Family, Intergenerational Solidarity, and Post-Traditional Society

Ronald J. Angel, Jacqueline L. Angel

• Publisher: Routledge
• Year: 2017
• Print ISBN: 9781138240322
• eBook ISBN: 9781351701761
• Topic: Psychology
• Subtopic: Developmental Psychology
• Index: Psychology

Almost all families will at some time have to make difficult decisions concerning aging family members, involving institutionalization, moving from medical interventions to palliative care, and even physician-assisted death. Yet, the historical transition from traditional to post-traditional society means that these decisions are no longer determined by strict rules and norms, and the growing role of the welfare state has been accompanied by changes in the nature of family and social solidarity. Advances in medical technology and greatly expanded life spans further complicate the decision-making process. Family, Intergenerational Solidarity, and Post-Traditional Society examines a range of difficult issues that families commonly face during the family life course within these contexts. The book explores both practical and ethical questions regarding filial responsibility and the roles of the state and adult children in providing financial and instrumental support to dependent parents. The book follows the experiences and deliberations of a fictional family through a series of vignettes in which its members must make difficult decisions about the treatment of a seriously ill parent. Advanced undergraduate and graduate students in family studies, gerontology/aging, sociology, social work, health and social care, and nursing will find this essential reading.

1

CHANGING INTERGENERATIONAL FAMILY DEPENDENCE

A Difficult Family Decision

As they approach retirement Mary and John Gallegos face a new and difficult situation involving John’s father, Phillip. Phil is 82 and during the last year his health has deteriorated rapidly. It is clear that his wife Louise, who is 79 and not in the best of health herself, cannot take care of him alone. Mary, who is non-Hispanic and white is 56, and John, who is Mexican American, is 61. The couple has been married for thirty-two years and they have faced crises before, but this is different. The situation is a bit difficult to explain, largely because there are so many family members involved and because of the potentially serious consequences of a parent’s loss of autonomy. Mary and John’s situation, though, illustrates many of the ethical and practical aspects of the almost inevitable decisions that families must face in dealing with aging parents. In order to better understand those ethical and practical challenges we must describe Mary and John’s situation and that of their family in some detail.

This is the second marriage for both Mary and John. Mary has a daughter, Sharon, from a previous marriage. Sharon is 34, has two children, and lives with her husband in another state. Together Mary and John have a son named Randy and a daughter who they named Eloise after an aunt. Eloise is 18 and a business major at the local state college. Mary and John are paying her tuition and board. Randy, who is 24, has been unable to find employment after being discharged from the National Guard and serving two tours in Afghanistan. He has no income and is living temporarily with Mary and John. John is a high-school physics teacher and Mary works as a receptionist at a real estate firm. In addition to a mortgage on which they owe $98,000, paying for Eloise’s college education and supporting Randy represent major expenses that leave the couple little to save for retirement.

Mary and John have lived in the city in which John grew up since they were married. His parents, Louise and Phil live a few miles away. Phil worked at many manual jobs over the years and has been retired since he was 65. Louise was a full-time homemaker. They own a modest home worth $158,000, have savings and other assets that are worth approximately $102,000, and have a combined income of $3,500 per month from Social Security and a small pension from one of Phil’s previous jobs. During the last year Phil has become incontinent and has experienced serious memory and mood problems. His physical and mental decline is accelerating and Louise can no longer take care of him, nor can she deal with his confusion and frequent emotional outbursts. As we noted, Phil’s condition is the source of Mary and John’s new dilemma, but in order to understand the situation and the possible courses of action open to them we need a bit more information about the family.

John has a younger sister, Carol, who is married and has two children. She lives in Philadelphia, Pennsylvania with her husband Andrew, an attorney who makes a comfortable living. Carol has been a fourth grade teacher for over 20 years. She has seniority, earns a nice salary, and participates in the school district’s pension plan. But let us return to Mary, John’s wife. Her parents are both remarried and in their late seventies. They and their new spouses are functioning well, although as they age their health is declining and it is clear that all four could eventually need assistance. They live in another city in which Mary’s brother, Neil, also lives with his wife and their two children.

Herein lies the dilemma: since Phil can no longer live at home with only Louise to care for him something has to be done, but the options are neither obvious nor particularly attractive. Like most of us, John had never given any thought to the fact that his parents might one day become dependent. Life had just gone on as usual until the crisis came upon them. Phil and Louise had always supported and cared for themselves. They put John and his sister Carol through school and were as generous as parents on a modest income could be. Both John and Mary feel a strong bond of affection for Phil and they share a sense of filial responsibility for him. But here noble sentiments meet practical reality.

Through most of human history elderly parents lived with their family until they died, which usually occurred at a much younger age than is typical today, or they would have had to seek the charitable support of their local congregation or gone to the poor house or asylum. As families have changed fewer are either structurally or financially able to assume full responsibility for aging parents. Smaller families, the migration of children far from their parent’s home, and the fact that women no longer stay at home to care for children or aging parents have resulted in a brave new world of eldercare. Let us review the potential options in Phil’s case, as well as the decisions that he and his family members must make. One option would be for Mary to quit her job and become a full-time caregiver. Although daughters-in-law might have been available to do so in earlier eras, such a possibility is less common today. Mary and John have a daughter in college and an unemployed son to support, they have a mortgage to pay off, and they must save what they can for their own retirements. For either John or Mary to quit working could result in financial disaster.

Perhaps John’s sister, Carol, could assume the role of caregiver. Again, though, Carol has children and other responsibilities. Even though her husband’s income is high, the family has come to rely on her salary to maintain their upper middle class lifestyle. In addition, for Carol to assume the role of main caregiver Phil and Louise would have to move. Although many adult children live with their aging parents, given the social and structural changes in the family and greatly increased lifespans, that living arrangement is less common than in the past. If Phil and Louise do not move in with one of their children or if the children do not move in with them, the family must consider other options.

There are really only two other options, although there are many variations among each that we will discuss in detail in later chapters. The first is for Phil to remain in his home in the community with the help of skilled professionals and perhaps volunteers to help with his basic needs. Given Phil’s incontinence and serious cognitive impairment, that care would need to be nearly constant. The second option is for Phil to enter a nursing home. Both of these options raise important moral, as well as practical issues largely related to who pays for either community or nursing home care. As we describe later, although many adult children provide some level of material support to their aging parents, for the most part we have socialized the financial support of the elderly through Social Security, Medicare, and Medicaid which pays for long-term care for those who do not have the resources to pay out-of-pocket.

Although Social Security was never meant to be one’s sole source of income, for nearly 65 percent of older adults it makes up over half of their total income. We characterize Social Security as the socialization of the financial support of the elderly because of the fact that it is not an annuity. One might imagine that one’s Social Security payroll deduction goes into a personal savings or investment account during one’s working years, but it does not. Current retirees are supported directly by current workers. This arrangement represents a practical way of supporting retired workers as long as there are many workers contributing to the support of each retiree. Increasingly, that is not the case, and situations in which only two or three workers are responsible for the support of each retiree are unsustainable. The solution in many nations has been to move from traditional pension systems to systems that require individuals to save for their own retirements in 401K type plans. Although this might deal with the long-term fiscal problems of traditional pension systems, such reforms do so at the expense of the intergenerational solidarity on which such systems were based.

A major ethical issue that Phil’s situation highlights relates to children’s responsibility for dependent parents. Simple equity would require that since one’s parents provided all of one’s financial support during one’s childhood and often beyond, one is obliged to support them if they cannot support themselves. In Phil’s case, why shouldn’t John, Mary, John’s sister Carol, and her husband pay for any care that he needs? As we discuss in Chapter 6, several states have laws on the books that require adult children to provide financial support to their dependent parents, although those laws are rarely enforced.

Since Phil and Louise own a home and have some savings, as well as their own income, one might imagine that there really is no problem. Phil and Louise can pay for Phil’s long-term care from their savings and they can sell their house if necessary, even if that means that their estate might be depleted, leaving little or nothing for their children to inherit. The problem arises from the fact that given increasing lifespans many individuals have far too little saved to last until death. Care in skilled nursing facilities is extremely expensive and can quickly deplete an individual’s or a couple’s assets. Before they can receive Medicaid, which is the major source of funding for nursing home care for individuals with few assets or income, individuals and couples must spend most of their wealth, as well as a portion of their joint income. In the case in which one spouse must be institutionalized and the other remains in the community, the community dwelling spouse often has to survive on very little. Again this situation raises important ethical issues concerning the responsibility of adult children.

Although the decision concerning Phil represents the immediate family dilemma, if we look into the future we come to the realization that it represents only a small part of what John, Mary, and their siblings will have to deal with in the years to come. Remember that Mary’s parents are each remarried and they and their new spouses are in their late seventies. This means that in addition to Phil and Louise, the couple could find themselves responsible for four more aging individuals who might need long-term care. If there are many children who live close to their parents, as was often the case in the past, those children could potentially pool their resources to support their aging parents. Today’s smaller families, like Social Security systems with fewer workers for each retiree, can be quickly strained to breaking point. If adult children were legally required to support their impoverished parents, John and Mary could find themselves at least partially responsible for up to six older adults. Clearly, such a situation is untenable and in the modern world the socialization of much of the care of aging parents is basically inevitable.

Since some decision must be made concerning at least Phil’s short-term living arrangements, John, Mary, and John’s sister Carol decide that they have no choice but to place Phil in a local nursing home. Louise and Phil will draw upon savings and their other assets to pay for the care. There is a four-month waiting list for a semi-private room, and the annual cost will be over $75,000. A private room would be far more expensive. Clearly, at this rate Louise and Phil’s savings will not last long, but the family sees no immediate alternative. They clearly need expert help and a longer-term plan. A family friend suggests that they contact a local non-governmental organization that deals with eldercare issues for advice. There they are placed in touch with an elder attorney who is an expert in estate planning and all aspects of long-term care. With his help they begin educating themselves concerning various legal and practical issues related to Phil’s needs, as well as Louise’s situation. For the present, Louise will continue to live in the home she and Phil bought and have lived in since they were married. How long she will be able to stay there and what will happen to the house when she dies are questions we will revisit in later chapters.

It is clear that Mary, John, and Carol will confront increasingly complex family decisions for many years. Louise and Phil’s health will deteriorate further, as will that of Mary’s parents. These changes will require difficult decisions that can create strains and conflicts among family members. Decisions concerning where older parents live, though, are only part of the problem. In the future Mary, John, and Carol will be faced with decisions related to medical care, and at some point they may face truly difficult decisions concerning the end of life and the cessation of therapeutic interventions. Such decisions must be made by families whose members are often in emotional turmoil. We will follow Mary and John, and other family members, as they face these difficult decisions in the following chapters.

If families shoulder less of the financial and perhaps even the day-to-day care giving responsibilities for aging parents, who picks up the slack? Clearly, someone must pay for expensive acute and long-term care. During the twentieth century, and especially after the Second World War, the modern welfare state has evolved to guarantee the material welfare of citizens. Even in the United States, which has a far less extensive welfare state than European countries, individuals turn to the state in times of need. Although most of us take most aspects of the welfare state for granted, debates over the morality and consequences of this shift to a greater dependence on the state continue. Many critics of the welfare state subscribe to the traditional Catholic principle of “subsidiarity,” a term that refers to the provision of care at the lowest possible level, preferably at the level of the family and local community. Socially and ethically, a world in which the care of elderly parents and other dependent individuals shifts to the state and becomes professionalized is very different than a world in which one is exclusively responsible for oneself, one’s family, and one’s neighbors.

In the following chapters we examine the profound implications of the major social changes that have affected the family and discuss the ethical, as well as the practical dimensions of a range of social problems related to the care of a dependent family member, focusing primarily on aging parents. This is far more than an idle academic exercise. Most of us will find ourselves having to make major decisions, in conjunction with family members, concerning aging parents and perhaps younger family members who lose their autonomy.

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Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• About the Authors
• Preface
• 1 Changing Intergenerational Family Dependence: A Difficult Family Decision
• 2 The Ties that Bind? Changing Family Options: A Long Way from Ozzie and Harriet
• 3 Socializing the Financial Support of the Elderly: Who Pays for Care at the End of Life?
• 4 Manufactured Risk and Reproductive Technology: There are Many Ways to Have a Baby
• 5 Where Will We Put Mimi? When Family Members Do Not Agree
• 6 Mandatory Support of Aging Parents: A Moral Obligation
• 7 Respect for Autonomy: Difficult Decisions Concerning Medical Care: Who Decides When Treatment is Useless?
• 8 Family Decisions at the End of Life: Une mort très douce
• 9 Physician-Assisted Death: I Am the Master of My Fate
• 10 Civil Society and the Family: If You Can’t Be with the One You Love…
• 11 The Future of Intergenerational Solidarity: Families Caring for an Aging America
• Index