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Abstract

The glaring lack of formal and informal caregivers in Germany has not only become apparent in hospitals and nursing homes but also in home care arrangements. One tension is particularly pertinent in such arrangements: a ‘family-oriented’ logic of the long-term care insurance and the individual wishes of those in need of care meet the actual possibilities of family carers. This care gap has been compensated for by 24-hour care workers, so-called ‘live-ins’, from Eastern Europe for some years. This contribution maps the ‘live-ins’ situation comprehensively from an ethical perspective. Based on different constellations regarding the ‘live-ins’ status as a professional nurse or non-professional caregiver, which ethical principles and moral norms are affected by whom and potentially conflict with each other in such home care arrangements at a micro and meso level of care are outlined. Special attention is paid to the tension between self-care and care for others, and to questions of the shared responsibility in and social responsibility of those external services that are involved in home care in addition to the ‘live-in’.

In order to uncover, understand and influence the current ethical problems, an ethical framework that considers both the divergent interests of all individuals involved in the home care arrangement and their mutual dependency and vulnerability is needed.

Keywords

Live-in care market professional ethics organisational ethics social responsibility vulnerability

Introduction

The employment of 24-hour care workers in home care arrangements in Germany is being increasingly discussed in academic discourse and the public media.^{1, p. 115-170} However, concrete approaches to solve at least the most critical aspects of this home care model have not yet been presented. The situation of these workers, who are also called ‘live-ins’ because they live in care recipient’s home, hence directly at their workplace, has further deteriorated during the COVID-19 pandemic.² The term ‘live-ins’ is used for migrant 24-hour care workers throughout the manuscript. As the vast majority of ‘live-ins’ are female, only the female form is used here. However, the authors note that there are also a few male ‘live-ins’.^3,4 A lawsuit involving a Bulgarian ‘live-in’ working in Germany is paradigmatic of the current situation. She sued for continued payment of wages for the work she had actually done and which exceeded the work by far that had been stipulated in her contract (a 30-hour week). The Regional Labour Court Berlin-Brandenburg approved a daily working time of 21 hours (ruling of 17 August 2020–21 Sa 1900/19). The result of the revision by the Federal Labour Court was that the ‘live-in’ is entitled to the statutory minimum wage for the entire time she worked, including on-call time (ruling of 24 June 2021–5 AZR 505/20). Whether this decision will change the current ‘care market’ practices is contested.

This market is neither a new nor an exclusively German phenomenon. It is, instead, a global market trend (see e.g. Italy,⁵ Switzerland⁶ and Israel⁷) that has developed at the interface of changing circumstances (inter alia, changed family structures and labour mobility with decreasing family caregiving potential and an increase in the need for long-term care) and the differing political approaches to safeguarding long-term care. It is estimated that approximately 600,000 Central and East European care migrants are employed in German home care arrangements.⁸ They come from countries such as Poland, Slovakia, Romania, Bulgaria, Hungary or Lithuania⁹ and take over responsibilities for household chores, support and nursing care.

The situation of the ‘live-in’ is not only legally and politically but also ethically controversial and relevant. Although ethical aspects are repeatedly addressed in situation analyses, the considerations focus only on single principles and levels,^3,10 or they only implicitly address ethical issues.¹¹

The aim of this article is to map the situation of ‘live-ins’ in domestic situations from an ethical perspective. Given the various descriptive analyses and studies on the topic in question, the presentation of the prevailing circumstances for ‘live-ins’ in Germany is limited to the main aspects. Cross-references are disclosed for an in-depth engagement with the topic. Based on different constellations, the ethical principles and moral norms which are primarily affected are explained, and by whom the ‘live-ins’ are (potentially) ethically harmed and what the ethical harm looks like will be identified. Ethical harm is understood in an inclusive manner as any kind of infringement or violation of legitimate, personal interests the ‘live-in’ may have. This includes, but is not limited to, questions of freedom and privacy, health and wellbeing. This ethical analysis focuses on the micro and meso level. This synopsis not only raises the awareness of the complexity of the problem, but also points out ‘blind spots’ of previous approaches. In the future, these spots should also be illuminated in theory, particularly regarding an appropriate design of solutions that are not limited to legal issues.

The focus of this article is on the identification of ethical harms and, hence, primarily actions and omissions that infringe the interests of the live-in are at the centre. However this does not imply the absence of positive experiences made by individual ‘live-ins’ and the possibility of individual job satisfaction.^12,13 Nevertheless, current evidence on – among other things – mental illness of ‘live-ins’¹⁴ tends to show that live-in care arrangements are anything but a win-win situation.

Background

Long-term Home Care in Germany

Long-term home care in Germany is characterised by the priority given to home care by the Social Code Book XI, on the one hand, and the only partial coverage of home care arrangements by long-term care insurance, on the other. Furthermore, the desire of most care recipients to be cared for at home encounters an extreme lack of skilled workers in (elderly) care. The family caregivers that step in are confronted with far-reaching changes in their daily private and professional life (e.g. reduction of employment). For them, caring for an elderly relative comes with temporal, financial, psychological and physical burdens. This enduring level of strain endangers the health of the family caregivers¹⁵ and the stability of the home care arrangement. The search for other relief strategies¹⁶ and the relatives’ efforts to avoid inpatient long-term care facilities in accordance with the care recipient’s wish to stay at home as long as possible are major motivations for recruiting a ‘live-in’.¹⁷

‘Live-ins’ in the Context of Long-term Home Care

The recruitment of ‘live-ins’ can either be related to a ‘live-in’ who cares for the care recipient for an indefinite period of time, or the work is carried out in rotation with another ‘live-in’. In the case of such a transnational rotation system that is based on circular migration, a network of at least four parties arises at the micro level: the care recipient, the relatives and two (or more) alternating ‘live-ins’. Additionally, at the individual level, there are family members in the ‘live-in’s’ country of origin, some of whom also need care (e.g. (grand-)children or parents).¹⁸^, ^{p. 160} If care and rotation are not organised individually by the ‘live-ins’ and the care household, the arrangement is done in an intercessory manner via an agency (usually transnational).¹⁹ In these cases, ‘live-ins’ are either employed by the recruitment agency or by the care recipients and their family. Instead of the term recruitment agency, the terms “brokering agency”, “placement agency” or “employment agency” are also used as synonyms both in the self-description of these agencies and in scholarly literature. The different recruitment and employment relationships come with a multitude of yet unsolved legal questions regarding liability, insurance and payment. In addition, governmental care regimes²⁰ and subsequent (migration) regulations differ between countries and, thus, the legal situation might even be different from ‘live-in’ to ‘live-in’.^2,21 Given the ethical focus, the legal challenges will not be elaborated further in this article, but have to be addressed at the macro level by legal scholars, legislation and jurisdiction.

‘Live-ins’ are called into the home care arrangement especially if the care recipient has a “high, complex and time-consuming”^{22, p. 198, own translation)} need of assistance and care. Despite the high need of nursing care, ‘live-ins’ are mainly recruited and employed as household aides or attendants. However, in addition to instrumental tasks (e.g. shopping, housekeeping), they also provide “social engagement care”²³ and take over basic activities of daily living, such as assistance with personal hygiene, mobilisation, food intake or incontinence care.²⁴^, ^{p. 166f.} Other tasks, such as administering medication and wound dressing, are often added during the course of the care recipient’s illness,²⁵^, ^{p. 37} – even though the majority of the ‘live-ins’ are not professionally trained nurses.¹⁸^, ^{p. 161}

Home care arrangements can be complemented by home nursing services and/or specialised outpatient palliative care services, which are referred to as ‘external care providers’ in the following.²⁶^, ^{p. 257} However, these services are only intermittent. Human interface and transition problems arise because all of these actors only take over a specific care task. If none of the care recipient’s relatives are directly on-site, the ‘live-in’ is also the main contact for these actors. This results in additional co-ordination and communication tasks and, consequently, additional responsibility. The working hours also get out of hand more easily with the content-related delimitation of the tasks. As a result, boundaries between employment, on-call time and free time are blurred or even non-existent.^{27, p. 131} Nonetheless, the job description profile is not reflected by the income of either legally or illegally employed ‘live-ins’. Their income is usually below €1000 net/month.²⁸ For these and other reasons, Rogalewski and Florek state “that 90% of ‘live-in’ care work is precarious and exploitative.”⁵^, ^{p. 20} This statement calls for an ethical reflection on the situation of ‘live-ins’ in German households.

Ethical Perspectives on the Situation of ‘Live-ins’

The analysis of the situation of ‘live-ins’ is located at the intersection of different disciplines (inter alia, nursing science, public health) and research fields (gender, migration and health services research). So far, the systematic investigation of ethically relevant phenomena in connection with ‘live-ins’ has been carried out independently by each subdomain (i.e. medical and nursing ethics, public health ethics, organisational ethics) and with a focus on their specific methodological approaches, theoretical frameworks and perspectives. However, when choosing a framework, such as deontological or consequentialist ethics, a topic is already illuminated from a specific point of view, for example, regarding the distribution of resources or responsibilities. In the following and with the aim of a comprehensive ethical mapping of the situation of ‘live-ins’, the ethical questions at the micro and meso level of the health system are not examined in the light of a single framework but the ethical principles and moral norms that are prevalent for the respective status of the ‘live-in’ as a “professional nurse” or a “non-professional caregiver” are considered. This differentiation is necessary because ‘live-ins’ can be either (in their country of origin) trained nurses or individuals without formal education. For the latter, neither the standards for ‘caring relatives’, ‘friends’ nor professional caregivers can be applied. Consequently, ethical challenges arise that affect all care arrangements at the micro level and may result in different ethical harms with partly different underlying ethical principles that become relevant.

Micro Level

Moral agents involved in ‘live-in’ arrangements at the micro level

Although the situation of the ‘live-in’ is the focus of this article, it cannot be examined without looking at the individuals in need of care and their family carers, as they mainly determine the actual working and living conditions of the ‘live-ins’. Therefore, and according to the principle of reciprocity, they are crucial for the identification and reflection of ethical challenges. As moral agents themselves, they might perpetrate or prevent the ethical harm ‘live-ins’ befall.

At the micro level, ethical harm may originate from the care recipient him/herself and/or informal (family) caregivers who take over a part of the daily care. Moreover, the behaviour of individual professional caregivers sent by external care providers has to be taken into account at the micro level. However, their institutional embeddedness must also be considered when looking at their individual behaviour. For a comprehensive picture of the moral agents at the micro level, it must be also considered that not only the care recipients and their relatives in Germany are involved in all scenarios. Although they are the focus of this article, the micro level also extends to the family members of the ‘live-ins’ in their home country. Due to the absence of the ‘live-ins’, care work, both child-care and care for elderly family members, must be restructured.²⁹ Associated conflicts at the micro level and social norm concepts on ‘good motherhood’⁸ – transported from the macro level to the core family or extended family – are tantamount to the tensions in the German home care arrangements. Good motherhood cannot only be understood as a sociological concept, but also as a concept that leaves space for normative reflections. What is considered good and how one comes to this conclusion is not only an on-going negotiation process at the societal level (macro level). These negotiations also take place – overtly or covertly – in every family. Harms may occur if widely diverging value systems clash within one family and the ‘live-in’ is denied the chance to be a good mother. Nonetheless, they cannot be explored in detail here. Finally, and so far often neglected, the ‘live-in’ herself is a moral agent who might harm herself or, at least, finds herself in morally challenging situations.

Potential ethical harms for ‘live-ins’ irrespective of their professional status

‘Live-ins’ may face a number of ethical harms irrespective of their professional status. Although these harms are discussed separately from each other in the following, it has to be considered that they often occur together and a conglomerate of harms is more than the sum of its single parts (i.e. harms).

The ‘live-ins’ obvious continuous proximity to their workplace – or rather the workplace as the living space – affects their individual rights to recovery, free time and the limitation of working time, as granted in Article 24 of the Universal Declaration of Human Rights. The resulting danger for the physical and/or mental health¹⁴ of the ‘‘live-in’’ also potentially violates their right to physical integrity. Emunds, therefore, states that the work as a ‘live-in’ is unjust and impinges on the prohibition of instrumentalisation.^{10, p. 143ff.} Thus, at the same time, this work also disregards human dignity. Under these circumstances, the freedom of movement can also be severely restricted as the radius of movement is often limited to the place of living and working.³⁰^, ^{p. 312} Additionally, and especially in cases of high care need and/or sole care responsibility, ‘live-ins’ (co-)live the care recipient’s everyday life. This not only restricts the ‘live-in’ in shaping their (everyday) life but also has an impact on the evaluation of their life as split and their time in Germany as lost.¹⁰^, ^{p. 210f.} In addition to this harm that can be coined as emotional or psychological, the situation just described points to the possibility that the ‘live-in’ is treated as a mere means (to fill the care gap) by the care recipient and their family and not as an end in herself. This comes with no or a highly diminished respect for the ‘live-in’ as a person with equal (human) rights.

Moreover, the circumstances leading to employment as a ‘live-in’ and the prevailing situation under which the ‘live-in’ carries out her work can restrict her self-determination. These include a lack of privacy, social isolation, possibly undeclared work, and the fear and insecurity associated with these factors. Economic dependency most often adds to the ethically harmful situation of reduced personal autonomy. This is not only the case when the ‘live-in’ is employed illegally. It is more that every ‘live-in’, notwithstanding her type of employment, has a weak bargaining position regarding the care recipient and their family. That they consider the ‘live-in’ to be easily interchangeable makes this most obvious – and is another aspect pointing to a violation of the principle of non-instrumentalisation. Moreover, another ethical harm may result from the undermining of trust that comes with such an attitude. This is aggravated by conscious or unconscious discrimination tendencies against the ‘live-in’ which are often rooted in the structural level (leading to structural discrimination), but also play out at the micro level. These include devaluations based on gender and stereotypes linked to the origin of the ‘live-in’.³¹ Depending on the former experiences, time spent in Germany and coping mechanisms, she might even ethically harm herself by conducting self-stigmatization.

By the very nature of the ‘live-in’ arrangement, it is possible, especially due to emotional labour,³² that a personal relationship develops between the ‘live-in’ and the care recipient and/or their relatives.³³ The care recipient’s needs are the fulcrum of everyday life and a strong emotional bond arises based on the non-stop closeness.²⁷ This results in an extraordinary moral pressure because “a live-in often has to realise that she is the only one who feels responsible for the well-being of the person in need of care.”¹⁰ ^{p. 208, own translation)} This is aggravated by the fact that, in the eyes of the relatives, the perception and evaluation of competence is particularly characterised by the caring behaviour and compassion of the ‘live-in’.⁶ She is expected to identify needs and respond to requests with flexibility.⁶ External care providers cannot meet this need to the same extent. Professional/occupational and private aspects and, thus, professional/job-related and personal duties can become increasingly intermingled over time. Depending on the individual relationship – if it is based on mutual understanding and respect or, alternatively, if the ‘live-in’s’ emotional courtesy and bond towards the care recipient is exploited – such a development can result in fostering or diminishing her autonomy. In a relational reading, “the capacity to find one’s own law can develop only in the context of relations that nurture this capacity”.³⁴ Therefore, relationships that consider the ‘live-in’ as a mere pendant of the care recipient are not the best precondition for supporting her in making self-determined decisions.

Additional ethical harms for ‘live-ins’ without professional nursing education

These considerations also show that nursing professionalism is generally not a criterion for employment as a ‘live-in’. Instead, they are expected to do relational work and act in accordance with the specific rules of a household.¹⁸^, ^{p. 155} Nevertheless, ‘live-ins’ employed for household chores also take over care tasks.^35,36 The inappropriate performance of such tasks – due to a lack of knowledge and skills – may, on the one hand, (potentially) endanger the care recipient’s health and, on the other hand, also pose a risk to the ‘live-in’s’ own health (e.g. risk of injury from cannulas, back injury).²⁵^, ^{p. 37} In addition to a violation of the harm principle towards the ‘live-in’, they are sometimes given more responsibility than they can handle because they are required to carry out tasks that do not fall within their job description or meet their knowledge level. The line to coercion is fluid and expressed, for example, by the threat of dismissal or the suspension of wages in case of non-fulfilment of the task or adverse events for the care recipient. This does not only affect the relationship between the ‘live-in’ and the care recipient and family caregivers, but also the external care provider. It is conceivable that ‘live-ins’ are involved in care activities (e.g. when positioning the care recipient) by professional caregivers. However, there are hardly any task profiles and rules to which the ‘live-in’ could refer and no feedback from colleagues or superiors.³⁷^, ^{p. 178f.} This is the case despite the fact that ‘live-ins’ have the desire for training but do not get access to such a qualification.^{30, p. 312} Consequently, the traditional confusion of informal lay care and professional nursing care in this field is perpetuated on a continuing basis.³⁸^, ^{p. 49}

‘Live-ins’ as professional nurses: ethical standards and potential harms

Other ethically harming situations can occur in cases where the ‘live-in’ is a professional nurse. The code of the International Council of Nurses (ICN)³⁹ explains the fundamental values and principles of the nursing profession. Three points from the code are particularly problematic for the ‘live-in’ as a moral agent. Although they are the origin of the situation in which the ‘live-in’ finds herself, the behaviour of the care recipient, family caregivers and other agents at the micro level is not elaborated in this sub-chapter because they are not addressed by the ICN code.

The confusion of informal lay care and professional nursing care mentioned above can also be observed for ‘live-ins’ who are professional nurses, but the other way round: from the perspective of the demands on a profession, it also becomes pertinent that work below the actual level of training (“de-skilling”) is carried out when simultaneously taking over household chores.³⁹^, ^{p. 12} This can influence the professional identity and professional pride of the ‘live-in’ negatively.⁴⁰ It might even lead to self-stigmatizing processes and undermine the ‘live-in’s’ professional autonomy. The ICN also points to further potential challenges:

1. “Nurses’ primary professional responsibility is to people requiring nursing care.”^{39, p. 7}

The special employment and living conditions for ‘live-ins’ raise the question to whom are they primarily responsible. They find themselves in a tension field between different interests of those involved.^{41, p. 190} Relatives perceive an equally strong moral (self-)obligation to care for and support their loved ones at home.⁴² However, the actual extent to which they can realise this obligation depends on numerous influencing factors. The ‘live-ins’ compensate for existing gaps and problems with the relatives’ work and, thus, make it possible for the latter to fulfil their need to care in harmony with the care recipient’s understanding of autonomy. The ‘live-ins’ provide relief in time-consuming, intricate home care arrangements that are particularly burdensome for relatives. The lack of such support would often mean a transition for the care recipient to a nursing home. Consequently, the needs and well-being of care recipients and family caregivers can conflict to a greater or lesser extent, placing the ‘live-in’ in dilemma situations. This is unproblematic as long as the family caregivers and ‘live-in’ agree on what ‘good’ care and support is. If this is not the case, according to the ICN, the ‘live-in’ would have to balance her care and advocacy role for the care recipient with the (potential) harm that an unstable relationship with the family may cause for her if she prioritizes the responsibility towards the care recipient. This can lead the ‘live-in’ to experience moral distress or even moral residue and, thus, undermine her moral integrity.^43,44

2. “Nurses value their own dignity, well-being and health.”^{39, p. 12}

According to the ICN code, the demands and stresses/burdens occurring in the context of the care work must be balanced against the respect for one’s own physical and mental integrity, so that carers are also able to exercise their profession in the longer run. This responsibility can be violated by the professional nurse herself in several ways when working as a ‘live-in’. In addition to the extensive working hours of up to 21 hours per day, as stated in the ruling of the Regional Labour Court Berlin-Brandenburg, that bring about physical and mental harm, the potential instrumentalisation and reduced self-determination undermine the nurse’s dignity. It would be too short-sighted to state that the ‘live-in’ harms herself in such a situation by not valuing her dignity. However, this kind of ethical harm has to be kept in mind when evaluating the individual situation, taking into account the ‘live-ins’ economic constraints, (subjective) lack of alternatives and external forces pushing her in the situation.

3. The ICN Code of Ethics also holds nurses accountable for each other in two ways within the profession: How they should interact with each other and that they should intervene when colleagues engage in undignified and/or harmful behaviour.^{39, p. 8,12} Nurses from external care providers are, therefore, directly responsible for not only respecting but also supporting the dignity and human rights of their colleagues. Consequently, the ‘live-in’s’ professional and moral integrity is harmed in cases where the external care provider’s staff exploits or instrumentalises her to, for example, save time or avoid the care recipient’s referral to a nursing home. Furthermore, it can be argued that the ‘live-in’s’ (moral) integrity is harmed and her dignity disrespected by colleagues if they remain idle in the face of instrumentalisation or exploitation happening through the care recipient and their family. In the context of home care arrangements in which ‘live-ins’ are involved, however, the possibilities for mutual influence are made even more difficult by the surrounding factors.

4. Finally, the possibility of an evolving personal relationship with the care recipient and/or their family mentioned above, bears the extra potential of conflict for ‘live-ins’ who are employed as professional nurses. In contrast to other professions’ codes of ethics (e.g. psychologists), the ICN Code of Ethics does not explicitly comment on ‘dual relationships’ (concurrency of a personal and professional relationship). The code only entails that nurses “recognise and maintain personal relationship boundaries”.^{39, p. 12} However, the ‘live-in’ may harm herself, overriding the harm principle, when she exhausts her own health. According to the ICN, services that – motivated, for example, by the close personal bond to the care recipient – go beyond what the professional role entails (and what is remunerated), may only be provided up to the point where these services interfere with the self-care of the ‘live-in’.

In summary, several professional ethical principles, as stated in the ICN codex, might be violated by the ‘live-in’ herself. The (repeated) violation of moral integrity can result in moral distress, moral residue and moral injury, which by themselves again undermine a nurse’s autonomy and integrity.^45,46

Meso Level

Moral agents involved in ‘live-in’ arrangements at the meso level

Leaving the centre of the ‘live-in’ arrangement, i.e. the relationship between ‘live-in’, care recipient and their family, the meso level comes into play. Recruitment agencies are often the link between a ‘live-in’ and the client.⁴⁷ Even though their business models are highly problematic, for example, a premature termination of the contract by the ‘live-in’ is often linked to high penalty payments to the agency, and the adhesion contracts of some agencies lead to a large restriction of the ‘live-in’s’ work arrangement (e.g. rotation, working hours),²⁷^,^{p. 132f} these areas of conflict are not directly related to care in the domestic situation and will not be examined further here.

However, a specific characteristic of home care is that external care providers, whose primary attention lies on the care recipient, are often involved. Although these care providers depend on the support of the ‘live-in’ for everyday tasks, such as positioning the care recipient (especially if family caregivers are absent), considerations of the ethical ‘behaviour’ within these organisations towards ‘live-ins’ are completely missing in previous studies. Whether an organisation is, or can be, a ‘moral person’, entity or a ‘moral actor’ is a controversial issue in (business) philosophy.⁴⁸ When we speak of the ‘behaviour’ or ‘decisions’ of an organisation, we refer to the decision-making premises that underly the organisational members’ behaviour. According to Boss and Mitterer, these are the organisation’s culture, organisational processes and structures, programmes (such as a mission statement or strategy), as well as people such as those who work on and with the premises.⁴⁹^, ^{p. 51ff.}On the one hand, (1) the external care provider (in the ductus of organisational ethics hereafter also called the organisation) can directly harm the ‘live-in’. On the other hand, the ‘live-in’ can also observe (2) how the external care provider harms the care recipient or – vice versa – (3) the external care provider can observe that the ‘live-in’ is harmed by the care recipient and/or the contracting family, leading to some kind of “second victim ethical harm” through being involved passively/indirectly in the situation of wrongdoing (also see the micro level). The first scenario, the morally questionable behaviour of the external care provider towards the ‘live-in’, can be discussed referring to the ethical principles outlined above, most particularly, non-instrumentalisation. Given the organisational embeddedness of the external care provider, further problems arise when, for example, questionable behaviour occurs several times and, thus, the actual state contradicts the declared mission statement of the organisation. Moreover, and closely linked to scenario 3, the ‘live-in’ may be ethically harmed by the organisation and its members. One can imagine the situation where the ‘live-in’ reports to the external care provider that she is being harmed by the family with which she lives. Given the case that she is not believed, for example, due to structural discrimination, and not taken seriously as an epistemic agent, the ‘live-in’ is treated epistemically unjustly by the organisation. Therefore, instrumentalisation of and/or discrimination against the ‘live-in’, or, generally, the denial of grievances can occur in scenario 1.^{50, p. 4} This behaviour, in turn, might not only be committed by employees of the external care providers themselves but also observed by them in the domestic situation (see scenario 3).

Apart from this direct, straightforward harm, the ‘live-in’ can also be harmed in cases where she observes that the care recipient is harmed by the external care provider. Firstly, this results in a loyalty conflict between the care recipient and their family, on the one hand, and the organisation with its relieving services and support, on the other. Put bluntly, the ‘live-in’ has to decide between harming the care recipient (due to the organisational members’ behaviour) or harming herself (due to speaking up which may result in a withdrawal of the service without replacement). Secondly, and interlinked with this first point, is that the ‘live-in’ bears witness to the care recipient’s suffering. In turn, this harms the ‘live-in’s’ moral integrity, undermines trust in the organisation and, in the case where the ‘live-in’ is a professional nurse, leads to her non-compliance with the ICN.

Regarding the third scenario, where the organisation’s members observe that ‘live-ins’ are treated in a morally problematic way, two approaches from business ethics are borrowed to clarify how the ‘live-in’ is harmed by the organisation in this case. According to stakeholder theory, not only the clients or care recipients can be considered as stakeholders but also the ‘live-ins’ have a – partly even fundamental – significance for the operation of the organisations in the care arrangement.^{51, p. 56f.} To a certain extent, the external care provider competes with inpatient care facilities, as one can assume that a large number of care recipients can only remain in the domestic situation due to the permanent presence of another person and that they would otherwise be cared for in a nursing home.¹⁸ ^{p. 156,161} Accordingly, a certain economic dependency of the organisation on the ‘live-in’ exists indirectly.

The concept of corporate social responsibility,⁵² which is frequently connected with stakeholder theory in business ethics and has also been applied occasionally to healthcare institutions,⁵³ places the principle of ‘responsibility’ at the fore. Similar to situations within an organisation and in view of this third scenario, personal moral ‘gut feelings’ need to be brought up and clarified. This can, for example, occur when it becomes obvious that a ‘live-in’ works for 21 hours a day or is only allowed to leave the house at certain times. On this basis, it can be argued that the ‘live-in’ is harmed twofold in this third scenario: she is harmed by the care recipient or their family and by the organisation that acts as a bystander. If the organisation does not step in here, the ‘live-in’s’ trust and personal autonomy is undermined. In cases where the organisation values the financial advantages of contracting with the care recipient higher than the ‘live-in’s’ situation, the latter is not respected as a person with equal rights and human dignity.

Conclusion and Outlook

The mapping of ethical conflict areas at a micro and meso level has revealed various ‘blind spots’ and suggests that ‘live-ins’ have, so far, fallen through the cracks not only in terms of legal but also ethical issues. The scenarios presented do not claim to be exhaustive and the principles elaborated cannot, of course, address all ethical problems. In summary, it can be said that regarding the micro level, questions are raised concerning ethical harms the ‘live-ins’ can experience. They may be harmed by the care recipient or their family caregivers, and the ‘live-ins’ may even harm themselves. The particular vulnerability of those involved is an overarching theme in home care arrangements in all the situation constellations discussed. The care recipients are vulnerable because of their permanent dependency on the support of others and the constant experience of restrictions and losses.⁵⁴ The relatives find themselves in a ‘balancing act’ between caregiving and self-sacrifice or -abandonment. The ‘live-ins’ are confronted with a profound power imbalance, restrictions in freedom of movement and the organisation of everyday life, as well as excessive care responsibilities. As demonstrated, all parties involved can harm the ‘live-ins’, respectively, contribute to the ethical harm, which appears as instrumentalisation and a lack of privacy and autonomy. Particularly regarding instrumentalisation and beyond the ‘lowest common denominator’ of vulnerability, the ethical explosive power of the problematic situations identified both at the micro and meso level becomes evident when human rights in their moral nature are applied to the situation of ‘live-ins’. Whether the human rights, as a moral-philosophical instrument, are specific enough to solve the conflicts mentioned is, however, questionable.⁵⁵

The mapping also revealed ‘blind spots’ at the meso level but could not fill them. It became clear that business ethical approaches, such as stakeholder theory and corporate social responsibility, can only capture such a close and mutual dependency as exists between the external care provider and the ‘live-in’ for the care of the person in need to a limited extent. The organisational ethical perspective ‘inwards’ does not, so far, include considerations of participants beyond the client-customer relationship in a systematic manner. It must remain unanswered, for example, whether external care providers have a moral responsibility or even a duty to quit their service in a household if a ‘live-in’ is ‘exploited’ there.

It should be noted that the perspectives at the micro and meso level that have been used to date do not reflect the ‘live-in’s’ situation adequately. This results in the desideratum to systematically capture and work on the ethical problems related to the employment of ‘live-ins’ in German households. A framework is needed that enables a comprehensive view of the problem situations, without losing sight of the stakeholders’ interests, and their mutual dependence and vulnerability. Only by doing so is it be possible to capture, understand and influence the closely interwoven problem situations. The ‘blind spots’ at the macro level have also still to be uncovered and an attempt of an ethical reflection of these spots has to be undertaken. Only such a comprehensive view can grasp the situation of the ‘live-ins’ in all its complexity, interprofessionality, transnationality and vulnerability.

For sustainable changes on all levels, ethical considerations have to go hand in hand with broadening the empirical basis regarding the situation of ‘live-ins’ world-wide. This implies to gather reliable data on the number of migrants working as ‘live-ins’, their terms of contract and professional background. Moreover, future empirical research should aim at drawing a comprehensive picture of all stakeholders involved, their motifs to engage in 24h home care as well as socio-cultural, ethical and other considerations pertinent in the context of ‘live-in’ care. However, the ethical harms that have been mapped in this article can only be mitigated if the ‘live-ins’ themselves are actively included in the framing, conducting and analysis of the research and, even more so, respective policies.

Footnotes

Acknowledgements

We would like to thank the reviewers for their appreciation and important advice on how to improve the manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Anna-Henrikje Seidlein

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Ethical harms for migrant 24h caregivers in home care arrangements

Abstract

Keywords

Introduction

Background

Long-term Home Care in Germany

‘Live-ins’ in the Context of Long-term Home Care

Ethical Perspectives on the Situation of ‘Live-ins’

Micro Level

Moral agents involved in ‘live-in’ arrangements at the micro level

Potential ethical harms for ‘live-ins’ irrespective of their professional status

Additional ethical harms for ‘live-ins’ without professional nursing education

‘Live-ins’ as professional nurses: ethical standards and potential harms

Meso Level

Moral agents involved in ‘live-in’ arrangements at the meso level

Conclusion and Outlook

Footnotes

Acknowledgements

Declaration of conflicting interests

Funding

ORCID iD

References