Immediately before Jesus institutes the sacrament of the Eucharist at the Last Supper, he kneels before his disciples to wash their feet. Peter objects to being served by his Lord, finding it improper, but Jesus tells him that, “Unless I wash you, you will have no share with me” (John 13:8). Peter fervently acquiesces, and Jesus instructs all the disciples, “If I, your Lord and Teacher, have washed your feet, you also ought to wash one another’s feet.” (John 13:14)
Moments later, Jesus gives the disciples His broken body, which they will offer in the Mass. But the preparation for the supernatural gifts of priesthood is the habit of care for the natural needs of the person. The disciples will hold God in their hands, but their hands must be ready to be dirty with the dust of the world as they care for Christ in the poor, hungry, and sick.
In some ways, Maundy Thursday could be considered the feast of care workers. Those who care for others, whether they are paid or unpaid; family, friend, or professional; consecrated religious or layperson live out Jesus’s commandment to love one another as He loved us. But the love and service that Jesus shows us lies uneasily alongside the way our culture treats care workers and the vulnerable people they care for.
The slogan “Learn the dignity of serving, rather than being served,” is nearly a recapitulation of Jesus’s instruction to his disciples that, “Anyone who wants to be first must be the very last, and the servant of all” (Mark 9:35). But what was lovingly taught by Jesus to his friends is soured in its later context. As Evelyn Nakano Glenn reports in her book Forced to Care: Coercion and Caregiving in America, this particular instruction to be humble came from the Bureau of Indian Affairs’ 1901 “Course of Study for the Indian Schools.”
Jesus “emptied himself, taking the form of a slave” (Philippians 2:7), but the people who are His hands and feet are subject to exploitative practices, wage theft, and sometimes slavery and human trafficking. Our throwaway culture does not treat them with the dignity befitting people made in God’s image. And when it uses a call for humility as an excuse to humiliate and dehumanize, it does deeper damage.
How could attendees of the Indian schools have heard Jesus’s call clearly, if they had first heard it distorted by their teachers? Misvaluing care work and care workers can, at its worst, approach spiritual abuse, as the relationship that Jesus calls us to is distorted. Our culture becomes an anti-catechism, hiding the face of the Father.
Jesus calls us to be humble, and to be content to offer hidden sacrifices that will be seen only by the Father. It can be hard to know what challenges we should offer up as penances and which we should push back against as injustices. In the secular world, the dignity of workers is often safeguarded by strikes and political action, and victories are measured in minimum wages and maximum hours.
Any advocacy for the elderly, the disabled, the ill, or the very young runs into a tricky clash of rights. If people who need care have a right to be cared for, from whom can they demand that right? Other kinds of claimed rights, to housing, to food, to schooling, etc. don’t involve the degree of intimacy that care work frequently entails. Parents seeking childcare for young children are entangled in a system that is both too expensive for many families to afford and pays such low wages to workers that turnover is high and there is a shortage of teachers. Care is expensive, and frequently beyond the means of the people who need it most.
Who steps into that gap? In some times and places, the need is answered by religious orders, who don’t need to worry about fair wages or the sustainability of their business model. Modern hospitals have their roots in the care for pilgrims offered by the Knights Hospitaller. And when the profit-minded medical establishment turns away the poor, they are met today by orders like the Missionaries of Charity founded by Mother Teresa. These consecrated religious offer service without counting the cost; they have already given all through their total gift of self to Christ.
But the model that suits a religious vocation and the total abandonment to providence does not fit the life of a teacher who needs to pay for his own children’s daycare or a home health aide who is sending remittances home to support her family half a world away.
Care work doesn’t fit neatly into the paradigm of wage work. In her book, Love’s Labor: Essays on Women, Equality, and Dependency, Eva Feder Kittay notes that when your work is taking care of someone who depends on you, you don’t have the power to walk away from a job the way someone on a manufacturing line might. In group homes and some other 24/7 care situations, Kittay notes, “workers are mandated to work overtime if their replacements fail to show up and must remain on duty until relieved.” Preschool teachers similarly can’t simply clock out if a parent doesn’t show up at pickup.
Even when no worksite policy mandates that a care worker remain on watch, many workers stay for overtime or take on tasks that go outside the work they are compensated for, because they know their charge intimately and are moved by their need. This can be framed as a kind of emotional blackmail — the worker has their “no” taken away. But Kittay sees an alternative way of thinking about it: the worker wants to be able to say “yes” to their charge’s need, but the “yes” can be too costly for them to be free to offer.
Workers who care directly for the vulnerable have the relief of knowing they aren’t working what David Graeber terms “bullshit jobs.” They can see that their work matters. Without their help, their charge could not use the bathroom, might not eat, would die. But that means they lose the leverage other workers have to strike, engage in work stoppages, or sometimes even to quit.
In Full Surrogacy Now, author Sophie Lewis claims that abortion is the kind of strike available to surrogate mothers. When they face exploitation, Lewis suggests, they can refuse to work, which means severing the connection between themselves and the child who depends on them, delivering a corpse where their employers hoped for a child. Few consider this option, no matter how dire their circumstances. Care workers are close to the people entrusted to them; they learn to see the world through their charge’s eyes in order to understand their needs.
To be able to demand more, it can help to bring a third party into the relationship. Kittay sees an advantage when care work is paid by a centralized, governmental program. The care worker has new leverage, both to advocate for themselves and for their charge. “Where the provider is not privatized and individualized as it is in families,” Kittay writes, “the dependency worker has an option that is available to other workers— and that is to organize.”
In Kittay’s view, care is never a private matter, something that can be contained in a single dyad or family. Dependency creates a chain of need, which extends out into the wider world. She takes the relationship of mother and child as paradigmatic: “The relation between a needy child and the mother who tends to those needs is analogous to the mother’s own neediness and those who are in a position to meet those needs.” Caring for a child makes the mother more dependent, and gives her a just claim on others, just as the baby has a claim on her.
Kittay terms this framework doulia. She adapts doulia from doula, a person who offers care to a laboring mother. In her broader term, she encompasses “a concept of interdependence that recognizes a relation — not precisely of reciprocity but of nested dependencies — linking those who help and those who require help to give aid to those who cannot help themselves.”
Governmental support can be a response to the claims of doulia. A public, universal benefit recognizes that need is universal and that it does not obey a law of reciprocity. A baby cannot pay back the time and attention he needs from his mother; a mother does not need to earn or recompense the care she receives from others. Instead of clean-cut transactions, there is a circulatory system of care and need, where each gives to the one they can, and receives from the person who cares for them, without concern for balancing the books.
This is the spendthrift logic of the communion of the saints, who know that “whatever you did for one of the least of these brothers and sisters of mine, you did for me” (Matt 25:40). It is the action of the woman with the alabaster jar, who pours out perfumed oil over the feet of the Lord without calculation. But the economy of grace, drawing on the inexhaustible power and love of God, doesn’t map neatly into the economy of appropriations, bills, and state-run welfare programs.
Secular programs are more focused on preventing fraud and minimizing waste than meeting need. Their pinching ways are sometimes motivated by contempt for the poor and an anxiety that anything could be received without being recompensed. Other times, the straitjacket regulations come from a sense of scarcity — if we can’t meet all need, we need rules and priorities to sift out the greatest need.
With every additional bit of red tape, the scope of care work becomes narrower. To be legible to state programs, it must be possible to track hours and enumerate duties. As Glenn recounts, this is why American law excluded care work from many employment protections — it seemed unnatural for the home to operate like a workplace, with carers clocking in and out. Legislators appealed to privacy, calling on the logic of Griswold v. Connecticut avant la lettre. The home should be spared from surveillance, they argued, and any law that would require auditing the everyday relations of the home should be treated skeptically.
This delicacy left caregivers vulnerable to exploitation by their employers and made familial caregivers frequently ineligible for assistance. Vulnerable people receiving care through Medicaid can sometimes arrange payment for caregivers of their own choosing, including family members. These programs, known as “consumer directed care” are authorized under Medicaid waivers. That is, when a vulnerable person chooses a caregiver themselves, rather than having one assigned to them or entering a facility, this is treated as an exemption that the state may choose to allow, rather than as a natural way of approaching an intimate relationship.
Because this program is all administered through states waiving particular Medicaid rules, each state can set its own terms for payments and programs, since they are creating their own variants on the law, rather than the law providing directly for the most natural kind of care. Many states specifically restrict “the legally responsible individual” (i.e. the person who is already most closely linked to the vulnerable person, like a spouse or a child who has taken a parent into their home) from receiving payments.
The person who cares most for the person who needs care cannot be paid, because they are viewed to simply be doing their duty. In the eyes of the state, compensation is for extra work, something that would not be done but for the money changing hands. A few states (including Virginia) made temporary exemptions to these exemptions at the height of the coronavirus pandemic. With a shortage of professional care workers (and added risk in having them enter the homes of vulnerable patients), the state made an exemption to their exemption and allowed some spouses to be paid.
This framework of careworker compensation sees payment through a market lens — what would it cost to change someone’s mind about providing care? What does it cost to get them to sell their services to this particular client? The programs are worried about fraud, auditing timesheets, requiring licensing and certifications. These programs are built as though the primary risk is giving money to someone who may not have earned it.
But, in Kittay’s model of doulia, the reason for payment isn’t to persuade a caregiver to provide care. It is to enable them to offer the care they frequently already wish to provide. Compensation is often framed as wiping out altruism. If money changes hands, then the caring doesn’t count the same way it would if it were offered for free, or even at considerable cost.
In his prayer for generosity, St. Ignatius of Loyola asks the Lord to teach him, “to give and not to count the cost; to fight and not to heed the wounds; to toil, and not to seek for rest; to labor, and not to ask for reward.” The labor of uncompensated caregivers, caregivers who are strained past exhaustion, who are consumed and eaten up by their work, can sound like the fruit of this prayer. But St. Ignatius concludes his prayer by specifying the one reward he hopes for, “to know that I am doing your will.”
Although it is admirable when someone makes tremendous sacrifices to care for others, there is always something tragic about it, too. We see the saintly person at the center of the story, disregarding their own needs for the sake of another, but, at the peripheries of the story, there are others passing by, like the priest and the Levite who hurry by the man left broken and bleeding on the side of the road. The Catholic Church recognizes certain lives as embodying “white martyrdom” — the laying down of one’s life not in a single moment of death, but denial of self through poverty or celibacy. The martyr’s witness is always a testimony to God’s goodness, but, as with the “red martyrdom” of those killed for the faith, the actions of the person demanding the sacrifice can be wicked. It is good to serve the poor, it is sinful to impoverish. It is not God’s will for anyone to be neglected or left for dead, whether they are the initial victim of misfortune or someone who, in giving all they have, is newly vulnerable as a result.
We are not called to stand by and admire the white martyrdom of hard charities. We are called to answer need with our own gifts. But too often, our systems of care work presume that they can wring more and more work out of the families of the vulnerable, trusting that they will sacrifice themselves if we hold back our own help.
One egregious example of this that Glenn discusses is the case of Tina, a 40-year-old high school teacher, whose brother needed a bone marrow transplant for his leukemia. After the transplant, he would need 24-hour care for a period of time, and the hospital and insurance company viewed it as Tina’s job to arrange it. Her brother’s insurer had approved the procedure, but wouldn’t pay for the prerequisites of the procedure. It was as though they greenlit a surgery, but required Tina to supply the doctors or the operating room.
The hospital wouldn’t approve her brother for treatment without a post-discharge plan. The hospital social worker repeatedly suggested to Tina that she would need to quit her teaching job for her brother to receive the treatment he needed to live. Tina eventually won her brother care by coordinating the schedules of 30 friends and relatives to provide 24/7 care for him. Her work was admirable, as was that of her friends and relatives, but it is hollow to praise her without condemning the hard-hearted system that handed her this cross to carry, and then abandoned her.
Care work isn’t folded into a holistic picture of health — specialists focus on one part of the body and disclaim responsibility for everything else. Tina’s brother’s surgeon and his insurance adjusters saw their jobs as narrowly defined. The problem isn’t limited to medicine. Just as doctors outsourced Tina’s brother’s medical needs to her, our policy makers frequently rely on the free labor of the people they are ostensibly helping to make programs run.
Welfare beneficiaries face a skeptical bureaucracy that disclaims responsibility for correcting errors or explaining their procedures, forcing people who are in dire straits to take on the part-time job of navigating red tape. Private insurers use similar tactics, making it their customers’ jobs to correct erroneous bills or negotiate with hospitals. The true price of any policy or procedure is hidden, since so much work is being done, unpaid and unlogged, by the person supposedly being served.
There is no sacrifice we make out of love for another that God disdains. But when we leave caregivers and their charges without support, we are like the Pharisees, who, Jesus says, “tie up heavy, cumbersome loads and put them on other people’s shoulders, but they themselves are not willing to lift a finger to move them” (Matt 23:4). From the beginning of the Church, the martyrs gave testimony of the depth of their love for God in their willingness to die rather than to renounce Him. We benefit from their witness, but we have no reason to be grateful to their persecutors. Paul addresses this question in his letter to the Romans, “Shall we go on sinning so that grace may increase? By no means!” (Rom 6:1-2).
Persecution can make visible the love that might have otherwise expressed itself in more hidden ways, but we must learn to see the quiet virtues, rather than rely on sin and suffering to expose these loves to light. In answering the needs of caregivers, in living out Kittay’s vision of doulia, we respond rightly to others’ willingness to become lowly out of love. We honor the willingness to suffer by not demanding sacrifice. Love answers love, and our strengths are given to us only that we might be good stewards in spending them.
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