
but
may
include
hand-holding,
feeding,
and
bathing.
Verbal
exchanges
will
not
continue
to
involve
the
same
give
and
take
but
may
involve
reading
a
story.
Spontaneity
may
remain
but
be
ex-
pressed
through
laughter,
grimaces,
smiles,
or
winks
But
what
if
the
qualities
that
form
a
relationship
that
is
personal
are
not
mutual
and
are
not
reciprocated
in
any
meaningful
way?
For
exam-
"
75?
/
u",
1
IO"8"
reC°8ni2es
hi*
caregiver
as
his
wife?
The
disabled
spouse
may
then
feel
to
the
careoi„«
11
«
aic&lver
like
a
pres-
What
Do
Husbands
and
Wives
Owe
Each
Other?
ence,
but
no
longer
a
companion
...
as
though
his
body
has
been
taken
over
by
some
alien
being,
as
in
some
Hollywood
Grade
B
movie"
(Meyer,
January
9,
1982).
Taking
this point
further,
what
if
a
disabled
husband
treats
his
wife
as
if
she
were
a
different
person
on
each
new
oc-
casion
she
tends
to
him?
One
caregiver
who
found
herself
in
such
a
situ-
ation
expresses
its
ludicrousness
and chaos:
I
have
been
as
many
as
seven
people
at
one
time
to
him.
According
to
my
function
and
the
room
I
was
in,
he
had
me
separated
into
all
these
different
people....
He
would
warn
me
against
the
woman
who
had
just
given
him
a
bath:
"She's
a
bitch.
Watch
out
for
her.
Watch
out
for
the
old
lady
who's
out
in
the
hall.
She's
always
watching."
He
would
warn
me
against
me—the
person
he
would
perceive.
He
would
warn
me
sometimes
if
I
would
kiss
him.
"Watch
out!
My
wife
may
find
out."
(Meyer,
January
9,1982)
Is
it
possible
to
love
a
person
who
does
not
know
you?
Even
infants
soon
learn
to
recognize
their
parents
and
smile
and
coo
at
their
presence.
Even
pet
cats
rub
against
their
owners
and
saunter
over
to
greet
them
when
they
arrive
home.
How
can
the
commitment
to
carry
out
a
per-
sonal
relationship
proceed
when
the
possibility
of
its
mutuality
is
so
wholly
ruined?
Should
the
caregiver
in
the
above
example
struggle
to
carry
out
seven
different
intimate
relationships?
Should
she
attempt
to
be
the
seven
different
people
her
spouse
perceives?
If
she
does,
can
we
call
the
fractured
relationship
"personal"?
Can
we
recognize
the
ex-
changes
as
"intimate"?
Clearly
there
are
some
kinds
of
others
with
whom
a
personal
rela-
tionship
is
not
possible.
For
example,
it
is
not
possible
to
have
a
personal
relationship
with
inanimate
objects,
such
as
works
of
art;
or
with
places,
such
as
Denver;
or
with
living
unconscious
things,
such
as
a
tree
or
flower.
Certainly
it
is
possible
to
love
such
things
and
to
care
for
and
nurture
them.
It
is
also
possible
to
respond
spontaneously
to
them,
with
joy
or
aesthetic
feeling,
for
example.
But
the
dance
of
relationship
in
which
we
partake
remains
a
solo
performance,
and
no response
is
ever
elicited
in
the
object.
In
the
case
of
severe
dementia,
a
dance
of
two
may
endure,
but
are
the
exchanges
that are
carried
out
intimate?
Consider
the
following
example.
CASE
1
Rae
had
battled
carcinoma
of
the
breast
for
a
decade
and
now
had
an
inop-
erable
bowel
obstruction.
Discharged
from
the
hospital,
she
had
been
told
l6z
NANCY
S.
JECKER
by
the
medical
team
"There
is
nothing
more
we
can
do
for you."
She
went
home
to
a
hospital
bed
and
bedside
commode
placed
in
the
living
room
and
waited
for
death,
wished
for
it
to
come.
She
waited
for
two
months,
while
her
spouse
of
thirty
years,
Sander,
cared
for
her.
She
had
massive
general-
ized
edema
and
persistent
nausea;
her
skin
broke
under
the
pressure
of
fluid
and
had
to
be
taped
in
places.
She
began
a
course
of
morphine
a
week
be-
fore
the
Thanksgiving
holiday.
That
was
when
she
first
began
to
experience
episodes
of
delirium.
Rae
saw
spiders
on
the
walls,
hurled
objects
across
the
living
room,
spoke
of
imaginary
persons.
These
episodes
became
more
fre-
quent
until
finally,
in
the
end,
she
ceased
to
recognize
Sander
altogether.
In
reflecting
on
this
case,
one
wants
to
say
that
the
personal
relationship
between
Sander
and
Rae
had
ended
before
the
event
of
Rae's
death.
Its
ending
was
a
process
beginning
with
Rae's
delirium
and
becoming
final
when
Rae
ceased
to
have
lucid
moments.
By
this
point,
although
Sander
tended
to
Rae
with
love
and
attention,
the
interactions
he
had
with
his
wife
were
no
longer
mutual
or
close,
the
relating
no
longer
constituting
a
shared
intimacy.
If
this
analysis
is
correct,
then
the
view
that
sees
marriage
as
a
com-
mitment
to
a
certain
kind
of
valued
relationship
cannot
support
a
duty
to
care
for
disabled
spouses
under
all
situations.
When
the
valued
rela-
tionship
that
one
is
committed
to
having
with
a
spouse
becomes
impossi-
ble
to
fulfill,
the
commitment
is
no
longer
in
force.
Sander
continued
to
care
for
his
wife,
but
he
was
not
obligated
to
do
so
according
to
this
view.
Instead,
his
conduct
was
morally
praiseworthy;
it
revealed
his
courage
in
the
face
of
loss
and
his
devotion
to
the
memory
of
Rae.
Love
or
Friendship
A
different
source
of
ethical
responsibility
in
marriage
is
the
present
friendship
and
love
that
a
marriage
manifests.
This
position
denies
out-
right
that
there
are
marital
obligations
as
such,
not
grounded
in
ongoing
bonds
of
affection.
It
suggests
as
well
that
long-married
partners
can
conceivably
make
much
greater
demands
and
have
far
higher
expecta-
tions
of
each
other
than
younger
and
newly
married
partners
can.
After
all,
even
if
people
can
"fall"
instantly
in
love
or
can
be
besieged
by
strong
feelings
toward
each
other,
a
loving
relationship
does
not
begin
at
once.
Rather
such
a
relationship
develops
only
over
time
and
derives,
at
least
in
part,
from
a
series
of
intimate
encounters.
These
include
for
ex-
ample,
making
private
revelations,
sharing
time
and
property,'having
What
Do
Husbands
and
Wives
Owe
Each
Other?
163
contact
with
each
other's
body,
becoming
involved
in
shared
projects,
and
entrusting
promises
and
commitments
(Graham
and
LaFollette,
1989).
With
a
slightly
different
interpretation,
ongoing
affection
not
only
grounds
marital
ethics
but
also
shapes
this
ethics
in
a
special
way.
Ethics
grounded
in
love
does
not
consist
of
rights
and
duties;
instead,
the
ethi-
cal
calling
that
love
supports
is
best
characterized
in
terms
of
virtues,
such
as
loyalty,
honesty,
and
trust.
This
is
because
"We
share
ourselves
with
those
with
whom
we
are
intimate
and
are
aware
that
they
do
the
same
with
us";
it
follows
that
"traditional
moral
boundaries,
which
give
rigid
shape
to
the
self,"
do
not
apply
and
that
"talk
about
rights
of
others,
respect
for
others,
and
even
welfare
of
others
is
to
a
certain
ex-
tent
irrelevant"
(Schoeman,
1980,
p.
8).
Expressed
differently,
"the
lives
of
those
who
are
close
are
not
separable,
to
be
close
is
no
longer
to
have
a
life
entirely
your
own
to
live
entirely
as
you
choose"
(Hardwig,
1990,
p.
6).
Taking
this
idea
further,
marriage
might
be
thought
of
as
a
spiri-
tual
union,
in
which
two
individuals
are
literally
joined,
and
a
new
entity
is
created.
Thus,
in
the
traditional
Christian
conception
of
marriage,
husband
and
wife
become
one
holy
union,
and
their
former,
separate
selves
cease
to
exist
(Graham,
1989).
If
one
agrees
that
close
relation-
ships
blur,
or
even
obliterate,
the
traditional
boundaries
that
exist
be-
tween
persons,
then
a
language
of
rights
and
duties
is
indeed
misplaced.
For
rights
are traditionally
applied
to
distinct
individuals;
duties
ordinar-
ily
presuppose
prior
acts
of
consent
by
particular
persons.
Furthermore,
the
motivation
for
respecting
rights
and
meeting
responsibilities
is
gener-
ally
the
moral
requirement
itself,
whereas
those
who
love
each
other
should
be
motivated
by
the
love
and
affection
that
exists
between
them
(Blum,
1992;
English,
1991).
According
to
both
of
the
above
conceptions,
persons
who
have
ceased
loving
their
spouses
but
remain
legally
married
are
no
longer
eth-
ically
called
upon
to
show
their
partners,
for
example,
sexual
fidelity.
For
it
is
only
the
value
of
"loving
someone
deeply
and
completely"
that
makes
sexual
fidelity
"an
ideal
worth
the
sacrifice"
(Steinbock,
1992,
p.
531).
Likewise,
the
initial
promise
to
stay
with
someone
in
sickness
and
poverty
remains
in
force
only
so
long
as
the
relationship
that
loyalty
pre-
serves
continues
to
be
characterized
by
bonds
of
affection.
Therefore,
where
love
withers
the
ethical
responsibilities
of
partners
wither
as
well.
Sustaining
conventional
social
duties
in
the
absence
of
love
is
undesir-
able,
a
"trap
of
self-abnegation
and
sacrifice"
(Poirier
and
Ayres,
1991,
p.
104).
164
NANCY
S.
JECKER
To
return
to
the
case
described
previously,
such
a
conception
helps
to
explain
why
Sander
remained
ethically
indebted
to
his
wife
even
after
a
personal
relationship with
her
had
ended.
He
continued
to
love
his
wife,
although
she
did
not
continue
to
love
or
even
know
him.
This
kind
of
love
is
not
mutual,
and
this
kind
of
relationship
is
not
shared
or
per-
sonal.
Nonetheless,
Sander
related
to
his
wife
in
a
manner
that
was
deep
and
abiding,
and
she
evoked
in
him
potent
feelings,
images,
and
memo-
ries.
It
was
his
love
for
her
that
fortified
him
and
made
him
feel
that
he
must
forge
on.
Yet,
however
appealing
this
perspective
may
be,
it
faces
a
serious
difficulty.
It
cannot
explain
why
Sander
continued
to
have
obligations
to
Rae
even
if
he
no
longer
loved
her.
But
surely
the
thirty
years
between
them
did
not
mean
nothing.
Sander
was
not
free
to
walk
out
the
door
and
leave
his
wife
alone
and
bewildered.
Even
if
he
could
not
muster
the
courage
to
continue
loving
her
as
she
deteriorated
physically
and
men-
tally,
he
was
not
ethically
free
to
jump
ship.
Commitment
to
a
Particular
Person
These
reflections
suggest
a
somewhat
different
reading
of
the
ethical
underpinnings
of
marriage
and
the
need
to
return
to
the
idea
of
commit-
ment
with
which
we
began.
A
final
account
of
the
source
of
ethics
in
marriage
sees
marriage
as
founded
on
a
commitment,
but
not
just
a
commitment
to
have
a
certain
sort
of
valued
relationship.
Instead
mar-
riage
is,
or
is
in
addition,
a
commitment
to
a
particular
person.
Thus,
Sander's
commitment
was
not
only
to
have
a
personal
relationship
with
Rae;
it
was
also
a
commitment
to
Rae.
This
can
explain
why
he
re-
mained
obligated
to
her
even
if
a
special
and
intimate
relationship
was
no
longer
possible,
and
even
if
he
ceased
to
love
her
entirely.
Marriage
commited
him
to
support
his
wife's
welfare
and
interests;
leaving
hei
when
she
was
dying
would
have
betrayed
this
commitment.
The
Meanings
of
Caregiving
The
preceding
discussion
reveals
that
the
ethical
responsibilities
o
spouses
may
spring
from
distinct
sources.
On the
one
hand,
the
promisi
we
make
to
those
we
wed
may
express
out
commitment
to
continue
1
certain
sort
of
loving
relationship
with
them,
or
our
shared
desire
t,
bring
such
a
relationship
into
existence.
Alternatively,
the
ongoing
lov
that
marriage
relationships
exhibit
may
form
the
basis
for
moral
assess
ment
based
on
duties
or
virtues.
Finally,
ethics
in
marriage
may
be
under
What
Do
Husbands
and
Wives
Owe
Each
Other?
165
lain
by
the
commitment
each
side
makes
to
support
the
welfare
and
inter-
ests
of
the
other.
Yet
even
if
marriage
is
ethically
rooted
in
love
or
com-
mitment,
how
do
spouses
make
caregiving
meaningful?
How
do
the
eth-
ical
sources
that
help
to
sustain
marriage
also
shape
its
meaning
in
the
caregiving
context?
In
the
later
stages
of
dementia,
spouses
who
love
and
care
for
de-
mented
partners
may
find
that
their
partners
cease
to
recognize
them,
lose
touch
with
their
past
selves
and
identities,
and
no
longer
understand
their
current
situation.
This
process
of
deterioration
is
surely
bewildering,
ter-
rifying,
and
degrading
to
the
demented
person,
yet
its
end-point
has
been
described
as
ultimately
"merciful"
(Smith,
1992).
Once
demented
per-
sons
forget
their
personal
history
and
lose
touch
with
their
present
predicament,
none
of
their
prior
self
remains
to
know
or
grieve
this
loss.
The
situation
is
quite
different
for
the
demented
person's
husband
or
wife.
When
demented
persons
are
no
longer
able
to
appreciate
their
plight,
their
spouses
remain
painfully
aware
that
"this
is
no
longer
the
same
person."
The
substantial
loss
of
personal
identity
that
accompanies
severe
dementia
lends
itself
to
the
thought
that
marital
duties
at
this
stage
are
duties
to
a
past
person
who
no
longer
exists.
Perhaps
they
be-
come
similar
to
the
duties
persons
have
to
those
who
are
literally
de-
ceased,
such
as
a
duty
to
execute
a
will
faithfully
or
keep
a
deathbed
promise.
In
support
of
this
suggestion,
some
philosophical
analyses
of
personhood
hold
that
persons
continue
to
exist
over
time
only
if
mem-
ory
remains
intact
(Perry,
1975)
or
only
if
psychological
connections
continue
(Parfit,
1975).
These
accounts
lend
credence
to
the
idea
that
whatever
ethical
responsibilities
spouses
continue
to
have
are
to
a
being
that
no
longer
exists.
Yet
in
reply
to
this
reasoning
it
can
be
said
that
personal
identity
en-
compasses
not
only intrinsic
qualities
of
individuals,
such
as
rationality
and
memory,
but
also
the
relational
features
individuals
possess
(Jecker
1990a,
1990b).
For
example,
a
partner
who
no
longer
retains
his
mem-
ory
continues
to
have
the
quality
of
being
someone's
husband
or
wife,
someone
else's
father
or
mother,
this
person's
neighbor,
that
person's
pa-
tient.
These
relational
features
may
not
suffice
to
establish,
in
a
strict
and
philosophical
sense,
that
the
same
individual
continues
to
exist
over
time.
Nonetheless
they
show
that
an
individual's
identity
in
a
social
sense
persists,
even
survives,
despite
grave
losses.
The
social
sense
of
person-
hood
underscores
the
abiding
place
individuals
have
in
the
lives
of
others.
But
how
does
the
ethical
relationship
between
married
persons
itself
166
NANCY
S.
JECKER
change
shape
when
one
party
loses
some
of
the
essential
features
of
his
or
her
former
self?
Do
all
previous
responsibilities
remain
in
force?
Are
new
ones
created?
Clearly,
the
demands
of
caring
for
individuals
in-
crease
in
end-stage
dementia.
Care
for
such
persons
"is
not
just
suste-
nance
of
the
individual's
body,
but
protection
of
the
person.
The
values,
choices,
and
dignity
of
the
demented
are
also
vulnerable
to
harm
or
ne-
glect.
The
caregiver
is
the
keeper
of
the
psyche
as
well
as
the
soma"
(Martin
and
Post,
1992,
p.
59).
The
case
described
below
illustrates
that
the
relationship
that
re-
mains
when
one
spouse
becomes
seriously
demented
may
resemble
more
closely
a
relationship
between
parent
and
child,
rather
than
husband
and
wife.
Reported
in
the
Washington
Post,
this
is
the
story
of
Helen
and
Snowden
Chambers,
a
long-married
couple
in
their
sixties.
CASE
2
Helen's
and
Snowden's
life
together
started
disintegrating
10
years
ago....
Snowden
...
worked
for
the
United
States
Information
Agency
[and]
was
a
widely
traveled,
urbane
linguist
who
knew
his
way
around
world
cap-
itals.
Suddenly,
on
a
trip
to
Europe,
he
seemed
to
lose
control...
a
man
known
...
for
his
phenomenal
memory
. . .
began
writing
notes
to
himself,
reminders
of
his
son's
or
his
mother's
name.
In
the
following
months,
his
be-
havior
became
erratic.
He
wandered
off,
became
lost,
forgot
how
to
get
home,
suffered
blackouts,
so
that
hours
later
he
could
not
account
for
his
whereabouts
or
what
he
had
done
[Years
later,
Helen]
learned
that
[her
husband]
...
had
Alzheimer's
disease.
(Meyer,
January
8,
1982,
p.
Ai)
[A
long
and
frightening
decline
had
ensued,
and
at
age
68,
Snowden]
no
longer
recognized
his
wife
...
and
had
[entirely]
lost
the
ability
to
control
his
bodily
functions.
From
being
the
wife
of a
sick
and
profoundly
disturbed
man,
Helen
...
became
the
caretaker
of
an
adult
with
all
the
characteristics
of a
very
young
child.
(Meyer,
January
9,
1982,
p.
Ai)
Yet
the
analogy
with
the
child
in
this
case
is
not
entirely
adequate.
Al-
though
in
both
parent-child
and
spousal
relationships
caregiving
in-
volves
care
and
love
for
a
dependent
and
vulnerable
family
member,
in
the
case
of
the
spouse
the
history
of
the
prior
relationship
informs
a
dif-
ferent
ethical
course.
The
caregiver's
concern
is
nor
only
to
care
for
someone
who
,s
ch.ld-hke
and
helpless,
but
also
to
make
sense
of
the
re-
lationship
that
now
exists
in
light
of
its
history
to
fi„,t
j
viy,
ro
nnd
meaning
in
adver-
What
Do
Husbands
and
Wives
Owe
Each
Other?
167
sity.
How
can
Helen
construe
the
relationship
she
now
has
with
her
hus-
band
in
light
of
what
it
once
was?
One
view
holds
that
it
is
the
love
that
endures,
and
only
this
that
enables
the
caregiver
to
carry
on
with
grace
and
dignity.
According
to
another
view
it
is
only
the
caregiver's
rever-
ence
for
a
shared
history
and
relationship,
a
prior
commitment
and
promise,
that summons
strength.
The
Limits
of
Caregiving
Love
is
not
merely
a
desire
to
do
good
to
the
object
beloved
...
it
includes,
beside
the
benevolent
impulse,
a
desire
of
the
society
of
the
beloved:
and
this
element
may
predominate
over
the
former,
and
even
conflict
with
it,
so
that
the
true
interests
of
the
beloved
may
be
sacrificed.
(Sidgwick,
1981,
pp.
Z44
and
145)
Even
if
caregiving
can
be
rendered
meaningful,
this
does
not
yet
ad-
dress
the
problem
of
its
ethical
limits.
For
example,
to
what
extent
can
Helen
ethically
relinquish
caregiving
for
her
husband?
When
can
she
do
less?
When
must
she?
Love
and
relationship
can
conflict
with
individu-
als'
interests,
sacrificing
these
to
the
"society"
of
marriage.
Each
of
the
ethical
analyses
discussed
so
far
seems
compatible
with
identifying
limits
to
marital
responsibility
in
the
event
that
such
a
conflict
arises.
Thus,
all
are
consistent
with
the
idea
that
marital
responsibility
ends
where
re-
sponsibilities
have
become
impossible
to
meet
or
where
competing
obli-
gations
or
virtues
take
precedence.
The
accounts
premised
upon
commit-
ment
are
consistent
with
the
view
that
commitments
can
be
waived
or
relinquished
by
recipients
(Post,
1988).
The
position
that
holds
spouses'
ethical
obligations
to
be
founded
on
love
and
affection
permits
the
possi-
bility
that
obligations
cease
when
love
and
affection
sour.
Yet
how,
more
specifically,
do
limits
to
marital
responsibility
emerge
in
the
context
of
caregiving?
Consider
the
following
additional
comments
about
Snowden
and
Helen
Chambers'
case,
made
by
a
Washington
Post
reporter
cover-
ing
the
story.
CASE
1
(continued)
Over
the
last
10
years
her
life
had
come
to
be
dominated
by
her
husband
and
his
condition
At
60,
Helen
...
says
she
yearns
for
the
warmth
and
comfort
of
a
normal
human
relationship.
The
times
she
and
her
husband
looked
forward
to
sharing
after
their
children
were
grown,
the career
she
had
embarked
upon,
the
friendships
the
Chamberses
had
cherished—all
i68
NANCY
S.
JECKER
shattered
by
her
husband's
disease.
"My
initial
reaction,"
she
says,
"was
what
a
waste!
It
is.
It's
a
waste
of
two
people—him
and
me."
Since
her
hus-
band
requires
almost
constant
care,
she
can
leave
the
house
only
when
she
can
find
someone
willing
and
able
to
watch
and
take
care
of
him.
One
adult
son
lives
in
a
basement
apartment
in
the
house
and
helps
when
he
can,
but
he
has
to
be
away
much
of
the
day.
Her
other
two
sons
live
elsewhere....
Theoretically,...
[Snowden]
could
be
in
a
nursing
home,
but...
[Helen]
would
have
to
pay
out
of
pocket
between
$17,000
and
$33,000
annually
for
such
care,
an
expenditure
that
would
deprive
her
of
any
resources
to
take
care
of
herself
in
her
own
old age.
(Meyer,
January
9,
1982,
p.
Ai)
To
avoid
these
high
costs
and
become
eligible
for
public
support
through
Medicaid,
the
Chambers
would
be
required
to
reduce
their
assets
sub-
stantially
(Omnibus
Budget
Reconciliation
Act
of
1993).
For
example,if
they
had
assets
of
$150,000
the
Chambers
would
(in
most
states)
have
to
spend
half
their
assets
on
Snowden's
nursing
home
costs
before
Snow-
den
would
be
eligible
to
receive
Medicaid
(Jones,
1993).
If
the
Cham-
bers
had
devoted
money
to
a
son's
college
education
or
assisted
with
a
son's
mortgage
payment,
Snowden
would
not
be
eligible
for
Medicaid
for
three
years
from
the
date
these
assets
were
dispersed.
If
monies
had
been
transferred
to
a
trust,
the
waiting
period
would
be
five
years.
Even
supposing
Helen
and
Snowden
can
overcome
these
obstacles
and
receive
Medicaid
funding,
states
can
later
seek
recovery
from
a
person's
estate
for
Medicaid
expenses.
Thus,
if
the
Chambers
spent
down
their
assets
to
receive
Medicaid
coverage
for
nursing
home
care
or
home
and
commu-
nity-based
services
(or,
at
the
option
of
the
state,
any
service
provided
under
the
state
s
Medicaid
plan),
then
at
Snowden's
death
the
estate
left
to
Helen
could
be
depleted
to
reimburse
the
state
for
these
expenses.
Given
these
financial
constraints,
Helen's
caregiving
responsibilities
may
seem
de
facto
unlimited.
Putting
her
husband
in
a
nursing
home
may
simply
not
be
a
financially
viable
option.
Yet
neither
a
promise,
nor
a
commitment,
nor
ongoing
love
and
affection
can
support
assigning
un-
limited
caregiving
responsibilities
to
Helen.
None
of
these
ethical
foun-
dations
can
make
moral
sense
of,
much
less
justify,
Helen's
and
Snow-
den
s
predicament.
The
Caregiver's
Interests
If
love
and
commitment
can
take
.-
locate
their
limits?
When
can
we
expect
that
rh°
^
c™
sh
WC
expect
that
the
ethical
foundations
ol
What
Do
Husbands
and
Wives
Owe
Each
Other?
169
marriage
will
begin
to
crumble
under
the
weight
of
burden
that
caregiv-
ing
entails?
Even
if
caregivers'
de
facto
responsibilities
are
open-ended,
when
do
they
ethically
exceed
what
any
individual
can
bear?
Traditional
answers
to
this
question
in
the
bioethics
literature
are
for
the
most
part
inadequate.
Thus,
the
literature
on
surrogate
decision
making
for
mentally
incompetent
persons
assumes
that
family
members
have
presumptive
decisional
authority
(Buchanan
and
Brock,
1989).
However,
they
are
advised
to
act
in
accordance
with
what
the
incompe-
tent
individual
would
have
wanted,
or
if
this
is
not
possible,
in
accor-
dance
with
the
incompetent
person's
best
interests.
Thus,
taking
a
part-
ner
to
a
nursing
home
is
justified
if
this
is
what
the
partner
would
want
if
he
or
she
became
suddenly
lucid
and
able
to
make
a
rational
decision.
Or
nursing
home
care
is
ethically
defensible
provided
it
is
in
the
best
interests
of
the
disabled
person.
Yet
this
analysis
gives
little
guidance
in
situations
where
a
disabled
and
incompetent
patient
would
have
wanted
to
remain
"forever"
under
his
or
her
spouse's
care.
And
it
provides
poor
direction
in
instances
where
it
is
indeed
in
the
best
interests
of
an
incapacitated
spouse
to
re-
main
at
home,
but
home
care
places
undue
burdens
on
caregivers.
Stud-
ies
show
that
the
burden
to
caregivers
is
substantial
(Zarit,
Reever,
and
Bach-Peterson,
1980),
with
caregivers
experiencing
high
prevalence
rates
of
depressive
symptoms
and
disorders
(Gallagher
et
al.,
1989),
triple
the
normal
incidence
of
self-reported
stress
symptoms
(George
and
Gwyther,
1986),
almost
double
the
normal
use
of
psychotropic
agents
(Clipp
and
George,
1990),
reduced
immune
function
(Kiecolt-Glasser
et
al.,
1987),
and
increased
susceptibility
to
health
problems
(Pruchno
et
al.,
1990).
An
approach
that
requires
putting
the
best
interests
of
the
disabled
spouse
first
is
unwieldy
in
caregiving
situations
because
it
discourages
justified
self-concern
on
the
part
of
caregivers.
Thus,
it
elicits
guilt
when-
ever
caregivers
pay
legitimate
attention
to
their
own
needs
and
interests.
A
fuller
picture
of
long-term
care
decision
making
would
place
vari-
ous
options,
ranging
from
occasional
respite
care,
to
regular
day
care,
to
placement
in
a
nursing
home,
in
the
context
of
the
interests
of
both
the
disabled
person
and
the
caregiver.
Reflecting
this
broader
perspective,
I
have
argued
elsewhere
that
family
relationships
place
ethical
limits
on
how
far
respect
for
individuals'
wishes
extends
(Jecker,
1991).
Rather
than
picturing
the
individual
as
an
island,
the
individual
should
instead
be
situated
in
a
family
context,
and
the
family's
resources
should
be
re-
garded
as
a
commons,
a
resource
open
to
all
that
can
be
depleted,
if
What
Do
Husbands
and
Wives
Owe
Each
Other?
89).
To
the
extent
that
married
persons'
commitments
are
a
function
of
unjust
or
questionable
social
attitudes
and
practices,
or
are
at
odds
with
other
ethical
considerations,
the
ethical
basis
of
their
commitment
be-
comes
problematic.
Even
a
view
that
regards
going
to
great
lengths
for
those
we
love
to
be
morally
heroic,
rather
than
morally
mandatory,
requires
important
qualifications.
Although
it
is
occasionally
heroic or
admirable
to
subor-
dinate
one's
own
interests
in
order
to
go
out
of
one's
way
to
benefit
an-
other
person,
doing
so
is
not
always
ethically
acceptable.
The
Caregiver's
Projects
So
far
I
have
proposed
that
those
who
serve
as
caregivers
should
not
categorically
subordinate
their
own
interests
to
the
interests
of
the
cared
for.
A
further
constraint
might
hold
that
a
person's
commitments
to
oth-
ers,
even
those
the
person
loves,
should
not
imply
forsaking
other
goals
and
projects
in
life.
Caregiving
frequently
compromises
a
spouse's
health
and
well
being,
leading
to
depression,
anxiety,
frustration,
helplessness,
sleeplessness,
and
lowered
morale;
it
frequently
consumes
a
person's
en-
ergy,
leading
to
physical
and
emotional
exhaustion
(Older
Women's
League,
1989).
Hence,
it
can
readily
interfere
with
the
pursuit
of
other
life
goals.
The
problem
that
the
proposed
restriction
encounters
is
that
we
rou-
tinely
allow,
or
even
de
facto
require,
individuals
to
make
a
career
out
of
caring.
Thus,
women
have
historically
made
a
career
out
of
parenting
offspring
(Holstein
and
Cole,
Chap.
2;
Wilson,
Chap.
3).
If
such
a
career
is
ethically
allowed,
even
touted,
it
seems
inconsistent
to
deny
devoted
spouses
a
similar
opportunity.
Although
cultural
scripts
assign
caregiv-
ing
to
women,
it
is
also
possible
for
caregiving
to
be
a
freely
chosen
vocation,
meaning
one
that
persons
select
when
they
have
other
options
from
which
to
choose.
Under
these
circumstances,
serving
another
seems
compatible
with
pursuing,
rather
than
giving
up,
the
important
goals
and
projects
one
has.
Under
these
conditions,
caring
need
not
be
destruc-
tive
of
identity;
it
need
not
entail
that
caregivers
lose
sight
of
their
most
important
aspirations
and
plans.
If
this
analysis
is
correct,
then
choosing
a
life
of
caring
is
not
tantamount
to
deferring
uncritically
to
others
or
acting
reflexively
and
uncritically
to
please.
Instead,
it
may
reflect
a
high
degree
of
love
for
another
human
being
and
a
deliberate
decision
to
act
m
light
of
that
love
(Friedman,
1991).
However,
it
might
be
argued
that
the
situation
of
caregiving
for
a
What
Do
Husbands
and
Wives
Owe
Each
Other?
1991).
Self-respect
also
designates
persons
who
show
self-confidence
about
their
ability,
as
far
as
it
is
within
their
power,
to
carry
out
their
plans
(Hill,
1991)-
By
contrast,
those
who
lack
self-respect
may
feel
per-
petually
unsure
of
themselves;
they
may
retreat
from
their
own
goals
and
plans,
feeling
immobilized
by
their
situation.
Caregiving
places
caregivers'
self-respect
at
peril
because
it
routinely
requires
deferring
to
the
needs
of
others.
When
the
needs
and
interests
of
others
are
not
only
elevated
but
allowed
to
eclipse
the
caregiver's
needs
and
interests
altogether,
caring
has
become
exploitive.
Yet
even
when
this
occurs,
caregiving
may
not
yet
show
damage
to
the
caregiver's
self-
respect.
For
caregivers
may
respond
with
anger
and
outrage,
believing
that
their
welfare
and
needs
deserve
consideration.
It
is
only
when
care-
givers
succumb
to exploitive
situations,
coming
to
regard
exploitation
as
fitting,
that
caring
becomes dangerously
destructive
of
the
caregiver's
self-respect.
In
such
instances,
serving
others
has
become
servility,
be-
cause
caregivers
construe
their
rightful
place
in
a
moral
community
as
lowly
(Hill,
1991).
As
self-respect
is
linked
to
feelings
of
self-confidence,
caregivers
whose
self-respect
is
diminished
may
come
to
feel
trapped
by
their
situa-
tion
and
may
be
less
able
or
inclined
to
pursue
viable
options.
As
self-
respect
is
interwoven
with
feelings
of
self-esteem
and
self-worth,
when
self-respect
is
undermined
caregivers
may
also
be
more
easily
coopted
to
others'
purposes.
Thus,
they
may
accede
more
readily
to
the
wishes
of
the
cared-for
in
carrying
out
daily
routines,
agreeing
to
give
up
private
meals,
or
Sundays
off,
or
vacation
plans,
in
order
to
meet
the
cared-for's
wishes.
Or
caregivers
may
acquiesce
more
readily
when
family
members
press
for
transferring
additional
responsibilities
to
them.
In
these
ways,
an
initial
erosion
of
self-respect
can
set
in
motion
an
avalanche,
which
builds
gradually
but
brings
ultimate
devastation.
The
end-point
of
this
process
may
be
that
caregivers
feel
spiritually
and
emo-
tionally
crippled
and
cease
believing
that
their
own
welfare
and
interests
merit
concern.
In
such
situations,
devoted
caregivers
have
gone
to
great
lengths
on
behalf
of
their
spouses
and
have
paid
an
enormous
toll.
Al-
though
frequently
distorted
by
the
language
of
altruism,
self-sacrifice
under
these
conditions
becomes
a
nightmare
of
self-devastation.
Al-
though
frequently
flaunted
as
an
ideal
for
women,
caring
labor
under
these
circumstances
brings
the
destruction
of
women's
identity
and
char-
acter.
\
174
NANCY
S.
JECKER
The
Societal
Context
of
Caregiving
I
have
already
alluded
to
the
point
that
the
burden
caregiving
im-
poses
may
perpetuate
injustices
within
the
family
by
riding
roughshod
over
the
caregiver's
interests
and
projects
or
eroding
the
caregiver's
self-
esteem
and
self-respect.
It
is
important
now
to
underscore
this
point
and
also
to
call
attention
to
the
fact
that
wives
and
daughters
make
up
by
far
the
largest
share
of
caregivers
(Wilson,
Chap.
3).
When
a
married
older
person
becomes
disabled,
a
female
spouse
almost
invariably
becomes
the
principal
caregiver.
This
is
due,
in
part,
to
the
discrepancy
in
life
ex-
pectancy
between
men
and
women
and
to
the
fact
that
men
usually
marry
younger
women.
When
spousal
caregivers
become
too
frail
or
ill
to
perform
as
sole
caregivers,
the
most
frequently
enlisted
helper
is
an
adult
daughter
or
daughter-in-law
(Brody,
1990).
All
told,
two
of
every
three
family
caregivers
to
the
elderly
are
women
(Stone,
Cafferata,
and
Sangl,
1987).
Men
tend
to
assume
the
role
of
primary
caregiver
only
when
there
is
no
female
to
do
so,
and
when
they
do
function
as
primary
caregivers,
men
generally
provide
less
extensive
support
services
than
women
do
(Horowitz,
1985).
Although
women
are
more
likely
than
men
to
perform
as
primary
caregivers,
assisting
with
feeding,
bathing,
grooming,
toileting,
meal
preparation,
housekeeping,
and
transportation
services,
both
sexes
contribute
emotional
support,
financial
aid,
and
linkage
services
in
roughly
the
same
proportions
(Horowitz,
1985).
In
light
of
gender
disparities
in
primary
caregiving,
some
caution
that
concepts
of
family
obligation
or
debt
"can
serve
as
maleficent
ideo-
logical
warrant
for
the
destruction
of
daughters
(and
wives]"
(Martin
and
Post,
199Z,
p.
63;
Rapp,
Ross,
and
Bridenthal,
1979).
Others
warn
that
contemporary
beliefs
about
family
responsibility
perpetuate
gender
inequity
and
must
therefore
be
abandoned
(Osterbusch
et
al.,
1987).
As
wives
are
more
likely
than
husbands
to
function
as
caregivers,
talk
about
marital
ethics
and
virtue
does
indeed
sound
eerily
familiar.
It
is
reminis-
cent
of
the
traditional
patriarchal marriage,
in
which
the
male
head
of
household
represents
the
family,
and
the
interests
of
women
(and
chil-
dren)
are
subordinated
to
him.
Applauding
wives
who
devote
themselves
wholeheartedly
to
caregiving
for
disabled
husbands
is
also
hauntingly
familiar,
echoing
stereotypical
views
about
women.
Thus,
women
have
been
considered
guided
by
their
feelings,
and
especially
their
attach-
ment
to
their
husbands
and
children
.
.
.
lacking
in
both
the
need
and
the
capacity
to
participate
in
public
life"
(Okin,
x98i,
pp.
8y
and
88).
In
What
Do
Husbands
and
Wives
Owe
Each
Other?
light
of
this
social
and
historical
backdrop,
acknowledging
ethical
limits
to
caregiving
is
imperative.
Only
when
the
interests
of
female
caregivers
are
considered
on
a
par
with
the
interests
of
cared
for
persons
can
soci-
ety
avoid
reinforcing
destructive
family
values.
Only
when
the
self-
respect
of
caregivers
is
safeguarded
can
society
avoid
perpetuating
a
spu-
rious
ideal
for
women.
Gender
disparities
in
the
caregiving
burden
experienced
by
spouses
show
that
wives
experience
a
significantly
greater
burden
than
husbands
do
(Fitting
et
al.,
1986;
Pruchno.
and
Potashnik,
1989;
Pruchno
and
Resch,
1989),
a
fact
with
a
long
history,
as
described
in
Chapter
1.
This
suggests
that
women
in
particular
should
be
encour-
aged
to
develop
greater
awareness
of
the
moral
legitimacy
and
impor-
tance
of
setting
limits
to
caregiving.
Family
members,
case
managers,
health
professionals,
and
others
should
not
only
recognize
ethical
limits
to
caregiving
but
should
initiate
conversations
with
caregivers
about
set-
ting
appropriate
limits,
two
themes
central
to
this
volume
(Arras,
Chap.
10;
Brakman,
Chap.
9;
Kane,
Chap.
5;
McCullough
et
al.,
Chap.
11;
Wetle,
Chap.
4).
In
addition
to
justice
concerns
arising
within
the
family,
caregiving
simultaneously
poses
justice
concerns
outside
the
family
in
the
larger
context
of
society.
Caring
labor,
both
inside
and
outside
the home,
has
not
been
borne
equally
by
different
groups
in
society.
Historically,
it
has
been
performed
by
women,
minority
groups,
the
poor,
the
lesser
edu-
cated,
and
those
with
the
least
power.
Caregivers
often
work
long
hours
while
earning
no
or
meager
wages.
They
often
find
their
efforts
devalued
by
society
and
even
by
the
beneficiaries
of
their
care
(Kane,
1990).
The
situation
of
spouse
caregivers
raises
special
justice
concerns,
because
spouses
who
care
are
among
the
most
vulnerable
of
all
caregivers.
They
comprise
the
largest
number
of
sole
caregivers
and
are
typically
older,
in
poorer
health,
with
lower
incomes,
and
provide
more
intensive
care
for
longer
periods
of
time
(Montgomery
and
Datwyler,
199Z).
Societal
justice
is
also
at
stake
when
society
makes
decisions
about
investing
financially
in
long-term
care
and
helping
to
underwrite
the
costs
of
nursing
homes,
home
care,
and
community
services.
At present,
the
United
States
devotes
relatively
few
public
resources
to
caring
for
chronically
disabled
persons
(Wilson,
Chap.
3).
In
1991,
more
than
43
percent
of
nursing
home
care
expenditures
were
paid
out
of
pocket
by
individuals
and
families
(United
States
Department
of
Health
and
Human
Services,
1993).
Society
has
chosen
instead
to
invest
large
amounts
in
acute-care
medicine,
largely
in
the
form
of
intensive,
short-
176
NANCY
S.
JECKER
term,
hospital
care
that
is
crisis-driven
(Jecker,
1995).
Some
argue
for
efforts
to
maintain,
or
even
increase,
"free"
labor
by
family
members,
because
without
such
labor
public
expenditures
would
be
much
higher
than
they
presently
are
(Rivlin
and
Wiener,
1988).
It
is
precisely
such
an
attitude
that
has
led
to
intolerable
conditions
for
caregivers,
exemplified
by
Helen
and
Snowden
Chambers'
situation.
Helen
had
scant
assistance
with
caregiving
chores,
no
economic
compensation
for
her
efforts,
mea-
ger
opportunity
to
participate
in
an
outside
social
life,
and
little
chance
to
lead
a
semblance
of
a
normal
life.
Caregiving
under
these
circumstances
knows
no
reprieve.
It
is
intim-
idating
and
isolating;
it
breaks
the spirit
of
the
carer
and
ruins
the
mean-
ing
of
relationship
between
the
cared-for
and
caregiver.
Although
we
like
to
think
of
individuals
and
families
as
self-reliant,
reflection
on
the
burden
of
caregiving
fast
explodes
this
myth.
Such
reflection
reveals
that
families
cannot
function
well
or
at
all
as
"a
closed
circle
of
reciprocal
obligations
with
no
public
institutions
to
support
it"
(Post,
1988,
p.
13).
A
philosophy
of
self-help
has
already
been
tried
and
failed:
it
has
led
to
absent
or
spotty
coverage,
ruinous
burdens,
and
physical,
emotional,
and
economic
hardships
for
families
(Binney
and
Estes,
1988;
Nickel,
1985).
Although
such
brief
remarks
cannot
do
justice
to
the
larger
problem
of
burden
sharing,
it
is
imperative
at
least
to
mention
societal
responsi-
bility
in
tandem
with
any
discussion
of
family
ethics.
For
both
the
mean-
ing
and
ethical
nature
of
the
family
show
the
imprint
of
societal
values
and
decisions.
Unless
society
acts
as
a
brake
on
family
responsibility
and
shares
caregiving
burdens
more
equitably,
the
idea
of
family
morality
will
become
a
moral
travesty.
Alas,
caregiving
can
stand
for
moral
excel-
lence
only
when
society
prevents
caregiving
from
becoming
an
unwieldy
and
self-destructive
hardship.
Caregiving
can
fulfill
moral
duties
only
when
society
prevents
caregiving
from
leading
to
unwise
and
unbearable
demands.
REFERENCES
American
Medical
Assoc,ation,
Council
on
Scientific
Affairs.
(i,93).
Physici
and
famtly
caregivers.
Journal
of
the
American
Medical
Associalion,
;
H82.-IZ84.