Envisioning a Gerontology-Enriched theory of Care

Abstract

Care in old age is not a citizenship right in the United States, and unmet needs remain a hidden struggle. When measured against an ethics of care, long-term care (LTC) falls short. A critical step toward more just systems of LTC is to bring feminist theories of care into cooperation with gerontology and disability thought. Doing so will entail keeping all participants in the care relationship in focus and reworking the relationship of ethics of care to justice. This article draws on the capabilities approach to justice, as developed by feminist philosopher Martha Nussbaum, which has care, dependence, and dignity at its core.

Long-term care (LTC) in the United States is characterized by fragmentation and bias in public funding to institutional care in nursing homes (Kitchener & Harrington, 2004). Absent coherent programming across states and a universal LTC policy, care for elders and disabled adults has been negotiated within families or obtained by individuals with various degrees of support from public, semipublic, or private agencies. Approximately 90% of noninstitutional LTC is provided by unpaid family members or friends (Kaye, Harrington, & LaPlante, 2010). The costs of an inadequate LTC system and policy are inequitably borne by these caregivers who forego nearly $660,000 over a lifetime in lost wages, social security, and pension benefits (MetLife, 1999). Paid care is often prohibitively expensive. Widely preferred over nursing homes but with an average hourly cost of $21 (U.S. Department of Health and Human Services [DHHS], 2010) long-term home and community-based care is unaffordable for the middle class and largely unavailable to those who qualify for Medicaid (Dawson, 2010).

The combination of these costs with the often-unrealistic expectation that family members and friends can provide high levels of care has led to a significant unmet need for care. Surveys have found that the prevalence of unmet needs among elders falls between one fifth and one third of the population with the need for personal assistance services (LaPlante, Kaye, Kang, & Harrington, 2004). Using data from the Second Supplement on Aging to the 1994 National Health Interview Survey, an analysis of the unmet needs of people aged 70 and older revealed a range of 10.2% (eating) to 20.1% (transferring into or out of chair, bed, or wheelchair; Desai, Lentzner, & Weeks, 2001). Race and gender are highly correlated with poverty in old age, and as poverty, disability level, and the likelihood of living alone increase, so does the prevalence of unmet needs for personal assistance (Desai et al., 2001; LaPlante et al., 2004). The adverse consequences of unmet needs include depression, the move from the community to an institution (Desai et al., 2001), falls and injuries, burns, dehydration, hunger, and weight loss (LaPlante et al., 2004). It is worth noting that although functionality is measured routinely at the individual level, no federal survey regularly measures unmet needs for LTC at the population level (Kaye et al., 2010). The data collected from the most recent federal survey, cited earlier, are more than 15 years old (Kaye et al., 2010).

Public sources of paid LTC funding are primarily Medicaid and Medicare. Medicaid pays for approximately 50% and Medicare pays for 20% of all LTC costs, excluding the cost of unpaid care (Dawson, 2010). Another 18% of care is paid for out of pocket, and 7% is paid through private LTC insurance companies (Dawson, 2010). Although Medicare pays for short-term health services for people who are aged 65 and older or who qualify for Social Security Disability Insurance, Medicaid benefits vary by state and require recipients first to become impoverished (Feder, Komisar, & Niefeld, 2000). Institutional bias is built into the Medicaid Program, which is obligated to cover nursing care but not home and community-based services. Medicaid spending on home and community-based services more than doubled from 1995 to 2008, from 19% to 42%, with wide discrepancies among the states (Ng & Harrington, 2011).

A large qualitative study of the political consciousness of family members in support groups of elder caregivers examined beliefs about responsibility for care. It revealed a reluctance by family caregivers “to reallocate the risks of long-term care provision—even in the face of well-documented unmet needs,” suggesting that “the relationship between unmet health care needs and political claims for state entitlements is more complex than conventional accounts allow” (Levitsky, 2008, p. 580). The belief in the United States that care is not a public matter contributes to the invisibility of the care work done for pay as well as unpaid family care. Paid reproductive work done in households (such as child care, elder care, housework, and cooking) remains hidden and may be seen by policy makers “as providing a substitute for women’s unpaid labour” (McGrath & DeFilippis, 2009, pp. 68–69), complicating the claims of workers’ rights and livable wages. In 2010, approximately 10.9 million people who were not living in institutions and 1.8 million people who resided in nursing homes needed LTC (Kaye et al., 2010). With a surge in both the population of people aged 85 and older and rates of disability and chronic illness, the need for LTC is expected to double between 2000 and 2050 (DHHS, 2003). Over the same period, jobs in paraprofessional health care are expected to grow between 200% and 242% (DHHS, 2003).

The crisis of care is alleviated by the crisis of workers’ exploitation. According to federal statistics on dangerous professions, truck driving is the only profession ranked more dangerous than that of the occupation of nursing home aide; yet, employer-based health insurance coverage for nursing home aides is lower than for most other occupations (Service Employees International Union, 2009). With annual job turnover rates ranging from 45% to 105% for nursing homes aides, direct care work is frequently available to people who lack credentials that are required for jobs with opportunities for advancement (Stone & Weiner, 2001). Low pay, no benefits, and minimal training contribute to job dissatisfaction and overextension, leaving workers worried about financial and family issues while doing physically dangerous work on the job (Harris-Kojetin, Lipson, Fielding, Kiefer, & Stone, 2004).

Overview of the Article

A critical step toward more just systems of LTC is to bring feminist theories of care into cooperation with gerontology and disability thought. Gerontological social workers engage issues of care and old age in various public policy, direct practice, and scholarship capacities. They operate and advise LTC systems, yet care is undertheorized in gerontology (Dannefer, Stein, Siders, & Patterson, 2008). Gerontologists have not engaged in debates that feminist care theorists and disability scholars and activists have had for decades, but they are uniquely positioned by demographic trends and the recognition that elders’ perspectives are absent from care theories to push LTC into the public arena.

The aim of this article is to begin to map contemporary theories of care and theories of justice onto gerontological discourse to identify ways in which gerontology may contribute. I highlight three necessary actions: cross-fertilizing gerontology with disability thought, upholding the concept of care as relationship by keeping both participants in focus, and reworking the relationship of ethics of care to justice. I do not attempt to measure the state of LTC against an ethic of care (see Brandsen, 2006) or against an ethic of justice, although the fact that it falls short has motivated this call to action.

This article is divided into three sections. I begin by tracing the development of feminist theories of care from the early 1980s, when ethics of care were defined in opposition to ethics of justice. To situate both the critiques of disability theorists and the deficit of care theory in gerontology in relation to broader feminist conceptualizations, I describe key contributions of three feminist scholars: Carol Gilligan, Joan Tronto, and Evelyn Nakano Glenn. Glenn’s and Tronto’s theoretical work is used in contemporary care scholarship that is concerned with pushing the concept of care into the arena of political scrutiny. The section that follows discusses the perspectives of those who receive care. I provide an overview of the tensions between feminist ethics of care and the independent living philosophy and social model of disability before turning to the status of care in gerontology. Finally, I describe Nussbaum’s (2006) capabilities approach for a threshold for basic justice. Nussbaum’s contribution of a revised theory of justice that has care, dependence, and dignity at its core should greatly influence the feminist conversation about the relationship between ethics of care and justice and further legitimate the language that disability activists have already adopted and that gerontological social workers may adopt.

Feminist Theories of Care

Gilligan (1982) introduced an ethic of care in In a Different Voice. She contested the findings of psychological research that girls develop moral maturity slower than and have inferior reasoning to boys (see also Held, 2006; Koggel & Orme, 2010). Through her own empirical research, she revealed a “different voice” among women participants who cared about care; this moral concern was expressed by few of the men in her study (see also Held, 2006; Koggel & Orme, 2010). Although the empirical conclusions that Gilligan drew about differences between men and women have been called into question, her work set in contrast two moral perspectives: the justice perspective, which represented the traditional moral approach that prized rationality, and a care perspective, which valued relatedness and attention to needs (Held, 2006). While Gilligan argued that ideally both men and women would acquire both perspectives for moral judgment (Held, 2006), care was associated with femininity and justice with masculinity (Ruddick, 1998). Feminist scholars who saw that a morality related to care had no representation in dominant liberal moral theories appreciated Gilligan’s work. An ethic of care engaged and framed concerns that were relevant to their lives as moral, providing an alternative to a discourse about individual rights, justice, and universal principles that undervalued interdependence and human connection (Held, 2006; Koggel & Orme, 2010).

Ten years after Gilligan’s publication of In a Different Voice, Tronto (1993) set forth a broader ethic of care, conceptualizing care as a practice and a disposition as a way of featuring an ethical ideal, rather than a form of women’s morality. She called for a caring political order that prioritizes the social goal of meeting needs for care over the goal of profit. An ethic of care recognizes interdependence and helping others flourish as a “fundamental aspect of human life” (Tronto, 1993, p. 162). The implication is that care and care workers will no longer be ignored. Moral aspects of an ethic of care include (1) attentiveness to the needs of others; (2) responsibility, favoring “implicit cultural practices” over obligation based in rules; (3) competence; (4) responsiveness, acting on needs as expressed by others; and (5) the integrity of care—the integration of the preceding four principles (Tronto, 1993, p. 132). Tronto (1993, p. 126) stated, “After we have recognized the complexities of care as a practice, and how completely care is implicated in structures of power in society, it will become clear that a metaethical position that starts from the standpoint of ‘the moral point of view’ is incapable of making the kinds of judgments necessary for care.” She asserted that an ethic of care will not enable change unless care becomes a political idea, which requires a shift in moral boundaries, particularly in understandings of dependence, autonomy, and moral engagement.

Tronto’s explication of an ethic of care that is oriented to political–economic change has been incorporated widely, including in research on the inequities of care work (Glenn, 2000). Part of this project requires acknowledging the defamilization and commodification of care so that employment practices in care work are brought to light.

Care and Intersectionality

Through the late 1980s, feminists defined care work primarily as that provided at home by relatives for able-bodied individuals who were dependent (Graham, 1991). Antiracist scholars observed that early feminist theories of care relied on universalizing assumptions about women’s relationship to reproductive labor. Marxist feminists described the gendered division of labor as the root of women’s oppression. Care theories described it as a dynamic between husbands and wives and excluded families that did not mirror that division, such as single-mother households (Glenn, 1992; Tong, 2009). Antiracist scholars have challenged exclusionary concepts of reproductive labor with historical, quantitative, and ethnographic research to recognize various organizations of reproductive labor that include paid care work and work done outside the home (Glenn, 1992).

Like the partial concept of unpaid care work, a one-dimensional concept of care work as gendered masks the racial division of labor. The foundation for theories of intersectionality was laid in the 1980s and early 1990s by Patricia Hill Collins, Angela Davis, bell hooks, Cherie Moraga, Gloria Anzaldua, and others (Duffy, 2007). The term intersectional was coined by Crenshaw (1989) to describe how employment experiences of African American women could not be fully understood in separate terms of racial or gender discrimination. Care researchers have used an intersectional approach to incorporate multiple sites of analysis and to describe relationships among identities and categories to understand the racial division of paid reproductive labor (Duffy, 2005, 2007; Glenn, 1992, 2000). Researchers have applied theories of intersectionality to illuminate how and why certain populations are concentrated in low-paying, low-status work.

Intersectionality differs from an additive model in which woman of color who do care work are viewed as “doubly” subordinated (Glenn, 1992, p. 1). It requires integrating the study of multiple sources of oppression and privilege. An additive approach remains the norm in many types of research and fails to portray the real ways in which systems of oppression are interrelated (Duffy, 2007). Such analyses are singularly focused, and race or gender or class or nationality or citizenship are overlooked despite their historically rooted ties and shared patterns.

Glenn (1992) argued that race and gender are relational constructs and that women have conflicting interests in reproductive labor. Relationships of domestic labor are hierarchical and interdependent. One woman’s low-wage work enables another woman’s higher standard of living. This relationship ensures that the care worker will remain a member of the working poor (Glenn, 1992). The failure of women in supervisory roles to concern themselves with this inequality and their employee’s family needs is a manifestation of racism, and the relational nature of race and gender must be examined in this context (Glenn, 1992). As Barker (2005, p. 2191) wrote:

There is a contradiction between the emancipatory potential of gender equality in the workforce and the exploitation and inequality associated with the global feminization of labor. Moving past these contradictions entails acknowledging the instability of the category “women” and analyzing the ways in which gender, race, class, sexuality, and nation mutually constitute the meanings, content, and economic valuation of the work that women do.

The racial division of reproductive labor reveals interlocking, relational systems. In a similar way, an intersectional approach may be used to understand and address unequal relationships to care among elders.

The Person on the Other End of the Care Relationship

Care and Disability

The 1980s marked the greatest divide between care and disability scholars (Thomas, 1993). Disability scholars have pointed to how feminists tend to emphasize the experience of the care worker without theorizing the experience of the person who is receiving care (Kröger, 2009). Critics charged feminist care theorists with ignoring “the womanhood of disabled women” and the right of disabled women to receive assistance (Kröger, 2009, p. 404; see also Morris, 2001). Care theorists emphasized the relational, ethical, formal, and informal aspects of care, whereas disability theorists and activists wrote about citizenship, access, and human and civil rights, contesting the exclusion of people with disabilities from care decisions that would directly affect the quality of their lives. Indeed, the independent living movement was built on calls for user-led services in the face of paternalistic norms of care.

The social model of disability and the independent living philosophy are two transformative lines of thinking that were developed by disability rights activists (Beresford, 2008). The social model counters a medical model that aims to improve the patient through medical or therapeutic intervention (Burchardt, 2004; Krogh, 2004). Krogh (2004, p. 118) explained that the social model “locates communities, institutions and governments within society as sites where impairment (i.e., functional difference) is transformed into disability (i.e., oppression or barriers) and thus identifies society as the central place of intervention.” The independent living philosophy promotes the language of citizenship rights and support of the language of care (Beresford, 2008). Independence means having control over how assistance is provided, rather than having no need for it (Morris, 2001). Support in the form of personal assistance services is required for individuals with disabilities to contribute as citizens and should not be framed as an allowance of welfare based on neediness (Krogh, 2004).

Disability scholars and activists have challenged the use of the word care for its role in perpetuating the stigma of dependence, although some have incorporated the word in their own work (Kröger, 2009). As Garland-Thomson (2002, p. 17) put it, “Disability itself demands that human interdependence and the universal need for assistance be figured into our dialogues about rights and subjectivities.” Dependence, it is argued, is a concept acknowledged through the concept of interdependence (Fine & Glendinning, 2005). However, with the recognition of interdependence at its core, the ethic of care has not bridged the divide between the concept of care and the social model of disability (Lloyd, 2006). The call for an alternative to “care” is based on the argument that it implies and promotes unequal power relations (Beresford, 2008; Krogh, 2004). Within the medical model, “disabled” and “dependent” necessarily go hand in hand, and those who are dependent “become objects of control” (Krogh, 2004, p. 129). Beresford (2008) pointed out that our systems of care for adults with disabilities are modeled on child care, assuming “unequal relationships” of dependence.

The argument between feminists who promote an ethic of care and disability scholars and activists comes down to a debate between the assertion that all are interdependent and that dependence must be normalized, on one hand, and the assertion that an ethic of care obscures power relations and perpetuates inequality on the other (Krogh, 2004). While the idea that dependence must be reclaimed is appealing for a number of reasons, unequal power relations between the person requiring assistance and her care provider are not genuinely addressed. Advocates of disability justice make a powerful case that the language of care and its association with dependence, neediness, and passivity should be replaced with a new conceptual framework (Beresford, 2008).

Some recent work on disability and care has framed the approaches as less antithetical, although there is much room for mutual learning. If mutual learning is achieved, coalitions may be built on shared concepts of rights, citizenship, and justice, as is discussed next (Kröger, 2009).

Care and Gerontology

Seventy percent of people in the United States aged 65 and older, including people with disabilities and those who acquire disabilities in old age, will require LTC services (DHHS, 2010). Despite high rates of disability in old age, cross-fertilization between gerontology and disability thought is rare, although coalitions are becoming more common in public policy; the successful advocacy for the passage of the CLASS Act (i.e., the Community Living Assistance Services and Support Act) is one recent example, although its future is uncertain. Torres-Gil (2007) identified the source of reluctance from each perspective: Gerontologists and advocates for old people perceive that they have a lot at stake in the emerging public image of the vibrant, active, independent elder, an image that is threatened by “visible manifestations of disability,” while for younger disability rights advocates, “the thought of being labeled an old person and having to use senior citizen centers, adult day care programs, and—the ultimate horror—nursing homes is galling at best, and a betrayal of their fundamental beliefs at worst” (p. 254).

The independent living movement has been slow to influence gerontology. Its influence has helped shape the terminology and trajectory of supportive housing for elders (e.g., “culture change”). States are expanding their consumer-directed home and community-based services programs that serve elders and nonelders as “consumers” or “participants.” Rebalancing initiatives are intended to direct a higher portion of funding to home and community-based services and to correct the institutional bias of Medicaid funding. These initiatives affect both elders who require services and nonelders with disabilities. The initiatives include the consolidation of home- and community-based services for young and old people. In some cases, professionals in these organizations have been trained to work with either young adults with developmental disabilities or physical disabilities or with elders, but are now asked to serve all three populations (Putnam, 2011). This situation makes the need to articulate what must be considered to enable good care for elders more pressing, so that it can be communicated across networks.

Care has been undertheorized in conventional gerontology (Dannefer et al., 2008). The dominant gerontological discourse of care is based in social work, with a heavy focus on interpersonal relationships, elder abuse, and care management (Twigg, 2000). Social workers and health care professionals measure disability, health, and the need for personal assistance services according to an individual’s ability to perform activities of daily living (ADLs). The resulting knowledge is described by disability scholars as lacking in both political analysis and a phenomenological understanding of relations of care (Williams & Busby, 2000). Institutional care is described in administrative terms of efficiency and economics (Twigg, 2000) and in the language of the scarcity of public funds and human resources (Brandsen, 2006).

Within gerontology, geriatrics takes the physiological old body as its subject. Some gerontologists have argued that the dominance of narratives that frame old age in terms of the public cost of maintaining people with low ADL scores perpetuates a negative and incomplete story of aging (Twigg, 2000). Until recently, social gerontologists have not fully engaged the body. As Twigg (2004, p. 64) explained: “It is at this point that radical or humanistic social gerontology wants to pull back, to fight off the dominance of the bodily in the forms of the biomedical account and assert other aspects of the person and the situation.” Critical gerontologists have critiqued the universalizing tendency of conventional gerontology, using tools of critical theory, feminist theories, and political economy to deconstruct age and describe power relations (Biggs, Lowenstein, & Hendricks, 2003; Calasanti & Slevin, 2006; Estes, 2004, 2006). Yet it has stopped short of analyzing themes that are central to the very old body, such as frailty and dependence. Critical gerontologists have pointed out that although women provide the vast majority of care, they receive less and a poorer quality care in old age than do men (Canneto, 2001); the bodily experiences (including embodied emotion) of old women in contexts of care relationships are unexamined.

Wary of a history of misogynistic discourse and biological determinism that has reduced women to their bodies, social gerontologists have chosen not to focus on the bodies of old women, perhaps viewing that project as “doubly deplorable” (Twigg, 2004, p. 60). Disability scholars have contended that the phenomenology of the body can be compatible with a social model of disability and that attention must be paid to the body living within its social world (Krogh, 2004). It follows that a phenomenological grasp of receiving care in old age is a prerequisite for the capacities of “attentiveness” and “responsiveness,” as discussed by Tronto (1993).

The dominant policy discourse about elders’ needs reproduces what social work scholar, Aronson (2000, p. 52) called the “pattern of inattention.” Aronson described home care as a site of political struggle and challenged the dominant image of passive recipients of care with the voices of old women who are afforded care by the state. Framing her qualitative work around Nancy Fraser’s explication of the “interpreted identities and needs” used in social welfare that “are not always recognized as interpretations … and are rendered immune from analysis and critique” (Fraser, 1989, pp. 153–154 quoted in Aronson, 2000, p. 53), Aronson highlighted the narrowness of dominant interpretations in relation to old women’s own experiences. In doing so, she revealed the true political nature of home care experiences. Inattention is produced through narratives that are preoccupied with fiscal constraints that produce “reductive images of elderly people” (Aronson, 2000, p. 52). Aronson drew attention to the void in care policy discourse where voices and alternative images of elders are missing.

Aronson (2000) grounded her work in the materiality and daily actions of old women who receive care. She bracketed abstract images of care in favor of women’s daily practices and the contexts of care activity. Drawing on qualitative data from multiple studies of older women and care workers, Aronson identified three representations of old women who receive care: being managed, managing, and making demands. Managing and making demands are active interpretations, while being managed is expressed by resignation to unsatisfactory care, compliance, and adjusting expectations in the face of unmet needs. Managing is characterized by a determination and unwillingness to give up. Acts of resistance to the scrutiny of care experts, including the refusal of services, are representations of managing. Making demands occurs most obviously at the level of activism and the claiming of rights, when elders push at the boundaries of care discourse to connect issues of economic security, housing, and ageism. Active engagement with care needs and services is a practice that is neither equally accessible nor valued. Some participants who best fit the image of being managed stated that they did not complain precisely because they did not want to be negatively perceived. Aronson noted that elders have different access to each of these images; not all can make demands without negative consequences.

The popular positive paradigms of aging, including productive and active aging, paint an image of old people as perpetually independent contributors to society. Ironically, the interpretations of old women who are actively managing and making demands are frequently excluded from ideas about active aging, defined by productivity and the maintenance of health and social ties. Dependence remains the “elephant in the room” (Kittay, 2005); positive paradigms of aging not only divert the attention of social gerontologists from issues of disparities in the way people age and experience care but also inhibit the discovery of acts of resistance and the struggle for agency that are compatible with dependence and the need for care.

Care and the Capabilities View of Basic Justice

Attention to the ethics of care is a relatively new development, having been set forth, critiqued, amended, and revised over just three decades (Held, 2006). Using Tronto’s (1993) integrated principles, Brandsen (2006) contrasted the state of LTC in the United States with an ethic of care and concluded that it does not satisfy any of the principles. A public ethic of care would locate the responsibility for care in the public sphere where the work of care is assigned value because it is a public good and a demanding, skilled activity that can be done well or poorly, and it matters that it be done well. In place of this ideal is a social welfare LTC system that is highly mechanized, promotes paternalism, and has been deemed “uncaring” (Engster, 2004). State LTC programs are the first to experience cuts during a budget crisis. Advocates of LTC are in a constant state of defense of their underfunded programs. Unmet needs remain invisible with no federal survey to inform the public and policy makers with current data. Direct care workers, many of whom are immigrant or migrant women and disproportionally women of color, continue to be exploited without real training, adequate wages, or labor protections (Glenn, 2010).

From the perspective of the user, care is hierarchical and inattentive to individual needs, with experts allocating services according to established interpretations of need (Engster, 2004). Far from realizing an ethic of care in which the needs of each participant are recognized and tended to, the social organization of care sets up care relations in ways that lead to failure. Care relations are characterized by unequal power relations and the struggle for identify, agency, and dignity in a system that would deny them.

Disability scholars and activists have often described these issues as the denial of human and civil rights. From their perspectives, these are structural problems of injustice. Feminist care theorists also recognize a role for justice framing. As Brandsen (2006, p. 210) wrote, “following Tronto, policies regarding care that flow from a public ethic of care must be firmly grounded in a liberal, democratic, pluralistic society and be connected to a theory of justice.” Although the first part of this assertion deserves debate, the recognition that ethics of care should be tied to a theory of justice is something feminist care theorists have agreed on for a long time (Lloyd, 2006).

Feminist care scholars have been reluctant to allow theories of justice to subsume ethics of care (Held, 2006); after all, the origins of ethics of care lay in the frustration with the exclusion of women in dominant liberal traditions of justice and morality. Tronto (1993) set the stage for theorizing a caring political order and, together with care scholars like Nancy Folbre, has promoted a caring social policy agenda, but the ethics of care have not been translated into an institutional political theory (Engster, 2004). Citing how “justice is deprived of a language in which response to need becomes a matter of social justice” when need and dependence are reserved for care, Ruddick (1998, p. 6) argued that the two frameworks should not be viewed in opposition. The definition of care as both labor “thoroughly intertwined with emotions” and relationship do not necessarily set it against justice (Ruddick, 1998, p. 10). Held (2006) maintained that the emphases in ethics of care and justice are different enough that one without the other will fall short against a full range of moral questions. Concepts of “interrelatedness and responsiveness to the needs of particular others” she warned, would fall to the wayside without a distinctive ethics of care because different notions of “fairness and rights” dominate ethics of justice (p. 16). Yet the question remains for feminist care theorists: Is it possible to have both an ethic of care that supplements an ethic of justice and truly to move care into the political and public spheres?

In an elaboration of the capabilities approach developed by Amaryta Sen, Nussbaum (2006) highlighted the inherent role of care in each of the 10 capabilities she proposed. Originally a project for the ethics of economic development, Sen set forth the capabilities as an indicator of poverty superior to wealth and income. These capabilities were incorporated into the Human Development Report of the United Nations Development Programme (United Nations, 2010). In her book Frontiers of Justice (2006), Nussbaum applied the capabilities approach to the three areas where theories of justice in the liberal tradition consciously have not been able to go. Her project was to extend and critique the theory of justice developed by Rawls (1993, 1999). Nussbaum focused on Rawls because, in her view, “the contractarian type of theory is … the strongest theory of basic social justice we have so far,” and among them, Rawls’s is the strongest” (Nussbaum, 2006, p. 161). The three areas that liberal theories of justice are unable to address include impairment and disability, nationality, and species membership. For the purpose of this article, Nussbaum’s application of the capabilities approach to impairment and disability is useful.

Rawls did not attempt to extend his theory of justice to people with severe impairments. Nussbaum (2006) explained how his fundamental assumptions about reciprocity, mutual advantage, personhood, and dignity prohibited that extension. The social contract is theoretically driven by cooperation between equal, independent parties for the purpose of achieving mutual advantage. Nussbaum drew out two problematic assumptions about the bases of social cooperation: equality of power and a limited concept of personhood. In social contractarianism, the parties are defined by their capacity to reason, where rationality and animality are binary terms. Personhood and, by implication, human dignity, hinge on reason. Nussbaum offered the alternative conception of rationality as but one aspect of personhood: “Bodily need including the need for care, is a feature of our rationality and our sociability; it is one aspect of our dignity, then, rather than something to be contrasted with it” (p. 160). In addition to a revamped view of personhood, she added altruistic motivation to the motivation for mutual advantage. As Nussbaum (2006, 158) noted: “Living with and toward others, with both benevolence and justice, is part of the shared public conception of the person that all affirm for political purposes.” In these ways, need becomes a legitimate component of personhood and a consideration for justice.

Nussbaum’s capabilities represent a threshold for basic justice. The capabilities approach is not a theory of justice; Nussbaum (2006) likened it to the Bill of Rights—basic entitlements that a just society extends to all its citizens. The capabilities are minimal thresholds for justice because they “are held to be implicit in the very notions of human dignity and a life that is worthy of human dignity” (Nussbaum, 2006, p. 155). The 10 capabilities are opportunities for all in the following areas: life; bodily health; bodily integrity; sense, imagination, and thought; emotions and attachments; practical reasoning; affiliation with other humans and “the social bases of self-respect and nonhumiliation;” relation to nature and animals; play; and political and material control over one’s environment (Nussbaum, 2006, pp. 76–77).

Following this framework for basic justice, the issue for equality is no longer how much money one has, but what one can do and be (Nussbaum, 2006). Nussbaum offered the example of the question of income level for a person who uses a wheelchair, which she argued is insufficient without asking other questions, such as whether the person has mobility (bodily integrity). The next step is to know the barriers, like the lack of curb cuts, and to make changes to enable the full range of capabilities for that person (Nussbaum, 2006, p. 168). This outcome-oriented approach is different from Rawls’s process-oriented liberal theory of justice that assumes a symmetry of power. Here, procedural justice is less important than the achievement of a just outcome (opportunity to live a life with dignity).

Another divergence from the liberal tradition is Nussbaum’s (2006, p. 1) rejection of a separate private sphere in which the family is “immune from justice.” Nussbaum did not isolate care as its own capability, but argued that the capabilities view makes it “easy to make the role of care in a conception of justice as fundamental as it ought to be” (p. 169). Indeed, this role is unmistakable in her explication of the capabilities.

In accordance with care ethics and the liberal tradition, in which individual liberty is a goal of justice, the care required for the provision of capabilities is highly personalized and responsive to individuals’ unique needs. However, in contrast to feminist care philosopher Eva Kittay’s image of the state as “a universal mother” (Nussbaum, 2006, p. 218), Nussbaum embraced the liberal tradition of privileging the goal of independence. Dependencies, she stressed, “must be understood and supported,” but always along with one’s individuality (p. 219).

Much of what ethics of care attempt to convey is integrated into a capabilities framework. Both views normalize interdependence and dependence and both are structured to be attuned to the situation of the provider of care (the capabilities are entitlements for all). It is not a matter of choosing one over the other; however, the contribution of a revised theory of justice with care, dependence, and dignity at its core should greatly influence the feminist conversation about the relationship between ethics of care and justice. As Nussbaum (2006) argued, there are additional analytical benefits to embracing the capabilities approach. In the following conclusion, I highlight those that are the most pertinent to gerontology in light of current trends and vulnerabilities.

Toward a Gerontology-Enriched Theory of Care

Feminist care theorists have recently called for a commitment to understanding the perspectives of people who receive care or, in Tronto’s (1993) terms, emphasizing the principle of responsiveness (see also Lloyd, 2006, 2010). These perspectives are largely missing from feminist care theory. When we ask what is lost without these perspectives, in view of specific trends in aging services, enriching theories of care with elders’ perspectives becomes more than a theoretical exercise. As I described earlier, “rebalancing initiatives” in home and community-based services are leading to the consolidation of service organizations in which professionals are asked to coordinate care for populations they have not been trained to serve. If Medicaid funding remains on the table for cuts, both the exploitation of care workers and unmet needs will intensify. New technology-assisted care, including monitoring technologies that are intended to enable the gold standard of independence in old age, have important ethical implications that have been understudied, particularly in relation to issues of autonomy and privacy, but also concerning problems of social exclusion and isolation. These trends make the need to inform theories of care with elders’ perspectives urgent.

The capabilities approach can support gerontologists’ contributions to understanding care in at least three ways. First, the approach provides a framework to speak coherently in the language of justice (i.e., citizenship entitlements and social and political rights) that disability thought has already adopted, and it is compatible with the social model of disability. A rights discourse is a powerful strategy for bringing resources to devalued social groups (Gibson, 1995), and there is potential for stronger political potency in a justice imperative than in an ethic of care. The capabilities framework reconceptualizes the political subject as a human animal with needs and may also provide a more effective claim to dignity.

Although finding a common ground for gerontology and disability thought is important for building a coalition toward more just systems of care, so is acknowledging differences. For instance, gerontologists may interrogate the idea of the empowered elder consumer of Medicaid-funded personal assistance services. Some elders are positioned to make claims and to assert their rights as users or even distance themselves from the category old; others are not. Gerontologists must recognize the practical limits of a rights discourse when using a justice framework. An old person who is frail and depends on Medicaid-funded services is differently positioned to self-advocate than is a young person with a physical disability. The responsibility to assert users’ rights cannot fall to those who are unable (Gibson, 1995), but this is no reason either to exclude care for elders with severe disabilities from considerations of justice or to appeal to justice in a superficial way. The capabilities approach that incorporates care, dependence, and dignity at its core has the potential to do the work.

The second way in which gerontologists may use a capabilities framework is to problematize the narrow interpretation of need according to ADLs. A capabilities approach to basic justice requires more than dependent care; it requires that opportunities be available for people to achieve individuality and have direction over their lives. Accordingly—although without an explicit capabilities framework—Aronson (2000) insisted that the resistance old women actively express to being reduced to “dependents” be recognized and contribute to a new image of old, frail women as citizens with entitlements. Gerontologists like Aronson have complicated dominant notions of dependence with qualitative research that has built knowledge on elders’ own (political) interpretations of their needs and identities. More work that turns toward lived experiences of dependence is needed.

Finally, this is a theory of justice through which gerontologists can claim injustice in unmet needs and the oppression of people who provide care. The tendency to drop one side of the care relationship from view is also a pervasive problem in care research. Not only are many caregivers elders themselves, but the status and pay of direct care work are linked to the social status of the people who receive care, making the structural injustices that affect experiences of old age relevant to care work. The conditions of work have a direct impact on a worker’s access to her own future care. Paired with a relevant theory of justice, contributions to theories of care that are built on knowledge of both sides of the relationship have the greatest potential to bring care theory into cooperation with disability theory and gerontology.